Red and Orange Flags

PTs are taught to thoroughly screen for “red flags” that could indicate serious medical pathology like cancer, neurologic issues, or immune compromise, and to proactively refer patients with these flags to medical providers for further work-up. (1)

While medical screening is often prioritized during an initial evaluation, patients won’t always present with these clinical flags at the start of care: they may emerge later as the patient progresses through therapy. Additionally, patients may not immediately think to mention certain new symptoms, like urinary retention, because they might think that “it’s not related to PT”.

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If your patient develops new or worsening symptoms during care with you, it’s worth considering whether they could be presenting with new clinical red flags. If so, it’s important to place therapy on the back burner while the patient seeks attention from the appropriate medical provider. (1)

Physical therapists are also taught to consider psychosocial factors that could negatively impact a patient’s response to PT. “Orange flag” is the term for the signs of a severe psychiatric disruption that requires skilled intervention from a mental health professional. (1) Orange flags include things like uncontrolled personality disorders, severe clinical depression, and substance abuse. (1,2)

While you may be able to continue treating some patients with these orange flag conditions while they are receiving psychological care, other patients may need to address these issues prior to continuing with PT.

Other Significant Medical Concerns

What if your patient doesn’t present with any red or orange flags, but there is still something fishy in their clinical presentation? If your spidey senses are tingling, you should consider that your patient may need more help than you alone can give them. (3) Consider the following scenarios:

• Your patient reveals that their Type II diabetes is poorly controlled and they rarely check their blood glucose levels. You’re concerned about the potential for exercise-induced hypoglycemia.
• Your direct access patient presents with significant laxity upon Lachman’s and anterior drawer testing of the knee. They have not yet consulted with an orthopedist.
• You’ve been treating a patient for an irritable L4 radiculopathy for four visits. They don’t have measurable strength or sensation deficits, but their pain levels are just getting worse and worse.

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Any of these patients could benefits from additional specialty help beyond the scope of physical therapist practice – from a primary care physician, an orthopedist, and a pain management specialist, respectively.

Again, some patients may be able to continue therapy with you while also seeking medical attention for these types of concerns. However, others may need a break from PT while addressing their medical issues. Failing to suggest consultation with the appropriate medical provider will only waste the patient’s time and yours.

Extenuating Life Circumstances

Sometimes, even the most motivated patient won’t be ready or able to fully engage in their rehab, often for circumstances outside of their control. Perhaps they are in the middle of an unusually busy season at work. Maybe their family obligations are currently complicated by a new baby at home, or an ailing parent who requires continual care. Did your patient just get laid off from their job? That could explain their rising concerns about the cost of care.

The time commitment and expense of physical therapy may lead an already harried patient to feel more overwhelmed. For some of these patients, you may be able to offer alternatives, such as hybrid telehealth services or payment plans to ease the burdens of travel time and cost. As always, consider your patient’s priorities first: some folks may simply need to put therapy on hold until their life circumstances become more manageable.

Lack of Progress

For the therapist, this is perhaps the most frustrating reason to suggest a patient stop PT. It can make you feel as if you’ve failed as a therapist—like you simply lacked the knowledge or skills to help your patient improve. However, sometimes patients just hit a wall and aren’t going to improve with physical therapy, despite your best efforts and theirs. (4)

You’ve tried a variety of treatment approaches and modified you initial plan of care. You’ve consulted the literature and talked with peers to get new ideas. You’ve sent the patient to your trusted coworker to see if they can help, and still, no dice. You know your patient is invested and working hard on their home program—so why aren’t they improving?

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If you’ve done your due diligence as a therapist and your patient still isn’t making measurable progress, it’s time to consider that physical therapy might not be what they need. (4) Be willing to refer your patient out to other non-PT providers when necessary: in the end, you’ll be saving your patient time, money, and potential heartache.

Lack of Effort from the Patient

Last but not least, the bane of every hardworking PT’s existence: the patient who simply isn’t willing to put in the work to get better. (4) You know the type: the patient who repeatedly cancels or no-shows to their appointments, or who comes to the clinic expecting strictly passive treatments. This is the patient who swears they just haven’t had any time in the past month to do their three home exercises, and can’t understand why they aren’t getting better.

We’ve discussed strategies to improve patient attendance (link to reduce cancels/no shows piece) and HEP adherence (link to custom HEPs piece) elsewhere on the blog. If you’ve tried all the tricks up your sleeve and your patient still isn’t prioritizing physical therapy, then perhaps it’s time to suggest a break from PT. (4)

Wasting hours obsessing over a patient who cares less about their own well-being than you do is a recipe for burn-out, and it limits your ability to focus on the patients who truly value your help. Do yourself and your other patients a favor by pruning your non-compliant clients.

In the end, be kind:

Regardless of your reasons for suggesting that a patient stop physical therapy, make sure you deliver the news compassionately. Take the time to clearly explain why you think a break from physical therapy is the right choice. (3)

Failing to explain your reasoning can lead some patients to feel that they are being abandoned or that their condition is hopeless – neither of which is true. Circumvent these issues by making a plan with your patient for their next steps, and be sure to remind them that you’ll be there for them when they are ready to return to PT.

Source: https://t-tees.com
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