John Breckenridge in Sydney deals with lots of tricky shoulders – here is one
A problem shoulder
Amanda first presented to our clinic reporting fairly constant, moderate to severe, chronic pain in her right (dominant) shoulder, sometimes referring into her upper arm, no paraesthesia and elevation limited to 80°. She could not write or use her computer keyboard and was unable to drive or catch crowded public transport. There had been fall down some stairs at work several months prior, with an initial diagnosis of a small cuff tear, later revised to brachialgia. After initial improvement she plateaued to the current level of pain and disability. A few attempts at physiotherapy had given her some relief but had not resolved the situation. Her work was supportive but she was frustrated at being forced to work from home and extremely keen to return to full duties and driving.
Odd symptoms for a shoulder?
In Amanda’s first session what struck me was her vivid description of her non pain symptoms. She said that the limb “did not feel like it was part of her”, and she had “difficulty in making it do what she wanted”. Amanda even avoided looking at her shoulder in the mirror. Tight sleeves increased her pain, her pain levels rapidly increased with use and she spent much of the time holding her arm in a protected ‘sling’ position.
I tested Amanda with a set of shoulder laterality cards that I’d made up myself. She was less accurate – less than 65% – with the images that corresponded to her painful shoulder and also relatively slow to recognise these images, around 4.5 seconds per image. Important to me was her comment that she “was really struggling in my head to do this”. My typical musculoskeletal assessment included scapula stability and control – and yes, modifications here did help slightly. However, her comments about her limb and her poor show on the left/right judgement test led me to head down the GMI treatment path.
I sent Amanda home with a promise that she would practice with her laterality cards for 5 minutes every waking hour. A week later her reported pain levels had dropped to a more moderate level and she reported that her shoulder no longer felt so alien to her. Shoulder elevation had improved slightly to around 90°, but she was using her arm for lighter tasks, at lower levels, more frequently. On left/right shoulder judgment testing with the cards, accuracy was back to normal (around 98%) and her speed had improved to around three seconds per image. Amanda reported that the cards were now easy.
We progressed her treatment to include imagined movements, which to be honest we both struggled with. So we tried the mirror. We found that Amanda could look at the reflected image of her good shoulder moving into flexion, but if she tried to move her painful limb behind the mirror her symptoms would increase. So we agreed she would practice this mirror exercise but not move her affected shoulder over the following week. Amanda returned two weeks later and had progressed herself to small movements, up to 45°, behind the mirror whilst looking at the reflection of her good arm. Amanda confessed that she still really enjoyed using the laterality cards and had continued to do these frequently. Amanda no longer had any resting pain, and maximal shoulder elevation had improved a little more to 100° or so.
Amanda’s treatment program was gradually progressed and she continues to make a steady recovery. I guess the message here is that the laterality cards and slightly modified GMI approach allowed us to fly under her ‘pain radar’ and establish a baseline of function that we could build on. We were able normalise how she felt about her shoulder – it no longer felt not part of her, and from there move on. Amanda’s treatment program now includes more traditional scapula stabilisation exercises and graded upper limb strengthening, she is driving and has returned to full duties at work.
John is currently well into a PhD on left right discrimination and shoulder pain. He is still seeking people with or without shoulder pain to do an online study. If you can help, it takes about 15 mins and here it is.
Thanks for this nice clinical piece John,
Lots to reflect on.. A common question to us here is “when should I consider assessing left right discrimination as part of a potential graded motor imagery treatment? As you note, the language used may help – in Amanda’s case “my shoulder does not feel part of me” and the expressed dislike of the shoulder. It all needs more research but I believe that such hints of disembodiment may predict left right discrimination changes which could be clinically adressed, i.e. Amanda is not just a “one -off”.
I hope our readers can contribute to your research. We would love to hear other verbal hints of disembodiment as well.
No matter how well rehearsed we are for the situation when we hit the ground reality plays by its own rules! Applying our knowledge is what it’s all about and this article is a beautiful example of front line thinking.
Hopefully we are all on our journey from, unconscious incompetence to conscious incompetence. Evolving through to conscious competence hoping to arrive one day at unconscious competence ….in other words all the knowledge we have won’t help the patient if we don’t evolve in being able to “fly by the seat of our pants”