RE: Information Exchange: Adhesive Capsulitis (Full Version)

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TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 2:04:11 PM)

quote:

ORIGINAL: avalon

quote:

Who knows why.


hmmm... CNS?


With respect avalon, you make the assumption the CNS is the primary reason for the efficacy of the treatment without any substantiation. 

I think this is one of the trappings of the SomaSimple folks.  Very very bright people who make very strong statements about the mediating role of the CNS...scoffing at us who implicate the musculoskeletal system as low-brow.  Of course the CNS plays a role...so does connective tissue.  This is not a revalation a select few have stumbled upon.  When you can begin making a measurable physiologic connection between pathology-treatment-outcome, I will be all ears.

Until then...simply saying "CNS" as if we could have had a V8 just smacks of elitism. 



buckeye -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 4:02:01 PM)

Interesting comments - a scientific basis for explaining how things work. Perhaps there is truly a dearth of evidence to support the primary neural v. primary musculoskeletal corners. There seems to be much theory and each side tends to explain away whatever happens (for the shoulder to improve) using their own terms.

How many of you 'stage' the shoulder versus just diving in and working on the issues?
How do you handle the patient who has very limited visits - maybe only 15 PT visits in a year?
What is different about the diabetic frozen shoulder that gives it a poor prognosis?

Let's stay civil and keep the discussion on the topic and not about the smaller issues.



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 6:52:44 PM)

quote:

ORIGINAL: buckeye

Interesting comments - a scientific basis for explaining how things work. Perhaps there is truly a dearth of evidence to support the primary neural v. primary musculoskeletal corners. There seems to be much theory and each side tends to explain away whatever happens (for the shoulder to improve) using their own terms.

How many of you 'stage' the shoulder versus just diving in and working on the issues?
How do you handle the patient who has very limited visits - maybe only 15 PT visits in a year?
What is different about the diabetic frozen shoulder that gives it a poor prognosis?

Let's stay civil and keep the discussion on the topic and not about the smaller issues.



Agreed...apologies avalon. I've been so freaking busy at the clinic and wore (as my wife calls it) the cranky pants today.



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 8:04:40 PM)

Ummm... I didn't believe that you were cranky, Rod.  Avalon shouldn't have any apologies.  It's ALWAYS the CNS according to the group at SS.  So,
Avalon, what part of the CNS was the reason as to why ultrasound provided an effective response described by the therapist's observation?  I'm not letting you off the hook with such a flippant response!



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 8:06:05 PM)

Oh... and if it is the CNS, why don't all patients have the same response?  CNS is CNS is CNS, right?  Or maybe not?  It probably depends? Yeah, it must depend because the same response is not consistent across the board.  So, for this case, why?



ysumpt2006 -> RE: Information Exchange: Adhesive Capsulitis (February 22, 2008 11:24:27 PM)

I don't know why it worked, but it did.



Kaden -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 12:36:48 AM)

Avalon,

For those of us on this forum can you explain what part of the CNS - a rationale or mechanism at least.  To simply answer every question with CNS doesn't educate others as to what you are thinking.

If you asked me the cause of AC, radiculpathy, referred pain, etc. and i answered every time with musculoskeletal I don't think you would accept this response.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 2:13:12 AM)

quote:

When you can begin making a measurable physiologic connection between pathology-treatment-outcome, I will be all ears.


Read this condensed material
http://www.ppaonline.co.uk/publications.html

If saying that brain is everywhere is being an elitist then I'm an elitist.
But... But it is just a way to rearrange the things as they work.

1/ a body without a brain is... dead.
2/ a muscle without a  nervous connection is paralysed.
3/ an unconscious body doesn't feel pain.
4/ an amputee may feel it even in the "removed " part.

SJ,
once again, you refuse evidences:
Why this perfect method doesn't work on everyone?
Does this guy has a mental disorder?
Is he refractory?

If you take 100 patients and 10 PTs who learned the same method, why have they a different rate success? The method is the same and applied the same way... for you! Not for me.

According the same rules to you: give me another reason it worked (not a CNS one)???

Kaden,
See point 2.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 2:21:49 AM)

quote:

CNS is CNS is CNS, right?

Wrong.
That is continous problem with you, SJ!
Patients aren't robots with interchangeable pieces.



jlharris -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 3:00:57 AM)

Avalon,

To be clear, are you implying, then, if you took 10 PT's from SS frame of reference/treatment/philosophy and treated 100 pt's you'd all get the same results?



