Jared Powell:
Jeremy. Welcome.
Jeremy Lewis:
How are you? Nice to meet you again. Nice to spend some time with you.
Jared Powell:
That's good. So we've, we've known each other for a little bit. We've been collaborating, writing together. I'm lucky to have you as one of my PhD supervisors. We've never, we've, we've never really discussed frozen shoulder in depth. Although we have written something together and I'm really interested to get your thoughts on it. You're, you're an industry leader. You've published extensively in the area, frozen shoulder rotator cuff related shoulder pain, subacromial impingement etc. You've got, I think I saw on your research gate profile, you've got over a hundred publications to your name. So I mean all of your, of your productivity, how do you do it? That's very
Jeremy Lewis:
Kind of you I'd like to say it's a few more now, but I I'm, I I haven't been on research for a while, but oh, there you go. Yeah, it, it's not the quantity. It's the quality
Jared Powell:
Absolutely. And I'll, I'll say this and I just, you've been a huge influence on me personally in, in my career. I, I read your paper, the subro impingement. Is it an illusion or I can't remember the exact title nearly 10 years ago. And it made me question everything in physiotherapy because that, that sub Chromal impingement for me was a Nongo easy diagnosis, easy treatment centralize the head in you're on your way, but but you ruin that for me. And here we are nearly a decade and we're thanks for that.
Jeremy Lewis:
I'm quite unsure. Am I supposed to apologize now or celebrate? I be both. Okay, fine. Yeah, no, that was an interesting time. Actually. I, I remember I was very nervous about, I was really excited about writing it and, and, and when it came out, I got a little bit of a sure, you know, what you're talking about. And I then started getting a lot of flack from, from physios and and, and from surgeons and, and it wasn't comforting. I dunno if that's the right word. But it was, it was, it was interesting to see over the period of time, since that was published a number of studies that really do suggest that the chrom isn't impinging like discs don't slip the Chromin don't impinge. And that would be a fantastic chorus to a song that maybe we could write at the end of this
Jared Powell:
I can't, I can't help you. I'm not, I'm not gonna sing Jeremy to save everyone, but I do like it, it does have a ring to it or, or even if, even if AROM means, do impinge, they impinge in everybody or, or most of society anyway. So it's,
Jeremy Lewis:
Well, they touch them. They don't impinge cause impinge has got it's negative and, and I, I would say they touch and touch is a good thing, you know, you know, so, so I, I, I think they touch
Jared Powell:
Good. I, I agree. And so that, that was that was a really, that was a really interesting time in my life as well. So, so thanks. So thank you for that. And I can speak for a lot of other people as well, and it's a, we really value the, the work that you do. So keep it up. Thank you. Okay. Enough of the company,
Jeremy Lewis:
A lot of what I'm doing is the devil's work for a lot of people, but, but yeah. Thank you. That's to nice. It's nice to start if you don't it's morning here in London and it's nice to start the day with with a nice, nice, nice conversation. Thank you. Well, the,
Jared Powell:
The, the civilities end now, Jeremy, I'm gonna, we're gonna into the, we're gonna get into the, the hard stuff. Well, firstly, actually, oh my,
Jeremy Lewis:
My broadband looks like it's about
Jared Powell:
Well, firstly, can you just talk, tell us a bit about you and your history, Jeremy. So I know you are, you're a Kiwi trained in Australia, I believe. And you've made your home in, in London now for, for several years or decades. So, so what's several decades now in, in a few minutes sort of, what's been your, your story.
Jeremy Lewis:
Well, just as the wheel was invented, I was born in New Zealand. I roamed the planes of New Zealand fighting off Brotus Sori. As we were talking about before this, I did, you know, my, my, my, my junior school in New Zealand. I had a absolutely privileged life in New Zealand living by the beach and driving tractors at, I think age nine by myself and taking boats out and net. Where
Jared Powell:
Were you down south up north?
Jeremy Lewis:
Just, just to the, the, the, the, the west, the very south of the, of the north island, a place called para Paramo. Okay. Which is just outside of, of in, in, in those days it was, I we'd go to Wellington. My grandmother would take me to Wellington once a year for a Chinese meal and a new pair of shoes, and it was a really big trip. And, but now it's just sort of like a satellite outside my, and then economically New Zealand wasn't doing too well. And my, my parents were economic migrants to Australia. And and so, you know, that's how I got to Australia and finished high school in Australia and, and went to physio school in Australia. And then 21 years ago came to London cuz I wanted to see what it was like living in Europe and got a really fabulous job in a major London teaching hospital and, and loved living in Europe and and have been here ever since, but come back to Australia once or twice a year to teach and to visit my mom who lives in Melbourne and, and catch up with, with friends.
Jeremy Lewis:
So are you a, are you a Kiwi? Are you a Aussie? Are you a PO, are you you keep with quiet and don't tell anybody I've got three passports. And what it means is I've become incredibly superficial. So whoever's winning that particular sport on the international stage. I am that country yeah, so I become quite superficial and it just depends what suits me and what visas are is made. It's made traveling around the world. Very simple for me. I bet that's a good way to initially in the UK, I've, I've been really privileged. I came at a time when there was huge waiting lists to see orthopedic surgeons. So the government at that stage was really I think quite progressive. And so was opening up the possibility for physios learning to do injections and then physios learning to refer patients for blood tests and all sorts of imaging and, and then managed to get on to a a postgraduate diploma and ultrasound.
