The Shoulder Complex Assessment and Rehabilitation
13th May 2017
With our second MSK CPD course fast approaching I caught up with Andrew Cuff to explain his background and get a flavour of what we could expect from him talking all things shoulders in Exeter.
A – Hi Ben, great to speak to you from sunny Delhi, enjoying a cold beer after delivering my Shoulder Assessment and Rehabilitation Workshop to 105 Indian Physiotherapists!
B – I hope it went well. Andrew, first things first is Cuff your given name or is it an exceptionally clever ploy to hide an extra key search term for the benefit of google?
A – Ha, very good old boy! Almost as witty as the Orthopaedic Surgeons at the annual BESS meeting! Merely a happy coincidence, my late fish on the other hand were intentionally called ‘Glenoid’ and ‘Fossa’ (much to the better half’s displeasure!); Glenoid died first within a few days so Fossa took a lot of explaining!
B – Fossa the fish, I note you gave Dolly your Chihuahua a non-anatomical name, presumably to distance yourself from the ownership of such a beast. To more pressing matters, I know you’re very proactive both attending, hosting and developing courses yourself. When designing your own courses, what are you prioritising for delegates?
A – I’ve been teaching for a number of years now; initially in a University setting and then was fortunate enough to start being invited to deliver talks and workshops within a variety of settings – primarily related to the Shoulder or to Spinal Red Flags. I’ve been fortunate through my newly acquired position as Director within Remedy Courses Ltd in Sheffield to host a number of fantastic lecturers; naturally you don’t just gain the theoretical and clinical knowledge but you also get a lot of opportunity to discuss amongst peers ideas that often there isn’t time for during the normal working week. As a practicing clinician myself that’s something I really value.
I now try and balance a medium between three driving forces; theoretical knowledge and reference material; clinical application and insight; practical application and refinement. I hope that attendees to my courses have fun, are challenged and walk away with not only things to implement immediately into their practice but also material to reflect back on.
B – That’s certainly a feature of our first CPD course that I noticed. Some of the discussions going on during the coffee and lunch breaks were very interesting and at times it was tough ushering people back into the seminar room to continue. So you’ve forged yourself a reputation as an upper limb specialist what do you think about the benefits and pitfalls of physios specialising? And who are you influences?
A – Whilst I’m often referred to as an Upper Limb Specialist, more so Shoulders and Elbows (I didn’t realise things existed distal to the radial tunnel..), I’m mindful of the limitations of channelling one’s self down such a route. Whilst the majority of my caseload are cases involving the Shoulder and Elbow, I ensure that I still see all Musculoskeletal presentations. One of my big issues with the ESP model is that of the ESP that works alongside an Orthopaedic Consultant within Secondary Care, becomes biomedicalised themselves and forgets their professional routes as a Physiotherapist! I know I’ve spoken to you before about my annoyance with this and this was the inspiration behind the current paper that we are at work on, but unfortunately that data is cloak and dagger at this moment in time.
In turn, my influences in practice are thus not ‘Upper Limb’ per se. A good friend and mentor of mine is Dr Steve Hodgson from the Hallamshire Physiotherapy Clinic in Sheffield; his PhD was on fractures of the proximal humerus whilst more locally he is renowned for his ability to help those with persistent pain! My Physiotherapy practice is influenced heavily by Steve, Peter O’Sullivan and ultimately my patients who teach me a hell of a lot!
You can’t talk about shoulder courses today without mentioning Adam Meakins, I consider him a friend of mine (Adam may disagree!) and my practice is undoubtedly influenced by his passion and drive demonstrated over recent years. The Shoulder and Elbow Consultants, Registrars and ESPs that I’ve interacted with will have shaped my practice and I think it is important to read widely and thus I’m always reading what the likes of Jeremy Lewis, Jo Gibson, Anju Jaggi and Chris Littlewood are putting into the public domain; whether that be publications, presentations or through social media – I’ve been lucky in recent years to be able to communicate directly and undertake projects with such people.
B – Many of the delegates attending your course will be looking for ideas to develop skills with difficult shoulder patients; with that in mind what are the key challenges that you face in your second opinion clinic when you see a failing shoulder that in your opinion does not need a surgical solution.
A – With regard to the Shoulder and Elbow, I provide a second opinion in a private capacity for those people that have previously seen a Physiotherapist and may have been recommended to see me or may have not responded to previous treatment but do not wish to proceed to an Orthopaedic opinion – this is often an easier conversation to navigate!
Within my ESP practice, I see those patients that haven’t responded to Physiotherapy and have been escalated by the Physiotherapy team to see me for either a Physiotherapeutic opinion, consideration of Injection Therapy or for further investigations as part of the work up towards secondary care.