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 3:18:13 AM)

Not at all.
I'm just implying that looking at the neural/CNS components of every participant (patient and PT) is a chance to improve outcomes.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 5:08:10 AM)

http://ptjournal.org/cgi/content/full/81/7/1351

quote:

Thermal effects are those due to heating and are accepted as including increased metabolic activity and blood flow and an analgesic effect on nerves.


http://physther.org/cgi/content/full/81/7/1339

quote:

In the remaining 8 studies, no statistically significant differences in outcome between subjects treated with ultrasound and subjects treated with placebo ultrasound were found.



Kaden -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 5:28:22 AM)

Good for you Avalon, you can provide some studies to discount the US and MS argument contributing to adhesive capsullitis.   Can you fine one credible piece of evidence that talks about CNS involvement contributing to AC.  Don't get on SJ for discounting your take on the problem if you can't offer one piece of credible evidence - or even a rationale argument that the CNS is the primary cause. 

You reference me to the statement a muscle without a nerve is paralyzed.  How does this contribute to adhesive capsulitis.  I am sure the psychological makeup of a patient plays a huge part in their response to a rx but I am not going to simply go off on the every patient with AC has a psychological component tangent.

I am not trying to trash your ideas about the CNS playing a role but if you can't provide a single sound argument as to why the CNS plays a significant role then you simply need to go away.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 5:53:28 AM)

Kaden,

Can you give a single argument where AC doesn't involve a single nerve?
It would be hard for you since Pain involve nerves and brain.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 6:38:05 AM)

Br J Gen Pract. 1999 Jan;49(438):39-41.Related Articles, Links[image]http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--images.ingentaselect.com-images-linkout-ingentaconnect.gif[/image] [image]http://www.ncbi.nlm.nih.gov/corehtml/query/egifs/http:--www.pubmedcentral.nih.gov-corehtml-pmc-pmcgifs-pubmed-pmc.gif[/image]
Comment in:
Suprascapular nerve block for the treatment of frozen shoulder in primary care: a randomized trial.

Jones DS, Chattopadhyay C.

Wrightington Hospital, Wigan.

BACKGROUND: Frozen shoulder is a common problem in general practice, but its treatment is difficult since none of the currently used therapies are proven to be effective. AIM: To assess the effectiveness of suprascapular nerve block to relieve pain and improve range of movement, and its suitability for use in primary care. This small study by a single practitioner aims to justify a larger multicentred trial. METHOD: A randomized trial of 30 patients to compare a single suprascapular nerve block with a course of intra-articular injections. Patients' pain levels and ranges of movement were assessed over a 12-week period. RESULTS: Suprascapular nerve block produced a faster and more complete resolution of pain and restoration of range of movement than a series of intra-articular injections. These differences were confirmed by statistical analysis using the Mann-Whitney U-test (P < 0.01 for pain levels and P < 0.05 for range of abduction and external rotation.) CONCLUSIONS: This study suggests that suprascapular nerve block is a safe and effective treatment for frozen shoulder in primary care, and justifies a larger multicentred trial using independent blinded assessment. Such a study should include a third group treated by suprascapular nerve block without steroid; a more comprehensive assessment of patient debility.

Publication Types:
  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

PMID: 10622015 [PubMed - indexed for MEDLINE]

Question: Why a nerve block that has nothing to see with muscle and joint "things" works?



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 8:35:06 AM)

That study alludes to the suprascapular nerve being a factor.  Was the nerve was a factor though?  (No sham nerve block.)  How familiar are we with that pain scale?  What is the minimal clinical important difference of it?  The outcome range of motion - was it active or passive?  Range of motion is nice to know, but what about function?  The study could have been better if function were captured.

I also definitely agree that there should have been some sham intraarticular injections and sham nerve blocks as part of the study.

I also wouldn't consider a suprascapular nerve to be "central nervous system."  This was an intervention targeting the peripheral nervous system.



PTupdate.com -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 8:52:07 AM)

Perhaps part of the problem is delineation of what is truly adhesive capsulitis versus a tight shoulder, or perhaps one that caused the other.

From a biomechanical point of view, the true adhesive capsulitis patient may have had either a CNS or PNS involvement that eventually lead to the physical constriction of the anterior/inferior capsule.  Anybody who has ever participated in MUA with some of these patients has seen where once "knocked out", their PROM was the same as when in the clinic the day before.  This, to me, rules out direct CNS at that point, and implicates the connective tissue.  Lysis and MUA both resolve that physical component.

