Jared Powell:
All right, Filip we're back for round two of our conversation on the always controversial scapula. Thank you for joining me again. We had some really good feedback from our last conversation, which touched on the physical examination of the scapula as it relates to the shoulder. So welcome back.
Filip Struyf:
Yeah. Thanks or inviting me again to the gold coast or wherever you, something like that. It's always a privilege to do so. Yeah,
Jared Powell:
Yeah, no problem. And we're just, we're just speaking about this is your last media engagement prior to your summer break. So I hope you enjoyed it. What, what are your plans? Have you got anything planned?
Filip Struyf:
Wow. The plans are a bit mixed now because we we cannot go to to foreign countries due to the COVID story. So it'll be in, in Belgium holiday today, but this, this summer, but we have some nice places in Belgium. So you should visit Belgium once if you can. Yeah, definitely.
Jared Powell:
I've been to Brussels train station on the way to Germany or something from, from the UK. So I haven't been outside of it, but it was a beautiful train station.
Filip Struyf:
Laugh> OK. That's a,
Jared Powell:
So before we, before we get into the, the theoretical stuff something I've been trying to do is sort of try and reveal the personality behind people that I've talked to. And I haven't, I haven't given you any preparation for this. So what do you, what do you like to do in your spare time? What are some of your hobbies and recreations? What do you enjoy doing outside of being a shoulder expert?
Filip Struyf:
Oh, wow. A, well, it's not, not, not so much a difficult question because if AC as academics, we we, we don't have a lot of hobbies. We are a bit of nerds in, into our job. And but then if, if we, if we have some some, some time there are two things that I really like to do and that's go for a walk with my dog. It's a really empty stress thing. And you do some physical activity at the same time. So that's one thing. And then the other thing is I'm a, I'm a cyclist actually. You wouldn't guess that from me probably, but I'm still cycling mountain biking, et cetera. And road cycling. That's one of the national sports in Belgium. So for us, it's it's, it's normal. It's like walking and, and, and eating sandwiches. You have to cycle in Belgium. So that's something we, I like to do also yeah. In a, in a local cafe club, but it's fun. Yeah. That's my spare time actually cycling and walking with my dog
Jared Powell:
And two kids. Yeah. I'm sure they occupy some time.
Filip Struyf:
Yeah. They're two, they're still young nine, oh, sorry, 10, 10 since yesterday 10 and 12. So they're they're grow, they're growing, but it's, it's fun. Two daughters and I hope they make some sense in their life.
Jared Powell:
Well, that's, that's great. So soy, so cycling cycling is such a European, well, at least road cycling anyway, very historical sort of leisure activity in Europe. And I think I was watching a Lance Armstrong documentary the other day. And his team manager was at Joha Bruni. He was, was he he's Belgium.
Filip Struyf:
Yeah. He's Belgium. Yeah.
Jared Powell:
Yeah. So there you go. He's a, he's a famous Belgium cyclist, or at least part of the Lance Armstrong story, which we won't discuss. Okay. So cycling aside and Lance Armstrong aside, let's, let's talk about the shoulder and specifically the scapula. So last time we talked about the inaccuracy and potentially biased view of the scapula. When we try and assess it with our vision, our vision is historically quite poor or can be poor. It can be prone to bias as any of our senses can be. So a way to offset that or troubleshoot that problem has been this the scapular assistance test has been devised. Now the scapular assistance test is essentially promoting upward rotation and maybe a bit of posterior tilt of the scapula manually. So the therapist doing it, or somebody else doing it, could you speak a little bit about this scapular assistance test if you use it in your practice and if you do, why do you use it?
Filip Struyf:
Yeah, yeah. It's it's, it's actually maybe the best the best question to discuss about this is really scap assistant test because by discussing that test, you can, you can discuss several other things related to scap to the shoulders. So well the scap, well, we, we have several tests developed, I think maybe 10, 10, 50 years ago, they were developed as a sort of a Mo symptom modification test using the scapula. And you got the scapular assistant test, which focused on upper rotation and the modified scap assistant test, which, which you can push the inferior angle and, and pull towards the OID to make some poster tilt together with the upper rotation. Then also these tests like scap retraction tests and repositioning tests, which are actually using a pain provocative tests combined with retraction or poster tilt, which, but they all have the same intention.
