Adhesive Capsulitis

[Jon Newman]

Hi Rod,

I'm posting before/after comments and then I'll add my comments/questions to make referencing the original easier. Also, this might be something worth moving back into the Consensus On Pain thread.

9. There is little correlation between tissue length, form or symmetry and the prevalence of pain.

There is insufficient evidence to suggest a direct connection between tissue length, form or symmetry and the prevalence of pain.

Number 9 is attempting to tackle quite a bit but I think the main point we were trying to make is that

a.) Once someone is in pain their current presentation is altered
b.) We can't know their prior presentation in most circumstances
c.) Evidence indicates the referenced elements are poor predictors of subsequent pain.

By "direct connection" do you mean causation?

It seems you are averse to the use of correlation in this instance. I think this should be explored more carefully if we are to improve understanding.

Manually applied forces will almost never directly result in clinically relevant and lasting change in tissue length, form or symmetry.

Manually applied forces as they are often applied in the clinic are unlikely to directly result in clinically relevant and lasting change in tissue length, form or symmetry.

How about: Clinically applied manual forces are unlikely to directly result....

The effects of manual therapy are more plausibly regarded as the result of reflexive neurophysiological responses.

While evidence exists supporting the notion that mechanical therapies elicit some form of mechanical response in connective tissue, the effects of manual therapy must also be regarded as the result of reflexive neurophysiological responses.

How about: The enduring improvement in ROM, symmetry and form seen after interventions utilizing clinically applied manual therapy are regarded as the result of reflexive neurophysiological responses.

Some closing thoughts I have are regarding the title. The title of the list is Ten steps to understanding manual and movement therapies for pain. Maybe we could start a similar list titled Ten steps to understanding manual and movement therapies for tissue architecture.

What do you think?

[HeadStrongPT]

Here's something else might be helpful here.

Schleip, 2003-

I'm not sure I fully understand. A tonic change in motor units and altered tissue viscosity may account for this significant change in volume? I unfortunately don't have evidence to state otherwise, it just seems like a bit of a reach.

Does this change the fact that the manual intervention led to a decrease in pain, increase of AROM, improved scapular kinematics, and perceived function. Let me see if I can correctly encapsulate our beliefs: one side of the argument appears to state this is an entirely neurological event, while the other states that there must be at least some mechanical event involved as well. Please correct me if I am misinterpreting Diane or Luke's comments.

[HeadStrongPT]

Hi Rod,

I'm posting before/after comments and then I'll add my comments/questions to make referencing the original easier. Also, this might be something worth moving back into the Consensus On Pain thread.



Number 9 is attempting to tackle quite a bit but I think the main point we were trying to make is that

a.) Once someone is in pain their current presentation is altered
b.) We can't know their prior presentation in most circumstances
c.) Evidence indicates the referenced elements are poor predictors of subsequent pain.

By "direct connection" do you mean causation?

It seems you are averse to the correlation language. I think this should be explored more carefully if we are to improve understanding.


How about: Clinically applied manual forces are unlikely to directly result....



How about: The enduring improvement in ROM, symmetry and form seen after interventions utilizing clinically applied manual therapy are regarded as the result of reflexive neurophysiological responses.

Some closing thoughts I have are regarding the title. The title of the list is Ten steps to understanding manual and movement therapies for pain. Maybe we could start a similar list titled Ten steps to understanding manual and movement therapies for tissue architecture.

What do you think?

I think this makes a lot of sense as we likely agree that pain and tissue architecture are not necessarily linked. In this thread, I am trying to focus on these statements as they pertain to AC. I agree with Luke's comment that changes in pain are likely due to some alteration in the nervous system. However, in this specific context of AC, there is evidence supporting that the change in ROM is due to a mechanical event. In this sense, we may indeed be talking about two seperate issues and may need to reframe the boundaries of the debate.

[Luke Rickards]

Hi Roderick,

I have been speaking predominately to the link between pain and tissue architecture. Tissue architecture and ROM is something else, and I see we agree on this.

In addition, you asked

What neurological event could cause an expansion of capsular volume?

This is, of course, a different question to does increased capsular volume mean less pain. I presume that the hypothesis from the evidence you cite is that CTs are being directly stretched leading to expansion of the GH 'container' and thus an increase in volume.

I cited Schleip above because if we are talking in terms of "support to at least implicate" then it appears there is some basic science research to suggest that the effect of mechanical forces on CT directly involves neurological mechanisms.

As you state though, "(For AC) The degree to which each contributes is up for debate not only on this forum, but among professionals in the medical community who research it directly. Until the answer is found with a larger degree of certainty, this debate is likely to continue with little chance of a resolution."

