Day 10: The 10th of 12 Hip Tips today. We've talked about the patient interview, the physical examination, some management tips and now for the most important part. This is the bit where we determine if we are really making a meaningful difference to those who have sought help from us, their health professional. If you've missed any of the previous hip tips, you can visit the blog listing page here.
Tip #10 Set Goals
Sounds a bit obvious, I know, but it's easy in busy clinical practice to fall into the trap of just treating each appointment as a troubleshooting session for immediate issues - chasing pain, dealing with flareups, while the road ahead becomes increasingly indistinct. I'm not saying we should ignore day-to-day concerns of our patients, but just that we need to have our shared goals front and centre, so no-one gets lost along the way. How many patients have you seen that are completely engaged at that initial assessment, get some moderate relief in the first few sessions ... and then just disappear. Weren't they happy with the progress? They were doing well, right? What went wrong?
Most often, they simply lost sight of what you were trying to help them achieve and where on that continuum they were. They were happy with the early gains, but thought 'maybe that's all there is now?' They can't afford to come forever, so decide that perhaps its time to go it alone. But had they completed the intended course of treatment, they may well have achieved superior medium and long term outcomes, with less chance of recurrence (assuming your management plan was set up to address underlying impairments and modifiable drivers).
This is where some good goal setting assists in showing people the value of staying the path. There has to be something enticing at the end of that path - something meaningful to that patient, something they really want to achieve and believe they can achieve, with your assistance. Goal setting can take a while if the patient has not really thought about what it is they want to achieve before walking in your doors (apart from immediate pain relief). This is one area where we've found our online pre-assessment questionnaire that we discussed in Day 1 of 12 Hip Tips, a huge asset. One of our questions asks people to nominate their goals, things that are meaningful to them. At the initial assessment then, it makes it much easier and quicker to set goals together, as you have the raw material already. You just need to fine tune them into clear and measurable goals.
Using SMART Goals in the management of hip pain
There are myriads of different ways to set goals and you may have your own favourite method of formulating goals for your patients. I quite like the SMART goals format as a framework for developing goals. I have presented one version below but there have been a number of variations over the last couple of decades.
These are a good start for clarifying goals:
Setting a goal such as 'Return to Sport' is of little value if you and the patient have very different ideas of what achievement of this goal looks like. What sport? What competitive level? What personal performance level? What frequency? When? ... Be as specific as possible so there is no misunderstanding of where you are going and when you are there.
It needs to be measurable, otherwise how will you know you're there? As the saying goes: 'How long is a piece of string?' A goal such as 'be able to walk without pain' is difficult to monitor. Initially the patient might only be able to walk 10 metres without pain. They can now walk 100metres without pain (a 10-fold increase), but they still have pain with walking, so the goal has not been achieved. Set some parameters to make the goal measurable, and be specific: To be able to walk painfree for 1km on the flat pavement, within 15minutes.
It's great to have a substantial longer term goal to work towards, but to keep the motivation up, setting smaller interim goals in a stepwise fashion is ideal. That way, you can celebrate the small wins along the way, reinforcing engagement with what can often be lengthy periods of rehabilitation. Where progress is naturally slow, having set markers to see the progress, helps to reassure the patient that they are making gains.
While we all want to make our patients happy, setting unrealistic goals is just setting them, and you, up for failure. This is why talking about goals and expectations early in the process is so important. By the same token, try to avoid underselling what may be possible for fear of failure.
When deciding on whether your goal is realistic, don't forget to consider biological healing times. I would recommend listening to this great podcast from Professor Erik Witvrouw on the BJSM podcast on this topic. Certainly worth the 15 minute investment.
i) Tissue specific factors
Consider biological healing times as mentioned above. Type of tissue will influence rate of recovery. Tendon tissue for example will be slower to recover - cell turnover is much slower than muscle tissue. For most degenerative tendinopathies, the patient should be prepared for 3-6 months or more of focused rehab. Promising a 6 week 'cure' is not advisable. It doesn't mean you can't make rapid changes to pain and function, but to really get on top of these tendinopathies, a prolonged period of targeted load management and conditioning is required. Once the patient has a firm grasp of the education and exercise plan, visits can be stretched out, but the patient needs to continue a regular loading program. An App-based exercise prescription and monitoring tool can be useful here.
Be aware of what's happening at a biological level and how that relates to patient goals and expectations. For example, a patient presents with FAIS or hip OA with significant osteophytosis. If the patient's hip has a hard end feel produced by early bony impingement and the patient suggests that their primary goal is to restore/increase range of motion, some education will be required. Pushing a bony restriction will at best be fruitless but at worst be very provocative. Educate, manage expectations compassionately and develop a realistic goal together.
ii) Patient specific factors
Who is the patient in front of you? - conditioning level, type of pathology, stage of pathology, type of and response to previous interventions, general health factors, mental health factors, functional demands - occupational/recreational.
Develop realistic and relevant goals (sometimes Relevant is also used as the R in SMART).
Putting a timeframe on a goal really does assist with the whole 'how long is a piece of string' concern that patients have when embarking on a rehabilitation plan. It also assists with keeping goals realistic.
So our final goals might look something like these:
To run 5 kilometres on the flat in March (3 months time) and complete this without pain and within 25minutes, to equal my previous best time and restore my mental health outlet.
To climb the 13 steps in my house by the end of February, with minimal pain (<3/10), no rails and carrying a washing basket, so I can contribute to the household chores again and take the load off my partner.
Our job then is to educate, enable and empower our patients to achieve these goals. Check in along the way, remind them where they started and where they're going. The best way to do this is by measuring things ... but we'll be talking more about this tomorrow.
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