10 Tips For The Practical Application Of Pain Science


Knowledge about pain science is rapidly growing with articles and blogs aimed at everybody from personal trainers to doctors and surgeons springing up on the topic. It could be argued that anyone who deals with the body should have a basic understanding of how pain works.

We have criticism that we still have not gone far enough in this field and others seeing the pendulum as having swung far to far already!

Whilst it is important to digest this barrage of information, we also need to think about the real world application of the academia to the end user, e.g. the person you are trying to help understand all this information, and often this is the bit people find hard.

1. Pain Science Can Help Us To Understand What Not Ts Say, But Not What To Say


At the very LEAST a better understanding of pain science should influence us to know that what we say can have a profound affect on the way someone perceives themselves and their current state. Unfortunately words that hinder rather than help can often easily trip off the tongue as they have been used so many times before!

Just staying away from certain words may help to not create detrimental nocibo effects.

• Rip
• Tear
• Instability
• Damage
• Degeneration
• Chronic
• Out of place

These words have the potential to alter people’s perceptions of their capabilities, beliefs and expectations for recovery. ‘Thought viruses’ is a catchy term regarding negative beliefs and how they can be generated and passed between people.

What should we say? Well that is an infinitely harder question to answer and will vary between individuals, there are certainly are no recipes here.

Hence why learning what NOT to say is often a great start!

2. Learn More About The Subject!


A criticism of our current educational processes is that they do not teach much about the mechanisms behind the experience of pain at undergraduate level or in many courses that deal with injury.

While it is a start to watch a few videos or read a few blogs, using the concepts of modern pain science should be underpinned by a good working knowledge of how pain works. A few buzz words or analogies probably aren’t quite enough to get it across to the target audience, especially when they have a habit of asking tricky questions.

Here are some questions it may just be worth knowing the answer to or how to explain:

What is pain?
How does nociception work?
What is central sensitisation?
What is peripheral sensitisation?
What are the supra spinal mechanisms involved in the pain experience?
What are descending inhibition & facilitation?
Why do stress, context & emotion have an effect on the pain experience?

3. Explanation Of A Complex Subject Like Pain Takes Practice


Everything is hard before it is easy - motivational slogan on a clipboard with a cup of coffee

People can feel under pressure to be able to ‘explain pain’ like an expert. Firstly you need the basic science then you need to learn how to articulate it and this does not happen over night.

As Einstein says, “If you can’t explain it simply you don’t know it well enough”.

Complexity and confusion during an explanation may lead to confusion and uncertainty in someone’s understanding and actually increase rather than dampen down someone’s pain experience.

Perhaps it is something that should be practiced away from a ‘live’ environment to build your own confidence and communication skills? Fuck it up a few times, learn from this and be ready to roll it out when you need it.

All the best presenters practice after all!

4. You May Need More Than One Analogy


Analogies have been promoted as a great way to get across complex subjects such as pain. As we use analogy so much in everyday life this makes a lot of sense but it is good to keep in mind always that these things depend on the person receiving the analogies previous experiences, cultural factors and education level.

SO if it ain’t working then switch it up.

5. Challenge Concepts And Not People


A great way to ruin rapport, which can be vital to the success of what you are trying to achieve, is to tell people they are wrong or make them feel stupid. Beliefs can be like superglue and adding confrontation into the mix can make things go downhill quickly. If it is not working STOP, maybe you can come back to it later or drip feed in over time.

6. Always Find Out How Someone Has Perceived What You Have Told Them


This is vital, it maybe the information you have presented is perceived in precisely the way that you did not mean it to be! Prof Kieran O’Sullivan promotes a most sensible course of action by asking “What would you tell your friends and family about what I have told you”.

This means any miscommunications can be (hopefully) remedied before they turn into ‘thought viruses’ such as “they told me the pain was all in my head”.

7. There Are No Recipes Or Protocols – It Is About The Individual


What works for one person may not work for another. Perhaps a plus for pain science is it points towards being person centred rather than having a specific protocol across humans such as more protocol based approaches do.

Strategies that have been promoted from the fields of psychology involve techniques such as exposure therapy and expectancy violation. We have to be careful that the patient/client identifies the specific fears and beliefs to be addressed, and hopefully inhibited, and this is not seen as a general concept.

8. Changing Beliefs Is Not An Instantaneous Process, An Exact Science Or Even Always Possible


As discussed in point 5, beliefs can be sticky and contagious between friends, family and work colleagues (even more so with Dr Google!). Rarely do people walk out from chatting with their therapist or trainer and suddenly change their outlook and opinion on themselves or beliefs they hold.

