IF WE compare the simplicity and results of the non-surgical treatment employed in bursitis today with that of twenty years ago, at the dawn of physical therapy, we can say with regard to the latter: “Sibi gratulentur homines talem tantumque humani liberatorem doloris existere.” Even the most clever physician or surgeon did not possess any proper non-surgical method for the cure of bursitis, though such methods were employed. Among the notables surgeons that employed non-surgical methods in those days was Codman. But the methods were very poor, even dangerous and soon abandoned.
In fact, Codman 1Quoted by Brickner: “Subacromial Bursitis,” Med. Recorder., 15, January 2, 1915. himself admitted that his treatment “was a very arduous are for the surgeon and cause a good deal of complaint from the patients.” Brickner, 2Brickner, Walter: “Concerning the Non-Operative Treatment of Subacromial Bursitis,” Amer. Jour. Orthopaedic Surg., vol. 14, No.4, p. 231, April, 1916. discussing Codmans method, says, “he (Codman) seems to have abandoned both the apparatus and the “brisement force of the bursal adhesions- a procedure which is much more uncertain and more dangerous than open operation.”
Other surgeons like the just mentioned Brickner recognized for the relief of pain in bursitis, especially with lime deposit, only one method-operation. “None of my case with lime deposit,” says Brickner, 3Ibid. “has been relieved of pain except those operated upon”.
Today we have definite physical therapy methods for the cure of bursitis. They are, however, wrongly employed by the average practitioner, though he possesses the apparatus. Many pitiful examples corroborating this statement could be cited, but for lack of space, I shall use of an illustration the following case only. A man of thirty-eight, a laborer by occupation, suffered from an acute traumatic subdeltoid bursitis.
His physician, in order to relieve the pain, administered an injection of morphine and applied diathermy to the acutely inflamed shoulder. The patient felt relieved for two hours. The pain then returned with greater severity. The doctor repeated the same treatment. This was done for three days with the result that the pain grew progressively severer with every time the effect of the morphine wore off; and the patient, according to his statement, nearly became insane from the unbearable pain.
In this condition he came under my care. The treatment that I have instituted in this case, with rather rapid results, is the standard treatment which I have employed successfully in my clinics and office for a number of years, probably in 99 cases our of 100.
According to Alexander Monro: “Description of All Bursae Mucosae of the Human Body”, p.8, edited, 1788. (Obtained at the New York Academy of Medicine.) (Professor of Anatomy of University of Edinburgh) there are 140 bursae in the body: thirty-three in each of the upper extremities and thirty-seven in each of the lower extremities. Such a vast number of bursae warrants the necessity of some proper treatment of this structure in disease.
The bursa, however, most often affected is, I believe, the subdeltoid +The subacromial bursa is next in frequency, though in reality it is a part of the subdeltoid one: if the arm is abducted, the bursa is subacromial; when in contact with the side of the body is (or at least a large part of it) is subdeltoid (Codman Quoted by Da Costa: “Modern Surgery,” p. 728, 1915 edition. one, as it was the subdeltoid bursitis that most often came under my care, and was of traumatic etiology. I shall, therefore, refer to it in discussing the treatment which holds good for any other bursitis usually met with in practice and having the same etiology.
Bursitis, just as any other “itis,” has there stages: acute, subacute and chronic. For the appreciation of the methods of treatment employed, I shall refresh out knowledge, when deemed necessary, of the pathologic, physiologic, or biochemic processes that take place in these stages as well as of the physiology and biochemic effects of some of those methods. For it is the considerations of those three staples of medical science (pathology, physiology, and biochemistry) together with years of experience, that form the basis of the treatment discussed in this paper.
Pathology of the First Stage of Bursitis.- In this stage we deal with an acute inflammation, the cardinal symptoms of which, as we all know, are: rubor, tumor, calor, and door. When the bursa is located superficially, the first three symptoms are well noticed. If the inflamed bursa is situated in the deeper tissues, the signs can be detected with difficulty, if at all. The bursa is distended by fluid; thee is hyperemia and edema of the tissues surrounding it, producing pressure upon the neighboring nerve structures. This pressure is, as we know, a factor in the causation of pain. Treatment of the Acute Stage.- This consists of (1) cold applications (home treatment), and (2) galvanization (office treatment).
