The patient was a 62-year old man who had suffered a grade 3 rupture of his right supraspinatus muscle from a fall. He underwent a biopsychosocial assessment and a 6-session musculoskeletal rehabilitation program. This program improved his range of motion, strength, and aerobic fitness. It also significantly reduced his fear of reinjury and improved his perceived work capability. After treatment, the patient was able to avoid shoulder surgery, had full range of motion in his shoulder, and had gained employment prospects.

1. BIOPSYCHOSOCIAL APPROACH TO REHABILITATION OF A GRADE 3 RUPTURE OF RIGHT
SUPRASPINATUS MUSCLE
A Case Study. Rigg, D.
I don’t know why am I here I need an operation
1. Patient details
This patient is a 62 year old man who worked as a cabinet maker or in manual work all his adult life.
He presented with an eight month history of right shoulder pain following a fall from a ladder.
2. Presenting complaint and symptoms
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On the 5 October he fell from a ladder. He was taken to the local accident and emergency
department by his wife where his shoulder was examined and x-rayed. He was discharged later that
day as nothing abnormal has been detected.
Following this he had constant shoulder pain for three weeks and paid for eight sessions of private
physiotherapy with very little improvement in his condition.
He waited inactively for an MRI scan, which lead to the diagnosis of a full thickness tear of the right
suprasinatus muscle.
He was awaiting a date for an operation for a surgical repair of the suprasinatus muscle.
3. Chronological history of presenting complaint, including its current status and behaviour
The patient was referred and a Biopsychosocial assessment was conducted.
Treatment Beliefs
Causal Beliefs: The patient reported that he was happy with the medical treatment he had received
but believed that his condition should have been diagnosed sooner and he felt the if he had been
younger he would have received a more thorough investigation and not had his continued pain and
slow progress attributed to his age.
Coping strategies: He thought he ‘knew what he could and could not do’ so he ‘just got on with’
that.
Social support: The patient was closely supported by his wife. He reported that she advised him
to rest and not to use the arm if it was painful. He admitted over protection of his shoulder following
previous experience of a misdiagnosed foot fracture.
Stress: The patient has some savings and did not receive state benefits of any kind. He reported
not liking the department of work and pensions.
Hopes and expectations: The patient was waiting for a date to have an operation on his shoulder.
He believed that this would improve his shoulder function and improve his employment prospects.
He also suggested that the reason he had been unsuccessful in finding work in the past was that 62
he was too old and would be retiring soon.
Functional tests indicated that, along with his shoulder, his neck, spine and lower limb movements
were stiff and restricted. He was slow and guarded when walking and he was unable to lift from the
floor.
4. Past history relevant to presenting complaint and other significant past history
Previously he had injured his left foot at work. He had been x-rayed at the local hospital but as no
bony injury had been detected he was discharged and told that it would take time to heal because
of his age.
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2. He continued to work and suffered constant pain for approximately eight months before he returned
to see his GP who referred him for further x-rays on his foot. This time three fractures were detected
and he has since had three operations to fuse three bones in his foot.
5. Medication
There is no medication relevant to this case study.
6. Detailed treatment programme
Following the biopsychosocial assessment the patient attended six sessions of the musculoskeletal
programme consisting of group exercise, education sessions, optional individual reviews and a
progressive home exercise programme.
Outcome of treatment
Range of Movement
Assessment and Discharge
Assessment Discharge
200
180 180 180 180
180
160
140
Angle Degrees
120
120 110
100
100 90
80
60
40
20
0
Active Passive Active Passive
Flexion and Abduction
The table of physical measures below shows that the patient completed the treatment and achieved
an overall improvement in his posture, flexibility, strength and aerobic fitness.
Test Assessment Discharge Norm / Goal
Back Flexion 30cm 14cm 0cm
8 cm 7cm
Mallar to sternum <5cm
Left = 27cm Left = 21cm
Wall stretch Right = unable due to range Right = 24cm <5cm
limited by pain
Power position 20cm 0cm 0cm
6 Minute walk 400 metres 600 metres 600 metres
Dynamic lift from Unable to bend and reach 25 kg with good lifting 25 kg
floor box on the floor technique
Reedco posture 55% 95% >90%
score
The patient completed questionnaires at the start and end of the programme to produce a physical
and psychosocial profile. This allowed the therapist to understand his beliefs about his condition so
that they can be challenged and assisted to consider an alternative that enables them to adapt and
self manage his condition.
A change or 8 to 12% on these scales is required to be clinically significant.
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3. Tampa Scale of Kinesiophobia (TSK) is a scale used to measure fear of movement or re injury and
is a risk factor for chronic pain. The chart below shows that this has been achieved with a 30%
reduction on the TSK.
EPIC Hand Function Sort (EPIC Hand) indicates indicate perceived work capability. The chart
below shows that the level of perceived function had improved by 31% from a light to a medium
physical demand level.
PSYCHOSOCIAL and FUNCTIONAL
QUESTIONNAIRES
250
205
200
156
150
Score
Assessment
Discharge
100
46
50 32
0
TSK EPIC Hand
At discharge the patient had full range of active and passive movement and needed to continue to
improve his through range strength.
Follow up
After his follow up the patient voluntarily attended a patient satisfaction meeting aimed at finding
ways of improving the programme from the patients perspective. He reported that at the start of the
programme he had been confused as to why he would have rehabilitation before his surgery but
now he fully understood. He also volunteered to become and ‘Expert Patient’ and to be put in
contact with any patient that had beliefs or fears that prevented them complying with an exercise
programme for their condition.
Patients who would other wise not have attended the programme have since successfully
completed the programme.
Conclusion
After this small amount of intervention the patient has demedicalised his condition and has been
prevented from having unnecessary shoulder surgery with obvious benefits with regard to cost, risk
of complication and well being.
His improved psychosocial profile shows a reduced risk of chronicity. His shoulder function has
significantly improved as has his overall functional ability. He has lost weight, joined the gym with
his wife and reports that he now feels better than he has for more than 10 years.
He is currently actively seeking employment and has been offered opportunities in both the
transport and hardware retail industry.
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