Help! Patient X with Y Condition is Not Getting Better!

There are most likely 3 scenarios why a patient with any condition is not improving.

1) You haven't educated them enough about their condition, so they don't understand why posture is important, or the mode of their HEP is not an option

• Make a point to explain the pt's condition in a way they understand. 
• Give them limits to what they can and cannot do.
• Tell them that soreness is not the same as worse, explain the differences.
• Educate the chronic pain patients especially on the importance of movement, decrease their anxiety as much as possible.
• Make it a point to say, "If you improve after each visit, but at least some of the improvement does not remain between visits, you are not being compliant enough." 
• Physical therapy does not work without compliance! 
• If I say, "Do cervical retraction exercises 10 times/hour," that means 10 TIMES AN HOUR!
• the psychology of hourly exercises for derangement reduction or stretching will hopefully get someone to realize it's not just 2-3 times/day
• 2-3 times/day often translates to forgetting to do their HEP for most of the day, and squeezing it in at the end
• Don't hesitate to play the "never" card
• I can only help you so much, if you are not compliant, you may NEVER get better
• My secretary warned me that an eval did not want to come in, but his doctor was making him. He questioned all of our exercises and treatments, he didn't want to do his exercises. He didn't want to schedule the next day because the NBA finals were on that night and he had to work at 11 am
• My colleague and former protege asked him, "Hey, do you think the ladies like it when you lose bowel/bladder control, and have to wear diapers? Because that's where you're headed!"
• I told him it was kind of harsh, but you know what? That patient not only followed up 3 days consecutively - very important for a lateral shift, but after 6 visits and returning to 100%, we had a hard time discharging him!

2) You are using the wrong/treatment or approach

• I base my initial method of treatment whether it's mostly OMPT with some MDT or vice versa on the pt's subjective
• give each method of treatment at least 3-5 visits before you modify something, you should notice SOME change by then
• for those of you struggling with getting MDT to work, remember "end range is where the magic happens"
• the patient may need some self generated overpressure on their pressups - try having someone stand on a beach towel over their hips at home
• they may also need some overpressure for cervical retraction, have them push A/P on their maxilla until their sternum slightly raises, that ensure end range!
• try prolonged postures - duration + end range may be the key
• I've had patients get nowhere in the clinic with OMPT and MDT, then try lying in a hips offset or a lumbar flexed/rotated position for 30-60 minutes, and then finally improved
• look at adjacent joints
• one of my assignments for a DPT project was to write about a "lower back patient" that improved by only treating their hip
• always screen at least one joint up and down
• unilateral lumbar patients often have a hip capsular pattern on the ipsilateral side
• knee patients often have hip and ankle dysfunction
• shoulder patients often have thoracic and 1st rib restrictions

and finally...

3) Physical Therapy is just not working

• it still drives me crazy when I can't get someone better, but the more con-ed I took, the less failures I had in terms of treatment
• I tell patients they should notice SOME change in at least 6 visits
• if they don't improve in function, ROM, strength, pain, or any other measure AND they're compliant, AND you've tried your best - it's time to either refer back or to another specialist of your choice if the pain is unbearable
• It was tough, but I just referred a pt back to their PCP. He was referred to me by 2 MDs, both of whom recommended me. He was laterally shifted, said he had lumbar pain that worsened over 30 years, and no matter what I tried, could not get him to centralize and he always came back shifted. His compliance was questionable, but I did not want to waste his time because after 5 visits, he was essentially no better. He was actually very appreciative that I tried my best.
• I am paraphrasing Paris' Foundations Course quote "If a patient needed intervention other than PT, they either did not see a good enough PT, or saw one too late."

There are countless more examples, but I hope that you got some tips on how to handle patients that may not be getting better. You win some and you lose some, but you'll find the more education you have and the more eclectic you are in your assessment and treatment, you will have a much better record.