Articles Of The Week July 12, 2020


During a time when gyms, yoga studios…and well, everything else was closed. Many people took to running for their exercise regime. With that, quite often comes new kinds of injuries people have never dealt with before. Fortunately, our friend Laura Dunkley has and sheds some advice on this.

“Running In The Time Of The Coronavirus: Reducing Fear, Tolerating Uncertainty & Promoting Resilience” – Laura Dunkley

This is a phenomenal resource you can download to both use for yourself, but also to educate our patients on pain management.

“Pain Management Guidebook” – The Honest Physio

Most of us aren’t psychologists and yet we look at the biopsychosocial aspects of pain. Sometimes this can leave us wondering how to understand the psychological aspects of this, and how we can help our patients. Well, here’s a great chat from two people who are great at this and hoping to show us what we can do.

“Bronnie & Laura Chat: Compassionate Care, Not Just Clever Care” – Laura Rathbone & Bronnie Lennox Thompson

We all know how important mental health and well being is, some would even say it’s a super power. Here’s six steps you can use to improve your mental health with psychological flexibility.

“Psychological Flexibility: The Superpower of Mental Health and Wellbeing” – The Weekend University

We all know how big a fan I am of Walt Fritz, so I had to include this. In this podcast he talks about the importance of critical thinking and changing our narratives in manual therapy.

“BPS Aspects Of Manual Therapy” – Walt Fritz & Daniel Pablo Arbilla


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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Willy, R. W., & Meira, E. P. (2016). Current Concepts in Biomechanical Interventions for Patellofemoral Pain. International Journal of Sports Physical Therapy, 11(6), 877.

Rabelo, N. D. D. A., & Lucareli, P. R. G. (2018). Do hip muscle weakness and dynamic knee valgus matter for the clinical evaluation and decision-making process in patients with patellofemoral pain? Brazilian Journal of Physical Therapy, 22(2), 105–109.

Kim, Ji-Won, Oh-Yun Kwon, Tae-Ho Kim, Duk-Hyun An, and Jae-Seop Oh. 2014. “Effects of External Pelvic Compression on Trunk and Hip Muscle EMG Activity during Prone Hip Extension in Females with Chronic Low Back Pain.” Manual Therapy 19 (5). Scotland: 467–71.

Lehman, Gregory J. 2006. “Trunk and Hip Muscle Recruitment Patterns during the Prone Leg Extension Following a Lateral Ankle Sprain: A Prospective Case Study Pre and Post Injury.” Chiropractic & Osteopathy 14 (February). England: 4.

Suehiro, Tadanobu, Masatoshi Mizutani, Hiroshi Ishida, Kenichi Kobara, Hiroshi Osaka, and Susumu Watanabe. 2015. “Individuals with Chronic Low Back Pain Demonstrate Delayed Onset of the Back Muscle Activity during Prone Hip Extension.” Journal of Electromyography and Kinesiology : Official Journal of the International Society of Electrophysiological Kinesiology 25 (4). England: 675–80.

Dwyer, Maureen K, Kelly Stafford, Carl G Mattacola, Timothy L Uhl, and Mauro Giordani. 2013. “Comparison of Gluteus Medius Muscle Activity during Functional Tasks in Individuals with and without Osteoarthritis of the Hip Joint.” Clinical Biomechanics (Bristol, Avon) 28 (7). England: 757–61.

Tumminello, N., Silvernail, J., & Cormack, B. (2017). The corrective exercise trap. Personal Training Quarterly, 4(1), 6–15.

Articles Of The Week June 14, 2020


This is a PHENOMENAL resource for both practitioners and patients alike. Not only does it provide some education on the current research around Osteoarthritis, it provides exercise recommendations, and exercise programs…it’s FREE.

“OA Optimism” – Greg Lehman

Over the past couple weeks, I have taken some time to reflect and have conversations with friends who are far more educated and experienced than me on race and diversity. This is a great resource we can all use to help educate ourselves so we can all have a better understanding.

