Does symptom modification need a procedure?

an 8-minute read…

The term ‘symptom modification’ is used to describe a lot of stuff therapists do to patients in an effort to reduce their pain or get them to move better immediately after, often claimed to be opening the ‘window of opportunity’ that I have discussed before. But is there any magic formula, secret recipe, procedure or standard algorithm that has to be used when trying to do this?

Now before I start I will state that I do occasionally use some symptom modification techniques for some patients, for various things, for various reasons. But, I also question their use a lot, as well as the common biomechanical explanations of how they allegedly work, and the necessity to use them in a formal standardised procedure as some advocate.

Formal standardised symptom modification procedures are often associated with shoulder pain as first mentioned by Jeremy Lewis (ref). But they are also used in other areas such as neck, back, knee and hip pain.

A symptom modification procedure is a term that covers any intervention a therapist does to a patient in an attempt to reduce their pain immediately afterwards, be that a joint manipulation or mobilisation, some soft tissue work, assisting or facilitating a movement, taping, dry needling, or even some exercise and psychological interventions.

These can ALL be classed as symptom modification, as they can ALL modify a patient’s sensations and perceptions of pain stiffness, weakness and fear (ref, ref).

How these symptom modification techniques help reduce pain is often explained in biomechanical terms. For example, Lewis states his Humeral Head Procedures in his SSMP depress, elevate, or anterior or posteriorly glide the humeral head during movement to ‘re-centre’ the humeral head on the glenoid or change the sub-acromial space (ref).

These biomechanical effects are also claimed in other symptom modification interventions such as spinal joint manipulations, which are often said to achieve their effects via realigning joints, or creating gas bubbles in the facet joints to increase space or improve joint gliding.

And soft-tissue techniques such as myofascial release, deep friction massages, or trigger point pressures are also often said to free up tissues stuck or tethered together such as adhesions or scars, or they reduce muscle tone, tension, or spasms.

And even some exercise-based symptom modification interventions are also claimed to address biomechanical dysfunctions such as so-called muscle imbalances, poor motor control, lack of stability, or improving faulty movement patterns such as scapula dyskinesia, pelvic tilt, overactive upper traps, or underactive glutes.

But How Do They Work?

Well despite many claims made by many people, the simple answer is nobody really knows how any of these symptom modification techniques work.

This is because there is always a mixture of many possible effects both biomechanical, neurophysiological, psychological, and of course contextual and placebo factors all occurring together, and there is NO way of being able to separate them.

Of course, biomechanical factors may explain some of the changes in patients’ symptoms with these techniques… BUT… there will be a host of other neurophysiological and psychosocial factors also contributing to how these interventions do or dont help people.

And although we can’t say with any confidence exactly how these symptom modification procedures work, I think we can say with more confidence how they don’t work.

Lumbar spine manipulations do NOT re-align joints that were out of place, or even alter their stiffness or flexibility much (ref, ref, ref).

Myofascial release massage does NOT release fascia or any other connective tissue or change their mechanical properties much if at all (ref, ref, ref).

And there is NO evidence that humeral head symptom modification procedures work by significantly changing the humeral head position (ref) or that scapula assistance testing affects scapula dyskinesis (ref)

We also know there is poor reliability among therapists performing many of these symptom modification techniques (ref, ref), and there is high variability in the way they are performed and the forces with which they are applied (ref, ref). Meaning two therapists attempting to do the same technique on the same person will most likely have different results and outcomes.

Does It Matter?

However, it may not matter if we don’t know exactly how these techniques work, or if therapists do them differently because it has been shown you can apply symptom modification techniques at random and get just as good results as doing them specifically (ref, ref, ref, ref, ref).

And Just because we can’t conclusively show how these techniques work it doesn’t mean we can’t use them, we just have to accept that we can fully explain them and ensure we are open and honest with others about this.

Being an evidence-based physiotherapist is about working with unknowns, uncertainty and probability, not about claiming to know everything or having all the answers.

