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The first question I’ll respond to is: What shoulder conditions have evidence to support the use of surgical intervention? Please come up with 1-2 conditions, and offer a couple citations to support your answer.
(I inadvertently touched on this question as well: Critical appraisal of evidence is essential to quality clinical practice. What are some of the challenges with research trials investigating surgery versus other interventions?)
I chose this question knowing that it would be difficult for me to answer. My first thought was that surgical intervention is typically the “go-to” after failure of conservative management. The conditions that I initially thought may benefit from surgery included advanced shoulder OA as well as massive rotator cuff tears/tears with OA. I did not expect it to be that difficult to find evidence supporting these procedures, but through my search I found a lot of conflicting evidence. One systematic review by Petrillo et al found that reverse shoulder arthroplasty restores ROM and improves shoulder function in patients with massive RTC tears or cuff tear arthropathy, but there is a high level of complications and lack of evidence for understanding the limitations/benefits of this treatment. Another systematic review following up from a previous review in 2010 that focused on surgical management for advanced shoulder osteoarthritis (Craig 2020) found very low level evidence for greater improvement in pain and functional ability with TSR compared to hemiarthroplasty. Both of these studies emphasized the need for more research, especially research comparing surgical intervention to sham and non-surgical management and research studies with longer follow-up timeframes. I think the lack of evidence comparing surgical interventions to non-surgical management makes sharing advice with patients and patients choosing surgical intervention quite a difficult task. Most of the time I think that patients expectations of surgical procedures relates to their personal experiences. I’ve had multiple patients name a friend or family member who had a similar surgery and base their choice partially from hearing that experience.
Craig RS, Goodier H, Singh JA, Hopewell S, Rees JL. Shoulder replacement surgery for osteoarthritis and rotator cuff tear arthropathy. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD012879. DOI: 10.1002/14651858.CD012879.pub2. Accessed 30 October 2022.
Petrillo, S., Longo, U.G., Papalia, R. et al. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: a systematic review. Musculoskelet Surg 101, 105–112 (2017). https://doi-org.ezp.slu.edu/10.1007/s12306-017-0474-z
The second question I will address is: What role should diagnostic imaging have in surgical management of shoulder pathology? There are a lot of times where we see abnormality of imaging in asymptomatic individuals – when does imaging become relevant?
I think that imaging becomes relevant when it matches objective findings and correlates with the patients function and pain. Like Emily said, I agree that imaging is important initially for those with traumatic injuries, red flags, etc. I think that knowing what is found on imaging can help patients understand why they are in pain, and as a clinician can further justify treatment, but I also think this needs to be “taken with a grain of salt”. I commonly explain to patients that imaging results do not always match how they feel (small tears but massive amounts of pain). I try to use the imaging results as an avenue for education although this does not always work. Some patients are always going to get caught up on the imaging results and just want their impairments “fixed”. At this point, I think advocating for conservative treatment for the first few months and reassessing after that time is the best way to go.
Hi Emily, I like your thoughts about openers and I am in the same boat about often wondering if I am starting the subjective interview on the right foot. I typically explain the concept of PT and then I think I fluctuate between using, “Your referral says that you’re here for ____. Is that correct?” which I typically use if I’m unsure if it is indeed correct and “Let’s talk about where you are having symptoms” with immediate referral to the body chart and going through that. This often guides the patient to talk about their symptoms before explaining the MOI and often lengthy backstory so that I can make initial hypotheses without the bias of their HPI/PMH. Of course this hypothesis may change as soon as they give me this information, but I feel like it’s helpful to have the body chart mapped out sometimes before the whole story. Have you tried this method?
After reading these articles, I was thinking of switching it up too. I’ve had similar situations to the first patient encounter you described and I’ve used the “what were you hoping to get out of today?” with pts responding with “idk” or “whatever you thinks best”. That being said, I definitely think the opener and what’s best is situational and one thing doesn’t work for each patient, but its hard to tell when you’ve only just met them.
I read “On Opening the Clinical Encounter”, “Enhance placebo, avoid nocebo: How contextual factors affect physiotherapy outcomes”, “I need someone to keep an eye on me:”, “Evaluation is treatment for low back pain” and “What influences patient-therapist interactions in musculoskeletal physical therapy? Qualitative systematic review and meta-synthesis”. All of these resources had similar features regarding patient interactions and what we can do as clinicians to facilitate the best outcomes for our patients starting at the initial evaluation. While reading these different articles, I found that I was deeply reflecting about my recent patient interactions.
“STOP TALKING”. If you look at my work computer you’ll find a sticky note at the bottom right corner below the keyboard that reads “Clare” (because all of our computers look the same and I can never find mine) and directly below that “stop talking” written in all caps. While reading these articles, but especially “I need someone to keep an eye on me” and “What influences patient-therapist interactions in musculoskeletal physical therapy?”, I was reminded of my sticky note and a recent interaction with a patient. I have established good rapport with this patient and we have had some very open, honest conversations. At her last visit, I had to leave the room for a moment and when I returned, she was giving me a look representative of a concerned/disappointed teacher. I gave her the band and explained the exercise anyway. She acknowledged what I said, but then immediately stated, “I saw your note that says “Clare, stop talking”. I laughed and explained that I wrote that because I found that I had been over-explaining things to patients and potentially was being confusing. This patient proceeded to counteract that thought and told me not to lessen my voice and that my detailed explanations were much appreciated and actually really helped her understand our treatment and goals. She ended the conversation with “don’t be too hard on yourself”. My patient’s words and these readings have caused me to rethink my poorly placed sticky note. Education is at the forefront of our jobs and sure, maybe I explain a lot, but based on these readings, it is clear that patients benefit from education about their condition, our intervention choices and attention to detail/feedback during exercises. It’s likely that I sometimes lack confidence, feel as though I blabber when educating patients and thus I thought my note would be the solution to help me re-center my thoughts and be more concise. Let’s just say this sticky notes has been folded over.
Another one of the common themes from these readings was the importance of being an active listener. I have often prided myself on being a good listener but as a new clinician I have noticed it is sometimes a challenge for me to be a great listener when I am also trying to document, clinically reason, and respond to the patient all at the same time. I find myself looking at my computer instead of the patient, and actively try to adjust this, but it’s been difficult as I am getting used to the documentation system. This also relates to the flow of the clinic. I can’t help but wonder if I’ll be able to give all my patients the appropriate amount of attention when I start to see multiple patients with overlapping treatment times. “I need someone to keep an eye on me” was a good narrative report sharing the importance of having a clinician observe the patient’s exercises and this having a large effect on the patient’s motivation, commitment, and understanding of their care. I know that once I start seeing more patients, this will be an obstacle I will have to overcome in order to determine the best way to care for each of my patients.
I enjoyed reading Testa’s study regarding placebo/nocebo as this concept is generally interesting to me. When talking about the strategies to enhance placebo, the concept of facial expressions caught my attention because I’ve only been a clinician in the time of COVID. I am generally someone with more of a flat affect, and sounding outgoing or excited about a patient’s progress has been something that I’ve learned to do. Especially in the era of face masks, I’ve found myself having to use a lot more movement of my head (nodding) or eyes (smiling big to cause creases) or even giving verbal “yeses or “uh huhs” as the pt is telling their story to let them know that I am still engaged and not checked out. If we ever transition out of masks, I know this will be another challenge as I’ve also been able to hide my facial expression in more difficult situations.
Overall, these articles facilitated reflection on my initial patient encounters in a new way. In the future, I may try starting evaluations with a different phrase, use different strategies to show the patient I’m actively listening during care and be more conscious of how I may be encouraging placebo or nocebo effects during care.