Why Some Patients Fail Physiotherapy, and How to Minimize This

Earlier this year I read a brilliant piece by Adam Meakins discussing the concept of patients failing physiotherapy (1). All in all it was a great piece, although I’d like to expand on it. In this article I discuss: 1. Is your patient really failing physiotherapy?, and 2. How you can help improve your therapeutic alliance and adherence to reduce the likelihood of your clients’ failing physiotherapy.

Is your patient really failing physiotherapy?

It can be easy to think that your patient isn’t getting any better when their pain may not have changed in a visit or two. But before pressing the panic button consider the following:

1) Have realistic expectations and goals been set?

It’s tough as some patients won’t be happy with anything other than a full cure on day 1, but as we expect doctors to provide realistic expectations with regards to the outcomes of injections or surgery, it’s better to be realistic upfront than have disappointed patients later on. I just tell patients in most cases “I can’t guarantee that you’re gonna be pain-free and fully recovered given how long this has gone on for, but I do think you will experience a significant amount of symptomatic and functional improvement.”

2) Are there realistic timeframes?

Some conditions may take the better part of a year or more to make a full recovery from, or even see a significant improvement in symptoms. This can be very tough for patients to swallow, but you have to be realistic or some clients may drop off when they’re not ‘fixed’ in 1-3 visits.

That said – you also need to have timeframes to see small incremental improvements along the way. This, from both the evidence and my experience, can generally range from:

• ROM: mostly session to session
• Strength: 2-3+ weeks to 1-3 months
• Pain: 1-2 sessions to several months (or more)

Setting smaller goals along the way and having timed periods to measure these is critical in order to keep reinforcing patient progress along the way.

3) Are you looking at function or just symptoms?

Let’s face it – many look at the almighty pain scale and the number of pain-free patients as the main (or even sole) indicators of success. However this can be very shortsighted, especially for patients who are recovering from a long-term condition.

It’s quite common, particularly for chronic cases, to have functional improvements (i.e. improved strength, activity tolerance) prior to having significant pain improvements. This also needs to be mentioned and measured. It’s also important to mention that some patients may have no functional limitations and just want their pain to decrease. This is fine as long as the goals are realistic.

Before panicking, take the time to consider the above – and you may find that your patients are likely more on track than you think.

What if I’ve set realistic goals, expectations and timeframes, and my patient still isn’t getting better?

The 64 million dollar question is – are they sticking to the plan?

Option A – They aren’t sticking to the plan

This can come down to numerous factors including:

1) Poor therapeutic alliance

This can be related to poor patient confidence in the clinician; poor clinician self-confidence; and/or the patient feeling rushed, dismissed, or not listened to. Unfortunately sometimes the nature of the clinic can contribute to the latter. Slowing down, really listening to the client and appearing confident are all critical.

2) The treatment approach not fitting with patient’s goals and expectations

Patients should understand the ‘why’ for the treatments and how they transfer to the patients’ goals. I like when clients ask me the reasons for certain exercises or manual therapy techniques as it keeps my work in line with their goals. If patients don’t understand the “why” then good luck with adherence.

Having realistic expectations for the end outcome is critical, but so is having realistic expectations for the process. If a patient comes in expecting ultrasound, laser and acupuncture but gets exercise, pain science education and recommendations for lifestyle change that’s gonna be a big issue. There’s gotta be some give and take (within reason) as well as education on what’s in the patient’s best interest. Is it really that big of a deal to give the patient five minutes of passive treatment if you can also give them exercise, education, reassurance and self-management strategies?

As Mike Studer talks about in his Masterclass on Behavioural Economics and psychologically informed techniques (link here) sometimes you need to give them what they want so you can give them what they need

3) The program doesn’t fit with the patient’s lifestyle

While I’m definitely an exercise and education first physio, I’m stunned when I get a patient who’s been to a previous provider who gave them ten exercises without any patient input. For most non-surgical and non-fracture clients I am a fan of 1-3 goal-focused exercises that are easy to fit in (i.e. can be done sitting or standing, no fancy equipment needed).

For instance – a lunge or split squat with controlled eccentric both strengthens the glutes and stretches the hip flexors without the need for two separate exercises.

This fits in with what Mike Studer’s Masterclass above discusses, and yes this isn’t always perfect, exercises should be fairly convenient wherever possible.

There needs to be a lot of collaboration between therapists and patients. I try to ask “is this too much or too little?” when I give exercises on the first day.

It’s also important to understand that some patients may not always be in a position from a lifestyle perspective to commit to physiotherapy. If a patient is busy with a physical job or sport that aggravates their symptoms and they don’t have time or energy to do exercises, a successful outcome is much harder to achieve. Some may disagree, but I’d rather be upfront with expectations than see a patient (and clinician) waste a lot of time and money to go nowhere.

4) Is it intolerable or too easy?

