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[Physio Explained] The patient perspective: rethinking shoulder pain rehab with Prof. Karen McCreesh

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In this episode with Karen McCreesh, we explore shoulder pain and what patients really want. We discuss:

  • The mismatch between what patients want and what clinicians think they need
  • Role of pain and how to explain this to patients
  • Role of group exercise for those not improving with individual exercises

Prof McCreesh is an experienced musculoskeletal physiotherapy educator, researcher, clinician, and sonographer. She is a Professor in Physiotherapy at the School of Allied Health at the University of Limerick, Ireland. She has an extensive track record in shoulder pain research, with a multitude of peer reviewed publications in leading journals. She has been awarded over €1.7m in research funding and leads a team of 3 PhD and 2 post doctoral researchers within the Health Research Institute at UL.

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Our host is @James_Armstrong_Physio from Physio Network

SPEAKER_01:

The way that the explanations were being given around, maybe you don't need imaging, maybe you don't need to have surgery, were not framed in, I acknowledge that you really hurt it. And this has really been a big upheaval for your life. However, here's why it really hurts. And here's what the natural history is of this condition. That mismatch of not giving people an understanding of what the natural history of, particularly I'm thinking about rotator cuff tears, frozen shoulder, you know, we can give people really good information about natural history of these things that helps support that question of why am I hurting so much?

SPEAKER_02:

Welcome to Physio Explained. In today's episode, we are thrilled to have Professor Karen McCreesh, an esteemed musculoskeletal physiotherapy educator and clinician, joining us today. Professor McCreesh, who has an extensive experience in shoulder dysfunction and musculoskeletal disorders, will be sharing her expertise on the topic of shoulder pain, what patients really want. We'll explore the common mismatch between patient expectations and clinical consultations and how we can improve communication around clinical findings, prognosis I'm James Armstrong and this is Physio Explained. Karen, welcome to the PhysioExplained podcast. It's fantastic to have you on today. Thanks, James. Good to talk with you. So we're talking, as I said in the introduction, about shoulder pain and particularly looking at what patients want. And we're going to be diving into some of the discrepancies around that with what we maybe give our patients, what patients want. And we're going to go into that into lots of detail in the short time that we have. So should we start off with this mismatch, Karen, in terms of our patients are coming to us with shoulder pain and they've got an idea of what they want from their clinical consultations, but are we always giving them what they want is the question.

SPEAKER_01:

We often aren't. So this is based on a body of work from a couple of PhD students, one in particular, Christina Maxwell, who did a body of qualitative work with patients with shoulder pain and healthcare practitioners. And this was a series of meta-ethnography, which was gathering together all of the qualitative data that we have around this topic. And then also doing some primary work with patients, healthcare practitioners here in Ireland, having to understand, first of all, what they need from consultations, and then a recent piece of work that we published where she looked at what people felt would foster more evidence-based management of care. So that series of work started out with understanding that patients have very strongly held biomedical beliefs, which drive both their beliefs and their expectations of care. And that's no surprise. We know that's the case, not just for shoulders, but for all of this degenerative musculoskeletal conditions that we treat. But by driving the pathways of care, those biomedical beliefs led to certain feelings from the patients in terms of what they wanted to support better management of their care. And the things they really, really wanted to know was why was their pain? What was causing the pain? Why was it hurting? And really understanding that from often, yes, very much a labels perspective. So there was definitely a demand for MRIs. There was a demand for diagnostic labels for the condition. But the core of that really was about why is it hurting? Why is it hurting so much? And so That tends to come out in, I want an MRI because I want to check there's no damage that's been missed in my shoulder. I want an MRI because I think that that's going to change the kind of care that I need. But really, it was coming from a place of, why is it hurting so much? Because shoulder pain is an enormous upheaval for a lot of people. And often the level of that upheaval wasn't being acknowledged by practitioners, first and foremost. It was maybe being a bit minimized. And the way that the explanations were being given around, maybe you don't need imaging, maybe you don't need to have surgery, We're not framed in, I acknowledge that you're really hurting and this has really been a big upheaval for your life. However, here's why it really hurts. And here's what the natural history is of this condition. And that mismatch of not giving people an understanding of what the natural history of, particularly I'm thinking about rotator cuff tears or frozen shoulder, you know, we can give people really good information about natural history of these things that helps support that question of why am I hurting so much? That doesn't dismiss. bad experience of pain. And then when we move on to try and teach them that they need to do exercise, I remember again, they're framing that expectation around exercise in this really, really hurts. And nobody still has quite explained to me why it hurts so much. And now you're saying to me, exercise is the answer. And yet what I'm feeling is, is exercise going to hurt? And I really don't want to be in pain or further pain. And you still haven't really checked if I've got damage because somebody along the way told me I had a tear or I have this shoulder that's frozen up. So this mismatch, I suppose, in us feeling like, well, you know, it's very important for us to tell them that they don't need imaging and tell them that they don't need surgery. But maybe without acknowledging this is coming from a place of fear of movement, a fear of having pain, a fear of being hurt and of a lack of acknowledgement, maybe of the extent of the disruption and distress that shoulder pain can cause.

