Ep 200: Excellent exercise for shaky shoulders, with Dr Karen McCreesh

[00:00:00] [SPEAKER_01]: The American Academy of Sports Physical Therapy and JOSPT are joining forces to bring you the second virtual sports PT conference on Saturday, the 2nd of November.

[00:00:11] [SPEAKER_01]: This is the premier online event for people interested in sports injury rehabilitation in 2024.

[00:00:17] [SPEAKER_01]: The three main blocks of content cover assessing and managing fear of re-injury, how approaches to pain monitoring have evolved,

[00:00:25] [SPEAKER_01]: plus the latest in wearables and how to get the most out of wearables in your sports rehabilitation practice.

[00:00:31] [SPEAKER_01]: You'll hear from world leading clinician scientists including Drs Terri Chemielewski, Lori Mishner, Karin Silbernagle, Liz Welsent and Rich Willey.

[00:00:41] [SPEAKER_01]: There's something for everyone at the virtual sports PT conference so that you're in the best position to help the patients and athletes you work with.

[00:00:49] [SPEAKER_01]: Join us on Saturday, the 2nd of November. Register now by following the link in the show notes and take advantage of the opportunity for up to 13 contact hours towards your continuing education.

[00:01:06] [SPEAKER_01]: Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice.

[00:01:13] [SPEAKER_01]: I'm Claire Ardern, the editor-in-chief of the Journal of Orthopaedic and Sports Physical Therapy.

[00:01:19] [SPEAKER_01]: It's great to have you listening today.

[00:01:24] [SPEAKER_01]: Today's podcast is a refresher on best practice in managing non-traumatic shoulder pain.

[00:01:29] [SPEAKER_01]: We're diving into the best available clinical practice guidelines and running the ruler over different approaches to exercise therapy.

[00:01:36] [SPEAKER_01]: Joining me to guide us is Dr. Karen McCreish, Professor of Physiotherapy at the University of Limerick in Ireland.

[00:01:44] [SPEAKER_01]: Karen's research focuses on the most effective ways to manage musculoskeletal pain, especially shoulder pain and tendon problems.

[00:01:53] [SPEAKER_01]: Dr. Karen McCreish, welcome to JOSPT Insights.

[00:01:57] [SPEAKER_01]: Thank you, Claire.

[00:01:58] [SPEAKER_01]: Karen, it's wonderful to have you on today and we are taking a dive into managing shoulder pain.

[00:02:03] [SPEAKER_01]: I'm going to jump straight into the questions and I'm going to frame this as a bit of a clinical scenario for you and for our listeners.

[00:02:11] [SPEAKER_01]: So imagine that we're working with someone who has had a diagnosis of rotator cuff related shoulder pain.

[00:02:17] [SPEAKER_01]: Let's start with the clinical practice guidelines.

[00:02:20] [SPEAKER_01]: What do they tell us about how to approach managing non-traumatic shoulder pain?

[00:02:25] [SPEAKER_00]: Going back historically a little bit, back to 2021, at that time there were no high quality contemporary clinical practice guidelines to draw from for physiotherapists in non-traumatic shoulder pain.

[00:02:36] [SPEAKER_00]: More recently in JOSPT, we have the clinical practice guideline, which was led by Simon Lafralse and Francois Desmueaux's group, focused very much on return to work for workers presenting with rotator cuff related shoulder pain.

[00:02:51] [SPEAKER_00]: And so that's the guideline I think we can draw from very nicely in terms of it being contemporary and being high quality in terms of its development.

[00:02:59] [SPEAKER_00]: So the kind of things that guideline tells us, although it is framed very much in occupational medicine, are that in terms of assessment, unsurprisingly, I suppose, we've got to listen to the patient's story and we've got to understand where they're coming from in terms of their perspectives and expectations.

[00:03:14] [SPEAKER_00]: From a sort of physiotherapy nuts and bolts point of view, impairment-based assessment continues to be important and measuring strength with a handheld dynamometer, measuring range of motion with a goniometer still has value within the physiotherapy process.

[00:03:29] [SPEAKER_00]: Assessment of patient-related outcome measures, although there is no one particular recommended measure.

[00:03:35] [SPEAKER_00]: The DASH and the SPAD-E seem to come out fairly well when we look at measures with good psychometric properties.

[00:03:40] [SPEAKER_00]: Beyond that, in terms of outcome measures, we'd certainly be looking at recommendations for assessing psychological well-being.

[00:03:48] [SPEAKER_00]: Being honest, many clinical practitioners struggle to see what do I do with that when I get it?

[00:03:53] [SPEAKER_00]: So I understand that.

[00:03:54] [SPEAKER_00]: Psychological well-being is one of those that in tendinopathy has been shown to influence outcomes, but I don't think we have clear guidance on which measures we should be using

[00:04:02] [SPEAKER_00]: and how a practitioner in face-to-face individual practice can apply some kind of a cutoff to show whether the level of psychological distress is important or not.

[00:04:12] [SPEAKER_00]: I think imaging is the other thing that we all wonder about, and depending on the clinical environment that you're working in,

[00:04:19] [SPEAKER_00]: you may or may not have direct access to that.

[00:04:20] [SPEAKER_00]: Your patients may already come with the imaging done and you may not be allowed to have any influence on that.

[00:04:25] [SPEAKER_00]: If you can influence that in some way, then the guidelines, including the recent one, would suggest that that is at least delayed for 12 weeks in non-traumatic presentations

[00:04:35] [SPEAKER_00]: because it can have a multitude of iatrogenic levels of influence on disability in very negative ways.

[00:04:43] [SPEAKER_00]: The jury's a little bit out in things like frozen shoulder and on the role of imaging, but certainly in terms of rotator cuff-related shoulder pain,

[00:04:49] [SPEAKER_00]: there doesn't seem to be any value of imaging in the very early stages.

[00:04:53] [SPEAKER_00]: Moving on to planning management, education and exercise continue to be the key tenets of our management approach that are the most evidence-based.

[00:05:01] [SPEAKER_00]: But the guidelines, I suppose, at present don't have clear direction on what those need to look like for each patient.

[00:05:10] [SPEAKER_00]: And maybe that's a good thing, and we'll talk a little further about that.

[00:05:13] [SPEAKER_00]: But up to 12 weeks of individualized progressive exercise appears to be important and would be recommended in all of the guidelines.

