I.

SHOULDER CASE 1: PHYLLIS

ASSESSMENT OF THE BODY CHART: what areas/structures must be considered as possible sources of the
patient’s symptoms? Consider the following:
Joints & Muscles & Ligaments, MSK Pain NON-MSK
bony Tendons, Nerves and producing structures or
structures UNDER & IN other Soft structures conditions
UNDER THE the area of Tissues which may which must
AREA of symptoms UNDER & IN REFER be examined
symptoms the area of into the or ruled out
symptoms area of
symptoms
Acromion Supra Glenohumeral C5-C6 Liver
Humerus Subscap Ligaments C6-C7 Pancreas
Scapula Infra Cervical Perforated
Clavicle Teres minor Accessory N Spine Duodenal Ulcer
Glenoid Fossa Suprascapular (GI)
Biceps Tendon N
GH joint (long head) Axillary N Breast
AC joint Brachial Plexus Cancer/Hormone
SC joint Scap Lungs
Scap/Thoracic Stabilizers: Subacromial Cancer
Joint Teres Major Bursa
Rhomboids Heart: male L
Cervical Spine Traps Joint Capsule shoulder
Levator Scap (AC) Vs.
Deltoid SA Female often
Tuberosity Deltoid both shoulders
(common (common
referral for referral for
RTC) RTC) Co-morbidity:
Age
Suboccipital Diabetes
Overhead
Paraspinal activities
(semispinal,
longissimus)
INITIAL HYPOTHESES AFTER THE BODY CHART
Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:
(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 non-MSK hypothesis
requiring referral)
1. Musculoskeletal wear and tear over 1. Cervical Problem Only – such 1. No musculoskeletal Pain:
time mix of cervical/shoulder as radiculopathy 2. Less likely because she experiences
2. Patient lacks true exercise regime to 2. Shoulder Problem Only – the pain at the end of the day in a
challenge shoulder strength and such as Adhesive capsulitis patterned movement fashion and she
integrity while she is overusing and does not seem to have symptoms is
tearing down RTC when sitting at a she is just sitting or while/after eating
desk, typing, and quilting specifically
3. Older adult is high risk factor for RTC 3. Age and activity pattern and work
tears environment also steer more towards
4. Patient poor and constant forward a musculoskeletal breakdown rather
posture decreases strength and than a visceral problem but we cannot
integrity of shoulder musculature rule this avenue out yet

What questions will you ask to clarify or gather information to support/refute each hypothesis? (planning the interview)

September 2020
Aggravating factors?
Alleviating factors?
History of onset?
(specifically loading history)
Recent injury – if recent neck injury?
Recent changes in daily life that would link
to onset of pain.
24 hour pain history/behavior patterns?
Sleep?
Ask patient goals of shoulder and activities
in which she wishes to return to – this to
direct interventions.
Identify expectations of therapy.
Identify current activity level and relative
lifestyle factors.
History of Onset:
Does your shoulder pain arise after
your neck pain?
Did your pain begin with cervical and
overtime contribute to should
pain/irritation?
Aggravate/Alleviate?
-here, patient may experience pain at
different times OR different triggers
-when you have shoulder pain, do
you have cervical pain
AND VIS VERSA
-when you have cervical pain, do you
have shoulder pain?
Are you experiencing night pain?
-pain c̅ sleeping on shoulder OR insidious
pain
Are you experiencing pain without a
pattern – for example, not in relation to
movement/mechanical aggravation
Are you experiencing a change in weight
without direct cause?
If thinking GI problem?
-as about medication list – often c̅ NSAIDs
a patient may experience gastrointestinal
distress
-ask if patient has problem during or after
eating/digestion

Ask if patient has co-morbidities?

(general health, DM, smoking)

In class answers to our interview:

-chronic neck pain – 20 years Shoulder: slight movement and Goals:
-shoulder pain – 15 years ago ibuprofen relieves pain -fasten bra
-achy sore, sharp -washing her hair
-increase in sitting and typing at home -sharp: near deltoid tuberosity -at home projects
-increase work in the garden – trimming -dull: widespread shoulder -live with husband – able to help
--immediate shoulder pain R arm dominant
-increase time quilting – hours Can get to 0/10 but 7/10 MRI: partial tear in rotator cuff
Current Pain: 4/10
-pre-diabetic, overweight, and borderline -pt guarded R shoulder
hypertension, smokes years ago = Outcome Measures:
EDUCATE!! Neck: pain after working at the desk Shoulder: dash, quick dash, SPADI
-dissipates in a few minutes c̅ breaks Neck: neck disability index
-tight and sore
-mild bump on the of cervical spine
-hot shower feels good
Can 0/10 and 4/10
Current pain 0/10
II. INFLUENCE OF THE SYMPTOMS ON THE EXAM. Detailed by Area of Symptoms as Mapped on Body Chart
What is the anticipated vigor and extent of your physical exam?

