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Re: Restricted Shoulder Abduction
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Re: Restricted Shoulder Abduction - September 17, 2005 11:12:00 PM
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ginger
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From: Melbourne Victoria
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Dear Yves,
thankyou for your charming and erudite reflections. I would do well to examine your words at length , there is much to consider here. While I have some fundamental diagreements with you, theoretically I think we work with the same guernsy.
Geoff
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The Grand Pediculator
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Re: Restricted Shoulder Abduction - September 18, 2005 6:19:00 AM
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Bournephysio
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Thanks Yves, I read gingers post as a lack of respect and responded rather bluntly. I've edited the post but it is still blunt. There are plausible and probably much more likely mechanisms for why treating the neck can effect shoulder pain that have nothing to do with either cervical dysfunction (if you don't like the word pathology) or nerve mobility. Steve from this site and Shaun Lapenskie have put together what looks to be a very good review of neurophysiological effects of manual therapy. They managed to get original submissions from Walter Herzog, Anthony Wright and John Childs. Its this months edition to the CPA Orthopaedic Division Review.
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Re: Restricted Shoulder Abduction - September 18, 2005 7:46:00 AM
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srcase
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Mike T.
I agree with the above in using AAROM and antigravity exercises to train the rotator cuff and deltoid for timing and neuromuscular reed. Try a sidelying shoulder abduction exercise with a cable and light weight. Also works well with supine flexion in that 90 to 120 range and above.
I also agree with the thoracic component. Try PA mobs to T1-T8 and test active shoulder abduction movement before and after....gets some nice results.
Sounds like you are targeting the capsule (posterior and inferior glides) already.
Some practical ideas off the top of my head....hope it helps.
Sarah
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Re: Restricted Shoulder Abduction - September 19, 2005 10:45:00 AM
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apolipo
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News of note:
Based on Jason's suggestion, I checked a pt. today with the base median neurodynamic test (MNDT), I think Shacklock's MDNT II. Positive for her shoulder pain with elbow extension that can be relieved with decreased scap depression OR decreased contralateral cervical sidebending. Interestingly, this is a pt. I saw prior to RC repair and I thought she had neurodynamic issues, but is was hard to treat them or definitively diagnosis them due to her overall level of pain as well as the torn supraspinatus/LHBT.
Also, prior to surgery, I tried Simple Contact with this same pt. and it was unsuccessful. There are many possible reasons it was unsuccessful and I have been trying to figure out why. No answers yet.
This does raise questions especially after reading Ginger's and Yves posts. I will try to read Ginger's post on his theory and give my opinion.
mike t
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Re: Restricted Shoulder Abduction - September 19, 2005 11:07:00 AM
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Barrett
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Mike,
Is this patient primarily displaying the consequences of an abnormal neurodynamic? Is there evidence of unresolved pathology? The answers to these questions might explain the difficulty you're having, especially the tear in the supraspinatus/LHBT. Instinctive movement isn't going to help such a thing-healing and/or repair will be necessary and, I would guess, her brain already knows this.
Simple Contact will be an inadequate way to approach patients "on the left side" as I say and demonstrate in lecture. I suspect she is one of these. Mike, I appreciate your effort and your continued posting.
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http://barrettdorko.com
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Re: Restricted Shoulder Abduction - September 19, 2005 12:24:00 PM
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apolipo
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From: Grand Rapids, MI
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Agreed. Her injuries were sustained in a MVA. No amount of instinctive movement will heal a torn tendon. Now that she has had time to heal, I am thinking the abnormal neurodynamic may be holding her back, specifically in abducting her shoulder.
Interestingly, she can abduct her shoulder to about 110-120 degrees when she starts in a position of elbow flexion, rather than 80-90 degrees abduction where she abducts with her elbow straight (neurodynamically unloaded vs. loaded).
Ginger,
I read your posts where you have outlined your theory as to why sustained, passive IV jt. mobs are beneficial. Your theory on the protective response of the paraspinals is interesting and certainly logical. I not sure I buy that a 30-90 second mob would allow enough joint nutrition to have the drastic effects you describe. I can't quite believe it would work that quickly. The only thing that could adapt that fast would be the nervous system. If the relief of pain has nothing to do with increased joint nutrition/O2, then the original theory does not hold up. Unfortunately, I don't have a nice, concise theory about nervous system adaptation to add. I guess I should work on that.
mike t
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Re: Restricted Shoulder Abduction - September 19, 2005 5:31:00 PM
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Jon Newman
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Hi Mike,
I'm not sure if your initial concerns have been addressed, have they? I had the impression that you weren't speaking of a particular patient but rather making a general observation that shoulder abduction is difficult to get back regardless of diagnosis or techniques utilized.
jon
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Re: Restricted Shoulder Abduction - September 20, 2005 5:32:00 AM
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Bournephysio
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I thought Julie did a pretty good job of answering his question. The shoulder is a very complex system and requires looking at many areas such as the neck, thoracic spine, scapula and glenohumeral joint (and sometimes distal). Rehab after repair is a very slow process.
