Care Completion Movement Perfected

Initial diagnosis: Right shoulder impingement syndrome Mechanism of injury or cause: Gradual onset, exacerbated by overhead activities at work. Date of initial appointment: 1 November 2024 Referral source: Self-referral --- Clinical Summary Key findings at initial assessment: Limited active range of motion in shoulder abduction and external rotation. Positive Neer's and Hawkins-Kennedy tests. Palpable tenderness over the supraspinatus tendon. Treatment interventions provided: Manual therapy to address joint restrictions, soft tissue massage, and education on activity modification. Response to treatment: Reported reduction in pain levels and improved shoulder movement after the first two sessions. Residual symptoms or functional limitations: Occasional pain with overhead activities and some stiffness in the morning. --- Functional Outcomes Functional goals achieved: Able to reach overhead without pain, improved ability to perform daily tasks. Outcome measures used: Shoulder Pain and Disability Index (SPADI) score reduced from 45/100 to 15/100. Client satisfaction and engagement: Client reported high satisfaction with the treatment and actively participated in the home exercise program. --- Ongoing Management Plan Recommended home exercises: Scapular stabilisation exercises, rotator cuff strengthening exercises, and stretching exercises. Advice on activity/lifestyle: Advised to avoid prolonged overhead activities and to take regular breaks. Red flags or signs to monitor: Monitor for any increase in pain or loss of function. Suggested review timeframe: In 3 months --- Communication and Documentation Discharge summary sent to referral source: No Client copied into discharge email: No Insurance provider updated: Not required --- Post-Discharge Engagement Relevant tag for future updates: Shoulder pain Added to check-in / newsletter list: Yes Ongoing service recommendation: Pilates --- Internal Business Notes Client status updated in Cliniq Apps: Yes Added to CRM or check-in calendar: Yes Testimonial or review follow-up: Sent a follow-up email to request a review. Suitable for case study: Consider in future --- Additional Notes Client is a keen golfer and is keen to return to the sport. Discussed a graded return to golf program.