Dr. Jared Powell, PhD:
Today's guest is Professor Jeremy Lewis. In the 1990s, Jeremy started a PhD to prove that poor posture causes shoulder impingement and that fixing posture would fix it. He finished his PhD convinced of the exact opposite, and then he sat on that awkward idea for 10 years, rereading his own thesis, looking for the mistake, certain he had to be the one who was wrong. The paper he eventually wrote, asking whether subacromial impingement was a clinical illusion, got him hate mail from physios and surgeons around the world. It also changed the way a generation of us, physiotherapists, and other healthcare professionals think about shoulder pain. Jeremy was also my PhD supervisor, but before that, he was one of the reasons I got interested in the shoulder. So this episode is part conversation, part catch-up, and part deep dive into the world of shoulder pain, shoulder impingement, and his thoughts on current best practice.
Dr. Jared Powell, PhD:
Without any further delay, I bring to you my conversation with Professor Jeremy Lewis. Professor Lewis, welcome.
Jeremy Lewis:
Dr. Powell, hello to you.
Dr. Jared Powell, PhD:
Jeremy, we've known each other for a long time, but we rarely get the opportunity to sit down and, and have a chat and catch up. So I'm gonna use this as a chance to do just that. But before we, we get in and start talking shop, for the couple of people that don't know who you are, Jeremy, can you please introduce yourself, let the audience know who you are and, and what you're doing these days?
Jeremy Lewis:
And do you want a truthful version or, you know, the one where - Truthful fan -
Dr. Jared Powell, PhD:
Followed by.
Jeremy Lewis:
Not my fantasy that I was one of the first astronauts on the moon and you don't want that one. No. No,
Dr. Jared Powell, PhD:
We don't want to hear about that stuff.
Jeremy Lewis:
You want the truthful one. So I was born in New Zealand. I moved to Australia. I did physio at Lincoln. I did the one year postgraduate minip therapy course. Jeff Maitland, we were lucky Jeff Maitland came across from Adelaide. I did a Melbourne, he came across and he taught a couple of times. So that was a privilege. Did the sports course a year later in Western Australia, got harangued there by Peter O'Sullivan, didn't like him for about 10 years, although we eventually made up. Then I moved, , to the United Kingdom in 2000. The plan was to live here for a year, but there was so many lovely opportunities. It was actually lovely living in Europe in the days pre-Brexit. , It was an evolution actually for, in our profession. So as soon after I got here, we were allowed to start referring for imaging and blood tests and then with a bit of training, nine months training to do joint and soft tissue injections.
Jeremy Lewis:
We, , many of us, they allowed us to do extended ultrasound courses, so a year and a half of ultrasound. I was allowed to integrate ultrasound, diagnostic ultrasound into clinical practice. Probably took longer to learn therapeutic ultrasound than that. And, and then 2013, they changed the law again to allow us with a year's training to prescribe any medicine that there was an evidence based for that could support patient care. Of course, with some exceptions, things like controlled drugs. And we're not allowed to, my knowledge, not allowed to prescribe cosmetic, medications for cosmetic purposes. So, so this is all real. It's not, it's not enhanced by Botox or anything like that. Yeah, so it's been a real interesting evolution. And, and I work two days a week clinically in the National Health Service here, and I work a couple of days a week in a couple of universities as professor of musculoskeletal research, supporting 10 PhD students.
Jeremy Lewis:
But none have been as good as you, Jared. I probably shouldn't say that should I. And yeah, , they, they're all equally good. Everyone's equally good. , I do my own research and also a bit of consultancy here and there and teaching a course for another few years and then I won't be teaching it anymore.
Dr. Jared Powell, PhD:
Awesome. What do you like to do for fun? What does Jeremy do for fun?
Jeremy Lewis:
Jeremy is rubbish at playing guitar, but loves playing it. Jeremy loves doing boxing and martial arts, but is always the first one on the map. Not meaning to be. He loves gardening. He's okay with that. , He loves being with his family and friends. And I love cooking, but nobody likes to eat my food. Usually when I cook, my children say, "Can we please get some takeaway, dad?" So I live a, live a very difficult life, Jared. I can relate to
Dr. Jared Powell, PhD:
That. Yeah. Pleased
Jeremy Lewis:
To be able to share this with you.
Dr. Jared Powell, PhD:
And this is the important question. So you have New Zealand heritage, you have Aussie influence, and you're a naturalized Brit. So are you an All Blacks fan? Are you a Wallabies fan? Do you go for the Australian cricket team? Do you go for the English cricket team? Where do your allegiances lie when it comes to sport? ,
Jeremy Lewis:
You should not have asked this question. This is a question that it takes months of lying with psychiatrists. So my rules are very definitive for me. If it's rugby, the All Blacks have to win. If it's cricket, Australia has to win. If it's, unless they're playing England and then England has to beat Australia, which I know is not probably gonna go down well on this podcast. I've got a whole lot of rules about which team to support depending on which sport. It's very confusing, but it's very ingrained and I don't know where it came from.
Dr. Jared Powell, PhD:
And you're not gonna change either.
Jeremy Lewis:
The English
Dr. Jared Powell, PhD:
Cricket team is an interesting one. That's probably been a tough, tough 20 years maybe. That was a good period there for a little bit. The All Blacks must be nice to support.
Jeremy Lewis:
Yeah. Well, yeah. I mean, that, that, that. I think it's, I think the sport and the team you follow is sort of p - becomes part of your DNA as a child, maybe. Agreed. Yeah. And then sort of following my parents to Australia and then making a decision to go to the UK and - Mm. And getting influenced by other people. It just sort of, like, everything seems so. DNA seems so diluted and confused and so I have to make my own rules. Mm.
Dr. Jared Powell, PhD:
No, I like them. My, my father is a New Zealander, a very, very proud All Blacks man, which is interesting. So I was born in Australia. My brother was born in Australia. My brother is an All Blacks fan, and I'm a Wallabies fan. So we both have the same upbringing, differently influenced by my father. So it's been a fascinating journey. Is he
Jeremy Lewis:
Older or younger?
Dr. Jared Powell, PhD:
He's older. So maybe that's - Right. Yeah. Maybe I did it to rebel, but it's, , I wish I chose the All Blacks .
Jeremy Lewis:
Talk to, talk, talk to us more about this, Jared. I think, I think this is an opportunity for you. No, no.
Dr. Jared Powell, PhD:
No, I'm sticking with Australia. We've got the World Cup here next year. I'm very happy with it, and we're gonna win it.
Jeremy Lewis:
Okay. All right. Good.
