Shownotes
In this episode, I'll be talking about hard patient archetypes. I want to help you get unstuck with this type of patient and help you reframe your approach to treatment. First, I will go over common pitfalls that impact our ability to engage fully with our patients. Then I will paint a path forward so we can begin to approach treatment with increased clarity and structure. I have organized treatments into three themes or buckets that will help you get results no matter what patient archetype you are dealing with.
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Transcripts
Welcome to the clinical flow podcast.
Speaker:I'm your host Andrew Koppejan.
Speaker:If you're a physiotherapist or other movement professional,
Speaker:who feels like you're stuck in a rut, then my podcast is for you.
Speaker:This podcast is focused on helping you unleash your best clinical self
Speaker:and move from a place of frustration to flow in your clinical practice.
Speaker:Each episode I'll share strategies and approaches, along with my latest
Speaker:thinking on how to improve your clinical performance and keep loving what you do.
Speaker:This is episode number 65.
Speaker:In this episode, I'm going to be talking about difficult patient archetypes.
Speaker:The four pitfalls that we can fall into as clinicians when
Speaker:we're dealing with hard patients.
Speaker:And also show you a path forward where I outline three different
Speaker:treatment approaches that will assist you in overcoming these challenges.
Speaker:Before I dive in, I want to let you know that I have a newsletter
Speaker:where I write about topics relating to improving clinical performance.
Speaker:Head over to 360 clinician.com to sign up today for free.
Speaker:Alright.
Speaker:Let's get started.
Speaker:I don't know about you, but I find that it's almost automatic that we
Speaker:can put patients into categories.
Speaker:We have our easy patients and then we also have our hard patients.
Speaker:Someone who is young and motivated body aware and has healthy beliefs
Speaker:around movement and pain can pretty easily fall into that easy category.
Speaker:But what constitutes a hard patient?
Speaker:There are a number of factors, but for the most part, I found that it can include a
Speaker:combination of all four of these factors.
Speaker:Oftentimes they're inactive.
Speaker:They can be unmotivated.
Speaker:They might have unrealistic expectations around treatment and they may have
Speaker:a less than adaptable body structure and they may have poor posture, poor
Speaker:muscle tone, those types of things.
Speaker:This patient archetype can really be a challenge for even the
Speaker:most experienced of clinicians.
Speaker:I was just talking to a physio friend recently about this type of
Speaker:patient and how draining and hopeless she was feeling after seeing these
Speaker:patients, successively in one day.
Speaker:In her situation, they came in with neck pain and they
Speaker:were looking for a magic cure.
Speaker:They could tolerate very little hands on treatment and they would often flinch
Speaker:at the first sign of body contact.
Speaker:It really can be disheartening having this type of patient archetype on our caseload.
Speaker:It's easy to feel like the situation is hopeless.
Speaker:And as therapists, we can easily resign ourselves to going through the motions
Speaker:with doing just half-hearted treatments.
Speaker:I really want to help you get unstuck with this type of patient archetype and help
Speaker:you reframe your approach to treatment.
Speaker:My goal is to move you from a place of disillusionment and despair to a place
Speaker:of flow where you can be curious and collaborative and creative with them.
Speaker:While these patient archetypes will still likely be challenging.
Speaker:My goal is to give you some fresh perspective to help you avoid the drain,
Speaker:the frustration and the exhaustion.
Speaker:But before we go into a treatment strategies, I think it's really
Speaker:important to look at some of the common pitfalls that impact our ability
Speaker:to engage fully with our patients.
Speaker:These pitfalls really center around how we get stuck in our thinking.
Speaker:Shifting our thinking is going to matter so much more than any specific
Speaker:treatment exercise or modality that we use with the patient.
Speaker:So here are the four pitfalls that I think we make with these patients.
Speaker:First pitfall is that we put everything on our shoulders.
Speaker:It's really easy to believe that it's a hundred percent up to
Speaker:us to get our patients better.
Speaker:With this patient archetype, I found that they can often assume that the onus is
Speaker:all on the therapist to get them better.
Speaker:That's why they've come to see you.
