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Let’s Stop Playing It Small Together

Alright, I have a confession to make.

I came to the realization a week or so ago while listening to a podcast that I’ve…well…I’ve been playing it small.

While I put out a blog post or so a week, teach some continuing education courses on first aid along with pain science and exercise, I’ve still been playing it small.

There are certain things I’m really comfortable with and other things that make me pull back and question myself, my abilities, and my thought processes. So rather than just face, those things head-on I shrink back.

This happens especially on social media.

I see some of the groups where people are asking questions, or making statements, and rather than throw my $0.02 in, I shrink, and it’s usually out of fear.

The fear I’ll get called out, fear I’m not smart enough, fear that my voice or my opinion doesn’t matter (well truly to some I know it doesn’t but that’s not the point here).

So, then a strange thing happened. I was sitting with my buddy Eric Purves telling him this as we started discussing doing a mastermind group. I looked at him and said f@#k it, I’m not playing it small, I’m putting this out there.

I opened the laptop and put it out on Facebook. To my surprise, the post got 83 reactions and 117 comments.

Also to my surprise was the response in the comments. From physio friends asking what they can do to help promote, lots of people wanting to attend, and of course a couple of negative ones. BUT, the positive far outweighed the negative.

As I pondered this I realized I’m not alone. It’s not just me that needs to stop playing it small…so does our profession, and here’s why.

Education

I will forever be a proponent of advancing our education and making it better.

As I talk to other colleagues in different parts of the world (and it happens here too) we sometimes shy away from sharing our opinions or challenging the opinions of other healthcare practitioners because our education was shorter, or not perceived to be as good a quality as theirs.

This was the way I felt for MANY years.

However, a few years ago I came to realize that if you talk to any of those other healthcare practitioners (if they’re worth their salt) they want their education to get an overhaul as well. If any of them are taking any quality continuing education courses, they soon come to realize that many of the things they were taught in college aren’t worth the textbook it was written in.

Now I’m sure there will be some who argue with me on this, but with those other professions, their education isn’t better, it’s just different. Yes, they get more recognition because they have a degree behind their name (and their associations probably lobby a lot harder) however, it’s no more evidence-based than ours (maybe even less in some cases).

In reality, we’re all fighting the same uphill battle, our entire healthcare system needs an overhaul when it comes to helping people in pain.

So if you’re trying to have a discussion with another manual therapist there’s nothing wrong with challenging their treatment narratives as long as you’re approaching it from an educated standpoint (and obviously done with some sort of decorum).

We can’t challenge and say ” your approach is wrong because I do ‘x’ treatment which works because I do it and I know it works!” However, if we can approach the topic with a statement like: “the newest research shows us that our understanding of ‘x’ isn’t what we thought it was and has since changed to …” will get us much farther into the discussion.

I realize this might be tough because there seems to be a hierarchy within our manual therapy world and for some reason, we are frequently seen as the bottom of this. But, I have to wonder, is this reality, or are we playing it small?

The reality is, our entire healthcare system needs an overhaul in education when it comes to helping people in pain, not just our education.

Time Is On Our Side…Yes, It Is!

This may be our greatest asset.

The more I come to understand the patient perspective on persistent pain (thanks to Keith Meldrum’s help) the more I realize just what a difference time with a patient makes.

I love this quote from Ken Leong from a Facebook thread, and glad I was able to use it with his permission.

Massage therapy is almost tailor-made for [the biopsychosocial] approach. The therapist has much more time than a MD to really get to know their patient or client: where they’re from, their culture, customs, what their family life is like, their history with athletics, sedentary actives, repetitive activities, their stresses, their sleep patterns, their nutrition, their living situations, who they live with and interact with daily and weekly, their commuting stress, their occasional (and therefore dangerous) heavier physical exertions, etc.
The patient or client also has time in treatment to reconnect with their mind and body, to figure out where the aches and pains came from, what are their self-perpetuating patterns are, how they can change them…
It’s like you’re tall and in front of the volleyball net, and someone sets you up for ‘the spike.

We’d be blind NOT to use all this biopsychosocial opportunity!

