Shoulder Overuse in SCI: Intervention Strategies For Physical Therapy Students

Amanda Friedline Weber – SPT

Background

Following SCI, individuals have to rely on their upper extremities to be their main mode of function. Shoulder overuse is caused by an increase in weight-bearing upper extremity demands for transfers, pressure relief, and wheelchair propulsion.¹ Additionally, in this population, most activities are performed from wheelchair level so activities tend to be performed in a forward and overhead position which places the shoulder in a prime impingement range. Evidence shows working above shoulder height leads to increased risk of pain and injury.² Prevalence of shoulder pain in individuals with SCI has been reported to be between 30-60% ,² with prevalence increasing as duration since injury increases (positively correlated).¹ Shoulder pain in individuals with paraplegia has been reported to lead to reduced subjective quality of life and physical activity³ by significantly impacting function and independence.

Project Overview

I had the pleasure of completing a clinical rotation last spring in the inpatient rehabilitation setting on the SCI team. Being on this rotation, I realized how wonderful the PHYT 785 curriculum was at preparing me to work with this population, however, the one area I felt less prepared was dealing with shoulder pain or overuse. While on this rotation, I was tasked with developing a shoulder exercise plan to prevent shoulder pain in a T-10 patient and then instruct and appropriately cue the patient with each exercise. This clinical situation sparked the idea for this capstone project.

In the Fall 2016, my EBP Critically Appraised Topic (CAT) set out to answer the following clinical question: In a 45 year old male with paraplegia from a traumatic spinal cord injury, is an exercise intervention to address shoulder strength more effective than wheelchair ergonomics/propulsion stroke education in reducing pain and/or improving function in shoulder overuse injuries? My CAT can be accessed here:  Friedline Weber_CAT

As I began to research the topic more, I came across the Paralyzed Veterans of America clinical practice guideline for health-care professionals titled “Preservation of Upper Limb Function Following Spinal Cord Injury”.² PVA-CPG_preservation UE function in SCI This is a wonderful, evidence based, comprehensive document that discusses shoulder strengthening/stretching interventions, propulsion stroke and activity modifications. This document was published in 2005 and includes evidence published through 2004. Utilizing this document as a resource, my capstone focuses on evidence related to the sitting pivot transfer and shoulder exercise programs from 2005 – present.

Through discussion with committee members, it was deemed that focusing on shoulder exercise programs paired with stresses on the shoulder during transfers would be more beneficial for students then looking at the evidence regarding wheelchair propulsion stroke. I appraised the evidence on the sitting pivot transfer, and applied it along with the evidence on shoulder exercise programs, in my voicethread lecture. Here is a reference list of the additional articles appraised: Friedline Weber_additional reference list.docx

When developing the presentation, I utilized various resources to aid in creating a learner friendly product. In order to not compete with my slides or force my audience to dual task, I limited the text on each slide and provided the depth of material through my voice delivery. I incorporated 5 main key components that are recommended to be included in a presentation, including motivational hook, objectives, content, content booster, and summary.⁴ Specifically for content boosters, I added a “clinical pearls” slide at the end of each major content section to reinforce the learning of the audience by summarizing the key take home – clinical points. This content was further supported with videos where the audience could watch and listen to examples of instruction and cueing to aid in proper skill performance with the goal of the audience taking practical, clinical information away from the presentation.

Project Products

The intended audience for this project is the 2^nd year DPT students during the PHYT 785 – Neuro Assessment II course. This project will serve as an educational supplement that students will have the ability to view on their own when course faculty provide students access via Sakai and Voicethread as it coordinates with SCI being covered in the course curriculum.

There are several products built into this presentation. First, I have recorded a Voicethread lecture (https://unc.voicethread.com/share/8956899/)  that discusses the evidence relating to forces on the shoulder with sitting pivot transfers and effectiveness of shoulder exercise programs, making sure to highlight the clinical pearls for students and clinicians. The power point slides without videos are available here for note taking:Shoulder Overuse in SCI_ppt

An additional product, that is embedded into the voicethread for easy access are videos of myself serving as the physical therapist, providing exercise instruction and feedback to a real patient performing exercises. There is also a video of the patient performing sitting pivot transfers, with discussion about the numerous elements that must be considered when doing transfer training.

