by Iwona Kedzierska, M.A., P.T.

The shoulder is one of the most mobile and complex joints in the body. Because of its frequent use in everyday activities, the shoulder is at risk for developing several pathological conditions. Frozen shoulder is one of them.

Anatomy

The shoulder joint, which functions in a ball-and-socket movement, is encircled by a sleeve-like capsule. When the arm moves, the sleeve relaxes or tightens depending on the direction of movement. Frequent shoulder movements, as they occur in daily activities, keep this capsule in good condition. If the arm does not move regularly, the capsule tends to form tiny strings of scar tissue and shrinks down. This is called adhesive capsulitis or frozen shoulder.

Diagnosis

The main symptoms of frozen shoulder are pain, which is felt in any direction of motion, and stiffness, causing restriction of motion when performing common tasks like combing hair, fastening a bra, putting an arm into a coat, or reaching into a hip pocket. When patients roll onto the affected side, they often wake up at night with pain.

Causes

The cause of frozen shoulder may not be clear. This is the case in primary adhesive capsulitis. The shoulder joint just becomes gradually stiff and painful. This is more frequent in older people and it affects women more often than men. Some may have diabetes or thyroid disease.  

The secondary form results from conditions that interfere with the frequent and full range of motion of the shoulder and arm, including:

• neurological conditions like Parkinson’s disease, stroke, pinched nerves in the neck, and muscle diseases such as polymyositis
• orthopedic conditions like shoulder tendonitis, bursitis, arthritis, and trauma — particularly rotator cuff tear
• surgery with prolonged immobilization of the shoulder
• medical conditions, which limit general mobility and/or necessitate prolonged bed rest

Stages

There are three main stages during the development of a frozen shoulder, each lasting from 3-6 months:

1 — The first or “freezing stage” is the most painful. The pain gets  progressively worse and the shoulder loses its motion. 

2 — In the second or “frozen stage,” the pain starts to improve but the stiffness worsens.

3 — In the third or “thawing stage,” which can last for more than six months, the motion improves gradually and the pain is minimal.

Treatment

The treatment for frozen shoulder depends on the stage and cause. Early mobilization and twice daily active and passive range-of-motion exercises by a caregiver or self-administered, along with pain medication when needed, are important to prevent adhesions when there is a known cause.

In the primary cases, where there may not be an obvious cause, early intervention is also important, especially in the first two stages. Physical therapy can shorten the recovery time and limit the severity of pain. The patient can then progress faster to the “thawing stage” with less functional limitations.

Anti-inflammatory medications and aggressive physical therapy are recommended in all stages – particularly the last two. Steroid injections in the shoulder capsule may help as well. Manipulation of the shoulder joint under general anesthesia may be needed in protracted and difficult cases in order to break up the adhesions. Surgery to release adhesions is generally not recommended.

Physical Therapy

Physical therapy is generally intense. The patient is instructed to continue the same exercises at home once or twice daily in order to maintain and gradually increase strength and range of motion. 

The physical therapist uses specific joint mobilization techniques, depending on the stage of the condition, in order to minimize capsular adhesions and restrictions in motion. Modalities like ultrasound for deep tissue heating; and moist heat compresses for superficial tissue heating are utilized in conjunction with exercises to help increase the extensibility of the tissue, promote relaxation, and minimize pain. Icing can be used in very acute cases.

Three major exercises are recommended and are easy for the patient to perform at home:

Pendulum exercises. The patient bends half way at the hip, supporting herself with the good arm on the back of a chair, and swings the affected arm back and forth, sideways, or in a circular fashion either free or holding a small weight.

In the wall-walking exercise, the patient climbs her fingers like a spider on the wall, either in front or to the side of her, until the arm can’t go any further. Each day, she should try to climb a little higher.

In the pulley exercise, a rope is strung from the ceiling or a tree branch. While holding each end of the rope with one hand, the patient pulls down on the good arm thereby lifting the frozen arm as high as possible.

Summary

A frozen shoulder is one of the most disabling and painful conditions, yet it is easy to prevent and is treatable with aggressive physical therapy.

 by Jaydeep M. Bhatt, M.D.

For many, neck pain is a source of frustration and disability. It is also a common cause of employee absenteeism.

There are several pain-sensitive structures in the neck (cervical spine), including nerves, bones, blood vessels, and connective tissue. Discomfort in the neck, coming from these structures, may require urgent attention. Therefore, it is important for you to seek medical attention as soon as possible. A competent neurologist will take a careful history and perform a neurological exam to determine the source of your pain and the appropriate treatment.

