Clinical assessment of subacromial shoulder impingement – Which factors differ from the asymptomatic population? – Land, Gordan and Watt (2017) – A Critique

An interesting paper has just been published in the Musculoskeletal Science and Practice Journal (formally Manual Therapy) which looked at the clinical examination of people diagnosed with ‘subacromial shoulder impingement’ (SIS) to see whether there were any factors that differed within a matched asymptomatic population.

The authors should be congratulated on the successful completion and publication of what looks to be an extensive project; research is never easy and neither is publication! The execution of their chosen methodology was to a high standard resulting in a well-powered study.

However, I have a few issues with this paper:

1 – The methodology chosen of a case-control study answers their research question, but I would propose the wrong question is being asked.

2 – The use of the term ‘subacromial shoulder impingement’ – please can we as a community stop using this term!? Please!

3 – The population utilised may not be reflective of all patients diagnosed with such a condition.

4 – The assessment procedures utilised are not wholly reproducible in clinical practice and may not necessarily represent best or contemporary practice e.g. the calculation of postural angle utilising computer software.

And most importantly;

5 – As a clinician, has it told me anything that hasn’t already been shown extensively before?

The methodology chosen of a case-control study answers their research question, but I would propose the wrong question is being asked.

The authors report that those patients with SIS, when compared to the asymptomatic matched population, had significantly increased:

  • thoracic flexion
  • forward head posture

Significantly reduced:

  • upper thoracic active motions
  • passive internal rotation range
  • posterior shoulder range

Within a case-control study, these factors are associations and as is well documented, correlation does not equal causation; essentially meaning that this study cannot determine whether these factors are a cause of SIS, or are an effect of SIS – the classic chicken and egg scenario. To determine causation in its broadest sense, there is a need for a prospective cohort study i.e. a population of asymptomatic people are followed over time, those that develop symptoms are then compared to those that don’t, for identification of causative factors for the development of symptoms. The authors in this study try and elicit cause and effect through the use of conditional logistic regression analysis which showed no independent predictors of SIS; they hypothesised that this was due to the study being underpowered – I would suggest it’s more likely due to measuring the wrong variables!

The use of the term ‘subacromial shoulder impingement’ – please can we as a community stop using this term!? Please!

The validity of the acromial irritation theory has been questioned extensively (Lewis et al. 2011) and probably does not best explain the cause of the problem in this population of people with Shoulder pain. It is important that the terms we use reflect our understanding and that we adapt as new evidence emerges – recently the term ‘Rotator Cuff-Related Shoulder Pain’ has been proposed (Lewis 2016) and probably is most accurate at this time. Not only is it important that we use terms that best reflect our understanding, but we need to ‘mind our language’ and use terms that do not induce harm or avoidance behaviour; I’ve just written a paper with Dr Chris Littlewood that is currently under review that I think will shed further light on this within this population of patients when published.

The population utilised may not be reflective of all patients diagnosed with such a condition.

A small point but one that I find intriguing, part of the exclusion criteria in this study was that of any individual that had participated in shoulder strength training in the six months prior to entering the study – defined as high load upper body weight training two or more times per week. I agree that for the small majority of patients that I see with SIS or Rotator-Cuff Related Shoulder Pain (from this point forward I will only refer to Rotator-Cuff Related Shoulder Pain) they have not been loading their shoulder sufficiently to build strength or tendon capacity that may have prevented the onset of symptoms; those patients that may be deemed to have a ‘weak and painful shoulder’.

However, what about those people that see me with Rotator-Cuff Related Shoulder Pain (RCRSP) that have recently returned to the gym or recently started the gym for the first time and have done ‘too much, too soon’ and overloaded their shoulder? What about the regularly gym goer who may have increased their weight ‘too much, too soon’ or may have introduced a new exercise or pushed themselves too hard in a session? What about those rugby players or climbers that I see who could often bench press their body weight or at least hang their body weight off one arm; those patients that may be deemed to have a ‘strong and painful shoulder’. What does this study tell me about these people that I see? I suspect my point here is related to my second critique point and is a reflection of outdated reasoning as to what maybe the cause of the problem in this population of people with Shoulder pain.

The assessment procedures utilised are not wholly reproducible in clinical practice and may not necessarily represent best or contemporary practice e.g. the calculation of postural angle utilising computer software.

In order to measure cervicothoracic posture, thoracic posture and active motions of the upper thoracic spine, the authors utilised a tripod mounted camcorder to take photographs as well as placing skin markers upon the participants before measuring such variables using digital software. Whilst the authors took lengths to calculate and demonstrate that this was a reliable assessment procedure, I question the clinical utility and therefore application of such an approach.

