The theme of this newsletter is the shoulder. The shoulders are in the top 5 of complaints that people have to visit the osteopath with. But for which shoulder complaints is an osteopathic treatment useful?
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Put your shoulder to the wheel
The theme of this newsletter is the shoulder. The shoulders are in the top 5 of complaints that people have to visit the osteopath with. But for which shoulder complaints is an osteopathic treatment useful?
Table of contents:
Take a deep breath and relax your shoulders
As an osteopath we regularly see patients with shoulder complaints. Now, several studies show that the underlying cause may also be a lung disease.
Research shows that patients with underlying lung disease often present with the same symptoms as people with shoulder pain: pain with daily activities, difficulty sleeping on the shoulder, and increased pain in recent times. This is often seen as rotator cuff problems, which did not improve during therapy. Research has shown that there may also be another underlying problem, such as a lung top tumor, (neglected) pneumonia or lung operations from the past (Petchkrua, 2000) (Al Shammari, 2020) (Brindisino, 2020).
In addition to the fact that another pathology can be the cause of a shoulder problem, the problems also often appear after operations on the pulmonary system. Bando (2018) has shown that 40% of people who underwent surgery on the pulmonary system had ipsilateral shoulder complaints.
The study by Miranda (2015) looked at the effect on ROM, pain and disability of the shoulders after lung surgery. After lung surgery, bilateral shoulder impairment with reduced ROM, with greater impairment in the ipsilateral shoulder, was often found.
Despite the fact that a small percentage of patients report to the practice with the lung as the cause, it is important to always do an extensive history and thorough examination, so that ‘red’ flags are recognized and referrals can be made in time. If a relationship is found between lung and shoulder complaints without serious underlying pathologies, fascial stretches and hold-relax techniques are recommended (Bischof, 2017). (Nadi Blokhuis)
Original title: The effect of a Traction-and-Hold technique applied to pectoralis major and minor on the lung capacity of healthy individuals with protracted shoulder posture
Auteurs: Bischof M.
Verschenen in: British College of Osteopathic Medicine
Original title: Shoulder pain as an unusual presentation of pneumonia in a stroke patient: a case report
Verschenen in: Arch Phys Medical Rehabilitation
Original title: Pancoast Tumor: The Overlooked Etiology of Shoulder Pain in Smokers
Auteurs: Al Shammari et al.
Verschenen in: The american journal of case reports
Original title: Bilateral Shoulder Dysfunction Related to the Lung Resection Area After Thoracotomy
Auteurs: Miranda et al.
Verschenen in: Medicine (Baltimore)
Original title: Ipsilateral shoulder pain in patients following lung resection in the decubitus position
Auteurs: Bando et al.
Verschenen in: Journal of clinical nursing
Original title: Recognition of pulmonary pathology in a patient presenting with shoulder pain
Auteurs: Brindisino et al
Verschenen in: Physiother Theory and Practice
Shoulder and spine relationship
What is the biomechanical relationship between the shoulder and the spine? Two researchers provide an overview.
Johnston (2021) looked at the biomechanical relationship between the shoulder and the spine. The aim of this cross-sectional study was to see the functional relationship between the range of motion (ROM) of the shoulder and the curvature of the spine.
This was done through a multivariate analysis involving 163 healthy, right-handed subjects. Measures contributing to the shoulder-spine relationship were shoulder flexion, internal and external rotation, trunk flexion and lumbar lordosis. The findings show that the examination of the shoulder should be interpreted in relation to the spine and vice versa, independent of the region in which the pain is located.
Another possible cause of shoulder and neck complaints is a dysfunction of the first rib. Mastromarchi (2020) investigated this via a Delphi survey, in which the opinion of a large number of experts was asked. He asked which methods were useful to diagnose a dysfunction. Consensus was reached on important aspects of first rib dysfunction, namely limited mobility, symptoms in the arm, and a possible sub-classification into two groups.
The main clinical findings were: painful and restricted neck movements and load-bearing capacity of the shoulder girdle; positive neural test of the arm; direct palpation of the first rib, neural structures, and the m. scaleni; pain and hypomobility of the first rib movements with improvement after mobilization.
The cervical rotation-lateral flexion test was considered useful but not widely used. There were doubts about the diagnostic accuracy and interpretation. These methods need further investigation to establish the reliability and validity of the tests.
Other biomechanical chains (from daily practice, J. ten Brink) that impose restrictions on the shoulder girdle are:
– absence of joint play (add/abduction) in the elbow restricts the elevation in the shoulder joint.
– limitation of pronation results in limitation of elevation and abduction in the shoulder joint.
Often the left and right restrictions are present to varying degrees, and therefore also limit the rotations of the cervical spine and thoracic spine (and sometimes lumbar spine/pelvis), partly due to the direct influence on the lattissimus dorsi m.
