neck vs. shoulder (Full Version)

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sslevins -> neck vs. shoulder (May 20, 2008 10:54:28 PM)

Good evening all,
I have a patient who was originally referred a few months s/p subacromial decompresion for shoulder pain. After the surgery she continued to do terrible with c/o terrible pain on any active elevation.
Eventually she went to a new ortho- a guy I referred her to because he is a great shoulder guy. He kept treating conservatively x 6 weeks with abosolutely no gains. His diagnosis was adhesive cap or shoulder inflammation (ie: I don't know) He eventually agreed with the patient to do an exploratory scope and debridement. Nothing major was found in the scope except for a little spur on the subacromial surface. I know it looked pretty good because I sat in on the surgery and saw it with my own two eyes. No RTC tear, some inflammation of the glenoid and a small spur . He cleaned it up and referred her back for ROM- stating "I'm not impressed with her pathology". We all agree that the symptoms and intensity of pain exhibited are far out of line with the pathology but even though she is a workers comp case I don't think she is faking. She still is working- just at lighter duty, and she seems genuine.
Her ROM is now better (can get 100 degrees elevation with pulleys) but severe pain with elevation persists.
I started thinking neck (I can hear Ginger already) and she does have severe pain with any even short range ULTT (neural tension tests) and replication of pain with some head movements - especially rotation/ SB away from shoulder.
I am at a los for what kind of testing I should do to confirm cervical involvement / neural involvement before I go to the doc with this theory.
Becuse the pain was in a C4 distribution I did some gentle PA mobs to C4 and I introduced the beginning of neural sliders for the arm- wrist ext and slight elb ext with ER of arm- but she can not go far at all.

Do you think I am on the right track? Her shoulder may have looked good because there was not significant pathology ever there.

Steve



ginger -> RE: neck vs. shoulder (May 21, 2008 5:02:02 AM)

You are on the right track steve. suggest AP mobs at C4 and C5. Not because this is a better method overall than Pa's , but because it is the most likely to both reproduce pain in the shoulder ( as a means to confirm the cx as the origin of her pain, and to relieve this referred pain  also. Pa's are less painfull and better tolerated . So ought to be the method used for most of the work required . Your task then ,is to restore normal pain free passive movements ( with mobs ) to C4 and C5. Clearly the search for" pathology", is a way to remain confused.
All the best, love to hear further reports after mobs to CX. Twenty minutes of CM should remove more than 50 percent of her pain as well as restore significant ROM of the shoulder.



buckeye -> RE: neck vs. shoulder (May 21, 2008 11:39:56 AM)

I think any testing that changes the pain without changing the position or the shoulder should help confirm your 'diagnosis' - ULTT, cervical mobility, cervical ROM, etc. When you go the doc - be prepared for some resistance. I think most orthopedic surgeons think shoulder pain comes from the shoulder, especially if shoulder movement makes the pain worse.



steve -> RE: neck vs. shoulder (May 21, 2008 11:49:19 AM)

"the symptoms and intensity of pain exhibited are far out of line with the pathology"
 
It would seem that this is the most consistant and identifiable issue with this patient. Be careful that treatment and assessment of the neck doesnt lead to her having a shoulder and neck problem that cant be figured out.

Steve 



Sebastian Asselbergs -> RE: neck vs. shoulder (May 21, 2008 12:29:00 PM)

I can't help but think there may not have been any pathology, UNTIL the subacromial decompression.
I remember a neurosurgeon - years ago - emphazising that pain is the worst kind of criterium for doing surgery. I tend to think he is right.
The suggestions so far are bang on, as far as I am concerned.

You may want really work on the neurophysiological educational part (if you haven't already) - brain and peripheral sensitisation, hyperexcitability of mechano receptors etc etc. I have found most patients improve when they know more.



sslevins -> RE: neck vs. shoulder (May 22, 2008 12:57:16 PM)

Ginger,

when you say 20 mins of CM , you mean continuous mobilization? As in manually doing a grade 2 PA mob for 20 mins? I don't know what others normally do, but rarely have I ever mobilized a segment for that long a period. I guess it brings up the interesting question of what is the best "treatment time" for mobilizations? Some say they do 3 sets of 20 oscillations or 1,2 or 5 mins etc...   Of course there are those that would likely advocate a HVLAT and be done quick.
Is there any research done in the area of time of mobilizations?

