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Clinical Reasoning Typical cases are discussed there. The cases are brought by practioners.

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Old 22-02-2012, 01:34 AM   #1
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Default Frozen shoulder: It remains a challenge! - Need ideas.

Hi all.

I am treating a female patient (40yr) pos mastectomy with a oblique scar over the pectoralis major. After surgery (4 mo) she developed frozen shoulder in the right arm. At this moment she has 140º flexion, 45º external and internal rotaions and 110º abduction. There are typical compensatory movements during flexion and abduction with hiperactivation of the superior trapezius.

Treatment is based in: pectoralis major, trapezius, deltoid and lastissimus myofascial release; umeral head mobilization (inferior, anterior and posterior glide - grade IV), scapular mobilization, motor control movements for flexion and abduction reproducing functional movements and wall slide.

The question is: How can I inhibit the hiperactivation the superior trapezius and how can I facilitate the dissociation between umerus and scapula during flexion and abduction?
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Old 22-02-2012, 01:54 AM   #2
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Is her primary complaint pain?

I would treat that first.
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Old 22-02-2012, 02:09 AM   #3
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No. She did not have any pain only limitation in ROM.
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Old 22-02-2012, 03:52 AM   #4
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In that case, I'll ask you another question: Why would you want to change the way she is moving now?
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Old 22-02-2012, 04:29 AM   #5
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Hi John. Thanks for your interesting. The question with this patient is that she move her arm into flexion and abduction but with activation of superior trapezius and consequentely shoulder elevation as a uinque structure. I would like some idea to facilitate the umeral depression during abduction and flexion.
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Old 22-02-2012, 09:29 AM   #6
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A recent paper in an interesting journal: The effect of heat applied with stretch to increase range of motion: A systematic review
Quote:
Application of heat to muscle is commonly advocated to enhance the efficacy of stretching. However, the effect of this combined therapy using different methods of heating, applied to different muscles, and after one or multiple treatments, is not known.
To perform a systematic review to address the question: Does stretching augmented by heat application result in greater gains in range of motion (ROM) compared to stretch alone?
The following databases were searched for original articles that evaluated our question: MEDLINE, EMBASE, CINAHL, the Cochrane Central Register of Controlled Trials, SPORTDiscus and PEDro databases. After title and abstract screening followed by full-text screening, the quality of included articles was assessed and their data was abstracted. Screening, data abstraction and quality assessment was performed and consensus was achieved by two reviewers. Range of motion (ROM) data were synthesized by meta-analyses for overall effect and subgroup analysis according to muscle group, method of heat application, single or multiple treatments, and reported tightness of muscle. Twelve studies were included and reported the effects of stretch with or without heat on ROM of 352 participants. Heat applications included ultrasound, shortwave diathermy and hot packs. Meta-analyses and subgroup analyses demonstrated greater increases in ROM after heat and stretch (H + S) than heat alone. Subgroup analysis of muscle groups and the method of heat application showed some trends, but no significant differences. Multiple treatments (more so than single treatments) showed consistent treatment effects of H + S versus stretch alone amongst subgroups. Muscles described as tight did not show a greater treatment effect in response to H + S compared to muscles not reported as tight.
Heating provides an added benefit on stretch related gains of ROM in healthy people.
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Old 22-02-2012, 12:49 PM   #7
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Felipe, John poses a very appropriate question.
If there is no pain, what is the reason to work on the shoulder?
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Old 22-02-2012, 01:19 PM   #8
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Quote:
Originally Posted by Karen L View Post
This is interesting if viewed from the switching of paradigms.
In light of the inside to out paradigm. If the sense of stretch is a projection of the brain as a protective threat elevation then the application of soothing warmth would be expected to work to improve range by decreasing the sense of threat.
The outside to in view would be about tissue extensibilty being proportional to temperature, muscle relaxation - when we know that the body dissipates the thermal load very effectively so that internal temperatures barely rise. Hmmm. Interesting times on the journey.

