Association of Shoulder Problems in Persons With Spinal Cord Injury at Discharge From Inpatient Rehabilitation With Activities and Participation 5 Years Later

Steering-by-leaning facilitates intuitive movement control and improved efficiency in manual wheelchairs

BACKGROUND

Manual wheelchair propulsion is widely accepted to be biomechanically inefficient, with a high prevalence of shoulder pain and injuries among users. Directional control during wheelchair movement is a major, yet largely overlooked source of energy loss: changing direction or maintaining straightforward motion on tilted surfaces requires unilateral braking. This study evaluates the efficiency of a novel steering-by-leaning mechanism that guides wheelchair turning through upper body leaning.

METHODS

16 full-time wheelchair users and 15 able-bodied novices each completed 12 circuits of an adapted Illinois Agility Test-course that included tilted, straight, slalom, and 180° turning sections in a prototype wheelchair at a self-selected functional speed. Trials were alternated between conventional and steering-by-leaning modes while propulsion forces were recorded via instrumented wheelchair wheels. Time to completion, travelled distance, positive/negative power, and work done, were all calculated to allow comparison of the control modes using repeated measures analysis of variance.

RESULTS

Substantial average energy reductions of 51% (able-bodied group) and 35% (wheelchair user group) to complete the task were observed when using the steering-by-leaning system. Simultaneously, able-bodied subjects were approximately 23% faster whereby completion times did not differ for wheelchair users. Participants in both groups wheeled some 10% further with the novel system. Differences were most pronounced during turning and on tilted surfaces where the steering-by-leaning system removed the need for braking for directional control.

CONCLUSIONS

Backrest-actuated steering systems on manual wheelchairs can make a meaningful contribution towards reducing shoulder usage while contributing to independent living. Optimisation of propulsion techniques could further improve functional outcomes.

Relationship of psychosocial factors and musculoskeletal pain among individuals with newly acquired spinal cord injury

STUDY DESIGN

Cross-sectional analysis of baseline data of a longitudinal cohort study.

OBJECTIVES

Little evidence exists on pain-related psychosocial factors in individuals with newly acquired spinal cord injury (SCI). To understand a biopsychosocial model of pain, we must first understand the presenting psychological pain-related factors at injury onset. Therefore, we assessed musculoskeletal pain and pain-related psychological constructs in a group of individuals with newly acquired SCI. We hypothesized that individuals with new SCI would report musculoskeletal shoulder pain with elevated levels of kinesiophobia and pain catastrophizing.

SETTING

Data were collected in three rehabilitation hospitals located in urban and suburban communities.

METHODS

Thirty-five individuals with newly acquired SCI participated. Demographics, Musculoskeletal Pain Survey shoulder subscale, Tampa Kinesiophobia Scale-11, Pain Catastrophizing Scale, Fear of Pain Questionnaire, Chronic Pain Coping Inventory-42, and Subjective Quality of Life Questionnaire were administered. Descriptive analysis of all measures was determined and relationships between pain and psychosocial measures determined.

RESULTS

Moderate shoulder pain existed in 40% of people with new SCI along with clinically elevated kinesiophobia, pain catastrophizing, fear of pain, and reduced quality of life. Shoulder pain was statistically associated with pain catastrophizing (ρ = 0.41, p = 0.01). Kinesiophobia positively correlated with fear of pain (ρ = 0.38, p = 0.02) with an inverse relationship to quality of life (ρ = -0.47, p = 0.01).

CONCLUSIONS

Elevated pain, and pain-related psychological characteristics, such as catastrophizing and kinesiophobia exist during the early stages after SCI. Early identification of pain-related factors can guide clinical intervention potentially ameliorating pain-linked functional impairments.

TRIAL REGISTRY

This trial is registered with ClinTrial.gov ID NCT03137394.

Changes to Biceps and Supraspinatus Tendons in Response to a Progressive Maximal Treadmill-Based Propulsion Aerobic Fitness Test in Manual Wheelchair Users: A Quantitative Musculoskeletal Ultrasound Study

Objective

To investigate if the completion of a recently developed treadmill-based wheelchair propulsion maximal progressive workload incremental test alters the integrity of the long head of the biceps and supraspinatus tendons using musculoskeletal ultrasound imaging biomarkers.

Method

Fifteen manual wheelchair users completed the incremental test. Ultrasound images of the long head of the biceps and supraspinatus tendons were recorded before, immediately after, and 48 hours after the completion of the test using a standardized protocol. Geometric, composition, and texture-related ultrasound biomarkers characterized tendon integrity.