Dr. Jared Powell, PhD:
Good luck. So, so I understand where you're coming from when it comes to sport. That's good. I'm sure the listeners wanted to know all about that. Thank you for the clarity you've provided. Jeremy, I wanna go to the shoulder because you are the, the original shoulder man, and you've, you've been my biggest influence. You've been my biggest influence, not just in terms of the shoulder, but more broadly in physiotherapy in terms of your writing, your thinking, your, your critical acumen when it comes to looking at the literature and getting interesting and different lenses to look at and not just going down the same group think pathway that a lot of researchers go down. And that's not any shade at anybody. I'm trying to just communicate what I like about your work. And I still remember 15, 16 years ago, Jeremy, when I read your f - your pa - one of your papers for the first time, it would've been 2010.
Dr. Jared Powell, PhD:
I was a student, a physio student, and I read your rotator cuff continual model, the application of the continual model to rotator cuff tendinopathy, , from Jill Cook and Craig Purdom. And I was in a ca - I remember sitting in the cafe. The cafe was called Blackboard Coffee. And I read this paper and I though, this guy's all right. Who's this Jeremy Lewis character? And then I followed your work over the next decade until we, until you were my supervisor for my PhD. And it's funny, I still do remember that moment. But the paper that really influenced me was about a year later on shoulder impingement. And I can't remember the exact title and perhaps I should have prepared a bit better and, and learned it, but - You
Jeremy Lewis:
Really should have, Jared.
Dr. Jared Powell, PhD:
Yeah, I should have. Is it a clinical illusion or su- subacromial illing?
Jeremy Lewis:
Yeah. I, I think it was, oh, there's a cou - there was a couple. There was one, bedrest for back pain is subacromial impingement a clinical illusion. Mm. And then there was another one about clinical illusion. Not, not very, . I used the word illusion a few times. And th- thank you very much for your kind words, but actually, I would say, reflect them right back to you. I think your writing's amazing and I think your philosophy is amazing. And I've learned probably more from you than you've learned from me. And, , and - Oh,
Dr. Jared Powell, PhD:
Just, I disagree, mate. And I won't entertain that. No.
Jeremy Lewis:
Yeah. No, you, you really are pushing boundaries and thoughts with your philosophy and writing, so hats off to you. Oh,
Dr. Jared Powell, PhD:
Thank you. I do apprec - that's means the world. Thank you. Can we talk about - My
Jeremy Lewis:
Birthday's in October. Can we talk
Dr. Jared Powell, PhD:
About how you arrived? Okay. I wanna talk about where you were in the early 2000s with respect to shoulder impingement, and I'm doing quotation marks here. Where were you in the early 2000s? And then what happened in around 2010, 2011, whenever it was that led to this perhaps about face. Now, I don't know when it happened for you, but tell me this evolution of thought. Describe it for us. Take us back to the early 2000s, Jeremy. If we all close our eyes, we can go back to that glorious time in the early 2000s.
Jeremy Lewis:
When I didn't have a mobile phone. Yeah, I had a phone connected to the wall in those days.
Dr. Jared Powell, PhD:
So
Jeremy Lewis:
My early part of my career, and that was sort of like evidenced by this desire, it was really hard to get into the manual therapy course in Melbourne when I did it, because I, my plan was to be the best fix-it physio you could possibly be. So I did the minip therapy, did the sports therapy, then did the biomechanics diploma in Strathclyde in, , Scotland, because I though if I could put all these things together, I would be, it would be sort of a f- formidable. , You know, you'd be able to help every patient that comes in. I remember, , I was let down the first patient I treated after finishing the nips, actually made her much worse. I think she went to hospital. , So I sort of let myself down a little bit with that. I still feel very guilty about that.
Jeremy Lewis:
And then I decided time to do a PhD. It was about after master's in 97, so about 97-ish, I would started thinking about doing a PhD. And I though I'd do it on the foot and ankle because I'm really interested in the foot and ankle. And then, , for some reason, I s - decided no, my contribution to the world is to demonstrate that posture, poor posture causes impingement. And when we improve posture, upper body posture, we can alleviate impingement and turn the world into a happy place for people with impingement. And so I think you said once, I think public, so I'm, I'm not saying anything secret. I think you said that, you know, during your PhD, y- you lost all, you f - you finished losing all your hair. I, during my, during my PhD, I lost my mind, which is much worse because as I got deeper into the exploring postural theory, the question was where, what is it based on?
Jeremy Lewis:
And, you know, you sort of, you go back 150 years to a cou- couple of German, I guess you call them biochemists, who sat down, I guess, over some schnups and just worked out when a joint's in this position to that position, it, , you know, it's perfectly aligned. And so they came up with all sorts of ways of constraining children and braces and whatever to, for them to do their homework in. A- and I think that's sort of like a modern origin. I mean, we've always been interested in posture, the ancient Egyptians were, Greeks were, the ancient Greeks. I, I think it's always been around, but the modern version started 150 years ago and it's just sort of seeped into our DNA. And of course, you know, if you go back to the 1972 paper written by Charles Near, where today when I read it, I'm thinking, well, I, if I'd known what a blog was when the first time I read it, I would have said, "This is a blog, this is not science." But when I first read it, of course it was science because it was published in a scientific journal, but the truth is it was an opinion piece.
Jeremy Lewis:
As I was going through my PhD, which I finished, I think in 2001, I got the o - the other end saying, "Well, there's no thing, there's no such thing as postural theory supported by research and impingement doesn't really exist." And I kept that to myself because I was certain that everything I'd done was incorrect, even though I passed my PhD. And it took me about 10 years to have the courage to write that illusion paper. And it was an interesting response. I, I got a lot of hate mail or hate comments, hateful comments, I guess is more appropriate from physios, a few from surgeons. After the second paper, which is an editorial for BJSM, and I presented at some conference in Edinburgh with 1500 shoulder surgeons, a very well-known French orthopedic surgeon basically jumped on the stage and took the microphone, and I though, "This is it.
Jeremy Lewis:
This is the end of my career, possibly the end of my life." But, , he actually grabbed the microphone and said, "This Lewis guy is right. , You know, we shouldn't be operating on this condition." And it was sort of like all of a sudden all the tension went out of, you know, wherever the tension is in your neck. And, , and it was sort of like being vindicated, if that's the right word. And he said, "And we're going out to smoke cigars and drink whiskey tonight and talk about this." We never went out to drink whiskey or smoke cigars or talk about it. But it was, you know, helpful. And, and then a few years later, I presented it to a group of, I think about 500 orthopedic surgeons in the States. And that always scares me because they're second amendment as they can walk around with guns, you know, so you spend the whole lecture looking for the laser, when's it gonna come?
Jeremy Lewis:
And, and a few people said, "Yeah, this is good synthesis of the literature." One guy came up to me and said, "You're condemning your patients to a lifetime of misery." Because at that stage, I was also starting to question the validity of repairing non-traumatic rotator cuff tears that were lateral to the rotator cable, you know, especially in supraspinatus, 13% of the rotator cuffs, how are most, a lot of the surgery fails, but people still have very good outcomes. You can be a professional baseball pitcher with a tear, full thickness tear in your tendon for five years and be pitching it up to a, you know, 160, 170 kilometers an hour with incredible precision. Yes, doing it in pajamas, so there's a yin and a yang about everything. But, you know, so just things didn't make sense. And then I guess the next layer was structural theory.