Filip Struyf:
And their idea was if you perform these tests and the patients complaints reduced well then the, the scapula might play a big role. And the, the explanation for pay reduction has changed over the last 15 years. The first time it was developed and published, there was times I think it was angio Tate and Phil MCLE who published a lot on that. They they said that it was all about, or mainly about mechanism behind in assisting or increasing upper rotation or increasing poster tilt which would be, which would have an effect on the subacromial space. That was the first explanation. So if you increase a port rotation, if you increase posterioral, then maybe the super Chromal space increases, and maybe that's the reason for reduction in pain. And then that would be a queue to steer your rehabilitation towards scapular training towards poster tilt and a port rotation.
Filip Struyf:
So that was the, the, the main thing it's still, that's still alive, by the way. It's not that it's gone that, that rationale, but it's, it's still alive, but that was one, I think, 10, 50 years ago. And then afterwards there were also other ideas because of course the whole super Chromal space relevance is getting some debate on that. And a lot of studies have been published since then that really discuss the relevance of it. And then of course, if you discuss the relevance of that, then you might also need to discuss the relevance of what are you doing with the scapular assistant test, because if you think you're doing upper rotation for increasing criminal space, and that's the reason why patients have reduction in complaints. Well, that, that doesn't really make sense if your next study is well super criminal space doesn't matter.
Filip Struyf:
So this is, this was a bit conflicting, and then other ideas other hypothesis were developed to talk about why, why a lot of people have pain reduction. I see my clinical in my clinic. A lot of patients feel better when I do this capital assistant desk. And I always, I wondering why, why, why is this? There was this study that, that, that said, okay, just because you put your hands on the, on the shoulder, you, you have some tactile feedback and it feels good for the patient feels confident, and that's, it's more like a touching effect of your hands, but then the other pilot studies and not, not, not big power, but there was some studies who did a sham comparison. So you, you just put your hands on, you don't do the assistance, you don't do the posterior tilt, you just put your hands on, but then they saw that the paining effect was a lot less than, than when you really performed the test.
Filip Struyf:
So it might not be the, the touch alone. And then I think we're now 2020, and since a few years the intrinsic role of the cuff is getting more and more attention. And I think we should definitely look at the scapular assistant test as a factor affecting the intrinsic role of the cuff. So if you, I'm not give us a very clear example, which, which might not be completely correct, but it's a, it's I think a good example. If you move your arm with a, with a weight or, or whatever your is, is highly active and other muscles, but your Dell is really performing that movement when the Dell is performing that movement, then your hits is challenged because a pulls on the, on the hum head. And it's our cuff that is dynamically active to, to stabilize the hum head during that movement.
Filip Struyf:
So the more activity you ask from yours, the more activity normally the, the rotator cuff should apply to, to get it all at its place. But of course, if you have a lot of cuff activity, you have a lot of cuff load. Then this cuff attaches to the scapula and the scapula is pulled towards internal rotation. So the winging during that activity, so the more cuff activity, then the more, the scap challenge towards internal rotation and the more the CTU and the trapezius needs to be active and strong to, to keep the Scapa controlled because only if the scap is controlled, then the cuff can have its perfect length, tension relationship to, to stabilize the, the Al head dynamically S stabilized Ural head. So the more cuff loading, the more the trapezes is challenged and, and vice versa.
Filip Struyf:
So I think this is a a, a chain that you can hardly separate. And that's why I think that might be a role for a cuff problems when patients have positive assistance tests. So, I mean, if I've had performance, capital assistant test and a pain patient has pain reduction, I'd rather think now 10 years ago it would be really capital problem. Now, I think we, we have some cues that might, that may be emphasizing that it's a cuff cuff related issue because you, you actually create a stable base basis for the cuff and you if you do the assistant test, you really have the cuff in performing that movement. So actually you, you, you unload, you do an unloading of the cuff by performing this capital assistant test. And if you look at it that way, then the, a positive test actually tells you that if you UN, if you unload a cuff and you have pain reduction that the complaints of the patients are load related would actually tells you then on the again, that load might be a preferential intervention towards a cuff.