Results

Participants propelled during 10.2 ± 2.9 minutes with the majority (N = 13/15) having reached at least the eighth stage of the test (speed = 0.8 m/s; slope = 3.6°). All ultrasound biomarkers characterizing tendon integrity, measured in the longitudinal and transversal planes for both tendons, were similar (p = 0.063 to 1.000) across measurement times.

Conclusion

The performance of the motorized treadmill wheelchair propulsion test to assess aerobic fitness produced no changes to ultrasound biomarkers of the biceps or supraspinatus tendons. Hence, there was no ultrasound imaging evidence of a maladaptive response due to overstimulation in these tendons immediately after and 48 hours after the performance of the test.

Movement Coordination During Humeral Elevation in Individuals With Newly Acquired Spinal Cord Injury

Humeral elevation is a critical motion for individuals who use a manual wheelchair given that, in a typical day, wheelchair users reach overhead 5 times more often than able-bodied controls. Kinematic analyses in individuals with chronic spinal cord injury (SCI) have focused on weight-bearing tasks rather than overhead reaching. This technical report presents shoulder movement coordination during overhead reaching in individuals with newly acquired SCI. Eight volunteers with acute SCI and 8 matched, uninjured controls participated. Three-dimensional kinematics were collected during seated, humeral elevation. Scapular and thoracic rotations during humeral elevation were averaged across repetitions. The linear relationship of scapular upward rotation to humeral elevation provided movement coordination analysis. Maximal elevation was reduced in SCI with increased thoracic kyphosis. Medium to large effect sizes were found at each elevation angle, with reduced scapular external rotation, posterior tilt, and increased thoracic kyphosis for those with SCI. The linear relationship occurred later and within a significantly (P = .02) smaller range of humeral elevation in SCI. Altered movement coordination, including a diminished linear association of scapular upward rotation and humeral elevation (scapulohumeral rhythm), is found with reduced maximal elevation and increased thoracic kyphosis during overhead reaching tasks in those with acute SCI.

Shoulder impairment and pain of individuals with newly acquired spinal cord injury compared to uninjured peers

STUDY DESIGN

Cohort study.

OBJECTIVES

Shoulder pain prevalence is high in those with spinal cord injury (SCI) and is associated with decreased function, participation restrictions and decreased quality of life. Limited evidence exists regarding physical impairments of newly acquired SCI. The current study compared musculoskeletal factors at rehabilitation initiation in individuals with newly acquired SCI to uninjured individuals. We hypothesized no impairment differences of shoulder pain, strength, mobility, muscle extensibility, or rotator cuff integrity would exist between groups.

SETTING

Multi-site laboratory setting.

METHODS

Thirty-five individuals with newly acquired SCI and age and gender-matched controls without SCI (n = 34) participated. Musculoskeletal Pain Survey, shoulder range of motion (ROM), strength, pectoralis minor muscle extensibility (PM) and tissue integrity [Ultrasound Pathology Rating Scale (USPRS)] were obtained.

RESULTS

Higher pain was reported by individuals experiencing new SCI along with lower strength across all bilateral measures, reduced elevation, external rotation, and horizontal adduction ROM, with large effect sizes. PM bilateral extensibility was reduced compared to controls, with moderate between group effect size; however, no USPRS score difference existed.

CONCLUSIONS

This study provided the first comprehensive clinical description for individuals with newly acquired SCI. In comparison to matched uninjured controls, participants with new SCI reported greater shoulder pain with impairments in mobility, strength, and extensibility. The identified early clinical impairments aligned with progressive impairment including further pain development and persistence. Awareness and modification of these early clinical impairments may lead to improved long-term outcomes, improving the overall health and well-being of individuals with newly acquired SCI.

SPONSORSHIP

Spinal Cord Injury Research Program Investigator-Initiated Research Award under Award No. W81XWH-17-1-0476.

Association of musculoskeletal pain, fear-avoidance factors, and quality of life in active manual wheelchair users with SCI: A pilot study

