Tuesday, March 15, 2011

shoulder rehab - a very (very) active approach - a journey log, pt 1

Shoulder injuries suck. Getting one on one side after months of rehabbing the other side sucks even more. One may also imagine a revision to Oscar Wilde - To injure one shoulder may be regraded as a misfortune; to injure both looks like carelessness. And perhaps it was.  So, can the knowledge gained in rehabbing one shoulder over months be applied to the other to rehab it in weeks?

The following posts are a few notes on my journey to take lessons learned about the shoulder from an injury last spring - 10 months ago'ish now - and applying them to my right shoulder. The result seems to be a surprisingly accelerated recovery occurring on the right.

I offer these notes not as a "here's what to do if this sounds like you" but just some observations on what i've found useful in my own rehab.

Cut to the Chase: main rehab strategy
If you want to cut to the chase, the biggest therapeutic work right now seems to be loaded mobility work exploring the edge of range of motion limits - where those limits are pretty clearly communicated by an edge of pain.

I am fascinated by how quickly this work into the edge of the limit seems to be having rapid restorative effects. I'll discuss the approach in more detail as we move on.

Pondering rehab at the office.
see the RKC II cert?
Last spring not long after getting back from the amazing RKC II weekend in San Jose, Feb 2010, i somehow woke up one morning and my left shoulder was in significant pain. Reaching behind me to put on my coat was the most awful experience. 

6 weeks or so after the initial pain, went to see the doc as things seemed to be getting worse. The doc suggested "painful arc syndrome" which meant rotator cuff issue and take some NSAIDs to bring down the inflammation. As i've written about before, the drugs really did bring down the pain, but my pressing goals got shot. I learned that a sore left side can screw up a functioning right side: i just could not press with as much vigour without inducing a pain response on the left. Yuck.

Where did this come from? What was it? 
I learned a lot about repetitive strain injuries, and about resarch into eccentrics for healing these kinds of issues. I learned about the differences between itis or osis, and why most up on current practice medicos and resaerchers just talk about opathies instead. Eccentric training was not doing it for me. Physio not so much. Secrets of the shoulder - awseome stuff but wasn't giving me a breakthrough. 

Mid October *finally* got some work done with me on finding a path into the shoulder; turned out, no not really a shoulder thing per se (the source of pain may not be the site of pain, i seem to recall hearing some where), more a biceps thing - got a super path to start rebuilding there.  If you'd like to explore the detail of that analysis and the specific rehab for what was happening, that story is linked here.

More Recently
Finally, a little more than a month ago, as i wrote recently, i got back into my double KB work via Return of the Kettlebell. It was hard to deal with how much ground i'd lost, where i was doing three ladders rather than five; max on left was a 12 for reps not the 16, but there were also some definite wins. It only took about a week of effort to be able to press the 16 on the left again for singles; two weeks to get three reps. That's a far cry from doing three - four sets of five ladders - or 15 reps - but there was progress. All good. I was starting to snatch again - with just the 12 on the left, but it's a start.

And then it happened: on heavy day of the RTK pressing cycle, third ladder in with the 16 on the right, and something felt really not good. As far as i could tell, my form had been ok; i didn't feel anything go, but that was it. And there was pain.

My immediate response was to try some neural dynamic/ mechanic work to get at the nerves that innervate the shoulder and the biceps. The shoulder work was fine; the supraspinatus work, not so much; musculo-cutaneous (biceps nerve) not great.

Emotional Experience More debilitating than Injury?
office kb pile
Perhaps one of the most challenging aspects of an injury is the emotional game: here i was just a month off one injury that happened to unhinge my passion - pressing a 24 - and now my *best* shoulder was hit. It can be challenging to find a way to stay up with one's practice.

Suffice it to say i think that i did not want this right shoulder to unhinge me again. But what to do?  Just lifting the covers off me in the morning was let's say a more sharply wakeful experience than an alarm; trying to reach my head to wash my hair, little own put any pressure on my head was not a good thing either. Big back away signals.

Strategy for come back
So what to do? Use what ya know; test it; refine it.