Ken G. Leong, RMT
If this quote doesn’t make you feel all warm and fuzzy inside for being a Massage Therapist, I don’t know what will.
Compared to every other manual therapist we have a massive opportunity to help patients simply because of the time we get to spend with them.
If we reel back to the above discussion around talking to other practitioners, how many of them spend the amount of time with their patients that we do? How many truly get to know their patients? How many understand what their patients are going through day to day?
While a few of them might, I’d say as a general rule (yes there are some outliers) they don’t get to in the same way we do.
This whole time thing isn’t just a matter of our interaction with the patient either. I’ve seen some discussions on different platforms where practitioners say things like: “I have a patient who wants a 60-minute treatment, but I only need 45min to get done what they need”.
While there’s nothing really wrong with this (as I hope the practitioner was trying to do effective treatment planning) but think about what that amount of time actually means to a patient.
This could be their time! This could be their break from the typical stresses of life. Maybe that hour is a break from being a parent, boss, caregiver, entrepreneur, or whatever other thing is causing stress in their life. That 60 minutes can make a massive difference in their weekly, or monthly (or however often you are seeing them) routine and life.
And this my friends puts us into a very valuable position in not only helping, but making a difference in our patient’s lives. 

Exercise & Movement

I know, I know, you don’t think this is in your scope. 

Well, in some places it is well within our scope and for others it’s questionable.

So I’d like to somewhat address where this is questionable.

From everything I’ve heard the argument is usually “it’s not in our scope to prescribe exercise, we have to refer out for that”. Every time I hear this I also notice that AROM (active range of motion) and PROM (passive range of motion) are still within scope. So, how is a patient actively moving not an exercise? If we are passively moving a part of the patient’s body while they’re on the table, how is this not exercise? If you can help a patient stretch on the table, how is this not an exercise?

We seem to think that recommending an exercise is always prescribing that you do a certain number of reps for a certain number of sets of ‘x’ movement (bench press, squat, deadlift, etc).

What if recommending exercise was simply recommending:

  • Go for a walk with a friend (one of the best things for low back pain).
  • Get on the floor and play with your kids.
  • Dig your hands into the garden.
  • Pick up your groceries.

Just get them to do something they enjoy!

Half of recommending an exercise for someone can be just giving them permission to do an activity. When they’re on your table if you can do AROM & PROM, then there’s no reason you can’t do isometric, concentric, and eccentric movements and this doesn’t require any fancy machinery or even a set of dumbells, you can simply just resist the movement while the patient performs them.

Doing this can be very effective in not only rehabbing an injury but they can also demonstrate self-efficacy, resiliency, capacity, and really isn’t that what we’re trying to do with any treatment? I hope so.

I think the bottom line here is that we have every opportunity (and probably more so than other healthcare professions) to make a massive difference to help people who are dealing with a painful experience. We need to use everything we have at our disposal to not only help our patients but to help push the profession forward. In no way am I saying everything is fine and we should stick with the status quo, we certainly need to continually push for better education to create evidence-based practice for all of us. So, I implore the profession to stop acting like me and playing it small. Let’s challenge the bad narratives regardless of who is using them and take a firm grip on the benefits we have as a profession to not only help our patients but help each other.

If you’re interested in learning more about these topics, we’ll be launching an online course about pain science and therapeutic movement soon and you can join the waitlist by clicking HERE.

 

 

Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

Are The Days Of Assessing Movement Over

In all honesty in its current format the answer here has to be an unreserved YES, we should STOP assessing movement.

This opinion is based on the two predominant concepts we appear to have currently when assessing movement.

Firstly the concept that a deviation from a movement or muscle firing ‘ideal’ is the cause of someone’s pain such as seen with the pathokinesiology model.

Secondly that we can also ‘screen’ movement to identify faulty movement that might lead to injury, this is FAR too big a subject to get into but it seems we weekly have new data suggesting screening does not fulfil the role it was designed for.

Both of these concepts have so far proved to be elusive in providing concrete evidence that they do exactly what they say they do.

A modern understanding of all the contributors to pain means the likelihood of pain being consistently caused by one single factor across ALL people is pretty absurd really.

IT’S VARIABLE

The more we study movement the more we find that it is in essence highly variable. This variability is not only between people but even the same person seems to move differently when they repeat a movement. It has been suggested, and with a fair amount of evidence, that healthy movement is variable and losing variability may be a problem within itself. It is important to realise this about movement because it allows us to appraise the idea of movement assessment more critically.

