Adhesive Capsulitis: the Frozen Shoulder

Adhesive Capsulitis (AC) is a real pain, and if you have it or have had it, you know what I mean.  First, lets start with a technical definition from the first article linked below.  ”Adhesive capsulitis is a syndrome defined in its purest sense as idiopathic painful restriction of shoulder movement that results in global restriction of the glenohumeral joint.”  So, in layman’s terms, what you have is a painful shoulder that is very difficult to move in all directions with no known cause of injury.  Many times AC is also called “frozen shoulder”, but I’ll stick with the more technical and anatomically correct name.

There are generally two classifications of AC.  Primary is the version above, with no known cause of injury, the secondary version is recognized to be caused by some prior injury that has brought on the AC (rotator cuff tear, tendonitis, bursitis).  There are other factors that seem to influence the onset of AC.  This article suggests that as many as 40% of diabetics may experience AC at some point in their life and that up to 16 % may develop it in both shoulders.

AC generally resolves in 1-2 years and goes through three phases.  First is the “painful” phase that lasts anywhere from 2-8 months and is characterized by (you guessed it) pain and a general decrease in range of motion (ROM).  The second phase is the “adhesive” phase, and though less painful, is characterized by even more decrease in ROM, lasting 4-6 months.  The last stage is the “recovery” stage and is pretty self-explanatory.  This is when ROM gradually is restored and the pain continues to decrease.  Most people will regain all or most of their ROM, though some (approx 10% or so) may have permanent restrictions in their motion though not enough to be classified as a disability.

For effective treatment, it is imperitive that AC is diagnosed early.  Physical therapy can play a great role in maintaining ROM and keeping pain levels down.  Ultrasound is sometimes used as research shows it can help increase soft tissue extensibility.  Iontophoresis can help to deliver anti-inflammatory medication to irritated tissues.  TENS units can help to keep pain levels down so that medication isn’t overused and making sleep possible.  Passive range of motion by your PT will help to keep as much motion as possible, though it is important to note that it can be quite painful, especially in the early stages.

More serious treatment options are manipulation under anesthesia, where the surgeon forces your arm through the full motion, and arthroscopic surgery to release the tightened capsule.  Both are usually only reserved for cases where conservative treatment has failed.

There is hope for those suffering with AC.  It is worth restating that this can be an incredibly painful condition, but there is hope.  PT won’t be comfortable, but shouldn’t be a torture session either.  Be open with your therapist and understand that there is no quick fix for AC.

Here’s the article I quote and refer to the most.  Thorough and technical - http://www.aafp.org/afp/990401ap/1843.html

Here’s an article that’s a little more concise, but still kind of technical - http://orthoinfo.aaos.org/topic.cfm?topic=a00071

The Wikipedia article - http://en.wikipedia.org/wiki/Adhesive_capsulitis_of_shoulder

Trigger Points – And How To Deal With Them

Wanted to spend a little time on a subject that I feel is undervalued by many in the rehab industry, trigger points.  Check the bottom of this post for links, as the anatomy of the subject is worth many pages alone.  There is some debate in the medical community on how significant a role trigger points play as a cause of musculoskeletal pain, but most PT’s and physicians recognize that trigger points are something to be considered, especially in cases of chronic pain.

First, a working definition of trigger points, from the AAFP article cited below: “Trigger points are discrete, focal, hyperirritable spots located in a taut band of skeletal muscle. The spots are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena.”  So, in laymen’s terms, you have a “knot” in your muscle that is very tender to the touch and may refer pain to other areas when you press on it.  The signs and symptoms associated with trigger points can vary quiet a bit from pain at rest, to pain with movement, decreased mobility from muscle pain, referred pain (headaches from trigger points in your neck) and many more.

The most common ways to acquire trigger points are from acute trauma (a fall, for example) or repetitive trauma (performing the same movement numerous times).  It is believed that chronically poor posture will also lead to trigger points from chronic overuse and/or shortening of certain muscles.  It is a condition that chronically effects those working desk jobs (from poor posture), to those on a factory line (repetitive motion injuries), and the athlete (repetitive motion).

