Jared Powell:
Good day for this episode, we're inverting things. Instead of me interviewing, I will be the interviewee, Emily and Andrew from the Knowledge Exchange. Ask me some probing and thoughtful questions about shoulder pain. Who would've thought with a particular emphasis on my qualitative paper that has just been published in the Physical Therapy journal? Exercise is an obvious and widely utilized treatment for shoulder pain. But does it work for all people at all times or like everything in biology? Does it depend on the individual scenario? Listen on to hear me bang on about the importance of my own research.
Jared Powell:
Without any further delay, I bring to you my conversation featuring myself and Emily and Andrew from the Knowledge Exchange.
Emily:
Hi everyone, and welcome to the Knowledge Exchange podcast. Today your host will be Andrew and Emily. Andrew and I will be pushing down off to the side and taking over the Knowledge Exchange podcast once a month to dive into a hot topic with a key researcher in field. For those of you who don't know, the knowledge exchange is a clinical education company running courses and mentorships designed to guide and support clinicians in private practice to feel more confident in applying person-centered care. So our first research review topic is on shoulder pain, and we'll look at surgery versus placebo. We'll look at specific versus general exercise, exercise compared to manual therapy and we'll delve into patient experiences. And today to help us better understand patient's lived experiences with shoulder pain, we have the one and only shoulder physio. Jared Powell with us.
Jared Powell:
Good day. Good day. Hi Emily. Hi, Andrew. Thanks for the invitation. I'm really looking forward to having a chat about my own research, which I arrogantly like to do, but don't get the invite to do often. So thank you.
Andrew:
Excellent. Thank you so much for being here, Jared. Now we do have a little bit to say on you first just to let everybody know kind of a little bit more on what you do specifically and to introduce you. You, you're an experience musculoskeletal physiotherapist from Queensland, Australia, and you have an interest in the quote shoulder complex, right? And currently you are studying a PhD in this area at Bond University, where you also maintain a visiting lecture position. So Jared, you've written several book chapters, peer reviewed articles and presented at various conferences on a wide variety of topics including frozen shoulder, rotator cuff related shoulder pain and shoulder instability. You are a clinician and scientist and you run a unique online telehealth shoulder practice, which is very interesting. We'd love to hear all about it. But today, em do you want to give a broad overview of kind of what it might look like and what we might run through?
Emily:
So today we'll be going over what we know in the shoulder pain literature. Currently we'll be covering Jared's recent paper on patient experiences the clinical takeaways from that paper and how those takeaways might look like in practice.
Andrew:
Jared, can you give the audience a little bit of context of where the shoulder pain research is at currently and where your work is more broadly?
Jared Powell:
Yeah, sure. So I mean, shoulder pain research is, it's in a funny place. It's come a long way over the last five to 10 years, but it's still, I, in my opinion, lagging behind low back pain and maybe osteoarthritis by 15, 20 years in terms of where we're at. So we're just coming out of like an obsession with shoulder impingement, which we were in somewhat of a nightmare for 50 odd years where shoulder impingement was the prevailing model of shoulder pain. And over the last decade we've, we've started to challenge and almost refute that diagnosis, which is, has a lot of implications for clinicians. We kind of need another podcast to talk about that, so we won't go too deep on that. In addition, like we've been testing a bunch of different interventions for shoulder pain for 30, 40, 50 years, essentially since the start of evidence-based practice really began in the seventies and the eighties.
Jared Powell:
And what, what we've found over this time in testing a bunch of different interventions is that they're all kind of equivalent to each other. So we know that a lot of things can work for shoulder pain. I like to refer to it as rotator cuff related shoulder pain, which is what we used to call shoulder impingement. And a lot of interventions can kind of help, you know, manual therapy can help exercise can help. My bias is to provide exercise and prescribe exercise, and perhaps we'll talk about that a little bit later. But acupuncture can help, dry need link can help, even electrotherapy modalities can help in the right person. So it all kind of helps. And exercise has this reputation as being superior compared to these other interventions. But when you actually look at the cold heart, the cold hearted data that is out there, which you know, is not meant to care about your feelings exercise is really no better than some of these other treatments, which I think is a bit of an eye-opener and is a little bit of, it makes you challenge your own biases, especially because you, you guys are eps, exercise professionals.
Jared Powell:
I assume you like exercise and you, you use exercise on a daily basis, you know, but it's not the be all and end all. I think that's important. So, so that kind of led me, partially led me into my research. I was interested in investigating exercise. And another thing that I noticed was that, okay, we, we know that a lot of interventions can work for exercise. So we know that if you, oh, sorry, can work for shoulder pain. If you prescribe exercise, for example, you say, here's a person with shoulder pain. Do this exercise program for three months, and then we check back in three months later, that person has improved pain scores, they have better function, and they're perhaps back to the meaningful or valued activity playing tennis or something like that. So we know that something happened, right, with that intervention. And if it's a randomized control trial, hopefully there's a control group or there will be a control group.
