Clinical Magic Tricks

A 4-minute read…

“Why doesn’t this feel as good as when you did it? This doesn’t make any sense… why has the pain come back? What am I supposed to do now?”

This was what a patient said to me who was suffering from severe sub-acromial shoulder pain as we tried to find a way to reduce her pain when lifting her arm, just like we had achieved 10 minutes ago when I used the Scapula Assistance Test on her. Unfortunately, I didn’t have a good answer, and this was also the last time I used this symptom modification 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 where a therapist attempts to ‘assist’ the scapula into upward rotation and posterior tilt as a person lifts their arm to see if this reduces their pain on movement. Many other symptom modification tests like this can be done around a painful shoulder to try and reduce painful movement many described by Lewis in his Shoulder Symptom Modification Procedure (SSMP).

Symptom modification testing has also been described around many other body areas such as elbows, hands, knees, hips, necks and backs and they sometimes go by the names of NAGS, SNAGS, or MWM’s as described by Mulligan.

However, I prefer to now just call these tests ‘clinical magic tricks’

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

However, after using them in practice, I began to realise this was not always true, in fact, I found it was often not true and often just the opposite happened as mentioned above.

Negative Effects?

I began to notice that these ‘clinical magic tricks’ were not reliable or reproducible on the same patient which led 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 talks about.

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

I found these ‘clinical magic 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 the patient and myself feeling unsure and uncertain about what was going on and what we should do.

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 after someone stopped pushing or pressing, do you think you would be reassured or confused?

Bullshit Explanations

I was also taught that the way to explain these ‘clinical magic tricks’ to patients was based on biomechanical explanations such as the scapula was out of position, misaligned, or not moving correctly, or that some 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 (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 finally, there is no evidence that these ‘clinical magic tricks’ help direct our treatment interventions better. Just because you reduce someone’s pain by assisting their scapula it doesn’t mean you need to give treatments or exercises that attempt to correct or change the scapula’s movement or position. Not that any of these treatments can actually do this anyway (ref).

Contradictions

Using symptom modification or ‘clinical magic tricks’ to reduce pain just doesn’t sit well for me in many clinical situations. It just doesn’t make any sense for me to spend my time fully assessing and reassuring myself and the patient that their pain is not dangerous or harmful, that their natural history is favourable, and that they can continue to do things that hurt without any fear of doing themselves or their prognosis any harm.

Only to then say…. “but let’s try and reduce this pain anyway”. I find it a huge contradiction.

I would argue that these ‘clinical magic tricks’ are more often used for the therapist’s benefit than their patients. They give therapists a sense of utility, worth, and an illusion of skill and specificity in being able to fix and correct things. But for most patients, these ‘clinical magic tricks’ are small in effect, very short lasting, and not that useful or that beneficial for many.

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’ the most, as well as a few others with fragile egos who often hide behind anonymous social media accounts and cannot tolerate anyone questioning, challenging, or criticizing their beliefs or ways of practising.

However, please do not let either the gurus or their trolls put you off from questioning, challenging, or criticizing their ‘clinical magic tricks’ 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.

So there you go… that’s a quick look at the Scapula Assistance Test and other symptom modification procedures or ‘clinical magic tricks’ that are often recommended and promoted to help reduce painful movements. 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, a bit, for a short while… please do not be fooled into thinking they are reliable, diagnostic, or essential to do with most people.

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