It could be a slow and laborious process (likely!) or in fact never happen at all!

9. People Often Have Their Own Epiphanies Away From You


Reconceptualizing can happen in mysterious ways with mysterious triggers, a bit like an apple falling on your head! You may have to wait for someone to come to their own realizations about the information you are giving them rather than expecting an epiphany in front of your eyes.

10. You Can’t Talk Tolerance Into A Tissue


One of the major parts of the BPS model is the B for biological. Just because you can help someone understand they are not fragile does not mean they suddenly develop an enhanced capacity for moving. The less you move the less likely you are to be robust at moving, that’s the SAID principle in action.

Someone once said “you can’t talk tolerance into a tissue” a very true statement. But you may have to talk to someone first to get them to do that work and get the tolerance!

11. BPS Model Is Still In The Minority Away From Social Media


For the eagle eyed yes it did say 10 and this is number 11!

It may feel like social media is awash with pain science from every angle to the delight of some and not to others! Go out into the wider world of the internet and shock, horror the actual real world and it feels like the information being delivered in the medical and training world regarding pain is still pretty traditional with structural and biomechanical factors being promoted.

Making Movement More About The Person, Not The Exercise

So I was on Facebook the other day.

And I saw somebody trying to make the argument that this exercise with a Theraband should be retired from anybody’s rehab toolkit.

And their argument was that there’s far better exercises for a rotator cuff injury.

And I’m sure there are, and I’m sure that you could even use this in different planes and do different things in order to help a rotator cuff injury.

But what we have to understand is that it’s not necessarily about the exercise itself.

It’s about the person who’s standing in front of us and we have to make that exercise meaningful to them.

Because maybe their biggest goal is to just be able to put their groceries away pain free, or maybe it’s to pick their child up and if this becomes a meaningful exercise to them that helps build capacity, build resilience and makes it so that they can do those activities we just talked about, then this is just fine as an exercise.



Are You All About The Exercise Or The Person Doing It? Making Movement Meaningful

This is the first in the series of a few mini/microblogs of about 500 words (famous last words) and in this first one I wanted to kick off by talking about making movement and exercise meaningful.

This is a term that is being bandied about more and more in rehab but still has the feel of a buzzword rather than something well defined.

So what the hell does it mean……..

Firstly lets separate the idea of meaningful from what many describe as ‘functional’. Meaningful exercise does not have to look or recreate movements, mechanics, or even physical qualities that people may need.

Lets PLEASE not go down that road again. PLEASE.

Something being meaningful is much more about the WHY behind doing it or the meaning it holds (as the title suggests : )

Too often it’s the therapists why, but it really should be the PERSON doing it’s WHY! As therapists, we often have a bunch of why’s, ROM, strength, and other outcome measures that are often not really very well aligned with the patients WHY.

Put yourself in the other person’s boots – why am I actually doing this? And ultimately, by doing it, how can it help me? We pretty much do this calculation for a lot of things in life.

What makes this person tick when it comes to moving…..

Now it could be argued getting out of pain should be a big enough WHY. But when it comes to exercise, especially for rehab, we know that is not enough from the data around adherence (commitment is a much better word btw) and this also extends to adherence to drugs and general health advice.

So really we have to consider HOW to get to people’s WHY. Well, I think this really has to come from HOW we as HCPs interact with our patients. Without knowing what they want to achieve or their valued activities it is very hard to create a real relevance, MEANING, or as I like to call it a ‘finding a HOOK’.

Essentially any movement could be framed as being meaningful with the right explanation and the link to a motivating and meaningful goal. Learning more about sets and reps might not improve your outcomes!

Recent research has shown some very good effect sizes for using goal-setting interventions in back pain *HERE*

Here is real life an example from a course I gave last weekend in Melbourne. An attendee was discussing Jiu-Jitsu training. He said 50% of the reason he goes is for the social aspect. Firstly imagine the impact firstly of NOT going on life (more than just pain!), secondly the motivation to get BACK to going.

Rehab should tap into the meaning of that person’s life and what they gain from doing it, not just doing an exercise because someone told me to.

The problem has been one of therapeutic exercise finding an exercise to fix the problem, such as VMO firing for knee pain or core firing for back pain. Potentially we could call this targeting the muscle but missing the person.  So we are now talking about movements not muscles, but how about talking people? Getting people moving perhaps needs a GOAL, a HOOK, a MEANING?

Maybe one of the benefits of working with a sporting or active population is that the WHY is often clear-cut, sometimes people can even be over motivated.  The meaning is built into the process.

