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Symptoms may or may not change

“It is clearly stated that the mechanisms underpinning any reductions in symptoms using the SSMP are not known”

The Shoulder Symptom Modification Procedure is studied and taught by Jeremy Lewis, out of England. I am a fan of this method because I like systems. Both systems that work and systems that tell tell the user when the system doesn’t work. I was able to watch Jeremy Lewis assess and treat patients on stage in front of a crowd of over 500 MDT trained clinicians. The patients that he treated were not just any patients off of the streets though, some of these patients were MDT trained clinicians that failed to improve with the MDT approach. When I saw that he was able to go from one patient to another and abolish symptoms over two days, I was sold!

I wanted to know what he was doing. After I got back from the conference in Austin, I emailed him to ask some questions. He was gracious enough to not only answer all of my questions, but to also send me all of his research and articles on SSMP.

I obviously read through the research and started using the format within my own MDT evaluations. I personally found that this method blends very well with MDT because aside from names, the principles were the same, but he provided additional information for treatment that wasn’t provided in the text booms or course work for MDT.

We know that patients get better. It may not necessarily matter which methods are used, but many patients improve with treatment. How they improve…we have no clue! No one can give the exact mechanism by which patients improve symptoms because there is not one mechanism alone by which symptoms are produced.

For all you reading at home, if your therapist is pompous enough to give you an answer that is an absolute, you may not need to find a new therapist, but you better watch your ears for they may be taking in false information.

“A common aim is symptom reduction,which, if achieved, allows the individual to move with less pain. How this is achieved is unknown”

For the most part, we all have the same goals. Get the patient better. Mind you, there are some that have goals clouded by $$$, but hopefully you find someone that is pure of heart.

I want my patients not only to be able to return to what they were doing prior to an injury, but to inspire them to do more. When a patient gets better, I’d love to take the credit, but I also know that Father Time is pretty good at what he does also.

In the end, the patients get better and we have to be able to say šŸ¤·ā€ā™‚ļø how it happens sometimes.

“Symptom reduction might not be possible, and attempting symptom change that does not achieve its goal may create hypervigilance or unreasonable patient expectations that ultimately become demotivating and sensitizing.”

We work in a team. We always work in a team. That team is either with the other professionals or with the patient. We can’t allow our biases to infect the patient and we must be vigilant to notice when our own preferences are frustrating the patient.

Enjoy! Any questions you can find me on FB at Dr. Vince Gutierrez.

Excerpts from here

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Frozen shoulder: when it doesn’t move

Frozen shoulder, when it doesnā€™t move.

 

Frozen shoulder is a common diagnosis in the clinic. I have seen this problem treated in so many different ways that some PTā€™s are able to drive Escalades. The problem is that not all treatments are created equal. Educate yourself on what the problem is and how it can and should be treated. Itā€™s your bodyā€¦understand it at least.

 

  1. ā€œFrozen shoulder, or adhesive capsulitisā€¦painful and limited active and passive range of motionā€¦reported to affect 2% to 5% of the general populationā€

 

To be frank, frozen shoulder means your shoulder is frozenā€¦it doesnā€™t move. Adhesive capsulitis is the medical term forā€¦your shoulder doesnā€™t move! If you take something that doesā€™t move and you try to move itā€¦it is painful. It is not as common as everyone would like to believe and honestly I rarely see it in the clinic. You can have a stiff shoulder and not necessarily have ā€œfrozenā€ shoulder. It affects those that are diabetic more often than those that arenā€™t, but aside from this, the reason for it is still not certain.

 

  1. ā€œThe absence of standardized nomenclature for frozen shoulder causes confusion in the literatureā€

 

We know some things for certain. Your frozen shoulder will go through stages from start to end, what we arenā€™t certain of is how many stages, and what do we call these stages?

 

  1. ā€œSecondary frozen shoulder was defined by 3 subcategories: systemic, extrinsic, and intrinsicā€¦secondary frozen shoulder related to insulin-dependent diabetes are more likely to have a more protracted and difficult clinical courseā€

 

If you have frozen shoulder because of some other problems, this is classified as secondary. If that problem is due to a body disease, extrinsic is due to an injury outside of the shoulder and intrinsic is a known problem of the shoulder.

