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Department of Rehabilitation Medicine
Volume 21 Issue 2 • Spring 2012
• Ultralight Wheelchair Skills: From Rehab to Real World... 4
• Literature review: 12 abstracts of SCI research................... 6
My Shoulder Hurts! My Wrist Aches!
Upper Limb Pain in Spinal Cord Injury
By Deborah Crane, MD, MPH, Assistant Professor, Rehabilitation
Medicine, University of Washington
Pain and SCI
Pain is an unfortunate but common reality for people living with spinal cord injury
(SCI). Persons with SCI may suffer with musculoskeletal pain (affecting the muscles,
bones or joints), neuropathic (“nerve”) pain, or both. Musculoskeletal pain is typically
described as dull or achy, occurs above the level of injury, and is usually triggered by
specific movements of a joint or body region. In contrast, neuropathic pain usually
occurs at or below the level of injury, is often described as burning or stabbing, and
does not have specific triggers.
Shoulder pain
People understandably worry about developing shoulder pain after SCI because
it is such a common problem and can be so disabling. Surveys have found that it affects 30-60% of the SCI population. It is thought that using the arms for propelling a
wheelchair or performing transfers over time leads to injuries and arthritic changes
in the shoulders. Tears to the rotator cuff (tendons of the muscles that support the shoulder) are a common culprit, but other causes of shoulder pain after SCI include impingement (pinching of the tendons),
arthritis (inflammation of the joint), biceps tendonitis (pain in the tendon that attaches the biceps muscle
to the shoulder), and bursitis (inflammation of the bursa sac that cushions the joint). In addition, muscular
shoulder pain may occur when a person is forced to use his or her shoulder muscles to maintain posture
or has muscle imbalances due to the SCI.
continued on page 2
New remodel…new independence
Like many others who become paralyzed suddenly due to
injury or disease, Larry Mohrman could no longer live in his
house after sustaining a C-5 incomplete spinal cord injury in
2003. “It was a two-story home with the main living quarters
on the top floor—not at all wheelchair accessible,” he said. “A
contractor friend told me remodeling it would be too expensive
and suggested that I sell the house and buy another one later
that could be remodeled more cheaply and easily.”
Mohrman went to live in an adult family home after leaving
rehab. He worked hard at regaining as much recovery as possible. After 2 ½ years was able to walk 200 feet with a walker,
but still used a wheelchair for his primary mobility. He moved to
an apartment where he was able to live independently.
In 2007, however, fate struck another blow: “A car hit me
while I was in a crosswalk in my wheelchair. This caused further
injury, and I can no longer stand, balance or walk due to spasticity. Now I use a power wheelchair fulltime.”
After that he started looking for a house to buy—one that
could be remodeled for maximum accessibility and independence. “I wanted a one-level, 2-3 bedroom, 1-2 bath house with
a 1-car attached garage for storage and 2-car detached garage
for his accessible van.”
In June 2010 he found what he was looking for in southwest
Seattle. “Although it was useless for a wheelchair user when I
bought it, I could see the potential if it was done correctly, and
the price was right,” he said.
continued on page 3
spinal cord injury
continued from page 1
Arm and hand pain
The shoulder is not the only upper limb joint at risk for
injury. Elbow pain is present for 5-16% of those with SCI. It is
commonly caused by tennis elbow, ulnar nerve injury, bursitis,
and arthritis.
It is likely that more than 10% of persons with SCI have hand
and wrist pain. Carpal tunnel syndrome (when increased pressure in the wrist puts pressure on the median nerve) is overwhelmingly the most common cause of pain in this region. The
risk for developing carpal tunnel syndrome increases the longer
a person has been living with SCI. Extreme wrist extension
(bending the hand back)—a position often used when transferring or propelling a wheelchair—is the likely cause of carpal
tunnel syndrome. Arthritis, ulnar nerve injuries, and tendinopathies (injuries or degenerative changes to tendons) also cause
hand and wrist pain in the SCI population.
Back and neck pain
Many people with SCI also have back and neck pain. Depending on level of injury, this may be neuropathic or “nerve” pain,
musculoskeletal pain, or both. After SCI, individuals may develop
spine deformities that can cause pain, including scoliosis (curving
of the spine) or kyphosis (“hump back”). Frequently, people with
SCI complain of a “ring of fire” or “iron corset” around their
shoulders or torso, which typically occurs at the level where
their sensation changes from normal to abnormal. This can be
very painful and, at times, very difficult to treat.
How can I avoid upper limb pain?
For those with relatively new SCIs hoping to prevent upper
limb pain, there are some things you can do.