Jeremy Lewis:
So the idea was to incorporate imaging in clinic, so you could offer a one stop shop but it also allowed me to do op and guided injections. It also also the deregulated prescribing. So in 2015, I did the independent prescribing call which allows me to prescribe medicines that are relevant for patients. Unfortunately not allowed to prescribe Botox. So this is all real it's L'Oreal because I'm worth it. And and and yeah, so, so there are some restrictions, but it's been a really interesting evolution of the, the profession in this country. Where'd you do your PhD? I started initially in Melbourne, but I moved it to Coventry university and I had just the very, very best PhD supervisor, Ann Green one of the nicest self, most selfless people have ever met in my entire life. And she's just, just retired sadly. And yeah, it was, that was such a, a wonderful experience. Such a great learning lonely as you are fine with your PhD. It can be a very lonely time, but also very inspirational time as well. Yeah, since, and especially if you, the team around you is a supportive team. Now at this point in time, you say, and you are such a supportive supervisor, Jeremy
Jared Powell:
Could, could you not see my, my, my vigorous nodding? No. Did come through. Absolutely. No, you, you have been a tremendous help. Thank you for that as have my other supervisor, so share them. Okay. So, so what, what's a typical week looking like for you now? So I guess it's a pandemic. What, what's your, what's your work week? Are you, are you sort of working university based? Are you working clinically?
Jeremy Lewis:
What are you doing? So it's been a, an amazing year in some ways, a very positive in some ways, but also incredibly sad. Yeah. I've lost family members to COVID and had the virus myself and my daughter who, my youngest daughter who is a junior doctor sadly had it as well. And yeah, so it's been a humbling year. It's been a year of reflection, but from professional point of view, I work a couple of days a week as a professor of musculoskeletal research. I've got positions in a couple of universities in different countries but all that's gone on to zoom and emails, et cetera. And in the national health service where I work initially it was telehealth. So you would go to, well, some people were working from home, but I, I just couldn't do any more work from home.
Jeremy Lewis:
So I go to the hospital community hospital that I work in and, and just speak to people on on, by the telephone or they have a system like zoom called blue jeans where you could which is apparently more secure or something. But Zoom's great. I don't want anyone from zoom to come and get us. And and just recently last month we were allowed to see patients face to face again. So yesterday it was my frozen shoulder clinic day and saw patients face to face a couple of injections. And most of it was normal physio rehab for frozen shoulders and advice and education. And then my reflective moment on the way home, on my bicycle on the way home thinking have I done any good? So awesome. Yeah. So, yeah, so, so it's a mixture of, it's a lot of like everybody, I guess, like you, for sure as well. A lot of it is learning to adapt to this new normal.
Jared Powell:
Yeah. Yeah. I mean, I think it's we've been less affected down under, but although we have had a, a, a few issues in Victoria, sadly, and then also we've got a bit of an outbreak in south Australia, but anyway, we're all on high alert.
Jeremy Lewis:
I saw that yesterday in the news at south Australia. And I know my mom, she's quite elderly now and I mean, this has been a hard year for her. She's spent most of this year talking to me, poison in her garden and yeah. It's yeah. And so it's been a hard year, but now I think the lot, what she's saying, she's, she's been out in the last week or so she's finally gone to a nursery and, you know, and, and starting to enjoy life again, but you sort of think that Ireland nations should be doing well on the new Zealand's done extremely well Australia, very well, UK island nation, but not so well.
Jared Powell:
Yeah, we won't, we won't venture into that political conversation, but I could it's anyway,
Jeremy Lewis:
After a couple of vodkas, we should yeah,
Jared Powell:
That's offline, offline. Okay. So, okay. We'll leave, we'll leave the heavier topics and we're gonna get into an interesting I have a question for you. It's state of origin night here in Australia. It's Queensland on new south new south Wales.
Jeremy Lewis:
Come on, new south Wales. Okay.
Jared Powell:
Well, all right. Being a passionate Queenslander, I'm gonna, I'm gonna send you an email at midnight tonight when we win. Cause it's game three and it's one, one game all. So this is the decide
Jeremy Lewis:
And do it. I wish I had my new south Wales.
Jared Powell:
You are in blue, so that's ominous anyway. Okay. We're gonna get, we're gonna, we're gonna get into frozen shoulder Jeremy. Now I'm gonna start with a quote from the famous earnest Coman frozen shoulder is difficult to treat difficult, to define and difficult to explain. And he ushered those words in 1934. We are in 2020 right now. We ended better. Are we ended better off? Do we understand it at a deeper level? What are your thoughts?
Jeremy Lewis:
No, probably probably not a whole lot better, but I, I love medical history and I, I dunno if you've had a chance to actually read his book, you can read it online. The shoulder doc website, I believe has got it all available online, which is a fantastic, fantastic resource that they've provided for people. And I thank the them for that. And it's really interesting when you read his book, isn't it, you know, that he based a lot of what he's saying on the assessment of four people in 1933, where he hospitalized them, tied them into elevation for 20 hours plus a day, which must have been absolute torture. They were allowed up an hour a day or so to do the famous Codman pendulum exercises. And surprisingly after a week or two weeks, they said, don't need any more treatment.
