Kørestolstype og skuldersmerter. Lone Skriver Rose, MPhil, Fys National Spinal Injuries Centre Stoke Mandeville Hospital Aylesbury, UK

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1 Kørestolstype og skuldersmerter Lone Skriver Rose, MPhil, Fys National Spinal Injuries Centre Stoke Mandeville Hospital Aylesbury, UK

2 Introduktion Hvor stort er problemet? Typiske årsager Faktorer forbundet med udvikling af OE smerter, specielt skulder Hvad kan (skal?) vi gøre?

3 Boninger et al. Manual wheelchair pushrim biomechanics and axle position. (Arch Phys Med Rehabil.2000:81) Individuals who use a wheelchair as a primary mode of ambulation need to have a properly fitting wheelchair to avoid secondary disability.

4 OE smerte prevalens blandt kørestolsbrugere: Skulder: fra 30% (Ballinger, 2000) til 60% (Subbarao, 1994) Albue: 5-35% Håndled og carpal tunnel syndrome (CTS) op til 66% Hånd: op til 48% OE smerte forbundet med hvor længe man har haft sit handicap, ikke ens alder. Problemet betydeligt større blandt kørestolsbrugere

5 Skuldersmerter typiske årsager Grundliggende problem: muskel ubalance Impingement syndrome Biceps tendinitis Capsulitis Rotator cuff tear Degenerative changes

6 Hvor stort er problemet med skuldersmerter blandt manuelle kørestolsbrugere i UK? Hvilken rolle spiller kørestolstypen?

7 Methodology Data from wheelchair provision survey ( ) Multi-centre study 10 participating Spinal Cord Injury Centres in the UK. Data collected by postal questionnaire Inclusion criteria: 1. Full-time use (indoors and outdoors) 2. Manual wheelchair at time of survey 3. More than one year post-discharge 4. Completed Wheelchair User s Shoulder Pain Index - WUSPI (Curtis,1995) N = 705

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9 Population demographics (N=705) AGE* 0-19 yrs yrs yrs > 60 yrs 2% 39% 36% 23% Gender: 75% / 25% Tetraplegic: 27% Paraplegic: 73% * Age at time of participating in survey.

10 Prevalens litteratur oversigt Clinical practice guideline: Preservation of upper limb function following spinal cord injury Published by Consortium for Spinal Cord Medicine (2005) Free download from

11 Author/yr Population Time since inj Investigations Shld pain Nicholls, 1979 Para + tetra Median: 7 year Symptom survey 51% N= 491 Silfverskjold, 1986 Para = 20 Tetra = 40 >6 mths Questionnaire Para: 35% Tetra: 78% Gellman, 1988 Para > 1 yr History 35% N= 84 Exam Sie, 1992 Para = 103 Tetra = 136 History Exam Para: 36% Tetra: 46% Pentland & Twomey, 1994 Para = 52 Symptom survey 39% Subbarao, 1994 Para + tetra Symptom survey 60% N= 451 Curtis, 1999 Para = 103 Tetra = 92 >1 yr (1-13 yrs) Self-report survey Para: 42% Tetra: 59% Ballinger, 2000 Para + tetra >9 mths Questionnaire 30% N= 89 (all male) 1-48 yrs Aver: 10 yrs Exam Radiographs Boninger, 2001 Para = 28 Questionnaire 32% Exam; MRI Alm, 2008 Para = 88 >1 yr 1-47 yrs Questionnaire WUSPI 40%

12 Author/yr Population Time since inj Investigations Shld pain Nicholls, 1979 Para + tetra Median: 7 year Symptom survey 51% N= 491 Silfverskjold, 1986 Para = 20 Tetra = 40 >6 mths Questionnaire Para: 35% Tetra: 78% Gellman, 1988 Para > 1 yr History 35% N= 84 Exam Sie, 1992 Para = 103 Tetra = 136 History Exam Para: 36% Tetra: 46% Pentland & Twomey, 1994 Para = 52 Symptom survey 39% Subbarao, 1994 Para + tetra Symptom survey 60% N= 451 Curtis, 1999 Para = 103 Tetra = 92 >1 yr (1-13 yrs) Self-report survey Para: 42% Tetra: 59% Ballinger, 2000 Para + tetra >9 mths Questionnaire 30% N= 89 (all male) 1-48 yrs Aver: 10 yrs Exam Radiographs Boninger, 2001 Para = 28 Questionnaire 32% Exam; MRI Alm, 2008 Para = 88 >1 yr Questionnaire 40% 1-47 yrs WUSPI Rose, 2012 Para = 420 Tetra = yrs Questionnaire WUSPI 66%