[00:05:21] [SPEAKER_00]: And equally, education that's designed and developed to meet the needs of your patient and to support them to build the skills for self-management.

[00:05:29] [SPEAKER_00]: I guess questions continue around the role of injections in those early stages.

[00:05:34] [SPEAKER_00]: I think on balance of evidence, corticosteroid injections in particular are not a key first-line intervention for rotator cuff-related shoulder pain.

[00:05:41] [SPEAKER_00]: And something that, again, should be revisited potentially at that three-month stage if we don't have progress in terms of symptom improvement.

[00:05:48] [SPEAKER_00]: So those are the kind of key things that you want as part of your package of care that allow you to say, well, look, I'm following practice guidelines.

[00:05:56] [SPEAKER_00]: We have another guideline forthcoming.

[00:05:58] [SPEAKER_00]: So it became clear that there was a need for a broader guideline and a guideline that had some more international impact or international input.

[00:06:05] [SPEAKER_00]: So Francois broadened out the team and gathered together a group of physiotherapists from a number of different countries.

[00:06:12] [SPEAKER_00]: And we have developed a guideline for rotator cuff tendinopathy management and assessment, all of the non-surgical management.

[00:06:19] [SPEAKER_00]: So it includes both the rehabilitation and medical management of the condition.

[00:06:23] [SPEAKER_00]: That's almost finished and will be published.

[00:06:25] [SPEAKER_01]: That is a fantastic overview of where we're at, Karen.

[00:06:29] [SPEAKER_01]: Thank you so much.

[00:06:30] [SPEAKER_01]: And I was thinking when I first asked the question, I thought, oh, clinical practice guidelines are so huge.

[00:06:35] [SPEAKER_01]: And sometimes they're really hard to distill into those key messages.

[00:06:38] [SPEAKER_01]: And you've done an absolutely brilliant job.

[00:06:40] [SPEAKER_01]: So thank you for that.

[00:06:41] [SPEAKER_01]: I want to hone in on exercise therapy and talk specifically about what the different options are for exercise therapy.

[00:06:48] [SPEAKER_01]: Where does the research currently sit on exercise therapy, especially if we're thinking about the rotator cuff tendons?

[00:06:56] [SPEAKER_00]: Repeating it again, really, exercise still remains the most evidence-based first-line tool that we have.

[00:07:01] [SPEAKER_00]: And now to pick it apart.

[00:07:04] [SPEAKER_00]: So that evidence is certainly not without its weaknesses.

[00:07:07] [SPEAKER_00]: There's a lot of uncertainty and there's a lot of challenges in distilling that evidence to the patient that sits in front of you.

[00:07:15] [SPEAKER_00]: So we definitely don't have a one-size-fits-all program.

[00:07:19] [SPEAKER_00]: And I don't believe we ever will.

[00:07:20] [SPEAKER_00]: So clinicians don't sit waiting for it because I don't think it's going to be a valuable thing to think about.

[00:07:25] [SPEAKER_00]: We have published a recent systematic review with the question of what do we know about exercise programs that have been directly compared to each other?

[00:07:33] [SPEAKER_00]: So with the knowledge that exercise generally improves outcomes in these patients, if we inter-compare different types of exercise,

[00:07:40] [SPEAKER_00]: so rather than reviews that have compared exercise to nothing or exercise to something else,

[00:07:44] [SPEAKER_00]: if we look at exercise alone and we hit one type of exercise program against another, have we got anything?

[00:07:50] [SPEAKER_00]: Because that was definitely a question all of my clinical partners want to know.

[00:07:55] [SPEAKER_00]: And we based that around the FIT principle.

[00:07:57] [SPEAKER_00]: We thought, okay, let's compare exercise programs that differ in some way according to either frequency, intensity, type of exercise or the duration of the program.

[00:08:05] [SPEAKER_00]: One surprise was that we've never compared exercise programs of different durations for this condition.

[00:08:11] [SPEAKER_00]: So we have no direct comparisons of exercise for four weeks versus exercise for 12 weeks.

[00:08:15] [SPEAKER_00]: And yet we do continue with this story within the guidelines of saying 12 weeks is kind of a marker for how long people need to do this for.

[00:08:23] [SPEAKER_00]: And we are probably basing that to some degree on biological evidence about whether we can change tendon structure over time or not,

[00:08:29] [SPEAKER_00]: and maybe some evidence from the lower limb.

[00:08:31] [SPEAKER_00]: It still suggests that that's a shaky foundation, even that 12 weeks magic number.

[00:08:36] [SPEAKER_00]: We didn't have any studies that compared exercising for different frequencies.

[00:08:40] [SPEAKER_00]: So, for example, seven days a week compared to three days a week.

[00:08:43] [SPEAKER_00]: I haven't got anything really to base that on, I'm afraid.

[00:08:47] [SPEAKER_00]: What we were able to see was that there were plenty of programs that had been compared, which were more nonspecific in nature.

[00:08:54] [SPEAKER_00]: So generalized, either range of motion or broader shoulder exercise compared to what the authors might have described as specific programs.

[00:09:01] [SPEAKER_00]: So these would be programs that were labeled either as eccentric only programs, programs that focused on scapular exercise,

[00:09:09] [SPEAKER_00]: programs that focused on motor control exercise.

[00:09:11] [SPEAKER_00]: And we were also able to make comparisons between studies that used higher or low intensities of resistance exercise.

[00:09:18] [SPEAKER_00]: With the great hope that something would roll out at the end of those complex analyses.

[00:09:22] [SPEAKER_00]: And I suppose what we can say is lots of uncertainties remain within that.

[00:09:27] [SPEAKER_00]: The one area where we were able to identify some significant differences was that motor control exercise did seem to offer some superiority in reducing disability

[00:09:36] [SPEAKER_00]: in the medium and short term to some degree pain in the short term.

[00:09:40] [SPEAKER_00]: And that was compared to programs that were a bit more generic.

[00:09:43] [SPEAKER_00]: We couldn't make conclusions about any of the other types of exercise.

[00:09:47] [SPEAKER_00]: And interestingly, there was no difference in the outcomes between high and low intensity exercise programs.

[00:09:53] [SPEAKER_00]: So where does that leave us?

[00:09:55] [SPEAKER_00]: We also did a scoping review of those same studies to try and understand what are the characteristics of the programs within the research studies.

