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Hi, my name is Jo Gibson and I'm an upper limb rehabilitation specialist working at rehab for performance in Liverpool in the UK. I previously worked as a shoulder specialist in the Liverpool Upper Limb Unit for 27 years.

I always like to think about patients I've seen in the clinic and some common issues that perhaps arise and some really simple things that we can get wrong without really thinking that can set us up to fail.

So I'd seen a guy in clinic a couple of weeks ago and he was very typical of a lot of the patients that I see. He had a long history of problems with their shoulder, still fairly local shoulder problem, very mechanical. And it had all started like most non-traumatic shoulder pain. There was no real cause. It was mechanical. Very definite patterns of movement that caused his pain to get worse. It was a nuisance.

He'd stop going to the gym, he'd stop swimming because all these things aggravated his pain, and here he was three, four years down the line, still having significant problems. Now, he was clearly distressed. He was fed up with lack of successive treatments. He'd had two surgeries. The first was a subacromial decompression.

The second was an AC joint excision. But essentially, these things hadn't had any effect. He'd had numerous injections, but again, expected them to make the difference. Expected them to give him an opportunity for rehabilitation to work. But unfortunately they didn't. Now, when I asked this guy what his understanding was of the problem that he had, so what had he been told by all the people he'd seen so far? Because he'd seen about eight different specialists. He said that he didn't really know.

But in trying to make sense of all the different things that he'd been told, he had focused on the fact that, one, he had some asymmetry of his scapula, that he was using the wrong muscles, he had impingement but he really wished he understood what was causing his pain.

So essentially he was going round, trying to correct where his scapula was all the time. He was things that he perceived would make that impingement worse, and so you can see that he was consciously protecting the shoulder in everything that he was doing. Now, scans had failed to show anything at all for this guy.

He'd been told there was some early wear and tear in the joints. And not a lot of space, but this was despite the fact that all the scans I got hold of had essentially been reported as normal. Now, those are the things that he'd heard. He was really worried about his scapula being in the wrong position, and that could accelerate that wear and tear and further reduce the space that was in the joint.

Patients try and make sense of pain. So when I said to this guy, you obviously you've been told lots of different things and what does that mean to you? He said he felt his muscles were constantly in spasm and pulling everything out of position, and as a result, he was avoiding many of the things he wanted to do and was seeking regular input from lots of different healthcare professionals, osteopaths, chiropractors, soft tissue massage, and all of the things gave him a temporary improvement or a temporary change in how it felt to move. But essentially there was no carryover. He had tried exercises and stuff, but he said they tended to exacerbate his pain and his arm felt really heavy and he was starting to develop some neck symptoms too.

He was really fed up, stuck in this cycle of pain, and his quality of life was clearly suffering. He said it was having an impact on his relationship with his wife because they couldn't do many of the things that they used to do together, play golf or go swimming, and he wasn't actually working because he'd taken early retirement. So this guy really was in a little bit of a mess. Now, why am I telling you about this chap because I'm sure that's not an unfamiliar story to many of us.

I guess it's a great illustration for me that sometimes in our need to help patients, we don't necessarily check what they've been told before. And even if we do, we perhaps don't ask the question, what does that mean to you? So not only what have you been told, but importantly, what does that mean to you? Because that gives you a real insight into somebody's true beliefs about what's going on and how they've made sense of their pain experience.

With this guy, there was a constant theme that he didn't feel listened to, and really importantly, the explanations that he'd been given had far from reassured him that there wasn't something wrong, and that he was good to go in terms of rehab, but actually the wear and tear and the impingement models that he'd been given left him feeling that something had been missed and that actually, the scans were saying everything was normal, but the doctor said there wasn't much space and the doctor said there was wear and tear. So perhaps those things had got worse over time, and that more scans would actually give him an explanation.

Don't think that I'm criticising anybody because the fact is everyone this man went to see, wanted to help him. That's what we all do, isn't it? We're all there to help. No one set out to confuse him.

However, sometimes in our need to help people, we can be a little bit guilty of rushing in with more information in our need to help patients make sense without first establishing where they're at in their own understanding, and importantly, what the other things that people have said meant to them.

So I often use an example if somebody's been told they've got impingement and then I say, what does that mean to you? And they then say it means I need physiotherapy to help get my muscles stronger and they're happy with that framing, then why would I challenge that narrative? I might put it into the context of the other words they might see out on Google or their friends might use.