13 Dyson-Hudson, T.A. & Kirshblum, S.C Shoulder pain in chronic spinal cord injury, Part I: Epidemiology, etiology, and pathomechanics. J.Spinal Cord.Med., 27, (1) 4-17 Resumé over de faktorer som er forbundet med skuldersmerter: 1. Faktorer, som vi ikke kan påvirke 2. Faktorer, som vi kan påvirke

14 Faktorer forbundet med skuldersmerter dem som vi ikke kan påvirke:

15 Demographics - with pain* Age < 40 yrs (N=267) Age yrs (N=217) Age > 60 yrs (N=125) 64% 60% 70% p=0.036 Female (N=97) Male (N=323) 64% 65% n.s Paraplegics (N=420) Tetraplegics (N=147) 62% 74% p= % 20% 40% 60% 80% * Pain defined as reporting pain in at least one WUSPI activity

16 100% Shoulder pain : Time since discharge (N = 667) 80% 60% 65% 70% 68% 75% 55% 67% 65% 64% 40% 20% 0% 1-2 yrs 2-3 yrs 3-4 yrs 4-5 yrs 5-6 yrs 6-7 yrs 7-8 yrs 8-9 yrs

17 Faktorer forbundet med skuldersmerter dem som vi kan påvirke:

18 Kørestolen Anbefalinger for bevilling: 1. Consortium for Spinal Cord Medicine (CSCM), 2005: People with a SCI should be provided with a highstrength, fully customizable manual wheelchair made of the lightest possible material. 2. Orthosis on wheels Bengt Engström (2002)

19 3. WHO Guideline (2008): For many people, an appropriate*, well-designed and wellfitted wheelchair can be the first step towards inclusion and participation in society Providing wheelchairs that are fit for the purpose not only enhances mobility but begins a process of opening up a world of education, work and social life * WHO definition appropriate wheelchair : a wheelchair that meets the user s needs and environmental conditions; provides proper fit and postural support; is safe and durable Guidelines on the provision of manual wheelchairs in less resourced settings

20 4. United Kingdom: Healthcare standards for NHS-commissioned wheelchair services, 2005 (revised 2010): Full-time, active user with independent mobility: self-propelling standard or high performance wheelchair. Definition of active? Does independent mobility include car? Definition of high performance = movable rear axle

21 Kørestolstyper (N=705) Custom Rigid multi-adj 26% 30% Folding multi-adj 12% Rigid min adj 8% Folding min adj Basic 13% 11% 0% 10% 20% 30% 40% 68% of wheelchairs used complied with CSCM recommendations: strength, customizable and light.

22 Skuldersmerte : kørestols type 35% 30% 25% 20% 15% 10% 5% 0% 13% 7% Basic 11% 12% 10% 8% Folding min adj No pain (N=209) Rigid min adj 11% 13% Folding multi-adj 27% 27% Rigid multi-adj With pain (N=402) 30% 31% Custom

23 WUSPI resultat N = Mean Median SD Transfer chair/bed Transfer chair/car Transfer chair/bath Load chair into car Push > 10 minutes Push up ramps/slopes Objects down from shelf Put on trousers Put on t-shirt or jumper Put on button down shirt Washing back Usual ADL Driving Household chores Sleeping

24 WUSPI Push > 10 min 60% 50% 40% 30% 20% 10% 0% 42% 27% 21% Folding N = % 50% 30% 16% Rigid N = 381 4% No or negligible pain Min Pain Mod Pain Severe Pain More severe pain noted in folding frame users (p=0.01)

25 WUSPI Push up ramp 60% 50% 40% 30% 20% 10% 0% 43% 26% 19% Folding N = % 53% 29% 15% Rigid N = 379 4% No or negligible pain Min Pain Mod Pain Severe Pain More severe pain noted in folding frame users (p=0.001)

26 Vægt Bodyweight linked to median nerve injury (Boninger, 1999) Significant relationship between imaging abnormalities and body mass index (BMI) (Boninger, 2001) Consider combined weight of total seating system (wheelchair and cushion/backrest) and user

