Bad News – managing poor prognosis

Physiotherapists are frequently in a position of attempting to provide care and define management strategies for patients with persistent, ongoing symptoms. This is particularly so in low back pain and whiplash patients. Some of these cases may have undergone radiological investigations, surgical reviews or other forms of interventions without success.  This of course is a typical history of patients with resistant chronic low back pain.  The challenge for the treating therapist is to identify if there are elements of a symptom pattern which can be improved with targeted therapy or whether these avenues have been explored adequately without successful outcome.  In order to determine whether useful, relevant treatment has been undertaken it is important to determine what precise treatments were undertaken and what the response characteristics were.  Simply acknowledging that the patient had “physiotherapy, exercise, hydrotherapy or machines is not sufficient to make a judgement as to whether there is still merit in including these regimes as part of a management plan – or importantly excluding them as futile..

Equally important is the identification of patterns of symptoms, which do not appear directly related to mechanical factors which are potentially intractable and unresponsive to physiotherapy.  The delicate balance to be struck here is whether to pursue legitimate treatments which have some realistic possibility of producing significant improvement, countered against the potential for giving the patient false hope with the consequent negative impact of yet another failed intervention.

What factors constitute significant improvement?

Now there’s a topic for another day!!

Factors determining information delivery:

Previous response to treatment

Type of interventions prescribed.

Patient expectations

Patient confidence in care providers

Patient attitude towards collaboration between the care providers (hostile, enthusiastic, detached, despondant)

Patient attitude to the level of disability associated with their condition.

At the other end of the spectrum are patients who present with  acute symptoms  in “high risk” areas – where know there is a strong propensity for chronicity (whiplash and acute low back pain). There is a delicate balance to be struck between trivialising modest physical findings and associating them with a short response time.  This of course fatally damages the therapist’s credibility if the symptoms have not resolved within the predicted short response time.  Alternatively, stating protracted recovery times or extended periods of disability may well become a self fulfilling prophecy.

In this situation the way to manage all acute presentations is to have structured milestones and goals in order to assess the rate of progress.  If this format is applied then patients who are responding at a slower rate can be recognised early and the therapist can equate the level of progression observed over time with the sequence of stages required to achieve full return to function.  This is not the same as telling a patient it may take a year to get better but they are unlikely to see improvement in a given specific functional deficit if they still have symptoms or discomfort when challenged at a lower level.  Therefore, equating functional tolerance with symptom characteristics is an important yardstick for both therapist and patient to monitor.

Enjoy the clinical challenge.
David

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