Speaker:Feeling like everything is up to us can really stifle our creativity,
Speaker:communication, and collaboration with this type of patient.
Speaker:Pitfall number two is we try to manufacture motivation for them.
Speaker:As therapists, when we come across an unmotivated patient all too
Speaker:often, our first instinct is to try to manufacture motivation for them.
Speaker:I know for myself, we try to bring more energy to the room
Speaker:when we see this type of patient.
Speaker:We might think that we can actually muster up enough motivation to build
Speaker:momentum for them in their recovery.
Speaker:But as I'm sure you're aware, this is impossible to sustain.
Speaker:Oftentimes our own efforts to instill motivation in our
Speaker:patient can actually just create resistance in our patients instead.
Speaker:Pitfall number three, is we chase symptoms.
Speaker:As a physiotherapist, it can be tempting to focus exclusively on treating symptoms.
Speaker:The further we slide into a place of frustration with this patient archetype.
Speaker:We can easily stop being curious.
Speaker:We then stop exploring the other potential drivers of their pain and dysfunction.
Speaker:Pitfall number four, is that we ignore patient resistance.
Speaker:One of the biggest pitfalls I think we can make when engaging with this patient
Speaker:archetype is ignoring their resistance.
Speaker:We pretend that they're motivated, we pretend that they're on
Speaker:board with doing exercise.
Speaker:But the reality paints a different story.
Speaker:They exhibit limited motivation.
Speaker:They aren't doing any of their exercises that we've given them.
Speaker:They talk about how they find manual treatment helpful, but
Speaker:then wince when we touch them.
Speaker:Once we understand these four common pitfalls, we can begin to approach
Speaker:treatment with more clarity and structure.
Speaker:I think it's really easy to get flustered when one treatment approach
Speaker:doesn't work and then we jumped to another treatment approach.
Speaker:That can quickly result in just feeling disoriented and unsure
Speaker:of how to approach treatment.
Speaker:What I found useful in my own clinical practice is organizing
Speaker:treatment into themes or buckets.
Speaker:And so then what you can do is approach your treatment by shifting
Speaker:which bucket you focus on and you have options to work with when you're
Speaker:hitting a bit of a roadblock with this type of patient archetype.
Speaker:I found that there are three treatment buckets that have worked well for me
Speaker:with this type of patient archetype.
Speaker:And one that doesn't really rely on a poorly tolerated manual therapy.
Speaker:The first treatment bucket is really about downregulating the nervous system.
Speaker:When patients are sensitive to any kind of manual therapy, it really is important
Speaker:to have some different strategies to down-regulate the nervous system.
Speaker:I think one of the most important aspects and strategies that we
Speaker:have is breathing intervention.
Speaker:Breath is such an important nervous system regulator, and it's something
Speaker:that you can use on different levels.
Speaker:In some pain science training I did with Neil Pearson.
Speaker:He highlighted experimenting with both breath awareness and breath regulation.
Speaker:From his experience, patients respond differently to
Speaker:different breathing strategies.
Speaker:So I wanted to just go through that in a little bit of detail here.
Speaker:So breath awareness is where you just have the patient focus
Speaker:on being aware of their breath.
Speaker:They're inhale and they're exhale.
Speaker:They're really not trying to control their breath.
Speaker:They're not trying to control the amount of time that their
Speaker:breathing in or breathing out.
Speaker:They're just focusing on the awareness of their breath.
Speaker:As a therapist, you can help the patient tune into becoming more aware
Speaker:of their breath, helping them to tune into the awareness of the air going
Speaker:in through their nose or their mouth.
Speaker:The movement of their chest as they breathe in and out, that type of thing.
Speaker:Breath regulation is where you have the patient control the
Speaker:length of their inhale and exhale.
Speaker:So for example, you have them breathe in for three counts and out for four counts.
Speaker:The goal is to find a comfortable rhythm and something that they can sustain
Speaker:for a couple of minutes of practice.
Speaker:When you're working with a patient on deciding whether breath,
Speaker:awareness or breath regulation is going to be better for them.
