38: Frozen Shoulder & Adhesive Capsulitis: Updating our Approach
Episode Transcript
Summary: Whitney Lowe & Til Luchau give a crash course on frozen shoulder/adhesive capsulitis, discussing recent research and comparing their respective views and strategies. Download the free handout with detailed episode notes, techniques and tests, and join them at the upcoming Shoulder Jam event via Whitney or Til’s sign-up link.
Episode topics include:
- Types, terms, stages, and debates
- Who gets it, why, and what makes it stiff?
- What can we do about it, from biomechanical and biopsychosocial perspectives?
Whitney Lowe:
Welcome to The Thinking Practitioner. Hi, this is Whitney Lowe. ABMP is proud to sponsor The Thinking Practitioner Podcast. ABMP membership gives massage therapists and bodyworkers exceptional liability insurance, numerous discounts, and great resources to help you thrive like their ABMP podcast, which is available at abmp.com/podcast or wherever you happen to listen.
Til Luchau:
I’m Til Luchau. Even if you’re not a member, you can get free access to Massage & Bodywork magazine where Whitney and I are frequent contributors and special offers for Thinking Practitioner listeners at abmp.com/thinking. Hey Whitney, how are you doing there? What’s going on?
Whitney Lowe:
I’m doing mighty fine, sir. It’s good to talk with you again. We are doing a second episode, I believe on some shoulder stuff today. Is that correct?
Til Luchau:
Yes. I’m looking forward to that. In celebration of you and me both being part of The Shoulder Jam, we thought we would focus on the shoulder. Today we’re going to talk about what? What are we going to talk about, Whitney?
Whitney Lowe:
Well, we’re talking about the mysterious mythological world of frozen shoulder.
Til Luchau:
Frozen shoulder.
Whitney Lowe:
Yes. What is it? What is it not? How do we figure out what to do about it? How do we deal with it? So big dilemmas there with this particular condition. Lots of debates and concerns and discussions in the literature about what it is and how to grapple with this challenging condition. We’ll dive into that a little bit today.
Til Luchau:
Great. Well, I’m not doing so good at following the outline, so I’m jumping around a little bit. But I want to make sure that I mention that there is a handout for today if you’re listening. Please go download the handout from Whitney’s site or my site. We’ll put the link in the show notes and then we should give a plug to The Shoulder Jam. We’ll put links there on our sites as well. It’s coming up in May if you’re listening to this soon after we broadcast. Or it’s going to be available by recording too later if you’re listening to the recorded version later.
Whitney Lowe:
Yeah. Just so that you know what that is, actually, it’s an online presentation. It’s going to cover several days with a number of different practitioners all focusing on shoulder issues. It’s a primary focus on that particular body region with lots of good stuff from people around the globe that are going to be participating. I’m looking forward to seeing what they got out on there.
Til Luchau:
Likewise. Check us out. Whitney, what is frozen shoulder? Don’t a lot of things get called frozen shoulder. What are we talking about here?
Whitney Lowe:
Yeah, absolutely. This is one of those things where it’s really difficult to nail down exactly we’re dealing with because when you get a common name like this, it gets batted around a good bit. A lot of people will have a limitation in their range of motion in their shoulder and say, “I’ve got frozen shoulder.” Or somebody will tell them you have frozen shoulder because you have this particular type of range of motion limitation. In our last episode, which was number 37, we dove deep into subacromial pain and talked about how that may significantly limit motion capability in a lot of different planes of the shoulder. That’s the kind of thing that could be easily mistaken for frozen shoulder. There are some instances where this actually involves some anatomical structures in particular, the glenohumeral joint capsule. We’ll dive into that in a bit more detail. Sometimes this is a problem involving the joint capsule where it’s more technically referred to as adhesive capsulitis.
Whitney Lowe:
Which also has its own problems with the name, and we’ll talk about that some more. Then sometimes it’s just more of a range of motion limitations, some specific directions. But very, very painful, very problematic for people who are grappling with that.
Til Luchau:
Okay. You find it a useful distinction to think about frozen shoulder or adhesive capsulitis as this discrete thing. You’re going to share with us how we might be able to tell and then you also will give some ideas for working with that. Sounds good?
Whitney Lowe:
Yeah. That’s where we’re going to hit. I do want to make one other distinction here that often is talked about in the descriptions of this condition. Then we’ll sort of move into talking about some of the characteristics of it in these different phases. But there is often a distinction made between what’s called primary frozen shoulder and secondary frozen shoulder. The primary is often what we refer to as idiopathic, meaning we don’t have a really good explanation for why it occurs. This seems to just occur out of the blue many times without a particular inciting factor or anything that’s sort of started it off. The secondary frozen shoulder is one that often occurs as the result of some other type of problem. For example, after a shoulder surgery or after another shoulder injury, where there is … Maybe let’s say you’ve had acromio-clavicular joint injury and you have to keep your shoulder in a sling for a couple months. Keeping the shoulder in-
Til Luchau:
Immobile.
Whitney Lowe:
… immobility for long periods of time, that’s secondary to the other injury, you will develop frozen shoulder as a result of that. That is kind of a clear, important distinction that we often hear about.
Til Luchau:
It’s important for me as a therapist because I may not always agree with the conventional distinctions between primary and secondary and my way of thinking about it. But I think if I think about “adhesive capsulitis” or frozen shoulder as its own thing, something just arises on its own without another cause, that actually makes me think about it differently. There is some interesting models or narratives or even evidence that says it’s almost more like a disease than an injury often that-
Whitney Lowe:
Yeah. I find that fascinating. I heard another description of it speaking of it as an underuse syndrome as opposed to an overuse syndrome, which I thought was an interesting way to refer to this. Because it often develops because of prolonged periods of immobilization or prolonged periods of disuse in that glenohumeral joint.
Til Luchau:
Right. Then if only if it’s that simple, if we could pin it down to one thing, it would be a lot clearer. But yeah, sometimes it does seem to be underuse. There are times, like you said, that it can be secondary to a period of immobilization or even an injury. There’s a whole bunch of other things that might play into that, that we’re going to discuss.
Whitney Lowe:
Yeah. Historically, from the time that this was first described, there have been some descriptions of this condition involving several different phases of it when we talk about frozen shoulder. What are those phases?
Til Luchau:
It’s helpful to understand that any given client doesn’t always follow these phases. Then like you had said, Whitney, there’s a lot of things that get called frozen shoulder that may not fit this model at all. But classic adhesive capsulitis or frozen shoulder in that subset of people that we can put there often do seem to follow these three classic phases. With the first one being what’s called the freezing phase. Which is probably inflammatory, although there’s sometimes debate about that. But there’s some decent evidence that there’s inflammatory factors involved in that. The pain quality there will be distinctive. It’ll be achy, it’ll be irritable, but really the key indicator there when you’re working with it, with your client or experiencing yourself, is that it will flare up. Then if it gets painful, often the pain will linger. It’ll stick around. So that pushing it too hard, doing too much with it, or getting a bodywork say that’s too aggressive, could make the pain worse.