The authors here have stated that they have measured both ‘posterior shoulder range’ and ‘passive internal rotation range’, whilst I understand that these can be seen as two separate measures, I would suggest that these are in fact measurements of the same variable and thus expect that if a patient has reduced ‘posterior shoulder range’ as measured by the Tyler Method that they would also have reduced passive internal rotation range and vice versa (Walton and Russell 2015).

It has previously been considered that a deficit in glenohumeral internal rotation (GIRD) needs addressing (Cools et al. 2012) however, more recently best practice would dictate that internal rotation measurement needs to be interpreted in relation to external rotation available and compared to the opposite side. This is due to measurement of internal rotation being influenced by humeral torsion, but also in certain populations (for example throwers), the shoulder adapts by increasing the amount of external rotation range available leading to a shift in the arc of rotation and naturally an apparent ‘reduction’ in the amount of internal rotation movement available when measured; in such a situation, the total range of motion is maintained. If there isn’t a concomitant increase in external rotation with an apparent reduction in the amount of internal rotation movement available, this can be deemed a total range of motion deficit or ‘TROMD’ (Manske and Ellenbecker 2013; Wilk, Macrina and Arrigo 2012; Wilk, Hooks and Macrina 2013).

What new information has this study told me as a clinician that hasn’t already been shown extensively before?

It has told me that in RCRSP, static scapula postures probably don’t play a role in the development of symptoms. However, stronger, (including prospective data) has already told me this with greater confidence as we know already that static posture doesn’t tell you how the scapula is going to move, and how the scapula moves doesn’t appear to correlate with the development of symptoms (Morais et al. 2013; Ratcliffe et al. 2013); I suppose this paper adds further support to this notion but it is hardly a hammer blow to the scapula!

“Currently, there is insufficient evidence to support a clinical belief that the scapula adopts a common and consistent posture in SIS. This may reflect the complex, multifactorial nature of the syndrome.” – Ratcliffe et al. (2013).

It has told me that RCRSP is associated with a thoracic kyphosis or forward head posture; it has not told me that it is a causative factor. However, stronger, systematic review data has already told me that a thoracic kyphosis does not appear to be an important contributor to shoulder pain (Bartlett et al. 2016) but an increased kyphosis may limit the amount of elevation available at the shoulder which in turn may have implications for certain occupations that require prolonged use of their arms overhead; although the systematic review authors do suggest further research is required.

It has told me that RCRSP is associated with posterior shoulder tightness; it has not told me whether this is a cause of RCRSP or an effect of RCRSP; this association has already been widely documented (Dashottar and  Borstad 2012; Gates et al. 2012; Bach and Goldberg 2006). Due to limitations in the measurement method (Manske and Ellenbecher 2013), I do not know whether there was in fact posterior shoulder tightness as the amount of passive external rotation available is not documented to allow me to determine if indeed a TROMD exists.

To conclude, I’m not sure what this study adds in terms of informing clinical practice. It is a nice study, one that is well conducted but to what end? RCRSP is a clinical presentation that is multifactorial, and individual in nature. It is apparent that there is a complex interplay between structural, psychological, sociological and lifestyle factors that ultimately lead to each presentation being unique and individual in nature. This needs further investigating within research not more reductionist papers trying to identify the magic bullet.

Please do let me know what you think!







Our final day in Delhi

Our final day in Delhi did not start too early as you can imagine following a late finish. With the hectic teaching schedule, meetings regarding future workshops, combined with a small tourist schedule alongside a four-day wedding itinerary, we were beginning to feel the effects and with the weather humid and cloudy, we decided to have a day of rest.

After a leisurely coffee, we again practiced what we preached and forced ourselves to the gym for our second (two sounds more committed than one!) work out of the trip before packing our things ready to depart. I’m not quite sure how they did it but having wrapped up their wedding at midday(!), managing one stolen hour of sleep, the newlyweds came and collected us from our hotel and took us into Delhi for the evening.

We dined at what turned out to be my favourite restaurant of the trip ‘United Coffee House’; an establishment that has been around since colonial times with the service, the décor and the ambience highly suggestive of British influence! It was not this however that secured its place as my favourite restaurant, the food was incredible (I really do not know how Joe and I will survive on return to bland food in the UK!).

