And we also have to be honest, when we look at adherence, painful exercise is a big reason why people don't do them. And the other reason people do do exercise is because they see that it's meaningful to them. So there's nothing much more meaningful than taking the movement that matters to them, changing it and then making that into an exercise.
SPEAKER_00:Our understanding of shoulders has changed so much. Do we need to get down to a specific diagnosis to get good outcomes? Well, today we had Jo Gibson, who is a national and international educator and lecturer. And what stood out to me about Jo is how she made very complicated issues sound so simple with wonderful communication and great analogies for patients. She guided us through her clinical reasoning process with shoulders and how to approach treatment. My name is Michael Risk and this is Physio Explained. Hello Jo, thank you for joining us.
SPEAKER_01:Hi Michael, it's great to be here. Thanks for having me.
SPEAKER_00:We're going to talk shoulders and I'm going to go straight into this first question, which is the old subacromial impingement or the term impingement. We're starting to move away from that. Could you explain why and what's happened?
SPEAKER_01:Well, life was certainly a lot simpler when I was a baby physio, that's for sure, when we had this really nice biomedical or biomechanical model from NEAR, which really was based on no more than an opinion piece where essentially there was this belief that you kind of lost out on the genetic lottery, had a certain shape to chromium, and essentially you could then get attrition or irritation of the superior part of the rotator cuff. And so treatment then was very much aimed at removing that by chopping off a bit of bone and giving the rotator cuff more space. And really that was a model that was really taken on by the orthopedic establishment and guided treatment and everything was designed at increasing the size of that space. But I think the bottom line is that as we've learned more and more, we just realized that that model's flawed. I think initially understanding the majority of rotator cuff tears were on the articular side rather than the bursal side kind of challenged that top-down model. also increased understanding that it was almost the size of what's in the space rather than anything that's impinging on it that seemed more relevant. But I think also this real lack of correlation with structure and function in non-traumatic shoulder pain. So I think a great example is if you Take 100 scans, 50 of people with no shoulder pain and 50 of people with shoulder pain, and you give them to a radiologist, he can't tell you which group have pain. So we just have really had to question the validity of our special test in this non-traumatic group and really this reliance on structure and had to really kind of take on board that probably we can't be accurate about the source of symptoms. So I think also a lot of the prognostic research and what relates to pain in terms of sleep, health, comorbidities, People's education level, their genetics, choose your family really carefully. All those things seem to have more relevance in terms of whether somebody gets better together with, of course, psychosocial factors. And so, again, it's really moved us away from this very structural kind of anatomy based model.
SPEAKER_00:We could just end the podcast now. There's enough reasons to stop using impingement. So now are we talking semantics? Do you still use the word impingement or do you use something else?
SPEAKER_01:I really like that question because when I knew I was talking to you tonight, I think what we have to be really honest about is in physio, we all kind of go, we wear this badge of, oh, we so don't call it that anymore. But, you know, there's still hundreds of thousands of healthcare professionals are still using that term. I personally don't, unless I'm talking to a healthcare professional who does use it, because then what's important for me to know is what they mean by that. And at the end of the day, we've got a patient in the middle of this. So it's also what they understand by that. And I guess another reason that we've really tried to move away from it is qualitative research that shows us that impingement as a model, whilst it's a nice example, Some patients really like it in its simplicity, but to them, a lot of the time, it will then mean they need something doing, i.e. chopping off that bit of bone. So the problem is, as physios, it makes our job difficult because they don't see how we can address that bit of bone. So I think we have to be careful because we've very much shifted away from it in physio, but it's still something that if, for example, a patient goes onto Google, they'll see bursitis, tendonitis, impingements, etc. Those terms are out there. So what's important for us, I think, is to contextualize that, know what they've been told before, and then use a term that kind of dictates a positive framework and then what's going to happen treatment-wise.