Til Luchau:
That pain often sticks around. That’s a sign that this immobilization could be in the freezing or inflammatory stage. It’s probably … None of these phases are fun, but this is often the least fun of the stages. Because it’s really hard to sleep on a shoulder that’s that painful and that motion restricted. The sleep disruption itself doesn’t help you deal with that inflammatory process or whatever it is that’s causing that pain or feeding into that pain. Then there’s also a lot of disagreement around how long these different phases last. Everybody says that there’s a variety, but then even there’s a lot of variety amongst the variety of people give in the sources. I went back and reviewed it before our podcast. It could be as short as six weeks for this freezing stage, but other people say it could be as long as nine months for this freezing stage. Does that fit with how you think about it?
Whitney Lowe:
I noticed that as well. It is, yeah. I notice the same thing as well, that there’s a lot of variability in those timeframes. For that reason, it’s something that we have to kind of take with a bit of a grain of salt. I was also just going to make this one other comment. I assume this doesn’t really need to be stated, but I think it’s worth at least stating again. That note that these three phases have descriptors all having to do with things that are thermal related, freezing, frozen and thawing. But please do understand there is no thermal component to this condition. It’s just a sort of a metaphorical thing that we’re talking about there.
Til Luchau:
Then you hinted at this, but even when we call it adhesive capsulitis, maybe that’s a metaphor more than an actual histological finding. So that we have these metaphorical ways to talk about it, frozen shoulder, adhesive capsulitis, but we need to suspend for a second our decisions about what might actually be going on there as we go through these descriptors of the phases. The next phase after the “freezing” phase, that initial inflammatory phase, would be the “frozen” stage. Where it’s often still painful, but the pain might not linger as long. It can still get irritated or flared up, but it’ll typically resolve a lot quicker. Which is a signal that the inflammatory processes are starting to resolve some. But often it’ll still be pretty stiff. Sleep can still be difficult, but often it’ll be getting better. You won’t always be woken up every two hours like you can be in the freezing phase. Then the timeline that’s often given for that is anywhere from four to six months beyond that initial inflammatory stage.
Whitney Lowe:
We will be making some distinctions a little bit later on in our discussion here between sort of structural and functional differences in terms of what might be causing this. Some of those can have an impact on how long those stages go and the way in which a person experiences those stages as well. Those are just other variables they get added into the equation that make those things hard to pin down, I think.
Til Luchau:
Okay. Well, I look forward to hearing your thoughts on that. Ready for the third stage?
Whitney Lowe:
Yes, let’s have the third stage.
Til Luchau:
Third stage is the thawing stage. Third and hopefully final stage is the thawing stage where it will be more stiff than painful. There’s still movement restriction say, but it’s often getting less and less painful. Although it can still be a certain level of discomfort for sure. But the big thing is that there is a sense of improvement. Although, I got to say too, there’s an exception there too. This can be a plateau that can go on for the classic times, given anywhere from six months to two years. But there is reasonable evidence that a lot of people spend an indefinite amount of time here, either in that phase two phase, the frozen painful stage or in this thawing stage where it’s more stiff than painful. But for a good number of people, this is a sign that it’s drawing to a resolution of it, at least to a major degree and that’s that improving. The sleep gets better and things like that. Those are the three phases, the freezing, frozen and thawing. Then in the best of all worlds, you live happily ever after. You’re thawed and you’re good.
Whitney Lowe:
That’s right, yeah. One of the things also that I found interesting, I ran across some discussions about this, that these phases and especially the length of that thawing phase at the end of it being somewhere around two years, there’s been a lot of discussion in the literature saying that frozen shoulder is something that just runs its natural course with most people and will generally resolve within about two years. One of the other authors that I was reading saying, they looked into this and doing sort of an overall review of a lot of different studies found that that actually isn’t true or isn’t consistent in a lot of the different cases. Like you were just saying a moment ago, this can often go on for a very long period of time and it’s not necessarily going to just naturally dissipate on its own. It may do that in a certain number of people, but that’s not something I think we can count on happening with them.
Til Luchau:
I think you’re talking about Wong, 2017, who said that, yeah, there’s this thing we’ve been telling our patients for years. He’s a physiotherapist. That there’s a natural history that it runs its course, that you got to be patient. For a good number of people, that’s true. But his meta-study, his metaanalysis of different reviews say that actually there’s a whole lot of variability and there is a pretty sizable group of people that it doesn’t seem to even follow that two year time cycle that it keeps on being painful for people. But I’ll put a reference to that in the show notes.
Whitney Lowe:
Yeah. Good. Those are some of the characteristics on those different signs or those different phases of it as well. We also drilled down and got some more specific stats on who is particularly vulnerable to this because there are some categories of people. Again, I would just want to emphasize this is really helpful information to be pulling out and another really good reason why a detailed client history is so important, so valuable. Because there are some interesting things that we’re going to get into here in just a second, talking about some of the characteristics of who gets this problem. Some of these things won’t come up if you don’t dig deeply with your inquiry in the history. That’s a good reason to look into some of these things and make sure you’re asking those questions to probe deep enough for some of the background factors that might be present with people.
Til Luchau:
I’m with you. In spite of-
Whitney Lowe:
[inaudible 00:14:50]. Yeah.
Til Luchau:
Well, in spite of the fact that we just said that the timelines are really variable, that is such an important question, how long has this been going on? At least you can begin to make your working hypothesis about where they might be in the cycle.
Whitney Lowe:
Yeah, absolutely. What are some of those statistical factors of who happens to get this?
Til Luchau:
The incidents rate that’s often given is somewhere between one and 2% of people overall. Although there are so many things that are called frozen shoulder. It’s a little hard to say. But one or 2%, it sounds pretty small, but actually that’s a good number of people. That’s one in 50, one in 100. Which means you’re going to probably encounter several of those people a year in a medium-sized practice. It tends to be four times more common in females between the age of 50 and 65 than in other populations. Some of those people that have the adhesive capsulitis/frozen shoulder have a history of surgery for the shoulder. There’s a theory that perhaps it was an coinfection that happened during the surgery that started the inflammatory reaction or an inflammatory reaction to the physical trauma itself. I think there’s probably more support for the infection thought now than there is for the mechanical. Although that varies quite a bit. There’s still quite a bit of people there thinking the mechanical factors are important. But maybe I’m just talking about my own thinking.
Whitney Lowe:
Yeah. I want to also backtrack for just a moment here and what you said before with it being four times more common in females. Because I’ve always asked this question and I’ve been asked this question numerous times by our students, what is the reason for this? I, at least in my perusing through the literature have never been able to find any good explanation for why that is so much more common in females. I don’t think we have a really good understanding of it. We just know that that happens to be the case.
Til Luchau:
Yep. I don’t know either.
Whitney Lowe:
Yeah. Anything that you’ve encountered? Yeah. Okay.