Jared Powell:
And if that control group is natural history or supervised neglect or something like that, and we see that exercise had a, had a meaningful difference in terms of being better between the control group, then we can sort of say with confidence, depending on how big the exercise is, that exercise did something. But what we can't say with a randomized control trial is how exercise led to a reduction in pain or an improvement in in function. In other words, what were the causal mechanisms underpinning exercise that led to a reduction in pain? So when we look at the shoulder pain literature, especially in regards to exercise or really any treatment, but my focus is exercise. We have no idea how exercise works. Like literally none. We, we can speculate and often in, in clinical trials, there's a lot of speculation about how exercise works. And then I, in, in one, in one of my reviews, I, I went through and actually collated all of the speculative theories as to why exercise might work for shoulder pain.
Jared Powell:
And there's like 30, 32 or 33 different proposed causal mechanisms for why exercise works. And like 90 to 95% of those are biomechanical or biomedical in nature. So overwhelmingly we have a theory that exercise works via increasing strength or improving scapular control, but we haven't really tested it. So, you know, we, we, how you would test it is with a mediation analysis typically, and that's usually like an adjunct to a randomized controlled trial. It's a secondary analysis typically where you would actually deconstruct how an exercise program might help someone with shoulder pain. And there's only two of those that exist in shoulder pain, which is pretty poor. There's, there's, there's many more that exist in, in low back pain and, and osteoarthritis. So in summary, the shoulder pain literature is in a, in a funny spot, we're getting better. We're starting to actually understand that we might need to investigate causal mechanisms and not just describe that something happened. And we're doing this via mediation analysis at the moment. We're still in its infancy, but hopefully over the next five to 10 years, we've got a lot more knowledge.
Andrew:
Love it. Such a great overview. And if I can just talk to kind of your last two or three publications as well. I love how you did that. You scoped everything. You're like, okay, well what is it that we think is happening? And then you ask some questions from clinicians by doing a survey next after that. And then you finally ended up at doing a qualitative study looking at those causal mechanisms, or at least what people thought, whether causal mechanisms. Right. And I'd love to go into that of your recent paper. The one restoring That Faith in My Shoulder. Love that as a title, I must say. Excellent. Because it really shows the emotion and of what people need more of straight away. So could you maybe bring us through that methodology of that paper and kind of why you used that and investigated into those causes and conditions that you ended up putting into all these different themes?
Jared Powell:
Yeah, yeah, no worries. Yeah, it's a good title. So restoring that faith in my shoulder was a quote from a patient and it really just resonated with me. And I think a lot of patients can resonate with that as well. And it goes beyond just the biomechanical and it really acknowledges, as you said, the emotion and the, and the feeling associated with, with getting better, you know, anyway, so that's, that's besides the point. But picking a title is a really important part of doing a PhD, so you guys might want to consider that because honestly, the more captivating and perhaps viral it goes, the better para like perversely for your for your research. Anyway, what, what were you asking? So why did I pick the method? Yeah, so, so I picked a kind of left field research paradigm, which is, which is a critical realist philosophy of size, which perhaps listeners don't know much about.
Jared Powell:
And I'll try and keep it basic. So usually when you do a thematic analysis type of qualitative research, you'll do the classic reflexive thematic analysis, which was proposed by Brown and Clark in 2006, which is what everyone quotes and references and sites in their, in their papers in physiotherapy, in allied health in general. And I think if you look on Google Scholar or whatever your preferred medium is, or checking research, that paper has like nearly 200,000 citations that Brown and Clark 2006 paper. So that shows you how many people have used reflexive thematic analysis over the last 15, 15 years. Anyway, so I kind of like to do things a little bit differently. So, and also I was asking a causal question, right? And that's super important. So a critical realist method or methodology is proposed as being a useful paradigm to use in qualitative research.
Jared Powell:
When you are asking a causal question, what critical realism is, it's a realist ontology. And so what that means is that you think there is some, there is an independent reality out there in the world that is separate from you and me and everybody else, like separate from our, our viewpoint, our mental, our mental life effectively. So there's something out there that we can study and we can find out about. That's, that's what a realist ontology is. And I, and that's my personal belief as well, which is, which is kind of good there. So there's a, a synergy between my personal belief and, and the method that I use, which I think is important. But then the, the crucial difference is between a critical realist method methodology and perhaps a positivist methodology, which is common in quant. Well, the only quantitative philosophy that, that you can really use is that it has a, a relativist epistemology.
