RE: Information Exchange: Adhesive Capsulitis (Full Version)

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Jon Newman -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 3:46:09 PM)

quote:

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 may be nitpicking but it isn't just for fun.  You created a thought experiment based on the point I was nitpicking. 

Those that choose to particpate at SomaSimple define the majority.  There is an energy medicine proponent, a DNM proponent, a Simple Contact teacher, an osteopath or two and maybe even a chiropractor, etc.  As Rod has pointed out, we have an ecclectic group.  If there is a frame of reference that is often employed in trying to understand what we observe in the clinic and read in journals it is something akin to the biopsychosocial model or the mature organism model.



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 4:28:06 PM)

quote:

Those that choose to particpate at SomaSimple define the majority.  There is an energy medicine proponent, a DNM proponent, a Simple Contact teacher, an osteopath or two and maybe even a chiropractor, etc.  As Rod has pointed out, we have an ecclectic group.  If there is a frame of reference that is often employed in trying to understand what we observe in the clinic and read in journals it is something akin to the biopsychosocial model or the mature organism model.


I'm not sure they "define" the majority Jon.  I think it is quite the diverse group over there, but the opinions are certainly not representative of many therapists I see in the field.  The tone does get pretty dogmatic at times with little room for an alternative explanation to unproven phenomenon. 

Although the somasimple folks make some very strong cases for the relationships between pain and function, the lack of williness to even slightly acknowledge a "mesodermal" contribution will quickly place them in the same category as the Barnes and Palmers of the world.  This was my reason for wanting to modify one of the rules on pain (old #9 [:)]).  I hope I can learn some good things over there, and share my perspective without getting ridiculed for my "orthopedic" approach.



Jon Newman -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 4:48:12 PM)

quote:

I'm not sure they "define" the majority Jon.  I think it is quite the diverse group over there, but the opinions are certainly not representative of many therapists I see in the field.


I'm not saying that those that currently participate represent the majority opinion.

quote:

Although the somasimple folks make some very strong cases for the relationships between pain and function, the lack of williness to even slightly acknowledge a "mesodermal" contribution will quickly place them in the same category as the Barnes and Palmers of the world.


I personally invited you to create a "10 steps to understadning manual and movement therapies on tissue architecture."  I wouldn't exactly call that a lack of willingness. 

quote:

I hope I can learn some good things over there, and share my perspective without getting ridiculed for my "orthopedic" approach.


I can't guarantee anyone's ideas will be free from ridcule but we try hard to make sure people are not the targets. 



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 5:14:56 PM)

Jon.  You invited me to offer my thoughts and YOU were the only one who addressed my revisions.  No one has been rude (other than the back-handed name calling), but you have to admit there is a general bias toward this neuroreflexive approach that simply hasn't been effectively examined in a clinical setting.

I am looking forward to more interactions but the first conversation, while interesting and engaging, was a little like banging my head against concrete with a few folks. (not you! [;)])



Jon Newman -> RE: Information Exchange: Adhesive Capsulitis (February 23, 2008 9:46:44 PM)

Hi Rod,

I wouldn't take it personally. I guess my point before is that SomaSimple is a discussion forum like Rehab Edge. We are not, believe it or not, the Borg. People might have simply forgotten about or lost interest in the thread, figured that repeating something that's already been said wasn't worth their time, were waiting to see how things unfold, etc, not to mention the usual read and don't write folks.

When you say "this neuroreflexive" approach, to what are you referring? The context of the phrase is with reference to manual and movement therapies for pain, both of which have certainly been demonstrated to be effective in the clinical setting.



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 12:16:27 AM)

Hey Rod. There is NO neuroreflexive "approach" - there is a lot of attention given to exploring the absolutely fascinating world of the nervous system, including brain, and the person using that brain and  the neuroimmunology....  Without these, there is simply no...pain..and no problem. 
No specific approach; one uses mostly skin techniques, another includes a little ortho-type manipulation, yet another uses tons of education as the first interaction with the patient....But a common factor is the acknowledgement that all that we do and all that the patient perceives and experiences, is through neural interaction-at all levels.





SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 8:57:54 AM)

Neural interaction is always a component.  The problem is that a variety of components all have an impact on the neural component.  Olecranon bursitis hurts - apparently it hurts a lot.  Well... if the bursitis aspect is treated and reduced (you can see it and it is very, very obvious), the pain diminishes and goes away.  The nerve was communicating there was a problem; the nerve is what was irritated; intervention directed to the nerve just isn't going to cut it.  The problem with the thought processes of the majority of those who post at SS are overly focused on the nervous system as THE solution. 

When it comes to adhesive capsulitis, I do believe there are patients who have more of a neurological component to their complaint versus a true tissue tightness shrink wrapped upon itself issue.  There is already research suggesting that thoracic manipulation can be beneficial for some patients with shoulder complaints - why would that be?  That would have to be due to the neurophysiological response to thoracic manipulation. 

