Clinical Insights: Tips for Assessing Complex Patients

A few weeks ago I wrote a post about the level of clinical competency required at specialist levels of physiotherapy practice which generated a bit of interest. I mentioned that my experience of working at this level (compared with other levels of practice) is the expectation that the specialist physiotherapist will have a solution we are others have failed. Often we are ‘expected to know’. 

In the previous post I discussed some of the factors that contribute to ‘complexity’. So how do I approach and interpret my assessment and make decisions about appropriate treatment given that many people I see have already had many investigations and treatment, often from very competent professionals?

In my practice, people tend to fall into one of two groups:

1. Missed diagnosis (e.g frozen shoulder) or treatable impairment such as loss of ROM, muscle function or cognitive/psychosocial modifiers such as patient beliefs and expectations.
2. Complex rehabilitation presentations. These are less common conditions (e.g symptomatic os acromiale) or those with persistent pain or sensorimotor deficits. This group requires a higher level of clinical reasoning including diagnostic reasoning and rehabilitation expertise.

With these two groups in mind, I’ve put together some of the common processes I have found helpful for guiding my decision-making when seeing specialist patients.

1. Assume nothing.
2. Find out what the patient and referrer want (sometimes not the same thing).
3. Do the basics extremely well:
   • Diagnosis: exclude significant conditions that need onward referral.
   • Treatment: Assess for specific physical impairments (e.g ROM, muscle function) that might influence symptoms or function.
4. Identify persistent pain mechanisms (e.g neuropathic or nociplastic pain) and other health or psychosocial “modifiers” that may be influencing response to treatment.
5. Understand the clinical pathways for specific conditions and the role of physiotherapy in the context of non-surgical and surgical treatment.
6. If not improving, get another opinion. Build a local, multi-disciplinary referral network that you can refer to for advice or further assessment and/or management.

​I’d love to hear whether other Specialist Physiotherapists have any other tips, or whether this helps other physiotherapists out there to organise your thinking and develop a framework for troubleshooting challenging clinical presentations.
If you’re interested in hearing more about how to reason through challenging clinical situations you may be interested in this recorded webinar hosted by Physio Academy.
Problem Solving the Problem Shoulder: 3 Reasons They’re Not Improving