Jeremy Lewis:
I'm going home. Things are great. and you know, and then you get this comments that, and everyone gets better based on four people, you know, and, you know, the, the, the, the history of frozen shoulder was punctuated by small observational studies where too much has been generated too much UN, unquestioned thought has been generated from, from the, those small observations. And it's an interesting history how, you know, if you look at Codman's four subject for participants in 33, and then, you know, we had the never see a study in the 1940s that observed 10 people and said, no, it's not a frozen shoulder and adhesive capitis. And those two, the two, the two description of the two conditions, isn't the same, a frozen shoulder. Isn't an adhesive, capitis somewhere in the 1960s and seventies. They seem to merge somehow and they've become a synonym for each other, but they were absolutely not the same condition for, for most, for most of the last century. And, but that was based on 10 people. So who, who knows what's really going on? I, I certainly don't know what's going on. I'd be wary of anybody who knows.
Jared Powell:
Yeah. So, so what do you, how, how do you, how do you define a frozen shoulder? If somebody ask you in clinic, Jeremy, why is my shoulder so sore? Can you, can you give me, what's your Ted talk or what's your two sentence spiel on frozen shoulder to describe it in lay terms to a, to a patient.
Jeremy Lewis:
Okay. That's, that's a really good, I like that question. So for me, you know, after the, so, so often when a patient's yesterday, someone's coming in the room in the clinic seeking care for this incredibly painful shoulder, that's way out of proportion to anything that could have precipitated it, you know, and you ask the question in the interview stage, you know, what's it like living with this and, and, and five times outta 10, that's the time you've gotta pass the, a patient in a physically distanced manner. The tissues, because they just break into tears that that you know, no one understands work for the fir first few days, people were very kind and understanding, but then I started getting comments like, but you haven't had a fracture, you haven't had surgery and no one at home understand that it's agony for me to get dressed.
Jeremy Lewis:
Everything has to be done slowly attending to personal hygiene is, you know, like running a marathon now. You know, and, and so, you know, once you've been through the interview stage and, and, and, you know, set the scene for the patient we've, we've got now together or whatever it is, I like to talk to you about, you know, how the started, how it's been affecting you. And then with your permission, like to assess your shoulder, once we've set on the assessment your permission to sit down and, and talk to you about what I think's going on and the different management options, and together, we can decide how best to move forwards. So at the, at the end of all that I don't really have a test to say, you have got frozen shoulder, but for me, the clinical cluster has to be, the person is around 50 years of age, that physiological movements are actively and passively equal restricted.
Jeremy Lewis:
One of those physiological movements has to be external rotation. And if, even if you want to discuss that later on, we can and that, that the external rotation has to be a limited active in possibly at least 50% or more in comparison to the other side. And more or less the x-ray is normal. If I'm gonna do an intervention, I need an x-ray for cause I'm a clinical coward. And and, and so I'd save the, to the individual, you know, trying, you know, validate all their, their pain and their, the difficulty. It's really important not to, to, you know, to do that with, with people. And and so it's most likely you've got a frozen shoulder. And then in my head, I don't like to stop just to at a, at that umbrella term, frozen shoulder, you know, you know, you've clearly got a, you know, the patient is sitting within the umbrella of a stiff and painful shoulder, and then there's so many stiff and painful shoulders, and you've gotta be a clinical detective to try and work out what it's likely to be.
Jeremy Lewis:
And often it's imaging with stiff shoulders that helps differentiate the frozen shoulder to the arthritic shoulder, to the osteo nerotic shoulder, to the SAR, the poor individual, who's got a osteo sarcoma to the lock dislocation shoulder. There's so many reasons to have a stiff shoulder that sort of looks similar in many ways. So for me, imaging's quite important, especially if I'm gonna do an intervention. So it's save the patient. I guess my, my, my, my line is, it is like you've clearly got a stiff and painful should, and it is like, there's many different reasons for that. And what's likely is you've got a frozen shoulder and here are the different management options that we could discuss and consider and work out what's the right way for you to move forwards.
Jared Powell:
Cool. So, so certainly validate their experience. Do some, some physical examination testing. You'll looking at external rotation, obviously either in neutral or through range. I imagine. I've been having some interesting ones lately where I see people come in with pretty good, not pretty good. It's in they're okay. In neutral, external rotation. And then up at 90 degrees have zero or sometimes negative which is fascinating. So I see them coming to me and I'm sure you've seen this for a second and a third opinion, and they've, they've been diagnosed with bursitis based on an ultrasound scan. Yeah. It's a, it's a raging frozen shoulder. Nobody's just thought to test it up, up through range of motion, because they're probably using their thoracic spine or, or something else to, to do the external rotation. Do you see much of that stuff like false positives or false negatives in your, in your clinical practice?
