Friday 5! 5 Reasons Your Patient May Not be Improving

When patients say "physical therapy" did not work for me, it's often not the treatment, but their comprehension, passive treatments, and HEP. What's this all boil down to? It's the clinicians's fault!

Here are some reasons your patient may not be responding

1) They do not have a clear understanding of why

• they need to do their exercises in the mode prescribed
• the exercises are important and what the effects of your treatments are (and are not)
• they need to be responsible for their own condition

2) You are wishy washy with their HEP

• when they leave moving and feeling better, and they don't keep at least some of the improvements, that is their fault for not being compliant
• it is also your fault for giving them an option
• it's not acceptable for them to say "Well, I didn't do my homework as much as you wanted..." if they can't lock in the improvements
• assertiveness, not aggressiveness is key
• "Do I really have to do this?" - "Only if you want to get better."

3) You are relying on your passive treatments to improve their condition

• remember that the effects of our mobilization or manipulation are transient
• anywhere from 5 minutes to 1-2 hours
• manual therapy is just a cheat to get them moving better and more comfortably to make their HEP easier
• this works for corrective exercise as well as a MDT approach
• it's the HEP that keeps them better, because they can keep the window of improvement open if performed at the correct mode
• my explanation to patients, our treatments keep the window of improvement open
• it starts to gradually close the longer you do not keep up the corrections
• keep it open long enough, it starts shutting more slowly, until it stays open and you feel better, that's when you can slack off a bit

4) You chose the wrong treatment and/or direction

• it's only a duck that looks and walks, and talks like a duck until it's not really a duck
• we all fall into patterns, and what worked for your last 10 cervical pain with radiating arm pain patients may not work for the 11th
• give your tried and true patterns of assessment and treatment 2-3 visits before modifying something or changing approaches
• most patients should have a rapid change within 2-3 visits
• the thing to remember the most is that very few patients with intermittent pain cannot get it to go away completely
• my explanation: "your complaints come and go, if we can just get them to go so much that they don't come back, you're better"
• stick with a particular system, MDT, FMS, general mobs/manip along with HEP prior to mixing. 
• mixing systems often leads to skipping of steps that were probably implemented by the creators for a reason

5) The patient is stuck in negative land

• this is listed last, but should be addressed first
• patients who do not believe they can improve will most likely not improve
• you may need to spend a majority of your first several visits on education, decreasing fear avoidance, positive thinking, etc
• reading texts like Mindfulness, Explain Pain, and watching this 5 min video on pain are great ways to decrease fear avoidance and central sensitivity
• coming up Monday, COTW for a TMD patient with central sensitization after facial trauma and what educational pieces we (my current intern and I) provided to get her over the hurdle

Now get out there and go be tough and compassionate simultaneously!