Overuse injuries in disorders of the central nervous system

Author(s): Ryan Lirette, LSUHSC-NO and Stephen Kishner, MD

Originally published:10/22/2013

Last updated:09/05/2018

1. DISEASE/DISORDER:

Definition

Overuse injuries (most commonly, impingement syndrome/rotator cuff tendinitis and carpal tunnel syndrome) are injuries to the musculoskeletal unit resulting from cumulative trauma.1 For many individuals with central nervous system (CNS) disorders, performing repetitive motions is a vital part of general mobility and activities of daily living (ADL). This can lead to repetitive microtrauma of bones, joints and soft tissues and can contribute to pain and increased functional limitations.2

Etiology

Pentland, et al describe the development of overuse injuries as a combination of individual factors such as genetics, previous trauma, and other co-morbidities and their interplay with behavior and lifestyle (conditioning and activities), age-related musculoskeletal changes, and environment (equipment, layout and design of home, etc.).3

For many individuals with CNS disorders, the most common etiologies of these injuries result from altered biomechanics of weight bearing through joints (shoulders, elbows, wrists) not designed to sustain submaximal, repetitive motions or significant amounts of weight over time. Examples include upper limb activity with wheelchair propulsion and transferring the body between surfaces. Additionally, as most environments are adapted to the able-bodied population, the individual in a wheelchair will be required to place joints in mechanically compromising positions, such as with overhead reaching, which may, over time, contribute to the overuse injury. Individuals with CNS disorders are also more likely to have muscle weakness, leading to relative imbalance between muscle groups that can lead to injury.3 The majority of research in the area of overuse injuries in CNS disorders is with wheelchair users, but long-term reliance on walkers, forearm crutches, and other assistive devices also can contribute to some of the same overuse injuries.

Epidemiology including risk factors and primary prevention

Most of the information on the epidemiology of overuse injuries comes from literature on persons with spinal cord injury (SCI). Some of the most common injuries include, by region:

    • Shoulder injuries: prevalence of pain symptoms range from 30-71%2,4
      • Shoulder pain in paraplegics versus tetraplegics is more likely to be orthopedic or musculoskeletal-related (73% versus 45%, respectively).5
      • Rotator cuff (RC) injuries: 20% unilateral, 29% bilateral for paraplegics, with full thickness tears more prevalent than partial thickness6
        • Prevalence of rotator cuff tears 4x higher in paraplegics vs. control with tear of supraspinatus most common.7
      • Impingement syndrome: incidence as high as 75% in symptomatic shoulder pain patients with SCI8
      • Bicipital tendinitis
      • Osteoarthritis (OA): glenohumeral OA 14-32%, AC joint 31-42%7,8
    • Elbow injuries: prevalence of pain symptoms range from 4-32%2
      • Lateral epicondylitis: 17% in wheelchair users that play sports1
      • Ulnar neuropathy at the elbow (UNE)/cubital tunnel syndrome
    • Wrist/hand injuries: prevalence of pain symptoms range from 9-63%2
      • Carpal tunnel syndrome 40-60%2
      • DeQuervain’s tenosynovitis
    • Myofascial pain of the neck and low back: 16% with neck pain, 83% with back pain9

Risk factors include longer duration of injury, older age, higher body mass index (BMI) and wheelchair propulsion style.10 Primary prevention includes early and comprehensive rehabilitation that teaches proper, joint-sparing techniques in transfers and wheelchair propulsion.

In a 2015 study by Mulroy et. al., decreased muscle strength especially in the shoulder adductors and low physical activity were weak predictors of shoulder pain development over a 3-year period. They speculated that weaker shoulder adductors (for example, pectoralis major) may be unable to unload the rotator cuff effectively leading to injury. Interestingly, this study found that higher UE weight-bearing activities were not risk factors for development of shoulder pain, and development of shoulder pain was related to low activity, although this was not a significant predictor of onset.4 In the 2011 STOMPS RCT, improving strength in the shoulder external rotator muscle group was the strongest positive predictor of reduction in shoulder pain.11

