Development of a Model of Shoulder Pain Following Spinal Cord Injury

Study Overview
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Brief Summary
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This study will investigate the progression of musculoskeletal (shoulder muscle flexibility, muscle strength, movement coordination, and rotator cuff health) and psychosocial (fear of movement, pain catastrophizing) impairments for the first year following SCI, starting with inpatient rehabilitation, at 6 months, and at 1 year following SCI. We will use the information obtained from this study information to develop a biopsychosocial prospective surveillance model, a method for early detection, intervention, and moderation of shoulder pain. Specifically, we will identify sources of biopsychosocial shoulder pain to establish effective physical and cognitive-behavioral treatment to prevent loss of function and independence in individuals with SCI who depend on their arms for activities of daily living, transfers, and wheelchair propulsion.

Detailed Description
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Shoulder pain is a common secondary condition in people with spinal cord injury (SCI) that often results in loss of function and of independence and imposes limitations on self-care, work, and leisure activities, and leads to decreased quality of life. More than 40% of individuals with SCI report shoulder pain at the beginning of inpatient rehabilitation; this number increases to 50% at hospital discharge. The onset of shoulder pain within the first year after injury may lead to lifelong chronic shoulder pain. Although information is known about shoulder pain in patients with long-term SCI, little is known about the beginning of shoulder problems and how they progress early after the injury. In addition to physical problems, psychosocial factors are also associated with chronic pain. This study will investigate the progression of musculoskeletal (shoulder muscle flexibility, muscle strength, movement coordination, and rotator cuff health) and psychosocial (fear of movement, pain catastrophizing) impairments for the first year following SCI, starting with inpatient rehabilitation, at 6 months, and at 1 year following SCI. Age- and gender-matched controls will be compared at baseline and at 1 year. Instead of routinely screening patients to identify and treat related factors before shoulder pain and dysfunction become problems, the current practice is to start treatment after shoulder pain occurs. We will use the information obtained from this study information to develop a biopsychosocial prospective surveillance model, a method for early detection, intervention, and moderation of shoulder pain. Specifically, we will identify sources of biopsychosocial shoulder pain to establish effective physical and cognitive-behavioral treatment to prevent loss of function and independence in individuals with SCI who depend on their arms for activities of daily living, transfers, and wheelchair propulsion. Early identification of problem areas may provide a method to refer a patient for treatment or to change ongoing intervention. Development of a biopsychosocial prospective surveillance model will provide a proactive approach to reduce the debilitating consequences of activity limitations and participation restrictions in individuals with SCI, reducing the burden currently experienced by military service members, veterans, and their families and caregivers.

Official Title
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Development of a Biopsychosocial Prospective Surveillance Model of Shoulder Pain in Individuals With Spinal Cord Injury

Conditions
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Spinal Cord Injury

Intervention / Treatment
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* Other: Observation