Jeremy Lewis:
Yeah, I do. I dunno, what's going on here that it's such a, a lovely sunny day morning in London, and I seem to be thrust into darkness. I don't know what's going on. But but anyway, yeah, so I, I totally agree with that. I think you know, when people want to try and stay as normal as possible, they do exactly what you see. You couldn't have described it better. They, you know, they they're twisting on their hit. So to give the, the impression that the movement's the same, and I published a paper in 2006 with Rachel Valentine. And we, we had a look at a, a, a, some, some ways of measuring physiological movement of the shoulder, looking at some reliability. It was a, it was an earlier study. And and we came up with a suggestion to run a tape measure from your belly, but, and to your styloid process to keep your arms loosely by your side externally rotate.
Jeremy Lewis:
And it doesn't matter how much tricking you're doing. So, and we it's a linear measurement. So the way that I would use it for quickly, clinically is simply to say, okay, on, on the stiff side, it's 20 centimeters. On the other side, it's 40 cent is 20 on 40 over 40 is a 50% reduction. So it's a super fast way to get a cause goniometry and visuals really difficult for me. And so it doesn't matter how much tricking you're doing. You can't trick the tape measure, but I totally agree with you that, you know, when you come up into higher range and you can do exactly the, the same thing it's probably more revealing, but a lot of patients in the early stage, you can't get them up into higher ranges. Absolutely. About the embarrassment of screaming coming out of your clinic.
Jared Powell:
Yeah. It, it is such a, and I'm glad you touched on the, the emotional aspect or the mental load of frozen shoulder, because it is, it's a condition. I probably, with a really acute sciatica, it might be similar mm-hmm , but a frozen shoulder. I've been reading a little bit of some qualitative research around frozen shoulder, and there's not much out there sadly and embarrassing.
Jeremy Lewis:
The, the Jones study from, from two and keep an eye out for will king. He's doing some stuff in down the south of England and also Christine borough, Chris borough who's doing a PhD injection study that I'm supervising for pros and shoulders. And she's just putting the finishing touches to what will be a qualitative piece to her PhD as, as well. So I agree with you, there's not enough qualitative patient perspective information. I'm sure every day in your clinic, you, you have the patient who's crying and desperately trying to understand what's going on and desperately confused that everybody is saying something different and looking on Google and Google saying the best treatment is organic. Ginger picked at six o'clock in the morning, on the west side of a mountain by people, pure of heart. You know, so there's, there's so much, yeah, well, you know, unsubstantiated stuff and, and I don't think we've got enough about the patient's voice in this, and I'm sure you that's your experience as well. Absolutely.
Jared Powell:
It's the, the Joan study that you mentioned is, is fascinating in that people just want to know what it's going on. So they want an accurate diagnosis who would've thought, right? That goes back to Louie Gifford's full principles of what, what patients want when they present, present to you. And they, and often they're just going around from GP to physio, to chiro, to osteo or whatever. And they've all been telling different things. It's your alignment, it's your posture ITSA. It's the rotator ter it's this, it's the it, it flumes me as to why frozen shoulder is such a hard diagnosis for, for some clinicians to make it should be the most obvious presentation that you can see. Surely what, what what's going on. Are we too, are we too entrenched in the biomedical model where we're looking at macro optic structure on ultrasound, or we're looking at the tightness of trigger points of tissue, and we just, we just lose sight of a, of an obvious clinical presentation. Why do you think we, we miss, or it is common to miss a diagnosis of frozen shoulder.
Jeremy Lewis:
I, I love the way you reflect and you think you, you thought carefully a lot. And I, I really admire that. So thank you. Yeah. Thank you. I like the way you are, you're pitching this. I, I don't know. I mean, I make lots of mistakes. I, someone comes in with a terribly painful shoulder and my first thought is, is this more likely a, you know, without the benefit of imaging is this a, a Cal Pacific tendinopathy, you know, patients rubbing up and down their upper arm, is this a, is nerve root compression. You know, is this a, is this someone who really has pushed themselves beyond their absolute pH and, and really does have some evidence of shoulder pain, which there is some evidence that, that can happen or is this just the person's interpretation of what pain is inside their body?
Jeremy Lewis:
And, you know, at the same time that they're desperately financially struggling because of the pandemic and the children are not being educated. So, you know, so it's sometimes really complex to say, and I, I make mistakes and I, and I'm, I'm not ever critical of anybody saying, oh, this is a rotator car. Or I would be critical if I said, this is an impingement, but, but, you know but but but you think this is coffee. Anyway, so and and you know, but, but so sometimes it takes a while to declare itself, but I agree with you that, you know, there are, there are ever, everything's a hypothesis in our world. You know, rotator cuff related shoulder pain is a hypothesis it's likely to be there based on these sets of circumstances from the interview, from the clinical examination.
Jeremy Lewis:
And that hypothesis may change over time. So, you know, so for me, the hypothesis of frozen shoulder is the factors I mentioned earlier up 50 active passer ranges, restricted that one of them has to be ExOne rotation and, and a normal image. And, and, but then why the shoulder is a frozen shoulder is another huge question itself. You know, what to category of frozen shoulder are they, I don't think we can just stop it. This is a frozen shoulder and it's, without any shadow of a doubt, your capsule that's contracted, but, but the overarching theme is this is if you want to come up with a different term, that's fine. But for today, it's called a frozen shoulder. And based on those features, so I, it might take some time, but I think you can get there.
