[#9] Messy Middle or Actually Stuck in Rehab? How to Know When to Change

In this episode, I continue the conversation from my previous episode on the "messy middle" of recovery by discussing what it actually looks like when you're stuck in rehab. Through several patient stories, I break down common signs that your current treatment plan may no longer be moving you toward your goals, including exercises that never progress, a lack of meaningful improvement, and treatment plans that don't align with what you actually want to get back to. I also share questions you can ask to determine whether you simply need more patience or whether it's time to seek a second opinion.

Main topics covered:

• The difference between being in the messy middle and being truly stuck in rehab
• Common signs that your rehab plan is no longer moving you forward
• Why exercises should progress as you improve
• How rehab can miss the mark when it doesn't align with your goals
• Questions to ask when deciding whether to stay the course or seek a second opinion

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Transcript

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In my last episode, I talked about the messy middle of recovery and how it can feel like you're stuck when you actually just need to give it more time. But what if you really are stuck? So in this episode, I go over how to tell when it's time to try something else with examples from previous clients. Hello and welcome to Candid Conversations with Dr. Kelsey. I'm your host, Dr. Kelsey, and this is the space where I share my honest thoughts, real experiences, and the no BS conversations I wish more people were having about movement, training, injury recovery, and life as an active human. The goal of this podcast is to help you better understand your body, think more critically about rehab and fitness, and feel more confident making decisions so you can stay active long term. Before we start, a quick reminder. I am a physical therapist, but I am not your physical therapist. Nothing here is medical advice. So if you're dealing with something specific, please reach out to your PT or schedule a session to work with me. Alright, now let's get into today's conversation. Okay, so quick recap from my previous episode. So I talked about being in the messy middle of rehab, which is when you have already done a lot of work, but the initial excitement of starting something new has worn off and you still have a ways to go towards meeting your goals. So when you're in the messy middle, it can sometimes be hard to tell if you just need to keep trusting the process and stay the course, or if you're actually stuck and need to go in a different direction. And obviously, you know, you want to be able to tell the difference because you don't want to be wasting your time. Like if you know you're doing the same thing over and over again and you're waiting for something else to happen, you know, something to change, like you don't you don't want to stay there. And also, um, if you are believing that you're in the messy middle when you're actually stuck, um, this can also lead to people thinking that they failed PT because again, you're kind of wasting your time, you're doing the same exercises over and over again, you're not really seeing results, and then you know, a lot of times people will think that, like, well, this is the best that, you know, this is the best that I'll ever get. And so they just kind of think that whatever level they end up at, they're gonna stay there forever, um, which is not usually the case. And so this brings me to my first client story. So um it was actually multiple clients that had pretty much the same story. But um, so this previous client had come to me after doing physical therapy at um one of our local like chains, uh physical therapy chains here in town, and they'd been going for about six weeks. Um and so initially, um, so you know, they got their ex or they got their assessment, uh, they got their exercises, and initially their pain was kind of getting better, um, their mobility was getting better, but then after, I think it was really quick. I think it was like after about two or three weeks, um, I mean, they quickly outgrew their exercises. They realized like, okay, well, these exercises are getting easier. And um, but at this particular uh uh clinic, um they um I'll talk about it in a little bit too, but at this particular clinic, like you don't see the same physical therapist every time, you kind of just like see whoever is like you get put on the schedule for whoever is there that day. And so whenever they uh uh asked the physical therapist in charge of, you know, that they were scheduled on that day to like, hey, you know, should I be doing harder exercises or should you know should I be doing something different? The physical therapist would just say, like, oh no, you know, your exercises are like these are fine, like just keep doing what you've been doing. And so so they did for another four weeks, uh, mostly because their referral was like for six weeks or something. And then eventually they just like nothing happened, like nothing changed besides like their initial like improvement, and so eventually they left. And so that's like a that's a pretty common story I've heard a lot. And again, I've had multiple clients with that exact same story. Either sometimes they just leave and go somewhere else, or sometimes