6 minutes reading time (1114 words)

Jeremy Lewis - The Shoulder: Theory & Practice

AAP Education


Just returned from Perth and attending Jeremy Lewis's course, The Shoulder: Theory & Practice.

The course reminded me of playing with LEGO as a kid. Block by block, I would construct the next Taj Mahal. In the same way Jeremy has put together this course, using blocks of research over a period of time. An evolving work, it provides clinicians with a structured protocol, going from assessment to treatment, backed by research, at a time when there is greater awareness of the lack of sensitivity or specificity of orthopaedic tests and inappropriateness of early surgical intervention.

The first LEGO block looked at the epidemiology of shoulder pain. In the field of MSK pain the frequency of shoulder pain is less than back (under age of 65, then reverses), but what I found interesting is that people with MSK pain reported comparable disability as those with chronic liver disease, chronic diabetes, and terminal cancer.

The second LEGO block reviewed function, and knowing that my scapular wasn't designed for hanging from a tree, was a great comfort in explaining my lack of progression with chin ups! Screening tests and discussions about the role of the whole body in assisting shoulder function, gave a more holistic viewpoint when considering rehabilitation of the shoulder.

The third LEGO block covered was assessment. Both the history and inadequacy of standard of orthopaedic tests was covered. Then we looked at what tools, questionnaires and methods, do have validity to be used in clinical practice. This flowed into the Shoulder Symptom Modification Procedure (SSMP). This procedure provided clinicians with a step by step process to determine if spinal, scapular or humeral head positioning influenced pain. This section had a Mulligans feel to it, as combinations of external load were applied to test symptom changes, in association with the primary painful movement.

Assessment techniques flowed easily into treatment and subsequently into home program development.

The fourth LEGO block (starting to develop some serious structure now) looked at rotator cuff tendinopathy. Treatment staging was based around the tendon continuum model: underloaded, normal, asymptomatic overload, reactive and degenerative (Lewis BJSM 2010) and included a lively discussion about the relevance or other of acromion shape, does impingement exist and the key roles of tendon structure and function. This was great stuff.

A lot of the non traumatic shoulder conditions we see involve some form of tendonopathy. Basic science tells us that it is not medications or surgery that promote the development of quality type 1 collagen, rather it is exercise. As prescribers of exercise, we are in the driving seat to stimulate the development and growth of fibroblasts (tenocytes) to provide a long term solution. Hand in hand with this is the need to educate our clients that the development of quality tenocytes requires a combination of critical factors; nutrition (healthy food choices, healthy body weight, non smoking) exercise progressions aimed at tendon repair and sleep. With collagen taking 300 - 500 days to build, rehabilitation is in no way a quick fix situation, but a longer term commitment to individual health and an example of how critical, our client education is, to ensure clients understand the bigger picture and their role in the solution.

The fifth LEGO block involved sensory motor control testing pursuit, repositioning and drift. Rehab programs in both open and closed chain environments were examined.

The final blocks of this 2 day course involved a discussion on Frozen Shoulder and examples of client management to consolidate information learnt over the 2 days. Throughout all sections, relevant research was presented, guiding discussions and decisions making processes.

Course Comments

"Hi Doug, Fantastic course! Jeremy is a very dynamic and knowledgeable presenter.

With all of the current evidence that orthopaedic tests for the shoulder are non specific and insensitive, it was great to be shown an alternate assessment tool to help guide treatment." Tania Althorpe

"Hi Doug, I really enjoyed the course with Jeremy such a wealth of information that is certainly going to change my practice. Also due to the presentation of research I will be much more confident in dealing with tricky shoulders and pathology that may otherwise be leaning towards surgery." Jonathan Wray

"Hi Doug, Great course, one of the best I have been to in a long time (except your dry needling of course!!) I loved the way Jeremy used recent and older research to explain/ justify clinical reasoning and clinical experience. Well done on getting Jeremy to Perth, I hope he can return here again next year. I would definitely like to send staff to his course." Terri Pope

I raise a glass (of purified water of course) to all the new Consultant Fibroblast Stimulators who attended and wish you a great weekend.

"If You Liked This Course ... You Will Love Nick's Courses!"

Of the same quality as Jeremy's Shoulder Course, Nick Clark has developed from his PhD a range of advanced lower limb assessment and rehabilitation courses. Recommended to AAP Education by a past course participant, we are very happy to be able to facilitate Nick's courses in Australia for the first time. Here is a link to his 2 day Proprioception & Neuromuscular Control in Lower Limb Rehabilitation available across Australia. Nick''s other courses available in Australia are Functional Testing: After Knee Injury and Clinical Strength Training in Orthopaedic & Sports Rehabilitation. Check them out.

All the best,

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

email: doug@aapeducation.com.au

ph/fx: 08 90715055

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