“Race, Diversity and Cultural Competency Resources for Massage Therapists” – Meg Donnelly

This is a great resource you could share with your patients around some of the myths of low back pain. The best part is it’s presented by people who have lived with chronic back pain!

“10 Facts Every Person Should Know About Back Pain. Presented By Patients”Pain Ed

Much like the last article, it is always important to understand the patient’s perspective when it comes to pain. With this small blog post, a chronic pain patient shares their thoughts on overcoming fear and movement.

“A Path Forward” – Keith Meldrum

I honestly didn’t know that ankylosing spondylitis may be portrayed as a ‘man’s disease’. According to this article, there are hundreds of thousands of women living with it, many undiagnosed. Here are eight things to understand about AS and how it affects women.

“Ankylosing Spondylitis in Women: 8 Key Facts to Stop the Stigma” – Lauren Gelman


Crossed Arm Syndrome


I understand the trend toward patient-empowerment, trying to build self-efficacy without risking dependency on the clinician. This has elevated the interventions of education and exercise over manual therapy in terms of best-practice recommendations for physical therapists.

As a long-term PT, I can understand this movement, but the trend comes at a price.

First off is the belief that manual therapy, viewed as a passive intervention, should be dosed sparingly as to not encourage dependency. In contrast, I contend that if manual therapy allows movement with less fear, pain, and caution, this, in itself, builds independence.

I do accept that more common view of PT is the exercise-based model, though I have HUGE issues with intellectual lazy PTs who blame weakness on pain. What I don’t and will not accept is an apparent lack of engagement on the part of my profession.

I have great respect for the time, patience, money, and emotional investment that a budding PT student makes to become a DPT, as it is not an easy path. But what are we building?

Recently I had dropped my car off for a service at a local repair facility. Rather than join the squad impatient chair-sitters, waiting for word of the bill in need of payment, I chose instead to take a long walk. This walk afforded me an opportunity to cruise through the nearby picturesque village, able to see the sights while getting my exercise. My walk took me past the village PT clinic…twice, once on my outbound journey, and again on my way back to the garage.

On my first pass, I was easily able to view a good handful of patients dutifully working out on at their respective stations, all seeming to be completely engaged in their tasks. But at the center of the facility, I viewed two individuals who I am assuming where the resident PTs. How did I know this?

Apparel, for one. They were the only ones NOT engaged.

Instead, they stood side by side, talking with each other, in the dreaded arms-crossed posture. Argh! OK, I thought, as I passed, maybe I caught them at a bad moment. Maybe it was a fluke. I’ll take a look on my way back, hoping that they would not be caught in such a compromising position.

The walk took me through the rest of the village and, with a bit of a divergence, along a roaring creek. Quite lovely. But as I again approached the PT clinic my suspicions rose and, sure enough, there they stood. Maybe they have moved and returned to the exact same spot to converse again…or maybe not. But there they stood, arms-crossed and conversing, while their patients dutifully went through their paces.

A PT may argue that those patients were engaged in self-helping behaviors, learning self-reliance, and building upon their own potential. Quite possibly.

But why did the PTs need to be standing there so unengaged? We can be more than arm crossers, we can be cheerleaders, encouragers, coaches, teachers, and, yes, occasionally, applying manual interventions. Self-reliance is key, but what has the PT profession become; a bunch of arm crossers? Manual therapy PT has its own skulls in the closet, but that’s not what this post is about. It’s about arm crossing.

My bias is toward using manual therapy as a primary intervention and evidence exists for this as a viable treatment strategy. I strongly discourage dependency of any sort and abhor it in other professionals. My work is set up to empower my patient to feel like they can move and with less fear. I teach them to self-treat, based on my examples, and make it a strong encouragement to engage in the movement of their choosing. I recognize that a good majority of patients seen for exercise-based PT improve, though those that don’t often come through my door.

