Cognitive Deficits Impacting PT Rx

Hi guys,

During December I completed my musculoskeletal placement in an outpatients department. In the first week of my placement I was presented with the following patient.

A 65 y.o. male, presented with right shoulder pain that had a 10 month history with an insidious onset. He had been treated by numerous physiotherapy students previously. Upon reviewing the patient’s notes it had become quite clear that progress had plateaued in the previous 5 months. Medical imaging investigations (X-ray, U/S) had been conducted and no abnormalities were found in his shoulder (normal acromian, rotator cuff intact).

The first session with this patient I had a lot of difficulties with obtaining accurate information from his subjective assessment with patient being very inconsistent with reporting their aggravating and easing factors. This was further compounded with the objective assessment with the patient having difficulty understanding simple instructions to perform AROMs even though I demonstrated and described how to perform the movement a number of different ways. His pain response to the objective examination also made my findings inconsistent. For example in standing he had markedly different shoulder ROM than in supine. As this was my first week in my musculoskeletal outpatient’s placement it was difficult to determine what was going on and to have confidence in my abilities.

After consultation with my tutor about my subjective and objective findings it was quite difficult to determine what factors were causing his pain. My tutor then informed me that this patient had cognitive deficit’s that had been documented in his notes but not the patient’s notes. After discussing treatment options, scapulothoracic exercises were given and the patient could perform these very well and these were also given for his HEP.

The next Rx the patient’s HEP was reviewed. The exercises he performed did not resemble what he had been prescribed despite the fact that he could perform this extremely well in the clinic in his previous treatment and a handout with pictures given.
This highlighted to me the fact that performing exercises for motor control was quite difficult, and further complicated by the patient having cognitive difficulties.
Ax findings were quite similar to the first session. After consulting with my tutor it was decided that a different approach was necessary but with the same goals in mind of trying to improve and obtain optimal scapulothoarcic movement in order to decrease the shoulder pain being experienced. Once again treatment was implemented and upon re-Ax symptoms were improved (decrease pain) and the patient sent home with a different HEP.

At the patients 3rd PT session, his HEP was reviewed and the patient once again performed exercises that did not remotely resemble what was learned previously.
It was becoming quite clear that the patient’s cognitive deficits were impacting on his ability to rehabilitate his shoulder.

As a PT is was frustrating that the Rx being provided was not having the desired effect and the HEP was unable to be performed appropriately. In this case I was able to implement some different strategies to try and achieve Rx goals. However I do need to develop further strategies to achieve PT Rx goals.