SPEAKER_02:

I suppose also you see patients who haven't got any healthcare background and the knowledge that some of us have, and their thoughts are, but why has it been hurting for so long? Why hasn't it got better yet? And it's also that element to it, that how do you know what's going on if you haven't looked inside? And all those other kinds of things are going through their head. Is that something else you found?

SPEAKER_01:

Yes. So in the more recent work where we asked patients, okay, well, we understand a lot of these things that you're finding difficult about your care. So what would foster... actually engaging in evidence-based care. So we spoke to 21 patients and over 100 healthcare practitioners in that study, and we mapped lots of concepts that we felt were important. And the patient still said, you know, we need to specifically understand what's going on from a kind of medical anatomy perspective. I need to build a strong relationship. I need to trust this person because I'm getting too much uncertainty. I'm getting different messages from different people. And so I don't really trust any of them. Or I trust the one who tells me the most about the labels or the biomedical things. So building that trust was something that patients felt would be the one thing that they felt could help them engage with the more evidence-based types of care. And that education needed to strongly link to time scales of recovery, which when I step back as someone who's looked at this for a long period of time, I think often needs to be framed much better in natural history of this condition. And again, I'm going to go back to rotator cuff related shoulder pain because it's the most common and it's certainly the one where we're probably not doing as well as we could be in terms of actually delivering evidence-based care. And we know that these things can occur hugely commonly as asymptomatic phenomena in people's shoulders. Certainly once we're over 65, the numbers really, really climb in terms of asymptomatic tears. What I find when I talk to physiotherapists, and it's easy to blame GPs and surgeons and other people, is we're very uncertain about what the word rotator cuff tear actually means. And we're passing that uncertainty on to our patients. And so a rotator cuff tear is part of normal aging. The rotator cuff is programmed to fail in older age. We need to understand, actually, some of the biomedical anatomy of the cuff, which is that we have this crescent area of the cuff that's mostly stress-shielded, so it doesn't take a lot of load. And so as we get older and it's not taking load, it's destined to fail to some degree. So we're going to get these tears, particularly the interface between infraspinatus and supraspinatus, where the majority of these tears are, you know, if we go at 15 millimeters behind the biceps tendon, This is where the cuff tears, the degenerative cuff tears propagate. So it's at that interface point between supra and infra. It's at a part of the tendon that's essentially shielded from stress. And so when it tears, it doesn't really matter in terms of shoulder function because it's not an area of the cuff that's taking a lot of load. You know, surgeons are obviously very focused when they get in there on restoring the rotator cable if it's damaged. But so many of these tears our patients have probably 90% plus of the degenerative ones, certainly, are in an area of the tendon that's essentially shielded from load. And if we can get comfortable with that as physios, we can get a lot more comfortable with saying to our patients, I get it. You've got a picture that says there's a hole there. But did you know, actually, that part of the tendon doesn't really take a lot of load. And this is how the cuff is constructed and how it supports your shoulder. And even with some changes in that area, we can talk about it being a little bit threadbare. or like having a hole in a fishing net or whatever chimes, very importantly, with what your patient might believe or expect. Don't tell a climber that they're pulling on a frayed rope, all those sorts of things, which are the stories that we've all heard before. So something that chimes with them, but I would be a proponent of not running away from the anatomy. You know, I'm trained as a sonographer. So I've previously had the luxury, I suppose, I've been able to scan right and left shoulders and show people. The other one looks exactly the same. Now, again, dangerous territory because we know having one is a risk to get pain in the other. And so we don't want to propagate that idea. But it can be helpful to frame this in the natural history of the condition. The other thing we know about natural history of all these degenerative musculoskeletal disorders is that they wax and wane. So when you see the patients, particularly if they're seen fairly acutely, you're seeing them at their worst. There's a very high probability that in three months time, that would have waned down even without care. And that's not a saying that everybody needs to be sitting in a wait and see. And of course, we see patients who've sat in waiting lists for a long time and are quite distressed and in pain. But helping somebody to understand that natural history of this is going to wax and wane. And we're meeting you at the time when this is really bad. But let's commit to an operative type of management for at least three months, because the natural history of this is that it's likely to get better in that time scale anyway. And let me help you understand what the anatomy is behind these degenerative tears in particular and how... our kind of care can support you in getting better and then helping yourself to get better and stay well.