As a profession, PT and other similar professions, the view of us by the public matters. Arm-crossing and spending a good amount of your time conversing with your peer instead of your patient is simply a lame way to spend medical dollars, not to mention a very expensive education.

Next time I make that walk, my hope is to see PTs engaged with their patient. They may not be touching, using manual therapy as I do, but I hope to see them spending time speaking to their patients, coaching and encouraging, aiding and correcting, prescribing, and adapting. I hope to see them doing the things our profession(s) are capable of and not resorting to the stereotypes that pockmark our profession.


Articles Of The Week June 7, 2020

We published an article earlier this week about the therapeutic alliance. What we didn’t talk about in that article is how it is our responsibility to build and maintain that relationship. Fortunately, there are other therapists out there blogging and covering why this is important.

“Welcome to My Practice: The Rules of Conduct” – Jennifer Fleming

We preach regularly about evidence-based practice around here. This article lays out not only the importance of this, but also how to be reasonable about it when taking into account our clinical experience.

“Science versus Experience in Musculoskeletal Medicine” – Paul Ingraham

This past couple of months have been hard on everyone’s business. As a result, many of us could be experiencing some self-doubt regarding their progress and business success. This self-doubt can have major impacts on how we do things, but there are ways to curb this thinking and get back on track.

“Why Questioning Yourself STOPS Your Business – & How To Fix It!” – Vicki Marsh

If you’ve been following this blog for any length of time, you know how strongly we feel about exercise. While the findings and studies are new and limited still, there is emerging evidence to show how important exercise is an effective way to manage stress during to local public health restrictions.

We have published many an article showing how to do graded exposure with patients. While this article is directed towards mental health professionals, the same arguments can be made about exposure therapy in a massage clinic setting. But, if we buy into misconceptions we’re less likely to use something that’s REALLY effective, however, we should be using this with all the confidence that its evidence base deserves.

“Myths About Exposure Therapy” – Dr. Carmen McLean

Creating Sustainability With Therapeutic Alliance


As different parts of the world start to come out of isolation and begin pondering what work will look like, we have to acknowledge that things are going to be different…forever. 

I’ve seen the question asked “who in this profession is going to make it”? 

There was some debate around this and a few comments I’ve seen are things like:

  • “massage is a luxury, only those who have money are coming back”
  • “Only medical massage therapists will pull through”
  • “Only those who work in a clinical setting will be able to recover” 

Well, the reality is, none of that is true and it quite frankly doesn’t matter what setting you work in. 

This is what determines who will be successful after this pandemic, or any other one we may face down the road.

Using Trust To Create Sustainability

It’s not often I say this, but I have to give some kudos to our college. 

While they put in the effort to put together a return to work document1 for our reference and give us some direction on how we should handle things, there was a central point they made in the direction. 

Build trust with your patients. 

They outlined cleaning procedures, PPE protocols, and new consent instructions, yet at the heart of it all was the direction to do or wear these things in front of your patient, if for no other reason than to build their trust in you as the healthcare professional. 

It’s honestly the first time I’ve seen something like this from our regulatory body, and I applaud them for it. 

Along with this was a perspective piece written in the New England Journal of Medicine2, although it was written from a doctor’s perspective, I couldn’t help but see how this is applicable to us as therapists. 

In the article, they talk about the importance of relying on evidence-based practice. While this is always important, at a time like this that importance is amplified as patients and therapists alike could be making decisions based on fear and emotion, which in turn can result in falling prey to cognitive bias and making therapeutic errors. 

Since our role as therapists is to provide safe, effective care we need to have what this article calls a “healthy skepticism” and keep our clinical equipoise when considering any intervention. 

If we don’t retain this healthy skepticism we run the risk of relying on personal anecdotes where all too often in our profession we see people saying things like “I know it works because I’ve seen it work” while at the same time refuting and even sometimes refusing to accept research into their practice. 

