“On shoulder repair–an ounce of prevention is worth a pound of cure.” 	–Rory Cooper

Shouldering the Load


"On shoulder repair--an ounce of prevention is worth a pound of cure." --Rory Cooper
“On shoulder repair–an ounce of prevention is worth a pound of cure.” –Rory Cooper

A while back I had the good fortune to trade “locker room talk” with some of the legends of the wheelchair world, including Marty Ball, Jim Martinson and Steve Kaliszewski. When the subject of shoulders came up, it sounded like a bunch of retired NFL players–years of pushing have left all of us with major shoulder injuries. It turns out we were not unique–we all knew quite a few people that were having the same problems, some attempting to rehab their shoulders with therapy, others risking going under the knife for repair. The results were also similar–great success stories as well as scary failures with each approach. Studies show 68 to 70 percent of longterm wheelers have relatively severe degenerative changes in their shoulders, and one day, many of us will have to face the big question: To cut or not to cut?

Understanding how shoulders break down can help in avoiding a shoulder injury in the first place. Michael Boninger, M.D., is a scientist, professor and vice chair for research in the Department of Physical Medicine and Rehabilitation at the Veterans Affairs hospital in Pittsburgh. Dr. Boninger describes the mechanics behind the typical shoulder injury: “There are three mechanisms that lead to shoulder injury. Wheelchair propulsion, over time, wears and weakens the rotator cuff (a group of four muscles surrounding and supporting the shoulder); lifting things overhead greatly increases wear and tear; and over the years that micro trauma to the rotator cuff weakens the shoulder. Then one day you do a funky transfer or an awkward lifting move (like grabbing a suitcase) and the muscles or tendons in the rotator cuff give way,” he says.

“On shoulder repair–an ounce of prevention is worth a pound of cure,” says Rory Cooper, Ph.D., director of Human Engineering Research Laboratories, a joint venture between University of Pittsburgh Medical Center, the University of Pittsburgh and the VA Pittsburgh Health Care System. Cooper practices what he preaches. A T7-8 complete para for the past 25 years (with perfect posture, I might add), Cooper races wheelchairs, swims and handcycles. “My shoulders are fine–no problems at all,” he says. “The keys to keeping shoulders healthy are: Don’t gain extra weight (this puts stress on the joints); stretch and stay flexible; and develop the best, most efficient wheelchair stroke possible–minimize your strokes per minute and do a smooth semicircular pattern when pushing so when you let go of the hand-rim your hands fall and swing back for the next push.”

Cooper’s wife, Rosemarie, is a physical therapist and works in the mobility and seating clinic at the Pittsburgh VA hospital. Her advice is to do transfers in both directions. This avoids putting constant stress on one arm. And most importantly, she says, get the lightest chair possible and have it fit you perfectly. A lighter chair, set up properly, rolls easier and is easier to lift into the car, putting less stress on your shoulders. “Unfortunately,” she says, “some therapists are still stuck using outdated fitting rules like 1 inch of space on each side of the butt. This old fashioned kind of fitting makes for a bigger, heavier, poorly-fitting chair. They don’t understand or are afraid of the current technology in wheelchair design. A wheelchair should fit like a good-fitting shoe.”

Surgery: Be Prepared
All this preventative advice is great, but what if the years have already taken their toll? Karl Beck, 53, from Clearwater, Fla., has been an L2 para for 38 years–and he’s 7 feet tall and weighs 315 pounds. Beck was 23 years post-injury and played basketball for 16 years when his left shoulder really started to bug him around 1990-91. “I had it checked out and had some physical therapy on it and it was OK.” Then, in September 2002, in the midst of doing a car transfer, he tore the deltoid, the bicep and all four rotator cuff muscles in his right shoulder. “I actually heard it tear, the muscle was totally gone. I couldn’t even lift the shoulder,” he says. Surgery was his only hope.

Beck sought out the best in shoulder surgeons. Dr. David Thompson, from Morton Plant Hospital in Clearwater, Fla., did the surgery (Dr. Thompson is also sideline doctor for the Tampa Bay Lightning Hockey Team). Before the surgery, Beck did a lot of planning for post-op–rearranging the house, getting a power chair, hiring a nurse to help with transfers and daily care. Only then did he schedule the surgery.

