Refer Back to MD or Continue Treating?

During one of my recent mentoring sessions for my fellowship, we saw a patient that had plateaued in progress. The patient was being seen for right upper extremity pain. The patient initially presented with pain that was associated primarily with cervical radiculopathy signs, such as bakody's sign, (+) cervical distraction test, (+) ULNT, etc. The patient initially responded great to PT as the radicular signs completely normalized. However, some right anterior shoulder pain remained that presented with signs of symptoms of shoulder dysfunction (anterior glide medial rotation syndrome, weak shoulder ER, restricted IR mobility, etc.). We gave him a few exercises to address these deficits. After a couple weeks, the pain in his shoulder had not changed and we had to decide the next course of action.

The patient's initial reaction was to "give up and live with the pain." We initially talked about the possible benefit of an injection to address the pain, however, that was when our discussion switched to plan of care directly regarding PT. Upon examination, the patient still had restricted inferior GH capsular mobility, shoulder ER strength and scapular strength deficits. While the pain had not improved, the impairments had, but still had dysfunction remaining. When I first came out of school, I may have referred this patient back due to lack of progress, but with the deficits remaining, I would recommend continuing PT. His pain at this point still has impairments associated with it that can be addressed by PT, so we modified his HEP to focus on these strength and mobility deficits.

​Don't be so quick to give up on a patient's rehab. It is easy to become concerned when the patient isn't responding as we had hoped, but that is why it is essential to regularly evaluate the patient's progress in strength, mobility, flexibility, etc, instead of simply referring the patient back. It helps us track progress and helps the patient understand how they are responding as well. A change in the treatment plan or perspective may be necessary, or continue along the path the patient is currently on if progress is being shown.

​-Dr. Chris Fox, PT, DPT, OCS

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