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Shoulder Study Day 2017

I do love a shoulder….so big thanks to Prof Tony Kochar for the invite to this very good Shoulder Study Day. A great line up, which I hope I can do justice, and a great setting on the 18th floor of the Shard, and you can always tell a good study day by the quality of their food and drink and I can say they did alright :). A nod to Prof Kochar, great guy and a top consultant too. I say consultant rather than surgeon as I love his take on the non-invasive options and the view that the majority of shoulder and upper limb patients do NOT need surgery. A great multidisciplinary approach and and a pleasure to work with.

So to the conference itself. I got to meet a few more twitter friends which was excellent, getting used to this introducing myself as @bscanes from twitter. First of which was Rob Madden, again lovely chap and it was he who took centre stage first. His focus was on Taping, and whether that has a role to play in shoulder pain. All biases aside (I see he has a hand in a taping company ;)) it was a very measured and reasoned approach which aligned with my current views. There was none of the bullshit other courses feed you in that you have to tension 67.5% here and 36.2% there for it to be effective! Everything was based on his very good assessment which followed Jeremy Lewis’ shoulder modification process (here). He did have the unfortunate task of trying to tape a patient with a clear multidirectional instability who to Rob’s credit admitted she was not a patient he would normally tape which limited the live demo effect but gave a good example of tapings limitations also. The only thing you may have done taping wise was a rigid taping to lift and offload if she had pain at rest. What she really needed was some good supported cuff and weight-bearing / four-point kneeling work.

In summary, tape for a short period if it reduces a patient’s symptoms and allows them to do the important stuff (rehab). Be ultra-careful with your LANGUAGE, avoid reliance, challenge patients / athletes as to why if they feel reliance, and discourage use of tape in favour of resilience. I think it is always a good idea to lay out a weaning programme with a patient at the initial stages if you are to use tape. so that expectations are managed.

An interesting point that did come from the patient demo is how many physio’s can view a patient differently. It’s amazing how approaches vary and I’m sure by some way or another they would all improve the patients symptoms. What it did get me thinking about though (as did Jo Gibson’s presentations) is that we need to be able to switch between approaches and be guided by the patient. We all have our biases but if that fails with a patient we need to recognise this early and have the flexibility to adapt.

Next up was Dr Gajan Rajeswaran on musculoskeletal imaging. The favoured modality to image the shoulder is an ultrasound scan. CT’s are avoided if they can be as around the shoulder area it is the equivalent exposure of 200 x-ray’s! Crazy. We touched on injection therapy and a patient of the Prof’s was brought up who had had 7 corticosteroid injections! (elsewhere) At the same time the definition of insanity was also brought up. If it hasn’t had an effect at 1-2 injections then stop injecting. We also don’t know exactly the effects that it has on tissue (this blog is a good thinking point) so less is more…physio first!

Dr Mike Loosemoore then took us through a case study of a boxer working towards championships for Olympic qualification. The key message was timing. You have to work with the athlete and the whole multidisciplinary team to programme a timeline for surgery, rehabilitation, training and competition. Stuff that is transferrable and important not just in sport but also in the general population with work and events etc. and stuff we don’t really get taught in uni so if anyone gets the chance to learn in a sports environment, grab it with both hands, there is a lot we can learn and apply in a general clinic setting.

Then was my favourite talk. Jo Gibson aka @ShoulderGeek1. My favourite because it got me thinking about my bias and how some of my patients would benefit from stepping away from this. My bias is the cuff, and the strength in the cuff in all ranges and all levels of difficulty. However Jo took a great kinetic chain approach and suggested we also need to take a focus on the contribution of the lower quadrant and trunk towards force production. She presented some research (herehere and here) showing a relationship between hip abduction strength, fatigue of extensors and abductors and hip range of movement can all contribute to increasing the risk of shoulder injury, SLAP lesions by 4-5 times over the course of a season and affect throwing mechanics, creating increased rotation through a greater moment. When sore, patients often overestimateate force production making there movement strategy throughout the chain inefficient. A focus on the lower limb and trunk can increase capacity and optimise load (referencereference).

It all makes sense! Patients do need strength, and I won’t move away from my bias just yet, but when we think about how movement is organised in the motor cortex it is organised functionally and not anatomically. So we can change strength but this may not transfer into changes in motor cortex skill. Now I always introduce task and sport specific based rehab as we reach the end stages of our rehab programme but Jo suggested that this can be utilised much earlier in the programme and by using the kinetic chain to initiate movement it can be more specific to the cuff by achieving better recruitment. I can certainly picture a few patients that may have benefitted from this approach. Patients also find it easier with the lower quadrant added in….so time to add some squats, step ups and lunges. This can be particularly relevant in the athletic population as often athletes do great strength and conditioning and we need to think proprioception, switching on and fatigue and there are a couple of good objective measures to have a look at

Upper Quadrant Y-Balance Test

Closed Kinetic Chain Stability Test

Jo finished off nicely with a nod to the bigger picture. Patients main prognostic factors fall within the psycho-social domain, empathy
and expectations are key, it isn’t always what you know. Motivational interviewing got a lot of mentions and that gives me a chance to plug my article ‘Motivational interviewing: a way of talking’ and one question I loved was ‘Do you think physiotherapy can help you?’.

A great talk, thanks Jo.

Next up was Suzanne Gard who has done loads of great work on shoulder rehab took us through instability and rehab for that. I loved her suggestion of a fear of re-injury questionnaire for shoulder similar to the ACL-RSI (referenceapp) we have for knees post ACL rupture. There was another nice outcome measure discussed – The Rowe Score (reference) which has been shown to correlate with the shoulder apprehension test.

  

There was a overall message of us needing to do a better job of making it relevant for patients and we can do this by using an external focus, visual feedback and motor imagery (theres an app for that) all which are important in instability….no brain, no gain.

The final talk I caught was from the Shoulder Doc himself Professor Tony Kochar to who size really does matter. He discussed large cuff tears and surgery with his general view being that many cuff tears do not need surgery. However, we need to show that it has healed as a conservatively managed tear which goes wrong can then be problematic to repair – 50% of initially “repairable” tears were irreparable by 48 months. Configuaration matters, surgery more likely in younger, larger tears (>1cm) and tears that involve the anterior supraspinatus as these are more likely to propagate.

And then I snuck out the back door. Not before recording some videos though which I look forward to seeing….some interesting questions, thanks Prof! A good day all round though, probably a little lacking in strength, capacity and load, it’s amazing how many different physios view the same patient differently but that is the beauty of multidisciplinary working! However we know we don’t load the cuff enough (‘Conservative treatment results for subacromial impingement patients’ Clausen, 2017) and we know that load plays a huge role in injury (Reference) and now for the shoulder as well (Reference). But some cracking take away points which I hope I have been able to share and hopefully see you again next year.

Thanks for reading.

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