RE: Information Exchange: Adhesive Capsulitis (Full Version)

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bobmfrptx -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 9:00:20 AM)

Adhesive Capsulitis I agree can be applied to several "causes" of the painful less mobile shoulder.  The number one factor in returning function to me is to gain the trust of the patient and to do this you must :
1. Approach them like a scared rabbit.
2. Give them the stop button at any time.
3. Work within their available pain tolerant ROM.

I guess this treats the "brain".
I usually begin work in sitting if they can allow the arm to dangle straight to the floor.  If this is not the case I treat in supine with trunk elevated to an angle which is the most comfortable and the arm in anatomical position.
I always use MFR stretches to the neck and trapezius region to abolish the protective elevation found in most of these cases. This is followed by pectoral releases to gain ER and also quiet the protective position.  Next a longitudanal release with one hand on the ant deltoid and the other beginning on the biceps to aid in distraction from the GH joint.  I work in the pain tolerant, (i.e. no bracing,  not  no protesting,) range and have the client concentrate on breathing as well as visualization of the arm growing longer during this processs.
This treats the mesoderm as well as the nervous system, I guess.  Some will argue that the changes felt are all strictly NS, so be it.
Next, I have the patient keep visualizing elongation while actively trying to initiate shoulder flexion.  Keep movement to a minimum and watch for the associated protective contractions so the patient can become aware of this.  Without awareness there is no change.
When they can initiate movement without protection, have them raise the arm while elongating until slight pain is felt.  Repeat this several times.  They always gain more motion and confidence.
When they can lift to 45 or 50 degrees, place them in sidelying and  I have them practice the flexion with elongation while I do a lateral release of the medial scapula.    In the majority of the cases AROM continues to improve.  After 3 to 4 minutes of this have them go prone and dangle the arm over the edge of the plinth.  Most do actually get to 90 degrees.  I then release the scapula further in all directions and the triceps. 
Traditional pendulum clockwise countercw motions follow this.  If they have trouble and lift the scapula I place a ball under their finger tips so they can just reach it and have them roll the ball. this emphasizes elongation. 
That usually ends the first session.  I try to have them do the flexion/elongation exercise at home. Sometimes this means lying prone on the kitchen or picnic table. I also give them a pulley and have them do reciprocal arm swings  in the available painfree range for 5 minutes 3 times daily.  The entire first session lasts one hour and costs 50 dollars. I am a one man private practice office so I can do this.
Next session we try to progress to the prone exercises quickly . During this session I do arm pulls while prone and let the arm unwind.

I do use oscillatory mobs to the GH at times.  As well as US to the axilla. I did have one case years ago in my HVSA days return to full function after the use of the "kirkville crunch" thoracic manipulation.  So some anecdotal support for thoracic manip albeit slight. one case out of 1000?  I developed this approach after my first outpatient PT job where my boss literally treated all frozen shoulder patients in a walkin safe with the door closed and violently forced them in to ROM.  Surprisingly,  alot of patients did better. Not suprisingly, we had torn cuffs, 2 fractures and alot of no shows.  I didn't take to this approach well at all.

I'll let you digest this long winded post and add more later. Let me know which tissues I am treating? 

My 2 cents.
Bob



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 1:45:46 PM)

 
SJ, this is a bit convoluted (sorry Rod). First you say that according to "SS classification" the person has to have persistent pain without pathology. Obviously your lady patient DOES NOT fit this classification, because you are convinced that she has pathology. You are presenting a pt outside the classification, and then criticise the neuroreflexive or neurodermal approach to this type of patient.....

" 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? "

The above quote is equally valid to pose to yourself: if the answer is that no-one and/or no test can be 100% positive of the presence of pathology at all times, well then that applies to all PTs - and all techniques and approaches of treatment. If the answers are positive, well, then it means that ALL PTs are able to detect pathology reliably, and make treatment choices based on that. Thus far, your above questions have not made a great contribution to help to distinguishing between "SS"-ers and others......




Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 1:52:21 PM)

Bob, I have trouble with the "scapular release" (especially only medial scapula); in all my real CA patients, the scapulo-thoracic complex is already hypermobile to a great degree. "Releasing"  this further does not make a lot of sense to me.



bobmfrptx -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 2:00:50 PM)

In my experience, the patients hold the scapula rigid while trying to actively flex the shoulder.  Doing the medial release while performing the movement seems to increase humeral/scapular control and ratio. I do release in all directions...read further down the post. 
Hope this helps.
bob



TexasOrtho -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 2:12:58 PM)

Sebastian. Apology accepted...for what I have no idea.