SPEAKER_00:Yes. If a patient thinks it's impingement or pinching, it's very hard to not use structural treatment narratives like, we're going to do this, which will give you more space. So it is potentially nocebic. Is that a feeling?
SPEAKER_01:Yeah, absolutely. I love what you just said there, because I think it's very dependent on the individual patient and all the influences and their previous healthcare experiences. Because for some patients, let's say they've been told they've got impingement and then you might do some symptom modification or play around with why they're moving and it feels loads better. You can use that same narrative to say, look, you can change that just by getting your muscles working differently or making life easy for your shoulder. So it doesn't have to be nocebic. I guess my caveat is when patients come in and I I say, because I'm often not the first person to see them. I'll say, well, what have you been told about your shoulder? And they'll say, the GP told me that it was impingement. So the next question is not, wait, I'm this clever physio. We don't call it that anymore. The next question is, well, what does that mean to you? Because if they have a positive narrative around that, I don't need to change it. I just say, oh, yeah, well, we, you know, there's lots of things that we put under this umbrella of subacromial pain or rotator cuff related shoulder pain or whatever. But fundamentally, it means that physio is a good option for you.
SPEAKER_00:I was going to dig a little deeper. You almost went into that. So if they come to you and say, I have impingement and you ask, what does that mean to you? And they in turn gave you that more structural narrative, something's pinching, I need more space, or maybe I need to cut the bone or shave the bone. What will you then go into? Do you have a little bit of a script around, well, it's not that, but we don't want to say it that way. How do you say that?
SPEAKER_01:So at that point, I'd just be, well, thanks for being honest. It's really helpful to know what you understand and what it means to you in terms of what you've been told. But then I would do my assessment because I think for me, if I can change that pain or I can kind of influence using symptom modification approaches, we know from Peter O'Sullivan's lovely work that these kind of behavioral experiments or learning through change, if you like, are very, very powerful in addressing some of those negative beliefs. So that then, if you do get a change, makes it much easier to kind of challenge into that narrative, I think.
SPEAKER_00:That's great. So you're probably not spending a lot of time talking to them at that point but maybe start some assessment and show them that it can change?
SPEAKER_01:Yeah, absolutely. Because I think if we try and go with our explanation too quickly, and particularly when we haven't built up that trust or that alliance, or they just kind of see that we're interested in taking it seriously, despite what they might have told us, we're in a much better place, I think, to challenge that narrative. If we do it from the outset, then we kind of set ourselves up to fail.
SPEAKER_00:And I guess now we're talking about assessment, you mentioned symptom modification. How has your assessment changed and what will you assess? I still remember doing the empty can test and the Hawkins-Kennedy test, but now it's just like, how can I modify your symptoms in any way that's meaningful to you? What do you find yourself doing?
SPEAKER_01:Yeah, so I definitely don't do Hawkins and near tests anymore because I'm finding what I already know that the shoulder hurts. So I kind of acknowledge the limitations. I have to say I did write, I did put a whole booklet together for my team way back in 1989 of all the special tests with all the sensitivity and specificity. So embarrassed, but I thought it worked at the time. So no, for me now, I guess the key thing is making sure the shoulder's not stiff, just in terms of ruling out other potential diagnoses. The patient hasn't told me they're unstable. They don't have, again, the subjective is kind of 80% of my decision making. So again, hearing the story in terms of, is there anything that might suggest the cervical spine is more of a driver? But in the absence of those things, in terms of my objective, again, I'm going to check they're not stiff in terms of rotation. I'm going to get them to show me their range of movement. So I get an impression of how willing they are to move. I might look at their neck and do, you know, again, some modification there if I think it's relevant. But fundamentally, then I'm just going to try and change the movement that's painful by making it easier just changing the lever arm maybe giving a little bit of resistance to just change what's happening recruitment wise and rationalize that's what's happening but i realize it could be distraction it could be a million another one mechanisms or a scapular resistance test and then if those three things don't work then what i might do is just get them to exaggerate the kinetic chain with a step but the way i'm thinking in my head i'm just making life easier for the shoulder by playing with load And I guess also playing with processing, whether that's challenging their expectation by getting them to move differently, by distracting them, or because I'm putting my hands on or changing what they're doing, it's having an influence on how that muscle system is doing its job.