If however, they say it means I've got a little bit of bone that needs chopping off and I don't know why I'm here in physio, then of course we're going to have a very different discussion. Now, the evidence is really clear that the diagnostic labels we give can actually influence patient's perceived need for surgery and imaging, particularly if we don't check what it means to the patient and what they've actually heard.

Research is really interesting in that it shows patients often listen for the bad news or the information that's more likely to be associated with poorer outcomes, especially if they've had previous negative healthcare experiences. So the patients that we see that have seen several practitioners all have set out to help them, but unfortunately, the outcome has always been fairly negative.

Now we also know that diagnostic labels and explanations can influence the treatment preferences that patients have. I'm sure many of you will be familiar with the lovely Andrew Cuff study, which he did in 2018, which basically showed that a diagnosis of shoulder pain really remains firmly grounded in a very biomedical model where identification of whichever structure is at fault really is a kind of priority, and diagnostic imaging often forms a central component of making that diagnosis. Now, this is despite the fact that we see a plethora of research, which one challenges the relevance of scans in non-traumatic pain, and the fact that essentially being structure specific in the absence of any trauma is fundamentally flawed and makes no difference to treatment options.

We have numerous studies showing us if you stratify patients with non-traumatic pain according to scan findings, and then the other half you just treat as non-traumatic shoulder pain, there is no difference in outcome. And these are big number studies. The other thing we know is that people with non-traumatic shoulder pain that come to us with symptoms, if we image their other shoulder, will see similar things in 95% despite the fact they haven't got pain.

So some real challenges. The other emerging evidence shows us that if we scan patients too early certainly within the first 12 weeks of their initial presentation, it's actually shown that far from reassuring patients. What it actually does is make them more likely to become a persistent pain problem.

Why? Because it perpetuates that biomedical framing. So an emphasis that there must be something wrong. And then we have the issue that if it comes back and it's normal, the patient feels their pain has been invalidated because there's no cause. And similarly, we, if we find something like a degenerative rotator cuff tear, we then have the whole issue relating to what that means to patients.

So despite the recognition that shoulder pain is multifactorial and we need to consider it in a biopsychosocial framework, the fact is that many of these studies show that much of our diagnosis is still very much based in that biomedical domain. Now, what's really interesting as well is that patients actually quite like those explanations.

So in Andrew Cuff’s study, what he found was that explaining pain using the subacromial impingement model actually was quite acceptable to patients. The problem was it made them look for a structural fix. They were far more likely to look for a surgical solution. Now interestingly, another thing that got me thinking about this, was a follow-up paper by Josh Sadro, which is basically he followed a previous study where he'd looked at the impact of diagnostic labeling, where they did an online survey of many patients and they followed it up with this new one, which again, encompassed over 2000 patients. Now, this was an online survey. They had a vignette, a story about, an example, a patient with shoulder pain that they'd had for six months, that's where they changed it. So the patient had pain longer than in their original study. And then essentially they offered different diagnostic labels and different management options.

So the four different things, the two diagnosis were bursitis or rotator cuff tear because those were the two that showed the kind of most relevance in that initial study. And then the management options were either guideline based, which is basically positive outcome, the likelihood is you're going to get better, keep moving, don't get stiff, lots of real positive reframing.

And then the second treatment option was recommendations that were all about you need something to happen to get you better, so some sort of intervention.

Now, what was really interesting in this study is what it showed that in patients with non-traumatic shoulder pain, labeling rotator cuff disease or rotator cuff related shoulder pain as bursitis, significantly reduced the perceived need for surgery for imaging, and the need to see a specialist and the perceived seriousness of the condition.

And also meant patients didn't feel as fearful about needing to stay off work. Whereas if they diagnosed it as a rotator cuff tear, then the perceived need for all those things was much greater. Now interestingly, this study also reported that labels of a rotator cuff tear and subacromial impingement syndrome were more likely to be associated with feelings of psychological distress, that the condition was more serious, and that actually it had a poorer prognosis. Really fascinating.

Now, this study, as I say, also evaluated the impact of guideline based advice versus treatment recommendations, i.e. something needs to be done to get you better. The guideline based advice for rotator cuff problems encouraged basically stay active, positive prognostic information and as I say, had that very positive effect on patient expectations and the need for anything more invasive.

They didn't push for a second opinion. What was really interesting is that when they looked at the relative impact of the diagnostic label or the advice, what they found is actually advice seemed to have a larger effect than labels for most of the outcomes that they measured. In fact, two to three times stronger.

