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Sticky shoulders
Scary diagnoses, such as spondylolisthesis and Degenerative Disc Disease are often deconstructed during Explain Pain classes. Invariably, the metaphorical diagnosis ‘frozen shoulder’ gets a mention. We offer different names like “stiff shoulder” (quite literal) and inject some humour – “at least there is one benefit of global warming”. The name of this condition used in the literature, ‘adhesive capsulitis (AC)’ is equally fear inducing. It sounds horribly sticky, has hints of Araldite, and suggests that we really don’t know much about this condition.
The metabolic shoulder?
We have just read a great review on AC by Max Pietrzak (2016).
Here is some key thinking from the paper:
-AC is quite common, especially in the over 40s.
-It often resolves within 1-2 years, though there are many reports of longer term symptoms and disability.
-The most common risk factors for AC are age, diabetes and cardiovascular disease
-Diabetes and cardiovascular disease are commonly associated with obesity, with the underlying link being metabolic syndrome
-Metabolic syndrome is a cluster of biological changes including lipid abnormalities, elevated blood insulin levels and an immune response (increased pro-inflammatory cytokines) leading to a chronic low grade inflammatory state
-The strong associations between AC, age, diabetes and cardiovascular disease therefore suggests a common underlying aetiology of metabolic syndrome and chronic low grade inflammation
-Additionally, a dysregulated autonomic nervous system, shifted more to the sympathetic system through the effects of adrenaline, further induces and perpetuates low grade inflammatory states
When did you last throw a spear?
Pietrzak states that “the human shoulder evolved for high speed projectile throwing.” But, given our increasingly sedentary lifestyle (including lack of spear throwing, unless you’re into javelins) it is possible that parts of the shoulder-complex soft tissues are not exercised and stretched commensurate with their evolutionary function. Some of these shoulder tissues may now be subject to the buildup of metabolic by-products, increased pro-inflammatory cytokine production and detrimental effects on the cellular structure.
Within this context, Pietrzak suggests, an injury proximal or distal to the shoulder may trigger off a local and/or systemic pro-inflammatory cytokine, sympathetic and neuroimmune cascade resulting in AC.
Hang on, what is ‘chronic low grade inflammation’?
Chronic low grade inflammation differs from acute inflammation in that it is not localised to a particular part of the body, is of a lower ‘intensity’ and continues for an extended period. It is characterised by the systemic presence of increased numbers of inflammatory and immune cells and their products such as pro-inflammatory cytokines.
Chronic low grade inflammation is increasingly seen as a part of other orthopaedic conditions such as osteoarthritis – once considered a ‘cold’ wear and tear problem (as opposed to the far more overt and ‘hot’ inflammation of rheumatoid arthritis).
In the presence of chronic low grade inflammation, fibrosis of soft tissue can provide a ‘storage depot’ for immune cells and products. This is in keeping with the commonly observed connective tissue infiltration of cytokines, mast cells, macrophages, lymphocytes, T and B Cells in AC.
The psychosocial shoulder
Chronic low grade inflammation can be enhanced by psychosocial stress with complex interactions between pro-inflammatory cytokines, immune cells and compounds, and the extracellular matrix (ECM) – the main building material of dense and loose connective tissues. This process is associated with the formation of extracellular adhesions and cable-like structures – a common feature of AC.
The big picture
The overall picture of adhesive capsulitis that emerges is one of cascading chronic low grade inflammation, perpetuated by dysregulated autonomic function favouring a sympathetic dominance, with an immune balance tipped towards pro-inflammatory cytokines, showing up in a joint in a potential state of increased oxidative stress and acting as a storage depot for immune cells all on the background of a modern, unhealthy lifestyle that promotes psychosocial stress, a pro-inflammatory profile and that fails to fully express the joints evolutionary function, with lots of feedback and feedforward communication loops thrown in!
