[Physio Explained] Manual therapy improves outcomes in shoulder pain with Robin Kerr

In this episode with Robin Kerr, we explore a recent paper looking at the addition of manual therapy to an exercise program for subacromial shoulder pain. We discuss: 

• Discrepancies in current shoulder research
• Importance of individual patient treatment selection
• Exercises used within this paper for shoulder rehabilitation 
• Manual therapy within treatment
• Importance of subgrouping in research

👉🏻 See Robin’s full Research Review here - https://physio.network/reviews-kerr1

Reference to paper - Michener L, McClure P, Tate A, Bailey L, Seitz A, Straub R, Thigpen C (2023) Adding Manual Therapy to an Exercise Program Improves Long-term Patient Outcomes Over Exercise Alone in Patients with Subacromial Shoulder Pain: A Randomized Clinical Trial. JOSPT, Published Online, 0,1-31

Robin Kerr is an Australian trained physiotherapist with over three decades of clinical experience. Her special interests lay in helping patients with pelvic floor and lumbo-pelvic dysfunction. She is heavily trained in biomechanics and gait lab running analysis and continues to assist elite athletes with injuries. 

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Our host is @sarah.yule from Physio Network

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Transcript

SPEAKER_02 0:00

Progressive exercise and stretching works, and that if I have the right patient for whatever characteristics, and that's something that we need training on as well, that manual therapy can. It can be quite

SPEAKER_01 0:18

beneficial to them. Robin Kerr has owned several private practices around the world. most with a sports and spinal focus until turning her attention specifically to pelvic floor and persistent low back pain for the last 20 years. She has gained a psychology degree in the last eight years and uses this knowledge in her clinical work as a physio. In the Physio Network Research Reviews, Robyn has reviewed an interesting new paper that looked at whether adding manual therapy to an exercise program improved long-term patient outcomes over exercise alone in patients with subacromial shoulder pain. And today, we dug into some of the key findings and takeaways from it. To learn more about these research reviews and how they make keeping up to date so much easier for you, make sure you click the link in the show notes now. I'm Sarah Ewell and this is Physio Explained. Well, welcome, Robyn, and thanks so much for joining us today. You're welcome to have me. It's great fun. So this study is a 2024 JOSPT article titled Adding Manual Therapy to an Exercise Program, Improving Long-Term Patient Outcomes over Exercise Alone in Patients with Subacromial Shoulder Pain, a Randomized Control Trial. Quite the mouthful. Can you give a brief outline of what the study looked at, the methodology, results and conclusions, just a bit of an overview? Yeah.

SPEAKER_02 1:48

Sure. So this was by an American group of researchers. Laurie Mission is quite a well-known shoulder professor, researcher. It was a multi-clinic parallel CT, involved people aged 18 to 75 who had subacrobial shoulder pain. So what they basically did, they followed them over one year. The initial intervention was six weeks of physio twice a week. So one group got manual therapy plus remedial exercise and stretching, and the other group just got the exercise and stretching. They had a maximum of 10 sessions over those six weeks. And at 2, 4, 6, 26, and 52 weeks, they took some outcome measures. So the primary outcome measure was for pain and disability. That was the DASH, the disability of arm, shoulder and hand. And the secondary were satisfaction with the shoulder survey, the GROC and the additional healthcare sought during that period of time over that year as well. They had a fairly standardized set of exercises that everybody got to do. So there wasn't much variability in that. And also the manual therapy was quite standardized as well. So everybody got the same treatment, which is probably not something that happens in the clinic too much, but it's quite good for research. Too many confounders coming into it. So what basically happened was that it was a little bit unusual. They found that Significant results occurred at six months and at 12 months after the six-week initial intervention in favor of adding manual therapy to exercise. It's actually a little bit of an interesting thing because normally in the past, researchers said that manual therapy can give short-term benefits, whereas this one's come out and it's gone straight to saying these are long-term benefits. So that straightaway piqued my interest and got me looking at other research. So it was really, really quite interesting. The dash, the satisfaction for shoulder and the grok all were significant at six and 12 months. So then the question is, what do you make of all that? And what's happened to you? Because this is a bit different to what I'm used to reading about. I think this is one of the reasons why younger physios may be becoming quite uncertain and a bit stressed at work because the research is actually very conflicting when you jump back and you read the reference list. Mission has actually done high quality, 150 papers. And you're looking through her papers, it's all shoulder related. So she's a shoulder expert, probably on the same level as maybe Jeremy Lewis in the UK and Jared Powell in Australia. So the people who do all the high quality research on it. So when you go back and you have a look at it, you go, how can this happen at six and 12 months with the manual therapy? And if you look at the previous SRs and METAs that were done, PETAs in 2020 looked at the same problem. They found that there was short-term benefit to manual therapy in relation to exercise for shoulder rehab. Then we had in 2021, Babatund said it's not worth adding it because there's not enough difference. In 2023, Panakepoulos, I think is the way you pronounce it, said there was no benefit to adding manual therapy to shoulder rehab. And then in this one, this one actually came out in December 23, the Michener study, they're saying there is quite significant benefit in the long term for adding exercise and manual therapy together. So, you know, you can't blame anybody for being really confused about all this research. And my feeling is, is that With the outcomes in the long term, the grok has always had some questions raised about it, about recall bias. You're getting people to give an opinion on something that was 12 months ago. And if they had a good therapeutic alliance with the therapist, and I would assume that the therapist that they were using in this study were very bright-eyed and bushy-tailed and motivating, that their recall bias might be more positive. So maybe the grok wasn't the right one to use. They could have used another one. In relation to additional healthcare sort, there was no difference between the two groups. So that raises the question, well, the people in the manual therapy and exercise group had significant improvement in their outcome measures later on, but they were still seeking the same amount of help. To me, that's suggesting that there's some sort of psychosocial therapeutic alliance component to this result. It's kind of raised a few questions. When you read through the other research, there is no doubt that the gold standard is exercise for shoulder rehab. So exercise will always be something that should be done for shoulder rehab. But I think coming back to the effects of manual therapy, we're looking at Bialowski's work, contextual effects, the therapeutic alliance effects. I think that's something that we as clinicians don't have a lot of experience with. I've actually gone back and done a full psychology training. So I get that. I can understand how that would work. But I can see that this would be very, very confusing for younger therapists who are just trying to work out what they actually have to do with patients.