[00:10:03] [SPEAKER_00]: And we saw that us researchers are doing a rather bad job of reporting what we're doing,

[00:10:08] [SPEAKER_00]: a bad job of replicating what others are doing.

[00:10:12] [SPEAKER_00]: So in some ways, we're not serving the community well in that way, because what we need is some of that replication.

[00:10:17] [SPEAKER_00]: So where studies that are finding good outcomes are replicated by others in different settings and really using a more implementation science lens where we're saying,

[00:10:25] [SPEAKER_00]: that's working well in the UK.

[00:10:27] [SPEAKER_00]: Can I take it and put it in Canada and see does it work in our health service?

[00:10:31] [SPEAKER_00]: So there's a real need for us to maybe begin to fill that gap a lot more rather than coming with new programs or new ways of delivering programs.

[00:10:38] [SPEAKER_00]: I think if we want to understand what do we do with this information that tells us doesn't seem to be any difference between programs,

[00:10:44] [SPEAKER_00]: then we have to look at some of the qualitative research.

[00:10:47] [SPEAKER_00]: My team has done quite a bit of this type of work over the last five years.

[00:10:51] [SPEAKER_00]: Christina Maxwell and Catherine Fahey would be two graduate students who've worked in that area.

[00:10:56] [SPEAKER_00]: Exercise clearly needs to be tailored to patients' needs, particularly in terms of helping them understand what they're doing and why they're doing it.

[00:11:03] [SPEAKER_00]: Because these were clear gaps in a qualitative evidence synthesis that we completed,

[00:11:07] [SPEAKER_00]: where patients were saying, I didn't really know why I was doing what I was doing.

[00:11:12] [SPEAKER_00]: And also suggesting that they didn't have confidence often in what they were being sent away to do.

[00:11:18] [SPEAKER_00]: So instilling that confidence and supporting people in a way that they understand why they're doing what they're doing

[00:11:24] [SPEAKER_00]: might be just as important as exactly which exercises we're using for which patients.

[00:11:28] [SPEAKER_01]: I want to pick up on the motor control exercises,

[00:11:31] [SPEAKER_01]: because you mentioned that maybe they're a little bit better for reducing disability,

[00:11:36] [SPEAKER_01]: perhaps having an effect on pain.

[00:11:39] [SPEAKER_01]: And in my world of ACL,

[00:11:42] [SPEAKER_01]: people use motor control to cover all sorts of different things.

[00:11:46] [SPEAKER_01]: What happens in the shoulder, Karen?

[00:11:48] [SPEAKER_01]: What are we talking about specifically when we see the word motor control,

[00:11:51] [SPEAKER_01]: or the phrase motor control exercises?

[00:11:53] [SPEAKER_00]: In this study, I think we had maybe eight in that category or so,

[00:11:57] [SPEAKER_00]: and some of them were overlapped.

[00:11:59] [SPEAKER_00]: So they call them scapular focused programs.

[00:12:01] [SPEAKER_00]: But when we looked at them, we felt like they had the qualities of motor control programs.

[00:12:04] [SPEAKER_00]: And I think from our definition,

[00:12:06] [SPEAKER_00]: we talked about studies or programs that had a focus on the neuromuscular element of the program,

[00:12:12] [SPEAKER_00]: where patients were specifically instructed in how to do the exercise,

[00:12:17] [SPEAKER_00]: and where potentially there were some elements of biofeedback,

[00:12:20] [SPEAKER_00]: where there might have been some use of visual input.

[00:12:22] [SPEAKER_00]: But those would have been the qualities of the programs that we were describing.

[00:12:26] [SPEAKER_00]: When we compare those programs to other exercise programs,

[00:12:28] [SPEAKER_00]: it's important to notice that sometimes the progression approach is different in those programs.

[00:12:33] [SPEAKER_00]: So progression is often tied to things like, you know, changes in symptoms,

[00:12:37] [SPEAKER_00]: as opposed to capacity.

[00:12:39] [SPEAKER_00]: The fact that there's a little bit of a connection to mind-body,

[00:12:42] [SPEAKER_00]: maybe with some of those motor control programs,

[00:12:44] [SPEAKER_00]: may be a positive in terms of,

[00:12:47] [SPEAKER_00]: if you're thinking about this from a more pain science approach.

[00:12:49] [SPEAKER_00]: There may be an aid for some more qualitative research here,

[00:12:52] [SPEAKER_00]: but it may be that through those programs,

[00:12:54] [SPEAKER_00]: because it tends to be quite a bit of physiotherapy instruction involved in them,

[00:12:58] [SPEAKER_00]: the patient is getting a little bit more of that,

[00:13:00] [SPEAKER_00]: ah, this is why I'm doing that.

[00:13:02] [SPEAKER_00]: One thing that does tend to come out as a kind of predictor of improving expectations

[00:13:08] [SPEAKER_00]: and also of good outcomes within some of the shoulder studies,

[00:13:11] [SPEAKER_00]: are that early improvement is tied to,

[00:13:14] [SPEAKER_00]: so if you get some improvement early on,

[00:13:16] [SPEAKER_00]: you're more likely to get a positive outcome at the end.

[00:13:18] [SPEAKER_00]: And clinicians are not surprised when I say that.

[00:13:21] [SPEAKER_00]: But again, it may be that the likes of a motor control program,

[00:13:24] [SPEAKER_00]: because of that connection with the physio

[00:13:26] [SPEAKER_00]: and the fact that it's very much done as a pain-free type of exercise,

[00:13:31] [SPEAKER_00]: you know, the patient may see that as,

[00:13:33] [SPEAKER_00]: I'm improving early on, I'm moving without pain.

[00:13:36] [SPEAKER_01]: There's so much variation,

[00:13:38] [SPEAKER_01]: and in some ways that's a blessing,

[00:13:40] [SPEAKER_01]: because it gives you as a clinician an opportunity

[00:13:42] [SPEAKER_01]: to really tailor what you're doing to the person in front of you,

[00:13:45] [SPEAKER_01]: as opposed to feeling like you're following a recipe book

[00:13:48] [SPEAKER_01]: and you've got limited scope for your own tailoring.

[00:13:51] [SPEAKER_01]: And then I guess the flip side is,

[00:13:53] [SPEAKER_01]: for people who are perhaps earlier in their careers,

[00:13:55] [SPEAKER_01]: it can feel really overwhelming and you think,

[00:13:57] [SPEAKER_01]: oh my goodness, there's so many different options.