The challenge with persisting pain may be the motivation is not so clear cut, we need to dig a bit deeper as pain can narrow people’s focus and reduce the number of options they feel they have available to lead a full life.  This is where ‘finding a hook’ can be really important I feel.

Meaningful movement tips

  • Listen and ‘find the hook’
  • Take time to explain WHY moving will help
  • Relate the explanations back to the ‘hook’
  • Spend time building confidence and positive movement experiences
  • Think person rather than exercise

P.s I was close – 650 words ; )

The REAL Truth About Pain Science and Body Mechanics: A Response to Criticism

Joel Seedman, a personal trainer, recently wrote an article called “The Truth about Pain Science and Biomechanics”, which presents a lengthy attack on “pain science experts.”

Seedman claims they spread dangerous misinformation about the connection between movement and pain, including that pain is all in your head, that injuries or tissue damage don’t matter for pain, that there are no wrong and right ways to move, and that even athletes and heavy weightlifters shouldn’t worry about moving with good technique to protect themselves, even when high levels of force are involved.

Regular readers of this blog, and anyone familiar with the pain science community, will quickly recognize that these claims are very obviously not true.

But the article may be persuasive to those with less exposure to the subject matter. Following is a detailed response, geared toward people who are not familiar with the work of pain science educators like Lorimer Moseley, David Butler, Adrian Louw, Peter O’Sullivan, Greg Lehman or Ben Cormack. For those who are, this article might serve as a convenient reference or link in debates on social media.

Quick Summary

Seedman’s post is extremely long but boils down to a few major claims, which I answer in brief in this section and in more detail below.

Claim 1

Seedman claims pain science experts teach that pain is “all in your head,” and that people shouldn’t worry about tissue damage, injury, and movement technique. These are straw men arguments, and it is telling that Seedman doesn’t identify any specific individuals or quotes. The truth is that pain scientists don’t say these things and frequently disclaim them. See below for many examples.

Claim 2

Seedman claims pain scientists misinterpret MRI studies showing that high percentages of people without pain have significant tissue damage such as herniated discs, torn rotator cuffs, and degenerative changes in joints. Seedman claims these people will surely have pain in the future. However, several studies have found that MRI results for asymptomatic people have little or no ability to predict future pain, even after five or ten years.

Claim 3 

Seedman claims pain scientists have misinterpreted the research showing poor correlations between pain, posture, and “dysfunctional” movement patterns. The studies cited by Seedman are cherry-picked and run against the overall weight of the evidence, which is shown with a fuller examination of the research. Posture and habitual movement patterns are not irrelevant for pain but have been massively overemphasized in common practice.

Claim 4

Seedman claims pain scientists misunderstand the role of inflammation in pain, which is supposedly the key link between aberrant movement and pain. This is a strange claim, as the role of inflammation in pain sensitivity is one of the most basic aspects of pain physiology. Although chronic inflammations are clearly related to bad health and reduced function, there is no evidence it is caused by bad posture or movement patterns.

Claim 5

Pain science education has only a moderate effect on reducing pain, and the mechanism of effect may be getting people to move more. This is a defensible claim, but not inconsistent with the view of pain educators, who uniformly agree that we don’t have any magic bullets for chronic pain and that it can be a difficult problem to resolve.

Here’s more detail on the above arguments, supported by extensive citation to authority.

1. Pain Scientists Do Not Teach That Pain Is All In Your Head

Seedman’s article attacks “pain scientists”, but does not identify specific people or books. However, he seems to be referring to educators who teach basic pain physiology to physical therapists, chiropractors, bodyworkers, and personal trainers. The goal of this education is to help practitioners improve their treatments and to explain to their clients why they hurt, so they can take an active role in recovery.

The most popular source of information about pain science is the book Explain Pain and associated courses, from Lorimer Moseley (pain scientist and physical therapist) and David Butler (physical therapist and education specialist).

Another well-known educator is Greg Lehman, a physical therapist, chiropractor, and former biomechanics researcher who studied under Stu McGill. Lehman teaches a course called Reconciling Pain Science and Biomechanics, and his free workbook can be found here. I have attended all these courses, teach similar courses occasionally, speak at pain science conferences, and recently published a book called Playing With Movement which addresses similar topics. So I have direct experience with the message that pain educators are trying to send. Here are some of the major points that we think it’s important for people to understand:

  • Pain is multi-factorial and “biopsychosocial.” It depends on peripheral factors like tissue damage, injury, and inflammation (that’s the bio part), but also perceptions, thoughts, emotions, and social stress (that’s the psychosocial part). It is also complex, meaning these different factors interact in ways that are often individual, context-dependent, and unpredictable (O’Sullivan 2018).

