JOSPT-Corner

SPORTFISI@ 2022 45

JOSPT CORNER & SPORTFISIO 2022

Author: Giulia Caffini, PT Photos: GIULIA CAFFINI, MARIO BIZZINI

JOSPT Italian Coordinator for Italian Translations (Journal of Orthopaedic & Sports Physical Therapy - www.jospt.org)

Giulia Caffini Ariane Schwank Paul Blazey

I want to thank once again Ariane Schwank and Paul Blazey for their time and for their willingness to participate in this interview. Here are their interesting answers to our 5 questions.

46 SPORTFISI@ 2022

QUESTION 1. The methods used for creating the Consensus Statements are already well-defined step by step in the paper, starting from the reason why this work was needed, going through the two Delphi processes, and the inperson meeting in Bern in 2019. Would you like to tell us something more about how the idea of this work was born and developed?

PAUL BLAZEY (PB): “Clare Arden asked me, Ariane, and the other members of the board if we wanted to support the Delphi process to answer questions about return to sport with shoulder injury. Following my involvement with the shoulder return to sport consensus I have been involved in improving consensus statement methods and would at least retrospectively comment the modified-Delphi we used was ideal for the purposes of this consensus process. I enjoyed the modified Delphi process, with the in-person meeting, because in true Delphi you don’t actually meet, but that leaves a lot of things on the table which go unanswered. Equally, if you look to force agreement you quite often end up in a situation where there are things you get a bland agreement that doesn’t allow us actually say anything that will move the field forwards. Without the in-person meeting I don’t think that it would have been so helpful either to us, or to everyone else in terms of getting into the finer details of return to sport post shoulder injury. I am hopeful that the final paper got the nuance across to readers. For me, we used the correct methodology, and I think it ended up with a good result but I will let the readers judge that.”

ARIANE SCHWANK (AS): I remember that we based our approach also on Clare’s prior Consensus Statements as a continuation of a started series. The research group around Clare has already published the ‘2016 Consensus statement on return to sport from the First World Congress in Sports Physical Therapy, Bern’, and the ‘2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries’, and now we tried to continue that series. I think it is a great starting with high quality Consensus Statements, and we were so lucky to have the in-person meeting just before the pandemic. In retrospect, the in-person meeting really made a big difference and added so much value. I highly appreciated that.”

PB: “Ariane is right, Clare (Ardern) had experience writing the ‘Consensus statement on return to sport’ published in the BJSM, which covered the principles for all sports. That provided a broad template for us, which is great. I totally agree on the in-person meeting, it was at the end essential. Often when you look at consensus, the authors don’t tell you what was agreed at consensus (i.e. during the Delphi process) and what was agreed in the smaller group meeting. That is often one of the hard things because methodologically you want to know what the experts had agreed on and then you want to know where the smaller group (in our case the authors on the final paper) filled in the blanks. We took what people had agreed at Delphi as our template and highlight these by writing “consensus point” which is what the large expert group had agreed on. The rest came from the expert in-person meeting where we filled in the blanks, using as much evidence as we had available. Which in the shoulder isn’t a lot!”

QUESTION 2. Thinking about the in-person meeting in Bern in 2019, which moment of discussion would you remember as a highlight for the creation of the consensus? AS: “It was six-and-a-half-hour meeting, one short break with chocolate and coffee. The opening of the discussion was about the different sports and the question was: “where do we start?”. There are so many sports with so many different situations, we had to find the starting point. In this initial discussion the whole group contributed intensively with inputs and ideas on how to approach the statements with regards on the different sports, the different levels and the different pathologies. We quite early in that discussion skipped all Delphi statements on topics about pathologies, we quickly learned that we weren’t going anywhere if we started talking about bicep’s pathology or rotator cuff tears because the diversity of the problems are endless. Also, we early decided that a graphic would have helped. Paul can add something about it since he ended up doing the graphic based on the decisions we made in that meeting. The focus point was, what are the different demands on the shoulder in the different sports and positions. Later we came up with the idea to structure in rehabilitation section into key-principles. We were very straight forward in some sections and a bit less in others.