27 Indstilling af kørestolen Efficient propulsion Optimal posture From Engström, (2002)

28 Bevis for optimal drivhjulsindstilling Drivhjul frem/tilbage (manøvrering/stabilitet): Adjust the rear axle as far forward as possible without compromising the stability of the user (Preservation of Upper Limb Function following SCI Clinical Practice Guideline, 2005) Rulle modstand: Decreases rolling resistance therefore increasing pushing efficiency. (Brubaker 1986)

29 Bevis for optimal drivhjulsindstilling Drivhjul frem/tilbage fortsat: Increased hand contact on the push rim leads to lower stroke frequency and less rapid loading of pushrim ( rate of rise ) Less effort for the user (Hughes et al 1992,Masse et al 1992, Boninger et al 2000).

30 Bevis for optimal drivhjulsindstilling op/ned Position the rear axle so that when the hand is placed at the top dead-center position on the pushrim, the angle between the upper arm and forearm is between * (Van der Woude et al 1989, 2009; Boninger et al 2000). *Fuld extension = 180 = albue flexion Fingertip-axle Optimal mechanical efficiency Minimal physical strain

31 Drivhjul seat height From Clinical Practice Guideline, 2005 ( A: seat too low/ axle too high B: Recommended Q2= C: seat too high / axle too low

32 Drivhjulsindstilling - holdning Posterior seat inclination and more vertical (low) backrest results in more erect posture, greater ability to reach and decrease in pain in neck and trunk. (Hastings, 2003, 2010) Drivhjulsindstilling op/ned snæver vinkel eller tilt? Husk rygstøtte indstilling ved snæver vinkel fast ramme / krydsramme stol?

33 Stroke Pattern Recommendation: 1. Limit high impact on handrim long, smooth strokes (Boninger et al 1999) 2. Use semi-circular pattern (Boninger, 2002) One of 4 commonly seen patterns preferred because: No abrupt changes in direction No extra hand movements

34 Stroke Pattern Stroke Pattern Semi-circular pattern Poor propulsion pattern From Clinical Practice Guideline, 2005 (

35 Andre brikker i puslespillet - Tryk aflastning ikke længere stem læn fremover eller s/s hver time i 2 min (Coggrave & Rose, 2003) kørestols tilt ( >30 ) (Spriggle, 2010)

36 Andre brikker i puslespillet - Styrketræning 1. Curtis (1999): effect of exercise protocol in decreasing intensity of shoulder pain. 2. van Drongelen (2006): early onset of UL pain most important predictor for later pain: Avoid any direct pressure on shoulder in bed Increase strength before starting heavier ADL rehab (transfers)

37 Andre brikker i puslespillet - Forflytninger: 1. sitting pivot den arm, som fører an i forflytningen ( leading ) tager et større pres end armen, som er mere stabiliserende ( trailing ). (Gagnon, 2008) 2. bil sket en total ændring mht hvordan man får kørestolen ind/ud ad bilen

38 Det historiske perspektiv!

39 Resumé 1. Prevalens større end andre undersøgelser (66%) * alle deltagere var permanente kørestolsbrugere * alle brugte kun manuel kørestol 2. Statistiskt var der en stærk association mellem krydsramme: smerte? Sværere at indstille optimalt for holdning og funktion? Tungere? Større energi forbrug

40 Resumé - fortsat 3. Stor prevalens i betragtning af forholdvis ny rygmarvsskade (1 10 år)? association med ændringer i akut management? kortere sengeleje periode = mindre atrofi men mindre tid til optræning af relevante mm grupper

41 Hvad håb er der for vores borgere?? Forebyg muskel ustabilitet omkring skulderen ved regelmæssig træning Bibehold led bevægelighed Vælg den rigtige kørestol til dit behov God holdning God kørestolsfærdighed kend din stol!

42 Hvad håb er der for vores borgere?? Regelmæssig trykaflastning ved at læne frem eller til siden, absolut ikke ved stem Lær at bruge glidebrædt brug det på dårlige dage eller i uvante situationer Overvej at bruge power assist. Freewheel?

43 Kommentarer? Spørgsmål?? Contact details: Online link til afhandling:

44 Acknowledgement Local investigators in participating SCIC This study was funded by: Buckinghamshire Healthcare NHS Trust The David Tolkien Award UK Spinal Cord Injury Research Network (UK SCIRN)