Felpereis - If there is no pain and restriction is your concern then I would think that as a self-limiting condition frozen shoulder can be left to itself - re-assure her that she will improve and give her a medium to long timescale.

Last edited by ste5e; 22-02-2012 at 01:23 PM. Reason: Forgot to mention....
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Old 22-02-2012, 01:46 PM   #9
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I'd suggest you look into doing Feldenkrais movements. There are plenty to learn on YouTube.
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Old 22-02-2012, 03:49 PM   #10
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John and Bas,

I am assuming that if there is no pain then there is nothing we can affect? Even though her function is affected we cannot improve ROM this since we are dealing with collagen which we can have no effect on manually?
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Old 22-02-2012, 05:00 PM   #11
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No, I do think we can affect the the shoulder: we can convince/instruct the patient to do "X", or we can manually modify how the shoulder feels to the patient and thus change its motion.

How is the function affected? What is she unable to do? And why not? - these answers will provide with direction of therapy. But these issues did not get a mention in the original post.
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Old 22-02-2012, 05:22 PM   #12
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I agree with what Bas just said.

My concern is that this patient was just told to go to therapy to have a someone stretch her shoulder out as if this will alter the course of the connective tissue changes associated with this condition. She needs to be re-assured that this condition runs a certain course in terms of the connective tissue changes, so she will need to be patient

However, if she is having trouble doing something that she wants or needs to be able to do, then I think it's appropriate to teach her how she might better achieve that. Dissociative movements that improve interoceptive awareness of the various segments of the body involved in raising the arm I think are a good start.
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Old 22-02-2012, 05:45 PM   #13
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Could it be axillary web syndrome?
If it is all about turning off the upper trap and activating the cuff during elevation...I like to start in sidelying with ER followed by elevation in the scapular plane. This helps them activate the cuff first in my experience.
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Old 22-02-2012, 06:20 PM   #14
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Quote:
Dissociative movements that improve interoceptive awareness of the various segments of the body involved in raising the arm I think are a good start.
I'm not sure I'm familiar with tis approach. Is there anything you could recommend I read?
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Old 22-02-2012, 06:42 PM   #15
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Todd Hargrove has a good site worth reading

http://bettermovement.org/

I'd start there. As when you mobilise a shoulder you're having very little affect on the tissue but a massive affect on the nervous system, all of it, including the way the shoulder is represented in the brain. So if you want to increase the range you should do it in a away that interests the brain.
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Old 22-02-2012, 06:59 PM   #16
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Thanks Dave,

I am aware of the effects of manual therapy on the brain and neuroplasticity.

I wanted to know specifically what was meant by dissociative movements of the upper extremity to improve function (i.e. overhead reaching) in frozen shoulder patients with no pain.
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Old 22-02-2012, 08:41 PM   #17
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I can't answer on behalf of John, but as I understand it dissociative movements mean specific GHJ movement without movement of the scapular. Aiming to increase the representation of the GHJ in the brain to increase the movement options. Instead of the gross movement that people with "frozen shoulder" tend to adopt.
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Old 22-02-2012, 09:15 PM   #18
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Quote:
So if you want to increase the range you should do it in a away that interests the brain.
Ideomotion and/or DNM....

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Old 22-02-2012, 10:21 PM   #19
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or novel, interesting, mindful and playful movement...... could be consciously driven.
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Old 23-02-2012, 12:30 AM   #20
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Default Any particualr recommendation??

Quote:
Originally Posted by Barrett Dorko View Post
I'd suggest you look into doing Feldenkrais movements. There are plenty to learn on YouTube.
Hi Barrett,

I've been searching for that, but i cannot really figure out which series are worth having a look.

Could you kindly suggest some clips on Youtube that you think are good, please?

