I've written before about the benefits of being thorough with our examination to the point of not missing any contributing factor, but the same principle also applies to our treatments. Having proper technique with each examination method is essential in order to know the true results. A poorly performed Lachman's test can easily make a torn ACL appear intact, while a properly performed test is highly sensitive and specific. If a testing measure is not performed exactly how it should be, there is basically no point in actually using it.
In regards to how the principle applies to treatments, we should consider how a small variation makes an enormous difference. For example, when performing resisted clamshells, if the patient is getting the rotational motion from the spine, the gluteus muscles are no longer being targeted. If the proper load isn't applied, the exercise isn't even having a strengthening effect. This goes for other treatments as well: repeated motions, manual therapy, and more. I'm not saying that there is a perfect way to perform specific manual treatment techniques or other exercises, but there are things that can be done to significantly decrease their effectiveness. Our job should be to increase the likelihood of each intervention.
It is frustrating for me to hear that a patient failed to have success with physical therapy or a specific intervention and then have the patient say they think it is pointless to pursue it. With how frequently we see inconsistency in exercise prescription, examination and treatment techniques, and overall philosophy of practice, we shouldn't assume that just because a patient didn't respond to a treatment previously, they won't respond in the future. I can't tell you how many times I've had co-workers or students say a patient didn't respond to repeated motions, and then I take a look at the patient and with a couple of adjustments the patient has a positive response. We shouldn't be so quick to say a patient is a non-responder, especially with the inconsistencies out there. I recommend reassessing your asterisk sign after each intervention and avoid negative reinforcement about our interventions with our patients. With the benefits of placebo and pain science research, we often can hurt ourselves and our plan of care by telling our patients they for sure won't respond to a specific intervention.
-Dr. Chris Fox, PT, DPT, OCS
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