Carl Neal

@PeteOSullivanPT Sounds and looks great. Have done your three day course in London and will definately be signing up to this. Any ideas on cost and timeframes of the skills and mentoring training when they become available

It’s been a 2 year journey with a wonderful team to develop this educational platform. This is In response to the RESTORE trial of Cognitive Functional Therapy for people with chronic low back pain published in the LANCET. Let us know if you like it… evoolvepaincare.academy

@AdamMeakins I'm not sure rotator cuff related is all that specific it is saying the cuff is part of it. Still allows room for multifactorial discussion but also gives meaning to a rx approach which will help buy in.

@Carlthephysio You’re not sure if we assess movements? Why not? And avoiding specific labels for non specific issues is simply more honest and IMO allows for better conversations around the multifactorial nature of pain!

Using the term ‘rotator cuff related shoulder pain’ to describe non specific shoulder pain makes zero sense! Its like calling non specific low back pain… disc related back pain! Why use a specific tissue to describe a non specific issue?

@AdamMeakins I'm sure we can assess movements but I'm also sure we can say which muscles are producing the majority of the force. A marginally weak serratus isn't going to lead to a more profound weakness of external rotation.

@AdamMeakins Not sure I'm in agreement with your viewpoint however regardless how does avoiding the use of rcrsp and instead using non specific shoulder pain help the patient.

@Carlthephysio Yes thats right mate… often we are assessing movements of which multiple muscles are contributing, rarely do we assess sole or individual muscles! But there are some exceptions when we do! Just not around the shoulder!

@AdamMeakins That's quite an extreme case tho isn't it. If external rotation is weak and there is no major aberration of scapula movement then the likelihood is that infraspin and teres minor are weak no?

@Carlthephysio For example when a person has a long thoracic nerve lesion affecting their Serratus Anterior they are unable to produce much GHJ ER force yet their cuff is fine!

@AdamMeakins You believe rotator cuff weakness is not something you can assess? In that case can you assess any muscle for weakness. Almost all movements will have synergist activity.

@Carlthephysio There are a lot of muscles required to produce GHJ ER force! Eg, literally every peri scapula muscle is working to allow ER to be produced around the GHJ! So ER is not a test of just the cuff at all! It’s a test of ER! Not sure what quads has to do with this?

@AdamMeakins I would say its producing most of the force yes. What are you proposing is active? Is resisted knee extension an adequate test of the quads?

@Carlthephysio A lot of things mate! Do you think the cuff is the only thing active during external rotation of the shoulder?

@AdamMeakins What would you say resisted external rotation assesses if not the rotator cuff?

@Carlthephysio Without having any specific cuff isolation tests, how can we know shoulder weakness in someone with shoulder pain is due to their cuff?

@JackAChew @TPMPodcast @physiojack @FrancescaPeplow @JLTHphysio @Ruuqie @mehab_jo @keithgraham @AdamMeakins @TheHipPhysio @kieranosull I mean it's not the worst the daily mail have published. Never heard of anyone applying heat with a hair dryer and cling film mind. Perhaps this is the answer I've been missing

Hope everyone’s looking forward to another round of: ‘Patients clutching copies of the Daily Mail with questions’

@1gregorross @MPearsonPO @physiojack @DerekGriffin86 @TPMPodcast Nice thread thanks

@MPearsonPO @physiojack @DerekGriffin86 @Carlthephysio @TPMPodcast x.com/1gregorross/st…

Have been re-reading NICE guidelines on diagnosis of Osteoarthritis and I really can't fathom why people get stroppy about the x-ray recommendation

@DerekGriffin86 Definately true especially in those consultations where there isn't time to unpack it further. Can't see much harm mentioning lifestyle change tho with exception of losing rapport.

@Carlthephysio Simply that for many, the advice doesn't result in behaviour change.

This will ruffle a few feathers! acpjournals.org/doi/10.7326/AN…

@physiojack @MPearsonPO @suzy_speirs Nice will give this a watch at some point in coming weeks.

@MPearsonPO @Carlthephysio @suzy_speirs If my memory serves only grade 4 kelgren correlates but again I don't know how much this changes management. I discuss this in a webinar I did a bit where I consider decision making youtu.be/AlOFbjzHUu4

@MPearsonPO @suzy_speirs @physiojack Have you noticed any difference in outcomes in those two groups? Would you use it in someone with bicompartmental symptomatic oa but one side worse than the other?

@Carlthephysio @suzy_speirs @physiojack Yes, I probably see more people with some evidence of bicompartmental (or tri) than with isolated medial/ lateral. Personally, I don’t have an issue with using an unloader under these circumstances as long as I’ve discussed with pt like we talked about elsewhere in thread

@DerekGriffin86 @physiojack Would agree the negative beliefs around oa are more prevalent but there are still some who do not believe it (often younger, often don't want to believe it due to the negative beliefs around it). Classic one this week with 1st Mtpj oa. Knowing what it is can inspire pts sometimes

@Carlthephysio @physiojack It's rarely about someone with OA not believing the diagnosis; it's much more often the many negative illness beliefs about it that are so prevalent in the general population.

@MPearsonPO @suzy_speirs @physiojack Any experience @MPearsonPO of using a brace in a person with bilateral radiographic oa but unilateral symptoms?

@suzy_speirs @physiojack @Carlthephysio Probably worth pointing out that I have some colleagues who will insist on imaging before deciding if unloader brace an option. Personally I don’t.

@physiojack @suzy_speirs @MPearsonPO Would you say radiographic changes are a risk factor for developing pain or symptoms? The evidence would suggest it's a more common finding in symptomatic patients suggesting joint disease is relevant to some degree. Don't know if that would effect the success of a brace though

@suzy_speirs @MPearsonPO @Carlthephysio I don't see why an X-ray would change that conversation... Especially as symptoms don't correlate well with radiologic changes

@DerekGriffin86 @physiojack @AdamStenman Would you posit that it is largely a placebo effect then. If it takes enough of load to reduce symptoms why couldn't it add enough load to produce symptoms.

@Carlthephysio @physiojack @AdamStenman The redistribution of load is likely a lot less than we think.

@DerekGriffin86 @physiojack Can't be certain, but you can select the right patient, prime them appropriately and educate them after. If it helps engagement that is surely only a good thing. A patient not believing the diagnosis and in turn the management plan isn't going to do well.

@Carlthephysio @physiojack When used for reassurance, can you be certain it then won't have any unintended consequences? The common belief that scans reassure is not seen in the literature.