Ep 222: Where to next for research on shoulder pain? with Kristian Lyng

[00:00:00] Hey there, it's Claire here. I wanted to let you know about a new open access journal. It's called JOSPT Methods. Here you'll find a place that's dedicated to publishing the best new approaches to producing the highest quality evidence that supports your clinical practice in musculoskeletal rehabilitation.

[00:00:18] JOSPT Methods is published by Movement Science Media, the publisher behind the journals JOSPT, JOSPT Open and JOSPT Cases, and this podcast, JOSPT Insights. Head to jospt.org forward slash josptmethods, that's methods with an S, to read all the latest articles with no paywall and to submit your research. And while you're there, check out the front cover of the journal. It's a real beauty.

[00:00:51] Hello, and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Claire Ardern, the editor in chief of the Journal of Orthopedic and Sports Physical Therapy. It's great to have you listening today. Researchers are slowly getting better at actively and authentically partnering with patients, clinicians, and others who use research.

[00:01:17] Today, we hear about a big conversation with over 600 patients, clinicians, and carers who were supported to nominate their top priorities for research on shoulder pain. Christian Leung is the physiotherapist who led the work as part of his PhD at the Department of Health Science and Technology and the Centre for General Practice, both at Aalborg University in Denmark.

[00:01:39] Christian's currently in the end stages of his PhD, where he's developing a new intervention for shared decision-making with patients with subacromial pain syndrome. Today, Christian and I discuss the challenges and the opportunities in translating research to clinical practice, and the benefits to researchers of engaging patients and the public in doing musculoskeletal research. Christian Leung, welcome to JOSPT Insights. Thank you.

[00:02:07] Christian, there's increasing emphasis on engaging patients and the public, including clinicians in research, and JOSPT has published a whole editorial series on why it's important to engage patients and the public in research work, and some of the steps involved in doing it well. We'll link to those articles in the show notes for people looking for more information.

[00:02:30] JOSPT Insights listeners heard from Mel Haberfield in the beginning of 2025 about how she's engaging women with knee injuries to figure out what they want to know about their knees and their ongoing knee health. And you've recently finished talking with a very diverse group of people about what they want to know about shoulder problems. So tell us, Christian, about who you've spoken with and how your meeting or meetings have worked.

[00:02:56] We follow the Jameson Alliance for Priority and Settings partnerships, where we basically want to go through different steps, kind of ensuring that we get the right priorities from this diverse stakeholder group. Before the project actually started, we kind of laid out the foundation of who is the main stakeholders for our area. In our case, we started, of course, with the patients and the clinicians.

[00:03:26] And then from there, we kind of mapped out that, yes, okay, we have also the relatives, the carriers, as we call them in our project. And then we tried to map out also who are the different clinicians that are typically involved in caretaking of patients with atraumatic shoulder pain.

[00:03:44] So this was kind of the idea, the premise for our project to, at least in the beginning, try and see we can include as many people who were representatives of these kind of different stakeholders, so to speak. And how many in the end did you manage to include in the meetings? And I should say that you've published, recently published some of this work in JOSPT.

[00:04:09] And again, we'll link the article in the show notes for people who are looking for more information than what they hear in our discussion on the podcast today. As I said, we did multiple phases of this study and multiple steps. And again, in the beginning of the steps that we had quite a lot of people, so almost in the first two surveys, we had almost 300 participants with different backgrounds.

[00:04:31] And then we did like a thematic analysis between those two surveys, where we also included patients and relatives and clinicians on board. And then for the workshops, so the kind of the last steps, we had around, I think it was 11 clinicians involved in the first workshop. And then we have nine patients and relatives in the second workshops.

[00:04:54] And we separated these two kind of workshops to equal out like the power difference that there can be between those two groups. And that's also like based on our previous experience conducting these kind of studies. So, yeah, we tried really to bring people in with diverse backgrounds and also in terms of like duration of pain and conditions.