ƒƒ Try to maintain a healthy body weight. As you gain weight,
transferring and propelling your wheelchair become more
difficult and puts greater strain on your shoulders, arms and
ƒƒ Make sure your wheelchair fits you properly. For manual
wheelchair users, check that the wheel axle position and seat
height are correct for you. For all wheelchair users, your
seating system should provide enough trunk support so you
don’t rely on your shoulder muscles to keep you upright.
ƒƒ Maintain good technique for transfers and wheelchair propulsion.
ƒƒ If you walk using canes or crutches, a physical therapist can
show you how to use good biomechanics so you don’t harm
your upper body joints.
I already have pain—what can I do?
ƒƒ See a physical therapist to make sure your wheelchair still
fits you properly. Improper wheelchair fit can cause or
worsen pain and injury to the shoulders and arms.
ƒƒ Review safe transfer and wheelchair propulsion techniques
with a physical therapist.
ƒƒ Consider how many times each day you are transferring,
how far each day you are pushing your wheelchair, how you
disassemble and store your wheelchair in the car, and what
sorts of activities you do for work and fun. Could any of
these activities be causing you harm? What can you do to
reduce the stress you are putting on your body? Talk to your
SCI doctor and therapists about changes you can make in
your daily life to reduce harm and pain.
Treatment options for upper limb pain may include therapeutic exercise, weight loss, heat or ice, medications, injections, or
surgery. This will depend on the cause of your pain and what you
and your doctor decide is the most appropriate treatment for
Rest is often the best thing for musculoskeletal pain. Unfortunately, it is very difficult to rest your upper limbs if you have an
SCI because you rely on your arms to transfer, push a wheelchair, walk with crutches, etc.
If pain and injury are severe enough, you may need to consider switching to a power wheelchair, at least for part of the
time. Power wheelchairs will help to reduce repetitive strain and
overuse, conserve energy, and improve speed and ease of travelling over different distances and types of terrain. Of course,
there are downsides to using a power wheelchair, and you will
need to discuss the pros and cons with your health provider.
Finally, keep in mind that recovery from an upper limb injury
or surgery may take a long time. Even after relatively minor surgery, you may need to stay in the hospital for a while so you can
adequately rest your upper limbs to allow for healing, prevent
skin break down, and get help accomplishing basic daily activities.
Preservation of Upper Limb Function:What you should know: A
Guide for People with Spinal Cord Injury. Consortium of Spinal
Cord Medicine. Paralyzed Veterans of America (2008), (www.pva.
org; 888- 860-7244).
Bayley JC, Cochran TP, Sledge CV. The weight-bearing shoulder. The impingement
syndrome in paraplegics. JJ Bone Joint Surg Am. June 1987; 69(5): 676-8.
Boninger ML, RA Cooper, B Fay, A Koontz. “Musculoskeletal pain and overuse
injuries.” Spinal Cord Medicine: Principles and Practice. Ed.VW Lin. New York,
Demos, 2003. 527-534.
Escobedo EM, JC Hunter, MC Hollister, RM Patten, B Goldstein. MR imaging of
rotator cuff tears in individuals with paraplegia. AJR Am J Roentgenol.. April
1998; 168: 919-923.
Gabel GT. Gymnastic wrist injuries. Clin Sports Med. July 1998; 17(3): 611-621.
Giner-Pascual M, Alcanuis-Alberola M, Querol F, Salinas-Huertas S, Garcia-Masso
X, Gonzalez L-M. Transdermal nitroglycerine treatment of shoulder tendinopathies in patients with spinal cord injuries. Spinal Cord. 2011;48:1014-19.
Goldstein B. Musculoskeletal conditions after spinal cord injury. Phys Med Rehabil
Clin N Am. February 2000; 11(1): 91-108.
Goldstein B,Young J, Escobedo E. Rotator cuff repairs in individuals with paraplegia. Am J Phys Med Rehabil. July/August 1997;76(4):316-322.
Hastings J and B Goldstein. Paraplegia and the shoulder. Phys Med Rehabil Clin N
Am. 2004; 14: 699-718.
Krause JS. Aging after spinal cord injury: an exploratory study. Spinal Cord. 2000;
38: 77-83.
Nepomuceno C, PR Fine, JS Richards, H Gowens, SL Stover, U Rantanuabol, R
Houston. Pain in patients with spinal cord injury. Arch Phys Med Rehabil. Dec
1979; 60(12): 605-9.
Nichols PJ, PA Norman, JR Ennis. Wheelchair user’s shoulder? Shoulder pain in
patients with spinal cord lesions. Scand J Rehabil Med.1979; 11(1):29-32.