I have previously discussed this *Here* and *Here* along with the concept of corrective exercise.

Now this means that being able to identify a ‘faulty’ movement pattern will be highly likely if you are measuring it against a singular ‘ideal’ version. The problem is the singular ideal version does not really exist and also does not seem to be linked to very much, rendering the whole process a bit of a waste of time.Slide1

It makes little sense not to be variable:

  • Multiple options affords us redundancy
  • Ability to respond to varying stimulus
  • Spreading load over a joint in repetitive tasks
  • Avoiding fatigue through variable motor unit recruitment
  • Unavoidable at a biological level

We also may go further down the rabbit hole in that some now ASSUME that pain is simply the RESULT of a faulty movement pattern without any kind of critical analysis at all. Think how some people approach back pain, “Its your TvA not be firing” rather than lets find out if it is or not (obviously no clinical test tells us this, just an example).

MOVEMENT DOES NOT EQUAL FORCE

Now I am no biomechanist but we also must realise that just because a movement goes into a potentially ‘faulty’ position does not tell us the whole picture of how much damage that poses to a tissue. Sure it might increase the risk in some contexts but alone it does not give you the ACTUAL force applied and we would also need to know the acceleration as well. A fast movement within proposed ‘safe’ parameters that generates a large force (F=MA) could provide a much greater load to a tissue than one that was proposed as ‘faulty’ that moved much slower.

In fact under greater loads our movement seems to change, so assessing in a low load environment may not give you an indication of how movement is in another situation. This was an interesting piece from Frost et al *Here* showing exactly that!

Some seem to have developed the idea that if you get a movement right you can put it under ANY load. The way the body manages loads internally through the way it moves may be far LESS important the overall volume of load that the body may go through overall and this could be in volume, frequency or intensity.

A DIFFERENT PERSPECTIVE?

So can we STILL look at movement in practice?, I believe so. Everything has it uses and limitations and its working out WHEN thats the tough bit.

Pain DOES have an effect on the way we move, this is pretty well researched showing alterations in what happens with both kinematics AND kinetics at a joint, to adjacent joints and right up to avoiding movement completely for fear of pain. This is a great paper by Hodges & Smeets discussing this *HERE*

Like any other thing that we can measure, it may or may not be related to the problem and may or may not have to change to get a successful result.

Certainly it very difficult to suggest that the way someone moves is a cause of their problems. Do you know what it looked like before? Could it be the RESULT not the cause or pain? BUT is there also a possibility that a change in movement strategy COULD also have an effect on reoccurrence or another injury. We know that the best predictor of future injury is previous injury *Here* and this could be a factor. This has also been mooted with back pain *Here*.

It is a good place to use your reasoning skills. Is this the first time it has happened? Is it acute? Both of these simple questions might help to determine if it is currently an adaptive strategy (helpful) because of pain or is it a maladaptive behaviour (unhelpful) that maybe contributing to the maintenance or reoccurrence of a problem.

LOOK AT THE INDIVIDUAL

A potentially more individualised concept for how we view movement is that rather than a binary right and wrong view that we have currently, we could say your current strategy is unhelpful and swapping that for another might be more helpful, there are often a whole bunch of other ways that could be beneficial rather than the ‘right’ way.

This might only be for the short term, such as a symptom modification, or for the longer term if you believe a movement behaviour maybe coupled with a pain response.

Gait re-eduction for runners seems to follow this rationale, see whats going on, does that potentially relate to the issue and can we subtly alter it.

Now there maybe certain scenarios that do carry more risk such as loaded lumbar flexion or extreme knee valgus but they seem to be pretty load related. Unless someone is regularly under these loads perhaps it matters less. But ask yourself how many people in the gym have popped an ACL doing a single leg squat? Perhaps the caution can cause more problems than it solves here? Especially with the unhelpful beliefs people seem to be prone to forming.

SOME EXAMPLES OF UNHELPFUL

 

IT COULD BE THAT A MOVEMENT LOADS A SPECIFIC BODY PART THAT IS CURRENTLY SENSITIVE

Example

If some one has a very hip driven strategy whilst currently suffering from a proximal hamstring tendinopathy altering this could reduce further load/compression to the tendon to allow it to desensitise.

PRE MOVEMENT BEHAVIOURS

It could be that be that someone is bracing BEFORE they move and this is an unhelpful component. This maybe seen with lower back pain sufferers.