Til Luchau:
No, I don’t. But I’ve seen that. If I think back on the people that I think probably had this category of condition going on, they are maybe all female, the ones I can think of. Not to say that men don’t get it. Even if it’s four times more likely, that means that there’s a lot of guys that deal with this. But the classic demographic is female and they get on that middle aged 50 to 65.
Whitney Lowe:
Right. Yeah.
Til Luchau:
You mentioned periods of immobilization being a contributor. Paul Ingraham, who does the painscience.com website, he has a very thorough collection of the research on it. He does a really good job as usual with kind of laying out some of the theories and ideas about it. I just got to give him a kudos there and along with the caveat that he’s really good at I think distinguishing when he’s talking about his opinion and when he’s talking about the evidence. But they’re both woven in there and I don’t always agree with his opinions, but I love his thoroughness in his research. He has a theory that injections either even a vaccination injection, if it does somehow compromise the joint capsule, could introduce skin bacteria and initiate that inflammatory reaction. He says, this is conjecture and have no evidence, but that’s an interesting thought.
Whitney Lowe:
Yeah. I was going to mention, this is interesting, I was reading the similar thing of the stuff on Paul’s site and about the injections. I just got through with my second COVID vaccine two weeks ago. I have developed what feels to me like a capsular restriction weirdly enough, in my elbow. When he said that about the injections, I thought, “Wow, that’s really interesting.” Because what I feel is, I can’t straighten my elbow out completely. I get a pull on the anterior side of my forearm. Then when I’ve tried to flex it fully, I get a pull on the backside, on the posterior side of my elbow. It feels like the capsule is restricted in both directions. It feels deep. It doesn’t feel muscular. It really feels like the deep connective tissue in there, and I just thought, “Wow, I wonder if that’s related to the injection.” Because there are so many kind of weird side effects that people that [crosstalk 00:18:58]-
Til Luchau:
There are quite a few.
Whitney Lowe:
… to be reporting from the COVID injections too. Yeah.
Til Luchau:
Well, okay. Since you’re your own guinea pig, do you think that’s mechanical or inflammatory?
Whitney Lowe:
My guess would be it’s inflammatory. It’s-
Til Luchau:
It’s a trick question, by the way. [crosstalk 00:19:11]-
Whitney Lowe:
… something having to do with inflammatory.
Til Luchau:
I’m sorry. Yeah. Inflammatory. Yeah, no, I’m with you. I’m with you being inflammatory.
Whitney Lowe:
Right. That’s my guess.
Til Luchau:
With mechanical correlates is how I think about it. That it probably wasn’t the mechanical puncture or the injury to the fascia let’s say that caused the stiffening. It was probably … Who knows what the mRNA itself or who knows somehow a reaction that is [crosstalk 00:19:31]-
Whitney Lowe:
Yeah. Well, the thing that was weird is, yeah, I got the shot in my shoulder and it’s my elbow that has the problems. Yeah, that’s why it seems to be kind-
Til Luchau:
If I was to-
Whitney Lowe:
… reactive inflammatory.
Til Luchau:
… speculate , we can say maybe it doesn’t even require a puncture of a capsule. Maybe just an inflammatory reaction somewhere nearby could initiate some stiffening response. I think that’s pretty common in the short term. But when we get … I’ll check with you next episode and see how that’s doing. But if it were to go on longer, then we would start to call it a condition and such, but I think there’s lots of those kinds of things that happen in reaction to different things.
Whitney Lowe:
Yep.
Til Luchau:
Well-
Whitney Lowe:
Well, what else we got there?
Til Luchau:
Well, more … This is interesting. The non-dominant arm is more commonly affected. If you’re right-handed, it’s more often your left shoulder. It’s usually one sided condition, but it can definitely affect both sides at once in some people. Then it’s interesting too, that if you’ve had it in one shoulder, you are more risk of developing in the second shoulder as well. Which also starts to suggest maybe it’s not a mechanical primary cause that’s causing the frozen shoulder in those people at least. It is a lot more common in conjunction with other systemic diseases. Like 12% of people with diabetes get frozen shoulder at some point and 30% of people with frozen shoulder/adhesive capsulitis are diabetic. 30% of the people that have that condition are diabetic. There’s also things like thyroid issues, cardiac disease, Parkinson’s. Then a lot of speculation about other chronic, low grade, systemic inflammation conditions like metabolic syndrome and other kinds of things like that contributing to people’s shoulder symptoms.
Whitney Lowe:
Yeah. This is one that I find really fascinating. I mean, there’s certainly like when you look at all those statistics and a number of those things all having something to do with sort of metabolic components, this is one that just really makes me ponder what the connection relationship is there and why the glenohumeral joint. Why does it go there and not seem to affect other joints to the same degree? It’s puzzling.
Til Luchau:
Well, yeah the why does it go there is a really good question. Then even maybe more puzzling is why now? I mean, after something like an injury that’s obvious or after a period of immobilization is obvious. But then there’s other times it just seems to happen. We don’t know why. That actually in my way of thinking, I’m starting … Not that there’s clear categories, but the when question I think is probably a psycho-social question. The where question might be the biological question. Sorry to draw distinctions that probably don’t belong there. But why now? I’m thinking of there’s so many factors, including a psychological profile that’s been done for people with adhesive capsulitis. This is one study, so I don’t think this is widely accepted. But this is a study that’s just published last year, Chiaramonte of Italy had 76 adhesive capsulitis patients and they gave them various psychological profile instruments that are pretty well validated. It seemed like at least a decently designed study.
Til Luchau:
My first clients had it. But they showed that a pretty clear psychological profile of people with primary adhesive capsulitis, that it’s people that it just arose on its own without an injury or something like that. They said that there’s a prevalence of perfectionism, low levels of novelty seeking, and high levels of harm avoidance in that population, quite significant statistically in that group of people with primary adhesive capsulitis. I find that really interesting.
Whitney Lowe:
Interesting.
Til Luchau:
Yeah, it is interesting. I want to, for sure, stick in the caution that we don’t know what that means. They did in their study design correct for pain in general. They attempted to correct for that. It’s not like … Of course people in pain, they’re going to avoid novelty. They’re going to avoid harm just because they have pain. But their control group had pain too as well, so it’s just this points to the fact that there are some other probably non-mechanical factors involved as there are in a lot of inflammatory reactions. It’s a kind of reactivity that for sure is metabolic, it is physical and it probably is psychological. Our psychological immune system and maybe even beyond into collective responses too that might have parallels all the way through.
Whitney Lowe:
Yeah. It was fascinating what doesn’t it reach into? It seems to reach into all of these different things, metabolic things, connected tissue problems. You had mentioned also to the very high correlation with Dupuytren’s contracture also, which is kind of interesting, I think.
Til Luchau:
50% they say of people with adhesive capsulitis also have Dupuytren’s or Dupuytren’s, which is the stiffening of the palm fascia as well, or cords in the palm of your hand. You can make what you will out of that, but it suggests that there is some sort of systemic connective tissue reactivity or perhaps disorder that the shoulder joint is part of.
Whitney Lowe:
Yeah.
