The Frozen Shoulder
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Transcript of The Frozen Shoulder
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The Frozen Shoulder (Adhesive
Capsulitis)
This condition has traditionally been considered a medical
enigma! It is considered to be the worst of all shoulder
problems and is often the end-point of other problems. It is
also, unfortunately a waste can diagnosis, often madeincorrectly.
Frozen shoulder syndrome is a very painful and debilitating
condition of the shoulder characterized by pain and severe
stiffness. It is a clinical diagnosis and is only very rarely the
result of an underlying disease. Fortunately (and curiously)
once cured it (almost) never comes back on the same
shoulder. It often comes on for seemingly no reason at all
(primary) but may follow a trauma or shoulder surgery (also
following breast re-construction.)
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Frozen Shoulder Facts:
y 2-5% of the population.
y
It is more common in women (60%)y It is at least five times more common in diabetics
y It is slightly more common in patients with Dupytrens
contracture
and shares some of the same pathology
y It may have a genetic component i.e./ it can run in the family
y It may well have an hyper responsive auto-immune
component
y It seems to affect 40-70 year olds (in Japan it is known as
50s shoulder)
y About 15% of people get it on both sides
How long does it last for?
Symptoms lasts an average of thirty months (some say
longer)
There are four phases to frozen shoulder, (which lasts an
average of 30 months).
Pre-Freezing (0-1 week)
Freezing (1 - 8 months)
Frozen (9 - 16 months)Thawing (12 - 40 months)
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What is happening inside my frozen
shoulder?
Inflammation
In a Frozen ShoulderSyndrome the lax capsular
sack becomes sticky and can sometimes though not always
form adhesions; hence the name of the condition. The
stickiness is brought on through inflammation; research has
pinpointed the source of this is in the rotator interval, in our
experience this inflammation often starts in the groove
behind the biceps tendon. (This can occur after a small
injury, like reaching for the back seat of the car but often you
may not remember anything). Once established this
inflammation spreads into other shoulder soft-tissues and
can cause swelling in other shoulder sacks (bursae). This isbecause the muscles, ligaments and bursae within the
shoulder are very much interconnected.
Stiffness
The stiffness is due to an overreaction of the body to the
inflammation (within the rotator interval/biceps groove). The
body then seems to switch off muscles in a co-ordinated
sequence; this sequence is the same for everyone and we
call it the capsular pattern. In less than a week the arm
movements start to diminish, and within a few weeks the
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arm literally becomes frozen and for many, can not be
raised more than 40 in any direction. The muscles of the
rotator cuff become weak and start slowly to waste away,
leaving the arm to hang stiff and immobile.
Treatment for the frozen shoulder
Until now the current orthodox and alternative medical
approaches to treatment have not proven to reduce theduration of symptoms or reliably improve the range of
motion. Several treatment options exist but they are very
much hit and miss. The good news is that Frozen Shoulder
syndrome can be treated simply and effectively byThe Niel-
Asher technique. This unique hands-on, drug-free
approach is evidence based and works with the body to help
dramatically speed up recovery, even in very severe cases.
It has been shown by independent research to significantly
reduce the duration of symptoms, reduce pain and
significantly improve strength and power above and beyond
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traditional physical therapy. This technique is now being
used successfully by therapists all over the world, a list of
these can be found here.
The Niel-Asher technique works by reducing
inflammation in and around the shoulder capsule and
tendons and then re-programming the muscles which have
switched off click here for more information. You can even
start working on it yourself from home with our self help
products. Better still, all of our excellent and highly qualified
Practitioners have an excellent knowledge of the various
types of Frozen Shoulder syndrome and how to treat it.