Filip Struyf:
So that's maybe something different from the, the interpretation of a few years ago. But I think that might be an interesting path to think about. We also saw some studies relating this capital assistant test with cuff tears, for instance. So that was also a study emphasizing that in case of cuff tier that the patient had much more positive SIM assistance tests versus the patients who did not have any cuff tiers. So in that was also the, the Yoho said, okay, maybe this scapular symptom modification test tell you more about the cuff, then it tells you about the scapula. And it definitely doesn't tell you anything about scapular dyskinesis cause the that's not the, the, the thing you do with the assistant or retraction test. It's the scapular. Dyskinesis what we discussed last time is if, if you, you can, you can just visually observe that if, if it's there.
Filip Struyf:
So you don't need to capital assistant test for that. And a positive scapular assistant test doesn't tell me anything on the scapula it's the, the, the cost or, or a consequence of the problem, but it might tell you something that it's load related and that incorporating of course the scapula in your rehabilitation program might be, might be beneficial for your patients. But then there is another next point where we can discuss that later is how, how do you do that? So that's my, my, my first idea on the capital assistant test, going from a super criminal space reduction story to, to touching to, well, maybe it's more about the cuff during that test. And we should really consider the by performing ACAP assistant test. And maybe it's not the loading alone. Maybe it's also the length tension. You, you, you create, maybe it's just putting the, the, the, the glenoid in a, in a, a better position. Biomechanically. I, I don't know, it's, it's still not really clear. Maybe there are other reasons, but it might be more than capital dyskinesis in, at the end. It's, it's definitely, in my opinion, it's definitely not using that test to, to decide whether a patient has capital dyskinesis or not. That's not, that's not the goal of the test, I think.
Jared Powell:
OK. That's, that's excellent. So if I, if I can just briefly summarize, and that was very well said, so we've come a long way from the scapular assistance test as essentially meaning that there's a subacromial space. So now, so we've, we've gone from that. And then this concept of touch came into play, and are we just affecting or playing with somebody's cognitions or emotions, and that still might be relevant in some people I would say, and then sort of, and this is, and I agree with your point. It are, we just offloading sensitized tissue by facilitating a movement or creating, going from an active movement to an active assisted movement. And I think maybe it's a combination of all three in terms of the mechanism of action. So the problem is in, in a lot of the time in the literature though, it's the, the suggestion is that if the scapular resistance test is positive, then we must direct our treatment at the scapula.
Jared Powell:
Cause it's a scapular disc Kinosis issue. And what you are very articul said is that, or maybe not, maybe the problem is with a weak or, or maybe load intolerant, rotator cuff complex. So, so that is, that is a big change really from when you look into literature, I was just looking at a paper before that I'm doing a, a bit of a review on from 2018 by, and it says that still the, if a scapular assistance test is positive, then the assumption is that we must go on and treat S but nobody has ever done that study. Nobody has ever got, here's a group of, with a positive test do inter or do they just need progressive strengthening? The has not done. So, so if you, if you do get a scapular assistance test, and I know it may be a positive ULAR assistance test, and it may be different for every single person, but for the average person, how would that direct your subsequent intervention? Would you focus on progressive loading of the shoulder?
Filip Struyf:
Well, yeah, well, the, just to come back to the, to the scap assistant test I sometimes think it's, it's it's, it's really easy indeed, to blame this capital. If, if you do something with this capital and the patient that's pain reduction, it's, it, it, it sounds logic to do something with the scapula, but you can also compare this with a, I sometimes compare it for my students with if you, if you drive with drive with your car over a, a couple stone and you really go hard, you go 200 miles per hour on the couple stone and you get a flat tire. Okay. You get a flat tire. And then you, it's easy to say, okay, how are we going to fix this problem? Your, your your speed is gone. You're, you're there on the, on the couple stones.
Filip Struyf:
And you can say, okay, what's the problem. You, the flat tire is the problem. And but actually that, that might not be the, the issue. The whole issue is you are speeding on, on a cobblestone. So that that's a bit the same discussion, I think. Yeah. Okay. There is, there is a flat, okay. The, the, the trapes and the, and the S are letting this movement go for some reason or they can't, or they won't or whatever. But that doesn't mean that's, that's the biggest issue. The that's the biggest thing. Maybe there is something else going on. Why, why is this happening for instance, the I'm, I'm just thinking about the author. I think it's Mons who did a study on the or presented one of the other scaffolder tests, like the scap of flip sign in which you which is very easy test, which you need to perform an external rotation against resistance.