When things like this happen it is usually a result of what the article calls “the intense desire to try new and unproven remedies”. Think about how this applies to many of the continuing education courses we see in our profession. Many of them don’t have research to prove their unsubstantiated claims and yet we look to try this new intervention possibly making therapeutic errors.

Of course, all done with the absolute best of intention trying to help our patients. 

If we are going to be successful once this is all over and we want to build sustainability in our practice, this has to change. 

As tough as this whole shutdown has been, it has also created an opportunity for change. As we move forward trying to build trust with our patients while also gaining sustainability in this profession, there’s one other golden nugget we need to look at. 

Therapeutic Alliance

There are many things that influence our treatment outcomes that go well beyond whatever our favourite modality is. 

Some of these are referred to as non-specific or contextual factors.3

Part of these factors is the therapeutic alliance we have with our patients which can be defined as: 

“The working rapport or positive social connection between patient and therapist”3 




“Established between therapist and client through collaboration, communication, therapist empathy, and mutual respect”4


This systematic review4 showed there were 8 major themes associated with therapeutic alliance: 

  • Congruence
  • Connectedness
  • Communication
  • Expectation
  • Influencing factors
  • Individualized therapy
  • Partnership 
  • Roles and responsibilities 

Now, we could probably write an entire article on each one of these 8 themes, how it applies to us in practice,  and how we could effectively use them, but let’s leave that for a later date.

For now, let’s just consider what was most important to the patients. 

Of those 8 themes the most important determinants of a therapeutic alliance in the eyes of the patient were: 

  • Communication
  • Interpersonal aspects
  • Partnership
  • Roles and responsibilities

Another thing the review showed was both patient and therapist agree that effective communication improved treatment adherence. They also found that agreement on goals and tasks, sense of connectedness, positive feedback, genuine interest, individualized care, trust in the therapist, and feeling empowered were all important predictors of exercise or homecare adherence.

The way we communicate, listening, sending appropriate messages and words of encouragement actually has an influence on reduction in pain.However, it’s important to note that making inappropriate comments can actually make patient’s symptoms worse (which also demonstrates why communication is so important in the patient’s eyes).

They also came to understand a few more sub-categories important to build this alliance. Included are humour (I can only use a limited supply of this as my sense of humour is pretty offside), emotional intelligence, appreciation, honesty, clarity of information and feedback, support and follow up. 

Are you as excited as I am when looking at these lists?

I’m sure most of us are already doing many of these things in our practice, but how often do we practice them, get better at them, take a course on them? While they are deemed “soft skills” the research is showing us these things should be at the forefront of our practice. 

And the great thing…we get to spend more time with our patients than most other manual therapists and we can literally practice most of these things during our treatments. This was another one of the things that positively influenced outcomes, the amount of time spent with the patient along with warm, empathic interaction!So while there was no way for us to predict this pandemic, there are ways for us to create sustainability in our career. Massage therapy as a profession isn’t going anywhere, people will still need help, and still want to be touched in a therapeutic way. Unfortunately, some clinics won’t recover from this which is an absolute travesty that no one deserved to go through. But the best way to create sustainability is by enhancing and developing strong therapeutic relationships with our patients. With that strong relationship, should something like this ever happen again, those patients will be waiting for your clinic doors to open again because they trust you will do what’s best for them. As we start our clinics up again, while it won’t be the same, there is a genuine opportunity to start building that trust again while creating sustainability in your practice. 


  2. Zagury-Orly I, Schwartzstein RM. Covid-19—A Reminder to Reason. New England Journal of Medicine. 2020 Apr 28
  3. Fuentes J, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical therapy. 2014 Apr 1;94(4):477-89.
  4. Babatunde F, MacDermid J, MacIntyre N. Characteristics of therapeutic alliance in musculoskeletal physiotherapy and occupational therapy practice: a scoping review of the literature. BMC health services research. 2017 Dec;17(1):375.