Hey everybody and welcome back to another edition of the Physiotea's podcast. Today we have with us Philips Throwff, a physiotherapist, a researcher, an educator and the man behind our shoulder course as well. Now before we dive in I wanted to quickly mention this episode of the podcast is sponsored by our friends over at Kinvent, a company dedicated to helping you measure and track your client's progress, giving you objective data on which you can use the pinpoint areas for improvement to better program your patient recovery. There'll be a little bit more on them later in the podcast. Philips, I've given really small little bite size bit about yourself. Why don't you take a couple minutes, give us a little background on who you are and what it is you do and then we can take our first dip into the water of the shoulder complex here on the podcast. Okay, thanks, thanks and it's also thanks for inviting me here on the podcast. It's always nice to spread a shoulder word in the shoulder world. Thanks for the intro and for inviting me. Shoulders are my job, it's my hobby, my interest. I even have shoulder pain myself now so anyway it's a big part of my life now. Just short, I did my masters in physiotherapy in around 2000 something like that and I did another Master in Sports Physioterapy in Belgium and then combined that always with clinical work. So that's from the moment I graduated until now I kept on doing a clinical work together with the educations and then after a while I started as a researcher in the University of Antwerp. I did my PhD there on the role of the scapula and insular pain patients most specifically and I always kept that combination of clinical work and academic work at the University of Antwerp in Belgium. Now, yeah, finally I'm a full-time professor now in rehabilitation sciences and physiotherapy in University of Antwerp and I still combine that with my clinical work. Although the clinic I'm just seeing shoulder patients now varying from top athletes to complex chronic shoulder pain to elderly after shoulder after-plastic. So it's the whole range of shoulder problems we see and it's just about half a day per week so it's not that much anymore. It's just to keep the foot into the clinic when teaching and researching on shoulders so I think that's a good balance. Yeah, however I do have a life besides shoulders, I have a wife and two beautiful daughters and a white shepherd. I told you about white shepherd and I also love swimming, walking, mountain biking so that's my part for dating science. It's not that the wife here that bit. Alright, fantastic. I think that's really important as well with the guests that we have on that you see that combination of not just being a researcher or an educator but also still in clinic in practice. As it like you say you keep your foot in that you keep your toes a little wet you big wet with it it just keeps you as up to date as your researches on how things really are in the clinic sometimes not everything is applicable and it lets you know straight away. Before we get dive and deep into the shoulder can you give us a little bit about what's involved in an assessment and diagnosis about a shoulder because it's quite complex even even now when I get in shoulder patients and I've worked with baseball I've worked with some of the guys that play for the Dutch national team in baseball as well but even then the shoulder still has me scratching my head give me a knee a head for an ankle and I'm there and the shoulder I still have to take a moment to really think hard about what's going on so what goes into that for you. Yeah yeah yeah it's a complex joint and not only a complex joint it's also a complex patient often it's not only about the joint so maybe that's my first thing I would like to highlight here is that when looking at the shoulder we may never forget that good shoulder function depends on both the shoulder and the brain there was this study a few years ago published in Nature that looked into the evolution of shoulder biomechanics through history and they stated that we developed some sort of specific shoulder kinematics just to be able to hunt on animals to feed ourselves on animals and they even suggested that the whole reason why we as humans are so dominantly present here on earth is due to the involvement of our shoulders giving us the ability to hunt and to survive so that was quite a strong statement there in these articles a great study by the way anyway you can imagine that the brain scientist got a bit angry there and said well it's not only about your shoulder and they counter them by stating that pain comes from the brain the shoulder kinematics depend on motor programs in our motor cortex so it's all depending on the brain it gives rise to a beautiful but maybe if I can use the words stupid discussion which of both are most important so you can get you can guess where the discussion ended both are needed for proper shoulder function and I think that's really an important thing we sometimes tend to forget so if you ask me what is important in shoulder assessment then this will be my first and main advice shoulder needs both an ephymne biomechanics and a well functioning brain so and this is relevant in each patient so some might seem a bit more biomechanical problems and other small brainy problems but it's always important in each patient if you focus on the shoulder more specifically then of course the shoulder is more than a glenoyomeral issue it's a glenoyomeral joint but it's the scapula thoracic also the scapula in relation to the humorous has been subject to many studies the last decades and then also the acromioclavicler I have the impression that this is the joint that's also very important that we tend to forget or we tend to put the acromioclavicler joint in some sort of it's only traumatic corner while it's definitely is not there are really a lot of atromatic chronic ac problems that look like rotator-caffeinated problems but are aren't so there's a big thing here with the ectromioclavicular joint sternoclavicular neck thorax elbow etc and I say it quite fast but they're also important in the whole picture of the patient and we can use that in our diagnosis in our assessment we can use the whole movement pattern to see okay is this a tenderness problem is this a capsula problem what is really going on and in my opinion one of the most exciting things as searching for the patterns and especially searching what you can use in your rehabilitation strategy to get the patient better I think even more important than trying to find the exact structure that's maybe damaged so I'm for instance not bothered whether the supraspinators or the infraspinators is has a tendonopathy that's actually not so much I don't bother but I would like to know it's a tenderness problem or a capsula problem for instance or an article a problem that's important but for your rehabilitation it's it's more important to know what type of structure it's is important rather than the exact structure I think and then you've got other tools in which you can use in your assessment like symptom modification tools if you like but also just a trial error with an intervention with loading of structures and this all fits within the assessment to get the right dose of your intervention there and well that's my main thing I would like to emphasize here it's about the brain it's about the shoulder and if you look at the shoulder don't forget it's more than a clean or your moral joint and we tend to forget that but in your good visual observation you need to assess capital thoracic for instance very well to check whether there are any compensations in relation to the glenarumal joint for instance so this is like that basic part of the assessment that you taught in school of when someone's going through the painful arc for example watching the scapular thoracic movement there what is it that we're looking for there how important is scapular movement how much can we do for scapular movement if you get somebody in scapular movement and scapular discineases has been the topic of my PhD I've been in I think between 2005 and 2010 something like that it was at that time I remember I had a good supervisor and I asked my supervisor what's topic can you guide me and he said okay I'm a specialist in chronic fatigue syndrome fibromyalgia and I'm also starting my research in scapular discineases so it's up to you and at that time I think it was 2004 something I was thinking oh no I'm not going to do fibromyalgia or chronic fatigue syndrome research because imagine after five or six years of PhD they start discussing the relevance of it I couldn't believe that would be possible so I chose scapular discineases now 2020 and 2021 sorry and they're discussing the relevance of scapular discineases so it's it's bizarre turn that the whole thing as made it's really a way and while chronic fatigue syndrome and fibromyalgia are still a thing well scapular discineases is now under debate so that's yeah that what's happens I'm confident that scapular thoracic joints or physiological joint is important in well functioning on the shoulder that's really think something that's important and we cannot confuse that with the fact whether or not scapular discineases is predicted for shoulder pain or not for instance because that's another sort of discussion it's important for shoulder functioning but if we see something different on a scapular discinease or tilting of the scapular, a winging of the scapular then we tend to think that this is whole the whole reason why someone has shoulder.