Jared Powell:
So, so whilst we, we think that there is an independent reality out there, a critical realist philosophy of science emphasizes that or proposes that many people will come to sort of different, different interpretations or different perspectives of that reality. So that's different to a, a positivist account. It's also different to a, a pure, pure relativist account as well, where it's like there is no reality, and then everybody has their own different interpretations of their individual reality. So in essence, I used a cri critical realist method because it, it's, it's meant to be good for asking causal questions in, in qualitative research. And my question was how do people with rotator cuff related shoulder pain perceive exercise to have been beneficial or not for them? Which is a, which is a causal question. And basically I used that method to figure out and compile themes, which were causal explanations as to why they believe exercise helped or didn't help them. And then another really cool part of critical realism is that it appreciates context. And so what were, what were the contextual features of these people's individuals exp individual experiences, experiences that promoted or inhibited the, the causal mechanisms or causal explanations that they proposed or communicated to us. So like the context is hugely important for me, and I really wanted to tease that out, which is often what you can't get in large data sets, randomized control trials, et cetera, et cetera.
Emily:
Yeah, that is such an interesting viewpoint to have and it's so different to maybe traditional physio ep research. So based on that, what did you end up finding? What were the causal links?
Andrew:
I think before we even re repeat that question I wanna say that we did speak a lot about methodology there and there were some big words. So we will be including infographics that are gonna map it out and display a little bit more of what Jared's just gone over. 'cause I know that can be really demanding on the brain to to think about. But let's dive into those results, right? Em you can go ahead ask the question again. Where were we at?
Emily:
Yeah, so based on the methodology and the interviews and the analysis, what did the results come up with? What sort of causal links did you find? Yeah,
Jared Powell:
So great question. It found, well, we, I dunno if we say we can found, but we, that's a quantitative sentence right
Andrew:
There. We uncovered . Yeah,
Jared Powell:
Yeah. So yeah, we, at the end of our study, we concluded that in crucially there were three common conditions that were, that were really important for exercise to have causal power in producing a positive clinical outcome. And that might be reduced pain, improved shoulder function or returning to tennis or surfing or something like that. And these three conditions, which had to be there fully or partially in order to have a a positive clinical outcome, number one was a strong therapeutic relationship. And this was overwhelmingly the most common. Every single participant that we interviewed mentioned the importance of a therapeutic relationship. If that was there, that was often the foundation for a positive experience with exercise. If a therapeutic relationship a strong therapeutic relationship was not established or absent or it was strained, then often that participant would not go back to that therapist for obvious reasons or would not trust or perform the exercises that they prescribed.
Jared Powell:
And we've probably all had that experience before. So that's, I know that it's common sense and people might be like, oh, well, obviously, but it's really good to have that formalized in, in a scientific paper that we can now reference. Another, another common condition was that of the perceived importance of an individualized and tailored exercise program. And not just giving someone a generic handout of exercises that you print off your computer and you say, yeah, let's just do one, two, and three. And then you don't go out and test those exercises or experiment with those exercises and see how they actually feel. So participants overwhelmingly wanted an individualized, a fit for purpose exercise program that they felt was specific to their needs and their goals. Again, kind of obvious, but it's good to kind of tease these things out again. And then the last one was, and this is again obvious, but they wanted exercise to help them quickly, right?
Jared Powell:
They wanted to see progress quickly. They didn't want to just be fiddling away with doing these exercises for a year or two and seeing no progress. They wanted timely and tangible progress in their symptoms. So they were the three major conditions that needed to be present partially or fully in order for exercise to help someone. And then if those conditions were present, then these conditions often triggered three causal mechanisms, and these were often shoulder strength. So shoulder strength has been a, an interest of mine in, in my research for four or five years now. And I published a, an editorial a few years ago in J-O-S-B-T kind of challenging whether you need to actually get strong in order to, to get better with an exercise program. And I kind of, I, I stand by that editorial, but it's interesting to me to kind of reflect on that.
Jared Powell:
And now I see patients who believe that they are getting stronger. And so should I actually emphasize that? Yeah, look, this will get you stronger and therefore if you get stronger, you will have a positive clinical outcome. So should I accentuate that messaging in my clinical practice or should I be a, a firm peer A and say, well, there's no evidence that you're gonna get stronger, so therefore don't worry about it. So I'm kind of, there's a tension there that I need to figure out, and I haven't fully arrived in an answer, but I'm more amenable to using shoulder strength as a explanation as to why they might improve with exercise than I was before I did this study. So it's been a real cause for reflection for me doing this research, which has been fun. Another, another mechanism or causal explanation, which was commonly proposed by participants was that exercised, changed or influenced their psycho-emotional status, their thoughts, their feelings, and their behaviors.
