In the View last week, I told the story of Johanna who had determined her mother lived in her shoulder (and for those of you have not read or may be not as familiar with Blindsiding Broca, read the Visioneer View "Our Buddy Broca Part 1&2" from our web site under the archives section. Johanna used all of the principles outlined in those two Views in describing her conditon to me). We learned she had a "Frozen Shoulder" and also learned about the nature of the disease. The story ended with an invitation to come back and learn about the three dimensional solution for the Frozen Shoulder - the topic for this week.
All musculoskeletal conditions of the human body have at least three dimensions in which they manifest themselves: pathophysiologic, pathomechanical and psychodynamic. I think of these dimensions as three intersecting circles and its the interplay between these dimensions which creates difficult cases.
As an example, the three circles of the client with a Frozen Shoulder are the following:
1. Pathophysiology - the disease process is an inflammatory reaction of the synovium and surrounding soft tissues creating more pain than loss of movement in the initial stages of the disease. Accompanying the inflammatory reaction is an apparent disturbance in the sympathetic nervous system. There appears to be a relationship between the onset of the disease and onset of menopause implying a possible hormonal connection. To date, the evidence suggests a combination of a hormonal and sympathetic nervous system changes as the etiologic factors.
2. Pathomechanics - the person with this disease will not have a normally moving shoulder due to the pain and gradual loss of tissue extensibility. The scapula will move well before it should during lifting of the arm. Nearly all motions of the shoulder are affected.
3. Psychodynamics - the person with a Frozen Shoulder often has high levels of anxiety, may have mild to moderate levels of depression, is typically a woman in the 40-60 age range, a high achiever, and has recently experienced an increase in stress either positive or negative.
The question I am asked the most at Techniques, Tools and Tips for Tough Patients or at SportsCenter about frozen shoulder is "what do you do"? Here are the five things I do at the beginning or "freezing" stage of rebuilding the person with a Frozen Shoulder.
1. Women nearing menopause should consult with their physician regarding analysis of hormone levels and options to achieve optimal balance.
2. All movements of the body should create a sense of relaxation and well being. At least part of the disorder involves the sympathetic nervous system. Reducing the sympathetic tone will reduce the magnitude of pain.
3. Use a light, assistive, repetitive, motion performed at regular intervals through the day (every 2-3 hours) in positions of comfort. I avoid over stressing the shoulder especially in the initial stages. I use an OnX - a tool which combines elastic tubing with a pulley to help clients move their arms easier (http://www.gyminabag.com). For example, Johanna attaches the elastic end of the OnX in the door frame and lies down on the floor with padding or pillows under her head and knees. She then performs a variety of motions with her arms: circular, up and down, side to side in any sequence or combination she chooses. She moves through a range of motion which is comfortable to her. She performs this drill for 3-4 minutes then rests for 1-2 minutes and repeats. While doing this, she closes her eyes and imagines her shoulder moving gracefully through the air. With each motion, she "sees" herself moving with greater and greater ease. The imagery utilizes descending pat hways from the brain to lower the sympathetic activity.
In the second stage of the disease, the shoulder has "frozen". Johanna will hurt less but will feel more restricted in her motion. Her glenohumeral joint will have lost the ability to rotate freely. I focus on rotation in the transverse plane first since it is often the most difficult to regain. To improve the motion, I do the following:
4. In a standing position with feet staggerred, hold onto a rod about 2 inches in diameter and 6 feet long with the frozen shoulder side. Place the rod mid way between the side of the body and the front of the body (in the plane of the scapula). Grip the rod at a height that is just shy of the comfortable range of motion for the shoulder (we call this the "Moses" drill). Now the fun begins. Put on some music, use a cd player/walkman. The music should inspire movement. Something that makes you want to dance even if you cannot. To the beat of the music, reach under the arm holding the rod turning the entire body. swing the the arm under the arm holding the rod and then back up and out to the opposite side. Over and over. Keep swinging the arm while maintaining the rod in an upright position. This motion creates a rotation in the glenohumeral joint but includes all of the body. The sensory input from the music both distracts the brain from any pain signals and also cre ates a motor cascade recruiting muscles in a more functional manner. Johanna will do this for several minutes at a time for a total of 20-30 minutes. Her joint needs to move and the capsule needs to be stressed. To frob this drill, adjust the angle of the rod, the height of the hand, change the music, add forces against the body, alter the base of suport, or stand on one leg. Adjust your expectations to match those of the body. Remember, dense connective tissue changes slowly at only 3-5 degrees per week at best. Be patient.
5. Manage the mind. The brain is the great interpreter and can easily become filled with the dark cloud of doubt. Johnna needs to know she will get better and needs frequent, positive praise for her efforts and determination. Nothing extinguishes the fire of desire like isolation and doubt. This is what makes the recovery process so challenging. If I become impatient, Johanna will immediatley sense it and feel the same way before I can even blink. As a good friend of mine once said, "In the ER, take your own pulse first." Your calm, confident attitude will be infectious. Watch for words of doubt, despair, frustration and slowly begin carving them out of her vocabulary. Gentle reminders for a positive mental push.
Thawing a Frozen Shoulder is possible. Come back next week to discover how long the journey takes and what to expect along the way.
Make today count.
Doug Kelsey
Author. Teacher. Therapist.
