Treating the Shoulder… With Science!!

Another month has come and gone at Physio Direct, and in that time Remedy House have hosted another excellent course, which has kicked off the series of training opportunities focusing on the shoulder.

For me this course was of particular interest, being taught by one of my old university tutors Dr Chris Littlewood. In the time since my graduation Dr Littlewood has worked extremely hard, first in gaining his PhD, and since then being involved in many research projects and publications on the shoulder. With all the work he’s done I was very keen learn what I could from him, and put it into practice in my own day-to-day work.

Why the Shoulder?

When looking at the statistics around shoulder pain, you can understand why Dr Littlewood has spent so much of his time dedicated towards improving our knowledge and understanding of this topic. Shoulder pain is the 3rd most common (physio related) reason people to visit their GP, with generally poor outcomes for recovery (with 50% of people still having pain 6 months after seeing their GP). It should stand to reason then, that this is an area we need to understand better and treat more effectively.

What’s in a Name?

Language is important. Thats the first message Dr Littlewood wanted to get across; pointing out as our understanding of chronic shoulder pain progresses, so must our use of terminology. The interesting thing however, is that as we begin to scratch the surface of the complex nature of chronic shoulder pain, the harder it becomes to accurately describe what’s going on in simple terms and provide a ‘diagnosis’. If you turned up to a physio appointment just to be told you have ‘mechanical shoulder pain without restriction’. You might justifiably think… “well duhhh, I could have told you that”. With that reaction in mind, the term Chris favours is ‘rotator cuff tendinopathy’. A description that’s more specific about what structures might be causing your pain, but hopefully wont be alarming in a way that older terms such as ‘subacromial impingement’ might be.

”Special tests really aren’t that special.”

The topic of discussion then moved onto how to assess the shoulder. I won’t go into detail too much with this, but in summary – physio’s overcomplicate shoulder assessment, with most of the fancy orthopaedic tests not really giving us much useful information. The information someone tells us, is often far more helpful than any ‘special’ test we can perform.



Sigh… I’m about to talk about Exercise..

Dr. Chris Littlewood
Dr. Chris Littlewood

Now onto treatment. This was an area Chris was passionate about, pointing out that exercise was the most promising form of treatment for the shoulder, even compared to surgery!

“We follow dentists advice when brushing out teeth twice a day, so why don’t we when it comes to our physio exercises?”

The above quote is one Dr Littlewood emphasised during the day. I think it’s a nice reminder of how important what we do outside of the physio session is. After all, if you didn’t brush your teeth for half a year and turned upto the dentists to find you need five fillings, would you be surprised to find your teeth hadn’t stayed perfect and pearly white? Some things take a bit of work and consistency. So why do we think differently when it comes to physiotherapy and exercises? More importantly, why do so many of us just not do them at all?

One explanation might be how much we ask you to do. A more than common scenario people experience is going to see a physio, being given a long list of long and complicated exercises, and leaving the session feeling slightly confused and overwhelmed. It’s not surprising most people find it hard to stick to what they’re given.

It may be refreshing to hear that Chris proposes just one simple exercise that’s specific and relevant to your problem. One strengthening exercise done consistently every day and progressed over time. Thats it.


Setting Expectations

We need to be realistic. With chronic shoulder pain it is SO important to accept that things don’t change over night. Dr Littlewood’s work highlights this, showing that often with rotator cuff tendinopathy, it can take 12 weeks to see improvements. Often people go to a few sessions over a 4-6 week period, but stop persevering because thing just don’t seem to be changing. The message here.. keep going!

Isn’t this just an excuse they use in the NHS to get you in and out in 15 minutes?!

No. No it’s not. You may be surprised to hear that the research conducted was done in private physiotherapy clinics, and the feedback was pretty much positive. People bought into it! Feedback from participants highlighted these points:

  • Simplicity
  • The positive and supportive environment of the clinics
  • Clear explanations and realistic expectations from the start
  • A good understanding of the reasons for doing the exercises


Dr Littlewood feels the key to keeping people onboard is all down to quality of care. Giving someone the time and attention they need, along with excellent support, really makes all the difference.