Example

Before bending over to do their shoelaces someone specifically braces and this has become coupled with the pain they are experiencing. Attempting to change this part of the motor strategy MAY affect the outcome.

IT COULD BE THEY ONLY HAVE ONE MOVEMENT STRATEGY

We see decreased variation linked with chronic pain at a number of areas of the body. This could cause repetitive loading or consistent patterns ASSOCIATED with pain.

Example

A specific task maybe is performed in a repetitive way. This might be the way someone lifts, reaches or even runs. A way to assess this could be to provide variable challenges and see how well someone can adapt.

What we do have to remember that this is all TRIAL & ERROR.

It may or MAY NOT have an effect and essentially this is everything we do. We should try to be informed by current best evidence but also  remember is just a probability generated in a controlled environment and may not directly translate to this person you are dealing with.

TAKE AWAYS

  • Specific movement ideals are pretty unsupported, especially linking them to pain
  • Movement screening is literally a can of worms
  • Movement is variable, EMBRACE it! This means it is tough to assume causative link with pain
  • Low load assessment tells little about high load behaviour
  • A movement does not simple equal the force applied to the tissue
  • Look at the individual
  • Be prepared that altering movement may have NO EFFECT or a very positive one

Pain Education – What Might Make It More Effective

 

Pain education is a valuable tool for some, but certainly not all, patients. It can help to provide a narrative or explanation for problems that may remain unexplained by ‘traditional’ medicine or therapy.

This paper HERE regarding chronic lower back pain explores what people are looking for from a visit to a therapist.

more than 90% of patients expected a physical examination, tests or investigations, a diagnosis, reassurance and advice, and clear explanations of causation, symptom management”

How tough is this in many instances with no clear diagnosis or causation available?

Up to 90% of back pain is described as ‘non-specific’ for this very reason. We know that uncertainty is a big deal for many patients. Mishel first proposed this in the “theory of uncertainty of illness” HERE.

Carroll’s paper HERE How Well Do You Expect to Recover, and What Does Recovery Mean, Anyway? Qualitative Study of Expectations After a Musculoskeletal Injury” also discusses the process of diagnosis, uncertainty and the subsequent effect on expectations of recovery.

But although data suggests pain education can help it can also be very tough to deliver.

This quote from Louis Gifford sums it up nicely.

“The patient that learned from their pain explaining therapist that their pain didn’t really mean anything, who suddenly got out of the chair, went home and went riding their bike for the first time in 5 years…just doesn’t really exist!”

SO HOW CAN WE IMPROVE THE DELIVERY OF PAIN EDUCATION?

A question I often ponder is have we replaced anatomy with neurobiology? Do we now bombard people with complex processes involving brains, nerves, and receptors rather than complex biomechanical stories? How much neurobiology or neuroscience is actually required?

In some cases certainly it will be useful, but in many cases maybe it could actually hinder. This does not mean that some of the key concepts such as plasticity, sensitization and the brain’s role in pain are not important but maybe the minutia of information that can be focused on is unnecessary.

Perhaps we can apply some of the information in this paper HERE. Simplifying MRI reports appears to have a positive effect on how they are received. This may also apply to the delivery of pain education. What does nociception or Ion channel mean to a patient? It could end up very similar to VOMIT (Victims of Medical Imaging Technology) HERE if poorly delivered.

Should the focus now be on the delivery and context of information rather than the information itself?

CONTRIBUTIONS

I thought it might be nice to get some other opinions on some of the key elements that go into making successful pain education and reached out to colleagues from around the world, using social media, to pitch in.

Some of the key components I already advocate, but I must admit some others I had not considered and provide valuable food for thought for myself and perhaps also the wider therapeutic community.

I was pleasantly surprised by the elements discussed, almost none related to the actual information itself but instead on the delivery and thought process involved.

Here they are

Slide1

LISTENING

The most consistent point made by the contributors as a whole was listening.

Listening is a key clinical tool. Although pain education is often thought of as the delivery of information, it should start with listening. I think this is advocated on many fronts but as we know patients can often be interrupted pretty quickly HERE and this is always worth keeping in mind.

The desire to be listened to also appears to be valued from a patient perspective and helps to build therapeutic alliance HERE. This is probably vital for those receiving and processing the information. delivered.