Filip Struyf:
And then during this external rotation against resistance, you just look at the scapula and if the scapula starts to wing, that was a positive scapular flip sign. And then the conclusion was you have some, you have a problem at your, your scapula. So that's, that's a bit the same thing, but from the, from the strength rationale, it's, it's quite logic. Again, you do the external rotation at the, the infas and, and, and the posterior cuff, all the posterior cuff and the deltas are working a lot. And of course they, they pull on the, on the scap, maybe in these patients the, the traps and the, and the PSS, they don't have the strength, or they won't want to have the strength, or you need to the internal rotation for sufficient cuff activity and the, in the PS. And they just do, don't do anything just to fix, to fix the, the issue. Whatever attention is went to the, to the scapula. Okay. That's just something on the, on the assistance test again. Then your last, sorry, your last question on the, when, when I have positive test in clinical practice.
Jared Powell:
Yeah. So, so when you have the positive test, do you, you and you touched on this a moment ago, do you take this as a sign that you need to increase the strength or the capacity of the rotator cuff? Or do you just view it as a sign? I've gotta, I've gotta apply some sort of load to the entirety of the, of the shoulder complex, including scapular, thoracic muscles rotated, cuff muscles, double PS, all of the above. How do, how do you then deal with a positive scap assistance test?
Filip Struyf:
That's that's the, the, that's the big question. Of course. Yeah. That's also maybe a bit, bit difficult question indeed, because like 10 years ago, that would be the, the goal of, yeah. Okay. Let's, let's focus on the scap alone. Especially if you have a large pain reduction, cause that's something that's something we, we use more and more that's the or the literature uses more and more. That's the amount of pain reduction during that test. If you have seven on 10 during a, a normal movement, and during the capital assistant test, you go to six, then they say, okay, maybe the operat rotation is important, but actually not so much. It's just one point reduction. So you don't really need to focus on that, but if it goes from seven to zero to one, yeah. Then there would be an idea.
Filip Struyf:
You only need to do something about scapula and, and all the rest isn't, isn't that important? The good thing is that if you if you want to do something about scapula, you need to, you need to trigger the cuff. That's the, that's the, the, the best direction, if you really want, if you, if you're convinced that scapula is a problem, so that's, that's still a discussion, but if you're convinced that's the problem, you still need to need to use the cuff to do, to do the whole work. So if your patient has a pain reduction, you might think that it's all about the, your scapular focused treatment, but actually it might be your great cuff loading you've done during your exercises. Cause that's, I'm not sure maybe we discussed that last chat also. I'm not sure about if you want to challenge this CAPA in, in or if you want to challenge the, the trapezes and the Seras, well, you need to challenge the cuff.
Filip Struyf:
Otherwise these muscles won't do anything. So these go go together and you cannot separate them in, in any way. And so the good thing is in your rehabilitation process from start that you start moving your arm, you're doing it, you're doing it all it all together. And there are only a few patients maybe that really have a problem with scap control even with, without any loading at all. And in these patients, it's, it might be suggested to do some some, some first, some orientation exercises some posterior tilt activity, or some focus on the Serato, some push exercise, some focus on the trapezius. Maybe in these specific patients, which there is immediately a lot of tilt, tilting and winging just by, by moving the arm, even unload it you might consider that, but even even if you start with these orientation exercises, you will need to go towards cuff loading quite fast.
Filip Struyf:
And then maybe the, the I think the progression might be a little bit how do you say it? Slower the progression might be very low from low load, not, not the highest load again, so that's something I, I use. So I use the, my progression, and you can maybe look at the scapula as some sort of sign whether or not your cuff loading is, is is adequate. I don't know whether I make sense but I it's from the moment that's, that's what often is suggested now literature also maybe the, these scapular winging or, or this dyskinesis is some, some sort of first sign that, that the cuff isn't coping with the load. So maybe that if you increase your cuff loading that you can use, okay. Whether or not the Scapa is a bit controlled, you can still increase your, your cuff load from the moment on the scap. I starting to, to wing winging or tilting, that may be your load on the cuff at that time might be too much and the scap trying to, to fix the, the whole thing. So maybe you can rather use it in your progression rather to that than say, okay, now I'm only doing I'm only trying to activate some scap things or only trying to activate the cuff. Cause they're, they're, they're one and one system.