pain. And we did for a long time. We did a lot of studies in case control studies and we saw that these patients with shoulder pain had scapula discineses in the and the subject without shoulder pain had less scapula discineses. Not saying none but less. And then we, okay, so so scapula discineses was the whole thing, the whole cause and basis of shoulder pain. But after a few years and actually especially after a few good strong longitudinal trials in which we followed healthy athletes, healthy subjects with scapula discineses, we saw that well after a few years, they did not develop shoulder pain. Not more than someone who didn't have scapula discineses. So actually from the last evidence we have in the last five, six years, we see that this whole scapula discineses isn't maybe the one that's predictive for shoulder pain. And maybe it's the other way around that the shoulder pain itself has an effect on the somatosensory cortex and has an interaction with our motor cortex. And maybe that's the reason why first of all, the scapula thoracic muscles have different activity. But also maybe this whole scapula thoracic joint tries to help the cuff to get the shoulder where the patient wants the shoulder to be. So maybe the patient that has problems with his cuff has extra help from the scapula to get there. And then we see scapula discineses and we think that's the whole reason for the pain. But well, that it can easily be the other way around. So we also see that in as you just said, the painful arc, which is often for the, okay, you've got a pain flask that's because of there is a reduced supercromial space between 60 and 120 degrees of abduction. That's the reason for a pain flask. That's also something that is under discussion now in which we think, well, maybe that's not the case. And maybe it's not the supercromial space that's reduced in this 60 between 120 degrees. But maybe this position has the highest load on the cuff because the arm is actually almost that when it comes at 90 degrees, it has the highest load on the cuff. So maybe that's the reason why the patient has the most pain in that position, rather than an extreme position, extreme abduction or in just relaxed position. So we're a lot of explanations we had in the past are now under debate and we start to rethink them and we start to have a feeling of some sort of more common sense, more logical look on the movement of the shoulder and we see it okay, no, it's not that simplistic, it's not just the scapula that develops shoulder pain. It can be the other way around. It's not the pain flask, that's not because of the supercromial space, it's not because of that region that maybe is reduced or not. No, no, it can just be the load on the cuff and we are rethinking some of these rationales now and I think we're making more sense than we did 10 or 20 years ago, a lot more sense. And we see that also in rehabilitation, we have a more stronger rationale for exercise therapy rather than 20 years ago in which pain was from supercromial space and now we know it might be just an intrinsic tendon related thing. Okay, great. So that's a little bit about the scapula. Now can you talk us through what your assessment strategy would be when you get somebody in? I think you mentioned a couple things there, biomechanics, you've mentioned the joints or you've mentioned looking at whether it's a tendon or an articulation or the capsule. What's your strategy in going about evaluating and eliminating all these different things or ruling in or ruling out so to speak? Yeah, well to follow upon my previous talk about scapula, it's also in this part of the discussion that there has been some changes and we we focused a lot on special tests over a decade ago or longer even actually from 1970s when the whole supercromial space decompression theory was there then we developed a lot of special tests and we thought that was the golden bullet. We now know that actually these special tests aren't so special and they're maybe not the thing you should use in your clinical reasoning. I believe it's not easy to let go of the special test concept. I agree that's not that easy and maybe that's because that would mean that we need to reason more, we need to think more. If you let go of the special test, we need to use our own clinical reasoning more and also the uncertainty rises again and that's not something we like as a clinician or as a person at all. That's not something we like and it's a but it's a normal reaction but as you say it doesn't always make sense any more to rely on specific tests. It can be an interesting way to provoke typical pain in your clinic and for instance if you want to use this testing combination with symptom modification procedure or if you want to score pain or do an evaluation over a period of time but using them as a gold standard for your diagnosis appears to be tricky. Especially if you want to use pain as the outcome measure. Pain is we know that in the in chronic pain population it's not a most reliable outcome so it's extra tricky and we see that the diagnostic value of tests that doesn't use pain as an outcome such as the apprehension, inshoulder apprehension relocation release tests while they they're significantly better than when we use pain as an outcome measure. So that's the first thing and then of course these tests have been developed to find to track supercromion compression. We now know that maybe this whole compression theory doesn't make sense anymore so what are you searching with these tests? What are you looking for? If you want to find compression you use some special test for that but compression is not the issue anymore then you're actually searching for something that's not there and then of course then the validity of your test is gone. So that's actually something we took a swing away from the special test now and we're looking at okay which structure is damaged now and we look at the patient we go for screening for a history taking of the patient to make some sort of profile of the patient and we know that okay maybe this for instance is a more tenderness problem we want to rule out cervical issues we rule out articular or capsular issues like frozen shoulder we rule out trauma course and dislocations or linear instability and we actually know okay if we rule if we rule out all these more articular capsular things and there was no trauma and it's not a cervical thing well the likelihood