um they're just kind of like, well, it's been six weeks, so I guess I'll stop now. Um, because there's like no and like they weren't given a timeline, also. And so this leads me to the two of the biggest indicators that you're actually stuck, like you're not in it the messy middle, but like you're actually stuck, and continuing on this path is probably going to be a waste of your time. So the first one is like the biggest one is that your exercises haven't changed, even though they are easy, and there is no explanation why. So, in this example, like the patient was proactive, like they did ask the physical therapist, like, hey, these exercises are easy now, like should I be doing something else? And instead of giving an explanation of why they were continuing to do the same easy exercises, the physical therapist kind of like brushed them off and said, like, oh, well, you know, for example, you're here for knee pain, like, yeah, all these exercises are good for knee pain, so just keep doing what you're doing. Um, and I mean, I'm gonna give the I'm gonna give them the benefit of the doubt. Um, in this instance, because I know like um I've never worked at this place, but I have heard of it. So I have heard of what it's like to work there. So I'm giving them the benefit of the doubt, and like they weren't intentionally doing this to like sabotage the patient or anything, or because they didn't care. Um in this particular instance, it's because they likely had no time. Um it was like um because so unfortunately, with lower insurance reimbursement rates, a common business plan for physical therapy clinics is to do what we call like share patients. So I think what a lot of people think, and and the clinic that I used to work at um is is was pretty rare where I had all my own patients. So whenever a patient scheduled, it would always be with me, unless you know I was on vacation or something. Um or um now they have a PTA, a PT assistant, so a licensed assistant. And so um so now whenever I go back to help out, cover vacations, like like he's there. So but um so sometimes patients will see the PTA, but for the most part, it's either like it's pretty predictable. You're either seeing the physical therapist, um, the one who did your evaluation, or you're seeing the PTA. Like, so so you know, like, so um, so we're able to, as a clinician, we're better able to kind of like keep track of your progress and we know, you know, you know what you're there for and we know your plan, because there's only two people who you're seeing, versus um a lot this versus like in in this in the example, so the other clinic, like they share patients. So um this from a business perspective, this makes more sense. From a healthcare perspective, it's not as super great. Um, but you as a patient, you just get put into whatever time slot is available, like when you go to schedule. And so it can be like the the f with the physical therapist that did your evaluation, or it can be with whoever is available at that time. And so what really happens, um, so what happens if you're at a clinic that shares patients is that sometimes you can fall through the cracks because you're seeing different providers. And depending on how busy that clinic is, like maybe the the maybe the physical therapist um or even PTA, the assistant, like they just don't have the mental bandwidth to keep track of everyone's because you it's not you're not just keeping track of the patient, like your own patients, like your core group of patients. You're essentially keeping track of the entire clinic's patients. So whereas in my old clinic, like maybe I had like 20 patients at a time that I needed to keep track of, and like the clinic as a whole, if there's like four of us, then there's like 80 patients. So like you can see how it gets it can get really muddled. Um and so this this was the case of in this example where like they're at a clinic, they share patients, and um you know, this per like this particular people, like they kind of just get a generic plan, and even though they outgrew the plan, um, because they the clinician, the physical therapist didn't have time to like really sit down and look at the plan and come up with like uh exercises to progress their plan, they kind of just had them continue doing the same exercises. Um and when the the patient voiced their concerns, um, you know, the physical therapist didn't really have an answer as to why they had to keep doing the same exercises. Because, like I said, the only reason why they're continuing continuing to do the same exercises is because um they didn't have time to progress their plan. And so that's the first indicator. The second indicator is um again, nobody can explain your current plan. So these two go hand in hand. Like if they're if the physical therapist is unable to explain why your plan isn't changing, um, then they're most likely not able to explain why you're doing the exercise that you're doing and how it relates to your actual goals. Um, and so again, a lot of times with at these places you're gonna get like a generic plan. Um, and for the most part, because it's generic, so it applies to a wide range of people. So maybe you've gotten you maybe you've been at a uh at a clinic like this before and you actually did get better. Like you, you know, you you progressed through everything and um it progressed um along with or as you progressed, the exercises progressed with