Does symptom modification need a procedure?

The term ‘symptom modification’ is used to describe a lot of stuff we therapists do to patients to get them to move with less pain, more comfortably, more confidently, more often, opening the so called ‘window of opportunity‘ that I have alos challenged recently. Now I will admit that I use some ‘symptom modification’ techniques occasionally, but I do question the explanations given as to how they work, as well as the need for them to be performed in a procedural fashion as some advocate.

Symptom modification procedure is  often associated with the shoulder (Lewis) but realistically it can cover any area. Basically symptom modification covers anything a therapist does to a patient, be that joint manipulation or mobilisation, soft tissue work, assisted movements, kinesio taping, dry needling, even exercise and psychological interventions. These can ALL be classed as symptom modification procedures, as they ALL can alter and modify a patients sensations and perceptions of pain stiffness, weakness and fear via interaction with a patient (Bialosky, Pickar).

However, many of these techniques are still explained in biomechanical terms and usually given some fancy sounding name or acroynym. For example manipulations are often called HVLA’s and said to get their effects via realigning joints, or creating gas bubbles that can gap joints. Soft tissue techniques are called by a bewildering array of different names such as myofascial release, trigger point therapy, ART, DTFM, etc and are said to release things stuck or tethered together such as scar tissue, fascial adhesion’s, or reduce muscle tone, tension, or even knots.

Even corrective exercises can be seen as symptom modifying by addressing so called muscle imbalances, poor motor control or lack of stability. Sometimes these techniques are described as improving faulty movements patterns, such as the scapula assistance test increasing scapula upward rotation, core stability training maintaining lumbar lordosis, or a glenohumeral mobilisation with movement re-centring a humeral head.

So how do they work?

The simple answer is nobody knows, despite many claims, the simple fact is they are multifactorial. A scapula assistance test does not just affect a scapula, it affects the person with the scapula. There will bio-mechanical factors, neuro-inhibatory and/or excitatory factors, and psychological factors. But, due to an almost infinite number of variables, as well as difficulties in being able to measure small and unmeasurable things, I doubt we will ever be able to say definitivly what the predominant effects are, or if we need to.

Scapula Assistance Test

However, we DO know a few things that DON’T happen with these techniques. For example know that joint manipulations don’t change its alignment or position (Tullberg). We know that joint mobilisations do not alter its stiffness (Ianuzzi, Aguirrebeña). We know that forces we apply during manual therapy are far below anything that can alter connective tissues (Harms, Threlkeld Chaudhry). We know that connective tissues don’t change easily (Konrad, Magnusson, Weppler), and definitely not with a few minutes of manual therapy (Vardiman).

We also know that there is poor reliability in therapists performing many of these techniques (VanTrijfell, Stovall), with high variability in the way they are performed and the forces which they are applied with (Snodgrass, Harms). This means that two therapists attempting to do the same technique on the same person will most likely have a different results and outcomes.

It doesn’t matter

However, it may not matter if we dont know how these techniques work, or if there application is different from therapist to therapist. For example, it has been shown that you can apply a randomly selected technique and get just as good results as a clinically reasoned specific one (Chiradejnant, Cleland de Oliveria, Aquino, Schomacher)

But just because we can’t conclusively show how these techniques work, doesn’t mean we can’t use them. This is not how evidence based practice works. Instead we work with levels of probability and if there is plausible rationale, with no risk of harm, and demonstrable and repeatable effects, then crack on. However, many need to be more honest when explaining to patients how these things work, and like it or not this often means saying…

We don’t know…

Many don’t like saying I don’t know, it tends to scare them, and I can understand this, it can be very uncomfortable and challenging to admit our ignorance. It can be risky as well. Patients can misconstrue it as thinking we don’t understand or know what we are doing. However, with further explanation patients can a dn do understand this uncertainty and eventually will be better informed and so able to make better decisions (Elwyn)

However although this uncertainty can be challenging I also think its liberating as it removes the need to work in a systematic or procedural way. No longer do therapists have to choose a technique based on biomechanical principles, or becuase some gurus says do this before that. Therapists have the freedom to explore many ways and means to modifiy patients sensations and perceptions of pain, weakness and stiffness based on a whole host of factors. However, this freedom doesn’t give therapists the excuse to go bat shit crazy using overly complex ridiculous interventions or techniques or woo.

So do we need a procedure?

We all tend to use systematic approaches or frameworks both in assessment and treatment, and a methodological approach to history taking and examination does ensure we are thorough and efficient. For example observing an area before checking its range of movement, before checking its strength is usually a good idea. However, using a procedure for symptom modification techniques is going to be highly unreliable due to the many variables I mentioned already.

People are variable, problems are variable, so assessments and management need to be. If you think that when you find A, and you do B, you will always get C, you are going to be very disappointed very quickly. I know that procedures, frameworks and algorithms can be reassuring and comforting for clinicians, but they can lead to complacency, false beliefs and expectations, for both therapists and patients.

As I said at the beginning I do use some symptom modification techniques, I find them sometimes helpful in reducing the negative associations of pain and movement some patients have, as well as helping to reinforce that if symptoms can be changed this quickly then they are NOT broken and so movement does NOT equal harm, not to mention the help they can give some to move more and do their exercises.

However, I do also recognise the other side of the coin with symptom modification techniques. They could for some patients actaully reinforce the message that pain needs to be, or should be reduced and avoided before they move or do their exercises, and perhaps via implict learning they can create dependance and loss of self efficacy despite the best explanations and education given. As Derek Griffin says sometimes what patients ‘feel’ far out weighs anything we ‘say’.

I also can not tell you which patients they will work well with or which techniques will work if any, and if I am being honest my decision as to which technique I will apply is based on some very loose principles, some intuition, a bit of guess work and a pinch of luck.

Of course there are many out there who don’t agree with this thinking or approach as it challenges their own thinking, teaching, and courses. Some don’t want to, or like to admit that we don’t fully know the exact mechanisms of how these techniques work, preferring to believe they get reliable consistent results each and every time. This is not my experience or understanding.

So does symptom modification need a procedure? Does pain have an algorithm? Does human behaviour follow flow charts? Simply put, NO to all of the above!

As always, thanks for reading



4 thoughts on “Does symptom modification need a procedure?

  1. Cheers for another well written and supported blog post Adam. I feel that it’s the uncertainty and different patient responses to treatment that keeps the profession interesting, right!

  2. Morning Adam,

    Your writings are very interesting. I sometimes use symptom modification but tell patients what they really are. I think it can be useful to show patients their symptoms can be altered, but I am not sure of their true worth in the bigger picture. They occasionally have a dramatic effect, but I suspect no one really knows why. However, it is one of those terms like holistic and BPS approach that I hate as much as I like due to these terms allowing people to use quackery and drivel; an approach favoured by special interest groups interested in cognitive dissonance.

    I think people like algorithms and flow charts because they offer structure and simplicity in a complex environment.

    I have had shoulder pain since January. I have used myself as a guinea pig and continued my hobbies which involve high demands on the shoulder. I tried some symptom modification exercises which only helped temporarily so stopped them. At first, loading the shoulder to 3/10 did not seem to be beneficial so I changed to allow up to 8/10; gritting your teeth stuff. Things started to improve significantly then. Now almost resolved. So, in a way, the opposite of symptom modification seems to work for me. Which for me begs the question; are we faffing about too much?

    Cheers for the continuing debates,


  3. “However, I can not tell which ones will work on which patients and if I am being honest my decision as to which technique I will apply is based on some very loose principles, some intuition, a bit of guess work and a pinch of luck.” That is so true and sometimes you get it right and sometimes your intuition fails you and you blow it…..

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