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RE: Shoulder Impingment: Improving External Rotation
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RE: Shoulder Impingment: Improving External Rotation - March 6, 2008 4:10:54 PM
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proud
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Ryan,
quote:
Someone can have a stiff and painful shoulder (ie. capsular restriction) without having adhesive capsulitis.
While this is true, it seems we would have a circular debate you and I about the relevance of the capsular restriction. People do not show up to PT for my "capsular restriction". They show up for pain. As such, we dip into our differential diagnosis skills and come up with our best diagnosis( hopefully as highly sensitive and specific as the litertaure allows). And depending on that diagnosis will determine what should...or should not be done with the capsular restriction. To wit, most 70 year olds will have Ghjt capsular restrictions but not all 70 year olds have shoulder pain. Again, capsular restrictions is a finding, not a diagnosis.
So when you say:
quote:
The original post was concerning RCT with ROM limitations (I assumed they were speaking of capsular limitations)
I would not immediately assume capsular restrictions there. I would look at the timeline. I would look at the movement and determine the irritability of the situation and from there formulate a treatment plan which may or may not include mobilization of the capsular restriction and may or may not include sufficient force as to produce pain.
also:
quote:
On a side note, though, would those pts with a painful RCT be a candidate for painfully aggressive stretching either?
Depends I think. Loss of collagen continuity and associated poor repair with ground substance and fibroblasts can respond to stretching. I believe the Mills stretch for lateral epicondylosis represents just such an example.
Then you asked:
quote:
1. If your mother presented to a clinic with capsular ROM restrictions in her shoulder, considering the current evidence, what would you hope her treatment plan to look like?
Oddly, I pointed out above the flaw with this question. I have yet to have any patient show up for treatment for capsular restriction. They show up for pain. So avoiding a blanket nixing of all things painful....I would hope the PT had the differential diagnosis skills to ascertain the relevance of the capsular restriction and treat the diagnosis. If the diagnosis is RC tendinosis...then let there be pain( ie temporary exacerbation which represents reinvigoration of the remodelling process).
< Message edited by proud -- March 6, 2008 4:21:01 PM >
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RE: Shoulder Impingment: Improving External Rotation - March 6, 2008 8:02:00 PM
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cottonra
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Proud,
I am remembering why I don't participate in these blogs, because it becomes a semantics tete-a-tete versus anything of substance. The discussion has become over the wording of how I stated something vs any evidence contrary to what I presented.
So again I ask(in a more clear, punctual form): If a pt presented with a main c/o shld pain (perhaps secondary to a RCT, impingement) and thru our diligent diff dx, medical screening, and examination process we come to the conclusion that a tight and irritable capsule was the cause of her pain and ROM limitation, how would you increase her ROM and minimize her complaints in order to maximize her functional outcome?
Strengthening aside as another topic, on which we agree.
If you would mob at end ROM and stretch within the contraints of pain, I would have to agree as this is evidence based.
If you would agressively mob and stretch into the patients end ROM to the tolerance of the pts pain level, I would disagree as I feel this would increase their pain level, local inflammation, and does not have a base of evidence to support it.
If you, or Steve, whole-heartedly think this is the best option and get good outcomes with this method, that is great. Then I challenge you to produce some evidence of that fact. I am pretty sure none exists at this point (other than contractile tissue healing models as discussed earlier....BTW, there are plenty of tissue healing models concerning therapeutic US, which over the last 30 years has held no water concerning clinical outcome, but a bunch of rats and frogs have awesome tendon strength).
The more evidence in our literature, the better guidelines we have to our practice. And as new evidence emerges (on a daily, weekly basis) we need to reevaluate what we do daily with our pts. We can not become any better at what we do if we never change.
Ryan Cotton, PT, DHS, OCS
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RE: Shoulder Impingment: Improving External Rotation - March 6, 2008 8:57:50 PM
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kiwi PT
Posts: 60
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From: MI, USA (dreaming of New Zealand)
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quote:
ORIGINAL: cottonra
If you would mob at end ROM and stretch within the contraints of pain, I would have to agree as this is evidence based.
If you would agressively mob and stretch into the patients end ROM to the tolerance of the pts pain level, I would disagree as I feel this would increase their pain level, local inflammation, and does not have a base of evidence to support it.
