British Elbow & Shoulder Society (BESS) Conference – Coventry, 21-23 June 2017

2017 just gets busier! The paper that I have co-authored with Dr Chris Littlewood (University of Keele) has been accepted for presentation at this years BESS Conference hosted by the Shoulder & Elbow team from University Hospital Coventry & Warwickshire (University of Warwick). The paper is a qualitative study investigating what patients understand when they are diagnosed with ‘Shoulder Impingement’ and what this means for both their subsequent behaviour and expectations of treatment. Having previously worked as a Research Physiotherapist at the University of Warwick, it will be with great pride that I return in a couple of months to share our work.

4th International Mulligan Conference – Copenhagen, Denmark 20-21 May 2017

The Easter break was well welcomed at Sheffield Shoulder Physio, with an ever growing client list and busy clinic ensuring that the last few weeks have been not only busy, but challenging and productive – it’s been great seeing so many people improve and achieve their goals.

In addition to guiding people through their rehabilitation to recovery, 2017 has been a hectic year with increasing teaching commitments, presentations and research publications. In addition to my recent ‘Letter to the Editor’, I was proud to see a paper that I was co-author on be published earlier this month. The lead author on this was Joe Palmer, not only a colleague who I’ve had the pleasure of teaching with in Delhi earlier this year, but also a great friend of mine. This paper investigated whether the ‘Functional Movement Screen’ (FMS) was a reliable outcome measure to be used in UK Physiotherapy practice; particularly within clinicians i.e. intra-rater reliability.

The FMS is a series of seven component movements that are scored from 0 (Lowest) to 3 (Highest) before being totaled to give a composite score out of 21 with the aim of predicting injury in the asymptomatic population. The validity of the FMS has been questioned by a really nice study due to each of the seven component movements measuring a different ‘thing’ (construct being the technical term); i.e. two people can score 14/21 with a completely different make up of points score – does this mean that they are both at equal injury risk? As such, it has been suggested that the component movement scores should be utilised in isolation rather than tallied up to a composite score.

Whilst the validity of the FMS has been questioned, the saving grace is often ‘yeah, well at least it’s reliable’; reliable refers to it being reproducible i.e. if I complete the FMS twice on the same person at two separate time points do I get the same score? Indeed, our paper showed that the composite score demonstrated excellent reliability. However, with this composite score being invalid and not really measuring one or the same ‘thing’ and the suggestion to use the component movement scores for greater clinical utility, are these component scores reliable? For a measure to demonstrate acceptable reliability, it is suggested that it must demonstrate a reliability co-efficient greater than 0.7. Of the seven component movements, only two demonstrated acceptable reliability and thus questions the wider clinical utility of the FMS within this population. Want to know which two? Read the paper, it’s open access!

I know what you’re thinking, what about inter-rater reliability? Watch this space, this data is currently going through peer review and may be even more damning..

Copenhagen, Denmark

Copenhagen, Denmark

To the title of the blog, it is an honour to be provided with the opportunity to deliver two presentations at the 4th International Mulligan Conference in Denmark.

We will be discussing some work that we have completed at the clinic which looks at the clinical reasoning, approaches and opinions of contemporary Musculoskeletal clinicians with regard to the use, role, mechanisms and indications for Manual Therapy. We hope to combine this insight, with our own analysis of current UK practice to discuss, critique and hopefully reconceptualise the use and application of Manual Therapy. Following our presentation, we intend to make both the slides and the data accessible for you all to enjoy!

Manual Therapy: Is there a generational shift in practice?

Manual Therapy: Is there a generational shift in practice?

Excitingly due to the interest shown in my course in Exeter next month, the organiser emailed me today informing me that he was opening up two additional places. If you wish to attend please see here – it would be great to meet you.

Thanks for reading this post and I welcome all comments, queries and critique below!

A

Assessment and Rehabilitation of the Shoulder Complex – Exeter – May 13th 2017

Hi guys,

It’s been a busy month in and away from the clinical coalface – I tweaked and submitted my recent blog post offering a critique of a paper investigating the potential differences of those people with, and without Rotator Cuff Related Pain for publication within the original journal. The reason for this was that it seemed to be well received and also well read; in the face of common practice, it would appear that critical blogs like these receive more traffic and interaction than academic journals. This is both disappointing but insightful. As such, I wanted to ensure that the authors were made aware of my critique and also given the chance to respond.