Back to the clinic
Here’s a few thoughts:
- Explaining ‘frozen shoulder’ as a “self–limiting, treatable, low grade inflamed, and stiff shoulder” might reduce some threat and stress with anti-inflammatory neuroimmune benefits
- Vigorous manual therapy probably leads to more pain, more stress and potentially more inflammation
- A biopsychosocial approach, addressing unhealthy lifestyles (all therapists and medical practitioners have a role here) would seem to have a place, both in treatment and prevention
- Regular, overhead, full range, context-rich, novel, meaningful movement is vital for the over 40s (and the rest)! If you can’t move it, at least imagine moving it.
- Appropriate exercise has a role and is also likely to assist with addressing diabetes and cardiovascular disease if associated
- What about other upper limb pain states, e.g. rotator cuff tears and ‘tennis elbow’?
- Immune buffering behaviours would seem to have an important stress reducing, anti-inflammatory enhancing, lubricin generating role
We’ve heard a bit of a shift from therapists recently in relation to low grade inflamed stiff shoulders – a bit of a lament that there is nothing we can do other than let natural history take its course. But here’s another hypothesis – by understanding the underlying neuroimmune/neuroendocrine biology, and adapting an emergent, biopsychosocial approach, we can help prevent the incidence and reduce the pain associated with this condition.
Please share your thought and comments, and any experiences with low grade inflamed shoulders below.
-David Butler and Tim Cocks
We’re hitting the road and taking our NOI courses right across this great southern land:
Townsville 29 April – 1 May Explain Pain and Graded Motor Imagery
Canberra 3 – 4 May Mobilisation of the Neuroimmune System (only Australian MONIS course for 2016)
Canberra 6 – 8 May Explain Pain and Graded Motor Imagery
Adelaide 14-15 May Pain, Plasticity and Rehabilitation (only Australian PPR course for 2016)
Noosa 17 – 19 June Explain Pain and Graded Motor Imagery
Perth 15 – 17 October Explain Pain and Graded Motor Imagery
EP3 events have sold out three years running in Australia, and we are super excited to be bringing this unique format to the United States in late 2016 with Lorimer Moseley, Mark Jensen, David Butler, and few NOI surprises.
EP3 EAST Philadelphia, December 2, 3, 4 2016
EP3 WEST Seattle, December 9, 10, 11 2016
To register your interest, contact NOI USA:
p (610) 664-4465
e noius@noigroup.com
sounds like what Ive been through for many many years. Fibromyalgia! Thoughts?
Hi MsCathOz,
Thanks for your comments and question. You might be interested in the extensive work of John Quintner (who has also joined this discussion below) and his colleagues. John has written widely on the topic of Fibromyalgia (just google his name together with fibromyalgia) for numerous forms of writing (scientific papers, blogs etc). Lyon, Cohen and Quintner wrote an excellent paper in 2011, which is open access here –
https://www.researchgate.net/profile/John_Quintner/publication/51238163_An_Evolutionary_Stress-Response_Hypothesis_for_Chronic_Widespread_Pain_Fibromyalgia_Syndrome/links/0fcfd50c5dfa745923000000.pdf
Their hypothesis – “that the form of central sensitization that leads to the profound phenomenological features of chronic widespread pain is part of a whole-organism stress response, which is evolutionarily conserved, following a general pattern found in the simplest living systems.” may or may not have similarities and/or commonalities with the hypothesis proposed by Max Pietrzak, but this is something perhaps best left to John to comment on, if he so wishes of course.
Thanks again,
Tim
Tim, our hypothesis concerns the symptoms clustering around chronic widespread pain (aka fibromyalgia).
Adhesive capsulitis is not an associated clinical problem.
However, I feel sorry for those myriads of pain sufferers who, over the past 25 years, have been awarded the label of Fibromyalgia by my enthusiastic rheumatological colleagues.
We first identified the inherent tautological nature of the diagnosis in 1993, but all to no avail. In 1999 we pointed out that the American College of Rheumatology had only succeeded in rediscovering the 19th century condition known as “neurasthenia”.
