S- Mrs A was referred to me with R shoulder pain. After a thorough examination, I concluded she had a R shoulder impingement secondary to poor posture, namely a stiff and stuck thoracic spine (into flexion), protracted and ante-tilted scapulae, and an anteriorly sitting and internally rotated humeral head.
Taking her history, I began to realise she was also very dejected about her shoulder and the treatment she had received. The initial injury occurred 19 years ago (a SS tear). She was put on the waitlist for surgery. After being on the list for so long the surgeon told her it had gone beyond repair, and due to her age etc surgery was no longer an option. She was under the care of GP following this, and seemed to get lost in the system. She said she had been waiting two years to see a physio. She really felt like no one took her problem seriously. She knew it wasn’t going to miraculously recover, but she desperately wanted guidance in things she could do!!
T- Provide appropriate treatment and create a meaningful home exercise program.
A- I spent so long with the assessment I actually had to re-book Mrs A the following day for a treatment session. At this session I decided that my best tool was communication. I needed her to understand how posture causes shoulder pain to have any hope of her getting on board and performing her HEP. Most importantly though, I needed to reassure that her problem was important to me and that I was going to go out of my way to treat her as best I could. If I could get her feeling more positive about the care she received I felt we could make a real difference to her problem.
We spent 20 mins going over shoulder impingement and I made use of skeleton to demonstrate. I then performed a passive physiological in thoracic extension, provided an individualised HEP and referred Mrs A to the upper limb hydro classes.
R- Mrs A was extremely happy to have been listened to, taken seriously and be given the tools to start to take control of her life. At her follow-up appointment, 2 weeks later, she stated that her pain had reduced by up to 80%! And that she had regained function of the arm.
E- I was really amazed at the success Mrs A experienced! I’m not so sure she would experience benefits that rapidly from exercise, but I do think having an understanding of your problem and being given the ability to self-manage would make a huge difference….the power of the mind!! No one had explained any reason for her shoulder pain. Once she had an understanding she could start to control it. She no longer viewed her problem as completely unfixable and ruining her life. I’m sure that positivity changes your pain experience.
I was really proud that I could do that for her. I think it helped that I booked an hour appointment for her following our assessment. I feel that she benefited most from the time I put into education and demonstration and I feel that I communicated this really well.
However, my assessment time management DEFINITELY needs some improvement. I spent so long with her assessment that I needed to re-book her for a treatment session. She did benefit from the extra time I was able to put into her treatment, but I can’t be doing that for every patient I see! What would make everything flow faster and smoother, would be not to perform every single test I know. I need to be more streamlined, right from my initial observations. For example, I only really need to test what I see. Looking at Mrs A’s posture (as described above) the key muscles to test the length of probably would be pecs, infraspinatus and lats. Whereas I tested every muscle around the shoulder/neck. In retrospect this definitely was a time waster, and had no impact on my treatment. I need to know what tests to omit rather than doing every single test I know! I’m hoping this improves with experience.
S- listening!
-education
-communication
These 3 things are, I think, what made my treatment successful, more so than any hands on treatment I could offer. I'm realising how important this is with every patient. You need them to be confident in you in order for them to do any home exercise/self management.
TIME MANAGEMENT! omit those things that are unnecessary to test in order to make my assessment smoother and faster!
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