Oorspronkelijke titel: Multivariate shoulder and spine relationship using planar range of motion assessment
Auteurs: Johnston, H.A., Drake, J.D.M.
Verschenen in: Musculoskeletal Science and Practice, Volume 54, 102398, August 01, 2021
Oorspronkelijke title: First rib dysfunction in patients with neck and shoulder pain: a Delphi investigation
Auteurs: Mastromarchi, P., May, S.
Verschenen in: Journal of Manual & Manipulative Therapy, Volume 29, 2021 – Issue 3 Pages 181-188 | Published online: 21 Sep 2020
Take a look
With shoulder complaints, it is often good to include the neck and jaw region. Is this interaction being used enough or is this relation not as large as it seems?
In the treatment room we often examine the neck, jaw and shoulder region as a whole. Van Selms (2020), for example, conducted research on musicians and investigated complaints of the neck and shoulder girdle and temporomandibular dysfunctions. This was substantiated by the neuroanatomical links where there is convergence of nociceptive input for pain. Also, in patients with neck, shoulder and/or jaw complaints, predominantly psycho-socio-economic causes are often found – which cannot always be substantiated with clinical tests.
In the case of, for example, a shoulder impingement syndrome, research shows that treating the neck with manual therapy significantly improves the complaints of the shoulder and hand. However, there was no significant added value if the neck region was treated on top of treating the shoulder itself. This may also be partly due to the patients; it may be that the shoulder complaint does not lead to complaints in the neck and jaw at that time.
Research shows electromyographic activity of the neck and shoulder musculature during active contractions of the jaw muscles. Different positions of the temporomandibular joint (protrusion or retrusion of the mandible) indicate different measurements of muscle activity. From this a hypothesis was formulated that isometric contraction of jaw musculature in retrusion of the mandible increases the risk of neck, shoulder and back complaints. This compared to contraction in a position of protrusion of the mandible.
Another study in patients with intra-articular changes in the temporomandibular joint showed that the neck muscles were significantly more sensitive to pressure. Temporomandibular problems can be part of the cause of shoulder and neck complaints. (Marlotte Lagendijk)
Titel: Reliability of Clinical Tests in the Assessment of Patients With Neck/Shoulder Problems—Impact of History.
Auteurs: Bo C. Bertilson, MD, Marie Grunnesjö, DN, and Lars-Erik Strender, MD, PhD
Verschenen in: Spine Volume 28, Number 19, pp 2222-2231, 2003, Lippincott Williams & Wilkins, Inc.
Titel: The addition of cervical unilateral posterior-anterior mobilisation in the treatment of patients with shoulder impingement syndrome: a randomized clinical trial.
Auteurs: Cook C, Learman K, Steve Houghton, Christopher Showalter, Bryan O’Halloran
Verschenen in: Manual Therapy, volume 19, Issue 1, Feb 2014, pg 18-24.
Titel: Interactie tussen het craniomandibulair gewricht en de schouder (magazine)
Auteurs: F. De Bakker
Verschenen in: ‘De Osteopaat’, dec 2009, jaargang 10, nr. 4
Titel: Muscle activities in the region of neck, shoulder and back during isometric horizontal jaw exercises in various postures
Auteurs: T Yoshimatsu
Verschenen in: Nihon Hotetsu Shika Gakkai Zasshi. 1990 Feb;34(1):157-66. doi: 10.2186/jjps.34.157.
Titel: Changes of muscle activities in neck and shoulder region during sustained isometric contractions of jaw muscles
Auteurs: T Yoshimatsu, T Namikoshi, Z Koyama, K Suga, H Fujii
Verschenen in: Nihon Hotetsu Shika Gakkai Zasshi. 1989 Oct;33(5):1044-9. doi: 10.2186/jjps.33.1044.
Titel: Temporomandibular disorders, pain in the neck and shoulder area, and headache among musicians
Auteurs: Maurits K A van Selms, Jetske W Wiegers, Hedwig A van der Meer, Jari Ahlberg, Frank Lobbezoo , Corine M Visscher
Verschenen in: J Oral Rehabil. 2020 Feb;47(2):132-142. doi: 10.1111/joor.12886. Epub 2019 Sep 24.
Titel: Comorbidity of internal derangement of the temporomandibular joint and silent dysfunction of the cervical spine
Auteurs: M Stiesch-Scholz, M Fink, H Tschernitschek
Verschenen in: J Oral Rehabil. 2003 Apr;30(4):386-91. doi: 10.1046/j.1365-2842.2003.01034.x
The burden on your shoulders
250,000 women in the UK undergo laparoscopy every year. Approximately 35% to 80% of patients experience shoulder-tip pain (STP) or shoulder pain postoperatively. The underlying etiology suggests a neurological rather than biomechanical cause.
