ORIGINAL ARTICLE Shoulder Ultrasound Abnormalities, Physical Examination Findings, and Pain in Manual Wheelchair Users With Spinal Cord Injury Steven W. Brose, DO, Michael L. Boninger, MD, Bradley Fullerton, MD, Thane McCann, MD, Jennifer L. Collinger, BSE, Bradley G. Impink, BSE, Trevor A. Dyson-Hudson, MD ABSTRACT. Brose SW, Boninger ML, Fullerton B, McCann T, Collinger JL, Impink BG, Dyson-Hudson TA. Shoulder ultrasound abnormalities, physical examination find- ings, and pain in manual wheelchair users with spinal cord injury. Arch Phys Med Rehabil 2008;89:2086-93. Objectives: To investigate the presence of ultrasound (US) abnormalities in manual wheelchair users with spinal cord injury (SCI) using a quantitative Ultrasound Shoulder Pathol- ogy Rating Scale (USPRS). To investigate physical examina- tion (PE) findings using a quantitative Physical Examination of the Shoulder Scale (PESS), and to obtain data about pain and other subject characteristics such as age, years with SCI, and weight. Design: Case series. Setting: National Veterans’ Wheelchair Games 2005 and 2006. Participants: Volunteer sample of manual wheelchair users with SCI participating in the National Veterans’ Wheelchair Games. Interventions: Not applicable. Main Outcome Measures: Presence of relationships between US findings, PE findings, pain, and subject characteristics. Results: The USPRS correlated with age, duration of SCI, and weight (all P.01), and showed a positive trend with the total Wheelchair User’s Shoulder Pain Index (WUSPI) score (r=.258, P=.073). Several US findings related to presence of PE findings for specific structures. The PESS score correlated with the WUSPI (r=.679, P.001) and duration of SCI (P.05). The presence of untreated shoulder pain that curtailed activity was noted in 24.5% of subjects, and this was related to increased WUSPI scores (P=.002). Conclusions: PE and US abnormalities are common in manual wheelchair users with SCI. The USPRS and PESS demonstrated evidence for external validity and hold promise as research tools. Untreated shoulder pain is common in man- ual wheelchair users with SCI, and further investigation of this pain is indicated. Key Words: Rehabilitation; Shoulder; Spinal cord injuries; Ultrasonography; Wheelchairs. © 2008 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation M ANUAL WHEELCHAIR USERS have increased de- mands placed on the structures of the shoulder. In addi- tion to neuropathic phenomena, many factors contribute to mechanical shoulder stress. Activities such as transferring the wheelchair in and out of vehicles, bathing, and even dressing contribute to stress on the shoulders. The mechanical forces created by increased intra-articular pressure and repetitive mo- tions necessitated by manual wheelchair mobility are believed to contribute to the development of shoulder pain, impinge- ment syndromes, and rotator cuff injuries. 1,2 Weakness in specific muscles can cause an imbalance in the forces placed on the rotator cuff as well as lead to shortening of antagonists to weak muscles. 3,4 Another proposed source of increased de- mand on the shoulders is overuse of structures that compensate for weakness in other muscle groups. 4 Persons with tetraplegia use alternative muscle groups for the lost contribution of the normative primary movers for a given task; an example of this phenomenon would be a person with C6 tetraplegia performing inferior reach. This leads to compensatory use of rotator cuff muscles to perform the task previously accomplished by prime movers. 5 Established risk factors for shoulder pain in persons with SCI include increased body mass index, duration of in- jury, and age. 6 Investigations have been conducted to identify ways of re- ducing shoulder related complaints in the wheelchair-using population. Examples of this include identifying which wheel- chair propulsion techniques may contribute to progression of shoulder pathology 7 and improving wheelchair design. Despite From the Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, PA (Brose, Boninger, Collinger); Human Engineering Research Laboratories, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA (Boninger, Collinger, Impink); The Patient-Physician Partnership, Austin, TX (Fullerton); Children’s Hospital of Austin, Austin, TX (Fullerton); De- partment of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, Washington, DC (McCann); Thomas Jefferson University, Philadelphia, PA (McCann); Spinal Cord Injury Research, Kessler Medical Rehabilitation Research and Education Center, West Orange, NJ (Dyson-Hudson); Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School, Newark, NJ (Dyson-Hudson). Supported by the Veterans Affairs Center of Excellence for Wheelchairs and Associated Rehabilitation (grant no. B3142C), the National Science Foundation (grant no. DGE0333420), the National Institute on Disability and Rehabilitation (grant no. H133N000019), and the Paralyzed Veterans of America. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organi- zation with which the authors are associated. Reprint requests to Steven W. Brose, DO, Dept of Physical Medicine and Reha- bilitation, University of Pittsburgh Medical Center, 3471 Fifth Ave, Ste 201, Pitts- burgh PA 15213, e-mail: brosesw@upmc.edu. 0003-9993/08/8911-00154$34.00/0 doi:10.1016/j.apmr.2008.05.015 List of Abbreviations AC acromioclavicular MRI magnetic resonance imaging PE physical examination PESS physical examination of the shoulder scale SCI spinal cord injury US ultrasound USPRS ultrasound shoulder pathology rating scale WUSPI Wheelchair User’s Shoulder Pain Index 2086 Arch Phys Med Rehabil Vol 89, November 2008