Jeremy Lewis:
You know, we spent so much time as undergraduates learning to identify the structure and then fix the structure. And then I learned that also big time in the minip therapy course and then the master's course I did in the UK. It was very much based on structural theory, but how can you have a theory so definitive when so many people are walking around with asymptomatic tears, labral tears, tendon tears, calcification in the other side of their body or a comparable group the same age? How can it be so definitive? There's no MRI that rings a bell or flashes a light that says this is causing symptoms. And so I, my world really became very confused and it probably took me about 10 years to start articulating what I'm sure you could have done in a few months, but it took me a long time.
Dr. Jared Powell, PhD:
So that's amazing to me that what I want to explore here out of that amazing story, thank you for sharing that, is how do you feel - This is
Jeremy Lewis:
Between you and me, right? No one else is gonna hear this. No, no,
Dr. Jared Powell, PhD:
Just a few thousand clinicians will listen to this. How, how did you hold that information for that decade? Were you working or what, were you writing something in the background and iterating upon it and improving it and editing it and doing your own research or was it in the back of your mind? And when, when the situation, you know, one night you though, "I've just gotta write this bloody thing and get it off my chest." What did that decade feel like and what in the end prompted you to actually publish it? I
Jeremy Lewis:
Was sure I was wrong and I read my PhD thesis and the papers I published too many times looking for the mistakes. That was the early part, 20 to 2025. And I'm still not sure, you know, because we don't have enough evidence to really be positive about anything, as you, as you know very well from the things you've been writing. The, 2007, Dr. Hinkes, he's a orthopedic surgeon in the Netherlands, published a paper. I think they took 56 people with impingement and randomized them to a group that had a subacromial decompression and a bursectomy and another group that had a bursectomy and there was no difference in outcome at two years. And subsequently, their 12-year follow-up showed no difference in outcome. And I had a good friend who's an orthopedic surgeon, who was an orthopedic surgeon, and we could talk about a lot of professional things.
Jeremy Lewis:
You know, we knew each other socially, but, , but we talked, I'd say, more deeply with him than anybody else in my career about, tell me when you go to surgery, what are you doing? What are you believing? And, and, and he said, you know, I, I really think, he didn't say exactly in these words, but, you know, not that you opened my eyes, but, you know, I'm a technician. I use these tests. I do this surgery. I never understand why some people say it's good, some people say it's bad. And we've learned a lot since then why some people will respond to the, differently to the same treatment. And he said, you know, I think that it's probably quite unnecessary surgery. And then Sarah Katola, very influential orthopedic surgeon in Finland who's influenced my career a lot, made statements about, you know, there's no need based on her PhD work and her clinical practice that she can't justify doing a subacromial decompression.
Jeremy Lewis:
And then the UCAF trial, which I was involved in, which in the, in the data monitoring group didn't seem to suggest that repairing the tendon, you get good clinical outcomes, but it doesn't really seem to associate with the success of the repair. Everything started that didn't make sense to make more sense. And then started, you know, thinking a lot about with the introduction of CT and MRI in the 1970s. And I know when I left Australia, you know, if you could get an MRI, you were the luckiest person in Australia because it was gonna answer all the questions about where your pain was coming from. And then I think on the plane to the United Kingdom, because I had a research job and I wanted to be really up-to-date, I was reading this paper done by radiologists who compared people with and without pain on an MRI and said exactly this, 52 to 55% of peop - you know, 52 in the asymptomatic group and 55% of people symptomatic group had rotator cuff tears.
Jeremy Lewis:
And they said, as radiologists, tears relate to age, but don't relate to pathology. And I was like, who's put legal s - hallucinogenic substance in the water I've been drinking on the plane? 'Cause It just didn't make sense to me and I just could not understand what I was reading. And then I guess after that, it just started to gel that, you know, maybe this experiment with, in non-traumatic presentations, this need to find a structure and fix it, maybe it's a failed experiment. I, I still don't know, and I won't know when my career comes to an end, but that's how I go to work. It's not, the structure's not important. It's the identification of red flags. It's the shared decision making. And I think our profession can offer amazing help to people if we move away from a structural perspective into a functional perspective, sort of where we were in the 1950s, helping people after the Second World War and treating kids who unfortunately had succumbed to the poliovirus.
Jeremy Lewis:
We were not a. It was about function, you know, how can we help this person return to their valued activities and how can we even exceed their expectations if possible?
Dr. Jared Powell, PhD:
Yeah, you're right. I went down a little bit of a, a rabbit hole on the old Swedish gymnastics where, you know, our profession has roots in and - uh-huh. Looking at their model of care, and it's kind of better than, than what we promote in a lot of senses today, or certainly a decade or more ago. So that's interesting that we, we regressed for. You know, there's been, there's, there's always schools of flawed and different countries do things a slightly different way, but it was, it was actually quite shocking to see how good some of that practice was. And I'm okay actually with. Because a lot of this stuff, '70s, '80s, '90s maybe, was the advent of we had technology right, Jeremy. You, you're very interested in medical history. We had things that came out where we could look inside the body and we started to be more empirical and we looked at deficits and things that we could see and then philosophically or ideally we could correct.
Dr. Jared Powell, PhD:
And I'm okay with us running that experiment for a period of time. But now we have a significant critical mass of evidence that suggests that model, now I'm not gonna say wrong, is, is near enough wrong that we must do something to change our practice. And I think we have to go through these things, right? And I think medicine more broadly is starting to contend with that. Whenever I talk with surgeons now, they're starting to contend with the idea that, you know, , there's surgeons now in Australia, as you know, Ian Harris and the like, who is actually openly talking about the placebo nature of some elective orthopedic surgery. So it's. I, I, I think it's justifiable that we, we pursued a particular avenue of inquiry and now we're humble enough to change our practice. Would you agree with that? Yeah,
Jeremy Lewis:
I think it's beautifully summarized the last 20 years. I mean, I'm not saying we shouldn't operate. I mean, I, I've been accused of it. I mean, you said it, but to me, it would make sense if there are, if the limited, little bit of research that we have seems to suggest that when you compare, as best as we're able, expensive surgical elective surgery followed by, often associated with a lot of post-surgical pain that people aren't aware of, that is also associated with quite a few weeks, sometimes six weeks of immobilization where people may be also not as aware of that as they, they might, should be, followed by at least three months of rehabilitation. When you compare that just to rehabilitation over the same, you know, 12-week period, outcomes aren't that different. Now, we don't have natural history to compare it to, so the question still is, are we babysitting patients while they.