As I see it, these pain sufferers have been cast adrift upon the seas of diagnostic uncertainty.
Instead of having a distinct diagnosable condition, it now appears that they have been experiencing various clinical manifestations occurring along a spectrum of “polysymptomatic distress” in the community.
I have heard that the 2010 classification criteria are about to undergo another revision, but the committee of the American Rheumatology Association responsible for devising and updating the criteria has continued to studiously avoid commenting upon the important matter of pathogenesis. This is because there is no consensus on this matter.
Our 2011 paper, to which you refer, was written in an effort to provide a modicum of scientific validity to those with the condition(s).
Although others have invoked stress responses as being important players in the condition, to date ours is the only scientifically credible hypothesis that has been published.
Tim, here is some good animal experimental evidence to support our stress-response hypothesis for CWP: http://relief.news/the-stress-pain-connection/
Thanks John. Would you allow the possibility of some commonality in the underlying aetiology of the manifestations of “chronic wide- spread pain, mechanical allodynia, and their frequently associated comorbidities” and AC? Particularly given the potent role of the SP/NK1R pathway as a pro-inflammatory cytokine stimulator along with its other influences in the body?
Tim, if I was looking for a scientifically credible explanation for “adhesive capsulitis” of the shoulder joint (which indeed has multiple clinical and metabolic associations), the clues that I would pursue are (i) the close anatomical and biomechanical relationships of that joint with the mid-cervical spine and its emerging nerve roots; and (ii) the possibility of the demonstrated inflammatory changes being neurogenic. Perhaps someone in the physiotherapy profession could assemble a testable hypothesis along these lines. But I may be way off the track.
The hypothesis article brought to mind a few questions that may be relevant: (1) did women ever have to throw spears for their livelihood? (2) why is “adhesive capsulitis” largely confined to the shoulder as opposed to it occurring in other diarthrodial joints?
Hi John
Many thanks for your thought-provoking questions. Do you think that these questions (and their potential answers, assuming the queries were not rhetorical) pose challenges to Pietrzak’s hypothesis?
My understanding of Max’s hypothesis, is that the shoulder joint is particularly vulnerable due to its under-expressed evolutionarily derived function. Having spent some number of years within the workers compensation scheme, where work ‘above shoulder height’ is seen as anathema to a healthy work environment, I must say that Max’s hypothesis seemed particularly relevant and plausible to me, at least.
On your first point, do you think perhaps that the abundance of goddesses presiding over hunting in various pantheons may provide a clue?? Diana, Artemis, Devana, Bendis, Neith, Pakhet, Flidais, Banka-Mundi…
My best
Tim
Tim, you could be on the money. I have yet to see a goddess with adhesive capsulitis. But I live in hope!
Further evidence, percase, for Max’s hypothesis!?!
Perhaps ecclesial pronouncements, often made with the upper limbs raised in praise (or submission…) can replace, for some, the evolutionarily imposed imperative to hurl objects (although this act has its own, more sinister, religious links), while simultaneously according the deity so worshipped with vicarious protection though the actions of her faithful (granted, a rather unfalsifiable hypothesis that I have no desire to pursue).
Best
Tim
Enhanced expression of neuronal proteins in idiopathic frozen shoulder.
Xu Y et al
CONCLUSION: Increased expression of nerve growth factor receptor and new nerve fibers were found in the shoulder capsular tissue of patients with frozen shoulder compared with those without a frozen shoulder. These data suggest that neoinnervation and neoangiogenesis in the shoulder capsule are important events in the pathogenesis of frozen shoulder and may help explain the often severe pain of patients with frozen shoulder.
http://www.ncbi.nlm.nih.gov/pubmed/22005128
Hi Marcel
Thanks for sharing this.
I’m wondering whether you might think it adds to, or challenges, Max’s hypothesis, or it’s place otherwise in the discussion.