Old Coffee House, New Delhi

United Coffee House, New Delhi

Old Coffee House, New Delhi

United Coffee House, New Delhi

Gaurav informed us that when he was in England for the two-years completing his MSc that he struggled with eaten ‘Indian’ food that did not compare to the taste or quality that was found in abundance in Delhi. We reminded Gaurav that he merely had to endure this for two years; we will now have to endure this for the rest of our lives!

Dinner at the Old Coffee House with Joe, Gaurav and Parul.

Dinner at the United Coffee House with Joe, Gaurav and Parul.

With one final drive around Delhi’s ‘inner circle’ we took some final photos to remember our maiden trip to India before departing to the airport, including the biggest flag I think I’ve ever seen!

Connaught Place, Inner Circle

Connaught Place, Inner Circle

We have really enjoyed our maiden trip teaching in, and visiting India; so much so that plans are already being talked about to host us again in 2018. To everyone that we had the pleasure and honour of meeting, interacting with, sharing experiences with, thank you for making us feel so welcome.

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Wedding Day!

Wedding Day! I woke up with a spondylitic neck thanks to sleeping on the drive back from Agra as a pseudo-contortionist! Having consumed our body weight in carbohydrates, paneer and alcohol since arriving and with the limited opportunity to exercise, we decided this morning would be the morning we got in gym session at the hotel. After downing some instant coffee in espresso form we headed up stairs to the gym. Thankfully, we were the only two in there as with no air-conditioning and a week of eating/drinking however we liked, I can safely say we were borderline dead after four rounds of HIIT and looked abysmal!

Practicing what we preach!

Practicing what we preach!

We freshened up and were picked up by Gaurav’s brother to take us to the tailors in order to get fitted for some indo-western dress; a form of Indian clothing that whilst traditional, has some western inspiration from colonial times that we were going to wear to the wedding later on this evening. To say that we both looked incredible would be an understatement (…!); a tailored, fitted outfit for £25 was a steal and on the way back to the hotel we stopped off to get some fresh new creps for the evening.

Taking 'Indo-Western' very seriously!

Taking ‘Indo-Western’ very seriously!

To say that a traditional Indian wedding is unlike an English wedding is at best an understatement! Whilst the wedding itself has been ongoing for the last few days with a variety of rituals, gathering and ceremonies, the wedding itself culminated today. The evening started with Gaurav’s friends and family gathering at Gaurav’s house for music, dancing and a largely religious series of events. There were a variety of animals, a lot of drums and a lot of dancing; Joe and I were embracing Bollywood as if we were the best dancers the world had ever seen – that was Mr Johnnie Walkers doing! Whilst wearing our Indo-western dress, we were sweltering – so much so that I had to decline the offer of having a turban tied although Joe fully embraced this and actually looked better with a turban..

Joe rocking a turban.

Joe rocking a turban.

Following completion of the rituals and having a series of photos with Gaurav; his head was adorned with silver and he was mounted upon a horse. This was when the night really started; to the tune of a brass band and six-fire breathing Dhol players the wedding procession danced for the next 30-minutes, covering a distance of around 100m out of the apartment complex and on to the main road. Here there was a slight pause in proceedings as at the rate that we were proceeding it would mean that to cover the remaining 20km to the wedding venue would be pushing a few days! Following a quick drive across Delhi, we reconvened the dancing procession about 400m away from the venue.

Wedding selfie.

Wedding selfie.

The evening was one far less of debauchery that you would typically expect at an English wedding with the ceremony being conducted within relatively strict Hindu protocol. Have no fear, this had been fully catered for and the amount of men in the car park outside the venue with car boots full of alcohol was a sight to behold!

Like any wedding, you find the guys at the bar..or the Whisky stocked car boot if needs must!

Like any wedding, you find the guys at the bar..or the Whisky stocked car boot if needs must!

When the bride (Parul) arrived, it was time for the happy couple to take pride of place up on stage and begin the three-hour photo-shoot! It is expected that every guest has their photo taken with the Gaurav and Parul; it was clear to see how sore and achey their facial muscles became during the evening! While Gaurav and Parul channelled their inner vogue, the majority of the remaining wedding party took to the dancefloor to channel their inner strictly come dancing and burn off some calories!

I told you we looked incredible..

I told you we looked incredible..

At the grand hour of 1am, the photo shoot started to wind down as the close family took their place for the final few shows. This scheduled the start of the 30-minute pre-ritual main meal for close friends and family; at 2am approached, Joe and I were starting to demonstrate our British roots as we were flagging – not even four cups of chai were enough stimulation and we left the rituals at around 3.30am. The rituals themselves were due to finish at about 6-7am; I’m not sure how Gaurav and Parul managed it – they’re troopers. We were told by more than one guest that evening that the Hindu wedding ceremony is the longest and that it is generally accepted that you do not enjoy your own wedding day! I’m not sure if that holds true for everybody as the wedding couple appeared beside themselves with happiness and excitement.