[00:13:59] [SPEAKER_01]: Where on earth do I go next or where do I start?

[00:14:02] [SPEAKER_01]: So let's talk about that starting point.

[00:14:04] [SPEAKER_01]: Where would you suggest people start

[00:14:06] [SPEAKER_01]: when they're thinking about planning an exercise program,

[00:14:10] [SPEAKER_01]: specifically focused on managing pain?

[00:14:13] [SPEAKER_01]: I think exercise prescription is such an art.

[00:14:15] [SPEAKER_00]: You know, we like to see it as science,

[00:14:18] [SPEAKER_00]: but it really, really is very much an art

[00:14:20] [SPEAKER_00]: and one of those places where physiotherapists

[00:14:23] [SPEAKER_00]: really draw on so many of our different kinds of skills

[00:14:26] [SPEAKER_00]: and do it maybe in a different way to sometimes our SNC colleagues

[00:14:29] [SPEAKER_00]: that we do layer that art into it.

[00:14:33] [SPEAKER_00]: When I present to students on this and conferences at times,

[00:14:36] [SPEAKER_00]: I put up a picture of a mixing desk,

[00:14:38] [SPEAKER_00]: you know, where you're looking at,

[00:14:40] [SPEAKER_00]: well, for this patient,

[00:14:41] [SPEAKER_00]: I need a little bit more specificity

[00:14:43] [SPEAKER_00]: and a little bit less behavior change

[00:14:44] [SPEAKER_00]: because they're already, you know,

[00:14:46] [SPEAKER_00]: already a really strong exerciser.

[00:14:48] [SPEAKER_00]: But for this other patient,

[00:14:49] [SPEAKER_00]: I need to have lots of adjuncts

[00:14:51] [SPEAKER_00]: because they really love a few toys

[00:14:52] [SPEAKER_00]: and I need to have, you know, a lot of supervision.

[00:14:54] [SPEAKER_00]: So it's very much experience

[00:14:59] [SPEAKER_00]: and rounded personality for you as a physiotherapist

[00:15:02] [SPEAKER_00]: to kind of get that exercise prescription right

[00:15:05] [SPEAKER_00]: and know that science alone

[00:15:07] [SPEAKER_00]: probably won't give you the answer at the moment.

[00:15:09] [SPEAKER_00]: I think it's important when we're talking about pain

[00:15:11] [SPEAKER_00]: that for people who are presenting with pain,

[00:15:15] [SPEAKER_00]: we have to remember the concept of exercise

[00:15:16] [SPEAKER_00]: is really quite counterintuitive.

[00:15:18] [SPEAKER_00]: I mean, a movement hurts me.

[00:15:20] [SPEAKER_00]: Why am I exercising?

[00:15:21] [SPEAKER_00]: It's a basic concept that we have to make sure

[00:15:24] [SPEAKER_00]: we have had a frank conversation about.

[00:15:27] [SPEAKER_00]: So be mindful of how we present exercise

[00:15:29] [SPEAKER_00]: and what its role is.

[00:15:31] [SPEAKER_00]: So it's not always about increasing strength.

[00:15:33] [SPEAKER_00]: It's not always about, you know,

[00:15:34] [SPEAKER_00]: huge changes in the impairments.

[00:15:37] [SPEAKER_00]: But it needs to be about changing symptoms

[00:15:39] [SPEAKER_00]: because that's really where the buy-in

[00:15:41] [SPEAKER_00]: from your patient will be.

[00:15:43] [SPEAKER_00]: We've got to address any discrepancies

[00:15:45] [SPEAKER_00]: that they've been given to date

[00:15:46] [SPEAKER_00]: in their information.

[00:15:47] [SPEAKER_00]: If you're lucky to be first contact practitioner,

[00:15:49] [SPEAKER_00]: great, you can set the expectation from the start.

[00:15:52] [SPEAKER_00]: But so many of us meet our patients downstream

[00:15:54] [SPEAKER_00]: from lots of really bad mixed messages

[00:15:58] [SPEAKER_00]: about rest, don't exercise, don't load,

[00:16:01] [SPEAKER_00]: stop doing your valued activities.

[00:16:03] [SPEAKER_00]: And again, unless we address those,

[00:16:05] [SPEAKER_00]: I don't think we can move into prescription

[00:16:07] [SPEAKER_00]: in a really healthy, helpful way.

[00:16:09] [SPEAKER_00]: So I suppose set ourselves up for success,

[00:16:12] [SPEAKER_00]: explain, understand, deal with any discrepancies

[00:16:15] [SPEAKER_00]: in their information about exercise.

[00:16:16] [SPEAKER_00]: I think we've good qualitative data

[00:16:19] [SPEAKER_00]: from the PANDAS trial,

[00:16:20] [SPEAKER_00]: which is a trial looking at shoulder prognosis

[00:16:23] [SPEAKER_00]: where clinicians genuinely believe

[00:16:25] [SPEAKER_00]: they discuss things like prognosis

[00:16:27] [SPEAKER_00]: and management and patients said,

[00:16:29] [SPEAKER_00]: I totally denied that they'd had

[00:16:31] [SPEAKER_00]: those discussions at all.

[00:16:33] [SPEAKER_00]: And it is, you know, to some degree,

[00:16:35] [SPEAKER_00]: acknowledging that in that initial

[00:16:37] [SPEAKER_00]: first communication,

[00:16:38] [SPEAKER_00]: everything we say doesn't land

[00:16:40] [SPEAKER_00]: and that it's a process over time.

[00:16:43] [SPEAKER_00]: So preferences, really, really important.

[00:16:45] [SPEAKER_00]: How is your patient willing to engage with exercise?

[00:16:48] [SPEAKER_00]: And then what am I good at?

[00:16:50] [SPEAKER_00]: Because again, as clinicians, we have our biases,

[00:16:52] [SPEAKER_00]: but generally our biases come from,

[00:16:53] [SPEAKER_00]: hopefully, a place of evidence,

[00:16:55] [SPEAKER_00]: but also a place of something I'm really good at.

[00:16:58] [SPEAKER_00]: You know, I really enjoy motor control

[00:17:00] [SPEAKER_00]: because I like that being close up

[00:17:02] [SPEAKER_00]: with the patient and instructing movement.

[00:17:04] [SPEAKER_00]: I'm much more comfortable in the gym

[00:17:06] [SPEAKER_00]: or I'm much more comfortable with the idea

[00:17:08] [SPEAKER_00]: of teaching patients to do their exercise through tech.

