Dr Chris Littlewood (PhD) was recently interviewed by David Pope on the Clinical Edge podcast discussing rotator cuff tendinopathy(1). If you’re a clinician or therapist interested in treating shoulders, I strongly encourage you to listen to it.
In episode 82 of PT Inquest(2) Erik Meira and J.W. Matheson discuss a paper by Dr Chris just published in the Journal of Clinical Rehabilitation this month(3).
‘Usual care’ for shoulder issues is typically chucking everything at it – manual therapy, exercise and everything in between. This study compared usual care with one single self-managed exercise; a pain tolerable isotonic shoulder abduction motion progressively graded in range and load.
The outcome: no difference.
The isotonic exercise was the one thing most noticeably consistent between the two groups, but it’s not possible to say that increasing tissue tolerance was the active component (although very likely) as natural history and the non-specific effects of therapeutic alliance could also have had a positive effect. What is possible to say however is that all the other ‘stuff’ wasn’t helpful.
“As we practice for longer and longer we start to think that the important things we do are not skilled, but the reality is that those couple of things are very skilled. The funny thing is that all this complex mumbo jumbo that a lot of people use that sounds really smart, it turns out they’re not specific. Those fancy scapular stabilisation exercise makes you feel really smart, but it’s not really skilled at all. You can just push something. So that’s not the skilled part with it.
It’s great to identify what’s not skilled and allow unskilled providers to provide unskilled service at unskilled prices.
We need to focus on the skilled component and focus on the skilled part to provide that. So many physical therapists have it flipped in their head that the hands-on touching type thing is the skilled thing when we have plenty of evidence that shows that it doesn’t matter how you touch them they’re still going to have the same outcome. It’s how you get that patient buy-in, get them on a home program that they have bought in to and can do competently; that’s the skilled part of what we do”. Erik
“We have to be a tour guide. We have to sit the patient down, develop a strong therapeutic alliance and then load them, but that’s harder to do then it seems. There’s a whole context. To get that patient buy-in and develop something that’s unique to that patient in those unique circumstances, I think that’s a high level skill. Because we’re not using a fancy intervention, that’s not short-changing the years of experience, and effort, and reading, and clinical reasoning that it takes to take someone and develop a program like that. That’s unique to Physiotherapy and we often sell ourselves short on that.” J.W.