I suppose the challenges that I see most commonly relate to the language used by the attending clinician which may serve as a barrier to engagement to Physiotherapy. For example, the validity of the acromion theory with regard to ‘Subacromial Impingement Syndrome’ is highly questionable however, reasoning within such a model influences patient understanding and subsequent understanding of expected treatment whilst serving as a barrier to engagement with Physiotherapy; Chris Littlewood and I have just submitted a paper on this and it will hopefully be in press by the time of the course.
Probably the second most common challenge relates to the patient that has received outdated, insufficient or poorly reasoned Physiotherapy input that now considers that they have “done or tried Physiotherapy” and thus in turn need either further investigations or Injection Therapy. With these patients, more often than not the patient has been underloaded, not tried progressive Physiotherapeutic intervention for an appropriate period of time or been provided with bad advice regarding the ‘limits’ that Physiotherapy can achieve; for most conditions, the outcomes of Physiotherapy are at least equivalent to Surgical outcomes and it is important that we don’t undersell ourselves.
B – I think there is certainly a lot to be said for preparing some fertile ground with our use of language and setting out our stool for what is considered good exercise prescription. Our threshold for ‘exhausting’ physio probably needs to be a lot higher particularly as you alluded to in subacromial pain. So moving onto assessment, which special tests if any do you have confidence in in the upper limb.
A – I’ve recently published an article on Sensitivity, Specificity and Likelihood Ratios within the ESP Journal. I think it is important for clinicians to be able to understand such concepts as well as reliability to be able to inform a meaningful and relevant clinical examination and thus guide appropriate management. It has been well documented in recent years that on the whole, Special Tests of the Shoulder lack reliability. Furthermore, the tests are Sensitive but not Specific which means that they are good at reproducing symptoms but not informing the attending clinician what is causing those symptoms; as such they should be considered ‘Pain Provocation Tests’. Despite this, there are some tests which are useful to inform the clinical examination and subsequent measure which we will go through in the Workshop in May.
B – Andrew I know you are trained in injection therapy – what role does this have in sub-acromial pain?
A – I use Injection Therapy less and less; I’m not what you may call ‘trigger happy’ by any means. We discuss the role of Injection Therapy during the workshop; do we need to be using Corticosteroid? Should we be performing via Ultrasound Guidance? Can it be detrimental to clinical outcomes?
Sub-acromial pain is probably better described currently as Rotator Cuff Related Shoulder Pain and we will discuss the reasons for this in May however, within this there is potential to sub- classify in to ‘Irritable’ and ‘Non-Irritable’ Rotator Cuff-Related Pain in order to guide management. When more conservative methods such as appropriate load management and pharmacological interventions as well as symptom modification or low-level loading programmes fail to provide significant relief to the patient in order to allow them to engage with a period of progressive conservative management, injection therapy can be highly effective.
B – I can see I’m going to have to watch my language when you’re down in May. Now coming away from shoulders for a moment you are also published in reflex testing – what sparked your interest there? How has this informed your practice and where can we find your paper?
A – Yes, I’ve recently published on the lesser known reflexes such as TFL in the Lower Limb and Posterior Deltoid in the Upper Limb. This forms part of my practice when I am trying to differentiate a problem arising from the Cervical Spine masquerading as a Shoulder problem. We routinely test C4-T1 and L2-S2 myotomes and dermatomes but then only cover C5, 6, 7 and L3, 4, S1 with reflexes for some reason.
Reflex testing is probably a larger part of my MSK Interface practice within my Spinal Clinics. The paper is published in the ESP Journal but you are more than welcome to forward a copy of my reflex paper to those attending the Spinal Red Flags workshop that I’m delivering at your place in August. This workshop will include practical time devoted to being able to use these reflexes in clinic.
B – Finally what are you most looking forward to about visiting Exeter?
A – I’m looking forward to meeting the local Physiotherapists. I’m a firm believer that we can all learn something from everyone and I am sure there will be some rehab ideas that become apparent during the workshop from delegates that we can all benefit from. Additionally, I am a keen runner and even keener Ale enthusiast! I’m therefore excited to trail both the local running routes and scenery before recovering with a local brew!
That can certainly be arranged. Andrew thanks for taking the time to chat and we look forward to hosting you down south soon.
Andrew Cuff will be teaching both his shoulder (12th May) and spinal (5th August) courses in Exeter this year and all bookings can be made online here
Our full course listing in Exeter including Greg Lehman and Steve Nawoor can be found here.