There are three main treatment methods: injection, spray/stretch technique, and manual therapy.  The AAFP article details the injection method, and I will say that I have seen many patients benefit from it, but if you go this route you really should have it done by a physician who specializes in it.  Most specialized pain clinics will have a doctor who specializes in trigger point injections.  The spray/stretch technique is only something I’ve heard of in theory, never seen or met someone who practices it.  That is mostly because the spray is expensive and the technique isn’t something learned in PT or medical school.  The manual method is what physical therapists practice, and is usually the method of choice for chronic trigger points or for those who have a fear of needles.

Your physical therapist will assess not only where the trigger point is and how to deal with it, but will also focus on what are the potential causes and what to do to make sure they don’t come back again.  There are a couple different methods of treatment, one with sustained, direct pressure for approximately 90 seconds or more, and with a roll through the trigger point method.  I generally use whichever one is more tolerable for the patient.

There are some awesome tools out there both for self-use and to save your hands if you are a therapist.  A quick Google search will come up with all sorts of items, but my favorite for self use are the foam roll and the Thera Cane.  There are countless tools that you can use as a therapist, but I personally try to use my hands whenever possible and only use tools on the big muscles.

Lastly, some anecdotal notes.  I usually see trigger points in the following muscles, upper traps, rhomboids, gluts, hamstrings, and soleus.  The most common place is in the suboccipital area (where your neck attaches to your head at the back) and is a frequent cause of chronic tension headaches.  My favorite story is of a college basketball player with 2 months of sciatica symptoms that weren’t improved at all with chiropractic care.  A quick exam revealed trigger points in his piriformis and biceps femoris (lateral hamstring) were referring all his sciatica symptoms.  After one treatment he was 50-60% better and was 100% after just three treatments.  That won’t hold true for everyone, but a good story to show that the cause of pain can be both easily overlooked and easily treated too.

A book I own and highly recommend for therapists and those afflicted by trigger points (and it’s very reasonably priced!) - http://www.amazon.com/Trigger-Point-Therapy-Workbook-Self-Treatment/dp/1572243759

The Wiki article on trigger points (not the best article out there) - http://en.wikipedia.org/wiki/Trigger_point

American Academy of Family Physicians article on trigger points (very technical) - http://www.aafp.org/afp/2002/0215/p653.html

Physical Therapy versus Chiropractic Care

Hatfields and the McCoys, Capulets and Montagues, Ali v Frazier.  Just as these names instantly are known for their legendary rivalries, so are physical therapists and chiropractors.  This won’t be a complete rundown of the differences, that would be potentially hundreds of pages long, but will focus on the main differences, their at times heated rivalry, and what the future holds for their relationship.  I’ll try to be as objective as I can, though it should be pretty obvious that I’m on the side of PT.

There are generalities that can be made about both PT’s and Chiro’s, but it is very important to note that there are great practitioners on both sides, just as there are bad ones.  Twenty or so years ago, the line in the sand was very clear, with PT clearly within the traditional bounds of medical practice and Chiropractors in the alternative field.  PT’s would use statements like “voodoo medicine” when talking about Chiro’s, and they would call PT’s “puppets of the medical community”.  In general terms, if you find a PT or Chiro over the age of 50, you have a good chance that they look at each other with suspicious eyes.

I suppose if you boil it down, the main difference is that the heart of chiropractic care is centered on spinal manipulation.  True, they do other things, but even they will admit that this is their bread and butter.  Physical therapy’s heart is focused on muscular imbalances and asymmetry.  Like many things in life, there are different ways to look at the same situation.  If someone is experiencing back pain due to limited mobility of the spine, Chiro’s will generally say they need to be adjusted to restore that motion, PT’s will generally say that certain muscles need to be increased and certain muscles inhibited to restore that normal motion.

There are still battles brewing in many states over who can do what and see who.  Chiro’s claim that only they can do spinal adjustments and have taken to court and state legislatures to protect this area of practice.  But, many people don’t know that Osteopathic Physicians and PT’s can also do the same types of adjustments in most states, and are taught how to do them in their respective medical schools.  PT’s are also bringing lawsuits and attempting to change laws that only allow PT’s to perform certain interventions (like ultrasound and other modalities).  We’ll just have to see where the dust settles on all this.