SPEAKER_01 7:13

Very true. It's how do we integrate it into our schema of treatment, isn't it?

SPEAKER_02 7:18

Yeah. And I think the main thing is that it has to be patient-centered care. It has to be an agreement between, you know, therapist and patient about how they're going to attack the problem. For example, if I have somebody who has very high fear avoidance, they probably wouldn't be somebody that I would just give exercise to. I would be probably using some manual therapy to help them feel that they're supported and help to settle their pain, hopefully. We know that manual therapy has neurophysiological downregulation effects. albeit I've always believed they were short-term. So, yeah, I actually had to read this paper about three times. It was like, oh, what have they done here? So I think it's basically the big problem that we have is the evidence-based practices in a way has been a bit of a mess. I think we've had a lot of research done that was very poorly done, low-quality research, and there's a lot of chit-chat, you know, on social media about low-quality care and how manual therapy is low-quality care. I actually flipped that back the other way and say, I think the research has been low-quality research. And so I think we're probably right back at the beginning of this. We have to standardize. We have to subgroup. Subgrouping is something that's been not really appreciated, I think. And I know that Paul Hodges, with all his back research on back pain, he's starting to look at subgrouping. I think we're going to have to subgroup different types of patients for something as common as shoulder pain. You will have patients who will have primarily a fear-avoidant psychological driver, and you will have athletes and people who have predominantly tendon issues. So putting them all into the same box, I think, kind of conflates and confounds the research. And that is the big– on all the papers I read through, that was the big issue. is that there was so much heterogeneity and really poor standardisation and really poor accounting for what they actually did to the patients. Every study that I read through, the treatments were completely different. So in this treatment, I actually think Laurie Mission has been in shoulder work for a long time. What they went through with these patients was very similar to what I would have. So they started... With the strengthening program, they started off with just neutral external internal rotation, easy stuff with a theraband with the humerus in neutral. And then the second phase of it, they built up more into rotations in 45 to 90 degrees. And then in the last bit, they were starting to add in a lot more resistance and they added in a thing called a power blade. The other thing I should point out too, this study The data was collected in 2008 to 2011. So this is what happens with academics. A good academic will beg data. And what they've done, you know, they've gone back and they've said this question is bugging everybody. There's so much uncertainty here. What have we got that we can go back and have a look at it? She and her group have gone back and been able to dredge up this data. And they were using a thing called a body blade, which I kind of remember from about 20 years ago. It's a metal strip and you kind of wobble it and it gives you sort of an unstable strengthening effect. Even just using a body blade instead of a two kilo or four kilo hand weight is going to be completely different sort of input to the system. So I actually thought what they did was okay. The manual therapy that they did in this, I think is pretty standardized for what most physios would do to somebody with a painful shoulder if they were doing manual therapy. So they were doing minips and mobs on the thoracic spine. They were doing PAs on the glenohumeral head. to stretching glenohumeral mobs for about 10 or 15 minutes. So pretty much if I had somebody with a stiff subacromial problem, 10 to 15 minutes of manual therapy and the rest of it exercising, I think they came pretty close to what a lot of physios would do in clinics. So I didn't think that there was a problem with their actual intervention and their methodology in this study. I think what's probably happened is that their patient-reported outcome cause there to be a bit of a shift in the bias.

SPEAKER_00 11:41

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SPEAKER_01 12:04

As you say, it's sounding like, and I've noticed that, noted the authors have also commented that, yes, even though this study was done or the data was collected some time ago, would the study protocol be largely similar? And they've proposed that perhaps, yes. And you're also suggesting that perhaps subgrouping might further make the results a little bit more granular and help us decide who might be amenable to manual therapy and who perhaps is just for the fast track of exercise. Exercise, yeah.