Jared Powell:
Often they said that exercise helped them feel more confident in using their shoulder, it reduced their fear in using their shoulder. It those were the two overwhelming confidence and fear. And then it also, it encouraged them to use their shoulder again and not overprotect it and not avoid certain movements. And I, I sort of wrote up in the discussion of the paper that a lot of the participants ascribe this expectancy violation type of phenomena where they, they were expecting their shoulder to be sore with a certain movement. Their therapist encouraged them to do the movement in a safe and sort of not controlling manner, just asking, well, what will happen if we try a movement in this way? Can we give it a go if it's sore, we can change it, so on and so forth. And so the, the, the patient or participant felt really safe and they were heard by their clinician, but then they were surprised that, Hey, I'm doing this movement and it's not as sore as I had expected.
Jared Powell:
And so they were in real time sort of updating their beliefs about what that exercise would do for their pain. So that was a really fascinating aspect that participants were, were, were literally telling us. Then it really fits into that model of expectancy violation in graded exposure, which are common constructs in anxiety, in the anxiety literature, but now we're starting to use them in the musculoskeletal literature. And then the final causal explanation that was common was, people just believe exercise is good for you. It's like a, it's a universal good. It's like eating a nutritious meal. It's like sleeping eight hours at night. It's like not drinking excessively, smoking excessively, et cetera, et cetera. Exercise is good for us. And so there was this acknowledgement that, hey, exercise is good, so it's gotta be doing something good for me. I think that's a common sense approach for people to take. So, so yeah, again, a a lot to go through there. But exercise, whether it was beneficial or not, was conditional on factors such as a therapeutic and re relationship. And if those conditions were met, then often participants thought that shoulder strength, psycho-emotional factors and the, the widespread good and healthy connotations of exercise is what improved their shoulder pain.
Andrew:
That was excellent. This is how I can tell you've done great and you're gonna do great at dissemination in the future because I've read the papers and I understand them, but now I even have an even better understanding. So thank you. Really six big points there, kind of three preconditions that we can try to meet. Yep, that's the context of the situation from the perceived importance and having a tailored exercise program for somebody having a good therapeutic relationship with them, and then also having that client see timely results. Maybe we can address those three things first and how we can as clinicians set up that context well to have those preconditions because I know there's a lot that goes into, they can't just be like, oh, yeah, this is specific for you, but if they don't believe that it's specific for them, is that important too? And things like that.
Jared Powell:
Yeah, so look, it's hard. I don't have the answers on how to like, like optimize the conditions for exercise. I have theories, you know, I have speculations as always, I have conjectures that I can put forward, but I don't know, again, I'm just a person trying to figure it out as well. Like, overwhelmingly, the participants mentioned the word trust, like just straight up every single, I think like there were 11 participants in the study and all 11 mentioned the word trust in their, in their clinician. So that seems important, like gaining trust from your patient. And I don't like how to do that. Like, be nice, be honest, communicate, remember their name, remember their story, remember their spouse's name, remember their kid's name. You know, like be genuine. I, I think earning trust, like we can medicalize it, but I think it's just being a decent human.
Jared Powell:
And I, and I know, I know that we know what that is in like, it's hard to describe sometimes, but like earning trust or developing trust, we know what that looks like if, even if it's hard to describe. So I would say to clinicians, however, you can try and earn that patient's trust and it's sometimes it's, it's really challenging, you know, like especially when perhaps a person a patient is wanting you to do an intervention that you're not comfortable doing, or they're really strict and unerring in their belief as to why they have pain and that they need a particular, like medical intervention or surgery or an injection or something like that. But you know, from the evidence that that's perhaps not true. Like how do you, how do you get trust without hurting that person's feelings, but also having them understand the reality of that belief.
Jared Powell:
That's, that's a challenge. And we all, we all struggle with that. I'm sure. Another thing that, that that participants said a lot was, was communication. Like how they communicated my injury and then how they communicated what I need to do to do to get better was important. A lot of participants mentioned honesty and genuineness, and a person who had a bad experience said that their clinician gave them the impression that they just wanted them to keep coming back, you know, so they weren't really invested in getting them better, they were more worried about repeat visits and financial incentives, which is, which is a shame, but we know that that goes on on the daily basis as well. So like, there, there are key parts of building trust and, and building a therapeutic relationship, having empathy is another important one. So validate, listen and not just immediately cut to, I hear what you're saying, but you're wrong if they, if they're describing what they think is wrong with their shoulder, you know, like really empathize and say, this is a, we know that shoulder pain is a horrible condition.
Jared Powell:
It impacts all aspects of activities of daily living, so on and so forth. So really, you know, validate that first, validate all the time. And then when it comes to like providing an individualized program, I think a lot of it comes out of how I approach exercise prescription is I go out into the gym and we muck around and experiment with movement and exercise and you kind of reverse engineer, right? So what does this person want to get back to and what's a meaningful movement for them? You know, are they trying to play with their grandchildren? Are they trying to pick up groceries or are they trying to get back to a sport? Or do they just want basic pain relief? You know, in which case you can do many different exercises, but go out to the gym and experiment, conduct exercise experiments, try this movement, how does it feel, how does it make you feel?
