Post hoc, ergo propter hoc! and…. ‘Pink’ flags!!


Apologies for the rather tossy title of this post – ‘Post hoc,ergo propter hoc!’ –  it was actually the title of a PPA editorial I did back in December 2006.  I’ll come to ‘Pink flags’ in a moment…

I’ve posted the Post hoc editorial pdf up:

Gifford LS 2006 Post hoc, ergo propter hoc! PPA News Issue 22:3-7

The reason I’ve put it up is because David Collis posted the following…..

Healthy sceptism about predominently anatomical/biomechanical models of assessment/treatment lead me to your writing in the early 2000s and eventually attending your ‘aches and pains’ course in Tamworth 2004. Despite many influences (mainly signposted to by the somasimple crowd) it is you I credit for allowing me to see the much bigger picture in terms of pain, and that the mature organism model/neuromatrix should be applied with all patients in pain, regardless of time scales. Even though I have seen increased awareness of pain physiology over the years, it is still an approach that seems to be half-heartedly trotted out for those patients who have failed to respond to the obligatory correcting of ‘imbalances’ and pressing of sore spots.

I hope that your online presence will reach as many people as possible to help shape our profession for the future.

I would be interested in your thoughts about how you, if indeed you did, integrate manual therapy into your explanatory model/treatment? It is my experience that no matter how little percentage of your treatment time is passive treatment, then this is what the patients’ view of their treatment becomes. Explanations seem to become secondary to the “manipulation” you perform..

Thanks are not enough.

David Collis

Thanks David you’re very kind, as are many others, and you make some great points, …….and…… I hope the editorial linked above answers some of the points and questions you make!  See the case histories and my reasoning comments in particular.

To me, the shopping basket approach (see last post and the three associated papers in the downloads) actually helps you to see when and how to integrate ‘passive’ or ‘manual’ therapy into the management picture.

A very very brief case history that might help follows….(but please read the post hoc, ergo… editorial first if you can!)…. What I’m trying to illustrate in the case history is how the shopping basket approach is used to lead you and the patient to the most important requirements for their problem – and that this needn’t be ‘treatment’,’manual therapy’ or ‘explanations’……

Lets take a young fit rugby player who injured his right shoulder over a year ago and hasn’t played since. In fact ‘Stuart’ has been very protective of it and only feels confident with it when swimming.  He says it aches intermittently and there’s a ‘clunk’ when he rotates his arm backwards.  In his shopping basket ‘compartments’ are the following:

Biomedical, Compartment 1: – No red flags, no shoulder instability on examination, but I could reproduce the clunking by doing relaxed big range floppy postero-anterior glides of the glenohumeral joint in loose packed type position of about 30-40 degrees abduction.  My thoughts? – Possible labral tear… or… many shoulders clunk like this and work perfectly normally… so keep an eye on it… acknowledge…explain…. but don’t make a big deal of it…Could refer to orthopod but what’s the point until he’s got going, got it strong and seen if he can get back to rugby…. ?  Tissues safe to start loading far more….yes!  Tissues safe to get back to rugby once fit…. ?  Proabably but lets give it a go and wait and see….

Pain mechanisms – best way of thinking is ‘Is the pain adaptive/maladaptive?’,  rather than get tied in knots with nociceptive/peripheral neurogenic/central etc… So, to me, here’s a kid who’s suffered quite a nasty gleno-humeral joint strain – possibly injurying ligamentous and cartilaginous tissue and still has pain and compromised function after quite a long time period.  Is this length of time reasonable?  Well, considering the healing time of these types of tissues it could be…. but, he really hasn’t got going as well as he could.  So, maybe some adaptive pain – the tissues are still healing/mending…. but the amount of pain is a tad on the too much side – so a degree of maladaptive in terms of the amount of pain.  The biggest deal is his lack of confidence and fitness (local and general) …. see below….