This is a good paper on ‘listening as therapy’ HERE

VALIDATION

A couple of patients also contributed to the discussion and they felt that someone listening to and validating their experiences was a big part of their recovery. This also ties into the paper above regarding a patient’s perspective. If symptoms cannot be ‘medically’ explained or solved by traditional interventions, then patients may feel that they are being seen to ‘make it up’ or exaggerate their painful experience. All pain is real and although it can often be hard to describe it is also exactly the way that someone says it is. It cannot be anything else!

INDIVIDUALISATION

Another of the key points consistently put forward was about individualizing the delivery and placing into a relevant context. Now I personally have a bias for placing pain education in context with someone’s current situation. By weaving it into their story and using their painful examples to tie in some of the key concepts I think we are more likely to get some elements of comprehension.

This fits well with the key component of listening. Without listening we cannot place the information in the context of the patient’s narrative.

The question is, is this more effective than information generically delivered? I just don’t know. I think this would be an interesting comparison to study.

ASKING!

One thing I must admit to NOT asking was simply “do you want to know more about pain?” This was brought up by a number of people. This may avoid the very real problem of ramming pain science where it is not wanted. Pain science should be judiciously applied where it is needed AND wanted rather than a therapist dropping knowledge bombs expecting an instant epiphany.

IT IS NOT A PASSIVE EXCHANGE

Remember there are two equal people involved in this. It is not simply a teacher-pupil relationship. Patients lived experiences are also important. The therapist can also learn from the patient, especially when it comes to the patient experiences. Perhaps it should be seen as a journey by two people to find mutual meaning in a negative situation rather than simply an educational experience.

PAIN SCIENCE IS A WAY OF THINKING NOT AN INTERVENTION

One of the criticisms that I have seen recently of the application of pain education is that it is seen as a standalone intervention. So rather than bombarding people with statements or analogies that have been previously heard for explaining pain, the concepts and ideas should affect the way we reason, interact, explain and apply the treatment provided.

EXPERIENCES ARE AS POWERFUL AS TALKING

It’s not just about talking; doing is also a powerful educator. Perhaps sometimes talking is needed before and after the doing, but without the actual doing, we cannot ‘prove’ the point. Beliefs about the body are a good example of this. Without SEEING or FEELING a different, positive outcome to that expected, potentially a number of times, a belief may remain in place.

Again listening is key. What are the key experiences that need to be reconceptualized in a physical sense as well as a cognitive sense?

FIND OUT HOW YOUR EDUCATION HAS BEEN INTERPRETED

As with any part of the therapy process, pain education has the potential to have a NEGATIVE outcome as well as a positive one. We may well baffle people with talk of brains and outputs etc and HOW they interpret this information is the arbiter of success, however well meaning or comprehensive the input by the therapist.

This may boil down to wording, health literacy, and therapeutic alliance. The list of potential influencers is endless, but essentially the ability to mitigate any negative effects could be dependent on simply asking!

We may be able to influence this interpretation by being clear and concise, using bite-sized chunks of information, avoiding confrontation regarding beliefs and also avoiding negative or long-winded medical or anatomical jargon and terms.

REFLECTIVE QUESTIONING

Don’t just provide statements, also use reflective questioning. This may help to facilitate understanding and apply this new information to their own personal experiences and think critically about some of the beliefs they may hold.

Let’s say someone has a negative belief regarding their back because of a slipped disk a number of years ago. We could suggest that structure and symptoms don’t always display a consistent relationship. We could follow this up by asking if their symptoms come and go (as long term back pain generally does) and would this be a sole cause if the ‘slipped’ disc remained a constant.

Of course, this is just some opinion/s but collectively they could be valuable!

KEY POINTS

  • People are looking for answers
  • Uncertainty makes things worse
  • Pain education may provide some explanation
  • It is tough and often fails

SOME THINGS MAY MAKE IT MORE EFFECTIVE

  • Listening
  • Validation
  • Individualisation
  • Asking if it is wanted/needed
  • It is not a passive exchange
  • Pain science is a way of thinking not an intervention
  • Experience is as powerful as talking
  • Find out HOW your education has been interpreted
  • Reflective questioning

Everything I Wish I Knew About Rotator Cuff Tears

They came in frustrated, it was a two-year ordeal, I had never seen this patient before, but they clearly needed some help.