Patho-anatomy/physiology

Overuse injuries most commonly affect the musculotendinous unit resulting in tendinitis, tenosynovitis, and/or muscle soreness. Other tissues that can be involved include: bursae (bursitis), bone (stress fractures), nerve (compression neuropathies), and cartilage (OA).1 As the consequence of repetitive microtraumatic overuse, injuries eventually lead to an impairment in the tissue’s ability to repair itself. This results in the formation of scar tissue in place of the proper tissue matrix (e.g., bone, tendon, muscle, or ligament), which results in a decreased tissue function overall.1 Physical stressors thought to be potentiating factors in overuse injury include level of force, posture, duration, contact stress, vibration and temperature.8 Examples of highly repetitive and/or high-force physical stressor activities include transfers, pressure relief maneuvers, and wheelchair propulsion.4

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

In general, overuse injuries develop over several months to years after the CNS injury or disorder, but vary by individual and situation. Several conditions related to using a wheelchair, and thus development of overuse injuries, have changed in the past 40 years. Wheelchairs are now lighter, and can be better customized to avoid postures that are believed to contribute to overuse and injury (posterior pelvic tilt, excessive neck flexion, prolonged shoulder abduction, internal rotation and extension). Changes in rehabilitation technique such as moving away from overhead trapeze transfers have also altered the natural history of these injuries.8

Individuals, including those with cerebral palsy and spina bifida, who are lifetime wheelchair users, also face unique challenges. Yearly exams to assess range of motion, posture and proper equipment fit are part of regular health maintenance.12

Overuse injuries have an acute phase in which ongoing microtrauma is occurring, and more chronic phases characterized by maladaptive tissue formation, as above.

Symptoms become more prevalent as time from injury increases. For example, prevalence of carpal tunnel syndrome increased from 42% in individuals who were 5 years postinjury to 86-92% 15 or more years post injury.5

Three pain trajectories of self-reported musculoskeletal shoulder pain (0=No Pain, 1=very mild, 2=mild, 3=moderate, 4=severe, 5=very severe) over 5 years were identified in one prospective cohort study of 225 newly injured persons with SCI: “No or Low pain” (64%, n=148), “High Pain” (30%, n=63), and “Decrease of pain” (6%, n=14). The authors hypothesized that a fourth trajectory “Increase of pain” could be identified if a follow-up time of >5 years was used, which would hypothetically show pain problems in shoulders due to overuse. The trajectories were identified using latent class growth mixture modeling (LCGMM), which are contemporary statistical techniques that aim to identify unique trajectories of data, and in this case three trajectories optimally showed data. Two significant predictors of a “High Pain” trajectory were tetraplegia and having limited shoulder ROM at the beginning of active rehabilitation.13

2. ESSENTIALS OF ASSESSMENT

History

Initial history should include a comprehensive evaluation of pain symptoms (onset, location, radiation, character, severity, alleviating/aggravating factors, typical activities or sports that bring on pain). Special attention should be paid to history surrounding inciting injury (as in spinal cord injury or traumatic brain injury), as concomitant musculoskeletal injuries are often overlooked.

Other items to be considered in the history are level of SCI (if present), previous diagnostic evaluations, previous treatments tried and whether or not they were efficacious, any recent changes in wheelchair use, the presence of spasticity, and changes in body mass index (BMI). Additionally, a review of the functional impact of injury on ADLs, vocation, community reintegration, and recreation should be completed.

Probing questions to differentiate between types of pain (neuropathic, referred and mechanical) can be helpful.

Screen for any history or pertinent symptoms that may point to a non-musculoskeletal source of pain (e.g., new or changing neurologic symptoms, symptoms of an inflammatory process, etc.)

Physical examination

As with any general musculoskeletal exam, inspection of the region in question for deformity and atrophy, palpation for point tenderness, range of motion (ROM) (both passive and active), and neurologic exam including manual muscle testing, sensation and reflexes, are key. It is often helpful to have the individual demonstrate a maneuver that reproduces the pain. Evaluation of spasticity and muscle imbalances are special considerations in this population.