For me these were the highlights: to come out of this meeting with a clear view about what will be the next steps, the idea of Paul of the graphical design, and the literature research about the demand on the shoulder in different sport. During the meeting I could already imagine how the organization of the paper could have looked like.

A little anecdote should not be missed: we had a huge discussion about the term ‘neuromuscular’. A lot of experts in the Delphi round wrote: “neuromuscular testing and neuromuscular exercises are recommended”. The experts in the in-person meeting including us, decided that it is a useless term. We asked ourselves: “what does ‘neuromuscular’ mean?”. I remember Clare drawing a big ‘X’ on the term ‘neuromuscular’ because it means everything: strength, quality of movement, loading, proprioception, timing etc. But in the end it doesn’t really say much.”

PB: “Yes, it is a black box. If I ask someone to define what a neuromuscular exercise is, you can answer with almost everything under the (metaphorical) sun.

My highlights are going to be similar to what Ariane just said: the moment we started to formulate the ideas around the areas of sport and differences in demand placed upon the shoulder by each one. We divided them in to three main sporting areas: below shoulder height, with or without contact; above shoulder height, with or without contact and reverse chain demands. The ‘reverse chain’ sport is one where the

SPORTFISI@ 2022 47

upper limbs act as the primary point of contact, changing the usual force direct in the upper limb from distal to proximal. Normally it is the lower limb that acts as the primary point of contact with a surface, and we have to transfer forces up through the trunk via the shoulder/elbow to the hand (i.e. proximal to distal with respect to the upper limb). Therefore, we needed to consider these sports differently, think of examples like climbing or gymnastics. That was really enlightening, and I really enjoyed that part of the discussion.

After the meeting to try and summarise the burden of shoulder injuries in each sport I looked at the prevalence and incidence of shoulder injuries in the research literature. I found very quickly that you can’t combine those numbers because everyone measures them differently across different sports. But I was able to get a generic idea and that is what had led to the graphic (figure 2) in the paper. The graphic is divided into the three areas and into contact versus non-contact and there the size of the bubbles represents how big of an issue shoulder injuries are within that sport. There are often playing position differences as well, so in American football for example if you are the quarterback, you are more likely to have a shoulder injury than if you are playing in a different position. We added a couple of examples like that for context.”

QUESTION 3. You had the goal to create a balanced Athlete Shoulder Consensus Group, a team composed of professionals with clinical and/or research experience. If you have noticed it, what is the difference and therefore the advantage of having both clinicians and researchers in the Athlete Shoulder Consensus Group? PB: “In order to make this work clinician-friendly and approachable, we really needed both those from a researchbackground and a clinician-background, ideally mixed. There is actually research that shows that if you involve clinicians and researchers in the process then you tend to improve knowledge translation, and enhance application of your recommendations as people from both sides feel represented. We hope readers will see that there were clinicians involved (including Ariane and me) and realise this paper is written with them in mind. We didn’t want the reader to think: “oh this is all theoretical, we can’t apply this in practice”. Ariane and I are primarily clinicians as well as early-career researchers; and so most of all we want the consensus statement to be useful to both groups.”

AS: “You can notice some differences looking at the topics and sections: injury risk management, load management, rehabilitation, and return to sports. In injury risk management and load management include more literature than practical consensus statements as these are not well studied areas and a lack of research is clear. The co-authors (Merete Møller (PT, PhD), Martin Hägglund (PT, PhD), Martin Asker (PT, PhD) and Stig Andersson (PT, PhD)) who contributed to the two sections are conducting strong research themselves and were therefore adding a lot of knowledge and expertise. In the section of rehabilitation there is a nice mix of clinical expertise from the co-authors supported by the consensus statements, influenced by the in-person meeting and backed up by literature. Suzanne Gard (PT, MSc) and Christopher Skazalski (PT, DPT) could nicely introduce the seven key principle on the road to recovery. The return of sport section is probably the most practical section. It really highlights the special demands of athletes which are distinct to a non-athletic patient. Here the co-authors Ian Horsely (PT, PhD), Martin Asker (PT, PhD), Rod Witheley (PT, PhD) and Ann Cools (PT, PhD) provided insightful examples of athletes going through the different steps of the return to sports continuum.

