Frozen Shoulder and the brain connection

Shoulders are tricky complexes with lots of moving parts. It allows the shoulder to be so mobile. The movement depends on motion through the shoulder blade, the upper arm bone (the humerus), the collar bone, rib movement, upper back vertebrae movement. One thing that I have found to be constant clinically, is the position of the complex. It was once declared that many of us are fixed in a Flexion Dysfunction. The front of our hips are shortened, our heads are being pulled forward and our shoulders are being pulled inward. As the shoulders are pulled inward, the end range of motion is reached prematurely in all planes of motion. If the limitations of motion exist for long enough, the brain begins to assume that this is the new normal. If we try to push the shoulder too far, the brain will assume that we are in danger of going too far and produce muscle guarding around the shoulder to stop it from going further. It also will produce a pain response limiting us moving further as well.

Frozen shoulder is also called Adhesive Capsulitis. This means that deep in the joint, the ligament/capsule has adhered and shortened, also contributing to the limitation of movement. There are all sorts of receptors in the ligament capsule that will also send premature signals to the brain that the end range has occurred (when in fact, the shoulder is only at a portion of it’s motion). This also contributes to premature muscle guarding and pain on movement.

It has been said that frozen shoulder can exist for 6-12 months and maybe more. In my experience, this time frame can be reduced significantly if, as practitioners, be are slow, deliberate and gentle with our approach. Think of the whole system including the mobility of the ribs, the movement of the shoulder blade over the ribs, the movement of the collar bone. Most importantly we need to involve the brain in our attempts to convince it that it is safe to re-establish full range of motion again. We need to be good listeners as well as traditional orthopedic practitioners. Everyone presents differently so we can’t apply cookie cutter approaches.

It’s so important to involve the client as much as possible. Let them understand the mechanics of the shoulder and where the deficits are. Their success will be 50% of what the practitioner does and 50% what they do. If they understand what is happening and why they are doing what they are doing, success will come much more quickly.

Fascial Release and Finding Your Center

I feel like one of the most important things about fascial release is that it is so general. The fascial system is continuous throughout the entire body down to the cellular level. Dysfunction in one area can cause symptoms in other areas. It assists in providing form but also allows for movement as well. There is the nervous system effect of Fascial Release and there is the actual shortening of the Fascial Tissue itself in some circumstances. Ultimately, in my experience, what I have experienced is inappropriate shortening of tissue that takes the body out of it’s most efficient positions causing limited range of motion of the body and can include reduced range of motion, weakness, pain and neurological symptoms to name a few.

Finding your center is such an important process as it is this place where you are centered and moving most efficiently. What can happen with shortened fascia is that it can send inappropriate messages to the brain that you are at end range of your motion, whether it be in the shoulder, neck, ribs, hips, low back to name a few. After a while, the brain will accept this reduced range of motion as being normal and a cycle can re-occur.

An example of this that has become common is due to our postural positions during the day, our heads are pulled forward and down and our shoulders are pulled forward and inward due to computer use/ phone use/ sitting at a desk/ driving ect. When we are in this position for long enough the tissues in the front of the neck and the front rib area will send information about position to the brain and eventually, the brain will assume that this less than optimal position is considered normal. Clinically, it causes the upper back and neck to work harder and to fatigue more quickly causing things like reduced shoulder range of motion with pain, burning pain between the shoulder blades, neck pain with reduced motion of the neck, jaw pain, numbness/tingling/pain down the arm to name a few. From a treatment perspective, my approach is to reduce the symptoms where they present but more importantly to make it easier for the client to bring their posture back to a place for the shoulders function better, the upper back and neck muscles don’t have to work so hard and the jaw is able to sit in a better place.