Best
Tim
Very interesting article. I also think there is an underlying neurological component as well. The Pec Major and some of the axillary muscles seem constantly “on” (over-facillitated), and I can’t seem to turn them down (or off). Not sure if this is a cause or effect of the actual sticky-ness or not
Thoughts?
Hi Chris
Thanks for taking the time to comment.
The numerous reports I can recall reading from surgeons performing manipulation under general anaesthetic that stated “full range of motion of the shoulder was achieved” might suggest that some limitation of range is a result of protective muscle activity.
Cheers
Tim
In my opinion, capsular thickening and adhesions are more likely to be responsible for the limited range of movement.
Great article, thank you. This explains the apparent systemic changes that I often see in patients with long term pain. That is, that there is an inflammatory response taking place, experienced as palpable heat or ‘burning pain’. I therefore agree with the above comment (MsCathOz) that there might be a similar process occurring in Fibromyalgia and other complex pain disorders.
Hi Dave and Tim
Thanks for the excellent overview.
I wonder if there is any explanation for why this can resolve within 1-2 years, often with no treatment at all. Considering the immunological, inflammatory and the dysregulated autonomic system involvement why is it self limiting? Is the self limiting nature of it not somewhat unusual? I have certainly seen several which true to form improve drastically around this time frame.
Regards Blánaid
Hi Blá
Great question. I’ve not seen any speculation, let alone an answer to this in any of the literature I’ve come across. Perhaps there is, an as yet unidentified, signalling/feedback mechanism with a temporal scale of multiple months? As for the variously stated 20-50% of people that go on to have significant restriction for up to 10 years Mark Hutchinson’s recent talks at EP3 came to mind, with notions of biological ratcheting and progressive glial activation in response to life’s stresses.
Cheers
Tim
Excited to see you approach this condition from its systemic origins…we need more of this in the neuro-musculoskeletal field (or whatever you want to call it – physio anyway). Identifying the larger systemic context that our “physical conditions” critical if we want the patient to find success. This is what I do in practice as a functional medicine nutritionist and physiotherapist. So, in view of this, I was then astonished to see you make no mention of nutrition in the subsequent section on treatment. Please, let’s not pretend we can fix chronic inflammation using a combination of relaxation and exercise. We can’t ignore a huge piece of the puzzle: nutrition. It’s time that functional medicine/nutrition professionals were part of the multidisciplinary team for patients with musculoskeletal issues (if we can even categorize things like AC as that). Head to PubMed, search inflammation and diet and start working through the 13 000+ papers. A place to start is with Minihane et al’s British J of Nutrition 2015 review Low-grade inflammation, diet composition and health: current research evidence and its translation. Then network with a functional medicine nutritionist. I’m pleased to say that more and more physios are referring their patients to me to help with this component of the management.
Hi Alyssa
Thanks for taking the time to comment and share your thoughts. As simple physiotherapists, we do not have the required dietary expertise to make recommendations in this domain, but our thanks for raising this point. It is certainly not our position that we can ‘fix’ chronic low grade inflammation with any single strategy, although healthy activity (including physical exercise and relaxation) would seem to be a reasonably well supported aspect of any intervention aimed at promoting health and wellbeing.
I don’t think diet/nutrition has been completely ignored – it does feature as one of the five key approaches (third, no less) to dealing with chronic pain in the widely viewed (and translated) ‘Brainman’ video – https://youtu.be/5KrUL8tOaQs.
I’ve taken the liberty of posting this link http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4579563/ to the article you mentioned as it is open access and will allow readers to become acquainted with the ideas you mention, if they so wish.
May I ask however what the difference between ‘functional medicine’ and ‘medicine’ is? I can’t help but be wary of adjectival additions in front of the word ‘medicine’.
