Posted by AskNurseLinda on Feb 19, 2018 10:05 am

Some joints in the body move basically up and down or back and forth but some such as the shoulders and hips are ball and socket joints that allow much broader movement. Ball and socket joints are literally as they sound. One bone ends in a ball shape while the adjoining bone is a hallowed out cup-like receptacle that fits the ball perfectly. The combination of the ball in the socket allows the extremity to move and rotate freely in the joint combination. To keep the joint moving freely, there is a thick liquid called synovial fluid lubricating the joint.

The shoulder joint is extremely important to individuals with spinal cord injury or paralysis from diseases, especially, stroke. For individuals who lack movement in one arm or both, the weight of the dependent arm can be heavy which causes the ball and socket joint in the shoulder to separate. This can be painful either directly or through referred pain. The dislocation of the ball from the socket or the upper arm from the shoulder leads to problems with immobility making range of motion to the area difficult or even impossible.

Care must be taken in positioning the upper extremity so that it is anatomically correct and not dependent, allowing the weight of the arm to pull the shoulder joint out of the socket. Support should be reviewed to ensure that the positioning is correct over periods of time when sitting and when laying. There are shoulder harnesses that can be purchased which will support the arm in the socket if up and about. Otherwise, positioning will keep the arm supported and in proper alignment to avoid a dislocation.

There are stages to shoulder dislocation that can be assessed and appropriate treatment applied to avoid further complications from a complete dislocation. If you gently place one finger on the curve of the area where the top of the arm meets the end of the shoulder, you should not feel any gap.

Any gap in the shoulder joint is called a subluxation. A one finger dip in the area is a slight subluxation or separation of the joint. Two is more severe. Three or four finger widths is a severe gap. If the subluxation is minimal, therapy and a reassessment of positioning will correct the issue. Range of motion should be modified per your healthcare professional’s advice until the muscles are strengthen to support the weight of the arm.

Wide subluxations may require further treatment based on individual circumstances. Therapy should not be overlooked as a treatment. Even arms that are not functioning can benefit from strengthening exercises and treatments that will build muscles to assist the joint in maintaining its anatomical positioning. This can be very similar to arm strengthening for driving a vehicle and other activities. Positioning and adaptive equipment such as arm troughs and boards will keep the arm supported. Care will be needed during transfers when the arm is dependent. Sometimes, surgery may be necessary.

When sitting, the shoulder should be placed in a neutral position with the forearm fully supported and a 90 degree bend at the elbow. This takes the weight off of the shoulder and other joints in the arm. When in bed on your back, a pillow under the length of the arm will provide enough lift to the arm to reduce weight on the shoulder. Be careful to attend to the other end of the arm as well by providing support for the hand. Pillows can be just a little too short for support of the entire arm structure. The wrist joint can develop stiffness if hanging off the end of the pillow in a dependent position. Edema will creep in as well. When on your side, position the shoulder you are laying on at an angle or tilted just a bit so the weight of your body is not crushing your shoulder. The arm can be positioned on your pressure reducing bed surface. The arm that you are not laying on should have pillow support, again for the entire length of the arm and hand, to support the weight of your arm instead of pulling on your shoulder.

If you have arm function so that you are able to propel yourself in your chair or use crutches or other walking assistive devices, you will notice a different set of issues for the shoulder joint. Overuse injury is a hazard for those who propel themselves. All of us, regardless of mode of transportation, like to get moving and go fast. We are all rushing to get from one place to another. When using the arms to propel chairs, lift the body for crutch walking or transfers, overuse injury becomes a challenge.

Overuse injury results from reaching back with the shoulders to get a lower grip on the wheel of a chair to move faster with less strokes. The arm has this range, but it is not intended for people to use this movement continuously. When walking with crutches, the specific instruction is not to have the crutch support the body by using or leaning on crutch in the arm pit. However, people do because it is easier, not realizing they are pinching a nerve when applying pressure to the underarm. The shoulder and other arm joints can take a lot of force occasionally, but these joints were not designed for lifting the body in a transfer over long periods of time such as years.

Unfortunately, other injuries to the shoulder can also occur. These include a pinched nerve, tendonitis, or frozen shoulder which is when the shoulder ‘freezes up’ over time. As the collar bone intersects the shoulder area, the scapula and surrounding muscles can thicken leading to neck pain which is commonly found with shoulder pain.

Just as individuals who are heavily engaged in sporting activity develop overuse injury, so can people who use assistive mobility and alternative moving. In fact, your risk for shoulder injury is increased if you have spinal cord injury and participate in sports. That does not mean you should stop. But you can take precautions to help yourself avoid injury.

First, assess yourself in your shoulder use. This is not something people normally do but take just a moment and think about how you use your shoulders. If you are reaching way back to propel your chair, make a conscious effort not to reach back as far. You can still move your chair quickly with a shorter but more frequent stroke. Although the movements have increase, they are creating less pressure on your shoulders. There is quite a bit of research that indicates this is a good way to reduce your risk of shoulder problems.

You can also request power assist wheelchair adaption. This is an option that will add a lot of weight to your chair even though it is much easier to push. You will need to assess your ability to move the extra weight when loading your chair in and out of a car. Getting a power assist may help with overuse in your shoulders from pushing but without a lift for your car, it can hamper your mobility or lead to pulling a shoulder out of the joint. Get a picture of the entire use of power assist to assess your abilities and needs.

If you use crutches, be sure never to lean onto the crutch by putting your body weight on the crutch at the shoulder. Most individuals today will not have crutches with extensions into the shoulder or arm pit area but some people who obtained their equipment some time ago will still have these. Today, most crutches prescribed will have forearm rests to distribute the weight of the body more evenly and away from the shoulder.

Assess how you are resting in bed. Observe if you or your caregiver are positioning your arms to take pressure off of your shoulders. Change positions frequently not only for skin pressure relief but also to take pressure off of your joints.

Look at your transfer ability. Moving a lot of weight is more pressure on your shoulder joints, elbows and wrists. Be sure your chair is at a good angle for the transfer so you have less load to move. Use a transfer board if that will help you move your body. Shorter boards are available if you are able to use them. Be sure to remove your arm rest when transferring. This simple step will put less pressure on your shoulders by requiring less work to lift yourself over the armrest. Even if you can do it, you don’t need to exert the energy and pressure on your shoulders and arms. It will also reduce your risk for a sheering pressure injury if you drag your rear over the armrest.

Exercising your arms, carefully and within your ability is necessary for building muscles. You would think moving and lifting your body would be enough, however, this is only episodic movement. To build muscles, you need to have some repetitions. Don’t start with a ‘muscle man’ work out but start simple with ten reps and build up over a generous amount of time as tolerated.  Even if you have been moving yourself for a while, don’t forget this simple step. If you require assistance for movement from yourself or a caregiver, work your joints and muscles by doing range of motion exercises. These are good for everyone with or without paralysis.

Many individuals avoid shoulder injury. Others take every preventative action but still find they develop minor or major shoulder problems. It is important to discuss any issue with your shoulder with your healthcare professional. Early treatment and intervention will decrease problems further down the line. Even if you do end up with shoulder problems, the outcome can be better and the issue less severe with prevention.

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