SPEAKER_00:I found it saved time in a way. Have you found that? Not going through that list or the booklet that you created a while ago?
SPEAKER_01:Yeah and I think you know what if we in these days where we're all told to be person-centered it's all about the person and what matters to them I think what I would say the caveat is that you have that sound knowledge base so that your subjective has ruled in or ruled out and as soon as things don't fit then you might have to expand that further and look at things in more detail and you know I'll have a quick look at their thoracic spine if it's stiff and I will look at their cuffing prone just to see how well it's doing its job but my assessment isn't a lot more complicated than that but that is based on the features fit. It's a story that fits and what I'm seeing fits. So that's cool. I'm happy to continue. But it's having that knowledge base that as soon as those things don't fit, then I might have some other things that I add into my assessment.
SPEAKER_00:You mentioned that you might do some scapular assistance or get some activation going and see if that changes the pain. Once you've found that, let's go with scapular assistance. Once you've found that, do you lean on that narrative a little bit? So One, your pain is changeable. That's a great sign. And do you then go on to explain that we might add some exercise in that emulates this? How do you approach that?
SPEAKER_01:So again, I think when you look at a lot of the critics of symptom modification, they'll say you're making the patient really vigilant about pain. You're making all about changing the pain and that's bad. So I don't say to the patient, I'm going to do this and get rid of your pain. I just get them to move differently and say, how does that feel? So I don't say, how's your pain gone? How does that feel? Oh, it feels easier. They might say it feels less painful. So great. Well, let's see if we can get an exercise for you to do the same thing. And then depending on what they ask me, that will set the narrative because not all of this is, well, what's that doing? It's just making life easier. Why is that? Maybe it's getting your muscles to work differently. There's lots of potential mechanisms, but the key thing is it just shows that you can change your pain. So again, it's putting the locus of control back with them and it's kind of empowering. So again, I think a lot of people are a little bit anti it because they think it's about reducing pain. To me, it's not about that. It's about reducing pain. modifying all those descending influences that potentially stop people going on that rehab journey. And we also have to be honest, when we look at adherence, painful exercise is a big reason why people don't do them. And the other reason people do do exercise is because they see that it's meaningful to them. So there's nothing much more meaningful than taking the movement that matters to them, changing it and then making that into an exercise. So I love what you keep bringing up about the language. So I don't make it about the pain, but it's all a very positive narrative. See what you've done. just by changing this, right? Here's the exercise. So I might put a bit of TheraBand around their back and around their wrists so that when they do the same movement, they're kind of getting that sensation of the scapular assistance. I might get them with a ball behind them on the wall. I always like a little loop of TheraBand to, I think, get the cuff doing something, but who knows what it's doing. And the bottom line is then they're still getting that feeling of whatever changed their pain and that becomes their foundation exercise. So I think it feeds a very positive narrative. And I I don't kind of say, oh, that means I'm going to be able to get you better. It's all about this shows you can do it right off you go. This is your first exercise for sure.
SPEAKER_00:Well, I personally found it hard. Say if I did a scap assist or I helped the inferior angle of scap move, I found it easier to say, oh, well, if we use lower traps or if we get upper traps going, that's a similar motion. This will help. Do you go down there?