 Highly limited exam due to  Moderately limited exam  Minimally limited exam due  Unlimited exam due to
anticipated tolerance due to anticipated tolerance to anticipated tolerance anticipated tolerance
 ROM 1st onset of sx  ROM to active limit  ROM to passive limit  ROM to sustained/ combined
 Very low vigor and extent  Low vigor and extent of  Moderate vigor and extent  High vigor and extent of
of tests/measures tests/measures of tests/measures tests/measures
Pt presented guarded No, no recent acute injury -- just be
Pt is currently in minor pain so Does the nature, diagnosis, or co- mindful of aggravating the patient.
Rationale for this
slightly limited morbidities warrant special caution Keep in mind patient trust.
vigor and extent.
Pt can move and complete for exam or treatment? Yes / No
Justify your
everyday tasks so she should If yes, what?
assessment of
be able to tolerate most PT (e.g. Trauma / Inflammation / Red
severity &
examination movements Flags / Instability/ Pathological
irritability Process)
Remember Pt and PT trust!
Limitation of movement due to How is this activity limitation Limited in completing her hobbies
What is the pain in shoulder region affecting the patient’s participation activities of gardening and quilting
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 AND due to build up of pain
Pain in cervical region due to
primary activity increased sitting/typing/poor Limited with pain at the end of the
limitation (ICF posture in normal social roles (ICF day to confidently complete day to
classification)? She is in pain and want to get classification)? day tasks and be in comfortable
back to her activities of positions
washing her hair and clasping
her bra!
REVISED AND REPRIORITIZED HYPOTHESES AFTER THE PATIENT INTERVIEW
Most Likely Hypothesis: Less Likely Hypothesis: Remote Hypotheses:
(Primary Hypotheses) (Secondary Hypotheses) (Include at least 1 non-MSK hypothesis
requiring referral)
1. MRI and subjective examination 1. decreased likelihood of only a 1. shoulder pain after eating and/or
push us to believe more in the shoulder OR only a neck problem drinking alcohol specifically bringing on
musculoskeletal mix of shoulder due to pain pattern often paired referral pain from liver/pancreas
and neck pain! relatively together or in a specific
2. This d/t pattern of pain, onset of increasing pattern – therefore we But thankfully, she did not have this issue.
pain, symptoms of pain, etc all link should not categorize these After our questions, we are steering away
towards biomechanical pattern separately as they change pain levels from this as the primary cause/limitation.
and cause upon one another

III. PLANNING THE PHYSICAL EXAM

Patient Questionnaire: Physical Performance Measure: What movement test will be
Patient able to garden for 25 min your most reliable comparable
What outcome SPADI – shoulder disability index without needing break sign?
tools are most MCID: 8 Patient able to wash hair/put on Painful Arc – pt moving arm
appropriate? MDC: 18 bra s̅ compensations overhead to complete daily
MCID: activities such as wash hair/get
MDC: dressed
What do you expect to be treating at the initial visit? (Choose only one)
PAIN INFLAMMATION JOINT RESTRICTION JOINT STABILITY / SENSORIMOTOR
RESPECTING PAIN WEAKNESS DYSFUNCTION

Is a neurological examination necessary? If so, indicate what you will assess.