Jared Powell:
Like, like do you have any thoughts and feelings when you're doing this exercise? Does it aggravate your pain? How long does the pain take to go away? What happens if we make a subtle adjustment to the movement? What happens if we do heavier load versus lighter load? What happens if we go through range or, or at the start of your range? What happens if we do it in this range, so on and so forth. There are almost infinite variables that you can modify in an exercise experiment to really get a deeper understanding into how that person is actually feeling during exercise. Because you, at the end of the day, you want that person to go home and do an exercise program, right? And so you want them to be comfortable, you want them to be involved in the construction of that exercise program. I, I would think so they actually know why they're doing it.
Jared Powell:
'Cause If they don't know the why, then what the hell's the point? You know? Because so many times I hear patients come in and go, I had to do this little fiddly thing with a theand or a weight or a dumbbell. I don't know what it's meant to do. I think it's meant to make me stronger because obviously it's resistance exercise, but maybe there was something else it was meant to do. So really try and get that explanation down pat. Now as I as I'm saying that, like how do we explain exercise given that we don't know? So that's the honesty part. So I actually like to say, well, we don't exactly know how exercise can help you. We know that it could help from a number of different and related bio-psychosocial processes, and if it hits any of those processes, then great, then you, then it, then it might help you, but it might be different for you versus another person.
Jared Powell:
So I like to practice like, like brutal transparency when it comes to that. And yeah, so if you do all of that, you go out in the gym, you act, you conduct these exercise experiments, then what will happen is naturally, organically you'll develop an individualized program that will be different from the person before and the person after. So it, it logically follows that you'll give someone an individualized and tailored program if you have the time and wherewithal and care factor to actually conduct these type of experiments. And then the final condition was, yeah, it's gotta help them somewhat quick. Now this is the hardest, hardest one because there are no guarantees. One exercise might help someone and harm another or have no effect on the next. So it's literally trial and error. And I'm a huge fan of trial and error. In fact, trial and error is what underpins the scientific method, you know, through error correction, you get closer to something resembling the truth.
Jared Powell:
And I think that's the same in clinic as well, where you all you can do is try a series of exercises or movements and if they're not helping, you can try a different series of exercises and movements. Obviously you're trying to figure out why, and you're trying to, you're trying to get feedback from the patient. But that's the best way that I think that you can develop, you can help a patient make progress now at, at the end of the day, maybe it's not exercise that they need as well. And you need to be realistic enough to accept that. And you have to be self-critical enough to accept that perhaps I'm not the person to see this patient, or perhaps exercise isn't the medium to help this patient. Maybe they need something else. And for, for me, that's like gotten easier over the years. I'm like 12, 13 years into being a physio and now I don't like take it personally that someone might need to see somebody else. In fact, I, I'm like more than happy to refer that person to a more appropriate clinician or or specialist. And so they're, and so they're the, they're the conditions which I think you're asking about. I forgot your question now, Andrew. Sorry mate,
Andrew:
You answered it perfectly. Don't worry if you've forgotten anything because even everything, what you said of, of what you just said and talking to getting timely results, it's interesting because they can all slowly flow into the next three kind of causal mechanisms that people had beliefs in, right? So what is a result to somebody? Is it for instance, the shoulder strength? Is it changes in psychoemotional state? Is it the fact that hey, exercise is good for your health in this way and you might see changes for your heart, your lungs, your whatever it is, and you can sit down. And it sounds like we might need to start really getting good at a lot of different kind of counseling and communication skills as clinicians to tease these things out of people so that we can set up the context and expectations. And then funnily enough, same word use expectancy, violation theory, right? To experiment and tailor something that is really perceived to be individual and beneficial to the client and by the client.
Jared Powell:
Yeah, totally. I just wanna go back to what you said there a second ago. You just triggered a thought in my please chaotic mind about progress. And so we've got literature on progress in terms of like, you should give non-surgical interventions three to 12 months before you try before it is recommended that you escalate care to surgery or, or some other more interventional treatment. So three to 12 months is a hell of a long time and it's obviously a, a large confidence interval between three months and 12 months as well. Like, so how do we communicate that to a patient when they want and justifiably they want timely and tangible progress. So this is again, where you've gotta be honest and have these challenging conversations that, hey, you might, I know that you want this quick progress and so you should and so do I and so do we all.
Jared Powell:
However, the reality is when we look, look at the, when we look at the prognosis literature is that it might take three to 12 months and even then, maybe only like six out of 10 people on average will get better in that timeframe. And perhaps you are one of those 60% and maybe you'll get better in four weeks or, you know, so like it's, you've, it's really challenging to inspire belief and inspire a positive expectation in that person that they're gonna get better with a non-surgical exercise led approach whilst also paying homage to the sort of literature that suggests that maybe they won't get better actually. And so you're just lying if you're trying to convince this person that they are gonna get better. So yeah, it's a real challenge guys, and I don't profess to have all the answers and in fact I acknowledge the uncertainty of it and have written I and have a paper under review where we're exploring that uncertainty that sort of surrounds exercise prescription again, which might be a subject for another day when the paper hopefully gets published.
