How to Set Patient Expectations With Difficult Shoulder Case As An OT/PT - Hand Therapy Secrets

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How to Set Patient Expectations With Difficult Shoulder Case As An OT/PT

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Have you had trouble setting realistic expectations for your patients? 

It can get more difficult when it’s a more complex case. Practice makes progress, and I encourage you to assess just about everyone you know. 

What to look at when you’re evaluating a shoulder as an Occupational Therapist

We all know that there’s a certain rhythm to the shoulder. If I’m just looking for normal motion, I like to do both arms at a time. As the arm, the humerus, comes up, you’ll see the scapular move. Thumbs up, elbows straight. And what you want to be able to see is how smooth their motion is and if there is any clicking. 

You’re looking for elbows to stay straight, arms next to their ear, and don’t buy into when people tell you, “I’m not really flexible.” They’re going to go to wherever they’re going to go. But if their arms wing out a lot, they’re tight somewhere. They just are. They’re tight somewhere. You just have to figure out where they’re tight. People who work out and are bulkier, you’re going to see them a little differently. They’re not going to be able to go all the way straight just because of how bulky their muscles are. But for the most part, people can move their arms, and they should be able to get their arm next to their ear.

Anytime you look at someone’s arm, you’re going to see little nuances. So if they bring their arm up and one arm wings out a little bit, they’re tight somewhere. If they click, pop, and hurt, that’s what they’re there seeking help for. 

The other thing is when we’re looking and assessing scapula motion. You’ve got to look at how someone’s ribs move. Remember, the scapula sits on the second and seventh ribs, and your ribs go from the front to the back.

If someone moves up and they arch their back like that, you know that they might be stuck somewhere, and you have to actually get them to pull their ribs down to get better movement. When you’re first doing it, you might not get too specific. You might just say, “I just want to see how you move. Bring your arms up, bring your arms out, bring your arms back, put your hands behind your back, put your hands up behind your head, see if you can move your elbows up.” If you look at general motion, that’s where you might see some nuances.

When they go internal rotation, you’re looking for elbows to come forward. Elbows come forward, and shoulder goes back. If they can’t bring their elbows forward and their shoulders back, they’re tight, capsular tightness potentially, but it all plays, and scapula is always, always, for the most part, involved. Because they can’t go internal rotation, you will see them tip out. You’re going to see a tip out because it’s stuck. These are little nuances, little things that you’re looking for on one side compared to the other side. 

First, you want to look at the normal motion and then look for abnormal motion.

Setting expectations for function is really, really huge because your expectations and the doctor’s expectations sometimes differ. And it’s important that you set the expectations with her. 

We want function and function as the patient sees it and as you help the patient see. It’s very important to talk about avoiding false expectations. 

Have them show you with their good arm and compare both sides, and then that way you can set it. It’s important because they’re going to be upset with you. They’re going to talk shit about you. The doctor is wonderful, but you might be thrown under the bus. Sometimes the doctor is thrown under the bus, but you’re there to save the doctor’s ass, but the doctor is not always there to save your ass and be like, “No, your therapist is wonderful. It was me.” No, like no doctor ever has said that to me. 

For example, if a patient has comorbidities, osteoporosis is one of them. So you have to be careful with how much you’re pushing to a certain extent. You have to be careful because you don’t want to overdo it. You have to understand why the patient went for the surgery. They had an ORIF that failed. From a healing standpoint, there’s a lot of pain.

Most of the time, people go to those types of surgery because of pain. The expectation has to be that we want a certain amount of motion and a function based on pain levels. We don’t want to get more motion at the risk of more pain. We’d rather have functional motion and no pain or very little pain. Functional motion without pain is usually the goal. Even if you have less motion but no pain, that’s where I’d rather be with the patient. If they have decreased supination, what’s the problem? Work backward, not functioning bicep. Where does the bicep originally insert? Who is your strongest supinator? Your strongest supinator is your biceps. Your supinator muscle is xyz big. Your biceps supinator is xyz big. 

So if they can’t supinate, why are the biceps not working that well? Is it tight? Is it weak? Is it painful? Where do the biceps originate?

Your biceps have a long head and a short head. Where are they connected? In the surgery. What did they do? You have to cut it and pin it somewhere. So now your biceps has been affected. Very important to get an OP report if possible. But most of the time, in a total reverse shoulder, something has to happen to the biceps. So your biceps, you got your long and your short. And so the length is probably not long anymore. If something is going on in your supination, it’s because of the biceps. Then what can you do to help the biceps so that they can supinate again? It may be supposed to because the biceps also help with some elevation. 

We’ve got to reduce that pain down, reduce it down. You can work the tissue in a shortened position, get the pain to be reduced. 

Sometimes I’ll do some overhead like this without the biceps to kind of let the biceps relax a little bit. 

In this case, she had a reverse shoulder for pain and poor healing. Her rotator cuff is questionable. I had a guy whose rotator cuffs were like a mess. Usually, I like to ask the doctor what they see in surgery in terms of the rotator cuff. Which ones were intact, which ones were not intact, or what the tendon’s quality is. I repaired it, but the quality of the tendons is not good. You’re going to have insufficiency in the way those tendons work, and therefore, you’re going to have less like results. You’re getting functional like 90 degrees. So you know what, if I bend your elbow a little bit and you reach up, you will get that functional motion that you wanted. And then, I’m going to work on rotations because rotation brings more function. Internal and external rotation brings more functional flexion. You’re going to be limited in your external rotation with reverse shoulders. You just want 30 degrees, but you want it pain-free. That’s key.

Who cares if it’s forward flexion, abduction, or scaption? It’s functional at this point. And then triceps, the forgotten muscle. The triceps are huge because it helps stabilize the scapula too because where does the tricep originate, and where does it insert? Believe it or not, when you work out the triceps, it will help with the biceps, and it will help with forward flexion, because if you’re tight coming up here, guess what’s stopping you?  Triceps. Work that triceps out. Boom. 

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Hoang Tran

“I help Occupational Therapists develop their skills and grow their confidence in Hand Therapy. No matter where you are on your journey, build a happy and fulfilling career of your dreams. I’ll help you.”