Latest / The STA Clinician Podcast / STA196 ‘Treating The Shoulder: Steps To Success’ with special guest Jo Gibson

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STA196 ‘Treating The Shoulder: Steps To Success’ with special guest Jo Gibson · The STA Clinician Podcast

• 0:00
  You're listening to the Sports Therapy Association podcast, putting evidence
• 0:04
  back into soft tissue therapy.
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  Music.
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  And we're live. Hey people, how are you doing? Welcome to the Sports Therapy
• 0:21
  Association podcast, episode 196, 1996,
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  entitled Treating the Shoulder, Steps to Success, with my special guest,
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  Joe Gibson, a hugely respected shoulder specialist, educator and upper limb
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  rehab specialist at Rehab4Performance.
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  My name is Matt Phillips, creator of RunChatLive.com. And as always,
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  this episode of the Sports Therapy Association podcast is being recorded live
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  on a Tuesday at eight o'clock on the Sports Therapy Association YouTube channel and Facebook page.
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  So if you are listening to the podcast and you fancy joining us for the live recording one week,
• 0:53
  then all you need to do is head over to either of those at eight o'clock on
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  a Tuesday and and you'll be able to ask the questions to the
• 0:59
  guests directly you can hang out with like-minded individuals in the
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  live lounge and and generally just have a great time if
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  you do decide to join us live then I can bring your questions up onto the screen
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  like Nikki Mansfield has just come into the house hey
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  hey hey says Nikki how you doing Nikki thanks for joining us and
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  so it is also a chance for you to show your logo show your name and
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  network a little bit and cockray next to the door as well hey
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  and how you you're doing thanks for joining us and says hello hello hope you're
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  all good what lovely bunch of people so far so friendly that's how
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  we roll here at the sports logo association podcast so so
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  yeah there is your opportunity but if you do decide it's easy for you
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  to watch the podcast listen to the podcast and that's fine that's great just
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  do us the favor if you could of leaving a rating and review because it helps
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  the good word of our guests get out there even more right then before i bring
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  up my guests for tonight joe gibson then i must give a huge thanks to last week's
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  guest It was a very special guest, Professor Ian Horsley.
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  If you did miss it, then obviously the episode is on all popular podcast apps
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  and YouTube, if you like the video.
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  It was called Shoulder Assessment Qualitative versus Quantitative,
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  giving fantastic insight into the limitations of quantitative heavy traditional approach.
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  Which is really interesting because we've talked a lot on the shows about the
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  importance of having a dynamometer.
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  Try saying that three times, but yeah, a dynamometer and how it can be useful
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  to show tangible kind of progression in rehabilitation and that.
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  But it was a really interesting twist in the last episode, episode 195,
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  of how the limits of using that and how the importance of movement-based training
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  over folks solely on muscle groups,
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  including vestibular rehabilitation, rehabilitation which i heard people in the audience
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  screaming out and applauding because that's very interesting at
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  the moment a lot of people talking about that and there's also details of
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  upcoming webinars and courses with professor ian horsley as well links
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  are all provided in the podcast notes so
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  yeah that's all there for you to enjoy and educate yourselves as always like
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  i say if you are listening to the podcast you want to join us live and ask questions
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  directly then like i say just come along to the youtube at eight o'clock on
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  tuesday right the rooms are filling up So I think without further ado,
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  we can commence episode 196,
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  Treating the Shoulder, Steps to Success, with special guest, Jo Gibson.
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  Music.
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  You're listening to the Sports Therapy Association podcast, putting evidence
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  back on soft tissue therapy.
• 3:21
  Hey Jo, how are you doing? Hey Matt, good to be here. Thanks for the invite.
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  It's great. It's really nice. We were talking a little bit off air.
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  I think the last time we met and spoke, ashamedly for me, being the podcast
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  host, was probably 11 years ago at Therapy Expo 2013.
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  Sorry, I didn't mean to call. I said I'd call you, didn't I?
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  Sorry. Yeah, well, you couldn't escape. I've tracked you down finally.
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  It's nothing personal. But yeah, great to finally. It's ridiculous,
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  isn't it? 11 years. But anyway, here we are.
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  They do say that research takes about 13 years or something to get from research
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  to clinic floor, doesn't it? So that's fine. We'll just blame it on that.
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  Nikki says here, oh, look, we've already got some fan people in already.
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  Nikki says, I did Joe's course years ago. OK, don't make her feel too old.
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  Looking forward to hearing how understanding of shoulder issues has changed
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  or not over the years. That'll be very interesting as well.
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  Cecily Hisslop says, evening all, looking forward to this episode.
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  And Gary Benson found that the STA is here as well.
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  So evening all, looking forward to this one. No pressure. Thanks.
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  So, yeah, yeah, it's true. I mean, it was when I was thinking how to introduce
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  you because you've done so much.
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  And and it's great because in the circles I'm mixing, you are very well known
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  and we've got loads of colleagues in common.
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  But I always hope that it's a bit of a bubble and there's lots and lots.
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  I know there's lots and lots of people out there who fortunately haven't heard
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  of you. And that's exciting for me because it means they can learn and benefit from.
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  So but to introduce her, I just love your Twitter handle, which you created
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  a 2013 shoulder geek one.
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  One and the fact you've got the one there is like except no
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  imitation i am the geek no one
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  else you know i think i found about shoulder geek 36 on there as well so people
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  that follow but it's not the same and that was 11 years ago and now you've got
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  30.5 000 followers not that the number of followers is important and and we
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  laughed at how you hit that twitter button post 45 and a half
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  a thousand times traveling and sitting
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  in conferences usually when i'm a bit disengaged i think
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  that's a brilliant statistic amazing anyway for
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  people who are not aware of you and i'm hoping that people listening to the
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  podcast are not aware which is fine this is great it's what this is all about
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  could you give us a little bit uh tell us a little bit about yourself and how
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  you ended up being shoulder geek one and where you are today that just shows
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  my ignorance of social media and I didn't realise what I was doing at the time.
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  And now I just can't change it because it's just too hard.
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  Yeah, so my current job, as you very kindly introduced me, I'm an upper limb
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  rehab specialist at Rehab for the Performance in Liverpool in the UK.
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  And I'm also an Honorary Senior Research Fellow at Liverpool Hope University,
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  which is where Ian and I obviously overlap.
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  And then until two years ago, I was a clinical specialist working in the NHS.
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  And that was a job I did for 28 years.
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  I was in the NHS for 35 years altogether.
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  Hated treating shoulders at the very beginning. Did a rotation with a guy called
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  Angus Wallace, who is probably more famous now for doing chest drains on airplanes
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  up in the air, but was a very famous shoulder surgeon.
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  Massively passionate about arthroplasty, which I have to say is not the most
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  exciting thing in the world. And it just always resonated.
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  And then I hated treating shoulders. They never got better. A bit of ultrasound
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  and postural correction didn't get anybody better,
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  which now is probably not a great surprise but then went on
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  a what was then called a muscle imbalance course and
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  remember sitting there thinking oh yeah maybe I
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  need to do some exercise so that was a kind of eureka moment
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  and then needed a challenge and the guy who trained with Prof Wallace came to
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  Nottingham to be a professor so I was very lucky to get the job as his shoulder
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  specialist and yeah the rest is history really and just had an amazing opportunity
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  to set up a specialist unit which has just grown from from strength to strength.
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  And I've left in the hands of an amazing team.
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  Fantastic. I said, yeah, there's an awful lot. How long did you say,
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  28 years? 28 years in one job. Yeah. One unit. Yes. It took a long time.
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  That is incredible. You must get this all the time. But, and Nikki has kind
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  of summarized it as well. But, oh my God, Jo looks exactly the same as she did back then.
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  If there's time after. The camera, the lighting, the face.
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  She says, if there's time after this shoulder shizzle, please don't let
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  her leave without sharing the secret eternal youth oh
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  Nikki you're very kind you can come on the course again fabulous thank
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  you but that is yeah it must be crazy
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  when you look back and think of all the things you've done and the time you
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  spent there I'm interested what made you kind of come out from the NHS and was
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  it a couple years ago when did you two years ago yeah two years in January yeah
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  two years in January just gone oh such great question lots of reasons.
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  I already I'd had a private practice with a partner
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  she wants to retire we sold that to somebody who worked for us and I carried
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  on working there Matt and Chris who are the directors at rehab performance contacted
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  me and said look we're setting up this new clinic we'd love you to come and
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  do our shoulder consultancy and I said oh well I'm actually looking for a bit
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  more of a challenge because I'm seeing all these sports people and I kind of need better facilities.
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  And to be honest, I probably I did a retire and return in the NHS,
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  went down to two days, which is always a mistake because you end up doing a
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  four day job in two and taking everything else home.
