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Old 03-11-2011, 12:28 AM   #101
Steve Hill
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Hey John
What do you suspect you would find (ROM wise) in an unconscious patient with suspected frozen shoulder?
I am not asking this to be a smarty pants, I am actually serious. I think in some cases we would find normal range. But in those with the infamous capsular end feel, they would still lack the motion. This would be a fun study. I work in a large university hospital. This is not out of the realm of possibility.
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Old 03-11-2011, 04:16 AM   #102
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I agree with you Steve, there is a % of patients that I believe have a stiffened capsule. The broad majority of patients that have been diagnosed with a frozen shoulder by an MD. Have not had a stiffened capsule. From what I have seen the people that do truly have a frozen shoulder usually come to PT only when that shoulder has become a painful experience. Thus generally there is a layer of protection that surrounds the shoulder.

Meaning that muscles show decreased recruitment for voluntary movements and there is increased resistance to passive ROM in multiple shoulder planes. Which when the patient's shoulder is passively moved to a certain point the protective mechanism of the shoulder kicks in and you get increased resistance. Generally, this is before the patient's self reported pain is experienced. Often this increased resistance is slight. I can usually also tell I am getting close to the patient's end ROM because I start to see and feel reflexive contractions/fasciulations in the muscles of the shoulder and therefore never really need to pas much past this.

So therefore I spend a couple of sessions peeling back this layer of protection. This involves doing a whole host of specific isometrics for the shoulder, some soft tissue techniques, movement awareness techniques, sustained comfortable postures, light manual stretches (stretches are held for 30 sec to 1:00 min below any noticeable pain by the patient and evident reflexive protection) and pain free active motions.

Once the protection is gone after 2-3 weeks, 1 week with a really responsive and diligent patient then I can asses the joint. I don't do this through assessing the capsular end feel but through simple joint glides. If these are stiff, pain is gone with all movements of AROM, and during PROM the patient does not show protection. Joint glides are limited then I feel fairly confident that we are dealing with a true adhesive capsulitis.
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Old 03-11-2011, 04:51 AM   #103
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Steve,

Remember, I'm the guy who responded earlier that I thought the ER moment was more easily achieved at 90 degrees of elbow flexion. I don't deny for a second that patients develop contractures of their GH joints as a consequence of a true capsulitis. What I question is the validity and more importantly the clinical utility of identifying a capsular end feel.

If the patient has a contracture, no amount of mobilization is going to change that- unless the patient agrees to manipulation under anesthesia. I'm not sure if MUA has ever been done to a patient who lacked a painful stiff shoulder.

Your study design would help to validate that the test you describe identifies a joint contracture, but then I have to ask, So what?
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Old 03-11-2011, 05:07 PM   #104
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So what = identification of those patients who can expect to improve in a rapid fashion due to the lack of a true contracture. Those with empty end feels (and thus normal passive motion) would fall into this category and be realistically able to be treated with reassurance, down regulation, therapeutic exercises. Those with true capsular pattern would then have a more reasonable outlook on recovery in no less than 3 months. An interscalene block would be more appropriate type of anesthesia so that during this teaching, we would have the brain still capable of processing this.

Words to the effect of "when we took pain out of the picture, this is what your shoulder was capable of doing" would go a long way towards encouraging patients to explore normal movements.

I would like to agree that no freely moving joint has ever been manipulated, but to think that there are manipulators who consider tissues other than the joint as the source of a psuedocontracture is probably naive. Not calling you naive, just pointing out that those who often do the manipulation under anesthesia dont often have the deeper model in mind.
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Old 08-11-2011, 03:18 PM   #105
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Default Update on Wall elbow flexion in neutral forearm from 90 degree shld flexed position

Hi Jon,
2 of 3 patients with limited shoulder motion have now shown the inability to do the palm against the door movement completely. the third lacks only 15 degrees of ER now, so he could complete the task.
For one of the patients, an ipsilateral scapular shrug was significantly worse (pain) during this attempt to flex the elbow. He lacks the most ER at the shoulder currently. Contralateral neck flexion made this slightly better in terms of pain.
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Old 08-11-2011, 03:30 PM   #106
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Quote:
Originally Posted by Steve Hill View Post
Hi Jon,
2 of 3 patients with limited shoulder motion have now shown the inability to do the palm against the door movement completely.
Thanks for the update. I'm not sure where the "palm against the door" part comes in.
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Old 08-11-2011, 10:14 PM   #107
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Oops. I meant dorsum of hand against the door. Brain said dorsum, fingers said palm. Weird.

thanks for the catch.
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