I’ll keep this short, but don’t want to overlook the “bad” of both.  There are some Chiro’s out there that will claim that regular adjustments will cure everything from the common cold to appendicitis.  They will insist that you don’t need traditional medicine and that most or all of your ailments can be treated by them and to be skeptical of anyone else in the medical community.  On the PT side, there are some therapists who only do the old fashioned hot pack, ultrasound, and massage, making them a glorified masseuse.  Or they may practice a type of therapy or specific treatment that isn’t backed by research at all.  It is important to note that these folks don’t represent all practitioners in their respective fields.

Good PT’s and good Chiro’s realize that every person is unique and that just because someone presents with similar symptoms doesn’t mean that they will always respond well to the same treatment.  Make sure you go to someone who will spend quality time with you and develop a treatment plan that will work for you.  If they don’t have time to address your concerns, find someone who does.  Do your homework, many PT’s are trained specifically in different areas like orthopedics, manual therapy, women’s health, and pediatrics.  Search out someone who specializes in your field, trust me, they are out there.  There is no such thing as one-size-fits-all in the medical field.

Lastly, it seems that the younger generation of PT’s and Chiro’s are much more willing to recognize that we all play a part in the health field.  I personally had one Chiro tell me in private that he feels that he can help at least 60% of the clients he sees get back to normal, but that there are about 40% that still need further help of some sort.  In the PT field, while I’d like to say that we can help everyone, the reality is that some folks won’t be able to get back to “normal” with just PT alone.  In an ideal world, we all can work together so that our clients can achieve that perfect balance.  And in the town I work, there are a couple Chiro’s that we closely work with and have a great professional relationship.  My hope is that this becomes the norm someday.

Below are some links you can check out for more info, but most are biased one way or another.  There is research being done by both fields, but PT tends to put a lot more money into research in general.

A rundown of the myths and pros/cons of PT and Chiropractic Care - http://www.flzine.com/physical-therapy-and-chiropractic-unraveling-the-confusion/

About PT and myths - http://www.squidoo.com/aboutphysicaltherapy

About Chiro myths - http://www.chiropracticawarenesscouncil.org/myths.html

How to Stretch Correctly: Dynamic versus Static Stretching

I haven’t had a patient yet that doesn’t know it is important to stretch.  But not many know why, and it seems even fewer know how to stretch correctly.  First, lets cover the why.  Most soft tissue injuries I see in the clinic involve either hyper or hypomobility, meaning there is either excessive or restricted motion in a joint.  This can be from something inside the joint like unusually lax ligaments (hypermobility) or something like scar tissue restricting the joint (hypomobility).  The greater population though, especially men, have limited flexibility/mobility due to muscle restriction.  And when you have limited mobility, it puts a greater strain on the muscle and surrounding muscles, which in turn eventually leads to injury through tendonitis or sprains and strains.

Before we get into the nuts and bolts of stretching, a quick example.  Limited range of motion at your ankle, due to tightened lower leg muscles, means you have to compensate at your knee and hip to walk as normal as possible.  This compensation puts extra, and unusual, stress on these joints and surrounding muscles.  This is how you can end up with low back pain from a recurring ankle problem, by constantly favoring and putting strain on muscles that aren’t used to it.

There is much argument on stretching, how effective it is and when to do it.  So check the links at the bottom for further reading if you’re so inclined.  But basically, stretching can be broken down into dynamic or static.  First, lets cover the better known, but poorly practiced, static stretching.  Static stretching is what it sounds like, holding a stretch without movement.  The typical runners stretch or hamstring stretch is usually the first to come to most people’s minds when they think of stretching.  The key to a quality static stretch is to hold it for at least 30 seconds, as research shows that less than that doesn’t really have a lasting effect, and more than that doesn’t seem to help you any more.  It is very important to not force a stretch and to not bounce.  You can take the stretch a bit further if you feel the muscle relax, but again, don’t force it.  For example, if you find yourself holding your breath, you’re trying too hard.