[00:17:11] [SPEAKER_00]: Again, we don't have research to suggest

[00:17:13] [SPEAKER_00]: that therapist preference, you know,

[00:17:15] [SPEAKER_00]: is something that changes outcomes

[00:17:18] [SPEAKER_00]: from an evidence-based way,

[00:17:19] [SPEAKER_00]: but there's no question that patients buy in

[00:17:21] [SPEAKER_00]: to something that you are confident in

[00:17:23] [SPEAKER_00]: and that you can make them confident in.

[00:17:25] [SPEAKER_00]: So I think as a clinician,

[00:17:26] [SPEAKER_00]: if you're choosing what do I want to do,

[00:17:28] [SPEAKER_00]: then these reviews that are saying

[00:17:30] [SPEAKER_00]: it's all quite similar allow you to say,

[00:17:33] [SPEAKER_00]: I'm really confident when I prescribe exercise

[00:17:35] [SPEAKER_00]: through an app

[00:17:36] [SPEAKER_00]: or when I prescribe exercise in a group class

[00:17:38] [SPEAKER_00]: or whatever way.

[00:17:40] [SPEAKER_00]: And so you can work to your own strengths,

[00:17:42] [SPEAKER_00]: aligning those with your patient preferences.

[00:17:45] [SPEAKER_00]: Timescales are really important for exercise

[00:17:47] [SPEAKER_00]: because nobody wants to be given an exercise program

[00:17:49] [SPEAKER_00]: that feels like we're doing it ad infinitum forever.

[00:17:52] [SPEAKER_00]: So we're going to start here.

[00:17:55] [SPEAKER_00]: We're aiming to progress to there.

[00:17:57] [SPEAKER_00]: And by, you know, this point in time,

[00:17:58] [SPEAKER_00]: eight, 10 weeks time,

[00:18:00] [SPEAKER_00]: I expect to see a reduction in your symptoms

[00:18:02] [SPEAKER_00]: and I expect us to be able to,

[00:18:03] [SPEAKER_00]: you know, graduate you with taking control of this yourself.

[00:18:07] [SPEAKER_01]: I love your analogy of the mixing desk

[00:18:11] [SPEAKER_01]: and I'm imagining DJ McCreish here

[00:18:14] [SPEAKER_01]: with her exercise prescription.

[00:18:16] [SPEAKER_01]: And I love that you bring in the timing here, Karen,

[00:18:19] [SPEAKER_01]: because it gives me the perfect opportunity

[00:18:21] [SPEAKER_01]: to ask you about that discharge planning piece.

[00:18:24] [SPEAKER_01]: Because as you say,

[00:18:25] [SPEAKER_01]: this is very much geared towards helping someone,

[00:18:28] [SPEAKER_01]: helping to support someone

[00:18:29] [SPEAKER_01]: to move beyond needing to come and see you,

[00:18:32] [SPEAKER_01]: whether it's in person or virtual.

[00:18:34] [SPEAKER_01]: How do you get to that place of discharge?

[00:18:37] [SPEAKER_00]: Yeah, and everyone's kind of endpoint

[00:18:39] [SPEAKER_00]: that they're happy with is different.

[00:18:41] [SPEAKER_00]: So not everybody has the expectation

[00:18:43] [SPEAKER_00]: that they're going to be pain-free,

[00:18:44] [SPEAKER_00]: whereas others really, really do.

[00:18:46] [SPEAKER_00]: And they don't see an endpoint unless they're pain-free.

[00:18:48] [SPEAKER_00]: So having a frank conversation about that,

[00:18:50] [SPEAKER_00]: whether that's a realistic expectation or not

[00:18:52] [SPEAKER_00]: for somebody to be pain-free.

[00:18:54] [SPEAKER_00]: Your providers may well limit

[00:18:56] [SPEAKER_00]: what you can do in terms of time.

[00:18:58] [SPEAKER_00]: And I fully understand, listen,

[00:18:59] [SPEAKER_00]: I work in a system in Irish primary care

[00:19:02] [SPEAKER_00]: where there actually is a limited number

[00:19:03] [SPEAKER_00]: of engagements you can have with a patient.

[00:19:05] [SPEAKER_00]: We see research coming out of the NHS,

[00:19:07] [SPEAKER_00]: the GRASP trial,

[00:19:08] [SPEAKER_00]: pushing towards this idea of, you know,

[00:19:10] [SPEAKER_00]: one single session for patients

[00:19:11] [SPEAKER_00]: and moving them into the discharge point.

[00:19:13] [SPEAKER_00]: So it's certainly possible to do it

[00:19:15] [SPEAKER_00]: in lots of different ways

[00:19:17] [SPEAKER_00]: to meet the needs of your service.

[00:19:19] [SPEAKER_00]: And so I think sometimes physios are hands up saying,

[00:19:21] [SPEAKER_00]: but I'm only allowed to see them four times

[00:19:22] [SPEAKER_00]: or six times or,

[00:19:23] [SPEAKER_00]: and actually, you know,

[00:19:25] [SPEAKER_00]: work with what you have

[00:19:26] [SPEAKER_00]: because there's evidence to support all of it.

[00:19:29] [SPEAKER_00]: I think different patients have different needs

[00:19:31] [SPEAKER_00]: and we have to really be honest

[00:19:32] [SPEAKER_00]: about low levels of health literacy.

[00:19:34] [SPEAKER_00]: We have to be really honest

[00:19:35] [SPEAKER_00]: about people with lower education levels.

[00:19:38] [SPEAKER_00]: We have to be honest about people

[00:19:39] [SPEAKER_00]: who have, you know, chaotic lives

[00:19:41] [SPEAKER_00]: from a socioeconomic perspective.

[00:19:42] [SPEAKER_00]: They do need more support.

[00:19:44] [SPEAKER_00]: They do need more long-term help.

[00:19:46] [SPEAKER_00]: I think we need to move towards the idea

[00:19:48] [SPEAKER_00]: of people getting to have check-ins

[00:19:49] [SPEAKER_00]: after the discharged.