Jared Powell:
Yeah, no, that's, that's very well said. And it comes back to like the famous, you know, scapular strengthening exercise is a scaption exercise often in prone, and that's just a good rotator cuff exercise as well. So why I don't get why we're wasting our time in trying to differentiate, we've gotta do scapular only exercises or scapular corrective exercise, unless like you suggested there is profound scapular dyskinesia, even with unloaded movements. And that person just has no control of their shoulder as a result of a very unstable or disconnected scap. In that instance, I can understand it, but for somebody who has a degree or two of dyskinesia potentially, then I just can't understand why we need to divide the two systems. It it's all the same. So
Filip Struyf:
I agree. Yeah. That's that's the, the really anatomical view on rehabilitation, the structural view on rehabil rehabilitation we we've had for, for decades, of course. And that's maybe if you, if it's okay, I can discuss the, the, the randomized trial with it in 2013. Yeah. Go for it. Or actually the randomized trial we published in 2013, but it was done in, I think, 2011 or something like that. And that was the time really that
Jared Powell:
So this is so just, so this is your, your, this is your paper what's, what's it called for anybody who wants to go and listen? Look it up.
Filip Struyf:
It's yeah, it's a good question. How, how was these people it's 10 years ago, jar it's scap focus treatment in super impingement or something like that.
Jared Powell:
Randomized controlled trial,
Filip Struyf:
Randomized control trial, 2013. I think it's clinical rheumatology. It was published in, I I'm I'm even that I'm not sure actually . Anyway, that was, that was part of my PhD at that times. But actually it was published after my PhD defense, but anyway and that time we we were thinking, okay, let's let's take a grab of impingement patients that time's divide into patient that positive symptom modification patients that not positive modification with the idea that some patients will have benefit of scap treatment and the others, maybe not. And so we
Jared Powell:
Got modification tests, the scapular assistance test or something else. Yes.
Filip Struyf:
Capital scap assistance, scap assistance. So we divided them in, okay. These patients have scap assistance, a positive scap assistant test, and the others did not have scap positive scap assistant test. And then we gave the, these patients with a positive capital assistant test ACAP focused treatment. So I will explain immediately what we, what we thought it was, ACAP focus treatment, and the other group. Well, we thought let's, let's just do the the standard physical therapy for for impingement problems. And I will tell you right, right away what the standard conservative intervention was, was actually some mobilizations of the Glen humeral joint. We did some external rotation exercises with, with a band. I don't know if you can, you can see that it's really with a band. You can, can imagine some rotation exercises. And then have to think if we did anything more. I, I'm not sure. Maybe
Jared Powell:
I think you did a, did you do an eccentric exercise as well?
Filip Struyf:
We did eccentric exercises. But, but actually only in, in in, in almost all in the, in the zero rest position.
Jared Powell:
Okay.
Filip Struyf:
And then some ultrasound, even, I think at times that was the conservative intervention. And then for nine times, and then the other intervention was capital of focus. And we first for a focus, we were that time we were how you say it really close with the kin control, a concept company which developed the scapular orientation exercise. I think it's a paper from Sarah who published that scap orientation exercise in which you you put your fingers on the OID and you need to pull the code away from your fingers, which may creates a posterior tilt of the scapula. And then you, by doing that, you activate your trapeziums and PS, but actually we start with that exercise, but then we included a lot of movements during this, this control.
Filip Struyf:
So the, the, the, the instruction was okay, if you do a posterior tilt with that posterior tilt, now we're going to do elevation abduction rotations. We're going to do stability exercises in, in, in hand and knee position. We're going to do training with, with load, with bands going, going up and also in prone doing exercises, going to lateral and well, a lot of, a lot of training with which we thought this is, this is all capital focused. And we saw in nine sessions that the conservative intervention they improved, but they actually, they didn't improve that much. But the capital focused intervention, they improved a lot. And the first fault was okay. There's this really something that emphasizes the fact that you need to classify your patient into having ACAP dyskinesis or not, and then you can steer your rehabilitation towards the scap intervention, so that has the better outcome.
Filip Struyf:
And that made sense also, apart from the fact two, two discussion points here, one is the fact that we also measured the scapula. We measured the scapula positioning we had in INO and Cain. We measured it all, and the, the idea was okay, if the patient improves due to our Scapa folks treatment, then probably also the Scapa position or, or movements will, will change over time. But with the measurements we did, we didn't see any change of the Scapa over these nine sessions. And I think the nine sessions were divided over, or I'm, I'm, I'm, I'm had to recall this, think it was one or two, two two interventions per week. So, and we saw that actually the capital positioning did not change at all over that time. So maybe of course our clinical tools were insensitive enough.