Jeremy Lewis:
I, I think it's the biochemistry restores homeostasis. That's where I, that's where our research is, some of our research at the moment is going to. Mm. Because it's not the macro structure that's being fixed. And we're certainly not fixing the macro structure in our profession. So if we are having a benefit, whether it's what we're doing clinically or it's time or a combination, there's not a lot le. I know it just probably doesn't sit well with pain science, but I'm also not convinced that we've got all the answers in pain science as well, you know, that seems to. There's, there's a lot of uncertainties in pain science even though it's sort of sort of like manual therapy was a few years ago, fait accompli it was - Mm. But I'm sure the story's still yet to unfold. , So, , probably still a dinosaur in terms of thinking that a lot of the pain is generated in the periphery and not necess.
Jeremy Lewis:
Maybe it's the sensation of it, the perception of it is enhanced by your mood, your brain, but I think it's generated and, and what could it be in the periphery? It's not the macro tears, the things that we can see, it's possibly the biochemistry. Mm. So in my, my way of thinking is if there's two treatments and one's faster and cheaper, and it's likely to produce the same outcome, surely you should prioritize that. And the little bit of money you save, that could be going to cancer research or it could be going to homeless people or better education for children or whatever, you know, as a society. So the question is, if there are two treatments, one's more expensive and slower, why would you be suggesting that to a patient before you try something that's faster and cheaper? Who's benefiting from that advice? Mm. 'Cause Ultimately, we're all using the same research for our shared decision-making, and shared decision-making should be presented in the most unbiased way possible, almost like a third party should be presenting the shared decision-making.
Jeremy Lewis:
It's almost like watch this video of, you know, you've got rotator cuff-related shoulder pain, watch this video presented by bias actor, and these are your options, and, you know, we can talk about any uncertainties you have after you watch the video, and we, we can work together as to what's the best treatment way for you to move forwards. I don't know if shared decision-making's working the way it should be working, which is a meander from your question. Yeah, no,
Dr. Jared Powell, PhD:
That's good.
Jeremy Lewis:
Allow me to meander. I
Dr. Jared Powell, PhD:
Will allow it, but I'm gonna keep you. I'm gonna get you back on track always. So let's say 2011, 2012, 2013, landmark few years for you with your impingement story. How did you feel in the next five years when evidence just kept coming out confirming your hypothesis and your work and verifying that this is the beauty of science where, you know, it's a collegial enterprise. It's an international enterprise. You put out a paper, you put out a theory, and then other research groups around the world verified it independently. How did you feel, you know, and I'm not trying to, like, I don't want you to say I was just. I felt amazing. I felt like the most smartest person in the world or whatever, but I think it would be remiss not to talk about that because it's a pretty cool thing to have that thought, put it out into the world, given that you were, had extreme self-doubt about it for a decade, and then the next decade, everything seemed to verified your fairly tentative hypothesis at the time.
Dr. Jared Powell, PhD:
So
Jeremy Lewis:
Y- you're actually the very first person to ever ask me that question. And, , it scares me, that question, because when the paper started coming out, of course, there was a sigh of relief, and I was thinking about a lot of the people who live in their lives in social media who are a bit nasty, and I was thinking, "Okay, well, this is proving a point." But, but I spent also a ridiculous amount of time reading those papers looking for the mistakes, to be honest. I really looking for the mistakes like I was doing with my PhD in papers. Where were my mistakes? Where were mys? This can't be right. You know, so many people, millions of people have had their acromion chopped off based on the seven - 1972 blog. There must be s - you know, for it to last so long, there must be some validation to it.
Jeremy Lewis:
You know, and maybe there are a group of people that do benefit from it. I don't think we've anywhere near been able to diagnose them if there are a group. But every paper that came out, every paper that said, compared subacromial decompression to placebo, whether it's a true placebo or the best placebo that could be offered, showed no difference. Every paper that was published that compared subacromial decompression, immobilization, rehabilitation to rehabilitation at one, two, five, 10 years now, follow-up, 12 years. , If we look at the Hinker study from the Netherlands, not that it was comparing rehabilitation so much, none of them have, have actually shown there to be a value to the surgery. And so, yeah, I think it. If you take it from a scientific perspective, you propose a hypothesis based on the best evidence you can do. And I'm sure that's what Neer did.
Jeremy Lewis:
Near in 72 proposed his hypothesis based on what had come before him. So people before Neer were removing all the acromion, all the lateral acromion, but Neer said no, based on his observations, it's only the anterior inferior surface that needs to be removed in the acromioplasty. So he wasn't. You know, like everybody progresses from somebody else and, you know, bravo to him for having a hypothesis. So everyone has a hypothesis, and sometimes it's correct, sometimes it's not correct. I don't know if you can use those words in science, but you know, you know what I mean? And I was just pleased that at least once in my life, I had some thoughts who were more coherent and came together in a, in a way that, that made some sense. But I was scared when people were publishing, because I was just thinking, "Where are their mistakes?" But today, you know, sometimes when I teach, I have orthopedic surgeons in the course, not often, but sometimes, you know, I have no trouble with asking the question, "If a member of our society comes to you seeking care, help, help for their painful shoulder and you diagnose impingement, and you're recommending that a subacromial decompression is the way forwards, you know, what characteristics of that patient give you the confidence to say that this is an appropriate procedure to offer?
Jeremy Lewis:
What evidence are you using? You know, where are you drawing that suggestion to the patient from? Because I don't see where there is anymore. And more and more, I'm seeing the same thing for elective surgery for non-traumatic rotator cuff repairs, which in the UK, and I presume Australia, is nearly all in the supraspinatus, you know? Like I said, 13% of the rotator cuff's power that it doesn't seem. The repair doesn't always seem to be the important thing for a patient to say," I'm so pleased I've done this. "Yeah. And I'm sure you've thought about this as deeply, if not more, in different ways tha- than I have. Yeah, very similar thoughts. , I also wanna share
Dr. Jared Powell, PhD:
In. I don't wanna bash Charles Near either. I think the, the Isaac Newton quote comes to me now where," If we have seen further, it's through standing on the shoulders of giants. And, and I really think that, you know, like, I think good on him for 50-odd years ago for proposing a theory, for proposing a treatment, you know, writing up some results. Doing a case series on it, like that's what science is. And so it is our responsibility, the descendants of that, to progress it. And it just happened to be a slightly different theory. So yeah, I don't ever wanna like. I, and I hope, Jeremy, I hope we're wrong in the future as well, right? Like I don't think this is the final word and I think perhaps, you know, the story is. I think it's an infinite process and we're always gonna be refining and changing things.
Dr. Jared Powell, PhD:
I think it'll be. In fact, I, I would view it as a triumph if we are found out to be wrong and we have a better way to do things in the future, which brings me to. So we've been through impingement. Then in 2016 you proposed rotator cuff related shoulder pain. Now, I think that's the, the 10-year anniversary this year, Jeremy, so happy anniversary. Can you describe that? And then, like, were you searching for a few years for that term? So I know that you published under rotator cuff tendinopathy in 2010 - ish with that paper that I was referring to. Did you use subacromial pain for a bit? How did you land on that term? , Can you give me that backstory, please?
