British Elbow & Shoulder Society (BESS) Clinical Updates – Coventry 2017

It’s been a week since the recent British Elbow & Shoulder Society (BESS) conference held at the Ricoh Arena in Coventry. A predominantly surgical conference but one that is always good fun and packed with learning for the Physiotherapist attendees also. Whist there it was good to catch up with old friends as well as meet new colleagues that share a similar interest.

Our recent qualitative work was presented as part of one of the keynote talks delivered by Dr Chris Littlewood (co-author) as well as in poster format; the messages seem well received and when the full manuscript gets published I will deliver the key messages via this blog. The photo below shows one of Chris’ slides with some of the quotes from the patients in our study:

Slide from Dr Chris Littlewood's talk: Mind your language!

Slide from Dr Chris Littlewood’s talk: Mind your language!

The point of this blog is to provide some of the insight from this years scientific programme. The statements below are all from talks delivered at the conference and are those that I’ve highlighted as most relevant to my practice within Primary Care and as Physiotherapist.

For full references of to whom conducted and presented the work; as well as full abstract please see here:

Basic Science and Miscellaneous

  • There is limited evidence that steroid injections to the ACJ delivered by ultrasound guidance are more effective than landmark guidance in terms of pain reduction or increasing function in both the short term (3 weeks) and medium term (6 months) – there is no evidence for long term outcomes (12 months+). Further research is needed to justify the additional cost and wait times associated with Ultrasound Guided injections in light of similar clinical outcomes.

 

  • A new outcome measure; the ‘Combined Shoulder Assessment’ has been developed which appears to be a more convenient and patient-friendly method to obtain equivalent Oxford, Constant and QuickDASH shoulder outcome scores. This was awarded the prize for best presentation and comes from the Wrightington Upper Limb Team.

Rotator Cuff

  • Physiotherapist-led exercise in patients with ‘Subacromial Impingement Syndrome’ leads to greater improvements in pain and function than providing a standardised advice and exercise leaflet (Phew!). Ultrasound-guided injection confers little additional benefit over landmark guided injection.

 

  • A controversial conclusion next! The Exeter team presented that in patients randomised to arthroscopic capsular release (ACR), a significantly higher improvement on the Oxford Shoulder Score was seen compared to those randomised to hydrodilation (HD). On this basis, they recommend ACR as their first line therapy for Frozen Shoulder.

However, the study demonstrated no difference in External Rotation range or EQ5D and there were a few short comings that may weaken the strength of this conclusion. The difference on Oxford Shoulder Score was 6 points; 5 points is the Minimally Clinically Important Difference (the point at which patients notice a change). The sample was very small; 25 were randomised into each group, 19 were available for follow up in the ACR group and 12 in the HD group. Four of the HD group crossed over to ACR and were excluded from the analysis leaving the final standings as 19 in the ACR group and 8 in the HD group. Further, the procedural time and cost were not considered when drawing the conclusion.

  • An interesting study from Monash University in Australia looking at long-term rotator cuff integrity following repair of a tear. At an average of 16.25 years post-surgery a recurrent tear was noted in 37% of patients with only one of these increasing in size. 85% of patients were satisfied with their surgery and those with a recurrent tear had equivalent outcome scores to those with an intact rotator cuff. What may therefore be the mechanism by which they improve? The group identified no independent risk factors for recurrent tear.

Elbow

  • Four outcome measures satisfied the Evaluating Measures of Patient-Reported Outcomes (EMPRO) criteria for recommendation of use to quantify Health-Related Quality of Life in Lateral Epicondylar Tendinopathy (Tennis Elbow); DASH, QuickDASH, Oxford Elbow, Patient-rated Tennis Elbow Evaluation (PRTEE). The QuickDASH scored the highest and this may lead to a practice change within my ‘Tennis Elbow Clinic’ where I currently use the PRTEE.

 

  • The addition of a ‘Tenease’ device offered no benefit above ‘standard conservative treatment’ in a RCT from the Exeter team; which is pleasing as the scientific plausibility of such a device is poor and would not be something I recommend to patients with this complaint!

 

  • Another study from the Exeter team injected dye (either 1ml or 3ml) into the common extensor origin of 20 cadaveric elbows; in all cadaveric samples, the dye found its way into the joint and following injection, there was a 2.5% increase in tears attributable to the injection. Whilst this research is in vitro, the findings are interesting and may suggest that joint contamination may be inevitable following CEO injection.

 

Physiotherapy 

  • 3% of UK Physiotherapists (8/287 respondents) reported delivering supra-scapular nerve blocks to patients with persistent, complex and multi-component shoulder pain for whom shoulder surgery was either not an option or not preferred; suggesting that use amongst Physiotherapists is uncommon.

 

  • Patients treated by Physiotherapists using landmark-guided supra-scapular nerve blocks achieve clinically important changes in pain and function in both the short term (six weeks) and medium term (six months) that were not significantly different to those provided by an anaesthetist via ultrasound guidance.

 

  • The National Institute of Clinical Excellence (NICE) suggests that not only does treatment need to be clinically effective, but also cost-effective. This is calculated utilising the Incremental Cost-Effectiveness Ratio (ICER) in relation to Quality Adjusted Life Year (QALY) gained. NICE state that an ICER below £20,000 per QALY is indicative of cost effectiveness. This paper from the Nottingham unit shows that Specialist Shoulder Physiotherapy provides excellent value for money at £774 per QALY gain (Phew!). Whilst I don’t want to critique this paper as it fits my bias (!!), further work is needed to see how this compares to ‘Non-Specilalist’ Physiotherapists before we shout too loudly from the roof tops.

