During my musculoskeletal outpatients placement I encountered a ‘passive patient’. By this I mean that the patient came to physiotherapy each week, expecting the therapist to treat her passively, without her actively participating in any aspect of her rehabilitation, and expected to get better by simply the physio ‘fixing’ her problems for her. Granted, passive treatment by a physiotherapist on a patient is very much a part of musculoskeletal physiotherapy, however, it should be used in combination with other mediums of treatment that involve active participation by the patient, thus putting the onus on them for their own rehabilitation.
This patient was in her late 50’s or early 60’s and was nearly 3/12 post MVA. She had various investigations to clear her of any significant pathology, and had simply sustained soft tissue injuries to her ankle and contralateral hip. On assessment her main problems were; decreased dorsiflexion (especially functionally during gait), stiffness of TCJ into dorsiflexion, decreased calf strength and length, and poor balance, gait, and exercise tolerance. I had discussed with my supervisor the situation and we concluded that given she has no significant underlying pathology, her soft tissue injuries should be resolving at this stage, and that her treatment should involve; accessory mobilisation of TCJ, as well as predominately an exercise program to increase her strength, mobility, balance and gait. The patient would present each week with great pain, mainly in her ankle, and would say that she “couldn’t do anything today”. She would state she could only tolerate such treatment as ultrasound, and would refuse to give consent to mobilisations or participate in any active exercise.
I sufficiently explained to the patient her situation and the need for active involvement with exercises for her to get better. Throughout the few weeks I treated her she was very reluctant to do any active treatment and would constantly complain about her high level of pain. I found it difficult to believe she was in so much discomfort, however, after discussing the issue with my supervisor, she made me realise that pain is a subjective thing and people perceive pain differently, and regardless of whether or not a patient is ready to be progressed, you cannot neglect their perception of pain. We also discussed how the psychological impact of the traumatic incident may still be affecting her.
After talking with my supervisor I tried to approach treatment in an assertive way, emphasising the need for active participation, whilst still showing empathy with the patient. By communicating in a more effective way and giving plenty of education regarding her condition, I was able to get the patient to participate in exercises in the gym for a short period of time for the next few sessions that I saw her. She was still reluctant to push herself and presented with significant pain each week, but also acknowledged that she felt better after the physio sessions.
I will approach similar situations in the future knowing that just because I think a patient shouldn’t be in much pain or discomfort given their condition, doesn’t mean that they actually aren’t in any pain or discomfort. I will be more sensitive to their issues and use effective communication to provide the best option of treatment given the situation.
Has anyone else been in a similar situation where either they thought a patient’s perception of pain was ‘over the top’ given their condition, or where a patient would not actively participate in treatment, simply expecting passive therapies by the physiotherapist to ‘fix them’. If so could you please give me some advice as to how you addressed the situation?
1 comment:
Hey Patton,
I’m currently doing my musculoskeletal outpatients prac and I have a few “passive patients” too, so I know how frustrating it can be. There are a couple of techniques I have tried, some work better from one patient to the next, but I think they all involve some form of recognising the psychological aspect of pain, as you mentioned.
If you have someone who won’t consent to mobilisations because they feel their pain is too high see if you can convince them to let you try it on the other limb first. This might sound ridiculously obvious but, as you were saying, some people have different perceptions of pain, and if you can show them what is “normal” on an unaffected limb they may be more likely to let you do it on the affected limb. I think we, as physio students, become so used to be poked and prodded by each other that a simple glide or mobilisation technique which may be uncomfortable for some becomes nothing to us. People who aren’t used to being touched or moved in that way may feel it’s somewhat unnatural and fear it.
For people who won’t do their home exercises and take control of self management I think you often need to “scare” them with the facts. Eg “did you know you have an 80% chance of your back pain reoccurring if you don’t practice these pelvic floor and tummy exercises until they’re automatic!”. Let them know that unless they’re willing to take the advice you have to offer, and make their health and physical well being their own personal responsibility then there is nothing further that physiotherapy can do for them…then discharge them! As much as we like to help people with our hands and technical skills being educators is such a huge part of our profession and we need to make sure our patients understand this.
Meanwhile, if anyone else has some other strategies I’d love to hear them!
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