The title of this blog post may have provoked your conscious thoughts, feelings, emotions and beliefs toward religion and religious sin. However, the SIN(S) I speak of are not of religious context – unless you consider the Australian approach to manual therapy, pioneered by Geoffrey Maitland, a religion. According to Wikipedia, a religion is a cultural system of behaviors and practices, world views, ethics and social organization that relate humanity to an order of existence.One could say that the Maitland approach of evaluation and treatment of musculoskeletal disorders is a physical therapy religion, of sorts.

Having completed both Evidence In Motion’s Orthopaedic Residency and Orthopaedic Manual Physical Therapy Fellowship, I would say that EIM takes an eclectic approach to manual therapy, one that is guided by the evidence. While EIM does not follow a single manual therapy school of thought there are foundational roots in Maitland’s teachings. A key concept in the Maitland evaluation strategy is SINS: an acronym for “severity, irritability, nature, and stage”. EIM had adopted and teaches the same concept as SINSS, with the second “S” designated as “stability”. The SINS are gathered during the subjective interview and used to guide the objective evaluation to determine how much testing is needed, how much vigor is required, when the treatment threshold will be reached and so on.

But what about S”P”INS? I was fortunate enough to attend a course, Therapeutic Neuroscience Education from the International Spine and Pain Institute (ISPI), a sister company to EIM, and was recently introduced to the concept of “SPINS”. An adaptation to Maitland’s SINS, Steve Schmidt explained that the addition of “P” represents the “pain generator”. The simplest form of identifying the pain generator is the dichotomizing question of “is this a tissue issue or a pain issue?” (from Louis Gifford). Kory Zimney, instructor for ISPI, discussed this in his blog post titled “Tissue Problem or Pain Problem (Maybe Both)”, stating that pain identification is far more complex than simply differentiating “pain vs tissue” and most often is likely the result of both.

Keith Smart (yes, he is really smart), began publishing on the clinical reasoning of pain in physiotherapists in 2007. His work developed into a three-part publication in Manual Therapy on the mechanisms-based classifications of musculoskeletal pain. These works provide a structured classification system that can be used to make clinical decisions, similar to the clinical prediction rule for lumbar spinal manipulation. He proposed three different mechanism based categories, nociceptive, peripheral neurogenic (input arising from the peripheral nervous system) and central sensitization.

If the patient has all of the symptoms described for nociceptive pain, they are 100 times more likely to have nociceptive input as the primary driver of their pain experience. If the patient has the symptoms outlined in the peripheral neurogenic box, they are 150 times more likely to have peripheral neurogenic input as the primary generator of the pain experience. Finally, if they have the symptoms outlined under central sensitization, they are 486 times more likely to have changes in the central nervous system, that are the primary driver for the pain experience. Smart, right? But, how do we “SPIN” this into practice?

When working with my residents, we often co-treat the more challenging patient cases during mentoring hours. We have integrated the SPINS concept into the clinical reasoning, first starting with the dichotomizing question of “is this a pain processing issue or a tissue issue?” My astute residents reply “both” nearly 100% of the time. Yes, they are correct – but that leads us to the next question: Which is the primary driver? When they are struggling with a patient, more often than not it is because they have failed to recognize the primary pain mechanism and match this with the appropriate intervention.

In example, take a 25-year-old female with widespread pain in her neck and back for several years. She has had imaging, blood workups, her cat scanned, dog scanned, etc. and they all are negative. Her objective exam is remarkable with the exception of tight, sore, and tender muscles. She has some psychosocial issues related to her job, a car accident, and the medical gauntlet she has been navigating. She does not have aggravating and easing factors; everything hurts but she pushes through it. At first, her treatments sessions were largely manual therapy focused and passive in nature. She had temporary relief but nothing lasting more than a few hours. This is a mismatch, of sorts.Treatment largely focused on treating “nociceptive” input was not helping, because the primary driver of her pain experience was far more complex and more likely to be centrally driven. Once pain education was started, achievable goals established and a graded program to achieve them were set, she began to flourish and demonstrated large functional gains, and soon returned to the activities she loved.

In an effort to bring the concept of SPINS into daily practice, I now talk to my residents in the form of pies, not the kind filled with blueberries or apples, but pie charts. For each case I have them draw out what the patient’s pie chart looks like. How much is central sensitization, how much peripheral neurogenic, how much nociceptive? Here is the pie chart that may have represented the example patient case above. Where to start with this pie? Begin with the largest piece first, before sampling the other “flavors”.

Are you ready to stop SIN(ing) and start SPIN(ing)? I welcome your thoughts on this concept of integrating the pain-mechanism into the SINS of clinical practice.

Brett Neilson

• Koury MJ, Scarpelli E. A manual therapy approach to evaluation and treatment of a patient with a chronic lumbar nerve root irritation. Phys Ther. 1994;74(6):548-560.

• Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: Part 1 of 3: Symptoms and signs of central sensitisation in patients with low back (±leg) pain. Manual Therapy. 2012;17(4):336-344. doi:10.1016/j.math.2012.03.013.

• Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: Part 2 of 3: Symptoms and signs of peripheral neuropathic pain in patients with low back (±leg) pain. Manual Therapy. 2012;17(4):345-351. doi:10.1016/j.math.2012.03.003.

• Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (±leg) pain. Manual Therapy. March 2012:1-6. doi:10.1016/j.math.2012.03.002.

• Smart K, Doody C. The clinical reasoning of pain by experienced musculoskeletal physiotherapists. Manual Therapy. 2007;12(1):40-49. doi:10.1016/j.math.2006.02.006.