Nyland J, K Robinson, D Caborn, E Knapp, T Brosky. Shoulder rotator torque
and wheelchair dependence differences of National Wheelchair Basketball
Association players. Arch Phys Med Rehabil. Apr 1997; 78(4): 358-363.
continued on back page
2 • Volume 21, Issue 2
Spinal Cord Injury Update
spring 2012
spinal cord injury
continued from page 1
His contractor friend, Dean Sander,
checked it out before closing and said
“Sure, I can make this work.”
“My goal was to make it accessible,
convenient, safe and fully useable—on a
budget,” Sander said. “Larry gave me a
free hand to do what I thought was best.”
Sander stripped the house down to the
studs and rebuilt the whole interior.
He had done ADA compliance work
in the past and was familiar with the
codes. “But ADA is just a standard,” he
said. “It doesn’t necessarily work for the
individual.” For example, there’s an ADAcompliant toilet, but the flush is on the
right, and Mohrman can only use his left
hand since the injury. “I wanted to make
sure everything worked for Larry,” he
said. “I walked through the place daily and
put myself in his position.”
He removed walls between several
rooms, enlarged interior door openings
to 36 inches, added concrete ramps and
landings with guard rails at both outside
doors, installed lever-style door handles,
and made all the floors hardwood or
In the kitchen he installed a roll-under
sink and stove top, custom cabinets and
counters, and positioned the oven at a
height that was accessible from a wheelchair. (See photo upper right.)
The main bathroom has a custom
concrete sloping base, roll-in shower,
durable porcelain tile
throughout the bath floor
and shower walls, cathedral ceiling, both remote
and rain-sensor controlled
skylight, and single handle
faucets and shower mixer
The house has additional accessibility features such
as keyed-alike locks for
all entrances and remotecontrolled garage doors
and gas fireplace. It was
also rebuilt to be energyefficient.
Sander has worked on
many big projects over
the years, including sevLarry Mohrman’s kitchen was completely torn apart and remodeled
eral multi-million-dollar private
to be completely accessible to him. Now he can roll his wheelchair
homes and said, “not one has
meant more to me than this one. under the stove, sink and counter. and the oven for easy reach. Upper
cabinets have pull-down accessible shelf racks. See more photos at
It opened my eyes and made me http://sci.washington.edu/info/newsletters/articles/12_spr_remodel.asp.
aware of what a person with a
disability has to go through in life. I’ve
never seen Larry happier. He’s independent again.”
Mohrman agrees. “It’s all perfectly
done,” he said. He hopes that by sharing
ƒƒ A word about contractors—
his remodel experience with others with
When looking for a contractor, it’s
SCI, they can see what is possible and
important to find someone who really
how changes in their home can vastly
listens to you and is sensitive to your
improve their independence, comfort
specific needs, Dean Sander says. “The
and quality of life.
remodel has to work. It’s not just
aesthetics.” Sander is happy to talk to
people in the Seattle area about acv
cessible remodel questions. He can be
reached at 425-443-6204 or
Larry Mohrman’s remodel on our website at
See before and after photos of
The front of Larry
Mohrman’s remodeled house, left,
shows the accessible
ramp and entry.
The back entry
was also remodeled
with a new ramp and
doorway. .
Single keyedalike access for all
entrances provides
accessibility and
University of Washington School of Medicine
ƒƒ Accessible Home Design, 2nd Edition,
Paralyzed Veterans of America; order at
www.pva.org or call 888-860-7244.
ƒƒ Master Builders Association of King
and Snohomish County provides
practical information and referrals
about home building and remodeling.
Contact them at 425-451-7920 or
ƒƒ “Home Adaptations & Modifications
after SCI,” SCI Forum presentation,
June 12, 2007, Northwest Regional SCI
System; http://sci.washington.edu/info/
ƒƒ See more resources on our website at
Department of Rehabilitation Medicine • 3
forum report
The SCI Forum is an evening p­ resentation and discussion series on topics of interest to persons with spinal cord ­injury and their family members, friends, caregivers and health care providers, held at the U
­ niversity of Washington Medical Center. To learn about upcoming SCI Forums, read reports of past forums, watch
forum videos, or subscribe to the SCI Forum mailing list, go to http://sci.washington.edu/info/forums.
Ultralight Wheelchair Skills: From Rehab to Real World
Presented by Elisa Smith, DPT, on November 8, 2011 at Harborview Medical Center.
Watch the video of this presentation online at http://sci.washington.edu/info/forums/reports/wc_skills_2011.asp.
The wheelie:
an essential skill
A “wheelie” is the act of balancing on
your rear wheels. Wheelies may look like
tricks, but “they are the essential building
blocks of community wheelchair skills,”
said Elisa Smith, physical therapist at Harborview Medical Center. Unfortunately,
many people don’t learn this skill before
they are discharged home from rehab
and then have few opportunities to learn
them later on.
“Rehab stays now are getting so short
that therapists only have time to focus
on basic transfers, caregiver training
and testing different chairs,” Smith said.