Thank you,

Weni
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Old 23-02-2012, 12:43 AM   #21
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There must be a cut off point in adhesive capsulitis where the brain cannot override the reduced mobility of the connective tissue?
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Old 23-02-2012, 12:52 AM   #22
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http://www.youtube.com/watch?v=avLSpmW_VVA
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Old 23-02-2012, 01:01 AM   #23
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Dave's description is pretty much what I mean. But you can do dissociative movements of any segment to improve interoceptive awareness of that body region. You can instruct and/or cue the patient to perform isolated movements of the GH joint, the scapula and the upper trunk in a variety of sequences.

I've found myself more and more just exploring with the patient ways to move in different positions to increase awareness of movement in the painful area without provoking pain.

And definitely, Adv1, the brain is not going to be able to suddenly change the fact that the joint capsule has thickened and scarred due to chronic hypoxia from inflammatory processes- given that we're talking about a true frozen shoulder, and not just a stiff, sore shoulder.
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Old 23-02-2012, 03:51 AM   #24
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Do you think her problem is defect or defense?
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Old 23-02-2012, 05:26 AM   #25
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Defect is possible if there are CT changes in the joint, but there is no way of determining if there are CT changes other than surgery ()

I would assume it is defence and go from there before deciding to tell her to be patient. I have seen a shoulder or two where abduction has been limited to 30-40 degrees abduction for 3-4 months, recover fully within a week or so. It doesn't mean that will occur with this woman's shoulder, but who knows.

Her ROM is pretty good now, so I suggest try some mirror work; if it doesn't work, no loss.

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Old 23-02-2012, 11:20 AM   #26
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I would simply handle this patient in the fashion that I do and see what happens. The defensive muscular activity would move through resolution as was possible.

I think that going after the affected region of the shoulder to begin with is a mistake.

What's the resting posture of the legs?
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Old 23-02-2012, 12:50 PM   #27
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Hi all. Thanks for all answers in my post.

I found an interesting paper Adhesive capsulits: use the evidence to integrate your interventions. Page P, Labbe A.N Am J Sports Phys Ther. 2010 Dec;5(4):266-73.

This patient developed frozen shoulder imediately after breast surgery with a big amout of pain for 2 mo aproximately. I think that this period with pain and restriction in movement altered her cortical representation for shoulder movements.

I also agree with Nari and Diane that it can be a protective stage with a disturbed pattern of movement.This is also combined with the stiffness in shoulder capsula.

I did not mentioned before but I am also working in spine mobility and ideomotion. Nice ideas from Barret with Feldenkrais.

This paper can be helpful.

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Old 23-02-2012, 02:03 PM   #28
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Thanks for that article Felipe. The paper is still assuming that adhesive capsulitis is a diagnosis that we can readily make in the clinic. It is not. As nari says, surgery is the only way to establish the presence of the significant fibrotic changes in the capsule.
It dooes not address the many occurrences where so-called frozen shoulders or "adhesive capsulitis" have resolved in a very short time - which indicates the whole fibrotic changes concept does not apply to many frozen shoulders.
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Old 23-02-2012, 03:38 PM   #29
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I happen to think that we can indeed still make a diagnosis of capsular contracture in the clinic.

Sure, there is the element of threat and pain that can override our ability to truly move the joint without guarding, but I also think that when the patient has been educated on pain, the conditions associated with true capsular contracture, and the difference between this and pseudo contracture, we can indeed tell the difference. To determine this, I ask the patient to take their arm to the point at which they would like to stop moving it. This is done at 90 degrees of abduction, and I ask them to move it into external rotation to their level of comfort. When they stop, I take one finger, and apply a quarter's worth of force ( you will notice I did not say nickel), and then I let this off. We repeat this a few times, asking whether there is pain or not at this point, and there usually is none. If there is elastic rebound, I think it is safe to say that this is a tissue that has been moved to its elastic limit. Patient sees this, understands the idea behind this true joint contracture situation, and now feels safe doing some movements that may help to restore movements. Further education ensues that describes that these movements, along with the mobilizations I will be doing most likely allow for a more timely improvement through this neuromodulation and placebo effect. I tell the patient that these treatments help them come to terms with the idea that moving is OK. I use the words "exploring movement" at first.
I am able to convince them that if they should move to the point of pain, it is not a sign of damage in any way, and this is proven by the fact that the pain does not remain, nor does it become worse. If they are comfortable with this idea, they can push their motion. This is up to them.

