Knowing the Road Ahead
Why having a plan can make all the difference
"If you fail to plan, you are planning to fail"
This quote is widely attributed to Benjamin Franklin, although has been adapted in many forms over the years, most with the same general message. Today we talk about planning in therapy, and while it probably isn't as dramatic as 'failing', it can certainly make a lot of difference on your road to recovery. Recovery from pain, injury or illness is generally not a smooth road, and things don't always go to plan, but that doesn't mean not having one is a good idea.
Planning in life is something most of us generally recognise we should do.
Most of us have some form of plan, whether just in our heads, or written down in intricate detail, complete with colour coded goals and courses of action (I tend to be in the first category). These plans are often dynamic, changing over time, some being fulfilled, others moving aside for new, better plans.
Sometimes we have no idea what we're doing and no plan, and that can be quite frustrating.
I would assume most of us feel in life, that we should plan more, and if we had a better plan, we'd make better progress. This is true in the world of physiotherapy as well, and is an important part of managing a successful recovery.
I threw in the quote above to make something of a point.
Whilst not having a plan can still lead to a recovery, the chances of being derailed are higher.
A lot of the people who come to see us here at a clinic do so because they are being limited by something, whether it be pain, injury or illness. This limitation is generally something they want to do, such as sport or work. For those who are potentially having time off from either of those things, there is generally an end goal, which is getting back on the field or into the workplace.
Sometimes it's just not wanting to be in pain.
Without a plan, how will you know what steps need to be taken to achieve this?
I don't always necessarily put a large focus on goal-setting with people who come into the clinic, other than having a broader general goal they wish to achieve, as mentioned above. But as best I can, I try to have a general step by step process so you as the patient know what it is we are working towards and how we are going to do that.
As an example, let's look at something like an ankle sprain (I chose this on purpose, because it relates to an earlier post here). Now if you have sustained an ankle injury on the sporting field, most people are looking to know a few main things - how bad is it, what do I need to do to get it better, and how long will it take?
These are all valid questions, and answering those questions should be enough to give us a bit of a plan. Sometimes answering those questions can be difficult, other times not. Once I've had a look at the offending ankle and we've gauged the extent of any potential injury, I can then comment generally on rough time-frames for a return to sport.
My next course of action is to go through how we would go about that.
If you have read the ankle article I linked above (if you haven't, read it. Go on), you would see that I break the rehab down into progressions of activity. I would run the person through where we would start, what our goals are for the next couple of weeks, and what they need to be able to do before we progress to the next stage. Having an idea of where you need to be before you progress will help avoid progressing too quickly or pushing yourself too hard, too soon. That way you have a clear view in their mind of what you need to do and why.
It also means you can gauge how they are progressing through rehab, and what you need to get to before we'll talk about playing again. It also gives you peace of mind that we are working towards the overall goal.
Now that's relatively simple (in most cases), with something like an ankle but what about something that's less clear-cut?
What about an unexplained pain that you aren't quite sure about?
Well, the process would be the same, though the answers might not be as forthcoming. Someone who comes in with acute lower back pain (yes, I use this example a lot and it won't be the last time), or maybe a pain in the shoulder would want to know roughly the same things.
And I would take the same approach.
After meeting someone for the first time, my main goal is to get a feel for that person's situation. I'm not always looking for a cause or a structure to blame (though depending on the circumstance, this may be prudent). What I'm most looking for is a starting point to put together a plan for management and hopefully recovery.
As we well know, people are all very different, so while we might have a generalised idea of a plan, it needs to be individualised. Someone who has had pain for a longer, or shorter period of time, or who reports more or less pain, may have differences in tolerance to certain movements or treatments. By knowing this, we can find a starting point to form the foundations of a plan. I would usually discuss this with the patient, and, to the best of my ability, run them through the process. This would consist of what exercises/movements/treatments we are starting with and why. I would then explain what we are aiming to move on to.