Jared Powell:
Mm-Hmm for, for me, for me frozen shoulder, let's whenever I refer to frozen shoulder, I'm gonna refer to for this question anyway, a true idiopathic cap contract, somehow we've observed, let's just say that we've done a biopsy or we've gone in there for an arthroscopy or whatever that, that frozen shoulder is almost the most definitive observation that you can make. I think clinically in physiotherapy, if you took everybody, if you took a hundred people and contracted their capsule, they're all gonna move within 10 or 20% of each other. I think in terms of they're gonna come in and they're gonna have those Cardinal signs of how they move their shoulder. So this is where I, I think it's slightly different from a rotator cuff related shoulder paint presentation, where it could be, it be any number of structures. Now that's talking about nociception. It could be any number of psychosocial factors or, or physiological factors.
Jared Powell:
We we'll never truly know. I don't think it's just pain in the shoulder, but, but a frozen shoulder has a very clear pathophysiological profile in many CA and I certainly know that there are some that do not follow that, that we'll talk about in a moment with the, with the pseudo frozen shoulder, with the work from Louise Hellman mm-hmm . But, but do you agree that a, that a true sort of cap type presentation of a frozen shoulder is a, is a pretty definite once it reveals itself, once it declares itself after those first few months, mm-hmm should be an obvious clinical diagnosis.
Jeremy Lewis:
Yeah. And I, I agree with that with the with, with the proviso that how so? So I, I totally agree with everything you've just said, how are we determining that the capsule is contracted? So that's my question back to you. How do you, how would you, so absolutely. If you don't have the, you don't have the advantage of an athroscope or ology biopsy, how are we making that call? I mean, yes, we can see on MRI, we can see on ultrasound we can see some possible structural changes. Maybe that takes us to that, that point. I've certainly been speaking to some interesting there, there was a a radiologist I've just been speaking to. Who's convinced now that for those of people who are familiar with scanning the shoulder, when you put an ultrasound machine on the shoulder, you can clearly see the rotator cuff moving, and the Deloid not moving at all.
Jeremy Lewis:
When you do the, the scan and this, this gentle, one's been sending me some anecdotal imaging ultrasound videos, where in patients with frozen shoulder, he's observed that the rotator cuff and Deloid are almost like glued together, are moving together. And he's interested to, to research that, and I don't know enough about it. I certainly spent yesterday in the clinic with the scanner, trying to see if I could see it. And I couldn't, but, but, but I dunno, that could be my poor scanning technique. Yeah, yeah. But, but, you know, so I, I, I totally agree with you, but we can only do that once we've got definitive evidence of Corco humal ligament or some part of the capsule has contracted. Mm. And then I agree it should be the best, most simple clearest diff diagnosis in, in the history of diagnosis.
Jared Powell:
So absolutely that, that is, that's the thing that, yeah, the op the op the, the determination of whether the capsule is involved or not is a huge missing piece. And, and this sort of leads us into, into Louise's work that we've just mentioned, and her now pretty famous paper, and quite rightly so, which came out a couple of years ago, which put five people, I believe under anesthesia, general anesthesia, and then, and measured their range of motion versus when they're awake now diagnosed with a frozen shoulder and as, you know, substantial improvements under anesthesia and the, and the, and the assertion or the, or the, or the question is how do people with a frozen shoulder, a subset of a people with frozen shoulder have an active restriction or a muscle guarding, can you, can you speak to, to this? Do you have a theory around these potential patients or subgroup of, do you see them in your practice, do you think they're, they're out there? And if you do do, do you treat them any differently?
Jeremy Lewis:
Mm, great question. I mean, yeah. Head off to Louise and head off to Karen G I, and, you know, to, to enormous contribution, Karen G and, and her and her PhD in MSC students, and, and, and Louise's study was so profound and so interesting, and yes, it's small, but it needs it needs to be considered and we need to explore it further. And, and we are certainly doing some research in Illinois in, in the states at the moment of furthering Louise's research with a couple of colleagues internationally. And so, so I don't know how to work out the muscle guarding component. If we go back to your earlier sentence about the true cat ion, if we look at the research that's available to us, it's suggesting that physios can mobilize inferiorly, the GLI humor joint with around about 20 kilograms of, I dunno, 20.
Jeremy Lewis:
So if you're pushing on a bathroom, scaly doing a J thing it's about 20, any kilograms that the force we're applying is kilograms of force. No, I've got that wrong, but, but but you, you know what I mean? So let let's even put a whole body weight behind it. Let's say we are, we're mobilizing the inferior capsule, that a hundred kilograms. It seems to be that the force required from profess to Ito's work from Japan. We need about 683 kilograms of force to stretch the inferior capsule from my knowledge that the the heaviest deadlift last year was 500 kilograms. So the sort of the good news is that the heaviest deadlift is still not, you know, this better than I am. I think, I think you're a lift around you and
Jared Powell:
Can tell that's that's 600 kilograms of fourth, right. There's, how's
Jeremy Lewis:
Your subscap by the way. anyway, so whole anyway, so I'm, I'm far away now, you can't come and punch me. Yeah. So yeah, so, you know, the good news is that the heaviest deadlift is still not strong enough to stretch the posterior capsule, because if it was, we'd be in a lot of trouble trying to lift a heavy weight mm-hmm . So, but, and so it would be naive for physios and chiropractors and osteopaths to say, oh, I'm stretching out your inferior capture with this mobilization procedure. And there certainly is evidence that mobilization has some part to play that was in a paper we published last year. Our systematic review that Katherine Winslow led on. And and but, but it can't be that we're stretching the capsule, not even someone as immensely strong as you.