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  And if I'm honest, Matt, I think I was just burnt out. I kind of my life had
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  morphed into doing my teaching, my online courses, doing consultancy with sports
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  stuff, as well as seeing other patients that had failed elsewhere privately.
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  And I think I felt a huge responsibility with
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  the unit because I'd always driven it I'd always had the ideas and
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  the team coming up behind who who then
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  were alongside me were just phenomenal and
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  younger and energy and less spread responsibilities
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  and I think sometimes you just need to
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  recognize that it's time for the people to take the reins and
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  Simon who set the unit up with me died at the
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  the beginning of covid so there was a kind of changing of the guard
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  and you know all the people there I miss
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  them hugely but it was so the right decision because they're absolutely flying
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  and I would love to think I never stopped them flying but when the old bird's
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  still there it's easy to ask and what do you think and it's a bit like well
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  it's not what I think anymore it's kind of over to you and they're flying and
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  they've made everything we wanted to happen happen so I'm immensely proud Proud of them all.
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  Missed them horribly, but I do not miss my job, which all got very stressful
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  trying to do everything in two days and not really being able to do it terribly well. So, yeah.
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  So I guess now you're kind of spoilt about having, I mean, I'm presuming here,
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  but you've got more time with patients, I imagine.
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  There's a lot of kind of generalizations, but we assume that one of the things
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  of moving into private is you get more time, which has got its advantages as well.
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  Might take a bit more, well, not for you because you're like superstar,
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  but no, it takes a little bit more advertising and you haven't got patients
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  being given to you and handed to come through the door in 15 minutes.
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  But is it something that you think.
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  I mean, because the reason I ask is a lot of sports therapists,
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  a lot of audience are not physios, a sports therapist, a sports massage therapist,
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  and they kind of have this imposter syndrome.
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  We've talked about a lot like, yeah, I'm pretty good at my job, but I'm not a physio.
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  And it's like, oh, I'm not sure about this. I should send them to a physio.
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  And sometimes, depending on your level of experience, it is important to refer out.
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  And that's part of the most important things about being a sports therapist
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  and any profession, I think, is knowing what you don't know and being able to refer out.
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  Out but I think a lot of people don't realize that being a physio especially
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  NHS is like a totally different job it's not all MSK it's not going to be maybe
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  doing what you want to do so what advice would you have for sports therapists
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  who thinks oh yeah I'm a good sports therapist but I'm not a physio?
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  Oh I think you need to be really proud of the skills that you've got
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  and I think you know physio is in a in a very interesting place
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  at the moment because it's railing against many of the skills that
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  we thought were inherent like manual therapy and any of
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  our hands-on stuff and it's a it's quite a battle I think certainly for some
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  of the physios who've been around a bit trying to deal with some of the social
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  media noise at the moment but I think as sports therapists I think you kind
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  of you're in an amazing place because you kind of really recognize where healthcare
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  is going and you know the problem we've got in the NHS is that you have even in.
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  Musculoskeletal world you've got a waiting list which is 60 to
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  70 percent made up of people people with comorbidities
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  who are overweight who smoke who don't exercise etc
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  so to see sports in the nhs is
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  like a tiny tiny part of of what we
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  see and the other thing is if you do see them the opportunity to take people
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  to a level that truly gets them back to what they want to do is not without
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  its challenges particularly if you work in acute care because the priority is
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  to settle things down and then send people off so no i think sports therapists should embrace the
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  role that they've got, because I think, you know, they're masters of many different areas.
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  And I think it's something that really reflects where healthcare needs to be at the moment.
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  That's really cool. I'm sure that's really helped a lot of our listeners and
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  people out there because it's always kind of there. But we're also fortunate.
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  I think, you know, sometimes people kind of ask me, why do you have so many physios on the show?
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  But I'm like saying you shouldn't be looking at what they are looking at what
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  comes out of their mouth, what they're saying, because what you're thinking, oh, it's a physio.
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  You're forgetting the fact they're talking about, oh, yeah, multidisciplinary care.
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  Like some people, I guarantee, will just still be thinking, oh, do I give some physio?
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  And they're not listening to what you're saying, even though you're bringing
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  up their career. So it's getting a bit better.
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  I like to think I like to think it's getting a
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  bit better in places like therapy expert now where like this year we're
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  really striving to make sure the MSK conference is not a separate kind
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  of strange place over there what do they do in there it's kind of like all
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  part of looking after patient now you know exactly you
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  know that's what we're trying to do this year so which is very different
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  you know yeah and I think you know
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  going on from that I work with sports therapists the courses I
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  teach are not solely for physios we get sports therapists coming
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  my son plays football football and obviously and
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  the sports therapist of the kind of the physios in
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  the team and I've all given them all three places to my
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  course because I think we're all in this together and all I'm interested in
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  is making sure the things that I found have helped for
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  patients are available to as many people working with patients
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  so they feel confident empowered you know
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  whatever comes through the door so I think you know the
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  the boundaries I guess are professional and dictated by
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  our professional bodies but there's a lot of overlap and again it's
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  just respecting your your skill level and expertise
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  and I mean there's loads of physios that hate treating the shoulder you know
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  it's like it's not it's not a unique thing and at the end of the day we're just
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  all trying to do the best for the patient in front of us and that's what drives
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  me definitely it's a very good yeah just think about the patient and a lot of
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  these problems and questions just disappear.
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  Great I'm just going to put up on the screen for those of you if you listen
• 13:59
  to the podcast you can't see what I'm sharing on the screen so my apologies
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  but I'm just going to put up there for For people who have joined us live,
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  the website to have a little look at, rehab4performance.com. Very nice website.
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  I don't know who looks after it, but it's beautiful. Graphics are something to behold.
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  And also, it's lovely to see the different stuff that you offer.
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  I mean, you've even got a picture of somebody receiving soft tissue therapy
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  on there, which is like very progressive indeed. We have soft tissue therapists
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  working with us. It's a great, it's a real delight.
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  Check it out, people. True multidisciplinary care. You've got so much going
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  on there. It's lovely. Really nice website.
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  And it's like a great unit. Beautiful place. envious for a lot of people I'm
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  sure and that's in Liverpool isn't it so if people do want to check you out
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  then that's where you need to go.
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  Great. Right. Let's get into the question at hand then. The shoulder steps to success.
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  Now, this is obviously, we're not here, we mentioned this off air,
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  I'm not here just to sell Joe's course. I mean, not everybody will need Joe's course.
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  You might be like me and look after runners and run away from a shoulder and
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  you just don't see them anymore. So you can forget about them,
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  put them in a little box and nail it shut.
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  But if you are looking for some information on shoulders and that's what a lot
• 15:01
  of your clients are, then I'm just recommending that it's one of the options
• 15:04
  you should have a look at.
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  And for this show, I think it makes sense to have
• 15:08
  a look at what the course entails because that's stuff you've chosen which you
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  think this is what therapists out there need that's why it's on the
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  course so i'm interested with i mean the title itself shoulder
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  steps to success we kind of touched on last week
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  with with professor ian horsley that the shoulder is regarded
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  as quite a scary complex joint it's not like
• 15:26
  a knee which just flexes and extends it's got all this weird range of
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  motion and positions it can put itself in and then apparently
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  it's got these four rotator cuff muscles kind of things which one of those
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  goes in your stuff but do you find that this is
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  one of the things which makes kind of treatment and rehab of the
• 15:40
  shoulder difficult there's kind of a fear of it yeah 100 and
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  i think you know there's it's not just one joint you've
• 15:47
  got four or five joints if you include physiological joints it kind of you know
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  again it gets bad press it's complicated you know so much of its stability is
• 15:56
  dependent on the muscles all the research that comes out says we can't diagnose
• 16:00
  anything so So none of those messages are particularly helpful for people.
• 16:03
  And I think that's why it gets bad press.
• 16:05
  And I have to say, I usually start my course saying how many people actually
• 16:08
  like treating the shoulder. And I have to say they're generally in the minority.
• 16:13
  And when I ask them why, it's like, well, it's complicated. I can't work out
• 16:16
  what's happening. I can't diagnose anything.
• 16:18
  And I think the good news is certainly in non-traumatic shoulder pain,
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  a lot of the time, it doesn't matter whether you can diagnose it or not,
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  because there's some key things that will work with the majority of patients
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  done well for long enough.
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  And so, yeah, there's some kind of simple things that are very well supported,
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  but the evidence kind of questions our ability to really do anything very useful
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  in that kind of diagnostic domain.
• 16:40
  And I think that really underpins a loss of clinician confidence.
• 16:45
  It's interesting because I know you touched on this in your course with the
• 16:47
  kind of importance of language and stuff.
• 16:51
  I think when I do hear from patients or people, even in the street or who have
• 16:56
  got shoulder issues, one of the first things, and they've obviously been told
• 16:59
  it because they didn't come to this conclusion themselves, but they've been
• 17:01
  seeing one person and you can guarantee that therapist will go,
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  oh, well, the shoulder joint.