you, and you just coincidentally, um it was not coincidentally, because it's not necessarily a coincidence, but um it just so happened that the generic plan worked for you and you got better and you had no problems. Um, and that's great. But for some other people, especially more active individuals, so in my case, people wanting to do CrossFit, because that those were the the patients that I've had who have come from a clinic like this because they didn't progress, is that they reach that ceiling really fast. And so then they need something more uh personalized, and the generic plan is not gonna work for them. And so if so, if you're in this situation, obviously don't be afraid to ask questions about your exercises like my patient did, um, as well as the goals of the program. So, what metrics that your physical therapist is tracking. Um and if they're not able to give you like a really good answer besides like, oh, you know, you're on track, like this, you know, just keep doing these exercises, um, then you might want to consider getting a second opinion or going somewhere else. Um because your rehab plan really should evolve as you get better. And it and it shouldn't be like again, the generic plans are okay, they're not necessarily bad. Is that is just that because they are generic, they're not gonna necessarily apply to everyone, and especially they're they're gonna apply to the average person, but um for like people who want to be more active, so people um who come to see me who are who are like CrossFitters and triathletes and people who want to do high rocks, like they're gonna outgrow a lot of these generic plans really, really quickly. So that's the first example. And um, but maybe your plan is progressing and your PT seems to does seem to have a reasonable explanation for the exercises, um, but you still don't feel any closer to meeting your goals. So this brings me to another client I had. So this particular client, um she had re she had it was for pelvic floor physical therapy. So um years ago, when she first started having um, so she was basically leaking while running. So she would pee her pants while running. And um when it initially started happening, so when she came to see me, I think her uh kid was five, so five years prior, when she initially uh wanted uh started addressing this issue, she went to pelvic floor physical therapy, um, but she really didn't feel like it did anything. And so when I asked her, okay, like well, what did you do? So she described she did, you know, she got the exam and whatever, and she um her again, her referral from her the physician was for six weeks. And um so she she gets her exercises and she does them diligently. Um and but every time she goes to the clinic, all most of the exercises were like laying down ones. So so stuff that she was doing while laying down, and I think that the the only things that she would do standing up were some balanced ones, but they were like, you know, standing on one leg, and then that's it. Um but her goal was to be able to run without peeing her pants. So like it wasn't so much the you know, c uh uh peeing pants with like coughing, sneezing, like all that stuff. It was going back to running. Like running was really important to her. Um and you know, like halfway through, she's like, you know what, these exercises are dumb. Like I don't really see how these are gonna help me get back to running. Um but the physical therapist, like I think she did tell the physical therapist, um, I don't actually remember, but um I feel like the exercises sort of get harder, like more, you know, progress a little bit, but they never really progress to like actually doing stuff while she's moving. So they don't progress to past standing basically. Like they don't go to like lifting or whatever or even running. Um and so yeah, at the halfway mark, like three weeks, um, she's my pre my um the patient is basically like, you know, I'm just gonna keep like I don't think this is gonna help me, but I'm just gonna see it through. I'm gonna go to the six weeks, and then you know, maybe, maybe I'll get better by the six weeks. Um, you know, the last three weeks pass, nothing really happens, nothing really changes, and she's like, Yeah, I'm I'm not gonna continue. So she just gets discharged. And then for five years, she just thinks that she this is this is the best it's gonna get. She's just gonna have to like strategically plan her runs to like run by bathrooms and stuff. Like she she legitimately knew where all the bathrooms were, all the bathroom stops were along her route, um, so that she would know, like, oh yeah, after this much like I usually have to pee around this time, so the bathroom is here. Like it was like a whole thing. Um, and then so yeah, and then she met me, and then you know, we did. I'm like, okay, well, it seems like the this public floor physical therapy didn't really address your particular goals. And then so she worked with me, and now she's able to run without peeing. Um but in this instance, like I think the I think her plan was progressing, but it was progressing towards like again, I don't want to call it a generic goal, but it that that's what it really seems like. It was just progressing towards like the standard, like, oh, no, no more leaking with coughing, sneezing, laughing. But the the physical therapist didn't seem to consider her particular goal, which was being able to run without peeing. And