(1) Cold applications- To realize the importance of these applications in the acute stage, we shall consider the following physiologic process that takes place in that stage. This is increased oxidation which results in heat formation. The latter is responsible for the increased capillary pressure and edema, as shown by Landis and by Drury and Johnes (quoted by Wolf 6 Wolf, H.|: “The Physiological Basis of Wet Dressing,” Arch. Phys. Ther., X-ray, Radium, vol. 16, No.3, p. 153, March, 1935.): Landis has shown that he capillary pressure in the arterial limb in the skin of a finger is normally 32 mm. mercury and 12 mm. in the venous one, and that this pressure rises to 60 mm. and 45 mm. respectively at a temperature of 42 C.
Drury and Johnes found that edema formation is two to five times greater at 42 C. than at 16 C. Macleod points out the relation between edema and capillary pressure, stating that conditions capable of causing increased capillary pressure are likely to cause edema (“Physiology and Biochemistry in Modern Medicine.” p. 120, 4th Edition). We know now that heat brings about such a condition. It follows, therefore, that the application of heat in acute bursitis is logically and scientifically contra-indicated.
Indeed, experience has shown that the patient feels worse from the application of heat. It was also noticed by the writer that the application of heat prolongs the acute stage, while cold applications shorten it and relieve the pain. Nevertheless, some books still advocate the employment of heat in the acute stage especially in such a form as diathermy! “The early local treatment (in acute bursitis) consists of heat, particularly diathermy” (“Principles and Practice Therapy,” V.II, Chap. 6, P.54. 2nd Edition).
The cold applications are carried out in the form of a compress, the technic of which is as follows: two to three folded towels or sixteen layers of gauze are wrung out from ordinary tap water and applied to the shoulder. The compress is held in place by a spica bandage. The patient is instructed to keep it constantly wet and cool by instilling, now and them, some cold water directly into it. (An ice applied upon the compress or directly on the bare shoulder may sometimes to necessary.) The compress is changed daily and kept up for about a week or so. Experience has shown that during this time the patient is greatly relieved of his pain.
The consideration of the physiology of the cold compress will emphasize still more its importance in the acute stage. It causes a decrease in the capillary pressure and in the edema, establishing the proper circulation which is necessary for the relief of pain and repair of the injury. The compress achieves this by reducing oxidation, heat formation and creating an optimum temperature.
Such a temperature according to Starr, should range between 372 – 362 C. This temperature has proven to be so beneficial in inflammatory conditions that Starr has recommended it (and it is being used today successfully As corroborated by wolf (in his article on “The Physiological Basis of Wet DRessings” quoted above) and others.) in the treatment of gangrene of the foot. It is, however, remarkable to note that (as it has been shown) the temperature of the skin under the compress is also about 372 – 362 C.Quoted by Wolf: Ibid. Thus by applying cold compresses in the acute stage, we are bringing about that temperature which is most favorable for then relief of the pain and repair of the injury.
(2) Galvanization.- To explain the mission of this treatment in the acute stage, I shall consider the bio-chemistry of acute inflammations as well as the biochemic effect of galvanization upon the latter. In acute inflammation (as referred to by the author 8Echtman, Joseph: “Indications and Results of Ionization,” Arch. Phys. Ther., X-ray, Radium, vol. 14, pp. 489-491, August, 1933. elsewhere) a disturbance in the normal ratio of the hydrogen ion concentration and the hydroxyl (OH) ions takes place in the body fluids of the inflamed tissues: the hydroxyl ions (OH) increase. This means that the alkalinity rises. Alkali is an irritant, and when present in a relative excess becomes a factor in the causation of pain.
By galvanization we can, according to modern views, influence the restoration of the hydrogen on concentration and OH ions to their normal ratio. In employing galvanization for this purpose in the acute stage, the positive pole is placed at the region of the injury. This pole possesses the property +The positive pole is also a vasoconstrictor, i.e., it lessens hyperemia. This property still more adds value to its employment in the acute stage where hyperemia is always present. of collecting oxygen, from which acid Acid is a sedative, and its presence, too, contributes to the relief of pain. is formed.