Jeremy Lewis:
Okay. Yeah, well, it's 10 years. So I personally have. When I, when I, when I've experienced back pain in my life, I know that it would be classified as non-specific low back pain. And I'm thankful that when I go through in my head, do I have any red flags? I don't identify any. So I know it's probably gonna get better with a bit of walking. Sometimes I've really valued colleagues at work doing manual therapy on my back. Hard. I've really valued that because even though it's short-lived, the short-term benefit of that pressure-based treatment is sometimes keeps you up straight for a few hours and, you know, it feels so much like quasi-moto. And, , you know, so, so there's value to it. But I never sat comfortably with the term non-specific. I understand that it's al- almost impossible to come up with a structural diagnosis, but patient comes in and say, "You've got back pain.
Jeremy Lewis:
I've got back. How can I help you? What. Tell me your story. You've got back pain and you spend half an hour talking to them, doing all these fancy physical examinations, and yep, you've got non-specific back pain." So they're actually less diagnosed by you than they were by themselves. During my PhD, I had two folders. I had a folder called Impingement Syndrome and a folder called Rotator Cuff Tendinopathy, where I was putting my physical papers. And I got so confused, Jared. I didn't know half the time where do I put this paper? Does it go under impingement or does it go under tendinopathy? So sometimes I print them twice to put them in both folders. And I just got confused about the terminology. And then you read people like Hillary Mantel, which some people may know her. She's a, unfortunately passed away a few years ago at the age of 70.
Jeremy Lewis:
She's a very famous British author. She writes historical novels. But she's also a person, as you know, in papers you've written and stuff written with Paul Minkin and others. She writes things about. She, she suffered from persistent pain for a lot of her adult life. And she writes so eloquently. She wrote so eloquently about pain as others have. You know, the book you. The shoulder book that you brilliantly contributed to some of the patients who wrote in that book, you know, we learned from them about their experiences in healthcare, you know, and, and I guess the worst pain is the undiagnosed pain is a theme that comes out. And for Hillary, she would say things like, write things like, "If I'm suggested a treatment, but it doesn't make any sense to me based on why I've got my symptoms, I'm never gonna do this treatment, whether it's whatever." And so I guess a lot of those things, not knowing where to put the paper, which folder, patients wanting to make sense of their pain, the nociceptive concern about a pathoanatomical diagnosis that in my world no longer made sense to me because there was no such thing as impingement.
Jeremy Lewis:
And how do you know that the tear, the rotator cuff tear or labral tear is, or biceps tendinopathy is causing the problem? How do you know that? With certainty, we can't. And the, the 95% of people I see who present without trauma. So I needed a word. I needed a, as not, as non-pathoanatomical as possible that sounded like it could be used to say, based on what we've talked about, based on the assessment that we've been through together, it's likely. So I never say to a patient, "You've got frozen shoulder, you've got rotator cuff load shoulder pain. It's likely you have this condition and the rotator..." So I can then easily say. And so I'm not saying impingement or tear or itis. And so, because if you Googleize all of that, straight away you see injection surgery, injection surgery, et cetera. So I needed something that a patient could hold and that, you know, that could also explain, you know, the, the rotator cuff are the muscles and the tendons that hold the shoulder and move the shoulder and what do you know about muscle and, you know, why do people do exercise?
Jeremy Lewis:
What's the benefit of exercise? And so it sort of helped together with some of the assessment that I do, such as. So I don't do a lot of isometric testing around the shoulder. I do repetitions to fatigue or repetitions to pain. Two PhD students at the moment are looking at aspects of that, as you know, as you, as you've helped with, with one of them. Thank you. And so I think, you know, if you talk about muscles and tendons, you've shown there's a different side to side about with repetitions to fatigue, you know, let's talk about how we can bring this, the sore side up to the level, the functional level of the side that we're comparing against. How are we gonna improve the muscles and the tendons in the shoulder? And you can talk about exercise as being one way to do that. , You know, but I'll also talk about the, the importance of sleep and not smoking and being careful with alcohol and looking after your diet and all the other important things as well that we know can influence outcome.
Jeremy Lewis:
I can't influence social determinants of health, of course, but, you know, the things that we can modify, those things become part of the package. In my head, I rejected subacromial pain syndrome, which I know a lot of people prefer because it's just complicated. You know, what is the subacromion? Where is it? And what's in it that's causing my pain with the questions when I did use it clinically, because I thought, you know, that was the great advance of not using impingement or tear, was to use subacromial pain syndrome. So the feedback I was getting from patients is, well, where is this place? Some people, where is this place? What's in it? And what is the structure that's causing my pain? So I was none the better. I had an advance. I though I was, but I had an advance from the more difficult pathoanatomical diagnosis.
Jeremy Lewis:
So I don't know, I was probably vodka one evening. I don't remember exactly when, but I thought how, what could be something that makes sense that is not too pathoanatomical? And that's the best I could come up with. And I'm sure, like you said 10 minutes ago, and you're right, there'll be a better term in a month or five years or 10 years or, you know, my grandson and your grandson will be having a conversation when our grandfather's sort of like, you know, they made an effort to, to whatever to come up with some ways to help, but they were so wrong like we talk about near now. Of course, that will happen. It's how we advance as a, as a society and as a species.
Dr. Jared Powell, PhD:
Yeah. I agree with the subacromial contention also because when you Google subacromial, guess what comes up? Subacromial impingement immediately. And they're back where they started. So I, I think that's very limited. And I, and I do believe we should speak in a way that is clear and coherent and relevant to the health literacy of the patients that we're seeing and what subacro - it's a meaningless location. So fully agree there. How do you view rotator cuff related shoulder pain now and how do you explain it to your patients and how, how do you communicate it? And what does it look like in clinic versus what it looks like, , in your academic work?
Jeremy Lewis:
Okay, thank you. So I also now use the term biceps-related shoulder pain as well. If I hypothesize based on the patient's story, based on the best configuration I can do, which is not great, clinical, physical examination, you know, it's biceps-related shoulder pain is against biceps tendinopathy, biceps tendinosis, whatever. And what I think is happening in my head, it's an overload situation, and it's overload because of physical overload and/or lifestyle overload. And we obviously can't address the non-modifiable risk factors. So the biggest risk factor for shoulder pain is turning 50. Number two is diabetes. Number three is prolonged overhead work, because from, you know, from. I mean, we can talk about nuances and different studies that might say things slightly differently, but that's what sticks in my head, those three. So, and then there's a whole lot of others. You know, we can't, at the moment, in clinical practice, influence genetics or, you know, choosing the wrong grandparents or whatever else that.