Here is a good test for you. Drop your breast bone down an inch and slouch forward. Bring your arms out to the side, bring them back down and then rotate your head from side to side and get a sense as to when your shoulders tighten and to how far your neck will rotate side to side. Then bring up your breast bone 2-3 inches. You will feel your shoulder blades come together as you move out of the slouch position. Then bring your arms out to the sides, bring them back down. Then rotate your head again. You should feel like your arms move higher up to the side and that your neck rotates more easily from side to side. This is the position that you should be in, where the shoulders and neck work better. Tight fascial pulls you out of this optimal position and makes it feel unnatural to try to get to. This is why Fascial Work is so important. It will help make it easier to find this optimal position where everything works more efficiently.

Often it’s difficult to properly describe the full effects of fascial release but in a nut shell, it help you go where your body will work better, be stronger, more mobile and suffer less symptoms. It’s my job to help you to get there.

Deep Tissue Massage…..but not too deep.

With Deep Tissue Massage, the philosophy out there generally is deeper is better. Push hard, go deep. A teacher brought up a really important point about this type of treatment. They said “don’t think of the tissues as a one way system ie: the brain tells it what to do”. There are so many receptors in the tissues that also feed information to the brain. The connection is a two way system. If our work is too deep, too fast the brain may perceive this as a threat and tighten the muscles in response. In my teachers own words “if we think we can overcome a tight muscle by pressure that is too deep, we will probably lose that fight”. It seems to be a place of listening to the tissues. How much pressure will they allow us to use before beginning to tighten? The irony is, the more we listen and only use the appropriate pressure, the deeper we can get into a muscle or tissue. It will take a little bit longer but at the end the treatment was more effective and the patient leaves happy and not feeling like they were beaten up.

I have had instances where I can barely touch the tissue as it is too painful for the client. I only press to their tolerance, wait for the tissues to release, then go a little deeper to the edge of the patient’s tolerance again and repeat. It is amazing how the body will let us go to depths that would have been impossible in the beginning.

Be gentle and go deep.

Just move…

In my previous post, I wrote about Joint Mobilizations and how great the course was. It reminded me of the important of what lies beneath the musculature. It is an essential tool for helping to determine why the muscles tighten in the first place. It is important that we look past just releasing the muscles to find underlying causes to help to good prevention strategies.

To review, a joint is the point where a moving bone attaches to another bone. Good examples of this are the shoulder joint, where the arm bone attaches to the outside of the shoulder blade, the hip joint where the leg bone attaches to the pelvic and the spine, which consists of 31 vertebral bones stacked on top of each other with a gelatinous disc between each. Whether it is a wrist/ elbow/ shoulder joint or a hip//knee/ankle joint or spinal joint, where is an inherent about of motion for each. We have evolved to a place where each joint in our body must move a certain amount. If that motion is limited the effect can be muscles being overworked or weakened, nerves may be compressed, tendons may be impinged resulting in reduced range of motion and/or pain.

As a result of the above, one of my primary treatment philosophies have evolved into simply assisting the joints in the body to achieve their full range of motion. That makes a body happy. If you have a sore shoulder, I look at reducing your symptoms but also determine if any of the joints in the shoulder complex are not functioning to their full capacity. The bones that move in the shoulder complex include the upper arm bone, the shoulder blade, the collar bone and the ribs surrounding the shoulder blade the upper 3 vertebrae of the midback. All of these must be functioning to assure that the shoulder can move fully and freely. This can apply to any joint from the feet to the top of the head. I have found that most of my success in treating pain, weakness, overworked muscles, nerve compressions come from just allowing the body to do what it can’t. Once it can do this, then it’s capacity to heal improves dramatically. Any correction of a joint done in a treatment will tend to last for a while but exercises are also given to maintain and improve the effects from the treatment. It’s the importance of including the patient in the treatment so they understand why the symptoms are occurring and empowers them to be part of their success.

With improving the function of the spine, I have found my greatest success is using a more Osteopathic approach. Without the surrounding soft tissue (muscles/ ligament/ fascia) the spine would collapse so it’s integrity, function, strength and position is determined by the tension of the surrounding tissue. So we look balancing the tension of the tissue that surrounds the spine and ensures that there is proper support available for it. The Osteopathic approach has been so good on this level in that is so gentle yet effective.