[BB]

Hi Rod,

Even though the capsule is of non-contractile tissue, it is continuous with contractile components. Speaking mechanically, does it not make sense that the capsule's volume is affected by the various tensions placed upon it and that this tension can be altered by a neural event?

[nari]

In this country at least, AC is a diagnosis made without any evidence of the state of the capsule, other than severe restriction of movement and pain.
Are we talking about proven AC, or a 'painful shoulder' with potential to lead to AC...or both?
I find it interesting that many patients who have had a MUA on a GHJ do respond very well initially and then deteriorate afterwards, sometimes worse off than before. This is empirical - I don't have studies to hand.

Nari

[EricM]

Interesting point Nari. If it doesn't detract from the thread too much, I need a refresher on what currently defines adhesive capsulitis. How is this diagnosis made and confirmed?

[nari]

Hi Eric

Here, a definitive diagnosis is made by injection of radioisotope into the area. The volume is measured and if decreased, indicates shrinkage of the capsule. This assumes a 'normal' joint with reduced++ ROM has a 'normal' capsular volume. An assumption can be made that shrinkage occurs due to lack of movement as a result from pain.
But I dunno....again, empirically, I have seen some pts with a 'confirmed' diagnosis of AC resolve rapidly with simple neurodynamics.

So the picture, to me, is a confusing one.

Nari

[Diane]

Originally Posted by Diane
Rod, I'd lay odds on any favorable change happening in a wide-awake, conscious, pain-perceiving patient receiving manual treatment being completely a function of the two nervous systems interacting, not a function of a mechanical change to connective tissue caused by the manual application of force to it - this latter point is mostly perceptual fantasy/conceptual hallucination IMO.

I think there is only a small amount of disagreement here. I simply would replace the words "any" and "completely" with "some" and "partially". How do you reconcile a significant change in capsular volume following a mechanical treatment as perceptual or fantastic?

In this instance, I have provided measurable support to at least implicate a mechanical treatment in iliciting a mechanical change in the glenohumeral joint capsule.

Do you have any direct or measurable support for the two nervous systems interacting in adhesive capsulitis? What neurological event could cause an expansion of capsular volume? I can't think it should be too much of a strech to say some mechanical event is at play. I am prepared to eat crow here.

Rod,

How do you reconcile a significant change in capsular volume following a mechanical treatment as perceptual or fantastic?

What do you mean, "capsular volume"? Do you mean joint swelling?
It's not any change in volume that's perceptual or fantastic, it's the idea that you can manipulate connective tissue, capsule, joint or bone and accomplish this that is perceptually fantastic.

Changes in volume occur with neural self-regulation. Really, that is what you are stimulating, that is what is doing all the "heavy lifting" physiological, with volume changes etc.

Do you have any direct or measurable support for the two nervous systems interacting in adhesive capsulitis?

No, just my common sense that tells me that the skin of the patient is contacted by the skin of your hand. Both skins are full of nervous system.

What neurological event could cause an expansion of capsular volume?

How about neurally regulated blood flow/drainage?

I can't think it should be too much of a strech to say some mechanical event is at play.

Well, yes.. you have to dent the skin a little..

I am prepared to eat crow here.

Hope it tastes like chicken...

[HeadStrongPT]

What do you mean, "capsular volume"? Do you mean joint swelling?

No. The volume of a healthy glenohumeral joint measured via arthrogram is on the order of 10-15ml which isn't swelling. The volume of a typical shoulder affected by AC is considerably smaller and can approach volumes closer to 5ml. The decrease in capsular volume is often related to the degree of motion loss. During a procedure known as distension arthrography the capsule is mechanically expanded with cool saline with typically dramatic results.

It's not any change in volume that's perceptual or fantastic, it's the idea that you can manipulate connective tissue, capsule, joint or bone and accomplish this that is perceptually fantastic.

Surely you aren't implying that connective tissue has no viscoelastic properties and is incapable of elastic or plastic deformation? I think you are simply stating manual therapy in the manner in which it is often delivered does not effectively modify the tissue. I can accept the latter.

Changes in volume occur with neural self-regulation.

Always? Period? You mean when an orthopedist injects a sedated patient with 30-40ml of fluid during a distension arthrography followed by MUA and sees an immediate improvement in ROM, THIS is neural self-regulation? We may be at a serious impasse in this discussion Diane.

Let me try and see your perspective in a more practical sense. How might you manage a patient with acute, stiff, or recovering capsulitis of the shoulder?

[HeadStrongPT]

Hi Rod,

Even though the capsule is of non-contractile tissue, it is continuous with contractile components. Speaking mechanically, does it not make sense that the capsule's volume is affected by the various tensions placed upon it and that this tension can be altered by a neural event?