Compartment 2: Psychosocial barriers? Has been told he has a ‘bursa’ problem by some local therapist who has an ultrasound scanning machine – all treatments received have emphasised go carefully, and something  wrong, rather than something was wrong/injured its healing and needs normal forces through it to reach the best possible healed state…..  So, he’s been activity avoidant for over a year except for swimming – which he says feels good – and he can swim hard, any stroke… including backstroke and crawl.   He’s bored and fed up as Rugby is his life….he’s starting to feel he’ll never get better and won’t ever play rugby again.  He has intermittent sleeping problems due to his concern about turning onto and hurting the shoulder.  He’s bored out of his brains and put on a bit of flab.

Compartment 3: Disability/functional limitations. This guy had not only stopped all rugby, he’d stopped fitness training, gym, cycling, running…Plenty to start getting going with straight away.

Compartment 4: Physical Impairments… This is the compartment that most physio’s obsess about and get very possesive about…the little bits and pieces found on physical examination that we like to do manual therapy on…For example, I bet he had lots of ‘muscle imbalance’ and abnormal subtle movement anomalies…(yawn)   With this lad – he had weakness in all shoulder muscles, – tested using simple grey theraband pulled and pushed in all directions repeatedly – and getting him to compare the feeling of strength/tiredness/weakness relative to doing it with his good left arm first…. By doing this he could instantly see that he was considerably weaker…. He also had full range movement, but simple ‘stiffness’ feeling at end range of all movements. Although full range his movements were tense, slow and protective.  There were no signs of bursal impingement at all.

Compartment 5 and 6: General and Specific Physical fitness. – covered enough above – and needs addressing….

Compartment 7: Pain – the ache – which was around the point of the shoulder and the anterior joint line, plus increased tenderness to the tissues under the pain. As discussed a bit of adaptive due to slow nature of healing …. plus maladaptive as too much pain for length of time it’s been going on… I’m reckoning on it being helped by getting him fitter and changing his perspective on the pain – downgrading it to ‘normal’ and to not worrying about it so much.  Getting going and seeing that he can get going and stronger should help his confidence… distract….etc.

So, Stuart gets my summary of ‘his shopping basket’ – I could almost ask him the answers to ‘Stuart, what have I found?’ ‘what have I put in your shopping basket of things to start working on….?

‘OK Louis you found the following:

‘I can move it well but it’s a bit stiff at the end of all ranges…. It’s considerably weaker in all directions when I make it work under load….That I haven’t kept my general fitness up or the fitness of the shoulder up and it needs this to help the final recovery phase….. That I’ve been a bit too cautious with it, especially in the last few months…. That it doesn’t look like there’s anything seriously wrong, you’ve explained what the ‘labrum’ is to me and that small tears and clicking from it are very common, but needn’t stop me from using the arm strongly…and there’s always the option of an orthopod later if needs be…..and I’m being a bit of an over-protective wimp with it…. etc….

‘Good, Stuart.. now, lets get going…… I want you to start getting a lot fitter… but start easy…build slowly at first … (I make suggestions for bike, jog/run/get going…and keep going with swimming)…. also, lets get the shoulder muscles fitter – good strong muscles that are confident and react quickly are joint protective… they need to be as strong, if not stronger than the left side… – Start with the theraband – slow at first to get confident, then build up…and if all’s going well it’ll be back to the gym, pull-ups, press-ups and so forth… I’ll monitor and guide you for a week or two…if there’s anything wierd going on with your patterns of movement later on I’ll devise some special exercises to help improve that…  There’s nothing I can do about the clicking – though sometimes when people get fitter, the tone comes back in their muscles, the clicking gets less… best thing is to accept it, and not worry about it…. I’ll keep an eye on it.  Next time you come in I may spend a bit of a time giving the shoulder a good loosen-up… see if we can’t help some of that stiff feeling you’re getting.