Jared Powell:
So, so yeah, that's, that's another little tangent on on progress, which is, which I understand there are immense challenges in the, when you in day-to-day clinical practice in the coalface, which is e it's easy to write about. Like I can write a sentence about that and it's done because, you know, you cite a couple of things, but when you're living it, right, when you're a clinician and you're living that uncertainty, it's a side harder because you actually have to be the person who's getting that quizzical look from a patient or that like heartbroken look from a patient that, oh, this is like, I've gotta have to deal with this pain for like another year perhaps or more and maybe it won't even help me, so why should I commit to it? You know? So, so they're the real tough moments that I, that I can appreciate 'cause I'm still a clinician and I, I really think that researchers in general should be much more lenient and respectful to clinicians who actually have to deal with it. Okay, so moving, moving on from that Andrew, I've forgotten your question again mate, because this is the, my mind is like memento where it's like you just, I have these like random outbursts of creativity followed by, I've just forgotten everything I just said. So can you help me again?
Andrew:
That's absolutely fine. Jared, it's really good. I love the little memento moments. Don't worry. Actually I'm gonna pass it to m just in case she has anything to say there.
Emily:
So I really like how you mentioned the difficulties of clinical practice and that was kind of on my mind on, well my first question, and you and Andrew answered it, was how would you talk to a patient in terms of prognosis? So you answered that. My question now is how have patients responded to that and how have you managed that or dealt with it?
Jared Powell:
Yeah, so heterogeneous or heterogeneous, how you pronounce the word outcomes when you, when you say those things, as always is gonna be an individual response. So I'm in a, I'm in a privileged position now because I have a reputation as being a shoulder person. And so people tend to listen to me and I, I acknowledge that privilege that I have straight up and I, and not everybody has that. I didn't have it for a number of years. So yeah, I'm not diminishing that I have that privilege, but I'm acknowledging that I have that privilege. And so I, people will mostly listen to what I have to say, which is really great. Now, it doesn't mean they agree with it, and certainly I don't have a 100% success rate in helping people with shoulder pain far from it. So that's, that's the reality of it as well, early in my career, how people would respond, how you would expect them to respond when told, well, I don't really know what's causing your pain.
Jared Powell:
I don't know how long it's gonna take to get better. It could be anywhere from you could be better tomorrow or you could still have it in 12 months or two years. You know, people do not want to hear that. People want, typically they want, they, they want honesty, but they also want certainty. And so how you get honesty and certainty in the same sentence is a real struggle because we have no way of being certain, given the complex creatures that human beings are and the complex beast that pain is. And, and that's including shoulder pain. So you can perhaps talk in probabilities, which I've had success with in the past where you say, you know, you can look at the empirical data out there and like I said before, there might be 70 to 80% of people get better with a three month exercise program, get better, I mean, have tangible improvement with an exercise program versus doing nothing or versus another intervention.
Jared Powell:
We've got a, we've got a fair bit of data on that, so you can, you can quote that for sure, but I, I would provide no guarantees. I would say, however, given the complexity of pain, you might not be better and we might need to check back in frequently to see that you are on the, on the improve or do we need, do need to trial some other interventions along the way or do we need to just rubbish exercise completely and try a different treatment? Yeah. And those conversations are, are super challenging and you are always gonna get, I I think subtly you're always gonna get different responses from patients when you communicate that uncertainty. So just on that, again, like you can communicate uncertainty, and this is a podcast that I did with Natalia Costa recently on Uncertainty, and she, I urge you to listen to it.
Jared Powell:
I'm, I'm gonna plug my own podcast, but more just to listen to Natalia here or just read her papers because uncertainty shouldn't prevent action, right? So you can be uncertain about exact timeframes of recovery and that's, that's for sure. Okay. And normal, you can give broad outlines like using empirical data that it might take, it often takes three to 12 months. Most people will get better in the first few months though, you know, or make, make progress in the first few months. But then you say, well, but, but there are things that we can do along the way like that, that doesn't mean we should sit around and and and twiddle our thumbs. There are things that we control in the interim and maybe we're not gonna arrive at your perfect program or perfect treatment straight away, but we should just forget about that uncertainty and crack on and, and start trying some things out. And we may be surprised, you know, you might be feeling a hell of a lot better in a few weeks and if so, that's great, but what have you got to lose by actually just getting on with doing the treatment or doing the exercise program rather than just being infatuated with the uncertainty that's surrounding the, the prognosis and their outcome. So that's, so, so for me, a a huge part of my practice is acknowledging uncertainty but not being crippled by it intellectually.