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Two Physiotherapists walk into the Taj Mahal..

Today was going to be particularly exciting; Gaurav had arranged for a driver to take us the three hours to Agra to see the Taj Mahal. The day started 15-minutes later than planned as Mr Johnnie Walker played havoc with our ability to wake up at 6.30am after only four hours of sleep. Our driver was very understanding and despite not the smoothest of journeys with the suspension of the car being tested regularly, we both slept the majority of the journey.

Upon arrival in Agra it was clear to see that the way of life was a lot slower and the population were more accustomed with seeing a tourist. We negotiated with a local tour guide a reasonable price (about £20) to take us around both the Taj Mahal and the nearby Agra Fort.


Rumour has it, this will now forever be known as 'Andrew's Bench'..

Rumour has it, this will now forever be known as ‘Andrew’s Bench’..

The Taj Mahal interestingly was built by one of the late Emperors of the Mughal dynasty (Shah Jahan) at the request of, and to honour, his wife(Mumtaz Mahal) who passed away giving birth to their 14th child. It took a total of 16 years to build and cost around 40 million rupees to build at that time, roughly 820 million US Dollars in the present day; all from the public purse! The Taj is built upon a principle of symmetry; the Emperor had planned to build a black, identical copy of the Taj Mahal on the banks of the river opposite and behind the white Taj; whilst this was started, it was not finished as he was imprisoned by his youngest Son for the next eight years within Jasmine Palace of Agra Fort where he died.



Our guide was a part-time Photography..

Our guide was a part-time Photographer..

He REALLY enjoyed photography..

He REALLY enjoyed photography..

Agra Fort was inhabited by the British during colonial times, evident today by the local golf courses, convents and Christian schools. Today, only 25% of the fort is open to tourists with the Indian army occupying the remaining 75%. The fort is 2km in length and is far larger than the Taj; at its peak, it had 95 palaces on sight, today we can see 16.

Agra Fort

Agra Fort

Agra Fort

Agra Fort

Our drive back to Agra again tested the suspension and whilst asleep, tested the limit of my neck to withstand sustained torsion – I will feel that tomorrow I am sure! After an early start and a long day out in the sun, we decided to take it easy and rest in the evening (sorry Johnnie, catch you at the wedding mate). One unlimited barbecue buffet and a few cold ones later, it was time to sleep.

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Teaching complete – time to enjoy India!

Our fourth day here was a slow start after a late finish and being led astray by Mr Johnnie Walker the night before..

We wanted to experience as much of the traditional culture as we could whilst here and enjoying a few days of relaxation after long hours of writing and culminating in both the travel and the teaching. Gaurav in turn arranged for us to go to ‘Old Delhi’ where we were told we would experience the most delicious of all delicious curries.

The vastness of Delhi was evident with the taxi ride taking all of 90minutes (contributed to by the congestion of having 24million people living in one city) and for the price of 210ruppees (about £2.50). Upon arrival to Old Delhi we were welcomed with chaos – what a place! A bustling street bazaar driving the local economy with shops selling anything from livestock, shoe repair, stationery to food, meat and chai. We made our way to the Masjid (Mosque) which dominates the city – we were again seemingly celebrities here again as once again our selfie prowess was tested to the max.

Old Delhi - Chaos!

Old Delhi – Chaos!

Whilst the adherence to a strict health and safety policy was clearly evident (…!) we disappointingly did not feel confident enough to try the local cuisine without guidance on where and from whom we should purchase such delights. Instead, we thought we would add the experience of riding a tuk-tuk in Delhi (where 17 people die every hour from traffic related deaths and 1/10 all traffic related deaths in the world occur..) as we had relied upon either taxis or the driver provided to us by the institute so far. It was surprisingly comfortable and quicker than the car; the negative of our individual experience was that our driver did not speak English, did not know where he was going and in fact drove us 30minutes in the wrong direction before gesturing to us that we had, in fact, arrived at our hotel. Thankfully, Gaurav (who is increasingly becoming Delhi’s version of Mycroft Holmes) discovered our location and sent his driver within five-minutes.

That night, it was time for another wedding festivity as we were invited to Gaurav’s house for a celebration with close family and friends on the roof top. The ladies independently had a ceremony with music, dancing and the application of henna whilst the gentlemen were entertained by a certain Mr Johnnie Walker who was brave enough to show his face again after the havoc he had caused the night previously!