Over the past year i'd been training for my zhealth master trainer designation (the plaque just came the other day. cool. new wall gets started). Part of that training is a whole lot of anatomy, with a major focus on nerves and spinal sections related to joint movement. Cool stuff to get that something happening in one's neck is manifest in one's fingers, and that working with the source at the neck can affect the peripheral manifestation.

new plaque, functional side of office
Walk the Walk; Eat one's own Dog Food
There are a lot of expressions regarding integrity of practice: does one walk the walk or just talk the talk; does one eat one's own dog food - i.e. the products that one produces for a particular task.

My own injury has given me a chance to explore the techniques i know and the skills i've developed for investigating new (to me) approaches.

Coming Up
So here's a bit of a path i'll discuss in the upcoming posts:
  • looking at the new injury with the findings of the previous one: wrist extensors, brachioradialis and the tendon on the long head of the biceps
  • mapping out some key nerve-joint-breath connexions towards relief.
  • looking at the right shoulder/liver connection
  • exploring end range of motion, terminal flicking and isometrics
  • tuning the lat; locking the pelvis
  • the pleasures of rubber bands, anytime, anywhere: load to learn.
  • the importance of time: time to make an assessment and test and readjust

"I am not young enough to know everything"
attributed to Oscar Wilde

In the coming discussion, i will make no claims that what i've done, what i'm doing in my rehab is great for everyone - or for that matter anyone else. What i will say is that the protocol i've learned with my colleagues going through the Master Trainer progressions is test and reassess everything. We have a lot of tools; they're not total; i've learned a bunch outside that program as well, but the thing i've found has been working for me is this simple concept of test and reassess. Try anything: just have a way to evaluate if it's having an effect, and if that effect is positive.

Principled Hack. Something else i've learned in the process is that there is great value - at least for myself - in having learned something of our fundamental mechanics, but almost even more so, of our fundamental wiring. Knowing something about our inner organisation has given me a more principled way to approach at least to picking a starting point: i think i have a better model about why i might see an effect or not.

At times i'm still stunned by these connections: working with a young gal with arthritis with really high pain and limited range of motion. We tried a drill to work the nerves involved firing the painful muscles; nothing. So we then engaged that spinal segment of where the nerve starts along with the drill, and wow, the range of motion went up; pain went down. I get a little verklempt every time i think of that. It's not an isolated example. What it means tho, is that by having a better model of us - how muscles, joints, nerves, guts connect, that helps me apply the tools i have better. Makes sense, doesn't it? Sounds obvious, but initially i didn't get that as clearly as i have of late able to add these models to practice.

In computing sometimes one might refer to a hack in code as a fast fix for a problem. Hacks are great. They are like the coding equivalent of duck tape. And about as robust. A principled hack  will be something more robust, but no one is claiming that it's the absolute optimal solution to the problem. I guess i feel like i'm a bit further down the road where my approach to what i do is more principled. In many cases it's exactly the same, but perhaps more refined and efficient. Hence this test on myself.

Motivation to Learn: Load is a Great Teacher. One other thing i've found with respect to learning is that there is one thing that will accelerate learning: if one has to teach the material. Anyone who's had to teach at any level will know what it's like to be asked to teach a new course or fill in for a colleague. One has to get up to speed fast.

I'm finding that something else that drives one to learn, to develop new solutions is an injury. Perhaps with my left shoulder learning, the folks i've had the pleasure to work with on their pain/performance, and the fact that i have some great colleagues who are there to draw on for their experience, i have greater confidence to say i'm going to have a go at this myself; i'm going to treat myself as the client and see what i can do.

Progress. So far, i've been surprised (and occaisionally stunned) by the seeming rapidity of the results. It's too early to sign off on this injury: i'm in the middle of rehabbing, and i tell myself well maybe this is a way less intense injury than the left side was etc etc, but so what? i'll take it: it seems to be coming together much faster. I could lift the covers off me this morning without stiffling a yelp, and could almost put full pressure on my head when shampooing. Two days ago, i could not.

Gonzo Healing.
So why talk about this? I learned last night that what i had thought was gonzo journalism - no holds barred, deep risky reporting - was not right at all. Gonzo, it turns out, is more the destruction of the idea of journalistic objectivity; of being willing to put oneself explicitly in the story, rather than try to pretend one is an objective tape recorder.

So let's call this gonzo healing or healing practice: i'm in the middle of a process now; it may all end in tears; it may be great. Either way, it may be interesting to reflect on the process as it's happening.

Thanks for joining the investigation.

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