it's it seems like a I don't know, it seems like a basic thing to like work towards your patient's goals and not what you think that they the patient should work towards. But I mean that's it is a basic thing, but like I feel like a lot of times it's not something that's addressed. Um, but anyway, so in this case, um the client, this patient slash client had mostly been doing pelvic floor exercises while laying down or standing still. So if you really think about it, it's a really huge leap to go from either laying down or even standing up but like you know, standing on one leg. Like it's a huge leap to go from that to now running. So, like doing all of this, all the work that she did is a it's fine, it's a fine foundation, but it's not going to progress, it's not going to magically progress towards being able to control your pelvic floor while you're running. And even then, as an aside, like you're not necessarily trying to control your pelvic floor. Like when it comes to doing things like getting back to running, you're more like trying to how do I explain this? You're more like um trying to train your body to be able to do a contraction so that it's able to do it reflexively and you don't have to think about it. So that in a git like in that's the gist of like public floor physical therapy for like going back to running and pressure management, um, which we talked about. And we also talked about bladder hygiene. So so yeah, yeah, that's an aside. But again, like if you really think about it, like if all the exercises that you do are like laying down, like a bridge or whatever, like there there's no gravity here when you're laying down, there's no gravity pulling on your public floor. And then so then now all of a sudden you're standing and you're running, which are basically like a bajillion hops. So you're adding gravity plus impact, like it's a huge stretch to go from laying down to now running without like having some sort of in-between. Um and so even though like maybe her plan did progress, but it never progressed to like her actual goals. So a more appropriate appropriate plan for this particular person was for her to progress the exercises or for her to progress to doing exercises with her moving and it then eventually running, which is when when she worked with me, uh that's what we did. Like we did mostly exercises like with her standing and then like practicing certain things uh with her running. Um, because you know, overall or at the end of the day, like her goal, the thing she actually cared about was running without peeing her pants. Um, and so in in an instance like this, again, don't be afraid to ask questions about your exercises and the overall plan and how it would actually help you to achieve your goals. Because I mean, from what she told me about what her plan was, like it wasn't again, it wasn't bad. It's just was trying to meet a goal that this that the patient didn't have. Like it was trying to meet a goal of being able to like just you know, maybe cough, sneeze, laugh without leaking when this person wanted something beyond that. She wanted to be able to run without leaking. And so the goals that the patient had didn't match the goals that the physical therapist had for the patient. And so going back to being in the messy the differences between being in the messy middle and then being stuck, because they can be very similar, because at this point, again, um when you when you reach this point, you've already done a lot of work, maybe you've seen some progress, um, but like now like that initial excitement has worn off and then it's it's starting to get a little bit more repetitive, and you're like, Well, I still can't do all of my stuff, you know, I don't I still can't do what I want to do it yet. Um and so how do you tell if you're in the messy middle versus being stuck? So um so as a reminder, when you're being in the messy middle, you need to ask yourself, when have you been given a rehab timeline with a reasonable explanation? Um and this should not rely on the physician's referral. So all physician referrals, most of them are gonna say two to three times a week for six to eight weeks. So it's it's just based on, I don't know what it's based on, but I guess it's based on averages. Um, but again, it's really generic. It has nothing to do with you, the person. So this timeline should be based on the um the physical therapy exam or the assessment that the physical therapist does on you, because some people um like six weeks. Is usually a good like like timeline, like or good um what's that word? Like milestone. I would say most people they're not completely better by six weeks, but six by six weeks you're usually able to see like progress. Um, and that's usually like for most people, four weeks is usually when they start being in the messy middle when they're like, I don't know if this is ever gonna get better. And then six weeks is usually when they're like, oh yeah, I see progress, I think I am gonna get better. Um, for me, it's more like closer to two to three months, where again, I do work with people who want to get back to higher level things, but usually two to three months is when you get back to like 100% versus like you know 80, 85%. So, so again, going back to being in the Messi Middle, one, have you been given a rehab timeline with a reasonable explanation? So this should not be, oh, well, your referral is for six weeks, so we'll try