The shoulder is much more functional forward of the scapular plane so I concentrate on flexion first (you also need to look at ER through flexion).
Good scapular control is a must. Besides the typical lower trap serratus work, I find proprioceptive exercises can really bring this around. Pay particular attention to eccentric control.
For the GH in particular it is important to know what regions of the capsule tighten in what ranges. You can determine what to mobilize from there. The rotator cuff is closely associated with the capsule so I don't think that you can isolate one or the other. Soft tissue work can be very important to get back range. I tend to do a lot of needling before mobilizing. The combination works quite well. I'm starting to try doing more ims to teres major and that seems to be helping. There are different pole exercises to stretch out the pects.
Timing after rc repair is very important. You haven't said the size of repair on this particular patient or the time after repair. The worst thing you can do is to blow the repair by going to quick.
"The only thing that could adapt that fast would be the nervous system" Bingo! Read my above post.
Doug
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Re: Restricted Shoulder Abduction - September 21, 2005 9:27:00 AM
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apolipo
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Jon,
Yes, it was a general question re: a string of pts. in recent memory. I brought up one in particular because it was an good example. I should say that I have shoulder pts. who do quite well. I haven't been able to identify why exactly certain pts. progress well and others did/do not.
You can be assured that I do assess beginning at the SC jt. and work my way out and around until I have looked all the way to the t-spine.
I appreciate all the replies.
mike t
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Re: Restricted Shoulder Abduction - September 23, 2005 4:51:00 AM
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Yogi
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Hypertonus ala Ginger, joint mobs. Gamma bias or whatever ala Strain/Counterstrain, shorten muscle. NDT mobs, vibration, normalize tone. Simple Contact, neural flossing, ART, Nervous system adaptation, Bingo, I had been thinking the same thing. And that may be why a generalized manipulation works.
I still think there must be a valid technique utilizing Noggin Thumps. They used to work to make my brother behave anyway. Quicker than CBT, even.
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Re: Restricted Shoulder Abduction - September 24, 2005 9:55:00 PM
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ginger
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From: Melbourne Victoria
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Mike T,
thanks for the replies Mike, in relation to the effect of 30-90 secs of mobs to facet joints and the changes this creates, it is not joint nutrition that I theorise as cause for joint muscle tone losses. It is Oxygen flow to hyaline cartilage. Remember the joint has an impressive feedback loop in place related to muscular control for postural reasons already. I am simply proposing that the same control effectors give rise to a reduction in tone as oxygen reaches cartilage previously denied it by tightness and lack of movement.
What is certain is that there IS change related to facet joint movements. Where this becomes very usefull indeed , is when continuous mobilisation continues to effect tissues adjacent to joints and neuraly related to joints . By this method I regularly and permanently relieve musculoskeletal pain that may otherwise have been mysterious or thought pathological by others. It is worth noting that I deliberated and assembled this notion , my theoretical model,to explain the success I was having , not just with relieving spinal pain , but the much more exciting prospect of referred pain and altered sensations.
Exciting Mike because as the years went by I continued to refine my mobilisation method and found more and more musculoskeletal problems that turned out to be referred .The orthodox literature suggests that referred pain needs to be elicited by tests , the so called clearing tests, to be accepted as such. I say this is not good enough.
Referred pain and altered neural effecs are best proven by attrition. Deal with the likely joints first, discover by carefull use of the continuous method , that referred events did in fact create the reported symptoms. In this way I've come full circle over twenty years Mike. The assmbled minds here are only too willing to tut tut about my lack of "proper" research , while not listening and trying it for themselves.
All the best.
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The Grand Pediculator
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Re: Restricted Shoulder Abduction - September 25, 2005 3:42:00 AM
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Jon Newman
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Hi Ginger,
I think people are willing to try things when a compelling case to try it has been built. A firm persuasion as it has been called.
I've a few concerns. The oxygenation of "hyaline cartilage" with subsequent relief in pain I think misnames the structure that is being oxygenated. If the hyaline cartilage is the thing being oxygenated then the only way pain could have been being produced is through chemical irritation of nerves via the metabolic byproducts of hypoxic chondrocytes. Since your techniques tend to produce very quick results, it would seem more likely that you may be effecting the blood flow to nerves themselves versus chondrocytes. This makes more sense in that your results tend to be relatively immediate and the time frame for clearing inflammatory chemicals from the hyaline matrix would likely be longer than that.
Regardless, unless you believe in the "stuck facet" syndrome, why wouldn't active ROM produce similar results?
jon
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Re: Restricted Shoulder Abduction - September 25, 2005 2:15:00 PM
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ginger
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From: Melbourne Victoria
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Hi Jon, I'm not entirely sure what the "stuck facet" syndrome is, what's in a name. In the physiology you describe there is much to recommend. I don't claim this model to be truth, merely a useful way to lead those who ask the question, why does this work? to a logical progression of events. The cascade of events may well be as you say, I won't quivel.