SPEAKER_00:

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SPEAKER_02:

I think a lot of the time as well is actually trusting that our patients can take on board that information and can process a fairly decent amount of anatomy, physiology and sort of health understanding, which will help them with managing the psychological stress that they're probably not understanding.

SPEAKER_01:

Yeah, I mean, look, it varies. And of course, the people who do less well with conservative care are those who have lower educational levels, lower socioeconomic groups, who have mood disorders, who, you know, again, originally have more difficulty with health literacy. So there's no question the ones who do badly are the ones who are likely potentially to struggle with this. So we've got to try a lot harder. We are great at education around exercise. We're great at things like education around ergonomics and so on, but we're probably not using educational principles the way that, for example, I might do as an academic when I'm planning a module. I have to frame it really in understanding where am I students at now? What level are they coming at? What are the outcomes I'm expecting to see a change in their knowledge of? And I set up and frame an entire curriculum of information to support that. And of course, very importantly, I check in along the way to see how they're getting on. I give them feedback when it's not going the way that I hope. And I assess in some way to determine whether they've met the competencies of those educational outcomes that I've given. You know, you're not doing that with every patient, but there are elements of that skill as an educationalist that we can transfer better into physiotherapy care. So seeing where your patient's starting out, and I know Joe Gibson's a real expert at talking about this sort of thing, but what do they know so far and what does it mean to them? Really important because we can make expectations about or ideas about, oh, you've been told you've got a tear and that must mean that you think X or Y. So really knowing where they're starting out, getting some idea of their preferences. What do you want to know? What more do you want to know? And how would you like to learn it? Would be really useful for us to start to do a little bit more of. And then thinking about how am I going to deliver this education, but not just how am I going to deliver it? How will I evaluate whether they're getting an understanding of what I'm teaching? And this is the kind of teach back technique. Can they teach it back to us? But that alone is not enough because we want to know, have they embedded it? So when we see them again. Have you changed what you've been doing since I last saw you based on what we've discussed? Mark Olivier Dubé has published a lovely randomized control trial not that long ago where he compared motor control exercise to strengthening exercise to a purely educational intervention, which was in that study deemed to be potentially the control, where it was two weeks of patients watching educational videos, generating their own questions about the videos and coming back to talk to the physio about those questions. It wasn't individualized in the sense that the educational content was generic. But the outcomes at 12 months were exactly the same as those that received the motor control exercise or the strengthening exercise. Usually surprising at the strength of the effect of that two-week education intervention, which was bolstered then with this check-in discussion session. The GRASP trial tells us something similar, that patients who are given a goal-setting approach to their education can really do very well. So individualizing understanding where they're starting out. But even better again, probably, if we can give feedback along the way of that process of education, let it unfold slowly. I'm a huge proponent of group-based exercise. It's something I've looked at in a research perspective. I'm involved in a research study at the moment in delivering group exercise for generalized chronic pain. And I just see again and again enormous benefits for particularly the group of people with the lower health literacy or those people who struggle with mood disorders, coming back into a group setting and having the education reinforced, not just by the person who's leading the group, but also by the people who are around them. I've been seeing that too. And you know what? I've made that change and I'm now feeling different. So that ability to reinforce education, the same way as we do repetitions and sets with exercise. Thinking about reps and sets of education might be one way to think about it. And actually group exercise is one really nice way to achieve that for those who are not getting the good outcomes with the kind of self-management type approach.

SPEAKER_02:

Definitely. We focus so much on the exercise and even our outcome measures. I'm just thinking about it now and thinking, how am I assessing the patient's understanding? Am I doing any sort of outcome measure that's telling me how well they've understood it? How well have they implored some behaviour change to their lives from my education?