If there is evidence of a high probability that a symptom modification intervention may have a positive effect, with a low probability of risk or harm, then we can use it, even if we can’t fully explain how it works.

However, what we do need to do better is be more open and honest in explaining this uncertainty to others including our patients, and this often means saying…

I don’t know…

Many therapists don’t like saying ‘I don’t know’ and I can understand this. It can feel really awkward, uncomfortable and challenging to admit our uncertainty and ignorance to others.

It can be risky as well.

People often mistake uncertainty for a lack of knowledge, skill or expertise. But this is often not the case.

Most evidence-based therapists are uncertain not because they lack knowledge or expertise but becuase of the exact opposite.

Most evidence-based therapists are uncertain becuase they are aware of the conflicting research, and information, and responses that people have to treatments and interventions

Those who are more certain of how any treatment or symptom modification intervention for pain works are usually those lacking in knowledge, skills and expertise.

Although this uncertainty in many of our procedures and treatments can be frustrating and challenging, I think it’s also exciting and liberating as it gives us flexibility and freedom and removes the need for us to work in strict, systematic, or procedural ways advocated by the likes of Lewis and his SSMP.

And it has been shown that with some education and explanation patients can understand and respect clinician uncertainty, and often they feel better informed and so can make better decisions about their treatments (ref)

So no longer do therapists have to choose a technique based on strict biomechanical principles, or because some guru teaching a weekend course says so. Therapists now have the freedom to explore many ways to modify a patient’s sensations and perceptions of pain, weakness, and stiffness based on a whole host of factors.

However, a word of warning, taking away these procedures and frameworks doesn’t give therapists the excuse to go bat shit crazy and do whatever they want using ridiculous untested interventions or other quackery. Uncertainty isn’t an excuse to fill in the unknown with whatever stupid crap you feel like.

Do We Need Procedures?

We all use systematic approaches or frameworks in many areas of our lives as it tends to make things cognitively and physically easier. This is no different in our assessments and treatments as clinicians.

A methodological approach to taking a patient’s history and doing their physical 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 strict procedural format for your assessments and treatments is just not necessary.

People are variable, and their problems are variable, so our assessments and treatments need to be as well.

I know that procedures, frameworks, and algorithms during assessment and treatments can be quicker, easier and more reassuring for clinicians. But they can also be misleading, lazy, and reductionist, leading to sloppiness, complacency, false beliefs and expectations, for both therapists and patients.

Should We Use Them?

As I said at the start, I use some symptom modification techniques sometimes, and I do find them helpful in reducing pain and other negative sensations and beliefs about some movements, in some patients, for a short while. They can also help some to realise that their symptoms can be changed quickly and significantly and help them feel more positive and in control of their issues.

However, I also recognise there is another not-so-helpful side with these symptom modification techniques. For some patients, these techniques can reinforce beliefs that their pain NEEDS or HAS to be reduced before they move when in fact it’s perfectly ok and safe to move despite their pain.

They can also potentially create dependence and a loss of control and self-efficacy for some, feeling that the therapist is in control of their pain and not them. Often what a patient ‘feels’ can far outweigh anything a therapist ‘says’.

We can also not tell which patients these symptom modification techniques will or won’t work on, and how much or for how long. And If I am being honest this is often only found out afterwards and with a bit of guesswork, clinical intuition, and a big pinch of luck.

Conclusion

So there you go, these are my views on symptom modification techniques and procedures. In summary, use some of these techniques on some people now and then, but throw away those procedural forms, flowcharts, and algorithms and recognise there is a lot of uncertainty in how we should use them and when they do or don’t work.

Of course, many out there disagree with this thinking or approach, usually those with their own brand of symptom modification and their weekend courses.

Some like to believe they get far superior more reliable consistent results with their formulaic procedural flowchart-directed approach. I think that’s utter bullshit.

As always, thanks for reading

Adam