Jeremy Lewis:
The things that are not modifiable, for me, is what also is in my head academically, clinically and academically is similar, but I don't go to this level unless the patient really pushes me. I think what's going on is that the overload, whether it's a little bit too much smoking because of stress or not sleeping well because of stress or too much physical activity or some Venn diagram combination of both has changed the biochemical homeostasis. Well, it's taken the, the tissue out of homeostasis. It's. We've got more substance P, we've got more pro-inflammatory cytokines in the tissue. Yes, of course, the macrostructural changes as well. What's actually stimulating free nerve endings to cause pain? I think it could be biochemistry. And then I know I can't influence the non-modifiable risk factors to try and restore homeostasis. I would try and do whatever I can, improve sleep, exercise.
Jeremy Lewis:
We know exercise reduces substance P. We know substance P and some studies, earlier studies from our Japanese colleagues suggest there's more substance P in bursal tissue in people with shoulder pain, and this seems to be a almost direct correlation between the concentration of substance P and the amount of clinical pain people talk about. Of course, we need to do more of those studies and we're continuing some of that research in Sweden and Poland at the moment and you're gonna be involved in that. So I would explain it to patients in that way, that part of the pain is coming from chemicals in the tissues that are causing symptoms. And the really good news is that there's a lot of things that we can do. It's gonna take some time, but there's things that we can do together and, you know, we can form a partnership, we can form a team and, you know, things I can do, things you can do, and we'll, and it won't be a linear improvement.
Jeremy Lewis:
It's gonna be a bit bumpy and we'll work out together how we can get this as good as we can. I, I never use the words better because not everybody gets better, but get the best outcome we can. It should take around 12 weeks. So in my head, it's biochemistry. Again, probably a wrong hypothesis, but that's sort of where I go clinically as well. I do discuss that with patients and I really, really think, of course I'm biased, and of course the survivor bias as well. I really think people get it, especially if you draw and show them and explain to them, you know, and this is how sleep could impact on this and has this positively and negatively, and this is how nutritional choices could impact on this positively and negatively as well. A- and so it, it seems to work. And I love, I love still going to clinic and I love.
Jeremy Lewis:
It sounds a bit weird, I know, but my best days are the patients who have maybe had a lot of physio before injection surgery, are confused, have been given multiple diagnoses. And I often will say that, you know, this might take a year, but let's plan for what you're going to do, be doing in a year, and let's talk about the cycles to get there. Now, I don't have better outcomes than anybody else. No one does. I never believe anybody anymore who says their outcomes are better than. You know, I can't compete with the social determinants of health. I can't give people financial stability, a green space to live in, access to good quality healthcare easily all the time. You know, all the things that in education, I can't give people that. So I don't believe I get better outcomes, but what I love going to work is I'm not going to work thinking I can fix you, but I go to work, which I used to do a million years ago, but I go to work thinking, what are the things that we can modify?
Jeremy Lewis:
What's in the patient's gift to give themselves with the behavioral change that they need to do? And let's just salami slice or cucumber slice if they're a vegetarian, a treatment that, you know, hopefully over time gets the person to their valued activities. And hopefully, my plan is always to try and exceed that, you know, don't always succeed.
Dr. Jared Powell, PhD:
Beautiful. I love that. I love moving away from the find it and fix it. The, the way I think about physio is we're almost creating the conditions to allow that person to flourish where, you know, we're bringing an optimistic narrative, we're removing fear avoidance, where behavior change, what have you. And it's like just creating those conditions to allow that plant to grow and, you know, like, it's a different way of thinking about things, but I quite. And maybe it's a bit woo-woo and a bit alternative, but I quite like it. And, and, and you're right with the, with the rotator cuff like that. But
Jeremy Lewis:
Sorry to interrupt, but you as interested in mechanisms as I am, maybe you're even more interested in mechanisms. Mm. You know, and, and research that you've done, you know, to. As best as we know today, the mechanism of improvement is not necessarily improved strength. Not that improved strength is you write and correctly all the time. It's, you know, a great gift you can give an older version of yourself. It's so important to s - to help reduce sarcopenia and all the problems that people my, my age are, are facing. And, you know, who knows what's gonna happen to me next year. But, you know, but that's not the mechanism of why people say, "I feel better after 12 weeks." It's just not physiologically doable to hypertrophy in that time, especially for people who are older with comorbidities and haven't done much. And so, you know, I think your exploration through your PhD and through your philosophy, you know, it's also helped me have more confidence in what I'm doing as well.
Jeremy Lewis:
So it, you know, it's symbiotic. Everybody's helping everybody else to come to some sort of understanding for themselves how they can work clinically to try and help people who seek care.
Dr. Jared Powell, PhD:
Yeah. And I think it all comes down to explanation, which is the investigation of mechanisms because if we don't know, if we can't causally explain how our treatments work or how pain generates, then we're just throwing at a wall all the time and randomly something will stick and the next time it won't. And then we're back to just doing how come three sets of 10 works on this person and how come it doesn't work on the next person? Do I put this in the rotator cuff tendinopathy folder or the subacromial impingement folder? It's fifty fifty, right? And so I think we have to develop this in research I'm talking about here, not so much as clinicians, we need to be able to understand how and why things work. And as you. That was the topic of my PhD, and that's, I think, it's starting to gain momentum now.
Dr. Jared Powell, PhD:
Chad Cook over in the US is doing a lot of work in this area. Aiden Cashen down in Sydney, who's a master of mediation analysis is doing a ton of work in this area. We're starting to actually figure out how and why these things work. And when we've looked, our treatments are working not because of what we thought for 20 years, and that is something that we have to come to terms with, and not everybody's happy about that, as you know. But that's the reality of things. And I think it's a beautiful thing. I think here we are, we're looking at. Like in the philosophy of medicine, the study of causality has been pondered for thousands and thousands of years going back to the ancient Greeks. And here we are in the physical therapies in the 2020s, we're just starting to think that maybe it's a good idea to look at it.
Dr. Jared Powell, PhD:
And I know we are a young profession, and I know that, you know, we were. What's the, what's the quote? We were building the plane. We were flying the plane as we were building it or something. You know, we're a young profession and we're doing things on the fly. But I'm glad that we've got here now and we can start to investigate these things. Beau-
Jeremy Lewis:
Beautifully, beautifully summarized.
Dr. Jared Powell, PhD:
Sorry, mate. , I'm, I'm conscious of your time. I wanna begin to, to round out. So I wanna ask you one more question about the shoulder, if that's okay. I will have a final question. What do you make of - I wanna ask you
Jeremy Lewis:
One more question and then I'm gonna ask you a final
Dr. Jared Powell, PhD:
Question. One more proper question and one more semi-proper question. Okay. One plus one equals one.