"Now the shoulder feels great, and I have complete range of motion. But my left shoulder is getting pretty bad, too, and I'm not looking forward to spending another six weeks totally dependent on somebody, so I'm putting it off for now."--Karl Beck
“Now the shoulder feels great, and I have complete range of motion. But my left shoulder is getting pretty bad, too, and I’m not looking forward to spending another six weeks totally dependent on somebody, so I’m putting it off for now.”–Karl Beck

“I was lucky, my bones and cartilage were in good shape,” he says. “Dr. Thompson put the torn tendons and muscles back together and stitched them in two different directions to make sure they would hold. It turns out post-op wasn’t painful and I asked Dr. Thompson about that. He said it usually is, but wheelchair users and old farmers don’t have much pain following surgery because they use their shoulders so much, many of the nerves are worn out.”

After the surgery Beck remained in the hospital for 10 days doing physical therapy. When he got home he had his right arm in a sling, used a power chair to get around and needed the nurse/attendant for any kind of daily care. He spent four weeks at home recovering. Six weeks following the surgery he was able to use his right arm and start driving again. Within eight weeks he was back doing his normal routine and transfers. “Now the shoulder feels great, and I have complete range of motion. But my left shoulder is getting pretty bad, too, and I’m not looking forward to spending another six weeks totally dependent on somebody, so I’m putting it off for now,” Beck adds.

Dr. Boninger says Beck’s story fits all the right criteria for shoulder surgery. Boninger says research on successful outcomes following shoulder surgery on wheelchair users is pretty limited at this time, but what there is, isn’t very encouraging. “If you are considering surgery, make sure the surgeon is a shoulder specialist and has lots of experience. Sports medicine surgeons are usually top notch. It is vital to get a good physical medicine and rehabilitation doc involved with this process. If you are not near a major rehab center, it is well worth a 400 to 500 mile drive to get the best care possible.”

Boninger also stresses the importance of being prepared. “Are you ready to go from being independent to being totally dependent, bedridden and having an attendant?” he asks. Think ahead, he cautions. Be prepared to have only the use of one arm for a lengthy period of time–this means no transfers and having attendant care readily available. Also a power chair may be needed for the recovery period, as well as a vehicle with a lift. Avoid the danger of reinjuring the shoulder while you are in the healing process. “If it was my decision,” he says, “I would save the surgery for the case where pain or mobility loss is so great that even a bad surgical outcome is not going to be worse than where you are right now.” Boninger suggests a great tool for understanding shoulders and how to keep them healthy: Preservation of Upper Limb Function Following Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals, available at www.pva.org.

Three Case Histories
Jimmy Green from Loganville, Ga., is co-owner of SportAid.com. Green is 50 years old and has been a T4 para for 27 years. He is also a legendary wheelchair racer. “Back in the early days of racing, we didn’t understand proper training and were pushing massive miles on small hand-rims,” recalls Green. In 1989 he had surgery to repair a rotator cuff on his right shoulder–torn from overuse. Some bone spurs and a tear in the shoulder were repaired. The surgery worked. Green’s shoulder felt and worked better, although he was down for at least three months following the surgery and didn’t feel comfortable using the shoulder for six months. Then his left shoulder went out on him–it was torn so badly he couldn’t lift his arm over his head and hurt so much he had to quit sports. “I had surgery, and they had to clean out bone spurs and reattach a tendon that was torn from the bone,” he says. “I started to heal up, but it turns out I was allergic to the stitches and the wound opened up,” he says. His doctor put him on antibiotics, and after four weeks he went in for a second surgery. “I was down for a total of 20 weeks, much of the time on heavy antibiotics,” he recalls. The shoulder finally healed, but six months later he was in a car accident. When he went to catch himself with his left arm, he ripped up the same shoulder. “It has gotten so bad that I had to buy a van with a lift in it, which is a hard pill to swallow, pride-wise,” he says.

Green is set for another surgery on his left shoulder late this summer at DeKalb Medical Center in Decatur, Ga. “I’ve gotten several “second opinions” and they all say my doctor, Dr. Jove, is right on target. Plus he is so popular he works out of three offices. The damage is so bad this time that the surgery is considered experimental–there are no tendons to work with, so they will have to do a graft and bring muscle in from other parts of the back to supply blood. At this point my arm is so useless I don’t feel I have a choice,” says Green.