Cervical radiculopathy refers to a common cause of pain that occurs when large nerves or “roots” in the neck are irritated. This is usually due to compression from other structures.

Anatomy

There are eight roots emerging from each side of the spinal cord in the neck. They eventually form peripheral nerves that move muscles and convey sensation. The roots are initially protected by bones called vertebrae, but they are potentially vulnerable. Gel-like structures called intervertebral disks may shift sideways and compress the root.

Sometimes, the vertebrae themselves grow bony extensions called ridges or spurs that irritate roots. Often, the roots are affected at multiple levels by a combination of these two processes. 

Causes

There are a number of causes that may result in irritation or damage to cervical nerve roots:

• Compression from disks and bony elements arising from direct physical injury
• Compression from  misplaced disks and bony extensions due to degeneration and aging
• Compression from overgrown ligaments and other types of connective tissue
• Infections of the roots by bacteria or viruses, e.g., Lyme Disease

Less common causes include: tumors, inflammation of blood vessels, and conditions that affect small facet joints in the vertebral bones.

The first two causes (injury and aging) are responsible for the majority of cervical radiculopathies seen by neurologists.

Symptoms

The predominant symptom in cervical radiculopathy is sharp pain. It is usually located over the shoulder blade and radiates down the arm, the distance of which depends on the level of the affected root. The pain may be accompanied by numbness, tingling, muscle spasm, and even headache.

In several cases, there is a clear inciting event or action, such as a whiplash injury or a fall; but many patients simply cannot remember any incident and simply “wake up with it.” The pain usually worsens with neck extension and lateral movements.

Other conditions affecting the spinal cord or shoulder and its supporting structures may mimic the symptoms of cervical radiculopathy. This is another reason why you should see a neurologist when experiencing new onset pain or a change in the character of chronic neck pain.

Diagnosis

There are maneuvers that the neurologist performs to determine that cervical radiculopathy is the cause of neck pain. Pain reproduced on neck extension and lateral motion may offer a clue to the nature of the injury. 

Sometimes, a neurologist may order a nerve conduction study (NCS) with electromyography (EMG) to make a diagnosis. In other cases, an MRI of the cervical spine may be necessary to visualize the spinal cord, roots, and surrounding tissues to clarify the diagnosis. Less frequently, blood tests may be ordered to search for an infection or inflammation causing the symptoms.

Treatment

The treatment for cervical radiculopathy depends on the severity of your injury. The majority of patients with neck pain due to root irritation improve with conservative management. This entails physical therapy, some form of neck stabilization (especially at night), such as a cervical collar, and a limited course of anti-inflammatory medicine to reduce inflammation and swelling of the cervical root.

Sometimes the pain from this condition can be so severe that it may be necessary to administer a local injection of medication. This is known as a therapeutic cervical root block and the effects vary. They may be negligible, temporary, or may last for weeks or months. 

Physical Therapy

Adherence to a dedicated physical therapy plan in tandem with medical treatment is essential for improving your recovery from current injury and in preventing future neck injuries. Your physical therapist will design a personal regimen that will address:

- Strengthening exercises for the muscles in your neck and upper extremities

- The role of a cervical collar to promote healing

- Education on proper posture when at rest and during activity

- Living an ergonomic life to alleviate mechanical stress

- Ultrasound, heat/cold, and electrical stimulation techniques to reduce pain

- Massage therapy to reduce muscular tension and increase range of motion

Surgery

In some instances, the degree of injury in the neck due to trauma or aging can be so severe that it damages the integrity of the spinal cord and nerve roots. If ignored, sustained damage may lead to severe weakness and even disability. When conservative rehabilitative measures aren’t enough, cervical spine surgery may be required. Referral to a neurosurgeon, who works closely with a neurologist, is essential for the best outcome.

There are several sophisticated surgical techniques from the front or back of the neck that stabilize a patient’s neck. Since cervical spine surgery is an invasive procedure that requires significant post-operative rehabilitation, a competent neurologist and neurosurgeon should confirm that you are a good candidate for surgery.

Summary

Cervical radiculopathy is a common disorder with significant disability. The majority of cases can be easily treated with conservative management.

 by Myrna Ivonne Cardiel, M.D.

The cosmetic use of Botox injections for smoothing out wrinkles is well-known. Physicians also use the same chemical substance, Botulinum toxin, to treat a variety of neurological conditions.

Pathways to Our Muscles

When we use our muscles in daily activities, from simple tasks such as walking to complicated functions like playing the piano, the brain communicates with various muscles. It utilizes nerves as cables to transmit the messages to the involved muscles telling them to contract and move the joints.

