Frozen shoulder - the double burden

Frozen shoulder is something that I come across often in my practice. In my initial training as a massage therapist we were taught it was an unexplainable condition that came on suddenly, mostly in women of middle years and would last 1 - 2 years and disappear as suddenly. This intrigued me. How could a condition just disappear?

It is characterised by an inability to move the arm out from the body more than a few inches before intense pain is felt. usually when it first comes on it is noticed in the act of difficulty moving behind the body (as in doing up the bra in women). As it progresses movement will become increasingly limited and painful. What lies behind this symptomology? Is it a trapped nerve, or fascia - and if so how does it spontaneously resolve? What can a physical therapist do to help alleviate? These are some of the questions that have been troubling me.

In my subsequent study and practice of mindbody medicine, there appears to be a more logical explanation. If any of you have come across the work of Peter Levine, author of 'Waking the Tiger' (1) you will know that the mind and body work to keep the organism safe in times of danger or trauma. But, unlike the rest of the animal kingdom, we often do not discharge this energy after a brush with danger. The instinct to shake is often suppressed as we are told to 'pull ourselves together' or have a stiff drink. But in fact this normal body movement is necessary to remove the energy of the stress response from out of the muscles and if we don't do it, or can't do it we can get 'stuck' in an unresolved mobilisation to stress.

Now it is a fact that muscles move in concert with one another. Any movement needs the controlled response of two sets of muscles- the agonist and the antagonist. It is also true that emotions play a part in mobilising this response. Say for instance you are involved in a car crash and you go to move your hands up to protect yourself but they are held by the seatbelt. your instinct is thwarted. your life or the threat of injury has undoubtedly been saved but there may be a lingering response in your brain which is not discharged. It appears that this may be what lies behind such conditions as frozen shoulder. As Peter Levine himself states "the motor expression of two intense instinctual responses creates a conflict and results in frozen states... the energy bound in inhibited (thwarted) responses  is so powerful that it can cause an extreme bracing that often has profound effects" (2, P196).

But it's not only extreme trauma like accidents or shell-shock under war conditions that create stress in the body. I have already written extensively about 'everyday trauma' of common events like poor parenting, bullying, surgery, etc in my recent book (3). These stimulate our stress responses too. And it may be that when this is not cleared from the mind body of the person that conditions like frozen shoulder, or sciatica represent those undischarged muscular and nervous responses to threat.

What can we do then as therapists - or sufferers ourselves to help discharge and heal? Well, there are many ways but all of them involved becoming more aware of the body and helping to tune in (interoception) to the movements our body is trying to make. With frozen shoulder it is suggested to make the small movement you can make without pain extremely slowly while concentrating on what your body is telling you. with gentle encouragement you are often able to increase the range of movement when you discover what messages are being sent to the muscles which are stimulating both the agonist and the antagonist at the same time to lock the range of motion. Go even slower and do it again. The answers will often come spontaneously as a wave of shaking, crying or sweating relief - the is I sympathetic activation and shows you that your body is releasing. obviously for some people this happens spontaneously within 1 - 2 years. but to be able to do this yourself means you don't have to suffer so long.

Peter describes these techniques in much more detail in his books - but for now I leave you with one thought. As an example of how this ant/agonistic muscle stimulation happens - people who jump from burning building often break their legs before they hit the ground (or the net) due to the simultaneous in tense contraction of the leg muscles putting intolerable strain on the leg ,bones!  (2, p198). Food for thought how smaller but perhaps more chronic stresses, especially in a helpless situation may change the brain to lock the body in a protective response cycle. This, I believe explains frozen shoulder than any other explanation I know of. And it may explain too, why women suffer far more from this than men. helplessness is a state characterised by childhood but also by some women (and men of course) in their adult lives. A bullying boss, husband or just the intense suffering caused by living in a world that does not support or encourage you can be enough. Food for thought indeed.

Copyright Patrica Worby 2016. www.patriciaworby.co.uk and www.alchemytherapies.co.uk

1. Levine, Peter (1997). Waking the Tiger. North Atlantic Books.

1. Levine, Peter (2010). In an Unspoken Voice; How the Body releases Trauma and Restores Goodness. North Atlantic Books

1. Worby, Patricia (2015). The Scar that Won't Heal; Stress, Trauma and Emotion in Chronic Disease. CreateSpace.

The Neuroscience of Being 'Us' - Part 2 How threat and unresolved emotion changes the brain

Interactions between the cortex (frontal lobe) and limbic system; the anterior cingulate and insula

(Part 2 of a 2 part series see here for part 1)
There is another important part of the mid-brain (adjacent to the amygdala) that has a function in registering threat and helping to lay the foundations of trauma. It’s called the Anterior cingulate cortex (ACC) and is important as a filtering system. It is another part of the brain that is functionally degraded as a result of trauma. It possesses structures called spindle cells which wrap around the nerve bundle of fibres linking the left to the right sides of the brain. These connections between left and right may be very important for how emotions are integrated and the meaning made of the emotional events in our lives– and it may be key to why techniques such as EMDR which stimulate better integration allow re-wiring to occur .

