Strengthening Exercise for Shoulder Pain: Shifting Paradigms

they were the most common explanations proffered by clinical trialists to explain the beneficial effects of an exercise program. But we've got no evidence for any of that. So they're all just speculative hypotheses. if that's the hill you want to die on fine, but if you don't want to read the evidence, then you can stick with the guns. But if you do want to be an open minded, critical thinking kind of person, a simple search on PubMed will very quickly show you where the lay of the land is right now.

What if I told you were making false assumptions on what the secret sauce of exercises. It's a no-brainer that when we issue strength, exercise, and people get better, that it's because they're stronger. Right.? Or is it. In this week's episode, we're going to speak with Jared Powell an Australian physio and soon to be PhD who has studied this and published a bunch around this topic. We'll talk about the data out there to support the mechanisms of effect around exercise. And Jared's going to speak to his work on disecting this information and the challenges he's had, communicating it to the masses, especially on social media. We're also going to discuss how you can communicate this and conceptualize this as a young physio or as a physio who's really struggling to figure out what is going on when we prescribe somebody exercise in the clinic Don't forget that if you're looking to go deeper into these conversations and topics, make sure you check out our community at modernpaincare.com/community. Enjoy the episode.

This is the Modern Pain Podcast with Mark Kargela.

Welcome to the podcast, Jared.

Thanks, Mark. I'm really happy to be here, mate.

I'm happy for you taking some time. We chatted before the podcast. You are a parent of a young 10 month old, who's challenged with sleep. Yeah. You still soldiered on and joined us tonight. I really appreciate your time. Let's get into it a little bit. I'll let you, you discuss maybe a little bit about your insomnia situation at the moment. But what I'd love if you could just share your journey to where you ended up. Now, for those of I've known Jared a little bit just from Online interactions. We've had them in our past membership. We had a masterclass where he came in and talked and did some awesome class around shoulder pain and strengthening and things. We're going to talk a little bit about that today, but I'd love to hear your journey, how you started in physio and how you focus things around. I know you're up to some cool stuff as far as further advancing your degrees and your training. So I'd love to hear that.

Thanks, Mark. Yeah. So yeah, just as a caveat, I am wildly underslept at this point. When I'm attempting to sleep train my 10 month old at the moment and we're about three or four nights deep and he's resisting he's a stubborn young man, which I like. And I think that'll be good for him in the future, but right now I just want him to sleep anyway. I love him to bits and I've got two boys 10 months and. Nearly four. So yeah, I love it. And I love being a dad. So my journey professionally, let's say I've been a physio now for 12, 13 years. I took a bit of a long route. I went through an exercise science degree and a business degree. And then I eventually did the doctor of physio program. I always wanted to get into physio, but for some reason I just did some other things beforehand. And, I am happy that I pursued physio and got into it because I do think it's a wonderful profession. Although we have our problems at the moment, I do, I'm still very grateful that I am a physio and the utility and value that I think we provide to society. So I just want to make that clear. So whenever, we're criticizing physio and the treatments that we provide, It's on the background of I love this profession. So I think that's important to declare upfront. And so I guess I worked hard for a couple of years in private practice. I went straight into private practice as a new grad and I was worked to death basically. And that's not me complaining. It's just the reality of it. I walked straight into 70 patients a week 20 minute consults, and I was thrown in the deep end. So I had to learn really how to think on my feet and try and solve in inverted commas people's debilitating aches and pains with a textbook knowledge, like with superficial textbook knowledge of. Basic pathology and musculoskeletal pain. And then I tried to, had to reconcile why isn't this person's clinical presentation matching what the textbook stipulates. And that was fun. And that actually led to a little bit of a crisis intellectually and. I had thoughts of going back and studying medicine and doing this and that. Instead I left the country, I left Australia and I went to live in the United Kingdom for a couple of years in London as pretty much every young Australian does. And you get to travel around Europe and it was great. And I worked as a physio as well. And then also whilst I was in London, I got access to. A lot of, pioneering and clinicians at the vanguard of physiotherapy. So that's where I I got acquainted with Jeremy Lewis's work. Who's gone on to become my PhD supervisor and a bunch of other really great clinicians as well. And then I came back to Australia and then I decided that I wanted to do a PhD in shoulder pain. And here I am, I'm at the end of my PhD. Hopefully this is my last year and my. My basic thesis has been on exercise for shoulder pain and trying to, not solve that very complicated and complex question, but add to the literature, add to our knowledge base on crucially on the mechanisms of exercise for shoulder pain, which is something that we've overlooked. For a long period of time. So that's my story in terms of new grad fled overseas, came back, did a PhD and now I'm a part time clinician. I run a telehealth practice where I see people with end stage and really tricky shoulder pain pathologies. And whilst I do my PhD,