Allow the body to move as it is designed to do. Be strong, mobile and your body will be happy.

Massage Therapy and Joint Play

I took a really good course last weekend that covered Joint Play. This is a really important part of everything from injury prevention to rehabilitation. A joint is the place where two bones meet and one of the bones moves around the other in it’s intended range of motion. A great example is the shoulder joint. The main shoulder joint is where the top of the arm bone attaches to the outside of the shoulder blade. As the arm moves around the socket at the outer part of the shoulder blade, there needs to be small motion that occurs inside the shoulder joint. That is the joint play.  If the end of the arm bone is the ball and the edge of the shoulder blade is the socket, good joint play range of motion ensures that the ball stays within the socket space no matter where the arms moves to. If that small motion isn’t there, the arm movement will stop and reach the end of it’s range prematurely and can mimic Frozen Shoulder. It’s like a hinge in a door that doesn’t move well, so the door doesn’t close. It feels like it catches or pinches causing local shoulder pain that can begin to travel causing neck, rib pain and headaches. A lot of my success with treating the shoulder is just returning that small essential motion in the joint. These small motions can occur in the jaw (TMJ), the spine, shoulders, elbows, wrists, hip, Sacroiliac joint, knees, feet to name a few. Each of these joints have their own movements and often any limitations can be restored. The treatment for restoring joint mobility is a little different from standardized massage therapy as the treatment is very regionalized but I feel like it is such a crucial part of getting to the cause of dysfunction/discomfort. There is always treatment to the surrounding muscle tissue, especially the symptomatic one in addition to the joint play treatment. I remember one teacher saying that if you have a painful/tired muscle, look to see what joint they move. For example, if you have a sore biceps muscle on your arm, I look at the shoulder and elbow movement. If someone has a sore front leg muscle, I look at the hip and the knee joint. It’s not well known that the ribs are also very mobile during torso and arm movement and breathing, and in our society, the ribs are commonly stiff and can benefit from mobilization. Very often, I have found that treating just the tight muscle may feel good for a shorter period of time, but can return if there is an involvement in the surrounding joints.

Having said all that, there is opportunity for pain to refer away from where the joint is not functioning properly. Neck joints in the spine can cause pain down the arms or produce headaches. Low back spine joints can refer pain into the hip or down the leg and mimic Sciatica. A stiff joint in the foot can produce pain that goes up the leg. There is a thought out there that you find the pain but look for the cause elsewhere.

Having joint play in my treatment tool box has vastly reduced pain and dysfunction with patients, increasing functionality and improving daily activities. It is a gentle treatment and follows with the Osteopathic process, which often reveals very good results. Be gentle and the body will let you do more. As always, the patient’s success is partly what we do in the treatments, but just as much, it is important for the patient to be involved so they can continue to improve at home with stretches, exercises and movement/posture changes. It continues with the philosphy that we were designed to move a certain way and very often dysfunction can occur when we don’t.

Trigger Point Therapy

Trigger Point Therapy is a tool in my treatment toolbox that I use often with helping to relieve pain symptoms that the client is experiencing. They can vary from localized pain of taut bands of muscles that can occur throughout the body from feet to the top of the head. They can also exist with symptoms like jaw pain, neck pain, headaches, pain down the arm or leg or into the hips. They occur where there is a taut band in a portion of a muscle. There is debate as to the actual physiology behind trigger points but the symptoms or undeniable. These taut bands (trigger points) in hypothesis occur when the muscle tightens/ shortens due to fatigue or being put into a shortened position for an extended period of time, trauma, dysfunction of a nearby joint that it is involved in movement or stabilization of including anything from foot, knee, hip, spine, shoulder, elbow or hand. Often it will produce a vague, dull achiness, which can help to differentiate is from a nerve related pain. When there is pain down the arm or leg, it can often be misdiagnosed as a nerve related pain but special assessment can be done to determine if it is nerve or trigger point related. The tricky thing is that the trigger point can refer pain to another area, making it seem that there is a dysfunction in that distal area. For example, the outside of the thigh muscles can refer deep achiness right into the knee. The rotator cuff muscle trigger points can refer down the arm to the hand. Neck muscles can produce head aches in different areas of the head by different neck muscles.

