A respected and "high level" sport physio stated to a colleague the other day:

"I've heard of DNS; I heard it's too complicated"

"Patients won't be motivated to do it because it is too challenging for them"

(note: he's never taken a DNS course)

Of course, no treatment modality or exercise works for everyone. So we can't base our perceived effectiveness of any intervention on an anecdote, including mine. Regardless, we should always search for the most effective ways to interact and work with patients who have pain or injury. And the guiding principle should not be some estimation of whether we think patients will buy in and do the exercise. The guiding principle is: what are the underlying mechanisms that define the reason for the patients ongoing pain, and how do we best intervene on those mechanisms.

The question we need to answer is simple: what is the most effective treatment for THIS patient that presents to me NOW.

If a patient does not want to do the work - does not want to do the exercise - we should seek to find other options, within reason - that tackle our best estimation of the mechanisms underlying their CCP.

Motivational interviewing, collaborative clinical reasoning, interactive clinical reasoning - are ALL important. But to avoid taking a course or seeking the knowledge and skill that may help our patients, because we ESTIMATE that knowledge and skill is "too hard" to learn or apply, especially without actually knowing this to be the case or having experience with it, is just lazy.

There are just too many unknowns in the world of pain and especially chronic pain to approach knowledge like this. No one gets everyone better, so we have the responsibility to continue to seek, learn, grow, expand our knowledge and skills, so we can help more people.

I don't do "DNS" - or at least the strictly defined exercises commonly associated with DNS - with everyone. But it is an important lens that allows me to know whether motor control and stabilization based training is necessary or essential in the care of my patients. If it isn't, great let's train! If it is, we ought to address it.

I do MOVEMENT training with all my patients. Any half ass MSK practitioner does. Thus, shouldn't we seek to best understand the movement system?

I recall one of our Kinesiologists being very effective with basic exercise and training. But he'd often miss some, what I would perceive to be, essential specifics that led to patients not responding as well as they could. They were exercising, but not getting better. With some coaching and small tweaks that added specificity to his work, he began to notice those "hard cases" were not actually so hard after all.... he was just missing a key bit of specificity that was required for that case. This is not a mistake on his part - it wasn't a bug. The pursuit to learn why, ask questions, and seek better solutions and knowledge is the feature.

The less blind spots we have the better. I have em, for sure. Some blind spots I am aware of and seeking to make unblind. I suppose you could say it's not a blind spot if I am aware of, but a relative deficiency in expertise, which represents the areas of practice I know another practitioner is better suited to treat. This is to know our strengths and limitations, and to be humble and caring enough to refer when it's in the best interests of the patient.

Some blind spots I am truly blind to - things I don't know that I doin't know. We should always seek to eliminate these blind spots as they represent the areas of risk, with the risk being negligent acts of omission. To consciously choose to have a blind spot, makes no sense to me. It's... just... lazy. And when that blind spot resides in what is supposed to be our expertise, i.e. training and rehabilitating the movement system, my opinion is that we have stepped beyond lazy and into the unethical.

Many a patient have engaged in nuanced and detailed exercise programs. In my estimation one of the key reasons for poor compliance is when the intervention or exercise WASN'T HELPING, not when it is challenging to learn or perform.

Not everyone needs to take a DNS course. It's totally fine if you don't want to. Do your thing and do it well. But let's not lie to ourselves as to why. It's not because your patients don't care or don't want to do the thing that you've never done with them.

CHECK YOUR BLIND SPOTS.