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

Original Editor - David Gillette

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A 52 year-old male with co-occurring disorder was referred for neck and shoulder pain. Manual therapy and neuromuscular re-education were provided in an outpatient setting, along with a custom exercise tracker and motivational interviewing to enhance adherence. After eight weeks of treatment the patient had improved shoulder and neck ROM, pain level, DASH and Neck Pain Disability Scale scores, but adherence to appointments and exercise were low. There is no research for adherence to physical therapy in the mental health population. Additional research is needed to determine the best way to improve adherence for those with severe mental illness.

Patient characteristics

RS was a 52 y.o. left-hand dominant male referred by his doctor for treatment of left shoulder pain with no medical diagnosis. Prior to evaluation he performed heavy lifting and scrubbing activities for a food service company. At the time of evaluation he worked as a halfway house program coordinator which involved paperwork and standing.

RS had a diagnosis of hepatitis C, and tentative diagnoses of fibromyalgia and chronic pain. Psychiatric diagnoses included major depression, general anxiety disorder, social isolation, previous illicit drug use, alcohol dependence, and a GAF (Global Assessment of Functioning) score regularly in the low 40’s indicating serious psychiatric symptoms or impairment in social or occupational functioning. His view of smoking and alcohol use wavered between having no interest in quitting, to quitting or having a strong desire to quit but being unsure he could, to resignation.


RS reported chronic neck and anterior shoulder pain, attributed to years of excessive sleeping and social isolation making him weak and tight. The pain had increased in recent months, and was provoked by reaching overhead or prolonged side-lying. He rated it as 3/10 at worst, and only resting lessened it. He also reported intermittent tingling in the neck and arms with no attributed cause. His goal was to return to working out at the YMCA.

To determine the impact on his participation and activity, RS completed the Neck Pain and Disability Scale (NPDS) and the Disabilities of the Arm, Shoulder and Hand (DASH). The NPDS has high test-retest reliability (r=0.97, r2=0.93) and correlates well with other neck pain measures over time including the Neck Disability Index and the Pain Disability Index.[1] The DASH measures three levels of the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF),[2] correlates well to the physical component of the SF-12 (0.63, p=0.05) and is responsive to change for those with neck and shoulder pain.[3]

RS had forward head posture and a right neck shift. His shoulders were anterior, with the left 2cm more anterior measured from the acromioclavicular (AC) joint to the plinth. The left scapula was 3cm higher than the right. He used accessory muscles excessively during inspiration. Sensation and reflexes were intact, and there was no change with cervical compression or distraction. Key muscle strength in the C4-T1 distribution was 5/5, but right elbow extension and right wrist flexion caused pain on the left side of his neck. Neck and shoulder ROM limitations were recorded (Table 1). During shoulder flexion or abduction the left scapula rotated upward before the right. The left clavicle rotated incorrectly during the first 60 degrees of shoulder flexion, and the left AC and sternoclavicular (SC) joints were tender. Glenohumeral and AC joint play were normal, but the left SC joint was hypomobile in all directions. Protraction of the scapulae provoked pain in the left shoulder; retraction provoked pain in the left teres major and the right rhomboid areas.

Empty Can, Lift Off, and Drop Arm tests were negative for rotator cuff involvement. Neer’s, Yergason’s, and Speeds tests were negative for impingement or pathology of the long head of the biceps. Sulcus sign for inferior instability was negative on the left, and positive on the right for movement but asymptomatic.

Cervico-thoracic mobility tests demonstrated reduced C7/T1 extension, left T1-2 hypomobile into extension, a positive manubrial test with the manubrium rotating right with cervicothoracic extension, also indicative of T1/2 left hypomobility, and left T3-5 hypomobile into extension.

Clinical Impression

RS was diagnosed with a biomechanical fault caused by a stiff SC joint, and several areas of hypomobility in his cervico-thoracic spine, causing impairments of pain and reduced ROM in the shoulder and neck, limiting his ability to sleep, reach overhead, and participate in recreational activities. The therapist determined RS was an excellent candidate for physical therapy due to his motivation, cooperation, and active participation in therapy despite the chronicity, psychological comorbidities, and lack of social support. RS’ goal of returning to the YMCA directed the therapy goals of pain-free neck and shoulder movements, cervical and shoulder ROM within normal limits, and a return to recreational activities.