So, the next time he comes in – he’s a changed lad… he’s had the green light… I’ve told him not to get upset with the pain coming and going – that’s normal… it turns out that when it does come, it soon settles… all good… I tell him to be freer and less protective of it… Time to get down the gym… even get the boxing gloves on and thump the bag… but ‘start easy build slowly’ – a la graded exposure…. I taught him, he knows the rules… I get him doing pull ups on my pull-up bar and press-ups from his knees. Then I spend 20 mintues doing heaps of hands-on to his shouder – lots of big accessory glides in abduction and flexion, some easy stretches in all directions, lots of soft tissue into the shoulder… so that when he gets up he says… ‘ feels best its felt for a year…’

3 Weeks later he calls because I asked him to.  He’s back doing rugby training and building up.  It’s still clicking but it doesn’t bother him.  He uses ice pack if it goes a bit grumpy.  He’s positive and virtually stopped thinking about it. etc etc…

Moral of story… see the bigger picture – use a shopping basket… don’t wallow in the ‘Impairments’ compartment or some Guru’s cure all technique that only focuses on pain response… shopping basket it!!… rehab it!!…. put the whole thing in the context of normal recovery and natural history….don’t start harping on about central pain mechanisms and all the compexity of pain explaining – it’s inappropriate here… get the guy going and confident in himself again… We get so many patients at our practice who’s treatment has been over focused on tissue impairment.  For example, patients like Stuart who have been told to do shoulder stabilising exercises and movement abnormality correction routines..and nothing else….Jesus… this guy can swim for 45 minutes and feels great… sure he’s ‘compensating’ but that’s because his general shoulder/arm/right quadrant are inhibited/weak… just get them going like any good hunter-gatherer would!

So, I’d like David Collis, and everyone else who has the same problem, – that the patient sees what you did to them in terms of the passive hands on as the big deal, and all the rest as a lesser side issue…. to see that it’s how you go about it… explaining the findings from the shopping basket as you go along… so the patient can see what they need to do… (as I tried to illustrate, the patient should almost be able to tell you what you’ve found, what they need to do and what you can offer..) and… that there are bits and pieces that you can do for some of the compartments too… like me mobilising his shoulder…  It’s all about how you set the scene with the patient.

Now Pink flags!

(Click here to go to it)

They’re the opposite of ‘Yellow flags’ as you’ll see when you read the piece.  Just go find your ABCDEFW yellow flags, learn them and then turn them into the exact opposite to get the best results….. and… when you’re doing your history taking/subjective and objective – look for pink flags – look for the ‘good’ signs and tell the friggin’ patient….!

When I do a physical exam I tell the patient that they’re going to do movements and I’m going to watch and they’re going to tell me…. and that I want to tell me first up what feels normal and good…. and second up what doesn’t … and that I’m just as interested in both… the good the bad and the ugly… but more the good.  Get it?  That’s pink.

Medicine and professions allied to medicine are by their very nature an the search for ‘bad’ and fixing bad…. all research has been done on how things go bad, how they hurt, how they stop working…. the research on natural recovery is shockingly lacking.  If we knew more about recovery and the best conditions for recovery, we might just be getting somewhere… hopes, hopes…. the future is pink folks….

hope you enjoy anyway…

Big thanks to Zara Hansen for her wonderful memory of my ‘crap’, you made us really smile, Thanks Zara, and everyone who’s posted such supportive comments!  xxxxx


3 thoughts on “Post hoc, ergo propter hoc! and…. ‘Pink’ flags!!

  1. That’s the beginners version of the game…! My other sports related games are; ‘spot the safety seeking behaviours’ which I’m playing whilst watching Wimbledon, although since Nadal went out it’s not quite the same.

  2. Glad it made you smile. This post made me think of something you said once that I regularly quote when talking about the physical examination… (whilst trying to do your accent which is hilarious in itself)……”Find a few things, BUT DON’T FIND SO BLOODY MUCH’
    Which nicely links with a favourite game of mine – spot the asymmetry on the olympic athlete. I know, I should get out more.

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