This is a guest post by Bradley Scanes who attended the Shoulder Study Day and has very kindly written this review of the day, and the speakers’ presentations. Thanks Brad!
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The Prof and his team delivered again. Always a great day and always great to see everyone there, and of course talk shoulders. So what were my key take home points
1. Research is not all it seems. Take care.
I’ll start with this point as once again Chris Blunt completely blew my mind with his talk and brings up many more questions about physiotherapy and medical research than we are perhaps comfortable with. The CSAWtrial and the FIMPACTstudy were in spotlight from both Chris and the Prof with some really interesting points. We physios were rather quick to jump on the bandwagon that these trials were a nail in coffin for subacromial decompressions (SAD), but are they when RCTs are, in the words of Chris Blunt, “a shoddy way to do medical research”.
Some food for thought on the CSAW trial:
- 3 months of physio and a steroid injection didn’t help the 313 patients admitted to the study
- Small and large partial thickness tears were ignored in the 313 patients in the study
- Across 32 hospitals, was advice and post op physio at the same level? Was patients compliance without rehab programme monitored. Was it also enough? 1-4 sessions was reported.
- CSAW trial power calculations indicated that they needed 100 per group and they ended up with 72, 65 and 64 which may lead us to say it’s an underpowered study and could potentially be ignored.
- Confidence intervals at 12 months for SAD versus diagnostic arthroscopy were from -1.9 to 5.1, so some were worse, some had significant improvements…conclusions…?
Similarly in the FIMPACT study:
- They needed 70 in each arm to be 90% confident of effect, and they only had 59. Again an underpowered study and suggestive that the found outcome was probably likely
- 14 in the physio arm also went on to have SAD further diluting the power
So who has the better RCT, or who has the most data? This study(amongst a few others) found SAD better than physio….The answer, I don’t know, and not being a researcher some of this stuff travels way over my head. From a clinical perspective it is important to take each person coming into your care as exactly that….and individual person, and take a multi-disciplinary approach to help them achieve the very best possible outcomes for them. We know from our own practice that some people do need to be escalated on, and that good surgery with good and appropriate dosing of physiotherapy after works. Let’s not clear out something that may help some people just yet.
2. Context is key
We do not know what normal is. Or abnormal for that matter. And things change all the time. Adam Meakins produced a ton of research during his excellent talk, to show how scapulohumeral ratio changes depending on a number of different things: age, gender, what your dominant hand is, what plane of movement you are moving through, whether you are moving both arms or one, what speed you move at, the load you are moving, the sports you have played, whether you are fatigued or fresh and whether you are in pain. All of these change how the scapula moves, and we simply can not say that this is how scapula movement should or should not look like.
We also can’t agree on what increases the sub-acromial space with this study showing that an anterior tilt does, and this study showing that downward rotation neither does nor doesn’t. Contrary to the popular viewpoint that posteriorly tilting and upwardly rotating your scapula helps. Again we don’t know, and again it’s likely that in some people it might matter, but it is probably pretty low down on our list of priorities once we have tackled load management, lifestyle factors, strength.
This theme was also brought up by the once again excellent Jo Gibson talking about shoulder instability and the running late but great Ash James in his talk about communication. Which is key, as there is always a story behind the person, and it’s your job, through our methods of communication, whether that be motivational interviewing or otherwise, is to facilitate that person to tell their story and take control of the narrative.
3. Treat the person not the pathology
But don’t forget structural problems! As Jo took us through a couple of cases where instability patients were considered ‘hypermobile’ but actually had had a traumatic incidence to begin with, so taking a good detailed history is really important.
The person is key however and focussing on the whole system important. Even coming back to the bio side we very often make presumptions that the system is weak, but sometimes it is the muscles working too hard. We need to consider muscle recruitment, stability versus mobility, proprioception and movement error and the scapula. Then moving into the more psychosocial part of our model, a really interesting point Jo brought up was that a lot seems centred in a patients emotive centre rather than via cortico-spinal regulation which is really interesting and could have major implications when planning rehabilitation.
Some key papers that came out of Jo’s talk, the BESS / BOA consensus on atruamtic instability, if you are treating shoulders you should have read this, and for the rehab, Bateman’s Derby shoulder instability programme is really nice.