“There isn’t much time to practice many
ultralight wheelchair skills while still in
the hospital.” Once patients get home,
there may not be many therapists in
their communities who are familiar with
wheelchair skills.
“Newly injured patients often assume
wheelies are simply tricks and not essential to their rehab,” Smith said. “People
will say to me, ‘I don’t care about tricks
right now. I just had this major tragedy
in my life, and I don’t want to focus on
doing stunts.’”
Other patients are just too overwhelmed and fearful in the early weeks.
“They can’t imagine doing anything
outside of the hospital by themselves,”
Smith said. “They’ll say, ‘I’m always going
to have somebody pushing my chair, so
I don’t need to learn how to do this
on my own,’ or ‘It seems like wheelies
are impossible. I’m just getting used to
a chair, and I don’t want to do anything
where I’m going to put myself at risk for
falling back and hitting my head or losing
control of the chair.’”
Why learn wheelies?
ƒƒ Choosing the best wheelchair
“The more skills you learn, the more
you understand how a chair needs to fit
you and what kinds of features and acces4 • Volume 21, Issue 2
Spinal Cord Injury Update
sories you want,” Smith said. “Then when
you are talking to therapists or vendors,
you are more likely to get a chair that is
ideally set up for you.”
ƒƒ Improved quality of life
Several studies have shown that learning
wheelies and related skills can improve
your quality of life because they help you
be more independent and more active in
the community, such as going to school,
work and social activities. “And if you get
invited to a barbecue at a friend’s house,
you will be able to go through the grass to
get to the back yard,” Smith said.
ƒƒ Less pain, fewer falls
For example, if you are able to pop a
wheelie to hop off a curb at an intersection, you can see the traffic and have
more control of the chair and be less
likely to tip over than if you back down
the curb.
Where to learn wheelies
If you didn’t learn these skills while
still in rehab, or if you want to improve
your skills, you can get help and information from a variety of sources, such as:
ƒƒ Physical therapists: see your physical therapist in your clinic or other
outpatient setting.
ƒƒ Wheelchair Skills Training Program (www.wheelchairskillsprogram.ca)
from Dalhousie University (Canada).
This website features “how-to” videos
and detailed descriptions of many
wheelchair skills.
ƒƒ The Manual Wheelchair Training
Guide, by P. Axelson, et al. 1st ed. San
Francisco, CA: PAX Press; 1998.
ƒƒ Other wheelchair users
ƒƒ Visit online forums such as Rutgers’
CareCure Forum (http://sci.rutgers.
ƒƒ Local events like the UW’s SCI Forums (http://sci.washington.edu/info/
forums/) and SCI Support Group
spring 2012
Wheelchair skills
Following is a brief summary of the
wheelchair skills and techniques presented
at this forum. Watch the video to get the
full descriptions and see demonstrations
of these different skills.
Caution! Consult with your
physician and physical therapist
before attempting any of these
wheelchair skills. Always use
a physical therapist or trained
spotter to prevent falls while
learning wheelchair skills like
the ones described here.
A therapist also can train a family
member or friend to help spot you while
you are learning these skills. Spotting is especially important while you are working
on getting your balance in a wheelie.
Stationary wheelie & pop-ups
ƒƒ Training progression involves three
phases: take off, balance and landing.
ƒƒ Balancing in a wheelie: surface, balance, tipping back. “Have a spotter put
you back in your balance point on your
back wheels so you can see how far
back it is,” Smith said. “Usually it’s farther
back than you might expect.”
ƒƒ Popping into a wheelie: partial versus
full. “It’s good to practice going into a
partial wheelie, where you’re popping
up, but not all the way to your balance
point,” Smith said. “Partial wheelies help
you go over obstacles and with being
able to time a pop up so you can go up
a curb.”
ƒƒ Landing a wheelie: push forward on
the rim as you land to soften the impact.
ƒƒ Take-off strategies:
ƒƒ Backward: pull back and then push
forward on the rims.
ƒƒ Forward: push forward on the rims
to pop up. This strategy may be
continued on next page
forum report
spinal cord injury
slower and require more force, but
it enables pop-ups during forward
propulsion and in tight spaces.
ƒƒ Self-recovery: pull back on the rims
to tip forward out of a wheelie.
especially your shoulders.” Like using
escalators (below), going up and down
stairs is the kind of skill you might want
to know about just for emergencies, if
you’re in a building and there’s a fire and
the elevators stop working.”