Filip Struyf:
That's, that's one option. That's the first we thought then, or what we're doing actually doesn't affect affect this capital positioning at all. And, or it doesn't really matter at all. Maybe also then of course, the second, if we look at this trial now actually the intervention is capital focused. Intervention is now there are now great rotate of exercises there, the perfect rotative exercises. And we might be training our rotate of patients. Yes. And the other, the control group was just doing nothing. So that may, might be the reason for the big improvement. We don't know, but actually, it's, it's funny how your interpretation change of the same study can, can change over the years. You look at it. So that's yeah, that makes it sometimes sometimes more complex, but I think we did, we did better and, and loading of the cuff in the scap of focused intervention than just in a standard intervention.
Filip Struyf:
That's our conclusion now. And the conclusion in 2013 was it's a, it's a scap. You need to you need to focus on, and, and only, maybe only in case of a positive symptom modification test, but actually that's the conclusion you cannot make because we didn't include ACAP of focus treatment in the other group. So only then that would make sense maybe, but we, we didn't. So that's the, the research is never it's never perfect. And I think you need to admit that that also we've, if we've done the research ourself, it has added something to the whole discussion this RCT, but we must admit that it wasn't perfect and that the, our interpretations that time might not be the best interpretations, but who says our interpretations now, Garrett are, are the best I D just time. That's the only we,
Jared Powell:
Yeah, I think that's really of you to say that a, of a, of people stick to their opinions regardless of what the actual data suggests. So, so that's, that's funny to sort of track the interpretation of the same data set over the last 10 years and it, and now, so you are the lead author in that, and now it's essentially, maybe we had the best rotator cuff strengthening exercise in the scapular focus group, as opposed to the scapular focus is, is, is correcting scapular Matics, which it didn't do in your paper. And there's been a number of control, randomized control trials since then, and also a couple of systematic reviews. And they very rarely, I think, I don't think I've really seen any good randomized control trials that show the substantial improvement in Matics, after a scapular focus treatment, although pain and function improve and, and, and sometimes improve better than a general strengthening regime in the short term, but that's often lost by sort of 12 weeks or, or even earlier sometimes. So is there, so can I say, based on your paper and then based on papers that have come out since then, that the resolution or the improvement of scapular dyskinesis is not required to improve pain and function?
Filip Struyf:
We don't have any evidence to say otherwise so it's, I'm, I, I'm not sure. I think you can, in my clinic also, I see a lot of patients with scapular dyskinesis and rotated cuff issues, which are rehabilitated towards the rotator cuff problem and they get better. And at the end they go home with, with the same capital, the skins, but they're they're okay. So it's it's, it's really not the, the holy grail, I think indeed, and it's, it might be might be either an a moving pattern that's just different between between people like we, we have different way of walking. We have different way of of moving our our scapula or it's it's yeah, it, it might be a, a thing, but actually and that's the whole idea about, about the scapular focus treatments actually, they're they, they, they make sense in, in ch in reducing pain, because the best that's, that's the thing I said in the beginning, the best scapular focus treatments are those who activate the co the most cause otherwise you cannot have ACAP of focused intervention.
Filip Struyf:
So either you have pain reduction and your, of focus treatment was a great rotator cuff activity, or you don't have pain reduction, but then maybe your focus treatment didn't make sense because you weren't loading the cuff in the right way. So it's the, the scap of focus treatment is defined by a good cuff activity.
Filip Struyf:
And, and that just, well, if, if you go from there, go from there, then it's it it's a waste of time to discuss all the differentiation indeed. So you can, you can discuss that for years, but actually it's it's one system in our body and the, the, the one only works when the other activates. So we, we, we need to let that go, I think. And we can still use it, I think, to, to track progression. Maybe, maybe there is something going on with the, with the load with the load capacity, at what I said early on, maybe there's something on with the load capacity, and we can use this capital as some sort of a trigger. And that reminds me of the, of the papers from Marietta Miller about the, the prediction of shoulder pain when there is scap of dyskinesis going on, whether suggestion was also okay, maybe this capital of dyskinesis is like the, the how we say it, a, the bird in the, the Canary in the mile. Huh? It's it's the first sign, but it's not the can, the Canary is not the problem in the mind's problem. It's first sign. Maybe it's something that you, an idea of there might be something going on, but doesn't, you, you just need to replace the Canary and it's it's.