It is the patient's comfort vs threat level with pain that is important, not their therapist's. Its our job to tell them whether their current perception and interpretation of stimuli is accurate or not, and then help them understand better if it is not accurate. With this approach, I often see improvement toward the 3 month mark. Since the literature shows improvement most of the time in 3 to 36 months, I tend to prefer the lesser end of this time frame. This encourages functional use of the arm during the time frame mentioned as well. It also helps the patient have an expectation in mind for the duration of recovery, and we all know how important expectations are in the outcomes for our patients.
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Old 23-02-2012, 03:45 PM   #30
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Hi felipereis,

If the paper you posted is copyright, please take it out of your post, repost it in Sounds of silence and post a link to it in your post instead. Thanks.
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Old 23-02-2012, 04:00 PM   #31
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The picture on page 4 of the article shows a very Travell and Simons looking Big Red Spot right over where the axillary nerve (branch of radial) swings posteriorly and emerges through the quadrilateral triangle. Several sources point out that it is prone to entrapment syndrome there.

Bas is right.

Papers like this are not worth the effort of reading them, because of the deliberate conflation of mesodermalism into the clinical art of discernment, and the idea deliberately planted that spraying will somehow assist stretching with no clue provided about the neurology of it all, not anatomical (axillary nerve) or mechanistic (entrapment syndrome) or physiological (neural irritation), or of how treating in that manner might be presumed to help - really. This paper sources those impossibly simplistic trigger point books, and is therefore a completely suspect source of meme infection.
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Old 24-02-2012, 06:54 PM   #32
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Isn't it possible that the capsular contracture is what is responsible for the entrapment of the nerve? Sure it is. Studies show that intracapsular volume is decreased with frozen shoulder/adhesive capsulitis. One could argue with chicken or egg, and either might be right.
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Old 24-02-2012, 07:27 PM   #33
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Isn't it possible that the capsular contracture is what is responsible for the entrapment of the nerve? Sure it is. Studies show that intracapsular volume is decreased with frozen shoulder/adhesive capsulitis. One could argue with chicken or egg, and either might be right.
And supposing we entertain that hypothesis for a moment, what might be responsible for "increased capsular volume"?
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Old 24-02-2012, 08:33 PM   #34
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Are you asking what would bring about a return to the previous state of increased capsular volume? If so, a return to normal movement in all directions should return the extensibility of the contracted tissue, thus essentially restoring the axillary redundancy that is thought to magically disappear as the capsule contracts.

There are also studies of injections into the capsule with intent to distend it, but I have never seen this performed, nor seen someone on which it was performed. Those are supposed to achieve increased intracapsular volume.
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Old 24-02-2012, 10:36 PM   #35
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There are also studies of injections into the capsule with intent to distend it, but I have never seen this performed, nor seen someone on which it was performed. Those are supposed to achieve increased intracapsular volume.
Pushing on mesoderm from the inside out. Doesn't sound like a winner to me.
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Old 25-02-2012, 12:47 AM   #36
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Hi Diane.

Thanks for your advise. I am not sure if it is Copyright so I took it out. The paper is free acess and I prefer to use the link.

ADHESIVE CAPSULITIS: USE THE EVIDENCE TO INTEGRATE YOUR INTERVENTIONS

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3096148/
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Old 18-05-2012, 07:21 PM   #37
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I just found this thread. I had a new client the other day who has a DX of frozen shoulder. I've worked with 3 other cases over the years and came to the conclusion that they were some sort of neurological dsyfunction. I tried talking to an local PT I know about it and got no reaction. I've never known anyone who would understand the experience I was describing until I came here.