Dr Littlewood was supportive of the private physiotherapy world, feeling that it lends itself to treating long term conditions such as rotator cuff tendinopathies. This is mainly as people have to actively make the choice to come and see a physio in the first place, rather than being sent by their GP, and then have to choose wether or not to come back. Having this ownership of your pain is key. The ability to drop in and out for a session here and there gives you further control over how you manage your pain, and can be reassuring in the long term knowing there’s always someone there you can touch base with.


All in all I found this course a refreshing take on treating shoulder pain. Its nice to know the cutting edge science doesn’t always mean mind boggling fancy treatment, but instead encourages you to keep things simple. The simple stuff, done well and consistently, is often all we need.

The Mulligan Concept… We Like to Move it Move it!!

The last year has been a great year for PhysioDirect. Business has expanded, new clinics have opened, and the company branding has also been given a facelift. One of the other great features this year within the company has been the push to offer and fund training opportunities for its staff.

One of the most popular courses offered this year at one of our partner clinics Remedy House in Sheffield has been the 4 part series on ‘The Mulligan Concept’.

So.. What is the Mulligan Concept?

The Mulligan Concept is a popular form of manual therapy, first brought into practice by the charismatic New Zelander Brian Mulligan back in the 1970’s and 80’s. The Mulligan Concept centres around the idea of ‘Mobilisation With Movement’ (or MWM’s for short), where the therapist applies pressure over a joint whilst asking their patient to perform an active movement.

The Mulligan Concept has grown in popularity over the years. There are several reasons why I think it is such a popular treatment approach amongst both patients and therapists.

Firstly, the application of treatment; in order for it to be successful a technique must be pain free and feel comfortable. This all relies on the therapists handling skills, experience and communication.
The second reason why I feel this treatment method is so attractive; people can often notice quick improvements in a relatively short period of treatment time. For example, people can see a noticeable change in pain, with improved movement of a joint after only a few repetitions of a certain technique (compared to your typical 15 minutes plus of soft tissue/massage techniques).
Mulligan techniques are also a lot more transferable to how we actually use our bodies. Lets say you’re having trouble reaching the top shelf in the kitchen.. Techniques can be applied to ease this particular movement and therefore make it much more relevant straight away to your everyday life.

A Team Training Experience

Tim Ryan (PhysioDirect Clinical Manager) and Mr Brian Mulligan himself.
Tim Ryan (PhysioDirect Clinical Manager) and Mr Brian Mulligan himself.

Although the course was open to the general public, a keen interest was shown by many of the PhysioDirect team very early on. With PhysioDirect heavily subsidising places for staff, a good proportion of the places for the course were snapped up immediately. With a good number of our staff on the course, it was a great opportunity for lots of our team members that usually work in different clinics across the midlands a chance to meet and catch up (something usually reserved for the less than academic environment of the christmas party!).

The course tutor was friendly and helpful. With her guidance you could see how the slight changes in hand and body positions, subtitles in pressures applied along with good communication, could make a big difference in the outcome of your techniques. Everyone on the course worked well together, giving feedback on how things felt and differences noticed after each new technique was practiced. Overall there was a really positive feeling with everyone saying they took lots of useful handling skills back into their clinics after each part of the course.

The Benefits I’ve Found

I can honestly say I’ve found this training of great use in my everyday practice. The variety of techniques I’ve learned have given me lots more options when trying to help anyone that walks through my door. In particular I’ve noticed great results with certain types of low back pain, with excellent improvements in movement and pain in a short space of time. I’ve also found these techniques very easy to integrate into my existing practice alongside the active treatment methods that I normally like to use.

Don’t Just Take my Word for It! Here’s some thoughts from a few of our team members.

“The techniques have really helped my clients gain trust in my handling skills. I’ve found the techniques especially useful with stiff, painful shoulders and impingement type problems. I now use mobilisations with movement frequently in my daily practice.” – Anna Simmonds

“Following the 4 part Mulligan’s training course, it has allowed me to integrate a more gentle approach to treatment of both acute and chronic injuries as well as gaining quicker results in decreasing the pain levels of clients that I see. The Mulligan approach has added a further technique to the manual therapy based treatment that is used in my daily practice.” – Phil Rippon

So There you have it.. A great training opportunity offered by Physio Direct, taken up by many, with a great deal learned by all at the end of it. Hope you enjoyed reading, keep an eye out for the next article which should be up in a week or two!