But, we all treat those patients called AC that display duel components.  They have a limitation in motion, but as we gently stretch and coax the shoulder, we often gain 20 or more degrees in a few minutes.  That to me is not true connective tissue stretch, and I'd bet the literature supports that.  Instead, we are dealing with muscular inhibition, sometimes due to pain, sometimes due to apprehension, other times due who who-knows-what.  Throw in the hormonal issues (almost always female, post-menopausal always improve quicker when on HRT, etc) and also throw in psychosomatic issues (very often seen), and we have to admit nobody really knows why this occurs.

I did like the idea on SS that muscular contraction around the shoulder could be the source of the reduced capsular volume, and this compression could lead over time to connective tissue bridging and binding.  While taping my two fingers together for a few weeks would not cause a tissue union, peeling off and damaging the skin, and then taping together would.  So, the predisposing biochemical / physical trauma often seen (surgery, fall, humeral fracture) and the protective splinting due to pain could certainly cause the capsular binding.

So, if the CNS did have a central or partial role in the problem, which now may have developed into a true connective tissue condition, can and will treating JUST the CNS resolve that condition without concomitantly treating the connective tissue?  How?



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 9:03:33 AM)

Avalon.  Saying "humans are not robots with interchangable features" sounds familiar.  I think I've heard Diane say this on SS.  I think you need to make a direct (or even indirect) link between the pathology, a treatment, and it's outcome.  Otherwise you are making a generalization that of course makes sense but doesn't offer anything meaningful.

It's like saying "physiology" is responsible.  I think we can all agree everyone is different, but I like Jason's question earlier.  Would 10 SS'ers treat a patient the same way?  With all the free-thinking going on over there, I seriously doubt it.  That isn't a problem necessarily, BUT if we are trying to gain traction in the medical community, we must live and abide by these standards. 

I have said I am ready to learn more about this process those on SS proudly state is the end-all approach to therapy.  Help me understand it by providing some measurable link between this neuroreflexic approach and a salient outcome.  If you cannot do this, the SS'ers need to get started on it otherwise risk blending in with other great ideas - aka myofascial release.



Jon Newman -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 10:25:48 AM)

quote:

...if you took 10 PT's from SS frame of reference/treatment/philosophy and treated 100 pt's you'd all get the same results?--Jason


Hi Jason,

SomaSimple is a discussion forum, not a frame of reference/treatment/philosophy.



jlharris -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 11:12:48 AM)

quote:

Not at all.
I'm just implying that looking at the neural/CNS components of every participant (patient and PT) is a chance to improve outcomes.


Fair enough. 
quote:


Hi Jason,

SomaSimple is a discussion forum, not a frame of reference/treatment/philosophy.


I understand that.  You're nitpicking.  My point was, and it seems to be realized by Avalon, is that the majority of participants on the SomaSimple boards preach a certain way of treatment/philosopy.  Is there a name for it?  I know you all like to call anyone not 100% enthralled with the thinkings over there "mesodermists", "cavemen", etc.  Are they "ectodermists"?
quote:


Can you give a single argument where AC doesn't involve a single nerve?
It would be hard for you since Pain involve nerves and brain.

Here is the thing.  I seems to me a lot of the "ectodermists" posts are "well, duh, nerves are everywhere; prove that they are not the cause".  The problem is that the burden of proof falls on those making extrodinary claims.  I know nerves carry pain signals, carry the signal to elicit a mm contraction etc.  Just that fact doesn't make it the culprit in NMSK problems 100% of the time for all impairments.  It is a tissue just like muscle and bone.  Excluding the brain, nervous tissue does not have a consciouness of it's own (and I'd exclude the brain in true consciousness, but now I'm imposing my philosophy/theology).  Something (mechanincal, chemical) stimulates it and it fires. 

In my view, what happens with some great insight, is often times this tactic makes you come off like other "therapy extremists" such as Barnes and Upledger.  Their personal epiphanies most be self evident to everyone else, and any direct scientific evidence for their txs is un-needed as it is obviously correct and obviosly cures everyone of every condition.

Now, I don't think that is quit true for the majority of people over at SS, but what is brought to here and how a person with a differing view over at SS is treated, makes it appear to be so.



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