Check myotomes to rule out innervation problems and if suspect more you may test dermatomes and if you are later signaled
with major weakness without direct cause then you may check reflexes
PHYSICAL EXAM PLAN for day #1: Prioritize based on most likely or most concerning hypothesis and the patient’s tolerance
to exam. List in order of performance.
Prioritized P/E tests (finish in 20 min) Justification

Observe/Palpation: shoulder/spinal region/cervical Palpation: note areas of pain, tenderness, heat, swelling, etc if
region present
-clear cervical spine!
-observe overhead reach Observe: if compensation in shoulder (is decrease in range due to
stiffness, tightness, pain?)
Strength:
-test if strength is limited to pain Strength is key point to aide in decreasing impairment and will also
-flex, abduction, IR, ER aide in ROM

ROM: Appropriate ROM allows patient to complete daily tasks and currently
-test if certain positions are more aggravating/alleviating patient is unable to clasp bra or wash her hair.
-this often limits need to special tests b/c̅ you can find
many results in these sections listed Joint Play may show us a motion that relieves the patient of pain or
help steer away from capsular problems
Joint Play:
-help steer away from AC diagnosis and lead more into
relief in posterior/caudal direction

Exam items deferred to future visits Justification

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Dermatomes/reflexes as the patient does not present Dermatomes/reflexes as the patient does not present with neural
with neural deficits. If prompted later, add in these tests. deficits. If prompted later, add in these tests.

Cervical spine issues b/c̅ this pain is not as prevalent as Cervical spine issues b/c̅ this pain is not as prevalent as the shoulder
the shoulder pain pain and we first must calm down symptoms and then work into
functional and eventually global movement patterns.
IV.ASSESSMENT AFTER THE PHYSICAL EXAM
Yes, patient is appropriate for physical therapy to aide in decreasing
Is the patient an appropriate candidate for physical pain, increasing strength and increasing ROM in the shoulder and
therapy intervention? Do they require additional also the cervical spine.
referral?
(Treat, Refer, or Treat & Refer). Indicate reason for No, patient does not steer towards a referral because she tested
referral (imaging, lab work, etc.)? What? Why? Justify. away from non MSK causes and pt already met physician and MRI
also steers towards MSK tear in RTC
Most Important Baseline Subjective findings (Activity Most Important Baseline Objective tests and measure findings
limitations and Participation restrictions) from the Patient (Impairments) from the Physical Exam that are associated with the
Interview: Put most important findings at top Activity Limitation
Activity Limitation or Symptom(s) Time Related Impairment/ Results Symptom(s What limits
Participation to ease Movement Test or ) it
Restriction Baseline
Unable clasp bra Sharp Shoulder pain 30min R shoulder decreased ROM Positive Sharp pain in Pain limits range
and increased pain painful arc shoulder 7/10 and strength
pain
Unable to wash hair Sharp & sore shoulder 30min R shoulder IR limited Decrease Sore and sharp pain
pain ROM value
Pain with lifting overhead Shoulder pain sore 30min Decrease strength flex.abd, IR, 4/5 MMT Pain in all Pain
ER movements
Difficulty gardening at the end Progressive shoulder hours Caudal glide GH to grade IV Movement Relieving, less Shoulder
of the day soreness improves symptoms decreases stiff, less sore, tissues/protectin
sx no sharp pain g/guarding
Difficulty completing full day of Neck/back pain hours
work s̅ pain

Most Likely Hypothesis: Alternate Hypotheses:

1. Musculoskeletal wear and tear over time mix of Separate problems: cervical and shoulder problems separate
cervical/shoulder
What Clinical Evidence from above supports this hypothesis?
What Clinical Evidence from above supports this
hypothesis? Neck pain has been consistent for years 20+ years and shoulder pain
1. Patient lacks true exercise regime to challenge only recently started with change in activity  so not always
shoulder strength and integrity while she is overusing consistent together
and tearing down RTC when sitting at a desk, typing,
and quilting
2. Older adult is high risk factor for RTC tears
3. Patient poor and constant forward posture decreases
strength and integrity of shoulder musculature

V. CONTEXTUAL FACTORS: Are there contributing factors that may affect prognosis? (check all that apply)
Occupational
Personality Environmental Societal Health and/or Other (describe)
and/or Wellness
motivational
List and describe how these factors may act as barriers to recovery:

Occupation: induces patient into forward head and rounded shoulders posture
Motivation: poorly motivated d/t lack of compliance with body weight, diabetes mellites and hypertension
Environmental: poor desk conditions to support her body for long hours at her desk
Societal: COVID – less human interaction, increased stress, and less movement activity d/t restrictions to stay home
Health: currently pt is overweight, prehypertension, pre diabetic

List and describe how these factors may act as facilitators of recovery:

Occupation: patient may want to get back to work to feel accomplished, make money, and b/c̅ she enjoys her career
4
Motivation: patient may be motivated to feel better about one’s̅ body.
Environmental: changing her desk station to accommodate the long hours at the computer
Societal: fall weather promotes walking/biking – being outside to move and enjoy the weather!!
Health: currently pt is overweight, prehypertension, pre diabetic and she may want to take charge of her health finally!