Thanks again
My best
Tim
Hi Tim,
Functional medicine is the term used for a form of body systems-based health care that aims to identify and address the underlying causes of the patient’s symptoms, rather than focusing on symptom management or pharmaceutical/surgical management based on the name of the patient’s condition. Functional medicine refers not to the treatment, but rather to the framework or paradigm of evaluation and treatment. Within this functional medicine framework, you can practise medicine (in its contemporary sense), nutrition, physiotherapy, etc. So, for example, I practise physiotherapy – but within a functional medicine framework. So does any physiotherapist every time their evaluation identifies underlying causes and drivers rather then treating largely according to protocols, even evidence-based ones (e.g. the research tells me that laser is effective in plantar fasciitis, therefore I’m going to treat this patient with laser. N.B. I am pulling this example out of nowhere – I don’t know much about plantar fasciitis.) Nutrition practised within a functional medicine framework identifies underlying biochemical drivers behind the patient’s symptoms rather than assuming that every hypertensive patient, for example, is the same. The term “functional medicine” comes from the Institute of Functional Medicine in the USA – however, the name is irrelevant. Sometimes, the term “integrative nutrition” is used for this approach to nutrition. I tend to avoid that, as it is becoming a bit trendy. In the end, it doesn’t matter what it’s called – you could call it the “cause-based approach” if “functional medicine” doesn’t sit right with you – what matters is if it makes sense. To me, as a practitioner working in as complex a field of chronic pelvic and abdominal pain, it makes no sense to not look at the underlying biochemical mechanisms that are malfunctioning in the individual in order to correct the dysfunction and restore equilibrium within the individual.
Thanks Alyssa. I don’t think many would disagree with the assertion that all individuals should be treated as such, and certainly a worthy criteria to hold one’s interactions with people in the clinic to.
My best
Tim
Hi David & co.I’m a retired Physio & I have a chronic pain problem from an old dislocation & fracture of my R shoulder 30 years ago, and I hate to think of what my shoulder would have been like if I hadn’t become a Feldenkrais Practitioner! I’ve used the FM for 25 years to work with other people with chronic shoulder problems & it’s been more useful than Physio for most of them & teaches them how to get themselves out of trouble.The protective movement patterns around the initial trauma or repetitive movements can be changed neurologically but this must involve the whole person, not just the upper quadrant. I also agree that nutrition has a lot to do with chronic inflammation. Madeleine Edgar
Please pardon my skepticism, but is this the latest Physio Fad?
Hi Alyssa and co,
Thanks for the feedback and comments, another great discussion.
You raise an excellent point regarding, nutrition, and I agree with your comments.
The original version of the paper had a quite large segment on nutrition and the modern mismatch hypothesis of chronic disease and how that relates to CNS signalling. As it was, the peer review and editorial process led to submitting two separate papers, the second of which I am hopeful of completing once I have finished my MSc dissertation, paid off my credit cards, and had a holiday!
The questions regarding evolutionary biology and evolutionary medicine I also find really interesting, thank you. My readings on the topics thus far are limited, but this is probably not uncommon for physios and doctors. As far as the details of how much spear throwing women did as hunter gatherers, I think Tim hit the nail on the head in suggesting it may not matter that much aside from the fact that the trait is very unique to humans and it appears strongly selected for over a very long period of time.
Nevertheless there are those who argue that the homo sapiens sapiens hunter gatherer was a much more versatile, and arguably, more intelligent version of it’s species compared to that after the agricultural revolution! Therefore it’s not outrageous to suggest that apart from their vital foraging role, women may have thrown spears as a secondary function.
Thanks again to Tim and David for featuring the article,
Max
Max, I don’t want to hurry you up…but could you hurry up and publish that second article? (You don’t really need that holiday, do you?) I will be most interested to read it. Nutritional impact on CNS signalling and inflammation overlaps substantially with my particular area of interest – the nutritional biochemistry (including nutrigenomics) behind chronic pain, particularly central sensitisation – and is a major focus of my Master’s studies.
I appreciate your summary section in your review article “Chronic low-grade inflammation, autonomic dysregulation…” -getting this understanding out to the mainstream clinician would be a welcome development.
Thanks again!
‘Therefore it’s not outrageous to suggest that apart from their vital foraging role, women may have thrown spears as a secondary function’.
