Talk:Manual Therapy and Exercise Intervention in the Treatment of Shoulder and Neck Pain in a Patient with Mental Health Comorbidities: A Case Report

Article Review

This is an interesting case study about an oft-neglected subgroup of the population. This reviewer would have appreciated a slightly longer introduction to set the scene. Although the area of research is undoubtedly worthwhile, some degree of justification of why the research is novel and a brief literature review would have been useful.

The case report is logically presented and the patient characteristics/clinical findings are in- depth and appropriate. It might have been useful to provide some indication of the length of the individual’s psychiatric symptoms as this would permit the reader to get an idea of how chronic these psychiatric symptoms were. There is good justification for the inclusion of the scoring systems used (NPDS and DASH), and the examination section explicitly states a detailed and accurate assessment process. Based on the information provided, the clinical impression appears correct.  

The interventions section is clear and succinct and the form shown in Appendix 1 seems a sensible method to facilitate adherence. More details relating to which scapular muscle retraining exercises were prescribed would have been beneficial in allowing the reader to get a fuller picture of the rehabilitation programme. Appendix 2 is only very brief, and perhaps could have been included in the text instead of as an appendix.

I was happy to see a positive outcome for the individual and credit should be given to the therapist for that! Table 1 is orderly in presenting the findings, although the “HEP adherence column” is redundant and could have been omitted. The discussion section covers the main points well, however further depth would be useful in some areas (for example in paragraph 2 when discussion the relationships at the shoulder joint). In addition, more details relating to potential future research in the area would have been helpful too. 

In summary this is a well-written and worthwhile piece which would be a valuable read all clinicians, especially those with a caseload which includes patients with mental health comorbidities.

Osman Ahmed 12:21, 20 July 2011 (BST)

Response to recent review

Thank you for your review. When I revised my capstone project for PP submission, word limits required me to pare the draft significantly and much was cut. The original presented a better background and reason as to why I wrote the case report. Unfortunately, all I know is that he had been in the system for about 2 years, but his problems extended back farther than that. One of my concerns in the original was the exercise description – next time I will be more thorough or include pictures. Thank you again.

I had originally submitted this to a physical therapy journal in a different format (Physiopedia’s original word limit and an attempt to be more focused in my writing resulted in a major rewrite from it). It was rejected, and I think readers should be aware why as some of their points are valid (others I disagreed with, as noted below). I am only including the broad points by the editorial reviewer, and not the specific comments from reviewers #1 and 2 which the editorial reviewer kindly summarized and I have paraphrased

• It was written in an unscholarly manner with imprecise language and lacked a distinction between mental health and substance abuse disorders, therefore it would not provide a meaningful contribution to the physical therapy literature.

Agreed, to a point. As one reviewer wrote, co-occurring disorder is not a diagnostic entity of its own. While there is an increased incidence of substance abuse in those with severe mental illness, there is not a category in the DSM-IV for “co-occurring disorder.” This term is used in lay-language, but it is also found in the literature. It was my error in not fleshing this out fully, and while the paper would have been better to focus on these aspects than on the specifics of the musculoskeletal aspects, I would disagree that it does not provide meaningful contribution to the physical therapy literature as adherence in any population is rarely examined but is especially lacking in this one.

• There was some confusion as to whether or not I knew about his mental health (I stated I chose him based on his mental health comorbidity, then later stated I was unaware of the impact of co-occurring disorder).

I was aware of my patient’s mental health and substance abuse issues, which is why I chose him for the case report. What I was not aware of is how different adherence is for someone with “co-occurring disorder” versus someone with “just” a severe mental illness OR a substance abuse problem. Again, my error in not being more clear.

• A possible strength of the paper was to increase awareness of mental health/substance abuse and/or provide a model for physical therapist practice, or be a lesson in "what not to do," but I did not do that.

I wasn’t setting out to provide a model for PT practice, but I was hoping to increase awareness of mental health/ substance abuse. I could have written the original introduction more concise and with more clarity (Physiopedia has/had word count limits so I pared it way down from that even).

• The concepts/ components of motivational interviewing and adherence were underdeveloped.

Agreed. It would be a much better paper if I were to have focused on one aspect of the case (MI, adherence, or musculoskeletal), but because of page limitations (this was the final project in my PT education) and word count issues (for the journal and Physiopedia), my writing was very general, trying to cover everything that I did.

• Manual therapy was unwarranted for a low-grade musculoskeletal problem; even if it was, unsubstantiated measures were used which made it not useful for description of patient management.  It should have been focused on early detection and referral, not primary management by a PT.

As stated in the paper, this was a large urban hospital, and he was referred by his PCP who was aware of all these issues. I did not write that he was also being seen by a psychiatrist and a social worker, as this is a part of team medicine in our area. I did not present this clearly, which may have made it seem like I was the only one aware of his problems. Because his situation is being addressed as a team, it allowed a PT to be focused on his musculoskeletal complaint, being aware of the other factors and who was doing what to help him. I wrote broadly but focused a bit more on the musculoskeletal problem, specifically the manual therapy portion. I believe the treatment was warranted and it wasn’t the focus of the treatment sessions but rather a part of it, with exercises given to maintain the gains he made. I acknowledged in the original paper that the DASH did not have an MDC that I could find. The DASH and the NPDS were the best outcome measures I could find quickly, but I would welcome any suggestions for the next time I encounter a patient like this.

While this problem “was minor in comparison to the other health issues” it was very important to him. I talked to him about a year later, and he is doing relatively well with no further neck and shoulder complaints. While I may not have written the case report well enough, I made a difference in his well-being as a part of a medical team, and I think the route I chose was correct.

--David Gillette 05:17, 24 July 2011 (BST)