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  I mean, it's in this tiny socket. It's like a golf ball on the tee.
• 17:08
  It's like a saucer. It's amazing.
• 17:09
  It even stays in there without falling out. And I think sometimes.
• 17:12
  Because that's how you learn it with anatomy, you learn straight away,
• 17:16
  oh, the most unstable joint in the body.
• 17:18
  Now, if you say that to a patient, again, I mean, 20, 10 years ago.
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  I'm sure we all kind of said that without even thinking about it.
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  And then thanks to people like Mike Stewart and that, and Ope Mike and that,
• 17:29
  we're kind of thinking, actually, maybe I shouldn't say that.
• 17:31
  Maybe I should take that off my shelf with the kind of meniscus hanging off the knee.
• 17:35
  But it is it's it is really important
• 17:38
  i think with the shoulder the language we do use with patients because
• 17:41
  there is a tendency to describe it as the most unstable joint
• 17:44
  and then hope they get better oh absolutely and to
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  be honest i mean a lot of my job is seeing patients who've perhaps failed
• 17:50
  with other people and i would love to say i have some magic tricks
• 17:53
  and i do all sorts of voodoo to get them better but you know i can't
• 17:56
  tell you how often it's because of poor messaging or
• 17:59
  what the person's heard so of course we've been
• 18:02
  through this whole thing with impingement and now if
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  you're a shoulder specialist you kind of frown on the word impingement
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  oh we don't call it that anymore we call it cuff related shoulder pain
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  and then somebody else will say oh no we call it cuff tendinopathy and
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  then it's like nobody actually knows what they call it so we just put it
• 18:16
  under this big umbrella and for a patient that's the killer
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  because if your gp says you've got impingement and then you go see
• 18:22
  a physio who tells you you've got rotator cuff related
• 18:25
  shoulder pain and then you go to a chiropractor who says it's
• 18:28
  something else everybody thinks they're being clever in helping
• 18:31
  the patient and all they're actually doing is confusing them and not at
• 18:33
  any point checking what that means to the patient so I definitely have
• 18:37
  patients who come to see me and I say well what have you been told by the
• 18:39
  people you've seen and they'll say oh well I think I've got impingement I say
• 18:43
  well what does that mean to you and if they say oh I think I you know need some
• 18:47
  exercise or some treatment to help it get better then I'm not going to change
• 18:51
  that narrative but I will prepare them for what's out there on Google so yeah
• 18:55
  you know impingement's one term There's a whole lot of other terms.
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  And if you go and look in Google, you'll see cuff tears, impingement, bursitis, whatever.
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  The good news is it doesn't matter. It all comes under this umbrella and we treat it the same.
• 19:07
  So we kind of prepare them, the Google searcher, the person who comes in with it written down.
• 19:12
  However, if I have a patient and I ask them what it means and they say,
• 19:15
  well, it means I've got a bit of bone sticking in my cuff and needs chopping off.
• 19:19
  Then, of course, that's going to be a different conversation once I've done my assessment.
• 19:23
  But again, I think, I mean, I always smile and this is one of the,
• 19:26
  I guess the privileges of teaching is that I have to keep on top of the evidence.
• 19:30
  But, you know, it wasn't that long ago that people were saying to us,
• 19:33
  don't say anything about structure.
• 19:35
  So don't mention cuff tears, just say it's normal age-related change,
• 19:39
  which of course it is in a lot of patients.
• 19:41
  However, we now know for some recent studies that say normal age-related pain,
• 19:46
  sorry, normal age-related changes to some patients makes them think I'm never
• 19:50
  going to get better because it's my age.
• 19:52
  So we kind of try and look for this magic bullet of explanation and diagnosis and description.
• 19:57
  And the fact is, it's different for each individual. So where Mike,
• 20:00
  No Pain Mike, is so amazing, is it's not even about us finding the metaphors
• 20:05
  sometimes, it's just helping patients understand in a way that resonates with them.
• 20:09
  So the label directs a pathway of care and allows them to feel confident we
• 20:14
  know what we're going to do for that thing.
• 20:16
  But in non-traumatic, non-stiff non-unstable shoulder
• 20:19
  pain actually most things respond to
• 20:22
  the same interventions and i and i love what you said about the unstable
• 20:25
  shoulder because it's just like you know we i still
• 20:28
  can't believe we did this we had a clinic and we called it the complex instability
• 20:32
  clinic and that went on a letter to the patients and it was like guys what were
• 20:37
  we doing you know hindsight's a great thing so yeah i think you just have to
• 20:42
  that to me and again the steps to success the number one on is taught less, listen more,
• 20:47
  you know, because the patients give you the clues, but you also get to the nub
• 20:51
  of what they're scared about, worried about, the barriers that are going to
• 20:54
  stop you being able to get them back to what they want to do.
• 20:57
  That's brilliant. There's so much in there for people to unpack. They really like it.
• 21:00
  And maybe it is because therapists are a little bit more worried about the shoulder.
• 21:04
  They feel they need to kind of label and categorize it.
• 21:06
  And they're not as happy with the knee saying, oh yeah, they're just worried
• 21:09
  about it. So they love these terms.
• 21:10
  Even the term frozen shoulder, it's just like such a, I can imagine as a patient
• 21:15
  you know it's just a dodgy word it's going to make you think it's frozen you
• 21:18
  know it's like my child's frozen.
• 21:21
  And then obviously people start thinking, oh, surgery, I'm going to need surgery.
• 21:24
  And they're less likely to follow conservative measures because they think they've
• 21:28
  got something so serious that it's just not going to be able to,
• 21:30
  they're not going to be able to do anything to it.
• 21:32
  It's actually really interesting, Matt. Sorry, just because some recent research
• 21:36
  that came up that's really interesting about people thinking there's something
• 21:39
  seriously wrong with their shoulder.
• 21:40
  Because there was a study that looked at clinicians and patients and they videoed the consultations.
• 21:45
  And they said to the clinicians do you think people with shoulder
• 21:48
  pain worry that they have something seriously wrong with their shoulder and
• 21:50
  went oh no not as much as people with back pain and actually
• 21:53
  when they asked the patients it was the other way around so more
• 21:56
  patients with shoulder pain worry there is something seriously wrong
• 21:59
  and need somebody to say to them explicitly I am
• 22:03
  not worried there's something seriously wrong with your shoulder which is
• 22:06
  again it's just all these little bits that we can learn that are
• 22:08
  the potential barriers yeah 100% that's really
• 22:11
  interesting because I always kind of thought maybe lower back pain is on people's
• 22:14
  minds because you can't quite see it you can't your hands there and you're
• 22:17
  trying to feel around but surely you can see and yet people are still nervous about
• 22:20
  it and yeah very interesting i
• 22:23
  should give a shout out to israel who i know has hurt his shoulder and
• 22:26
  he's joining here tonight he's looking for some inspiration and also
• 22:28
  and obviously it's my barber so hence the expression lovely haircut
• 22:31
  i was going to say i think it's been rude about mine oh
• 22:34
  no sorry i shouldn't have said that there you go there's someone in there in
• 22:37
  my hair there joe so that's nice thanks israel it's
• 22:40
  really nice of you to say that i never get those comments that's for
• 22:43
  sure with this mop very kind we gotta
• 22:47
  actually let's go to questions here because we've got we've got so much we could
• 22:50
  cover and we really could fill it so easily this hour but i'm interested if
• 22:53
  any of you have got questions then do bring them up because now is the moment
• 22:57
  where you could really get someone to explain it clearly and accurately so israel
• 23:01
  actually has followed that up the question saying what about multiple shoulder
• 23:03
  dislocated how should that be treated thanks.
• 23:07
  There you go. Thanks. So bottom line is it's very dependent on the history,
• 23:12
  whether they've got a clear original mechanism of trauma or not.
• 23:16
  We tend to, in the UK, use a classification system called the Stanmore Triangle,
• 23:21
  which really looks at subgroups.
• 23:24
  So primarily your young traumatic dislocator who falls over,
• 23:28
  dislocates their shoulder, has to have it relocated by somebody else.
• 23:32
  And if they're under 25, want to get back to sport, there is some argument that
• 23:36
  if you scan their shoulder and find something that's relevant structurally,
• 23:40
  then surgery is probably the best way of getting them back to what they want to do.
• 23:43
  However, of course, there's a whole grey area within that. And objectively,
• 23:48
  Ian talked about the apprehension test last week, so you'd want them to continue to be apprehensive.
• 23:53
  However, there's lots of people with structural injuries that rehab really well.
• 23:57
  However, there's still a lot of surgeons that won't operate the first time.
