Those who want restoration from chronic pain, a prolonged recovery after surgery, or a state of the nervous system may have several diseases, several kinds of medicine, previous procedures, and limitations in function that must be considered together. A complex health history does not mean that restoration suits, does not suit, or must be more intensive than usual automatically. The plan depends on medical stability, the precautions, and the goals of each person
A reassessment that holds the patient as its centre helps show what has changed, what is still uncertain, and which result is important to the patient. Restoration has the goal of increasing function and participation in life; it does not guarantee that every symptom or underlying disease can be reversed (the World Health Organization (opens in a new tab))
A plan that is systematic may help meaningful progress arise, even though the previous care gave a limited result. But the results and the lengths of time differ. Some people need further examination and diagnosis, making the medical state stable, a review with the surgeon, or setting goals that are supportive and palliative, instead of adding procedures
The important points
This guide is for patients and families who are facing continuing chronic pain, a long recovery, or a result after surgery that does not yet meet clinical expectation
The next step begins from basic information that is current, namely the diagnosis, the medicine, the limitations after surgery, the state of the nervous system, the pattern of the symptoms of pain, sleep, mood, activity, support at home, and function that can be measured. The plan should be agreed together with the patient, and the benefit, the risks, and the uncertainty of each choice explained (the NICE NG193 guideline (opens in a new tab))
Caring for chronic pain after passing through several methods of treatment
Some people have consulted several physicians, used medicine, received physiotherapy, or have passed through surgery, but still have weakness, limited movement, or chronic pain. This does not prove that the previous treatment "failed", because the disease may have changed, the goals may have been different, or the benefit may have been only partial
The factors that may overlap are the underlying disease, the healing of the wound, a state of the body declining, the effects of medicine, sleep, mood, fear of movement, social burdens, and access to help
Symptoms that remain do not rule out the chance of improvement, but neither do they prove that there is a hidden "biomechanical origin". The reassessment should test the possible explanations and avoid repeating examinations or treatments without a clear indication
Why complex cases usually require a new clinical assessment
Symptoms that persist may be connected with chronic pain, changed movement, a state of the body declining, injury of the peripheral nerves, the change of the tissue after surgery, or fear of movement. These are possibilities that must be assessed, not assumptions for everyone
A plan of restoration after surgery that has been interrupted may have a part in some cases, while other cases may arise from the original disease, a complication, a new diagnosis, or the limits of recovery. Coordination between those treating helps the limitations correspond with one another and reduces contradictory recommendations
A comprehensive reassessment helps put these factors in order, without overlooking urgent states and the needs of the patient
The reassessment, the suitability, and the safety
Chronic pain may be of the primary kind, secondary to a disease that can be identified, or of both kinds. The change of the tissue, the working of the nerves, the processing of pain, movement, sleep, mood, and the social context may have a part. A state of sensitivity to pain from the central nervous system is a clinical concept; it should not be concluded from persisting pain alone
Each kind of examination should answer a clear clinical question. Ultrasound, Elastography, the examination of the physiology of the nervous system, or the assessment of biomechanics may be of benefit in specific indications, but no examination can map the "real origin" of a complex case on its own, and what is found incidentally should not be treated automatically
The suitability must be assessed before beginning exercise, a procedure, or equipment. If there is new or worsening weakness, inability to control excretion, fever or suspicion of infection, chest pain, difficulty breathing, suspicion of a blood clot, disease of the heart and the blood vessels that is not yet stable, an acute fracture, or limitations after surgery that have not yet been reviewed, there may need to be an urgent assessment, making the state stable, or asking for permission before beginning the restoration
PRP, Shockwave, Laser, stimulation with a magnetic field, and other supporting methods have evidence and contraindications specific to the state. They are not a standard set of treatment for every complex history. Stem cell products advertised for diseases of the bones and the joints, of the nervous system, or for chronic pain require special caution. The approvals differ according to the country, and the FDA of the United States states that there is not yet such a product approved for these indications (the consumer alert of the FDA (opens in a new tab))
A programme of restoration specific to the individual for complex cases
Those who have a complex health history may still get benefit from the standard principles of restoration, when they are adjusted to fit the diagnosis, the precautions, the symptoms, and the goals. Complexity is not a reason for having to use high intensity, more technology, or a programme specific to a brand automatically
A suitable programme should identify the baseline level of function, meaningful goals, the size of and the increase in the activity, the criteria for following it, and the time at which it must be stopped or a medical assessment asked for. The team should have only the fields that are necessary for the problem that can be identified
