My good little buddy Adam Meakins wrote another blog post about whether in-session changes in a patient's symptoms are important for long term recovery. As usual he is absolutely wrong (just kidding). He takes the position that they are not important and I am going to give the position on how there are important.
"I don’t think we need to actually change things that much or that quickly for many of our patients to have successful outcomes."
and then on twitter something a little more harsh:
Do you see the difference between the two statements?
The first statement leads us to a great clinical question that we should look at both in terms of research and for the patient in front us. Its actually an exercise that I lead my course with.
Are there conditions that require specific fixing? Is there ever a condition that requires a NECESSARY treatment? For example, a compound fracture is a specific conditions requiring a specific and necessary fix.
Adam's first statement is very open and reflects well on the multitude of options we have in treating people. It implies that you don't have to make changes in pain immediately to help out your patients in the long term. Of course you don't. I can't disagree with that. But that doesn't mean that it can't be helpful to try to make specific changes in symptoms. And trying to make specific changes in symptoms CAN help dictate future treatment. But its not necessary.
Thus making symptom modifications in a single session can be a sufficient but not necessary component of treatment.
And it can help dictate treatment decisions. Adam's second twitter screed that symptom modification should NOT dictate treatment decisions is false. It certainly can dictate treatment decisions but again it may not be necessary.
Who modifies symptoms and what is the utility?
The following approaches all modify symptoms. I would even argue that the consistent thing across these approaches is symptom modification and that that symptom modification is what helps dictate clinical decisions for the better. What is interesting is that these individuals or processes will often disagree on the biomechanics or the rationale behind their interventions but the consistent thing is symptom modification. Lets look:
- Cognitive Functional Therapy - find a painful movement and modify it (often involves moving with less bracing). Moving differently with less pain is also bolstered with a new meaning of pain and addressing of the false beliefs that may contribute to the unhelpful movement habit/behaviour. What I really like about CFT (and its how I think I practice) is that you teach someone to move in a different way. Not and IDEAL way. But something that is different that feels better. This keeps them moving and allows them to resume meaningful activities. After a time of desensitization the person can go back to moving in the way that was once painful but they can now tolerate it.
- Stu McGill - Stu finds the "pain generators" and then has someone perform a task in different way that does not hurt. This might be explained via concepts of changing stability but the consistent theme is that they move with less pain and begin doing things that they often avoided with less pain. Exercises might reinforce this new and less painful movement behaviour. Activity reactivation then follows. This might be valuable for those who are persistent/endurance pain copers.
- Mulligan/McKenzie: a painful movement is found - something is done differently to that painful region until there is less pain. Something the patient can do that also changes these symptoms is found. The patient does this repeatedly at home on an hourly basis. We have no idea the mechanism because the symptom relief does not correlate with the biomechanical changes that occur. Nonetheless, efficacy exists and the guiding principle is symptom modification. This intervention is performed in addition to other approaches addressing the multidimensional nature of pain (loading, cognitive restructuring, pain science education)
- Isometric Tendon loading: A patient has an achilles tendinopathy. Isometric exercises are given for pain relief to allow the patient to continue playing their sport or meaningful activity with less pain. This is performed in addition to other loading protocols and treatment that addresses the multidimensional nature of pain. Sound familiar? No one has ever shown that performing these pain relieving isometric exercises is NECESSARY for rehabilitation if a good progessive loading protocol is also followed for the tendon. Sound familiar?
- Neurodynamics: A positive slump test or median nerve tension test is found. The patient then changes something about that movement until there is less pain. That new non-painful movement is then repeated hourly for the next few days. Sound familiar Mulligan or McKenzie? This like all other therapy is performed in addition to other treatments
I could go on. And I will if you ask. No symptom modification technique exists on their own. Symptom modification is performed with other treatments because pain is multidimensional and we aren't really sure what needs addressing.
This is why we treat with a large net rather than a fishing pole.
But we can see that symptom modification and within session changes can help dictate treatment. It is still an appropriate way to work.
Our next question is whether there are times where you absolutely need it. I am with Adam in that it probably isn't necessary in many cases but it sure can be valuable. And yes, there are times when you can't change symptoms. I would argue when things are very sensitized (Fibromyalgia) or when they have low sensitivity.
There are many paths to Rome. There is no need to carpet bomb one of them.