[00:19:51] [SPEAKER_00]: And I know services often don't support that,

[00:19:53] [SPEAKER_00]: but I'm seeing more trials,

[00:19:54] [SPEAKER_00]: not so much in the musculoskeletal field,

[00:19:56] [SPEAKER_00]: but in the chronic healthcare field

[00:19:58] [SPEAKER_00]: where, you know,

[00:19:59] [SPEAKER_00]: people get their initial period of care

[00:20:01] [SPEAKER_00]: and then there's an open invitation

[00:20:03] [SPEAKER_00]: to come back if you need it.

[00:20:05] [SPEAKER_00]: And I think we could do better with that in MSK.

[00:20:08] [SPEAKER_00]: We're probably going to need to lobby for it

[00:20:10] [SPEAKER_00]: from a policy perspective.

[00:20:11] [SPEAKER_00]: But given the extent of disability

[00:20:13] [SPEAKER_00]: that MSK conditions are causing,

[00:20:16] [SPEAKER_00]: it seems to be a very important move

[00:20:18] [SPEAKER_00]: that we would say is,

[00:20:19] [SPEAKER_00]: yes, we have a discussion with people

[00:20:21] [SPEAKER_00]: and support them in terms of

[00:20:22] [SPEAKER_00]: discharging them at a point

[00:20:24] [SPEAKER_00]: that we're all happy with,

[00:20:25] [SPEAKER_00]: but not into a vacuum.

[00:20:27] [SPEAKER_00]: Because what tends to happen,

[00:20:28] [SPEAKER_00]: and we've done some work

[00:20:29] [SPEAKER_00]: with GPs actually in knee pain,

[00:20:31] [SPEAKER_00]: and they say,

[00:20:32] [SPEAKER_00]: well, when that happens

[00:20:33] [SPEAKER_00]: and the patient rolls back to us,

[00:20:35] [SPEAKER_00]: we often refer them through

[00:20:36] [SPEAKER_00]: to secondary care next time around.

[00:20:38] [SPEAKER_00]: Because we think,

[00:20:39] [SPEAKER_00]: well, that first-line care failed then

[00:20:41] [SPEAKER_00]: because they had it,

[00:20:42] [SPEAKER_00]: they were a bit better,

[00:20:42] [SPEAKER_00]: but now they're having trouble again.

[00:20:43] [SPEAKER_00]: They're having a relapse.

[00:20:45] [SPEAKER_00]: And that's really what we want to avoid

[00:20:47] [SPEAKER_00]: is having these sort of

[00:20:48] [SPEAKER_00]: just-encased referrals

[00:20:50] [SPEAKER_00]: to secondary care,

[00:20:51] [SPEAKER_00]: at least that's in the healthcare environment

[00:20:52] [SPEAKER_00]: I work in,

[00:20:53] [SPEAKER_00]: where the primary care practitioner

[00:20:55] [SPEAKER_00]: is saying,

[00:20:56] [SPEAKER_00]: you know,

[00:20:57] [SPEAKER_00]: I'm not finding a way to

[00:20:59] [SPEAKER_00]: access that physiotherapy care

[00:21:01] [SPEAKER_00]: quickly the second time around.

[00:21:03] [SPEAKER_00]: So I think thinking of all of those things

[00:21:04] [SPEAKER_00]: makes it complex,

[00:21:05] [SPEAKER_00]: but it's important for us

[00:21:07] [SPEAKER_00]: as practitioners to say,

[00:21:08] [SPEAKER_00]: yes, there's a point

[00:21:09] [SPEAKER_00]: where we can discharge the patient,

[00:21:10] [SPEAKER_00]: but think about the idea

[00:21:12] [SPEAKER_00]: that I can give them

[00:21:13] [SPEAKER_00]: a safety net in some way.

[00:21:14] [SPEAKER_00]: And if that's possible,

[00:21:15] [SPEAKER_00]: then you definitely will be saving

[00:21:17] [SPEAKER_00]: onward referrals

[00:21:18] [SPEAKER_00]: when they have a relapse.

[00:21:19] [SPEAKER_01]: Yeah, for sure.

[00:21:20] [SPEAKER_01]: When you talk about

[00:21:21] [SPEAKER_01]: this check-in appointment,

[00:21:23] [SPEAKER_01]: Karen,

[00:21:23] [SPEAKER_01]: are you thinking of something

[00:21:25] [SPEAKER_01]: along the lines of a booster session?

[00:21:26] [SPEAKER_01]: I'm seeing a few trials

[00:21:27] [SPEAKER_01]: where people will deliver,

[00:21:29] [SPEAKER_01]: say, a booster session of exercise

[00:21:30] [SPEAKER_01]: at much further on

[00:21:31] [SPEAKER_01]: in someone's trajectory.

[00:21:33] [SPEAKER_01]: How do you see booster

[00:21:35] [SPEAKER_01]: versus this check-in?

[00:21:36] [SPEAKER_00]: I spoke to the people involved,

[00:21:38] [SPEAKER_00]: Andrew Jaggi and co.

[00:21:39] [SPEAKER_00]: in the GRASP trial,

[00:21:40] [SPEAKER_00]: and they were offered

[00:21:41] [SPEAKER_00]: the possibility of returning

[00:21:43] [SPEAKER_00]: for additional sessions

[00:21:44] [SPEAKER_00]: after they had their

[00:21:45] [SPEAKER_00]: one hour long session

[00:21:47] [SPEAKER_00]: with a specialized,

[00:21:48] [SPEAKER_00]: not specialized physiotherapist,

[00:21:49] [SPEAKER_00]: but physios who were trained

[00:21:50] [SPEAKER_00]: in goal setting

[00:21:51] [SPEAKER_00]: and behavior change.

[00:21:53] [SPEAKER_00]: They got their one hour session

[00:21:54] [SPEAKER_00]: and then that was compared

[00:21:56] [SPEAKER_00]: to multiple sessions

[00:21:57] [SPEAKER_00]: of physiotherapy

[00:21:57] [SPEAKER_00]: with the end result

[00:21:59] [SPEAKER_00]: of the GRASP trial

[00:21:59] [SPEAKER_00]: suggesting that there was

[00:22:00] [SPEAKER_00]: no difference in outcomes.

[00:22:03] [SPEAKER_00]: And immediately we all think,

[00:22:04] [SPEAKER_00]: well, what happened

[00:22:05] [SPEAKER_00]: to the one and done people?

[00:22:06] [SPEAKER_00]: Did they end up

[00:22:07] [SPEAKER_00]: coming back for more care?