Adjusting specifically to the individual is important, but not everyone needs experts of several fields. Care of the multidisciplinary kind is most of benefit when the diagnosis, the precautions, or the goals overlap several professions
Achieving recovery after treatment that did not succeed
Meaningful progress may still be possible after the previous treatment gave a limited result. A new plan should identify the obstacles that can be adjusted, together with accepting disease that cannot be reversed, the uncertainty, and the possibility that the symptoms will persist
A good result may differ from the level before the injury. Meaningful goals may be moving more safely, doing the routine more easily, being more independent, going back to roles that give value, or managing oneself better, even though the pain does not reduce much
Setting milestones in function that can be measured helps in deciding whether to continue, adjust, or stop any method
The components of an integrated strategy of restoration that is comprehensive
When coordination is necessary, a joint plan helps reduce repeated examinations and contradictory recommendations, but it does not mean that everyone must use every field or every method. A strategy that can really be used may consist of:
- Reviewing the diagnosis: confirming the disease that is known, screening for new problems, and examining further when the result will change the care
- Reviewing the medicine and the procedures: checking the list of medicines, the previous response, the side effects, the contraindications, and the status of approval before adding a method of treatment
- Restoring function gradually: using exercise, training in activity, pacing, the giving of knowledge, and assistive equipment at a dose that can be tolerated
- Supporting methods specific to the state: considering equipment, injection, or manual treatment when the evidence, the indication, and the needs of the patient support it
- Following and referring: following the function and the harms, respecting the limitations after surgery, and setting criteria for a repeated medical assessment
The benefits and the limitations of coordinated care
Coordinated care may help the goals, the precautions, and the responsibilities be clearer, reduce duplication, and help those treating interpret the change of the symptoms or of the function together
Coordination does not prove that several methods have an added effect, "repair at the level of the cell", or adjust the nervous system at the same time. Adding methods of treatment may increase the burden, the cost, the interactions between treatments, and the difficulty in knowing what helps or does harm
Therefore the smallest set of methods that is reasonable should be used, the result reviewed at agreed periods of time, and methods that do not give a result stopped. It cannot be guaranteed that a relapse will be reduced
The big picture of a complex recovery
The previous treatment may have given a limited result from several causes, such as the severity of the disease, the uncertainty of the diagnosis, complications, access to care, obstacles to following the plan, or goals that no longer suit the situation. Fragmented care is only one possibility
Restoration may proceed alongside medical or surgical care when it is safe and of benefit. The goal may be recovery, adaptation, the prevention of complications, or maintaining independence, and shared decisions should be reviewed when the state and the priorities of the patient change
Frequently asked questions about complex cases of restoration
Why do some patients still have symptoms after several treatments?
→ Symptoms that persist do not always mean that the main pathology has been overlooked. The disease may still be proceeding, the recovery may not be complete, the treatment may give a limited result, or there may be a new factor. The reassessment should be based on the change of the symptoms and consider whether new information will change the care or not
Does restoration still help after surgery?
→ It usually helps, but the time and the content depend on the kind of surgery, the healing of the wound, the limitations from the surgeon, complications, and medical stability. If there is new swelling, a problem of the wound, fever, acute weakness, or symptoms of the heart and the lungs, a medical assessment should be made before adding training
What makes a programme of restoration suit a complex case?
→ A suitable programme has a clear indication, respects the contraindications and the precautions, uses realistic goals of function, identifies the dose of the training and the following, and adjusts according to the response. Experts are added when the diagnosis or the risk makes it necessary
Does treatment that did not succeed mean that recovery is unlikely?
→ Not necessarily. Another plan may still help the function or the management of oneself, but it should not be sold as a method of finding a "hidden origin" for certain. The benefit expected, the burden, the cost, and the alternatives should be discussed openly
The point of view of the patient
A large number of patients give value to an explanation that is coherent and to a plan that they have a part in setting. Progress is not a test of "discipline", because the symptoms, access to services, exhaustion, finances, the duty of caring for others, and the burden of the treatment can all affect participation. The team should adjust the plan instead of blaming the patient
In summary
For those who have chronic pain, limitations after surgery, or who received limited benefit from the previous care, the reassessment helps show what is important at present, and whether restoration, further medical examination, or supportive care should be chosen
Safe restoration after surgery must combine current medical information, the limitations connected, the goals of the patient, and following that is proportionate. The benefit cannot be guaranteed, and some people need a slower pace, a change of route, or the treatment of an urgent medical problem first
Managing symptoms that have not yet been resolved is a challenging matter. A joint assessment on the foundation of medicine helps set the next step reasonably, by identifying the uncertainty, the contraindications, and the limits clearly