Entry Number 2 - Communication

Situation: On Tuesday 16th February, a middle aged female presented at the Augusta rooms with a referral from her GP. The referral stated that the woman had been granted time off work due to ongoing pain that she had been experiencing in her upper back, neck and both shoulders and that she was to be assessed by a physiotherapist to ascertain what the cause of her pains were and provide treatment if deemed appropriate. I performed a very thorough subjective examination where I discovered that her pains in order of decreasing intensity/discomfort were the thoracic spine between the medial borders of her scapulae, the left shoulder, the cervical spine and finally the right shoulder. Among other things in the subjective I found out that she was a fly-in, fly-out truck driver, working 12 hour shifts and that her shoulder pains, particularly the left were long standing, but had been gradually increasing over the previous few months as the thoracic discomfort had been developing. After reviewing notes on this woman from previous treatments, it was revealed that she had impingement of her supraspinatus tendon in the left shoulder and was still suffering from some bursitis in the same shoulder. With assistance from my supervisor I then set out to perform an objective examination of this woman. What we discovered was that her thoracic pain could be more accurately described as a ‘tightness,’ which was equally reproduced with all active movements and overpressure of the cervical and thoracic spine. All upper limb neurodynamic tests were negative. However, we discovered that her scapula position and control were very poor on both the left and right sides and that with manual scapula position correction her ‘tightness’ with movement immediately decreased. Assessment of the left shoulder revealed pain and weakness associated with the supraspinatus muscle upon testing, which was the same discomfort that she had come to see us about. There were similar symptoms with assessment of the right shoulder, but they were less marked and less intense.

Task: After a discussion with my supervisor, we decided that the first treatment aim would be to decrease the pain and ‘tightness’ in the thoracic spine by improving scapular control. This would be done through scapular stabilisation exercises, involving teaching greater activity of the rhomboids and upper trapezius muscles to retract and elevate the scapulae position on the thoracic cage. We were hoping that this exercise in itself would partly improve the supraspinatus problem by stabilising its origin on the scapula, but in addition to this, the plan was to teach isometric external rotation of the shoulder as a strengthening exercise and provide stretches for this muscle, including hand behind the back and horizontal adduction at the shoulder. So these were my tasks for this particular treatment session.

Action: I decided to teach the isometric shoulder external rotation exercise first as I felt it would be quicker and easier for the patient to comprehend than the scapula stabilisation exercises. I demonstrated the exercise in the doorway initially and explained that it was to be performed as a static hold, with no movement occurring. Then I requested the woman to perform the exercise so that I could check she understood. She performed it well, so I instructed her to do 9 more repetitions on the left side, holding each for 3-5 seconds. These were well tolerated, so I explained that this exercise would form part of her home exercise program and that she should be performing 3 sets of 10 repetitions, at least 3 times per day for each shoulder. She said she understood and was confident at being able to perform this independently. I did the same for the hand behind the back and horizontal adduction stretches of the shoulder, which the woman also said she understood were part of her home exercise program.

I began teaching the scapula stabilisation exercises, of which the first step in the process was to educate about the position of spinal and scapula neutral and how this was the optimal position to be in because it meant there was minimal stress on spinal and scapular structures. Spinal neutral was easily attainable, but unfortunately scapula neutral was not so easy and it was requiring considerable effort to actively find this position, let alone maintain it for any length of time in the initial stages. After many attempts and manual guidance from me she was able to find this position independently by the end of the session. I then gave the instructions that this would also form part of her home exercise program and that her prescription would be 10 x 2 second holds per set, performing 3 sets, 3 times per day. Again, this was well understood.

Result: I saw the woman again 2 days later on the 18th and she told me that her symptoms were greatly improved after just a few days of independently performing her exercises. So I checked she was performing the isometric external rotation correctly by viewing 1 set on the left side. She was doing well, so I told her to continue at home in the same fashion, even maintaining the contraction for longer each repetition if she felt able. I then checked her ability to find scapula neutral and hold this position, which was also much improved. I then progressed the exercise program to include scapula stabilisation through shoulder flexion range, which was accepted well and included into the home program.

The woman then presented on Tuesday the 23rd and again was happy with how her symptoms were further decreasing, but complained that her right shoulder was now giving her more trouble than the left. I asked her to perform the external rotation on the right arm so I could assess if she was performing it correctly. Her response was that she hadn’t been performing those exercises on the right side. When I quizzed her as to why not, she replied that she didn’t think she was supposed to be performing them on the right. She said that when we initially ran through her program a week earlier, we didn’t practice it on the right shoulder, so she didn’t think it was part of her home program. I was then very quick to apologise and explain that yes, I most certainly did want her performing the strength and stretching exercises on the right shoulder in addition to the left. She then told me that over the weekend as the pain was becoming more noticeable she felt she should have been performing them but was afraid to begin without getting my okay to do so first. So again, I apologised for the confusion and miscommunication on my part and insisted that she should definitely be performing the exercises for both shoulders. The woman’s next appointment with me is on Tuesday (a week after her previous session) so I will assess her symptoms and review progress then and hopefully the right shoulder pain has settled in this time, and if not I will have to re-assess and take another approach to treating the problem.

Evaluation: Overall, I thought I performed my set tasks well, but it was just the communication and education specific to the right shoulder exercises that let me and subsequently the patient down in this situation. I felt that my initial explanations, demonstrations and technique education were performed well and the woman had a good grasp on how to perform the exercises independently. Unfortunately though, I did not effectively communicate the specifics of the home exercise program, which led to the confusion and eventual non-performance of the strength and stretching exercises for the right shoulder. At the original time of technique education, I really should have got the woman to perform a set of exercises for the right shoulder in addition to the left and then really emphasised the importance of performing all the exercises for both problems and for both shoulders. The fact that the thoracic spine and left shoulder problems appeared to be responding so well to the exercises was comforting and provided some confirmation that the treatment program was appropriate and that I had taught the exercises well. The initial assessment findings for the right shoulder were very similar to those for the left shoulder, so I wait in anticipation for the next appointment to see if the problem is resolving as the left shoulder is.

Strategies: What I take from this experience is that as a therapist issuing exercises and activities to be performed independently, you cannot take it for granted that the presenting subject understands exactly what you want them to do. What may seem like a simple concept to the therapist may not be so for the patient, so it is essential to ensure that all aspects of a take home program are understood. It also reminded me that our patients have different learning styles, just like student therapists do. Some will respond best to watching a technique, others to listening to an explanation and others to performing it themselves, so it is important that you do all of these and more when teaching someone an exercise so as to ensure they know exactly what they are to do when they leave your supervision. To have a checklist or know a specific routine appears to be the way to approaching exercise education, which in my case would have lead me to demonstrating and insisting the subject performed the technique for the right shoulder at the initial time of teaching, not just explaining that this should be done. This could have gone a long way to preventing the problems that subsequently occurred, but I will know this for next time.