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#ShoulderStudyDay2018

Thank you to Prof and his lovely wife Ashu. Another great Shoulder Study Day delivered. Top draw speakers, and not just because I opened it up. In fact Chris Blunt soon laid to bed my talk on how Social Media is great linking it in with how those who you follow, those you discuss with and those you seek new research from all pertain to your biases. In fact, I will start with Chris’ talk as it was fantastic, and mind blowing and made you wonder what you did actually know, if you knew anything!

 

Take Home Point 1 – What is good evidence? 

Thoughts on this:

“There are studies coming out showing that we as Physio’s are just as effective as surgery….Does this mean we are effective?”

Chris discussed evidence based medicine and how what we consider the gold standard of research really isn’t. What is good evidence? What is bad evidence? How many hands have been on the evidence before it gets to you?

Publication bias. Researcher bias. Funding bias. Where you get directed to it bias. Your bias.

A few of the many biases that can be involved. And then we come to the the research itself. A randomised controlled trial (RCT) only gives an average result, not a composition, so what can an individual expect from an intervention? Does it work? What benefits? What harms? He used a nice example of a cancer drug where a marginal average hid a strong high responder rate, meaning the drug was overlooked for this group. A high average can also hide a high risk group, where some may suffer harm. So what do we do with that….I don’t know. But what I will do is pay much closer attention to what I am reading, where it is coming from both researchers and where I found it, and how it is made up. Which kind of linked up with the message from my presentation that we can’t just take people’s 280 character summary line when they are posting research…read it and appraise it!

So Shoulders! 

 

Take Home Point 2 – Not moving has consequences

Jo Gibson is one of those speakers you can just continue to listen to. The pre-presentation Twitter Polls generated some great interest in what was coming and she did not disappoint. The big question was, should we immobilise shoulders post surgery. However this seems to negatively impact recovery: Longer immobilisation, less confidence. 

If we consider what impacts outcomes as well; deficits in external rotation, strength and proprioception, are associated with poor long term outcomes, increased risk of recurrence and an inability to return to play and return to previous level of performance (Gerometta et al, 2016; Orzturk et al, 2014; Stein et al, 2011).

So if you are using a sling, think of it as not for immobilisation, but for comfort and pain relief. And interestingly you can get up to 30% MVC with everyday activities in a sling anyway!! (Gurney et al, 2016; Long et al 2010).

 

Take Home Point 3 – Work work work the opposite side

What Jo often delivers very well is some key take away points you can use in clinic the next day and the same was true here: Some rehab gems.

3a. Working the ‘danger zone’ of movement early on the opposite side post operatively can create big cross overs in corticol patterns for the operated side (Lepley and Palmier-Smith, 2014; Magnus et al, 2013, Farthing et al, 2009)

3b. Engaging the hand early makes a big differences post operatively. We know already this creates a co-contraction in the rotator cuff (Horsley et al, 2016), but using functional activities lead to good outcomes up to three months compared to isolated strengthening (Gibson presentation, 2018). 

 

Take Home Point 4 – Yes Manual Therapy can be helpful, but on a Frozen Shoulder….Really!!??

First time listening to Neil Langridge, and the chap knows his stuff, very thoughtful and well reasoned and evidenced presentation. Even better when Adam Meakins is sitting next to you. 

To set the record straight away, everyone in the room appeared to be in agreement with;

You cannot:

  • Find something out of place
  • Test bony positions in the spine 
  • Put anything back in
  • Selectively mechanically effect one spinal segment (or other joint too!!)

Context, environment and expectation all discussed as key factors, some good discussion here, here and here for further reading, but the conclusion was there is a role for hands on with the right patient at the right time, which I agree with. The way Neil described it was great as well, in that we need to “change the experience”, and if the hands on helps with this, then good. 

What is not always shown in the systematic reviews (or other research, Chris), is that yes maybe we can change the experience and make someone feel better, however we can also make them worse!

This was one of things that cropped up in Doug Tannahill’s presentation. A very good workshop with some cool stuff to use with patients, all of which I can see being nice novel movements for patients to help reduce pain, however the terminology of ‘releasing’ could certainly lead to making someone worse, in particularly long term if they become reliant on these passive modalities. 

I’m sure at some point Meaks even nodded his head. Even if his question didn’t really get answered, which was all centred round the value of such therapy. And I get it. What often may be misconstrued as simply a bludgeoning disdain for manual therapy, he does have a point, that in the cash tight and time tight health care world, do we provide value for money by offering manual therapy, or would that time be better educating, advising, listening, exercising, planning. I guess there is no exact answer at the moment, but as a warning, if we do not provide value for money and get people better then someone else will change the shape of physiotherapy for us. 

To bring that into to some context, one of our survey results really surprised me. I can get behind manual therapy, but for a frozen shoulder, as a pathological change, I just don’t understand, and is an example of why manual therapy gets a bad rep for being ineffective. 

Take Home Point 5: It is actually pretty good to get strong

Amazingly the first time I’ve seen Adam Meakins talk, and I am certainly looking forward to his course in June even more now (Obviously because Erik Meira’s there).

My favourite quote of the whole day “If you are giving out pre printed exercise sheets to patients you’re a knobhead”. This is so true. We need to take the time to fully assess what is needed, what the patient can do, coach in the session, film them doing it, or let them film you, and set appropriate sets and reps ensuring the patient can complete them in the session. And pushing them as hard as we can; a big bug bear of mine is that we don’t bridge the gap enough between pain settling and returning to full strength and function. 

So we know exercise reduces pain, promotes healing, prevents disease, strengthens, improves mood, helps you live longer so what could go wrong. Good points from Adam that we often over complicate, under-dose and constantly change exercises. I’ve certainly been guilty of constantly changing things in the past when something hasn’t worked, the interesting question here then would be how long should we give an exercise before measuring whether it has worked or not? Also, often all this corrective exercise stuff can be nocebic, and patients start worrying about ‘doing things right’ rather than actually doing things. Does corrective exercise change kinematics…probably not, people will move how they move, so maybe we should be focusing on increasing there strength, tolerance and capacity. 

FInal point from me, and one of Adam’s first points is we, as physios, need to be better. A cross-sectional survey showed that only 38% of physio’s do the minimum amount of recommended physical activity. Maybe we should lead by example, maybe we shouldn’t, I guess that is individual preference, but what is unacceptable and quite frankly embarrassing for the profession is that only 16% knew what the recommended amounts are, and only 40% discuss it with patients. We are in an ideal position, be better people. Or someone else will. 

That’s my moan, but overall what a cracking day. Great work Tony and Ashu for hosting, smashing it every year. Great to meet up and chat with so many top people. This was suppose to be out ages ago, apologies for that, but they say reflections should always take place a little while after anyway right.

 

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