John Childs in a recent blog post asked for ISPI faculty to speak up about a recent podcast on Therapy Insiders. Since my mug shot appears within the link to the ISPI faculty page and have been with ISPI and working with Adriaan and the rest of the team for about six years I thought I would share my thoughts. To be honest at first listen I was a bit concerned with some of Dr. McGill’s comments, but as I listened and then listened a second time with a more open attitude I realized that I agreed with things that he said. I’m sure there are a few of the “staunch pain science advocates” that will disagree with me, please fill up the comments section for some healthy discussion. I had to put aside a few biases I had about Dr. McGill’s treatment philosophy that I had from the past to come to this conclusion from the interview.
Dr. McGill’s use of the term of “pain generator” did turn me a bit sour at the start of his response to Dr. Erson Religioso’s question about how current pain neuroscience fits into his treatment philosophy. Within our ISPI courses we are working on trying to get health care providers to change their language in regards to pain. Moseley was quite frank in an editorial in Pain Management that this is an erroneous term and an unfortunate trivialization. This sourness did turn me off with Dr. McGill’s next statement about his ability to be very confident about getting to the level of the disc as being the pain generator. But when I settled myself down and truly listened and thought about it, he was right. Well I’m not sure I would say “very confident”, but I think we have some evidence we might be able to classify people according to the Mechanisms-Based Classification of musculoskeletal pain as brought forth by Keith Smart and his group. This is in line with what the late Louis Gifford simplified for us in our clinical reasoning – is this a tissue problem or a pain problem? While I think there are always probably both tissue problems and pain problems going on with our patients; which one is more dominant? This is the question we need to consider in our treatment of individuals with painful problems. I get concerned when I hear people arguing on the “either/or” side of the pain/tissue problems debate and not considering and treating the “and” side.
I do agree with a gradual graded exposure approach with getting people back to activities and working on changing potential conditioned responses in regards to their movements, thoughts and pain. Especially with patients that have more of a pain problem. While the words I would choose might have been a bit different to explain it, I do think this is might have been what Dr. McGill was referring to when he discussed treating patients with central sensitization. He did make a comment about central sensitization and EMG, which did make me scratch my head a bit and would have enjoyed a follow-up question to clarify what he was referring to with that statement.
Obviously this was just a seven minute sound bite of Dr. McGill’s incorporation of pain neuroscience into his treatment approach and a more detailed discussion would be needed for me to fully understand his current treatment philosophy. While he talked mostly about the mechanical system and its role with potential nociception, I would be curious to know what he thinks about other systems such as nervous, immune, hormone and others as they all work together in the more complex dynamic system called a person.
So now it’s your turn: How confident can we be that it is either a tissue problem or a pain problem? Or is it both? Is one system more important than others in a pain experience and how do you know? – What say you?