 

  1. ā€œanother classification system based on the patientā€™s irritability level (low, moderate and high) that we (the authors of the journal article) believe is helpful when making clinical decisions regarding rehabilitation interventionā€¦Patients with low irritability have less pain and have capsular end feels with little or no pain; therefore, active and passive motion are equal and disability lowerā€¦typically report stiffness rather than pain as a chief complaintā€¦high irritability have significant pain resulting in limited passive motion (due to muscle guarding) and greater disabilityā€¦pain rather than stiffnessā€¦ā€

 

This is very easy to followā€¦walk with me. Your irritability is literally that, when you move how irritating is it? If it is not that painful and you have a capsular end-feel (only to be determined by someone that has moved thousands and thousands of shoulders so that it can be determined if the joint is normal or not very moveable), then it is lower on the scale of irritable. If your shoulder feels like a hot poker stabbing you in the eye and twisted every time you move the shoulderā€¦itā€™s probably highly irritable.

 

  1. ā€œrecent evidence identifies elevated serum cytokine levels as part of the process. Cytokines and other growth factors facilitate tissue repair and remodeling as part of the inflammatory processā€¦sustained inflammation and fibrosisā€¦although the initial stimulus is unknown.ā€

 

This is HUGE, for those that are nerdy regarding physiology. Tendonitisā€¦doesnā€™t exist. Thatā€™s a lie, but not far off. When you think that you have a tendonitis, by the time you see a doctor, it is probably a tendinosis. This means that after a short period of time, there are no longer inflammatory markers (chemical of inflammation) in the tendon. The fact that there is sustained inflammation isā€¦NO GOOD! Think about having constant cycles of inflammation going on in your body. It sounds painful. It is! Others have challenged the premise of adhesive capsulitis, in that the capsule itself doesnā€™t have the inflammatory markers. At this time, it is semantics, because the shoulder is still painful.

 

  1. ā€œ3 sequential stages: the painful stage, the stiff stage and the recovery stageā€ others have described ā€œ4 stagesā€¦the preadhesive stage, the acute adhesive or freezing stageā€¦the fibrotic or frozen stageā€¦the thawing phaseā€ these phases may take 12-18 months and ā€œmild symptoms may persist for yearsā€

 

Although we canā€™t fully agree on how many stages and how to describe the stages, we know that this is will take a long time in order to become fully functional.

 

  1. ā€œA full upper-quarter examination is performed to rule out cervical spine and neurological pathologiesā€

 

I canā€™t stress this enough. Just because your shoulder hurts, doesnā€™t mean that your shoulder is the problem. I refer to the spine as the great chameleon. It can mimic damn near any symptom that you experience in the periphery. If you donā€™t fully evaluate the spineā€¦or at least take a quick peekā€¦then you may be treating the wrong thing!

 

  1. ā€œtypically reveals significant limitation of both active and passive elevation, usually less than 120 degreesā€

 

Quick lesson, active elevation is your ability to raise your own arm. Passive elevation is your ability to allow me to raise your arm. Those with rotator cuff tears or issues typically have horrible active elevation, but passive elevation is much better and may be normal.

 

  1. ā€œScapular substitution frequently accompanies active shoulder motionā€¦ā€ and ā€œCyriax described a capsular pattern he believed diagnostic for adhesive capsulitisā€¦it is not consistently seen in patients with frozen shoulder when objectively measured.ā€

 

Scapular substituion is elevating the shoulder blade in order to perceive that your are raising your arm further overhead. I tell patients to look at the space between your shoulder and your ear. If there is a huge change in that space when raising your arm overhead, then something is wrong. Patientā€™s will understand this visual. Have them do it with their ā€œhealthyā€ side so that they can see how much space change actually occurs and then do it with the problematic side to compare.

 

Cyriax, think Alfred Hitchcock look-alike, is one of the greats that provided many thoughts in the infancy of our profession. His theories are still taught in school and we still have to memorize his paradigms for examinations. In real practice though, we donā€™t always follow his teachings becauseā€¦they arenā€™t always right. Each therapist will learn through seeing thousands and thousands of shoulders, that his patterns arenā€™t always right, but arenā€™t always wrong.