Every patient that walks through the doors has a neurological system that is reporting something or another to their brain and their brain is interpreting it.  Common sense is what is needed though - to automatically believe that addressing the nervous system manually is the answer is wrong.  Addressing the central nervous system directly via education is always, always an excellent idea.  When it comes to the light touch interventions suggested by many over at SS, without a clearly defined patient population, one needs to be careful until research suggests these folks are correct.

I do believe that overall, those at SS have a good grasp on pain.  I just believe they may be missing the boat on interventions to assist in alleviating pain because of the blinders that they wear.



Jon Newman -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 9:41:39 AM)

quote:

The problem with the thought processes of the majority of those who post at SS are overly focused on the nervous system as THE solution.--Sj


Sj, allow me to help you with the problem with your own thought process.  You seem to think you understand the thought process of the majority of people who post at SS but you're mistaken.  You conveniently ignore quite a bit of past conversation and focus on those conversations that serve your purposes.  It's annoying and I hope you stop it.

For those with no detectable pathology, clinical reasoning suggests we focus on the nervous system.  Where some confusion arises is that pain is a nervous system process and is thus a logically distinct category from non-nervous tissue (the mesoderm if you will) thus explaining why there are people with bursitis who don't hurt and people with no bursitis who hurt as if they have a bursitis.  As you pointed out SJ, it is only when the nervous system has acheived a certain state that the pain experience changes.  That may or may not coincide with the state of the non-nervous system (mesoderm is so much easier to say). 

Rod, you'll notice that a change has been made to point #9 on our 10 steps list.  Credit for the wording should be given to Luke R. who understands pain much better than Sj would have you believe.

Dave A., I will be posting a recipricol link to this thread.



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 9:51:25 AM)

SJ, of course we are NOT talking here about a broken leg or so.....
Jon's  " For those with no detectable pathology" is a good departure point. And when you really look at persistent problems like AC, paying close attention to the nervous system is essential.
And any manual intervention is "addressing the nervous system" - which starts as soon as the PT enters the room. The brain is never "off" in any interaction, and education of the patient is essential - through propriocepsis, experiencing relief, listening to the words of the PT, etc. etc. Manual care is a multi-level interaction with the patient's whole nervous system.



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 10:43:43 AM)

Jon, I said that there is a definite understanding of pain at SS.  The problem is in the application of that knowledge, in my opinion.  I don't believe I have issues with my thought processes, but I could be delusional.  To change gears and look at manual intervention - one of the types of interventions advocated by those at SS (simple contact)- the only published study out there that focuses on simple contact was an SSRD.  The results of that SSRD indicated a definite change in the outcomes measured after education alone.  The manual aspect did not have any strong indication that change in measured outcomes were due to the simple contact intervention.  When critically looking at that study, the findings are in align with Moseley's findings on education and persistent low back pain.

There are cases out there where supposedly there isn't any pathology, but reality is that pathology is present.  It is just a situation that sometimes patients aren't allowed the "gold standard" procedure to determine the pathology because the "gold standard" to determine pathology is invasive.  I have a patient who continues to have shoulder girdle pain post trauma (since June 2007).  Every medical diagnostic test has been negative.  I can assure you that no manual intervention is going to assist this patient with chronic shoulder pain.  I think we do have to be careful in assuming that a strong focus that mainly addresses the nervous system in persistent pain conditions will be effective.  There needs to be a very clear definition of the population that will respond, to what degree the response will occur, and in what time frame the response will occur.



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 11:06:57 AM)

SJ, this is confusing. How the "pathology" is present when no evidence of pathology can be found is not clear. Am I to understand that, despite the best efforts to detect a pathology, nothing is found? And that you somehow "know" that there is pathology?

And furthermore, you can "assure" us that manual intervention won't help your patient?

So far, I am only "assuming" (your words) that the nervous sytem is heavily involved in your patient example; yet, you are "assuring" with confidence, but without any basis.....  SJ, I can assure you that at no time will I forget, ignore or discard other systems; I am certain that mybest interventions will be those that acknowledge the role of the nervous system to the max.

(BTW, wasn't the SSRD on simple contact not about the neck?? Mosely's bit on education related to the lower back....Are you saying that that study is applicable to every condition? Then you actually support the notion that the nervous system - brain - is the key player....)



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 11:08:52 AM)

...furthermore:
"There needs to be a very clear definition of the population that will respond, to what degree the response will occur, and in what time frame the response will occur."

How would your lady patient fit the above criteria? What category would she be in?



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 11:48:07 AM)

Sebastian... yep, Moseley's study was with the low back.  Yes, education showed changes with fMRI.  Yes, the SSRD had a subject with cervical pain.  No fMRI was performed, but a substantial change in the measurements taken occurred right after the educational aspect.  Seems to be enough to suggest that education has a large role in centralized changes (as indicated by Moseley) and potentially functional changes (as indicated in the SSRD).  From my experience, I would agree with both findings.  There have been times that I have done nothing but talk and educate and functional and pain changes are recorded at the next physical therapy session.

