13. Before we decide if we should do a detailed investigation of a complaint, we look at whether there are signs the organisation has got something wrong. We do this by comparing what should have happened with what did happen. We have done this and have not found any signs that something has gone wrong.
First assessment
14. Mr E felt the Trust’s first assessment on 8 August 2022 was too short. The Trust recognised this in its complaint response dated 9 May 2023. To look at this fully, we have considered how long the assessment took, what it covered and if that was in line with relevant national guidance.
15. Our adviser referred us to the Chartered Society of Physiotherapy guidance. It says a physiotherapist should conduct an active range of movement (or AROM assessment) while noting the range of movement and pain, or lack of, which happened in this case.
16. The guidance also includes recommendations for assessment of the passive range of movement (PROM). Our adviser told us some clinical decision making would come in here. They said the PROM would normally be recommended if the physiotherapist found restrictions in the AROM assessment.
17. We can see from the notes of the first assessment that Mr E had pain in his shoulder. This was usually when rotating, pressing or twisting and this had been the case for over a year.
18. We can see the physiotherapist tested AROM. This showed Mr E had full movement but with some pain at the end of the movement. This was particularly when it came to external rotation (ER), internal rotation (IR) and abduction (raising the arms out to the side of the body).
19. The assessment led to a diagnosis of ‘trigger point at pectoralis major’ meaning the issue was in the chest muscle.
20. From discussing with our adviser, we understand the physiotherapist could have done other tests to rule out specific issues, but the AROM assessment effectively does this. We understand a PROM assessment was not needed in Mr E’s case.
21. Our adviser said the clinical impression and presentation suggested a weakness of the pectoralis major and that the assessment gathered enough information to understand Mr E’s condition.
22. We have decided that despite the shorter appointment, the physiotherapist gathered the needed information to diagnose the problem and come up with an appropriate treatment plan.
23. The evidence shows the physiotherapist acted in line with the relevant guidance. We have found no signs of failings with this part of the complaint.
Prescribed exercises but no physical manipulation
24. Mr E felt the physiotherapist should have done some physical manipulation on his shoulder during the sessions. The physiotherapist only prescribed exercises to do at home, that Mr E says were too easy and made his shoulder worse.
25. The Trust said in its complaint response that physical manipulation was never part of the treatment plan. It said it only provides ‘short-term benefits rather than long term strength and conditioning’ that is achieved by long term exercises. It said there had been a 40% improvement in Mr E’s condition and the physiotherapist recorded this in the session notes from 12 January 2023, the discharge/mid-point review.
26. The Trust suggested that perhaps there had been an issue with how the programme was described to Mr E and that is why he was disappointed by the service.
27. Our adviser said it is not unusual for an NHS physiotherapy service to include limited physical manipulation during the session. We understand a service based on home exercises rather than physical manipulation is normal for an NHS physiotherapy service, to treat the type of injury Mr E had.
28. Our adviser agreed with the Trust’s explanation that physical manipulation acts more as pain relief. They also agreed a long-term exercise plan, as prescribed by the physiotherapist, gives a better solution to the soft tissue injury Mr E had.
29. Our adviser told us the Trust’s explanation is in line with the Chartered Society of Physiotherapists guidelines which recommend a programme of exercise over a period of time to ‘restore range, strength and stability’ in the shoulder.
30. Our adviser noted there was little to no explanation for the 40% improvement figure in the session notes, which could have been helpful.
31. Overall, we believe the exercises were appropriate for the type of injury Mr E had, although the effectiveness could be improved by more regular sessions. We have considered this in more detail below. We are not investigating this further because we have not seen signs that something went wrong.
Short and irregular sessions
32. Mr E felt the sessions should have been longer and more often than they were. The Trust recognised that availability was low during the time Mr E used the service but said it has since increased capacity.
33. We can see that Mr E had four sessions which were: • 8 August 2022 - first assessment • 16 August– normal session • 27 October– normal session • 12 January 2023 – discharge/mid-point review.
34. We can see from the session notes from 12 January 2023 that Mr E agreed to continue the physiotherapy and had another session booked for 13 April, but he must have later decided to stop with the sessions.
35. Our adviser said there is no clear guidance for how often sessions for treating a soft tissue injury should be. We understand there is also no specific guidance for the length of sessions. Our adviser said the frequency is based on the individual’s condition, the severity of the pain and the prescribed treatment plan.
36. Our adviser gave an example of a patient having sessions more than once a week at first, and then reducing this over time to every two weeks or less. But they said how to organise the sessions is mainly based on clinical judgement.
37. Our adviser said the long gaps between sessions were not ideal and could have reduced the effectiveness of the programme. They said more regular sessions could have allowed the Trust to fine tune the exercises. But they said the exercises were still broadly appropriate for Mr E’s condition. We understand this would also suggest the length of sessions was not a problem.
38. We also considered how our adviser said there is possibly a commissioning and resource issue involved here. This is because the Trust explained availability was low at the time.
39. We judge whether there has been a failing based on the acceptable level of care at the time. Although our adviser said it would have been better if the sessions were more regular, we understand what the Trust offered was not unusual when compared to what was available within the NHS generally at the time.
40. Our adviser said although there were gaps in the sessions, they were broadly appropriate. While we have seen it could have been better if the sessions were more regular, we do not think we can say the Trust’s plan was wrong.
41. We have not seen signs of a failing with the sessions and have decided not to consider the complaint further.
42. We appreciate Mr E’s frustrations with the service. We hope he understands why we have made our decision. We are glad to hear Mr E has been able to get help and his injury has improved.