SCI Forum Reports
Common musculoskeletal problems after SCI: Contractures, osteoporosis, fractures, and shoulder pain
April 16, 2002
"Up until World War II, mortality after SCI was very high," said Barry Goldstein, MD, PhD, associate professor in the Department of Rehabilitation Medicine, attending physician at Harborview Medical Center, and associate chief consultant in the VA Spinal Cord Injury and Disorders Strategic Healthcare Group. During the past 50 years, the advent of antibiotics, blood transfusions, and other modern medical and surgical treatments have changed the prognosis after SCI immensely. Now people are living longer after a SCI than ever before. "We do not have very much information as to what happens to people who live for several decades and into their seventies and eighties with a SCI, because this is the first group of people who have survived into their older years," he said.
"Musculoskeletal problems are the most frequent cause of disability in the U.S. today," said Goldstein, and are more prevalent than either heart disease or cancer. "There are more complaints and more outpatient visits (ambulatory care) to doctors' offices for these problems than any other kind of health problem." Studies show that musculoskeletal complaints are the second most common reason for visits to surgeons, third most common reason for visits to family doctors, and the fourth most common reason for visits to specialists.
All tissues that make up the musculoskeletal system-tendons, bones, ligaments, and muscles- start going through changes associated with normal aging in early adulthood and continue throughout life. These changes in the uninjured population have been well-described and studied, but "we know much less about musculoskeletal conditions that happen after SCI."
People growing older with SCI experience the common problems related to aging superimposed on the unique problems of SCI, and Goldstein has focused much of his research in this area, especially on the musculoskeletal complications associated with SCI. "Musculoskeletal complications after SCI are frequent," Goldstein said, "both because these kinds of problems are common to getting older and because persons with SCI have unique risk factors.” “What little data we have suggests that the majority of people with SCI have musculoskeletal problems during their lifetime. For example, neck, back, and shoulder pain are reported in up to three-quarters of the SCI population. Shoulder pain is more common in people who use a manual wheelchair for many years than in people who use their arms for repetitive heavy labor, such as welders.
Recent studies suggest that people with a SCI have musculoskeletal problems that are similar to the general population but more frequent and possibly more severe because they use their upper extremities for weight bearing, mobility, and in awkward or extreme positions. "The importance of doing activities with good biomechanics cannot be overemphasized", said Goldstein. Furthermore, musculoskeletal problems may be much more disabling in the SCI population. For example, "if you have shoulder problems and you don't use a wheelchair, you have three other limbs that can compensate for it," Goldstein explained. "But if you're pushing a wheelchair, a shoulder problem may interfere with your ability to ambulate, transfer, and perform all of your activities throughout the day. Such pain or injury threatens the independence that people with a SCI have worked so hard to achieve."
Range of Motion
Loss of range of motion (known as a contracture) is probably the most common musculoskeletal problem following SCI, according to Goldstein, and has many causes. "Range of motion is very important for seating, transferring, and other functional activities."
The causes of decreased range of motion are numerous, although the most common cause is staying in the same position for prolonged periods of time, such as sitting. "It could be that the person wasn't doing range of motion exercises. Or spasticity could be pulling the joints into a shortened position, decreasing flexibility, and range of motion may become more difficult. Or it could be a joint problem like arthritis-people with joint problems commonly lose range of motion. Or finally it could be heterotopic ossification-an abnormal laying down of bone in the soft tissues around joints, like the hip."
Contractures can be prevented by performing regular, sustained range of motion 1-2 times a day and through proper positioning. If contractures develop, range of motion exercises are recommended as treatment in most cases. Diagnostic evaluations such as x-rays or bone scans aren't usually done unless this treatment is ineffective. Other treatments "such as spasticity medication, serial casting and surgery are available", if simple stretching does not treat the problem.
Osteoporosis and Fractures
"After SCI, there are many changes in bone metabolism," Goldstein said. An imbalance between bone formation and bone resorption rapidly develops, resulting in bone loss and osteoporosis.
Osteoporosis is characterized by a decrease in bone density leading to bone fragility. According to Goldstein, it is pervasive in society today and affects both men and women as they live into their later years. After peaking in young adulthood, men and young women normally lose about .5% of bone mass per year. Once a woman enters menopause, however, bone mass decreases about 2% per year, resulting in 20-30% bone loss over 20 years. Bone fractures usually do not occur until bone mass is 30-40% below normal.
