Limiting the risk of shoulder injuries in manual wheelchair users

The shoulder is the most mobile joint in the body, thanks to it being a ball and socket structure, similar to a golf ball on a tee. Because the shoulder has such a large range of movement, stability within this joint is compromised if limited strength is present. 

The shoulder joint is kept together by a structure of tendons, ligaments and muscles which, over time and with overuse, can become weakened and damaged. The risk of this happening is particularly important for people who use a manual wheelchair as they are at a higher risk of repetitive strain injuries (RSI). In fact, studies have shown that 30-50 per cent of people with paraplegia suffer from shoulder pain that interferes with their activity of daily living (ADL).

Repetitive strain injuries manifest as pain in the muscles and tendons caused by a movement being repeatedly performed either incorrectly or with limited strength. They commonly occur in the wrist, hands, forearms, elbows and shoulders. Symptoms tend to come on gradually and can include pain, tightness, dull aches, numbness and tingling.

Prevention better than cure

The standard form for recovery with an RSI injury is to rest. However, this is not always possible or recommended for wheelchair users as it impacts their independence. Far better to prevent the risk of the RSI developing in the first place.

Given that RSIs often arise due to incorrect movement and/or limited strength, it follows that by correcting the movement pattern and increasing strength can alleviate the problem.

Here at Neurokinex strength training is included in our activity-based rehabilitation programme for all clients to improve their balance, core stability, posture, functional movement and mobility.  

Strength training is often associated with athletic performance but it has many applications for everyday living. We know it improves muscular size and overall strength but our interest as rehabilitation experts lies in the broader lifestyle benefits these improvements bring including building confidence and reducing the risk of muscular injuries. 

A flexible approach

When it comes to safeguarding the shoulder joint against injury, we need to build flexibility as well as strength to allow the joint to work efficiently through its full range of motion.

The most common cause of shoulder pain is weakness within the rotator cuff muscles (a group of four muscles that support and surround the shoulder).  Wheelchair use typically puts these shoulder muscles under strain through:

1. Manual propulsion of the wheelchair 

2. Repeatedly lifting things overhead

3. Improper wheelchair transfers which force load onto weaker muscle groups

4. Muscle imbalances

5. Poor sitting position 

Focus on technique

Good technique is essential in strength training because if exercises are done badly and without due care, they make problems worse by exacerbating muscle imbalance, poor sitting and scoliosis. Rehabilitation should reinforce the importance of correct posture and teach safe transferring technique to limit the risk of injury. 

Combining strength and flexibility work

Key muscles to target through a progressive strength programme include the rhomboids, latissimus dorsi, triceps, deltoids and rotator cuff muscles. In addition, incorporating movements to encourage flexibility are vital to safeguard shoulder health. Stretching the pectoralis muscles (pecs) and scalenes (side neck muscles) can significantly improve flexibility as well as overall posture.

A strength and conditioning programme should include these vital components:

1. Muscle activation and motor control. Muscle activation and motor control are very important and are sometimes overlooked when developing a strength programme. Teaching proper technique and activating the correct muscle groups at the correct time is important in Activity Based Rehabilitation (ABR) as without practice and feedback, optimal muscle activation and conditioning cannot be achieved.

This requires repeated practice which then leads to the development of skills. When improving a skill movement, the Central Nervous System (CNS) organizes the Musculoskeletal system (MSK) system to create and improve skilled movements. Motor Control relates to how the CNS impacts muscle activation with neural input to gain the desired movement (Banks and Khan et al, 2010).

2. Muscle strength, power and endurance. Strength training is important when weakness compromises function. Strength training is useful in the prevention and treatment of degenerative changes that occur from the repeated use of the shoulder’s rotator cuff muscles.

Our Activity-Based Rehabilitation protocol addresses the common problems facing manual wheelchair users by improving muscle strength, endurance and flexibility while activating neurological function.  Several members our team are specially trained in strength and conditioning.  By combining this approach with physiotherapy techniques in the delivery of our activity-based protocols, we are able to build strength, increase flexibility and guard against repetitive strain injury in the shoulders and other joints.