Blaming Pathology or Lack of Pathology

I have blogged a number of times about how there is generally a very poor correlation between the “pathology” we see on scans and pain. The lower back being the most commonly cited example but there are many other examples (see here, here and here)  and over time the list appears to be getting longer.

In recent times the pendulum has swung, correctly, to the brain and pain. I for one don’t dispute at all that pain is a conscious experience and that we need a functioning brain to produce pain. As written about in numerous other papers and blogs, nociception is not sufficient itself to produce pain, and pain can clearly be produced when there is no nociception.

The problem I see with this approach now is that some patients are perceiving that the reason for their ongoing pain is purely because of a problem with their brain. This can, in my experience, create all sorts of trouble with patients then clearly wondering what the hell they are going to do to fix their brain!

brain

On the flip side of the coin, patient’s are also quite often fixated on pathology:

My disc bulge is the cause of my pain!

Being completely dismissive of this is another potential minefield. I will consistently tell my “disc bulge” patient that quite possibly their disc bulge is contributing to some or all of their pain. Discs can clearly create nociceptive signals. I think it is completely amiss of us to tell them that their is nothing wrong with their disc as I for one cannot guarantee that there isn’t. I can however completely guarantee to them that we can see pain free people with disc bulges.

So I wonder if we need to find a balance.

balance

We clearly cannot “Blame Pathology” completely for pain, likewise we cannot completely dismiss it and blame “Lack of Pathology”……..it is all in your brain!

Acknowledging potential “pathology” is important, as to is clearly explaining to the patient how this “pathology” can be seen in pain free individuals and that many other factors can contribute to ongoing pain whether that be stress/mood, lack of sleep, loss of mobility/strength, posture etc. The list goes on. Addressing those factors is the critical component the treatment.

Now I know what some of you going to say:

Gibbo has swung back to the pathoanatomical and biomedical stance!

darkside

Not at all. I have never said there is a problem with diagnosing someone as having a pathological source of pain such as discogenic pain, although I dispute if you can actually diagnose it as most of our special tests to diagnose these structures as a source of pain aren’t that special. I am also unaware of any research that reports that labelling patients with a pathoanatomical diagnosis is detrimental. The communication and impact of what we say about that diagnosis is the critical aspect. See this fantastic free access article for more information.

Similarly I have no problem if you want to diagnose someone as having “non-specific” back pain, or a “back strain”, as long as they don’t end up leaving your rooms with the impression that their brain is the problem!

I do however have a problem with diagnoses that are clearly lacking any significant evidence base such as:

upslip

I also heard something recently about thoracic rings?Saturns-rings-450x276

Really? Thoracic Rings? I need to find out more about these……

So overall, acknowledgement of the potential pathology is fine and arguably important. I cannot guarantee that someones disc bulge or facet joint degeneration is not contributing to their pain, but I can very confidently tell them that many pain free people will have similar findings on scan. Likewise we clearly we know that the brain is what produces the pain experience, but we shouldn’t be giving the message to people that their brain is the entire problem.

Thanks for reading.

About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Branch Councillor on the Western Australian Branch of the Australian Physiotherapy Association.

4 Comments on "Blaming Pathology or Lack of Pathology"

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  1. Cameron says:

    Mind is almost always the problem. This is evidenced by the fact that happy/wealthy/connected people tend not to get aches and pains.

    • Mark Gibson says:

      Hi Cameron,

      I know some exceptionally busy physio clinics in very well off socioeconomic areas with wealthy/happy/connected people as patients. 🙂

      Hope all is well.

      Cheers
      Mark

  2. Hi Mark, just discovered your website. I like your chatty approach!

    I agree with your comment about clients still needing a pathoanatomical diagnosis, combined with an emphasis on the mind’s role in pain. I find most clients are receptive, as you suggest, to the explanation that people with pain can have normal scans and people without pain can have severe changes on scans.

    A discal rather than facetal diagnosis helps us as Physios choose more appropriate treatment and advice and often fits the client’s impression of the pain site.
    Classification is really useful for providing the client with a goal and the means to continue to improve. They know they need to work on reducing load, increasing or improving segmental motion or strengthening and stabilising.
    A strong emphasis on the role of the brain is vital but not to the exclusion of practical aspects of their pain.

    I worry that there is a tendency with “newer” fads/approaches to treatment throwing out “the baby with the bathwater”. As Musculoskeletal Physiotherapists we have the skills to use symptoms and signs to classify pain and choose an appropriate movement technique, movement retraining approach, or motor control program.
    Hope this makes sense.
    Regards Helen

    • Mark Gibson says:

      Hi again Helen!

      I think I tend to get a bit too chatty at times! 😀

      Couldn’t agree more with your thoughts re: classification and appropriate individualised treatment.

      Thanks for taking the time to comment on my site.

      Sorry for the slow replies, the blog has been taking a back seat of late.

      Cheers
      Mark

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