Conventional approaches to treating the frozen
shoulder and the evidence for them:
y
Non-Steroidalanti-inf
lammatory medications these are
mainly ineffective. This type of medicine is good for reducing
acute pain and swelling but because frozen shoulders are
full of chronic inflammation NSAIDs rarely improve things.
y Oral Steroids Short courses of high doses of intravenous
steroids (500mgs of prednisolone IV for three consecutive
days) appear to improve the pain relief. A three week course
of 30mgs prednisolone daily has shown significant short
term benefit in adhesive capsulitis, but the benefits did not
persist beyond 6 weeks(Buchbinder R. Ann Rheum Dis
2004;63:11:1460-9). It must also be remembered that Oral
steroids can have significant and unwanted side-effects.
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y Streroid injections Your GP may initiate a course (up to
3) of hydrocortisone injections into the shoulder, these can
take away some of the acute pain but the effect seems to be
short-term and they are rarely useful on their own. (Bal A etal. Effectiveness of corticosteroid injection in adhesive
capsulitis. Clinical Rehabilitation 2008;22:6:503-12). They
also may have serious unwanted side effects such as facial
flushing and changes in sugar metabolism (especially in
diabetics).
y Hydrop
lasty
involveing distention of the glenohumeraljoint with an injection of 10mgs of combined bupivacaine
(Marcaine), lidocaine (Xylocaine) and corticosteroid followed
by injection of 30mls of chilled sterile normal saline (Callinan
N. J Hand Ther 2003;16:3:219-24). This is a surgical
procedure and s not risk free it is more effective when
combined with physical therapy and may also need to be
repeated.y Hydrodilatation involves inflating the capsule with
between 10 and 50mls of saline. Has shown to be
significantly better than manipulation under anaesthesia at 6
monts (p
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y A combination ofAcupuncture and physical therapy may
lead to a better outcome than using one method alone (Ma
T. Am J Chin Med 2006;34:5:759-75).
y Physical Therapy is of little or no use during the freezingor frozen phases but may help speed up recovery during the
thawing phase. (Vermeulen H. Phys Ther 2006;86:3:355-
68). Patients may have well over a dozen physical therapy
sessions and modalities include ultrasound, mobilization
and exercise regimens.
y
Transcutaneous electrica
lnerve stimu
lation(TENS) machines are also commonly used to alleviate night
pain.
y Manipulation under anaesthesia (MUA) followed by
several months of intensive physical therapy, or if severe,
more invasive surgery. Manipulation under anaesthesia
does not add effectiveness to exercise program with only a
small difference in the range of movement in favour of themanipulation group (Kivimaki J. J Shoulder Elbow Surg
2007;16:6:722-6). The risks associated with MUA include
fracture of the humerus, tendon rupture and brachial plexus
injury and the risks associated with anaesthesia.
y A series of three indirect bupivacaine supra scapula
nerve bl
ocks has been shown to be effective in reducingthe pain from frozen shoulder within one month (64% Vs
13%) in the control group (Daha TH. J Rheumatol
2000;27:6:1464-9).
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Other type of shoulder problems:*
Rotator Cuff Tendinopathy & the
Supraspinatus
The rotator cuff is made of four muscles
Supraspinatus, Infraspinatus, Subscapularis and Teres
Minor (see Anatomy). These muscles join together and
blend to form a muscular cuff at the top and back of the arm.
The job of the rotator cuff is to stabilize the ball and socket
joint of the shoulder pulling it down and back and holding it
into position; this affords a stable base for us to use the
arms and hands in manipulating our environment.
The cuff is vulnerable for a number of reasons, especially if
you have got a round-shouldered posture. Muscles of thecuff are prone to ware and tear (peri-arthritis) and the
tendons can be trapped and damaged (usually under the tip
of the acromion), sometimes leading to actual tears and
sometimes ruptures. The most common of the cuff muscles
to be injured is the Supraspinatus. This is because it sits on
top of the shoulder blade and its tendon drops down onto
the upper outside of the arm at an angle. The tendon can
get rubbed and inflamed, also variations in the under
surface of the arch of the shoulder blade (such as
osteophytes) can dig into it and sometimes cause tares in
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the tendon. Another common problem for the Supraspinatus
is that the muscle itself is vulnerable to ware and tear.
