Thoughts on long-term patients

This week I have been thinking about patients that seem to not be responding to treatment or making very slow progress.

There seem to be several categories of these patients in my experience. It all relates back to understanding the patient’s Values, Preferences and Expectations and also being aware of your own as their practitioner. There are several examples below but all left open-ended as to your conclusions, I’m not sure there are straight answers but it is interesting to consider motivations and goals in treatment.

  1. There are those patients who visit for the ‘maintenance’ treatments – they seem to make little progress in improvement but also don’t get any worse. A typical example is someone with OA knee. Their aim is to be able to keep going for walks and keep pain at a ‘manageable’ level. Your view may be that with dedication to exercise and goal-setting they have the capacity to overcome the pain patterns associated with their knee. You may try to persuade them of this but with no effect. They have the belief that their knee is worn out and with your treatment they are just delaying the inevitable knee replacement which many of their relatives have had to go through – it’s all part of getting old isn’t it?

 

This patient has just come to you asking for help with continuing to walk and maintain activities. You have offered them the potential to become pain free but for whatever reason they do not believe that is possible or do not want to engage in that process. Your agenda is different to the patients.

 

2. There are those patients who come in with a long-term pain and do not respond to treatment in the time-frame expected. A typical example is the female patient over 60 years of age with ‘sciatica’ which they have had for several months. These patients are often an enigma. You can work on them and see movement quality improve and tissues less tense. Symptoms improve temporarily but then fluctuating symptoms continue.

In these cases there is a common goal of pain relief shared between practitioner and patient. It can be difficult to fathom why patients are not responding and they can be quite closed to suggestions of underlying factors. It is necessary to build trust before certain conversations can be had and suggestions made especially regarding beliefs about pain and underlying factors. Make sure you understand your patients expectations of treatment and meet those expectations where possible – maybe they need an exercise programme to raise confidence, maybe they are worried about ‘old age’, etc. etc.

3. The third example I was thinking of is the patient who starts off visiting for example for knee pain, and then after a few visits they mention shoulder pain and then low back pain and then this pain and that pain….. There can seem to be an ever lengthening list of symptoms all of which appear to be coming on as treatment progresses. Factors underlying this could be compensations for injuries causing other symptoms or perhaps one pain masking another. Interestingly these symptoms often appear despite a thorough initial active and passive examination which did not reveal other areas of concern. I’m sure practitioners could come up with a multitude of suggestions as to why this occurs.

In this context I was just going to mention the fact that it often prolongs treatment well beyond initial expectations. Maybe that patient isn’t ready to “go it alone” yet or perhaps there is a goal ahead for which they want to be in ‘peak’ condition – a holiday, a sporting event, family event etc. I often find that there comes a point where everything just seems to fall into place and the patient returns reporting vast improvements in their general well-being and that treatment phase is ended.

Why?

Why are there some patients that don’t appear to respond to treatment or progress significantly? As we’ve discussed previously, some patients need their pain. For some it is their identity, for some it is their reason or excuse – mostly we have no idea what a patient is going through or has been through – personally, or mentally.

Make sure your agenda matches your patients – are you trying to give them more than they are asking for?

Some patients are happy with the benefit they feel from treatment and the fact their symptoms are not worsening. Maybe some simply benefit from and need the therapeutic effects of touch. There are many people who perhaps are rarely touched by anyone else if they live on their own or maybe in a cold marriage. Others will benefit from the conversation – a listening ear can do so much.

We often don’t know the answers and there can be benefits from treatment on so many levels. Sometimes it can be after several treatments that the patient mentions something that for the practitioner is that ‘light bulb moment’ and suddenly things start to make a lot more sense. The important thing is to review your maintenance patients regularly, and reassess patients who are not responding as expected to make sure there are no overlooked factors affecting the symptoms. If both practitioner and patient are happy to continue with the treatment and have discussed and consented to this then carry on… but be careful not to make assumptions and to re-assess on a regular basis.

As practitioners we have a great privilege of sharing in a patient’s journey towards good health – whatever that may mean to your individual patient. I like that picture of just being a helping hand for a while until the patient gets through a particularly difficult patch and then is ready to move on, not infrequently to a new phase of life.

 

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