QUESTION 4. Which aspects of the "2022 Bern Consensus Statement" do you find most innovative? AS: “Personally I think that the way it is structured is very innovative, starting with the injury risk management, going into load management, then to rehabilitation and return to sport. It is very logical, and I think it’s a good way to allow the reader to jump into the paper and jump out. That’s why I find it super user-friendly and that’s the innovation I see in it: you don’t have to read the paper all in one to be able to understand it, on the contrary you can have your own questions and then you can read some of the sections and potentially have your answers or have more questions and study further. I also think that all the exercises and the tests are very innovative, helpful, and practically oriented. We really tried to emphasise that it is a principle-based paper and not a recipe style. And this is the only method with who you can bring together this large field of different situations. Indeed, you can’t cover all the sports there is why you have the principle-based approach. You can use your own clinical reasoning, and not try to find a recipe for each situation.”

PB: “I also wanted to focus on the exercises. I am primarily a clinician, but I’ve spent the last three to four years working more in the research environment. One of the things I came to realise is that you are almost never going to prove effectiveness for just one set of exercises for one problem. What I really liked about this work is that we gave exercise examples that came from the big Delphi group of experts. Access to this big group was/is a privilege and we wanted to pass this on to readers so we are able to say to them “this is our big list, these are things that you can use and you can pick and choose the one(s) that work for you”. If you are looking for the ‘expert advice’, well, the exercises in this paper come from the entire expert group. I hope that people find the paper clinicallyrelevant and it has been a big validation for us when people started to come back saying that this paper had helped them clinically. Not many research papers have that template that is so easily usable, exercises are often listed in the appendix, in the back somewhere hidden. That’s a big benefit of having a mixed-methods (quantitative-qualitative) approach, and I feel we’ve applied this innovatively. In our paper we want you as a physio (or other MSK clinician) to go and use the exercises in the clinic the next day.

We included all the exercises that were recommended because there is not necessarily one that is better than the other: it depends on the situation. That’s why we avoided the recipebased approach. I would say to the people in the clinic: don’t try to do all of the exercises, choose the ones that work for you and your patient and the situation you are in.”

48 SPORTFISI@ 2022

QUESTION 5. Do you have any suggestions to give to the sports physiotherapists that are going to read the Consensus Statements? PB: “We wanted to be sure that people didn’t follow it as a recipe. Therefore, when you read it you don’t have to go through all of the sections and you don’t have to do all of the exercises with all your patients. The idea is that you look at the sport, you look at the demands of your athletes and then you go to the consensus statement, and you can find the things that fit to your athlete. You can use the consensus statement almost as a check list and say: “do I need to consider these things when I do the rehabilitation?”. For example: “how do I address the psychosocial needs of this athlete?” etc… Then when you get to the return to sport you can ask yourself: “how do I look at those 6 key principles in the return to sport section of the consensus statement?”. If you cover all of them, you have probably covered all the things need to successfully rehabilitate that athlete. My suggestion for the reader is: don’t read it and try to apply everything but read it and try to pick up the things that work for you in your area, or that you might currently be missing from your rehabilitation program.