this for six weeks. It should be like, well, um, you're dealing with like, you know, going back to my client example, you've been leaking while running, um, but it's you've you know you've been dealing with this for five months, or sorry, not five months, five years. So for most cases, like three months, but we'll see. But since we've been dealing with for so long, it might take closer to six months for us to see results, you know, something like that. So two, um, and then two, has there been progress at all? So this can kind of get tricky because, like I said, the two the clients that I've had who were actually stuck, they did see progress initially. But for some people, they see no progress. So, um, so it's still an important question to ask if if there's been like any sort of progress at all. So maybe you haven't been able to get back, maybe you're not back to running again, maybe you're not back to your overarching goal, but there's all these like mini checkpoints that you will meet before reaching your overarching goal. So usually the physical therapist will have those mini checkpoints, or they should have these minimi checkpoints. Um, we call them like short-term goals for you to meet. Um, so that you can see that, oh yeah, there has been progress. Like, yeah, I can't run yet, but like now I can do, like from my last episode, now I can do lunges without pain. So that's an example from the last episode. So has there been progress? And the last um the last question to ask is are the exercises progressing? And because when you're in the messy middle, like it seems like nothing's happening, but in reality, like, yeah, your exercises have been getting more difficult. Um, it probably doesn't seem like that because it's still pretty challenging, but like the very, very basic is like, oh, well, I used to use the yellow easy band, but now I'm using the green harder band. Um, that's like very, very basic. But it can also be like, well, before I used to have to do isometrics where, or I could only do isometrics where like you're contracting the muscle, but the joint isn't moving, but now I can do squats, or now I can do like heel raises or whatever without pain. So um the exercises might be prog progressing, but it might not feel like it because it still feels challenging. And that that's the point. The exercises should be challenging you. The only exception is going to be if you're so my only exception for this is if you're doing some sort of joint mobilization. So what I mean by that is um, like I've uh another previous client, um, we were I was helping her with her big toe, and so we were doing what's called like longitudinal distractions, so where you're kind of like basically pulling your big toe away, um, so that you're kind of trying to um create some space in that joint. Um, that's the idea, and there's a lot of other explanations behind it. But anyway, it feels like you're doing nothing, basically. And so she was saying, like, you know, I don't feel like this is doing anything. I'm like, okay, well, trust me, like, try let's try for like two more weeks of this particular exercise. Just keep doing this one, trust me. And then if you really aren't seeing any difference, then we'll try something else. And then yeah, after two weeks, she's like, Oh, now I can bend my toe more. So that's really the really the only exception to um not changing or progressing in exercise because it feels too easy is gonna be some like some sort of joint mobilization like that. Because a lot of times it feels easy, it feels like you're doing nothing, but you really are kind of doing something, and then eventually you um I mean you're not gonna do it for like six months, but like you do it for a few weeks and then and then see if you if it helps you. So to recap, being in the messy middle, should you you should have or have you been given a rehab timeline with a reasonable exception, uh reasonable explanation? Has there been progress and are the exercises progressing? So in the two examples that are uh stories that I went over today, none of them actually were really given a timeline except for like the phys the six weeks that from their referral. And their prog exercises weren't really progressing. Um the public floor story, I'm not 100% sure if they like it seemed like they were kind of progressing, but she didn't really see any progress. And in the first story, they initially saw progress, but then they didn't see any more progress, and also their exercises were not progressing. So if you answer no to any of these questions, then you're probably stuck. So, but to make sure, some other questions that you can ask yourself to wonder if you're stuck are if the exercises aren't progressing, can the PT answer why? Because in um the story I just told you about the like the big toe, like she we were working on multiple things, but for that particular issue, her big toe, I did not progress that exercise for like two weeks, but I was able to give her an explanation as to why I wasn't going to progress that exercise. I I didn't just say just trust me, but I did explain like the reasoning behind that particular exercise and the reasoning of why it might feel easy. And I also kind of gave I also gave her a timeline, like, okay, we're gonna try this for two weeks. If we if it doesn't work after two weeks, then we'll try something else. So I did give her an explanation and I did give her a timeline, and I uh did