Tissue Problem or Pain Problem (maybe both)

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?

10 responses to “Tissue Problem or Pain Problem (maybe both)

  1. John Childs says:

    Kory, very well stated. If you haven’t already seen it, have a look at Jason Silvernail’s comment on the original post. I have taken the liberty of re-pasting here as he was able to articulate far better than me some of what I was thinking. The below is Jason’t comments (not my words but hard to disagree with anything he says here).

    “Loved the podcast, Gene and Erson. Really interesting to hear Dr McGill walk us through his process. I’ve really been impressed with the way his research drove changes in our clinical understanding of back pain.

    I have been for some years a bit perplexed at the number of people who want to make Dr McGill out to be something he is not – a clinician. In this podcast, he reiterated his role as a consultant (seeing most people only once), exploring the biomechanics of back pain and trying to understand in detail it’s mechanical behavior so that the patient can take that understanding back to their medical practitioners and self-treat. But I think it’s unfair to expect him to be on point with all the clinical aspects of back pain since he has no clinical training. I would hope if I were discussing back pain and I was reviewing biomechanics of the spine that Professor McGill would forgive me if I was less than fully informed – that’s just not my forte.

    I listened and agreed with 90% of what he said – the 10% I disagreed on (specificity of structural diagnosis and such) is probably not much more than the 10% of things I disagree with from any other practitioner. I think something about the instant communication world we live in and the rarity of face to face communications causes us to focus more on our disagreements than maybe we should. God knows I’ve been guilty of that before.

    At the end of the day, here’s a guy who is bringing his considerable (dare I say world-famous?) expertise to bear to help people as a consultant, using a low cost, low risk, noninvasive method – exercise therapy. He’s got no loyalty to particular methods or groups, and is sincerely trying to follow the science while welcoming others to work with him as a team. Sure he says some things I don’t agree with. Doesn’t everyone? Isn’t this the very description of someone we as DPTs should be on board with?

    As I get more experience I have much more of a ‘big-tent’ mentality toward cooperating with others to improve things for our patients. I think people would do well to give Professor McGill credit for the considerable expertise he has (as a biomechanics consultant and researcher) and stop holding him to a standard that’s unrealistic to meet (that of a clinical expert).”

    1. Kory Zimney, PT, DPT says:

      I think Jason’s point about the 90% agree and 10% disagree is an important thought. Let’s look how to strengthen and improve on the 90% we agree upon. In regards to the 10% we disagree upon, recognize that 10% most likely has unknown answers and we should question each other and consider our biases for why we believe in our 10%. This will hopefully allow both to come closer to a better understanding.

  2. “How confident can we be that it is either a tissue problem or a pain problem?” I think this concept further validates the beautiful simplicity of G. Maitland teachings. He would categorize patients as being stiff-dominant or pain-dominant, and I think this still holds weight. I am not sure we can truly determine a tissues involvement (nor should we), given the complexity of pain, but we can determine if a patients would subjectively categorize their issue as being dominated by pain or dominated by the inability to move, which gives us a direction for intervention and reassessment.

    1. Kory Zimney, PT, DPT says:

      Joe, can’t agree more. Sometimes moving to the more simple side of the complexity of pain may be in our best interest when it comes to treatment.

  3. Thanks for listening Kory, Jason, John, and thanks for your insight. Honestly, I went into the interview with various biases, considering his 30 years of research into one biomechanical topic – the lumbar spine. A funny thing happened, after setting aside my biases, plus being disarmed by his very nice demeanor, I found myself agreeing with much of what he had to say.

    I was preparing for quite a debate, and even in the middle of the convo, once I realized that “pain trigger” may not be mechanical or discogenic, I saw that his terms, are most likely how I would teach a neurotag associated with a certain position or motion. I’m not sure if it was in recorded section or after we hit stop (as I asked him more questions), but he said something that surprised me, “I may not even even use the word ‘disc.'”

    This surprised me coming from someone who I thought was the lumbar flexion boogeyman. In essence he was talking about avoidance of things that trigger threat, promoting novel movement strategies to improve confidence in movement, and changing movement and positional thresholds – or what he called changing the amount a patient can buffer. I thought this was a great term that many patients would understand, and have been using it as well.

    There is a lot someone can accomplish in a 3 hour examination, and in the end, even if he is 75 biomechanical, he is still imparting the patient with empowerment and then referring them on to another expert that will help the patient achieve their goals.

  4. Kory Zimney, PT, DPT says:

    Erson, it is funny how our perspective can change when we put aside our own biases, the same happened to me while listening in on the interview.

  5. Pr McGill’s concept of finding pain “triggers” – ie movements which reproduce a patient’s symptoms – and then teaching alternate movement-based strategies which are less threatening seems to me to be consistent with “pain science” approaches. To me it is preferred to quota-based graded exposures to feared stimuli as the operant conditioning model assumes we should always ignore a patient’s pain report or behavior.
    Not all pains are created equal. McKenzie did a great service proving the value of centralization and that we should avoid activities which peripheralize symptoms.
    I’m a firm believer in the value of not all hurt =s harm. But there is a place for teaching sparing and stabilizing strategies as a way to reduce threat.
    Of course we should be careful to avoid creating pain hyper vigilance which I see frequently when people become overprotective because they accept a label of disc, unstable, degenerative, etc. Failure to do so can “wind up” the wide dynamic range neurons and promote central sensitization such that the “hurt one feels becomes the feeling they hurt”.

    Our choice of language is powerful and we should use our opportunity with patients to reassure, reactivate and empower them about the value of both self care and safety of resumption of moderate activities. As Diane Jacobs says, “if you want your body to feel better, feel your body move better”.
    We are all on the same team. Trying to give people a positive experience with movement. Exercise is medicine. It has minimal downside risk. Whereas the structural approach – MRI, surgery, and the palliative approach – opiates, injections, etc both lead to interventionism with great risk of negative outcomes.

    1. Kory Zimney, PT, DPT says:

      Craig, thanks for the comment. I think your line: “Our choice of language is powerful and we should use our opportunity with patients to reassure, reactivate and empower them about the value of both self care and safety of resumption of moderate activities.” sums it up well.

  6. John Seip says:

    Sometimes the best way to treat a pain problem is to explain the tissue problem. This can help people perceive pain as information without attaching emotions to it.

    1. Joan says:

      John Seip- could you explain what you mean by “tissue problem”? It isn’t clear, and has me wondering.

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