Evaluation

An evaluation component has been made in preparation for this presentation to be utilized in next year’s PHYT 785 course. Using Survey Monkey, students will have access to a custom survey at the end of the voicethread presentation (can also be accessed here: https://www.surveymonkey.com/r/WF3VSBK ).This survey seeks feedback on the quality of the videos and the audio, quality of the overall presentation, what could I have done better, and finally address if specific learning objectives were met through gauging the audience’s confidence pre and post presentation and testing their content knowledge. Feedback was also requested from committee members throughout the development of this presentation regarding content and correctness of instruction in videos.

Reflection and Self-Assessment

Overall, I am happy with the quality of this project. I feel the project meets the learning objectives for the audience and I hope will serve as a good educational supplement for the students. Additionally, this project helped me reach my specific self-learning objectives. One self-learning objective was to learn how to properly video and edit clips. I did learn how to properly video and edit clips the hard way as there were some trials to filming (some of the videos were shot out of focus). Though my videos don’t meet the quality I had originally planned for, the audience can still see and hear what the patient/physical therapist are doing which is the most important part. Furthermore, I underestimated the difficulty of finding and scheduling a patient to film. This experience further emphasized to me the need for pre-planning. In my proposed timeline, I had myself completing respective tasks and assignments several weeks early, allotting a built in cushion for various hick-ups and bumps along the way, which proved beneficial due to the delay in filming.

This project definitely expanded my knowledge on abnormal forces at the shoulder and proper patient instruction when completing exercises. I did not realize the large discrepancy of forces and body weight supported between lead arm and trail arm when doing a sitting pivot transfer, as well as the impact of surface height differences. Having appraised the evidence, I can pair this with my clinical judgement and discussion with the patient to determine when to begin transfer training without a transfer aid and determine which transfer may be best suited for the particular patient. I also think watching myself on video providing patient instruction was extremely valuable. It allowed me to see first-hand the things I did/do well and need to improve on, which will only allow me to further grow as a clinician no matter my potential practice setting. For example, though I had a “filming script” written out, I should have “gone off script” when I realized the patient wasn’t performing a neutral spine properly, providing better instruction and cueing. I didn’t realize she wasn’t doing it, however, until watching the video at a later time. This shows that my “eye” for technique still has plenty of room for improvement.

Acknowledgements

This project could not have been possible without the assistance of numerous individuals. First of all, thanks to my committee advisor, Karen McCulloch, PT, PhD, NCS for her patience, wisdom and guidance throughout this process. Also, thank you to my other amazing committee members, Courtney Matrunick, PT, DPT, Raheleh Tschoepe, MS, OT/L, and Margaret Kelly, PT, DPT who aided in finding patients to film, were patient with my numerous emails, and provided valuable feedback on the content of this presentation. I also need to thank Greg Kaliber, UNC’s Media Lab Manager, and the other media lab personnel, who answered numerous question about how to edit videos and properly upload them to power point and voicethread.

References

1. Haubert LL, Mulroy SJ, Hatchett PE, et al. Car Transfer and Wheelchair Loading Techniques in Independent Drivers with Paraplegia. Front Bioeng Biotechnol. 2015;3:139. doi:10.3389/fbioe.2015.00139.
2. Veterans of America P. Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals.
3. Gutierrez DD, Thompson L, Kemp B, Mulroy SJ, Physical Therapy Clinical Research Network, Rehabilitation Research and Training Center on Aging-Related Changes in Impairment for Persons Living with Physical Disabilities. The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia. J Spinal Cord Med. 2007;30(3):251-255. http://www.ncbi.nlm.nih.gov/pubmed/17684891. Accessed February 5, 2017.
4. Plack M, Driscoll M. Systematic Effective Instruction: Keys to Designing Effective Presentations. In: Teaching and Learning in Physical Therapy – From Classroom to Clinic. SLACK Incorporated; 2011:67-115.

Picture: http://www.dieselcrew.com/tag/shoulder-pain