Does the brain and immune system influence frozen shoulder?
As a soft tissue therapist specialising in myofascial release (MFR), I've always been intrigued by the intricate interplay between the body's systems and how they manifest in conditions like frozen shoulder. My approach to therapy is holistic, focusing on the whole body rather than isolated parts, and I believe this perspective offers a unique opportunity to assist those who have not found resolution elsewhere.
In my practice, sessions are structured around a comprehensive assessment, ensuring that I thoroughly understand each client's unique situation before commencing therapy. Frozen shoulder, often misunderstood, is a condition with three distinct phases and can last anywhere from 12 to 24 months. It's not a quick fix, and managing expectations while providing effective treatment is paramount.
A recent study stated the 3 phases as:
- Painful freezing phase in which pain precedes a loss of range of motion lasting 10–36 weeks
- State of freezing or adhesive phase, lasting 4–12 months where pain gradually reduces while the range of motion stays impaired
- Thawing or regression phase where range of motion improves progressively
(Navarro-Ledesma et al. 2024).
However, this paper continues to state that approximately 40% of those who presented with frozen shoulder don't appear to fit this timeframe making this standardised classification questionable. Could there be other considerations to the onset, progression and persistence of frozen shoulder?
Incorporating the latest research findings into my practice is essential. However, in the realm of soft tissue and manual therapies, evidence can often be weak across the board. Nevertheless, staying abreast of new evidence, concepts, and ideas allows me to enrich my practice and provide the best possible care for my clients.
One of the key elements in my approach is patient education. Many clients come in with misconceptions, often believing that pain equals damage. We now understand that pain is a protective mechanism, and addressing this misconception is crucial. Additionally, empowering clients with knowledge about their condition and the therapeutic process is fundamental in building trust and fostering a sense of control over their pain. Building a therapeutic alliance is central to my practice. Trust, self-efficacy, and agency are cultivated through effective communication and rapport-building. Encouraging clients and integrating motivational goals into therapy sessions further enhances the therapeutic relationship and facilitates progress.
The latest research on the interplay between frozen shoulder, the brain, and inflammation correlates with the emerging need for therapists to support an evidence based practice. Understanding that frozen shoulder is a complex process influenced by neurological and immune factors reinforces the importance of proactive management and maintaining a positive attitude.
This recent research paper published in Frontiers in March 2024 certainly highlights some new and interesting concepts and is well worth a read. Here are some key points:
'A new perspective of frozen shoulder pathology; the interplay between the brain and the immune system'.
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Introduction to Frozen Shoulder Pathology: The article introduces frozen shoulder as a multifaceted condition characterised by stiffness, pain, and restricted shoulder movement. It emphasises the importance of delving deeper into its underlying mechanisms.
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Neurological Factors: In discussing the neurological aspects, the article explores how alterations in sensory processing and pain modulation pathways contribute to frozen shoulder pathology. Specifically, it highlights the role of neurotransmitters such as gamma-aminobutyric acid (GABA) in regulating pain perception and muscle tone.
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GABAergic Mechanisms: GABA, the primary inhibitory neurotransmitter in the central nervous system, plays a crucial role in modulating neuronal excitability. Dysregulation of GABAergic signaling may lead to hyperalgesia, muscle spasm, and heightened sensitivity to pain, all of which are observed in frozen shoulder patients.
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Immune System Involvement: The article examines the inflammatory processes occurring within the shoulder joint capsule and surrounding tissues. It suggests that immune dysregulation, possibly triggered by local tissue damage or systemic factors, contributes to the development and persistence of frozen shoulder symptoms.
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Brain-Immune System Interaction: A significant aspect of the article is the exploration of bidirectional communication between the brain and the immune system in frozen shoulder pathology. It proposes that neuroimmune interactions, mediated by GABAergic signalling and other neurotransmitter systems, play a pivotal role in orchestrating inflammatory responses and pain modulation within the shoulder joint.
- Psycho-Emotional Distress Influence: The intricate interplay between psycho-emotional distress factors and frozen shoulder pathology involves bidirectional communication between the brain, immune system, and psychological states. Neurological mechanisms, including alterations in pain processing pathways and dysregulation of neurotransmitter systems (including GABA), may exacerbate psychological distress. Conversely, psycho-emotional distress, such as stress, anxiety, or depression, can trigger neuroendocrine responses and immune system activation, contributing to inflammation and pain sensitisation in the shoulder joint. Addressing psycho-emotional distress through holistic therapeutic approaches may therefore be essential in comprehensive management strategies for frozen shoulder.
- Implications for Treatment: Understanding the intricate interplay between brain mechanisms, GABAergic signaling, and immune responses in frozen shoulder pathology has profound implications for treatment strategies. The article suggests that targeting both neurological and immune pathways may offer novel therapeutic approaches for managing the condition effectively.
- Considerations: This article suggests that an overall holistic approach is required including diet, the use of (pro) biotics and an increased partial pressure of CO2 in breathing exercises (therapeutic hypercapnia) could prove beneficial to frozen shoulder. However, it also states that therapeutic hypercapnia has not yet been studied sufficiently in humans.
Overall, the article provides a novel perspective on frozen shoulder pathology, highlighting the intricate relationship between the brain and the immune system. By elucidating these underlying mechanisms, it offers new insights into potential therapeutic approaches aimed at addressing both neurological and immune components of the condition.
Where can MFR fit it?
Current evidence highlights that soft tissue and manual therapy mechanisms of action are weak despite the evidence we have from the therapeutic process; we can and do make a difference to people experiencing pain. Ultimately, this leaves us back to the question of how does MFR or any other manual therapies actually work?
What we do know is that all touch matters. There is a need for every human being to experience touch and more so for those experiencing persistent pain. People look for validation from therapists like us when they are in pain. We can help them understand their pain, loss of function, lack of sleep and general feelings of malaise. However, we need to be very careful not to bless or blame any particular structure or tissue as every client is different. Embracing a holistic approach brings a knowledge of muscles, joints, fascia and how pain works to the table helps to empower the client reducing their stress and anxiety. MFR and all other soft tissue therapies can influence mechanosensory touch receptors that can help with emotional regulation.
MFR encompasses not only hands-on techniques but also effective client dialoguing and comprehensive evaluation. By addressing the individual needs of each client and educating them on the mechanisms of pain and frozen shoulder, long-term results become achievable.
Ultimately, the most rewarding aspect of my work is witnessing the positive impact it has on my clients' lives. Even small improvements in range of motion or a reduction in pain can make a significant difference. By alleviating stress and anxiety through education and support, I empower my clients to navigate their journey towards recovery with confidence.
This new perspective on frozen shoulder pathology that explores the interplay between the brain and the immune system, sheds light on the complexity of this condition. By integrating this understanding into our practice as soft tissue therapists, we can offer more comprehensive and effective care for our clients.
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