How Changing Our Habits Can Change Our Practice

Change can be difficult. Like, REALLY difficult.

In fact, we’ve written posts on here a few times regarding different ways therapists are stuck (or refuse to change) the way they practice. Quite often because of not wanting to include research in their practice, or committing to the new narratives around pain science etc.

If we did change, it often feels like a daunting task where the things we have been doing for so long have to change, and in turn there is sometimes fear around how our patients would react when this change occurs.

In the past, I’ve often chalked this up to the methods we use, or techniques we love become part of our identity and thus we don’t want to change.

While I still believe this to be true, it can’t be the only reason.

While reading a book recently, it dawned on me there could be another reason, which most of us probably don’t even realize. Mainly because this occurs subconsciously, it happens routinely, is performed regularly, and most of the time just happens automatically.

What I’m referring to a simple word that most of us don’t realize we are doing with every patient who comes in to see us.


Little Seeds Of Change

Quite often when teaching or discussing different concepts around manual therapy with other practitioners, inevitably the topic always comes up “how do I incorporate this in practice”?

I’d say this is especially true with Massage Therapists and discussing how to begin including movement and exercise into treatments (this is just my take on discussions I’ve had with therapists, not the general rule).

There is usually a concern where the patient comes in and just wants to get on the table and get their treatment going. Even to the point of looking at their watch in an attempt to make sure they get their full hour on the table.

This was also true as I started getting interested in pain science and while learning along the way had to change my narrative with patients. I was genuinely worried (also due to my lack of confidence) that patients would think I sounded like I was out to lunch and start seeing a different therapist.

Well, the reality is, when I started doing more of both, not one of my patients ever looked at me and refused to do a movement, or told me they thought I was out to lunch (they may have thought it but never said it to me), and they very well could have because I’m sure it sounded like I was vomiting all this new information at them.

However, there is a way to do this in a much better way than I did when I first started trying to incorporate these things into my practice.

When we are trying to create change with a patient it’s usually about planting little seeds of information and playing the long game. It’s not always about making huge, grand changes all in one session. It’s about incorporating small changes over a longer period.

Perhaps it’s making one small change in an activity of daily living until eventually several changes are made and your patient adapts to a new routine or exercise until it becomes a habit.

So, if this approach can and does work for our patients, what if we took the same approach with our practice?

Changing Our Habits

In his book “Atomic Habits” James Clear breaks down how to build good habits and break bad ones.

One of the things I found really interesting was a quote from the book talking about habit change, I couldn’t help but relate it to how so often our techniques become part of our identity in our practice:

“The real reason habits stick is that it becomes part of your identity, improvements are only temporary until they become part of who you are”

“When you have repeated a story to yourself for years, it is easy to slide into these mental grooves and accept them as a fact. In time, you begin to resist certain actions because “that’s not who I am”. There is internal pressure to maintain your self image and behave in a way that is consistent with your beliefs. You find whatever you can to avoid contradicting yourself”

Just about everything we do in our clinic is a habit without even realizing it.

The way we greet a patient when they come in, the way we sit in our clinic room with them when they first arrive, the way our hands make initial contact with them when they’re on our table…all habits. We’re probably more likely to call it a routine, but these are all habits we’ve created, which is also part of the reason you’re successful.

Your patients REALLY like this routine.

And the thing is, so do we! It’s comfortable and familiar, which makes change all that much harder.

However, if we truly want to grow in our practice, it’s a matter of us deciding we will change, not making the patient change (although this will happen gradually).

This can also be daunting because it can feel like we’ll get left behind (making it all that much easier to stay in our groove), which is overwhelming, I mean, it takes 17 years before research is actually implemented in most medical practices, so it’s not like we’re going to get left behind by attempting to change what we do in our practice.

In this book, James talks about how to create new habits by doing something called “habit stacking”. To do this you identify a current habit you already do each day and then stack your new behaviour on top of the current one. As you begin to master the structure of doing this, you create larger change by incorporating more of these small changes until these new habits are formed.

Could we just start by asking one new question during our intake and do it with each patient one day, then the next, until it becomes part of our normal conversation with a patient? Once this becomes our new normal, we could include one graded exposure movement before each treatment? When this becomes part of the routine, start to incorporate movement into a treatment, then homecare, etc. Even if all we do is just change by a small fraction each day or week, this can have a profound change in our practice and our patients over the long term. As this adds up you can have some breakthrough moments that not only make you a better therapist but can enhance your career. And the best part is, while you gradually make this change, your patients will change with you without them realizing it. These changes will become an expected part of your treatment and hopefully, they won’t be checking their watch at the start of the treatment.

If you’re curious or want to know more about habit change and how it can help you and your patients, I highly recommend “Atomic Habits” which you can get HERE.



Articles Of The Week July 26, 2020

This is a great podcast from a pain researcher and an exercise physiologist so you can better understand central sensitization and pain. Great stuff!

“Central Sensitization And Pain” – Ben Cormack & Melissa Farmer

You know if there’s something regarding exercise and pain, we’re going to share it. This one I really like as it focuses not so much on a specific exercise, but physical activity, and the person in front of you.