Til Luchau:
Any other points you want to make about who gets it with-
Whitney Lowe:
Yeah. I think that covers the majority of things that we want to look at. I also did run across one mention too that had said that there was some correlation with obesity. Which to me kind of goes into a lot of these other metabolic factors, I think. We’re looking at overall things that may be related to some types of systemic metabolic things and lifestyle things that are all factored into-
Til Luchau:
Smoking [crosstalk 00:25:02]-
Whitney Lowe:
… the likelihood of developing this. Yeah.
Til Luchau:
That’s right.
Whitney Lowe:
Yeah.
Til Luchau:
Why does it get stiff? Do we know why adhesive capsulitis or frozen shoulder even gets stiff? We know the mechanism?
Whitney Lowe:
Yeah. This is another one of the things that’s really kind of puzzling and difficult to sort of nail down. But what we do see now is sort of a distinction being made between what we refer to as structural causes versus functional causes. Looking at the sort of structural condition first, this is the one that would more characteristically be defined as adhesive capsulitis. Where there is a pathology of some kind with the joint capsule, the glenohumeral joint capsule itself. Now, formerly there was a lot of narrative around this that described the very fact that when the shoulder is in a neutral position, just because you have such a great range of motion in the shoulder, there’s a lot of sort of slackness to the underside of the glenohumeral joint capsule when you’re in a neutral position. So that when you raise your shoulder out in full flection or in full abduction, that the slack and tissue on the underside becomes taut. That there’s got to be enough room for it to move and sort of stretch out and lengthen. It’s got to be kind of …
Whitney Lowe:
You can envision this as just sort of a fold in it to allow it to come back to a neutral position since it is a non-contractile tissue. But the original descriptions often described that we were having an adhesion that was sticking together the fold in that inferior glenohumeral joint capsule and that’s what was causing the restriction in adhesive capsulitis. Some of the more current descriptions that I was running across now are saying, we’re not seeing so much that that adhesion of the fold as we’re seeing something that seems more like a sort of a shrinkage or kind of well, essentially a contracture of the glenohumeral joint capsule of sort of fibersly contracting to prevent the full range of motion in there. That seems to be what some of the tissue pathology may be associated with in adhesive capsulitis.
Til Luchau:
I remember some pretty detailed debates about exactly which part of the joint capsule or which which ligaments were involved. But again, the more recent sources I went back and reviewed getting ready for our conversation, they’re avoiding that. They’re saying, well, there’s so much variety and there’s so much debate that maybe it is non-specific contracture of the entire capsule say more than a particular ligament. Classically, we used to say it was the anterior part of the capsule say that would inhibit external rotation. Well, that’s true in some people apparently, but maybe not in everybody.
Whitney Lowe:
Yeah. Those are some things that we can kind of think about as guidelines, but again like you said, it may be really somewhat unique among everybody and some of those things may not … Those patterns may not fall through as easily. But we have this structural one, that’s the connective tissue problem. Then there’s a very large percentage of these people, which seem to have what’s referred to now as sort of a functional frozen shoulder. Which seems to be a lot more of a neurological problem where there is excessive muscle guarding and muscle restriction, so that your joint range of motion is limited significantly, but predominantly by neuromuscular involvement. For example, we are having muscle tendon units that are being sort of hyperactive and preventing certain types of movement in these specific planes. To emphasize, we’ll talk about this a little bit more in just a moment, but we do tend to see some characteristic patterns with these external rotation of the shoulder being usually the motion that’s limited the greatest. Then abduction also limited very significantly.
Whitney Lowe:
In some of these people, not quite as many, a bit more limitation in internal or medial rotation. But those patterns of restriction oftentimes can be indicative predominantly of muscle involvement, which we found very interestingly. You referred to this too, of the fact that we have a lot of these people who were anesthetized and who had diagnoses of frozen frozen shoulder. Then under anesthesia, you were able to move their shoulder around very easily. There wasn’t some binding contracture in that connective tissue, but something with the muscles that were anesthetized was doing that.
Til Luchau:
That’s right. That’s really … It was Holman, 2015, who did a study. He only did five people. Unfortunately she actually only did five people, but when she put them under anesthesia, all five of those got quite a bit more movement and they’d all were scheduled for adhesive capsulitis surgery under the assumption that it was a structural or a connective tissue contracture. She has a cool video that I’ll put in the references. Then that replicates or is along the lines with of a more informal study, Robert Schleip, my friend and mentor did a long time ago where he tagged along with a knee surgeon and he did measures of people’s shoulder motion awake and under anesthesia. He found that two out of the three people he checked got considerably more emotion under anesthesia. One of them didn’t. There is a certain … We can say that maybe all, maybe at least some for sure of these shoulder restrictions have a non muscular contraction component. Sorry, have a muscular contraction component. Because when you go to sleep, your muscles relax.
Til Luchau:
If your muscles are relaxed and it gets better, it wasn’t the connective tissue that was holding it passively stiff.
Whitney Lowe:
Yeah. Which makes us wonder, maybe there’s a role for anesthesia in the assessment or evaluation process too. Can we just put people to sleep and see if their shoulders will move there as a distinguishing characteristics, but-
Til Luchau:
Yeah. We can try that. Put them to … There’s all kinds of things. Then the other interesting factor is that … Again, this is an opinion just put out there. I haven’t found a really hard reference about it, but they say about half of adhesive capsulitis shoulders … Sorry, adhesive capsulitis surgeries show actual tissue pathology. There’s visual pathology only in about half of those. A lot of people they’ve narrowed them down and think you’re a candidate for surgery based on everything we know. Then they do the surgery and there’s nothing visually pathological inside the shoulder.
Whitney Lowe:
Yeah. I think that’s one of the reasons why it is helpful and viable if we can find some ways to try to make some distinctions between these structural versus functional facets of it. Because, I mean, you don’t want to send somebody in for surgical interventions for a capsular adhesion when it’s primarily a neuromuscular thing that’s going on there that’s could be addressed through some other conservative measures that wouldn’t be as invasive as a surgical procedure.
Til Luchau:
Okay. We don’t want to send someone for surgery if it’s not structural. Are there other reasons or other ways that that information is useful to us? Why else would that be important, that distinction?
Whitney Lowe:
I think it’s helpful in that if we have some idea, if this is mostly a connective tissue involvement versus a neuromuscular involvement or vice versa, then our treatment strategies might focus more on the things that we have a sense might be more neurologically oriented. We might focus on a lot more movement oriented things that we feel like can really enhance or encourage neuromuscular relaxation through those areas. As opposed to trying to do some things that we have a sense might be forcibly able to elongate or make the connective tissue a little bit more pliable. Although again, there’s some really interesting research that’s saying there’s not very much supportive evidence for the capability of stretching contractures themselves. Those are some challenges and dilemmas, but I do still think it’s valuable and helpful if we’re able to identify those things to some degree.
