By Dominic Giraldes
From Total Access, Summer 2001

Physiotherapist Dominic Giraldes explains why CPA members are prone to overuse injuries—and how they can avoid it.

So, what does this term “overuse syndrome” mean? It’s a term used to describe a group of diseases that occur due to a repetitive stress on an area of the body. Microscopic trauma occurs as a single motion is performed multiple times, and the cumulative trauma leads to injury, pain and possible increased disability.

There are many different medical diagnoses that are associated with overuse syndrome. It’s a good guess that many of you have heard some of these terms from a doctor or therapist—bursitis, tendonitis, arthritis, impingement syndrome (swimmer’s shoulder), rotator cuff tears, trigger points, lateral epichondylitis (tennis elbow), and carpal tunnel syndrome are all different terms that are under the umbrella of overuse syndrome.

Persons with SCI are more prone to overuse injuries. Studies vary, but it can be said that people with SCI are 50 to 75 percent more likely to develop shoulder and arm pain than the general population. There are many reasons for this greater risk. Think of the all the repetitive motions that occur during your normal day: wheeling, transferring, working on high counter tops, even breathing with accessory muscles instead of the diaphragm. There is an unusually high amount of arm use for daily activities. Compromising postures are frequently assumed. Abnormal muscle control and tone is the norm. Overuse syndromes have a major impact on people who suffer from them. The most common complaint is chronic pain, primarily in the neck, shoulders and elbows. Pain can be very disabled. It may vary from mild discomfort to intolerable agony. Pain tends to bring about reactions throughout the body, such as increased spasms and autonomic dysreflexia. Other problems might include muscle and joint stiffness, skin problems that result from an inability to weight shift, decreased independence and quality of life, and even depression.

Causes of Overuse Syndrome
For people with SCI, there are several related causes that you need to be aware of.

Muscle Paralysis - Paralysis after injury compromises muscle strength and creates muscle imbalances. The joints of the body move by muscles working together in a synchronized fashion. A weakened muscle in a group can lead to abnormal motions at the joint and cause injury over time. Spasms may also be considered here. Spasms are rarely symmetrical and tend to overpower one side of the trunk or extremity over the other. Postural changes, such as scoliosis, may eventually occur and further exacerbate an overuse injury.

Increased Demands and Stress Placed On Joints - Persons with SCI must use their joints in abnormal ways to function throughout the day. During a transfer, for example, you pick up the weight of your body through the shoulder joints. The shoulder is designed to move the hand through space and, because of its design, has difficulty supporting the weight of the body. The shoulder is being asked to do a task that is more appropriate for the hip. Another important example is working on a high counter where the elbows are above the shoulder, such as washing the dishes at the kitchen sink. This is an unstable position for the shoulder and increases the risk of an overuse injury over time. The shoulder is a much more efficient joint when the arms are at the side.

Repetitiveness of Activities - There are many repetitive motions for a person with SCI. Some include wheeling, weight shifting, transferring, and for some, walking with crutches.

Muscle Imbalances - When a certain muscle is underused and the opposing muscle is overused, the overused muscle can become shortened and overpowering while the opposing muscle can become weak and overstretched. This can lead to abnormal movements at the joint and postural changes. A clear example of this type of imbalance would be the changes that happen around the shoulder after years of wheeling a manual chair. The musculature in the front of the shoulder and chest becomes strong and starts to tighten up while the underused back and scapular muscles become underdeveloped. There is than a situation of unbalanced muscular patterns around the shoulder joint and changes in posture due to unwanted tightness. Another common example is the practice of hooking. Many quadriplegics hook their arm around the can of the wheelchair back for balance and to increase their abilities to do many activities. Most people who use hooking tend to use one side only, usually the non-dominant hand, while using their other hand to do a task.

Posture and Seating - In my experience as a physiotherapist working with SCI, changing the posture of a client is the most important step to take for preventing overuse injuries and decreasing the pain and associated disability that can occur. Sitting posture is intimately related to neck, shoulder and arm function. Changing the posture of a wheelchair user can have vast implications on other aspects of that person’s life. Transfers may need to be changed, balance may need to be relearned, and environments might need to be modified to accommodate the new setup. One of the most common problems seen is sitting in a posterior pelvic tilt (sacral or slouched sitting) because the seat depth of the wheelchair is too long or the back angle is too open. Many people choose to sit this way because it improves balance. By changing this to a more erect posture, balance is compromised. It may take months to slowly change the posture and accommodate to the new position.

Management and Prevention
Managing and preventing overuse syndromes consists of understanding why the injury is occurring, problem-solving to find a reasonable solution, and then modifying your lifestyle and physical presentation. Physiotherapists, massage therapists, acupuncturists and chiropractors can be invaluable to help break the pain and inflammation cycle, but until the root of the problem is explored, the pain and injury will likely return. Here are some ideas to look at.

Correct or Lessen Muscle Imbalances - An exercise problem that incorporates strengthening and stretching is usually helpful. A good therapist can look at your present situation and assist with an exercise program. Usually, this incorporates strengthening the weakened muscles and stretching the overpowering muscles. By looking at your daily activities, you can be creative and come up with some simple and less time-consuming strategies. For instance, one might wheel backwards up a frequently negotiated hill or alter which arm one hooks with.

Posture, Posture, Posture - As discussed earlier, this is an important and ongoing step to take. Posture should be monitored frequently. A simple strategy is to pick one day of the year—your birthday works great—and take a front, side and rear photo of yourself, without a shirt on, sitting in your wheelchair. You can then compare your posture over time and take appropriate steps when needed.

Protect Joints During Activities - Be aware of the need for this. Decrease the amount of overhead reaching and modify the environment to lessen the amount that must be done. Be aware of how you transfer and be careful using an overhead trapeze. Modify your hooking and wheeling patterns. Pace yourself and take breaks. The phrase “use it or lose it” is passe.

Modify Activities and Look At Your Equipment - If a certain activity is causing you pain, change the way you do it. This may involve changing your transfer technique or using different adaptive aids. Equipment is always changing as more is learned about overuse and disability. Wheelchairs are lighter and easier to push and lift into a car. Proper wheelchair setup and seating position is a must. Sliding boards are helpful for reducing stresses on the shoulder. This doesn’t mean carrying a sliding board around wherever you go—instead, use it for the more difficult or frequent transfers and save your joints for times when you don’t have a board. Some people find changing to power mobility helpful as they age.

Modify Your Environment - Ergonomics is a growing and important new field. Many companies have persons employed, or will contract professionals, to modify workstations to prevent overuse syndromes. Take advantage of this. It’s a good idea for anybody.

Overuse syndromes occur in a large portion of the population. It’s more frequent and occurs earlier in persons with SCI, and can greatly impact health, function and independence. It’s important to catch overuse injuries early and consider possible causes. Overuse is part of aging, but with some knowledge and prevention, its onset can be avoided or delayed.

Dominic Giraldes is a senior physiotherapist at GF Strong Rehabilitation Centre in Vancouver.