Objective: Limited evidence examines the association of psychological factors, such as fear of movement and pain catastrophizing, with musculoskeletal pain patterns in active manual wheelchair users with spinal cord injury (SCI). This study investigated the relationship among musculoskeletal pain, fear avoidance factors, quality of life (QoL), activity and duration of injury in individuals with SCI. Design: Cross-sectional correlational. Setting: Community setting. Participants: Twenty-six individuals with SCI (age = 42 ± 14 years, duration manual wheelchair use = 17 ± 13 years, work/school/volunteer hours/week = 31 ± 14; recreation/sports hours/week 10 ± 12). Outcome Measures: Demographics and self-report measures including the Musculoskeletal Pain Survey (MPS), Wheelchair Users Shoulder Pain Index (WUSPI), Tampa Scale of Kinesiophobia (TSK-11), Pain Catastrophizing Scale (PCS), Fear of Pain (FPQ), Subjective Quality of Life Questionnaire (SQoL), and the Social Interaction Inventory (SII). Spearman's rho (ρ) assessed correlation among measures. Results: Strong association existed between age and duration of injury (ρ = 0.66, P < 0.001). SQoL offered a strong, direct correlation with age (ρ = 0.63, P = 0.01), duration of injury (ρ = 0.70, P = 0.001), and strong, inverse relationship with MPStotal (ρ = -0.66, P = 0.003) and MPS shoulder subscore (ρ = -0.64, P = 0.004). WUSPI demonstrated strong, inverse association with self-reported work hours (ρ = -0.52, P = 0.02) and a strong, direct relationship to PCS (ρ = 0.79, P = <0001). PCS demonstrated a strong, inverse relationship to work/school/volunteer hours (ρ = 0.71, P < 0.001) and strong association to TSK-11_total (ρ = 0.61, P = 0.001). A moderate, inverse relationship was identified for recreational/sports hours and FPQ (ρ = 0.48, P = 0.03). Conclusion: This cyclical relationship of musculoskeletal pain, reduced activity, and maladaptive psychological factors allude to interdependence of factors, supporting the multidisciplinary approach to care.

Factors Influencing Participation in Daily Activities by Persons With Spinal Cord Injury: Lessons Learned From an International Scoping Review

Background: It is important to develop further understanding regarding the facilitating and constraining factors that influence participation in daily activities, including social and human rights issues faced by persons with spinal cord injury (SCI) that affect their opportunities to lead full social lives. Objectives: To identify, describe, and compare factors that influence participation in daily activities by persons with SCI living in high-income countries (HICs) and in low- and middle-income countries (LMICs). Method: We performed a scoping review of 2,406 articles published between 2001 and 2016 that were identified from electronic databases. From these, 58 remained after checking inclusion and exclusion criteria. Analyses included (a) identifying factors that facilitate and constrain participation in daily activities; (b) categorizing the identified factors as issues related to medical, social, and human rights models; and (c) comparing determinants between LMICs and HICs. Results: The medical model factors pertained to long-term physical health and functional capacities, self-efficacy and adjustment skills, relearning capacities for performing daily activities, and availability of cost-effective adaptive equipment. The social model factors pertained to developing accommodating communities (accessible environments and mutual understanding). The factors of the human rights model pertained to autonomy (empowerment) and development of social justice (application of policies, advocacy, and negotiation). Conclusion: Eight lessons are proposed to enhance health and functional abilities, ensure disability friendly environments, develop social justice, and provide empowerment to enhance participation in daily activities among person with SCI living in LMICs.

Exosomes in Acquired Neurological Disorders: New Insights into Pathophysiology and Treatment

Exosomes are endogenous nanovesicles that play critical roles in intercellular signaling by conveying functional genetic information and proteins between cells. Exosomes readily cross the blood-brain barrier and have promise as therapeutic delivery vehicles that have the potential to specifically deliver molecules to the central nervous system (CNS). This unique feature also makes exosomes attractive as biomarkers in diagnostics, prognostics, and therapeutics in the context of multiple significant public health conditions, including acquired neurological disorders. The purpose of this review is to summarize the state of the science surrounding the relevance of extracellular vesicles (EVs), particularly exosomes, to acquire neurological disorders, specifically traumatic brain injury (TBI), spinal cord injury (SCI), and ischemic stroke. In total, ten research articles were identified that examined exosomes in the context of TBI, SCI, or stroke; these manuscripts were reviewed and synthesized to further understand the current role of exosomes in the context of acquired neurological disorders. Of the ten published studies, four focused exclusively on TBI, one on both TBI and SCI, and five on ischemic stroke; notably, eight of the ten studies were limited to pre-clinical samples. The present review is the first to discuss the current body of knowledge surrounding the role of exosomes in the pathophysiology, diagnosis, and prognosis, as well as promising therapeutic strategies in TBI, SCI, and stroke research.

Perceived influence of intrinsic/extrinsic factors on participation in life activities after spinal cord injury

BACKGROUND

Various types of limitations on community participation are experienced by people with spinal cord injury (SCI).