The laparoscopy is a procedure in which a surgeon uses a camera (laparoscope) to examine the abdominal organs. The layers of the peritoneum are separated to allow safe insertion of the equipment and good visibility. This is often done by using a gas, carbon dioxide. This is called a pneumoperitoneum. The phrenic nerve is probably stimulated and this leads to referred pain to the shoulder area postoperatively.
Kaloo (2019) describes multiple ethologies. It is thought that the carbon dioxide is locally converted to dihydrogen carbonate. The pH decreases and this would lead to irritation of the phrenic nerve and shoulder-tip pain (STP). During the pneumoperitoneum there could also be a lot of stretch at the level of the tendon of the diaphragm. It is sensory strongly innervated by the phrenic nerve. Because the tendon leaf is stiff, it is unlikely that damage will occur due to stretch. However, increased intra-abdominal pressure does increase the incidence of STP.
The laparoscopy could cause micro- and/or macroscopic damage to the fascia. This leads to a local inflammatory reaction. The application of gas could also possibly influence the suction effect between the liver and the diaphragm. This creates a traction on the liver ligaments. This could lead to STP. This hypothesis is not substantiated, but according to Kaloo (2019) it is supported by the fact that STP complaints often increase during movement and sitting up.
Choi (2016) refutes this. During the first few days, pain around the incision points and local visceral pain are often experienced during movement. Shoulder pain experienced at rest does not increase with movement (Choi, 2016). The shoulder pain seems to be caused more by neurological stimulation than by biomechanical influences. Could this mean that in practice we have more of a neurological influence to the shoulder by acting on the visceral fascia? (Joost Veldhuizen)
Originele titel: Interventions to reduce shoulder pain following gynaecological laparoscopic procedures.
Auteurs: P. Kaloo et al.
Verschenen in: Cochrane Database Systematic Reviews. 2019 Jan; 2019(1): CD011101.
Originele titel: Pain Characteristics after Total Laparoscopic Hysterectomy. Auteurs: J.B. Choi et al. Verschenen in: International Journal of Medical Sciences. 2016 Jul; 5;13(8):562-8.
Put your shoulders down
Recently I got a call from a patient. “I have chronic shoulder complaints, can osteopathy help me?” Sure, we’ll loosen that up, I say. But is that true?
While I am treating all joints and visceral connective tissues, I notice that mobility increases and the complaints decrease. Great, another satisfied patient! Three weeks later, however, the same patient returns with the same shoulder complaints. How is this possible? Did I use wrong techniques? The patient is extremely afraid to move the shoulder. She again appears to have a strong muscle tension with trigger points around the shoulder girdle and experiences a lot of stress at home and at work.
The scientific literature, as well as the five explanatory models, still help me every day to understand the complexity of a complaint and to frame my own work. What can I do for people who are afraid to move? And how does stress and the autonomic nervous system influence the development and persistence of trigger points?
This begs the question: “Is the treatment of these factors entirely within my domain or is more collaboration with other disciplines needed?” Can I manage this in four sessions at all? After a good conversation, the patient also underwent treatment from a psychosomatic physiotherapist, in order to reduce her fear of movement. She has made her workload negotiable. Her employer has taken action and two months later the ‘chronic’ shoulder pain is finally really subsiding. Great result when everybody puts “their shoulders underneath it” or “shoulders the load together”.
Frozen Shoulder, a puzzling phenomenon
Scientific studies show that we still have limited knowledge about the phenomenon of ‘Frozen Shoulder’ (FS). Both the pathophysiology and etiology are largely unknown.
The diagnosis of Frozen Shoulder (FS) is given on the basis of clinical examination, exclusion of other pathologies and also the absence of glenohumeral abnormalities radiographically. There are three stages: the freezing phase, the frozen phase and the thawing phase. We also know that the recovery time is 12-42 months.
The pathophysiology of FS is complex and largely unknown. There appears to be an abnormality in the volume of the glenohumeral joint. Normally this is 15-20ml, but with FS it turns out to be less than 5ml. It would also seem that the lig. coracohumerale may play a role in the development of FS.
FS appears to be more likely to occur if there was already chronic inflammation and elevation of pro-inflammatory cytokines. This includes people with Diabetes Mellitus (DM), cardiovascular disorders or thyroid problems. FS occurs in 2-5% of the entire population and 10-30% of diabetics. Studies have also shown that depression may play a role in its development.
No scientific evidence has yet been found that the menopause in women plays a role in the development of FS, but this group appears to be more sensitive to general musculoskeletal pain. Literature studies show that men and women are equally likely to have FS, that it is often the non-dominant shoulder and that in 17% it eventually develops on the other side.