Gaurav, Joe & I with the local chap that could actually play the Dhol..

Gaurav, Joe & I with the local chap that could actually play the Dhol..

After the lady’s ceremony finished, they joined us on the roof top for dancing to the beat, sound and rhythm of the Dhol played by a local chap. At this point, Mr Johnnie Walker convinced that I could in fact play the Dhol and I’m sure hilarity followed; however, testimony to Gaurav’s family and friends, they humoured me and made me think I wasn’t too bad!

The not-so-local chap that couldn't play the Dhol! Encouraged by Mr Johnnie Walker.

The not-so-local chap that couldn’t play the Dhol! Encouraged by Mr Johnnie Walker.

I told Gaurav three years ago that I would be at his wedding, playing the Dhol - I'm a man of my word!

I told Gaurav three years ago that I would be at his wedding, playing the Dhol – I’m a man of my word!

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International Workshop on Advancements in Shoulder and Spine Rehabilitation – Sitaram Bhartia Institute of Science & Research – Day 2 – Sunday 26th February 2017

The second day of the International Workshop was devoted to the Lumbar Spine with the lead tutor being Joe Palmer; it was great to be invited to assist with teaching this workshop.

A case study presentation by a member of the Teaching Faculty started the day and allowed for insight into current practice for low back pain by Indian Physiotherapists; the case was of a 22-year old male with lumbar radicular pain without any objective neurological features. The patient was treated with manipulation and exercise therapy with their symptoms resolving with two weeks of rehabilitation; interestingly, the presenting Physiotherapists working hypothesis was one of ‘piriformis syndrome’ and that he felt that the patient management would have been improved if he had received an MRI scan. The notion was also put forward that manipulation of the lumbar spine in the presence of a disc prolapse created a vacuum effect for the disc to be ‘put back into place’. This was an unfortunate start to the workshop as it highlights the over-reliance upon MRI as well as the mechanical reasoning processes within Manual Therapy practice.

The presentation did however allow for the opportunity to discuss the reasoning within the case. For example, in the absence of features of serious pathology and no objective neurological change, why would an MRI scan be indicated and how would it change management? Furthermore, with evidence clearly demonstrating that the effects of manipulation are both non-specific and reflect a neurophysiological process rather than a mechanical one, clarification was sought regarding the claim of a vacuum effect – I am due to be emailed this evidence and will update you all..!

A point of reflection from a UK perspective, all three cases presented by the Indian Faculty utilised Patient Reported Outcome Measures (PROMS); QuickDASH and SPADI for the Shoulder cases; and ODI for the Lumbar case – I wonder how many UK Physiotherapists could honestly commit to saying they use PROMs with all of their patients?

Then it was time for Joe to deliver his first lecture on epidemiology, anatomy and common presentations seen in the lumbar spine; there was an emphasis on the specific pathologies that present such as stenosis and high-grade spondylolisthesis on order to emphasise how rare these are and how in the majority of cases we are seeing non-specific low back pain. The lecture ended with the sharing of and explanation of the recent NICE Guidelines for Low Back Pain, these were embraced by the delegates and it was pleasing to hear the acupuncture and electrotherapy use is diminishing in India similar to that in the UK.

A slide from Joe's talk on the recent NICE Guidelines

A slide from Joe’s talk on the recent NICE Guidelines

Having finished the first talk, it was again time to attend Coffee and Breakfast in the gardens – I think I’m going to have go on a diet on my return from Delhi!

The downside of 125 attendees is signing all of the certificates..cramp!

The downside of 125 attendees is signing all of the certificates..cramp!

125 certificates later..

125 certificates later..

The post-Breakfast lecture session started with Joe introducing the biopsychosocial model, the identification of central sensitisation from both the history and the physical examination, and how there is a need for individualised care. It would appear that clinical reasoning amongst the delegates is currently rooted within the biomedical model however, the post-lecture questions showed that this lecture from Joe (which was excellently delivered) had begun the process of reflection and possible early change toward s a biopsychosocial approach to treatment.

In order to ensure the pendulum does not swing too far for the detriment of both patients and clinicians, Joe invited me to speak from an Extended Scope perspective. My lecture covered when to consider imaging the Lumbar Spine with the take home points being:

1 – When your index of suspicion suggests that the person in front of you may have an underlying serious pathology.

2 – When there has been a deterioration of neurological status.

3 – When the patient has not responded to conservative intervention AND it will lead to a change in management.