Jared Powell:
Yeah. And that, that's exactly right. It's, it's not the scapular dyskinesis in isolation. It's when it's coupled with something else. But I like your point in that maybe a scapular dyskinesis is revealing something about the strength of that person's shoulder, and maybe it could be a trigger or a Aine that we need to improve that person's strength and conditioning. However, it may not correct that scap Diskin and the trigger may always remain. So, so that's something that we just may have to deal with. Okay. That's that's I think, I think we can, oh, do you say something?
Filip Struyf:
Yeah, it just it's we, we see that in, in swimmers, for instance, there, a lot of swimmers have scap dyskinesis at baseline, but if you put them in the water, you let them train for, for an hour. Then scap dyskinesis is, is really increasing in incidents. So they go from like 20% capital dyskinesis prevalence to 80% at the end of training. So there is indeed a relation with, with the president of capital dyskinesis and the loading of the system. So that that's more important than, than saying, okay. It's it's there is someone to blame or something like that. Yeah,
Jared Powell:
Yeah, no, that's a, that's a great point. So, so fatigue and load can really sort of make the scap dyskinesis far more prominent, but again, we don't have to correct the dyskinesis we correct the load, right. So it's, it's without getting the focus in the right place. And this is the key point. It's focusing not on the dyskinesis, but on the load tolerance of the system. And I think, I hope we can make that point clear for everybody. OK. So let's, let's move on from that, because we're pretty, we're pretty clear on that. And I feel like we're, we're beating a bit of a dead horse there, but as we discussed a moment ago, we it's clear to us and clear to a lot of people in the shoulder community, but, but, but the clinicians at large, we still tend to focus or on that Essis factor.
Jared Powell:
So we're beating a dead horse for a reason. So what about, what about just quickly for before I take up too much of your time manual therapy? So, so manual therapy for, and I'm gonna, I'm gonna direct this more towards the scapula. I know there's not a lot of literature on that, but just as a hypothetical or a conceptual point manual therapy directed towards structures that are meant to be causing the scapula dyskinesia, like a tight Hector or a tight Trapt or a tight laal or scapula. And I say tight in inverted. S and then what about taping? Just taping have a role to play in the management of people with a scapular dyskinesia, number one, or people with subacromial shoulder pain or rotated cuff related shoulder pain. What do you think?
Filip Struyf:
Yeah, that's that's a good question. Well, from a, from a research point of view, as you, as you mentioned, it it'll be difficult to give clearer and strong recommendations for now because it's it's, it's very complex. It's like our trial in 2013, we're now changing the, the rationale 10 years later. So that's, that's the same for the the use of, of manual therapy, because if you do a trial you will be doing several things together with the manual therapy, and then if the patient get better, we, we never know what really know what, what was the reason for a patient getting better. But of course there is a clinical rationale. And if a patient has a scapula dyskinesis, if a patient has a positive symptom modification test scapula modification test, and you think, okay it might be important.
Filip Struyf:
We don't say it's capital to blame it. We might be important to include the whole the whole shoulder, the whole low training, but really this patient has a lot of tilting and, and a lot of internal rotation. Scap is really very protracted. And it's in that case also related to the patient's job, for instance, he's a, he's an office worker and he is always in that position. Then you might assume, okay, maybe this patient has a, has a tight, minor, or a tight Lato scar player, or OIDs, it's, it's an assumption, of course you, we don't know that, but you, you might assume that and that might play a role in the whole scaffold positioning. It might play a role in the, the position of the cuff then so maybe the cuff will have more issues in that position.
Filip Struyf:
So in that case, from the clinical rationale, you might say, okay, maybe in addition to, in addition to the exercise therapy maybe some P minus stretching or Lavato stretchers, the stretchings might be beneficial. And if we look at at the trials, we do have cause for instance, in, in our trial in 2013, we did also these stretches by, away in the scap of focus treatment, we did a Lavato stretch back minus stretch Andoid stretch as home exercises, all three. And we had, we, we had the effect. So we could, you could also say it's, it's due to the manual therapy that we have the effect. We, we, we don't know that but from a clinical rationale that it might make sense from a research point of view. We don't know actually. And if, if research reveals some success, it's, it's mainly short term the results we don't know whether it has any long term effects, if the patient keeps on doing his job and you can keep on stretching it manually.