Jeremy Lewis:
And and, and so are we really, maybe what we are doing is we're decreasing the muscle guarding and we, we're seeing the benefit from exercises and, and stretching and, and, and mobilization procedures. So maybe that's when it does change. Maybe that's maybe that's suggestive that part of the problems, muscle guarding a friend of a colleague and a friend of mine. Oh, and a con back in 2010 we were the first physios. We put in a grant to a brilliant funding source called the health foundation in the UK. And the health foundation gave us a lot of money to set up a, a hydro extension clinic led by run by physios totally just physios in community care. And we were, we were the first to do that, and we had some amazing help Allison hall teaching as a sonographer, teaching us how to do the procedures.
Jeremy Lewis:
We put a lot of effort into learning how to do hydro distinction for frozen shoulders. Cause we really wanted to offer a one stop shop and, and we, we tried to keep it as as accurate as possible. So if I did the injection, Owen would reassess the patients and, and if I heated the injection I'd re reassess so that we were not, not trying to buy a, our own findings. And and what we could never understand is that some type, you know, you've got an UPAM machine, the needles and you're in 30 MLS of saline. So, you know, you're not up against a bone and sometimes the injection would go so smoothly and you see this expansion of of the hum head and the G glenoid FOS. And sometimes you just, your arm would end up looking like the Hulk, because you just could not get any saline out of the, out of the needle, out of this syringe.
Jeremy Lewis:
And, and we, we just couldn't understand, and we talked a lot about it. And, and I wonder, cause if you sort of think about it, if it does require 680 kilograms of force to stretch the capsule, what could 30 mills of saline do against that? You know, you couldn't, I don't think I could generate enough force. I, I don't know. And when it's easy, maybe what we were seeing were muscle guard as the, the reason for the clinical presentation of the frozen shoulder. I, I don't do hydro distinctions anymore. I've stopped doing that for many years now, but but I know a lot of people do it and a lot of people talk about the success of doing it. But you know, this, this we're gonna leave this conversation knowing less than we started at the beginning of it. We, you know, it's such a hugely interesting topic that we know so little, I know so little about, you know, that trying to learn about it, but it's complex.
Jared Powell:
Yeah, no, I'm I'm with you. So, okay. I think that's this sort of leads quite nicely into an injection question. So I think the three obvious candidates would be just a low volume intraarticular injection. You got your high volume and then even the old subro injection, which is still done and doesn't make logical sense to me, but the data suggests it's not heaps worse than an intraarticular injection, as far as I can see it at the end. Anyway, maybe it lags behind initially. So you you've seems like you've retired your, your hydro dilatation or hydro distinction injection, which is interesting. They're becoming more and more popular here down under, and I know they're very common in the UK. I worked over in London for a couple of years and lots of the consultants love to do a hydro extension procedure. What's what's your experience or firstly, what's the rationale behind an injection from a pathophysiological perspective. And then how do you find they go anecdotally, of course. And you can make reference to the literature if you like.
Jeremy Lewis:
Okay. Well this is a PhD, this question. It's a fabulous question. How much time do we have
Jared Powell:
10 minutes to go, Jeremy. Okay,
Jeremy Lewis:
Cool. I'll get it done with two. So so this is, this is just a convers between me and you. No one else is gonna hear this that's right. Nobody else except
Jared Powell:
Thousands of people.
Jeremy Lewis:
So we know that lidocaine and steroid can reduce fibroblast populations Vicki, Ryan, and Hazel for their masters that I contributed to did a really interesting systematic review in 2016 and BMC MSK open access. If anyone else to read it look trying to look at the pathophysiology, the histology of frozen shoulders and what was really interesting. We could not find one naive study, meaning that we couldn't find any study that had the, the, the tissues that when they were being sampled had had no intervention, no injection, no physios. So there's no, we don't know. What's really going on at a pathological level, in a naive you frozen shoulder. And so we, we made our cutoff, the, the, I think the only thing they, the, the subjects the participants could have had was nonsteroidals, which still has a chance to influence tissue.
Jeremy Lewis:
One of the things that they reported was that in the Corco humoral ligament and in parts of the inferior capsule, my memory says me well, that there are fibroblasts in those areas of the capsule and they are myofibroblasts and myofibroblasts can cause contraction. And maybe that's where the contraction you were talking about before comes from now, if injections can, if that combination of, of lidocane and or steroid can reduce my fibroblast populations in other studies, I wonder if one of the reasons why injection work is that it is reducing fiber, my fibroblast populations and it is then stopping the progression of the contraction because the injections from my clinical experience, but also the paper we published the republished last year and journal of rehabilitation medicine suggested that injections work best in the painful stage. They don't seem to work in the stiff phase and the earlier the better.