This lecture concluded with the sharing of the recent NICE recommendations for invasive (non-surgical and surgical) interventions for people with low back and sciatica. I was keen to stress the point that for the majority of these patients, invasive intervention was only to be considered for those patients that had not responded to an appropriate conservative management period; highlighting the crucial role that we as Physiotherapists have in this cohort of patients. My lecture ended with a practical workshop of my recent paper around Advanced Neurological Examination, with a focus on reflex testing as well as how to utilise the history, and objective examination (informed by diagnostic validity research) can help to rule out the Hip and Sacroiliac Joint as part of the patient’s presentation. This demonstration was filled with good humour as my model became confused between the terms prone and supine resulting me demonstrating on the floor the position I wanted him in each time!

After lunch, Joe retook the stage and discussed some myths and misconceptions within Lumbar Spine assessment, in particular around posture, motion palpation and core stability. A true or false section with the delegates revealed the belief that a hyperkyphotic posture was bad and would result in pain was combined with the belief that an upright, erect posture was good and would result in less or no pain. The data was presented around posture from the current literature to some aghast!

A very brief overview of ‘Cognitive Functional Therapy’ was delivered by Joe with the work of Professor Peter O’Sullivan et al. highlighted as well as direction provided to the delegates as to where they can read and interact more with the resources provided by their research group whilst again highlighting the individualised nature of care within such a model.

After a short break for chai, it was time for the final practical workshop of the day that would take us to the close of the weekend’s teaching – this was the session that everyone had been waiting for as it included some manual therapy demonstrations!

Joe started the workshop demonstrating the practical application of neurodynamic theory within the assessment and how this in turn impacts upon subsequent management of patients. With there being a heavy bias towards the prescription of core stability within the room, Joe masterfully highlighted the potential nocebo associated with the term as well as how the subsequent compressive forces on the sensitised articular structures may in fact drive chronicity before teaching and practicing how to prescribe/perform both a squat and a deadlift with guidance on how to regress/progress.

Joe demonstrating a low grade rotation mobilisation.

Joe demonstrating a low grade rotation mobilisation.

The treatment philosophy of the majority of the delegates was aligned with the Maitland Approach; driven by subsequent undergraduate curricula similar to that seen in the UK. It was up to me to therefore reinforce my lecture from the previous day regarding the neurophysiological and non-specific effects of manual therapy and its subsequent practical application. I took the delegates through progressions of ‘rotational mobilisations’ of the upper and lower lumbar spine (delegates were informed that due to issues around reliability, that I do not subscribe to being able to mobilise specific spinal segments and that I in turn dichotomously divide the lumbar spine in both by documentation and treatment) with examples of how neurodynamic theory can be incorporated into such techniques and the subsequent exercise prescription.

So as to not impart my biases on the delegates too much, I took the opportunity to teach a basic application of the Mulligan Concept for those patients with difficulty either forward bending or backward bending. Within the teaching, I taught how these techniques are described from a purist Mulligan perspective i.e. specific thumb or pisiform position with the proposed theory effect being one of positional fault before inviting the delegates to critically appraise this with regard to what has been taught over the last two-days. It was great to see the delegates debate between specific and non-specific hand positioning as well as how the positional fault theory may not be a valid explanation of any effect seen.

Delegates practicing a 'Flexion SNAG' from the Mulligan Concept

Delegates practicing a ‘Flexion SNAG’ from the Mulligan Concept

With the teaching done, the final ceremony saw Joe and I presented with a memento of our time teaching at the workshop; in India, following your Bachelor’s degree in Physiotherapy you are referred to as ‘Dr’ and as a mark of respect to us both not possessing a PhD, this honour was bestowed upon us!

Slightly premature, and to the annoyance of my brother who possesses a DPhil but the sentiment was one of respect.

Slightly premature, and to the annoyance of my brother who possesses a DPhil but the sentiment was one of respect.

Post-teaching selfie during the closing ceremony.

Post-teaching selfie during the closing ceremony.The day finished with a photography session in the gardens of the Institute; we had our photos taken with the Organising Chairman, Dr Aman as well as the Teaching Faculty before a final shot of everyone in attendance. The chaos then ensued where Joe and I must have posed for a minimum 150 selfies with a variety of the delegates! For that 30-minute period, we had a brief glimpse into what it must be to be in One Direction!



The Teaching Faculty

The Teaching Faculty


Spot the tutors!

Spot the tutors!

Joe and I with one of the delegates.

Joe and I with one of the delegates.