Tina Roesler, M.S.P.T., a member of the American Board of Disability Analysts and director of training and education for the ROHO group, agrees with Dr. Boninger about being cautious when choosing surgery, but strongly adds: “Depending on the severity of the tear or damage to the shoulder and the lifestyle of the client, sometimes surgery is the only option. If you are going to attempt to rehab a damaged shoulder, one of the things you need to do is do your transfers toward the injured arm. The pushing arm during a transfer is more vulnerable.” She also advises that if you are going to try and rehab an injury, it is best to work to build up the core of your rotator cuff, which means doing pulling exercises that strengthen the muscles in the back of the shoulder and open up the chest.

Johnny Johnston, 57, from Gainsville, Fla., is a high school tennis coach and a T10-12 para for the past 38 years. Johnston is a world-class basketball and tennis player and has torn up both shoulders playing sports. The first one happened racing for the ball on a fast break. He finished the game but found when he tried to transfer, his left shoulder was in extreme, sharp pain. It turns out the supraspinatus (muscle above the scapula) was torn. “At the time I didn’t even want to think about surgery, I didn’t want the down time. I started a rehab program to open up the shoulder. I still can’t lift it over my head. Now I do my transfers to the car on the left side and take my right hand and lift the left hand up to the grab handle and can pull myself up and in.”

He injured his other shoulder two years ago. “I was playing tennis and hit a hard overhead shot and my right arm just went out. I knew it was real serious. I had a major tear of the supraspinatus and infraspinatus. I had an appointment for an MRI in three weeks, but in the meantime I tore my right bicep doing a transfer onto the commode, so I was really messed up.” The MRI showed massive tears and lots of bone spurs, so he made an appointment to have surgery at the Tampa VA hospital. “The day I went in for pre-op, things were not going well. I had a real bad feeling and I started thinking about being in the hospital for so many weeks and being totally dependent. At 10 that night I packed my bag, signed a paper to leave–against doctors’ orders–and went home and designed a rehab program. I got physiology books and started to read how the muscles work, and a friend of mine who is a PT helped me design a program of movements and exercises. I started doing a lot of work on the muscles in my back and started doing a lot of pull-ups.”

Within six months he was back playing tennis again. A year later he was back playing basketball in good form. “My shoulders are sore,” he says, “but they work.”

To Cut or Not To Cut?
Steve Kaliszewski, 51, a C6-7 complete quad from San Diego, has been using a chair for 30 years, has done 48 marathons, and played quad rugby at a world class level for 17 years. Three years ago he tore a muscle and tendon in his right shoulder in a bi-ski accident. “I went to see a surgeon because I figured that was the only way to fix it. He looked at it and said, ‘I can go in there, but at best I can only improve things about 5 percent.’ That was a great call because I decided to rehab it. Within about six months it was back to almost normal.” But in late June he had a bad spasm, went over backwards and caught himself with his left arm and tore the front of his rotator cuff. The following week he attended the VA games and spent a week pushing up ramps and across carpet and really messed it up. “When I got home, I went to transfer on the toilet and my left arm gave out–I flew back and cracked the tank, water started leaking everywhere, and I slipped off the side and was stuck. By the time my wife got home, the entire house was flooded.”

Now Kaliszewski thought he was ready for surgery for sure. But after having an MRI, his surgeon at Sharp Rehab in San Diego advised him, “I wouldn’t operate on that if I were you. It’s torn, but I think a cortisone shot or two will have you back to normal in a reasonable period of time.”

"The pain has totally gone away. Within 12 weeks the shoulder should be fully fused and my arm will be really strong."--Roxanne Furlong
“The pain has totally gone away. Within 12 weeks the shoulder should be fully fused and my arm will be really strong.” –Roxanne Furlong

Roxanne Furlong, 37, of Minneapolis, has facio-scapulo-humeral muscular dystrophy. The disease destroyed the muscles that hold her scapulas to her back. Her left shoulder got so bad she was in excruciating pain. “I couldn’t function at all, and nothing alleviated it. I found this great doctor, Dr. Anthony Romeo, at Rush Memorial Hospital. He’s a big-time sports doctor, the shoulder and elbow specialist for the Chicago Bulls and White Sox. He also specializes in FSH MD,” she says. Dr. Romeo fused the scapula to the rib cage. It has been two months since surgery and everything looks good. “The pain has totally gone away. Within 12 weeks the shoulder should be fully fused and my arm will be really strong. I won’t be able to lift my arm above my head, but I should be pain free and that is well worth it,” says Furlong.