Manual Therapy

The left clavicle was mobilized posteriorly with a grade II mobilization to improve clavicle rotation during shoulder flexion, followed by scapular muscle re-education while seated and reaching forward and flexing his trunk. This resulted in improved pain-free ROM. Additionally, myofacial release of the left subscapularis was performed, which resulted in his ability to reach overhead pain-free.

To address the reduced mobility in the cervical and thoracic spine, grade III mobilizations were performed in the following areas: C7/T1 into extension, left T1/2 into extension, and T3-5 into left extension followed by a capsular stretch of the left T3 capsule with manual traction. To improve his neck ROM, the therapist also did a Grade III right atlanto-occipital sidebend into flexion, myofascial release of lateral cervical musculature, and bilateral cervical rotation with resistance to retrain his cervical rotators to use the new range. After treatment the glenohumeral joint had increased range and decreased pain.


To improve his shoulder mobility, RS was initially given a home exercise program (HEP) with pectoral stretching in the doorway. It was expanded for more functional movements with D1 and D2 shoulder flexion and extension with a light resistance band anchored in the door, concentrating on eccentric control with concern for tendinosis, advancing to a moderate resistance band once he mastered the form in preparation for going back to work and the gym.

To improve neck ROM, diaphragmatic breathing exercises were added to reduce accessory muscle use. A “teacup and saucer” exercise for atlanto-occipital flexion was added to the HEP where he stabilized his cervical spine with his hands behind his neck (saucer) and then flexed his neck (teacup), and he was encouraged to flex his shoulders to end of range to improve thoracic extension. By his last visit, RS practiced lifting with correct body mechanics to various heights with various weights to reduce neck extension to prepare him for a future job he wanted on a manufacturing line.

Adherence interventions

To improve HEP adherence, the therapist designed a form (Appendix 1) between the first and second visit. Self monitoring via paper log or activity diary has been used to promote physical activity in patients with severe mental illness (SMI).[4][5][6] This form incorporated adherence techniques such as providing relevant health information (purpose of the exercises)[7], the setting of goals[4][6], and monitoring of symptoms in relation to SMI and exercise.[5][6] Barrier and Motivator columns were included so he could see what prevented or helped him complete his HEP. The recommendation for physical activity prescription in this population is to limit the intensity[4] and have low initial demand.[6]

The therapist also decided to address RS’ adherence through informal motivational interviewing (MI) during treatments by examining his attitudes and beliefs about his therapy and HEP and his responsibility for his health[8][9] and work with him on behavior/ lifestyle modification to meet his goals.[10] A brief synopsis of MI is in Appendix 2. MI included encouraging his self-efficacy in HEP performance by observing his movements and providing feedback when asked if he was doing them correctly, then brainstorming about incorporating his HEP considering his lifestyle and health.


Measurements (Table 1) were chosen across the three domains of the ICF: Body Structure and Function (pain, ROM, DASH), Activity (NPDS, DASH), and Participation (DASH). Pain was measured with a 0-10 numeric pain rating scale. ROM was measured with a standard goniometer. Appointment adherence was measured by the ratio of visits kept to total scheduled. HEP adherence was measured by a therapist-designed form (Appendix 1).

RS’ pain decreased, but his goal of returning to the gym was not feasible financially after being fired. Limitations in neck and shoulder ROM improved. RS missed the last three scheduled appointments; however he completed and returned the DASH and NPDS 42 days after his last appointment with the author. He improved on the NPDS and the DASH score; however, while both measures can measure change over time there are no minimal clinically significant differences reported in the literature. No data are available for HEP adherence as he did not return the forms. Based on self-report during treatments he started well but almost stopped doing his HEP by the end. During a follow-up phone conversation three months after his last session, RS reported he returned to work in a warehouse, and had no pain or limitations with upper-extremity movements.

