While contemplating what it means to be a physical therapist here in America where we are awarded merit for hard work, determination, and successful treatments, I realized this is a bit of an illusion. Those who came before have given the knowledge and skill we possess as, physical therapists today. The patients we are privileged to treat are not earned or “deserved”, they choose to come to us. The truth is that we are merely witnesses to a patient’s life that intersects with our lives for a brief time.
A few years ago, a middle-aged woman came into the outpatient physical therapy clinic with a diagnosis of right frozen shoulder. The patient’s right shoulder range of motion was limited to about 50% compared to the left. There was mild weakness in the right shoulder and scapular stabilizers as well. She stated the shoulder pain started insidiously about a month prior. The patient also reported neck pain and a migraine before the shoulder started hurting but no numbness, tingling, or weakness in the arm. Neurologic screen was negative. Cervical rotation limited with right rotation compared to left due to pain at end range. At the time of PT evaluation, patient had primarily right shoulder pain, secondary neck pain, and no headache.
I considered the research behind frozen shoulder and was honest with the patient that exercises, stretching, modalities, and manual therapy has not been shown to be all that effective. Frozen shoulder typically just runs its course; freeze, frozen, thaw, and that process can sometimes take a couple of years. The therapy goal is often to maintain as much function as possible, so it doesn’t get worse and maybe there is a chance it gets better sooner. I asked the patient if she was willing to try a non-traditional approach and I presented a theory.
I explained to her that nobody knows why people, and more specifically middle-aged women, get frozen shoulder but there is emerging evidence for neuroscience explanations. I have seen case studies where chiropractic treatment was successful and stated there is the possibility that cervical manipulation may have effect on the nervous system. I also explained to her that with frozen shoulder researchers have found adhesions can form in the absence of injury which to me that suggests the presence of inflammation. Furthermore, neuroscience research is showing that the nervous system can set off an inflammatory cascade of reactions in the presence of psychosocial factors. This is seen with patients who have chronic pain, chronic inflammatory disorders, and complex regional pain syndrome.
After explaining these concepts, I asked the patient questions about her life, her finances, and relationships and if there were things that she was currently worried about. She divulged many things about her current situation. She and her husband had a business that was struggling financially and her husband had been recently diagnosed cancer and was undergoing chemotherapy. The patient had to work both the business and home stating there is not enough time in the day. More importantly she realized, with her husband currently facing illness, she had been perseverating on some past situations that she had not forgiven him for. The patient told me she was angry and did not realize how bitter she had become until this conversation.
We discussed my role as a physical therapist and the treatments we would focus on here therapy. The patient was advised seek counseling in conjunction with the physical therapy because her stress may be contributing to her current shoulder pain. I laid out the following plan of care. I would perform cervical and upper thoracic thrust manipulations with the idea that for a brief time there would be a “change in conversation” between the spinal cord and the shoulder. The patient’s homework was to go for a 20 to 30 minute walk alone every day until following up with me the next week with the idea that her nervous system needed blood, space, movement, but also that walking could have a positive effect on her stress levels and give her time to process the day. She was given scapular tucks, shoulder shrugs, wall climbs, and chin tucks for an exercise program. I also mentioned to her again the possibility that she may have been carrying, what she reported as “un-forgiveness” on her right shoulder and now the shoulder is getting tired so maybe she should consider putting that weight down.
The following week the patient came back with a smile on her face. “I decided to forgive my husband.” was the first thing she told me. Her shoulder pain significantly improved and ROM almost symmetrical with the left side. Cervical ROM improved as well. I performed the manipulations one more time. In the sessions to follow we worked on restoring shoulder strength and scapular control. Patient discharged from physical therapy after 3 weeks.
I did not deserve this patient to walk through the doors. I accepted her offer to work with me and she accepted my offer to work with her. I shared with her my clinical reasoning and used the skills that had been given to me by life experience, other patients, college and continuing education to help her with her pain and loss of function. In turn, the patient came to the clinic, gave me information about her life, and decided to do the work to get better which may or may not have had anything to do with me. Though I often forget, I am slowly learning that every patient I get to see is a privilege. The skills and knowledge I have developed are not mine, but a gift given to me so that I can give to others.