Exercise related treatments are useful enough I guess, but in most cases take a long time to produce results. I'm happy to suggest exercise to my patients, though only after I've fixed the pain and restored normal movements to the ( usually) spinal structures involved. I cannot imagine going back to the bad old days of trying to fix difficult shoulders for instance with exercise. Most musculoskeletal pain and dysfunction has , as its root cause, a referred component.
Exercise does not isolate movements sufficiently to a joint for the necessary tone reduction to take place. At least not as immediately or as well. This is not to say exercise has no place. . Once a therapist has experienced the dramatic and lasting benefits of continuous facet joint mobilisation, , provided he or she persists where hand and thumb discomfort occurrs,few would anyone go back to exercise related treatments as a primary method.
I notice the geniuses have added yet another word to the already long list of medical euphemisms for " I don't know" . lets all enjoy, Meralgia Paresthetica for a while. Tragic, funny but tragic.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Restricted Shoulder Abduction - September 25, 2005 4:04:00 PM
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Jon Newman
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Definitions and language certainly do seem to be an issue, but deserve consideration if we are trying to understand what we do for a living. My understanding of a stuck facet is that a facet joint requires mobilization or manipulation to return to some optimal/painless position because it is otherwise stuck where it is. Another definition that would help to clarify is that of exercise. I mentioned active ROM versus exercise to try to be more specific. The reason I bring this up is that if a mobilization or manipulation is required because active ROM won't do it then there seems to be a more compelling reason to use those techniques.
jon
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Re: Restricted Shoulder Abduction - September 25, 2005 5:52:00 PM
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ginger
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thanks Jon, in that case stuck facet would suit, though I'm not convinced there is an issue about the position of the stuck joint ( that is a chirapractic notion , or at least very popular with them). I'm more concerned with the mobility of the joint than its position. Further I don't accept that position is a critical issue at all.
I've been discussing this post with my current fourth year undergrad student , we can't come up with active ROM that is not exercise. Can you clarify?
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Restricted Shoulder Abduction - September 25, 2005 6:12:00 PM
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Jon Newman
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Well there are many definitions of exercise hence my use of AROM instead. One could define AROM as exercise but to just say exercise also opens up the possibility for strengthening, stretching, stabilizing, which tend to be more popular as examples of exercise. Further, the type of AROM that I encourage in the clinic is not so productive and choreographed as stretching and strengthening, rather it is creative. Still, it is AROM none-the-less. More specifically, it is ideomotion.
I agree that stretching and strengthening have their role. They are particularly good for lengthening tissue or increasing the force producing capacity of tissue respectively.
May I ask why the facet joint cannot move and requires passively applied forces to become mobile?
jon
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Re: Restricted Shoulder Abduction - September 25, 2005 7:30:00 PM
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ginger
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why yes you may Jon, though this is a question I've sought to sddress here in this forum many times, you will find further detail in any of my posts , though perhaps the best might be in the open forum section under "the physiology of spinal pain, a theoretical model", but to add to that. Facet joint mobility and losses thereto are the effect of muscular control mechanisms surrounding these joints.Both postural and protective. When protective control is initiated , joint movements are reduced as tone increases. Tone can be reduced by movements to these same joints. Continuously applied low amplitude movements through a range producing facet joint pain, is seen to exert an influence over this tone. Significant reductions to tone are usually seen within a 30 to 90 second period of continuous movement, at a rate of about two per second.
The facet joint cannot move because it is held still. Its position may be seen to be altered also, though this is an artifact of a protective response , and not the cause of pain.
Inflammatory events accompanying and related to movement loss will be seen to dissipate over a 24 hour period.
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Ubi est mea anaticula cumminosa?
The Grand Pediculator
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Re: Restricted Shoulder Abduction - September 26, 2005 3:22:00 AM
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Jon Newman
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So a reduction in tone is the key to improvement, not the passive mobilization of the facet joint itself. I think there are many ways to accomplish this reduced tone. I prefer the active ones secondary to the self efficacy those techniques provide that passive techniques, by definition, cannot.
jon
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Re: Restricted Shoulder Abduction - September 26, 2005 5:50:00 AM
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Yogi
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Hypertonus, spasm. Protective reflex. Prolonged, unrelieved, causes malalignment, whether osseous or fascial, soft tissue, or neural, eventually resulting in pain, whether noiceptive, or central, sympathetic, referred, whatever. There was a rationale for e-stim for pain in the old pain-spasm-pain model, i.e., fatigue the hypertonic muscle and it had to stop contracting. S/Cs, put the muscle in the shortest position long enough and it can't maintain the contraction tension and has to relax. PROM will decrease tone to an extent temporarily, even in CP. I think the problem is locating and treating the actual muscle(s) that is in reflexive protective spasm. SC seems to allow the body to perform the AROM necessary to inhibit the reflexive spasm. Where does neural tension fall into this? I'm not sure but I have the feeling that it's kind of like joint play, it has to be normal, or things lock up and the old genetic pain threshold wall may be breached.
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Re: Restricted Shoulder Abduction - September 26, 2005 6:08:00 AM
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Yogi
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I'm not exactly a Steven Hawking for a Grand Unified Theory. (GUT) Basically, i think we are trying to reboot the system, we just can't find the off switch always.
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