What To Do When Your Patient Is Not Progressing

In the real world, not all of our patients will get 100% better on the first attempt. Sometimes patients stop progressing, which can be very discouraging for both us as clinicians and our patients. However, it is at this point that we must act. After about two to four weeks, we should see some significant changes in our patients' symptoms. When/If this does occur, there are three actions that you should consider as a clinician:

1. Reassess the Patient: Do another quick examination to check yourself (before you wreck yourself). We frequently are hurried in our initial evaluation and can occasionally get sloppy/lazy with our objective measures. Also, this allows you to expand your objective search. It's possible you missed an impairment that is a key contributor to the patient's symptoms but is located away from the symptomatic tissue (think regional interdependence). You may also want try consulting a more experienced or skilled practitioner if available.

2. Check Patient Compliance: This is a big one and a common culprit. It is our job to educate our patients on why it is essential that they are regularly performing their HEP. If you think how much time our patients spend working with us compared to being outside the clinic, any significant gains must be made (or maintained) independently. With regular performance of an HEP, we should expect to see a weak muscle get stronger, an adaptively shortened muscle lengthen, etc. If we are not seeing the expected improvements, it's time for another chat with the patient. Patients will often complain of not having time to do their HEP. It is here we must tell the patient that we cannot accomplish what we want to do in the clinic without the expected results from a regularly performed HEP. If they are too busy, maybe they need to reschedule their appointment once they have found time.

3. Refer Out: Physical therapy is sometimes used as a diagnostic tool for physicians. We are movement experts and often have a different perspective to offer when examining patients compared to medical doctors. This option actually has a couple different considerations. As you might have guessed, we all likely have impairments that would benefit from physical therapy. Whether or not these impairments are linked to the pathology is a separate issue. That explains why failure to respond to physical therapy after a month is a red flag. Another concern in this area is musculoskeletal pathology that sometimes benefits from skilled physical therapy. An example is meniscal tears. A study came out last year showing that conservative management of meniscal tears was just as successful as surgical outcomes. However, this does not mean that everyone will always respond to physical therapy. If after a few weeks the patient has not seen any significant improvements and is experiencing acute locking/catching in the joint, this patient may not be appropriate for conservative care. This applies to other pathologies as well.