The acid, as stated by Neiswenger,9Neiswenger: “Electrotherapeutic Practice,” o.32, 23rd edition, 1925. replaces the excess of the alkalinity, i.e., the excesses of the hydroxyl ions, resulting in the restoration of the normal ratio of the two kinds of ions. Favorable conditions are reestablished for the relief of pain and repair of the injured tissues.
Technic of Galvanization. I suggest that the application of the galvanic current, using just tap water without the addition of any medication, should be termed galvanization. My definition of the latter is: The employment of a galvanic current with the purpose of utilization of the properties of a given pole in diseases. This is distinguished from ionization, the standard definition of which is: Ionization or ionic medication is the introduction of chemical ions into the superficial tissues, for medical purposes, by means of a direct current.
Ionization with mag. sulphate is here preferred to galvanization. The author employs instead of plain water, a solution of 1 per cent mg. sulphate, because this medication takes the positive pole and possesses also a definite affinity for edema, i.e., the mg. ion reduces edema as pointed out by the author elsewhere. 10 Echtman, Joseph: “Infra-red Therapy,” Med. Rec., vol. 1142, p. 82, July 17, 1935.- Prepare and apply a compress to the shoulder as described above in discussing cold applications. Place a sufficiently large piece of blocked tin on the compress, taking care that none of the metal is in contact with the skin.
The compress and the metal constitute the active electrode. Attach the metal to the positive pole of your galvanic apparatus. A similar electrode, larger in size, but soaked in warm water, is attached to the negative pole and applied at the region of the neighboring spine (or the patient may sit on it). The current is opened, a straight galvanic current only being used. Increase the current gradually to the patients tolerance for twenty to thirty or forty-five minutes.
This treatment, which shortens considerably the period of the acute stage, is kept up until the latter is over. (In concluding the discussion of the treatment of the first stage, I wish to mention that aspiration of the fluid of the distended bursa, in addition to or independently of the treatment here described, has been employed by some with good results. The needle is inserted 2 cm. below the level of the acromion process. However, this procedure has been the direct cause of suppuration.).
Pathology of the Second Stage.- Fibrous adhesions are forming in the bursa, nearby tendon sheaths, and between adjacent muscles; the adhesions causing definite mechanical hindrances to abduction and rotation, atrophy of muscles and periarticular fibrosis may be present or forming.
Treatment.- This consists of (1) infrared radiation followed by massage, alternated by (2) ionization with sodium chloride followed by sinusoidalization.
(1) Infrared and massage.- The patients shoulder is exposed to infrared rays + The application of infrared radiation causes occasionally a return of the pain. This indicates that the acute stage is not yet entirely over. Infrared should be discarded and the treatment of the first stage continued for a few more seances. For twenty minutes or one-half hour. This is followed or accompanied by massage and manipulations to the point of causing no pain to the patient.
(2) Ionization with sodium chloride followed by sinu-sodialization.- The sodium chloride on the negative pole, because of its ability to in hence the “lytic” (dissolving) action of that pole, has proven to be one of the best treatments for fibrous adhesions. The sinusoidal current breaks up the latter and serves as a marvelous massage for the muscles that tend to become or are already atrophied. Technic: Prepare and apply the electrodes as for the electrode placed on the shoulder.
Attach this electrode to the negative pole. The galvanic current is brought up gradually to the patients tolerance for twenty minutes to one-half hour. After this treatment the electrodes are left in situ, and the galvanic current is changed to a sinusoidal one with a frequency of twenty interruptions per minute. A very mild voltage is employed at the beginning, increasing it gradually at each seance until a maximum tolerance is reached. The treatment time is started with two minutes and is increased by one minute at each seance until four to five minutes are given.
Diathermy, This treatment causes occasionally a sudden exacerbation, indicating that the subacute stage is still in its early phases. Diathermy is then discarded, and infrared and ionization continued for another week or so. instead of infrared, may be employed towards the termination of the subacute stage. When the latter becomes protracted or chronic (forming Codman type of adherent bursitis ++ Codmans prognosis for recovery is: about two years!) because the patient was not or was improperly treated, the method described in this paragraph is probably the most ideal.
