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Shoulder Rehabilitation The Gentle Pain Release Way

On Nov. 3, 2006 I had shoulder surgery and got to practice what I have preached for many years, a better, more physiologically sound and less painful way of dealing with pain syndromes including post surgical care. I took no pain medication and decreasing dosages of Ibuprofen. When I returned to practice I seemed to attract quite a few patients with a variety of shoulder problems including S/P rotator cuff surgery, frozen shoulder, fx of the head of the humerus, rotator cuff tear, and others. Two of these patients came to me directly and the others had received traditional physical therapy. All of those who received traditional P.T. experienced high levels of pain as a result of their therapy . One reported that she had an especially painful session prior to her next doctor's follow up visit. The therapist wanted to achieve more ROM prior to this visit so pushed the shoulder to especially painful limits. The patient felt like she had been injured and had the dr. order another MRI. Fortunately the surgery was still intact and the patient then sought another therapist. A large percentage of my patients in general, not just those with shoulder problems, report having their pain increased by traditional therapy.

As P.T.'s we are supposed to be knowledgeable about anatomy, kinesiology and physiology. When we do painful "stretching" of the shoulder , much of the time we are actually impinging the subacromial structures. It is easy to determine stretching vs. impinging by asking the patient, "what do you feel and where?". Pain in the top of the shoulder, taking into account referral patterns, is an impingement and will only perpetuate and exacerbate the initial problem. Working the shoulder joint at the 90 degree abduction position in general is to be avoided since it is very likely to create this impingement. Abduction ROM , ironically, will come by avoiding abduction during the majority of the rehab process.

Stretching is a really different quality of sensation as opposed to pain. Real pain should be avoided since it is the body's signal that something is wrong. When we inflict pain upon patients we are perpetuating the swelling and inflammation which is the condition that is mostly responsible for limiting motion and function. During rehabilitation tissues are healing and shouldn't be traumatized. This should be obvious!

So here is how I handled my surgery. I had a very large bone spur resected from the rotator cuff tendon, bone spurs removed by a subacromial decompression and the head of the humerus removed because of bone spurs there. I was given the partial tear rotator cuff protocol and was instructed to use the sling for four weeks while coming out of the sling five times a day to do pendulum exs. I was told by so many that shoulder surgeries are the most painful, but I didn't buy this mentally. I found by the end of two weeks my shoulder was more comfortable coming out of the sling for increasing lengths of time and within a couple days the shoulder did not want the sling any more. I did a little bit of pendulum exs, but not much. Each day I was able to do a little more motion and activity comfortably and used this as my guide. During my recovery I did almost no "stretching" and did nothing that significantly increased my pain. When I had my six week visit with the dr. the PT at the doctor's office saw me, checked ROM's, etc, did some "stretching" and other exs with me and told me as the doctor did that I was way ahead of schedule and to keep doing what I was doing. I had 140 degrees of flexion and abduction pain free passively at the time. I was also told by the P.T. that if I didn't do the (painful) exercises as instructed that I would get a frozen shoulder. I did not follow this advice. The moderately painful therapy session administered by the therapist set back my recovery a week.

The patients that I saw when I returned to work who came to me directly, not having seen another therapist prior to seeing me, I had them do a similar kind of recovery that I described above, following guidelines by their doctors. I did not see them very often, 2x/wk. initially, then 1x, then less frequently. They were given home programs with instructions not to inflict pain upon themselves. They recovered in a timely manner, with fewer visits than traditional PT and with no increase in pain as a result of therapy. If fact, I did hands on therapy to relieve the inevitable spasms around the affected joint, which helped to reduce their pain.

With the patients that had painful experiences with other P.T.'s I spent three to four weeks working primarily on reducing pain with relative rest, light active or passive ROM's depending on where they were in their rehab protocol, with instructions not to be doing the exs painfully. After the reduction in pain I then had them gradually increasing activities, which they naturally were doing and a bit of stretching for those who needed it. When one follows this kind of rehab it will be found that ROM increases naturally, without stretching and without much pain. Strengthening is easy once the structure is healed. One other thing I did after my surgery was to have lymhatic drainage done four times. There was the normal fluid accumulation at the shoulder joint as well as settling into the arm to the elbow. By the end of the first visit, the egg sized fluid knot at the elbow was gone and 75% of the fluid was removed and never returned. I never took any pain medication, not because I toughed it out, but because I didn't need it. I did use decreasing dosages of Ibuprofen. Most of the loss of ROM in the joint, be it shoulder, knee, etc., after surgery or injury is due to capsular distension due to inflammation and swelling. The treatment needed initially needs to address the swelling and inflammation which will result in increased ROM.

— Richard Fowler, P.T.

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