 

  1. ā€œAlthough authors of textbooks have described patients with frozen shoulder as having normal strength and painless resisted motionsā€¦revealed significant weakness of the shoulder internal rotators and elevators.ā€

 

In school we learned that frozen shoulder doesnā€™t affect strength. I am not sure if it is still being taught, but I have to believe so because the boards (think OWL exams from Harry Potter) are based on the text books and not on recent research. Regardless, theses patients do demonstrate weakness. In my opinion, this weakness may be related to disuse due to pain or pain inhibition, but that is a story for another day.

 

  1. ā€œSignificant loss of passive external rotation with the arm at the side, as well as loss of active and passive motion in other planes of movement, differentiates frozen shoulder from other pathologiesā€¦Early frozen shoulder may be difficult to differentiate from rotator cuff tendinopathy because motion may be minimally restricted and strength testing may be normalā€

 

Big pictureā€¦frozen shoulder will present with multiple losses of motion in many planes. Early frozen shoulder will still have ROM limitations, but not as bad as those that are in the second stage, which may make it difficult to see at first. The therapist/MD may not immediately recognize frozen shoulder and the treatment may be inconsistent with what is needed.

 

  1. ā€œThe definitive treatment for frozen shoulder remains unclearā€¦Establishing treatment effectiveness is also difficult because the majority of patients with frozen shoulder significantly improve in approximately 1 year; therefore, natural history must be consideredā€

 

In other words, we think we know how to treat it, but even if we donā€™t you will get better over time. Is it possible that you donā€™t need to come to therapyā€¦of course! Will you benefit from therapyā€¦of course! Even if the therapist is providing stuff that doesnā€™t workā€¦like ultrasoundā€¦the therapist should be spending adequate time with you in order to educate you regarding the condition and the overall prognosis. If your health care provider is not doing thisā€¦walk away! There are therapists on almost every corner if you look hard enough. Find one of quality.

 

  1. ā€œExplaining the insidious nature of frozen shoulder allays the patientā€™s fear of more serious diseasesā€¦prepares the patient for an extended recoveryā€¦because daily exercise is effective in relieving symptomsā€

 

This is my primary jobā€¦education. I gave up a career, as a teacher because I felt the system was broken. It is too hard to teach a group of kids when I had to cater to lowest common denominators. In this profession, I am still a teacher, but I only have one studentā€¦the patient in front of me. If I can teach you everything you need to know in one visit and you will go out and be the perfect patient, I may never have to see you againā€¦for this at least. Most patientā€™s canā€™t absorb everything and may not be overly compliant after the first visit, so more visits will be needed. My hope is that the frequency of our meetings will decrease over time as the patient takes more ownership over lifestyle changes and exercise performance. Alasā€¦sometimes it never happens.

 

  1. ā€œLittle data exist supporting the use of frequently employed modalities such as heat, ice, ultrasound, or electrical stimulation.ā€

 

If this comprises a majority of your therapyā€¦ā€Houston, we have a problemā€. Iā€™ve said it before and Iā€™ll continue to stand on the soap box. Health care is a business. All businesses need to keep the doors open and it would be nice if there was a profit at the end of the day. This means that you will be charged for unsupported treatments because of the following reasons: 1. Patients expect this, as this has traditionally been sold as physical therapy 2. It feels good 3. It pays well.

 

  1. ā€œGursel et al demonstrated the lack of efficacy of ultrasound, as compared to sham ultrasound, in treating shoulder soft tissue disordersā€

 

It is no better than a placebo! If you would pay for it out of pocket, then I would rub some lotion over you with an ultrasound and then tell you that it is not effective. Would you still pay for it? If the insurance covers it thoughā€¦why not? I will tell you why notā€¦it takes up valuable time that I could be focusing on something more effective.

 

  1. ā€œThe basic strategy in treating structural stiffness is to apply appropriate tissue stressā€¦think of the total amount of stress being applied as the ā€˜dosageā€™, in much the same way that dosage applies to medicationā€¦adjusting the dose of tissue stress results in the desired therapeutic changeā€

 

Tissue stress is anything that stresses the tissue. I know that it sounds simpleā€¦DUH. It is. I can stress the tissue by squeezing the tissue, stretching the tissue, forcing the tissue to contract against an outside force, but in the end, I need to provide the ā€œappropriate tissue stressā€. If the tissue is shortened, then it needs to be lengthened. This occurs by stressing with stretching. You will have to follow a prescribed set and repetition scheme at a specific interval frequency, which will be given by your therapist. Typically this is performed no earlier than every 12 minutes and no later than every 3 hours.