of being a tenderness a rotatica tenderness problem is it gets very high of course then you can use provocative tests just to provoke the typical pain and then you use your interventions but maybe on this way of eliminating some of the other diagnosis makes your likelihood of a rotatica related shoulder problem much much higher and we start to think in terms of probability of likelihood rather than you do that test okay he or she has pain it's a cuff problem we flashed that but if your special tests are coming further towards the end of that assessment then what are you starting it off with what is your basis for your clinical reasoning now you mentioned there your patient history you mentioned the obvious things like a trauma you know if someone falls and they fall dislocate their arm or they have a fall and they sprain their ac joint I know you said don't think of AC is just a traumatic issue but just for for I'm going to say for example how are you then going to systematically go through it are you looking at range of motion are you looking at functional movement are you looking at the what you mentioned earlier with the brain connection to the shoulder are you looking at the movement in the kinetic chain how everything's working together how would you structure that it's a good question but it's not not so easily answered actually but when you got your patient each way you you go through clinical reasoning changes a bit depending on which patient you have for you so I don't think there is this this gold standard way of looking at each patient the same way that's that's difficult I think but I go for a search on which type of structures are mainly giving the patient complete such as stand-in-us article or capsules so I don't so much bother the exact anatomical structure so whether it's a super spainators or an infraspinators I don't really care and sounds a bit bizarre maybe but I see that my rehab strategy doesn't need the info to be successful so my rehab strategy doesn't need the info is it a super spainators or a infraspinators if you track the the patient saying you just let the patient move and let the patient tell you which movements hurts and and explain when they hurts what reduces the pain what increases the pain gives you a good picture a good idea of what direction your rehabilitation strategy should go towards so for instance very very clear example if you're certain okay this is a tendinous problem this is for instance a an office worker who has done too much gardening and he tells you he has a shoulder pain since he worked in his garden and it tells you okay I've I've some pain at night and and and and just wake up sometimes at night when I lay on the shoulder and and in the day when I move my arm when I try to take something in the kitchen or whatever it hurts and you have excluded these other factors like trauma cervical frozen shoulder etc and you know there are no very relevant red flags in this patient well then actually then you can can can just check which direction the patient has his most pain so if it tells you oh in the flexion and the flexion forward flexion I don't have any problems but if I go in a scapula a plain direction
then really that's my typical pain around 90 degrees. My pain starts until 120 degrees. That's the most painful area. Well, then actually your patient has just told you which direction your exercise should go through. So I don't need an EMG, for instance, to tell me which exercise I should give my patient. My patient just told me if I do end the forward flexion, then I'm not loading my injured tissue. So then you can question yourself, what's the whole idea of doing a lot of forward flexion exercises. It's okay if you want to do that, but it will not target the injured structures. But if it tells you okay it's in this capital of playing that martial or hurts, then you know, okay, in that direction targets the injured or damaged tissues. I don't know whether it's the stupraspinatus or an infraspinatus. I still don't know or maybe even the biceps. I don't know. But if I do that, if I do exercises in that direction, and of course, maybe I just downsize them and make a shorter lever, leverage or whatever, or in a different position, I just downsize them for a while and then start to rebuild from there. But actually, I know which direction I should train with him, in which direction I should should load his shoulders. But still you have to let go the fact that you're not 100% sure which tissue is the most damaged here. You don't know that and well, you need to accept that, I think. And that's maybe a difficult step. But I see that you don't need to know that. And if you have a good training program with your patients, and you do a really good follow up, make the patients really motivated, compliant with the size, and you can focus on that. Well, you can put all your energy on that. Then you have the best way, the best chances of getting a good outcome in these in these patients. And whether it was a super spedial or a reenforated, sorry, don't know. You can even have an ultrasound in which shows that the super spedial is the more damaged and the infrasperate is not. But still the pain can come from the infras and not from the supra. So, but that's for me enough to say, okay, I don't need to know it. And I can use the functional testing and adjust the analytic testing and functional testing to show me what way I should go with the exercises. So that all but eliminates the. I suppose there are lines in the need on that special testing. So why do you think it is that we're still taught it in our universities. So you're a professor, you're teaching at the moment. Is it part of your curriculum for special testing or have you. You know, it coaxed the university to start moving the special testing at least for the shoulder stuff out a little bit. And what do you think is the reason that we're still so focused on it because it was drilled into us. We got the whole formula of impingement or what. So have you internal external or all the rest of it for the for the shoulder complex. It was heavily drilled in. What do you think so rationale behind still given the old hat to the new new school. Yeah, well, I can understand that for students, it's it's it's much easier to rely on a test and the test says yes or no. And then you can like in a flow chart, you can go towards a diagnosis. It's it's much easier than then telling them okay, it's