Sometimes you can’t avoid pain with patients but if a patient comes back and says that they were flared up for 2 days after trying their exercises, you may need to make some adjustments to keep them on target and keep symptoms within an acceptable range.

Sometimes you have clients who are flared up with everything regardless of how little you do or how gentle you do it. While I don’t like it when patients feel like “I’m in too much pain for physio today”, if a client is very hypersensitive, easy to flare up, and has psychosocial factors++ then it may be that those factors need to be addressed first before therapy can be effective.

On the flipside – a rehab program may be too easy and a patient may not buy in, or it may not be sufficient to prepare a patient for physically demanding goal activities. For example, basic glute bridges may not get your patient with a hamstring strain or tendinopathy back to sprinting or gymnastics.

Option B: They are sticking to the plan

In these cases:

1) Is it in line with patient goals?

Improving shoulder ROM is great, but if the goal is for the patient to pick up her kid, the patient likely doesn’t need 180 degrees shoulder flexion and abduction. The focus should be more on strength and load tolerance.

2) Is it too hard/too easy/too painful?

As above!

*Note – before going into the next 2 points it is critical for me to share Tim Mitchell’s Masterclass on A framework for optimizing the patient interview and clinical outcomes (link here) as a lot of what is covered in that masterclass pertains to points 3 & 4 below

3) Is the diagnosis correct?

Sometimes other diagnoses may be lurking under the surface. This does happen from time to time and it happened to me. I had a patient with a suspected disc herniation who started regressing and was later diagnosed (via imaging) with a cyst that needed medical management. While I’m not a fan of overusing imaging, it does have a time and place especially if the patient is regressing or things just don’t seem right.

There also will be cases where, and I’ve had this happen a couple times in my career, where a significant imaging finding (i.e. loose body, torn ligament) will show up on MRI yet every orthopedic test you did for those was negative. Orthopedic tests (even when clustered) and clinical histories aren’t perfect.

Also, let’s call a spade a spade – sometimes case presentations can be inconsistent from session to session and don’t always fit in a nice, neat box. This can be very frustrating when patients have (what I call) “moving target syndrome” where symptoms move in location and tests that may be painful/non-painful one session may be the opposite the next. This can also be an issue with patients who have a lot of psychosocial factors and/or pain behaviours, and as a result present with non-organic signs.

4) Are there other barriers?

One of the main reasons I’ve seen active clients “fail physiotherapy” with other practitioners is due to a lack of focus on what’s done outside of the clinic. If your clients’ neck pain is aggravated by 10 hours of desk work in a way or your clients’ hamstring tendinopathy is aggravated by countless of miles running yet no mention or effort is given to activity modification … then you and your client may bang your head against the wall without progress. Sometimes activities may not be modifiable and that’s ok however, as said above, realistic goals and timelines need to be made and reset if need be.

There can also be a myriad of physical health factors (i.e. diabetes, smoking, obesity) as well as psychosocial factors. Certain physical and psychosocial comorbidities may require involvement from other health professionals depending on your jurisdiction and scope of practice. I tell patients with complex presentations that physiotherapy can only address one piece of the “pain pie” and that’s why I can’t always guarantee that patients will be pain free when the therapy is done.

I group psychological factors, and yes this is oversimplified, into ones that fall within and ones that fall out of physio scope of practice (at least where I work and live)…

*Note some of these can move based on context. For example – depression due to being inactive due to pain can certainly be in our scope whereas depression due to losing a loved one is definitely not in our scope.

And there may be some barriers that can’t be addressed. A common one, from my days doing complex workers’ compensation cases, is workplace barriers. Although some strategies are in place to facilitate recovery and return to work, it still can affect therapeutic outcomes.

Before moving on it is also important to note that sometimes clients may not always think to tell or feel comfortable telling the clinician about certain factors that may have ramifications down the road. An example of this is a client of mine who had postpartum tailbone pain. During the process of giving birth there were major complications as well as physical and psychosocial trauma. It doesn’t necessarily change the rehab that’s done however it can necessitate a “goal reset” as well as referrals to mental health providers.

As Tim discusses in his Clinical Interview Masterclass it’s important to get a very comprehensive understanding of all the different bio-psycho-social factors that can contribute to a client’s clinical situation and presentation as treatment needs to be steered in those directions. For example, a treatment protocol that is largely tissue based isn’t going to go very far for a client who has significant psychosocial + avoidance issues as well as major lifestyle factors contributing to her pain. If you find you’re not going anywhere, despite good compliance, it’s important to make sure things haven’t been missed.

5) Sometimes clients are surgical candidates

If a client has symptoms that match imaging, doesn’t have major barriers to a good surgical outcome, and has been given a good run of solid therapy, I’m ok with surgery.

6) And sometimes quite frankly, physio (even when done right) just doesn’t work!

I hope this blog provides some useful tips to help enhance your therapeutic alliance, adherence and outcomes to minimize the amount of your patients that do truly fail physiotherapy.