I was just gonna let this go but then I thought why should I, just because you are usually right doesn’t mean you are always right, and for once I think my good buddy Greg Lehman is wrong.
Before I get into it let me explain what a ‘straw man’ is. A straw man is a classical logical fallacy of which there are many. Logical fallacies are errors of judgement and reasoning first described by Plato and Aristotle. These occur often when debating, discussing, or arguing the toss over the utility of symptom modification techniques.
The straw man is easily one of the most common logical fallacies. It is when someone distorts, exaggerates, or misrepresents your argument to make it easier to attack and knockdown. For example, saying teenagers should be taught more about safe sex, is often straw manned into saying teaching teenagers about safe sex makes them more promiscuous.
Anyway back to the subject at hand. Greg did a little counter blog here to my recent blog here on the role of symptom modification techniques, as well as commenting on a tweet I posted the day after here. Unfortunately in Greg’s blog he quickly builds a straw man by claiming I don’t think symptom modification techniques are important.
This Is Wrong.
If you are really, really bored read my blog again and you will find nowhere in there is my ‘position’ that I think symptom modification techniques are not important. In fact, I state just the opposite, I state when they work they can be fucking awesome.
My position is that symptom modification techniques that are taught or promoted by those that use them, be that the Mulligan-ites, Maitland-ites, McKenzie-ites, Lewis-ites even CFT-ites, all these techniques are up for questioning and challenging.
My position on symptom modification is questioning their necessity and their predictive value, and their mechanisms of effect. Be that joint mobilisations, spinal manipulations, taping, massaging, scapula assisting, corrective exercising, psychological interventions, even education. Because in my opinion, all these modification things are very uncertain and very unreliable.
This is NOT saying they can not be used or are unimportant.
I question the need to use symptom modification techniques with those in pain. I question the bio-mechanical explications that are often given when symptom modification techniques work. I question the need to do symptom modification techniques in a procedural format. I question the predictive value of symptom modification techniques. And finally, I question that symptom modification techniques do not ‘dictate’ our treatment decisions.
Dictating is not Guiding.
Dictate is to “lay down authoritatively; prescribe; boss around; give orders to”
Guide is to “have an influence on the course of action; direct; steer; manage”
We all know that language is important on the effect it can have on our patients. We should also be aware of the effect language can have on us. So when we say we can dictate a treatment is in my opinion to prescribe without thinking.
For example, the scapula assistance test is a simple and commonly used symptom modification technique used for shoulder pain. You press around the scapula as the patient lifts their painful arm and if it’s effective the pain is reduced. Great, but what now? How do you explain it? What do you do with this finding?
Many will say that the scapula assistance test increases the subacromial space by facilitating more scapula upward rotation and posterior tilt. Therefore you need to prescribe scapula exercises that promote upward rotation and posterior tilt, or that you need to use taping techniques that do the same.
This is a test dictating treatment. But this is not recognising or acknowledging the uncertainty of the effect of the scapula assistance test. This is flawed clinical reasoning.
I occasionally get great results with the scapula assistance test, but it doesn’t dictate to me what I do next with the patient. In fact, it often leaves more confused due to the uncertainty of why it worked in the first place.
I actually don’t scapula assistance tests have much to do with scapula upward rotation or posterior tilting most of the time, and it certainly doesn’t mean I have to give patients scapula rehab exercises focusing on upward rotation and posterior tile.
Instead, a successful scapula assistance test for me often ‘guides’ me to discuss with the patient about how quickly their pain can come and go, and how this means that they have a favourable prognosis and how their pain doesn’t mean there is a serious structural problem and how it is not to be feared or afraid of.
In my opinion, a scapula assistance test is more a tool that ‘guides’ education rather than a technique that ‘dictates’ a treatment, and this goes for all the other symptom modification techniques. A successful spinal manip doesn’t tell me which exercise to give, a successful MWM doesn’t tell me which structure is at fault. It’s just not that simple.
Summary
Greg is wrong, but I still love him! And I don’t think nor state that symptom modification techniques can not be used. I just think they are not necessary. Please use symptom modification techniques if you want, just don’t waste to much time on them, and just be aware of the uncertainty of how they work, and the potential negative effects they can have if they don’t work. And finally, don’t let them dictate to you what you can or should do next.
As always thanks for reading
Much love
Peace out
Adam
For me they are important not to use. It will only reaffirm a premise most likely not true. People may go to someone else who does, perhaps only for the (short) modification, but I stick to it. I do inform those people on the uncertainty of how they work and that it can have a negative effect on the total process on the long term (but also short term).
Spot on!
Adam,
As always a good read and a thought out point of view in my opinion. You said you use successful symptom modification tests as an opportunity to educate your client about the pain cycle and how easily it can change. In an instance like this, could you give me an example of how you would explain this to your client? I’m curious because I’m still a “young” physio and sometimes struggle to explain this type of thing to a client.
Jason Schexnayder
Understand your position. Nice exchange. Honest question or pondering:
What if the patients only (or even main) goal, hope, or stated desire is to modify the symptom?
Does that change how view (but not assess) such techniques? Does that create the need to possibly be MORE vigilant in assessment and criticism?
Killing it
C’mon man, just let it go