about clinical reasoning and just about thinking how the patient moves and what the patient needs. It's it appears to be some scary than then just using a simple simple specific test, which is says yes or no and then follow your flow chart. So I think that's partially the reason we thought the special tests for a long time in the curriculum and then I think about five or six years ago, we explained to the students that this special test weren't that special. But well, we weren't the only ones who teach to the students. So there were also what the paddock surgeons and also other teachers in which they still had the special test so that the students got confused a lot. And we saw that there needs to be a if for an education, you need to be on the same line with all the other teachers also from the ones who give practical classes and the ones who give lecturing and at stress, so you need to be on one line. We see that it takes a little bit of time to get everyone on the same line, but now I think we're there and we only mentioned them anymore. So we mentioned special tests so that they are aware of them that they know how they are performed without the fact that like in their masters, they don't don't need to perform them anymore. They need to know what's happening there. What is a clinical specific test? What is a special test? What is a near test? The Hawking is an empty can. What's what's that because sometimes they will reach reports or they will be asked from another clinician who tell them that they were positive on some special test. It's good to know about that, but we still train them to be critical and to be aware that the clinical properties are not that good for these tests and you need to rely on your clinical reasoning and sometimes use a way of exclusion diagnosis to get there and we teach them, but still I must admit we also still teach them and tell them which tests are there and how they are performed because they still need to have that knowledge, I think. Also, that's maybe an extra thing we sometimes use these tests as a standardized way to provoke typical pain and in that way it might be interesting and it might be interesting to use that test as a pain score and then use it as an evaluation after a few sessions or you can use them in combination with symptom modification tests in which you adjust for for instance, and see whether it affects pain on an empty can test or not and it can give you some extra information on where to go from there. So it's not all bad about this special test, but we need to use them in the right way and not in the way we do a test and then if it's yes you got the data for each other pain, if it's not painful, you don't got it. So that's too primitive and that's something we need to let go. Yeah, okay, fantastic, there's quite a thorough answer there is to the reasoning rationale behind still having to keep them just to be able to play ball with all our other partners in crime and healthcare and making sure that we're critical enough to evaluate what's relevant, what's not. So yeah, exactly fair. So just stick into the assessment bit before we move on a little further what key indicators would you say for someone to look out for to separate between tendon articulating structures or capsula what are the key elements that someone should look out for in their history taking or their physical assessment. Well, if the patient has tenderness problems like rotateica related shoulder pain. This then it's the way the patient explains their shoulder pain should be in some way, load related should be a load related to for instance, if you do passive testing, most of the rotateica, for shoulder pain patients are not reporting that much problems with passive movements. Sometimes with stretching of self of part of the cuff, then you can have some provocation, but mostly they don't they don't have problems with that. So it's mostly low related if you give them 1 kilogram and you let them move and you give them 5 kilograms, well, the five should hurt more than one, for instance, but it's maybe a simplistic example, but it's loads related and frozen shoulder patients if you give them 1 kilogram or five, well, that doesn't really matter. It will hurt anyway, even passively. So that's a big difference. It needs to be low related in in tenderness tenderness issues. If you look at more like frozen shoulders or our choices are also try this patients, there is a different profile of the patient also, I think. So, for instance, the frozen shoulder patients, they tend to have a specific age. First of all, so they'll around their 50s, which is not the case for tenderness problems, they can be 50 or, of course, but they can also be 30 or 40 or whatever. But the frozen shoulder, they tend to be around 50, they tend to be women, or also about 70% are women. They tend to have comorbidities like diabetes, thyroid problems. They tend to have all these whole cluster is this profile is a bit different. It's also often the non-bomberment inside, while rotator cuff related problems are mostly on the dominant side. While frozen shoulder can easily be on the non-bomberment side, and well, that gives you, like this bizarre feeling inside, from OK, this is not only a tenderness issue. Although, a lot of patients I see in a clinic that are frozen shoulders are actually actually first got in the practice as rotator cuff related problem, and because they just had pain, they had pain and they had pain with movements and they were giving this the stamp to diagnosis your rotator cuff related problem. But then you see in the patient's profile that they are in the patient's reaction on intervention, for instance, on therapy, on exercises, they don't react well on exercises. Frozen shoulders, they don't tend to react well on increasing the load of your exercises, while if you give a rotator cuff related patient and some exercises, then very often just by moving their shoulders, who would await the pain is reduced after a while, they get this hyper-well-gisia, induced by exercise, which is not the case in capsule or issues, then they just get more pain and they tell you a few days later that they, they turn it like hell, your exercises and it's not getting better at all, and they tend to reduce their range of motion, etc. So that's one of the first things you see in this rotator cuff related patients that are probably not rotator cuff related patients, but frozen shoulders.
