Archive for March, 2010

Did you know that between 2-5 per cent of the general population will experience a “Frozen Shoulder?”

Did you know it’s more common in people with diabetes and thyroid diseases?

Did you know that it’s more common in women between the ages of 40-60?

Did you know that over 80 per cent of clients with frozen shoulder (one study) respond to conservative treatment?

What is a Frozen Shoulder?

• Evidence that there’s an “elevation serum cytokine levels”
  • Which is an over production of the cells that help with tissue repair
  • This causes ongoing inflammation and fibrosis (scar tissue formation)
• Loss of normal collagen production – new collagen is too tight and restricts the movement of the shoulder joint.
• Contracture or tightening is typically found in the “rotator cuff interval” (RCI) at the front of the shoulder.

 

How Can I tell if I Have a Frozen Shoulder?

• Painful and/or stiff shoulder with all movement directions
• Typically starts without any significant incident
• Accompanied by progressive loss of motion (freezing) in all directions
• Significant night pain
• Loss of outward rotation of more than 50 per cent
• Weakness of the internal rotations

 

What Can I Expect?

• Initial first three 3 months
  • Pain is greater than stiffness
  • Pain limiting movement in all directions of motion
  • Muscle guarding on passive movements
  • Difficulty finding comfortable sleeping position
• Stage Two (3-9 months)
  • Pain with all movements
  • Stiffness may be starting to be more of a problem than pain in the later stages
• Stage Three-Frozen (9-15 months)
  • Less pain but more stiffness
  • Still limited motion
  • Improved tolerance for exercises and physiotherapy techniques
• Stage Four-Thawing (15- 24  months)
  • Minimal pain
  • Motion improving

 

What Should I Do?

• Research supports in the early stages (more pain from hyper inflammatory) the use of a cortisone injection (results of pain reduction are best when combined with a physiotherapy-guided exercise program)
• Ultrasound and other modalities might actually aggravate the pain in the early stages
• Do range of motion exercises that don’t increase the pain in the early stages
  • Aggressive stretching in the early phases can aggravate the condition
• Physiotherapy-guided home exercise program
• Physiotherapy joint mobilizations in the frozen or thawing stages

 

What Else Could the Problem Be if Not a Frozen Shoulder?

• Rotator cuff impingement
• Rotator cuff or labral tears
• Neck problems
• Severe osteoarthritis
• Acute tendon calcification
• Tendonitis or bursitis
• Humeral fracture (proximally)

References/More Information

1. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

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wendy@wendybowen.com

 

 

My interest in the shoulder has stemmed from having separated my shoulder playing hockey back when I was a teenager. I did not have any treatment to it until I was in my late 20s. Having to treat my own shoulder has given me personal insight into the shoulder joint and recovery from injury. 

When it comes your shoulder, you don’t have to live with the pain.

The Shoulder Joint

• ball and socket joint
• held in place by ligaments
• surrounded by a capsule

 Rotator Cuff

• group of four smaller muscles that work together to keep the ball centered in the socket                                                                                                                        

Rotator Cuff Tendonitis/Tendonopathy:

• a common problem with the rotator cuff is IMPINGEMENT
• supraspinatus and sometimes the biceps tendons get pinched as the arm is raised overhead
• may result in TENDONITIS (inflammation of the tendon) or TENDONOPATHY (thickening/changing of the tendon structure).                                                                                                                                                                                                                                                     

Common Cause of Impingement

1)     Poor Posture: Rounding of the shoulders. Slouching leaves less room under the arch.

• Stiffness and tightness in the middle back area can be contributing factors.

2)     Muscle Imbalances: Tight or weak muscles alter the movement and timing of the joint.

• Can be caused by repetitive strain or trauma injuries.

3)     Overuse: Too much, too soon, too frequently — not enough rest time.

4)     Trauma: Falls, sports (throwing, weight-lifting improperly, swimming etc.).

• The jarring of the muscle can cause a reactive muscle shortening.

5)     Shape of the Arch: Some collar bones are hooked, leaving less space for the cuff.

 Rotator Cuff Tears

• Rotator cuff tendons don’t get good blood flow and will often thin (attenuation) with age.
• Are common in middle age.
• Repetitive minor traumas accumulate, leaving the tendons weaker and more susceptible to tearing with a relatively minor injury.
• Rotator cuff tears can also occur with falling on the shoulder, or with major trauma in the younger individual.

 Frozen Shoulder (Adhesive Capsulitis) 

• The formation of adhesions (scar tissue) of the shoulder capsule usually secondary to inflammation.
• As the capsule tightens, there’s pain and loss of range in all directions. 
• There are three stages:
  • Freezing: loss of movement
  • Frozen: no loss but no gain
  • Thawing: gradual regain of movement
• The process can take 1-3 years.
• If you get it in one shoulder, you’re more susceptible of getting it in the other.
• Often termed “idiopathic” because we don’t really know what causes it.
• Higher incidence in people
  • over 40 years of age
  • with diabetes (10-20 per cent of individuals affected)
  • heart conditions
  • hypothyroidism
  • hyperthyroidism
  • Parkinson’s disease
  • post-surgery
• Physiotherapy modalities can make it worse rather than better

 Treatments

 Exercises

• Proper exercise prescription requires a thorough assessment by a physiotherapist to determine the underlying nature of the problem and what stage of healing the tissue is at.
• Shown in research to improve pain scores in clients with frozen shoulders *(see references below).

