Upper extremity pathologies and associated factors in patients with spinal cord injury: Ultrasonographic study

Objectives: The primary aim of our study is to determine the relationship between upper extremity pathologies in individuals with spinal cord injury (SCI) and sociodemographic data, assessment scales, specific physical examination tests, and musculoskeletal ultrasonography findings. Secondarily, we aim to compare upper extremity pathologies between SCI individuals who use and do not use a manual wheelchair (MWC), accompanied by musculoskeletal ultrasonographic evaluation. Material and methods: The study included 80 patients aged between 18 and 65 years who had sustained SCI at least 6 months prior and reported pain in at least one region of the upper extremity. Participants were divided into two groups: 40 MWC users and 40 non-users. Sociodemographic characteristics of the participants were assessed, including sex, age, body mass index (BMI), marital status, educational level, dominant hand, presence of comorbidities and manual wheelchair usage. The duration since SCI and the duration of MWC use were recorded in months, and daily average MWC use was recorded in hours. The neurological level of injury and etiology of SCI were documented according to the ASIA Impairment Scale. Each participant underwent physical examination tests including the Finkelstein, Cozen, Phalen and Tinel tests for both upper extremities. Additionally, all participants were evaluated using the Physical Examination of the Shoulder Scale (PESS), which included the Neer, Hawkins, Painful Arc, Jobe, Speed, Yergason, O'Brien, Gerber's Lift-Off, Horizontal Adduction and 0° Abduction tests bilaterally. Independence levels were assessed using the Spinal Cord Independence Measure (SCIM-III) and functionality was evaluated with the QuickDASH (Disabilities of the Arm, Shoulder and Hand Questionnaire). VAS scores at rest, during transfer, and during mobilization were recorded for the bilateral wrists, elbows and shoulders. Each participant's bilateral upper extremities were evaluated via ultrasonography by a physiatrist with at least 5 years of clinical experience and musculoskeletal ultrasonographic parameters were recorded. Results: The study was completed with 80 individuals with SCI, including 40 MWC users and 40 non-users. Although participants showed similar distributions in terms of age, sex, BMI, and dominant extremity, the duration of SCI and the frequency of ASIA A/B level injuries were significantly higher in the MWC user group. Significantly higher VAS scores were observed at the shoulder, elbow, and wrist levels during transfer and mobilization in MWC users. Moreover, SCIM-III scores were significantly lower and QuickDASH scores significantly higher in MWC users, indicating reduced functional independence and increased upper extremity dysfunction. In ultrasonographic evaluations, supraspinatus tendinopathy, supraspinatus impingement (SI) and subacromial bursitis were significantly more frequent in the MWC group. Additionally, carpal tunnel syndrome (CTS) prevalence was higher in this group, with significantly increased cross-sectional area (CSA) values of the median nerve at the carpal tunnel inlet and more pronounced mild, moderate and severe CTS cases. While other tendon/nerve pathologies were also observed more frequently in MWC users, these differences were not statistically significant. Logistic regression analyses identified reduced SCIM-III score, increased BMI and prolonged MWC usage as independent risk factors for SI. Similarly, decreased SCIM-III score and longer duration of SCI were found to significantly increase the risk of CTS. Correlation analyses revealed positive associations between SCIM-III and ASIA scores and neurological level, while QuickDASH was negatively correlated. Additionally, total USPRS score and shoulder pathologies were negatively correlated with SCIM-III and positively correlated with age, BMI and QDASH scores. Conclusions: This study demonstrates that MWC use in individuals with SCI poses significant risks for upper extremity pathologies, particularly supraspinatus tendinopathy, supraspinatus impingement, subacromial bursitis and CTS. Decreased functional independence (SCIM-III score) is significantly associated with both shoulder and wrist-level pathologies. Furthermore, increased BMI and longer MWC usage are associated with higher risk of supraspinatus impingement, while prolonged SCI duration contributes to the development of CTS. However, the single-center design, limited sample size and absence of a healthy control group limit the generalizability of the findings. Future studies with larger samples, multicenter participation and confirmation of ultrasonographic findings using other imaging modalities and EMG are needed in this population.