And then you have to switch a little bit to a therapeutic intervention that's not that's more focused on the tissue irritability of the patients in this for a shoulder patient. So yeah, it's it's based on load. I think that's an important one for tenderness problems, the past of restrictions that are for instance, in frozen shoulder patients are can be capsular together with the cuff and our for instance, if patients moves towards abduction. And you ask an external rotation together with abduction, then you will see that in the in the neutral position, their external rotation will be bigger will be larger than in 90 degrees of abduction. The external rotation will be reduced if you have extra abduction that's typical for for capsular issues while in a tenderness problem, often patients have maybe some reduction in external rotation, but if you go to 90 degrees of elevation, then suddenly their external rotation increases. So that's not typical for frozen shoulders. So in that way you can also distinguish more capsular issues from tenderness problems that few examples which you can use. So it's a little search, but that's the exciting. I think we're not using one simple special test, but it's a bit of a search in which you try to unravel the the pain problem, but most of the cases it's it's possible to distinguish them. So what are the most common pathologies that you would see then or mechanisms of injuries that you'd see coming into clinic, as you mentioned, you see quite a wide variety of patients from your pro athlete all the way to Joe blogs on the roads and he's got a chronic issue. Well, both in in the clinic and research, I think the rotated problems are the most most seen. There are the largest group, although they're not always the same, they're really not the same problems, but they're there a big group of course in which you sometimes have like athletes with long head biceps tenderness problems. But then also I exist 45 year old, office worker who has a super our infrastructure, and it's tenderness problems, which often the the overload is the issue or actually and I lie away. And tendons specialists now like to refer to it as it's not it's maybe not the overload, but it's the under load to the years before it's it comes to the same conclusion, but it's a good way to see it they often they often done very few with their shoulders and then they do something with their shoulders and they have a tendons overload. There are the biggest group I think also many frozen shoulders also see a little bit more frozen shoulder and then usual maybe it's the covid area now a covid period that's giving more frozen shoulders I'm not sure it didn't do a study on that relationship yet, but I see a lot of frozen shoulders and sometimes coming in the clinic as two separate diagnosis like you got a frozen shoulder or you got a circulated shoulder pain, but also as I said previously sometimes a rotator, a circulated shoulder pain patient comes in the clinic, but goes out with a frozen shoulder and not that we create frozen shoulders, I hope. But but the pathology looked like a rotate the cafe problem. A lot of the while it gets clear that's more frozen shoulder type pain so these two together are the biggest group, but besides these group I am I forget complex chronic shoulder pain problems in which they have more than only shoulder pain these are often younger tend to be more women than men younger women who have also have a busy busy life besides their work they have a busy family life or whatever, but I see elephant cities complex patients in which we tend to think about central sensitization in these in these patients and then we will see is we see also post trauma patients shoulder, arctic blast is instability all the rest, but the major groups frozen shoulder and rotator, the circulated shoulder pain by far. Hey everyone, I hope you're enjoying the podcast so far. I just wanted to take a little break there to talk to you about our sponsor, Kimber. I've been using one of their devices, the muscle controller, a handheld dynamic meter in my practice for the last while now, and it's been a bit of a game changer for me as it's easy to set up on your mobile to help you track and trace individual patients and monitor their progress as well as identify in areas that they may need little extra attention on. The app itself is really intuitive and can help with patient motivation, I'll leave that bit for you to discover yourself as well as providing many quote unquote games that you can use for your patients and many protocols in there for your assessments. There's a reason why they've been adopted by professional sports clubs and universities around the world. They've arranged a different products to aid in your assessment and evaluation for your patients and you can check them all out over at k-ythaninvent.com and have a look. And if you do, use the code PhysioTutors5, check out for 5% off. On top of that, I wanted to quickly mention Phillips online course that he's done with us, RotatorCuff related shoulder pain, separating fat from fiction. There, Phillips goes in depth on the latest shoulder research and rehabilitation, what is and isn't useful anymore. As we mentioned the podcast, why special tests might not be so special and exercises and little gems that you can take straight into your own practice on Monday morning. As this ends of the podcast, you'll get a discount code RCRSP50 for 50 Euros off. That's RCRSP50. So, RotatorCuff related shoulder pain. That's enough for me, that's the podcast. Step in forward a little bit. What is your approach to the initial stages of rehabilitation? You mentioned earlier about using weight for patients. How do you gauge what you're going to start with in terms of the load, be it weight, be it fairer band or what have you. And then my next question on top of that is then going to be about how you progress, but yeah, let's start from the start and talk about how you get cracking with the patient. Yeah, yeah, that's the important one. That's a good one and that's because I previously talked about exercise about load, but actually that's not that that's not the first step, but I'll take the example of a RotatorCuff related shoulder pain patients for now. In case of this RotatorCuff related shoulder pain, I start with explaining what's going on. I answer questions, questions they asked, but even if they don't ask it. So the questions they don't ask also what is going on in my shoulder, what's happening. They want to know what's what's the reason for my pain. It's the first important question you can address and explain about tendons that need to control the the humoral head a bit and there can be overloaded and they can give rise to pain. So you give an explanation about their problem and you can explain where, where does it all come from and maybe you can. So in case you can find some sort of reason like they did too much a painting in their house and they're not used to it or they just went to the fitness and they're not used to it or they were athletes, but you to COVID they did nothing for two months and then we started at the same level and then you can explain why they have overloaded their tendons. So you can explain why they are if they want to get to the same level and they restart at the same level as two months before yet why they have overloaded their their structures. So let's the way where does it all come from, but then I also try to answer the question how long will it take some patients will ask you but a lot of them won't and they but they think about that, but how long will I be hearing the clinic, how long do I have to train before my shoulder pain is gone. And then I think that's an important question and then a question that we address mostly as okay if you for a typical flavor of pain and we will go for the for the exercises. It's usually at least three months that you need to exercise to do your exercise to get a significant result. And even after three months it might not be completely gone so they need to know some some sort of timeframe they need to know that it's not going to be gone in a week they also need to know that it's not about two three years of suffering note we know from research about 12 weeks three months in order to get a clinical relevant effect but it's important they know that because if they don't know that and and they just start training and after a few weeks they have the feeling it's not better. Yeah and they didn't know that it was going to take 12 weeks of exercise well they might think I'm not getting better after two weeks I need a second opinion and I need to go somewhere else who gives me a good massage of my my shoulder and yeah well then you not only got your patient out of your clinic but you didn't help him also so it's important to tell the patient how long will it take and what does his exercise regime looks like. So are there any things the patient can do at home what can I do at home what can I do besides being in the clinic here and that's also something I I address I explain them the home exercises they need to do I tell them and I sometimes shock shock them by saying okay you're now you need to do your exercise each day like two times each day and then they're like oh but my my previous physio said I just said to do my exercises twice a week for five minutes you tell me two times a day. I have to train like 15 minutes that's about a half an hour a day and then they're a little bit shocked and I always wonder why that why that is it's just 15 it's a half an hour for their problem each day it's nothing I think but it appears to be a shocking for some some patients anyway. The clinic show you can't do that no exactly. Are there any things the patient can do at home that's a question I answer and then are there any consequences for my work or my hobby.