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 5:18:16 PM)

Bob, I did read the whole post - it was the scapula release that drew my attention.....
And your experience is vastly different that in the clinics I have worked at - with adhesive capsulitis, scapulo-thoracic ROM would increase to accomodate GH limitations.....And I seem to remember reading studies with that info (I'll check).



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 5:52:30 PM)

Here it is:

Three-dimensional scapular kinematics and scapulohumeral rhythm in patients with glenohumeral osteoarthritis or frozen shoulder.
Fayad F, Roby-Brami A, Yazbeck C, Hanneton S, Lefevre-Colau MM, Gautheron V, Poiraudeau S, Revel M.
Department of Physical Medicine and Rehabilitation, Cochin Hospital (AP-HP), Paris Descartes University, 27 Rue du Faubourg Saint Jacques, 75679 Paris Cedex 14, France; Laboratoire de Neurophysique et Physiologie du système moteur, Paris Descartes University, CNRS UMR 81 19, 45 rue des Saints Pères, 75006 Paris, France.
We aimed to describe 3D scapular kinematics and scapulohumeral rhythm (SHR) in glenohumeral (GH) osteoarthritis shoulders compared to unaffected shoulders and to compare the abnormal scapular kinematic schema for GH osteoarthritis with that for frozen shoulder. Thirty-two patients with stiff shoulder (16 with GH osteoarthritis and 16 with frozen shoulder) performed maximal arm elevation in two planes, sagittal and frontal. Scapular rotations and humeral elevation of the affected and unaffected shoulders were measured by the Polhemus Fastrak electromagnetic system. Patients with GH osteoarthritis were older, had longer disease duration (p<0.001) and less restricted humeral elevation in the frontal plane (p=0.01). Protraction was significantly lower for the affected shoulders except for arm elevation in the frontal plane in the GH osteoarthritis group. Furthermore, protraction was lower with frozen shoulder than GH osteoarthritis during arm elevation in the frontal plane. Scapular lateral rotation and SHR were significantly higher for the affected shoulders in both groups whatever the plane of elevation. SHR showed a fair to moderate negative correlation with maximal humeral elevation in both groups and appears to be higher with frozen shoulder than GH osteoarthritis. In addition, SHR of the affected shoulder showed a fair to moderate correlation with disease duration only with GH osteoarthritis. Scapular tilt did not differ between affected and unaffected sides and was not influenced by type of disease. In conclusion, the increased scapular lateral rotation described in frozen shoulder is also observed in GH osteoarthritis. SHR of the affected shoulder is inversely related to severity of limitation of shoulder range of motion, which suggests a compensatory pattern.
PMID: 17949728 [PubMed - as supplied by publisher]

(my bold)



bobmfrptx -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 9:37:32 PM)

"I then release the scapula further in all directions and the triceps. "

The clients I see, I have 2 right now, both hold the serratus anterior and when asked to flex the arm , elevate the scapula with levator scap and upper trapezius.  The medial border did wing slightly in one.  When I treat these conditions I am trying to mimic normal motion in painfree range.
As for the study, if lateral rotation is the inferior angle moving away from the spine, then I agree that is a compensatory motion seen with holding of serratus anterior.




SJBird55 -> RE: Information Exchange: Adhesive Capsulitis (February 25, 2008 11:03:28 PM)

Sebastian, all I'm saying is that over at SS there is no clear cut definition of "undetectable pathology."  Undetectable by who or what means?  Sebastian, you yourself listed all the medical diagnostic tests that could be negative.  This patient had all negative diagnostic medical tests prior to beginning physical therapy services.  The physicians are all booting because everything is coming up negative.  Since everything is coming up negative, those over at SS would advocate persistent pain (ongoing since June 2007) and undetectable pathology = skin stretching or simple contact or whatever gentle manual approach.  What I am trying to convey is that just because every medical diagnostic test is negative does not mean that physical therapists should immediately assume and immediately jump to clinical conclusions and believe that skin stretching or simple contact will be effective.  I believe my whole disagreement with the clinical reasoning process was due to something Jon N. wrote... but I don't recall. 



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 2:12:06 AM)

SJ,

The problem will remain unsolved for you.
You're focused on "true" image of pathology and can't accept dysfunctions.
That's why no communication will occur.
BTW, I didn't said a word about Simple Contact but was oriented on these concepts
http://www.somasimple.com/forums/forumdisplay.php?f=75
http://www.somasimple.com/forums/forumdisplay.php?f=74



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 2:39:48 AM)

quote:

I believe my whole disagreement with the clinical reasoning process was due to something Jon N. wrote... but I don't recall.