• 24:00
  So it's always about teasing out was their
• 24:03
  original mechanism of trauma particularly when they were younger so under the
• 24:07
  age of 25 who is now presenting with a recurrent dislocation in a very specific
• 24:13
  position and so in that if they've not had imaging for me then imaging is going
• 24:18
  to be up there particularly if clinically they're apprehension positive etc.
• 24:22
  However you will also get a group with hypermobility so this is a what's called
• 24:28
  the type 2 on the standard but I really wouldn't worry about it. It's traumatic or not.
• 24:31
  Difficult when it's minor trauma on a background of hypermobility because you
• 24:35
  don't need as much trauma to cause structural damage.
• 24:38
  But fundamentally at times of growth spurts, at times of stress,
• 24:42
  at times of change of activity, some of these young stretchy people can start
• 24:47
  to sublux their shoulder posteriorly and then get recurrent episodes over time.
• 24:51
  And in both situations, it's just about that dynamic stability system not doing
• 24:57
  its job as effectively as it can, highly correlated with the neuromuscular control
• 25:01
  elements that Ian talked about last week.
• 25:03
  But generally, about 80% of that non-traumatic group do well with rehab.
• 25:09
  Again, that's why it's so important to know what the original precipitating mechanism was.
• 25:14
  And there's a third group, which you're unlikely to see, and that we saw quite
• 25:18
  a lot in our tertiary referral centre,
• 25:20
  are those groups that don't necessarily have to have hypermobility or laxity,
• 25:25
  but the muscles around the shoulder, like the lats and the pecs,
• 25:28
  work so hard as a protective strategy.
• 25:31
  So again, highly correlated with growth spurts, times of stress,
• 25:35
  etc. et cetera, mental health issues, learning, there's a whole gambit that
• 25:39
  the muscles actually pull the shoulder out every time they lift it up.
• 25:42
  So I think the important thing to say is the majority of instability you see,
• 25:46
  irrespective if you're going to do conservative management, the ingredients are very similar.
• 25:51
  So as well as the kind of basic foundations that apply to any shoulder problem.
• 25:56
  The big difference with instability is you have bigger neuromuscular deficits.
• 26:00
  So both in terms of that get ready for action that
• 26:03
  feed forward at regulation but also that reactive stabilization
• 26:07
  so weight bearing closed chain exercises are
• 26:10
  brilliant for anything for that feed forward and then
• 26:13
  reactive stuff you drop and catch your plyometrics your
• 26:17
  cable catches all that kind of stuff as early
• 26:20
  as you can possibly do are great in terms of that reactive element
• 26:23
  and then another thing i know ian mentioned last time
• 26:26
  about the kinetic chain also making sure
• 26:29
  they're not protecting and they're engaging through their kinetic chain
• 26:32
  in a way that's functionally relevant so yeah again
• 26:35
  instability just signpost probably more even
• 26:38
  more focus on those neuromuscular elements that's very
• 26:42
  interesting because we're hearing a lot more about the
• 26:45
  neuromuscular element and it was kind of topic at therapy expo
• 26:48
  last november there was quite a few great speakers who were
• 26:51
  talking about that and i loved the term i can't remember who now
• 26:53
  who came up originally it might have been angela jackson it could be andrew mccauley
• 26:56
  but it was just this chaos i had heard the word that and recreating
• 26:59
  the chaos of a real life sport and
• 27:02
  most sports are pretty chaotic maybe not darts i
• 27:05
  don't know but but it starts a sport i don't know but it depends
• 27:09
  how many beers we've had i suspect i'm wondering whether i'm wondering whether
• 27:14
  that's an issue with rehab because it was interesting i think it was andy jackson
• 27:17
  actually who said that one of the things that sparked her interest was it keeps
• 27:22
  resurfacing that one of the biggest predictors of injury is past injury.
• 27:26
  And it was like, why is that the case?
• 27:28
  Maybe it's because we're missing something in the rehab because we're all giving
• 27:32
  these rehab out and it's kind of like gold standard and yet all these people
• 27:35
  are still getting injured again. And that's where hopefully you never know.
• 27:38
  It's not going to be everything, but maybe that's an element which traditionally,
• 27:42
  people haven't concentrated on. So is that something you touched on in the course?
• 27:45
  Is that one of the steps to success? Well, you've already kind of insinuated it is, but...
• 27:48
  How can we do that? Well, I think there's a couple of things in what you've
• 27:51
  just said there. I mean, Matt Tabiner is the guy who described the whole control to chaos continuum.
• 27:56
  Yeah. And he's he's actually applied it to a basketball example.
• 28:00
  So definitely worth looking up for anybody who's interested in rehab because
• 28:03
  it kind of takes you through that whole kind of phase, if you like.
• 28:07
  And I think I think when I look at my course, but I also look at the question you just asked.
• 28:12
  The bottom line is, say I get asked to review a rugby player top of his game.
• 28:17
  He's going to have passed all these strength and power measures he's going
• 28:20
  to be all over it in terms of the quantitative stuff and so it's
• 28:23
  like well how do i measure that neuromuscular system and so
• 28:26
  i think where people like claire minchell you know
• 28:29
  that have obviously done a lot of stuff about rate of force production ben
• 28:32
  ashworth who's described his ash test i now have
• 28:35
  things that i can measure that show me how well that patient can
• 28:38
  engage their neuromuscular system and how much they can maintain it
• 28:41
  working well and produce load at the same
• 28:44
  time so i can kind of use that as an objective test
• 28:47
  but then the great thing with the shoulder it's such an attention monster
• 28:50
  you give it a bit of peripheral input and you'll change something so
• 28:53
  I can immediately then look at the impact of closed chain exercise
• 28:57
  reactive exercise maybe just a three range recruitment
• 29:00
  exercise and then see has it improved that objective so again it tells me yes
• 29:05
  I've made a difference to how that neuromuscular system is functioning so I
• 29:08
  think in terms of the course it's like we'll just understand what it is that
• 29:12
  allows our system to do its job and how negatively it's affected by not only
• 29:16
  injury, but patient beliefs.
• 29:18
  And then fundamentally, also, let's understand all the really simple things
• 29:22
  that can change what it's like for somebody to move with shoulder pain.
• 29:26
  And once you've got those foundations, then it's the exciting bit is just making
• 29:29
  it look like what they want to get back to.
• 29:31
  And it was really interesting hearing Ian last week actually talking about,
• 29:36
  you know, and I get what he's saying about the qualitative, but I think in terms
• 29:39
  of empowering clinicians.
• 29:41
  It's having some baselines that mirror what we're
• 29:44
  doing with our rehab so there's that combination of those two
• 29:47
  things that give transparency but also the things
• 29:50
  that because i've just done it for a long time i look at i see it and i
• 29:52
  think yeah i need to address that so i've tried
• 29:55
  to break down if you like the approach to
• 29:58
  the influence of all those sensory things into a very simple approach to symptom
• 30:02
  modification but then when you get to that chaos level really once you're into
• 30:06
  chaos i want to know that athlete's ready to go but you can introduce lower
• 30:10
  levels of along that control to chaos continuum that really target that neuromuscular system.
• 30:18
  Hey there, Matt Phillips here. Sorry to interrupt the podcast.
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  Doesn't include already discounted bundles.
• 31:23
  So you mentioned rugby. I mean, for people who are still struggling with the
• 31:26
  idea of chaos, we're kind of just talking about when you go on the pitch.
• 31:29
  It's all very well doing your rehab where you're in a nice safe place with mats
• 31:32
  and you're doing a nice kind of shoulder rotation with a band or something.
• 31:35
  Even if you've got lots of weight, but it's what you're not doing is reacting
• 31:38
  to a 20 stone rugby player suddenly intercepting you laterally and pushing you
• 31:42
  over or attacking you or the case of Israel for example he's trying he's got
• 31:45
  to get back into jiu-jitsu that's where he injured it and that's where he wants
• 31:47
  to get back to doing so rehab for somebody like that can you give us a few ideas of.
• 31:53
  What sort of rehab people should be doing to prepare for that with regards to
• 31:57
  the shoulder which maybe they're not doing so definitely the foundations first
• 32:01
  because I think again in physio we've suddenly had this huge shift that we're
• 32:05
  all about strength all of a sudden even though we We don't really have any evidence
• 32:07
  of superiority apart from actually in sports,
• 32:10
  where there's definitely some performance markers of typical strength measurements.
• 32:14
  And we actually have quite a lot of normative data in rugby.
• 32:17
  So for me, it's all about the basics in terms of cuff strength.
• 32:21
  Rotational in relevant positions.
• 32:23
  Once they've got it mid-range, then have they got it inner and outer range?
• 32:26
  Then looking at power measures, absolutely looking at rate of force production,
• 32:30
  because to me, that's a really brilliant measure of their neuromuscular abilities as well.