There's also one I sometimes address. Some will ask you some wounds, but can I still go swimming? Can I still do my job and try to answer that question? So that's just a short but important start with educating your patient. So I believe, I really believe this short, but important part of education is mandatory. It's really mandatory. It can also be important, for instance, to counter wrong illness beliefs. If the patient still, when you're going to Google, it's a shoulder impingement syndrome. You see all the pictures of super spinatus cracking and exploding between the acromania and the urinal head. So they think, if I move my arm, then I will get my tendons encroached. So I will not do that, because I will get an impingement. So you need to counter illness beliefs that are like this impingement mechanism. And these things are so important, I think, to by explaining also, I think you build a good patient therapist relationship. That's really important. They make sure that they will not quit their exercises regime too quickly. Yeah, it builds confidence for the patients. So that's really my first goal. Now, next, I will start with planning the first exercises mainly depending on the pain pattern of the patient. This is sort of screening, searching towards the main, most painful movement pattern, as I explained previously, because that will be the basis for the exercises. I will then downsize these painful movements and create exercises that will load to injured tissue, but without creating too much reaction of the tissues and after loading. This all is dependent on the tissue irritability as a concept that comes from frozen shoulders mainly, but it's an important part is tissue irritability. And then when performing the first exercises, first physical therapy sessions, I also take advantage of the patient being in the clinic to explain benefits on general fitness. That maybe bizarre, I don't know, but I think it's really important than to take advantage of that moment of the patient being in a clinic to tell him, okay, it's in current gem to start or restart things they like to do, like running, cycling, walking, swimming, whatever. As long as they like it, this morning, I had a patient in the clinic. I think she was 23 years old. She was, she had athletics running all their all-in-life, but now she's shoulder pain and she stopped and she felt miserable. And I asked, why did you stop running? I said, well, if I run, I sometimes have a sore shoulder and that's why I stopped running. And well, that's one of the first thing I advised her is to restart running maybe from a basic level again, like to sort of start to run again, but just you can do that. And both apparently she got a big smile on her face, just saying, okay, I can restart my hobby, really I can restart running was the best Christmas gift I gave her, I think, for something like that. But yeah, that's, but it's not only for the motivation, it's also for the metabolic effect of running. It's this exercise induced hypoligia is a factor that's important. It's a really important thing, I think. So, and together with the exercise, I sometimes use manual mobilizations. I must admit that I use this often just to get a stronger bond with my patients. I don't know if that makes sense, but so mainly during my first therapy sessions after while these sessions are reduced and the impact of exercises are increased. But I use them, I think the importance of my entire piece mainly when there is a strong restriction in range of motion and you can do that together with your active exercises because I still believe that with active exercises, you can even get a range of motion better than with passive. But you can also, when the patient's in the clinic, most of the patient just comes once a week or once in two weeks in the clinic for a telegraph relief, shoulder pain. I am, especially in the beginning, I sometimes start with short mobilization session, but it's not that much and it's a way to ask the patient, how is he going? It's just the first, some sort of animesis again, just talking with the patient and I use these mobilizations for that and then he goes training. Yeah, fantastic. I find that myself as well. I try to limit the amount of hands on time that I'd have with the patient, the longer that they're with me. Yeah, in the first couple of sessions, you know, it gives it that analgesic effect a little bit and they're head that, oh, okay, it doesn't hurt that bad now. I can try the exercises, I can do it, they get that positive boost, all of a sudden for that first session, second session and then I try as quick as I can to get them as active as I can themselves so that we don't build in that reliance and if they have a setback, I do my utmost to not have to get hands on so that the patient doesn't get that belief in their head that, oh, there's pain, I need to go see them. No, for me, what I like to try to have with my patients is that they have this sort of manual for themselves of, oh, okay, this hurts, these are the steps that I can take to try and improve things and then if that doesn't work, yeah, go for a check again. And also just going back a little bit what you said there with regards to the patient education, that's so important. It's, I think just from my questioning, it's something that can sometimes be forgotten and it's great that you highlighted that 'cause I jump straight to what exercises do you give and then I pull back first and it's something that previous guest mentioned as well, explain the why and they will comply. If you explain what's going on, you get that compliance with them like you said, that therapeutic alliance is gonna be better as well. Didn't mean to rhyme it, but it did, hey, hey. And again, using that hands on time as well to just increase that bond with the patient and get that by and such valuable tips and tools for those listening, that fantastic. And you mentioned there the hands on techniques will be mobilizations, what type of mobilizations are you utilizing? But it depends a bit on the restriction of most of the rotator-caflated shoulder pain patients are not the biggest restricted shoulders. They sometimes have a more internal rotation deficit but I see that a lot of them have increased external rotation. So in case there is not really a reduced total range of motion, then I don't focus on that. Only when it's really reduced in absence of increased external rotation, I sometimes focus on internal rotation, range of motion mobilizations. But for the rest, it's actually nothing more than getting your hands on the shoulder and moving towards abduction with some little bit inferior translation of the humoral head. But actually, it's nothing big. It's a way of talking with the patient, getting actually it's more like, I see it as an extra educational part, which you can explain things, which you can give them new tips and tricks and then start with your training. You've increased the self-of-figuity a little bit and it's indeed like you say, you don't want the patient to be dependent on you. That's a tricky part there, but I don't have the feeling that the five or 10 minutes of manual mobilizations get the patient dependent on therapy actually. I don't have the feeling that's the case. Grant, do you ever use any adjuncts like shockwave, tens, complex, dry needle and anything like that at all? No, that's too expensive for me. I don't have all this equipment. And we do have them in the practice and then some colleagues sometimes use them, but actually, I don't. I haven't had maybe these type of patients in which I felt that needed. I'm not sure. I'm the feeling that the exercises itself has creates