[00:05:17] So, again, for us, it's really important with these kind of studies that we receive as many different priorities as possible. And at least also as many opinions and experiences. Because I think this is also where the magic happens within these kind of studies that we can enrich the discussion of the priorities for any given field. But in our case, it's shoulder pain.

[00:05:45] It's such a huge amount of work. And I want to say congratulations and thank you for taking this work on. It leads us perfectly to talking about what were the group's priorities? What did they tell you that they wanted to focus on and know about, about shoulder pain? It's really interesting to see how the paper has already been receiving a lot of recognition on different platforms. And I think our idea in the beginning was like the top 10.

[00:06:15] That must be the things that is most interesting to people. But I think that the top three is the one that really encouraged people in the discussion. So, I think what I want to say to that question is, I think that if I can say it very briefly, I think we are at a time now where our patients actually want more from us. And when I say us, it's mainly researchers. And then after that is the clinician.

[00:06:43] So, the top priority, the number one was about transferring or translating our research into clinical practice. And I think that's just so interesting that this is the top priority. Because I would say, as a researcher, yes, that is at least some of my top priorities with my research. But actually also realizing that this is also something that our patients actually also care about.

[00:07:10] And I think that speaks into so many different things for the patients in the future, that they actually want to be more involved. They want to be informed. So, they can also take a decision on an informed basis. So, I think the first and the biggest story I would say is that we have seen a change in how people, patients perceive themselves and how they want to be involved. And that is one of the main outputs from our study.

[00:07:38] Then we still have a lot of research to do in terms of also investigating what is the best strategies for managing shoulder pain. So, in our case, it was still surgery. And I know there have been much research on this area within shoulder pain.

[00:07:53] But I think it's important that, again, going back to the transferring knowledge into practice, I think our study kind of still shows that we have a lot of work to do in transferring all the knowledge, all the insights that we have gained from many recent trials, well-done, well-conducted trials, and actually transferring those out to clinical practice. I think that is the main takeaway analysis for me.

[00:08:22] And then I also think there are, like, within both the top 10 and also the top 25 list that we derive from this study, I think there are so many priorities that are novel to this field, which I think should be recognized as well. And I think there are also for shoulder pain in different conditions.

[00:08:46] So, I think it's great for us that some of the priorities that we've seen is actually already been taken up from researchers all across the world. And I think this kind of just backs up that we, in one way, need to do something different and we need to head new ways. So, it's just been really, really great to see how patients and clinicians have been telling us these kind of new stories. For sure. It's so interesting.

[00:09:16] And your comment about people wanting to know more about managing shoulder pain, particularly around surgery, got me thinking about who the patient populations were within your research project. Because when we talk about atraumatic shoulder pain, that can cover a broad range of different things. And I'm thinking particularly if we talk about rotator cuff tendinopathy, there's been quite a lot of work, I would say, saying subacromial decompression surgery is really not the go-to here.

[00:09:45] There are other populations within atraumatic shoulder pain. So, can you tell us a little bit about who these different patient populations were? And that might help give us some sense of where people are coming from when they ask about managing shoulder pain. So, that's a bit difficult because we didn't really collect that specific information. But if we have to go back to the phases, like the first two surveys, they were purely reported from the participants.

[00:10:11] So, we didn't really include any diagnostics. I think there's just been too many uncertainties in relation to that. But I can say that they were asked, what do you think we should prioritize in the future? And those kind of questions, I and my research team and a couple of patients and clinicians had to go through these statements.

[00:10:35] And from those, I'm quite certain that most of the participants either had frozen shoulder or rotator cuff tendinopathy or subacromial pain syndrome or what we should call it. So, again, I think that those are the two main ones. It highlights that if we are quite certain that these are the two different populations that were mostly involved in this study.

[00:10:59] I still think it's really interesting that the surgery part in our study, we were also quite surprised by that. But the surgery part actually was so highly prioritized. And I think that is really, really interesting because I think we have had so much good work that can actually give us a better answer in terms of who should have surgery or not. So, I think that's quite interesting to say the least. Yeah, for sure.