• 32:34
  We put them through a whole gambit of tests but in terms of
• 32:37
  then if I had somebody say after stabilization surgery
• 32:41
  we would start things like perturbation training
• 32:45
  so their opposite arm in the dislocation position maybe
• 32:48
  with a band attached walking around them pulling it in lots of different
• 32:51
  directions we might get them doing plyometrics we
• 32:54
  might get them doing drop and catch all on the unaffected arm
• 32:57
  because you get this cross-education effect that still
• 33:00
  lights up the same cortical pathways so we
• 33:03
  want somebody to be working in the position they dislocated in the opposite
• 33:07
  arm as soon as we can and then as the surgery or the injury allows then we're
• 33:11
  going to do exactly the same on the affected arm so almost i want to pause you
• 33:16
  there because that was you said like cortical blah blah blah and it's a really
• 33:20
  interesting point because i'm interested if that is like.
• 33:24
  That's been seen if that's shown up yeah so you're working
• 33:28
  the asymptomatic side so if
• 33:30
  there's a crossover yes if you look there's a whole kind
• 33:34
  of research base about cross education so i could
• 33:37
  put this arm in a sling and i could work this arm at 70
• 33:39
  of my one repetition max for six weeks
• 33:42
  and the arm in the sling would get stronger so some of
• 33:46
  its cortical effects some of its overflow because you're working this
• 33:49
  side hard so you're obviously going to get those postural perturbations and
• 33:52
  stuff but again somebody's had a fracture who's in a sling somebody's
• 33:55
  had surgeries in a sling it means there's stuff you can do to
• 33:59
  minimize the negative effects of that and when I think when we
• 34:01
  look at that link of injury and a risk of re-injury there's
• 34:05
  several things one of them that is neuromuscular control.
• 34:08
  Two is underestimating the impact that has on
• 34:11
  an athlete's confidence that when until recently we've not
• 34:13
  been so good at measuring and thirdly that
• 34:16
  that influences their decision making when they go back so if
• 34:19
  you go back to the rugby analogy I thought I had to to
• 34:22
  a talk recently actually at the IOC conference and it
• 34:25
  was it was kind of looking at that how can you make that
• 34:28
  athlete as robust as possible when they go back into a max
• 34:31
  situation where you can't predict what's going to happen and one
• 34:34
  of the big things is that you can actually see
• 34:37
  in some athletes who've dislocated their shoulder when you
• 34:40
  watch them go back to play that they go
• 34:43
  completely the wrong side of a tackle so they're more likely to re-dislocate
• 34:46
  because there's that subconscious conscious protection so i think where the
• 34:50
  evidence is cool is it's signposting all these things but it's then oh my goodness
• 34:54
  what does that mean to my rehab to then make sure they can cope with that chaos
• 34:58
  so there's so many different factors but that's what's fun.
• 35:01
  Yes exactly which is a really cool word to use we've had a great few great educators
• 35:05
  using the word fun because if your rehab isn't fun then potentially that's like
• 35:10
  a red flag that you're not actually preparing yourself for the fun you're going
• 35:13
  to have on pitch or something so there needs
• 35:14
  to be that element of surprise spontaneity invention reaction stuff i think
• 35:19
  that's that's probably quite a good sign because unfortunately unfortunately
• 35:22
  yeah unfortunately is probably the right word this is it's for my next question
• 35:26
  to you how if you are a patient how do you kind of make sure that you're going
• 35:31
  to go to a therapist who's up to date is going to incorporate all of this.
• 35:35
  That's a pretty tricky question but you just
• 35:38
  go there what you know it's hard isn't it because unfortunately there's a
• 35:41
  lot of therapists who don't listen to this show they don't know you and they just
• 35:43
  don't know these things because like research doesn't travel down they don't get
• 35:46
  a therapy expert and all that so for patients it's
• 35:49
  really tricky it's a bit of a minefield because you could end up with somebody who i
• 35:52
  don't want to dismiss the role of stuff like acupuncture or
• 35:55
  whatever because that can all regulate pain and bring sensitivity down
• 35:59
  and help that person then open to something
• 36:01
  else but if they're not doing this reactive stuff and not
• 36:04
  not thinking about this vestibular training and stuff how do
• 36:07
  patients choose these days I think it's really tough and
• 36:11
  I think certainly if you're going back to sport you need to be
• 36:13
  with somebody who doesn't have to actually be a specialist in
• 36:16
  your sport that needs to understand sport so there's no way I could be an expert
• 36:21
  in all the different sports for the patients that come to see me it's impossible
• 36:24
  but as soon as I see somebody who does a sport I had a guy that played underwater
• 36:28
  hockey for Britain the other day what is all that about I said of course so
• 36:33
  of of course, I had to watch some videos about that. But that's what's fun.
• 36:36
  You watch them and you work out where the shoulders under load and what that
• 36:39
  shoulder is going to be able to do.
• 36:40
  And then you almost reverse engineer it back to where you need to start with your rehab.
• 36:44
  And then it's okay, how do I make sure I filled in the neuromuscular demands
• 36:48
  of that particular task, and
• 36:49
  then the chaos is just putting it under more challenge as you progress.
• 36:53
  So I think for patients, somebody listens for sure.
• 36:56
  And somebody who's not afraid to, I mean, I've had patients where I've said,
• 37:01
  look, I don't really understand that.
• 37:02
  Can I speak to your coach or have you got a video or have you got this?
• 37:06
  And patients really respect that. So as long as you're all over the basics of
• 37:11
  good quality rehab and understanding how a shoulder functions and what it needs
• 37:16
  to function well, then you can work out the rehab.
• 37:19
  But if you don't have those basic things, then you'll potentially disturb your
• 37:24
  patient. So it is hard work.
• 37:26
  So a patient needs to trust you and know you're going to put the work in to
• 37:29
  understand what's relevant to them, I think.
• 37:32
  I think that's a really nice answer. I was worried then I was putting you on
• 37:35
  the spot, but I thought, hold on, Matt, you're talking to Joe Gibson. There is no spot.
• 37:40
  No, he's a diplomat. No, that's great. That's great advice.
• 37:44
  If you're a patient and you go to a therapist who is not listening,
• 37:48
  they've got the answer as soon as you walk in the door.
• 37:50
  They start putting on this program because it works for everyone else.
• 37:53
  And it looks like they're basically they're over certain.
• 37:56
  Uncertain then then that's probably a clue
• 38:00
  that they just know too much because it is uncertain every time
• 38:02
  an interviewer walks in it's a new person individual with
• 38:05
  a different history different physiology different expectations different
• 38:08
  fears so being at peace with uncertainty
• 38:12
  and working with you i guess is a really good indication that
• 38:15
  they're they're they're a bit more progressive and contemporary and
• 38:18
  up to date maybe yeah absolutely yeah i
• 38:21
  like it there you go that's good you've blown
• 38:24
  a few minds here mic drop moments here nikki mansfield
• 38:27
  says wow that contralateral shizzle stuff is amazing it
• 38:30
  is it's pretty cool i agree nikki it's very cool israel's
• 38:34
  gone he's gone what that's amazing with four
• 38:37
  or five question marks so yeah it's very very cool um i think there was a question
• 38:41
  about hillsack's lesion i think yes that when i pop my glasses on thank you
• 38:45
  very much anything without this is sharon from osteopathic clinic and sharon
• 38:49
  says hi sharon here can you explain the best treatment for an acute hillsack's
• 38:52
  bony injury with associated laparotia, would it always have been surgery?
• 38:56
  Oh, so great question. No, so no, it doesn't always mean surgery.
• 39:00
  So, and this is again, is where I say, you know, having, you always want an
• 39:04
  MR artogram to get the most information because plain MR is a little bit,
• 39:08
  a little bit fallible with label tears.
• 39:10
  But when it comes to Hill Sachs, which is that basically your humeral head,
• 39:14
  when it goes over the rim of the glenoid, you get an impaction fracture.
• 39:17
  So it looks a bit like Pac-Man.
• 39:19
  They're all probably all too young to know who pac-man is if you've
• 39:23
  got him out that's all good so pac-man now the thing is
• 39:26
  it doesn't really matter how big that impaction fracture is
• 39:29
  what matters is i'm trying to do this in the thing what matters is
• 39:32
  as the arm goes up into the risk position does
• 39:36
  that impaction fracture engage on the rim
• 39:38
  or does it stay inside the rim if it stays inside
• 39:41
  the rim it's called an on track or non-engaging hill
• 39:44
  sacks that has no increased risk of dislocation however
• 39:48
  if it engages on the rim and generally patients will
• 39:51
  be really apprehensive when you try and take them into that position it's
• 39:54
  an off track or engaging hill sacks and then you have a 100%
• 39:58
  chance of re-disclicating so then it's a no-brainer that
• 40:01
  surgery is going to be a good option for you so it's putting together that clinical
• 40:05
  picture of how apprehensive they are you know they've got a structural problem
• 40:09
  and therefore that helps you build things up in terms of the label tears themselves
• 40:13
  honestly it's not useful to go into all the different types of label tear that might
• 40:18
  make you have a higher risk of redistrication because that's kind of the surgeon and radiologist job.