Jeremy Lewis:
So I wonder, so of course it could be having an effect on inflammation, which we still don't really understand. The injections might be to diluting chemicals in the, in the joint. It could be contextual if it's muscle guarding who know, who knows anything really, but at a physiological level, which I'm really interested in. Is it possible that if it is a true frozen shoulder and there are my fibroblasts causing the contract and this medicine can reduce the number of fibroblasts, is it restoring homeostasis in the region? Why that I don't, I don't know. This is, you know I'm sure it'll be shot down by someone, but I'm saying it before in the end of this, I don't know it's hypothesis. So, you know, it'd be, be to explore what I see clinically and what I do clinically now is as long as there's patient understands the risk, cuz there are risks of injection.
Jeremy Lewis:
It's not that it's a risk free procedure. And as long as they consent to all the things I want them to do afterwards, I actually do two injections on the same day, I do an injection in side the joint and I'll do an injection in the Burer and it was interesting in 1850s due play, the first person to really talk about frozen shoulders was suggesting that the cause of the frozen shoulder was bursal stickiness. So he had a, like a, an he of theory as well, but it was the Burer sub Chromal Burer sticking together and that was causing the pain cuz you just couldn't move and it was causing restricted movement. And, and it does. And I agree with you, there's not a huge difference where you do the injection. So is it contextual? Who knows what's going on? But I think the evidence suggests that an intraarticular injection slightly wins that that competition a Bural injection by itself slightly loses that competition. But when you add the Bural injection to the Glen humeral injection, it seems to improve hand behind back range more than just the intraarticular injection. Now why that's the case? I don't know. We're, we're currently setting up an RCT to look at that. But you know, what, what the burst of contribution is, I, I don't know, maybe it's turning off pain a bit. I don't, I don't. Mm
Jared Powell:
That's a fascinating hypothesis in regards to lidocaine and, and steroid inhibiting or reducing fibroblasts or my fibroblasts that's that completely sort of goes in the face of a hydro injection, trying to distend these mechanical things that we're obsessed with physio. Right. But perhaps something is going on at a deeper physiological and certainly psychological level. I know from my experience, if I have someone who has had a hydro injection and they, they, they it makes it's makes sense. It's coherent to them. If they go and have an injection and it's gonna blow up their capsule, it's gonna dilate their capsule. And I'm sure there is some contextual effects to having a hydro dilatation injection. And plus they heard a bit as well. So I think they can, and sometimes they pop and they hear a rupture or they, they can hear that popping sound. And so they come in and those people who say it, they're like, it's so much free now. And the said, it's great. It popped. So that's another, that, that's an interesting actually, let me ask you that. Do you think a hydro dilatation injection can rupture a capsule can, can, given what we know about the force it's needed to do it, that that was the theory that a hydro dilatation would cause a rupture of the, a capsule? Does it, is it plausible?
Jeremy Lewis:
I, I, I guess it's plausible. I guess if it takes 683, you know, kilograms of four centimeter squared to stretch the capsule hard, you know, I can't imagine if you had an inject, you know, what's a half of Volkswagen golf. I don't know if that weighs half, 600 kilograms, but whatever, you know if you couldn't imagine putting 30 mills of fluid behind a Volkswagen polo, I'm not trying to advertise Volkswagens. This was brought to you by every car manufacturer. You know, I can't imagine 30 mill of fluid could actually move that car. Yeah. I can't imagine it, you know, a little bit of, but maybe in a confined area, it can certainly had situations where I have seen the fluid go in a noise happened and then the fluid dissipated. So I assume something has ruptured. I don't really not a hundred percent sure what, but my question was, and Owen and I had this conversation, you know, is it acceptable to cause a RUP and then let's steroid flow?
Jeremy Lewis:
Who knows, where are we causing any problems by? Cause the way you, so the way some people do the injection is it's Lido, cane and saline. Some people do the injection lidocaine first and saline. Some people mix saline, Lido, cane, and steroid. And is it acceptable to have these things free flowing somewhere? Does that cause any atrogenic problems? And, and I don't, didn't couldn't find an answer to that. So there was a whole lot of reasons why I decided that it didn't make sense for me to do hydro distension. I'm sure a lot of people who are listening to this or not listening to this, who do distinctions have very valid sound reasons for doing it, but I'm not convinced by the research and hydro distension. It certainly wasn't included in our recent paper. It certainly not included in the UK frost trial. So I'm not sure we've got definitive evidence for for distinctions and yeah, I dunno if that answers the question, but that's as good as I can get. I think that's
Jared Powell:
Good. That's good. So I think we'll, I'll, I'll ask one more question and you just, you just reminded me of the frost trial. I don't know if you've had a chance to read it. Interesting result. So, so three group three group RCT physio, standardized physio. It was a injection I believe to start with versus a manipulation under anesthetic versus a athroscopic cap release. Yeah. Seems to be no, no superiority of one over the other after 12 months, I believe there were some sort of, so physio needed more treatment. I think manipulation under anesthetic, perhaps the most cost effective, which was a fascinating
Jeremy Lewis:
Outcome. Yeah. It completely blew me when I read that, I thought, well, that's, that's really challenged everything. I, every surgeon I've ever tendered lecture on talking about it says manipulation under anesthetic, really rough damaged the shoulder ripped the labrum cause fractures cause Hema much more sophisticated, much more Finese to do a capture release. So I've sort of been towing the party line when patients are saying, listen, what you're, doing's not helping, what else can we discuss? So I I've saying for a long time, I's the way to go. Cause become part of my basically listening to, you know, surgeons experiences. And so the frost trial really has challenged that, you know, and rightly, rightly so to say huge credit to the, the researchers and the participants who part contributed to that knowledge. I guess for me, it sort of still does reinforce do the injections and do physio, I, after the injections and then if it's not making declaring itself and the, and the individual is looking for some other way forward and understands the risks and benefits go into a manipulation under, under an aesthetic. I, I presume that should be the care pathway now conversation that's the it's been happening is you, you are aware of on social media is, should have there been a fourth group, you know, the advice, education and wait and watch, which would've been really valuable and not for a minute criticizing the frost study, but you know, at, at some stage in the future, it would be really valuable to have that comparative arm as well. cause maybe it's just time. It doesn't really matter what you throw with the patient.