During the day, the weight of the arm shuts off the blood
supply to the muscle and at night, when the arm is off-stretch any damage that has occurred is repaired. This
leads to low grade aching and night pain. The area of the
muscle most vulnerable to damage (other than the tendon)
is in the middle of the belly. Damage and repair to this area
can cause a series of repetitive micro-bleeds which when
repaired leave behind calcium (chalk) deposits. These chalkdeposits can cause a wide range of low-grade problems
such as aching and pain and occasionally/rarely the chalk
can form a boil within the muscle which can burst causing
agony. There are two types of chalk soft and hard, and
depending on which one you have, there is a different
treatment plan.
Because of the inter-related nature of the rotator cuff
muscles injury in one can lead to changes, compensation
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and eventually failure in the others. The tendons blend
together to form a joint conjoined tendon.
The terminology for rotator cuff injuries can be a bitcomplex. We talk of partial tears, full thickness tears and
ruptures. This terminology refers to the scenario when one
of the individual tendons tears off from the bone and retracts
but the others in the conjoined tendon remain intact.
Unfortunately there is a scenario where the tears
progressively work their way through all of the tendons until
the whole cuff ruptures.
It is essential that a proper diagnosis is made to see which
of the cuff muscles is damaged and, if possible what is the
underlying cause for this damage. In most cases there is an
element of poor posture and/or occupational or sports
trauma. Often the mechanics of the shoulder can beimproved by conservative management. The good news is
that many of the most common Rotator Cuff problems can
be treated by a combination of The Niel-Asher
technique and simple exercises. All of our excellent and
highly qualified Practitioners have a good knowledge of
Rotator cuff problems and how to treat them.
Signs and Symptoms of Rotator Cuff
Tendinopathy
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y Night pain sometime relieved by side-lying on the same
side
y Weakness on certain movements especially lifting and
rotating the army Catching pain on certain movements
y Able to lift the arm with the other one
y Pain on certain movements on the rear outside of the arm
Treatment
y NSAIDs Anti-inflammatory medication can be useful forreducing the acute swelling around an injured tendon.
These are, however, rarely useful as a long-term treatment
for cuff injuries.
y Steroid injection this involves injected a cortico-steroid
+/- anesthetic into one of the inflamed rotator cuff tendons.
The technique is most effective when performed under
guided ultrasound (Ekeberg et al BMJ Vol 338 Jan 2009
p 273).Studies have shown this approach to very be useful
for reducing the acute swelling around swollen tendons
and/or bursae. There are, however, side effects and
injections are rarely useful on their own as a long-term
treatment for cuff injuries.
y Physiotherapy Several studies have shown that specificexercises which target the cuff muscles may be as effective
as surgery These exercises are incorporated into the
training programme for all Niel-Asher
technique practitioners.
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y Surgery Several types of surgical procedures have been
used to treat rotator cuff pathologies. Results vary for many
reasons, including. The health of the underlying tissues pre-
surgery, the age and health of the patient, occupation,activity/sport, post operative rehabilitation programme - to
name but a few. Some authorities report that up to 70% of
cuff repairs go on to fail again!
The two most common operations are:
y Decompression This is the procedure used if the tendondamage is due to arthritic changes on the under surface of
the acromion or due to their being insufficient space for the
tendons to run through. It is usually performed by key-hole
(arthroscopy) as an out-patient procedure. An electric burr
drill is used to remove (abride) up to 1cm of the acromion
bone thus creating more space for the tendons to runthrough. It is sometimes accompanied by steroid injections
and usually by several sessions of post operative physical
therapy. Results of this operation vary dramatically; it does
risk complications (including a frozen shoulder).
y Surgical Repair This operation is used to re-attach the
two part of a torn tendon either to each other, to a bone or
both; most commonly the Supraspinatus tendon. Thisoperation can be peformed by key hole (arthroscopy) or by
open surgery. It is often performed with a decompression
Advice
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y We strongly advise icing the area morning and evening. For
more information click here.
y To help reduce the swelling around the shoulder tendons we
advise you use non invasive natural anti-inflammatorymedication.
y We are not saying there is not a place for surgery as it can
be effective but our practitioners are trained to offer
alternatives. The Niel-Asher technique offers a non-
operative decompression programme which, along with
specific exercises can be highly effective in pain reduction,increased mobility and long-term relief.