 Manual Therapy

• Joint mobilizations have been shown to improve pain scores in those with frozen shoulders* (see references below).

 Modalities

• Ultrasound and iontophoresis have been shown to increase pain in those with frozen shoulders* (see references below).
• I suspect the ultrasound, which increases blood flow to the area treated, causes increased pain because of an underlying hypervascularization (increased vascularization) in those with frozen shoulders.

 Intramuscular Stimulation (IMS)

• Personally I have found IMS to be very effective in treatment for:
  • shoulder impingement
  • rotator cuff strains
  • muscle imbalances (tight ropy bands of muscles)
  • anterior glenohumeral syndromes (muscles at front or back of the shoulder are pulling and/or pushing the shoulder ball out of its central alignment (often misdiagnosed as a “frozen shoulder”)
• I have not had success with lasting improved range of motion in “true” adhesive capsulities.

 Corticosteriod Injections

• While this is beyond the scope of physiotherapy, research has indicated good short-term relief of symptoms.

 References/More Information

 1. Information from Bahram Jam, APTEI newsletter: www.aptei.com

2. Jewell DV, Riddle DL, Thacker LR. Interventions associated with an increased or decreased likelihood of pain reduction and improved function in patients with adhesive capsulitis: a retrospective cohort study. Phys Ther. 2009 May;89(5):419-29. Epub 2009 Mar 6.

 3. Martin J. Kelley, Phillip W. McClurr, Brian G. Leggin. Frozen shoulder: evidence and a proposed model guiding rehabilitation. February 2009 | volume 39 | number 2 | journal of orthopaedic & sports physical therapy

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com

 

How do you know that traction will work for you (and you won’t hurt yourself)?

Physiotherapists have used traction as a treatment modality for decades (used medically for over 50 years). There are certain tests that we do to help determine who will benefit or not from traction.

Nowadays you don’t need to see a physiotherapist to have traction with the invention and sale of the inversion table.

Why would someone hang themselves upside down? 

The rational behind traction:

• Arthritis
  • light separation of the vertebrae (bones) in the spine
• Disc bulges or herniations
  • takes stress off of the discs

We, as upright walking humans, are subjected to the law of gravity. I have read over the course of the day we can loose up to 2 cm in height (so always measure your height in the morning). First thing in the morning we also have more fluid and height in the discs in our backs, which is why people with back pain from disc problems (herniations or bulges) often feel more pain in the morning. 

There is a list of contraindications for inversion table use. You should not use an inversion table if you have the following medical conditions:   

Glaucoma
Pregnancy
Hiatal hernia
Ventral hernia
Detached retina
Extreme obesity
Middle ear infection
Arterial hypertension
Severe vascular disease
Anti-Coagulants (use of)
Conjunctivitis (pink eye)
Bone weakness, recent fractures
History of congestive heart failure
History of space-occupying brain lesion
Vulnerable areas of stress from recent surgery

Why see a physiotherapist first?

1. Traction can aggravate the problem.

2. There may be other treatment techniques that would also be helpful.

• IMS
• Exercises
• Manual Therapy
• Education

3. There are several different causes of back pain (www.cbihealth.com).

4. May aggravate conditions in the knees and hips.

Bahram Jam reviewed Spinal Decompression in the APTEI report (www.aptei.com/report winter 2009). In this review, Bahram looks at an article published in Chiropr Osteopat. 2007 May 18; 15:7. This is more of a review based on marketing claims and scientific literature. 

The conclusion drawn is there are few studies that exist supporting spinal traction. 

There was a good study published in Spine 2007 Dec 15: 32 (26) again summarized by Bahram in the APTEI report on who might benefit from traction. 

People with the following symptoms are likely to benefit from traction:

1. Leg symptoms below the knee

2. Signs of nerve root compression (a pinched nerve where it exits the spinal column)

3. Peripheralization of symptoms with extension (backwards bending decreases the pain in your leg)

4. Symptoms down one leg when the other is lifted (positive crossed straight leg raise)

Conventional traction versus inversion tables

(Physiotherapy Theory and Practice (2000) 16, 151 –160 © 2000 Taylor & Francis)

• Randomized controlled – 29 clients with lower back pain and sciatic from disc herniations.
• Both groups benefited (as noted by clinical changes on CT scans) but there was no clinically significant difference between the groups.   

When making the decision to invest in the “spinal decompression” advertised in the newspapers, or on an inversion table, or physiotherapy, I would suggest doing your research and know what you’re getting for your investment. 

References/More Information

1. Bahram Jam’s reports: Chiropr Osteopat. 2007 May 18; 15:7 online: (www.aptei.com/report winter 2009) and Spine 2007 Dec 15: 32 (26)

2. (Physiotherapy Theory and Practice (2000) 16, 151 –160 © 2000 Taylor & Francis)

For more information:

1. http://www.energycenter.com/grav_f/contra.html

2. www.cbihealth.com

Start Line Physiotherapy (250) 746-7463

wendy@wendybowen.com