On my recent musculoskeletel prac I have come across patients who take on a very passive role to treatment. I had a quite a few pts who i saw weekly over the couse of the 4 week prac who would come back every week with no progress made. They were still in pain and there was no change to their impairments such as mm length and strength , yet when you asked them how they went with their Home Exercise Program they report that they didn't have time to do it this week. (yet again).
Post treatment they make gains and subjectivelt report that they feel better, however when they come back the next week they report that post treatment they felt good then experienced a gradual decline throughout the week and were back to the same level.
This really frustrates me, and ethically I feel that it can t be right for us to continue treating these patients when they are not making any preogress. The patients are not taking any repsonsibility for their injuries at all.
I tried expalining to the patients that the reason they are plateauing is becaause there is only so much we can do as a physio in a 1 hr treatment session, once a week, and now the rest is up to them to work on their exercises and stretches to make improvement s and to maintain gains amde in the treatment session. I said this quite firmly and it worked quite well with a couple of them, But as this was in the 4 th week I wasnt able to stick aroudn to see if they made any gains by doing their home exercises.
Similarly, I had a pt who injured his disc doing "dead Lifts" at the gym, yet continued to go to the gym, lifting weights week after week, even though his back was not getting better, and some week s even worse. In thsi situation simple education didnt work.. quite firm encouragemtn not to go to the gym, and expalining to him that he needs to take more responsiblity for his injury had a better effect.
I guess as physios we will come across these patients wuite frequently. Teh question is if they are not taking responsibility for theri injures and taking on a very passive role in their recovery where do we draw the line and stop treating th epatinet, or do we continue treating the pt even though they are not making any progress weeek by week ( although they are making progress by the end of the treatemt session)
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3 comments:
hi Kelly,
You are absolutely right by telling the patient to accept responsibility.
Sometimes patients think that by paying heaps of money is enough for physio to offer a complete cure for the session and that there is no part for him to play in the process.
This can be frustrating for the physio - as i have found as a student, not only in musculoskeletal but also neuro.
I think this needs to be made clear to the patient in the first session itself - that you are alone are not going to be part of a successful treatment - in fact the patient has a bigger responsibility.
Otherwise, the patient is likely to fall back on physio and keep coming back for a cure session, only to give the same complaints.
We can also warn the patients (if their condition in acute) that the condition is likely to go into chronic if they don't handle themselves carefully or play their part. If it is already chronic - then encourage them to go for regular fitness.
i think education and constant reminder of consequences is vital for patients like these.
Hi kelly,
I so totally understand. I had patients with RC and shoulder pathologies pruning tress over the weekends, and I had one who went back to work as a carpenter.
All we can do is educate the importance of self management and the need to perform these exercises. You should explain that the passive treatments in the early phases of rehab are over, and that the only way to achieve recovery is through active coping.We couldn't sit them down for 15 min a week doing RC strengthening - that's not enough!! If it doesn't get through to them, we've done all we could. We cannot force them to get better if they're not willing to take an active approach.
Mark
Hi kelly!
Like everyone else I totally agree with you. I found that a lot while on my bentley curtin MSkel prac. One particular lady with tennis elbow had had ongoing symptoms for years! She never took anyones advice to rest it & let it heal, instead she kept doing her own thing. Week after week she would come in for a massage, stretches and taping though she refused to manage herself at home.
One afternoon I was so upset with her progress that I asked my supervisor if I could tell her she wasn't to come back for the next few weeks, so that she could learn to manage it herself.
I have heard she came back in to the clinic the other day for a revision and her arm is doing really well. Apparently she stopped working for the paper round (which was causing her tennis elbow) and started umpiring netball instead.
In this instance, the push for self management worked a treat. In a lot of cases it might not have been appropriate though in her case that little extra shove made more difference than any physical treatment I could have given her.
Just a thought :)
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