Biceps tendinopathy (long head)
The biceps tendon (long head) is vulnerable to injury in
certain positions especially under its retaining transverse
ligament. Because of its unique anatomical strain it can
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sometimes tear, rupture and/or slip out of its ligamentous
fixation. Furthermore the biceps tendon often acts
(incorrectly) as a stabilizer in a range of shoulder problems
to prevent external rotation.
Symptoms include
y Sharp spasms of pain
y Pain reaching for the back pocket
y Pain reaching for a seatbelt
y Night pain - localized
An inflamed (long head) Biceps is often very involved in
many shoulder problems such as a frozen shoulder, so it is
important to get it treated. The biceps tendon lies in a
groove running up the humerus bone of the shoulder.
Advice
y We strongly advise icing the area morning and evening. For
more information click here.
y To help reduce the swelling around the shoulder tendons we
advise you use non invasive natural anti-inflammatory
medication.
y This problem responds well to The Niel-Asher technique.
y Other treatment options include physical therapy, steroid
injections (up to 3) and or surgery - if severe.
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Arthritis of the gleno-humeral (ball and
socket) joint
Recent medical research suggests that it is NOT just bones
that can get arthritis, but muscles and tendons too this is
known as Peri (or soft tissue) Arthritis and results from
injury, aging, posture, occupation, sports and ware and tear.
Osteoarthritis is a progressive weakening of the smoothjoint cartilage that is designed to allow the joint to move
fluidly. The smooth joint surfaces of the ball and socket joint
begin to become rusty. Most of the time the cause is not
known, but overuse and injuries can lead to the
development of osteoarthritis over time.
Although this condition is more common in other joints
(especially the knees and hands), shoulders can become
affected by osteoarthritis.
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Although we can not cure arthritis, the good news is that the
pain and mobility can be helped a great deal by a
combination of The Niel-Asher technique and simple
exercises. All of our excellent and highly
qualified Practitioners have a good knowledge of arthritis
and how to treat it.
Symptoms include
y Stiff shoulder (may appear like a frozen shoulder)
y Painful shoulder related to movement
y Clicking, crunching or clonking sounds on movement
y Loss of shoulder movement
y (Not usually painful at night)
y Clearly identified on x-ray
Treatment
y Conservative treatment include medication - pain
relieving and anti-inflammatory, physical therapy and
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exercise. Sometimes steroid injections and or artificial joint
fluid (synavistin) asre used.
y Surgical options include full shoulder replacement
(Arthroplasty) or partial shoulder replacement (Hemi-arthrotomy) and sometimes replacing the ball joint at the top
of the arm (humerus) with a larger artificial ball. Depending
on the state of the joint other operations may be performed
at the same time such as a decompression.
y The Niel-Asher technique - Although we can not cure
arthritis, the good news is that the pain and mobility can behelped a great deal by a combination of The Niel-Asher
technique and simple exercises. All of our excellent and
highly qualified Practitioners have a good knowledge of
arthritis and how to treat it.