Table 1: Tests and measures at selected time intervals

Initial evaluation (t)
t+29 t+48
3/10 1/10 0/10
Cervical extension
50° painful and stiff 55° stiff
Cervical sidebending  
25° bilaterally L 35°, R 45° 40° bilaterally
Cervical rotation

L: 60°, painful
R: 70° , painful
L: 65°, tight
R: 65°, tight
L: 60° (70° PROM)
R: 60° (80° PROM)
Shoulder flexion

L: 125°
R: 142°
L: 160°
R: 170°
L: 170°
R: 180°
L: 80%, overpressure increased pain; R WNL Equal bilaterally with elbow past chin, tight on L Not recorded
Neck Pain Disability Scale
20.5 NT 18.5**
10.34; work module = 0 NT 5.00, work module NA**
Visit adherence 
50% (1/2) 67% (4/6) 62% (8/13)
HEP Adherence
N/A No report No report

**Completed 42 days after last treatment, during which time another therapist saw him once. When he filled out the DASH for t+48 he was unemployed.


Shoulder and neck pain are common impairments, and the risk for both increases with factors relating to work ergonomics, psychosocial control, and mental health.[11][12][13][14]SMI and substance abuse can affect a patient’s adherence to appointments and therapist recommendations.[15][16][17] When an individual has co-occurring disorder, the problem may be magnified, however there is no report in the literature regarding adherence to physical therapy for this population. This case study is the first to present a physical therapy evaluation and treatment in this population while applying several strategies to promote adherence to appointments and therapist recommendations.

Evaluation and treatment of shoulder and neck pain can be difficult because of the relationship between the muscles and joints of the shoulder girdle as well as their relationship to the spine. Manual therapy and exercise of the cervical spine have been reported to be effective treatments for shoulder pain and disability[18][19]and for neck pain with or without upper extremity symptoms.[20] In the case of RS, manual therapy was utilized not only in the cervical spine but also in the thoracic spine and SC joint as these were also determined to be part of the biomechanical chain causing the impaired movement and pain.

Adherence strategies were based on literature for SMI. Because of limited research in adherence strategies for those with SMI, it was assumed that while adherence to one domain (e.g. medications) does not translate to adherence to another (e.g. exercise),[21] the strategies themselves may work. The therapist created a self-report log which incorporated ideas from the literature such as a low number of exercises to reduce demand, the purpose of the exercise, personal goal setting, and monitoring for barriers, motivators, and symptoms. The patient did not use it consistently however, and adherence could not be measured with it.

MI is one approach in the literature specific to co-occurring disorder that has shown promise for adherence which PT’s can utilize. MI helps the patient work through stages of change regarding their behavior, and has been shown to improve medication adherence.8 MI may have helped RS perform his HEP as he worked from contemplation to action. Another approach that could have promoted rapport was to personally call and remind RS of the next appointment rather than the automated system.

This report has several limitations. It is a case study and results are not applicable to another patient. The DASH and the NPDS were returned over one month after the last treatment, and a different therapist saw him once before he returned them, so results may be skewed. He did not return the HEP form, so adherence could not be verified.

MI appears to have great promise and relevance in the literature to a physical therapist treating a patient with co-occurring disorder. Further research is needed to determine if this is the best method to promote adherence. Physical therapists may benefit from employing this technique with other populations including the general population, as other patients may have inaccurate perceptions about their condition and require coaching.


This case report was completed as a part of graduation requirements from the PT program at the University of Washington for the corresponding author, who wishes to acknowledge the input of Dr. Kim Bennett, the instruction of Karen Seeley, PT as the Clinical Instructor, and the participation of RS.


References will automatically be added here, see adding references tutorial.

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Appendix 1

HEP Tracking form

Appendix 2.

Synopsis of Motivational Interviewing[1][2]

Theory basis Based on transtheoretical model of change
Stages of Change – interest/ motivation to change behavior 1. Precontemplation – unwilling to change; denial
2. Contemplation – weighing of pros and cons
3. Preparation – commitment to change
4. Action – altering behavior from 1 day to 6 mo.
5. Maintenance – behavior for 6 mo.
6. Termination (or relapse)
Important ideas • Help them work through ambivalence
• Elicit argument from them for new behavior, don’t try to convince them.
• Use reflective listening skills, directive questions, open ended questions about goals and how it may be different than current actions
• Avoid arguments
• Encourage self efficacy
  1. Cite error: Invalid <ref> tag; no text was provided for refs named U.S._Department_of_Health_and_Human_Services
  2. Cite error: Invalid <ref> tag; no text was provided for refs named Bosworth