SPEAKER_01:No, not really. I think when I first started talking about the shoulder, I definitely, I just want to give all those people their money back. This is a long time, like 30 years ago now, because it always used to be this muscle's doing this here, this muscle's doing that. You know, if you just change how the muscle system starts, then it will move differently through range. If somebody, I don't know, let's say had an AC joint problem, I might exaggerate a shrug during that improvement to reinforce those scapular muscles but no i'm probably it's not that i'm not thinking those things in my head but you know when you look at stuff we could talk like for an hour three hours about scapular dyskinesis and whether it matters or whether it doesn't but fundamentally when i push somebody's scapular yes originally it was based on a biomechanical model of upward rotation and protraction but it's also a massive unloading procedure again if i put my hand on somebody i'm giving them sensory input and i'm unloading their shoulders so i think what What we just have to be quite honest about is we don't really know the mechanisms. We're changing something and we're making it easier for the shoulder. I think what's key is that empowers the patient to see that they can do things differently. So that kind of may sound a bit lazy, Michael, I guess, but I guess I just keep my narrative as simple as I can. And then say somebody had been immobilized or had an injury or had a nerve injury or had surgery, then of course there might be true weakness that I might need to address, but I might use other tests to actually look at that more specifically.
SPEAKER_00:No, you've given some pearls about the narrative and how you describe that because I What we have seen is just like the bone needs to be removed to create more space, we have patients who say, my lower traps don't work and that's why my shoulder's sore. You just touched on treatment. How has your treatment changed as far as, similar to the booklet story, sidelining external rotation, everyone got and now we're doing more movements that emulate their movement. How has your treatment changed?
SPEAKER_01:I think I was always passionate about communication. I had a psychiatrist father that went on a kind of mission to change the way medical students were taught. So I guess I always had that influence. And I think to me, what the evidence has done is make me even more so invest in that person the first time. So I always talk about investing in the individual in terms of their beliefs, their expectations, their concerns, that kind of wider psychosocial framework. Because I think if you don't and you don't listen to them, then you miss a trick because that's what sets you up to succeed. And actually, if you look at the evidence about our treatment, one to three exercises that are progressive and meaningful to that patient seem to matter. So my go-to is a foundation based on the improvement test, something to look at that taut production role of the cuff, which usually starts supported, and then just progress it in a functionally meaningful way, depending on what that patient wants to get back to. And it really is no more complicated than that.
SPEAKER_00:You touched on one to three exercises. Are you still looking at something a bit more meaningful and then that isolation type rotator cuff or are you all in the meaningful space or all in the isolation space?
SPEAKER_01:No, again, I kind of reflect on this with myself all the time. Karen Jin's research, I think, has been lovely in terms of a way of looking at the rotator cuff differently. And I assess that. And if it's dysfunctional, I do my improvement test and reassess it. And if it's still dysfunctional, I'll give them a supportive cuff exercise. And it's just like, you need to be able to do that with the weight of your arm. Again, it's quite a nice positive narrative to the patient. This is the target that you've got to hit. And it's all achievable. So those two things probably figure and then really it would just be a question is if they're stiff in their thorax and they're wanting me to do stuff to it I'll show them they can actually loosen it up by doing similar things and then add that into their exercises if they want to get back in the gym we'll look at how we translate the things that work to what they want to get back to and then just make at the point I'm confident they're strong enough to do what they need to do that's the journey we go on and I mean I say one to three that's in a non-sporting population but we know adherence wise we do much more than that patients They're over it. It's like, I'm not doing that. I
SPEAKER_00:want to get the
SPEAKER_01:best bang for my buck in those three.
SPEAKER_00:That's a good range to stay in. Jo, we've covered everything. Terminology change, assessment, diagnosis, treatment. I didn't think we could, but we did. Where could people find out more or learn more?
SPEAKER_01:If you follow me, I've got really the uncoolest Twitter handle, at ShoulderGeek1. I didn't know what I was doing when I chose it. I've learned a lot about it since. So that's certainly where I post about my courses and stuff. I've got an online course with Clinical Edge, which has been great fun to do, particularly in these COVID times. But yeah, those are probably the two best places to find out about me. I do a load of free podcasts on a Monday on Facebook Live as well that anybody's welcome to join in.
SPEAKER_00:Amazing. Thank you for your time, Jo.
SPEAKER_01:You're so welcome. Thanks for having me.