Describe how you will manage or address any relevant contextual factors:

Occupation: teach patient positive effects of proper desk ergonomics to reduce neck/shoulder pain
Motivation: teach how of compliance with body weight, diabetes mellites and hypertension all will make her feel better and move easier
Environmental: teach patient positive effects of walking and being outside to uplift mood and aide in cardiovascular fitness
Societal: take part in fitness program virtually or with a group to stay accountable
Health: currently pt is overweight, prehypertension, pre diabetic so again teach health holistically and how each small step is a success towards a healthier body!

VI. PROGNOSIS:
What is the natural history of the disorder? How will it progress over the life span?

If untreated, a continual wear and tear will continue to strain the shoulder joint, muscles, and tendons. Lifting, reaching overhead, and poor posture of forward
shoulder will promote a negative continuation of wear and tear.
In time, scapular stabilizers will weaken, blood supply will decrease, and ability to complete day to day activities without pain will become even more difficult as
the shoulder joint continues to wear and tear.
Likelihood of recurrence: MILD / MODERATE / HIGH – if patient does not comply with therapy, pain may persist
How will you attempt to prevent a recurrence of symptoms? How will you educate the patient to manage an exacerbation if it
does happen?

To prevent recurrence, a patient needs consistency in a workout program to continuously strengthen the shoulder joint, maintain ROM, and promote proper
posture.
Additionally, the patient needs to be mindful of her age and her activities. RTC tears occur more frequently as one continues to age so proper nutrition and
holistic exercise will be beneficial to strengthen her body’s̅ system to help in systemic healing.
The patient should prepare an ergonomic work setting to promote proper poster and decrease forward shoulders while working and quilting. Additionally, the
patient need to work on holistic body care. This regarding better sleep quantity and quality to assist her body’s̅ natural healing processes and to decrease
exacerbation of pain. With this by promoting a healthy diet and cardiovascular fitness she will feel the difference a health lifestyle makes on the body’s̅ system
systemically.

To educate patient how to manage exacerbation of symptoms, I would teach the patient how to best listen to her body.
Truly listening to the body is difficult as patient’s̅ often want to be strong and push through the pain, but we need to listen to what the pain is telling us about the
body.
If the patient experiences a flare up, she should continue to complete isometric strengthening exercises to maintain strength but while giving the body a rest from
overhead motions or lifting too heavy of objects. With this, the patient should avoid overhead activities and reset herself for proper posture. Finally, she should
use our symptom easy techniques to decrease pain.
Functional SMART goals: a behavior characteristic duration time and
Short Term (indicate timeframe):
1. In 2 weeks, patient will demonstrate the ability to incorporate meaningful breaks in her work day to allow time for pain decreasing exercise (shoulder
pendulum/codman) in order to decrease shoulder joint pain (no greater than 4/10) and to reset the spine for proper posture to also help decrease
cervical pain (no greater than 2/10)
2. In 2 weeks, patient will become a part of a walking fitness regime of walking 4x a week for at least 15min a day to promote cardiovascular fitness.

Long Term (indicate timeframe) – briefly explain why you selected the goal
1. In 12 weeks, patient will be able to paint room (arm overhead) for 1 hour at a time with pain no greater than 1/10 in order to reintegrate into her normal
life habits

2. In 12 weeks, patient will be able to complete a full workday (8 hours) without shoulder and neck pain no greater than 1/10 in order to rejoin her work
routine without interrupting her evening activities with pain.

VII. PLAN OF CARE

How many visits over what period of time do you expect to see this patient? Why?
2x a week for 12 weeks – research shows it takes 12 weeks to see clinically meaningful outcome changes
-she needs proper re-education of her shoulder and cervical region AND she needs time to learn and create long lasting habits that will decrease her current
pain but to also create a plan for the next few years to keep her shoulder/cervical pain in control.
-I believe this patient could use a wellness program following PT to continue to promote holistic body fitness and to keep the patient accountable for her physical
fitness.