Jared Powell:
Yeah, absolutely agree. I, I think it's an interesting outcome because I I've, I've never, so I'm, I've been out of, I've been practicing for about 10 years and I've never, I don't think I've seen a frozen shoulder after a manipulation under anesthetic in the past decade. I've certainly not. I've, I've sort of sat in and watched a few arthroscopic releases where I work with some surgeons here and they do well postoperatively, to be honest. But yeah, it's gonna, it, it must inform practice and, and a manipulation under anesthetic. I don't know how, how much we should extrapolate. I didn't go in and have a look at, at the, at the patients who did it anyway. I don't know how, if we can just extrapolate it across the board to every country, to every, every patient demographic. But it's interesting, nonetheless, we should be thinking about a manipulation under anesthetic, which for me it seems like a barbaric procedure as you alluded to, it seems like it's, it's contrary to sort of everything that I believed in. So it's really gotta make me look at my own clinical practice as well. It's
Jeremy Lewis:
Interesting, I guess that's the value of research and acquisition of knowledge, you know, and not being stuck in one place and just in hypothesis trying and what, what, what are we all trying to do? We're all trying to make the, the lives of people coming in, seeking care as better as possible. And I know there's huge debates, especially in social media about how dare you do this and why would you do that? But the truth is we are all just trying to, you know, make our little corners of the world the best possible and try to help people as much as, as we can. And, you know, certainly my experience of the privilege of teaching around the world has been that physios are really nice people. They're really trying to make a difference and trying to learn and trying to work out what works. And and, and yeah, so I guess what we're all trying to do is just add to our knowledge and add to our ability to help people. I'm certainly a different person today than when I finish minute therapy and in Melbourne, you know, and
Jared Powell:
Yeah. Is that reminds me of a, of a quote, another quote from Carl popper who I've been reading his book recently, and he's like, all knowledge is temporary provisional and capable of being refuted at any point. So don't hold your beliefs too tightly or too closely. And it, they sort of that rings home with that frost trial as well. We've gotta be adaptable and where the evidence takes us. And you know, there's not enough of that. I don't think we're just seems like, I don't know, maybe we're just in these silos, but we're just getting more polarized by the day, both in physio and politically all around
Jeremy Lewis:
The world as well. And, and, and you, you mentioned Louis Gifford before, and I, I remember, I mean, just finish on, on this, cuz I we've gotta all sit down and pray for new south Wales to win tonight. And as he, the screen goes blank I don't really, I'm not really invested either way. I, I did a five day course with with Louis Gifford and David Butler. I was a student in a five day course and it was at the beginning of it was an ABI of any in Wales and I flew across to participate in it. I really wanted to made in it. It was an amazing course. And it was sort of the time where they were really challenging, mechanical, you know, mechanical ideas and talking about more about pain. And, you know, I didn't even realize it was a brain before I did this course and know that thing existed and, you know, and and, and Louie was just so eloquent and, and clever and, and a philosopher and knowledgeable, and he was talking about pain the whole time and you know, how, how we have to reframe re conceptualize.
Jeremy Lewis:
And then the last day, or the last two days they had patients and this first patient came in and this is after four days of just so no hands on, think about different ways of think, you know, working with patients, it was revolutionary. And and the first patient came and said, I got a really sore neck and, and what's happened. And Louis asked him, you know, what's, what's been beneficial in the past. And he said, oh, I've had these manipulations. And it's always helped me for years. So without any thought, Louis put him in supine, manipulated his neck. And the guy said, thank you. And this, and we, we look at other, you know, and then when we were sort of saying, why Louis, you know, we've just, just learned about the brain and there's this thing called pain that no one ever heard of before. And he said, because that's the, you know, in terms of conceptualization, why would've I have done anything else for this patient? And it was really, really interesting and insightful and really mature. I thought, you know, that he was listening to patients and not just listening to ourselves as health professionals, it was really yeah.
Jared Powell:
Being being intellectually humble and not putting your own biases onto your patients is, is such a golden rule. So thank you for sharing that story. That's amazing. That's a good place to finish. Thank you, Jeremy, for, for joining me for the half hour or so. You've got so much knowledge mate, and I really appreciate you taking the time early, over there in London to, to, and to, to everyone who watches this. So thank you very much. Thank you very much for the invitation and, and come on Queensland. .
