Abstract
A 75-year-old female who was 16 weeks post motor vehicle accident was seen for physical therapy treatment for her right shoulder over 12 sessions from 06/21/2022 to 08/02/2022 at an outpatient orthopedic clinic. Treatment was provided by a student physical therapist under the supervision of a licensed physical therapist. The patient was evaluated at the initial encounter employing observation, the Numeric Pain Rating Scale, goniometry, manual muscle testing, special tests, passive accessory movement assessment, palpation, the Patient Specific Functional Scale, and the Quick Disabilities of the Arm, Shoulder, and Hand. A plan of care was established to address moderate to severe shoulder pain, moderately decreased range of motion and strength, moderately restricted accessory glides of the glenohumeral joint, and severely restricted thoracic spine accessory movements, resulting in a moderate limitation when vacuuming around the house, and severe limitation when pruning trees in her garden. These limitations severely restricted her participation in household chores and activities.
The main goals for the patient were to decrease right shoulder pain and increase active range of motion and strength of the right shoulder so the patient could complete home chores. Interventions used included pain-reducing modalities, manual therapy, and therapeutic exercise. The patient responded well to the physical therapy interventions as seen by decreased shoulder pain, increased active range of motion and strength, and an increased ability to perform activities at home. The patient was discharged to her home to continue a home exercise program independently.