  • Pain is the output of a highly sophisticated protective system that functions like an alarm. Potential threats to the body are detected in the periphery and then communicated to the brain. The brain interprets the meaning of the information and creates pain if it perceives the need for protection. The sensitivity of this system can change based on many different factors, including injury, inflammation, emotions, stress, memories, and general health (Melzack 2010).

  • Because pain depends on perception, tissue damage does not always cause pain, and pain can be felt in the absence of tissue damage. For example, people without pain frequently show significant damage on MRI, and back pain usually cannot be linked to any specific pathology (Brinjikji 2015).

  • The link between pain, posture, and allegedly defective movement patterns has been overemphasized. Research shows poor correlations, and often no correlation, between these factors (Lederman 2011). Further, pain treatment focused on correcting specific “dysfunctions” rarely outperforms general exercise (See, e.g. Foster 2018; O’Sullivan 2016; Riley 2018; Smith 2014; Ferreira 2007).

  • On the other hand, psychosocial factors have been underemphasized. For example, anxiety, catastrophizing, and fear of movement increase the risk for chronic pain, while optimism and self-efficacy predict recovery from injury (Marcuzzi 2016). Part of the purpose of providing education to patients is to favorably alter these variables (Louw 2016).

I can assure you that pain science educators do not teach that pain is in your head, that tissue damage doesn’t matter for pain, and that movement doesn’t matter for injury. In fact, I have frequently stated the precise opposite on many occasions. Here are just a few examples, all of which date back several years. From a blog post on the poor link between posture and pain.

Don’t misinterpret the research on posture to mean that biomechanics and good form don’t matter at all. Vigorous exercise is different than just sitting or standing around, and it may require more attention to proper alignment. . . .So your posture and alignment matters in a heavy deadlift. It matters when you land a jump. It matters when you sprint, lift weights, or engage in any activity involving a great deal of mechanical stress. In these cases, it is a good idea to use conscious effort or coaching to ensure that your biomechanics and spinal alignment are optimized to distribute stress, reduce risk of injury and increase performance.

Here’s a line from my book A Guide to Better Movement, discussing the role of the brain in creating pain.

Here is a very important point of clarification: none of this means that pain is not real, or that it is all in your head. Pain is real. Pain is a real feeling, but that feeling does not necessarily reflect real damage in the body. Further, although pain depends on brain activity for its existence, this does not mean you can simply think pain away or that pain is your fault. Unfortunately, the processes which create pain are mostly unconscious and outside your control. Although your conscious thoughts about pain can change it, the effects are in many cases small.

From a blog post on pain science confusion:

pain is of course related to conditions in the body. It is just not determined by them. Even though pain requires brain activity, it remains true that in many circumstances, tissue damage will almost certainly cause that brain activity. Thus, we would all prefer to have less tissue damage than more.

Here’s Greg Lehman making the same point in his (highly recommended) workbook:

Its not all in your head! Even health professionals get this confused. As soon as people start talking about emotions, psychological factors or the brain, the assumption often slips in that we are saying your pain is now just in your head. Just because psychological factors or the brain is involved does not mean the body is not important or the pain is imagined.

Another source of nuanced information on the practical implications of pain science is Jason Silvernail, a doctor of physical therapy and strength and conditioning coach. Here is an informative interview he did with Bret Contreras.

2. MRI Research Shows Clearly That Tissue Damage Without Pain Is Common And Normal

Extensive research shows that almost no matter where you point an MRI on a person over twenty, you have a very strong chance of finding significant damage, even in places without pain. Here’s an excellent infographic from Jørgen Jevne summarizing part of the evidence.


For more research see my blog post here.

This research does not mean that damage is not linked to pain. Higher levels of damage are indeed correlated with more pain, but it remains interesting that the correlation is far less than we might imagine (Brinjikji 2015). Greg Lehman provides a useful analogy – damage in the spine or other joints is like kindling for a fire that may or may not be lit by other factors.

Seedman argues that the people in these studies aren’t hurting right now, but will surely have pain in the future. But several studies have already addressed this concern. A seven-year follow-up study found no correlation between initial MRIs and future pain (Borenstein 2001).  Another study did a ten-year follow-up, looking at the extent of disc degeneration, spondylolisthesis, disc bulge, and other findings. The conclusion: “our data suggest that baseline MRI findings cannot predict future low back pain.” (Tonosu 2017). A study on shoulders of pain-free overhead athletes found that forty percent had rotator cuff tears, and none had pain five years after the study (Conor 2003).

