The first day that I returned to USC, Maria’s case was being presented to the Rheumatology/Orthopedic Surgery Conference. She was in her early twenties. Only a few years before, she had developed ravaging arthritis in her right shoulder. On x-ray, the joint was essentially destroyed. Any movement was so unremittingly intensely painful that she was completely unable to elevate her arm. A year of physical therapy hadn’t helped at all, and now she was being considered for surgery.
The orthopedic surgeon proposed that since the pain was apparently caused by her humerus impacting the top of the bone structure of her scapula, she might be more functional if the scapular roof was excised. No one had ever attempted such a procedure. He wanted to. I saw it as a mutilation, and asked for a few weeks to try the methods I had just returned with. The surgeon didn't want to wait. In his thinking, “physical therapy” hadn’t helped. Of course, he was right, but the habit of thinking of physical therapy as a generic, like “cottage cheese,” is one of the consequences of the Fundamental Flaw. When the breadth of concepts is not considered, even a profession, like physical therapy, can be diminished to procedural modalities and exercise.
Some of the methods I had learned are based on restoring restricted joint motion by moving them in directions different from their natural way of going, as I discussed with Lisa’s hip. As I explained previously, an extremity is grasped close to its articulation and a specific force is applied that stretches the restricted soft tissues without unduly stressing the joint. The force is predominantly a shearing transverse to the joint's surface. The prime purpose is to loosen the capsule, thus providing a degree of joint “play” that allows the bones to move freely on each other. It is surprisingly pain free.
Relating to the arm, the theory is that before it can elevate, the humerus must first descend a little into the lower capsule of the joint. That is not traditional thinking. Regardless, Maria's shoulder capsule was so contracted from the arthritic inflammation that her humerus was too tight and “up” into its joint. Since the head of the humerus couldn’t descend a little, it immediately impacted the tender, inflamed tissues as soon as movement was attempted.
Maria was small, frail, febrile, and clinically malnourished from the recent ravaging of the disease. The rheumatologist stated that surgery couldn't be performed for about two weeks, anyway,, until she was clinically stabilized, so I had that time.
I showed the physical therapist a few techniques that needed to be done for a few minutes twice a day. I taught Maria how to use a door hinge space as a clamp into which to insert a strap, and how to use it for gentle traction. She would assure that the strap was well secured, and then wrap the other end about her hand and wrist and lean away so her arm would be distracted a little from the shoulder socket. I told her how important it was to remain relaxed and just let the gentle pull happen, and to do it periodically so long as it was comfortable.
Note: The end of the strap can also be placed on the floor and stepped on. Then leaning away provides “axial traction,” as well. By stepping on the strap with the opposite foot, closer-in pull can be accomplished. You can also “open” the joint while sitting on a chair by holding onto the seat with the involved hand and leaning away. Staying relaxed. Every little bit can help.
Two days later, Maria was at the sink crying when I entered her room. Immediately concerned, I asked, "Maria, por que lloras? (“Why are you crying?”) "Look," she exclaimed with eyes shining. For the first time in over a year, she was able to take a washcloth in both hands and painlessly wash her face. Then she picked up her ponytail clip and, with both hands behind her head, comfortably put it on for the first time since her disease had started.
Maria’s shoulder joint was obviously just as destroyed as it had been. So, where did so much painless motion come from? As I previously described, full upper extremity range of motion is only partially the movement of the arm at the shoulder, the scapulo-humeral range. It remained unchanged at only ten degrees, as before, but the therapy had stretched the capsule sufficiently and desensitized the area, likely freeing entrapped tissue. Now, I could restrain her scapula and pull against her arm with considerable force, and, though the joint was still locked, she just smiled. Now she was able to maximize her scapular range, which gave her another sixty degrees of motion. I taught her husband how to do the techniques, and Maria left the hospital a very happy young lady.
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