We know...
quote:

I don't believe I have issues with my thought processes, but I could be delusional.



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 8:03:31 AM)

Bob, the article states clearly that scapulo-humeral rhythm is inversely related to the severity of the GH limitations. It means the scapula has an INCREASED range of motion that is larger as the GH ROM is less. I honestly think your grasp of the arthrokinematics of true CA is not up to speed here.  (And remember, I am NOT saying your hands-on approach doesn't work, so it is not necessary to say that most of your patients benefit; it seems obvious that the benefit is not from "releasing" something, since that is already very, very mobile...)



Shill -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 1:50:12 PM)

I too struggle with the term "release", and always have.  What is being released?  If one has a cage full of pigeons, and opens the doors, the pigeons fly out, and are "released" and now gone, free to scatter droppings amongst the world.  Count birds in cage, come up with zero = objective evidence of a release.  How does one know when things are "released" in PT Land?

Avalon.  If you were to reflect upon your posts towards SJ, and ask yourself  "Who am I helping with this post?", what would be your answer?



TLB -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 2:45:48 PM)

quote:

ORIGINAL: bobmfrptx

"I then release the scapula further in all directions and the triceps. "

The clients I see, I have 2 right now, both hold the serratus anterior and when asked to flex the arm , elevate the scapula with levator scap and upper trapezius.  The medial border did wing slightly in one.  When I treat these conditions I am trying to mimic normal motion in painfree range.
As for the study, if lateral rotation is the inferior angle moving away from the spine, then I agree that is a compensatory motion seen with holding of serratus anterior.




Bob,

Curious as to what a MFR release may be and is it related to the mfr in your screen name. 



bobmfrptx -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 5:34:40 PM)

quote:

ORIGINAL: Sebastian Asselbergs

Bob, the article states clearly that scapulo-humeral rhythm is inversely related to the severity of the GH limitations. It means the scapula has an INCREASED range of motion that is larger as the GH ROM is less......... "releasing" something, since that is already very, very mobile...)


Bas,
The scapula is abnormally moving, correct. Subscapularis and serratus anterior tightness, perhaps.  Releasing medially goes in the direction of ease.  A JFB MFR concept. This is like openning the control panel on your TV. Push in it pops open....Compressing the attachments on the inferior and lateral scapula helps them let go.
A demo would probably help, typing the movement is tough for me.  Hope this helps.  Thanks for not doubting the effectiveness .  The exact pathology of AC is not really known is it?  Once I had complete restoration of movement with a release of a tricep trigger point. Each case is different and handled accordingly.  My example is my usual and customary approach however.



buckeye -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 5:59:03 PM)

The bout will be a draw because both sides are firm on their convictions. Maybe the gloves can come off and we can recapture this thread.

Let's see - the title is "Information Exchange: Adhesive Capuslitis." I will grant there is information being tossed around, but I think the content is drifting away from AC. Can you all offer information related to the AC topic - instead of sparring about treatment philosophies?



Sebastian Asselbergs -> RE: Information Exchange: Adhesive Capsulitis (February 26, 2008 7:12:19 PM)

OK Buckeye. "Information" excludes treatment "philosophies"?  Please let us all know next time before the thread develops exactly WHAT is understood to be acceptable "information".....
I promise I will leave the whole "release" issue alone now. It really is dead. (I mean, how can you go from increased scapular ROM to TIGHT serratus?!?)



avalon -> RE: Information Exchange: Adhesive Capsulitis (February 27, 2008 1:59:23 AM)

quote:

Avalon. If you were to reflect upon your posts towards SJ, and ask yourself "Who am I helping with this post?", what would be your answer?


Simple: The PT community.



Shill -> RE: Information Exchange: Adhesive Capsulitis (February 27, 2008 9:28:18 AM)

Right.....I could comment further, but that would only be doing what the ad hominem arguments (not just yours) have been doing.  Not helping.  Let me just briefly review how one effectively communicates.  He or she takes ownership of the problem he or she has with others' ideas. 

Its not playground politics like "yeah but", or "I know you are but what am I".  Sure, it might feel good to stick in a barb here and there, but really, other than stroking one's own ego, what does that accomplish?



buckeye -> RE: Information Exchange: Adhesive Capsulitis (February 27, 2008 9:52:03 AM)

Sebastion - I just thought the thread was supposed to be about adhesive capsulitis. Sure treatment philosophies can be information in the exchange - but it is still possible to stay on track with the AC topic and remain professional and respectful.



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