Til Luchau:
I’m on the fence about that. Or let’s say I’m not even on the fence, I’m on both sides of that fence because I find it’s really interesting. My training and my practice for these decades has been, yeah, if it’s structural, that’s going to make me think one way about it. If it’s functional, I’m going to think another way about it, even work in different ways. In that sense, I think there probably is an important role for that distinction. It informs the way I work with someone. Now on the other side of the fence, I think, does it really matter to me as a hands on practitioner because I’m still going to try something. I’m still going to get a working hypothesis, try it, and if it seems satisfying and seems to be getting good results, I’m going to continue it. If it’s not, I’m going to change it. Actually, I don’t think it’s useful for me to start with the assumption it’s not going to change. Which is sometimes goes along with the structural assumption. If it’s a structural problem, the plausible and normal conventional thinking would be, we’re not going to change that.
Til Luchau:
There’s not really good evidence that manual therapy changes connective tissue in a permanent way. Except in certain cases, which probably don’t apply here. We can think, well, we can have a lot of effect on neurological inhibition. We can relax muscles, we can increase stretch tolerance, we can increase the safety. Maybe the functional ones are more our bailiwick you could think, but I don’t go there. I don’t think … I think we can help both of them. Even some of the tests like if you get warmed up, it said, if you get warmed with exercise and your shoulder is more mobile, that points to a functional restriction. Some people say. I don’t know about that because connective tissues do get more pliable when they’re warmed up too, even structurally. I think it’s really hard to tease these apart. It’s really hard to tease them apart. It is a … As a practitioner, it’s great to make a distinction, so I know how to think about it. But again, I’m going to work it and see if it helps. If that helps, I’m going to continue that. If it doesn’t help, I’ll do something different.
Whitney Lowe:
Let me sort of press into that just a little bit more here. How would you warm up connective tissues of the glenohumeral joint in terms of creating a thermal change that might make that tissue more pliable?
Til Luchau:
Okay. Yeah. I’m not someone who uses thermal approaches in my treatment. I wasn’t saying, yeah, I would do that as a diagnostic. I would find out if somebody, when they’re exercising, when they’ve warmed up, their whole body let’s say has more range of motion. But honestly, like I said, I’m not spending a lot of time trying to tease those apart. I’ll put them on the table and see if a very gentle, supportive approach gets results. Then I think, “Okay, I probably haven’t used a mechanical force yet that’s caused any sort of tissue change if that’s even possible.” What I’ve done is I’ve probably dethreatened movement in a way that they can move more. Great, that’s really useful. And … No, you go ahead.
Whitney Lowe:
I was thinking also just in terms of the treatment approaches, for example, if we had sort of clarified that something might be a bit more neurological than structural than maybe some of our treatment strategies that might be trying to … Man, I hesitate to say the phrase, but maybe fool the nervous system a little bit into increasing range of motion. Like gentle eccentric loading where the person is thinking about pushing in the opposite direction, but they’re actually lengthening and going in the direction of the barrier, might those things be more helpful in a situation like that?
Til Luchau:
Well, if they were more helpful, then I would go the other way. I would try them and see if they were more helpful. If they’re more helpful, I think, “Okay, that was good.” There probably wasn’t a neurological component there. The treatment becomes the test. That supports my hypothesis. I like the fool the nervous system thing though, because what we’ve done, let’s say in an inhibited motion that you have them press into, it’s like, we fooled you into thinking you’re safe. Guess what, you are.
Whitney Lowe:
Correct, that’s right. Yeah.
Til Luchau:
Yeah. Actually, we dethreatened that direction by having someone play with it, either with contraction or even supporting into it passive or active. We’re reminding the nervous system that maybe you don’t hurt as much as you thought. Especially towards the later stages, that recovery stage or after it’s become habituated, that is so useful. Just that reset of the protective habits.
Whitney Lowe:
Yeah. I want to also just ask you a question too, about treatment approaches in here that’s related to both these things. I know we’re going to talk a little bit more about some treatment things later on. But as we’re talking about this right here, it came to mind, one of the things that I have seen so frequently with a lot of clients who have this condition is this sort of defeatist, catastrophizing kind of mindset about like, “I’m never going to get better. This is going to be going on for a long period of time.” It’s very easy for people to kind of get sucked into this lack of progress kind of thing. Is this one of those things? I certainly think that there’s value in anything that we can do that can show even the smallest incremental improvements being really valuable for therapeutic progress by showing people, “Hey, you couldn’t do this last week, and now you can.” I mean, this is even one of those instances where I think even something like measuring range of motion with a goniometer might have some really value here.
Whitney Lowe:
It’s like, “Look, we have a numerical proof of greater motion this week than we had last week.”
Til Luchau:
That’s so important. Your numerical movement range or less pain. The fact that I can change your pain is a hopeful sign. Your pain isn’t permanent. Then, yeah, you’re right, there is well, that psychological profiling study showed a prevalence of perfectionism. My shoulder has to be perfect for it to be okay. Low levels of novelty seeking, I better not try that. High levels of harm avoidance, don’t do that. That might be built into the complex of causative or correlating factors that are part of this condition. Yeah, I think anything I can do to begin to soften the edges of those reactions, whether they’re inflammatory reactions or guarding reactions or assumptions narratives, anything I can do to soften those can help. Usually, it is supportive more than challenging.
Whitney Lowe:
Yeah. Those are important things, I think with any of our treatment approaches to keep in mind as we’re trying to find the most effective results in working with this. Because it can be certainly so challenging to find those effective strategies, regardless of structural versus functional or whichever it is.
Til Luchau:
Is it a good time to say a little more about how you start those out? Some of the methods or tests you would do to start to make that-
Whitney Lowe:
Yeah. Let’s-
Til Luchau:
… guess on your side.
Whitney Lowe:
… look at this kind of assessment-wise. We can also look at this in terms of some other things that will be helpful to maybe distinguish it from some of the things that we were talking about in our last episode, like the subacromial pain syndrome or rotator cuff disorders and things like that. I do find it valuable to try to dive a little more deeply into the assessment process and seek patterns that might be indicative of one of these things going on versus the other. First of all, as we mentioned, if there’s a way to try to … If you can look at this at all with decreasing the role of the nervous system and try to find if there is capsular involvement of restriction versus a neurological one, that is really helpful. But it can be really difficult to tease those apart sometimes if you don’t have the capability to do something that will turn the nervous system off like anesthesia or something like that.
Whitney Lowe:
I mean, there’s always, have your client drink excessive amounts of alcohol before they come into your treatment and do the evaluation and see if that’s impairing the motor function.
Til Luchau:
You’re talking about home experimentation-
Whitney Lowe:
But that’s not advice.
Til Luchau:
… with anesthesia, right?
Whitney Lowe:
That’s right. Something like that. That’s right. Probably not advised. But one of the other things that I would encourage in terms of some distinctions, certainly between this and some of the other subacromial pain syndromes is, look for those patterns that would indicate … Usually with the subacromial pain syndrome and rotator cuff involvement, you’ve got the primary nociceptive driver in that instance is contractile tissues being the muscle tendon unit. If you, for example, try to perform a resisted abduction movement with no motion occurring at the joint, and that is painful, especially up in the region of the anterior and/or lateral shoulder region, that would tend to be more indicative of something like a subacromial pain complaint than would be a frozen shoulder. Which is generally going to be painful during active or passive movement, but not painful during the resisted movements of abduction reflection of the shoulder. Because you’re not moving the capsule and not moving the restricted tissue.