“Jamie, for the past two years, I haven’t been able to lift my arm past this point”!

They raised their right arm to about 90° abduction. When asked I why they explained there had been a previous surgery to repair a torn rotator cuff. The frustration had more to do with life circumstances than just the limited range of motion.

Two years ago a surgery had taken place to repair this torn rotator cuff, but more concerning was the altered life because of it.

This person had a job they loved but were unable to do anymore due to the surgery.

You see, the job required holding their arms up for extended periods, so they had to quit that job in favour of a desk job. The worst part (other than the limited range of motion) was they HATED the new job. Sitting at a desk doing computer work was not what they had in mind as a satisfying career.

When asked why they weren’t doing the job they loved the response was bone-chilling to hear as a healthcare practitioner:

“My surgeon said I could never go back to that job, and the other therapist I went to told me that if I went back to my job, the surgery I just had would pale in comparison to the surgery I would need if I continued”.

I hope my face didn’t reflect what was happening in my head after hearing this, otherwise, the patient probably would have walked out the door. How could two other healthcare professionals say this to a patient!?

Reliability Of Orthopedic Tests

The rotator cuff consists of the “SITS” muscles: supraspinatus, infraspinatus, teres minor, and subscapularis which all work together to produce movement and stability of the glenohumeral joint.

While rotator cuff tears are quite common, it doesn’t always mean the person is going to experience pain as this generally depends on the degree of the tear. A partial tear is when one of the muscles is frayed or damaged, whereas a full tear indicates the muscle is completely torn, or the tendon has pulled off the bone.

When we look at some of the orthopedic tests recommended to use clinically as a test for rotator cuff tears, it is important to look at how accurate they are between sensitivity and specificity. Sensitivity is the ability to detect that something is actually happening (in this case it could just be a sore shoulder), whereas specificity is used as a true representation of the condition you are trying to test for (in this case specific to a rotator cuff tear).

There are three orthopedic tests generally used, so we will look at two of them here.

The drop arm test has a sensitivity of 73% and a specificity of 77% and also has a 26% chance of coming up with a false positive and a 4% chance of a false negative. This tells us this test isn’t likely to give us an accurate chance at predicting a full-thickness tear of supraspinatus or infraspinatus.

The external rotation lag test has a sensitivity of 46% and specificity of 94% which tells us that we have a good chance of a positive test indicating full-thickness tears in supraspinatus and infraspinatus. 

It has also been suggested that the subacromial bursa contains a high amount of nociceptors and doing the orthopedic tests we talked about could place pressure on the bursa, in turn recreating the pain.

While we can still use these tests to give us an idea what’s going on with a patients shoulder there is no guarantee these tests will conclusively tell us there is a full rotator cuff tear. While it can be more accurate to use imaging to see the difference between partial and full-thickness tears, there is poor relation between imaging and clinical signs. 

Using Education To Help

Time and again we are told biopsychosocial aspects are crucial to treating our patients, and this pathology is no different. Although the “bio” may be less important as we think. When looking at the movement of the glenohumeral joint in the scapular plane between symptomatic and asymptomatic people with tears, pain-free movement was still possible even with abnormal kinematics.

So this shows us that abnormal biomechanics alone are not the only reason for painful symptoms.

One study showed that 55% of rotator cuff tears are asymptomatic, had more to do with age, and didn’t correlate with pain. In fact, one study showed just how much age is a part of the degeneration and should be considered normal with age. They found:

  • Age 50-59, 13% had tears.
  • Age 60-69, 20% had tears.
  • Age 70-79, 30% had tears.
  • Those aged over 80, 51% had tears.

While asymptomatic tears can become painful, studies show it is probably more important to take care of pain management with these patients in order to maintain functionality, rather than being concerned about the tear itself. In fact, one study points out that our treatment should centre around clinical findings and not imaging results.

So, if we understand how pain management should be our primary concern, we have a massive opportunity to make a difference for these patients.

How many people over the years have come into your clinic either waiting on surgery or at least contemplating it for their rotator cuff issue? If we can educate them how this is usually an age-related issue (unless there was a traumatic injury), reduce pain, and increase their functionality maybe we can negate a surgery.