Seedman cites one study to support his claims, showing that MRI evidence of stenosis predicts future back pain. But the same study also showed that many other positive MRI findings did not predict future pain, and concluded that “No consistent associations between MRI findings and future outcomes were identified.” (Hill 2018).

3. Posture Has Been Overemphasized As A Contributing Factor For Pain

There is a large body of research that looks for correlations between pain and measurements of postural alignment. Most find none. Here is an excerpt from my recent book Playing With Movement that summarizes some research from more than thirty years of studies:

  • No association between leg length inequality and back pain (Grundy 1984).

  • No difference in lumbar lordosis or leg length inequality in 321 males with either severe, moderate, or no back pain (Pope 1985).

  • No association between neck pain and neck curvature in 107 people over the age of 45 (Grob 2007).

  • No significant difference in the lumbar curve, pelvic tilt, leg length discrepancy, and the length of abdominal, hamstring, and iliopsoas muscles in 600 people with and without back pain (Nourbaksh 2002).

  • Teenagers with postural asymmetry, excessive thoracic curve, and/or lumbar curve were no more likely to develop back pain in adulthood than peers with “better” posture (Dieck 1985).

  • Pregnant women with larger increases in the low back curve during pregnancy were no more likely to develop back pain (Franklin 1998).

  • A review of ten studies found no correlation between thoracic kyphosis and shoulder pain. (But there was less shoulder ROM) (Barrett 2016).

  • Teenagers with slumped forward head postures didn’t have more neck pain (although they were more depressed.) (Richards 2016).

  • No association between low back pain and spondylolisthesis (a condition where a vertebra has slipped forward, and which is often corrected by fusion surgery (Andrade 2015).

  • In a group of women aged 65-91, those with substantial kyphosis had no more back pain or disability (Ettinger 1994).

  • No association between neck pain and “text neck” as assessed by physical therapists (Damasceno 2018).

  • Ergonomic programs do not reduce the risk of future onset of neck pain, but exercise reduces the risk by half (Campos 2018).

Although some studies have found a positive association between measurements of spinal alignment and pain, these are exceptions to the rule, and the correlations are relatively weak. (Chaelat-Velayer 2011; Smith 2008). The weight of the evidence is perhaps best represented by a systematic review done in 2008, that analyzed more than fifty-four studies on the link between pain and posture. Together they did not produce evidence supporting an association between measurements of sagittal spinal alignment and pain (Christensen 2008). Although back pain is associated with scoliosis, this condition refers to relatively large lateral asymmetries that are not present in 98% of the population. (Theroux 2015).

Other relevant studies examine the effects of jobs that involve repetitive use of postures thought to be awkward or stressful. These have found that:

  • Sitting at work is not associated with low back pain (Hartvigsen 2010).

  • A systematic review of 35 studies found that occupations that require lifting weights probably do not cause low back pain (Wai 2010).

  • A systematic review of 99 studies found no good evidence of a causal connection between back pain and occupations that involve awkward postures, lifting, bending, and twisting (Kwon 2011).

  • Although occupations that routinely require heavy lifting are associated with increased risk for back pain, the effect size is modest (Waddell 2001).

The above research indicates that if any correlation exists between posture and pain, it is weak. Further, even if a correlation between pain and posture does exist, this would not prove a causal relationship. It may be that pain causes bad posture, or that some unknown factor causes both. This is highly plausible. People who are injected with a solution causing back pain will spontaneously adopt different postural strategies to reduce discomfort (Hodges 2003). Yet another unproven leap is that posture can be corrected and that the corrections serve to reduce pain.

Does this mean posture never matters for pain? No, and most pain science educators will readily admit this. For example, here’s a diagram from Greg Lehman’s workbook, showing the different factors we might hope to modify to help with pain. Note that posture is one of them. But importantly, only one of many.


4. Biomechanics Are Complex And Not Easy To “Correct.”

Pain science does not overrule the basic laws of physics, and therefore it is obvious that moving with bad technique under heavy load can cause serious injury. But the question remains whether we are likely to get chronic pain from every day habitual movement patterns in low load activities like sitting, standing, breathing, bending, or reaching.  Do these cause repetitive stress and injury, or do we simply adapt to handle the stresses we encounter regularly, just as we do with exercise stress?

This is best answered by looking at a substantial body of research that is similar to the research on posture discussed above. It shows:

  1. Movement patterns that are commonly alleged to be dysfunctional are not correlated with pain or increased injury risk;

  2. Treatments aimed at correcting specific dysfunctions often work no better than general exercise; and

  3. Corrective methods may create good results even when no “correction” occurs, suggesting these methods work by some other mechanism.