Emily:
Yeah, I think that's what you said there is just really helpful and something people can take away because I can imagine clinicians get stuck at that bit of, how am I supposed to say the actual prognosis to a patient if that might stop them from coming back. And then how if people don't come back, then I don't get financial security. Also, I can't say to someone, you know, this might last 12 months and the patient's like, I can't access treatment for 12 months. So there's like so many other maybe repercussions clinicians might think of when we are honest and upfront with the timeline. But you bring that back in, what do patients actually want? And that's the therapeutic relationship, that's a plan and it's an individualized plan. So we can say all that and be like, but let's look about what's happening for you and these are the steps that we can take and this is what we can look at. While also having that nuance of we're not a hundred percent sure what's gonna happen and putting it back on them on are you open for this trial and error ride? Yeah. In amongst the uncertainty.
Jared Powell:
Yeah, that's really well said, Emily. That's exactly it. Like embracing uncertainty does not mean like I'm crippled by by this, I dunno what to do. You know, like, I like people like uncertainty is genuinely the most uncomfortable feeling in the world for me. Like, like that, that's what anxiety is. It's like I, I have no idea what my future's gonna look like. And so that, like, we should not diminish that, but like in patients if they're feeling that, but we, we need to accept that that is an ever omnipresent reality of, of clinical practice, that uncertainty. But then again, there are so many steps that we can take along the way and as you said, embrace the wild ride of trial and error. That's a really nice way of putting it. Yeah, like that's, that's something I'm gonna start to use now in my practice. Well done.
Emily:
So I was gonna move on. Andrew, do you have anything else to say? Yeah, yeah. So if there's any other findings that we missed Jared, just please let us know. I wanna kind of bring it all together now and give some takeaways or some practical tips for clinicians for tackling shoulder pain.
Jared Powell:
Well, yeah, okay. It's a big big open-ended question. Practical tips. I teach a whole whole course on this, you know, it takes a whole day.
Andrew:
Let's put a constrain on that. Maybe em like, maybe just like two of your top tips that you would say really improve practice for people with dealing with shoulder pain.
Jared Powell:
Okay, two top tips. Number one for me, I'm gonna go straight to exercise prescription, which I know is skipping a lot of steps along the way, but I can do what I want. You know, freedom of, freedom of speech. So I think if you're going to prescribe exercise in your clinical practice, and I'm probably speaking more to physios here because maybe EPS might be better at it, it's conduct these exercise experiments. So don't just go to your generic three sets of turn external rotation program, which is to be fair, I don't wanna rubbish that. It's okay, it probably helps a lot of people at the start, but if people want an individualized program, you've gotta go out in the gym, you've gotta put the yards in, you've gotta put the time in, and you've really gotta play around or experiment with a bunch of different movements with a bunch of different loads and then get that real time response from the patient.
Jared Powell:
I think you have to do that if you want them to be part of the journey and feel like they're equal partners in the construction of their exercise program. And also that you can feel like they have full, they can comprehend the meaning or the purpose of their program. You know, they're doing this exercise because they might want to get their rotator cuff stronger or doing this exercise might help them confront their feelings of fear or anxiety about moving, so on and so forth. And you, a lot of these things are like when I'm doing, when I'm in a clinical consult now, so these days I do telehealth and exclusively, so they'll, I do one hour consultations and there might be 20 minutes of like chatting at the start and then it's like, all right, get your weights out and let's, let's play around with some movement.
Jared Powell:
And it's a bit weird on telehealth to start with, to be honest. 'cause You're like, what, what movement do you want me to do? And do you want me to take my shirt off? And all this kind of stuff. And it's like a bit bit creepy sometimes, but but you get, you get the hang of it and a lot of it is just playing around with these movements and you can do it just as well in telehealth versus in person I've found. And a lot of it is, like I said, just, just trialing out these movements and then you are creating that exercise program based on the results of that exercise program. So that, that would be my top tip. It would be not just reverting to your tried and tested favorite exercises, although they can help. I know they can help, but if you've got the time, why not just like go out and give that person the, the feeling that you're really invested in designing an individual program for them.
Jared Powell:
And another tip that I have, and it might be a bit fluffy and a bit generic and a bit like a lot of people have said, but it's like really validate their experience. Like shoulder pain is often diminished compared to low back pain and other, and neck pain for example, or spinal pain in general because it's a peripheral joint and blah blah blah, blah blah. But we have a ton of like qual research that really shows the, the profound impact that an episode of shoulder pain can have on someone's mental health, on their work, on their recreation, on their home life. It can really affect every dimension of someone's quality of life. So a shoulder pain episode, especially when it goes on, right? 'cause A lot of the time they can, 50% of shoulder pain patients still have pain after a year and that's a hell of a long time to be experiencing pain. So really have empathy with that and that will come into that, you know, building a therapeutic relationship which will down the line help you with your clinical outcomes. I would conjecture.