Very nice. Very nice. I always find it just amazing, striking that how many physios I talked to and in my story as well, where there's this existential crisis of man, do I want to do this for a living? Is this really what I chose as my career and my profession? Am I going to be able to last in this thing? We have some folks in our community and I always feel like it's a support group. We have meetings weekly and talk about cases and different things. But yeah it's interesting how that all works out. Now, I think having you come on and talk about shoulder pain, I'm excited about it, and especially exercise's role in shoulder pain because I think there's a degree in physio school where we're just assumed that, we strengthen, we get maybe told some things about upper cross syndrome and different things, and that strengthening is just going to work. And it does work, but there's some beliefs that the mechanism behind it, we think people get stronger, they get less pain. And maybe that's not the case. I'd love if you could unpack a little bit about maybe your journey as a physio and with the thoughts of what exercise meant around shoulder pain and how it's evolved over time to where you're, where you sit now, where your PhD is dissecting some of those mechanisms.

yeah. So exercise, as a physical therapist. We use physical interventions, right? To help people be it manual or movement based interventions. And I think, it's really a non negotiable that if somebody comes in with pretty much any, let's say non traumatic musculoskeletal condition, a physical therapist will have a predisposition to give that person exercise. And that's probably a good thing. I'm not going to argue with that. We actually have data that suggests that for the shoulder that if somebody comes in for the classic rotator cuff related shoulder pain, rotator cuff tendinopathy, formerly subacromial impingement diagnosis, 99 percent or more than 99 percent of clinicians will provide an exercise program of some description to that person with said shoulder pain. But there's a bit of a tension because, whilst exercise seems to work and there's many different approaches which can work without there being one superior exercise intervention, which confers benefit over another. So motor control exercise, resistance, exercise, stretching, exercise, range of motion, exercise, flexibility, exercise. Proprioceptive exercise, any, you name it, any different kind of exercise or movement based approach can help someone in terms of pain. So we see an effect, right? If we test exercise versus natural history, doing nothing, watchful neglect, supervised neglect, whatever you want to call it, the exercise seems to marginally outperform that. Not by a great deal, it must be said. And so that's something perhaps we'll talk about later and we might need to confront. When we compare exercise to placebo, there's only been one clinical trial in the shoulder, which has actually done that. And they compared exercise and manual therapy to a sham ultrasound. And that, scarily resulted in no significant difference between the two treatments, which seems to be a little bit neglected in the shoulder world. So we have no efficacy in terms of exercise and manual therapy. Which is again, something that I think we need to talk about a little bit more, but in saying that. Of all the treatments available to physiotherapists and even GPs and surgeons and sports physicians, exercise seems to be a pretty good intervention. It's low cost, it's available to most people it makes sense on why you need to exercise if you've got a sore shoulder or a sore knee or whatever. It's intelligible and it's cogent and patients can understand it. As I said, it's accessible to most people. So I think it's a pretty good treatment when you compare it to surgery, when you compare it to corticosteroid injections, when you compare it to platelet rich plasma injections when you compare it to a bunch of other things, you can do it at home as well. And that's the other thing you don't need to be in the clinic three to four times a week, getting a manipulation or immobilization. So there are lots of upsides to using exercise. Now, I guess what I'm getting at here is we know there might be a modest effect. It works for pain marginally, but how does it work and why does it work? And this is when we start to seek the, what are the causal mechanisms underpinning an exercise program for shoulder pain or for any pain, mind you. And there's lots of great work going out going on out there for the low back and for osteoarthritis for people who are investigating causal mechanisms as well. And it's slowly coming into the shoulder and the stark truth of it right now is that we have no idea how exercise works. For shoulder pain. We, I did a scoping review a few years ago where we looked at the causal explanations, which were proposed in the literature for why exercise might work for shoulder pain. And those causal explanations were overwhelmingly 95 percent of the time. biomedical in nature or biomechanical in nature. Most of the time, we broke it down into four different groups, but the most common group was neuromuscular. So that's muscle strength. That's motor control. That's changing the subacromial distance in the shoulder. It's flexibility. It's. Tendon stiffness, it's all of these kinds of things. And they were the most common explanations proffered by clinical trialists to explain the beneficial effects of an exercise program. But we've got no evidence for any of that. So they're all just speculative hypotheses. We've got really no evidence that confirms or corroborates any of those theories. We, there's just as I say that in the last six to 12 months, there has been a couple of mediation analyses, which have come out, which have actually tried to deconstruct or disentangle how an exercise program might work for rotator cuff related shoulder pain. And there's one paper that's just come out, which shows that a mediator. Might be reducing kinesiophobia. And so we're seeing that a lot of times in the chronic low back pain literature, but now it's just starting to come out in the shoulder pain literature, we have no evidence that getting stronger is causally responsible for a reduction in pain. So if you give someone a resistance exercise program, it might be logical to think that I'm giving them this resistance exercise program, they're going to get stronger and that's going to causally lead to a reduction in pain. And I totally get that. And maybe that is the case. In the future when we actually conduct some trials to investigate this, but at the moment we have no real data to corroborate that we don't know if changing scapula mechanics works. It doesn't seem like it does work. We have had one mediation analysis look at that and it shows that it wasn't causally responsible for a reduction in pain or an improvement in function. We have no evidence that suggests that changing the subacromial space or acromiohumeral distance leads to a reduction in pain. At the end of the day, we've got a ton of different theories. Most of them are neuromuscular in nature. They don't seem to be borne out in the literature. We have some tentative and promising evidence that suggests that exercise might reduce fear of movement, which may lead to a reduction in pain.