For example, general exercise works just as well as stabilization or motor control exercise for low back pain. (Smith 2014; Ferreira 2007; Saragiotto 2016.) This is true even when the treatment involves an attempt to correct a specifically diagnosed movement “impairment.” (Riley 2018, Dillen 2016, Azevedo 2018).

There is a similar pattern for shoulders. General stretching and strengthening works just as well as motor control exercise to correct scapular “dyskinesia.” Further, people improve on motor control programs even when movement patterns stay the same, suggesting the active ingredient is simply exercise, and not a correction of any defect in coordination (See Camargo 2015, McClure 2005, Timmons 2012, Ratcliffe 2014, Struyf 2013). For example, Struyf 2013 concludes that most scapular movement patterns alleged to be dysfunctional probably represent “normal movement variability.”

For knee pain, it seems that the most effective treatment is simply strengthening the muscles around the hip and knee, even when this is done through allegedly “non-functional” exercises with knee extension machines (Willy 2016, Rabelo 2018).

Although Seedman talks at length about the importance of correcting defective movement patterns, he does not specify any such patterns in his article, or how to assess and correct them. He makes vague references to the importance of strong glutes and core muscles for back pain but does not cite any studies on this issue. In fact, core strengthening works no better on average than general exercise for back pain (Lederman). Further, the idea that inactive glutes cause pain is not well-supported by research, which has often shown that pain is associated with more glute activity not less (Kim 2014, Lehman 2006, Suehiro 2015, Dwyer 2013).

The lesson here is that the connection between movement and pain is complex. There’s no doubt that exercise can reduce pain, improve function, and help to prevent injury. But we should be very skeptical about claims concerning the assessment and correction of ”dysfunctions” and their relevance for pain in everyday movements (Tuminello 2017).

5. Inflammation

Seedman suggests that pain scientists ignore the role of inflammation in pain. I have no idea what he might mean here. The role of inflammation in sensitizing nociceptors is one the most basic facts about pain physiology, and also illustrates a key principle of pain education – pain sensitivity can change even as tissue damage stays constant.

Seedman notes that high levels of chronic inflammation are associated with bad health, pain, and reduced function in gait pattern, walking speed, strength, stability, and mobility.  This is in no way surprising. If someone is in poor health and has high levels of inflammation, we would expect that they won’t be moving well or feeling well. Seedman’s evidence demonstrates this obvious connection, but it doesn’t show that the inflammation is caused by poor posture or movement patterns. If it was, then research would easily find correlations between posture and pain, but it doesn’t.

Conclusion: The Truth About Pain Matters

I think getting this information right is incredibly important. Chronic pain is one of the biggest health problems in the world. We have no magic bullets to cure it, but the best hope for progress lies with understanding it better through science and getting people moving. Personal trainers are in an excellent position to do both. There is still much we don’t know, and healthy criticism is needed to move the ball forward. But we know enough to take action – there is a huge gap between common practice and well-established evidence, and that needs to be closed.

Thanks for reading this far! Please share this article with anyone who has questions about pain science. Or point out mistakes if you see them. Please also remember that debate is far more productive when it is respectful and polite.

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Campos, Tarcisio F de, Chris G Maher, Daniel Steffens, Joel T Fuller, and Mark J Hancock. 2018. “Exercise Programs May Be Effective in Preventing a New Episode of Neck Pain: A Systematic Review and Meta-Analysis.” Journal of Physiotherapy 64 (3). Netherlands: 159–65.

Chaléat-Valayer, Emmanuelle, Jean-Marc Mac-Thiong, Jérôme Paquet, Eric Berthonnaud, Fabienne Siani, and Pierre Roussouly. 2011. “Sagittal Spino-Pelvic Alignment in Chronic Low Back Pain.” European Spine Journal 20 (S5): 634–40.

Smith, Anne, Peter OʼSullivan, and Leon Straker. 2008. “Classification of Sagittal Thoraco-Lumbo-Pelvic Alignment of the Adolescent Spine in Standing and Its Relationship to Low Back Pain.” Spine 33 (19): 2101–7.

Christensen, Sanne Toftgaard, and Jan Hartvigsen. 2008. “Spinal Curves and Health: A Systematic Critical Review of the Epidemiological Literature Dealing With Associations Between Sagittal Spinal Curves and Health.” Journal of Manipulative and Physiological Therapeutics 31 (9): 690–714.