ƒƒ Safe falls. There is no ideal way to
ƒƒ Escalators: “Some places will ask you
fall safely, Smith said. If you are falling
not to go on
backward, “try to
an escalakeep your head as
tor because
Watch the video on our website:
far forward as you
can so the frame
afraid you’ll
hits the ground first,
get stuck,”
and do some comSmith said.
bination of blocking
“You need
your knees (so they don’t hit you in the
face) and blocking your head, or blockand
” There
ing your head with both arms.”
is a risk of falling or getting stuck, so
proceed with caution.
Dynamic wheelie
A dynamic wheelie is moving or propelling while balancing on your rear wheels.You
can go forward, backward, turn, and pivot in
Practice going forward by setting up a
slalom course to propel around obstacles
in a wheelie.
“Reverse is the most difficult and
requires a lot of practice because pulling
back to go in reverse tips the chair forward out of a wheelie,” Smith said.
Indoor Skills
ƒƒ Thresholds or flooring transitions:
perform a partial pop-up to ascend.
ƒƒ Thick carpet: propel in a wheelie.
ƒƒ Tight spaces (restrooms, elevators):
back into the space and turn in a wheelie.
ƒƒ No-hands wheelie (against wall):
back up against a wall, tip back, and lock
your wheels. “The idea with a no-hands
wheelies is that you can lean back and
not have to be balancing your chair,”
Smith said. “This can be good for reading, making phone calls or giving your
back a rest. It can be used for pressure
reliefs and provides a better neck position for looking up during conversations.”
ƒƒ Stairs: Stairs are challenging and can
be risky, Smith said. “Doing stairs is one
of the most physically demanding skills.
It’s not just about balance and technique,
like most of these other skills. Stairs,
especially going up, takes a tremendous
amount of arm strength, and it can really
go wrong. Even if it goes smoothly, there
is a lot of wear and tear on your arms,
Outdoor Skills
ƒƒ Uneven terrain (snow, grass, gravel,
sand): “You pop up into your wheelie
and keep the front wheels up as you
propel forward,” Smith said. “This is a
dynamic wheelie and is very labor-intensive because there’s a lot more friction to push against.” Consider knobby
tires or larger casters for these activities. Also, be aware that some surfaces
can damage wheelchair components.
ƒƒ Depressions (potholes, grates): Pop
into a partial or full wheelie, which lifts
your casters out of the depression, and
go across on your rear wheels.
descend, letting the rims slowly slide
through your hands. “Descending in
a wheelie allows you to control your
speed a little better,” Smith said, “and
if the hill is really steep, it keeps you
from pitching over as you go down.”
Plastic rims will burn when descending
quickly, so use gloves to increase your
power and decrease burning.
ƒƒ A word about chest straps: “Even if
it gives you some stability on the levels,
if you’re always cinched down into the
backrest with the chest strap you can’t
lean forward and back enough to keep
your balance with many of these skills,”
Smith said.
ƒƒ Curbs—going up
ƒƒ Timing of caster pop up: Low
or late pop up may result in casters
hitting the curb, abruptly stopping
the wheelchair. High or early pop up
may result in rear wheels hitting the
curb too soon, decreasing momentum.
“Practice going up to the curb and
popping up without worrying about
getting on top of it, so you can get
comfortable with the timing of the
pop up and with how high you need to
get the casters up,” Smith said.
ƒƒ Rear wheel ascension: getting the
rear wheels up on the curb after
your casters are up there depends on
wheelchair pitch angle, velocity, trunk
position, and hand position.
ƒƒ Freeing wheels from being stuck in a
grate or hole: rock side to side.
ƒƒ Raised obstacles (roots, railroad tracks,
hoses): Pop your casters over the obstacle, flex your trunk, and use push strength
or momentum to go over the obstacle
with the rear wheels as your casters land
beyond the obstacle.
ƒƒ Hills and ramps
ƒƒ Crossing a slope: push faster with
one hand than the other.
ƒƒ Going up: If you don’t have enough
balance or momentum and you can’t
stay forward enough to go up hills,
get your chair configuration and fit
evaluated by a therapist.You might
want to consider mechanical assist
or power assist options such as hill
climbers, Magic Wheels, or even a
power chair.
ƒƒ Going down: pop into a wheelie
while you’re on a level area, find your
balance point, and lean back as you
University of Washington School of Medicine
ƒƒ Curbs—going down
ƒƒ Face forward for improved visibility
and shock absorption, and to avoid
flipping over backward (see photo
above). If you do go down backward,
flex your trunk to avoid flipping.
Descending backward can cause more
pain and discomfort than descending forward because the shock goes
through the front casters, which can’t
absorb it as well as the rear wheels.
Department of Rehabilitation Medicine • 5
literature review
The articles previewed below were selected from a recent screening of the National Library of Medicine database for articles on spinal cord injury. In the
­judgment of the editors, they include potentially useful information on the diagnosis or management of spinal cord injury.You may obtain copies of the complete
articles through your local medical library or from UW Health Sciences Library Document Service (http://www.lib.washington.edu/ill).
