In this episode, Erson sees a family friend and luckily at home. He finds out his wife is a great distraction that enables him to range a frozen shoulder much higher than when the patient was focused on treatment. Later while showing some home exercises, his wife (also a PT) discovered another surprise that enabled much better loading into further ranges.
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[00:01:12] Welcome to Untold Physio Stories Podcast. Your perfect commute resource with
[00:01:26] physiofalers, successes, interest in cases and more from the physio and rehab world.
[00:01:34] With your host Dr Andrew Rothschild and Urson Rilihioso.
[00:01:39] Welcome back to Untold Physio Stories and one of your hosts Dr. E with Mydermanual Therapy,
[00:01:46] Edge Mobility System and our four month online mentoring program. Mydermanhyad mastery.
[00:01:52] My co-host is going to do an asynchronous reply to this because we just can't seem to get together
[00:01:58] or get with it. Get on the same Google Meet to record these episodes these days.
[00:02:04] This would be part two of a case I recently talked about where I saw a good friend of mine
[00:02:11] for shoulder pain and it turns out that she has very high fear of weightings, very high
[00:02:17] kinesophobia after dislocating her patella multiple times. She was very worried about me
[00:02:22] tractioning her neck. I was doing a cervical retraction, traction and side bending with
[00:02:31] overpressure to the left to improve her shoulder pain. She was convinced her shoulder pain
[00:02:36] was coming from her shoulder but it turns out that her shoulder had significantly limited
[00:02:43] and painful mobility to overhead and scaption type movements and upon doing the cervical
[00:02:51] retraction inside bending and getting the end range with her permission and me convincing her
[00:02:57] that her jaw was not going to be dislocated and in fact it was more stable with the compression
[00:03:03] rather than without then she let me do it and her shoulder was better. Fast forward several months
[00:03:09] later, her shoulder has been on and off painful. It was confirmed that there was a cervical component
[00:03:17] however she got into the habit of avoidance of using her shoulder the more she used her shoulder
[00:03:24] the more her anterior clavicle, I should say anterior upper trap superior clavicle area swelled.
[00:03:32] She would get injections that would reduce the swelling and improve her pain and mobility for a while
[00:03:38] but again her strategy was just not to use her arm. The more she used her arm the more painful it got
[00:03:45] and even though the cervical retraction would help, I surmise that she wasn't doing them as often
[00:03:51] or to end range as she could have. So anyway again, this is the reform months later after that initial
[00:03:57] reporting of the case. She asked me to take a look at her shoulder now it's frozen. It is hard
[00:04:03] and feel in all planes particularly restricted in abduction and external rotation but the time I
[00:04:09] finally saw her I kept on trying to get her to follow up and I thought that maybe she didn't want
[00:04:15] to bother me because she was my friend and not necessarily like a patient. She didn't want to get
[00:04:21] my schedule. Sometimes she would cancel sometimes I had to cancel due to the weather or something
[00:04:26] happening with our families, kids or whatever but it turns out that she was fear of avoidance again.
[00:04:33] She was afraid of me moving her shoulder she was afraid of getting dislocated if I stretched it too
[00:04:39] much. So again by the time she finally saw me it was actually at my house and luckily my wife was
[00:04:46] there to distract her and again I didn't notice that I didn't put two and two together until her mother
[00:04:52] and mom told me that she was glad the visit was actually at my house because my wife who's her
[00:04:56] friend was able to distract her and talk to her. Another type of distraction that actually
[00:05:01] occurred was that anytime she looked at me testing or ranging her shoulder it was immediately empty
[00:05:07] or early hard end feel and when she would look away at my wife I was able to stretch her more.
[00:05:13] So then I said hey you know what you need to stop watching me so she would rotate away.
[00:05:20] And as soon as she rotated away she actually was able to raise her arm from like say 50 degrees
[00:05:26] with a hard end feel to about 120 degrees with the hard end feel. So you can make the argument that
[00:05:32] yeah you know maybe it was a neurodynamic issue I was kind of opening up for Aiman and that allowed
[00:05:38] me to move her shoulder more but then we also tried it as well when my wife actually instructed
[00:05:45] her on just simple ranging and stretching exercises and extension resets that if she closed her eyes
[00:05:53] she's actually able to move quite a bit further. So it's purely that perception of threats but also
[00:06:00] that visual neuro tag that's oh if my shoulder goes so far it's going to be dislocated but as long
[00:06:06] she doesn't really know how far it's going if she that turns away or closes her eyes she's actually
[00:06:11] able to range it to about maybe 70% of where she should be as opposed to initially when I saw her
[00:06:19] she's only maybe 30% there with hard end feels and pain in all planes. So let me know what you think
[00:06:25] about that Andrew if you ever had a similar case where even just closing the eyes you were able
[00:06:29] to range them quite a bit further. Looking forward to your thoughts. Hey Erson another
[00:06:37] interesting story as usual as I'm sure a lot of the listeners are aware there's been more and
[00:06:43] more coming out research wise about frozen shoulder and how a very strong component for a lot
[00:06:48] of patients is muscle guarding in tone often driven by fear apprehension anxiety these kinds of
[00:06:57] things that may be instead of or on top of actual structural capsular changes and this was just
[00:07:06] another great example of like you said fear just a history of fear avoiding behavior but also
[00:07:13] just that fear and apprehension about you know potential injury to her shoulder really ramped up
[00:07:18] that guarding and made it a lot more made it look worse than it actually really was. It makes me think
[00:07:25] of a recent posting that I think was on either Twitter Instagram a show of a patient with diagnosed
[00:07:31] frozen shoulder you know had her in the at her in the OR had her actively abductor arm had somebody
[00:07:38] passively abductor arm should the limitations put her under anesthesia and she had full range of
[00:07:43] motion so no actual tissue limitations just pure guarding. And then the clinic it can be really hard
[00:07:50] to make that this determination because we can't legally put patients under anesthesia unfortunately in
[00:07:55] some cases but it's hard to distinguish sometimes but this was a really good example of you're changing
[00:08:04] the visual of the patient you know having looked at something else every not paying attention
[00:08:08] to something having her take her focus off something in this case even closing her eyes which
[00:08:14] for some people potentially could be more scary but in this case you know really took away so she
[00:08:19] didn't have that visual fear as you could know added layers of protection into the system. And so
[00:08:29] that was a nice example of sort of it happened sort of accidentally but then became you know an
[00:08:35] essential part of the treatment plan to get her to help improve her motion. I have found in some
[00:08:41] patients who have a lot of guarding with sort of hands on type treatment if that doesn't seem to
[00:08:48] work sometimes let them do that themselves they tend to get better movement when they're sort of
[00:08:53] very in control with self mobilization versus any kind of hands on stuff so there are there is a
[00:08:59] patient population where they just will not you don't be able to relax but I think that's a great
[00:09:06] idea of changing that sort of the visual focus may make a nice difference in terms of maybe
[00:09:14] with some progress with this patients it's almost not exactly the same but kind of similar to
[00:09:19] almost myratherpy which we use with some people with like CRPS in an extremity where you're
[00:09:26] changing sort of that visual input and it changes changes the output and this goes to that sort
[00:09:32] of back to that mature organism model that Louis Gifford you know constant inputs changes those
[00:09:39] outputs so anything you can do this can be a little bit different can maybe have a positive
[00:09:43] beneficial effect but all right that's all I got and talk to you later or some hopefully in person soon
[00:09:52] if you found this case interesting or have any similar cases you have a story a big physio failure
[00:09:58] you want to come on the podcast make sure to DM me or reach out on any of my socials make sure
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[00:10:13] and as always you guys have a great day