Initial Day 1 interventions.
BE SPECIFIC and include dosage.
In class discussion:
Warm up c̅ bike:
-warm up shoulder muscles 5min warm up
-joint mobs/stretching (specifically pt stated
Rationale (What from the interview or
physical exam indicates this treatment is
important?)
We must decrease pain for patient to be able to
move into functional patterns and eventually into
global movement patterns. Patient stated she felt
relief with the arm swing when walking and during
distraction joint play so this exercise promotes
Expected Response (What movement
test will you reassess to prove that your
treatment was effective?)
Asking patient overall pain scale and pain after the
work day will help to reassess if this pain relieving
exercise is aiding in minimizing pain symptoms.

5
distraction felt good) to warm up and ease pain, movement and motion for lubrication and nutrition of
esp if pt has flare up shoulder joint. Patient also stated she is already
taking breaks and feels better after resetting her
ROM/Stretching body.
-in general, passive ROM if flared up vs.
AAROM when pt is having a good day
--seated roll back passive shoulder flexion
stretch maintain for 45 seconds at home (this
also has component of distraction to ease pain
while also combo of ROM)
-active assisted to also work into range with
strengthen factor
--towel slides on table at home
-for neck: gentle chin tucks in supine as a break
from the arm

When working into strength/loading, if in pain,

begin with isometric in neutral positioning
(change to in range isometrics when she is
feeling well).
Strengthening:
-isometrics at home against the wall c̅ a towel to
load the rotator cuff (flexion/extension, IR,ER)
--isometric into your own hand to hone in on
amount of force for isometrics
--6-10 sec hold for 10 reps
--you may start every day for motor learning but
as you load more and add resistance 3x a week
for muscle building and recovery
--isometric education: push within your pain
limits, ramp on and ramp off
-supine flexion c̅ cane OR progress to standing
-standing flexion against wall c̅ towel
-seated push towel OR roll backwards
Pulleys:
-patient love it
-easy active assisted motion is lotion activity
-aide in eccentric control

Scapular Positioning
-posture shoulders back and down – educational
piece!!
-pectoral stretches (doorway stretch, seated
scap squeezes – 10x for 10 seconds)

Education:
-motion is lotion
-chin tucks/change in posture to relieve tension
-activity pacing with shoulder b/c̅ she feels good
with mild motion but too much irritates patient
--get patient involved: when you garden take a
break when you pull weeds after 20min

1. When pain flares about 4/10 take a

break and complete shoulder
pendulum exercises until pain
decreases and subsides.
2. Specifically when at the desk, plan to
take a break every hour to walk
around the house to promote
movement holistically but also slight
movement of the arm swing/shoulder
region to decrease shoulder pain.
3. This will also reset the cervical region
as she stands and takes a short break
from the computer.
4. 8 hour work day = 8 breaks at a
minimum but patient may complete the
exercise more frequently if she prefers

3. Shoulder flexion on the table with a
towel/ball. Press into the towel/ball to
activate shoulder muscles and
gradually push into forward flexion to
promote strength and comfortable
ROM
Patient presented with decrease flexion strength and To test if this exercise is effective, shoulder strength
ROM. By keeping strength as the key component, in flexion range and ROM in flexion while
research shows this factor will be a primary aide in demonstrate an effective or ineffective response.
healing and adding in the piece of ROM will promote
motion in overhead motions to allow patient to better
reach overhead to grab her coffee cup, etc.

6
 4. 3x a day (breakfast, lunch, and dinner
when sitting at the table)
5. 8 repetitions to promote patient
adherence without getting
overwhelmed
6. 4x a week
3. isometric internal and external rotation Patient struggles with IR and ER to wash hair and To assess effectiveness, shoulder IR/ER can be
exercises to continue to promote clasp bra so this exercise will promote range and tested or more specifically we can see if the patient
strength (esp as she states she strength to complete this daily task. can reach to clasp bra or washing hair has
struggles with washing hair and improved.
clasping bra)
4. 3x a day for 8 repetitions
5. Hold isometric position for 6 deep
breaths
6. 4x a week

Assume good patient adherence and no red flags are present. At the next visit, what treatment will you consider if the
patient is:
Better: Worse: The Same:

