S3-E65-Get unstuck treating hard patients: 4 pitfalls & 3 treatment buckets for results

Welcome to the clinical flow podcast. I'm your host Andrew Koppejan. If you're a physiotherapist or other movement professional, who feels like you're stuck in a rut, then my podcast is for you. This podcast is focused on helping you unleash your best clinical self and move from a place of frustration to flow in your clinical practice. Each episode I'll share strategies and approaches, along with my latest thinking on how to improve your clinical performance and keep loving what you do. This is episode number 65. In this episode, I'm going to be talking about difficult patient archetypes. The four pitfalls that we can fall into as clinicians when we're dealing with hard patients. And also show you a path forward where I outline three different treatment approaches that will assist you in overcoming these challenges. Before I dive in, I want to let you know that I have a newsletter where I write about topics relating to improving clinical performance. Head over to 360 clinician.com to sign up today for free. Alright. Let's get started. I don't know about you, but I find that it's almost automatic that we can put patients into categories. We have our easy patients and then we also have our hard patients. Someone who is young and motivated body aware and has healthy beliefs around movement and pain can pretty easily fall into that easy category. But what constitutes a hard patient? There are a number of factors, but for the most part, I found that it can include a combination of all four of these factors. Oftentimes they're inactive. They can be unmotivated. They might have unrealistic expectations around treatment and they may have a less than adaptable body structure and they may have poor posture, poor muscle tone, those types of things. This patient archetype can really be a challenge for even the most experienced of clinicians. I was just talking to a physio friend recently about this type of patient and how draining and hopeless she was feeling after seeing these patients, successively in one day. In her situation, they came in with neck pain and they were looking for a magic cure. They could tolerate very little hands on treatment and they would often flinch at the first sign of body contact. It really can be disheartening having this type of patient archetype on our caseload. It's easy to feel like the situation is hopeless. And as therapists, we can easily resign ourselves to going through the motions with doing just half-hearted treatments. I really want to help you get unstuck with this type of patient archetype and help you reframe your approach to treatment. My goal is to move you from a place of disillusionment and despair to a place of flow where you can be curious and collaborative and creative with them. While these patient archetypes will still likely be challenging. My goal is to give you some fresh perspective to help you avoid the drain, the frustration and the exhaustion. But before we go into a treatment strategies, I think it's really important to look at some of the common pitfalls that impact our ability to engage fully with our patients. These pitfalls really center around how we get stuck in our thinking. Shifting our thinking is going to matter so much more than any specific treatment exercise or modality that we use with the patient. So here are the four pitfalls that I think we make with these patients. First pitfall is that we put everything on our shoulders. It's really easy to believe that it's a hundred percent up to us to get our patients better. With this patient archetype, I found that they can often assume that the onus is all on the therapist to get them better. That's why they've come to see you. Feeling like everything is up to us can really stifle our creativity, communication, and collaboration with this type of patient. Pitfall number two is we try to manufacture motivation for them. As therapists, when we come across an unmotivated patient all too often, our first instinct is to try to manufacture motivation for them. I know for myself, we try to bring more energy to the room when we see this type of patient. We might think that we can actually muster up enough motivation to build momentum for them in their recovery. But as I'm sure you're aware, this is impossible to sustain. Oftentimes our own efforts to instill motivation in our patient can actually just create resistance in our patients instead. Pitfall number three, is we chase symptoms. As a physiotherapist, it can be tempting to focus exclusively on treating symptoms. The further we slide into a place of frustration with this patient archetype. We can easily stop being curious. We then stop exploring the other potential drivers of their pain and dysfunction. Pitfall number four, is that we ignore patient resistance. One of the biggest pitfalls I think we can make when engaging with this patient archetype is ignoring their resistance. We pretend that they're motivated, we pretend that they're on board with doing exercise. But the reality paints a different story. They exhibit limited motivation. They aren't doing any of their exercises that we've given them. They talk about how they find manual treatment helpful, but then wince when we touch them. Once we understand these four common pitfalls, we can begin to approach treatment with