By Sharon Puszko
Originally published in Massage & Bodywork magazine, April/May 2003.
Associated Bodywork and Massage Professionals. All rights reserved.
Living in a wheelchair for one week, one month, one year or a lifetime can cause significant physical discomfort. Luckily, whether someone uses a wheelchair because of cerebral palsy, HIV or an athletic injury, proper positioning and massage therapy may help ease the associated pain.
While injuries to the elbow, wrist and hand are common among wheelchair users, shoulder injuries are the most predominant. Torn rotator cuffs and tendinitis are often the causes of shoulder pain. Muscle imbalance caused by overuse can lead to abnormal biomechanics and, thus, injury. The most common disparity in strength associated with rotator cuff tear or tendinitis is an imbalance between the internal and the external rotators of the shoulder. Also, the prevalence of carpal tunnel syndrome among manual wheelchair users is between 49 percent and 73 percent.
Proper positioning in the wheelchair is probably most important for the prevention of repetitive strain for manual wheelchair users. A combination of manual mobility and powered mobility may be a workable compromise for some wheelchair users. Modern manual wheelchairs are easier to transport and easier to carry than powered wheelchairs. However they may not offer the same degree of independence for users with chronic arm or shoulder pain.
“Massage therapy is seen as a positive method of pain management, but just treating the pain is not an end in itself,” says James Laskin, M.S., P.T., adjunct professor for the division of rehabilitation services at the University of Oklahoma and the Health Services Center of Oklahoma City. He emphasizes the importance of treating problems like improper positioning and mechanics, not just the symptom.
Many people who spend their time in a wheelchair will develop pressure sores. These lesions are caused by unrelieved pressure over a period of time sufficient to cause the destruction of soft tissue cells. The pressure between bone and searing surface compresses the soft tissues of the buttocks and forces the blood out of the tissues. The longer one sits without movement to change the pressure areas, the greater the cellular damage. The same process occurs for those of us who can walk when we sit on a hard surface for too long. However, our subconscious nervous system causes us to move periodically, shifting the pressure points and allowing blood to re-enter the compressed tissues. Spinal cord injury causes a loss of the sensation so vital to this process. Most paraplegics and quadriplegics have no feeling in their soft tissues. They feel no distress, fail to move periodically and consequently develop pressure sores. Chair-bound individuals are advised by their physicians and therapists to change their position every 10 minutes or so by doing “pressure lifts” or other pressure point changing routines designed to stimulate the flow of blood to soft tissue. This allows the blood to re-nourish the tissues that have been under high pressure. The sad fact is that people forget to move, or may be unable to move themselves. The use of massage therapy on the coccyx, ischium (pelvic bone) and lower back can help prevent pressure sores on wheelchair users.
Even with the best passive cushion technology available, pressure sores are one of the greatest health risks a chair-bound person can have. They can cause a drastic decline in quality of life. Curing a sore may require weeks or months lying face down on the stomach or even skin grafts. Deep sores may very well develop into life-threatening bone infections, and can change a productive self-sustaining individual into a bed-ridden patient dependent upon others for a long period of time.
Passive Stretching versus Massage
In an article for Rehab & Community Care Management, Stephanie Nixon, B.A., B.HSc. (P.T.), M.S.C., et al. writes about an HIV-positive male who began experiencing lower back and buttock pain five years after his diagnosis.1 The pain led to weight loss and muscle atrophy and, as a result, he became depressed and needed the help of a wheelchair to move around. “According to his rheumatologist, the most likely diagnosis was transient osteoporosis, although avascular necrosis and spondyloarthritis were possibilities.” He received support from a physiotherapist and a registered massage therapist (R.M.T.). At the beginning of his therapy, he “reported the pain in his hips and lower back varied daily from 4 to 7 on a pain scale of 1 to 10. Heat applications and light to moderate pressure massage were tolerated well. However, passive forced stretching and stage one traction were discontinued after an increase in pain was reported. As massage therapy treatments continued, he reported a decrease in pain to 2 out of 10. However, his relief would only last for a day or two, depending on his subsequent activity levels after the treatment.” While passive forced stretching normally helps people, we can see from this experience that light massage and heat application were more beneficial.
Ultimately, the benefits of massage therapy for wheelchair-bound clients include improved range of motion, circulation and alleviated decubitus ulcers. This specific modality is also important for the massage therapists who are led to the rewarding practice of working in nursing homes and with assisted-living residents.