Managing Difficult Patients

We all got into physical therapy because we want to help people relieve their pain, and help them move and perform better. Besides paper work, one of the most challenging part of a physical therapist’s job is managing difficult patients. By this, I mean a patient that does not put in the effort to get better and may only want passive treatments. These patients are difficult to treat because their dysfunction does not follow a typical pattern and you are having extreme difficulty in making a change to their pain. They challenge a therapists intellect, and can be emotionally draining as well. In my opinion, I would rather have a patient with a difficult dysfunction who will put in the effort to get better as opposed to a patient who is nonchalant and only wants passive treatment. The latter will never get better, while the former will eventually get better as different techniques and approaches are attempted. In this write up, I will give my experiences and how I handle seemingly difficult patients.

Let me begin with patients who simply do not put in the effort to get better but would rather rely on passive modalities and treatment. I find these patients to be very frustrating because although they come for therapy, they are not actively engaged in their treatment. They are with us for one hour every other day or so, but what are they doing for the rest of the 23 hours that they are not with us is the question that needs to be asked. If they are not engaged in the rehab process, then they are most likely undoing every treatment that has been done in the clinic when they go home. There is only so much that you can do in the clinic. This can be very frustrating because your patient might go home with no pain, and when they come back to the clinic, they are back in pain.

An example is a patient who has low back pain from faulty lifting mechanics. After movement modification, strengthening exercises, proper education on lifting mechanics and soft tissue manipulation to the paraspinals, the patient feels good. He/She then goes back to continue lifting with the wrong technique or may not engage in home exercise programs. This makes the recovery process very difficult. The way I deal with these patients is by confronting them. A typical question I would likely start with is asking them if they did their home exercise program. If their response is no, I would then ask why. The next vital question I ask, “Is being able to lift without pain (whatever their situation is) important to you? At this point, the patient will say yes and then you must follow up with so why aren’t you doing your exercises at home? If you feel that you cannot get a patient to engage in their rehab then you should probably discharge them on the spot because you will not make any progress. If they do not appreciate their own health, then you are wasting your time.

This patient described above can be very draining on a therapist, but I find them enjoyable if the patient is engaged and actively working to improve their health. It allows me to think outside the box and this can be used as a good learning tool. The best way to treat these patients is to have intra treatment test. This will allow you to be able to check the effectiveness of your treatment and see what is working and which treatments are ineffective. Another important key when treating these patients is to think outside the box. You cannot treat them like any other patient. Sometimes you have to think outside what is usual or even do a test to an extreme degree to attempt to reproduce the patient’s pain. I have been reading the Anatomy Trains book recently and have come to realize that the body is connected in intriguing ways. I have learned that there are some interesting connections in the body, such as the plantar fascia and the thoracic parapspinals. It is important that if something is not working, you should try something new.

These are some of the hardest patients to cure, but I believe that it is also the most satisfying when you can help them. The reason we follow the PT route is to help others, and it does not get any better than to help someone who may have tried everything else and assumed they would always have pain. Work hard to help those who want to better themselves and learn to let those go who do not want to put in the time to better their health.

Jordan Cardoza

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