Clinical Magic Tricks

A 4-minute read…

“Why isn’t this feeling like it did when you first did it? This doesn’t make any sense… what the hell am I supposed to do now?”

This was what a patient said to me about 5-6 years ago, who was suffering from severe sub-acromial shoulder pain as I was trying to find a way to reduce her pain on movement, just like I had achieved 10 minutes ago when I used the Scapula Assistance Test on her. Unfortunately, I didn’t have a good answer to give her, and this was also the last time I used this test and many others like it… let me explain why.

The Scapula Assistance Test is a commonly used shoulder symptom modification test first described by Ben Kibler in 1998 in which a therapist attempts to ‘assist’ the scapula into upward rotation as a person lifts their arm to see if this reduces their painful shoulder experience. There are many other tests that can be done around a painful shoulder to try and reduce a painful movement, most of them conceived by Jeremy Lewis in his Shoulder Symptom Modification Procedure (SSMP).

But symptom modification tests have also described around many other body areas such as elbows, hands, knees, hips, necks and backs and they sometimes go by the names NAGS, SNAGS, or MWM’s as conceived by Brian Mulligan.

However, I now just refer to all these kinds of tests as ‘clinical magic tricks’.

Now I was taught many of these ‘clinical magic tricks’ by some very well-known and influential physios on their courses and they assured me that if you can get a patient’s painful movement to quickly change using their ‘techniques’ it will help patients understand their pain is changeable and help them move more and with more confidence and improve their prognosis and outcomes (ref).

However, after a few years of using them, I began to realise this was not always true, in fact, I found it was often not true at all.

Negative Effects?

I began to notice that these ‘clinical magic tricks’ were first of all not reliable or reproducible on the same patient which lead me to conduct my first clinical research trial to check my observations under more controlled conditions (ref). Not only did I find very little reliability or reproducibility, but I also noticed that these ‘clinical magic tricks’ can have some negative and detrimental effects for some patients that no one ever mentions or talks about.

I found that sometimes if I suddenly and dramatically reduced a patient’s painful movement with one of these tricks… after the shock and excitement had calmed down it left many patients, and myself, feeling a little confused and uncertain about what had just happened, and what should be done next.

I found these tricks confused me and my patients the most when we couldn’t repeat the results the next time we tried them, or if we couldn’t reproduce the results without me pushing, pressing, or pulling on them. This left both of us feeling unsure and uncertain about what was going on and what we should do.

I mean just think about it for a second… if you had a pain that suddenly changed or disappeared completely when someone pressed or pushed something, only for it to reappear just as suddenly unless someone was pushing or pressing you, do you think you would be reassured or confused?

Bullshit Explanations

I was also taught that the way to explain these tricks to patients if they worked was based around a biomechanical explanation such as the scapula or another joint was out of position, misaligned, or not moving correctly, or that a muscle was weak or unbalanced. But this is just outdated reductionist bullshit.

First, there is no evidence that when we push or pull on someone’s scapula or any other joint and they feel less pain, it tells us if their muscles are or are not functioning (ref). Next, there is no evidence that pushing or pulling on a scapula actually significantly changes the scapula position or movement (ref). And finally, we see no difference in the effects of these symptom modification tests when we compare them against sham or placebo tests, telling us that the biomechanical explanations can not explain the results alone (ref).

Simply put there are many, many probable reasons why someone’s pain changes as we push, press, and pull on their scapula or any other body part. It could be due to increased proprioceptive input from the therapists’ hands, or increased feelings of safety and security for the patient as they move, or expectation violation as they move… the list of alternative explanations as to how these clinical magic tricks reduce pain is almost endless.

And if we do try to explain the complex and multifactorial nature of pain and how there is a lot of uncertainty in the why or how their pain changed as we do these clinical magic tricks this, in my opinion often doesn’t help reassure many people, instead, it just adds another level of confusion and more uncertainty unnecessarily into an already confusing and uncertain situation.

And finally, I was also told that these symptom modification tests help us direct our treatment interventions better. But again this is a complete load of bullshit. Just because you reduce someone’s pain by assisting their scapula it doesn’t mean you need to or can give treatments or exercises that change the scapula’s movement or position well at all (ref).

Contradictions

So using these symptom modification tests or clinical magic tricks to reduce pain just doesn’t sit well for me today in many clinical situations where I have fully listened to the patient’s history, thoroughly assessed their movement and pain levels, and reassured myself, and hopefully, the patient as well that there is nothing serious or harmful to be concerned about.

It also doesn’t make sense for me to spend time explaining and reassuring patients that the natural history of their issues is complex but favorable, and then discuss with them how they can continue to do things they need or love to do without any fear of doing any further harm or detriment to themselves or their prognosis, only to suddenly say…. “but hey… lets still try to reduce this perfectly safe yet unpleasant pain anyway”. This seems like such a huge contradiction.

So there you go… that’s a very quick look at the Scapula Assistance Test and the other symptom modification procedures or tests that are often recommended and promoted to help reduce painful movements. And although I do understand why they can be appealing and attractive to learn and use in clinical practice, and they can help some patients, sometimes, for a short while… please do not be fooled into thinking they are reliable, diagnostic, or essential to do with most people.

In fact, I would argue that these clinical magic tricks are often more for the therapist’s benefit than the patients, giving therapists a sense of utility, usefulness, and skill in being able to fix and correct things. For most patients, they are not really that useful or that beneficial, and as I have mentioned they can have some negative and detrimental effects that no one ever discusses or talks about, which I hope this blog changes.

Vested Interests and Weak Egos

Now I know this blog will upset some people, usually those with vested interests and strong biases into teaching these ‘clinical magic tricks’ as well as a few other therapists with fragile egos and low emotional intelligence who often hide behind anonymous social media accounts and cannot tolerate anyone questioning, challenging, or criticizing their beliefs or ways of practicing (see below for a perfect recent example)

However, please do not let either the gurus or trolls put you off from questioning, challenging, or criticizing anything with their lame personal attacks claiming you need to ‘do more research’ or ‘criticize less’ as this reflects more about their issues and insecurities rather than yours.

As always thanks for reading, and please stay skeptical, keep questioning and remember there are no sacred cows in physio… even those who teach ‘clinical magic tricks’.

Adam