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.

 

 

Teaching in Delhi – February 2017 – We’ve arrived!

I’m currently writing this blog having just finished dinner at a restaurant not far from our hotel; I’m honoured to be joined on this teaching trip with my good friend Joe Palmer. Following 18-hours of travelling and enduring a gruelling 10-hours of flying with a seemingly endless supply of complimentary food and drinks (!!) we’ve made it to New Delhi, India.

Crispy Chilli Paneer - Spicy!

Crispy Chilli Paneer – Spicy!

The local barman appears to subscribe to the Continental European model of beer pouring with that head; maybe it was subtle Brexit Humour!

I am honoured to be invited to teach on both days of the ‘International workshop on Advancements in Shoulder and Spine Rehabilitation’ hosted by the Sitaram Bhartia Institute of Science and Research. The Sitaram Bhartia is is a 70-bed, multi-specialty hospital located in New Delhi’s Qutab Institutional Area, they have a strong emphasis on ethical medical practice that always puts the interest of the patient first.

My first impressions of New Delhi are that in the UK we could make a lot more use of our car horns (!); the roads appear to represent a process of uncontrolled mayhem that somehow works seamlessly with little road rage, accidents or undue delay! Parking is readily available and never really an issue as you can just park the car where you’ve left it without too much concern – you merely need to be able to contend with an ever-growing use of the car horn to inform anybody in the vicinity that your vehicle is indeed present and moving. Naturally, you need to be a heavy sleeper to cope well in New Delhi!

Delhi_Parking

Car Parked in the Right Hand lane of the carriageway – not a problem!

Having slept off some of the resulting jet lag from the previous day’s travel, we were welcomed to the Sitaram Bhartia by Dr Aman Sachdeva; Dr Aman is the organising chairman of the workshop and the Head of Physiotherapy at the institute and we were duly given a tour of the facilities. The institute is a working, functioning hospital and outpatient clinic that is closely integrated with the research faculty; allowing clinicians to both practice and regularly undertake research within the same setting – the UK could learn a thing or two here.

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation - Biographies

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation – Biographies

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation - Poster

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation – Poster

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation

Sitaram Bhartia Institue of Science & Research: International Workshop on Advances in Shoulder and Lumbar Rehabilitation

Having both attended and hosted a number of courses in the UK, it will be a refreshing and valuable experience to see how courses are delivered by Professionals in other countries. There are 105 Physiotherapists attending the workshop over the weekend and I am excited to be able to deliver my workshop, share knowledge and learn with clinicians from a different culture.

Please see here to read about the next day.

Shoulder Assessment and Rehabilitation Workshop: Delhi: Saturday 25th February 2017: Booking Available Now!

Due to demand, 20 extra places have now been opened for this Workshop. If you wish to attend, please see the details on the poster to book directly or email secretary@sheffieldshoulderphysio.co.uk to register your interest.

Should you or your department wish to host Andrew for his workshop, please email all inquiries to secretary@sheffieldshoulderphysio.co.uk