Dynamic stretching involves moving the muscle and joint through its full range of motion in a controlled manner.  Examples of this are running with high knees or leg swings like you’re kicking a ball.  This helps to bring blood flow to the area and prepare the muscle for activity.  This is especially important in high intensity and high impact activities, but is a good practice for any sport.  Many people do this without realizing it.  For example, many people will swing their arm in a circle a few times before trying to throw something, or golfers will take a few “practice swings” at half speed, in essence performing a dynamic stretch.

While there is research going both ways, it seems the current consensus is to perform dynamic stretching before your activity and static stretching after your workout for the most benefit.  Stretching is still very important where there is restricted motion, but just remember that you can overdo it or underdo it, so make sure you’re doing it right!

An article on dynamic and static stretching referencing several research articles - http://www.elitesoccerconditioning.com/Stretching-Flexibility/DynamicStretchingvsStaticStretching.htm

A research article comparing dynamic and static stretching - http://thesportjournal.org/article/effect-dynamic-versus-static-stretching-warm-hamstring-flexibility

What is Sciatica?

First off, before we get too far into this, it is important to note that sciatica is a set of symptoms and not a true diagnosis.  Just like how low back pain is a symptom, but can have many different causes, so is the case with sciatica.  And if you have it or have had it, you know it can be a real pain in the butt!

Lets start with some of the main symptoms of sciatica.  Most of the clients that I’ve worked with display a very typical pattern of pain.  It usually starts in the SI region – where the sacrum (base of your spine) connects to the ilium (wide brimmed bone of your pelvis/hips).  But it doesn’t end there.  It most often travels from there down into your butt, down the back of your thigh, and into your lower leg and foot.  It usually is a sharp, zapping type of pain (as nerve pain usually is), that can come on in any number of ways depending on the actual cause (which I’ll discuss below).  Since the sciatic nerve has a motor (muscle) component as well as a sensory (feeling/pain) component, there can be muscle and/or reflex inhibition as well.  This may show up as knee buckling or the feeling that your leg is just going to give out on you.  Most people experiencing sciatica only have the symptoms on one side, as pain in both legs probably signifies a different (and usually more serious) problem.

The hard part about treating all this is that there can be multiple causes, each with a slightly different treatment method and prognosis (chance for recovery).  If the problem is from degenerating discs in the spine (which can lead to spinal and foraminal stenosis), compressed nerve roots may be alleviated from a program designed to promote lumbar flexion and increase abdominal strength.  If the symptoms are due to a herniated or “bulging” disc, lumbar extension exercises may help to center the disc back and relieve the pressure on the nerve root.  Piriformis syndrom is caused because the sciatic nerve is entrapped underneath a tightened piriformis muscle.  This can be treated though stretching, gait training, and even something as simple as orthotics (custom or over-the-counter shoe inserts).

As mentioned above rehab will vary depending on the source/cause of the sciatica.  Often in the early/acute stage therapy will focus on abdominal bracing exercises, which focus on activating the transverse abdominus muscle.  The TA is the body’s natural back brace in that it provides support for the low back.  Other exercises will generally be performed in either a flexion biased (Williams) or extension biased (McKenzie) posture – click here for a description of each method.  Modalities like electrical stimulation or a TENS unit may be helpful in controlling pain levels and decreasing the need for pain medication.  Advanced exercises will focus on continuing to strengthen your abdominal muscles, as well as hips, legs, and even your back muscles.

Nerve pain can take quite awhile to get rid of.  Persistent sciatica will usually warrant further testing (MRI or CT scan) to determine if there is disc involvement.  Surgery is only recommended in serious cases or where long-term nerve damage is threatened (like severe spinal stenosis).  Most surgeons and neurologists will recommend injections and conservative measures like physical therapy before even considering serious measures.  Don’t lose heart, it may take awhile but you’ll get there.  Don’t give up.

Pub Med article - http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001706/

Web MD - http://www.webmd.com/back-pain/tc/sciatica-topic-overview

Wikipedia sciatica article - http://en.wikipedia.org/wiki/Sciatica

Piriformis syndrome - http://en.wikipedia.org/wiki/Piriformis_syndrome

Flexion vs Extension based rehab - http://www.backtrainer.com/Williams-Flexion-Versus-McKensie-Extension-Exercises-For-Low-Back-Pain.html