Moving Beyond the Symptomatic to Building Resilience
However, as we come to the point where symptoms are eased there is a tendency both within physiotherapy and osteopathy to think the job is done, that the patient is symptom free now and they can come back if they need to.
What is the potential problem with this approach? Well, it can be argued that we haven’t finished the job at symptom resolution, we may in fact have some way to go.
For instance, we know that proprioceptive (balance) deficit is associated with both acute and chronic musculoskeletal pain (Roijezion 2015), and quite often this deficit can persist (Meier et al 2019). The same can be said of range of motion and ability to do certain tasks as well (Arendt-Nielsen et al 2011).
If we look at these functional elements of a problem with the patient we can build a personalised programme and/or treatment plan with them. This may extend the number of sessions a patient comes in for but could lead to greater compliance and build resilience within the patient over the longer term.
Exercise therapy has become much more dominant in manual therapies, as the evidence base has shifted over the last decade or so. It is right that the patient has the locus of control. However, it could be argued that the patient needs to be gradually educated and exercise protocols selected that suit them (and the function they want to perform), as much as the particular condition they come in with. This allows for easier graduation and progression of exercises within a treatment plan and potentially greater compliance (Holt et al 2020).
Quite often a deficit in spatial co-ordination or proprioception may have persisted around the patients existing activities or exercise. This is because the patient may have adapted around these deficits over a period of time (Meier et al 2019). A personalised and targeted performance driven approach can potentially amend these deficits and allow the patients routine activities they enjoy to become the preventative exercise for them.
This is where a pathway focussed on these performance outcomes within a clinic could be of such benefit. If a whole practice is geared towards a resilience building approach there is a potential to deliver a high quality of service in practice, improve patient engagement and at the same time remove practitioner dependency in the long run. Another advantage to this is that it enables easier cross referral within a practice and therefore makes both the practice and patient much less dependent on one sole practitioner.
How to Build a Pathway
I suggest there are 3 stages to think about. The first is symptom relief and/or management. The key thing here is to focus on active listening, what is the patient saying? What activities are effected? What are they currently stopped from doing? The aims then of this stage are to soothe and support any irritated structures, to calm the pain reported and to begin to sketch out what long term plan might look like.
The first stage should be seen as coming to an end when the acute pain has subsided to a significant extent. It is all too easy to give some exercises or develop a plan without following through at this point. It is at this stage however that we need to look at them again and see how we can improve things further. This is done by working with the patient to develop, agree and deliver new treatment aims over the longer term.
Here communication is vital can you explain to the patient and build a programme with them that they can both understand and perform? Are the exercises being asked of the patient challenging enough without being too easy or too demanding? Are they happy with all elements of the plan or have they been given activities we think are good but they don’t like? Do you have regular reviews with the patient to see how they are doing? Are they progressing at an appropriate pace?
Once it is clear that progression is being achieved, and they are moving into a space where they have improved control or are beginning to develop new movement patterns we can look at the third stage. Here we are looking at building in a relatively challenging progression over a period of time. The idea at this stage of programming is to build a regime with the patient that is going to help and develop them over the longer term and help them in performing specific new tasks if they wish to do so.
I would also suggest looking for any potential weaknesses that maybe in their current programme or plan. For instance does it contain aerobic, anaerobic and proprioceptive elements? Is it targeted appropriately at the patients weaknesses and built around specific activities they wish to perform? If it were to fail or the patient was to regress could you see why would that would be?
These are questions that can really help to build long lasting effective programme for patients. Using such a programme means they can hopefully continue to strengthen their ability to function effectively in their day lives and do much more on their own.
Underpinning all of the above is a patient centred approach built on active listening, effective communication and working with the patient. This creates a plan and programme that should last. Obviously each patient and practice is different, how you implement or design a pathway is going to be heavily influenced by this. Hopefully this post gives you some ideas on creating your own pathway, best of luck!
Arendt-Nielsen L, Fernández-de-Las-Peñas C, Graven-Nielsen T. Basic aspects of musculoskeletal pain: from acute to chronic pain. J Man Manip Ther. 2011 Nov;19(4):186-93. doi: 10.1179/106698111X13129729551903. PMID: 23115471; PMCID: PMC3201649.
Holt C, McKay C, Truong L, Y. Le C, Gross D, and Whittaker J Sticking to It: A Scoping Review of Adherence to Exercise Therapy Interventions in Children and Adolescents With Musculoskeletal Conditions Journal of Orthopaedic & Sports Physical Therapy 2020 50:9, 503-515
Meier ML, Vrana A, Schweinhardt P. Low Back Pain: The Potential Contribution of Supraspinal Motor Control and Proprioception. Neuroscientist. 2019 Dec;25(6):583-596. doi: 10.1177/1073858418809074. Epub 2018 Nov 2. PMID: 30387689; PMCID: PMC6900582.
Röijezon U, Clark NC, Treleaven J. Proprioception in musculoskeletal rehabilitation. Part 1: Basic science and principles of assessment and clinical interventions. Man Ther. 2015 Jun;20(3):368-77. doi: 10.1016/j.math.2015.01.008. Epub 2015 Jan 29. PMID: 25703454.