Our time teaching was finished which meant that we now have a few days taking in the sights, sounds and culture of the local region. One of my clinical roles is as a Consultant Physiotherapist for Artisan Healthcare based in New Delhi, India; the Director of Artisan Healthcare is our good friend Dr Gaurav Kumania, whom we had the pleasure of building a great friendship with during his time in the UK studying for his MSc. Gaurav has been hosting us since our arrival and it is with great excitement that we are now joining his wedding celebrations. After a quick freshen up, we made our way to the first of his Wedding celebrations whereby we became quickly accustomed with the tradition of Whisky drinking!

From teaching to the party in less than an hour..

From teaching to the first wedding function in less than an hour.

Thankfully, this facilitated Joe and I to become (what I’m sure we thought at the time) the best Bollywood dancers ever to grace Delhi (!). Gaurav looked incredible in his Indo-western dress and his family and friends really welcomed us into the celebrations. There is a rumour that this may not be the last time we seen Indo-western dress…

Joe, Gaurav and I

Joe, Gaurav and I

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International Workshop on Advancements in Shoulder and Spine Rehabilitation – Sitaram Bhartia Institute of Science & Research – Day 1 – Saturday 25th February 2017

Today started early with a delivery of the morning papers and Indian Tea (Chai) to our room; for those of you that haven’t had the pleasure of tasting Chai, it is a spice-filled, milky, sugar-infused delight but one that should definitely be enjoyed in moderation.

Morning Papers with Chai

Morning Papers with Chai

The driver from the Sitaram Bhartia Institute picked us up and ensured our hectic journey through Delhi was both quick and car-horn filled, allowing us to arrive at the venue in good time. Upon arrival, we were welcomed by the Organising Chairman, Dr Sachdeva; the Director of the Institute, Dr Bhargava; the 25-strong Delhi Senior Teaching Faculty and 80 Physiotherapist/Occupational Therapist Delegates. After the welcome, we were invited to partake in a lamp-lighting ceremony in order to ensure culturally that the environment was one optimal for learning and sharing knowledge.

Teaching Faculty - Feb 2017

Teaching Faculty – Feb 2017

The workshop was opened with a short presentation from Assistant Professor Zubia Veqar, highlighting the same issues that we see consistently in the UK; that of over-reliance upon imaging, the unnecessary focus upon specific structural diagnosis and the belief of surgery as the ultimate cure. An interesting case was presented regarding Post-Chikungunya Arthralgia; a rheumatic disorder that was once eradicated from India before a case reoccurring in 2006. Naturally, evidence with regard to how to manage such a case is rare and Prof Veqar did well portraying both the complexities and the role of Physiotherapy within such presentations.

After Prof Veqar had completed her talk, we were treated to coffee and breakfast in the gardens of the institute under the glorious Delhi sunshine.

Teaching Faculty - Feb 2017

Breakfast in the Gardens

After this unique experience I was up to present the rest of the Scientific Session, below is a summary of my workshop:

The Shoulder Scientific Session started with a lecture covering the epidemiology of shoulder conditions, anatomy and biomechanics of the shoulder complex, spinal red flags and ruling out the cervical spine. The incidence and prevalence of shoulder conditions in the general population as well as a review of specific populations with relation to nationally and associated co-morbidities was presented initially. A theme of the lecture and throughout the day was that of variety; how anatomy is variable; how biomechanics are variable and how people are variable – In turn we as clinicians need to be variable in our approaches to assessment and treatment. The lecture finished with a practical workshop demonstrating and practicing how in addition to the patient history, the objective examination can be performed in order to differentiate the cervical spine from the shoulder.

Demonstrating how a pain free, familiar task has innate variability by asking a delegate to repeatedly write Delhi!

Demonstrating how a pain free, familiar task has innate variability by asking a delegate to repeatedly write Delhi!

The second lecture of the day covered shoulder assessment and presentations that make up The Unstable Shoulder. A large emphasis was placed upon the need to consider the patient from a Biopsychosocial perspective and how this naturally feeds into considering the patient as an individual rather than an anatomical region i.e. a person with a painful shoulder, rather than a painful shoulder! We discussed the limitations of orthopaedic ‘special tests’ in terms of reliability and diagnostic validity, highlighting the underlying theoretical and anatomical rationale for this. To help them navigate the murky waters of clinical diagnosis and underpinning literature, the delegates were taught a critical evaluation of my ‘two-minute shoulder examination’ before beginning the presentation on The Unstable Shoulder. An introduction to the Stanmore Classification was given, as well as a discussion around the indications for and roles of both surgery and immobilisation for the unstable shoulder. The principles of rehabilitation were taught prior to demonstrating the practical application of these. The lecture finished with a practical session of the best supported special tests for both posterior and anterior instability as well as teaching the delegates how to use the Derby Instability Programme as designed by Marcus Bateman from the Derby Shoulder Unit.