give her assurance that we would try something different if we didn't if uh if it didn't work or help. So the ex so ask yourself if the exercises aren't progressing, can the PT answer why? And it has to be besides, oh, these exercises, you know, your your uh what do they say, your um these exercises are are good for knee pain or whatever, just keep doing them. Like that's kind of a cop out, actually. And two, can the PET explain how your current plan relates to your goals? So in relation to the the pelvic floor client, the I'm sure the physical therapist gave her a reasonable explanation of how all of the exercises she was doing are gonna help her pelvic floor, but she never really related them to running, and which is what my uh patient wanted to do. She wanted to get back to running. That was her goal. And so, again, I'm sure her plan was fine for someone who just wanted to be able to um laughkoff sneeze without peeing, but her goal was to be able to run without peeing, and so the plan that she was given was not gonna help her with the goals that she had. Um, and so those two things are really important. And so again, if the exercises aren't progressing and the PT cannot explain why your current pla how your current plan relates to your specific goals, then you know, and you've plateaued, then yeah, you you probably are stuck. And if the physical therapist can't really give you if the current one that you're seeing like can't r really give you an explanation or um can't seem to be able to progress you towards your goals, then it might be worth seeing a different physical therapist. So and it's not because the one that you're seeing is bad or anything, it's just you probably outgrew them. Um and yeah, so that's kind of the difference between being in the messy middle and figuring out, okay, am I actually stuck actually? And when it's time to try something else or get a second opinion, go to a different physical therapist, one that more closely aligns to what you want to get back to and uh more closely aligns with um the goals that you want to get back to. And so at the end of the day, if there's one thing that you take away from this episode, it's that slow progress and no progress are not the same thing. So if you're in the messy middle, you are making slow progress, um, there is, you know, there is a plan, and the plan is reasonable, there's a reasonable timeline, like there's an explanation for everything. Like there needs to be an explanation for it besides just trust me, bro, or like, oh, these exercises are good for knee pain, just keep doing them. Like don't feel like you're annoying the physical therapist because they really should everything, all the exercises that they're giving you really should have some sort of explanation behind them. Like, I don't just like choose I don't just choose random exercises. I like really think about like, okay, what is going to get this patient to like the next step towards their goals? So there really should be a reasonable explanation behind all of the exercises, as well as the overarching plan. So sometimes it's just kind of like a loose framework because rehab, again, is not linear. Like we don't know how you're going to respond to these exercises. So there's like a general framework, there's like a general structure to the plan. It might not be like all the details ironed out yet, but there should be like some sort of framework or like structure or like outline, you know. Um so yeah, so slow progress is fine, but if there's absolutely no progress, like you reach a point and then after that there's zero progress, then um then you're probably stuck. Um but again, recovery isn't always linear, and the messy middle is just gonna be part of the process. Um, but your rehab plan should still be moving forward and you should still understand like where it's taking you. Like it shouldn't just be like, oh, you know, yeah, just you know, just keep doing what you're doing. It should be um so uh in my last episode when I was talking about the pr the person who had Achilles tendon pain that was in the messy middle, they really were doing still continuing to do the same exercises for a few weeks, but that's because tendons take a long time to respond to that load and stuff. And so even though they were doing the same exercises over and over, they the exercises were still appropriate for them. They were still challenging because if we progressed the exercise, it would trigger the pain. So we were trying to be at a good um a good level where it wouldn't continue irritating the tendon, but we were still trying to get uh improve the tendon's ability to handle load. And so having that explanation, like the client um presumably understood where the re the plan was taking them, or at least you know, I was able to explain like why we were not progressing in the exercises, because that's where they were during in that stage of rehab. Um, and there was like a loose framework of where uh of the rehab plan as well. So so yeah. Um that's it for today. So if you're currently rehabbing an injury and you're not sure whether you need to be patient, whether you need to be more patient, or if you need a different approach, I'd definitely be happy to help. You can learn more about working with me by visiting my website at anteaterptp.com, which will be linked in the show notes. Um but as always, thank you for listening, and I'll see you in the next conversation.