As you've been perusing this literature and I've seen you have these discussions online and I'm fascinated. I like to lurk because they get, obviously somewhat get a little bit folks get challenged. We get so bought into this theory of I get people strong, they get better. And I know Adam Meakins has had some challenges and I've seen him and Greg Lehman go back and forth. Cause Greg, another one like yourself, who's brought, just brought up the literature that way. And we really don't have any. Evidence that it's somebody getting strong. That's the mechanism behind why they're pains relieving and you bring up some of the stuff, bro, and kinesiophobia. I think it's fascinating. We see that with core and stabilization as a lot of the stuff around the T the holy grail, the TA, that timing doesn't change yet. People get better. Cross sectional area of the abs doesn't get more, yet people get better with that type of thing. How's your interactions been with the physio profession and maybe others too, because we're not the only ones that use exercise. And what do you see as far as like some common issues people have with it? And I think some of it probably, some biases that we all hold. And I'm just curious what your experience has been as you've tried to discuss this literature with the masses.

Yeah, so to be clear I was a person who Before I started to systematically look at the evidence, thought that getting stronger was a crucial aspect of reducing somebody's pain experience. And I went into my PhD under that premise and that's what I wanted to explore and prove. In fact, so I quickly had to pivot and change my mind, which wasn't, it really wasn't easy. So I, I doubted my interpretation of things many times, and I thought it was my fault. Not the evidence fault, it was my interpretation that was the issue. And I don't think it was. And now we've started to see that's really been corroborated across the board. There was a really fascinating paper, which just came out. I forgot the author's name. It might've been Nadine Foster. It showed that for osteoarthritis, that getting stronger explains only 2 percent of the effect of an exercise program for osteoarthritis. So 98 percent of the effect of exercise remains unexplained. And yet we're obsessed with this 2 percent strength or we have been obsessed. Maybe the pendulum, I hate to invoke the pendulum metaphor but maybe that's starting to swing a little bit. I don't think it is, we're in our echo chambers online and I'm not convinced that's a meaningful sampling of society at large when it comes to physiotherapists. Anyway so my interactions online have been, they started out a little bit rocky when some of these things started to come out, but honestly it's not been too bad because the evidence is fairly inarguable at this point. There's not, and again, to be clear, and I hate making all these caveats and statements. Surround, I'm just, I don't want to get misinterpreted and strawmanned and I don't like using the term strawman because everybody uses it on Twitter, I really do recommend exercise and I do recommend resistance exercise. I love it. I do it personally. I give it to patients and I will do in the future. I am just challenging or subtly posing questions about how and why it might work might be different to our a priori thoughts and conceptions of it. And that's it. And I, and to be honest, over the last three, four or five years the evidence has come out so thick and so strong for a multitude of musculoskeletal conditions that it really is hard to argue against it, unless you just wanted to, You put your flag in the, whatever the saying is, you just, if that's the hill you want to die on fine, but if you don't want to read the, if you don't want to read the evidence, then you can stick with the guns. But if you do want to be an open minded, critical thinking kind of person, a simple search on PubMed will very quickly show you where the lay of the land is right now. And so it's not really a tough conversation.

We appreciate you, you having those conversations. I know I always learn when I see you and others, Jeremy Lewis, I know your PhD supervisor often, although he's not as active on Twitter these days, but probably a smart move for him. But I'm curious as a, if you're seeing a young physio come into your clinic, say, I know you're doing more telehealth, but say you're in a clinical setting, how do you help them cause that's a common question we get where does exercise, how do I explain it? Like, how do I conceptualize in my practice? How do, where do you feel like you can, you would have it sit with a young physio who's trying to figure out how does this all work and how do I use this with patients? What are your thoughts on how to guide somebody who's struggling with the social media of it's not strength you're improving, but how would you guide a young physio through that?