There are still many questions about the effectiveness of treatment methods for FS. Treating FS by mobilizing the shoulder with mechanical stress in the pain threshold is even detrimental in the recovery process. This is in contrast to mechanical stress within the pain threshold. Intra-articular injections of corticosteroids have also been shown to be useful, especially in the early stages of the development of FS. This has an effect on the inflammatory processes but not on the fibrotic changes. When injecting corticosteroids around the lig. coracohumerale may be more effective than when the injection is placed posteriorly in the glenohumeral joint.
In the literature study by Kraal et. although it is suggested that the use of nasal spray containing calcitonin may be effective in treating FS. A deficiency of calcitonin can also be seen in people with osteoporosis or a thyroid disorder, among others. (Liesbeth van den Berg – van Esch)
The puzzling pathophysiology of frozen shoulders – a scoping review
Auteurs: T. Kraal et. al
Verschenen in: Journal of Experimental Orthopaedics, 7, 91 (2020). doi.org/10.1186/s40634-020-00307
Shoulder pain prevalence and risk factors in middle-aged women: A cross-sectional study
Auteurs: F. Khosravi et. al
Verschenen in: Journal of Bodywork & Movement Therapies 23 (2019) 752-757
Frozen shoulder contracture syndrome – Aetiology, diagnosis and management
Auteur: J. Lewis
Verschenen in: Manual Therapy 20 (2015) 2-9
Musculoskeletal complains among menopausal women at musculoskeletal department of center for the rehabilitation of the paralyzed
Auteurs: R. Shrestha
Verschenen in: http://hdl.handle.net/123456789/338 ,5-30-2018
Working on someone's nerves
Shoulder pain is a complicated phenomenon. First of all, there is the actual local damage to the musculoskeletal system: the shoulder. This gives nociception, or stimulation of the pain nerve. This neurogenic pain occurs in 11-18% (St. John Smith, 2018). Then there is the damage to the nerve itself, the neuropathy (occurs in 7-10%). The clinical pictures of both phenomena can clearly differ, but there is also overlap.
Ottiger-Boettger (2020) investigated whether the neurodynamic testing (stretch of the nerve) provides a clear clinical picture of neuropathy. Her conclusion is that this is quite mixed up. There can be negative tests and damage, or vice versa. Nevertheless, she considers the probability that patients with positive neurodynamic tests do have nerve damage is high (however, she does not indicate how high). In addition to the pain that occurs, there may also be loss of sensation, even on the heterolateral side. This indicates how central the problem is.
However, nociception is not yet an unambiguous concept. There may be local tissue stimulation or overstimulation higher up in the pain system (central sensitization). Ingraham (2019) even argues that this should be referred to as a third category: primary pain, in which it is purely a matter of the phenomenon of pain and not of damage to tissue or nerves. In addition, there are of course also the “referred pains” within nociception.
Fernández-López (2020) investigated with a literature study whether there can also be nociception in shoulder pain from the Nervus Phrenicus (C3-C5) to the arm: the so-called visceral pains. First of all, she indicates that there is a high incidence of shoulder pain after abdominal or chest surgery, even up to 95%. According to her, several studies have shown that the Nervus Phrenicus often anastomoses with the different parts of the brachial plexus. The Nervus Phrenicus contains, in addition to motor, many sensory fibers of the pericardium, pleura and peritoneum. Irritation of these structures then causes shoulder pain.
Bordoni (2020) has extensively researched and reported on the Phrenicus to further clarify the neurological model within osteopathy. His first finding is that the nervous and lymphatic systems are a two-way street. Poor mobility of the neuron already stimulates a lymph node, which in turn promotes inflammation. Neuron mobility can also affect fascial mobility, for example in the brachial plexus. Bordoni describes not only the peripheral nerves but also the ganglia and their influence on the vascularization of the head. In short, this article is a must read for every osteopath and offers many explanations for the relationship between pain and regional problems.
In conclusion, it can be said that shoulder problems are again a multivariable issue. By examining the presentation of the various pains, the osteopath can differentiate whether it is a neuropathy or nociception/neurogenic (often also visceral/referred) pain. This differentiation is important for us to provide insight into which subpopulation of shoulder complaints osteopathy is useful for. This way we can effectively get on someone’s nerves.
Fernández-López, I., Influence of the phrenic nerve in shoulder pain: A systematic review, IJOM 36 (2020) 36–48
Ingraham, Three types of Pain, Mar 17, 2019, https://www.painscience.com/articles/pain-types.php
St. John Smith, E., Advances in understanding nociception and neuropathic pain, J Neurol (2018) 265:231–238
Ottiger-Boettger, K., Somatosensory profiles in patients with non-specific neck-arm pain with and without positive neurodynamic tests, Musculoskeletal Science and Practice 50 (2020) 102261
Bordoni B (June 20, 2020) The Five Diaphragms in Osteopathic Manipulative Medicine: Neurological Relationships, Part 2. Cureus 12(6): e8713. DOI 10.7759/cureus.8713