 

  1. ā€œThree factors should be considered when calculating the doseā€¦intensity, frequency and duration.ā€

 

Think of these as variables. Any good scientist knows that the best way to find the variable most important is to only change one variable at a time. If the patient presents to therapy and is not making progress, then I can change any of the three variables. I will choose to change the variable that 1. Best fits with the patientā€™s schedule 2. Gives me the lowest chance of making the patient worst 3. Gives me the predicted best result. All in this order. If I give you an exercise that you canā€™t do, then it doesnā€™t matter if I believe that it will help you. For instance, if I give you an exercise that needs to be done lying, but you work in a sewer system, you may not like me after the exercise.

 

  1. ā€œAggressive stretching beyond the pain threshold resulted in inferior outcomes in patientsā€¦tissue stress is progressed primarily by increasing stretch frequency and durationā€

 

Going to therapy 3 days per week and expecting the therapist to get you better is a pipe dream. If you only go to the therapist for stretching, then the intensity will be high. This will result in an inflammatory effect, in which you will not want to/be able to move your shoulder. At this point, the stiffness will worsen. Be smart and move to tolerance. If you are worse for more than 20 minutes after stopping, you made a mistake and went too intense (there is research to support this timeline, but I donā€™t have it onhand).

 

  1. ā€œPatients with the worst perceptions of their shoulder before treatment tended to have the worst outcomes.ā€

 

Butterflies and rainbows. If you think you are disabled, then you are. Please move. PSA.

 

  1. ā€œMany authors and clinicians advocate joint mobilization for pain reduction and improved ROM. Unfortunately, little scientific evidence exists to demonstrate the efficacy of joint mobilization over other forms of treatment for frozen shoulder.ā€

 

I can easily spend 20 minutes mobilizing your shoulder and small talking about the weather, politics and religion. How else are we going to talk for 20 minutes?! Thatā€™s a long time for me to hold your arm. I need something to pass the time. The evidence is conflicting regarding me pressing on your shoulder to try to free up some room. I do mobilizations sparingly. They are good to know and if nothing else is working, then sureā€¦why not do them? If something else works better, then thatā€™s why I donā€™t do them often.

 

  1. ā€œimproved extensibility of any portion of the CLC (joint capsule) results in improved motion in all planes.ā€

 

I love using this example in the clinic: There was an episode of Seinfeld in which George and Jerry were staying in a fancy hotel. George went on this rant regarding tuck vs no tuck. Big pictureā€¦when the sheet is tucked in too tight, it is impossible to move your feet. You have to loosen up the sheets by kicking at them. Once youā€™ve loosened it up a little, it seems to free up a ton of room everywhere. This is the circle concept of the shoulder.

 

When we loosen up on aspect of the capsule, then the laxity that is created just moves around the capsule through additional mobilizations. We donā€™t actually stretch out the capsule in multiple planes.

 

  1. ā€œAt 7 weeks, 77% of the patients treated with injections were considered treatment successes, compared to only 46% treated with physiotherapy.ā€

 

Hell, this stat makes me want to advise patients to do this first before seeing me…or start gambling for the night. Does anyone else see the 777?

 

  1. ā€œThe core exercises include pendulum exercise, passive supine forward elevation, passive external rotation with the arm in approximately 40 degrees abduction in the plane of the scapula and active assisted ROM in extension, horizontal adduction and internal rotationā€

 

We spend a fair amount of time discussing this diagnosis in PT school. I wish they had just covered this type of study so that we would know the way to treat this type of patient, instead of all of the theories and possible ways to treat this patient. It is good to have understanding, but it is better to have successful outcomes.

 

Excerpts taken from:

 

Kelley MJ, Mcclure PW, Leggin BG. Frozen Shoulder: Evidence and a Proposed Model Guiding Rehabilitation. JOSPT. 2009;39(2):135-148.