“Treating the person not the pathology” was a key theme throughout the rest of the talks as well. Ash brought it back to self-determination theory and how we need to structure around autonomy, competence and relatedness but remembering that we need to act as a communication bridge and not to follow our traditional rooted righting-reflex.
We might know what the patient needs to do, but they need to be the ones to get there, and a nice way to facilitate that is via our motivational interviewing / talking skills, of which I write about here. Ash used the nice example of myth busting early on can lose a patient straight away, and I know we have all been guilty of that….so validation not invalidation….”Physios should be more Alfred and less Batman”
Once we are on our way, the focus can then switch to building resilience, and the things we can effect is nicely demonstrated in the slide below.
This was further validated by Doug Tannahill’s holistic outlook and some key pillars to consider; Activity, recovery, mindset, nutrition and bringing it all together but in a sensible way. Again we might know what a person needs to do….yes they need to exercise more, yes they need to drink less and eat better, yes they need to sleep more, but what small things can we facilitate the patient to change to get small wins each time. Leo Babauta suggests that when trying to instil habits, if you go for three daily habits a person is only 10% likely to do them, if you go for one, 85% likely.
4. We need to take our patients or athletes far enough
This has always been a hot topic for me. I never feel that with many physios prescribing stretches, and banded exercises that we sometimes fail to get a patient back to an appropriate level. And that doesn’t just mean out of pain but strong enough to complete everything they want to do again without any worry. And that starts with Nick Grantham’s very first point of the day about knowing your athlete and the constraints of the sport you are working in, or simply the activity or work task they need to do. Ben Ashworth followed this up with a great line also; Prepare your athlete or patient for the chaos of their sport or life. I have also heard “prepare for the worst case scenario” before as well, and this means that we need to plan back from what an individual wants to do and build a rehab programme specific to them based on that. For example a football goalkeeper close to returning following a shoulder dislocation needs to be doing controlled landing on that shoulder before introducing external factors to reduce that control (This is a good read).
So how might this look in clinic. It starts with the objective assessment and ensuring we take someone far enough in that or as Ben put it, get as close to function as possible when testing. It is definitely not enough just to test isometric strength in the mid range, and some of the excellent work Ben is producing now is giving us ideas of how we can improve our assessment and put some values on it. He discussed using isometric hold tests or repetition max tests as good clinic assessment tools.
Then comes the rehab, which needs to be well planned with an end outcome in sight. If you can, a nice tip from Nick is to try to connect this outcome to the rehab or exercises you prescribe. Provide pictures or videos of the athlete or the movement occurring in the sport or activity.
Rehab in fatigue has been a hot topic before as well and Ben in closing the day off with the excellent data he is producing, showed us some really nice stuff that the medical team at Saracens have produced showing reduced strength in the ASH test (not named after him :)) post rugby smash. Some of the other data also suggests that rate of force production maybe an important issue, beyond when an individuals strength has fully returned, therefore we also need to be mindful of retraining speed, power and reactive stiffness too.
There is certainly the scope for being better though, and the CSAW trial highlights our deficits as well as surgeries, in that 313 patients failed physio. This brings me to my final point and a quote from this paperbrought to us by Nick; “Unimodal rehab interventions and generic prescriptions based solely on evidence based medicine are unlikely to be optimal in rehab” which sums up that not one side fits all.
5. It takes time!
This was another theme throughout the day reiterated by just about everyone. It brought about a nice discussion between speakers and delegates and a loose consensus was drawn out that. 12-16 weeks and a patient should be improving but it can take longer. It is important to recognise those that are not progressing and stop flogging a dead horse as it were. So if symptoms are not improving or they deteriorate then escalate and have those conversations involving the patient, the physio and the surgeon. If they are not progressing at all in the first 4-6 weeks then this is a good time to escalate as well.
Discuss this with the patient from the first session. A lot of what we do is centred on expectations, and we should be making these plans with the patient from day 1…and plans can change, treatment is ongoing and is not a one time consideration; those that may be appropriate for physio or surgery one time may not be at another.
And on that note I have already gone well over what I was aiming for. Hopefully I got all the key points from everyone, once again thank you to Tony, Ashu and the great team they have for organising such a good event once again, a cracking line up which will be one to top next year. I’ll leave you with one of Alfred from Batman Forever, “broken wings mend in time” ….but I wonder if they get strong again!