The nerve then releases just the right amount of a chemical, acetylcholine, to stimulate and activate the muscle. If too little of this chemical is released, there is no movement or a very weak one; too much, and the muscle contracts excessively, causing a painful spasm. Abnormal and sustained muscle contractions (muscle spasms) are seen in a number of neurological disorders that interfere with the smooth execution of various bodily movements.

Botulinum toxin, which is produced by a bacterium growing in poorly sterilized food, causes paralysis by blocking the release of acetylcholine from the nerve terminals to the muscles and can result in death.  

Scientists have produced this chemical commercially. Physicians inject very weak solutions under the skin to paralyze the tiny smooth muscles causing the wrinkles.

Neurological Disorders

Neurologists also use botulinum toxin to block abnormal muscle contractions or spasms in various neurological disorders:

• Blepharospasms are muscle twitches or spasms that prevent the eyelids from staying open, usually affecting both eyes. These spasms can impact a person’s ability to keep the eyes open while driving. 
• Hemifacial spasms involve muscle twitches on half of the face.  They cause discomfort and can be disfiguring or embarrassing.
• Dystonic postures are caused by the simultaneous contraction of several groups of opposing muscles. This condition can be generalized (dystonia musculorum deformans), where several limbs and trunk muscles contract together; or it can remain localized (focal dystonia), as occurs in writer’s or violinist’s cramp, where the flexor and extensor muscles of the wrist contract together. In torticollis (wry neck), the muscles on one side of the neck go into spasm.

Other neurological disorders, such as stroke, cerebral palsy, multiple sclerosis, and brain and spinal cord injuries, cause spasticity. In this condition, sustained muscle contractions in one muscle group cause an abnormal limb position that the patient cannot control. These abnormal positions make the person unable to use the affected limb and can lead to permanent contractures. The affected person cannot use the hand to eat, the leg to stand on, and walk; and it may be impossible to wash that limb, causing skin ulcerations and infections.  

The conditions mentioned can be treated successfully with botulinum toxins.  In addition, migraine and tension-type headaches can also be treated with relatively good results. 

Botox and Myobloc Treatment

There are two types of botulinum toxins available: botulinum toxin type A (Botox), and botulinum toxin type B (Myobloc). 

Aside from cosmetic procedures, Botox is also FDA-approved to treat several of the neurological conditions mentioned above. 

Some physicians prefer Myobloc over Botox usually because of familiarity. Others use Myobloc only in patients with contraindications to Botox. Both are similarly effective.

The main advantage of botulinum toxin injections over orally administered drugs is their efficacy. Also, they work locally having no significant absorption or systemic toxic effects on the liver or kidneys. There is no significant interaction with other drugs and no significant side effects like dizziness and sedation. Mild side effects can include bruising or soreness at the injection site, difficulty swallowing, body aches, eye dryness, headaches, and skin rash.

What to Expect

During botulinum treatments, a small amount of the toxin is mixed with a saline solution and injected in the appropriate abnormally contracting muscle. Typically two to ten injections are needed during a single treatment session.  Some conditions require more than one session for the full benefit to be achieved. Electromyography (or EMG, a small acupuncture-like needle connected to a computer screen) is usually used to help identify the muscles involved and inject the medicine in the correct spot. 

It usually takes about two weeks for the injections to take full effect. The effects are temporary, lasting about three months. Over time, the effects of botulinum toxins are lost, and then another injection will be needed. Patients require regular follow-up treatments, usually every three months, to have a continuous benefit from the injections.

Botulinum toxin is safe when injected by a neurologist trained in clinical neurophysiology who is familiar with its use. Thus, several previously untreatable conditions are now being treated routinely and successfully.

Physical and Occupational Therapy Post-Injection

One of the main benefits of botulinum toxin treatments is that patients are able to participate more actively in physical rehabilitation after having suffered a stroke, brain and spinal cord injury, multiple sclerosis, cervical dystonia, or other medical conditions causing unwanted muscle spasms. 

Following botulinum injections, physical therapy helps patients move better, exercise more, and become more independent. Having the ability to control certain unwanted muscle contractions or spasms allows the therapist to stretch the affected muscles and strengthen the opposing muscles. This in turn, allows patients to be retrained to adopt easier positions for everyday activities, such as eating and dressing, and to enhance personal hygiene. It leads to an overall improvement in quality of life and well-being. A more independent and functional patient also requires less caregiver support.

Similarly, occupational therapy helps patients deal better with handicaps, and complements the use of adaptive and orthotic devices (splinting and bracing) designed to improve patient’s functionality during the activities of daily living.