However, the authors are very honest that it's unclear if this effect is clinically significant, so a little bit more work to be done. However, what's really important is what we see, again, is the impact of something like telling somebody. Particularly with non-traumatic shoulder pain, that doesn't give us any history of trauma, who, if they're above a certain age, is likely to have a degenerative cuff tear there anyway, like an erosion, if you like it as an age related change. The fact is, using the term rotator cuff tear from this study certainly seems to be very unhelpful. Now, the authors are very honest because obviously this was an online study, so it's possible that the effects of labels and advice in-person consultations. Maybe a little bit different. However, the other thing is that they're very honest. They didn't exclude participants who might have seen somebody before, had other diagnostic labels, had other advice, and so maybe it wasn't clear how those things could have impacted decision making. However, what I think is so nice about this is it just give us some really key ideas that actually the terms that we use for our patients just have an immediate effect in influencing treatment decision making, and we know that from surgical studies, again, if an orthopedic surgeon prioritises more invasive interventions and uses a lot of biomedical language, patients are more likely to go for the more invasive option.

Now, as you recall, I said bursitis, which is actually a term that many studies would suggest we shouldn't use because it doesn't accurately reflect what we know about the pathology. And it's potentially a very niche group and a very nociceptive type of label. Now that's really interesting. And I think we need to be a little bit cautious, because I certainly know a lot of healthcare professionals wouldn't be comfortable using that as a term. But I think where that leaves us is the need for some consensus in terms of terminology.

We see studies in low back pain patients and the impact of terminology. With my patient, what he's been told before and what it means to him. It's really important that I don't then rush in with a whole lot new explanation and I need to know how he's made sense. And if you think of all the influences on patients, so this guy's seen eight different healthcare professionals.

He's got his friends, he's got his family. He spent a whole lot of time on Google trying to find stuff out. There's cultural variations in pain behaviors and how people rationalise pain. And also he's had all this previous experience in different healthcare specialties. If I introduce more information without checking what he knows already and importantly, what it means to him.

You can see that I just add to that confusion and uncertainty. So of course I'm not saying that we should necessarily use the term bursitis. What I am saying is certainly using the term, rotator cuff tear and impingement are consistently shown to have some negative connotations for patients.

So you'll remember that things like rotator cuff related shoulder pain and subacromial pain were really meant to illustrate a shift away from that impingement model, which is no longer really supported that top-down model. And actually to recognise our increased understanding of the multifactorial nature of shoulder pain.

But the bottom line is whatever we say to our patients, we need to prepare them for what they're going to see out there. Now, I've talked before about nonverbal communication and how patients will give you the clues if they don't like what you are saying. We just need to pick them up.

Now, if they put their hand over the front of their throat, that's a real defense mechanism. I don't like what you're saying. If they frown or they turn their body away, or they cross their arms, their body language often will give it away. But equally, just listening to their voice. If they've been talking and using lots of words, and suddenly it becomes very staccato or limited, or the cadence or tone of their voice changes. Just be conscious where that might relate to what you are actually saying to the patient or the explanation you're trying to give them. The fact is your safety net is checking what the person has heard. What we know from the literature is our auditory system is like any other of our sensory systems, it prioritises information. Think of that game we used to play at school, Chinese whispers. So when a patient tells you something that another healthcare professional has said, and it sounds a bit scary, and you think I wouldn't say that. How stupid. Don't assume it's what that healthcare professional actually said, because actually what it might say is what that patient heard and tells you a lot about their belief system and why they continue to avoid or protect their shoulder.

Now, of course, we do get it inadvertently wrong sometimes because of our comfort zone and the things that we've been taught, but it just really illustrates the importance of thinking about these things, reflecting, and importantly, checking what we've said means to the patient in front of us because otherwise our messages can cause conscious and unconscious protective strategies that essentially will perpetuate symptoms for that patient.

So of course with this guy, the bottom line was he was trying to hold his scapular in place and avoiding things where he thought that the shoulder must be impinging. I don't always get it right either.