Whitney Lowe:
When you do those resistive tests in a static isometric position, that would be a way to help distinguish between the more muscle tendon unit oriented subacromial pain and that of something in frozen shoulder.
Til Luchau:
Okay. If you do a resisted isometric contraction and it hurts, go listen to the last episode. If that isometric contraction doesn’t produce the pain, you’re in the right episode here. Is that right?
Whitney Lowe:
Keep listening. Yes, right.
Til Luchau:
That’s right.
Whitney Lowe:
Yeah. There we go. Something like that. Yeah. Another thing, you mentioned this earlier in our discussion too, that there’s different portions of the capsule that may be involved. Some of those patterns have been described in the literature with the particular types of restriction. But as you noted, they’re not always entirely consistent, but I do think it’s still at least helpful to understand a little bit about why you might see some of those patterns. For example, when the anterior or superior part of the capsule is involved, the descriptions usually are, you see the greatest range of motion in external rotation of the shoulder with it in a neutral position. If it’s the underside of the capsule, where that axillary pouch is that we formerly thought was getting stuck to itself, the underside of the capsule at that point usually is more problematic when you try to externally rotate the shoulder from an abducted position. This would be the position that you’d use if you were trying to reach up behind yourself and scratch the back of your head, for example.
Whitney Lowe:
So with a shoulder being in abduction and external rotation simultaneously. Then the sort of third pattern was, if there seemed to be more capsular restriction on the posterior aspect of the capsule, that was more likely to show involvement with limitations in medial or internal rotation of the shoulder. Helpful, I think to look at some of those things, but not to put all your eggs in that basket of really trying to narrow down and say, “We can know for certain this is where the capsular restriction is if that pattern happens to be there.” Because there are some other things that can be factors there.
Til Luchau:
Well, I know I made a case for why I don’t tend to start with a lot of tests myself, but use the treatment as a testing. But what you just described there is checking specific motions and combination of motions to identify what might be involved. I think that’s really useful, and I think I would use that again to form my working hypothesis as to where to start. Because I’m not just saying nothing matters, let’s just try the shotgun and see what works. That’s part of the skill that comes with doing this again and again, and maybe with studying something as specific as you’re offering us. When you can really dial it down that makes you really intelligent and really efficient about where you can begin at least your hypothesis in your work.
Whitney Lowe:
Yeah. I think that’s true. The other thing, for me, one of the reasons I like doing this in advance with a bit more detail, is that it gives me some understanding of what motions I need to really watch for when I try to move my client around on the treatment table or try to get ready to do some positioning things. To be very cautious know, this is a motion that I know they’ve had some problems with, so I’m going to be really careful here. I’m also going to let them know I’m being really careful here and I’m really going to watch this and make sure we don’t go into the place that’s uncomfortable for you.
Til Luchau:
That’s important.
Whitney Lowe:
Those are things that I think are really helpful. Yeah.
Til Luchau:
How do you reconcile that with the statement you’ve made before about special tests not necessarily being so special? That’s like … I listen to Jeremy Lewis talking about this recently. He says it’s really hard to be accurate in terms of reliability for these tests in terms of identifying the specific structure. I know you that and you agree with that. But he says that the test can be really helpful to identify a painful movement or a range. I mean, we’re checking for pain, he says, more than say being definitive about identifying the structure involved. How do you reconcile that for yourself?
Whitney Lowe:
Well, for me, the thing is, again, I think people tend to use a lot of these special tests in a bit more isolation. It’s interesting when I hear a lot of people in the world of orthopedics, and this is across the board, orthopedist, PTs, athletic trainers, massage therapists, chiropractors, whoever, when they talk about the use of these special tests, they talk about them frequently as isolated evaluation tools and evaluation methods. Without talking about first, going through an identifying particular patterns of restriction that would point to one particular or one or two particular tissues being your major suspects. It’s almost like they jump through that part and then go immediately to just performing some of these special tests because it’s quicker to do that. But I think you miss important information that you’re building a case. It’s a whole like a detective process. You’re trying to gather clues and build a case, and is there enough evidence to point us in this direction?
Whitney Lowe:
One or two special tests alone don’t provide the sufficient evidence in the absence of looking at some of those patterns, like I was talking about before of what happens during active abduction versus passive abduction, versus active and passive, versus resisted external rotation and those types of things. For me, it’s all about the patterns and are you building up enough evidence to indicate one particular type of thing being more suspect than another?
Til Luchau:
Okay. I like the suspect piece, because what you’re saying is that you’re using the test to form a hypothesis, not a diagnosis, say. You’re going to identify in your mind a structure, but knowing that that structure may or may not be the structural part as much as the nociceptive or the sensation or the perceptive part of what’s involved.
Whitney Lowe:
Yeah, absolutely.
Til Luchau:
Are there any other tests you’d want to mention or assessment factors about-
Whitney Lowe:
Well, one of the most common things that’s used a lot for evaluating this is something called the Apley scratch test. Where basically you’re just trying to put your hands in a position to either scratch your upper back or lower back region. That tends to test, for example, when your hand is trying to scratch your upper back, you’re looking at abduction and external rotation range of motion in one shoulder and the lower shoulder. When you’re trying to scratch your lower back is, adduction, A-D duction and internal rotation on that shoulder. Then you switch them, go to the other side and compare them and just see, is there a significant difference in range of motion or is somebody’s unable to do those things because it’s just too darn painful to do it. It’s a kind of quick and easy range of motion evaluation that can give you some important information about what’s going on there.
Whitney Lowe:
But the thing that I also find interesting is that, in teaching this in a classroom, I would often go through these procedures with people and we’ve got lots of people in there with non symptomatic shoulders and they do these Apley scratch tests and found very significant differences between the sides. Like you mentioned earlier, the dominant versus non-dominant side in the-
Til Luchau:
In terms of motion?
Whitney Lowe:
… range of motion. Yeah. Does that necessarily mean there’s a pathology there? Not necessarily. But we already have in a healthy individual, significant differences between range of motion on those sides. You got to be careful about how much weight you put on those procedures as telling you something, when in essence, they may just be reflecting a pretty close to normal situation that we see a lot of times anyway.
Til Luchau:
Nice. Then for myself, more and more, I think I’m thinking about pain as its own thing. So then I’ll do those tests, a similar test, but I’m looking not for necessarily where the motion restriction is, but where the pain provocation is. Then I will think about going to work with that sensitivity or that guarding or whatever it is. I’m coupling that from the motion restriction because it may or may not be related. Sometimes you get things less sensitive by getting them more mobile, but not always. Sometimes things are sensitive without being immobile.
Whitney Lowe:
Yeah. Right. With those things in mind, how would we work with this? What’s going to … One of our strategies, we mentioned a few things already. What kind of things also do you like to focus on here?