I apreciate your points, some of this is semantic and some isn't. I really don't think that the "Eyeball Meter" we use to determine what is within constraints of pain and what is to the the pt pain tolerance has been adequetely tested for interrater reliability. Yet I think most of us use such a method (and rightly so), thankfully, as part this is part of why we won't be replaced by machines :). Evidence is of paramount importance, but our handling and ability to detect and discourage guarding in preparation for mobs and stretching is also important, not much research in this area but it doesn't mean its not important just because its difficult to measure.
Ryan please don't get discouraged you have much to add, I hope you become a regular contributor.
Kyle PT
_____________________________
"I have never let my schooling interfere with my education."
Mark Twain
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RE: Shoulder Impingment: Improving External Rotation - March 6, 2008 9:03:25 PM
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proud
Posts: 873
Joined: March 22, 2006
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Ryan,
fair enough. I hope you do not see our discussion as lacking substance. I am not sure why you would. You are correct though, I did have some problems with the semantics within your first post:
quote:
Where in our education did we learn that inflicting this pain during a tx session is OK?
This is a general comment and I took it as a it stood.
As for this question:
quote:
thru our diligent diff dx, medical screening, and examination process we come to the conclusion that a tight and irritable capsule was the cause of her pain and ROM limitation, how would you increase her ROM and minimize her complaints in order to maximize her functional outcome?
Then I agree. No pain please.
But....I have never aside from adhesive capsulitis diagnosed that. In the true spirit of learning....I am curious, how do you come to that conclusion? If I see 10 shoulder patients, I generally get 6 better through what I figure was directly because of my treatment( we keep pretty good statistics where I work with a unique ability to track both the short and long term outcomes). I think that's not bad. Let's say 1/10 of those actually required surgical intervention....then I am missing something in 2/10. Perhaps an irritable capsule is the culprit?
The genohumeral capsule is highly vascularized and as such, it follows that there is a rich supply of nociceptive fibers. So I thinks an irritable capsule is feasible. Can you shed some light on how you might Dx that? Assuming we are NOT talking adhesive capsulitis.
quote:
The more evidence in our literature, the better guidelines we have to our practice. And as new evidence emerges (on a daily, weekly basis) we need to reevaluate what we do daily with our pts. We can not become any better at what we do if we never change.
No question. And I don't think a huge revelation to the regulars here at Rehabedge. Glad to have you posting Ryan as any PT who strives for evidence based, best practice will be a welcome addition.
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RE: Shoulder Impingment: Improving External Rotation - March 6, 2008 10:59:06 PM
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Shill
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From: Madison WI USA
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Good Evening Ryan,
I did not intend to back track, and let me be clear that the pain I allow a patient to go through during the course of a treatment is what they tell me they are willing to go through. Whether this causes them to grit their teeth, raise an eyebrow, or sing yankee doodle, is their choice. I ask them to stop me when they reach their limit, not some preconceived notion that I have of what they should put up with. Its their call. You will note that I have penned earlier that if given the right instruction and education, patients will not let a rational therapist harm them. I stick to that, and hope I have cleared up what I meant earlier. Let me create further clarity by mentioning that I apply this principle to any patient I see with a joint contracture that includes adaptive tissue shortening. I believe that there is confusion as to when I would apply this idea, and in the face of limited active range without tissue shortening, or true passive motion loss, stretching regardless of pain or not would be rather foolish I agree.
Clearer?
_____________________________
Steve Hill PT
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RE: Shoulder Impingment: Improving External Rotation - March 7, 2008 10:17:54 AM
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proud
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Sorry guys. I thought I had a pdf on a really nice study on Mulligan mobilization( MWM) for the shoulder. I think it might be available somewhere on the net but I could not Find it.
Pamela Teys, Leanne Bisset, Bill Vicenzioo; Manual therapy July 2006: The initial effects of a Mulligan's mobilization with movement technique on range of movement and pressue pain threshold in pain-limited shoulders.
Study Conclusion: " The results of this study indicate that the shoulder MWM may be a useful manual therapy technique to apply to participants with a painful limitation of shoulder elevation in order to predominantly gain an initial improvement in ROM and PPT".
If anyone can locate the pdf to post here that would be helpful I think. The article describes the technique.
Regards.