The Anterior Cingulate Cortex ACC is primarily involved in fear conditioning as it normally inhibits the amygdala, which as we know is the primary area for threat encoding. However, it also appears to play a role in emotionality, selective attention, and certain social functions, including emotional attachments and parenting, as well as generation of the concept of the self in relation to society. It is my contention that this is the part of the brain that fails in attachment disorder, and other more chronic relational trauma disorders. I have particularly noticed that the sense of self is often highly distorted, even in very outwardly functional people. They operate despite their own self-loathing to become very respected/hard-working/ achieving people but when questioned they cannot see that anything they have done has any worth. If you press them they will acknowledge grudgingly that it might have value but they do not feel that emotionally, it is more of an intellectual awareness. The ACC might be the part of the brain that we bring ‘online’ in trauma treatment, as when we do EMDR. We rewire the responses by a process of extinguishing the conditioned response of self-hating or limiting. I will discuss this within the tools section.

The insula (another part of the cortex just behind the PFC) is an area that helps interpret incoming sensation, rating it dangerous or not. It is highly involved in our subjective experience of pain, for example, and can become active just by imagining pain as well as in more pleasant experiences like music appreciation. It monitors incoming signals from the body (particularly the physiological experience of emotions like sadness, fear, anger, etc) and combines this information with the limbic system and brainstem to generate appropriate responses. As we will see later, when the signals get scrambled by unresolved emotional memory, stress is able to overwrite any inhibitory stimulus and most incoming signals are interpreted as painful, dangerous or life-threatening, causing all sorts of chronic pain and stress-related diseases.

Left and right sides; the Corpus callosum connection

Despite the fact that the cortical structures are split into left and right hemispheres, the brain remains undivided at the level of the lower reptilian brain structures - sometimes referred to as the ‘subcortical bridge’ In treatment, the client and therapist may also be able to capitalise on this. Nonverbal information, including “unconscious or preconscious codes, nuances we can never attach a name to,” cross most readily (Austin, 1999) . Using somatic experience as an entry point in therapy and maintaining mindful awareness of the body may facilitate information processing by enhancing information transfer between the hemispheres. This is what is aimed for in clinical hypnotherapy intervention by engaging the imaginative right hemisphere. However, there is controversy in hypnotherapy as to the nature of hypnosis as we have already shown with regard to whether it is a state separate from normal everyday experience or not. This was developed further by the great hypnotherapist and psychologist Pierre Janet.

We have already intimated that in subjects with PTSD and other lesser traumatically encoded states, the amygdala may become hyperactive towards “a generalisation of the fear response” or conversely underactive which “may allow continued functioning in situations characterized by ongoing threat” such as that experienced by a child who is under threat from their caregiver. That this may be in part to do with the alteration in function of the left and right hemispheres and specifically their inter-communication is an ongoing debate with psychotherapy.

This is an extract from my book The Scar the Won't Heal - available now on amazon. In the next instalment I look at Interactions between the cortex and the limbic system.

The ups and the downs of ageing and selfhood

Having had a strange few days of highs and lows I have been pondering the nature of ageing and what it means to inhabit our bodies. My mother had some sort of heart arrhythmia a couple of weeks ago and has had a pacemaker fitted. I went to visit her for the first time yesterday (having not been well enough really to visit at the risk of passing on whatever flu bug I had).  My mum is 81 and has previously been a healthy and active person, working one day a week in the local PDSA charity shop and visiting my brother every Saturday on the bus. I fear that may have come to an end.

She collapsed while having her hair done at the hairdressers, she doesn't remember passing out, she only knows she woke up in an ambulance. She was out for approximately 10 mins and they were worried they wouldn't be able to rouse her. She was then taken to hospital for assessment and endured what sounds like a typical A&E experience in this country, where she was left hooked up to a ECG machine on a trolley for 8 hours while they waited for a bed. She says all she had with her was her handbag and they had put her in a gown but not given her a blanket or drink until she begged the nurses saying how cold and thirsty she was. She says they looked annoyed when she asked (which mirrors my experience - they are all under such tremendous pressure with not enough staff that the basic kindnesses go out the window).

