Man versus Machine

I have been asked a few times : "How come your treatment can be effective if you don't use any machines ?".

How fantastic are these machines ! They make some noises, vibrate, send some electric shocks, alter your magnetic field and boost your cellular regeneration ! They are widely use by physiotherapists and other physical therapists.

You may know these machines by the name of TENS, Ultrasound, Sonic wave..


The US and TENS are not really effective

Human kind loves these types of gadgets and tends to rely blindly on it, while their effectiveness is in fact relatively approximative.

TENS (Transcutaneous Electric Nerve Stimulation) does not seem to do much better than a placebo (http://intl.elsevierhealth.com/e-books/pdf/135.pdf)

UltraSound does not do any better, it has been used for more than 35 years in the treatment of musculo-skeletal pain and studies clearly shows that it is not more effective than a placebo treatment (http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=11444997&dopt=AbstractPlus&holding=f1000%2Cf1000m%2Cisrctn).


The machine : a good excuse

These machines are an answer to the inhability of the conventionnal medical field to deal with the dysfunctions of the body classified as musculo-skeletal problems.

The therapist uses the machine as an "excuse" for not being able to help the patient :

"I use the best machine for your pain and yet you do not get better... You really suffer from a chronic problem !"

It sounds much better than saying :

"I can't help you, I don't know what is going on, and my therapeutic competency is really questionable as you are not getting any better".


The machine is used symptomatically

If these machines really help to relax a muscle or an organ, their lack of effectiveness on treatment could rely on the fact that their are not used at the right place ! As we have seen in the previous posts treating the symptom is rarely effective compared to treating the cause. If the patient complains of a chronic knee pain caused by an old ankle injury it might be more interesting and effective to use the US on the ankle rather than on the knee for example.


The machine will always be obsolete, the hand will never be

In 10 years time the most modern machine will look like a prehistoric equipment, and 10 years later it will be the same for the latest model.

The human hand has been used for thousands of years and is still not obsolete ! Far from it ! More and more people seek massages, and other manual therapies.


The Human Hand has fantastic abilities

The hand is able to massage, to drain, to push, to pull, to vibrate, to twist, to be firm, to be soft, to warm up, to cool down, to feel and to adapt to the patient' s body response.

The hand is the part of the body which is the most represented in the cortex (in the brain) this means that it is one of the most sensitive and precise part of your body. It can detect variation of temperature as little as 0.1 Cdeg.

J.P. Barral (One of the most talented Osteopath) says : "The hand is at the Osteopath what the nose is at the Oenologue". It is recognised that wine testers can differenciate and recognise different vignards and different years of production. The Osteopath with a bit of experience can easily pick up old injuries and with more experience can even date them.


The Hand cares the Machine does not

Physical contact is very important. I do believe that during the treatment an Osteopathic hand talks to the patient's body. A treatment is a real physical communication between the patient and the practitioner.

Does the hand of a serial killer around your neck will feel the same than the hand of your lover ? Certainly not ! The "ruffness", stiffness, heavyness, "speedness", clumsyness (actually if it is a real serial killer he may not be that clumsy), coldness(...) will clearly give you a different feeling.

The hand of the practitioner cares about you but the machine does not.



The human hand is definitely winning this contest, no appeal !

Frozen Shoulder or Adhesive Capsulitis

This is a very annoying, painful, and debilitating long term condition.

The Shoulder is made of 4 joints : the gleno-humeral joint, the acromio-clavicular joint, the sterno-clavicular joint and the scapulo-thoracic "joint".

Adhesive capsulitis or "frozen shoulder" is a retraction and stiffening of the capsule of the gleno-humeral joint. This retraction limits anatomically the range of movement of the G/H joint and therefore limits the shoulder itself.
While all movement are severely impaired, the most limited ones are the abduction, the internal rotation and flexion.

It affects predominently women at the menauposal age. People with diabetes, stroke, lung disease, rheumathoid athritis and heart disease, are at risk. History of a fall or a physical/emotionnal trauma in the previous year is not unusual.

The good news is :

-the recovery is generally good, you should be able to recover more than 90 % of the range of movement.
-it is very unlikely to develop twice on the same shoulder
-women are more often affected than men (good news for us ;))


What is the evolution of the condition and how long does it last ?

There are three stages in this condition :

• the first stage is called the freezing stage :

This stage last from 6 weeks to 9 months. Insidiously the shoulder becomes stiffer and the range of movement is more limited. The patient may feel some pain at night and with any movement involving the affected shoulder. Some discomfort may arise all around the shoulder (neck, upper back, and down the arm) as the three other shoulder joints try to compensate for the lack of movement and pain from the "freezing" joint.

• the second stage is the frozen stage :

The shoulder is now stiff and the range of movement is limited but does not get any worse . During the first part of this stage the shoulder is still quite painful. Slowly the pain decreases unless extreme range of movements are reached but the stiffness remains. This stage lasts for a period between 6 weeks to nine months. At that point muscle pain and tension are clearly felt all around the neck and shoulder area due to compensation/adaptation.