When I was doing some teaching, it was in France, I'd like to blame the language barrier. But a young lady who I said, had a long head of biceps tendinopathy. I was happy to do that because she had a definite loading history and she was generally hypermobile. So I also talked about the fact she wanted to be a dancer, and if we got the rest of her stronger, it would make life easier for her shoulder. We have some nice evidence in a hypermobile population that strengthening seems to have some additional value. When I asked her to tell everybody in the group what I told her about her shoulder pain, her answer was to say, I have a problem with my shoulder that is so bad that my hips are starting to break down. Now I was a little bit horrified, and of course the group had all heard what I'd actually said to her. But what a fantastic illustration of when a patient hears things because of preexisting fears. And she was very worried about her hypermobility, what it might mean in the future because of messages she'd had from other healthcare professionals and how she had interpreted them.

So I'm not saying it's the patient's fault, what I'm saying is we need to be cautious. So what can we learn from my patient? The guy I was telling you about, he'd been given all these different messages and in terms of how he'd made sense, obviously he was really continuing this cycle of protection. Always check what patients understand about their pain, how they've made sense, or importantly, what they've previously been told, and importantly, what it means to them. So what's your current understanding of why you have these issues with your shoulder? Yeah, they say, I don't know. Great. You've got a blank canvas. Or what have you been told before? And then when they tell you, when they give you that explanation, the important thing there is to follow up with and how does that make you feel? Or does that give you a sense of what needs to happen to get your shoulder better? It's not enough to know what they've been told.

We have to know what it means to them because that gives us the rich narrative of any negative beliefs that might drive fear avoidance, kinesiophobia, and things like pain catastrophisation. So this really gives us an insight into somebody's beliefs and concerns. Now, as I say, some of the terms that now are postulated like subacromial pain and rotator cuff related shoulder pain were to really help have a consistent message. So if you are in a team or work with consultants or have pathways to communicate with your GPs, try and have a consistent message, a label that everybody knows what it means in terms of how it directs care, but also try and have some consistency amongst colleagues so that patients aren't getting mixed messages. And importantly, the fact is if we prepare them for what's out there, then again, if there's somebody who's going to go out and look at Google and we say, look, we put this under an umbrella term of subacromial pain. The fact is there's lots of different terms that will be represented like this if you go onto Google, but the good news is it makes no difference to treatments, some simple things and advice, et cetera. So again, you can see, we can almost prepare patients for the negative things they might see, but always after understanding what they've heard first. When I was lecturing , I was chaired by the amazing Kieran O'Sullivan. Kieran is often attributed with the Kieran O'Sullivan test, which is at the end when you've given patients explanations, is essentially check what it means to them.

So what are you going to say to your husband, wife, partner, friend, whatever, when you get home about what I've told you about your shoulder pain? This was actually described in the teach back method. Kieran was very honest that it actually wasn't his, and it's a tool that's been shown to improve health literacy and actually retaining information.

But it's also really important to back this up with education beyond words so we can use written or visual material, pamphlets, websites, diagrams, scribbles, whatever's useful for that patient to reinforce the key messages that we've given them. And importantly, if we ask them how they want to remember, or things that would be useful to them to back it up. Patient autonomy that reflects their learning style, it's likely to work even better. Now, studies have shown that. 40 to 80% of the medical information patients are told during their consultation is forgotten immediately and nearly half of the information retained is incorrect. So you can see the importance of one, checking that understanding. And secondly also just giving them additional resources to reinforce the key messages. And whenever a patient comes in the second time, one of my first questions is, how did you feel about what we discussed last time? Now, very quick tip is don't try and change or challenge beliefs at the outset if a patient gives you a very negative narrative.

This chap talked about the scapula and impingement. Now it was good for me to understand and actually his sense making wasn't far off the mark. His muscles in spasm and protecting him was what was happening, but because of his negative beliefs. I can challenge that with my symptom modification, just get him to relax and breathe and move differently. And those can be very powerful ways of changing movement expectations, which we know can then modify those negative beliefs. So if this guy feels his arms heavy and then I show him to way to move where it doesn't feel so heavy, I've then got a great vehicle to then start positively challenging those beliefs and reframing his pain experience for him at the end of the session. So guys, I wanted to share that with you because it was obviously something I feel very passionate about. Thanks as ever for joining us for another night of all things shoulders. I really hope you took some things from that today because to me, when I look at all these poor patients that have had a really difficult journey, there are often some common themes in terms of their negative understanding of all the different messages that they've had.

And sometimes one of the most helpful things that we can do is to reframe that in a positive way. But listen. And always, it's never enough to know what they've been told. You've got to know what it means to them. So guys, as ever, thanks for joining. Bye for now.