Selected provocative maneuvers by potential diagnosis:

    • RC tear:
      • Supraspinatus: Empty can, Drop arm test
      • Infraspinatus: Hornblower’s
      • Subscapularis: Lift off test
    • Impingement: Neer’s and Hawkin’s tests
    • Bicipital tendinitis: Speed’s and Yergason’s tests
    • Lateral epicondylitis: pain with resisted wrist extension
    • DeQuervain’s tenosynovitis: Finkelstein’s test
    • Carpal tunnel syndrome (CTS): Phalen’s, median nerve compression, and Tinel’s test

Functional assessment

Exploring mechanics of transfer technique and wheelchair propulsion can be helpful, as well as evaluation of equipment, including wheelchair set-up and seating arrangement. Boninger et al suggest that the optimal position of a wheelchair’s rear axle is 2 inches forward of the shoulder.14

Laboratory studies

Blood tests are usually not necessary, unless something in the history or physical prompts further evaluation of possible systemic causes for complaints (e.g., concern for inflammatory process). Electrodiagnostic studies may be considered to evaluate for carpal tunnel syndrome, ulnar nerve entrapment, radiculopathy, or to rule out other possible causes for pain.

Imaging

Imaging is often not needed initially, as majority of diagnoses can be made by history and physical examination. Plain radiographs of the area in question can be considered to rule out fracture or to evaluate for osteoarthritis. Diagnostic ultrasound may be of use, as well. If more invasive interventions such as surgery are considered, more extensive imaging can be considered. For example, for rotator cuff tears, MRI arthrograms are the most sensitive, and are helpful in operative planning.

Supplemental assessment tools

    • Constant Murley Score (CMS): 100 point score; components include degree of pain patient experiences subjectively, ability to perform ADLs, objective testing of ROM and shoulder power.
    • Wheelchair Users Shoulder Pain Index (WUSPI): 15-item self-report questionnaire on effect of shoulder pain on ADLs
    • Klein and Bell ADL index: 170 items assessing six domains: dressing, mobility, elimination, hygiene, eating and emergency communication; score can range from 0-313. Predictive validity obtained by correlating score to number of attendant hours needed.15

Environmental

Details on the layout of the individual’s home, automobile and/or work environment, specifically amount of overhead reaching and transferring that must be done, can be helpful when considering activity modifications.

Social role and social support system

Strong social support and access to resources will be important when prescribing relative rest from likely essential activities, or in case of referral for surgery with long recovery times and periods of immobility.

Professional Issues

Gutierrez et al interviewed 80 persons with spinal cord injury with the WUSPI and several quality of life measures and found that shoulder pain intensity was inversely related to quality of life and physical activity scores.16 Ergonomic assessments of the workplace environment may offer alternative equipment or set-up that will decrease the particular overuse activity in question.

3. REHABILITATION MANAGEMENT AND TREATMENTS

Available or current treatment guidelines

Sidall provides a useful algorithm for assessing pain after spinal cord injury, including musculoskeletal pain from overuse.17 Many of those recommendations will be outlined below.

At different disease stages

  • New onset/acute
    • Goal at this stage is to control pain and inflammation while limiting further tissue damage.
      • PRICE treatment (protection, relative rest, ice, compression, elevation)
      • +/- oral or topical non-steroidal anti-inflammatory drugs.
      • Use of splints where appropriate
      • Physical modalities such as ultrasound, iontophoresis
      • Targeted corticosteroid injections to problem area can be considered.
    • Subacute
      • Focus at this stage is preventing exacerbations and new injury by addressing modifiable factors.
        • The clinician should reiterate proper posture, and optimizing static alignment rather than relying on muscular strength.
        • Ensure proper wheelchair fit (positive seat plane, perpendicular, low backrest, appropriate seat depth, adequate seating system).
        • Targeted therapeutic exercise program focusing on strengthening, stretching
          1. Reduction in shoulder pain was found in seven studies of therapeutic exercise after spinal cord injury (three randomized controlled trials and 4 cohort studies) and was determined by reduction in WUSPI score (outlined above).18
          2. Norrbrink, et al described an intensive exercise program to reduce musculoskeletal and neuropathic pain: subjects trained on a double-poling ergometer three times per week during a 10-week period, in small supervised groups. Each session lasted 50 min. and included a warm-up, four intervals of 6-7 min, followed by a cool-down. Improvements in both neuropathic and musculoskeletal pain complaints were seen.19
        • Activity modification
    • Chronic/stable
      • One option in this stage may be transitioning to a pushrim-activated power-assisted wheelchair to prolong a person’s ability to use a manual wheelchair (MWC).20
        • Power-assisted wheelchair reduced potential risk factors of overuse injuries in one pilot study.21
      • At the point where pain becomes too severe or limits function in a way that makes it unsafe to perform certain activities, transitioning from a MWC to power mobility to preserve current function should be considered.
      • For certain diagnoses (e.g., CTS, RC tears), surgery may be an option when conservative treatment has failed, but can have significant morbidities. Recovery times with periods of absolute or relative non-weightbearing could mean the difference between the patient being able to live independently and not.
    • Pre-terminal or end-of-life care
      • NA