Jeremy Lewis:
- Are you negoti - are you negotiating with yourself
Dr. Jared Powell, PhD:
Here? Perhaps, yeah. Subscapularis. So it's the beautifully. I think there is a paper out there called the subscapularis, the forgotten rotator cuff muscle. I love the subscapularis now because the supraspinatus gets all the attention. Most of the pathology is in the supraspinatus. I understand all of that. It contributes to movement. It's an important muscle. But we know that people can function perfectly well with a full thickness supraspinatus tear. People don't function that well with a full thickness subscapularis tear, particularly when the inferior subscapularis is compromised. Particularly if you've got a full thickness subscap tear and a full thickness subscapularis tear. I feel like a lot of people don't give the subscapularis its dues in terms of. Now, I'm not saying we should go in and spend a thousand hours doing the Gerber's liftoff test and, and this and that, but when we're talking about full thickness rotator cuff tears and we're, and we're thinking about surgical intervention, in my opinion, unless they have profound pseudoparalysis, in which case they've probably got a subscapularis rupture, which it tends to only come on in that case, or a huge, huge, huge retracted supraspinatus tear.
Dr. Jared Powell, PhD:
In the presence. And this may be a bit of a brash opinion. In, in the presence of a full thickness supraspinatus tear, I'm almost always going to try a period of non-surgical rehabilitation. And that, that will depend on the clinical presentation. But if somebody comes in with a full thickness subscapularis tear and they have profound pain and weakness, plus or minus a full thickness supraspinatus tear, my, my hunch is that that person I'm thinking is more amenable to a surgical review. One, because the subscap has an important function in the biceps pulley. And in my opinion, I tend to see some issues with the biceps after a subscap tear, or maybe it occurs at the same time, chicken and egg, I don't know what comes first. And I find that I, I don't have great results with a full thickness subscapularis tear non-surgically. What's your experience and what's your opinion on that, Jeremy?
Jeremy Lewis:
I, I think they're completely different issues. Yes, there's part of the rotator cuff, but, you know, we said supraspinatus is 13%. Subscapularis is 52% of the rotator cuff's power. It balances front and back. If you add supraspinatus to infraspinatus, which is 35%, you've got 52% at the front, 48% in the back, so it's nicely balanced. I know you can rehab the shoulder with a full thickness subscapularis tear, but my experience has been that it's an inadequate rehabilitation in people who could have had surgery. , And I've had elite sports people who suffered a full thickness tear, but it's so close to the games or the qualifying, you know, the next Olympic games or Commonwealth games that they can't go and have surgery. So you can rehab it non-surgically, or you can rehab, not it, but you can do rehab non-surgically, but you're always left with a weaker, more deficient shoulder.
Jeremy Lewis:
So, you know, I'm a coward, I think, clinically, and I don't often see full thickness subscapularis tears. I'll. It's coming the end of summer here now, excuse me, as you're going into summer, and there'll be some people I'll see over the next few months who will have had subscapularis tears skiing. And if they come in, I'm gonna say, "Let me drive you to the surgeon. Let me take you now to the surgeon." If you would consider surgery, and there's no contraindication for surgery, and it's very often not, that should be repaired. , You know, I've had a few people coming off. Riding bicycles around London's not particularly safe. I've had a few people who've come off bicycles, someone's opened a door, or they've got. Something's happened, and they've come off the bike, and biceps is dislocated and cut through the subscapularis, so they've got a, a biceps dislocation and a subscapularis full thickness tear, like it's, you know, that cheese cutter type mechanism people sometimes talk about.
Jeremy Lewis:
I'm not gonna waste their time. So I tend to send people s - as soon as possible to see, you know, a surgeon with that, for me, rare presentation. I don't know, maybe other people see it much more commonly, but I don't see more than a few a year in my practice. Of course, if it's a elderly person with massive inoperable rotator cuff t- tear that might be seeing a surgeon for prosthesis or never c - someone who'll never consider surgery or. Of course, then you can throw your heart and soul at rehabilitation. But I don't think I've ever really got someone back to a point where I'm saying I'm really proud of, you know, where this person got to. I don't think I've ever achieved that. I'm sure other people might have, but I've never done that. I don't know what your experience is. But I think.
Jeremy Lewis:
Aren't you living with a tear? Didn't you rehab a subscapularis tear non-surgically?
Dr. Jared Powell, PhD:
Not. Yeah, I don't know if I have a subscap tear. My suspicion is that I do. I never got the scan. I've definitely, I've ruptured my pec and my, , long head of biceps. So - Was
Jeremy Lewis:
That surfing? Was that, was it. How was that? ,
Dr. Jared Powell, PhD:
Fast bowling and cricket was the peck. And then last year was pushing a boat off a trailer and it would pop out of formity. Gotcha. My suspicion is that my subscap is gone because very symptomatic of it. And I just don't. I'm not in
Jeremy Lewis:
A position - Are you, are you, are you weak in internal rotation and throwing or weak? Yeah,
Dr. Jared Powell, PhD:
Weak and sore. Yeah. I can still. I'm, I'm strong enough. I can do what I want to do, but I'm definitely symptomatic of it, and I'm not in a position to have surgery in, in the next few years, and I'm gonna see if I can get away with it. But if it was my patient, I'm with you. I, I tend to refer them for at least a review straight out of the gates. , Which is, which I, I wanna make this point, Jeremy, because I wanna defend the charge that we are, we, that we are anti-surgery. We absolutely not. And when the clinical indications are there, then I don't wanna speak for you, but, but my. I love referring somebody to a surgeon who I think they're gonna get benefit out of.
Jeremy Lewis:
Absolutely. And if you do share decision-making and you say. You know, I've had. When I do talk about injections for subacromial pain syndrome or rotator cuff related shoulder pain, whatever you wanna call it, you know, I'll often go through the same sort of liquidy that you have to inject five people for one person to benefit, and the benefit might be four to eight weeks, sometimes a little bit longer. There's a slight increased risk for the need for surgery, and there's a theoretical potential damage for tendon and cartilage because of the medicines can have an effect on those tissues. If a patient says to me, "Listen, I'm a single parent working two jobs. I haven't got the capacity. I'll never do a rehabilitation program. I can't take time off work to do surgery. My best option is an injection." I respect that, as long as the shared decision making is as honest as I can do it.
Jeremy Lewis:
And it's the same for surgery. If a patient says, "Listen, yeah, I get what you're saying, but I think surgery's the right thing for me. I've done physio in the past, and it's just not helped, and I'm not too good at doing my exercises, but I think I'll do them after surgery, or maybe my boss will give me a better understanding of the time I need if I have surgery." That's a. I'm not the most important person in healthcare, the patient is. What I'm against, and I think, , from previous conversations you and I have had, is that why would you prioritize something that, you know, just recently taught in the States, and someone told me that a rotator cuff repair can cost $54,000, up to $54,000, and some people mortgage their house or take a loan if they haven't got the right insurance. Now, why would you put someone in that situation telling them that they must have surgery in the supraspinatus, and if they don't operate, it's gonna go, you know, there's this whole sequence of horror stories will happen when we've got evidence to suggest you might get just as good outcome non-surgically.