 

  • A local study from Doncaster presented an update on current Physiotherapy practice in relation to rotator cuff disorders. There were 191 respondents; the most commonly used intervention was advice/education (91%) and exercise therapy (isotonic 67%; isometric 53%; scapula 50%; general exercise 50%). There is less reliance on both physical tests and further investigations to inform treatment as well as less reliance on passive modalities. We often quote that it takes 17-years for research to get into practice; this study shows a changeover 5-years which is progressive.

There are of course some questions; the majority of the respondents were from twitter which has been suggested as more evidence-based, evidence informed forum – does this study reflect wider practice? 91% of respondents provide advice/education, what does this consist of? And ultimately, has this change in practice resulted in better outcomes…?

  • Due to widespread uncertainty in relation to the reliability and validity of examination procedures around the Shoulder; the Shoulder Symptom Modification Procedure (SSMP) has been suggests as an alternative. This study showed that the inter-rater reliability was moderate (k = 0.47); for a procedure to have clinical utility it is reported that it should reach a level of reliability above k = 0.70. Thus, the authors concluded that they were unable to recommend the SSMP as a reliable physical examination tool. There are some limitations of this study, it was underpowered, the washout period between trials was only 10-minutes and there is some difficulty assessing the reliability of a procedure that aims to change symptoms as one could argue that the patient presentation has not remained stable between trials implicating on the measure of reliability.

 

  • Another paper from the Nottingham group presenting a case series of Physiotherapy rehabilitation of atraumatic shoulder instability (Type II/III axis). They showed a non-significant correlation between posterior instability and better outcome scores; a significant relationship was seen between earlier provision of Physiotherapy and better outcome following diagnosis. Previous surgery significantly increased the risk of re-referral and further operation; patients re-referred after initial discharged were more likely to undergo subsequent surgery if they had anterior or multidirectional instability symptoms, versus those with posterior instability.

 

  • The previously described scapula dyskinesis test by McClure (2009) demonstrated reliability of k= 0.48-0.61 in an athletic population with a BMI < 30. This study from Cardiff looked at replicating the results in an NHS population; they found not only did it lack reliability (k = 0.33) but it appeared to also lack ecological validity as a lot of the patients (42%) were unable to elevate their arm through a full range of motion under load due to pain or weakness.

 

  • An interesting paper from Ireland demonstrated that an Extended Scope Physiotherapist and Orthopaedic Surgeon agreed on initial diagnosis 70% of the time; this increased to 90% when the secondary diagnosis was considered (k = 0.87). They agreed on treatment recommendations 90% of the time and the agreed need for further investigations required was 70%. The findings suggest high diagnostic concordance which is encouraging. However, the limitations of this study were that it only compared one Consultant with one Physiotherapist. Further, the two clinicians had worked together for many years and this study may reflect a merging of clinical reasoning due to familiarity.

 

  • You can’t have a Physiotherapy session at BESS without a paper from the Stanmore group on Instability. They presented a cracking insight into the burden of shoulder instability on both work and health provision. Upon admission at Stanmore, 37% of patients (31% adults, 53% paediatrics) were attending A&E for their dislocations; at 12-month follow up only one paediatric patient had the need to attend A&E. At admission, 30% of adults were in full time work, this increased to 54% at 6-month follow up. They concluded that a focus on self-management strategies and return to function can lead to an improvement in patient outcomes, help facilitate a return to work as well as reducing dependency on emergency services.

 

  • The Stanmore group are like London buses; you wait for one cracking paper and along comes a second in quick succession! They presented an association between developmental milestones and atraumatic shoulder instability; there was a higher prevalence of non-crawlers in the instability group compared to controls. This association did not appear to simply be due to hyperlax joints; supporting the findings of Ghibellini et al. (2015) who demonstrated that the literature collectively suggests that there is a non-causal association between generalised joint hypermobility and impaired motor co-ordination. It would appear therefore that asking about their developmental milestones as part of a full subjective history could assist in the classification of the Type III unstable shoulders.

 

Could crawling be a key gross motor developmental activity which provides some of the foundations for motor pattern? Could crawling promote development of the cuff? Could crawling increase proprioceptive mechanisms?

Or, is an adaptive behaviour? Could the lack of crawling be due to the shoulder already being unstable?

 

  • Significantly reduced pressure-pain thresholds and enhanced temporal summation was observed between symptomatic and asymptomatic sides in young adults with shoulder pain. This difference was maintained between the symptomatic side and the control group at both distal and remote sites.

 

  • Further, there was a significant difference in neural mechanosensitvity, measured through nerve palpation, between the symptomatic and asymptomatic sides in young adults with shoulder pain. This difference was maintained between the symptomatic side and the control group. There was no significant association between hypermobility and any of the measures of neural sensitisation.

This paper therefore suggests that in this sub-group of patients presenting with shoulder pain, we should be aware of, and assess for the presence of both peripheral and central pain mechanisms.

 

For those of you who have read this far, well done! I hope you found it useful and wish you the best applying it to your patients in clinic!

Best,

Andrew

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.

 

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!

Cheers,

Andrew

 

 

 

 

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.

Please see here for the previous day.

 

 

 

 

 

 

 

 

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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