OBJECTIVES

To determine: 1) the perceived influence of six intrinsic/extrinsic factors (i.e. physical impairment, emotional condition, thinking skills, environment, lack of assistance, discrimination) on participation in 26 life activities, 2) if this influence varied based on extent of participation, and 3) if personal or environmental characteristics influenced perceptions.

METHODS

Secondary analysis of a cohort (SCI Community Survey, n = 1508) using the SCI Person-Perceived Participation in Daily Activities Questionnaire. Frequency tables, Fisher's exact tests and correspondence analyses.

RESULTS

Respectively, 79.6% and 38.5% of respondents perceived that their physical impairment and the natural and/or built environment were the main factors that limited participation across all activities. Considering participation between three groups (no participation; less than wanted; as much as wanted), significant differences (p < 0.001) of perceptions were observed in 65% of the combinations (26 activities x 6 factors). The hypothesis that respondents who did not participate would perceive the highest proportion of limitations was confirmed in 41% of the combinations. Perceived influence of the intrinsic/extrinsic factors on participation was not significantly influenced by other personal or environmental characteristics.

CONCLUSION

A majority of people with SCI perceived that their participation is limited by one or more of intrinsic/extrinsic factors. Perceptions regarding which factors influence participation differ between activities and these perceptions appear related to the extent of participation suggesting that those who actively participate could be the most sensitive to limitations in certain activities.

Association of Pectoralis Minor Muscle Extensibility, Shoulder Mobility, and Duration of Manual Wheelchair Use

OBJECTIVE

To assess the relation of pectoralis minor muscle (PMm) length and extensibility to shoulder pain, shoulder girdle motion, and duration of manual wheelchair (MWC) use, and to compare differences in muscle length, muscle extensibility, peak humeral elevation, and pain among groups based on duration of wheelchair use.

DESIGN

Cross-sectional cohort study.

SETTING

Laboratory setting.

PARTICIPANTS

Individuals with spinal cord injury (SCI) who used an MWC for daily community and home mobility (N=22; 18 men; mean age, 41.7y; duration wheelchair use, 14.6y). Participants were stratified into groups based on duration of wheelchair use: <5 years (n=6), 5 to 15 years (n=8), and >15 years (n=8).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Clinical measures of PMm length and extensibility, shoulder girdle motion, and shoulder pain (Wheelchair User's Shoulder Pain Index).

RESULTS

Significant high correlations were found among duration of wheelchair use, passive PMm length, passive PMm extensibility, and peak humerothoracic elevation. Moderate correlation of peak humerothoracic elevation to pain was found. Individuals with >15 years wheelchair use had reduced PMm extensibility and reduced peak humerothoracic elevation than those with <5 years duration of use.

CONCLUSIONS

To our knowledge, this is the first investigation to identify the association of reduced PMm extensibility with reduced shoulder girdle mobility, pain, and duration of wheelchair use in individuals with SCI.

Living With Chronic Pain After Spinal Cord Injury: A Mixed-Methods Study

OBJECTIVE

To identify the relative importance of positive (facilitators) and negative (barriers) contributors to living with chronic pain after spinal cord injury (SCI).

DESIGN

Mixed-methods: (1) Qualitative (n=35): individual, semistructured, open-ended interviews identifying facilitator/barrier themes; (2) Quantitative (n=491): converting the most common themes into statements and quantifying agreement with these in an online survey to determine relative importance, underlying dimensions, and their associations with perceived difficulty in dealing with pain.

SETTING

University-based research setting and general community.

PARTICIPANTS

Volunteers (N=526) with SCI experiencing moderate to severe chronic pain.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Interview guides, facilitator/barrier statements, and pain inventories.

RESULTS

Exploratory factor analyses reduced agreement ratings into 4 facilitators (information regarding pain and treatments, resilience, coping, medication use) and 5 barriers (poor health care communication, pain impact and limitations, poor communication about pain, difficult nature of pain, treatment concerns). Greater "pain impact and limitations," "difficult nature of pain," "poor communication from provider," lower "resilience," greater "medication use," and younger age predicted greater difficulty in dealing with pain (r=.75; F=69.02; P<.001).

CONCLUSIONS

This study revealed multiple facilitators and barriers to living with chronic pain after SCI. The principal barrier, "poor health care communication," indicated that consumers do not receive adequate information from their health care providers regarding pain. "Information regarding pain and treatments" had greater agreement scores and factor loadings than all other facilitators, indicating that most participants view provider-patient communication and educational efforts regarding pain and pain management as priorities and critical needs. Further initiatives in these areas are important for improving pain management post-SCI.