My letter to the editor can be found here and the authors response here.

I’m teaching my workshop on the Shoulder in Exeter next month, the course is filling well with only a few places left and I’m sure will be an enjoyable and insightful event. I was recently interviewed by the course organiser and the transcript can be seen here. If you’re reading this and local to Exeter it’ll be great to see you at the event!

Best,

A

 

How can ICE help us communicate with patients?

Ice is something historically and traditionally associated with the Physiotherapy profession, however this blog isn’t about the brittle transparent crystalline solid, nor is it a post outlinig the benefits, role and indications for cryotherapy. No, this blog is about communication!

It has been shown that on average, it only takes a patient 92 seconds to explain their problem to you however, the average time a patient is given to speak prior to interruption by the clinician is only 23 seconds.

It is becoming increasingly recognised how the way that we communicate is highly important for our therapeutic relationship with patients, clinical outcomes, guidance of expectations and so as to not induce iatrogenic disability. ‘ICE’ is a model of communication that historically has been used by GP’s to help structure their consultations to provide maximum effect within often limited time, whilst providing clarity to the clinical encounter (Matthys et al. 2009).

Ice, Ice, Baby..

Ice, Ice, Baby..

I was introduced to ‘ICE’ on the Clinical Maze course delivered by Steve Nawoor . Since attending this course, I’ve been utilising ‘ICE’ in my practice to guide my consultations with the aim of improving the outcomes of my patients.

ICE stands for:

– Ideas

– Concerns

– Expectations

Traditionally, the model proposes exploring these three constructs in that order however, I’ve personally adopted a more ‘laissez faire’ model (or maybe I should pioneer a new term, the ‘Modified ICE Model’ a.k.a Water!!) whereby I let the patient speak and guide the consultation in the way they feel appropriate whilst ensuring that I have the ‘ICE’ model in my mind. In doing so, during the conversation I can entice out what the patient may think is going on, any concerns they have, why they think this, where these concerns may have come from and what they expect from both the consultation and by the way of future management. Our qualitative work that is currently under review demonstrates that patient expectation of treatment matches their understanding of the problem and ultimately this will determine satisfaction and potentially outcome; the ‘ICE’ model therefore may help provide those of us at the clinical coalface with a method or framework to be able to influence patient understanding and expectations.

The purist ‘ICE’ model also suggests that you should consider that if a third party is present (i.e. a friend or family member) or the patient brings a third party into the conversation (e.g. my partner thinks I’ve torn a muscle and therefore shouldn’t be going to the gym), that it may be beneficial to consider ‘ICE’ with them also due to the influence that they may exert on your patient’s beliefs, compliance and ultimately outcome.

There are some fantastic resources on communication during the clinical encounter from the GP literature. As we move more into First Contact Practitioner roles and taking on tasks historically undertaken by GPs, we find ourselves consulting in less time than we may normally be used to; interacting and learning from these resources is invaluable.

Some questions that may help you apply ‘ICE’ to your practice are below; these were developed for GP Training but are equally applicable to Physiotherapy practice:

Ideas (beliefs)

  • ‘Tell me about what you think is causing it.’
  • ‘What do you think might be happening?’
  • ‘Have you any ideas about it yourself?’
  • ‘Do you have any clues; any theories?’
  • ‘You’ve obviously given this some thought, it would help me to know what you were thinking it might be’.

Concerns

  • ‘What are you concerned that it might be’.
  • ‘Is there anything particular or specific that you were concerned about?’
  • ‘What was the worst thing you were thinking it might be?’
  • ‘In your darkest moments …‘

Expectations

  • ‘What were you hoping we might be able to do for this?’
  • ‘What do you think might be the best plan of action?’
  • ‘How might I best help you with this?’
  • ‘You’ve obviously given this some thought, what were you thinking would be the best way of tackling this?’

Increasingly, people are presenting with more complex problems, a greater amount of co-morbidity and often persistent pain. Don’t just assume that the person is presenting to you because they expect 100% pain resolution; understand their expectations, work with them to achieve this and ultimately we may see higher satisfaction and improved outcomes.