• 40:23
  But for you, objectively, with that finding, ongoing apprehension,
• 40:26
  not getting better with rehab surgery is definitely an option.
• 40:29
  But just having the Hill SATs alone is not a reason.
• 40:33
  Great question, Sian. Thank you very much. Feel free to ask questions,
• 40:35
  people, because it's so nice getting questions from clinicians.
• 40:38
  It's like, that's what the podcast needs is more questions from clinicians.
• 40:41
  There's another great question here from Cecily, a great question that this
• 40:45
  is being asked on podcast.
• 40:46
  So, hi, this is perhaps a bit generic, but what do you think can help menopausal
• 40:49
  women if they're experiencing shoulder pain?
• 40:51
  We as therapists can't affect hormone levels, but what can we do? Cheers.
• 40:54
  Oh, what a topical question. Yeah, so we suspected the link between hormones
• 40:59
  and a risk of frozen shoulder for years and years and years.
• 41:03
  But there's actually a paper came out with Steinertal, 3,000 ladies,
• 41:07
  and they actually found that ladies who had symptoms of menopause who weren't
• 41:11
  on HRT were twice as likely to get frozen shoulder.
• 41:15
  Interestingly, people on HRT with well-controlled symptoms were half as likely
• 41:19
  to get frozen shoulders.
• 41:20
  So there is definitely finally some evidence to support that hormonal link.
• 41:25
  Again, it seems to be a symptomatic menopause or perimenopause that matters.
• 41:29
  And certainly 71% of ladies who are perimenopausal with symptoms,
• 41:34
  so sleep disturbance, brain fog, hot flushes, not sleeping, you know,
• 41:38
  any myriad of symptoms, 71% of that cohort will describe musculoskeletal pain.
• 41:44
  And it's rare that it is, you know, one joint, usually it's multiple joints.
• 41:49
  So I think in answer to your question, Cecily, no, we can't affect hormones.
• 41:53
  But what we can do is flag up the potential contribution of hormones,
• 41:57
  how they make the pain system more sensitive, how they're likely to slow down
• 42:01
  any response to treatment.
• 42:03
  And importantly, if ladies are suffering from any of those other symptoms.
• 42:07
  Signposting that speaking to their GP might be a really good idea because it
• 42:11
  really can transform their quality of life.
• 42:13
  Now, the big problem is when you send patients back to GPs, they might do blood
• 42:17
  tests and unfortunately,
• 42:18
  blood tests are notoriously unreliable in the early stages because
• 42:21
  the hormone levels fluctuate so there's a brilliant
• 42:24
  thing called the menopause symptom checklist and
• 42:28
  apparently it's more sensitive than blood tests and basically your
• 42:30
  patient can you can get it on the internet there's some fantastic resources
• 42:33
  i think there's the balance website has it on but essentially the lady can tick
• 42:39
  that and if you tick so many then basically she can take that to the gp and
• 42:43
  the gp will now listen so again you can be that's that safe place that that
• 42:49
  person that's actually listening,
• 42:50
  that is a really great place to then reflect that back to the patient and actually
• 42:55
  say, do you think this is something you could do with some help with,
• 42:57
  or maybe explore some of those associated symptoms?
• 43:00
  Because it's not, and again, I kind of love what you said, Matt,
• 43:03
  about, you know, that not trying to be too certain about things,
• 43:06
  because it's really important.
• 43:07
  We're not blaming the hormones. We're not saying they're the reason you've got pain.
• 43:11
  But what we are saying is they could affect your recovery, and they could affect,
• 43:14
  you know, how sensitive you are to pain, etc.
• 43:17
  If you've got other symptoms, is related to it maybe it's a time to have a chat
• 43:20
  because that's just going to make everything easier,
• 43:23
  fantastic great answer and great question sassy thanks
• 43:26
  so much for that and cock cranes come back with wow can you
• 43:29
  share the link to this paper i have a client for this scenario yeah any
• 43:32
  links which joe's talked about i'll make sure i make sure they
• 43:35
  go in the show notes and yeah really interesting love
• 43:38
  the idea of the questionnaire you can get the patient or client to fill out and
• 43:41
  then that'll make the gp actually listen a
• 43:44
  bit more which is which is a thing of today isn't it gps are pushed
• 43:47
  we know how hard work they are they get limited time and
• 43:50
  it's very much a case have come back in four weeks if the symptoms are still there
• 43:53
  but gosh what it is so if we can help and and
• 43:56
  and provide that assistance in pushing
• 43:59
  things further then that's great and this is again something we've
• 44:02
  talked about so much on the show because soft tissue therapists when this person
• 44:05
  comes to see you and they need an hour away from a hectic lifestyle and stress
• 44:09
  they know they're going to get it because they feel safe with you you're going
• 44:11
  to make them feel great through the touch and the massage then this is where
• 44:14
  you can get this information out of them build that alliance clients and then have them, you know,
• 44:19
  peel back a few more layers and get them to reveal this information to you about
• 44:23
  what they're suffering and that.
• 44:24
  So yeah, amazing answer. Thank you so much. Great.
• 44:29
  Cecily says as well, yes, that was a great answer. Thank you so much.
• 44:32
  Thank you. No, great answers. We're so lucky to have you on the show,
• 44:36
  Jo. We've still got 15 minutes.
• 44:38
  I can't believe it's gone that quickly.
• 44:42
  It's your fault. It's just like mouth open,
• 44:45
  been writing notes down so really cool you mentioned frozen shoulder
• 44:48
  a few times what what is
• 44:50
  a frozen shoulder is it easy to define or eye roll
• 44:54
  for those who listen to the podcast that was joe gibson yeah the
• 44:58
  more we know the more we don't know really i think so i think the bottom line
• 45:03
  is primary frozen shoulder so an insidious onset frozen shoulder the evidence
• 45:08
  is absolutely clear now that 80 of people will have a risk factor that predisposes
• 45:14
  them the The typical age is in the 50s.
• 45:16
  If you go to China, they call it the 50-year-old shoulder.
• 45:18
  The evidence says between 40 and 60, but you look at well-controlled trials,
• 45:23
  the majority of patients are in their 50s. So there does seem to be some age-related thing too.
• 45:28
  And then there is potentially a trigger. So there's a great paper by Miller
• 45:32
  et al, which again, I can send a link to, which basically kind of summarizes where we're up to.
• 45:37
  And it's basically people are predisposed to get it and then something triggers
• 45:41
  it. It could be a change in activity. It could be stress. it could be,
• 45:45
  illness, it could be poorly controlled diabetes, whatever, but the risk factors
• 45:49
  are all the things you'd expect, like diabetes, thyroid, cardiovascular disease,
• 45:53
  stroke, it can be an early sign of.
• 45:58
  Parkinson's, hyperlipidemia, lifestyle type stuff.
• 46:00
  So basically you have a risk factor and then something tips the balance.
• 46:04
  So you get this synovial hyperplasia, you get this transition of fibroblastomia,
• 46:09
  fibroblast, and then this thickening of the capsule.
• 46:12
  But I think where it's challenging, once somebody's stiff and they've got those
• 46:16
  risk factors, then it becomes arguably less difficult to make the diagnosis.
• 46:21
  The hard thing is when somebody first comes to see you in that age group with
• 46:25
  a really acutely painful shoulder that isn't stiff yet, because if you can get
• 46:29
  those people early, then injection can be a game changer.
• 46:33
  There is some emerging evidence it can shorten the overall course of recovery,
• 46:37
  but importantly, it can make a massive difference to people's pain
• 46:41
  and it kind of down regulates that whole response that's
• 46:44
  happening in the capsule so again it's if somebody comes
• 46:47
  to me with a really painful shoulder particularly if it's
• 46:50
  very diffuse kind of deltoid region and maybe down to the elbow that basically
• 46:54
  abduction and external rotation are horrible particularly if they do it quickly
• 46:59
  and they're really struggling to get to sleep can't find a position of comfort
• 47:03
  where tendon problems can normally find a position that's comfortable frozen
• 47:07
  shoulder really struggles.
• 47:09
  And if they do fast movements, their eyes are watering and they can't usually
• 47:12
  give you any kind of change in load.
• 47:14
  They can't give you any history of trauma apart from maybe they reach to get
• 47:17
  something from the back of the car.
• 47:19
  So, again, in my I'm kind of like a shoulder detective, if you like,
• 47:23
  I'm stacking up all that evidence.