Bone loss is very rapid after SCI. Within the first 4-6 months, 25% or more of bone mass is lost. By one and a half years, more than one-third of bone mass is lost. "The amount of bone lost in the first 18 months after injury is so high that fractures are a risk soon after the onset of SCI," Goldstein said. A quarter of the SCI population reaches fracture threshold at one year after injury, and half after 10 years.
Although we don't know how to completely stop bone loss after spinal cord injury, steps should be taken to minimize bone loss and prevent fractures. The basic building blocks for stronger bones can be remembered by the acronym CDF (Calcium, vitamin D, Falls prevention). Add an "S" for stop smoking to complete the prevention strategy, Goldstein said.
Blood tests (e.g., albumin, calcium, phosphate, creatinine, alkaline phosphatase, liver enzymes, and electrolytes), urine tests (24-hour calcium), x-rays, and bone density tests are used to evaluate the extent and cause of osteoporosis and metabolic bone disease.
"I think it's important for people to get a baseline bone density measurement after SCI to better understand their bone mineral density, risk for fracture, and to help evaluate subsequent therapy," Goldstein said. "You should consider talking to your doctor about these tests."
There are many treatments for osteoporosis aimed at preventing or reversing bone loss. "Bone is a very dynamic tissue, and there are several choices to treat osteoporosis and prevent fractures," Goldstein explained. Medications such as estrogen, bisphosphonates (etidronate-Didronel, pamidronate-Aredia, alendronate-Fosamax), calcitonin, and Selective Estrogen Receptor Modulators (known as SERMs) have been used in older people with osteoporosis. Recent reports about the increased risk of cardiovascular disease in a group of women who had been taking estrogen plus progestin has cast doubt on the role of estrogen to treat osteoporosis. Calcitonin, previously available only as an injectable medication, is now available as a nasal spray. As always, you should discuss the potential benefits, risks, and side effects with your doctor, Goldstein said.
Experimental approaches have been used to treat bone loss after SCI. In a recent study evaluating the effect of electrical stimulation (ES) on bone loss, subjects with long-time SCI had ES applied to one knee for three months and found that bone density in that knee increased slightly while the unstimulated knee lost bone mass. The researchers had hoped to see an increase in bone density in the stimulated knee, but the loss of density in the unstimulated knee was unexpected. It was as if a gain at one site came at the expense of another, Goldstein said. Unfortunately, the improvements in the stimulated knee were rapidly lost. After six months of treatment to one knee, both knees had returned to baseline. At one-year follow-up, the bone mineral density of both knees had decreased 2.4%.
Unfortunately, fractures are very common in people with SCI. Data from the Model SCI Systems show that 14% of people with SCI get fractures five years after injury. This increases to 28% after 10 years and 39% after 15 years. The frequency of fractures increases with age and completeness of injury, and is higher in women than men.
Although most fractures are in the lower extremities and result from falls, people with the most brittle bones can actually break them when doing daily activities such as range of motion.
Fractures often occur from only a mild slip, Goldstein warned. "People often don't feel anything when they fracture, so you must have a high index of suspicion after trauma, even relatively minor trauma." Undiagnosed, untreated fractures can have serious consequences, including blood clots and compromised blood flow to the limb.
Treatment of fractures is somewhat controversial, Goldstein said. "Some physicians treat fractures with a closed cast. There are risks of skin breakdown and pressure ulcers with this approach. With a closed cast, you cannot do skin checks. Therefore, I recommend a bivalve cast that is well-padded around bony prominences. You can remove it and check the skin twice per day."
Having a fracture can create complex accessibility issues. "Remember, people with SCI who fracture can take months and months to heal," Goldstein said. "And maneuvering your wheelchair with your leg stuck out in an extended position creates terrible accessibility problems. Maintaining independence at home is an incredible challenge."