It's a really good question. And, I think the new graduates and the young clinicians are the one that suffer the most when it comes to watching all of these online debates and reading the literature, because I see a lot of seasoned clinicians going at it and they're just trying to figure out what the hell do I just give this patient in front of me, help me out here. And we're actually taking steps to help those clinicians. We're writing a paper right now Jeremy and a few other people on how to help the young clinician navigate all of this stuff, because that's, I honestly think we, we're very good at we're getting better at recognizing the patient's voice and things, but I do think we leave the young clinicians behind, but anyway, that's a conversation for another day. So how do we have this conversation? about the uncertainty of exercise for any musculoskeletal condition? It's a really good question. And I just, I go back to just be honest. And I'm the same when I communicate with my patients as well. We, I say here's an exercise. Okay, I'll say firstly, my bias is to provide exercise for these conditions. And I say that to the patient and to the student or new graduate, that I've taken tons of students in my time as well. But, and then I very quickly say after we're not exactly sure. How this exercise program might work, but here are some speculations that we might have, which are biologically plausible. That's a crucial thing. We can have theories about musculoskeletal health and they can be wacky and weird, but they're pretty biologically implausible. A lot of the time, when you're removing someone's blockage in their energy, which is causing their low back pain it's absurd, right? But when we. We can't have theories about how exercise might work, even though we don't have evidence to support those theories, but they are biologically plausible. So I say what they, what it could do is I still say it could increase their strength. It could increase their confidence. It could increase their their perception and their ability to perform a desired and valuable movement. It might force them to confront, why do I have fear of this movement? Movement or why do I have fear of lifting something overhead? These are classic graded exposure Guided behavioral experiment type movements, which are becoming more and more popular now with the rise of cognitive functional therapy Especially for lower back pain. So so I have really open honest and transparent conversations with students and patients about our lack of knowledge regarding how exercise works for any musculoskeletal condition, but these are how it might help. And then I put the ball in the patient's court and I say, would you like to trial a period of exercise for, X period of time and see what it does to your symptoms? There are You know, in shared decision making you offer other treatments, which they might like to sample or try, they might be more interventional in terms of injections or whatever, or they might be more manual therapy based, so on and so forth. I now I say my bias is exercise and I try to explain why it's exercise up front. I like exercise because you can do it at home. It will, it. It can have general health benefits. Although, there's an argument about will an exercise program have general health benefits when it's only done for six weeks or 12 weeks and then it stopped? Or is that program even dosed sufficiently to elicit a general health? Outcome, if you're just doing perhaps I'm not going to rip on three sets of 10 here for shoulder pain, but I will rip on three sets of 10 for having, a general health benefit if it's never progressed or never changed or never, titrated to that person's context or what they're trying to do, if they're an elite sportsman or sports person, or they want to go back to just playing weekend golf or tennis, you're probably going to need to up the ante in terms of regaining function rather than just doing three sets of 10 external rotation. Or maybe not, but that's just my bias. I like to try and when I think this is a, this is actually an interesting tangential point, if you will just humor me for a minute. So when we talk about pain, I think anything goes when it comes to exercise. You can literally do three sets of six. You could do four sets of 15. You could do four sets of a hundred. I don't care. All of it can work when it comes to dose. You can do it once a day, three times a day. You can do it every other day. So on and so forth. We don't really know. There is no optimal prescription because there is no optimal prescription. I think everyone will respond differently when it comes to pain. And we've published some qualitative research on that as well, which we might want to get to in a minute. But when it comes to function and return to sport and all of these things. Yeah. Higher demand goals and ambitions that people might have, then that's where I think our specificity of exercise prescription might need to become more of a focus and not just yield to the anything works. I think we need to go, okay, you want to play golf. You want to do tennis. You want to go back to powerlifting. I think it would be wise to consider You know, intensity of your exercise program and load of your exercise program and periodization and all these kinds of things come into the conversation a little bit more. So I forgot what your question was now, but I've I've gone through a bunch of different things. Tell me if I've answered it or not. And we can keep going.

No, absolutely. You've, you nailed it. You bring up uncertainty cause I think that's a common thing in clinical practice and you alluded to it earlier on to how and in school we're taught this kind of, And I even posted about it on social media of we get taught this kind of black and white, you're going to fill in the ABC or D so you can pass your licensure exam. And it's a very kind of black and white world. And then we hit the clinic where we got a lot of complex things going on with pain. And like you said, to exercise, there's just a lot of complex things mechanistically and all these different things I would love if you can share how you've learned to cope with that complexity. Cause I think it's hard for a young physio. To have that conversation of, I don't exactly know, but I can offer you all these options, which I find, I used to think patients are going to think I'm some sort of inferior, intellectually deficient human or physio because I can't give them the exact mechanism why this thing's working yet. I have not found that clinically that I haven't had anybody. What do you mean you don't know exactly why? I think they understand that you've perused the literature and you've done all these things. How have you navigated that kind of transition from being really desperate for certainty coming out of physio school to, to now being very comfortable to navigate it and have open conversations with patients? Have you found some things that have been really helpful for you along the way in the journey.

question. I still don't know if I am comfortable with uncertainty, to be honest. I think that violates a lot of, basic human instincts. We want. To know, it's that scientific curiosity that I think we're all in built with. It's wanting to know how and why. And that for me, finding explanations is the whole point of science. And arguably some philosophers think finding satisfactory explanations Is the whole difference of why humans are where homo sapiens are where we are today. And our ancestors, the chimpanzees are still where they are today. We have a difference in, in how we see the world and I tend to, I'm sympathetic to that. So I still do want to find the best explanation for somebody in terms of why their pain might be there and then why this treatment might help that person's pain. But I'm starting to become aware that. Those explanations might be context dependent, so it might come down to the individual in front of you. So this is where a lot of the work from the Cause Health Group and Causal Dispositionalism and Roger Kerry, which I think you've had on the show before, has really been helpful for me in trying to understand that if causation is context specific, then that changes the rules of the game. Like we're not wedded to this whole human notion of causation where a cause always necessitates an effect. It depends on the context of the individual scenario that you're in. That's the theory of causal dispositionalism. And I'm not saying that's true, there's, that's the philosopher philosophy of scientists job, but I'm sympathetic to it. I think it explains a lot of what we do in physiotherapy. So when I look at Musculoskeletal healthcare through that lens, I'm much more okay with uncertainty because I know that we can trial some things and there might be error associated with that. And then we can error correct, right? Which is the whole point of science. Some might say, and that might help us make progress towards achieving some outcome, like a reduction in pain or getting back to sport or something like that. And there's another really important saying that I hold dearly to me now. And it was introduced to me by Natalia Costa, who has done a lot of work in uncertainty in the literature. And she's a fabulous researcher, and I highly encourage you to read her work. And I've had a podcast with her on my podcast, and I'll give that a plug as well. She. She told me that exercise uncertainty doesn't prevent action. So we can be, we can be swimming in an ocean of uncertainty, but that doesn't mean we should be paralyzed by it. There are still things that we can do to make progress towards, Towards making progress on someone's pain condition, even though we're not 100 percent certain about what's causing it, and we're not 100 percent certain about how our treatments may or may not work, so we can still try something. It may not work. There may be a mistake. We can adapt, we can pivot and we can move on. So we're just not wedded to these algorithmic based approaches where this is your condition, this is your treatment. I expect a hundred percent success rate. If it doesn't work, then it's all psychosomatic. It's in your head, or we need to refer you to a chronic pain specialist to get all those nerves severed in your spine or in your shoulder, so that's how, I guess how that's I, that's how I navigate uncertainty. I'm still terrified of it, but reading a bit of philosophy and reading the work of people like Natalia Costa has really helped me with it.