[00:11:56] And I think some of the things that you can gain from our study is also, and I think it's a bit of a stretch, but I still think it's okay. But we sort of get an insight in what is it that our patients are actually asking of us. What is it they are interested in? What are the questions that they are interested in getting the answers to?

[00:12:18] So, I think for those who are not really orthopedic surgeons or something like that, I think addressing that our patients, they probably have questions relating to surgery or other modalities. It can be both the alternative therapies and so on. And, like, addressing these kind of thoughts and beliefs that our patients have in terms of that.

[00:12:46] I think that is really, really interesting. And also, like, again, the self-management, the patient education as a priority for our patients and clinicians. I think, again, it's important to say that we probably need to be more focused on these kind of things in our clinical practice.

[00:13:06] So, I think that is one of the main messages, that even though you can't do any surgical treatment, you still have to talk with your patients about it in a non-biased way. And then try and see what is their, like, preferences and needs and beliefs about surgery. And is there anything that you need to address there? And I think, I don't think we are, we're not focusing too much on that in current care.

[00:13:32] It's such a central component of shared decision-making, isn't it? Knowing the breadth of the evidence for all of the different options that might be available for treating or managing this shoulder pain. Injection therapy, I would imagine, is another common thing that people would want to hear about. You mentioned, Christian, this idea of partnership with patients and researchers in particular, and I would add clinicians in that mix, in terms of translating research into practice.

[00:14:02] How do you think about doing that, both as a researcher and as a clinician yourself? So, again, I think, if I can say, like, one of the main messages, other than just, like, we need to transfer knowledge, is that I think, I hope these, and my study, including these kind of studies, can be, how can you say, like a trampoline or a stepping stone for creating better partnerships in the future.

[00:14:28] So, for us, it's having a reference group that we kind of have, like, scheduled meetings four times a year and sometimes even more. Just to hear, like, are we doing something that is actually, like, interested to you as a patient? Is it something that's meaningful? And I hope that we can see this, like, much more in the future. And I know, like, in JSPT, to think about these things.

[00:14:54] And I think that's really, really, really, really good because I think it has been needed. Because I think we have seen, at least in this field as well, that much of the research that we have been doing hasn't really been meaningful to our patients. So, I think right now, instead of getting more research waste, we actually have to ask those who are suffering, like, what is it that we need to fix? What is it that we need to focus on?

[00:15:18] So, for us, it's really, really important to have these kind of partnerships where we are facing the people that we try to research for, do research for. But it's important for us. It sounds a lot like recognising the value and the inherent knowledge that patients bring about their own health and that that's really important knowledge on equal footing to what you're bringing as a researcher,

[00:15:44] as opposed to what we might have done in the past, which is very paternalistic, saying, we think this is important, so we're going to study it and then we're going to tell you what you should do. And I think, again, some of the things that we gained from this study was also, like, the patients know so much and they are willing to be engaged more. And that kind of personalistic care is, it's like, it's really, really outdated.

[00:16:09] And even though that as a clinician, we sometimes, and I did that, I heard that before, that some of the clinicians say, like, ah, I kind of got the feeling that they didn't really want to. And I have never really, or at least the literature doesn't really tell us that that's the case. It's just that they have difficulties in conveying that they actually want to or seeing how they can actually contribute to their own health.

[00:16:33] So I think our study just shows or at least confirms a hypothesis that our patients, or at least the future patients, they want to be more actively involved and they don't really like the paternalistic care anymore. Christian, you talked about your work being part of a springboard and you've been springboarding off earlier work. You're going to springboard to future work.

[00:17:00] So tell us what the future looks like for the work you're leading and where you see this area of managing atraumatic shoulder pain going, particularly when it comes to more authentic partnerships with patients and with clinicians. It's a twofold question there. So for my own sake, there is probably a lot of validation work that we need to do.

[00:17:23] So obviously our study was done on Danish people, but with often not the most diverse background. But what we're doing right now is also trying to validate the findings in ethnical minorities, in different groups that we often know doesn't really get a voice in these kind of studies. So that is one thing.