Théroux, Jean, Sylvie Le May, Carole Fortin, and Hubert Labelle. 2015. “Prevalence and Management of Back Pain in Adolescent Idiopathic Scoliosis Patients: A Retrospective Study.” Pain Research & Management : The Journal of the Canadian Pain Society 20 (3). Pulsus Group Inc: 153–57.

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Why Weak Glutes Aren’t A Reliable Predictor Of Low Back Pain

It seems we are constantly trying to find causes for low back pain with our patients.

Quite often we are caught up looking for biomechanical issues (which there often are) and avoiding other things that could influence a person’s pain.

One such instance is the possibility that weak glutes are a contributing factor.

I recall seeing one of my instructors demonstrate this (what I perceived to be) complicated movement test where my patient was lying prone and having them extend their leg. There was a specific pattern where the muscles in the low back down through the glutes and hamstrings were supposed to move.

This would be followed up with the comment: “your glutes aren’t firing”!

While I watched this all I could think was…”there’s no way I’m going to remember what order all of this goes in”!

But, when done with confidence and a really good explanation, it seemed to make sense to me, and the patient.

So, I worked through the low back, glutes, and hamstrings, and the patient felt better after the treatment.

I proceeded to pat myself on the back for a job well done!

However, the next time a patient came in for what I thought was the same issue, I couldn’t remember this specific pattern of movement and what it was supposed to tell me! Why couldn’t I get this!?

Well, in reality, I really didn’t have to and here’s why.

Limitations With Testing

There are a couple of tests used to see if the glutes are a contributing factor to low back pain, so let’s look at both of them.

The prone leg extension test1 is pretty commonly used to test for low back pain and lumbopelvic function (this is the one my instructor was demonstrating to me).

The pattern of movement you’re supposed to see is (if you were testing the right side) right glute max, right hamstring, left lumbar erector spinae, right lumbar erector spinae, left thoracolumbar erector spinae, then the right thoracolumbar erector spinae. A delay in glute max recruitment is supposed to show a dysfunctional pattern of movement.

There is a whole list of other patterns that are supposed to mean other things, but it’s a long list and more than I want to get into for the purposes of this post.

A studyshowed there was no consistent order of activation during the test and glute max was the last muscle to become activate with time ranging from 0.07 to 0.676 seconds in delay.

Now, these tests were done with proper EMG testing, so I have to wonder…how would we ever be able to properly assess this just using touch and vision!?

Another test we were taught was “Trendelenburg”, or “SLS” to assess for glute weakness possibly contributing to back pain. 

With this test, a practitioner stands behind the patient and has them raise one leg so the hip is between 60°-90° of flexion. A positive test shows lateral pelvic tilt on the stance leg, which is supposed to represent glute weakness on that side.

One study 2 compared the differences between those with chronic low back pain vs. a control group using Trendelenberg. It actually showed the number of positive tests was no different between the groups. There was also no difference in glute med strength between those who scored a positive and negative test.

Since there was an equal number of positive and negative tests between both groups it showed this test is unreliable to differentiate between those with chronic low back pain and those without, nor was it reliable for demonstrating a difference in glute med strength.

Another study 3 actually injected a superior gluteal nerve block to see if there were any alterations in different movement variables. They found after the injection there was no difference in contralateral pelvic drop, hip adduction, or hip abduction due to reduced strength of the glutes post-injection.

The researchers found this surprising as an impaired gluteal nerve has always been associated with the SLS test.

So, in other words, lateral pelvic drop is not associated with weak glute med muscles in our patients who are dealing with chronic low back pain. It was even suggested that glute med strength of less than 10% of body weight is required to actually get a positive SLS.

The suggestion was also made that in order to maintain your stance during this test it is because of all muscles attaching to the greater trochanter working together combined with the mechanical force of the iliotibial band. This shows a positive SLS is more likely a global issue rather than a specific spine and pelvis issue.

In light of their findings they showed how this test could not distinguish between who was experiencing low back pain and who wasn’t, nor could it identify those who had weak glutes, and in fact demonstrated the test was probably due to some other issue altogether.

Another study 4 showed the presence of low back pain was a combination of higher BMI, signs of hip abductor problems, significant glute med weakness, gluteal tenderness, and a positive SLS (but the strength testing was admittedly not reliable in the study). However, this study showed something else that is probably far more significant which we will look into next.

It was unclear if glute med muscle weakness was the cause of the low back pain…or just a consequence of it.

Muscle Activation, Weakness, Or Protection?

Quite often when discussing this kind of thing and it’s relation to low back pain, the discussion can revolve around not only issues with the glutes, but also hamstring length and activation patterns between the two.

Inevitably when discussing “weak glutes” it’s due to an S.I. joint “dysfunction”, or this dysfunction is causing the weak glutes. But really, what is dysfunctional with the S.I. joint in this case?