Arthritis of the acromio-clavicular joint
Symptoms include
y Catching pain at the tip of the shoulder
y Painful shoulder related to specific over head movements
y Painful clicking, crunching or clonking sounds on movement
y Pain may radiate to the back of the thumbt
y Reduction in certain shoulder movements (such as reaching
behind the back)
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y (Not usually painful at night)
y Can be identified on x-ray
Advice
y Steroid injection up to 3 injections may be performed
directly into the joint these are best performed guided
under x-ray or ultrasound they rarely provide more than
symptomatic relief
y Physical therapy usually with prescribed x-rays
y The Niel-Asher technique- Although we can not curearthritis, the good news is that the pain and mobility can be
helped a great deal by a combination of The Niel-Asher
technique and simple exercises. All of our excellent and
highly qualified Practitioners have a good knowledge of
arthritis and how to treat it.
Bursitis
The body has many folded bursae throughout. These fluid
filled structures are designed to stop tendons rubbing on
muscles or bones. Under certain circumstances these canbecome inflamed and swollen and this inflammation can
linger on and on this is called chronic inflammation. Once
this type of inflammation has occurred it generally requires
treatment of some kind.
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Advice
y We strongly advise icing the area morning and evening. For
more information click here.
y To help reduce the swelling around the shoulder tendons we
advise you use non invasive natural anti-inflammatory
medication.
Treatment options include
y Medication including steroidal or non steroidal - anti-
inflammatory. These may have unwanted side effects.
y Steroid injection it is not uncommon to have up to 5
steroid injections for this problem. These may improve the
situation but often provide only short term relief they are
best performed in combination with physical therapy (and/orthe.)
y The Niel-Asher technique- Although we can not cure
arthritis, the good news is that the pain and mobility can be
helped a great deal by a combination of The Niel-Asher
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technique and simple exercises. All of our excellent and
highly qualified Practitioners have a good knowledge of
arthritis and how to treat it.
y Acupuncture
Dislocation
The shoulder is designed for mobility and allows a largerange of movement, this freedom of motion is however at
the expense of stability. The shoulder is vulnerable in
certain ranges of motion and the ball can sometimes slip
out of the socket. The shoulder can dislocate anteriorly
(forward), posteriorly (backward) and superiorly (upward).
Unfortunately once you have had one or two bad
dislocations the there is often irrevocable damage of thetissues inside the ball and socket joint and the shoulder will
require surgery. A truly dislocated shoulder often needs to
be put back in by a doctor at the A & E department.
Some people are born with anomalies within the joint which
makes dislocation more likely, they can pop them in and outas a party trick. Also the socket joint of the shoulder has a
small cartilaginous cup which holds the ball in place which
can be too short and stubby leading to dislocation.
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Some people dont fully dislocate the shoulder but instead,
sublux their shoulders in what we call a-traumatic
dislocation. This type of dislocation often pops itself back in
spontaneously. If the dislocation has occurred more thanonce, there is a strong chance of some permanent internal
damage and stabilizing surgery is to be advised.
Although we can not promise to cure subluxation, the
unique sequence of manipulations performed in The Niel-
Asher technique have been shown to increase
the strength and power of the shoulder muscles. The
technique is especially effective as part of a post-operative
regime.
Symptoms of dislocation
y
Pain
can be very severey Complete or partial loss of function
y Weakness
Treatment
y If you suspect a dislocation go straight to the emergency
room
Painful arc/impingement
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This condition is easily confused with a frozen shoulder as
there are similarities; however, they are very different
problems. Painful arc describes the symptom of pain, when
the arm is lifted up to shoulder level and then has a severe
crippling spasm of pain. The pain causes immediate
weakness and the arm often feels like it needs to be
dropped by the side. The MAJOR difference between this
and a frozen shoulder is that the arm can actually be raised
all the way up once it goes through the painful arc. In afrozen shoulder the stiffness is there in all directions even
when someone else tries to lift the arm. The pain is usually
caused by inflamed tendons being pinched between the
narrow top of the ball and the under surface of the collar
bone. This is usually the supraspinatus tendon but bursitis,
arthritis of the acromioclavicular joint and/or several other
problems may present as impingement.