My Initial Response: My Initial Response: Maintain pain relieving symptom exercises but
Flexion strengthening activities in Ask when patient feels worse (if related to specific increase sets and repetition and intensity of
concentric/eccentric pattern with hand held exercise) exercises to promote a change in shoulder/neck
weight and increasing repetitions to promote an Ask where patient feels worse (to narrow in on if it region.
increase in challenge for shoulder strength. was from an exercise prescription from myself) OR
Ask patient if they have exercise they found
Continuing with IR/ER no longer in isometric More patient education in treatment to teach the beneficial, analyze it and work more collaboratively
pattern and similar to above with weight/more need for strength exercises to find exercises the patient feels a response from
resistance and loading to the shoulder to again the shoulder and closely monitor the changes.
promote further shoulder strength and If patient is in too much pain, I would provide more
stabilization small movement activities and holistic body exercise
programs. We need to calm the painful symptoms
Additional holistic body movements with the before adding too much motion and by also adding in
shoulder as a priority – meaning changing from a holistic approach we are promoting increased
supine position to standing or moving exercises healing time. I would promote more supine/relaxing
to increase resistance against gravity and breathing techniques into the exercises to strip the
incorporate lower body exercises into the program down to a relaxing level.
exercise routines.
In class discussion:
In class discussion: -did you do anything different
-if she is doing well, add in weight, resistance for -light stretching, modalities  work to minimize pain
example, rows, pull downs,
Treatment Progression: Describe how you plan to progress this patient over the next 4-6 weeks. BE SPECIFIC AND
DETAILED including all appropriate parameters. This may include the following: Physical Agents, Therapeutic Exercise,
Manual Therapies, Neuro Re-education, Motor Learning/Skill Acquisition Strategies, Activity Modification, & Home
Education.
*Be sure to include principles of dosage and progression for all interventions.

Relaxation Methods/Warm Up Activities:

Backward Shoulder Rolls 2 sets of 8 4x a week
Scapular Retraction 2 sets of 8 4x a week
Doorway Stretch 3 sets for 30 seconds each and/or during breaks at work
Earlier in intervention program, PT include caudal glide, posterior mobilization and distraction to promote movement and pain relief but in time decrease amount
of manual therapy to prepare patient for home and completing all exercises on one’s own.

Shoulder Flexion ROM and Strength:

Begin with isometric exercises against one’s OWN hand to start and eventually work into range
Supine cane shoulder flexion – active assistance of cane at first and progress to holding weights for increased resistance
Increase to resistance band flexion/extension c̅ band anchored to the wall
Begin 2 sets of 12 to learn to exercise and transition with resistance to 4 sets of 8 with 30 seconds in between
Over time increase resistance and change to hand held weights if necessary

Shoulder IR/ER Strength:

Begin with isometric exercises against one’s OWN hand to start and eventually work into range
Increase to resistance band IR/ER c̅ band anchored to the wall
Begin 2 sets of 12 to learn to exercise and transition with resistance to 4 sets of 8 with 30 seconds in between
Over time increase resistance and change to hand held weights if necessary
Eventually work into the range of motion and when properly achieve add resistance/weight

Aerobic Activity of Choice:

-begin with 20+ min a day (walking is great!) and progress to at least 150min of exercise per week
-ideally 30+ min 5x a week

Home Education!!!!: Patient expectation is major factor of prognosis!!

7
To educate patient how to manage exacerbation of symptoms, I would teach the patient how to best listen to her body.
Truly listening to the body is difficult as patient’s̅ often want to be strong and push through the pain, but we need to listen to what the pain is telling us about the
body.
If the patient experiences a flare up, she should continue to complete isometric strengthening exercises to maintain strength but while giving the body a rest from
overhead motions or lifting too heavy of objects. With this, the patient should avoid overhead activities and reset herself for proper posture. Finally, she should
use our symptom easy techniques to decrease pain.
For work, teach patient positive effects of proper desk ergonomics to reduce neck/shoulder pain and understanding importance of breaks and variety of
posture.
Additionally, teach how of compliance with body weight, diabetes mellites and hypertension all will make her feel better and move easier and all will aide in
healing process.
Teach patient positive effects of walking and being outside to uplift mood and aide in cardiovascular fitness
Advocate for the patient to take part in fitness program virtually or with a group to stay accountable
Currently, pt is overweight, prehypertension, pre diabetic so again teach health holistically and how each small step is a success towards a healthier body!