Yeah, no I enjoy that. I think, it's where we think critical thinking, clinical reasoning skills to, to navigate that to where you have, you lean on a lot of the work from like Mark Jones and others and understand some of the philosophy that underpins. Our pursuit of certainty and a lot of it around causation. And we'll link some of the cause health stuff in some of the articles that you mentioned, because I do think those are good reads for folks to wrap your head around it. And you're a great example of somebody who's found a way to be comfortable in that uncertainty. Doesn't mean you like it, but it, I would prefer to have it very black and white. It might get boring if everybody was black and white and you didn't have to like really, thinking and nimble on your feet as you work with people, but. Yeah it's finding a way to be comfortable with it. I'd love if you can touch, you mentioned a little bit about some of the qualitative work that's been done around this stuff. And I think the patient's voice, and you already talked about that a little bit of how that's been somewhat a missing piece or around exercise and pain and probably just pain in general. I'd love if you could touch upon some of the qualitative work that has incorporated the patient's voice and perceptions around what we're doing, maybe around strength and pain, but maybe some other things that you found helpful.

Yeah, so we just published a qualitative paper last This year, last year. I don't know. When is it? January. Okay. So last year in PTJ about the perceptions of people with lived experience of rotator cuff related shoulder pain on how or why exercise helped or didn't help them. The classic way of determining causal mechanisms is via quantitative research specifically via causal mediation analysis, and that's very important. But nobody has asked before as far as we're aware, people with pain doing an exercise program, why do they think it helped them? Or how do they think it helped them? And so we took a group of people with shoulder pain, with a history of shoulder pain, and we asked them, How do you think exercise helped you? And it was pretty fascinating. So the causal mechanisms I proposed were what clinicians might think. So it was muscle strength. That was the number one reason why they thought they got better with an exercise program. When I say number one, it was the most common. But patients were actually much more willing to propose psycho emotional mechanisms to explain their improvement with exercise and not just say muscle strength or biomechanical. So many people who said strength also said it made me feel more confident and it reduced my fear of doing a movement. And so when we compare that to the clinical literature or the clinical trial literature, As I said at the start of the podcast, 95 percent of their explanations were biomechanical in nature and only 5 percent mentioned the word psychological or psychosocial. So patients are much more in tune with the fact that their psychology and their emotions might be underpinning their improvement with exercise as well. And they also suggested that, People just think exercise is good for them. It's like eating a nutritious meal or quitting smoking or not, getting drunk every single night or getting eight hours of sleep. It's a truism and that exercise is good for you. And so they think that, just by engaging with exercise, it's going to make them healthier, which may causally lead to a reduction. in pain. And all of that sort of made sense to us researchers when we were doing the coding and the analysis of these of these interviews. But the real difference of this paper that we published is that we weren't just interested in the causal explanations and the causal mechanisms. We were interested in what were the conditions, the clinical conditions that promoted or inhibited said mechanisms. Alright so what were factors that may have actually inhibited muscle strength from causing a reduction in pain or inhibited psycho emotional factors from causing a reduction in pain? And these are, these were super important. So things like developing a strong therapeutic relationship. Was the foundation for any improvement with an exercise program. And if you didn't foster a strong therapeutic relationship, then it didn't really matter what your exercise program was because those mechanisms weren't going to bubble to the surface because they wouldn't do the buddy program or they would go and see a different therapist. So that, that was crucial. Another clinical condition was the perceived individualization or of the exercise program or the tailoring of an exercise program to an individual presentation and not just being presented with a cookie cutter print out of 10 exercises that they had to do three times to 10 three times a day. They wanted a, an individualized program that was fit for their purpose, that was going to get them to their specific goal. So that was another crucial condition. And another one, which might make a lot of sense and seem obvious is that. It's got to work and it's got to work quickly, so if these exercises, they're still plodding away after 12 months and they're not doing anything, then those mechanisms aren't really going to be activated to lead to a reduction in pain. So that's what we found. We found that exercise, most people had a positive experience with exercise. But that was a conditional success. So there had to be a strong therapeutic relationship and individualized exercise program, et cetera, et cetera. If those conditions were partially or fully satisfied, then that promoted the mechanisms of strength, psychoemotional factors, and the general health benefits of exercise to produce a reduction in pain or return to meaningful activity. So that's the, that's a quick summary of our QUAL paper, which I found like. It really reinforced and reiterated to me that, you read about the importance of therapeutic alliance and all of these things, but I just gave it lip service personally, hope, hopefully you guys are better than me. And I just, I thought there was some expertise that we had to portray and, therapeutic relationship came secondary to that, but now I'm, I've totally revolutionized my thought on that. And I'm striving to be a better clinician for it.