• the third stage is the defreezing stage :

At last the shoulder is slowly becoming more mobile. By the end of this stage you should recover at least 90% of the range of movement with adequate physical therapy. This stage lasts for 5 to 26 months.

What are the common conventionnal treatments ?

-Cortico-steroid injections are applied locally. The aim is to reduce the inflammation but after a temporary relief the pain comes back and the movement is still restricted.

-Use of anti-inflammatories, parcetamol, muscle relaxant. This does not improve the mobility of the shoulder it merely masks the symptoms and long term use is not advisable.

-Manipulation under aenesthetic : the aim is to stretch and force the shoulder to move while asleep. As your shoulder is generally excruciating as soon as you arrive at the limit of the movement I do not dare to imagine how traumatising it is for the tissue and the surrounding structure. Risk of tearing the capsule exists, which enhances the presence of scar tissue and therefore limits the movement of the shoulder even more in the long run.

The outcome is uncertain, if you choose to have it done you need to be regular and disciplined with the following up physiotherapy treatments

-Physiotherapy : the physio will give you different exercises, may mobilise the shoulder and use various "machines" on the shoulder (TENS, sonic wave, electro-stimuation... welcome to the 21st century !)

What can I expect from osteopathic treatment?

As each Osteopath is different and they practice differently, I will describe the way I approach and "treat" frozen shoulder.

In general I believe that pain should be avoided at all cost !

Because as soon as the pain is experienced all the muscles protecting the shoulder will tense up and this will definitely not help the patient to relax and recover some mobility.

While the treament approach of the shoulder itself will depend on what stage the patient is at, the aim is first of all to treat and realign the rest of the body : rebalancing the pelvis, improving the mobility of the spine and treating any dysfunctional organs. The organs will have a great influence on the mobility of the ribs and diaphragm as well as on the posture of the patient. The biomechanic of the shoulder being greatly influence by the thorax it would be foolish to hope a good recovery without treating this part of the body.

The osteopathic approach of the shoulder itself :

• Beginning of the first stage :

At the beginning of the first stage the restriction is relatively minor and the pain bearable. It is often misdiagnosed as a rotator cuff syndrom or as osteoarthritis of the acromio-clavicular joint.

I do believe that mobilisation of the glenohumeral joint at that point is benificial as long as it is not too painful. It is important to quickly restore a maximum of mobility through the other joints of the shoulder.

The complex first rib and clavicle is vital as the brachial plexus and artery might be slightly impinged (thoracic outlet syndrome) which can perturb the neuro-vascular activity around the G/H joint. Increasing the mobility of this area improves any slight "thoracic outlet syndrome".

The biomechanic of the clavicle is crucially important and needs to be restored to its "normal" state. It is important to understand that the sterno-clavicular joint is the only real joint linking the shoulder to the body !

Deep soft tissue massage is helpful to release the muscular tension emanating from the compensation pattern ; we may insist on the trapezius, levator scapulae, rhomboids, supraspinatus, infraspinatus, subscapularis and of course the pectoralis major and minor.

After a few treatments, the shoulder should improve and the condition avoided. It is true that as the condition is avoided it is hard to know if it really was a "beginning of frozen shoulder".

• Middle of first stage to middle of second stage :

The patients often come to see an Osteopath at that stage of the condition, because they generally tried with poor results the conventionnal therapy. At that moent the pain is very bad and the limitation of movement is severe.

This is a long and fastidious stage. It is difficult to know how much the treatment is helpful because there are often tiny or no improvement. The patient may report some ease in the intensity of the pain, or improvement in the sleep pattern, but the mobility of the shoulder stays more or less the same. Some patient find it benificial enough for coming once a week. I want to believe that the treatment helps to shorten this period of the condition

The treatment will focus on the structures cited above but mobilisation will be avoided because of the pain it will create. The aim is to calm down the inflammation. Once the inflammation stopped we move to the next step of the treatment.

• Middle of second stage to end of third stage :

At the middle of the second stage the shoulder is limited in its range of movement but free of pain. The recovery is coming at last !

During that period the Osteopathy can clearly helps the recovery. As well as using the techniques described above we can now use a combination of Muscle Energy Techniques (MET) and gentle mobilisation. The MET is a type of stretch applied after a gentle isometric contraction of a muscle. This technique gently stretches the G/H joint while respecting its integrity. The mobilisation techniques gently explore the joint mobility.

At that stage we can clearly notice some improvement between two treatments.

Conclusion

A frozen shoulder will definitely take time to recover fully It is frustrating for the patient as well as for the practitioner.

While the help from osteopathy is relevant straight at the beginning of a frozen shoulder and after the middle part of the second stage, it is hard to know how effective it is during the "painful-freezing" and "painful-frozen" part. A recent study has shown that physiotherapy mobilisations and stretches of the shoulder during this period actually increases the length of recovery. Remember that pain should be avoided at all cost...

Do not hesitate to use your arm within the pain free range of motion and keep any type of stretches for the later stage. An alternance of hot and cold pack might help (30 min hot, wait 15 min, then 30 min cold...) and position the pack all around the shoulder. you can repeat this procedure 2-3 times a week.