[00:17:47] Another thing for me is also my PhD is actually based on one of the priorities. So my PhD is about shared decision making. That's why I'm a bit biased towards these kind of things. But this is actually something that directly was out as a spin-off from this study. So early on, we kind of realized that shared decision making was not on the top 10 list, but it was within the top 10 to 5 list.

[00:18:12] And if I can also say that, we really encourage other researchers and clinicians to just say, like, look at the lists. And even though we have kind of rated them based on voting and so on, we still think that the top 10 to 5, they are still equally, still really, really important. So we need to answer all of the questions. And I think that also leads me kind of to where I think we have to move towards for the entire field is that we can start by saying, like,

[00:18:42] is there any priorities of our list that as a person, as a researcher, as a research group, that we have the competencies to actually do something about and then try and do something about them. But please do it together with patients and other stakeholders. Involve them, take them to your meetings. And I know sometimes my fellow researchers, they are often afraid that it costs too many resources.

[00:19:08] And maybe it does in the beginning, but my own experience is that quite, quite soon after the first couple of meetings, they contribute as equal partners as everyone else. So I think it's just been so meaningful for us. And I think other researchers would probably feel the same after just a couple of meetings that it's meaningful in so many different ways. For sure.

[00:19:34] Now, Christian, I can't let you go without talking a little bit about shared decision making. We've got someone who's doing their PhD on shared decision making. We hear a lot about shared decision making in musculoskeletal rehabilitation practice in all areas of healthcare. Really, it's become much more prominent. What are your messages?

[00:19:52] What would you like clinicians listening to us today to take on board about shared decision making, how to do it well, how to think about approaching shared decision making in clinical practice? It's not the easiest thing to do. It requires a bit of a shift in mindset. So how would you suggest people go about implementing shared decision making or embracing shared decision making in their practice? And that's a really good question.

[00:20:21] And that's basically one of the key points of my PhD. But I think from a personal view, don't be afraid to fail. I would say like studying the field, I haven't come across the one definition of it all. So I think I want to say that when we don't really know exactly what shared decision making is, we still have a quite good idea about what it isn't.

[00:20:46] And I think that that should give some encouragement to just try and be more active in terms of engaging the patient. We have done few studies where we have observed like the clinical practice. And we can actually see if we were trying and do better in shared decision making, it's oftentimes just a few questions that we need to do better. Trying and ask the patients about their preferences, about their beliefs, about their needs.

[00:21:16] Before talking too much into me as a physiotherapist, do we want to do exercise? Try and ask them beforehand, like what is it that they want to do? And also try and ask for what they know. What is their opinion? Do they have anything, experiences beforehand? I mean, oftentimes those sort of questions, it's my experience, lead you towards more like shared decision making centered approaches.

[00:21:43] So again, based on seeing how we are actually doing it, like we are much focused on and I completely get why, but we are much focused on getting a diagnosis and getting to the talk where we can say like, you have to do this, you have to do this. Or if I can't give you anything, please move forward to the next mission.

[00:22:01] And I think in that process, we need to do like a bit more digging in terms of what is it they're actually thinking and what is it they want out of it and asking them to say like, what fits your schedule? What is it that, can I tailor anything around you? And then try and be more weight for their response and also be patient enough to not always try and answer everything.

[00:22:27] So I think those are my clinical tips, I would say, to be more involved in shared decision making, but do not be afraid to fail. I think trying to be more kind and polite is also moving quite far towards the decision making. But it's difficult. It's really difficult. And again, I can see we have tried multiple interventions for actually helping both clinicians and patients.

[00:22:53] And hopefully very soon we can reveal those kind of results. But I can say that it looks like it's quite promising that with quite simple tools, we can actually get patients more satisfied with the shared decision making process and also making clinicians more comfortable in actually being more centered around shared decision making. What a great place for us to finish. Positive messages. There's hope for the future.

[00:23:21] Being humble and patient as clinicians. Christian Leung, thank you so much for joining me today on JOSPT Insights. And thank you for having me. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice,

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