more clarity and structure. I think it's really easy to get flustered when one treatment approach doesn't work and then we jumped to another treatment approach. That can quickly result in just feeling disoriented and unsure of how to approach treatment. What I found useful in my own clinical practice is organizing treatment into themes or buckets. And so then what you can do is approach your treatment by shifting which bucket you focus on and you have options to work with when you're hitting a bit of a roadblock with this type of patient archetype. I found that there are three treatment buckets that have worked well for me with this type of patient archetype. And one that doesn't really rely on a poorly tolerated manual therapy. The first treatment bucket is really about downregulating the nervous system. When patients are sensitive to any kind of manual therapy, it really is important to have some different strategies to down-regulate the nervous system. I think one of the most important aspects and strategies that we have is breathing intervention. Breath is such an important nervous system regulator, and it's something that you can use on different levels. In some pain science training I did with Neil Pearson. He highlighted experimenting with both breath awareness and breath regulation. From his experience, patients respond differently to different breathing strategies. So I wanted to just go through that in a little bit of detail here. So breath awareness is where you just have the patient focus on being aware of their breath. They're inhale and they're exhale. They're really not trying to control their breath. They're not trying to control the amount of time that their breathing in or breathing out. They're just focusing on the awareness of their breath. As a therapist, you can help the patient tune into becoming more aware of their breath, helping them to tune into the awareness of the air going in through their nose or their mouth. The movement of their chest as they breathe in and out, that type of thing. Breath regulation is where you have the patient control the length of their inhale and exhale. So for example, you have them breathe in for three counts and out for four counts. The goal is to find a comfortable rhythm and something that they can sustain for a couple of minutes of practice. When you're working with a patient on deciding whether breath, awareness or breath regulation is going to be better for them. What I'll do is I'll typically run an experiment where they engage in an assisted movement. For example, let's say that it's shoulder flexion while they're doing the breathing technique. And once one version of breathing with movement is completed, then I retest the aggravating movement. If there is no change, then we run the experiment again with the other breathing technique. During these experiments, I provide simple explanations of the power of breathing to influence the nervous system and how breath work can calm the nervous system. Another related strategy with down-regulating the nervous system and improving breathing is really focusing on breathing pattern dysfunction. Oftentimes with this patient archetype, they may have a poorly functioning diaphragm. They may be a really engaging in apical breathing, or they may have limited diaphragm contraction ability, or they may have poor movement through their ribs I've often found it beneficial to perform some manual therapy and breathing instruction to assist in improving diaphragm and rib mobility. Now another really important way to down-regulate the nervous system is focusing on the whole aspect of sleep. I think it's important to understand if this patient archetype has disrupted sleep and sleep is such an important modulator of the nervous system and helps to down-regulate the nervous system. I found that patients who are struggling with persistent pain can often experience breakthroughs by addressing sleep health. Treatment bucket number two is about shifting patient beliefs. With this patient archetype, they have some pretty entrenched views about their pain and body. They may believe that it's up to someone else to fix them, that there is a magic cure and that the treatment is something that is done to them rather than them being an active participant in the treatment. Trying to treat within this patient paradigm, is really pretty much near impossible and one that is likely destined to treatment failure. It's important to begin to shift and challenge the patient's beliefs toward their body. They need to understand there really isn't a magic cure and treatment requires both the patient and the therapist to work together. Sounds easy, but I've found that how you approach these conversations really is so important. Beliefs are based on a perception of reality and it's important to challenge one's perception of reality in order to begin shifting those beliefs. This patient archetype believes they need hands on therapy, but can't tolerate light touch. Then we have a problem. And I found that it's helpful to highlight this discrepancy to the patient. I might say something like this. I know we agreed that we'd incorporate some hands on therapy to help your neck. But I'm seeing that your body is quite sensitive whenever I start to work on your neck. Wouldn't you agree? I think it's important that we look at maybe some other options that might be