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  • Writer's pictureDr. Richard McIlmoyle BSc, DC, PgCPain

Don't sweat the technique...

Practitioner thought process... "I don't know why this patient isn't responding like the last patient I treated with the same presentation!?!?" "I guess I need to find a different/better technique to assess and treat..." Patient thought process... "My friend had this technique done and they recovered, so I should find someone doing that technique" "That technique didn't work for me, I'm not going to see anyone doing that technique, I need a different one." I believe we have this ALL WRONG. ...and here's why. If we look at various "techniques" to help people who are experiencing lower back pain, they are all pretty shitty when we do large scale analysis of outcomes including pain reduction and functional improvements. (1-5) (I'm using lower back pain because its easy to find data on it) Most studies are of poor quality and we can't be definitive on our assertions of "THIS DOES WORK" or "THIS DOESN'T WORK" A lot of folks who are entrenched in the find it, fix it mentality, or "silver bullet" mentality like to say that our problem is heterogeneity of the groups and If we could just find the correct way to stratify folks we will find how to "match the technique to the patient" AKA "the RIGHT treatment at the RIGHT time for the RIGHT patient" I get it... As a practitioner, treating people daily who respond extremely well to the treatment modalities that are supposed to have "meh" results, I used to think the same thing...

"I see this working every single day with most patients, and there are some who don't respond. Is there something I'm missing or the research is missing???"

"Is there a technique that would allow me to figure this out, or an assessment system that is better????" I searched for years...trying active release technique, kinesiotape courses, running biomechanics assessment, dynamic neuromuscular stabilization. I've done all of those and still there was a "gap in my framework" that could not help me explain why this discordance between research of techniques/approaches and clinical outcomes. OR why some people responded and others didn't.

All I needed to do was to expand my conceptual framework around what is happening in the clinical encounter and it was A REVELATION. It was so freeing to gain the insight that this was not at all about my lack of ability to understand how to correctly diagnose, or that I needed to find all the techniques to use so that I had the right tool at the right time and have the skill to know exactly when to use which tool. Chasing all the techniques will not make you a better clinician. Learning more about the complexity of how humans work and how we can help people change will help you help more people create the change they are seeking. The technique is almost the least important thing we do with people to help them improve. People want to have confidence in your recommendations, they want information about what you can do, what they can do, how long it will take and an idea about why they are hurting. If you can confidently relay this and figure out what they need to keep them active, you are most of the way there, even before you worry about technique. (6-7)

A big piece of this is how do you relay to them that no one will be able to find "the thing" that is "causing the pain"?

Becoming adept at helping people understand that the exact "thing" matters less than figuring out what they need to keep moving forward and how they can mange it. Letting them know that the process is ... As soon as we figure out it isn't something serious (red flag) we treat all the other stuff essentially the same.

It's a helpful message to relay and provides confidence in the person suffering as well as for the practitioner that there is a logical path forward. Become comfortable in the uncertainty and it will build confidence. I am biased in that I believe we need to gain much more of an understanding about how humans experience pain, and themselves when experiencing pain as that relates directly to what we do. We help people change their perceptions of themselves. So many psychological theories and constructs are much more helpful to understand that techniques as we can plug all sorts of different interventions into that broader understanding to have a positive effect on the lives of people seeking our help. Constructs and frameworks are the keys to helping more people live with less suffering, not more techniques to assess and treat tissues. So like Eric B and Rakim said

🎶 🎶 🎶 They wanna know how many rhymes have I ripped in rep

But researchers never found all the pieces yet

Scientists try to solve the context

Philosophers are wondering what's next

Pieces are took to last who observe 'em

They couldn't absorb 'em, they didn't deserve 'em

My ideas are only for the audience's ears

For my opponents, it might take years Dont sweat the technique. 🎶 🎶 🎶

1. Rubinstein SM, Terwee CB, Assendelft WJJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for acute low‐back pain. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD008880. DOI: 10.1002/14651858.CD008880.pub2. Accessed 04 September 2023. 2. Gattie E, Cleland JA, Pandya J, Snodgrass S. Dry Needling Adds No Benefit to the Treatment of Neck Pain: A Sham-Controlled Randomized Clinical Trial With 1-Year Follow-up. J Orthop Sports Phys Ther. 2021 Jan;51(1):37-45. doi: 10.2519/jospt.2021.9864. PMID: 33383999. 3. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database of Systematic Reviews 2021, Issue 9. Art. No.: CD009790. DOI: 10.1002/14651858.CD009790.pub2. Accessed 04 September 2023. 4. Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry‐needling for low back pain. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD001351. DOI: 10.1002/14651858.CD001351.pub2. Accessed 04 September 2023. 5. Almeida MO, Narciso Garcia A, Menezes Costa LC, van Tulder MW, Lin C-WC, Machado LAC. The McKenzie method for (sub)acute non‐specific low back pain. Cochrane Database of Systematic Reviews 2023, Issue 4. Art. No.: CD009711. DOI: 10.1002/14651858.CD009711.pub2. Accessed 04 September 2023. 6. Bishop, M. D., Bialosky, J. E., Penza, C. W., Beneciuk, J. M., & Alappattu, M. J. (2017). The influence of clinical equipoise and patient preferences on outcomes of conservative manual interventions for spinal pain: an experimental study. Journal of Pain Research, 10, 965–972. https://doi.org/10.2147/JPR.S130931 7. Lim, Y. Z., Chou, L., Au, R. T., Seneviwickrama, K. M. D., Cicuttini, F. M., Briggs, A. M., … Wluka, A. E. (2019). People with low back pain want clear, consistent and personalised information on prognosis, treatment options and self-management strategies: a systematic review. Journal of Physiotherapy, 65(3), 124–135. https://doi.org/10.1016/J.JPHYS.2019.05.010

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