While surgery is usually recommended for full-thickness tears or more extreme disability, conservative measures can and should be recommended before going under the knife. The person I spoke about at the beginning of this post was obviously post-surgery for two years but still had limited mobility and functionality. This was certainly a case where biopsychosocial factors were a major influence. The person was told by two practitioners they would never get better and their shoulder would always be damaged, to the point they had to change careers. Once we actually got the shoulder moving, used a little education, and were told they were going to be okay…that shoulder went from 90° to 160° abduction. It was also followed up with the statement: “how the hell did you do that!?” It’s amazing how giving a patient a little confidence can make a massive difference. In the coming weeks, we will go over some movement techniques that can help with this.

Movement That Gives You the Feels

A baseball player walks into the batter’s box. He shifts weight from front foot to back while circling the bat. Rotates his right heel into the ground. Orients his gaze to the pitcher while pointing his bat to center field. Slowly swings his bat three or four times to an imagined contact point with the ball. Then crouches lower to wait for the pitch, still shifting weight from foot to foot. What’s the point of all this seemingly useless motion?

You can see similar routines in any sport that allows an athlete a few free seconds before taking action.

Waggling the club before a golf shot.

Bouncing the ball before a free throw or tennis serve.

Doing all manner of bizarre shit before a deadlift.

 

Are these rehearsals for the upcoming action? Sure doesn’t look like it. Do these movements get you in the groove? Maybe so but why? And, did you actually watch the deadlifting video? Go back and watch please, show Jujimufu some respect.

Epistemic Actions

I think these movements might be what are called “epistemic actions.”

David Kirsh and Paul Maglio introduced this term as a way to distinguish between physical movements done directly in the performance of a physical task (“pragmatic actions”) and movements done to reduce the difficulty of the information processing necessary to control the task (“epistemic actions”).

Accurate motor control requires you to have information about the moving parts in the body and environment. You also need to interpret the meaning of that information so that it helps you plan the right movements. An epistemic action is one that either delivers the right information at the right time, or assists in the interpretation of that information. You might say it is a movement that gives you a good sense of “feel” about how to move.

Here’s an example of an epistemic movement that is trivially obvious – turning the eyes or head to see objects in the environment. Check out this video of Frank Lampard playing soccer with his head on a swivel.

 

 

Part of the reason he is turning so much is that he needs updates on a changing environment. But even when analyzing a static scene, such as a room full of objects, you must constantly shift your eyes back and forth to make any practical sense of the information (for example, finding where you left your keys.) The information won’t arrive passively just by staring in the right direction. Vision is therefore a very activeprocess – you need to move to perceive, and you need to move the right way to perceive the right things.

Proprioception is the same way, it is an active process, not a passive one. Many of the our movements have a primarily epistemic purpose – they are not done so much to directly accomplish a physical goal, but to create proprioceptive information that optimizes or simplifies motor control.

I think this is what the batters are doing in the box while waiting for a pitch. They are moving in a way that actively seeks all the sensory information that will help them hit the ball. They are looking for the “feel” of the position of the feet relative to the plate and the pitcher; the angle of the head; the place where they will contact the ball; and the orientation of the hands, shoulders and hips relative to the bat.

Of course these players have already built, through many years of practice, maps or representations inside their brains that have information about all of these factors, and this allows them to “feel” the right stance even in the absence of these preparatory movements. But all this representing and mapping places a burden on memory and information processing. “The best map for the world is the world itself”, therefore it is far more efficient to gather information about the body and environment right when it is needed, as opposed to constantly maintaining an internal model of that information. Epistemic actions are a way to check in with the state of the world through movement.

(By the way, the idea of “offloading” the demands of information processing to the body or environment is very consistent with the ideas about “extended mind” that I discussed in my previous post.)

Conclusion

So why is this interesting? Well it just is. Here’s a few more reasons.

I think a good deal of the movements seen in various forms of corrective exercise are much more epistemic than pragmatic. That is, their value consists more in feeling your body than in rehearsing actual movements you might do some day. And remember that this feel is temporary – you need to keep refreshing it through movement.

Another reason epistemic action is interesting is that it should be a caution to analyzing the technical merits of a movement with too much reliance on its biomechanical “pragmatism.” What appears to be a pragmatic bug in someone’s movement technique might actually be an epistemic feature. Put another way, some ways of moving just “feel” better, and this might be more important than how it looks to the coach.