Marty Ball, vice president of sales for TiLite Wheelchairs and a member of the Wheelchair Sports Hall of Fame, is a polio survivor. Ball spent 26 years on crutches until his back gave out. He has used a wheelchair for the past 30 years. His right shoulder gave out during a basketball game in 1982. Rather than consider the down time for surgery, Ball retired from basketball. Ball has a passion for improving and selling the latest in wheelchair technology, a commitment that has put millions of road miles under his chair. Last year he tore up his left shoulder falling out of a van during a transfer. “I considered surgery, but I can’t fathom sitting still for six to eight hours, let alone six to eight weeks.”

The left shoulder damage has changed Ball’s lifestyle a bit. “I can’t do ‘single lift’ floor to chair transfers anymore,” he says. “But luckily the chairs have gotten light and compact enough that I can still do car transfers, and I still pass everybody on the sidewalk or in an airport, so I don’t think I’m slowing down too much.” Ball says he is constantly rehabbing his shoulders. “I do a daily stretching program and lots of gentle hill climbing waiting for flights at the airport.”

To cut or not to cut? The answer is different for each individual and requires a lot of research, talking with a good surgeon, a good physical medicine and rehabilitation doctor and a good therapist to help make an informed choice. If you have a relatively recent injury, take this article to heart. For those of us with 20 or more years in our chairs, a time machine would help. As Steve Kaliszewski puts it, “We usually get hurt at age 21 to 25 and we feel invincible. We push hard and work out like crazy. Going back in time, I would have balanced out my training a bit and backed off on the excess pushing. Who knew we would live so long? It’s time to talk about this and help people learn to pace themselves a bit. We’re in this for the long haul.”


What’s the IQ of a SmartWheel?

Michael Boninger is not the only Boninger with close ties to wheelchair users. There’s also David, whose Three Rivers Holdings company is a leading innovator in wheelchair technology. “Yes, Michael’s my brother,” explains David. “Although he is not part of our company, he and Rory Cooper at the University of Pittsburgh have been research partners with us on many of the grants that we have submitted.” Those grants, says David Boninger, have played a critical role in helping spur innovation in wheelchair technology.

Michael Boninger and Cooper are co-inventors (along with a former graduate student) of the Natural-Fit Handrim, one of the wheelchair user products now being marketed by Three Rivers. Several years ago Three Rivers executed a licensing agreement with the University of Pittsburgh in order to develop and test the Natural-Fit and bring it to the marketplace. But that’s not their only product. Other products are the GameCycle, an exercise hand cycle that combines upper body exercise with playing video games–not a bad way to keep your mind interested while your body works up a sweat–and the SmartWheel. “The SmartWheel will play a growing role in wheelchair selection, wheelchair comparison, and assisting with insurance justification,” says David Boninger, “all of which are important to saving one’s shoulders.”

The SmartWheel is used mainly in a clinical setting to gather data that can be useful in not only preventing shoulder problems, but also in assisting with rehab when a shoulder problem already exists. “It enables wheelchair users to be active participants if they find themselves back in the clinic due to increased pain, functional changes, etc.,” says Boninger.

The data gathering device can be mounted quickly and easily to most standard wheelchairs. In the hands of a doctor or therapist, the user-specific data can be included in a letter of necessity that justifies the need for a newer, lighter wheelchair. “The SmartWheel is an amazing tool,” says Marty Ball, a mainstay in the wheelchair industry since the advent of the first lightweight chair. “It scientifically quantifies how well a wheelchair fits and is set up. It’s the ‘wheelchair fitting/setup tool,’ equivalent to the pressure mapping system for proper cushion choice. Plus, like the pressure mapping system, it’s a great educational tool for the wheelchair user–to learn their most efficient pushing stoke.” For more information about Three Rivers Holdings and their innovative wheelchair products, visit www.3 rivers.com.


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