Physiotherapy Appointment

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Following the acute pain of my frozen shoulder, the GP suggested I made an appointment with the physiotherapist. By the time this morning’s appointment came around, my shoulder was so much improved that I had thought of cancelling it, but on balance I decided to go, because I thought she might give me some exercises and some advice to prevent the problem recurring.

As it turned out, I am very glad I went. She said immediately that she thought the frozen shoulder could well be merely a symptom of something else.

She examined me and got me to move my arm in various ways, asking me to tell her when, and how much, it hurt, and measured the amount of movement I was able to achieve. She felt the back of my neck with her fingers and said that the muscles were quite tight and knotted.

She said that both shoulders were affected, and that the pain in my neck was connected, although she agreed that the right shoulder and neck could be reacting to my having used different muscles during the period my left shoulder was immobilised.

She said that medication was fine in the short term, to reduce inflammation and acute pain, but in the long term it was not so good as it affects other parts of the body, and in any case it only treats the symptoms and not the underlying cause, which was her function.

She said that the main problem lay in the anatomy of the shoulder joint – there are muscles north, south, east and west around the ball-and-socket joint, and these should be in balance. Even in repose, they are used to maintain posture, and to keep the joint in proper alignment. There is a connection between the shoulder joint itself, and the muscles across the upper back and the joints where the ribs join the spine, the shoulder blades and the neck, and if the shoulder muscles are not balanced, this can affect the whole of this anatomical area, which she called the shoulder girdle.

Many people get problems with this, if they are using a computer keyboard all day, for instance, and for people who use their arms a lot in an extended position, or carry out activities bending forwards, for instance over a desk or work station. What happens is that one set of muscles gets over-used, while its opposite number becomes under-used, and the brain learns this pattern, which then feels normal.

However, if this state of affairs continues, it puts a strain on the tendons in the joint, causing pain, and it is at this point that people seek professional advice. There can be swelling and damage caused by the wear and tear due to continuous bad positioning of the joint, and the brain needs to learn a new way of holding the posture and maintaining the joint in its correct position.

Since it is impossible to see one’s own shoulder blades, she demonstrated on herself what was happening with me. She said that my shoulder blades were too far apart, throwing the shoulder joints forwards, and that when I was moving my arms forwards, I was moving my whole upper trunk, when I should have been keeping the shoulder blades down, and moving only my arms. The muscles in the “north” position were being over-used, while their opposite number were being under-used, throwing the joint out of balance.

Moving on to my neck, she said that my head was too far forward in relation to my upper back. She got me to stand with my back to the wall and try to align my ears, shoulders and hips as if gravity were pulling me downwards in a vertical line. She said that in a normal situation, one should be able to get one’s neck far enough back that there was only room for one finger between the neck and the wall, but in my case, she could fit four fingers into the space, and I couldn’t get it any closer. She said that for some people, it was impossible for them to get their head to touch the wall at all, so it wasn’t as bad as it might have been!

All the muscles across the base of my neck are very knotted and tight and she could tell that the shoulder joints were being pulled slightly out of position because she could feel the “clickiness” that I was aware of. When I asked if this could give rise to arthritis in the long term, she said no, as the shoulder is not a weight-bearing joint, but it would cause soft tissue damage.

As for the cause of these problems, in my case it is not just my activities with my art and computer use (although the latter isn’t such a problem because most of the time when I’m on the computer, I am lying back on the recliner), but mostly it is due to my use of mobility aids. Self-propelling my wheelchair and walking with elbow crutches over several years has thrust my shoulder joints forwards and this now needs to be corrected.

I had thought she would give me exercises involving lots of arm movements to keep the shoulder joints moving, but on the contrary, I have been given only two, and the movement is surprisingly minimal.

Firstly, I have to lower my shoulder blades and hold the position for a few seconds and then release, and repeat, and I am to do this throughout the day. Whenever I reach forward for anything, or propel my wheelchair, or walk with my crutches, I am to be conscious of the position of the shoulder blades and keep them in the down position. This movement brings the shoulder joint back into a healthier position.

The other exercise involves standing against the wall several times a day – she suggested each time I went to the loo, as a good reminder to do it several times a day – and get everything into alignment, and to try and get my neck as far back as possible, so that my chin is more tucked in, without bending my head forward. She said that the gap will gradually decrease, but I should look at at least three months before I notice an improvement in this.

She told me not to go mad with these exercises – a few times, several times a day, is better than 25 times all at once and every five minutes! She was aware that my M.E. gives me rapid muscle fatigability anyway, so I can’t do too much. She said it was very important when carrying out activities which keep one in the same position for prolonged periods, to remember to move around from time to time, and change one’s position.

As I progress with these small but crucial movements, my brain will gradually relearn how my posture should be maintained. Our bodies are designed to be in perfect balance and when we get into bad habits, for whatever reason (in my case the need to use a different method of getting around from that which the body is designed to do), this puts a strain on our anatomy and eventually causes us pain.

I asked her what would have happened if I had not sought help. She said that the wear and tear on the tendons would have become worse, causing more inflammation and pain, until eventually I would not have been able to move the joints at all and my arms would become immobilised (the idea of having a permanently frozen shoulder is appalling!!). I know that many wheelchair users have problems with their shoulders because of this unnatural use of their arms over many years, and without the necessary training to prevent damage, and many manual wheelchair users eventually have to resort to a power chair for this reason. It was fascinating having the mechanics of it explained to me.

On the subject of wheelchair use, I feel very strongly that there should be professional training for all wheelchair users, whatever the cause of their disability. For spinal injured people, the rehab in the spinal units is very good and covers correct wheelchair use as well as all other aspects of regaining a full and independent life, but in most other areas this is simply not addressed. A wheelchair is prescribed and you are on your own, for the most part. There should be training on how to do wheelies, for instance, which hugely enhance one’s independence, and all wheelchairs should be properly fitted to their individual users. A badly fitted wheelchair can do as much damage as badly fitting shoes to growing feet, and on a greater scale, too. Modern lightweight wheelchair design is a vast improvement on the old style (I call them iron maiden wheelchairs!) and this certainly helps reduce problems in the long term, but just as important is the use of correct technique. I thought I was doing pretty well, and I do employ an efficient propulsion motion with my arms, but had no idea what was going on with my shoulder joint position.

What I have to do is really very simple. She said that as the pain decreased, the temptation would be to think, “I’m all right now – I can stop doing the exercises” or to forget to do them, but it was crucial to continue, until my brain has re-learned the correct muscles to use when doing different activities and it becomes automatic, and my new, better, normal.

I found the whole thing quite fascinating. She explained everything very well. Although of course all doctors have to study anatomy, the physiotherapists have specialist knowledge of how our muscles and related soft tissue interact, and which movements are healthy and which are not. I thought my posture was good, but it clearly hasn’t been, and the smallest adjustment can make a world of difference.

She sent me home with a printout of my “homework” with diagrams showing me the correct movements, and said it was in my hands now – the muscles are all there, and they are all functioning properly, and I have now learnt how to use them correctly, so it’s down to me now to work on this and put things right. Unless I have any problems she doesn’t need to see me again, but said their door was always open if I needed them.

At the moment, the pain is worse, after she pulled me around and prodded and poked me this morning, and since I have been repeating the required movements during the day. I expect I shall be stiff for a few days as my body adjusts to the new way of doing things, but I am very optimistic about the future, and am very pleased to have been made aware of what was going on, and to have caught it in good time before permanent damage has been done.