Each person experiences a reduction of symptoms in different ways so there is no one way to relieve a trigger point. In addition to releasing the trigger point, it is important to determine why that muscle, or portion of the muscle is tightening and help educate the client to avoid a reoccurrence in the future. Writing this entry reminds me of trigger points that can occur in the upper back and neck that can produce head aches. We are in a society that is spending a lot of time in a slight forward slouched upper back and head forward position and the end result is that the muscle in the back of the upper back and neck just get tired. Our heads are heavy and produce a greater force the more forward they are. Good upper body and head position is important as it dramatically reduces the exertion put on the upper back and neck muscles. It is part of the posture and movement pattern re-education that I teach in treatment so that a client can be empowered to make posture/ movement changes when the symptoms of trigger points occur (in addition to others). It’s about treating the symptoms, finding the cause and helping the client to make movement/ postural changes to avoid reoccurrence in the future.

Here is an interesting tidbit

I remember in my 30’s I had a reoccurring issue with my low back. There were acute back spasms, pain going down the leg, numbness and tingling on the shin. I was often in getting treatment and trying to figure out what was happening. I remember getting an x-ray done of my low back through a walk in clinic. I got the results and was told that I have some arthritis in my back. Honestly, it felt like it was the beginning of the end. Arthritis. They talk about how pain is a signal elicited by the brain if it feels like you are under a threat. This can be cause by tissue damage, visual, audio, tactile and many other stimuli. There is a good possibility that if I am told that I have arthritis in my back, and that is responsible for my pain then the pain can become chronic. I have learned to become careful in practice with the language that I use when talking about what I find or what they have found out about their pain/dysfunction. I found something interesting (below) that talks about how things like arthritis/ bulging discs/ torn rotator cuff and meniscus/ osteophytes may not be responsible for the pain being experienced. These different studies/ scans, in the study that I am attaching, were done on asymptomatic people. The result of the attached study is that there are all these people in the pool that have no symtpoms, yet here they are with torn this and that and bulging discs and arthritis ect. Maybe the Orthopedic world is looking too hard for something to be wrong or something to blame for the pain if they find something on a scan. Arthritis, for example, is a totally natural occurrence. Everyone gets it. Maybe in extreme cases of advanced arthritis or rheumatoid arthritis can perhaps cause some pain/stiffness, but for the most part it can be a perfect benign presentation. Maybe the symptoms are just from the way we are moving or sitting. Something that we can remedy easily and quickly. The picture below shows the studies, the number of participants and the results from the scans. There are lots of special tests to rule out and scan results like meniscus or rotator cuff, disc issues but we shouldn’t depend just on the scans to make determinations as to the source of the pain. It’s good to ask questions like “I see that I have a bit of a rotator cuff tear, but how can we know for sure that is what the issue is?”. When we see someone about an injury or pain we are feeling, we need to be part of the conversation.

