One of the biggest struggles I have as a physical therapist is knowing when to give in to the plateau. Or rather, I have a hard time accepting it when that time comes. My instinct is always to keep trying. I think that maybe if I just try one more thing, that will be the thing to get them where they want to be, and to make all the difference.

Sometimes that persistence is called for, but often, if we have reached a true plateau in status, it can be a disservice to the patient to prolong physical therapy services instead of taking the next step. If they are not making the improvements we would expect, then they may need further diagnostic testing. Or there could be another intervention out there that will get them to their goals.

My Plateaus

I’ve seen it more than once throughout my physical therapy career.

One patient was being seen for shoulder impingement. They got 90% better with physical therapy, but that last little bit eluded us. When we addressed the plateau the patient went back to the doctor and one injection was the trick to eliminate the symptoms.

Another patient had severe bilateral knee pain with sudden onset and unknown etiology. There were also coexisting systemic symptoms that made the diagnosis even more unclear, especially as initial testing came back negative. Physical therapy yielded little to no improvement in symptoms. In the end, MRI revealed bilateral meniscus tears, even though none of the symptoms or testing seemed to fit that diagnosis. Meniscectomy eliminated all symptoms.

I have certainly had more than two cases of plateau in my career, but I have learned some lessons with patients like these. Think outside of the box, and accept that there are things that I can’t fix.

Worst-case Scenario

I think we’ve all heard of those cases where a course of physical therapy does not fit the pattern, and the actual diagnosis ends up being much more significant than the referring diagnosis. It could be lupus, multiple sclerosis, an undiagnosed fracture, rheumatoid arthritis, or any number of other pathologies that need medical intervention. It could be cancer.

Problem-Solve the Plateau

If you are starting to suspect that the patient has reached a plateau with physical therapy, ask yourself some questions:

Have I tried everything I can think of? Does the research support any other type of intervention?

Is the patient compliant? If not, what more can I do to educate or persuade them to understand the importance of following the program?

Do I know any colleagues who have an area of expertise outside of my own that could help? Or advise me?

Is there another type of professional intervention that may help in conjunction with physical therapy- acupuncture, massage therapy, chiropractic care?

Can I truly expect that there will be any significant change in status if we continue for another week or two?

The answers will guide you. Trust your clinical instincts. It is our responsibility as their physical therapist to make our patients’ goals our priority. Most of the time we can be the professionals to facilitate the healing they need, but, for their sake, we need to accept the plateaus and know when when our patients should move on.