Finding a direction in which to head is important.
Walking in a Straight Line
As I've mentioned, the recovery process isn't always straight forward. It can be a little less 'Point A to Point B' and a bit more 'Point A to Point B, then back to Point A, then to Point D with a long stopover at Point C'.
Below is a great image taken from Adam Meakins, a Physiotherapist from the UK. He runs a website called The Sports Physio, which is a great place for honest opinions on physio things. You can find it here.
Looking at this image of 'The Road to Recovery', we can see just how the process can sometimes go. Having a plan can help you identify when things aren't going the way they should and adjust accordingly. Occasionally, things might go better than expected, and the process can be sped up a bit.
If you haven't been given the education and information on what to expect, how will you know how you're going?
A Process of Tangents and Curves
"Plan B. You've always got to have a Plan B"
- Sylvester Stallone
Yes, I just quoted Sylvester bloody Stallone. Deal with it.
Sometimes the best course of action isn't immediately clear. Or it doesn't work out as expected.
One of the joys of working with people is that they are all different. When it comes to injury or pain, that statement is never more true. With many injuries and pain presentations, we have, through experience, developed general patterns with the way various presentations progress.
This allows us to give some insight into how a person will progress.
But it doesn't always work this way.
Because everybody is different, they can respond differently. The way their pain responds can be different.
So if a patient comes to us with a certain presentation, to the best of our ability we put a plan in place. Even more so, we try to keep it as individual as possible. When someone is in a significant amount of pain, it can be difficult to be very specific. We might look at more generic movements, with the aim of assessing further as they improve to get more information and individualise things.
It might be that we look at changing some of the loading (the amount of strain being placed on the body or tissues) they are doing through exercise, or we give them some focused, or just different, movements to trial to see how it affects their pain.
Quite often, that period between the first time we see someone and the second is really still part of our initial assessment, and can provide us with valuable information about how they respond to certain interventions or advice.
Based off how the person responds to this we can build on that plan.
Or we can change it.
And go to Plan B.
But there needs to be a Plan B. And in order to have a Plan B, you need a Plan A.
Know your Plan!
If you are unsure what the plan is, ask. Your therapist or clinician should have a rough idea in which direction they are trying to work. It might not always be a detailed plan, and they may not be able to formulate that after seeing you for the first time, but there should be some idea of direction once they come to understand your situation.
And there should be an end point.
This end point might be a return to sport or work. For those with persistent pain it might be a goal of self-sufficiency with exercise and movement to control pain. For people after surgery it might be a return to general daily activities or the gardening, but there needs to be that a general idea of what you're working towards.
It might not always be the case that we are able to make a step by step plan through this whole process, and to be honest, that's not really necessary all the time. We don't always know how it will progress, but we need to have a bit of an idea of the direction we are heading. The plan might simply be 'this is what we are going to focus on for now, and if that doesn't help, then we'll go in this direction' or 'it could be a couple of things, lets trial an approach to either help or help us rule this out as an issue'.
If the only plan is to come back each week with no aim at progressing your treatment, then that needs to change. Any recovery plan should be aimed at you not needing your therapist, either because you have achieved a near full recovery, or you know what you need to do to get there. If our plan doesn't appear to heading in that direction despite our best efforts, then we may need a different approach.
We'll call that Plan C
Things to remember:
The goal of any therapy should be to get you managing without the help of the therapist;
Some management plans can be more difficult than others to work out, but that shouldn't excuse the lack of a plan;
The Road to Recovery isn't always smooth, and plans don't always work out perfectly. Sometimes they'll need to be adapted, or even scrapped;
Have an end to that plan in sight. Not matter how long the plan (rehab from an ACL surgery can take 12 months), you need to be working towards something, not just working.
References
Meakins, A, 2017, Why treatments appear to work..., The Sports Physio, https://thesports.physio/2017/08/02/why-treatments-appear-to-work/, Accessed 20 August 2017.
