A lack of evidence doesn’t mean that something doesn’t work, but as soon as there is evidence of little or no specific benefit, the scientific process forces us to at the very least become skeptical; where there’s one failure, there will be more! Time and time again in Physiotherapy we’ve shown ourselves to be applying principles and practices which transpire to be next to useless.
This morning, Adam Meakins shared on Twitter a study from the Journal of Manipulative Physical Therapy (Guimarães JF, et al) which found the ‘Mulligan’ Mobilisation with Movement™ (MWM) techniques were no better than a sham intervention for improving range of motion, strength or function in patients with ‘shoulder impingement syndrome’.
In his own blog posts Adam has also pointed out that ‘impingement’ is a normal process with the biomechanics used to support the idea of a pathological mechanism to be invalid; ‘impingement’ of anything is a nonsense clinical diagnosis – much like ‘shin splits’ refers to a sore leg but doesn’t give any indication why (“owie” doesn’t sound nearly as valid as ‘impingement syndrome’ though does it.)
We also know that ‘techniques’ (irrespective of philosophy or profession) have no specific physiological effects and that improvement in movement and pain are ‘outcomes’ rather than ‘effects’ of an intervention.
The results of an RCT were presented at the SECEC-ESSSE Congress in Italy last year which showed that natural history (improving on its own) plays a significant role in change of symptoms and that patients who have ‘failed’ conservative treatments do not recover following arthroscopic acromioplasty; with the suggestion that it (the surgery) “cannot be recommended” – and that’s coming from the surgeons!
We’ve also recently seen the ‘SELF’ study from Dr Chris Littlewood (PhD) which found that in the short, medium and long-term, ‘usual care’ of Physiotherapy was no better than a self-managed single exercise performed at home twice per day. This means that we can no longer justify ‘usual care’ (together with its investment of time and $) if it provides no better outcome than a single home exercise.
And if those didn’t cast sufficient doubt over shoulder treatments, in June this year Dr Rachel Chester published a paper in the BJSM showing that psychological factors were consistently associated with patient-rated outcome, whereas clinical examination findings associated with a specific structural diagnosis were not. Baseline disability, a patient’s expectation of complete recovery, higher self-efficacy and lower pain severity at rest are all better predictors of the outcome than our clinical findings or a specific diagnosis.
And let’s not drag those ridiculous therabands and (supposed) isolated external rotation exercises into the mix else we may find ourselves back at the turn of the Millennium mixing it up with the ab cruncher and clam-shells too.
Painful shoulders can be extremely difficult to live with but the solution *should* be a very simple one based on the current evidence of what’s effective and what’s not.