Speaker:What I'll do is I'll typically run an experiment where they
Speaker:engage in an assisted movement.
Speaker:For example, let's say that it's shoulder flexion while they're
Speaker:doing the breathing technique.
Speaker:And once one version of breathing with movement is completed, then
Speaker:I retest the aggravating movement.
Speaker:If there is no change, then we run the experiment again with
Speaker:the other breathing technique.
Speaker:During these experiments, I provide simple explanations of the power of breathing
Speaker:to influence the nervous system and how breath work can calm the nervous system.
Speaker:Another related strategy with down-regulating the nervous system and
Speaker:improving breathing is really focusing on breathing pattern dysfunction.
Speaker:Oftentimes with this patient archetype, they may have a
Speaker:poorly functioning diaphragm.
Speaker:They may be a really engaging in apical breathing, or they may have limited
Speaker:diaphragm contraction ability, or they may have poor movement through their
Speaker:ribs . I've often found it beneficial to perform some manual therapy and
Speaker:breathing instruction to assist in improving diaphragm and rib mobility.
Speaker:Now another really important way to down-regulate the nervous system is
Speaker:focusing on the whole aspect of sleep.
Speaker:I think it's important to understand if this patient archetype has disrupted
Speaker:sleep and sleep is such an important modulator of the nervous system and helps
Speaker:to down-regulate the nervous system.
Speaker:I found that patients who are struggling with persistent pain can often experience
Speaker:breakthroughs by addressing sleep health.
Speaker:Treatment bucket number two is about shifting patient beliefs.
Speaker:With this patient archetype, they have some pretty entrenched
Speaker:views about their pain and body.
Speaker:They may believe that it's up to someone else to fix them, that
Speaker:there is a magic cure and that the treatment is something that is done
Speaker:to them rather than them being an active participant in the treatment.
Speaker:Trying to treat within this patient paradigm, is really pretty much near
Speaker:impossible and one that is likely destined to treatment failure.
Speaker:It's important to begin to shift and challenge the patient's
Speaker:beliefs toward their body.
Speaker:They need to understand there really isn't a magic cure and treatment
Speaker:requires both the patient and the therapist to work together.
Speaker:Sounds easy, but I've found that how you approach these
Speaker:conversations really is so important.
Speaker:Beliefs are based on a perception of reality and it's important to challenge
Speaker:one's perception of reality in order to begin shifting those beliefs.
Speaker:This patient archetype believes they need hands on therapy,
Speaker:but can't tolerate light touch.
Speaker:Then we have a problem.
Speaker:And I found that it's helpful to highlight this discrepancy to the patient.
Speaker:I might say something like this.
Speaker:I know we agreed that we'd incorporate some hands on therapy to help your neck.
Speaker:But I'm seeing that your body is quite sensitive whenever
Speaker:I start to work on your neck.
Speaker:Wouldn't you agree?
Speaker:I think it's important that we look at maybe some other options that might
Speaker:be better tolerated by your body.
Speaker:Rather than putting the onus on yourself to come up with all the solutions,
Speaker:which is one of the pitfalls I talked about, it's important to begin to
Speaker:shift to a more collaborative approach.
Speaker:You know, I provide some other options and then it's important to
Speaker:come to a joint decision together between patient and therapist.
Speaker:Treatment bucket number three is channeling patient motivation.
Speaker:I think this is such a big one.
Speaker:It's easy to fall into the trap of assuming that you, as a physical
Speaker:therapist are responsible for motivation, especially when we want
Speaker:our patients to succeed and get better.
Speaker:But it's really not up to us to create motivation for our patients.
Speaker:Instead, I think we have to actually step into our role as a health coach and
Speaker:help them find a source of sustainable motivation to support them moving forward.
Speaker:For this type of patient archetype, they may have few if any movement habits.
Speaker:What I like to focus on initially is just to help them
Speaker:build a simple movement habit.
Speaker:I focus on consistent action that's easy for the patient to do and that
Speaker:doesn't wind up the nervous system.
Speaker:For example, with the patient archetype, with neck pain, I may have them start with
Speaker:some simple shoulder slides up the wall.