They 5 described S.I joint dysfunction as; low back pain below L5, pain over the posterior aspect of SI joint around PSIS and buttock with or without above the knee leg pain. They used a combination of three SI joint provocation tests (posterior shear, compression, distraction, and sacral thrust) that showed good sensitivity and specificity (although the sensitivity rating was much higher).

When we look at the discussion around which muscles are “activating” with certain movements it is usually centered around the context of the pain-spasm-pain model which suggests pain results in increased muscle activity, in turn creating more pain.4

Or, the pain adaptation model which suggests pain reduces activation of muscles when active as agonists and increases activation of muscles when active as antagonists.They say this will reduce movement and ROM which would, in turn, prevent mechanical pain and further damage to the tissues.

The funny thing is that while both of these models are trying to prove the same thing, they end up contradicting each other quite a bit and neither of these ideas can predict how back pain will affect muscle activation.

There is lots of discussion around both increased and decreased muscle activation due to pain which results in disrupting motor control. However, this systematic review 6 argues that increases in muscle activation is an adaptation that occurs for various reasons, and those changes are mainly to avoid harmful stress placed on already injured structures, and to increase stability around the spine.

In each case, they looked at any changes that were task-dependent, related to an individual problem, and highly variable between each patient. This also shows those changes are functional since they are trying to reduce unpleasant stress and provide stabilization to the spine.

One common thread through most of the research cited is glute weakness in relation to back pain. However, it’s a bit of a chicken or the egg, is the weakness a result of reduced use because of pain, or did the weakness cause the pain? I’d venture to say it’s due to the reduced use.

While this can all sound maybe a little complicated and like word salad, when we look at everything we know about pain, what is this actually telling us?

One thing we know for sure that pain is ALWAYS a protection mechanism. So, if something in our body has a decreased ROM for a period of time in order to prevent stress in a sensitive area, this is just simply a way to protect that area. If those altered movements are also providing extra support to stabilize something, it’s actually doing this to protect the area! With this understanding we have to ask, does it really matter what order a muscle fires in (especially because we’d never be able to accurately assess this with just the human eye)? What we should be concerned with is calming those sensitized areas down, reassuring the patient they aren’t broken, and educating them as to why they’ll be okay. Then get them moving in pain-free full ranges again and help strengthen the area, build up that resilience!



  1. Lehman GJ, Lennon D, Tresidder B, Rayfield B, Poschar M. Muscle recruitment patterns during the prone leg extension. BMC Musculoskeletal Disorders. 2004 Dec 1;5(1):3.
  2. Penney T, Ploughman M, Austin MW, Behm DG, Byrne JM. Determining the Activation of Gluteus Medius and the Validity of the Single Leg Stance Test in Chronic, Nonspecific Low Back Pain. Archives of Physical Medicine & Rehabilitation [Internet]. 2014 Oct [cited 2020 Apr 17];95(10):1969–76. Available from: https://search.ebscohost.com/login.aspx?direct=true&db=s3h&AN=98597253&site=ehost-live
  3. Pohl MB, Kendall KD, Patel C, Wiley JP, Emery C, Ferber R. Experimentally reduced hip-abductor muscle strength and frontal-plane biomechanics during walking. Journal of athletic training. 2015 Apr;50(4):385-91.
  4. Cooper NA, Scavo KM, Strickland KJ, Tipayamongkol N, Nicholson JD, Bewyer DC, Sluka KA. Prevalence of gluteus medius weakness in people with chronic low back pain compared to healthy controls. European Spine Journal. 2016 Apr 1;25(4):1258-65.
  5. MassoudArab A, RezaNourbakhsh M, Mohammadifar A. The relationship between hamstring length and gluteal muscle strength in individuals with sacroiliac joint dysfunction. Journal of Manual & Manipulative Therapy. 2011 Feb 1;19(1):5-10.
  6. van Dieën JH, Selen LP, Cholewicki J. Trunk muscle activation in low-back pain patients, an analysis of the literature. Journal of electromyography and kinesiology. 2003 Aug 1;13(4):333-51.




Knee Tilt Mobilizations – Improve Knee Flexion Past 90

This is one of my favorite old school manual therapy techniques I learned while in Fellowship with the University of St. Augustine.

When my current techniques of tibial IR, lateral tibial glide, or other Functional Mobilizations I do in closed chain don’t work to improve knee flexion, I try this knee tilt.

It can be enhanced or made much more comfortable with an EDGE Mobility Band. Try this mobilization and let me know what your results are!