All four cases are women over 40 - three are post-menopausal and one in her mid-forties. All had fairly sudden onset. Two eventually had full recovery. Whether what I did made a difference or not, I don't know. The one in her 40s only saw me twice and the last one, I've only seen once. She lives 80 miles away, is a farm wife, so I don't know if I'll see her again.

The first person I worked with was a regular client who was already coming for weekly massage. Obviously, this did not stop her from developing it. It came on suddenly after a weekend of playing a lot of golf. My first approach was to use the "trigger point" approach since that is what I was schooled in at the time. It became immediately apparent this was not going to be helpful.

What I noticed was that when I had my hand on the back of her shoulder, when she was lying supine, relaxed, on the table, and I went to move her shoulder even very gently and just a little, I could feel muscles contract reflexively. The slightest movement initiated this strong, protective reaction. So, I tried doing some very subtle, Trager-like movement, inspired by a Feldenkrais class I'd taken years ago. My intention was to try to create some safe movement, get the brain to accept movement, even if it was subtle.

It "worked" in the sense that we were able to achieve very very incremental improvements at each session. This was long before I knew any of this neuro stuff we take for granted here. However, it was a long, slow recovery. I'm not sure if what I did made a significant difference or not. The client was already a weekly client. However, she regained complete ROM and has maintained it for several years.

It was clear to me that the problem was not "adhesions" but seemed like a neurological problem. I've never known anyone I could talk to about it.

With the most recent client, she has restricted ROM and so it interferes in her life. She does not have pain at rest but has pain with certain movements. I did some Explain Pain pain education. On the table, I did some of the DNM I learned in Montreal and also made up some of my own. I didn't do any sort of "massage." She does have an area of tenderness on palpation near the biceps tendons at the shoulder, don't remember what nerve that is. I don't know the names of nerves very well. When she got off the table, she had less pain and a small but noticeable gain in abduction.

Talked to her about graduated exposure to movement, looking for and building on successful movement. I gave her a link to Cory's Novel Movements for the Shoulder and suggested she see if any seemed like a good thing to be doing.

She had been in PT where they did painful stretching. It seemed to make her condition worse. One movement they gave her which she found helpful was letting her arm hang down loosely and letting it swing in circles. She found it relaxing but, ironically, developed an aversion to it because they had her do it just before they did the painful stretches, so she associated it with that. We talked about the possibility of doing it - since the movement itself felt good and useful to her - but now doing it with the awareness that it was not going to be followed by pain.

If I see her again, my approach for now is DNM and continuing to look for easy, comfortable movement and reinforce that. I told her if she wants to try, we could do three appointments and see if it seems to help. I gave her as much info as I could - including a link to Moseley's Why Pain Hurts TED talk - so she has some tools to work with at home.

IF I see her again, if there are any suggestions here, I'm interested in hearing them.


As for "adhesive capsulitis," the idea that there are adhesions restricting movement doesn't seem plausible in many of these cases, certainly not the ones I've seen. The two clients I saw over time both had complete recovery. How did the "adhesions" appear so rapidly and then, months later, mysteriously go away? Perhaps there are cases where there are adhesions, I don't know about this, but the ones I've encountered seem like a very strong, protective action and in that case the name is a misnomer.
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Old 18-05-2012, 08:14 PM   #38
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I agree that it's neuro.
Here is my little story about getting, then getting rid of "frozen shoulder." Mine lasted less than two weeks.
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Old 18-05-2012, 09:39 PM   #39
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Dissociative movements that improve interoceptive awareness of the various segments of the body involved in raising the arm I think are a good start.
I agree, and with regards to terminology, would this describe, Feldenkreis, and somatics?

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