When Clients Get Worse- Seth Will

When Clients Get Worse.. 101

I can recall many a time during a PNMT course, hearing Doug Nelson preface this topic by saying, “if you haven’t made someone’s symptoms worse, you haven’t been in practice long enough.” So assuming that you’re reading this to gain some insight because you have indeed, made your client’s symptoms worse; congratulations. You’ve been in practice “long enough.” Seriously, this can be a real problem. Though depending on how you and your client interpret it, you may not be sunk just yet and you may have gained some valuable information about the nature of their disorder.

Let’s start with the basics. In the simplest terms, what could have made your client worse? This could be an almost endless list, however I suggest we start with a few of the most obvious: 1.) It could’ve been the treatment that you did. 2.) It could’ve been something that the client did. 3.) It could’ve been something else entirely. There is no absolute, gold standard for determining this, of which I’m aware, so what this largely comes down to, is what you and your client can agree upon in what makes the most sense.

#1. It could’ve been the treatment that you did that made them worse. This certainly could be the case, however there are a number of factors to consider in breaking this down further. One consideration is how soon after the treatment did their symptoms exacerbate and how long did the exacerbation last?  When we’re looking at pain symptoms, we’re largely looking at irritability of the nervous system. Within basic neural responses to a stimulus we’ve got a couple options of which way this can veer. In a very simplified sense, we could either crank up the signal or turn it down or we could cut the cord and extinguish it. Other terms for this would be sensitization or habituation. When we apply any stimulus (our treatment) to the person, there may be a transient increase in responsiveness (sensitization) to the irritable area, which then ideally subsides to a new baseline of irritability which is less than it was before the intervention. In my and other PNMT therapists’ experience, the most common time for the “dust to settle” is either by the next evening or for sure by the day after. If symptoms persist beyond that and it was deemed due to the treatment intervention; it was too much, at least that’s my opinion. I’ve seen other groups suggest 7 days. My experience on that is: good luck keeping them as clients. Though in practice, there may be times when treatment that provokes a longer exacerbation may be warranted, but that’s rare.

So, if your client feels a bit more irritable that same night or the next morning, don’t fret.. at least not too much. Your client may be upset upon feeling worse; however, if you’ve explained to them this possibility, hopefully, they’ll take it in stride, especially if you’ve explained to them the concept of “correct dosage” or titration. With any treatment, it’s crucial to determine how much or little should be given to improving symptoms or function. A person may take 5mg of aspirin and feel no better, 100mg and feel much improved or 10g and feel/be dead. Dosage matters. To determine “correct dosage” one usually has to start with some estimated amount and then adjust based on the response. That’s titration for anyone remembering from high school or college chemistry class. Estimations sometimes overshoot, which is how an extended (more than a day or two) exacerbation could occur. Once you’ve determined how much is too much, you’ve gained valuable information that may help pave the way for more effective treatments in the future. As long as you can convey to your client, that their exacerbation is actually important and vital information for the treatment of their disorder, you may be granted another opportunity to get it right.. or at least closer to right. The additional good news here is that the better you get at understanding and doing a physical examination, the better you get at dosing your treatment the first time.

One thing that may be running through your mind right now is: why don’t you just try to do gentle things that always feel good so as to avoid exacerbation? Short answer: not all change is comfortable. Slightly longer answer: In want of preventing exacerbation I will almost always conduct a gentler and more abbreviated treatment during the first appointment. Furthermore, in wanting the client to feel as though their time and money spent with me, in that first session, was worth it, I do enough treatment to see some change in a relevant biomarker, such as when symptoms arise within a movement or activity. When I’m unable to achieve a change in a biomarker that the client deems as relevant, the percentage of rebooking goes down.  Just to be clear; I’m not saying gentle treatment can’t be effective. I’m just largely working within the tenets of physical stress theory/mechanotherapy, where a goal is increasing tissue tolerance and reducing tissue irritability associated with mechanical factors, such as contacting, stretching, compressing, etc. If I can create a situation where a muscle or other sensitized structure can, through hands-on manipulation, become less or non-irritable to these mechanical factors, this should relate to decreased symptomology within their everyday life physical experiences that involve these forces. To do this, I’m grading exposure to these forces and until we do this for the first time, we don’t know how reactive their system will be to this exposure. This is what is often referred to as a “trial treatment” and for good reason. Anyone who is absolutely sure about the outcome is either lying to themselves or lying to you. In medicine, there are no guarantees. If I only did a pleasant and gentle intervention, there would be no “grading.” There would be a single level of therapeutic purgatory. In my treatment philosophy, you need options. And sometimes having an option to grade up to the next level of intensity can make all the difference, though it needs to be understood that along with potential benefits comes potential risk. Risk of exacerbation. That’s what we’re attempting to manage here.

#2. Something your client did made their symptoms worse. This also can clearly be the case in certain instances. I will always conduct follow up questions about things that may have occurred between appointments that could relate to increased symptomology, especially related to a determined activity intolerance. If there is something that the client is doing to make themselves worse, you need to figure this out before other treatments can be completely successful and in some cases, it’s the only thing you need to do. As much as this can be the case, I offer reserve and hesitation at ascribing blame to the client for worsening of symptoms. Why? It doesn’t make you a better therapist to “pass the buck” so to speak. If you can instead ask yourself, “what could’ve I done better to improve their outcome,” I personally think you’ll be further ahead as a therapist in the long run. Passing the blame is a slippery slope and an unhelpful and lazy habit to get into. How will you improve your skills if whenever a treatment outcome doesn’t go how you planned, you presume it to be something some else did? Blame yourself. You’ll be a better therapist for it. This isn’t often comfortable, but as stated before, change often isn’t. Hopefully, this is all good change. Welcome to being a conscientious clinician.

#3. Your client's symptoms got worse from neither your treatment nor something they specifically did, but something else altogether. Welcome to the world of ever more possibilities and greater considerations. Could this be a normal stage of their disorder? Could there be another disorder aggravating symptoms of this issue? Could they’ve have had a poor night sleep which led to lack of production of anti-nociceptors and increased inflammation? This is why Travell gave so much attention to perpetuating factors and conditions that could mimic these pain syndromes. This is a huge topic and I have no magic bullets to share with you, other than focus on the things that you might actually be capable of changing.  Don’t get distracted by the thousands of things it could be, focus on the handful you know about. YOU are the professional that should be able to best help those things, so do it. Frequently you only have to improve one or a few factors relating to someone’s symptoms, not all. So focus on what you know.

 If there might be something else going on, refer them to that person that might be able to help or at least help clarify what that is and how to treat it. And my advice on this always is to refer to a person you have experience with and not blindly to a profession. You’re the professional getting paid for your professional service and advice. Do the legwork to refer only to those that you would want to see. Lastly, with each of these 3 categories that I listed, there are numerous subcategories to consider. But that will be a topic for a later time.

Seth Will