Sexual Function & Fertility
 Pregnancy outcomes by intravaginal and intrauterine
insemination in 82 couples with male factor infertility due to
spinal cord injuries.
Eighty-two male patients with spinal cord injuries and their female
partners received infertility services in this study. Sperm were obtained
by masturbation in 4 men (4.9%), penile vibratory stimulation in 42 men
(51.2%), and electroejaculation in 36 men (43.9%). Intravaginal insemination (IVI), performed mostly at home, was undertaken in 45 couples, 17
of whom (37.8%) achieved 20 pregnancies. Intrauterine insemination
(IUI)was performed in 57 couples, 14 of whom (24.6%) achieved 19
pregnancies. Overall, 18 live births occurred by IVI and 21 occurred
by IUI. The authors conclude that IVI and IUI are reasonable options
for this patient population and should be used before proceeding to
assisted reproductive technologies (ART).
Kathiresan AS, Ibrahim E, Aballa TC, et al.
Fertil Steril. 2011 Aug;96(2):328-31.
 Assessing and conceptualizing orgasm after a spinal cord
A total of 97 men with SCI underwent sexual stimulation using various
techniques (natural stimulation, vibrostimulation or vibrostimulation
combined with midodrine). Injury level ranged from C2 to S5 and
involved both complete (49%) and incomplete (51%) lesions. Among
the 89 (92%) who achieved ejaculation, 50 experienced autonomic
hyperreflexia (AHR, also known as autonomic dysreflexia or AD) at
ejaculation and 39 did not. Significantly more sensations were described
at ejaculation than with sexual stimulation alone. Men with SCI who
experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who
did not. There was no difference between men with complete and
those with incomplete lesions. The findings show that the questionnaire
is a useful tool to assess orgasm and to guide patients in identifying the
bodily sensations that accompany or build up to orgasm. The findings
also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI.
Courtois F, Charvier K,Vézina JG, et al.
BJU Int. 2011 Nov;108(10):1624-33.
arm, hand & shoulder
 Changes in skills required for using a manual wheelchair
after reconstructive hand surgery in tetraplegia.
Surgical reconstruction of arm and hand function has developed tremendously over the last decade. Several studies have documented the
functional improvements after surgery and rehabilitation: better control
and strength of elbow extensors; lateral pinch; grip function; and opening of the hand. In this study, 16 individuals with C5-C7 tetraplegia
underwent a total of 23 grip and/or elbow extension reconstruction
surgeries to improve arm and/or hand function. Functional tests of
wheelchair control were performed before and 12 months after the
reconstructive surgery. Sixty-eight percent of the individuals improved
their wheelchair maneuvering skills after hand surgery. Improvements
were also observed in their ability to perform tests that were impossible to perform before surgery. The type of reconstruction and level
of injury affected the degree of improvement achieved. Hand and arm
function are highly prioritized goals in this population, and increased
mobility is a crucial factor in living a more active life.
Lamberg AS, Fridén J.
J Rehabil Med. 2011 Jul;43(8):714-9.
6 • Volume 21, Issue 2
Spinal Cord Injury Update
spring 2012
 A cross-sectional study of demographic and morphologic
features of rotator cuff disease in paraplegic patients.
Shoulder pain affects up to 67% of the SCI population, a rate that is
four times higher than the able-bodied population. In this study, 317
individuals with paraplegia between T2 and L3 underwent clinical exams
and magnetic resonance imaging (MRI) of both shoulders. Participants
averaged 26.7 years of wheelchair dependency (range, 5-56 years).
While 161 patients (51%) had no rotator cuff tears, 156 (49%) had
tears in one (unilateral, 20%) or both (bilateral, 29%) shoulders. Patients
with bilateral tears were older and had been injured longer than those
with unilateral or no tears. In patients with unilateral tears, a full-thickness rupture of the supraspinatus tendon was found in 67%, whereas a
partial-rupture was detected in 33%. Of the patients with bilateral tears,
75% presented with a full-thickness rupture and 25% with a partial rupture. These findings support the theory of “wear and tear” in patients
with spinal cord injury and that the occurrence of cuff tears depends
on the duration of wheelchair dependency as well as age.
Akbar M, Brunner M, Balean G, et al.
J Shoulder Elbow Surg. 2011 Oct;20(7):1108-13. Epub 2011 Jul 2.
Autonomic Dysreflexia
 Autonomic dysreflexia: current evidence related to unstable
arterial blood pressure control among athletes with spinal
cord injury.
