Failed Physiotherapy

The term ‘failed physiotherapy’ is a common one used by many doctors, surgeons, and physiotherapists. It is often used to justify further treatments and interventions but also to shift blame from physios to patients for not getting results that were expected?

To me, the term failed physiotherapy screams out poor communication, low motivation, shitty relationship building skills and general therapist apathy. I actually don’t think patients fail physiotherapy at all, I think more often physiotherapists fail patients, but also that the physiotherapy profession fails both physiotherapists and patients alike.

Over the years I’ve seen and heard many physios blame their patients for not making the progress they wanted or expected, and I still continue to see and hear it today. I will admit, much to my shame that I have done this myself in the past, often because it’s easier to blame others for a poor result rather than admit your own faults and failings.

No one likes to admit their own faults and failings and physios often find themselves in demanding and difficult situations that set them up to fail a lot of the time. This, in my opinion, is the crux of failed physiotherapy, either it’s due to inadequate teaching and training at universities and many postgraduate courses, but it’s also due to overloaded, underfunded, poorly managed working environments, with little to no support, guidance, or respect from other healthcare professionals!

In my experience, those physios who ‘fail’ patients at physiotherapy the most are those who are in the worst working environments, with the least support, and have the poorest training and understanding of how to develop a good working relationship with a frustrated, stressed out, worried and concerned person in pain!

Trust, Respect, Reassurance

It’s known that the therapeutic relationship a patient has with their physio and vice-versa can hugely dictate their outcome (ref, ref). And although not conclusive there is evidence that those therapeutic relationships that have the highest levels of trust, respect, and reassurance often tend to get the highest outcomes regardless of the severity or chronicity of the issues (ref, ref, ref,).

However, there is no doubt that developing good therapeutic relationships can be challenging and difficult to achieve at times. Why we don’t develop good relationships sometimes can be due to many things such as prejudices, prior experiences, personal choices and a multitude of other factors. All human relationships including professional ones are complex, nuanced and multifactorial and one of the many joys and frustrations of being human.

That being said one of the biggest factors for failed relationships between physios and patients I think is simply a lack of time, empathy, and understanding on both sides. Physios often don’t understand, appreciate, or recognise patients concerns, frustrations, or situations as much as they should, and patients I don’t think understand, appreciate or recognise physiotherapists pressures, demands, and limitations as much as they could.

I am in no way blaming patients here or justifying the poor, lazy, uncaring, apathetic physiotherapy that is rife within the profession. I am just trying to point out that it happens a lot due to a lack of support, guidance, leadership, respect, and recognition that many physiotherapists get.

If more physios were given better working environments with better caseloads that gave them time to breathe between patients, or better reimbursements for doing the simple things really well like education and exercise, or better recognition for the effort, time, and training they do, or were better respected for their place within healthcare, I’m sure many would try harder, go further, and listen more to patients in an effort to get them better results.

Non-compliant

However, regardless of the current healthcare systems and its shitty limitations, more physios need to realise that if a patient isn’t making progress or they aren’t following their advice or recommendations it’s not automatically the patient’s fault, and before they label them as non-compliant or failing physiotherapy they should reflect on and try to find out why the patient isn’t progressing.

A lack of patient progress can be due to many factors, such as simply insufficient time to let things settle or take effect. It could also be due to a misdiagnosis of something else masquerading as something else. But the most common reason for lack of progress I think is that the patient just hasn’t started or changed anything significantly since starting physio.

The classic scenario here is a patient not doing their home exercise program given to them by a physio to help a specific issue or to just get them moving more, and it’s a situation I’ve encountered many, many times. I used to think these patients were lazy or lacking discipline, or that I hadn’t found the right exercise for them to do that they found fun or engaging.

I now know it’s often non of those things and more because the patient simply doesn’t understand why they need to do these exercises, and that I haven’t helped them connect the process of doing them to an outcome that’s meaningful. A common misconception in physio rehab is that patients will only do exercises if they like and enjoy them. That’s just not true. People put effort into things that are important to them, regardless if they like or dislike them.

Take me and running as a perfect example here, I do it 3 times a week and have done so for most of my life, but I don’t ‘enjoy’ it, in fact, I find running tedious and mind-numbing. I run because I understand that cardiovascular training is good for my health, gives my body a different stimulus from the weights I usually do. But it more importantly means I can eat more, and I love to eat more. Running also has very few barriers or obstacles for me being quick, cheap and very easy to do.

This is what physios need to do with patients more, help them understand the why better and help them connect the process of what you’re asking them to do to something that has an important and personal meaning for them. Physios also need to check more for barriers or obstacles that may get in the way, prevent, or deter patients from doing what they have been asked to do such as lack of equipment, poor environment, or time constraints.

Granddaughter Rucksacks

A recent example of mine was an elderly female patient I saw with low back pain who had never done any resistance exercise in her life and had no interest in doing any now. She was a busy working grandmother with little spare time but her main issue was she couldn’t pick up her youngest granddaughter anymore without her back hurting.