the window of opportunity for themselves. So the exercises reduce pain in which they can use to do more exercises, maybe sound a bit bizarre, but I don't have the feeling I need to use other tools for that. But silly, depends a little bit on what you're used to. I'm not of trained to dry needle, for instance. I don't know how that works, so I'm not doing that, of course. So if someone can use that and thinks, well, okay, this gives me a window of opportunity for doing other stuff, I will not discourage them. But for me personally, I don't use extra things. - No. - We've spoken about exercises getting people go in. How do you decide when it's time to progress their program? What are the milestones or key points that you use in their trajectory that you think, okay, cool. Now we can go on or, okay, maybe not. - It's subjective, partially. It's difficult, but it is important to increase load capacity of your cough. So when a patient tells you he or she is not really reacting anymore on exercises, I think it's time to increase, increase the load, change the exercise, make it more challenging, fun, change positions, whatever. I often refer to running training. So if you have sore legs for two days after training, yet that was too much. But if you feel nothing at all, for instance, when you go up the stairs and you feel nothing at all after training, you probably did too few. So, or it's mostly recovery training. But anyway, I use reaction at for intervention, a theory to progress or not. So if they don't have any reaction or a reaction it's just an hour or two hours after intervention. And there on the low irritability level, yeah, then I think you can increase. Purely based on the reaction of the patient. - I mentioned it earlier. What is the kinetic chain in the shoulder? And how important is it to train within the whole kinetic chain? It's something we often. and hear about within the lower extremity, what is it, what does it mean for the shoulder? Is it something related to that brain connection that you mentioned as well? The shoulder is just one joint within the chain of joints, getting the hand where the brain wants it to be. And that's actually the summary. So yes, the whole upper extremity, even in combination with the trunk and the lower limbs are important. After a few therapy sessions, when the patient understands his exercises, is able to do these daily exercises, exercise routines and understand reaction to an exercise, it's often time to include more and more of the whole body, I think. I find it also a good time to keep challenging the patient, making sure that they don't get bored by doing always the same exercise day in day out. This kinetic chain can make the exercises really fun. You can use all this, all the equipment you have in your practice or even without an equipment, but challenging the whole body during their simple exercises and putting them on unstable basis or whatever challenges the patient, extra challenges the patient, and it really makes it extra fun for the patient, extra motivated. And by the way, I always do the patient's exercises together with the patient. So I'm not just staring at him or her like you're in a zoo, like looking at a monkey in the zoo, sometimes the patient has that feeling he's doing his exercises and just looking at them. But I have the impression that if you just join the patient with doing the exercises, that this way of working gets the patient more excited about the exercises and more motivated and it also feels less awkward for the patient, of course. Of course, I've the advantage I'm only half a day in the clinic. So it's easy for me to do all the exercises with the patient, but I can imagine if you're every day in the clinic, it can be exhausting. But still, it still choose your patients then. I would say, pick your moments, big days and choose a patient to say, "Which you think, 'Well, this might give them an extreme pulse' and join them with doing the exercises, I think, yeah." Okay, great. Another really big difference is in the different areas of the shoulder complex and the treatment we should use. So if you're suspecting someone with an AC joint versus a granite humoral or if you're suspecting someone with a capsula issue, then someone who may have some connect chain issues with the scapula or something. Also a very interesting question and also not easily answered, I think. It might sound like more a movement philosopher now, but I believe we should start with the end. What does a patient need to be able to do? Well, here she wants to do. So if we look at that, if we look at the end, the most cases the patient needs to perform a muscular contractions through a certain range of motion. You can make it very complicated if you like, but at the end that what's important in the clinic building, building capacity for moving the shoulder joint through a certain range of movement. So that's that's the basis for all participation level issues for the patient. So and this is irrelevant of the type of shoulder pathology in some way. So in basis exercises are in my opinion is the most often the core of your intervention. However, each patient is different. Of course, each exercise is different. Each shoulder problem is different and let's not forget the brain which I mentioned in the beginning. So each intervention will be different, but still actively moving the arm through range will be the basis of all interventions. But of course together with this tissue irritability which guides the intensity of an exercise or manual therapy, the type of impairments can play a role. And of course, the pathoan anatomical diagnosis of course, and whether or not a structure was repaired operatively, of course, it's a that will guide timing timing of your loading, but it's not that you will not load. It's another timing. At the end, you will always load them. I suppose it's probably something I should have asked earlier on within the chat that let's say we don't really say subocromial pain syndrome now anymore, right? It's more rotator cuff related pain. You mentioned as well that there used to be the thought of the decreased space within the subocromial space was the reasoning, the rationale behind the issues. What is the reasoning now? What is it that's changed and what is it that if we're talking to our patients and if we're explaining this to our patients, what should we tell them? How should we define what's going on for them? The rationalist change from let's say a more extrinsic cause of their shoulder pain like it's due to subocromial space reduction or due to shortness of your back minor or whatever, and more going towards an intrinsic cause of their pain like your pain rises from your tendons or actually thought from the tensors from the brain, but it rises from the cuff and you have a disbalance between your loading and your capacity. That's actually the main focus I think about your explanation is about explaining that the pain rises from the cuff while loading in the absence of another restricting pathology. What do you think is it about your approach to rehab? That really separates out what you do from our other colleagues in the field. What is it about your approach? Do you think that's the able to give you these beneficial results with your patients? I'm not sure whether it's so different with other therapists in the field, but in simplifying your rehabilitation, which is not the same as making it simplistic, but in simplifying rehabilitation, I think your patient will be more involved in the rehab process. Your patient will understand what's necessary to get there, and this will massively improve compliance to exercises. This will