AS: “What I mentioned before: the hopping in and out depending on the section where you can find your answers. Next to exercise videos examples there are videos about testing, which you can consult and adapt to your athletes. Processing these videos was massive amount of work, that was actually also fun to do. On a side note here; based on the exercise collection from the Delphi round one, we filmed about 40 exercises ourselves, which we then sent to the professional film company PhysioU who made these beautiful films. My suggestion is to use the consensus to inspire your brain.” PB: “When you are a younger clinician you tend to want a recipe (as they offer certainty), you want that specific advice. What you have to learn is that specific advice often doesn’t apply to most people in practice. Therefore, you have to get used to working through those grey areas, because patients/ athletes are never the same as the textbook, and we know that everyone has slight differences. That is why you can’t have a single recipe because it could work for one person and not for another. So again, that is what I think this consensus statement gives you a framework and offers the ability to flexibly apply it to your situation.”

AS: “In one way this paper provides some kind of recipe because there are so many examples. As a young clinician, I wished I could access something like this, to justify the choice of exercise towards my supervisor. But still, examples do not mean this is correct in any situations. Therefore, you start from one exercise as it is in the consensus statement and then adapt it to what works for your patient, and you start individualizing your treatment.”

You find the full text of the “2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels” and all the supplement materials at www.jospt.org/doi/10.2519/jospt.2022.10952 .

Back row (from left to right): Martin Asker, Ian Horsley, Ariane Schwank, Martin Hägglund, Merete Möller, Paul Blazey. Front row (from left to right): Suzanne Gard, Nirmala Perera (guest), Ann Cools, Clare Ardern, Mario Bizzini

SPORTFISI@ 2022 49

What’s JOSPT? AIM AND SCOPE

The Journal of Orthopaedic & Sports Physical Therapy®, Inc. (JOSPT®, Inc.) publishes scientifically rigorous, clinically relevant content for members of the health care community to advance musculoskeletal and sports-related practice globally.

When the JOSPT senior editorial team considers manuscripts, they ask three fundamental questions:

1. Does the work advance the musculoskeletal rehabilitation field?

2. Are the methods robust?

3. How will the work help clinicians and patients or athletes make decisions in practice tomorrow?

JOSPT prioritizes research with a clear clinical message and potential for immediate impact in musculoskeletal rehabilitation practice. JOSPT welcomes submissions covering issues in musculoskeletal health and rehabilitation from fields including physical therapy, orthopaedics, pain, epidemiology, and sports medicine. JOSPT does not publish basic science, cadaver, or animal research.

Based on the 2021 Journal Citation Reports, Science Edition, published in June 2022, JOSPT's current impact factor is 6.276. The Journal's 5-year impact factor is 6.372. Based on the current impact factor, JOSPT ranks second of 68 journals in the category of rehabilitation, the fifth of 86 journals in orthopedics, and the tenth of 87 journals in sport sciences.

JOSPT's website provides access to articles published from 1979 to date and seamless content delivery to mobile devices as well as desktop and laptop computers. Also available online are videos, downloadable slides of figures and tables, downloadable JOSPT Insights podcast episodes, a webbased continuing education program, Read for CreditSM (RFC), and a quarterly journal, JOSPT CasesTM .

JOSPT Corner is a collaboration between JOSPT and SPORTFISIO. We are working together to bring you the latest and best clinically relevant content from the Journal of Orthopaedic and Sports Physical Therapy, to complement the focused topic of our SSPA Conference each year. In 2022, the topic is ‘Best Practice’, and I had the amazing opportunity to interview Ariane Schwank, PT, MSc and Paul Blazey, PT, asking them the highlights that led to the creation of their work ‘2022 Bern Consensus Statement on Shoulder Injury Prevention, Rehabilitation, and Return to Sport for Athletes at All Participation Levels’ published on the JOSPT in January 2022.

ABOUT JOSPT

Website: www.jospt.org

Twitter: twitter.com/JOSPT?s=08

Facebook: facebook.com/JOSPTOfficial/

Instagram: instagram.com/josptofficial/

LinkedIn: linkedin.com/company/jospt/

Editor in Chief: Clare L. Ardern, PT, PhD