Coordination of care

Concomitant evaluation with physical therapy and occupational therapy, especially in regard to functional transfers, push mechanics, adaptive equipment and wheelchair fit, can be helpful. Workplace assessments if available can also be considered to review set-up and suggest equipment/workplace modifications to minimize joint stresses and injury.

Patient & family education

Proper body and push mechanics should be reviewed with family and caregivers, so that it can be reinforced with the patient at home.

4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE

Cutting edge concepts and practice

Over time wheelchair user’s needs will change requiring regular input from providers regarding adjustment; however, a new smart pattern recognition system is currently being developed to adapt to each user’s individual needs. The aim is to “provide the adjustable elements which can be used to improve the user’s own input quality.”22

Also, platelet-rich plasma and stem cell injections for chronic overuse injuries are currently being researched and are promising but currently with insufficient evidence to support clinical use; however, the use of these regenerative medicine techniques continues to expand secondary to the need for novel, minimally invasive treatments for chronic overuse injuries.23,24

5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE

Gaps in the evidence-based knowledge

Further research is needed on outcomes after treatment interventions as well as extended longitudinal studies to further assess development of chronic overuse injuries.

REFERENCES

  1. Apple DF Jr, Cody R, Allen A. Overuse syndrome in the upper limb in people with spinal cord injury. In: Sowell TT, ed. RRDS Physical Fitness: A Guide for Individuals with Spinal Cord Injury. Washington DC. Veterans Health Administration. 1996:97-107.
  2. Bonninger ML, Koontz AM, Sisto S, Dyson-Hudson TA, Chang M, Cooper RA. Pushrim biomechanics and injury prevention in spinal cord injury: Recommendations based on CULP-SCI investigations. J Rehabilitation Research and Development. 2005;42(3) (Supp I): 9-20.
  3. Pentland WE, Twomey LT. Upper limb function in persons with long-term paraplegia and implications for independence: Part II. Paraplegia. 1994;32:219-224.
  4. Mulroy SJ, Hatchett P, Eberly VJ, Haubert LL, Conners S, Requejo PS. Shoulder Strength and Physical Activity Predictors of Shoulder Pain in People With Paraplegia From Spinal Injury: Prospective Cohort Study. Phys Ther. 2015;95(7): 1027-1038.
  5. Sie IH, Waters RL, Adkins RH, Gellman H. Upper Extremity Pain in the Postrehabilitation Spinal Cord Injured Patient. Arch Phys Med Rehabil. 1992;73: 44-48.
  6. Akbar M, Brunner M, Balean G, et al. A cross-sectional study of demographic and morphologic features of rotator cuff disease in paraplegic patients. J Shoulder Elbow Surg. 2011;20:1108-1113.
  7. Akbar M, Balean G, Brunner M, Seyler TM, Bruckner T, Munzinger J, Grieser T, Gerner HJ, Loew M. Prevalence of Rotator Cuff Tear in Paraplegic Patients Compared with Controls. J Bone Joint Surg Am. 2010;92:23-30.
  8. Hastings J, Goldstein B. Paraplegia and the shoulder. Phys Med Rehabil Clin N Am. 2004;5(3):vii, 699-718.
  9. Nepomuceno C, Fine PR, Richards JS, et al. Pain in patients with spinal cord injury. Arch Physical Medicine and Rehabilitation. 1979;60(12):605-609.
  10. van Drongelen S, de Groot S, Veeger HEJ, et al. Upper extremity musculoskeletal pain during and after rehabilitation in wheelchair-using persons with a spinal cord injury. Spinal Cord. 2006;44: 152-159.
