Revitalising rehab: Strategies for patients with bad rehab experiences

8 min read. Posted in Other
Written by Eric Bowman info

If you’re an evidence-based provider reading this site then it’s likely you’ve seen lots of patients who have had a bad experience with one health provider or another. While I don’t claim to have all the answers myself, in this article I want to share some of the useful strategies I have learned when working with patients who have had a bad rehab experience.

 

Tip #1: Don’t throw the other provider under the bus

To quote a colleague of mine – “hold your fire”. It can be very easy to throw the other provider under the bus when a patient has had a bad experience, but a better way to approach the situation is to validate what was done.

Side note – in my articles, and my interactions with other professionals, both online and in person, I operate under the assumption that almost every health and fitness professional means well and wants to help their patients. If you’re reading this then you’re obviously someone who values your continuing education and professional development. While professionals mean well, there are some breakdowns in the system (e.g. depending on geographic region) that are areas for improvement such as:

  • Lack of training on exercise prescription, communication and the biopsychosocial model
  • Clinic structures which may:
    1. Overemphasise passive treatment and patient dependence on the treating clinician
    2. Not allow the required amount of time (e.g. 10-15 minutes per appointment) to implement proper care
    3. Be constrained by third party insurance providers (e.g. the National Health Service for those United Kingdom physios)

With the above information in mind, I understand it’s complicated. Some sayings I like to use are:

  • “There were some parts of your physio that were very good and some I’d like to build on.”
  • “They started it and we’ll finish it.”
  • “I like these parts of your physio and I’d like to tweak the approach slightly.”

 

Tip #2: Understand the specifics of rehab (as much as possible)

Now this can obviously be a very tricky and imperfect system, as patients often don’t remember much of what they learn from health providers. I’ll often hear things like “oh they gave me some exercises” and not a lot of detail. This is why I like to have patients bring in or email me their prior rehab programs.

That said – you can get some useful information from patients in some cases which leads me to tip number three…

 

Tip #3: Understand where the breakdown was

Breakdowns in patient experience can be due to both provider-related factors (clinic and individual practitioner) and patient-related factors.

I’d recommend reading my article on Failing Physiotherapy for common mistakes I see individual practitioners make. To quickly summarise, the main provider-related factors I have seen with previous physios are:

  1. Not pushing patients hard enough – and likely providing predominantly passive treatment.
  2. Nocebos and inappropriate activity restrictions.
  3. Not educating patients on what they do outside of the clinic (i.e. lifestyle factors, workload management).
  4. In less frequent cases, pushing patients too hard.

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This is where, as so eloquently noted in Tim Mitchell’s Clinical Interview Masterclass, it’s important to have a comprehensive understanding of the involved factors. Having a treatment that’s more tissue/injury focused when there are lifestyle/psychosocial-related factors at play doesn’t make sense!

Examples of patient-related factors can include:

  1. Patients looking for a quick fix: This is the number one reason I’ve seen patients that have had a bad experience with multiple different providers. This is a tough one as it is more of a psychological and cognitive-behavioural barrier than it is a physical one. How much training did you have in school for dealing with patients who didn’t cope well with pain, expected it to be over quickly, and bounced from provider to provider, likely digging themselves deeper into a hole in search of the magic fix? Yeah – me neither.
  2. Patients not being ready for change: We’ve all had those patients who want to be pain-free but have MAJOR barriers that they’re not ready to address (e.g. reducing volume of aggravating activities, addressing comorbid physical/mental conditions etc.)Side note: This along with number one above are where things like acceptance and commitment therapy, along with motivational interviewing can be helpful – but they aren’t sexy topics that get a tonne of focus in rehab, even though they can help a lot.
  3. And again, as I alluded to in my Failing Physiotherapy article, there are other factors which cannot be controlled. For example, sometimes there are tissue issues which need surgery, sometimes they’ve pushed through pain for a while and are very sensitive, and sometimes the best therapy just doesn’t work!