Andrew:
Sorry, you can conjecture as much as you want . So that's awesome. Yeah, really empathize. And I wanna hone in on that point. Don't just be like, oh yeah, no, I must suck to be in pain. No, empathize with your client. Yeah, understand where they are and why they think they're there. All of that. Get better at mi, get better at different types of counseling, all of it. Communication, it's needed. People need to feel validated definitely. And then also step away from traditional prescriptions. Love it. That's also very hard. I think the first one's harder or your second one. The first one I spoke about . But, okay, well with that I feel like unless you have something to crucially say right now, we can kind of wrap it up. One last question. Excellent. Because I don't wanna keep you here forever, Jared, but you've spoken a lot about uncertainty and you mentioned Natalia a Costa's name before. I know you two work together. Kind of where do you see the research going or like your research going next for shoulder pain?
Jared Powell:
Yeah, so my research is like at the real start of of understanding causal mechanisms for shoulder pain. So like ideally hope, I hope and maybe I can be involved in it down the line, my research like can be used to actually construct and implement these mediation analyses, which I've mentioned a couple of times where we actually like try and deconstruct or disentangle the causal pathways that exercise works through in order to reduce pain and improve, improve shoulder function. So like I'm, I'm hopefully just laying the groundwork so we can, we can, we can perform some really good mediation analyses down the line where we test these possible causal mechanisms or mediators of recovery. You know, is it about getting stronger? Is it about optimizing scapula movement? Is it about improving pain, self-efficacy? Is it about reducing kinesia phobia? Is it about increasing confidence?
Jared Powell:
Is it about changing, changing the biochemistry of our shoulder? Is it about systemic inflammation? It, I could literally go all day here. We don't know. So again, speculation. And so my, my work has been in laying the groundwork and suggesting hypothesize mediators for outcomes based on what patients tell us based on, based on what clinicians tell us and based on what the clinical research tells us. They're the three arms to that. And then to do a randomized control trial with a secondary median mediation analysis attached to it, you can pick from any one of these putative mediators and then implement, implement that in your trial and go from there. You know, we can, we can actually like make inroads into figuring out how it is this, this exercise works and not just speculate, add infinitum, which is okay at the start. Like, I love speculation because that is at its heart, the starting point of science, but at some point we've gotta test it and figure out where we're at.
Andrew:
Wow, that sounds juicy . And that's a really nice way to wrap everything up because for people that don't know, qualitative research is usually the groundwork. It's not usually about testing and actually figuring out something, but it's actually uncovering and finding what is there to then generate a hypothesis to test. And that's where our numbers and our statistics and everything come into play later. So that's gonna be really awesome. Yeah,
Jared Powell:
Like qual call research. I, I don't, I honestly don't think that a paper has been published out before my one that investigated how and why patients think they got better with exercise or not. Like genuinely causal mechanisms had just been proposed via theory by what we think and then tested in a mediation analysis. So like getting the patient's perspective is so important because I think this might be a bit weird and a bit metaphysical, but like they construct their reality to a point more completely actually. And while there is a singular reality out there, like coming back to critical realism, right? Like everybody has a different interpretation of that reality. And so why would we not wanna know how people believe they got better or why they didn't get better with exercise when their, when their thoughts and their feelings and their expectations are so influential on clinical outcomes. Like it's, it's a bit of a surprise to me that it's been neglected for so long.
Emily:
Yeah, for sure. And I can imagine that would be something really helpful to actually ask our patients in clinical practice as well. Like, why do you think that got better and reflecting on the trial and error that you have done? And then that can even potentially help self-management going forward that they know what's helpful for them, what's not, and just to get an insight on what they are liking about treatment as well. So thank you so much for this chat. Where can people find you to get a bit more information about? Obviously you've got your shoulder course and your Instagram, so yeah, please plug everything in. Anything.
Jared Powell:
I'll keep it simple. So shoulder physio.com, which is a great website. URL is where I'm at and shoulder physio and Instagram is where I do most of my damage. And yeah, that's it. So like I, I, I do have an online course. I do occasionally teach in real life, but I've got two young kids now and I don't like traveling and being away from them, so I don't do much of IRL teaching. So it's mainly the online stuff these days, which is good. And I've got a podcast as well, I've got everything. So just go to the website and you'll see where it's at. Great.
Emily:
Thank you.
Jared Powell:
Cheers. Thanks co.
Jared Powell:
Thank you for listening to this episode of the Shoulder Physio podcast with yours truly. If you want more information about today's episode, check out our show [email protected]. If you liked what you heard today, don't forget to follow and subscribe on your podcast player of choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon. The Shoulder Physio podcast would like to acknowledge that this episode was recorded from the lands of the Ang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