Steve



sslevins -> RE: neck vs. shoulder (May 22, 2008 12:58:56 PM)

Also thank you all for your comments and suggextions. It does help me to feel that I am on the right track.
I have been a reader of this fourm for a long time, but only an infrequent poster, and I respect the opinions of many of the people here.

Steve



ginger -> RE: neck vs. shoulder (May 22, 2008 8:26:19 PM)

Steve , for an overview of CM look into the manual therapy archives here under Continuous mobilisations. The method is somewhat comparable to Maitland , in only a few basic things , in most however it is very different. The purpose is to restore a  non protected state of normal facet mobility.  This will NOT be achieved with a few grade anything maitland mobs , and certainly not with a manipulation. I would urge you to go back and read the text on CM and aquaint yourself with its concepts. The only difficulty in most learners , is sustained mobs over more than five minutes. Your thumbs are almost certainly sensitive enough and strength will only be improved from an already better than average state. It will not be necessary ( or even possible ) to perform Cm on this woman , given her likely state of Facet hypomobility and pain , with pressures that  go beyond a "maitland 'grade two. At least initially . Don't be too hung up on grades of movement or on any thing other than her tolerance .
Cheers



ginger -> RE: neck vs. shoulder (May 23, 2008 12:14:59 AM)

CONTINUOUS MOBILISATION
METHOD.part one
unilateral passive mobilisation of facet joints requires therapists hands to be a connection to the ongoing protective state implicit in the activity associated with spinal joint pain. As such it is necessary to be sensitive to changes in the state of tone of intrinsic muscles intimate to facet joints. Any attempt to move a facet joint which has a protective hypertonic load ( of muscle) will be met with resistance and pain. Pain can be of differing intensities, feel and irritability. ( by irritability I refer to the prospect that any attempt to move joints in a highly irritated state may be followed by pain not associated with passive or active movements, initiated by that attempt to mobilise)
By this sensitivity it will be noted that as passive movements are attempted and continued, a changing picture of pain and resistance emerges.
Movement is applied in a natural direction predicted by the angles of therapists hand and arm, where he/she stands at the side of the patient nearest to the joint being mobilised.
Pressure is sufficient only to acknowledge both pain and resistance at the joint. Continuous movements then at a rate of 2 per second are provided such that both these variables are able to be monitored. At or around 30 seconds of continuous mobs there will be noted the first level of alteration to both variables. That is , pain will be felt to reduce at the same time as muscular tension providing resistance reduces. Further attention to the same joint will produce still more reductions till A. either no further improvements are noted, or B. a full pain free resistance free condition is established.
The effect of successful mobilisation will be noted in several ways.
Active and passive facet ROM will be improved. This will be associated with improvements to comfort locally as well as distaly. It will be noted that as these local improvements are appreciated , so will the prospect of a reduction in distal pain and dysfunction associated with the spinal segmental innervation of those related structures.
The improvements to facet mobility are essentially permanent. That is, provided that there are no severe local irritations given by pathology or injury, protective responses leading to facet hypomobility and inflammatory events of joint and nerves are restored to normal. Inflammatory events associated with these states of hypomobility are usually dissipated over a 24 hour post treatment period. Some liklihood of a post treatment painfull facet joint period exists. This can be viewed as an unfortunate feature of this form of treatment , but not a contraindication for it's use. In my experience about 20 percent of individuals will experiece a post Rx period of tenderness, which last pproximately 24 hrs. Usually noted is a highly irritated facet joint, or group of joints prior to Rx, in this group.
Summary
Continuous facet joint mobs is NOT
forcefull
difficult
contraindicated by the presence of age or disease related arthropathies, "instability", or previous injury .
Continuous facet joint mobs DOES NOT require
Your attention to detail in the placement of your thumbs- at or over the lateral mass , as near as able to the facet joint will be fine. Provided that , the two basic criteria are met, that is resistance and pain.
Periods of five minutes of continuous mobs are commonly associated with continued improvements to some facet joints as above, longer periods are usefull also , though strain the limits of the thumb comfort of those new to the method. Practice will lengthen considerably the time able to comfortably mobilise. A lot of pressure is rarely more useful than less, pain and resistance is the key.



bonez -> RE: neck vs. shoulder (May 23, 2008 2:37:19 AM)

Thanks for the review Ginger. Is there research to go along with your clinical experience with this method?



ginger -> RE: neck vs. shoulder (May 23, 2008 6:19:12 AM)

Bonez, No.