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RE: Shoulder Impingment: Improving External Rotation - March 7, 2008 11:44:10 AM
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ruralPT
Posts: 29
Joined: August 2, 2000
From: Concordia, KS USA
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Here is something that describes the MWM.
http://nzsp.org.nz/Index02/Publications/JournalPDF/31(3)Nov03p140-142.pdf
http://www.youtube.com/watch?v=VllZG2mpXXo
Mobilization Techniques in Subjects With Frozen Shoulder Syndrome: Randomized Multiple-Treatment Trial
Jing-lan Yang, Chein-wei Chang, Shiau-yee Chen, Shwu-Fen Wang and Jiu-jenq Lin
J Yang, PT, MS, is Physical Therapist, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, Taipei, Taiwan
C Chang, MD, is Professor, Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital
S Chen, PT, MS, is Physical Therapist, Department of Internal Medicine, Taipei Medical University–Municipal Wan Fang Hospital, Taipei, Taiwan
SF Wang, PT, PhD, is Associate Professor, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University
J Lin, PT, PhD, is Lecturer, School and Graduate Institute of Physical Therapy, College of Medicine, National Taiwan University, Floor 3, No. 17, Xuzhou Rd, Zhongzheng District, Taipei City 100, Taiwan
Address all correspondence to Dr Lin at: lxjst@ha.mc.ntu.edu.tw
Background and Purpose: The purpose of this study was to compare the use of 3 mobilization techniques—end-range mobilization (ERM), mid-range mobilization (MRM), and mobilization with movement (MWM)—in the management of subjects with frozen shoulder syndrome (FSS).
Subjects: Twenty-eight subjects with FSS were recruited.
Methods: A multiple-treatment trial on 2 groups (A-B-A-C and A-C-A-B, where A=MRM, B=ERM, and C=MWM) was carried out. The duration of each treatment was 3 weeks, for a total of 12 weeks. Outcome measures included the functional score and shoulder kinematics.
Results: Overall, subjects in both groups improved over the 12 weeks. Statistically significant improvements were found in ERM and MWM. Additionally, MWM corrected scapulohumeral rhythm significantly better than ERM did.
Discussion and Conclusion: In subjects with FSS, ERM and MWM were more effective than MRM in increasing mobility and functional ability. Movement strategies in terms of scapulohumeral rhythm improved after 3 weeks of MWM.
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RE: Shoulder Impingment: Improving External Rotation - March 7, 2008 10:16:07 PM
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proud
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To Ryan,
I sent along a PM but it does not show up in my "sent" items so I wonder if you recieved it?
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RE: Shoulder Impingment: Improving External Rotation - March 8, 2008 9:28:45 AM
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KAK
Posts: 200
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Treating shoulders is one of my passions which is probably why I took the “rotator schomater” post by Chocco so
%#@! seriously. Jason, I’m sure my gullibility makes you look exceedingly discerning. My family has a lot of fun with it!
I have an observation and a few questions around the painful resistive topic which has arisen from the original topic of gaining ER. For years, I have used eccentric exercises with my rotator cuffs and in general (avoiding a blanket statement) I have actually found these to be less painful then concentric when working ER. My questions are:
1. Clinically, how does one (in the context of the shoulder population defined by Vagus) “degenerative RTC tears and shoulder impingement cases”, differentiate between an itis and an osis?
2. How does the close communication of the capsule, cuff and bursa complicate matters (i.e. tendonosis combined with an “itis” of the bursa or a tear in the rotator interval)?
3. Are there histological differences between an “overuse” tendonopathy and changes in the tendon from direct mechanical compression (either internal or external impingement)?
4. Can we extrapolate that painful load bearing eccentric exercises found beneficial for tendonopathy of the Achilles are appropriate for tendons at the shoulder which have more of a stabilizing function at the shoulder?
< Message edited by KAK -- March 8, 2008 9:32:43 AM >
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RE: Shoulder Impingment: Improving External Rotation - March 11, 2008 9:11:33 PM
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proud
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Not sure why no one has taken a stab at this KAK.
All great questions.
If I get some time in the next couple of days, I will give my thoughts on the questions.
Regards.