 

Tip #4: Wherever possible – have a different approach

Giving patients a specific plan to get their goal activities (the big one)

The worst thing you can do for a patient who is already sceptical of working with a new provider is to repeat the same thing that the previous provider(s) did!

*Side note: sometimes this can be tricky and sometimes you may not have a lot of options to work with for patients who may have seen many providers or may have a lot of deconditioning, communication barriers, or other physical comorbidities that limit what you can do.

It’s also important to articulate your plan and what the differences are. Think about it – how many times have you asked a patient about their previous physio and the patient says “oh they gave me some exercises.” It’s not realistic for a patient to remember every facet of a treatment plan verbatim, and as such, it’s important to have some kind of a written or PDF’ed plan of what the treatment entails, as well as how it differs from the prior approach.

This is one of the big things that Mike Studer discusses in his fantastic Behavioural Economics Masterclass. Sometimes patients may have had a terrible experience with exercise or physiotherapy, and therefore perceive all physiotherapy or exercise as bad. It is absolutely critical to clearly illustrate the differences between your approach and a prior one.

Additionally, you can give patients exercises and pain education ‘til you’re blue in the face – but how do you get a patient back to playing with their nieces and nephews? How do you get a patient back to work or back to the gym? That needs to be part of the plan and is missing in a lot of cases. I find in many cases that treatment is cut and paste, and not goal specific.

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Taking things up a notch

The biggest reason I see patients fail to have success with previous providers, particularly ones who have physically demanding jobs or leisure activities, is that the patients simply weren’t pushed hard enough. A lot of recent research (1-4) has shown that you don’t need to have strength improvements in order to see pain improvements. I don’t disagree with that in the context of many people with pain. That said, it’s still important to make sure that patients’ physical capabilities match or exceed what is needed for their goal activities – in this context I would argue that strength and physical fitness matter.

Working on beliefs and behaviours

Maladaptive beliefs (e.g. hurt = harm, pain = tissue damage, should never be done) can easily prevent a progression of rehab regardless of how good the exercise or manual therapy is. I discuss various tips for belief change in a previous article, have a read HERE.

Maladaptive behaviours (e.g. excessive guarding or grimacing, looking for the quick fix, excessive avoidance) can be even harder to deal with and can require involvement of other professions such as occupational therapy, psychology, and psychiatry, as these can sometimes be related to cognitive and psychosocial drivers.

Approaches like Cognitive Functional Therapy (CFT), motivational interviewing, and acceptance and commitment therapy are all strategies which (depending on your jurisdiction and its scope of practice) can be used by rehab professionals to help with these issues.

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On rare occasions – adjusting or substituting exercises that may be problematic

This is an example of where, for some and not all, the popular ‘McGill Big 3’ core exercises can be very helpful as they can replace something that may be very painful (i.e. sit-ups, flexion stretches, twists) with something that’s not.

Hacking the program down and simplifying it

One pet peeve of mine is hearing clinicians complain about non-compliant patients – yet the patients were given 10-12 exercises!!!!!

As Mike Studer mentions in the first part of his Masterclass (and provides many great examples) making things more practical and easier to do wherever possible makes a difference. In some cases where higher physical fitness needs are required (e.g. return to sport or a hard job) you may have to be more specific, but in many cases simple exercises can make a huge difference!

 

Wrapping up

Working with patients who have had a bad experience elsewhere is all part of the game. There is no perfect solution as pain and people are complex, but I hope these tips help guide you next time you’re in a tricky situation. As always – thanks for reading!

If you’d like to know more about how expert physio Mike Studer engages his patients to get the best outcomes, watch his full Masterclass HERE.

Want to level up your soft skills?

Mike Studer has done a Masterclass lecture series for us!

“The missing link in patient engagement: Behavioural economics and psychologically-informed techniques”

You can try Masterclass for FREE now with our 7-day trial!

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