Yeah, I always think it's interesting when we do these qualitative studies. I think we come in with some preconceived notions of what we think people are going to think. And it's always interesting to me that there's some things that come out of there that, patients are much more willing to give psychosocial factors more credit than we as physios are, which always is fascinating to me. Having you here as a

I was just going to add one thing. Yeah, and it's surprising. So a lot of the times the guy, the people who mentioned psycho emotional factors, were your typical strong middle aged man who apparently doesn't have any emotions, and they were the first ones who, often the first ones who came forward and said that, I was fearful of this pain. I was, I didn't want to move my arm. I thought my shoulder was going to explode. So on and so forth. And they were the first to admit it. And then they were the ones who was so surprised that psychology needed to change in order for their pain and function to improve. And, at the start they wanted to get surgery. They wanted to get that biomechanical fix, Some of them were like engineers and really structural type people who deal with maths and physics and they want certainty because that's what maths and physics gives you. Actually physics doesn't, and there's lots of quotes on that from Einstein and Feynman, et cetera, but maths does, but, when it comes to health science and medicine and physiotherapy. There's uncertainty, which we've touched on. Anyway, they were the, they were really surprised to learn that they had, it was their psychology and their emotion, which actually was the force that drove their positive outcome with exercise and not some other structural or biomechanical variable. So that was really fascinating for me to bear witness to.

No, absolutely. You would think the last people Would be the middle aged men where, we're so out of touch with our emotions and anything beyond just the meat and you're just getting stronger and it can't go wrong getting strong with yet. Not wrong. Not a bad thing, of course. But I'd be curious cause expectations drive a lot of the things too. We know, especially like conservative rehab around rotator cuff tears. I forget the authors, but where, you're what predicted success with conservative management of rotator cuff pathology was. A person's expectation of what success might, or if they're going to be successful with conservative rehab, I'd love to hear, cause I know, having a shoulder expert like yourself on, it's a common discussion that, students who are either in physio school and doing their clinical rotations and early career conditions, even, we all struggle sometimes having these conversations around You have a patient coming in who's got a rotator cuff tear, be it partial or full thickness. How have you found, what have you found successful in your practice to start navigating those discussions to get people to maybe shift? Expectations or maybe at least give you the opportunity because this is where I think some of our work with behavioral experiments and things where we can, not try to talk them into it getting better, but to have them put them in situations where they can see and movement can help and maybe shift their beliefs a little bit. I'm curious what you're what you found successful when you're trying to navigate some of those tough clinical scenarios when patients might come in with varying degrees of expectations when they hear they got a rotator cuff pathology.