To stretch or not to stretch

With Massage Therapy, part of our focus is on the muscular system and maintaining good function allowing the client to reduce their pain and stiffness. In addition to releasing the muscle tightness/stiffness, it is also important to be able to determine why the muscles are tightening up. Often I find that a client may come in and say that they have been stretching and stretching but to no avail. This may be due to the tightness occurring when the muscles are activated to try to stabilize a part of the body that is too mobile. If you take, for example, the low back, the range of motion is limited by a few factors including the surrounding connective tissue. The connective tissue that surrounds the spine will stop you from bending too far backwards, forwards, side to side or rotation. Connective tissue is comprised of collagen fibres for strength and elastin fibers for flexibility. A certain part of the population, including me, have a little more elastin fibers to collagen fibers so we can bend a little more than everyone else. With a little less stability from the surrounding connective tissue, the muscles are recruited to work harder to stabilize our low back. If we use our backs too much, the muscles begin to fatigue and the brain says “stop what you are doing” and uses pain to get us out of the perceived threat. So the muscles are functioning overtime because of lack of stability. When our low backs begin to tighten and we begin to experience pain, we are inclined to stretch those muscles. If the muscles are short and tight, they will not want to lengthen as they are doing a job of trying to stabilize so they will respond to our stretching by tightening more. Our stretch becomes a tug-of-war and will ultimately end up not being successful. During the assessment portion of a treatment, I like to look at the joints and move them passively (without the client’s involvement) to determine if the motion in the joint is not enough or too much. If there is too much motion, the direction to go in is not to stretch the muscle but to help to stabilize the low back joints in the spine to reduce the need for the muscles to tighten so much. This is a much different approach from standard Massage Therapy where there is more focus on “releasing the muscles”. Make the body more stable and reduce the need for muscles to work so hard. Going back to my previous entry about movement patterns and pain/dysfunction it is also important that we learn to move around the joints that are strong and stable. The low back is a perfect example as really it is a very unstable structure. The spine is essentially a bone on top of a gelatinous disc on top of a bone on top of a gelatinous disc all the way to the top of the spine. We are not really designed to move mainly through the spine and especially not exerting a force. Keep the spine as still as possible and move through the two hip joints, for example. As someone that is hypermobile through my joints, this has been an essential component to maintaining a healthy, pain free back and I’m always happy to share with others what I found has worked for me.

The other component is that with most movement through the body, there are the muscles that move the joints and those muscles that help to stabilize the joints through that movement. It is essential that we maintain strength and function of the stabilizers to match the strength of the muscles that are primarily moving a joint (or group of joints). Someone once said, not having this support is like having a tree where the brances are  stronger than the trunk. If the proper stabilizing muscles are not recruited, other muscles are activated that are much less efficient as stabilizing also producing and short, tight, fatiguing group of muscles and consequently pain and dysfunction.

So muscles that have tightened may not need to be stretched. Of course we work on those muscles during the treatment to reduce the reactivity and pain but we also help the client to support and improve the way they move in preventing pain the future. The courses that I have taken in Mat Pilates Teacher Training provide a really good base of support to create a strong, mobile, well supported body.

The long stretch…

There are generally two schools of thought with stretching in terms of how long you hold the stretch. There is the 30 second stretch and the 3 minute stretch. I come from the place of the longer stretch in increase range of motion and the 30 second stretch in terms of maintaining the increased stretch. I think the important thing to think about with a stretch is that it is not just the mechanical stretch of the muscle but also the aspect of allowing the nervous system to adjust to the increased length of the muscle. Someone once described a 3 minute stretch in 3 parts.

1)The first minute of the stretch, there is a bit of resistance or protective shortening of the muscle as you are taking the muscle a little further than where it is used to going so you wait for that first minute for the nervous system to feel comfortable with the lengthening of the muscle.

2)The second minute, the protective tightening of the muscle reduces allowing the muscle to begin to lengthen.

3)The third minute is the time that the muscle is left in the lengthened position to allow the nervous system to experience not just the muscle in the lengthened position but also the joint going into that position. An example is the hip joint and a hamstring stretch. The stretch is not just intended for the hamstring but also for all the deeper tissue surrounding the hip joint.

When people ask me if I prefer foam rolling vs stretching, I think that both have their place but for allowing a muscle to lengthen and increase the joint movement in that direction, I always advise the stretch.

I always like to think of a stretch as slow cooking. A more gentle stretch for a longer period of time. All we want with muscle/skeletal system is for the body to be able to move in the manner to which it is designed.