Symptom-Modification Approaches in Musculoskeletal Practice
I wrote a Viewpoint article for JOSPT (link here). I like Viewpoints. They aren’t research papers and they are very opinion based. Often they are debatable opinions. But opinions often get us thinking and they are many clinicians whose opinions I like to hear. Ideally, a Viewpoint takes a large look at a topic area and focuses our attention in one area. Hopefully, to make things more clear and to inform our practice for the better.
One aim of my Viewpoint was to find a common thread amongst a variety of different clinical approaches. It was a “bridging” exercise…trying to find the valuable and common components of different clinical approaches. We have thousands of successful clinicians using thousands of different approaches that can differ greatly in how the mechanisms of their approaches are explained. These different views and proposed mechanisms can often be frustrating for clinicians. Because it makes people ask “what the hell are we doing” when all of these different gurus disagree on what we are doing. My goal was to distil a common element that we could all use to drive our clinical approach as opposed to avoiding approaches that were different from my own – I wanted to see how things were similar.
As a clinical self reflective challenge to you, I would suggest you try to do the same thing. Take a look at the different approaches that you are interested in. For example, exercise prescription, manual therapy or education taught by different professionals. And then try to see (or research) what is the ‘active ingredient’ in all of those approaches.
Do the therapists somehow build self-efficacy in their patients? Is there a strong therapeutic alliance? Do they all have some strong bullshit explanation? Does placebo seem to drive some change? Essentially, we are asking “what is good for patients in pain”? If we can find what is good then that is what we look to build in our own personal approach to helping people. Thus it is principles and fundamentalsthat drive care rather than techniques. In this Viewpoint I chose symptom modification as the common thread even though it might be something that I’ve probably done in less than 50% of my patients.
In the Viewpoint I compared and contrasted four different approaches. It was not a thorough review of those approaches. It was only one aspect. I compared the North American spine stability approach (exemplified in a case series by Ikeda et al) with the Cognitive Functional Therapy approach. I also compared the Mobilization with Movement approach with the Shoulder Symptom Modification Procedure. These approaches are all different. They all have different views of what is important for recovery. They all address different components of the person. They all explain how they work in different ways. But, one aspect where they sometimes agree is that they will use symptom modification as an occasional guide to their treatment.
I am not saying that they only use symptom modification. For example, CFT would use behavioral movement experiments called “exposure with control”. Essentially, patients are exposed to fearful, painful and meaningful movements while a number of factors are changed or modified. Factors that could be modified being their beliefs about their pain, their breathing, their muscle tension etc. But ultimately, symptoms are modified. Those symptoms being pain or even the fear, worry or stress response associated with the movement. This was contrasted with the North American spine stability approach (sometimes called the McGill Method) where it appears (from the published case reports as no trials have been published in this area) that a painful movement is found (called “pain triggers”) and modifications to that movement are made to change those symptoms. Possible interventions (not an exhaustive list) could be increasing or decreasing trunk muscle co-activation or changing the strategy involved in controlling that co-activation. Related, there might be changes in posture or kinematics during the movement. The explanation for the clinical success might be hypothesized to be related to changes in spine stability but since this can only be guessed at clinically I would argue that it is simply the change in symptoms that guides the therapeutic encounter. It should also be stressed that movement modifications within both of these approaches is not the sole component of therapy. It is part of a whole.
These approaches are no doubt very different in other aspects of their care and the proposed mechanisms of their actions are different. But, it appears that one component that guides at least part of the treatment is the same. I argued that it was not movement idealism, spine stability, tissue modifications, joint kinematics or ideal movement patterns that drove the clinical approach. All of these things might have been changed and all of these things might have been used to explain the effects of treatment, but it was the changes in symptoms that lead the clinician to know that they were doing the appropriate intervention. For example, the kinesiopathological model of dysfunction might argue that there is “correct” place for the scapula to be while moving the arm. If you were guided by this ideal you would put the scapula in that position and have the person move their arm. The symptom modification approach would be aligned much more in the Movement Optimism camp. Where its argued that the best position for the scapula is the one that hurts less while they move their arm and allows the person to perform their meaningful activity. Thus it is symptom modification that drives the movement changes rather than a-priori ideals of joint movement and control.