Yeah. So that's the work of Rachel Chester. Who published that in, in BGSM a few years ago, showing that expectations and self efficacy what's predicted a better outcome. And, that was revolutionary work from Rachel and it's mainly been corroborated since then. So how do we navigate those strong, let's say, biomechanical or biomedical expectations of mechanical issue needs and mechanical fix. tough, Mark. I struggle with it in every consultation, and sometimes I do well with an explanation and sometimes I do terribly and that person. Blanks and looks at me and never comes back. I'm definitely don't have a hundred percent success rate, but again I'm honest. I'm like, so you have a rotator cuff tear. Look, let's say for argument's sake, because it's the most common presentation we see, it's a partial thickness, articular sided tear of the supraspinatus. And, we can give some of the percentages and say you're in your fifties, you're in your sixties, 30 40% of people in their fifties and sixties and perhaps more will have a similar presentation to you in terms of rotator cuff tear. They may or may not have pain. If we were to take an MRI or an ultrasound of your opposite shoulder, there's a strong chance that it's gonna look. Pretty identical to what, to the shoulder that's currently experiencing symptoms. And we actually have data on that where they MRI both painful and non painful side of people. And they showed the, that it was exactly the same structurally in terms of cuff tears, bursitis, AC joint issues, labrum issues, the type of acromion, the only significant difference was a full thickness cuff tear. And so I'll guess I'll like, if someone comes in, they've got a full thickness rotator cuff tear. They're youngish, they're in their 40s and their 50s, I really respect that rotator cuff tear and I actually think that cuff tear is strongly contributing to their pain quite a lot. But the psychological and the emotional stuff on top will modify that pain experience. So it can amplify it or it can diminish it. I have full thickness cuff tears. I'm only 37. I'm a few old I'm 37, but I've got full thickness tears in both of my rotator cuffs. And, I don't have any pain in it. That's an anecdote, but I use that to to relate to somebody, if they come in, they've got a full thickness cuff tear, I've got a full thickness cuff tear, look, I'm still training like this. You can train like that. You don't say that to everyone. Cause that can be, I think it's a bit dismissive to say it's all about me. Especially I find. If somebody comes in there around my age group, I find it really helpful to relate your experience to them. And it's not to make it about you, but it's just to say that this is my experience. I understand you're going through that. I can relate, blah, blah, blah, blah, blah. Don't make it all about you. I just want to make that clear. But you can. And we can also reference the literature, that there's been a bunch of studies which show that partial thickness tears they don't reduce strength. So you can get stronger, you can improve your function even in the presence of a partial thickness tear. Typically, the bigger the cuff tear is going to be the more of a of an impact on their shoulder strength. So You might not want to go down that pathway if they've got a full thickness cuff tear, but you can say that you can have a fully functional shoulder in the presence of these these cuff tears. And then you go out in the gym and you try some stuff, you get into positions and. This is, this might not work well in a podcast. Maybe you can see the audio a little bit, so then they might have pain when they're doing a traditional chest press when they're on the ground with a dumbbell doing a chest press and their shoulders abducted to 90 degrees. The classic position that we see, but if you just drop that range of motion slightly. to 45 degrees of abduction, you'll find that the pain and their strength will go up. And then if you come down to a neutral position, so you're doing like a neutral press with their arm tucked in by their side, they're as strong as the other side. So you can shift the conversation and be, yeah you might be a bit painful and weak in this position at the moment. But that doesn't mean you're weak in general. You're still really strong and capable in a lot of positions. And so our aim might be to get you back to being really strong in that position. And I believe that we can, but I just want to reinforce to you that you're not a fragile and weak person in general. It's. Positional is dependent on where, on the sensitivity of your shoulder at the moment. Same thing with doing a full pushup. You can modify that and change it to a partial fuller pushup or a wall pushup. Same with any movement. Identify, and this is going to sound like very exercise experimenting again, and I'm a big fan of it. Identify any painful movement, modify any variable that you can, that can be physical, that can be psychological, that can be context. And then get that person to, to confront that prediction error, perhaps or expectancy violation that they're going through. And I just love seeing those moments where somebody has a preconceived limiting belief on what they can and can't do. You experiment with some movement and you see the light bulb go off in their head. And it's such an amazing thing. And I guess for me, and what's the famous saying education is to a person as spaghetti, spaghetti is to a brick or something like that, where you can talk the crap out of someone in terms of education and say, don't worry. Everyone's got a cuff tear. I've got a cuff tear. The prevalence is this, and this it's meaningless. And then I think a lot of it comes out when you get out to the gym and you actually show them what they can and can't do with, said cuff tear. And I think that's where a lot of the magic happens.

Totally agree. And I love those moments too. And I love that has made physio practice even more fun for me because you get to tinker and experiment and do things all with, good education and good reasoning behind it and being able to, still manage therapeutic alliance and expectations and stuff. But that is fun when you see those light bulb. Moments go off and you have that patient unpack it and you know again letting them explore what just happened compared to their What they expected going in and having that kind of behavioral experiment go in a good direction. I love your answer, too I mean you show great humility and authenticity as a physio. I think there's this belief like Jerry Pohl's gonna be a PhD and he's you know, there's the shoulder physio He must just get a hundred percent of his patients must just miraculously recover. And they have these amazing outcomes. That's just not the reality of human beings, man. If I always am more skeptical when somebody says, Oh yeah, all the, all my outcomes, man, it's amazing. And not a lot of people doing that anymore, but there are some folks where it put this kind of highlight real thing out there. So I really appreciate your humility with that and your honesty with it.

Can I just, can I touch on you said tinkering and I, that really resonates with me. I think we're, I think we're tinkerers. I think physios are tinkerers. I think where, because we have incomplete information. We don't like pain is a subjective experience, right? Surely that's not controversial to say these days we don't have access to that. experience, we have a third person account of it based on what they tell us. so because we have incomplete information on their experience and also how the hell our treatments may or may not work, we've got tons of incomplete information. We have to tinker. We have to try stuff. We have to conjecture a solution, and then we have to run an experiment. And this is the classic hypothetical deductive approach to clinical reasoning. Where you might have a hypothesis, you test it, and then you check the outcome, and then you tinker with it. And I'm fully at peace, and I'm not too stubborn or egotistical to say that. where tinker is. And I revel in that. And actually, if you read the work of Karl Popper and all these philosophers of science, they think science is tinkering as well. It's trial and error. There's not, science is very rarely the lone genius in the corner of the world who just comes up with revelations and how the world works, unless you're Einstein. But apart from that, then. We're all we're trying things, we're error correcting and we're in this whole program of error correction. And science as a communal project is going to get us somewhere closest, closer to the truth. And I think that physio is the same thing and we shouldn't be too arrogant to admit that. And, You also, if you read the work of William Osler, the famed American physician at John, at Johns Hopkins University he thinks medicine is a, is an uncertain science and a game of probability, and if that's medicine, we think medical science is maybe a little bit more scientific than physiotherapy. That might be our perception. I don't know if that's true. When you think about infections and all things like that, it's probably a little bit more. Quantitative versus pain, I'd totally accept that, if they're saying that about medicine, then we have to accept that a lot of what we do in physical therapy is grounded in uncertainty and probability and tinkering and trial and error. And I think we're going to be okay with that.