  11. Mulroy SJ, Thompson L, Kemp B, Hatchett PP, Newsam CJ, Lupold DG, Haubert LL, Eberly V, Ge T, Azen SP, Winstein CJ, Gordon J. Strengthening and Optimal Movements for Painful Shoulders (STOMPS) in Chronic Spinal Cord Injury: A Randomized Controlled Trial. Phys Ther. 2011;91(3):305-324.
  12. Groah SL, Stiens SA, Gittler MS, Kirshblum SC, McKinley WO. Spinal cord injury medicine. preserving wellness and independence of the aging patient with spinal cord injury: A primary care approach for the rehabilitation medicine specialist. Arch Phys Med Rehabil. 2002;83(Supp 1):S82-S89.
  13. Eriks-Hoogland IE, Hoekstra T, de Groot S, Stucki G, Post MW, van der Woude LH. Trajectories of musculoskeletal shoulder pain after spinal cord injury: Identification and predictors. J Spinal Cord Med. 2014;37(3):288-298.
  14. Boninger ML, Baldwin M, Cooper RA, Koontz A, Chan L. Manual wheelchair pushrim biomechanics and axle position. Arch Phys Med Rehabil. 2000;8(1):608-613.
  15. Samuelsson KAM, Tropp H, Gerdle B. Shoulder pain and its consequences in paraplegic spinal cord-injured, wheelchair users. Spinal Cord. 2004;42:41–46.
  16. Gutierrez DD, Thompson L, Kemp B, Mulroy SJ. Physical therapy clinical research network; rehabilitation research and training center on aging-related changes in impairment for persons living with physical disabilities. The relationship of shoulder pain intensity to quality of life, physical activity, and community participation in persons with paraplegia. J Spinal Cord Med. 2007;30(3):251-255.
  17. Siddall PJ, Middleton JW. A proposed algorithm for the management of pain following spinal cord injury. Spinal Cord. 2006;44:67-77.
  18. Cratsenberg KA, Deitrick CE, Harrington TK, Kopecky NR, Matthews BD, Ott LM, Coeytaux RR. Effectiveness of Exercise Programs for Management of Shoulder Pain in Manual Wheelchair Users With Spinal Cord Injury. J Neurol Phys Ther. 2015;39:197-203.
  19. Norrbrink C, Lindberg T, Wahman K, Bjerkefor A. Effects of an exercise programme on musculoskeletal and neuropathic pain after spinal cord injury results from a seated double-poling ergometer study. Spinal Cord. 2012;50:457-461.
  20. Chow JW, Levy CE. Wheelchair propulsion biomechanics and wheelers’ quality of life: an exploratory review. Disability and Rehab Asst Tech. 2011;6(5):365-377.
  21. Kloostermann MGM, Buurke JH, de Vries W, Van der Woude LHV, Rietman JS. Effect of power-assisted hand-rim wheelchair propulsion on shoulder load in experienced wheelchair users: A pilot study with an instrumented wheelchair. Med Eng Phys. 2015;37:961-968.
  22. Gillham M, Pepper M, Kelly S, Howells G. Feature determination from powered wheelchair user joystick input characteristics for adapting driving assistance. Wellcome Open Res. 2017;2(93):1-40.
  23. Moraes VY, Lenza M, Tamaoki MJ, Faloppa F, Belloti JC. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014;4: Art. No. CD010071.
  24. Im G-I. Clinical Use of Stem Cells in Orthopaedics. Eur Cell Mater. 2017;33:183-196.
  25. Hitzig SL, Eng JJ, Miller WC, Sakakibara BM, SCIRE Research Team. An evidence-based review of aging of the body systems following spinal cord injury. Spinal Cord. 2011;49:684-701.
  26. Preservation of Upper Extremity Function Following Spinal Cord Injury. Clinical Practice Guidelines from Consortium for Spinal Cord Medicine. Washington, DC, Paralyzed Veterans of America, 2005

Original Version of the Topic

Wei-Han Tan, MD, Felicia Skelton, MD. Overuse Injuries in Disorders of the Central Nervous System. Publication Date: 10/22/2013.

Author Disclosure

Ryan Lirette, LSUHSC-NO
Nothing to Disclose

Stephen Kishner, MD
Nothing to Disclose

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