Before continuing, have you read Parts 1 and 2?
Working with “Difficult” Patients In Physical Therapy Part 3: Salience
Written by author & guest blogger Geoff Mosley
Joe has all the potential in the world. His stroke was relatively mild, and his objective scores indicate that he is making good gains. However, his functional progress does not match his neurological recovery. He always seems lethargic and makes frequent excuses why he can’t go to therapy. He continually complains about staff and says, “people just don’t do their jobs around here!” As an example, he talks about how the therapists always have him playing “stupid games and things I would never do at home”. The therapists have labeled him a “problem child,” and jockey back and forth at the schedule board, debating who has to see him each day.
So, do we need to chalk Joe off as a lost cause? Is there be anything we could be doing differently? Why is Joe so poorly motivated when he has so much to gain from participating in his rehab? One possible clue into Joe’s behavior is his statement about therapy. Oftentimes we engage patients in activities that make little sense to them and do not seem related to the issues they are likely to deal with at home. While we may see the benefits of these exercises, we may have a hard time convincing our clients. Joe didn’t want to participate in therapy at least partly because he couldn’t see the carryover to his recovery.
The issue here is what researchers call “salience.” This is just a jargon word for “meaning.” In other words, we need to be able to connect what we are doing to some personal benefit in order to fully engage in the task. There is a growing body of evidence that this quality is vitally important to learning. In fact, it is also argued that salience is important for neurological recovery by way of neuroplasticity. We know that learning is best when the person is both motivated and focused. In terms of motor learning, it isn’t really that important if a person even remembers what they practiced (think patients with head injury or dementia). What matters is that they are paying attention and care what they are doing while they are doing it!
So how do we make this work in the clinic? Well first and foremost, patients need to be involved in their care. They need to feel like they have had a say in their plan of care and goal setting. If it matters more to Joe to be able to get back outside and enjoy the outdoors, and we are spending all of his time training gait in a sterile gym, then we are missing the boat with him. If the only time he is in the kitchen is to get a bowl of cereal and we have him baking cookies in the rehab kitchen, he will dislike his therapy time and learn to resent his therapist. Surveys show that one of the marks of an advanced clinician is someone who collaborates with her patient and treats him more as a partner than as a student. This builds rapport and pulls the patient into the decision making process. It also has the addition benefit of improving the patient’s self-efficacy and moving the locus of control of his situation back on himself.
Second, we need to set up the treatment session for the patient to perform tasks that are meaningful and progress towards a tangible goal. Simply walking until the patient gets tired is not very meaningful. I never cease to be surprised when I see a patient walk 50% further simply because they are aiming for a chair! Often just giving a definitive endpoint is all a patient needs to put in that extra bit of effort to progress. Another beneficial step is to set up training so that the patient is practicing different tasks throughout the session. Not only does this make the treatment more interesting, it also forces the patient to problem solve through each situation, which helps them to focus on each challenge.
Finally, let’s put the “Fun” back in “Functional”! Therapy is a lot more bearable and interesting if we can cut loose a little bit. Playing games, using video games such as the Nintendo Wii or Xbox Kinect, playing music… we can incorporate any number of things into the patient’s treatment to not only make therapy entertaining but introduce challenge and still work towards functional goals. I hope these tips have been salient for you! Enjoy!
About the Author:
Geoff Mosley, PT, NCS, is board certified in neurological physical therapy from the American Physical Therapy Association Board of Specialties. He has earned Vestibular Rehabilitation certification at Emory University’s annual course, as well as certification, from RESNA, as a Certified Assistive Technology Practitioner. His courses in the Physical Therapy University include “Body Weight Supported Gait Training for the Geriatric Patient“, “Treating Balance and Fall Prevention for the Geriatric Patient” and “Stroke Rehab for the 21st Century: Where Are We at and Where are We Going?“.
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