In the writers experience, some patients who started treatments early (on the third or fourth day after the onset of the illness) were cured with twenty or less seances. For instance, in the case above cited, the patient was cured with twelve treatments which he received almost daily. No other treatments, such as aspiration, were used. (He developed “acuphobia” – fear of a needle-due to the morphine injections.) Of course, the number of cases that get well so soon is rather small. The majority go into the third or chronic stage.
Pathology of the Chronic Stage.- This stage has two varieties: the protracted adherent one just considered and another one characterized by the deposit of lime salts, forming the calcified (Subdeltoid) bursitis. It remains for us to discuss the latter. 11Brickner: “American Atlas of Stereorentgenology,” vol. 1, No.2, January, 1916. describes the calcification as follows: It may be as small as a pinhead or so large a as to form a cap over the outer portion of the humerus.
Its shadow as revealed by x- ray may sometimes be obscured by the acromion process. The shadow is not due to thickening of the bursa. It is due to lime salt deposit, but the deposit is not in but beneath the bursa, or in and upon the supraspinatus tendon.” Others, like Montgomery, 12 Montgomery, Albert: “Subdeltoid Bursitis Associated with Deposit of Lime,” J.A.M.A. vol. 66, p. 269, January 12, 1916. state that “The amorphous masses of lime salts were deposited and confined to the upper wall of the bursa.” For our method of treatment the exact location of the deposit is immaterial.
Treatment of Calcified Subdeltoid Bursitis.- The only treatment employed by the writer with uniform success is diathermy applied to the affected shoulder.
Technic.- There are two methods. (1) The antero-posterior and (2) the cap method. In the former, two metal electrodes of equal and sufficient size, say four by four inches or larger are placed at the shoulder joint, one anteriorly and the other posteriorly, and held in place by a bandage. The current is gradually increased to 800 M.A. or the patients tolerance for one-half hour to forty-five minutes. From twenty to forty treatments may be necessary for a cure. The treatments are given daily or three times a week.
The Cap Method.- This consists of a cap-shaped electrode five by five inches or larger. Its concavity is molded so that it conforms to the shoulder curve and is the active electrode. The inactive electrode consists of a large plate ten by twelve inches applied to the opposite side of the body, its upper border being about two inches below the tendon of pectoralis major. From my experience in treating calcified bursitis, I feel that it is safe to say that diathermy is the treatment of choice for this condition.
It is the pleasant treatment that, in the hands of the writer, has seldom, if ever, failed to cure a bursitis associated with lime deposit. The writer believes with many others that the diathermy causes the absorption of that deposit. If x-rays are taken after each series of eight to ten treatments, they will show a gradual diminution of the lime deposit as illustrated by the following case. Mrs. M., aged forty-two, the wife of a New York physician, suffered from a chronic subdeltoid bursitis.
She was treated by her husband for over a year with baking and massage, manipulations, exercise, medications, etc., but without results. Her suffering was so great that during that year she lost twenty-three pounds (her usual weight being 130 pounds).
She was then referred to me. The x-ray of the shoulder taken just before she started treatments in my office revealed the presence of a large deposit of lime. Its shadow resembled a miniature skyscraper. She received forty diathermy treatment, during which roentgenograms were made after each of eight to ten seances. Each time the x-ray showed a diminution of the lime deposit as compared with the last one. The final x-ray plate showed a complete disappearance of the deposit which corresponded with a total disappearance of the symptoms and complete recovery.
Summary.- The three stages of bursitis described by the author coincide with the three types considered by Codman: (1) The acute or spasmodic type. Here-acute pain, local tenderness and Dawbarns sign are always present. In this article it is termed the acute stage. The treatment consists of cold complete and stage. The treatment consists of cold compress and galvanization (or ionization with magnesium sulphate).
(2) Codmans type two is the adherent type which I have discussed under the subacute and chronic stages. The treatment consists of: (a) infrared followed by massage. This is alternated by (b) ionization with sodium chloride followed by sinusoidalization; and, latter (c) diathermy instead of infrared. (3) Codmans third type is, apparently, the calcified bursitis which is fully discussed under the third stage. The treatment is diathermy.