Yeah, Mike Stewart, one of our friends was on the podcast and shared it recently in our community too about how he was listening to a podcast interview back years back when Stephen Hawking was still with us. And those podcast interviewers asked him why didn't you follow in your parents footsteps? I guess there were physicians. And he said I hung out my dad's practice and I saw all this chaos like medicine and healthcare seemed to be so chaotic and disorganized and not like this nice algorithmic or things. So he said, I wanted to study something more, more certain or more simple. And he, so I chose to study black holes, which obviously. The amazing complexity that man is able to grasp in his brain when he was this is just amazing, but it just goes to show you how this is not an exact science, a game of probabilities and for a physicist that doesn't bode well, I've treated a few physicists and folks, mathematicians who are very much in the certainty game are as close as they can get to it. And they just struggle when you try to give them this. Narratives of like uncertainty in practice. So it's always fascinating to see that.

So you mentioned physics and perhaps physicists strive for certainty, and that's for sure the perception. And, it's probably true to an extent I'm obsessed with early 20th century physics and the arrival of quantum mechanics and the overthrow of Newtonian mechanics. And. It's fascinating when you look at that and you look at the greats of our scientific history, you look at Albert Einstein, Niels Bohr, Richard Feynman Heisenberg, Wolfgang Pauli, all these people who were responsible for the rise of quantum mechanics. They all disagreed with each other on the interpretation of quantum mechanics. You throw Erwin Schrödinger into that as well. And then another guy came out 40 or 50 years later and he come up with this, a different interpretation of it altogether called the many worlds interpretation. And that's now going through a little bit of a popular run at the moment. It doesn't matter that you do know or don't know what that is. It just means that literally all of these bonafide geniuses who have won Nobel prizes disagreed with each other about the foundation of physics, which is at the level of electrons and the subatomic particles. If they can disagree about the nature of subatomic particles, Then it should be okay for us to disagree about something much more higher order in terms of pain and, consciousness and pain. In fact, it would be very strange if we didn't disagree on something as abstract, opaque, and abstruse as pain, so I think we've got to all be somewhat, a little bit nicer to each other when we've got our differences of opinion, providing, of course, you've got a biologically plausible And you're not just making shit up to sell some courses or sell whatever you want to sell. Yeah, you got to have a bit of humility and a bit of uncertainty about it. But I think if somebody comes with a proper theory of something and why it may be helping, I think it's okay for us to, Firstly, you don't have to agree with that person. You can disagree, but that person is entitled to their theory or entitled to their opinion. And then in the game of critical rationalism, you're allowed to critique that theory. People are allowed to watch that they're allowed to make their own mind up and then perhaps together you can make progress. And I think that, and that's the beauty of it all, so we should encourage different opinions. We should encourage. Criticisms of different opinions, and then we'll see where we'll get to.

Yeah, no, I love that thought process. I think you're right. I think too often on social media and everywhere we're denigrating each other. And I like the fact, have some scientific principles and biological plausibility, foundationals, some critical thinking, but. Like you mentioned, man, to me, it's what makes a clinic I enjoy clinic more than I ever have because I'm, I've embraced that uncertainty and I look at that N equals one that the whole cause health has pushed and, we have that opportunity to take a lot of this great research that you've talked about today, and Some of the, philosophical underpinnings and try to construct this kind of, educated, research, evidence, informed person centered tinkering to see if we can move somebody forward to a positive movement towards their goals. I think you covered a lot of great stuff that kind of elucidates what kind of goes into that and some of the complexity, even just around the shoulder. We know it goes around pretty much anything pain related, but I'd love if you could share what you're up to in any of the projects you're up to Jared, and I want to make sure you get time to get back into. Some rest. Cause I know you're, as you mentioned it, underslept humans. So where can folks find you and what are you up to?

Oh, I'm all, I'm full of adrenaline now, Mark. Thanks for that, mate. You're you're as good as a double shot espresso. So I'll be I'll be hitting the books as it were, doing some research. What am I doing? So I've got a, I've got heaps of things going on right now. I'm trying to there's a lot of studies happening in the pipeline, which is fun. A couple under review, so that hopefully they'll get accepted soon and they'll be published. I won't say too much about them. You've got to be coy when it comes to this stuff, Mark. Else am I doing? So I've got a podcast. You can listen to that as well. You've I've got go to my website, shoulder physio. com. You can find out about my online courses. You can find out about my podcast. You can find out about anything that I do. I'm pretty active on social media, Instagram, and Twitter. I'm sure we'll link those handles somewhere and. Yep. I tend to spend most of my time on Instagram these days Twitter's a strange place. It always was, but it increasingly is so yeah, I'm starting to spend less time on

Yeah, that seems to be a popular kind of pursuit from everybody. I talked to as well as definitely gotten to be a little bit awkward or weird there sometimes, but man, I really wanted to thank you for your time and thank you for all your work and the contributions you are making to, to our knowledge body around the shoulder and around pain in general. So thanks so much for your time and hope, hopefully we'll touch base again.

Thanks Mark. Appreciate it mate.

This has been another episode of the Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincare. com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain. This is the Modern Pain Podcast.