Sorry I missed your question Cory. I agree with you that there is a confluence of active and passive tissue subject to influence by a neural event. I just don't think a neural event could be entirely responsible for gains in ROM following mechanical interventions such as distension arthrograpy, MUA, and well placed conscious mobilization. I do agree that concious mobilization is most (not entirely) subject to the events articulated by both Luke and Diane.

[BB]

Hi Rod,

Unless you have reference inconsistent with the findings of Threkheld then it would be impossible for a well placed mobilization to have a direct effect.

Mobilization under anesthesia would likely create a magnitude of force such that it could directly change tissue length. A long lever arm is used forcefully.

I'm not familiar enough with the procedure of arthrography, but an internally generated stretch to inervated tissue could definitely bring about a neural event. Possibly even the magnitude of force created by the fluid would exceed that needed to have a direct mechanical impact, but the magnitude of force would still be the determinant.

Good discussion!

[Diane]

No. The volume of a healthy glenohumeral joint measured via arthrogram is on the order of 10-15ml which isn't swelling. The volume of a typical shoulder affected by AC is considerably smaller and can approach volumes closer to 5ml. The decrease in capsular volume is often related to the degree of motion loss. During a procedure known as distension arthroplasty the capsule is mechanically expanded with cool saline with typically dramatic results.

That's very cool. Do you perform these sorts of procedures? So the problem is not too much joint juice, it's too little. Got it.

Surely you aren't implying that connective tissue has no viscoelastic properties and is incapable of elastic or plastic deformation? I think you are simply stating manual therapy in the manner in which it is often delivered does not effectively modify the tissue. I can accept the latter.

I meant the latter.

Always? Period? You mean when an orthopedist injects a sedated patient with 30-40ml of fluid during a distension arthrography followed by MUA and sees an immediate improvement in ROM, THIS is neural self-regulation?

No, I didn't mean that. I'm thinking like the human primate social groomer I am, manual.

We may be at a serious impasse in this discussion

I hope not. I didn't pick up on the fact you were talking about injecting fluid into a joint, fluffing out a capsule from the inside. Sorry.

How might you manage a patient with acute, stiff, or recovering capsulitis of the shoulder?

First off, I would leave the assumption it was "capsulitis" (a mesodermal diagnosis) off to one side. I'd get busy with the nerves, the ones lacing through the axilla/shoulder girdle/neck/rest of the arm, and wouldn't stop until I was sure I'd covered all the territory, all the "upstream" possibilities that could possibly be contributing to a mechanical neural tension possibility at the shoulder, first. This would take up the first and probably most of the second visit.

By the time I did this there should be way less pain. I'd probably use some kinesio tape, just little pieces here and there to coax the brain into "feeling" something different/more comfortable from the body zone in question.

Once the pain issue had been addressed I'd teach the hand-on-the-wall 'exercise', or something the patient could do daily for a few weeks. Then I'd bring them in for another look. I would expect to see better shoulder movement, particularly in sidelying/arm in the air, dropping back into space.

I'd see if all this careful approach in directions toward relieving adverse neural tension in the shoulder would take care of most or all of the problem at the shoulder before ever even getting there, rather than jump all over the shoulder first, seeing it as the main event. I would expect by the time I got to it, it would be ready for me to be there without adversely reacting.

I'd do some mobing if I had to - I still do that a bit, for mere seconds at a time; but mostly, I just do long lengthy skin stretch things and get the patient to do neurodynamics in different positions relative to gravity, usually with the arm up in the air, supported by gravity. Maybe this approach seems weird to an ortho person, but it takes care of most everything that comes my particular way. Anything that doesn't respond in a positive direction in a visit or two, in any way, shape or form either subjectively or objectively, gets told to go visit an MD. I've found a few fractures etc. (not in the shoulder though). But I've never not had any effect for the better, either pain-wise or movement-wise, usually both, with a shoulder, working this way.

I would leave injecting fluid into a space behind a capsule to whoever does that where I live. (It's not me... that's for sure.)

[HeadStrongPT]

Directly from Threlkeld:

The real-world distribution,magnitude, direction, and time course of the internal and external forces involved in manual therapy have yetto obtain a satisfactory or comprehensive description.

As yet there is no sound foundation of research to delineate the range or distribution of manually applied forces. This information is needed in order to compare the basic mechanical testing and clinical techniques, to provide a reliable database for testing the efficacy of these techniques, and to assist in the instruction of students in manual therapy.

----

There is an absence of evidence, not evidence of absence. I think just as we mesodermalists have to concede there are more paradigms to explore, neuroreflexologists should concede that there have been relatively few proofs to stand on as well. We all have much to learn.

I'll keep the crow on ice until a later date.

[BB]

Fair enough.