Til Luchau:
Well, I’ll put some stuff in the handout as usual. I know you put some really rich texts about tests and things at our last handout. Anything you want to say here about this handout? Does some of the last hand out stuff apply to this topic as well?
Whitney Lowe:
Yeah, absolutely. I think we’ll try and do a similar thing here and put some clarifying characteristics that would be helpful in identifying this particular problem and discriminating between this and some of the other common shoulder complaints that we might run into as well. Those would be some things that we’ll try to make sure we include in there.
Til Luchau:
Greta. Because I want to say that a lot of the techniques I showed in the last episode’s handouts are also ones I would use for this situation. Then, again, I’ll put out some specified ones I might use for something that I suspect is in the realm of a inflammatory reaction or a frozen shoulder kind of thing. Then I’m also going to put in a chapter on the shoulder, on the glenohumeral joint, rather from The Advanced Myofascial Techniques Volume 1. I’m going to put that in the handout too, which then covers one of the movement directions that I think is the most helpful, and that’s the inferior glide or inferior translation of the humerus on the glenohumeral fossa. That’s one that I want to make sure is desensitized and mobile if I can. That seems to help so many people. In fact, I was so sure of myself, Whitney, in probably the first 10 years of my practice that I was one of those guys who thought I can fix 99% of frozen shoulders. I really thought that.
Til Luchau:
Maybe my track record was really that good. Until I practiced … Probably what happened is, I practiced long enough and saw enough clients to start to run into the ones that I could make better but then the improvement didn’t necessarily last. Then I really had to go to hit the books and do the homework and realize, “Okay, there’s a lot more to it than just, say the bag of tricks that I developed and learned in my first 10 years.” Much of it becomes, I’ll go through it now in terms of phase. If I suspect someone’s in that inflammatory phase, that first phase, the “freezing phase”, then I’m going to do it … That’s again, where it will flare up easily or where the pain could linger once it’s provoked. Then I want to do very careful experiments around how much movement is okay. Once I’ve made that connection with the client and help them settle, that might be a lot by itself. But even once we got that, then I’ll do very careful experiments to see exactly where is the painful range of where’s the painful movement.
Til Luchau:
Then how much support does it need? How much challenge does it need? I will give the homework of, tell me how this was later. To keep track of it, make some notes, so you can come back next time and tell me, did it get better and stay better? Does it better and then flare up later? Because we’re going to learn from that. That’s really what I need to know is, how do I need to dose and pace the work I’m doing? But my goal is really there in that first phase, that inflammatory phase or pain relief, education. Meaning I’m helping them start to think about this as a process, more than a fix. Something that they need to … This is a process of caring for your shoulder, not fixing your shoulder. Especially if they’ve been at it for a while already.
Til Luchau:
If they’ve tried a whole bunch of stuff and they often come to see me as a later stage practitioner, which is often the case, then it’s like, “Okay, so maybe then it’s a process of getting to know what your shoulder is comfortable with and can do, and finding ways to give it that. More than getting your shoulder to cooperate with what you’d like it to do.” That sort of reframing and reeducation, that’s the first phase, the groundwork. The next phase, the middle phase or the “frozen phase” where it seems to be more about immobility than pain per se, although pain can still be there, I’m still doing pain relief. But I’m doing more reassurance. I’m continuing with gentle mobilization. I’ve learned how much we can challenge, how much we should support. I’m mostly fostering patients in that time. Because a good number of people do get better, even though, like we said, not everyone does. But a good number of people do get better after a certain period of time no matter what they do or don’t do.
Til Luchau:
A lot of it is just, how can we live with it in this phase? How can you be comfortable? How can you adapt to what’s happening here? And letting the pain relief that I can often provide in that session be valuable in and of itself. Again, that’s more of that reframing away from, let’s fix it so it doesn’t hurt any more. To saying, “Okay, let’s find out about it. Let’s find ways to care for it and find out what you can do and I can do to help you be with this issue.”
Whitney Lowe:
Yeah. I want to also draw attention for just a moment back to something that you were saying at the outset here of our treatment discussion of, when you were thinking that you were making all of these frozen shoulder complaints resolve early on in your treatment process. There’s also the tendency for us to sort of, I don’t know, crossover our understanding of what’s happening in some of these instances and maybe develop some overly optimistic ideas about our therapeutic effectiveness. Because for example, we might’ve had people with a diagnosis of frozen shoulder who got better really quickly. I’ve seen this a lot in demonstrations by practitioners who are advocating a particular treatment strategy and then bring somebody up to the front of the room who supposedly has frozen shoulder. Do some things with them and all of a sudden, they’ve got this miraculous great range of motion and we’ve broken their adhesive capsulitis free. I think there’s an important distinction to recognize that’s one-
Til Luchau:
In quotes.
Whitney Lowe:
… really good-
Til Luchau:
You put that in quotes, right?
Whitney Lowe:
… illustration … Yes, in air quotes. Okay. That’s right. Yeah. That’s one really good distinction there of that’s not a capsular adhesion. In that instance, if you get that kind of immediate results with an individual, that’s a neurological response that’s happening. That, that one is clearly a functional problem and not a structural capsular adhesion. Because there is no mechanism that will miraculously cause capsules to lengthen and loosen from any type of manual therapy approach. That’s another reason why I’m … It’s helpful if we can make some of those distinctions so we can know, like if we got those kinds of results, we’re probably dealing with a functional neuromuscular one as well.
Til Luchau:
Yes. I’m looking for in myself as the practitioner, I’m suspending judgment. I don’t even know yet. Who knows? I mean, I am that guy who can take someone up in front of the room and show an amazing improvement and maybe it is 90 plus percent of shoulders in that session. It’s something pretty high. Enough to support my cockiness around that. But the question there is, does it persist? Not, can I get the results right there, because often I can. But how long does that persist? Then that’s where I start to think about maybe other mechanisms, but also like, “Okay. Nevermind the mechanism for a second, this is an ongoing project, more than a one-time fix.” That’s the big shift in my thinking and the one that I want to invite the client around.
Whitney Lowe:
Yeah.
Til Luchau:
Okay. That third phase, my treatments thoughts in that third phase, if someone’s had inflammatory phase, they’ve had the stiffening phase and then it’s starting to improve into the thawing phase, I want to support that with more mobility. Maybe I’m starting to renew the experiments around challenging it a little bit. Maybe I can go back and check and see what if we do challenge it a little bit more in terms of its range of motion? What if I think about mobility more than desensitizing and seeing how people response? It’s time to recalibrate my approach, but then that’s also helping the brain essentially recalibrate to the movement that’s becoming possible. Because a lot of times people will have forgotten they can move comfortably and they’re still acting as if they can’t. The brain is still acting as if it hurts when their body suddenly realizes actually I’m more range here than I thought I did. It’s encouraging people to be a little more novelty seeking, to take maybe gentle risks, and then especially to learn how to back off from that when inevitably someone goes too far with that process and gets too excited.
Whitney Lowe:
Yeah.