• 47:24
  And if I if I think they have the potential to be a frozen shoulder,
• 47:29
  as soon as I start to get an inkling of loss of range, then I'm going to send
• 47:33
  them for injection because I think one injection relative risk is small.
• 47:37
  And actually what it can achieve for that cohort of patients is
• 47:40
  you know can be a real game changer in terms of
• 47:43
  their experience of the disease that's great so
• 47:46
  again once again we've got if you're a massage therapist
• 47:50
  if you're a sports therapist if you've got that hour to
• 47:54
  look after somebody and you ask the right questions and recognize that the
• 47:57
  flags or absence of flags and then you
• 47:59
  could really change that person's life for the next five years by
• 48:02
  uncovering something which which could really help rather than jumping
• 48:05
  straight into a whole load of objective orthopedic tests
• 48:08
  and try to work out something which by looking at
• 48:11
  the case history there's not going to be a solution or an answer or diagnosis it's
• 48:14
  just very interesting yeah i love and you
• 48:17
  know i i was thinking that actually again when i was listening to in stuff last
• 48:21
  week you know for me we get all excited about special tests and everything else
• 48:25
  but to me 80 percent of your decision making is in that subjective so by the
• 48:30
  time i finish listening to somebody's story i'm I'm pretty confident what I
• 48:33
  think the issue is likely to be. And if I'm not, I need to ask some more questions.
• 48:37
  So my objective kind of proves or negates that hypothesis, I guess. That's great.
• 48:42
  And so, again, it's just, you know, if somebody's not giving you the answers
• 48:45
  or you still feel it's a bit muddy and not clear, then maybe a bit more about
• 48:49
  past medical history, maybe about family history, because that can be very telling.
• 48:53
  Or just a little bit more about the aggravating and easing to get some sort
• 48:57
  of pattern. And then it just helps you narrow down the likely culprits.
• 49:01
  Yeah, I love that. I love that idea. It's so useful, I think,
• 49:05
  for therapists to realize the subjective is where you build this hypothesis
• 49:08
  and then the objective is to test the hypothesis.
• 49:10
  But unfortunately, on courses, we're still taught. I don't know what physiotherapy
• 49:13
  is like, but I know that on a lot of sports therapy courses,
• 49:16
  it's still the case of, yeah, do a bit of objective, just get the name,
• 49:19
  make them feel good, and then bam, in with the objective. And that's when you
• 49:21
  work out what's going on.
• 49:22
  And it's like you've missed so much if you're just going in like that.
• 49:25
  But it's a shame that's the problem with education at the moment but
• 49:28
  there are some great courses coming out and hopefully with podcasts like
• 49:31
  this and guests like yourself and that's helping with education as well amazing look
• 49:35
  at that right 8 50 so frozen shoulder what
• 49:38
  else do i try and squeeze into i love the
• 49:43
  idea of i do i mean it's my
• 49:46
  bias but i love this idea of feeling at
• 49:49
  ease when you're not sure and I noticed that on
• 49:51
  your course there is kind of like a unit which
• 49:55
  deals with that what to do when it doesn't go to
• 49:58
  plan how to react and can you kind of enlighten us in some of the recommendations
• 50:02
  or things you do when things don't go to plan would it yeah of course so yeah
• 50:06
  because I think the whole purpose of the course is I just think for clinicians
• 50:11
  I know how I felt early in my specialist job I was meant to be a specialist and I was a bit like.
• 50:16
  Okay so I've suddenly morphed into this specialist and
• 50:19
  actually I just happened to treat shoulders for a little bit but not
• 50:21
  that long and then I was lucky to go and work with some amazing people and
• 50:24
  I did every flipping course that was out there but then you kind of have to
• 50:28
  stand back and have your own ideas and when I looked at it I thought you know
• 50:30
  really somebody comes to me and things aren't going as well as they should and
• 50:35
  I always love the example you know patient comes in how's it going and it's
• 50:39
  like well have you done your exercises which is like it's your fault yeah.
• 50:42
  Exactly don't say that so and and I
• 50:45
  had a lady in the other week and she came in and she was all and I
• 50:48
  said oh you know come on come on in have a sit down tell me
• 50:51
  about your week I said nothing about the shoulder I just said tell me
• 50:54
  about your week and it turned out she had this horribly stressful week and
• 50:57
  mum had been admitted to hospital she'd crashed a car she'd had
• 51:00
  to go back to work after a long layoff with sickness and blah
• 51:03
  blah blah and it was just you could just as she was and she just she
• 51:06
  just stopped and she said the first time I came
• 51:08
  to see you you said that stress and could all make
• 51:12
  my pain worse that's why my shoulder's been worse this week
• 51:14
  isn't it and it was just brilliant because because
• 51:17
  just letting her talk and say it out loud it just
• 51:21
  resonated because I'd introduced those things right
• 51:24
  from the outset so I send them back with a piece out with a piece of
• 51:26
  paper because we know patient recall is rubbish so when
• 51:29
  somebody comes in and things aren't going well the first thing I'd say don't panic
• 51:32
  because there's always a good reason maybe I've
• 51:35
  missed something so you know I had a I'll
• 51:38
  be completely honest I had a guy and I still don't know why I
• 51:41
  didn't do this but it was so obvious when you listen to his history that
• 51:44
  it was his neck not his shoulder and for some godforsaken reason
• 51:47
  I started him on shoulder stuff when he came back the next time I
• 51:50
  looked to my notes I was just like geez I've had a senior moment or something
• 51:53
  and he was improving and it met with his bias because he was a real lifting
• 51:58
  weight guy but guess what adding the neck he made a difference but if you've
• 52:02
  been very thorough at the beginning it's unlikely to be that so when we look
• 52:05
  at the most like reasons since people haven't progressed. They haven't given it enough time.
• 52:09
  They haven't got a good understanding, so they've not bought into it.
• 52:12
  The exercises aren't meaningful to them.
• 52:15
  They've got an expectation of something else and we haven't asked them.
• 52:18
  So if you don't ask patients what they expect of care, it doesn't matter whether
• 52:22
  you don't have to do it, but just ask them.
• 52:24
  We know that's a barrier. So often it's more in that communication domain or
• 52:28
  that lack of resonance with the patient about what you've given them to do.
• 52:32
  And so I quite often, if things aren't going well just sit down and
• 52:35
  say look things probably aren't progressing how we'd hope how are you
• 52:37
  feeling about it let's just go back and and
• 52:40
  how are you feeling and what do you understand and i just check their understanding
• 52:43
  and i would say 60 of the time it's in
• 52:46
  that communication domain sometimes it's just
• 52:49
  they've got a lot of noise from other people because there's always the experts
• 52:52
  aren't there on everywhere that the treatment shopper that speak to a million
• 52:56
  other people just don't take that personally that's a that's a psychological
• 53:00
  characteristic and you've You've just got to stick to your game and be true
• 53:03
  to what you believe and not be swayed by that because that will give them the faith in you.
• 53:07
  And then just being confident that if you're doing the right key things and
• 53:12
  giving it time and progressing in a sensible way.
• 53:15
  80% of your patients are going to progress if they trust you and they believe in the process.
• 53:21
  So if it's not going well, just sit back, reinvest in 20 minutes of re-evaluating
• 53:26
  where we're up to, and then perhaps reassessing those things.
• 53:29
  Because I don't know how much time I've got, Matt, but I think very,
• 53:32
  very briefly, when I have somebody with shoulder pain, I've already decided
• 53:36
  if it's the shoulder or whether it's the neck, apart from that one guy.
• 53:38
  And then basically, it's like is it torn and
• 53:41
  does it matter so have they had trauma and
• 53:44
  is it significant enough that they might have a label tear or a cuff tear in
• 53:47
  which case I might consider some imaging and referral there's
• 53:51
  all sorts of things around that around age and activity is
• 53:54
  it stiff is it stiff enough I need to address the stiffness before I
• 53:58
  can start getting the shoulder moving and generally need about
• 54:00
  70 percent of your rotational range in any direction to
• 54:03
  be able to work through full range with load and then
• 54:07
  finally is it irritable and that just means my symptom
• 54:10
  modification probably won't work so I'm just going to use some other exercises to.