Filip Struyf:
But I think a lifestyle coaching would be more beneficial in that case and, and some training that the patient can, can, can do his job better might be a lot of more interesting, but I can imagine it can have some additional additional effects and maybe also in increased compliance a bit. This is maybe a difficult one because I see that that's, that's not, this is not research I'm, I'm, I'm telling you, but it's more if, if I compare, it's a lot of discussions with me and my colleagues doing shoulder patients, that we, a lot of, a lot of them do really do active treatment alone. And and some of them do like 50, 50 manual therapy with, with active treatment. And we see on some somehow that the compliance of the patients where there is also manual therapy in is, is often larger, is often bigger than, than in the, in the active therapy alone.
Filip Struyf:
Maybe it's only in the Belgian population, I don't know, but somehow they the patient feels often more there's more attention on them. And they, they, they feel more understood when there's also some, some passive intervention and they that gives them a lot of trigger to keep on exercising. And if, if that's the case in your patient, everything is good as long as they keep on exercising. And also maybe manual maybe taping maybe taping is something that a patient needs as a, as a reminder that he needs to exercise. And if it's useful, as a reminder to, to exercise is great, but I don't think we can imagine we can assume that the taping will be the the holy grail, the, the golden bullet in its rehabilitation process. Cause that's, doesn't really make, make sense that a tape will, will do the thing. Also from research in, in shoulder pain, patients taping is is, is always had or either no results or a short term results. And the term is really after taping, not, not the day afterwards, so it's really after the, or the minutes after taping. So imagine the placebo also of,
Jared Powell:
And it, yeah, it often just affects pain as well. So it's not really improving function or changing mechanics or normalizing movement or anything like that, right?
Filip Struyf:
Yeah. Yeah. It's not, not only a placebo effect. You can also have some input there towards the, the Summa SOIC cortex by using that tape. So might have a pain inhibit effect. But it's all good. This triggers the exercise.
Jared Powell:
Yeah. I, that's a very good interpretation of all of that. You know, it's bit, it's a bit of an emotional discussion these days amongst therapists in terms of manual therapy and taping and all of these adjuncts, passive treatments, but potentially there is a role and maybe if it reduces pain and as you suggested improves compliance and then encourages people to move on with their exercise, we don't need to talk about the mechanism of action and the neuromodulation or neurophysiological effects all of this stuff. I think the key message here is exercise is probably the champion of the treatment or the central point of the treatment. And other things may just come and go, would you agree?
Filip Struyf:
Yeah. Yeah, exactly. And it's, it's big, a lot of patient specific if you use manual therapy or taping or, or other things, because it can, for instance, it can increase compliance, but on the other hand there's a, there's also the, the other side, of course, that in some patients we don't want to create too much dependence on the, on the therapist also. So we want to, to make them to have self-efficacy of the patient, we might want to make them dependent on their own. And if we do too much or, or we emphasize too much on the manual therapy, the patient might think, okay, he's, he's treating me and I'm doing a little bit of exercises also, but I'm, he's treating me and that's not the, the way we wanna go, but that's really, really patient dependent. I think some will need that and encourage them to train and others it's, it's maybe too much, and you need to reduce it to, to focus on the intervention to make sure they're not too dependent on, on you. But that's the, the, the, the great, exciting thing of every patient is different in your practice.
Jared Powell:
Yeah. And this is what patient centered care is all about. You gotta, you've gotta use what you've got in order to help that person in front of you, just as long as you are doing things for the right reason, you're not creating any dependencies and reducing self efficacy, which suggested then I'm okay for you use what you want use as long as movement is the champion of the regime. I can't even remember the last time I put tape on somebody's shoulder. It would've been many, many, many years ago. So anyway, I think, I think we'll we'll, we'll, we'll stop there. You probably gotta get to work or go for a, or walk the dog or whatever you've gotta do.
Filip Struyf:
That's
Jared Powell:
Good. Thanks for having another discussion with me about the scapula. I hope some people get some value out it and I'll direct people, your paper from, I think it might be very interesting for everybody to have a read. So thank you, leap and enjoy your summer break.
Filip Struyf:
Thanks, Jared. Very nice to talk to you and a very good discussion. I think very important one. Yeah.
Jared Powell:
Got it. Cheer mate.
