The Symptom Modification Strawman

I was just gonna let this go, but then I thought, why should I! Just because someone is usually right, it doesn't mean they are always right! And for once, I think Greg Lehman is wrong.

Before I get into it, let me explain what a 'strawman' is.

A straw man is a classical logical fallacy of which there are many. Logical fallacies are errors of judgment and reasoning first described by Plato. These often occur when debating, discussing, or arguing over things and are often used to derail or divert debates or discussions. And a strawman is when someone distorts, exaggerates, or misrepresents your argument to make it easier to attack and knock down.

Now back to the subject at hand. So Greg did a 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.

In Greg's counter blog, he quickly builds a strawman against me by claiming I don't think symptom modification techniques should be used. This is wrong!

Read It Again!

If you are really bored, go and read my blog again, and you will find nowhere do I state that I think symptom modification techniques should not be used, or that they are not important. In fact, I state just the opposite; I said that when they work, they can be fucking awesome sometimes.

My actual position is that symptom modification techniques that are taught and promoted by those who use them the most, be that Mulligan, Maitland, McKenzie, Lewis advocates or even CFTs therapists now. They are all up for questioning and challenging about how they work and what use they have!

My main position on symptom modification is in questioning their necessity, their predictive value, and their mechanisms of effect.

Be that scapula assisting, joint mobilising, spinal manipulating, taping, massaging, corrective exercising, psychological interventions, or even education. In my opinion, how all these modification things work is very uncertain and who they work on is even more unreliable.

This is NOT saying they can not be used or are unimportant.... thats a strawman!

I simply question the need to use symptom modification techniques with those in pain.

I question the bio-mechanical explanations that are often given when symptom modification techniques work.

I question the need to do symptom modification techniques in a formal procedural way.

I question the predictive value of symptom modification techniques, telling us who is going to get better or not.

And finally, I question whether symptom modification techniques help 'dictate' our treatment decisions.

Dictating is not Guiding.

We all know that language is important for the effect it can have on our patients. So we should also be aware of the effect language can have on us. So when someone says symptom modification tests dictate a treatment, this is, in my opinion, nonsense.

To dictate is to "be authoritative; boss around; give orders to"

This is not a good word for us to be considering or using around symptom modification.

The scapula assistance test is a commonly used symptom modification technique for shoulder pain. You push around the scapula as the patient lifts their painful arm, and if pain is reduced, it's considered effective

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 think 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 tilt.

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 respect him! And I don't think symptom modification techniques can not be used. I just think they are not necessary. Please use symptom modification techniques if you wish, but don't spend too much time on them. Be aware of the uncertainty surrounding their effectiveness and the potential negative effects they may 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