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Individuals will be eligible for participation if they are >18 years of age and included in the SCI group if they demonstrate a complete or incomplete SCI of American Spinal Injury Association grade A, B, C or D45; attend inpatient rehabilitation following SCI; use a manual wheelchair for at least 50% mobility; and are medically stable. The control group will able-bodied (non-SCI) and be age and sex matched to the SCI group Exclusion Criteria: Individuals will be excluded from participating in either group if they present with upper extremity radicular symptoms; preexisting neurological conditions; and complications from other health conditions that could influence upper extremity function. Control group: Individuals will be excluded from participating in any group if they present with preexisting neurological conditions; and complications from other health conditions that could influence upper extremity function.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Spinal Cord Injury<br>Participants with SCI in the acute, in-patient rehabilitation phase.Data for each participant in the SCI group will be collected at baseline, 6 months, and 1 year post injury; | Other: Observation<br>* Data for each participant in the SCI group will be collected at baseline, 6 months, and 1 year post injury; control group data will be collected at baseline and at the 1-year follow-up.<br>|
| Able-bodied control<br>Age- and gender-matched able-bodied individuals (matched to SCI group). Control group data will be collected at baseline and at the 1-year follow-up. | Other: Observation<br>* Data for each participant in the SCI group will be collected at baseline, 6 months, and 1 year post injury; control group data will be collected at baseline and at the 1-year follow-up.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Musculoskeletal Pain Survey (MPS)-Change over time | Change in musculoskeletal pain will be assessed with the self-report Musculoskeletal Pain Survey.[20] This questionnaire asks the person to rate the presence, seriousness, and frequency of pain in the joints or muscles of the upper extremities. A composite pain score is calculated for bilateral upper extremities, ranging from 0 to 90. The shoulder pain score will also be analyzed separately (score 0 to 30). This scale has been used to identify musculoskeletal pain in individuals with SCI.[20-22] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Pectoralis Minor Muscle Length Change over time | Manual palpation will identify the fourth rib and the coracoid process.[47] Pectoralis minor length will be measured as the distance between the fourth rib and coracoid process under two testing conditions: resting posture and passive lengthening.[48] Pectoralis minor muscle length will be measured as the distance between the two landmarks (cm) with the Palpation Meter (PALM, St. Paul, MN).[47] We have established excellent measurement properties for our procedure of measuring pectoralis minor muscle length under resting and passive lengthening conditions (ICC2,2=0.86-0.94, MDC95 =1.77cm).[49] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Shoulder Girdle Tissue Integrity Change over time | Musculoskeletal ultrasound with a multifrequency, broadband, 50-mm linear array transducer will be used to obtain images of the subscapularis supraspinatus infraspinatus and biceps tendons, acromiohumeral distance, and supraspinatus muscle fatty infiltrate.5[0] Accuracy of musculoskeletal ultrasound for detection of rotator cuff tears is reported to be 88.9% (95% confidence interval =74.1 to 96.21).[51] Dr. Trojian has extensive training in the use of diagnostic ultrasound of the shoulder complex and will perform the ultrasound examinations. One assessor, masked to participant group and age, will provide the clinical interpretation of the finding and identify changes over time. | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Tampa Scale of Kinesiophobia Scale (TSK-11)-Change over time | The TSK-11 is used to assess fear of movement (kinesiophobia).41,42 The validated 11-item version (TSK-11)[52] gives a score range of 11 to 44, with higher scores indicating higher fear of movement and reinjury. The TSK -11 comprises opinion-based items that evaluate the participants' general status on a scale of 1 to 4 (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree). TSK-11 offers excellent reliability (ICC=0.81, SEM=2.54).5[2] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Fear of Pain Questionnaire (FPQ)-Change over time | The FPQ43 is a 30-item measure of fear of painful stimuli. The FPQ includes three subscale scores for minor pain, severe pain, and medical pain. For each painful situation described on the FPQ, participants rate how fearful they are on a scale from 1 (not at all) to 5 (extreme). Previous research reported adequate internal consistency (α range, 0.86-0.87) on the FPQ scales.[53] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Pain Catastrophizing Scale (PCS)-Change over time | The PCS consists of 13 items rated on a 5-point scale (0=not all to 4=all the time).[27] Participants are instructed to rate the degree to which specified thoughts and feelings occur when experiencing pain. Three dimensions of pain catastrophizing are assessed: rumination, magnification, and helplessness. Only the total score was used in the current study. The PCS is validated for clinical and nonclinical populations.[27,36,53,54] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Subjective Quality of Life Questionnaire (SQoL)-Change over time | This questionnaire is a global measure of subjective perception of QoL.[55] The scale is a Likert-type scale measuring satisfaction with life as a whole: Participants are asked to take everything in their life into account and rate it on an ordinal scale from 1 (life is very distressing; it's hard to imagine how it could get much worse) to 7 (life is great; it's hard to imagine how it could get much better).[56] Test-retest reliability is high (91% agreement),[55] and this questionnaire is validated with the SCI population.[55,57,58] Dr. Mulroy holds expertise and experience in using psychosocial measures in individuals with SCI and will oversee the analysis and interpretation of these primary and secondary measures. | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Muscle Strength-Change over time | We will collect measures of shoulder girdle muscle abduction, adduction, internal rotation, and external rotation strength. Standard manual muscle testing positions of Kendall et al.[59] will be used when possible; a modification of the position will be used in an effort to perform all tests with participants seated in their wheelchairs. A handheld dynamometer will be used to record the peak muscle force over three trials; the highest value will be used for analysis. Dynamometry is a reliable method for assessing strength (ICC=0.97).60 We will determine muscle strength ratios for abduction/adduction, internal/external rotation, and protraction/retraction.[14] | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 
| Chronic Pain Coping Inventory-42 (CPCI-42)-Change over time | The CPCI, a 42-item abbreviated version of the original 65-item CPC [,6]1 asks individuals to self-report the frequency of use of particular behavioral and cognitive strategies to cope with pain; it has good psychometric properties.6[2] Specifically, the CPCI-42 lists coping strategies and asks participants During the past week, how many days did you use each of the following at least once in the day to cope with your pain? CPCI scales demonstrate adequate to excellent test-retest stability (0.65-0.90). | SCI Group: baseline, 6-months, one-year; Control Group: baseline, one-year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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spinal cord injury, shoulder pain, psychosocial