Critiquing my Viewpoint
While not a novel or new idea I’ve put forth that Symptom Modification seems valuable and seems to be common amongst different therapies. Not only is it prevalent in the four interventions previously mentioned it is also seen in Neurodynamic treatments, Dr Sahrmann’s movement system impairment approach, gait retraining, muscle energy techniques and even the addition of pain reducing isometric contractions during tendon rehabilitation program. It seems to be helpful but it has its limits and it leads to a number of clinical questions that we should answer.
1. Do you have to do it?
In my opinion, no. It is just one option. I don’t think we always have to modify symptoms in the short term. We certainly have evidence that poking into pain and doing painful exercises can be helpful so its unlikely that avoiding pain is always necessary.
2. Can it be harmful?
Yes. I think it certainly can. If someone is already very hypervigilant and catastrophizes over pain what does it tell them when we are searching for ways to control their pain or modify their symptoms? Especially, when quite often we can’t. If we have the simple message that hurt doesn’t equal harm and then we are always trying to chase symptom modification could we be creating more issues?
3. Is it the best way to guide treatment?
Probably not. Essentially, it is a reaction to the idea that structural or tissue changes may be insufficient to always guide our treatment. But, I doubt this is always the case. Symptom modification is in some sense a very general approach. At its simplest, it says “If this hurts, then don’t do that”. But I would argue that there are times when we need to be specific. If even for symptom modification to work well then something else must be specifically addressed. An example might help illustrate this point. If you have a tendinopathy then changing your movement patterns might help with symptoms during everyday activities. But, your tendon and you (and everything that encompasses) might also need specific loading in order to facilitate adaptation to tolerate future loads or stresses. At the same time, if fear of injury is also involved then addressing those psychosocial factors might also be necessary to contribute to the desensitization and even permit movement modifications.
Symptom modification might be helpful but we always need to ask when more is needed.
4. Should you be doing something else?
Yes. Absolutely. This isn’t something that I know to be published, but one other common theme amongst the four approaches I discussed was what the symptom modification often lead to therapeutically. All of the approaches seemed to champion that symptom modification or controlling symptoms would lead to the resumption of meaningful activities for the person in pain. It’s my favourite part of treatment. Essentially asking “What is missing? What is important to you? What do you want to do”? It seems like symptom modification permits this. But wait. Why not just start doing those meaningful activities? I think you certainly can but symptom modification seems to be helpful in permitting that in some people. Whether or not it is better I do not know. It is certainly worthy of a study.
5. Do all the approaches modify symptoms similarly? If not, what does that mean?
No they don’t and that is what is interesting to me. Some of them involve avoiding the painful movement and teaching movement strategies (breathing, muscle contractions etc) to facilitate that avoidance. Others involve a gradual progression into a feared or painful movement and then something is changed about the movement (hands on, breathing, beliefs, contractions etc) in order for symptoms to be controlled. Those that advocate initial avoidance (e.g. occasionally a directional preference in MDT) of a painful movement might then progress into that avoided movement slowly over time. This is an area of treatment that is very ripe for exploration and research. It is essentially the “Expose versus Protect” debate of treatment. When do we avoid painful movements and when do we confront them? If you ask me, that should probably be our next Viewpoint!
6. Are you missing something if you just let symptoms guide your movements?
Yes. I strongly argue against the kinesiopathological model of movement. I think that we have a variety of movement options and people are “built” to move in wondrous and weird ways. But, when it comes to performance I would argue that there are fewer options for lifting higher loads or producing the most force. Thus merely changing joint kinematics for pain relief may not be sufficient for all goals or rehabilitation. In these cases perhaps biomechanical changes, training and rehabilitation can be driven with other goals in mind besides symptom medication.
Symptom modification is not everything. It may not be necessary but it can be sufficient. The explanation of its mechanism is often vague and doesn’t provide any insights into the mechanisms of treatment. But it is commonly seem among many seemingly different approaches. It is a facet of care that seems helpful and can be used as part of comprehensive treatment approach.
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The Role and Value of Symptom-Modification Approaches in Musculoskeletal Practice. J Orthop Sports Phys Ther. 2018 Jun;48(6):430-435.