Chris Beardsley (@SandCResearch) interviews Adam Meakins (@AdamMeakins) about his experience in physiotherapy, specialising in shoulder injuries.
Chris: Thanks for making the time to do this interview, Adam. Please can you tell us, in your practice, what injury do you most commonly help rehabilitate?
Adam: I work in a busy sports medicine and physiotherapy department so I deal with the usual array of neuro-musculoskeletal injuries. However, due to my personal interest and my role as an upper-limb specialist I tend to see mainly shoulder complaints, from sport and non sporting trauma to degenerative joint and rotator cuff problems.
Chris: And what area of research have you found most useful in learning how to help rehabilitate this injury?
Adam: This is a tough question to answer! There are many areas that have helped me rehabilitate shoulders over these last few years, so I am going to cheat and state three, which are research into (1) tendinopathy, (2) pain, and (3) symptom modification testing.
The shoulder joint has a lot of tendons, and in my opinion most shoulder pains have an element of tendon nociceptive involvement to a lesser or greater extent. Understanding the causes of tendinopathy at a micro and macro level has helped me not only in the rehabilitation of them but also in possible prevention strategies.
The key papers for me are Lewis (2010), which provides a model for rotator cuff tendon pathology and management that expands on the Cook and Purdam (2008) seminal paper on the continuum theory for tendinopathy. More recently, key papers are Cook (2012) and Docking (2013) on the role of compression in tendinopathy, which I think is a key factor in shoulder tendinopathy.
Regardless of shoulder pathology or injury, everyone I see has pain. Understanding this complex phenomenon is key to achieving successful outcomes. We now know that pain is NOT just nociception, it is often POORLY correlated to structural damage, and that pain is NOT an input from periphery, it is an output from the brain.
Learning how to manage someone with pain rather than just their pathology has been one of the most influential developments on the way I practice since I graduated. There have been astronomical amounts of work done over the last few years on understanding pain, and there are far too many papers to list here, but Melzack and Katz (2013) is a great overview.
#3. Symptom modification testing
The work done on symptom modification testing I find really exciting and useful in the management of painful shoulders. It is well-known that most clinical tests for certain shoulder pathologies or damaged structures lack specificity and/or sensitivity. This makes them very difficult to rely upon. Therefore, tests that can modify and/or reduce a painful movement may be a far more useful for physios to assess and plan rehabilitation programs. These tests remove the need for the physiotherapist to try and identify the specific structure, which we can’t do accurately anyway, and instead focuses their attention on the more important task of trying to reduce painful movements.
There needs to be more work done here but papers by the likes of Lewis (2009) have been really interesting. I have a hunch that symptom modification testing will be in the near future a major part of how physiotherapists assess and manage most pains and injuries, with less and less focus on structure and pathology.
Chris: I think the increased use of symptom modification testing would be a fairly safe bet, Adam. What area of research do you believe is most commonly ignored or misunderstood in the treatment of shoulder injury?
Adam: In my experience the area that is most misunderstood by many physiotherapists is basic exercise physiology and strength and conditioning. The amount of poorly-designed rehabilitation programs I see or hear patients being given is really disheartening and not good for the reputation of the profession.
When I studied physiotherapy I already had qualifications in Strength and Conditioning but many other students do not. I was really shocked at how little time was given in the syllabus for exercise physiology. This lack of undergraduate teaching is why I believe many physiotherapists are ill-equipped to reason and plan how much and what type of exercise to give to those with an injury.
For example, I regularly hear physiotherapists prescribing a standard 3 sets of 10 repetitions for most of their patients for a lot of conditions. Why so many physiotherapists think that different patients with varied physiology and pathology need EXACTLY THE SAME exercise parameters for different injuries is completely beyond me. In strength and conditioning, you would not give a fit, well-trained 23-year old male the same exercise prescription as a 55-year old untrained female. So I see this 3 sets of 10 repetitions as lazy and poorly-reasoned prescription and it drives me a little bit crazy every time I hear it being used, almost to the point where I now find myself not wanting to use it even when it does have a role.
Also, in my experience many physiotherapists are too terrified to work an injured or weak tissue to its limit, fearful of producing exercise-induced muscle soreness or further muscle damage. However if physiotherapists had a better understanding of exercise physiology, used their clinical reasoning more and understood healing timeframes better, then they would see that this is usually what most injured tissues need.
In my opinion, many physiotherapists are too conservative with their exercise prescription and just don’t challenge the patient or the injured tissue enough. This is why physiotherapy fails a lot of people. Now that’s not to say physiotherapists should start being reckless or unsafe, it just means they need to think more about challenging the tissue at the right level at the right time, and be able to educate and explain to the patient why and how this needs to be done.
Also, injured tissues don’t necessarily need to be exposed to heavy loads straight away. The notion you can’t improve muscular strength with light resistance and high repetitions as this only improves endurance is not correct. Strength can be increased with low loads and light resistance, so long as the sets are taken to muscular failure over multiple sets, as demonstrated by Mitchell (2012). This is extremely useful for injured tissue in the early stages. We can build strength with lighter loads and higher repetitions until the tissue is ready to start being exposed to heavier loads.
However with all that being said, there are also physiotherapists who go too far the other way with exercise prescription. It is possible to make it far too complex and complicated, with 13 different exercises, with different numbers of sets, repetitions and percentages of 1RM. This in my opinion is also not needed or sensible. To my mind, this is usually done more to satisfy the physiotherapist’s ego in showing off their knowledge than for the patient’s gain.
Chris: I think we would all agree that physiotherapy would benefit from learning more about strength and conditioning, just as more and more strength coaches have in recent years been learning from physiotherapy. What currently unanswered research question would change the way you treat this injury (or injuries in general) if it were solved?
Adam: Although I have mentioned the role of exercise in the management of pain and we have seen some emerging work by Naugle (2014) on the role of isometric contractions in this area. I still think there are plenty of unanswered questions about what are the best ways and methods to achieve an optimal analgesic effect with exercise and how it does this. And more importantly, we need to know what are the best ways and methods to get those in pain to do them? After all, our role as physiotherapists is to try and instil a change in attitude and behaviour to do exercise when in pain. This is absolutely fundamental in our success as healthcare professionals. We could have all the latest scientific knowledge and all the best quality research in the world informing us what is best for the patient in front of us but if we can’t educate, advise and persuade them to do what is needed, then what use is it!
Chris: That’s true enough! Thanks for your time, Adam.
To learn more about evidence-based physiotherapy and the shoulder joint, please follow Adam on Twitter or visit his website The Sports Physio.
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