This key piece of information was simply found out by asking the question ‘what is the main thing your back pain is stopping you from doing currently’ and this clearly this was her most meaningful goal. Now all I had to do was help her understand the how and why to get there. I did this by asking her to judge how much her granddaughter weighed, which she estimated was around 4 stone (25kg). I then asked her to start lifting half that weight using a rucksack filled with books and bottles off the floor and to pretend it was her granddaughter when she was smaller.

I then got her to focus on lifting her ‘small granddaughter’ 3 x week doing a few sets each session until she felt her back tiring or aching. I asked her to add 2-5kg into the rucksack each week depending on how she felt until she reached the goal of her granddaughter’s weight.

The beauty of this was that she soon realised if she wanted to continue on picking up her constantly growing granddaughter she should keep trying to lift heavier and heavier weights. In the last session I saw her for a few months ago she was regularly lifting 35-40kg, had little in the way of back pain, but more importantly, had a desire to keep doing these granddaughter rucksacks lifts a few times a week for the foreseeable future.

Now don’t get me wrong it’s not always like this, with it often being much harder to find a meaningful personal goal for some patients that you can attach a treatment process to. This may be because some patients just haven’t thought that much about it and just need longer to think about it, other times it’s because their pain although annoying and frustrating actually isn’t actually stopping them from doing the things they value.

It’s in these cases that I think ‘formal’ physiotherapy treatment is often not be needed. These patients I think simply need to recognise how they are still continuing on despite the pain, being reassured that this is great and ok to continue to do, and perhaps that they just need to give it a bit more time or make a few simple activity or lifestyle modifications to help.

I think many patients are told they fail physiotherapy simply because their pain hasn’t suddenly or miraculously improved or disappeared, when in fact they don’t need the pain to improve or disappear because they are managing it very well. Some patients just need advice and reassurance that it’s ok to do this and to keep going and give things more time.

Some patients are also just not ready for physiotherapy at that time due to other factors going on in their lives meaning they can’t or don’t want to change anything currently. Again this isn’t them failing physiotherapy, this is just them being not ready for physiotherapy yet.

Conclusions

So that’s my quick look into the horrible term ‘failed physiotherapy’. In summary, patients don’t fail physiotherapy, rather physiotherapists often fail patients due to their apathy, lack of empathy, poor training and understanding.

But it should also be recognised that the physiotherapy profession fails both physiotherapists and patients with its culture of quick fixes and silly treatments, not to mention its woeful underfunding, poor working environments, inadequate leadership, outdated training and general lack of respect or recognition for what they do. And until these issues are addressed, I fear many more will continue to fail physiotherapy!

As always thanks for reading

Adam

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4 COMMENTS

  1. Brilliant blog. As a retired GP, I can say that it could just as easily apply to a GP consultation.

  2. “Now don’t get me wrong it’s not always like this, with it often being much harder to find a meaningful personal goal for some patients that you can attach a treatment process to”

    Please for the love of god do a blog about this at some point. It drives me nuts going on courses and hearing people batter on about making exercises ‘functional’ and meaningful’ for the patients, then when you ask the patient what they want to do, how their pain is holding them back etc (in other words, ‘what is your meaningful task?’) they just shrug listlessly and say ‘my back just hurts mate’. I wish the s+c gurus of the physio world would acknowledge this more, as it often makes treating physios feel like failures when we give the same pushup, squat etc we give to every other patient because they clearly DGAF about exercise

    .”I used to think these patients were lazy or lacking discipline”

    My other bugbear. Fucking hell sometimes this is the case. Whilst behaviour change, health coaching, motivational interviewing etc are useful, there are patients who just aren’t ready to take the step of actively managing their problem. I think sometimes physios give themselves more responsibility here than we really deserve or should have to take. If a person is at the appropriate stage of change, they will take your advice. If not the best you can do is probably nudge them on a tiny bit. We need to get over ourselves and stop pretending to be the patient’s parent who is responsible for their attitude towards their health. Yes we can help them, but not all of them in every case.

    • Hey Joe

      Great comments and I totally agree mate. I shall consider a follow-up blog about the difficulties of the day to day ‘jobbin’ of a physio trying to make exercises meaningful, and get sedentary, unmotivated, dare I say lazy people to move more! Coz I agree… its often not mentioned in the light of day, and its often occurring, and often a pain in the arse.

  3. We all “fail”, yes, absolutely true, every day… due to an incredibly unrealistic, overoptimistic, quickfix mechanistic “repair me” mentality of the majority of people under pain , who (like seen today) complain that they are not pain free 4 weeks after full blown back and leg pain attack and still have discomfort and need an ibuprofen from time to time…And who the hell implanted these “miracle worker” expectations in the broad public? Yes, damned right: If we’re honest, probably all of us PTs, Chiros, pain doctors, GP’s, orthopaedic wtfs- now we pay for overpromising and ignoring the bloody reality of very limited effects of what we are doing in MSk care for decades. We’re guilty of not communicating our limited role as an understander, motivator and mentor but not healer and now crave to bring ( talk) the ghost back into the bottle…

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