Well, if someone has pain, that means the nervous system is involved, right?  This person has had unresolved pain since June 2007, therefore the nervous system is involved, right?  Jon suggested that those with undetectable pathology by clinical reasoning alone the nervous system is the focus.  I am disagreeing.  I believe there are times that someone can be in pain (and I agree that the nervous system is the one determining there is pain), but I don't believe that the nervous system should automatically be addressed with the assumption symptoms will resolve.  At the same time, I am suggesting that there will be cases in which medical diagnostic tests will be wrong and will not indicate pathology.  Basing clinical reasoning on the sole fact that there is undetectable pathology may not be sound clinical reasoning. 

With this particular patient in which I described, I am assuming there is pathology.  I am very motivated to assist in determining the underlying factor.  I do not believe that any intervention directed toward the nervous system will result in a favorable outcome.  Instead of taking the stance that some might, based on the length of time pain has been occurring, that the nervous system is at fault and gentle manual therapy is advised, I am instead searching for an answer.  My answer is indicating a subscapularis tear... possible labral tear... and possible anterior shoulder instability.  All medical diagnostic tests are negative though, so it will be difficult for me to present my theory to the physicians/surgeon.  So, in my opinion, I believe that other tissues and their issues need to be resolved to quiet a nervous system that is screaming pain, pain, pain. 

The only criteria I have ever seen mentioned by those that fully believe in gentle manual therapy approaches is persistent pain and undetectable pathology.  So, this patient falls into both of those categories. 



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 12:01:23 PM)

SJ, undetectable means undetectable. Clear MRIs, CTscans, echograms, lab tests etc etc. According to you, this lady HAS pathology. Falls outside the category....



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 12:46:40 PM)

The established medical diagnostic tests indicate no pathology.  If we are to trust the MRI, CT, echo, lab tests... then this patient has no detectable pathology.  In this particular situation, I am taking the stance that the medical diagnostic tests are wrong and are not detecting pathology.  Based on what I have read over at SS, since this person has persistent pain and no detectable pathology (everything is negative), thus, my clinical reasoning should leave me performing some skin stretching or simple contact to alleviate the symptoms.  I'm just making the argument that there are and will be cases that there can be no detectable pathology but there is pathology (or I should say I believe there is pathology based on provocation tests -yikes another SS no no) - pathology that needs to be addressed before the nervous system to assist in alleviating the symptoms.



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 24, 2008 12:49:43 PM)

This thread has hit a bit of a tangent as it pertained originally to the discussion of adhesive capsulitis.  If we continue along this path, I might recommend a new thread.  One final point on the neuroreflexive approach I mentioned earlier.  I used that nomenclature for lack of a better word.  The folks on SS typically refer to the "mesodermal" approach as if it is a unified theory of treatment.  I simply fell into the same generalization in the opposite direction...definitely a mistake.

I think most reasonable arguments for/against specific methods of treatment have been articulated ad nauseum and we may be at the point where we simply agree to disagree.  Further discussion of treatment approaches might be better discussed in a new thread. 

My 2 pesos.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 2:08:06 AM)

quote:

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.

1/ Nerves do not carry pain signal. Nociception is not pain.
2/ It is not a tissue just like muscle and bone. It is an excitable tissue and its excitation is variable.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 2:27:28 AM)

quote:

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.


SJ,

That is quite Inquisition but coming from you it is just a way to answer when you have not a clear argument.
BTW, this kind of "article treatment" may be applied to each paper that is printed => It just means that none will get a piece of interest at your eyes.



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 2:39:12 AM)

quote:

There are cases out there where supposedly there isn't any pathology, but reality is that pathology is present.


Hmm a flagrant semantic contradiction there. To be or not be, that is a nerve question.Take my amputee example : He is a pain sufferrer but has no limb then he is a lier or has a mental disorder, right?



SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 7:51:10 AM)

Avalon.. an intra-articular injection basically reduces inflammation within the joint, right?  The tissues may be inflamed, right?  But... obviously, tissues don't talk, right?  So, technically, an injection in the intra-articular joint is truly aimed at reducing the chemicals of irritation which reduces the capability for those substances to create an action potential to send a message to the brain to be interpreted as pain, right?  In a backward way, intra-articular injections are also quieting nerves.

So... the study was attempting to figure out where the irritation may be located, in my opinion.  I would like to think that many of us are aware of placebo.  Anything can be a placebo - it all depends on how a patient perceives whatever is being done and it probably also depends on the communication/explanation that occurred prior to what is being done.  If we can agree on that, then reality is that it would probably be a good idea to introduce a sham intra-articular injection... a sham suprascapular nerve block and probably a control.  The way the study you shared is presented creates the assumption that the suprascapular nerve might be more relevant in adhesive capsulitis than the joint itself.  We don't really know though... the possibility of placebo wasn't considered or taken into account by not performing sham treatments.

I have a clear argument, maybe, Avalon, you don't have a clear undertanding of what I am communicating.

Avalon, no... I did not have a contradictory statement.  How is it to be determined that no pathology is present?  What tests or measures are used to determine no pathology?  How sensitive and specific are those tests and measures? 

Avalon, I believe years ago that I questioned the relevancy of using peripheral nerves to reduce pain (disagreeing with the theory of simple contact) and I used the example of a person without a limb who has pain.  Ask Dorko... he was the one I was debating.



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