TexasOrtho -> RE: neck vs. shoulder (May 23, 2008 8:10:32 AM)

Wow...asked and answered.



ginger -> RE: neck vs. shoulder (May 23, 2008 8:32:48 AM)

no point in stretching or embelishing the simple facts when a staright answer is best. I prefer them to fluffing around. The method has been working well for me , my students and patients for two decades. As yet no formalised RCT  has been undertaken to my knowledge.



TexasOrtho -> RE: neck vs. shoulder (May 23, 2008 2:33:50 PM)

No I completely agree and appreciate the directness of the answer.  Good stuff.



sslevins -> RE: neck vs. shoulder (May 23, 2008 7:02:18 PM)

Ginger et al

Thought you would like an update. Just saw her for visit this afternoon and gave it a try. At first even gentle touch over the C4-C5 facet led to symptoms in shoulder. I started as you described above and I think it went well. After a few minutes the resistance lessened and by 10 mins the facet was moving very well. The pain was minimal I am guessing as she actually fell asleep!or at least was very drowsy. I felt like it really improved the facet mobility, however she continued to have significant pain and no significant gains in active shoulder ROM afterwards. Is that a common occurance. Did I do it wrong? Is there perhaps both local and cervical issues?

Overall she has gone from 30 degrees of active flexion when she first came in months ago to 80 active / 120 AAROM. So there has been improvement. It just has not gotten better actively and I really felt that the neck was a culprit , especially when the inside of the GH joint looked good and neck motions reproduced shoulder symptoms.

Any feedback??



Kaden -> RE: neck vs. shoulder (May 23, 2008 7:19:09 PM)

I think you are on the right track and if the continuous mobs are working then continue to work at C4/5.  I tend to think a lot of referral events are from hypermobile joints.  I know Ginger would disagree and say that it is simply tone.  I think the tone is protecting against movement and thus think more along the lines of hypermobility.  If CM is working then continue.

However, as I often think the tone is protecting hypermobile segment I will do techniques to down train the tone but more importantly I look above and below the level to make sure everything else is moving and playing an equal part in movement of the cervical spine.

So, if you start to plateau with CM don't be afraid to find stiff joints above and below and get them moving to decrease stress on the C4/5.

I often find on can down train the guarding around C4/5 but it is not until I correct the joints not moving above and below the target that I get long lasting results.

You can do all the work you want with the cuff to stabilize an unstable shoulder but those patients never seem to do as well until one addresses stiffness in other areas such as the posterior capsule, T-spine, etc.



ginger -> RE: neck vs. shoulder (May 24, 2008 4:44:16 AM)

Steve, great you have proven a relationship between C4/5 and her shoulder pain , I would extend the effort now to include all the joints whose nerves may impact on the shoulder , C4 all the way to T5.



proud -> RE: neck vs. shoulder (May 24, 2008 11:19:08 AM)

Wainner et al. Cervical radiculopathy( off the top of my head so if I'm off....sorry):

1. Ipsilateral rotation less than 60 degrees

2. Spurlings +ve

3. +ve ULTT

4. +ve distraction test.

Nice specificity/sensitivity to identify pain of cervical origin.

I think you have established some relationship there between C-spine and the shoulder....but I'm not at all convinced. Remember, people are perceptive. I.e not blinded to what's going one. If this person "wants" to send you on a wild goose chase...they will.

And secondly, if the person is one with psyco-social problems, they often exibit variants of the Hawthorne effect.....meaning they tend to "respond" favourably for non mechanical reasons...but then digress once all the excitement has settled.

As PT's....we are generally "nice" people and never want to assume the person is a bit peculiar or worse.....a faker. But my money is on it.....

As for the CM's that people seem to have embraced. Remember....no RCT's. None. Zero. Seems funny that a profession is willing to listen to a person for whom the have never met.....ramble on about anecdotal claims.

Find out more about the work comp situation. Find out more about potential "gains". Find out more about the persons coping sourroundings( relationships,enjoyment of work, depression etc etc). Not so that you can then dismiss the patient....but so that you can better understand her impairment and factors contributing to it.




sslevins -> RE: neck vs. shoulder (May 24, 2008 1:53:30 PM)

quote:

Wainner et al. Cervical radiculopathy( off the top of my head so if I'm off....sorry):

1. Ipsilateral rotation less than 60 degrees

2. Spurlings +ve

3. +ve ULTT

4. +ve distraction test.