• 54:13
  Calm it down so that I can then feed into that and then
• 54:16
  the mainstay of my objective is can I change it using symptom
• 54:19
  modification and is it strong enough to do the thing that they want
• 54:22
  to do so really simple things and if
• 54:24
  I look at problem solving with patients that are sent to
• 54:27
  me if it's not the communication domain then it's one
• 54:30
  of those things so the stiffness that's not been addressed adequately
• 54:33
  there's something torn that somebody's not picked up or it's
• 54:36
  just really irritable and they've got loads of psychosocial stuff going on
• 54:39
  which is affecting their pain sensitivity so as i
• 54:42
  say i'd love to say i've got this magic box of tricks but i'm just
• 54:45
  thorough and just go back to those basic building
• 54:48
  blocks and what is it that stopped this helping this
• 54:51
  patient get back to what they want to do that's brilliant
• 54:54
  that's a great idea i love the idea of just sitting down and
• 54:57
  encouraging some conversation with the patient so
• 55:00
  one they're going to feel listened to which most patients will love and two
• 55:03
  you're going to get the answers from them and the answers will
• 55:06
  come from them rather than you thinking oh what have i missed what i've done wrong what
• 55:09
  am i not getting do i need another course should i be doing this you
• 55:12
  know so don't doubt yourself which is lovely and then and let
• 55:15
  the patient talk some more and they'll come out with maybe what they
• 55:18
  haven't done or what they didn't understand yeah very nice answer
• 55:21
  very cool which is a great segue to
• 55:24
  to your course now because it doesn't feel like i'm just trying to like sell you
• 55:27
  tickets now it's just makes it just makes sense now doesn't
• 55:30
  it it's like because you're you've got some stuff coming
• 55:33
  up and i really appreciate you just thanks again for being making time.
• 55:36
  To be with us tonight because i know that i've kind of like been making you
• 55:39
  jump through hoops and over styles and things to pin you down but i really appreciate.
• 55:43
  It so let's uh i'll bring this up on the screen now again remember people there's
• 55:47
  no such thing as cpd for everybody all depends i mean if you look after runners.
• 55:51
  Then the shoulder success course with joe gibson will be fantastic educating
• 55:55
  and it might not be the best way for you to invest your money.
• 55:59
  But hopefully, thanks to the episode today, you can see whether it's something
• 56:03
  you'd like to progress with.
• 56:05
  Shoulder steps to success by joe gibson i will
• 56:09
  make sure links to all of these go in the notes in case you are interested but yeah
• 56:12
  talk us through what's coming up i'll put it on the screen so you can see it as well but yeah
• 56:15
  what are you yeah well it's a bit yeah absolutely i've
• 56:18
  got a few i've may june september and
• 56:22
  november in the uk i think in fact there might be one
• 56:24
  in july as well i think there's five in the uk this year i do
• 56:27
  quite a lot of stuff in europe as well but those are the and generally
• 56:30
  if you just put joe gibson shoulder course it will
• 56:33
  take you to vital cycle performance which is certainly running
• 56:36
  four of those I think a couple of them are fully booked already but
• 56:39
  definitely worth a look and the other thing for people who like
• 56:41
  online learning I've got a online course with clinical edge
• 56:45
  we've got a level one and level two now but basically that you can sign up for
• 56:49
  and just watch at your leisure but equally very important to say that I've just
• 56:54
  done loads of free content loads of Facebook lives loads of podcasts if you
• 56:58
  just type in Jo Gibson shoulder and the subject you want to know about it's
• 57:02
  likely there'll be a Facebook live or a podcast about it.
• 57:04
  So if you don't want to spend money, but you still want to get some free education,
• 57:08
  there's lots of opportunities without having to sign up for the course.
• 57:11
  However, I'm very proud of the course and I'm very proud of the online course
• 57:14
  because I think we've got two different ways of meeting people with different learning needs.
• 57:18
  So yeah, it's been great fun putting those things together.
• 57:21
  And just to reiterate, I mean, the sort of people who will benefit from your
• 57:24
  course, do they need a certain level of knowledge already or?
• 57:28
  No, I think if they're just somebody working with patients, trying to get them
• 57:31
  back to what they want to do, then the course is, I mean, literally,
• 57:35
  I get sports therapists, chiropractors, osteopaths, physiotherapists,
• 57:39
  we've had Pilates instructors,
• 57:40
  a whole gambit of people. And I get to know everybody at the beginning.
• 57:44
  So if there's a bit of physio-centric language, shall we say,
• 57:48
  then we just make an idiot out of me.
• 57:51
  And then we just look at how we can explain those things or look at them differently.
• 57:54
  But the common themes of anatomy and application, it doesn't matter who you
• 57:59
  are or what your background is.
• 58:01
  Fantastic. Sounds great. And look at that. We even got, oh, what more,
• 58:04
  what better testimony could you have?
• 58:06
  You've got Andrew himself from ProQuest, Fox Medicine, saying,
• 58:09
  class course, communication is a superpower. There we go.
• 58:13
  Exactly. Get that off on the website now. Oh, a bit of an Andrew fan.
• 58:18
  You can never have enough Andrew McCauley in your life. He was on fire,
• 58:20
  wasn't he? Yeah. Amazing.
• 58:22
  I've got to get in contact with him to make sure he comes to the STA Theatre
• 58:25
  again this time. Andrew, good to see you. Thanks for joining us live.
• 58:29
  Yeah, he's got some courses going on about now, hasn't he? Yeah.
• 58:33
  Down in Cornwall, I think. But anyway, this isn't the Andrew Serling show.
• 58:36
  But yeah, good to see you, Andrew. Thanks. But yeah, great therapist.
• 58:39
  Great therapist. Really good.
• 58:41
  Right. Okay. So where are we? It's nine o'clock on the dot. Thank you so much, Jo.
• 58:45
  Really appreciate your time. There's so much in there. and it's and
• 58:48
  it's great as well because it's such a huge topic we haven't even touched
• 58:51
  on kind of like what sort of exercises or rehab or
• 58:54
  how to stimulate tendon or bone or any of
• 58:57
  those kind of fascinating topics so i feel the part two may be necessary um
• 59:01
  if we can i won't hold you to that now that would be crazy well as long as it's
• 59:05
  sooner than 13 years or 11 years or whatever i will call you i will call you
• 59:11
  you will i'm just going to remind you lots of other people People have heard
• 59:14
  that now, Matt. There's no escape. Oh, that's true.
• 59:16
  Yeah, no, it won't be. I feel really embarrassed about that. It's terrible.
• 59:20
  But yeah, amazing. Really appreciate your time. Gary Benson has said,
• 59:24
  thanks, Joe, sharing your knowledge and experience. It's been fantastic.
• 59:27
  Thank you, Gary. Oh, and also Gary has said here, Gary, can't keep my hands
• 59:30
  out of my pockets, has said, happy to find an STA member to attend or do the
• 59:34
  online option for Joe's course.
• 59:35
  We will work out how we choose someone to attend via our Facebook group.
• 59:38
  I'll speak to you about it, Matt, when you're free.
• 59:39
  Was that just to me or was that to everybody showing me that out loud?
• 59:42
  Yeah that'd be fantastic thanks gary that sounds great nikki mansfield has said
• 59:47
  tremendous clinical experience thank you so much for sharing it with us joe,
• 59:52
  And also Sabrina Monaghan is here saying thanks very much, Jo.
• 59:56
  Thank you, everybody, for giving up your very precious time.
• 59:59
  Yeah, yeah. Did I tell you, people?
• 1:00:01
  Did I tell you? Was I building it up too much? Not at all.
• 1:00:04
  So there you go. No, I really appreciate it. Right. So it just goes for me to
• 1:00:07
  say next week, I'm not sure.
• 1:00:09
  Next week, normally on the first Tuesday of the month, we do an Ask Us Anything.
• 1:00:13
  I haven't actually approached anybody yet. That's where we have a panel of people
• 1:00:16
  just looking at questions which come up across social media.
• 1:00:19
  If you are interested in in attending and ask us anything next tuesday which
• 1:00:23
  basically just means you're coming and sharing your experience then contact me matt at the sto.co.uk.
• 1:00:28
  We probably will do one it's just i've been busy this week i was in court this
• 1:00:31
  week very interesting yeah i won't go into it but i've never done it before
• 1:00:34
  have you done jury service before yes wouldn't want to do it again yeah very
• 1:00:37
  oh what a roller coaster of emotions very strange but anyway so yeah if you
• 1:00:41
  are interested in being on the panel for next tuesday i'll probably reach out
• 1:00:44
  to a lot of you as well but drop me an email make my life easier and then that's
• 1:00:48
  what we'll do Do, as always,
• 1:00:49
  keep an eye at UK underscore STA for details of what is coming up.
• 1:00:53
  And if you listen to the podcast and you do fancy joining us live after listening
• 1:00:57
  to this episode, then great. Just come along.
• 1:00:58
  Eight o'clock, YouTube or Facebook, Sports Topia Association, and you can do that.
• 1:01:04
  But for now, just once again, thank you so much, Jo Gibson, for joining us.
• 1:01:08
  Thank you so much for having me.
• 1:01:10
  Not a problem at all. Thanks, people. Thanks everyone for joining us live as well.
• 1:01:13
  And hopefully we will see a few of you listeners next week joining us as well
• 1:01:16
  online. Take care. Bye bye. Thank you.
• 1:01:19
  Music.