Saturday, March 13, 2010

physical therapy

I've been trying to create my blog posts in an orderly fashion, but I'm skipping ahead with this one.

Yesterday was my fourth physical therapy session. The whole session lasted about two hours.

By now they have me doing a regular series of exercises. In the first one, I spend eight minutes on the "hand cycle", which is essentially a stationary bike which you pedal with your hands. (The machine is way overbuilt for what it does, IMHO). I'm nearly convinced that it's doing more harm than good, since it's impossible to pedal without the feeling that pins are stabbing into my left shoulder.

Since that's first, it sets me up for pain and crackling during the entire session. I try to avoid crackling by easing into and out of positions slowly. Before I developed this condition, it was unusual for me to experience clicking or crackling in my shoulders, and I don't want to develop it in the long-term.

As is often the case with medical offices, my physical therapist was delayed, so I wound up doing all of my exercises, and more, before he could get to me. When he got to me, I was already in quite a lot of pain. Then, as usual, he started with a deep tissue massage, and ended by doing lots of extremely painful manipulations of the arm which are intended to get the shoulder rotating correctly again.

I've been concerned about the manipulations because, in addition to the frozen shoulder, I've also been diagnosed with tendinitis, bursitis, and a partial tear of the infraspinatus. I'm willing to put up with pain, but not if the pain is an indication that I'm doing excessive damage to the other constituents of my shoulder. I want my shoulder back to 100% when this whole episode is over. I fear that excessive pulling and tugging might worsen the existing tear, or produce new injuries in previously healthy tissue. This is speculation, based on a few points that are extremely painful.

I think of my frozen shoulder as if the joint is encased in a ball of cement. The tendons and muscles are coming out of that ball. Usually, they slide around efficiently and cleanly when the shoulder rotates, but my view is that now they are getting stretched with much more force than is natural, and probably in strange directions, too. Surely this is just aggravating the whole joint more?

I'm particularly concerned about the biceps tendon because it inserts into the shoulder capsule and can develop adhesions in frozen shoulder. If the biceps tendon is torn, it won't heal on its own, and I'll need surgery.

I brought up my concerns with the physical therapist once again - I've continued to mention them, because I feel the amount of pain I'm experiencing is unreasonable. Yesterday, he cautiously admitted that the pain I'm feeling may be due to stress on some tendons, in particular the biceps tendon, and suggested that I shouldn't push myself to the point of extreme pain. However, he still seems convinced that it will be necessary to go through a lot of pain to get my shoulder rotating again.

At the end of yesterday's session, he asked me to lift my arm in a couple of directions. He thought that my shoulder had improved marginally - that it was rotating just a little as opposed to being completely stuck. He didn't seem to be saying that to make me feel better, either.

He then offered some ice. I haven't used it so far, but I decided to try it. It seemed to help quite a lot. I kept it on for 30 minutes or so, and after that the pain had subsided quite a lot.

When I got a chance, I took a look in the mirror, and I think he's right. The shoulder does seem to be rotating very slightly now. But it has a lot further to go.

5 comments:

  1. Since I don't know all the ins and outs of your case, take my advice with a grain of caution. Being a physical therapist myself, a concern is being in Physical Therapy appointment for 2 hours? This seems like and aweful long time. I hope your not getting charged for all of that time as that is going to be a hefty bill. Also they should only charge you for the time the PT or PTA is actually with you one on one. If you do any exercises on your own they should not charge you.

    Again since I am not in the room when you are getting the manual therapy and therapeutic exercises take this input with caution as well. But I would be a little concern with the extreme pain you are complaining of especially if the treatment seems to significantly make it worse.

    It seems like you have been doing some research on your injury which is good. Ask the Physical Therapist if he has some peer-reviewed literature (research articles from professional journals) that he has studied that may be of interest for you to read and understand your injury more.

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  2. Hi Kory,

    thanks for the feedback!

    Initially, I was told each session would cost $150 if my insurance didn't cover it. Since my insurance does cover it, I have a flat co-pay of $10 per session.

    When the session ran to two hours, it was because the therapist was delayed with another patient. I've only been to four sessions so far, and each session has gone differently, but they always run over an hour (sometimes they start a few minutes late too). They have a scheduling problem, but I'm used to that in general for any medical care, so I try to tolerate it.

    Each session, aside from the first, started with an aide telling me to do some exercises, followed up with work by the therapist himself. Then they may give me more exercises to do while there.

    In the case where the session took 2 hours, I was finished with all the exercises I'd been told to do, and my therapist was still working with another patient. I'd been there an hour and 20 minutes. I could have left (I am taking time out from work for these sessions), or I could have sat there. I asked an aide if it would be okay to do more exercises, and she said that was fine, so I spent time repeating exercises until the therapist could get to me.

    The physical therapist told me that the more time I spend doing these exercises, the sooner the condition will improve, so I didn't really mind spending 2 hours there.

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  3. Hi Kory,

    addressing the remark about pain in this separate comment:

    But I would be a little concern with the extreme pain you are complaining of especially if the treatment seems to significantly make it worse.

    At the time when the PT is manipulating my arm, the pain is worse in the extreme. The pain reduces to a bearable level immediately when he releases my arm, but there is residual pain which can last for hours. Applying ice seems to help significantly.

    Since I started physical therapy, my overall average pain has increased, I believe. OTOH, I have greater range of motion, and I can do more things without the extremely sharp pains that I was experiencing prior to PT.

    So I have mixed feelings. The PT seems to feel pretty sure that he is doing no damage, so I've been going along with what he tells me to do, despite strong misgivings which I have communicated to him (and he constantly reassures me).

    I suppose I could switch to another PT mid-treatment, but I have no surety that the treatment won't just be more of the same. Even if it's more comfortable, that might mean it's not as effective. I'd prefer to work through this with the PT that I have, unless things get too bad.

    It's not easy to find many details about frozen shoulder treatment online. The American Diabetes Association has a good, lengthy article which says Physical therapy, though painful, is generally recommended.

    On top of all that, each person experiences a different level of pain. It could be that I'm just more sensitive to pain, and I'm just overreacting to something which is harmless.

    Thanks for the suggestion to ask for literature; I will do that.

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  4. Glad to hear it is getting better. Yes, PT, should make it better. The key I have found through the years is making sure you are getting a combination and balance of mobility (the motion) and stability (the strength) back along with making sure they work together to make the motion normal again. Just because it is moving doesn't mean it is moving properly. An example I use with patients is: just because I am blowing on a horn doesn't mean I am making music. And blowing louder or longer doesn't mean it is better music either. You need to play the horn right to make the music.

    Best of luck on your progress. From the sounds of things I don't think the therapist is doing any damage to anything, so try to put your fears aside about that.

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