Symptoms
y Crippling pain as the arm is raised to shoulder level
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y Pain diminishes as push through this point
y Full range of motion
y Night pain especially lying on the same side
y Aching after the pain has goney Bursitis
Treatment
y NSAIDs Anti-inflammatory medication can be useful for
reducing the acute swelling around an injured tendon.
These are, however, rarely useful as a long-term treatment.y Steroid injection this involves injected a cortico-steroid
+/- anesthetic into one of the inflamed rotator cuff tendons.
The technique is most effective when performed under
guided ultrasound (Ekeberg et al BMJ Vol 338 Jan 2009
p 273).Studies have shown this approach to very be useful
for reducing the acute swelling around swollen tendons
and/or bursae. There are, however, side effects and
injections are rarely useful on their own as a long-term
treatment for cuff injuries.
y PhysiotherapySeveral studies have shown that specific
exercises which target the cuff muscles may be as effective
as surgery These exercises are incorporated into the
training programme for all Niel-Asher techniquepractitioners.
y The Niel-Asher technique- employs a range of
manouvres to sooth and relieve impingement long term
our practitioners look at the relationships between muscles
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which are not working properly and can offer you an
alternative non-surgical hands-on only decompression
technique which is highly effective.
y Surgery Several types of surgical procedures have beenused to treat rotator cuff pathologies. Results vary for many
reasons, including. The health of the underlying tissues pre-
surgery, the age and health of the patient, occupation,
activity/sport, post operative rehabilitation programme - to
name but a few. Some authorities report that up to 70% of
cuff repairs go on to failagain!
The two most common operations are:
y Decompression This is the procedure used if the tendon
damage is due to arthritic changes on the under surface of
the acromion or due to their being insufficient space for the
tendons to run through. It is usually performed by key-hole(arthroscopy) as an out-patient procedure. An electric burr
drill is used to remove (abride) up to 1cm of the acromion
bone thus creating more space for the tendons to run
through. It is sometimes accompanied by steroid injections
and usually by several sessions of post operative physical
therapy. Results of this operation vary dramatically; it does
risk complications (including a frozen shoulder).
For more information about a range of other shoulder
problems, I suggest you visit my colleagues
atwww.shoulderdoc.co.uk
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Reflex Sympathetic Dystrophy (RSD) or CRPS I
Whats that?
Severe cases of Frozen ShoulderSyndrome can be
associated with Reflex Sympathetic Dystrophy; now also
called complex regional pain syndrome I (CRPS I). This can
be a serious and unwelcome complication or it may precede
the Frozen Shoulder. It can come on after fracturing the
shoulder and or splinting it. It is also associated with
shoulder surgery (including manipulation under
anaesthetic).
Mostly on the affected side, the massive inflammation in a
Freezing Shoulder can spread to a nerve bundle at the
base of the neck that regulates blood flow to the wrist and
hand. This causes a host of more unwelcome symptoms in
the hands and fingers:
y We strongly advise icing the area morning and evening.
This couldnt be easier with our state of the art icepack. For
more information click here.
y To help reduce the swelling around the shoulder tendons we
advise you use non invasive natural anti-inflammatory
medication.
Key features of RSD
Hands
y white-blue or reddish, cold, numb, stiff, swollen fingers
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y painful & swollen knuckle joints
Other
y increased sweating and odour
y strange odour from arm pit
y severe cramping in shoulder, elbow, wrist, hand
The RSD associated with frozen shoulder syndrome can be
effectively addressed with The Niel-Asher Technique; it
usually improves in tandem with the shoulder, but the longerit has been there, the longer it takes to get better. If you
think you have RSD you really should consult your doctor
and or a qualified Niel-Asher Technique practitioner (for a
list of practitioners click here).
Advice
y Seek conventional medical advice
y The Niel-Asher Technique
y Squeezing a squash ball for 5 minutes 10 times per day
y Putty and hand home exercise products
y Ginko Biloba
y Ruta Gravis & Rhus Tox
y MSM
y Specialized deodorants