Speaker:They may feel comfortable doing this exercise and they can see the connection
Speaker:between shoulders and the neck.
Speaker:So it's a meaningful activity for them to do.
Speaker:And then what I do is I write down what that small action is going to be and the
Speaker:frequency of how often they should do it.
Speaker:And then I make sure that the patient is on board.
Speaker:It's important that they feel confident in taking on this action on a daily basis.
Speaker:So I ask about what their confidence is and how confident do they
Speaker:feel doing this on a daily basis?
Speaker:And does it seem reasonable in terms of the number of times that they
Speaker:would do this wall slide up the wall.
Speaker:If they don't, then it's really a collaborative approach with your
Speaker:patient to then figure out what those parameters need to be so that
Speaker:they can have a higher level of confidence to do this on a daily basis.
Speaker:Something that helps overcome hesitancy on the part of the patient,
Speaker:is to frame this small action within the context of an experiment.
Speaker:So I tell them, we're doing a time limited experiment and then
Speaker:let's take stock after, you know, X number of days to reevaluate.
Speaker:If it's something that we should continue doing, I think it's a
Speaker:lot easier to do something when we have an end time in mind.
Speaker:And then we can reevaluate and see if it's something that makes sense for them and
Speaker:what we need to adjust moving forward.
Speaker:Once the patient is consistent and doing the small action, then I look
Speaker:to move to more challenging and likely a little more functional in specific
Speaker:exercises related to the issue at hand.
Speaker:So getting that patient to be successful early on.
Speaker:Is really such an empowering step in that patient's recovery journey.
Speaker:The beautiful thing is that you've shifted the relationship from one
Speaker:where the patient expects all the answers from you the therapist.
Speaker:To one where there is a collaborative partnership, where the patient is
Speaker:building self efficacy and autonomy.
Speaker:All right.
Speaker:So in wrap-up of today's episode, I want to just briefly review the four pitfalls
Speaker:and then the three treatment buckets.
Speaker:So the first pitfall that I talked about was the pitfall where we put everything
Speaker:on our own shoulders when trying to treat this challenging patient archetype.
Speaker:Pitfall number two is we can try to manufacture motivation for them.
Speaker:Pitfall number three is we will end up chasing symptoms and then pitfall number
Speaker:four is we ignore patient resistance.
Speaker:Then I talked about how it's helpful to actually look at treatment buckets.
Speaker:So that you can be more flexible and agile as you're working
Speaker:with this type of patient.
Speaker:The first bucket was the importance and the approach of
Speaker:downregulating the nervous system.
Speaker:I talked about the importance of breath in downregulating the nervous
Speaker:system and highlighted how you can experiment with both breath
Speaker:awareness and breath regulation.
Speaker:I also talked about the importance of addressing sleep health, such an
Speaker:important modulator of the nervous system and pain processing systems.
Speaker:For treatment bucket number two, I talked about the importance
Speaker:of shifting patient beliefs.
Speaker:And challenging beliefs to help create more realistic expectations
Speaker:of how treatment can take place and the importance of developing
Speaker:a collaborative relationship between the patient and yourself.
Speaker:Treatment bucket number three was about improving how we can channel patient
Speaker:motivation for creating healthy movement habits in their life, and how we need
Speaker:to put on the hat of health coach when we are working in this capacity to help
Speaker:patients manage and sustain motivation.
Speaker:I realized that this patient archetype can be challenging to treat.
Speaker:But when you identify the pitfalls that you typically experience with this type
Speaker:of patient, then you can move forward by reframing treatment within one of
Speaker:the three buckets that I discussed.
Speaker:Thank you for hanging out with me today and hearing about how you can
Speaker:improve your clinical performance.
Speaker:Specifically around how to treat that hard patient archetype.
Speaker:Make sure to subscribe on iTunes or Spotify to stay up
Speaker:to date on future episodes.
Speaker:And I'd also encourage you to sign up for my free newsletter by
Speaker:heading over to 360 clinician.com.
Speaker:Here's to less frustration, more flow and better clinical results.