Very interesting thoughts on the variability and influences on the shoulder stiffness conundrum . Max , by your comments above you may have observed Glasgow city centre on a Saturday night where spear throwing fuelled by Buckfast is quite a popular sport.
Years ago I read Nesse and Williams book on evolutonary medicine which was recommended by a very thoughtful therapist and the ideas within influenced the ‘adaptive’ and ‘maladaptive’ pain behavours I beleve.
However, back to the shoulders . In terms of the stiff/frozen shoulder theories, in former times most people would not have lived long enough to get one -whether they were javelin champions or not!
With so many theories and influences around it is no wonder outcomes and understanding of the conditon is so variable . Clinically, the resistent shoulder varies tremendously from the brick hard end feel of those that seem to be linked to diabetes and indviduals who seem to have an associaton with abnormal scarring (dupytrens) to the much more common farily inactive person . There are many more females so hormonal change may be a factor ? Learned disuse is a very common issue particulalry with non dominant shoulders and anedotally many complex upper limb presentations appear to be linked into this scenario . ( I usually expalin this with the analogy of knocking a nail into wood the dominant shoulder fully mobile and varied mobility whilst the non dominant fixes and stabilises etc.
Tim I think above shoulder work maybe a factor in occupational problems particualry in boring work but many plasterers I know are never bothered particualrly self employed ones ………..
I think minimising threat and not torturing people with all in wrestling mobilsations like I started off doing as an enthusiastic junior physio is commendable . Maintaiing motivation and reassurance with a simple home pulley is all that most people need if the explanation is good and the person is on side .
I dont think there are that many people who are inflenced by Cx mobilisations and the like as this seems clinically to be a different scenario with hypersenstivity and more n root/neurogenic symptoms .
As far as nutrtion is concerned unless the person is drinking Red Bull and eatng ready meals ful time I don’t think its that relevant myself .
Interesting view!
I am having a frozen shoulder myself right now starting about 9 months ago, and I think I am on a recovery track since about 4 weeks.
Both the biopsychosocial and the “javelin”-theory are interesting.
The first one may apply to me. Turned 50 and get this as a birthday present. Quite some stress and sadness also as I had to let go both my parents in a short time.
And the Javelin? Ha, being an avid sailor, maybe I should not have thrown my 140 kg Javelin dinghy. Iit was just a bit to heavy for my shoulder.
Seriously, I went to see an orthopedic doctor and although we both agreed that a steroid injection would not affect my condition much, I thought there was nothing much to lose, with the sailing season being round the corner again.
So I took it, and although it didn’t seem to do a whole lot in the first two weeks, it didn’t mark the starting point of the return of some range of motion.
So destress, take it easy on the shoulder. Don’t work it too vigorously when ROM is decreasing , be patient and figure: what’s the rush? It will go sometime.
I expect to have full ROM by the end of June the way it’s going now.
Really interesting post and comments. I have enjoyed the discussion. I have been treating (massage therapy) a client with this condition for the past few months. Stress has been a big factor for her over the past 12 months. A comment she made to me recently is that the massage therapy treatment has taken the fear out of her shoulder, helping her to feel more confident about moving it. Reading “Explain Pain” has also led me to incorporate some additional elements in my treatment approach that I believe have helped. Seeing the whole person and not simply their symptoms is critical.
Great summary thanks, be fascinating to know if treating the underlying metabolic condition (insulin sensitivity raising its head again!) has a tangible effect on recovery duration.
I would like to say “ the weight of the world is taken by the shoulder” I take a biopsychosicial approach when seeing this condition and generally work on the stressors the person has in their life. Stressors which usually involve the person being unable to shake off the issue with a close relationship, an issue that sticks like glue and weighs them down just offering some clues as to language to use to uncover some of the relevant stress issues for the shoulder.
Very much so. A question could be “do you feel the weight of the world on your shoulder(s) “. And then “what’s in that world”?
David