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RE: Shoulder Impingment: Improving External Rotation - March 11, 2008 10:44:12 PM
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TexasOrtho
Posts: 423
Joined: December 22, 2007
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quote:
I have an observation and a few questions around the painful resistive topic which has arisen from the original topic of gaining ER. For years, I have used eccentric exercises with my rotator cuffs and in general (avoiding a blanket statement) I have actually found these to be less painful then concentric when working ER. My questions are:
1. Clinically, how does one (in the context of the shoulder population defined by Vagus) “degenerative RTC tears and shoulder impingement cases”, differentiate between an itis and an osis?
I think history plays a big role here. Age, mechanism of onset, patterns of activity, irritiblity etc...I have found anecdotally tedonitis to be the cause of highly irritable shoulder pain and suggestive of chemical irritation (constant pain regardless of position). I manage these case much like I would an acute inflammatory response. Tendonoses on the other hand (again my observations) are more difficult to irritate, often after prolonged activity. Resisted testing can also be beneficial in discriminating.
quote:
2. How does the close communication of the capsule, cuff and bursa complicate matters (i.e. tendonosis combined with an “itis” of the bursa or a tear in the rotator interval)?
History and inspection again helps me a bit. If the patient carries their arm splinted at the side as if in a sling, they are often protecting against tensioning of the cuff/superior capsule. If they experience relief with their arm in a pendulum position I begin to build suspicion of a bursitis vs tendonitis. Clinically, there is a "pull test" where resisted abduction is tested with axial traction applied through the shoulder that is ostensibly designed to differentiate between bursal vs tendonopathy. I need to look more into the spec/sens of that test however.
quote:
3. Are there histological differences between an “overuse” tendonopathy and changes in the tendon from direct mechanical compression (either internal or external impingement)?
I have to think due to the nature of the different pathologies that there must be some histological differences as well. One is likely more a tension event vs a compression event that I would imagine there would be some significant changes on histology. I am purely speculating.
quote:
4. Can we extrapolate that painful load bearing eccentric exercises found beneficial for tendonopathy of the Achilles are appropriate for tendons at the shoulder which have more of a stabilizing function at the shoulder?
We can...and I do. You see similar literature in treating medial and lateral epicondyloses. I think I even recal seeing a few investigations on eccentric training for shoulder tendonosis as well. Great questions.
_____________________________
Rod Henderson, PT
Board Certified Orthopedic Specialist (or Super-Freak)
Certified Strength and Conditioning Specialist
www.texasorthopedics.blogspot.com
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RE: Shoulder Impingment: Improving External Rotation - March 13, 2008 8:31:28 AM
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Shill
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From: Madison WI USA
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As an aside regarding extrapolation and application to other areas, I have experimented with myself on eccentric exercises for the lumbar spine (extensors, quadratus, and likely multifidi based on need to control rotation), and much to my surprise and delight, I have had quite nice results.
I did this by simply doing only the eccentric portion of a roman chair exercise. Feet supported, hold isometric and lower self down, then, use a chair placed in front of me to pull myself back up with my arms (climb back to neutral).
Again, its just what I did, not very meaningful or scientific, but for the first time in years I dont have morning pain.......wait, this is where I am supposed to copyright my own approach, right?.......
_____________________________
Steve Hill PT
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RE: Shoulder Impingment: Improving External Rotation - March 13, 2008 10:40:30 AM
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KAK
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Right Steve! I’ll be watching the mail for the brochure advertising your course!
Interesting …Along the same line-I read a study; though I don’t have the reference here at home with me, about quadruped leg lifts for multifidi strengthening. It was found that an isometric hold and slow eccentric lowering was necessary to increase multifidi cross section.
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RE: Shoulder Impingment: Improving External Rotation - August 25, 2008 8:45:54 PM
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mmr-pt-atc
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I know I'm jumping in late on this one but I have a general rule as to when I push through pain:
If they have an empty or spasm end feel with guarding then I consider that there is still an inflammatory reaction within the capsule or other soft tissue. I will not push through this discomfort but rather resort to continue to break the pain/spasm cycle, work soft tissue, and perform gentle stretching and Grade I-II joint mobs for pain modulation.
If they have a firm end feel with loss of motion, then crank away, unless of course you feel a bony end feel from DJD. Just dont go to fast too soon or you'll regress back to spasm.
_____________________________
******
Visit my rehab blog at http://mikereinold.com
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