better tolerated by your body. Rather than putting the onus on yourself to come up with all the solutions, which is one of the pitfalls I talked about, it's important to begin to shift to a more collaborative approach. You know, I provide some other options and then it's important to come to a joint decision together between patient and therapist. Treatment bucket number three is channeling patient motivation. I think this is such a big one. It's easy to fall into the trap of assuming that you, as a physical therapist are responsible for motivation, especially when we want our patients to succeed and get better. But it's really not up to us to create motivation for our patients. Instead, I think we have to actually step into our role as a health coach and help them find a source of sustainable motivation to support them moving forward. For this type of patient archetype, they may have few if any movement habits. What I like to focus on initially is just to help them build a simple movement habit. I focus on consistent action that's easy for the patient to do and that doesn't wind up the nervous system. For example, with the patient archetype, with neck pain, I may have them start with some simple shoulder slides up the wall. They may feel comfortable doing this exercise and they can see the connection between shoulders and the neck. So it's a meaningful activity for them to do. And then what I do is I write down what that small action is going to be and the frequency of how often they should do it. And then I make sure that the patient is on board. It's important that they feel confident in taking on this action on a daily basis. So I ask about what their confidence is and how confident do they feel doing this on a daily basis? And does it seem reasonable in terms of the number of times that they would do this wall slide up the wall. If they don't, then it's really a collaborative approach with your patient to then figure out what those parameters need to be so that they can have a higher level of confidence to do this on a daily basis. Something that helps overcome hesitancy on the part of the patient, is to frame this small action within the context of an experiment. So I tell them, we're doing a time limited experiment and then let's take stock after, you know, X number of days to reevaluate. If it's something that we should continue doing, I think it's a lot easier to do something when we have an end time in mind. And then we can reevaluate and see if it's something that makes sense for them and what we need to adjust moving forward. Once the patient is consistent and doing the small action, then I look to move to more challenging and likely a little more functional in specific exercises related to the issue at hand. So getting that patient to be successful early on. Is really such an empowering step in that patient's recovery journey. The beautiful thing is that you've shifted the relationship from one where the patient expects all the answers from you the therapist. To one where there is a collaborative partnership, where the patient is building self efficacy and autonomy. All right. So in wrap-up of today's episode, I want to just briefly review the four pitfalls and then the three treatment buckets. So the first pitfall that I talked about was the pitfall where we put everything on our own shoulders when trying to treat this challenging patient archetype. Pitfall number two is we can try to manufacture motivation for them. Pitfall number three is we will end up chasing symptoms and then pitfall number four is we ignore patient resistance. Then I talked about how it's helpful to actually look at treatment buckets. So that you can be more flexible and agile as you're working with this type of patient. The first bucket was the importance and the approach of downregulating the nervous system. I talked about the importance of breath in downregulating the nervous system and highlighted how you can experiment with both breath awareness and breath regulation. I also talked about the importance of addressing sleep health, such an important modulator of the nervous system and pain processing systems. For treatment bucket number two, I talked about the importance of shifting patient beliefs. And challenging beliefs to help create more realistic expectations of how treatment can take place and the importance of developing a collaborative relationship between the patient and yourself. Treatment bucket number three was about improving how we can channel patient motivation for creating healthy movement habits in their life, and how we need to put on the hat of health coach when we are working in this capacity to help patients manage and sustain motivation. I realized that this patient archetype can be challenging to treat. But when you identify the pitfalls that you typically experience with this type of patient, then you can move forward by reframing treatment within one of the three buckets that I discussed. Thank you for hanging out with me today and hearing about how you can improve your clinical performance. Specifically around how to treat that hard patient archetype. Make sure to subscribe on iTunes or Spotify to stay up to date on future episodes. And I'd also encourage you to sign up for my free newsletter by heading over to 360 clinician.com. Here's to less frustration, more flow and better clinical results. Take care.