Blog #61 Back to the Drawing Board- My Patient is not Progressing??

So you are treating a patient that you have spent time objectively assessing, making a rehab plan for and treating but they are not progressing…

So many new graduates and physiotherapists that have had years of experience find themselves in this situation because every patient presentation various and can progress differently to what we would initially expect. In this moment often what happens is that the patient feels like it is either a waste of their time and money, they discharge themselves early and likely go on continuing to experience their initial problem. So how do we avoid this?

As a physiotherapist, it can be easy to find yourself either repeating the same things you have done for a previous patient or diving straight in for a diagnosis and not being open minded for any secondary conditions that can be affecting a patient’s pain.

Example:

You have been referred a patient from a colleague physiotherapist for the treatment and rehabilitation of a rotator cuff tear. They have all the imaging to support this diagnosis and have been given some progressive exercises. They have posterior shoulder pain which can refer down their arm. They have had multiple sessions however have seen minimal to no improvement. Typically as a new grad we continue treating like we normally would for a rotator cuff tear however often what we need to do is step back and complete a reassessment consultation with the patient- a thorough objective assessment to work out is there anything else contributing to this person’s pain? Is it neural irritation or should I be sending this person for further imaging to rule out further pathologies? Has the patient been assessed and treated for thoracic or cervical stiffness? It is important to not just focus on the painful shoulder but also look further into the surrounding joints that may be contributing to this pain. Try some treatment direction tests within a consult or use exercises to see have I made the pain better, worse or the same. With this information, they patient will feel more confident in your abilities and will put their trust in you.

Often if you sit down with a patient and explain that pain associated with a rotator cuff tear normally settles a little quicker than what we are seeing and that you would like do a further assessment, they often appreciate the honesty and will look to you more as a thorough physiotherapist, rather than someone who wants to continue to see them with no improvements being made. I think we are often so scared of coming off as incompetent to our patients that we can avoid these harder conversations. This can also be applied to an initial consult if you are not 100% sure on the diagnosis or how the patient will progress. Often pre-framing to the patient that if after 3-4 sessions we are not making improvements, we will sit down, reassess and then can work out the best course of action they will feel like it is not a money grab, however a therapist investing in them and being mindful that you may need to involve other services such as dietician, GPs, psychologists, exercise physiology etc.