Jeremy Lewis:
So why wouldn't you present it? Let's go for a, a 12-week non-surgical approach. It's gonna be a bit hard, but, you know, it's gonna have to involve behavioral change and, you know, whatever. And if you're not happy in 12 weeks, my door's always open. Come back and see me. You know, why wouldn't you go for the safest, cheapest, not affecting quality intervention before you prioritize something more expensive? Mm. And it's, you know, a six-year-old granddaughter could work that out. It's
Dr. Jared Powell, PhD:
Not a hard concept to grasp, is it?
Jeremy Lewis:
Yeah, but if the patient says surgery's the right thing, , you know, I've never said don't operate, and, and I'm sure you haven't said it as well.
Dr. Jared Powell, PhD:
Yeah, I agree. Okay. In, in closing, Jeremy, what are you excited about for the future of physiotherapy? What are you excited about? What are you scared of?
Jeremy Lewis:
So, I think this could become our golden time. I know there's a concern about exercise physiologists prescribing exercise and strength and conditioning people, , prescribing strength exercises. And, you know, you know, what's our place? I think our future. I think the difference between those other groups is typically someone without symptoms. You know, if I wanted to go to the gym and I wanted to do a specific program to build up strength in an area or this, you know, that, there's people very good in the gym, hopefully, who can, who can help me on that journey. But our job is to help people who have some, some form of symptoms. And, and I think if we acknowledge that the experiment to come up with a structural diagnosis based on imaging and based on clinical tests, , and non-traumatic presentations possibly hasn't worked. And if we go back to a time where we were all about function and we can, you know, for the shoulder, you know, what level of pushing, pulling, lifting, carrying, throwing, catching would restore this person's function and how can we try and exceed their expectations, you know, and stuff I've written recently about, you know, how could we possibly do that as an exercise if the patient's having a cigarette and a Big Mac at the same time and not sleeping well.
Jeremy Lewis:
So if we start also to. If we stop this ridiculous discussion about manual therapy and acknowledge that all pushing, in my opinion, all pushing treatments are probably the same thing with a different philosophy and don't over-explain what you're doing because you're not palpating this and you're not repositioning this and you're not deactivating this. These are just pressure-based techniques that when we add them to other interventions such as exercise can have a short reduction of pain and improvement of function. And we can include it, but it can't be the only thing we include. We can finish that debate now. What we need to be discussing as a profession is how do we become experts at assessing lifestyle? How do we sensitively discuss that. Those issues together with the need for a physical activity with the patients? How do we take them through that journey? How do we get more into prognosis?
Jeremy Lewis:
How do we get more into prevention? You know, why aren't our junior physios, once they finish undergraduate training, rotating, if they're doing rotation in unit hospitals, whatever, why aren't they also doing a rotation in the, in the community where they're going to junior schools talking to pa - to kids about how do you stay physically healthy for your, the rest of your life? You know, and if one kid goes home and says, "Mom, I want dad. I, I want some broccoli, , tonight, and I want to kick a football around," if one kid out of every class says that and does that for the rest of their life, what a great contribution we've been making. So for me, there's a lot of things that we could be doing. I think if we stick with what we are doing, we probably don't deserve to exist in, in 10 years time, you know, if we just keep on teaching the same things in our schools and concentrating on exercise and manual therapy and, you know, spending a lot of time with another passive technique and another passive technique, you know, it just, to me, it doesn't make sense.
Jeremy Lewis:
If I go to a doctor or a dentist or a nurse or whatever, I want to be given the best treatment possible. You know, I don't want to be given endless amounts of hazard treatment just to fill in a, an appointment slot or, you know, what, for whatever the reason that's being done. And maybe that's a bit unfair. But, you know, so I, I'm excited about AI. I think AI is gonna be helpful. It's very scary as well. If you look at lectures given by health futurists, it's potentially all the good things that are negated by some of the bad things. Yeah, so, you know, there's that. There's virtual reality I'm really interested in. I'm really, like you talked about before, about how do you reduce somebody's fear of movement? And that was the experiment with the symptom modification procedure that some people love and some people think it's the devil's work.
Jeremy Lewis:
But I've always been interested in how do you reduce. How do you encourage somebody to move when they're frightened to move? And, and that was the idea behind that suggestion, you know, how do you encourage movement? But today, I'm seeing maybe virtual reality is some of the best symptom modification for some people. So the way I see rehab, it's restore movement, muscle performance, and then at least two months on high level, building to high level function with chaos, , because our lives are very chaotic. So for me, the first stage is restoration of as much movement as possible. And you can do that with exercise, you can do that with symptom modification, you can do that with VR, you can do it in a hundred ways, you know? So for me, the future has to be function with, with behavioral change. And, and I think that puts us in a place where we're offering the best non-surgical intervention available.
Dr. Jared Powell, PhD:
Professor Lewis, you are a treasure trove of wisdom. , Thank you so much for your time. Where can people still find you? Are you on the socials? Where are you active? Less,
Jeremy Lewis:
Less, less so, but I'm always telling myself, "Next month, I'll start again. So for sure, next month, I'll start again." I try and use it to promote research we've done. I don't like getting into debates anymore on social media. It doesn't do anybody any good. My garden a lot, those sort of places.
Dr. Jared Powell, PhD:
Good. Instagram, is that the, is that the social of choice?
Jeremy Lewis:
I think I use LinkedIn a little bit more. Linkedin? Okay. I think. If I've got a research a student has finished or something I've written, I tend to post it across Instagram. And, and yours are amazing, by the way. I love the way you put things on Instagram. It's so clever how you educate in those reels of, if that's the right word. So I've learned a lot from you. Thank
Dr. Jared Powell, PhD:
You. Thank you. We'll have to get you more active on there, Jeremy. We need you.
Jeremy Lewis:
Absolutely. All right, you have a - Thanks. Nice day, weekend, and, , it must be night for you. And, , I'm gonna go and have lunch
Dr. Jared Powell, PhD:
Now. Thanks, mate. I appreciate your time. Be well. Bye-Bye. Thanks for listening to this episode of the Shoulder Physio Podcast with Professor Jeremy Lewis. If you want more information about today's episode, check out our show notes at www.shoulderphysio.com. If you liked what you heard today, don't forget to follow and subscribe on your podcast Player of Choice and leave a rating or review. It really helps the show reach more people. Thanks for listening. I'll chat to you soon.
Dr. Jared Powell, PhD:
The Shoulder Physio Podcast would like to acknowledge that this episode was recorded from the lands of the Terribalang people. I also acknowledge the traditional custodians of the lands on which each of you are living, learning, and working from every day. I pay my respects to elders past, present, and emerging, and celebrate the diversity of Aboriginal and Torres Strait Islander peoples and their ongoing cultures and connections to the lands and waters of Australia.
