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!

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.

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!

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:

I also heard something recently about thoracic rings?

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.