“Exercise And Pain, An Opinion Piece” – Rhyesson Cornilla

I really like this one, as I have a disdain for insurance companies due to my former life before being an RMT. But, this shows us how to help those who have pain, yet no objectionable measure of pain to in turn satisfy said insurance companies.

“Secondary Gain, Really?” – Bronnie Lennox Thompson

We are constantly talking to patients recommending self-care. But, what are we doing for ourselves when it comes to self-care? Here’s some dynamite advice on how to do just that.

“How to Customize a Self-Care Plan That Works For You” – Aleksandra Slijepcevic

This pandemic has changed a lot of things. One of which is the way we provide first aid to people. For me at work, we’ve gone through massive changes in the way we do things at the Firehall. For those of us in sport, this outlines some changes we should take into account.

“Medical Care And First Aid: A Framework For Organised Non-Elite Sport During The COVID-19 Pandemic” – Steffan Griffin


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 ; )

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.

References (in rough order of appearance.)

O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Physical Therapy, 98(5), 408–423.

Melzack, R. (2010). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378–1382.

Brinjikji, W., F. E. Diehn, J. G. Jarvik, C. M. Carr, D. F. Kallmes, M. H. Murad, and P. H. Luetmer. 2015. “MRI Findings of Disc Degeneration Are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis.” American Journal of Neuroradiology 36 (12).

Lederman, E. (2011). The fall of the postural-structural-biomechanical model in manual and physical therapies: Exemplified by lower back pain. Journal of Bodywork and Movement Therapies, 15(2), 131–138.

Foster, N. E., Anema, J. R., Cherkin, D., Chou, R., Cohen, S. P., Gross, D. P., … Woolf, A. (2018). Prevention and treatment of low back pain: evidence, challenges, and promising directions. The Lancet, 391(10137), 2368–2383;

Riley, S. P., Swanson, B. T., & Dyer, E. (2018). Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain? A systematic review. Journal of Manual & Manipulative Therapy, 1–10.

O’ Sullivan, P., & Caneiro, J. P. (2016). Unraveling the Complexity of Low Back Pain. J Orthop Sports Phys Ther 2016;46(11):932-937.

Smith, B. E., Littlewood, C., & May, S. (2014). An update of stabilisation exercises for low back pain: A systematic review with meta-analysis. BMC Musculoskeletal Disorders, 15(1);

Ferreira, M. L., Ferreira, P. H., Latimer, J., Herbert, R. D., Hodges, P. W., Jennings, M. D., … Refshauge, K. M. (2007). Comparison of general exercise, motor control exercise and spinal manipulative therapy for chronic low back pain: A randomized trial. Pain, 131(1–2), 31–37.

Marcuzzi, A., Wrigley, P. J., Dean, C. M., Graham, P. L., & Hush, J. M. (2018). From acute to persistent low back pain: a longitudinal investigation of somatosensory changes using quantitative sensory testing — an exploratory study. Pain reports, 3, 1–10.

Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 3985(September).

Borenstein, D G, J W O’Mara, S D Boden, W C Lauerman, A Jacobson, C Platenberg, D Schellinger, and S W Wiesel. 2001. “The Value of Magnetic Resonance Imaging of the Lumbar Spine to Predict Low-Back Pain in Asymptomatic Subjects : A Seven-Year Follow-up Study.” The Journal of Bone and Joint Surgery. American Volume 83–A (9): 1306–11.

Connor, Banks et al. (2003) Magnetic Resonance Imaging of the Asymptomatic Shoulder of Overhead Athletes. A 5-Year Follow-up Study. Am J Sports Med September 2003, Vol. 31, No. 5, 724–727.

Hill, A. L., Aboud, D., Elliott, J., Magnussen, J., Steffens, D., & Hancock, M. (2018). Recover Injury Research Centre and Centre of Research Excellence in Recovery Following Surgical Outcomes Research Centre ( SOuRCe ), Royal Prince Alfred Hospital , Sydney. The Spine Journal.

Tonosu, Juichi, Hiroyuki Oka, Akiro Higashikawa, Hiroshi Okazaki, Sakae Tanaka, and Ko Matsudaira. 2017. “The Associations between Magnetic Resonance Imaging Findings and Low Back Pain: A 10-Year Longitudinal Analysis,” 1–10.

Grundy, P F, and C J Roberts. 1984. “Does Unequal Leg Length Cause Back Pain? A Case-Control Study.” Lancet (London, England) 2 (8397): 256–58.

Pope, M H, T Bevins, D G Wilder, and J W Frymoyer. 1985. “The Relationship between Anthropometric, Postural, Muscular, and Mobility Characteristics of Males Ages 18-55.” Spine 10 (7): 644–48.

Grob, D., H. Frauenfelder, and A. F. Mannion. 2007. “The Association between Cervical Spine Curvature and Neck Pain.” European Spine Journal 16 (5): 669–78.

Nourbakhsh, M R, and A M Arab. 2002. “Relationship between Mechanical Factors and Incidence of Low Back Pain.” The Journal of Orthopaedic and Sports Physical Therapy 32 (9): 447–60.