Spinal cord injury is commonly associated with a range of autonomic
dysregulation that can interfere with cardiovascular, bladder, bowel,
temperature, and sexual function. Individuals with a cervical or highthoracic SCI face lifelong abnormalities in systemic arterial pressure
control. In general, their resting arterial pressure is lower than that in
able-bodied individuals and is commonly associated with persistent
orthostatic intolerance. In addition, they experience fleeting episodes
of life-threatening hypertension, known as autonomic dysreflexia (AD),
which often is associated with disturbances in heart rate and rhythm.
AD occurs in up to 90% of individuals with a cervical or high-thoracic
SCI and requires immediate medical attention. During athletic activities,
self-induced AD is used by some individuals to improve their performance, a technique known as “boosting.” For health safety reasons,
boosting is officially banned by the International Paralympic Committee. Medical practitioners who are involved in the care of wheelchair
athletes should be aware of the unique cardiovascular dysfunction that
results from SCI and may occur at any time, even with seemingly harmless triggers. Prompt recognition and management of these conditions,
including episodes of AD, could be life saving.
Krassioukov A.
Clin J Sport Med. 2012 Jan;22(1):39-45.
Urological Problems
 Multicenter randomized controlled trial of bacterial interference for prevention of urinary tract infection in patients
with neurogenic bladder.
This study involved individuals with neurogenic bladder due to spinal
cord injury and a history of recurrent urinary tract infections (UTIs).
Participants were randomized to receive a bladder inoculation of either
Escherichia coli HU2117 (experimental group) or sterile saline (control
group). Urine cultures were obtained weekly during the first month and
then monthly for 1 year. Of 17 patients colonized with E. coli HU2117
and the 10 control patients, 5 (29%) and 7 (70%) developed more than
1 episode of UTI, respectively. The average number of episodes of UTI
per year was also lower in the experimental than in the control group.
literature review
spinal cord injury
continued from previous page
E. coli HU2117 did not cause symptomatic UTI. The authors conclude
that bladder colonization with E. coli HU2117 safely reduces the risk
of symptomatic UTI in patients with spinal cord injury. Effective, but
less complex, methods for achieving bladder colonization with E. coli
HU2117 are under investigation.
Darouiche RO, Green BG, Donovan WH, et al.
Urology. 2011 Aug;78(2):341-6. Epub 2011 Jun 17.
Technology and mobility
 Technology for mobility in SCI 10 years from now.
A person’s level of disability is an interaction between their impairment
and the environment. Technology impacts this in a number of ways
and has the potential to fully eliminate disability. The authors believe
technology will eventually allow complete independence someday, but
economic factors and systems of care will impact the extent to which
individuals with SCI will fully benefit from technological advances. The
authors review expected advances in specific areas of technology, such
as power sources, processing, sensors and software, and describe the
ways specific devices will be impacted by them. They also discuss the
social context of technology for mobility and how the political, social
and economic environment is likely to impact advances. Although
technology advances are exciting, a large challenge for the research
community will be how to effectively apply and deploy this technology.
Advances occurring in the next 10 years that reduce cost of technology may be more important to the population with SCI than brand
new technologies.
Boninger M, French J, Abbas J, et al.
Spinal Cord. 2012 Jan 17.
Electrical Stimulation
 Muscle changes following cycling and/or electrical
stimulation in pediatric spinal cord injury
Muscle atrophy (wasting) is common in people with SCI and has negative health effects such as increased risk for cardiovascular disease,
insulin resistance, glucose intolerance and type 2 diabetes. Children
with SCI also are at higher risk for these problems, and intervening at
an earlier age may be beneficial. Functional electrical stimulation while
cycling (FESC) can increase muscle mass and strength in adults with
SCI, and this study examined whether it can be helpful for children
with SCI. Thirty children with SCI aged 5-13 were randomly assigned
to do FESC, passive cycling (no electrical stimulation) or electrical
stimulation without cycling (ES) at home for 1 hour, 3 times per week.
After 6 months, tests showed that children receiving either FESC or ES
exercise had changes in muscle size, stimulated strength, or both. The
ES group had greater changes in quadriceps muscle size, and the FESC
group had greater changes in strength.These changes may decrease their
risk of cardiovascular disease, insulin resistance, glucose intolerance, and
type 2 diabetes. Children in the PC group had no improvements.
Johnston TE, Modlesky CM, Betz RR, Lauer RT.
Arch Phys Med Rehabil. 2011 Dec;92(12):1937-43.
 Increased aerobic fitness after neuromuscular electrical
stimulation training in adults with spinal cord injury.