[00:22:08] [SPEAKER_00]: And in fact,

[00:22:09] [SPEAKER_00]: there was an absolutely

[00:22:10] [SPEAKER_00]: tiny proportion,

[00:22:11] [SPEAKER_00]: I think less than 10%,

[00:22:12] [SPEAKER_00]: who took up the opportunity

[00:22:14] [SPEAKER_00]: of having an additional

[00:22:15] [SPEAKER_00]: check-in appointment.

[00:22:16] [SPEAKER_00]: So it was quite a surprise.

[00:22:17] [SPEAKER_00]: The offer was there

[00:22:18] [SPEAKER_00]: and only a very small number

[00:22:20] [SPEAKER_00]: of them took it up,

[00:22:20] [SPEAKER_00]: which might reassure

[00:22:22] [SPEAKER_00]: some services who say,

[00:22:23] [SPEAKER_00]: oh, if we offer that,

[00:22:24] [SPEAKER_00]: we're going to be inundated

[00:22:25] [SPEAKER_00]: with people.

[00:22:26] [SPEAKER_00]: I think boosters

[00:22:26] [SPEAKER_00]: in terms of scheduled appointments

[00:22:28] [SPEAKER_00]: might be quite reassuring

[00:22:29] [SPEAKER_00]: for patients,

[00:22:30] [SPEAKER_00]: particularly with low self-efficacy

[00:22:33] [SPEAKER_00]: because those patients

[00:22:34] [SPEAKER_00]: are less likely to,

[00:22:35] [SPEAKER_00]: you know,

[00:22:36] [SPEAKER_00]: ring up and make

[00:22:37] [SPEAKER_00]: the next appointment.

[00:22:38] [SPEAKER_00]: They're less likely

[00:22:39] [SPEAKER_00]: to seek that care

[00:22:40] [SPEAKER_00]: at the point of time

[00:22:41] [SPEAKER_00]: when it might be helpful

[00:22:42] [SPEAKER_00]: and tend to maybe wait

[00:22:43] [SPEAKER_00]: until it's not too late

[00:22:44] [SPEAKER_00]: but things have got worse.

[00:22:46] [SPEAKER_00]: But it's an area

[00:22:47] [SPEAKER_00]: ripe for research

[00:22:48] [SPEAKER_00]: and ripe for practitioners

[00:22:49] [SPEAKER_00]: to kind of lead on.

[00:22:52] [SPEAKER_01]: Let's finish up

[00:22:53] [SPEAKER_01]: by talking about

[00:22:54] [SPEAKER_01]: someone whose condition

[00:22:55] [SPEAKER_01]: might have plateaued

[00:22:56] [SPEAKER_01]: and they feel like

[00:22:57] [SPEAKER_01]: they're really

[00:22:57] [SPEAKER_01]: not getting better.

[00:22:58] [SPEAKER_01]: They're still having issues,

[00:23:00] [SPEAKER_01]: they've still got symptoms

[00:23:01] [SPEAKER_01]: but it doesn't seem

[00:23:02] [SPEAKER_01]: like it's making a difference

[00:23:04] [SPEAKER_01]: and that can feel

[00:23:04] [SPEAKER_01]: incredibly frustrating

[00:23:06] [SPEAKER_01]: as a clinician.

[00:23:07] [SPEAKER_01]: Where do you go with that?

[00:23:09] [SPEAKER_01]: And I guess

[00:23:09] [SPEAKER_01]: where does

[00:23:10] [SPEAKER_01]: a discussion about

[00:23:12] [SPEAKER_01]: either referring

[00:23:12] [SPEAKER_01]: onto a surgeon

[00:23:13] [SPEAKER_01]: if we're talking

[00:23:14] [SPEAKER_01]: about rotator cuff

[00:23:15] [SPEAKER_01]: related shoulder pain,

[00:23:16] [SPEAKER_01]: where does that all

[00:23:17] [SPEAKER_01]: fall into the mix here?

[00:23:19] [SPEAKER_00]: Yes,

[00:23:19] [SPEAKER_00]: and it's really important

[00:23:20] [SPEAKER_00]: to continue

[00:23:21] [SPEAKER_00]: to consider surgery

[00:23:22] [SPEAKER_00]: as a realistic option

[00:23:23] [SPEAKER_00]: for many people

[00:23:24] [SPEAKER_00]: with painful shoulders.

[00:23:26] [SPEAKER_00]: I think we have

[00:23:27] [SPEAKER_00]: some clear guidance

[00:23:28] [SPEAKER_00]: in terms of things

[00:23:29] [SPEAKER_00]: like patients

[00:23:29] [SPEAKER_00]: who are presenting

[00:23:30] [SPEAKER_00]: with a more acute

[00:23:31] [SPEAKER_00]: presentation at a younger age

[00:23:33] [SPEAKER_00]: who have a job

[00:23:34] [SPEAKER_00]: with high physical demands,

[00:23:36] [SPEAKER_00]: possibly those

[00:23:37] [SPEAKER_00]: who've experienced trauma,

[00:23:38] [SPEAKER_00]: although Chris Littlewood's

[00:23:39] [SPEAKER_00]: forthcoming clinical trials

[00:23:40] [SPEAKER_00]: may show us

[00:23:41] [SPEAKER_00]: that trauma

[00:23:42] [SPEAKER_00]: may not be such

[00:23:42] [SPEAKER_00]: an immediate

[00:23:43] [SPEAKER_00]: surgical indication

[00:23:45] [SPEAKER_00]: as we might think.

[00:23:46] [SPEAKER_00]: If they've had imaging

[00:23:47] [SPEAKER_00]: they need to have

[00:23:47] [SPEAKER_00]: an absence of

[00:23:48] [SPEAKER_00]: fatty infiltration

[00:23:49] [SPEAKER_00]: of their rotator cuff muscles

[00:23:50] [SPEAKER_00]: because that would be

[00:23:51] [SPEAKER_00]: a negative predictor

[00:23:53] [SPEAKER_00]: for surgical success.

[00:23:54] [SPEAKER_00]: And then it's really

[00:23:56] [SPEAKER_00]: about having close

[00:23:57] [SPEAKER_00]: conversations and relationships

[00:23:58] [SPEAKER_00]: with your referrers.