Shoulder Pain
Shoulder pain is a common problem in both paraplegia and tetraplegia, Goldstein said. "There are many different mechanical causes of shoulder pain after SCI such as stiffness, tight muscles, muscle tears, inflammation, arthritis." Yet the reason why people develop shoulder pain - such as overuse, biomechanical problems, disuse, impingement - is largely unknown. Because people with SCI rely on their shoulders to perform many daily functions, shoulder pain can be extremely debilitating if not completely incapacitating, and treatment of shoulder pain is challenging,
Shoulder pain requires a comprehensive evaluation and a treatment approach that includes both short-term methods, such as medications to reduce pain and biomechanical changes, and long-term management, such as making changes to the home environment.
The presenting features of shoulder pain are diverse. Shoulder pain may present from one or both sides. Symptoms may begin rapidly or gradually. Pain might be a short-term discrete, self-limiting problem or one that is chronic and persistent. Individuals may report no functional limitations or severe limitations with activities such as pressure releases, wheelchair pushing, or transfers. Sleep is frequently disrupted and finding a comfortable position in bed is often a problem.
If the pain is mechanical-i.e., it hurts during use-treatment is directed toward restoring strength, stability, mobility and smoothness of the joint. So it is important that your doctor or therapist test your shoulder for impairments (e.g., weakness, instability, stiffness).
Biomechanical problems frequently lead to shoulder pain. Frequent overhead activities, difficult transfers (for example, transfers from the bottom of the bathtub or reaching up to transfer into a car), posture problems, and poor wheelchair set-up are some of the reasons why people develop shoulder pain.
In other cases, an unbalanced shoulder is the problem. Pushing a wheelchair for years can over-develop the muscles in front relative to those in back, not unlike what happens to athletes. Exercises to increase strength in the shoulder muscles in the back are often prescribed to restore balance. An unbalanced shoulder may also develop when some of the shoulder muscles are paralyzed while others are not.
Excess weight is another factor in shoulder pain. Losing weight, which Goldstein admits is challenging for people in wheelchairs, can reduce strain on the shoulders that can cause pain.
Goldstein is a great believer in adapting the environment. "Lower your world," he said. "If you have a shoulder problem, reaching up over and over, every day, is probably the worst thing you could do for your shoulder."
Finally, posture and seating are extremely important factors in shoulder pain. "If you sit in a rounded (kyphotic) posture and reach overhead, your scapula is unable to rotate, and you can't fully elevate your shoulder," Goldstein said. "That puts your shoulder in a terrible position."
"You need to be sitting upright with good posture, which gives free mobility of the scapula, allowing the entire shoulder complex to work. Several people have had remarkable relief of shoulder symptoms by correcting their posture and seating," he said. [Note: Dr. Goldstein will devote a future SCI Forum talk entirely to seating and posture.]
Goldstein has not found medications to be very effective in treating shoulder pain, particularly if the cause is biomechanical. Frequently short trials of medications are tried. "But I encourage people to stop the medication it if there is no relief." Spasticity can sometimes cause a stiff and unbalanced shoulder, in which case spasticity medications can be an effective treatment for shoulder pain. Goldstein no longer injects steroids into the shoulder both because he did not find that it was very effective and because research suggests that steroids can hinder repair if the patient eventually needs surgery. "The risks outweigh the benefits," he said.
People with shoulder pain frequently lose the ability to make good transfers and pressure releases, putting them at risk for developing pressure ulcers, so Goldstein urges them to modify pressure release techniques and do frequent, thorough skin checks.
While switching to a power wheelchair may seem like a logical choice for people with shoulder pain, Goldstein believes it has many drawbacks. First, power wheelchairs create accessibility problems. Second, many people who switch over to power wheelchairs continue to have shoulder pain. Third, "people usually gain weight, and lots of it," after switching to a power chair, often 10-20 pounds per year! "Then the person has shoulder pain and a much heavier body to transfer. It's a vicious cycle."
Goldstein also sees no evidence in favor of using a power chair to prevent shoulder damage and believes it doesn't make sense in terms of long-term health. Pushing a manual wheelchair provides some degree of exercise through the day. Manual wheelchair design has also significantly improved during the past several years. "We don't know who will and who won't develop shoulder pain. But we do know that wheelchairs have never been better with regard to design and push mechanics. It makes more sense to stay in good shape and do exercises so you have a well-balanced shoulder and good posture than to use a power chair to prevent shoulder problems."