By Caroline Florescu, M.D. and Martin Young
Shoulder problems in older adults and wheelchair users are common--and often difficult to cure. This conservative program offers some help.
We often abuse our shoulders without realizing it. When we habitually rest on an elbow for long periods while reading, eating or watching TV, we are stretching the ligaments so that the humerus (the head of the upper arm bone) is no longer in the center of rotation. If we exercise this joint irregularly and without warming up, or apply heavy stress in an awkward position, we may tear something, and we are inviting trouble. This problem is compounded for paraplegics and quadriplegics who, unlike able-bodied people, can never really stop using this joint.
As soon as a ligament is injured or stretched, the body senses the joint is not on dead center. Signals to surrounding muscles force them to restore joints to their proper position. These muscles go into spasm, and constant pain results. Too often we merely treat symptoms with anti-inflammatory pain relievers (aspirin), heat, cold, massage, electricity, etc., to get muscles to relax without solving the underlying cause.
Geometry
The home position for the upper arm in the shoulder socket is the anatomically correct (least stressed) resting position--i.e., with the body held straight and erect, arms hang loosely at the sides with the palms facing in. The humerus is supported in a position that is in its natural center of rotation.
Why is this so important? If a standard door hinge is not deformed, it rotates smoothly. If the hinge post is bent of our of alignment, it is difficult to operate and, if forced, might even be destroyed.
Most body joints--knee, elbow, etc.--have strong, tightly interlocking sockets and tend to turn around a well-supported center of rotation. Shoulder joints are different. The upper arm has a huge range of motion (ROM) in all three axial directions, even allowing the humerus to rotate in its socket. But no well-shaped socket holds the humerus tightly as it goes through this extraordinary ROM. Instead, the head of the humerus relies on its network of ligaments and tendons to keep it tightly in the center of rotation while moving under stress. For wheelchair users, this stress may involve supporting or moving the body's entire weight on one arm.
Treatment
The only way to cure this problem is to get circulation and exercise to the ligaments and tendons so they will heal, strengthen, and restore to their correct configuration. Rest alone will not do the job. Injured tendons have a long memory and may not heal completely for years. The best way is through systematic, frequent exercise using careful warm-ups, more repetitions, and less weight. Exercise brings internal heat and circulation to the injury site, providing more effective healing. The goal is to return the humerus to its properly aligned and centered home position.
Workouts
The workout exercises are listed at the end of this article. Do the easiest, least stressful exercises first. Gradually warm up, use smaller weights, more repetitions; slowly increase ROM.
Work out at least four days per week (five is better!).
Each month, systematically increase the above variables (repetitions, range, weights, etc.).
Over time, this will increase circulation at the heart of the injury. Circulation--the flow through blood vessels and lymphatics--carries heat, oxygen, and nutrients to healing tissues. It removes lactates (salts of lactic acid) and other byproducts of metabolism. It strengthens supporting structures by healing stressed tendons, shortening overextended tendons, building muscles, and increasing ROM.
When the arm is in the home position, circulation should be maximal. Avoid holding the arm in an awkward position, under pressure, for any significant length of time.
Exercise Hints
First, consult a physician. Make sure nothing is torn or broken, and that no chips are in the joint.
Perform the exercises in sequence. The first ones are the least stressful.
If an exercise is painful, reduce the weight, move it to the end of the workout when youíre more warmed up, or omit it for a week. Then try again.
Always start with the injured arm. Then do the same amount with the other one.
Repeat the process for at least three sets (four is better) while sitting upright.
When possible, if the exercise permits it, try to keep your elbow tucked into your body so the upper arm is in its home position (Every time you use your arms, hold the elbows in!)
Whenever you work with only one arm, use the other one to stabilize your trunk. (When exercising the arm, it may help to maintain balance if you hook that shoulder over your wheelchair.)
Lifetime Program
Every time you use your arms, keep your elbows in. If youíre driving, your arms can be almost straight out, horizontally, to the top of the steering wheel, or they can (and should) be strongly bent, so that the elbows are much closer to the body and its home position.
When you transfer, keep the elbows in, close to the body.
Change positions often and avoid leaning on your elbows. If you must do so, keep them against your body. If you're worried about a stressful transfer, do some warm-ups. Stretch your arms first. Do some body push-ups, etc.
If you continue this exercise program for one or two months, youíll see benefits: reduced pain, greater strength, and a wider ROM. But you should relax during this process and think of it as the initial phase of a lifetime program. Good luck!
The Exercises
Pendulum Swing
Sitting upright, holding a weight (5 - 20 LB), swing the loosely hanging arm in small circles for 20 - 40 repetitions (reps). This is a minimum-energy exercise emphasizing a completely relaxed arm.
Wing Flaps
Put the backs of your hands against your hips. Rotate the elbows forward as far as possible without pain. Then bring them back. Do 20 - 40 reps.
Scarf Arm Throw
"Throw" the relaxed arm diagonally across and above the opposite shoulder, as far around and back as comfortable, for 20 - 30 reps. The other hand may assist by pushing the elbow around and back.
External Shoulder Rotation
With the upper arms in home position, elbows tucked in close to the body, forearms forward and horizontal, and the back of the hands facing up, hold a rope, bungee cord, or cloth tightly with both hands about six inches apart. Slowly pull one hand around as far as possible to one side, while the other hand is resisting. Then use the other hand to go the other way. The grip may be easier if you wrap the cord around each hand or knot the cord. Go back and forth 10 - 20 times.
Curls
With the arm hanging down against the body, palms or thumbs facing forward (your choice), hold a weight ( 1- 15 LB). Without moving the elbow, raise the weight to almost touch the upper arm. Then lower it slowly. Do 10 - 20 reps.
Military Press
Hold a weight (1 - 15 lbs.) in your hand, touching the shoulder, upper arm in home position. While sitting straight, raise the weight straight up as far as you can. Your arm should point to the ceiling. Then lower it to the shoulder. If you have balance problems, use the other to stabilize your body. Do 10 - 20 reps.
Straight Arm Raises
Face forward (facing 12 o'clock). With your right arm extended but relaxed in the home position, hold a weight (1- 5 lbs.). Slowly raise the extended arm (pointing at 1:30 for the right arm, 10:30 for the left arm) until the weight is above the shoulder with the thumb pointed up. Lower it slowly to the home position. Do 10 - 20 reps.
Wheelchair Push Ups
Sitting upright, place the hands at the top of the wheelchair tires. Push down and raise the body until your arms are straight. Then lower yourself slowly. Try to keep the elbows close to the body. Do 10 - 20 reps.
Internal Shoulder Rotation
Tie a long bungee cord to a closet doorknob. Put some knots in it to make it easy to grip. Grasp the end of the cord in a taut position with your back to the door. The elbow is tucked into the body, upper arm in home position. If the body faces forward at 12 o'clock, the right lower arm is horizontal and points to 3 o'clock. Still holding and gradually stretching the cord, rotate the lower arm around in front of the body, till it points to 12 o'clock--then rotate it back.
Martin Young is a physicist, wheelchair user and athlete who developed the conservative approach described in this article as a method of dealing with his own recurring shoulder injuries. Caroline Florescu is a physician and wife of a wheelchair user who has also experienced shoulder injuries. This article, which first appeared in Paraplegia News (January 2000) is reprinted with permission of the authors. |