[00:23:59] [SPEAKER_00]: When I work with surgeons

[00:24:01] [SPEAKER_00]: they say

[00:24:01] [SPEAKER_00]: I want to know

[00:24:03] [SPEAKER_00]: that they've successfully

[00:24:04] [SPEAKER_00]: engaged

[00:24:05] [SPEAKER_00]: in a really meaningful way

[00:24:07] [SPEAKER_00]: with 12 weeks

[00:24:08] [SPEAKER_00]: of non-surgical care.

[00:24:09] [SPEAKER_00]: And if you

[00:24:10] [SPEAKER_00]: as a physio

[00:24:11] [SPEAKER_00]: can tell me that

[00:24:12] [SPEAKER_00]: then I as a surgeon

[00:24:13] [SPEAKER_00]: feel more confident

[00:24:14] [SPEAKER_00]: in saying

[00:24:15] [SPEAKER_00]: that next step

[00:24:16] [SPEAKER_00]: is appropriate.

[00:24:17] [SPEAKER_00]: But the surgeons

[00:24:17] [SPEAKER_00]: often say

[00:24:18] [SPEAKER_00]: we often get these patients

[00:24:19] [SPEAKER_00]: arriving with us

[00:24:19] [SPEAKER_00]: who say

[00:24:19] [SPEAKER_00]: well I've had physio

[00:24:21] [SPEAKER_00]: what was that?

[00:24:22] [SPEAKER_00]: So those meaningful

[00:24:24] [SPEAKER_00]: relationships with your surgeon

[00:24:25] [SPEAKER_00]: are very important

[00:24:26] [SPEAKER_00]: because then

[00:24:27] [SPEAKER_00]: it's a really

[00:24:28] [SPEAKER_00]: evidence-based conversation

[00:24:29] [SPEAKER_00]: about we have

[00:24:31] [SPEAKER_00]: met the guideline

[00:24:31] [SPEAKER_00]: in terms of 12 weeks

[00:24:32] [SPEAKER_00]: of non-surgical care

[00:24:33] [SPEAKER_00]: where the patient's

[00:24:34] [SPEAKER_00]: really engaged

[00:24:34] [SPEAKER_00]: with education

[00:24:35] [SPEAKER_00]: exercise

[00:24:35] [SPEAKER_00]: I've seen a shift

[00:24:36] [SPEAKER_00]: in their understanding

[00:24:37] [SPEAKER_00]: of their condition

[00:24:38] [SPEAKER_00]: and we're still

[00:24:39] [SPEAKER_00]: at a place

[00:24:40] [SPEAKER_00]: where they're not

[00:24:40] [SPEAKER_00]: comfortable

[00:24:41] [SPEAKER_00]: with their symptom improvement

[00:24:42] [SPEAKER_00]: or they're not engaging

[00:24:43] [SPEAKER_00]: with their occupations

[00:24:45] [SPEAKER_00]: or the sports

[00:24:45] [SPEAKER_00]: in the way that they want to.

[00:24:47] [SPEAKER_00]: That's when the conversation

[00:24:48] [SPEAKER_00]: begins

[00:24:48] [SPEAKER_00]: and of course

[00:24:48] [SPEAKER_00]: it starts potentially

[00:24:49] [SPEAKER_00]: with porticosterid injections

[00:24:51] [SPEAKER_00]: or other types

[00:24:52] [SPEAKER_00]: of injections

[00:24:52] [SPEAKER_00]: and then might move

[00:24:54] [SPEAKER_00]: towards the idea

[00:24:55] [SPEAKER_00]: of a surgical solution.

[00:24:57] [SPEAKER_00]: Diane Slater did

[00:24:57] [SPEAKER_00]: a really lovely piece

[00:24:58] [SPEAKER_00]: with you

[00:24:58] [SPEAKER_00]: I'm not going to repeat

[00:24:59] [SPEAKER_00]: it on shared decision making

[00:25:00] [SPEAKER_00]: because it's a jam

[00:25:01] [SPEAKER_00]: so I would say

[00:25:02] [SPEAKER_00]: if that's an area

[00:25:03] [SPEAKER_00]: where you don't feel confident

[00:25:04] [SPEAKER_00]: then jump in

[00:25:05] [SPEAKER_00]: and listen to Diane

[00:25:06] [SPEAKER_00]: because she did

[00:25:06] [SPEAKER_00]: a wonderful job.

[00:25:08] [SPEAKER_01]: And our listeners

[00:25:08] [SPEAKER_01]: can find the link

[00:25:09] [SPEAKER_01]: to Diane's podcast

[00:25:10] [SPEAKER_01]: in the show notes

[00:25:12] [SPEAKER_01]: plus links to all

[00:25:13] [SPEAKER_01]: of the resources

[00:25:13] [SPEAKER_01]: we've talked through

[00:25:14] [SPEAKER_01]: today.

[00:25:15] [SPEAKER_01]: Karen

[00:25:16] [SPEAKER_01]: it's been wonderful

[00:25:17] [SPEAKER_01]: having you walk us

[00:25:18] [SPEAKER_01]: through where

[00:25:18] [SPEAKER_01]: the guidelines are at

[00:25:20] [SPEAKER_01]: where things are headed next

[00:25:21] [SPEAKER_01]: and also just giving

[00:25:22] [SPEAKER_01]: a bit of a sense

[00:25:23] [SPEAKER_01]: of starting points

[00:25:24] [SPEAKER_01]: and how to build

[00:25:25] [SPEAKER_01]: your thinking

[00:25:25] [SPEAKER_01]: around exercise therapy

[00:25:27] [SPEAKER_01]: for people with

[00:25:28] [SPEAKER_01]: sore shoulders.

[00:25:29] [SPEAKER_01]: Dr Karen McCreish

[00:25:31] [SPEAKER_01]: thanks for joining me

[00:25:32] [SPEAKER_01]: on JOSPT Insights.

[00:25:33] [SPEAKER_00]: Thank you Claire

[00:25:34] [SPEAKER_00]: it's a pleasure.

[00:25:39] [SPEAKER_01]: Thanks for listening

[00:25:40] [SPEAKER_01]: to this episode

[00:25:41] [SPEAKER_01]: of JOSPT Insights.

[00:25:42] [SPEAKER_01]: For more discussion

[00:25:44] [SPEAKER_01]: of the issues

[00:25:44] [SPEAKER_01]: in musculoskeletal

[00:25:45] [SPEAKER_01]: rehabilitation

[00:25:46] [SPEAKER_01]: that are relevant

[00:25:47] [SPEAKER_01]: to your practice

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