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, opening the so called ‘window of opportunity‘ that I have challenged recently. Now I will admit that I use some ‘symptom modification’ techniques occasionally, but I do question the explanations how they work, as well as the need to use them in a procedure as some advocate.

Symptom modification 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, a mobilisation, some soft tissue work, assisted movement, taping, dry needling, even exercise and psychological interventions. These can ALL be classed as symptom modification, as they ALL can alter and modify a patients sensations and perceptions of pain stiffness, weakness and fear (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 adjustments and said to get their effects via realigning joints, or creating gas bubbles that can gap joints. Soft tissue techniques are called a bewildering array of different names such as myofascial release, active release, trigger pointing etc and are often said to free up things that are stuck or tethered together such as scar tissue or fascia, or that they reduce muscle tone, tension, spasm or knots.

Even corrective exercises can be seen as symptom modification by addressing so called muscle imbalances, poor motor control or lack of stability. Sometimes these techniques are described and explained 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. I guess that these techniques achieve their affects via multifactorial reasons. To put it simply a scapula assistance test does not only just affect a scapula, it affects the person with the scapula. There will I’m sure be some bio-mechanical factors that can modify the symptoms but there will also be some neuro-inhibatory and/or excitatory factors, as well as 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 withy any certainty what the predominant effects are of these techniques.

Scapula Assistance Test

But, 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 not with just 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 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 we can crack on. However, many therapists do need to be more open and 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 as it tends to scare them, and I can understand this, it can be 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 and do understand uncertainty and eventually will be better informed and so be able to make better decisions (Elwyn)

Although this uncertainty can be challenging I actually think its liberating as it removes the need to work in systematic or procedural ways. No longer do therapists have to choose a technique based on biomechanical principles, or becuase some guru says do this before that. Therapists now have the freedom to explore many ways and means to modify a 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 ridiculous interventions or woo.

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 is only going to be unreliable due to the many factors and variables I’ve already mentioned.

People are variable, problems are variable, so assessments and management need to be as well. 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 before, I do use some symptom modification techniques, I sometimes find them helpful in reducing negative associations of pain on 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.

However, I also recognise the other side of the coin with these symptom modification techniques. For example, 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 by the therapist. As Derek Griffin says sometimes what patients ‘feel’ far out weighs anything we ‘say’.

I also can not tell you which patients these symptom modification techniques will work on and who they won’t. If I am being honest my decision as to which technique I will apply is based on some some intuition, a bit of guess work, and a big 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 think this is a caviller unprofessional approach. Some don’t like to admit that we can’t fully explain the exact mechanisms of how these techniques work. Some like to believe they get reliable consistent results each and every time. This is not my experience.

So does symptom modification need a procedure? Well does pain have an algorithm? Do humans 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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