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August- Pediatrics Part 1
A 12 year old young lady is in her 3rd month of physical therapy and has been progressing well. She is 95% as strong as her unaffected side, is running, and able to cut/jump without impairments or difficulty. Her season is starting in 3 weeks and she is almost ready to return to sport testing.
You notice she has been struggling with her exercises and is not sweating or pushing herself like she did the first 2.5 months of care. She has also cancelled twice and is not wearing her warm up and school colors as she did before.Questions for thought
How would you address this with the patient? Who would you include in the conversation?
Would you treat this different from a 24 year old patient?
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Great topic, Kyle – question: what was she coming in for? I’m assuming post op ACL based on the article.
How do you address it, who do you include: I think this really depends on the therapist/patient relationship as well as the involvement of the parents. Some kids I’ve worked with are dropped off by the parent and I never see the adults unless I seek them out. In that scenario, I would start with just talking to the patient. Other times, the parent is over involved and stays for every PT session and is a helicopter parent. What I’ve learned about the patient/parent relationship would determine if I start by talking to just the patient or the parent as well. Middle school is such a tough time – it’s hard to know if the change in behavior is due to hormones or boy trouble or friend trouble or something more serious like a home life issue. Hopefully by this point you and the patient have bonded fairly well, so I usually take a rather direct approach and just bring it up. Like “hey Emily, where are those school colors today?” and just see what she says. I go that route for a while until I can get them to open up and talk with me about what’s going on. If I’m not getting anywhere, I may then opt for a sit down conversation with the patient and the parent in a more serious setting to discuss the drastic change in behavior. Side note – I would also try to be introspective and see if I had changed anything in PT to correlate with the behavior change. Like did I start spending less time with the patient or did I bring in a student to help? Likely not the true cause but things like that can matter a lot to patients sometimes.
I like that the article broke down 3 major themes that influence ACLR recovery and that the themes incorporated the biopsychosocial model. I think the big things for this patient would be confidence, accountability, and social support. She may have shifted away from sports focus because she is having confidence issues and is not sure she’ll be able to keep up with her teammates or be as good as she was prior to surgery. Again, hopefully that therapist/patient relationship is solid and you can bring this up. If it’s not, maybe that’s the issue.
How is this different from a 24 year old: Again, hormones! Being a kid can be rough and their perspective on life is obviously much different than a 24 year old. It can seem like the end of the world for a 12 year old who got in a fight with her best friend. I try to relate to kids and meet them on their level to justify their feelings and provide support. I would have a conversation with the 24 year old if the situation was the same, but it would look a little different. I’d still try to figure out what’s leading to the change in behavior but may start by just pointing it out to them and asking what happened.
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Helen, a lot of great points. I resonate with your idea of sending out feeler questions then moving to more and more direct questioning. As you said, the lack of enthusiasm may be related to something non-MSK. For all we know, may the patient’s dog just died, or they’re in a fight with their best friend who also plays the same sport. The ability to poke and prod will depend on your rapport with that patient.
If attempts to gather information fall short, I would then look to involving the parent. However, this can indeed be tricky. Some parents overstep their boundaries, while others have nothing useful to say at all.
Finally, I like what you mentioned about therapist reflection. Perhaps the patient is being overloaded, and therapy needs tapering, or maybe therapy has become stale from doing similar exercises. The variables go on..
If this were a 24-year-old adult, I would have the conversation and be direct. “Hey, how’s everything going? I’ve noticed that you seem less enthusiastic about therapy. Is something wrong? How can I help?”
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In the same boat as the folks above. I think it is huge to make sure you have good patient rapport, but what this looks like may be different based on age I feel like. I like how the one article gives a nice little flow chart and think that to some degree “checking” the boxes associated with PT factors can help us to reflect a little bit on how we are relating to the patient and guiding their care to see if this may be a contributing factor to the changes in affect.
I would hope that after seeing this patient for 3 months now you have the relationship where you can ask her questions about how things are going with school, how she feels her progress is going, etc. I think general questions to start may lead into some opportunities to get more specific. Ultimately we can’t be motivated for her if she doesn’t want to be. This will definitely have an effect on outcomes, so with noticing such drastic differences, it would be helpful to prod a little bit.
Like Steven, my approach would probably be more direct with a 24 year old compared to a likely more sensitive 12 year old. I feel like you can build a more mature relationship with this patient and if you have done your job to have good patient rapport then likely can ask forward questions and dive right into the changes. Although this still will depend somewhat on the patient’s personality and affect.
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I really enjoyed this article. It helped highlight the importance of different aspects of the patient-therapist relationship. A lot of times patients post-op need that reinforcement of expectations and realistic goals. This can involve very touchy conversations and careful navigation.
I think everyone has made great points about this case. Reflecting on the article, perhaps the therapist can start to take the role as the motivator (gently at first). If this patient is nearing return to sport testing, it would be within the normal conversation to talk about sport-specific needs. This could open up a conversation about the sport and may help you gauge her enthusiasm. This may be a more direct communication approach, but if it is started more from goals and treatment perspective maybe it could avoid the emotional aspect until you have more information.
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