She had her pacemaker fitted the next day in what seems like a miracle procedure - local anaesthetic and inserted through the artery under her arm. She was discharged after 2 days and now has care from 2 lovely ladies who come morning and evening to help her dress. She seemed well enough when I saw her but she shows signs of having lost a lot of weight, she has lost the use of her left arm (which is her dominant hand) so is severely restricted in cooking and dressing. I was a little surprised by how quickly she has become 'old' and passive. She is scared of using the microwave in case it interferes with the device; the booklet she was given says she is not to get within 6 inches of microwaves or hairdryers so, my Mum being ever cautious, she goes out the room completely when the microwave is on and hasn't washed or dried her hair yet, preferring to use dry shampoo. She seems convinced that she can't use her arm, even though the advice was just to not to lift it above her head for a few weeks.

Nothing I say can convince her, she waits for the consultant appointment this week to tell her whether she can have her hair washed, risk walking, etc. Women of my mother's generation (and class I guess) are in awe of their doctors and their word is God. Anyway it was a mixture of relief (that she has survived with her humour intact) and exasperation that I attempted to help and be a good daughter. I did her hair for her. It was a strange but oddly healing experience. We've never had the greatest relationship but I am slowly building it, as she ages and I find more compassion in my heart for her strengths (famously dotty, genial and good natured) and try hard to ignore her weaknesses (lack of empathy for those closest to her, judgemental at times).

And in that reflection of course is the fact that, as I approach 51 (this week!!), I feel, well, surprisingly young in comparison! I had gone to visit feeling quite down about my approaching birthday but seeing her passivity and helplessness, I realise I am not there yet and still have a lot of living to do. We are all ageing and we are quite terrified if we're honest but as I continue to work with my clients and learn so much through the work we do together I realise that our fears are universal and very, very human.

I had a dispiriting Saturday exhibiting at a Wellbeing day where I sat, ignored for the most part, as people who read cards or palms, sold crystals or even, gasp, make-up were well attended. Working on your emotional health just isn't that high up the agenda for most people. They'd much rather have a foot-rub! Can't say I don't understand that but I kept feeling that wellness is so one-dimensional if all it means is attending to the physical needs of the body.. I mean I love massage, (and I do it for goodness sake) so I'm not denying the importance but I SO believe in this stuff that I do and I get such great results when people are able to release their subconscious fears and beliefs that I can't understand why everyone doesn't get this excited. :)

I did have one 'client' on the day - she was another therapist who was interested in trying a taster session of EFT as she'd heard of it but she couldn't think what we could work on as she'd 'sorted everything previously with other therapies'. I asked her 'is there anything troubling you?'. She said 'well only this nagging back pain' so we decided to work on that. Now, I use Faster EFT with a few extra touches of my own from my training in trauma and hypnotherapy, and it's quite a quick and incisive tool. In fact within minutes I had my poor lady in tears as she reconciled the fact of not loving or forgiving herself for stuff that happened to her in childhood. I had not expected to go so deep so quickly but then I am not in control of what comes up. All I can do is take the person into their own resourcefulness to counteract the pain and move them in and out of that experience very gently - what we call 'pendulation'.  I hold the space and trust that their brain/mind will allow them to move through it. A feeling of safety is paramount and must be created beforehand.

I watched her face all the way throughout - the facial muscles and expressions are intimately connected with our emotions - via the vagal nerve - and are very instructive. Her face suddenly looked very scared and childlike. as we worked through what had come up and gradually defused the emotional charge, the adult began to creep back in. At the end of what had been perhaps 20 mins she asked me what I saw and I told her. She said it was very odd because that day she had grabbed a crystal to take with her (I don't know much about them myself but she was obviously convinced that their energy helps her); the one she had grabbed was for 'the inner child' apparently.

As we drew to a close and I asked her how she felt she said 'my back pain is gone' and looked astonished. This is no longer a surprise to me as it used to be. I now know that emotional stuckness can be expressed in bodily pain and it seems clear from the work I've done that the pain will often shift, or move or change its character in response to clearance of these old emotional memories. She walked away feeling and looking quite different. I don't know if she'll venture to come back and see me for a longer session - I can't control that but I know I did good work with her and I felt that my purpose for going that day had been realised. I then wondered as I looked at the young women handing out free lipstick whether they could say the same.