SPEAKER_01:

Yeah, the behavior change element. I think all the pain neuroscience education literature, there's tons of it, and they've done a really good job of that, has told us knowledge alone is not enough. So there's lots of really well-resourced studies around giving pain neuroscience education and it not really changing patients' outcomes. But then we look something more like the CFT and Peter O'Sullivan's work where it's about saying, well, yes, we're giving you neuroscience education or making it individualized to you. And we're ensuring that you embed it with real change in your behavior, your movement or whatever is needed. So I think that combination of knowledge, but very importantly, layering it into what we're really good at, layering it into your day to day movement, your day to day behaviors.

SPEAKER_02:

It was brilliant. And it comes full cycle, doesn't it, back to our mismatch, as you were talking about right at the beginning in terms of what our patients come in wanting or thinking they're wanting, their beliefs, their understanding, and how we address those is potentially slightly different to how many of us do try and address or not address some of those things.

SPEAKER_01:

And look, be in absolutely no doubt that we've got to address them. A fantastic prospective study from John Kuhn and the Moon Shoulder Group in the US, a group of surgeons, followed up 450 people for 10 years, non-traumatic rotator cuff tears. They followed up these 400 people and just tracked who had surgery and who didn't over 10 years. So it wasn't a trial. It was a prospective cohort. 70% of that cohort did not have surgery and had successful outcomes at 10 years. And the improvements that they saw at six months and for non-operative care were sustained right through to that 10-year stage. Of the 30%, sorry, there wasn't 30% who wanted to have surgeries, but they had some dropouts and so on. But of those who had surgery in that cohort in the first six months after onset of pain, the biggest predictor was their expectation of recovery with non-operative care. So by a tenfold difference compared to the other predictors that we would have thought, how big the tear was, how high the pain was, how much disability, whether they had an annual job, none of those had anywhere near the impact of having asked them do you think you're going to get better with physiotherapy care, with non-operative care? And if the patient said no, they were 10 times more likely to have surgery in those first six months. I mean, there's nothing more important, clearly, to us delivering non-operative care than to find out about that, to find out about where their expectations lie. And look, Rachel Chester's work is another really landmark piece of work that helps us understand how important expectations are. Changing them will involve a really kind of embedded approach of education, behavior change and empathy and empathy really understanding this is horrible and it's been distressing for you and i know you you really want to get better soon but let me help you understand as i said the natural history and how this kind of care can support you

SPEAKER_02:

wonderful i can't believe how quickly time is flying with this carol we've covered so so much already we're definitely gonna have to do a part two of this i think at some point but just finally before before we leave we talked off air about the importance of getting some of this across in terms of the evidence of what works. And do you want to signpost some listeners or let us know about some more recent things that have been going on that you think might help listeners with that?

SPEAKER_01:

Yes, so I've talked about a couple of the trials there. So Christina Maxwell's work, if you're interested in those qualitative pieces of work and expectations. Something I'm really proud of that I've been involved in recently, I've been trying to be involved in a shoulder pain guideline for about 10 years because we looked a couple of years ago and found there were really no high quality guidelines out there for clinicians So I've just been involved in a group led by Francois Desmules in Montreal, where we've developed a guideline for managing rotator cuff tendinopathy. It's a really high quality clinical practice guideline that was published in JOSPT just before Christmas. So I'd really like listeners to engage with that, please. Tell us more. Tell us what you think of it. Like all guidelines, it's hard to come out and say, you've got really definite things that you need to do because the evidence lets us down often. It's uncertain. But it's the most robust, I guess, high quality technical practice guideline that we have for rotator cuff tendinopathy at the moment. So please have a look in and use that. We also published at the same time to support the guideline and systematic review and a scoping review looking at the effectiveness of different types of exercise for rotator cuff tendinopathy as well. No surprises. That was quite a mixed bag. We probably had a little bit of suggesting that motor control exercise was helpful for disability, but actually nothing else. No other type of exercise comes out any stronger than another. And for me, That tells me exercises are to not science for these patients. It's understanding who needs the most of what and delivering something that they first of all like, enjoy. believe in and both have the opportunity and capability to do. Yes,

SPEAKER_02:

and the understanding of why they're doing it and what's going on. Yeah. Karen, thank you so much for your time recording today's podcast. It's been absolutely brilliant and really eye-opening. I'm sure lots of listeners have got some things to go back into clinic with tomorrow or when they next go back in to sort of think, are they addressing that mismatch that may be occurring occasionally or quite often with some of their patients. So thank you very much, Karen.

SPEAKER_01:

Thanks, James.

UNKNOWN:

Thanks, James. you