Nice specificity/sensitivity to identify pain of cervical origin.


#1.....check,   #2...check,  #3...check,  #4.....check   

Proud,
I am not some uneducated moron grasping at whatever someone on the internet tells me to do. (as I feel you implied)  I follow the evidence in our field and employ it into my practice as much as is possible everyday. I am more than familiar with all the recent work of Flynn, Childs, Fritz, Wainner etc....  It is great stuff and I am whole heartedly behind the push for evidence based practice in our profession.

It is not as though Ginger instructed me to rub a quartz crystal over her left big toe three times clockwidse while reciting some latin incantation backwards and I jumped at it like a dummy saying "Sounds like a great plan!".

There is plenty of good scientific evidence behind the neurophysiologic effects of spinal mobilization and manipulation and the benefits of spinal treatment on distal symptoms. Just because Ginger has a specific type of mobilization called CM does not mean that it is really any different in its neurophysiological effects that any other mobs. Who is to say that it is any better or worse than Paris' techniques, maitland, mulligan, PAs, PUIVMs, NAGS, SNAGS..........we all have tried diffent types of mobilization and much of it is not backed specifically by an RCT.

I understand the need for evidence and science, but therapy and particularly manual therapy has to me (maybe because I have been a PT for some time) also been somewhat of an art. A really good manual therapist that is "in the zone" is not always able to describe specifically "well I pushed at that facet at a 30 degree angle with 20 newtons of force for 30 repitions ...etc etc as though there is some cookbook that we can follow that boils down the human body and all its possible dysfunction into an easy to explain symptom that can be tested with an RCT.

In this case, if you remember I have a lady who I have seen for months doing the standard "evidenced based" treatment. She may be a wimp when it comes to pain but I do belive she has pain. If she is faking then she is not doing too well with cheating the system. She is continuing to work daily and underwent 2 surgeries for nothing.  I tend to also be quit ejaded when it comes to workers comp cases and see many people who are full of it. I probably assume so until they prove otherwise. I know a great deal about her social and work situations- I just can't include everything in these posts- and I tried to summarize stating that she seemed genuine. (believe me I rarely feel this way with the workers comp I have been getting)
I saw with my own eyes in the OR that there is little pathology in her shoulder and then tested the neck an replicated her symptoms. Then you want to insinuate that I (and Ginger ) are looney for trying some treatment to her neck.

Would it have been better that I just told her. "I tried standard treatment and it hasn't helped. Even though you tell me your symptoms come on with neck movements and my professional literature is filled with studies of neck problems related to extremity symptoms...I can't find a RCT that explains your exact symptoms and tells me exactly what I should do. So therefore you must be full of **** and I am just going to give up."

There is a danger at both ends of the scale.  On one end there is craniosacral therapy, therapeutic touch, etc and at the other end there is those that try and treat only with 100% perfect, RCT validated techniques without imparting some clinical resoning and deduction. The human body is complex and to assume we will ever understand all of the connections and interactions through scientific studies and have the answers to everything is as foolish as those who would say to rub a crystal over her shoulder for relief.



proud -> RE: neck vs. shoulder (May 24, 2008 4:46:51 PM)

If it sounded as though I implied something....I apologize.

rather, I suggested a piece of research that you apparently are already familar with. And I suggested that you delve into some of her social Hx as the grand majority of PT's tend to either avoid or not understand it's profound implications. Apparently you have that covered as well.

As for Ginger's CM. Yes the technique is yet another neurophysiological party trick with some useful clinical application. I took issue with the manner in which it seemed and seems( from my history here...) that PT's embrace the description. I would be suprised if most people have not gone into the clinic after reading the description of CM and attempted to apply it. But why? Why?

At least Mulligan has some published literature on his stuff which then allows me to tranfer to other techniques...somewhat.

Perhaps it's ginger's communication style. CM is served up as an unquestionable technique that most foolish PT's should be using....

If I had a mob that I witnessed anectodal benefit from. I may post it with tons of caveats to claerly indicate the number of extraneous variables that COULD have decreased the validity of my claims.

I'm not sure Ginger understands these potential variables exist....

CM here....patient get's better...must have been the CM. When perhaps Ginger has a communication style with her patients that has that "Benny Hin" impact short term on patients. Who knows?



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