improve motivation. This will give space for you as a therapist to focus on building a good relationship with the patient getting more motivated, building a good exercise routine, personalized to the patient's capacity and interests. You have time for that and you can really focus on that. There are so many advantages, I think, to it then. In the absence of any proof that the complex approach gives you better outcome, I really think we should choose that path. It gives you time to focus on the thing that in my opinion really matters and that's getting the patient motivated to do their exercise routines and getting a more healthier lifestyle, also if possible. What would be your top three tips for anyone who's getting into shoulder rehabilitation or wants to refine their skills with it? Make it complex, but then return to the basics. Understand the shoulder, I think that's the main thing. Understand the shoulder and look at it as like your favorite team sport. If one player makes a goal in soccer, it's not the keeper to blame at the end. Why do we use to look at the shoulder that way? It's never one structure alone. It's a team. Try to understand the team as a whole and make the shoulder better as you would make a team better. It's a whole team. They are defenders, the attackers, the keeper, even the trainer by the side, which is maybe your brain then. It's the whole team that needs to function well and don't stare at one player at a soul. That's maybe my main message here. I absolutely love that and I hope I'm going to steal that and use that in clinic so much. You're welcome. Thank you. Are there any particular learning moments that have happened for you? You've had a long career, you've also had your masters in everything. You've been working in clinic from the very start up until now. You must have some particular learning moments that something happened and maybe didn't go the way you quite wanted and after that something twinked for you. Is there something a little gem that you can share with the listeners? Yeah, maybe I had a long career but not that old yet. I'm 41. Sorry, I may have come out a little bit. That'd be longer. That's true. I've had a lot of learning moments and maybe it's not about a shoulder problem. I remember actually I remember low back pain patients. I believe I was 23 recently graduated and I had learned that chronic low back pain had a large psychosocial component in glasses and so I had this patient in the Netherlands. I believe I wasn't working then and I started to explain the function of the brain during her first visit but I wasn't really skilled to do pain education or I wasn't really skilled in the social aspect and getting the note knowing the patient better at also but what I didn't know was that the patient needs to be ready for this type of explanation and that and also the way you do so is very important. Again, I explained the role of the brain to the patient and guess what she never came to her next appointment. I'll never forget that and you need to bind with your patient somehow in order to get through some barriers sometimes and that's really some less than I learned that. So yeah, anyway, I learn every time I'm in the clinic, you learn different pain patterns, you learn about different ways of patients cope with their problem, you learn about different ways of patients report their pain. A six on ten is not the same in every patient it's at all and I also learned that making
mistakes is okay, that's the best way to learn so not doing anything, not daring to choose a certain intervention or load is worse I think so you will make mistakes but it's okay. Have you any particular reading recommendations? Reading recommendations. Oh, well I have a few papers on, I did one with Jeremy Lewis two years ago on the update of systematic reviews examining the effectiveness of conservative physical therapy interventions for supercriminal shoulder pain. 2020 in the internal for the bed exports physical therapy which is an overview of cuff rehabilitation evidence so together with one of these of Jeremy's papers in 2016 I wrote data cuff related shoulder pain assessment management and certainties also a good one. What are several, several but if you want just one or two papers just to get an overview of cuff problems I think you can get very far with these papers so it's one by Peter's in 2020 and the other one is by Lewis, Jeremy Lewis in 2016. Fantastic and as I mentioned at the beginning you're also the man behind the physiatures course for the shoulder separating the facts from fiction can you maybe talk to the listeners a little bit about that and yeah for those that are interested just so they can get a little bit of an overview about what they can expect from the course. Well the course is I didn't choose a certain concept to follow in the course it's really translating current evidence to clinical practice and I just start with the beginning with the assessment what does a rotating cuff related pain patient look like and what is it not what should your education look like what's what's the tenderness problem really from a histological point of view and then go from assessment towards what's the evidence now 2021 what's the evidence in rotating cuff related shoulder pain what should we do should we use some sort of tool exercise manual therapy whatever what's the the biggest evidence at the moment translating that to the final parts of the course is really focusing on that rehabilitation strategy like manual therapy and exercise therapy I remember we did we did a few days of filming in in in physioteur just to getting lots of exercises in there which you can pick from and use as some sort of inspiration with your patients to to train with and also a part on the scapular of course it's my PhD I had to put a chapter on the scapular in there separate the facts from fiction there because that's really an important thing and it's gone through a whole evolution but we're maybe getting there with the scapular so that's also a thing that you can expect in the in the course yeah but expected to be from research perspective going really to the clinic trying to make it as practical as possible so you can use it the day afterwards in your clinic with your shoulder pain patients and for anyone listening as well there is also a little 50 year discount code there as well rcrsp50 so that's rcrsp50 and for anyone listening pop that in on the physioteur's website when you get in the course and that'll get you a little bit of discount on there as well look where can people find you if they've got any other additional questions or anything? Well they can always email me at philipp.stref I was thinking about my email address sorry
[email protected] I'm not super reactive on social media I am on instagram and twitter but mainly on twitter maybe I tried to tweet some shoulder related topics there so that's always an option and they can always email me of course yeah okay and what's your twitter in instagram? Just my name just my name on twitter and it's my name with a pt after it's on instagram I think I'm sure that I'll find you philipp thank you very very much for being able to spend some time with us and have a chat with us really appreciate it and yeah it's really informative and I hope everyone listening enjoys it as much as I did recording it with you thank you well ladies and gents thanks again for listening in and we'll catch you next time as always wherever you're listening to this we appreciate your time and if you have any comments or suggestions feel free to get in contact and let us know until next time peace you
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