The symptom modification straw man…

I was just gonna let this go but then I thought ‘fuck it’ why should I. Just because you are usually right doesn’t mean you are always right, and for once my good little buddy Greg Lehman is wrong.

Before I get into Greg’s wrongness 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 knock down. For example, saying teenagers should be taught 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 immediately builds a straw man by claiming I don’t think symptom modification techniques are important.

This is wrong.

Read my blog again if you are really, really bored 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. However, my true position is that all symptom modification techniques that are taught or promoted by all those that use them, be that the Mulliganites, Maitlandites, McKenzieites, SSMPites, even CFTites, all these techniques are up for questioning and challenging.

My true position is about questioning the necessity, the predictive value, and the mechanisms of effect for ALL symptom modification procedures, be that joint mobilisations, spinal manipulations, taping, massaging, scapula assisting, corrective exercising, psychological interventions, even education. Because in my opinion they are all very uncertain and all very unreliable. This is NOT saying they are not to be used or are unimportant.

I question the need to always use symptom modification techniques with those in pain. I question the potential negative effects of dependency and reliance of using symptom modification techniques. I question the bio-mechanical explications often given when symptom modification techniques work. I question the need to do symptom modification techniques in a procedural or codified format. I question the predictive value of symptom modification techniques working or not. And finally I question if symptom modification techniques should ‘dictate’ our treatment options and decisions, which also seems to have been semantically straw manned by Greg into me saying they can not ‘guide’ treatment options.

Dictating is not guiding.

To dictate is to “lay down authoritatively; prescribe; boss around; give orders to”

To guide is to “have an influence on the course of action; direct; steer; manage”

dictate

We all know that language is important, we all know the effect it can have on our patients. Well we should also be aware of the effect it can have on us. To 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 effective the pain is reduced. Great, but what now? How do you explain it? What do you do with this finding?

Well many will tell you that the scapula assistance test increases the sub acromial 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 dictating treatment. This is not recognising or acknowledging the uncertainty of the effect of the scapula assistance test. This is flawed clinical reasoning. This is being a dumb ass.

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 I often don’t think it has much to do with scapula upward rotation or posterior tilting most of the times I do it, and it certainly doesn’t mean I have to tape or give patients scapula rehab exercises focusing on upward rotation and posterior tile. In fact I often don’t.

Instead a successful scapula assistance test for me often guides me into being able to discuss and educate the patient about the weird and wonderful nature of pain. It allows me to demonstrate really well how quickly pain can come and go, and how it is not to be feared or afraid of. In my opinion the scapula assistance test is more an educational tool than a technique that ‘dictates’ any 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. Its just not that simple.

So in summary. Greg is wrong, but I still love him thou! I don’t think nor state that symptom modification techniques are unimportant or can not be used. I just think they are not necessary. Please do use symptom modification techniques if you want, just don’t waste to much time on them, just be aware of the uncertainty of how they work, just be aware of some potential negative effects they can have if they don’t work, or indeed if they work too well. 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

 

6 thoughts on “The symptom modification straw man…

  1. 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).

  2. 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

  3. 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?

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