Til Luchau:
Then throughout that process, I’m thinking about my CALMS acronym, the inflammatory acronym that we use in our inflammation training work. The C of CALMS is really the context we’re working in. Because there’s so much about our conversation and our relationship and the fact that this person is coming to me, et cetera, et cetera, that is part of the results we’re going to get with an inflammatory situation. The A being the autonomic responses. I’m helping them calm down their reactivity, their autonomic fight or flight reactivity around the pain and problems they’re having. The liquids, the L in CALMS is the liquids. I’m helping perfusion and circulation. No matter what phase it in, that’s going to be helpful. I’m not pumping them around, but I’m thinking in my mind, “Okay, how could the profusion of their interstitial fluids, their lymphatic system, their blood, et cetera, be part of what I’m providing or fostering or encouraging?”
Til Luchau:
Then the M being the movement safety. How can I help someone find movements that are more safe? Even if they’re micro movements in some phases? I should say though, if CALMS with an S on the end, I’m not typically doing the S if I really suspect adhesive capsulitis or frozen shoulder. The S is the stimulate inflammation. That’s where we’ll really challenge it sometimes, in certain cases, with certain clients, and certain conditions. Frozen shoulder is probably not one of those. Where I won’t necessarily try to stimulate inflammatory response through really pushing it to see if that will resolve the inflammation. That’ll tend to flare things up pretty predictably.
Whitney Lowe:
I think that’s also reflected a lot in the traditional physical therapy approaches for dealing with this. That when individuals try to try more aggressive exercise routines, it often flares the problem up more significantly than helping it. That would tend to support that idea as well.
Til Luchau:
So much of what I’m helping people with is the pacing. Helping to learn how to pace what they do.
Whitney Lowe:
Yeah.
Til Luchau:
Okay. Any key points we should repeat here and a wrap up? What do you think?
Whitney Lowe:
Yeah. There’s a couple of things that I think that we sort of highlighted as key points here that we would want to look at. You had mentioned that just because some shoulders have a limited range of motion or stiff in certain planes, it doesn’t necessarily mean the individual has frozen shoulder. That’s certainly, I would emphasize again, the crucial importance for trying to go through a comprehensive evaluation process and have a good idea of what’s going on there. That doesn’t necessarily mean that that is a frozen shoulder. Especially if it’s not following a characteristic pattern that we would likely see with that. Yeah. What else you got? Yeah.
Til Luchau:
Well, it’s that last point I made, I’ll just repeat it. Be aware of the potential for flaring it up or backlash if you get too ambitious or aggressive. Even if it seems to be okay in the moment, you got to learn how your clients are responding and keep that in mind as you’re working as well.
Whitney Lowe:
Yeah. You had mentioned too, just trying some things out and seeing what happens both in terms of range of motion capabilities, both in the assessment evaluation process and also in the treatment process. Kind of just seeing where we can try to restore some functional movement in even very, very small little increments as much as possible. I often encourage people to do this in ways that don’t load those tissues too at home. Because this is a real important part of this, is trying to reinforce ideas in home. There are things like the doorway stretch where you place your elbow in 90 degrees of flection and put your hands straight out in front of you against the edge of a doorframe and just try to turn your body a little bit. You’re not thinking about turning your shoulder, just turning your body, and that moves your shoulder a little bit and just doing those kinds of things repeatedly. Just a little bit at a time each day is really helpful for, especially those neurological problems where you’re sort of teasing the idea of moving farther into that barrier and telling your body it’s safe to move.
Til Luchau:
Yeah. A nice variation on that to grade that back, is a corner stretch. Instead of a doorway, just go into the corner, facing the corner and put your hands on the opposing walls and lean into that. That can be a little less intense than the doorway stretch. But the key there, like you said, Whitney, is to really the grading. The ability to pace what you’re doing and learn from how aggressive you’re being with yourself and back it off if you need to. That’s the patience, the experimental approach, the patience of caring for it rather than fixing it. Then I got one more. Should I share mine?
Whitney Lowe:
Yeah, definitely do.
Til Luchau:
That’s the pain relief, even if it’s temporary, is really often possible and it’s really valid as a benefit. Even if it’s temporary, even if it doesn’t last. Because again, that can shift someone’s thinking about what’s going on. Any relief from an ongoing situation is a godsend and it helps people reevaluate their expectations and what they’re demanding of themselves. Just to give them an experience of some relief and pain, and that being itself being part of the care that we can give something like a frozen shoulder.
Whitney Lowe:
I think this taps into what we were saying earlier too, about just small wins. What you’re talking about there is finding ways to give people small sensations of progress and making some headway. Those are always particularly valuable in this condition because it can seem so long and so debilitating. We’re talking about a condition that frequently goes on for 18 months or two years in many cases. Those little bits of improvement give the person encouragement to keep working and keep trying things. That’s so important.
Til Luchau:
That’s great. Well, we’re probably ready for our closing sponsor.
Whitney Lowe:
I think so. I think we kind of wrapped that up pretty thoroughly there. What do we got here closing us out today?
Til Luchau:
Books of Discovery is our closing sponsor. They’ve been a part of massage therapy education for over 20 years. Thousands of schools around the world teach with their textbooks, e-textbooks and digital resources. In these trying times, this beloved publisher is dedicated to helping educators with online friendly, digital resources that make instruction easier and more effective in the classroom or virtually.
Whitney Lowe:
Books of Discovery likes to say, learning adventures start here. They see that same spirit here on The Thinking Practitioner Podcast and are proud to support our work knowing that we share the mission to bring massage and bodywork community enliving content that advances our profession. Check out the collection of e-textbooks and digital learning resources they have for pathology, kinesiology, anatomy, and physiology at booksofdiscovery.com. Where thinking practitioner listeners can save 15% by entering thinking at checkout. Thanks again to all our sponsors. If you will stop by our sites for the handout that Til mentioned earlier, show notes, transcripts, and any extras, you can find that over on our sites. For me, that’s over at academyofclinicalmassage.com. Til, where can people find that from your site?
Til Luchau:
I am advancedtrainings.com, advancedtrainings.com. We’ll be sure to put the link to The Shoulder Jam there as well. We highly recommend you come check that out with Whitney, me and a bunch of other teachers. If there’s any questions or things you want to hear us talk about in our podcast, email us at [email protected] or look for us on social media. I’m at my name Til Luchau. Whitney, where do people find you on social media?
Whitney Lowe:
They can also find me on social under my name, Whitney Lowe. We would also encourage you follow along with us on Spotify, rate us on Apple Podcasts, wherever you happen to be listening, Stitcher, whatever is your podcast app of choice. As of course usual, if you are unable to find us in any of those locations, you can always find a railroad track that runs from north to south across Saskatchewan and put your ear to the track and listen to us there. Thanks again for another interesting episode. Til, great to talk with you about this. We will see you again in two weeks.
Til Luchau:
Likewise. I enjoyed it. I learned a lot and always a pleasure. See you again in two weeks, Whitney.
Whitney Lowe:
Okey-doke.
