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.
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.
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.
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.
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.
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.
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.
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.
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.