In full flow..instability tests of the Shoulder.

In full flow..Instability tests of the Shoulder.

After building up a healthy appetite from plyometric push ups, lunch was again served in the gardens of the institute. Any course/workshop/conference that I attend in the future will unfortunately pale into insignificance with regard to the food that they can offer – the hosting and cuisine has been top notch during our stay so far.


Indian Food for lunch is going to be a hard habit to break on return to the Uk

Indian Food for lunch is going to be a hard habit to break on return to the UK

Making the most of the Sun between lectures.

Making the most of the Sun between lectures.

The post-lunch sleep was unfortunately delayed for the delegates whilst I presented the third lecture of the day, The Stiff Shoulder! The presentations of Glenohumeral Osteoarthritis, Frozen Shoulder Contracture Syndrome, The Missed Dislocation and the Secondary Stiff Shoulder following Rotator Cuff-Related Pain (or the pseudo-stiff shoulder!) were presented. A really insightful discussion took place regarding the use of imaging in the presentations and whether or not they should be indicated as part of the diagnostic work up prior to Physiotherapy intervention; the delegates were very interested in the role of an ‘Extended Scope Physiotherapist’ as this is something that their organising body is striving towards; the confusion over the title however highlights the recent movement to change the title to Advanced Physiotherapy Practitioner. Culturally, there is a reliance upon the use of manual techniques either combined with or without electrotherapy, it was refreshing to see the delegates engaging with the neurophysiological mechanisms of action as well as working hard practicing eccentric loading exercises to induce Sarcomereogenesis – the creation of new sarcomeres that in turn leads to physical or real increase in tissue length.

The final lecture of the day was on Rotator Cuff-Related Pain. The presentation questioned the validity of the acromion theory of irritation as the cause of pain in the mobile shoulder with the subsequent diagnosis of sub-acromial impingement. It was interesting to see that the same trends regarding sub-acromial decompression were evident in Indian practice that we see in the UK. The ‘two-minute shoulder examination’ was built upon with the use of the ‘Shoulder House’ analogy for Symptom Modification as described by Adam Meakins, to enable the clinician to encourage movement in the early stages of management. Teaching was supplemented with an interesting discussion regarding the latest developments for the subsequent need, or lack thereof, of between-session changes as well as how the analogy could be changed to best reflect the local culture. This session was completed with a practical strength and conditioning session, highlighting the theoretical principles of each rehabilitation phase guiding progressive loading from reducing pain, increasing strength, improving tendon capacity through to the development of power.

Loved this message in the Physiotherapy Department,

Loved this message in the Physiotherapy Department.

As the last session of the day, this was followed by an open question and answer session and it was really heartening to see delegates questioning the rationale behind test procedures in terms of standardisation, uncontrollable variables and how these may impact upon the reliability and validity of assessment procedures.

After a long day of teaching, it was with great relief that the hotel bar opened early for us to allow a quick liquid refreshment prior to the Teaching Faculty dinner hosted by Dr Sachdeva once again in the gardens of the Sitaram Bhartia Institute – you definitely couldn’t host an outdoor garden party in the UK in February! The cuisine and the hosting was again of the highest quality and this was supplemented with some great conversations over local practice, local pathways and how they compared to that seen in the UK.

Patient/Family Rights & Responsibilities upon entrance to the Sitaram Bhartia - a great idea. UK Hospitals/Clinics should follow this example.

Patient/Family Rights & Responsibilities explicitly displayed upon entrance to the Sitaram Bhartia.

Goals of the Institute displayed at the entrance of the Sitaram Bhartia - these are both great ideas. UK Hospitals/Clinics should follow this example.

Patient Safety Goals of the Institute displayed at the entrance of the Sitaram Bhartia – these are both great ideas. UK Hospitals/Clinics should follow this example.

Within Indian practice currently, patients still have to see a Doctor prior to being referred for Physiotherapy management; the faculty were really inspired by the UK model of Physiotherapists working both within a First Contact role and an Extended role; both the responsibility and opportunity this provides to the profession as a whole. My overriding impression from the evening was that the current status of Indian Physiotherapy is one of a workforce that is driven, keen and more than capable of beginning to challenge the current convention to drive the international profession forward.

Please see here to read about the previous day, or here for the next day.