Fourteen participants with SCI (T4-11; ASIA A and B) completed
training of a new neuromuscular electrical stimulation (NMES) system
designed to improve aerobic fitness in persons with SCI. For the training, four electrodes were placed on the quadriceps and hamstrings
muscle groups, and subtetanic contractions were elicited using the
NMES device. Participants did the training unsupervised at home for 1
hour, 5 days/wk for 8 weeks. A treadmill wheelchair propulsion exercise
test with simultaneous cardiopulmonary gas exchange analysis found
a significant increase in Vo(2) peak and HRpeak between baseline and
follow-up testing. This novel form of NMES is an effective method of
improving aerobic fitness in a sedentary adult SCI population. Compliance with training was high, possibly indicating the convenience of using
this system. Results compare favorably with current functional electrical
stimulation exercise systems. This system offers a portable and convenient method of aerobic exercise, with the potential to provide the
associated health benefits of exercise to the SCI population.
Carty A, McCormack K, Coughlan GF, et al.
Arch Phys Med Rehabil. 2012 Mar 21.
Pressure Ulcers
 A telerehabilitation intervention for persons with spinal
cord dysfunction.
Pressure ulcers and depression are common preventable conditions
in people with spinal cord dysfunction (SCD). However, few successful, low-cost preventive approaches have been identified. The authors
developed a dynamic automated telephone calling system, termed Care
Call, to motivate people with SCD to improve their skin care, seek
treatment for depression, and appropriately use the healthcare system.
This system supplements face-to-face health care with a clinician. It
uses a digitized human voice and functions as an at-home monitor,
educator and counselor for reinforcing or changing health-related
behaviors. Individuals with SCD pilot-tested the system and provided
feedback. Results of a randomized controlled trial using this system will
test whether the intervention will successfully promote self-management in a cost-effective manner.
Houlihan BV, Jette A, Paasche-Orlow M, et al.
Am J Phys Med Rehabil. 2011 Sep;90(9):756-64.
 Necrotizing fasciitis in patients with spinal cord injury: an
analysis of 25 patients.
A retrospective chart review found 25 SCI patients (19 with paraplegia and 6 with tetraplegia) who were treated for necrotizing fasciitis
during a 9-month period. Necrotizing fasciitis (NF) is an infection that
causes tissue to die (sometimes called “flesh-eating bacteria”). In 18
cases, NF developed due to pressure sores. Grade 4 pressure sores
were identified in 15 cases and grade 3 pressure sores in 3 cases.
The incidence of developing NF is significantly higher in patients with
grade 4 pressure sores than in those with a lower-grade lesion. The
most common bacteria were streptococci. During the hospital stay, six
patients developed sepsis and two died because of septic multi-organ
failure. The authors recommend that close clinical and laboratory monitoring of all patients with grade 3 or 4 pressure sores is appropriate so
that any early clinical signs of NF can be recognized and evaluated for
early and aggressive treatment.
Citak M, Backhaus M,Tilkorn DJ, et al.
Spine 2011 Aug 15;36(18):E1225-9.
 An exploration of modifiable risk factors for depression
after spinal cord injury: Which factors should we target?
A total of 244 community-dwelling individuals with SCI (77% men,
61% white; mean age, 43.1y; 43% with tetraplegia) who were at least 1
month postinjury completed questionnaires on depression (PHQ-9),
physical activity (International Physical Activity Questionnaire [IPAQ]),
pleasant and rewarding activities (Environment Rewards Observation
Scale [EROS]), and self-efficacy to manage the effects of SCI (Modified
Lorig Chronic Disease Self-Management Scale). The study found that
more severe depression was associated with being 20 to 29 years of
age, not completing high school, not working or attending school, and
being 4 or fewer years post-SCI. Having rewarding activities and, to a
lesser extent, having confidence in one’s abilities to manage SCI, were
associated with being less depressed. Treatments designed to increase
the level of rewarding activities and positive reinforcement in the daily
lives of people with SCI may be an especially promising approach to
treating depression in this population.
Bombardier CH, Fann JR,Tate DG, et al.
Arch Phys Med Rehabil 2012;93(5):775-781.
University of Washington School of Medicine
Department of Rehabilitation Medicine • 7
Spinal Cord Injury Update is
supported by grant H133N110009
from the National Institute of Disability and Rehabilitation Research
(NIDRR), U.S. Department of Education, Office of Special Education and
Rehabilitative Services (OSERS), to
the Northwest Regional Spinal Cord
Injury System, one of 14 model SCI
care systems nationwide. Project
Director: Charles Bombardier, PhD.
Editorial Board of Advisors:
Charles Bombardier, PhD; Stephen
Burns, MD; Chris Garbaccio; Barry
Goldstein, MD, PhD; Jeanne Hoffman, PhD; Cathy Warms, PhD, ARNP,
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Medicine, Box 356490, Seattle WA
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Upper Limb Pain in SCI
continued from page 2
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Spinal Cord Injury Update
Spring 2012 • Volume 21, Number 2
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