SPEAKER_02 12:35

And you've got an 18-year-old to a 75-year-old. 70, 65, 75-year-old shoulders are a lot different to an 18-year-old shoulder. They did do some quite good exclusions in this study that they went through and pretty much excluded anything that could confound it. I thought they did

SPEAKER_01 12:51

a good job with that. I also noted that they did a nice job of identifying how they progressed from phase to phase. It wasn't sort of time dependent. It was based on, correct me if I'm wrong, it seemed to be based on If they couldn't do two or three sets of 10, if they were flying through it with no fatigue and symptoms, they progressed to the next phase.

SPEAKER_02 13:12

Yeah. And look, I think if you were a physio who was really getting confused about how do I manage this shoulder problem, looking at this study and they've outlined their program quite well, how they did it. To me, it's what I've been doing for 40 years. So to me, it's pretty straightforward. But if you're a bit stuck, I think, you know, people out there in physio network world, it would be worthwhile looking at that study and looking at their program and seeing what they're doing. But it's just the program. You've got to take into account the contextual effects, which are Now I'm much more aware of those. I think back on my physio career and when I've thought I've done really, really well with the treatment. And I think it's more just because I handle people well socially. So

SPEAKER_01 13:57

we've got to take all that into consideration too. It comes down to the therapeutic alliance and the context and the narratives, probably the narratives that we attach to what manual therapy is actually doing as well, isn't it?

SPEAKER_02 14:10

Yeah. And look, the way that I explain manual therapy these days to patients is totally different to how I would have explained it when I did my Masters of Menips in 1985. I mean, it was all about, you know, adjusting and moving and putting things in different places. Now, you know, we've got much more neuroscience behind it. We know we're just getting down regulation. You know, if you've got something stiff around a shoulder, you could probably stretch it a bit. They did focus a lot on posterior hip cuff stretches in this study, which is, you know, I always seem to end up there when I'm working with folders. It's kind of a common thing. So, yeah, I think the main thing, just reading through all this research, is that I think it's the evidence-based research methodologies and the way that we've gone about doing research for the sake of doing research. We've really got to be holding conferences and getting people who are academics involved with statisticians and people who are good with methodology and making sure that we don't let studies start that aren't going to be high quality. Because, you know, we've got these really eager, keen young therapists wanting to do these research processes. And we don't know, we're physios, we don't know a whole heap about methodology. And we've actually got a background in stats. Before I started physio, I finished school a bit early and they made me do stats Boring, but anyway, I've learned something from it. And it's one of those things is if you don't know, you don't know. You really do need to sit down before you start any research project, even if it's just your fourth year final research project at uni, with somebody who knows about stats and just say, can you have a look? The main thing that people forget to do in physiotherapy is they don't use a placebo control. So I can be quite hard on studies that I read, that are A versus A plus B, but you do not have a C control, you're basically wasting people's time. That's low quality research. And I would say probably 80% of the papers that I read about this treatment's better than that treatment or this treatment works. You can't say that because they haven't got decent placebo controls. So You know, I've been watching the evidence-based practice develop over the last, I've been a physio now for, gosh, 40 years. And I've been watching it develop since the 90s. And honestly, I would say 80% of it's been a waste of time. But, you know, you live and you learn. We didn't know any better. And we've got to trust people like Laurie Mishner. Jared Powell really impressed me. I like his work. I think we've got to trust people like that to get the methodology right so we don't get this heterogeneity through the research. It's too stressful when you're a young physio trying to work out what you're meant to be doing to have all these little silos with their biases and opinions, cherry picking sometimes research. And I think that's where we've got a bit of stress in the profession at the moment. I think we've gone evidence-based practice, but we haven't done very well with it. And we've got a whole bunch of people picking sides with the bits that they like and don't like. We've

SPEAKER_01 17:14

got the baby being thrown out with the bathwater and we've got black and white where there's actually grey.

SPEAKER_02 17:20

Progressive exercise and stretching works and that if I have the right patient for whatever characteristics, and that's something that we need training on as well, that manual therapy can. It can be quite beneficial to

SPEAKER_01 17:33

them. So my final question to you then, Robyn, would be what is your advice for younger physios listening then looking at this article and going, oh, my goodness, which one is it?

SPEAKER_02 17:47

Yeah, my feeling is that you should read what they did with the patients, what they did in the study, see whether that correlates with what you would normally do with the patient, see why they did it. And I think that... Manual therapy, there's a lot of disagreement about it at the moment, and I think it's getting very polarizing. So I think that not discount manual therapy. Being a manip therapist for a long time, I know that what I do is due to downregulation and lots of contextual things, but I know mechanically what I do does something. And I think it's unfair to people who are good at manual therapy to say that it's a waste of time. I don't think it is. I think there is benefit for the right subgroup of patient. We don't know how to subgroup properly yet. I think Hodges is just starting to do that with all the low back pain. I think that's still probably going to be

SPEAKER_01 18:39

10 years away. I'll probably be retired by then. Well, thank you so much for coming on today, Robyn. I think there's plenty to think about and a really nice lens of how to view studies as well. Yes. Well, I hope that was my hope. That was wonderful. Thank you so much. Thank you. Thank you.