Spinal cord injury (SCI) is frequently accompanied by joint problems, but these can often be overcome with careful management and exercise.
The so-called “over-use syndromes” seen in SCI are widely known. Both in paraplegia and in independently functioning tetraplegics, the upper limb becomes the remaining functioning unit, and therefore the shoulder, elbow and wrist are critically important for the patient to retain any form of independent function.
Independently functioning SCI individuals rely on their upper limbs for weight-bearing activities-such as transfers and pressure relief. In addition, wheelchair dependent persons who can self-propel their wheelchairs are likely to place excessive strain on the shoulders, wrist and elbows which can result in these “overuse syndromes”. This results in pain and limited use of the affected limb further exacerbating their disability.
Shoulder
The shoulder joint has a complex anatomy and there are a series of ligaments surrounding it, known as the rotator cuff. Inflammatory conditions of the rotator cuff can be acutely painful, while tears of these ligaments, due to excessive use can also cause severe pain – which prevents functional independence. Naturally prevention is always better than cure and so it’s vitally important to preserve the shoulders and ensure that the shoulder muscles are kept strong to protect the joint. Regular, well-crafted strengthening exercises are important to maintain shoulder integrity. However, if the shoulder becomes painful, it’s important to investigate the possibility of a tear through an MRI – this is expensive, however, doctors would usually request an ultrasound of the shoulder if a rotator cuff injury is suspected. If there is evidence of only inflammation or the tear is not severe, rest, anti-inflammatories and/or a steroid injection can be prescribed to manage this condition. On occasion, surgery may be needed to repair the rotator cuff tear or to remove a bony spur that may be causing the inflammation.
A more chronic condition seen in older SCI persons are arthritic changes in the shoulder joint itself or the acromioclavicular joint – the joint between the collarbone and shoulder. This normal wear and tear is mostly unavoidable and conservative treatment with anti-inflammatories is usually the only option. Joint replacement is not usually considered, because the unnatural forces applied to the prosthesis tend to negate the viability of such an option.
Elbow
Strain may result in an inflammatory condition of the tendons at the elbow – this is commonly known as tennis elbow. Treatment is primarily with rest, physiotherapy, anti-inflammatories and occasionally steroid injections.
Wrist
The long tendons of the forearm are carried in fibrous tunnels in the wrist. Again, due to excessive use, an inflammatory process resulting in pain, pins and needles of the fingers and weakness of the hand severely restricts the use of the affected limbs. This condition,
known as carpal tunnel syndrome, can become chronic in a SCI person. It is treated the same way as tennis elbow. If conservative means do not cure the problem, surgery may be indicated.
In all these conditions, pain can limit the use of the limb to such a degree that independence is lost. Treatment involves rest and medication – and often the condition resolves after several weeks. Surgery should be reserved for failed medical treatment.
Dr Ed Baalbergen is the medical officer at the Vincent Pallotti Rehabilitation Centre (Cape Town) and is a member of the International Spinal Cord Society and the Southern African Neurological Rehabilitation Association. email: ed.baalbergen@lifehealthcare.co.za