Dieck, G S, J L Kelsey, V K Goel, M M Panjabi, S D Walter, and M H Laprade. 1985. “An Epidemiologic Study of the Relationship between Postural Asymmetry in the Teen Years and Subsequent Back and Neck Pain.” Spine 10 (10): 872–77.

Franklin, Mary E., and Teresa Conner-Kerr. 1998. “An Analysis of Posture and Back Pain in the First and Third Trimesters of Pregnancy.” Journal of Orthopaedic & Sports Physical Therapy 28 (3): 133–38.

Barrett, Eva, Mary O’Keeffe, Kieran O’Sullivan, Jeremy Lewis, and Karen McCreesh. 2016. “Is Thoracic Spine Posture Associated with Shoulder Pain, Range of Motion and Function? A Systematic Review.” Manual Therapy 26 (December): 38–46.

Richards, K. V., D. J. Beales, A. J. Smith, P. B. O’Sullivan, and L. M. Straker. 2016. “Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents.” Physical Therapy 96 (10). Oxford University Press: 1576–87.

Andrade, Nicholas S., Carol M. Ashton, Nelda P. Wray, Curtis Brown, and Viktor Bartanusz. 2015. “Systematic Review of Observational Studies Reveals No Association between Low Back Pain and Lumbar Spondylolysis with or without Isthmic Spondylolisthesis.” European Spine Journal 24 (6). Springer Berlin Heidelberg: 1289– 95.

Ettinger, B, D M Black, L Palermo, M C Nevitt, S Melnikoff, and S R Cummings. 1994. “Kyphosis in Older Women and Its Relation to Back Pain, Disability and Osteopenia: The Study of Osteoporotic Fractures.” Osteoporosis International .4 (1): 55–60.

Damasceno, Gerson Moreira, Arthur Sá Ferreira, Leandro Alberto Calazans Nogueira, Felipe José Jandre Reis, Igor Caio Santana Andrade, and Ney Meziat-Filho. 2018. “Text Neck and Neck Pain in 18–21-Year-Old Young Adults.” European Spine Journal 27 (6).

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.

Hartvigsen, Jan, Charlotte Leboeuf-Yde, Svend Lings, and Elisabeth H Corder. 2002. “[Does Sitting at Work Cause Low Back Pain?].” Ugeskrift for Laeger 164 (6): 759–61.

Wai, Eugene K., Darren M. Roffey, Paul Bishop, Brian K. Kwon, and Simon Dagenais. 2010. “Causal Assessment of Occupational Lifting and Low Back Pain: Results of a Systematic Review.” The Spine Journal 10 (6): 554–66.

Kwon, B. K., D. M. Roffey, P. B. Bishop, S. Dagenais, and E. K. Wai. 2011. “Systematic Review: Occupational Physical Activity and Low Back Pain.” Occupational Medicine 61 (8): 541–48.

Waddell, G., Burton, A.K., Mar 2001. Occupational health guide- lines for the management of low back pain at work: evidence review. Occup. Med. (Lond) 51 (2), 124e135 (Review).

Shiri, Rahman, Jaro Karppinen, Päivi Leino-Arjas, Svetlana Solovieva, and Eira Viikari-Juntura. 2010. “The Association between Smoking and Low Back Pain: A Meta- Analysis.” The American Journal of Medicine 123 (1): 87.e7-87.e35.

Hoogendoorn, W E, M N van Poppel, P M Bongers, B W Koes, and L M Bouter. 2000. “Systematic Review of Psychosocial Factors at Work and Private Life as Risk Factors for Back Pain.” Spine 25 (16): 2114–25.

Hodges, Paul W., G. Lorimer Moseley, Anna Gabrielsson, and Simon C. Gandevia. 2003. “Experimental Muscle Pain Changes Feedforward Postural Responses of the Trunk Muscles.” Experimental Brain Research 151 (2): 262–71.

Saragiotto, Bruno T, Christopher G Maher, Tie P Yamato, Leonardo O P Costa, Luciola C Menezes Costa, Raymond W J G Ostelo, and Luciana G Macedo. 2016. “Motor Control Exercise for Chronic Non-Specific Low-Back Pain.” The Cochrane Database of Systematic Reviews, no. 1 (January). England: CD012004.

Riley, S. P., Swanson, B. T., & Dyer, E. (2018). Are movement-based classification systems more effective than therapeutic exercise or guideline based care in improving outcomes for patients with chronic low back pain? A systematic review. Journal of Manual & Manipulative Therapy, 1–10.

Azevedo, Daniel Camara, Paulo Henrique Ferreira, Henrique de Oliveira Santos, Daniel Ribeiro Oliveira, Joao Victor Leite de Souza, and Leonardo Oliveira Pena Costa. 2018. “Movement System Impairment-Based Classification Treatment Versus General Exercises for Chronic Low Back Pain: Randomized Controlled Trial.” Physical Therapy 98 (1). United States: 28–39.

Dillen, L., et al. 2017. Efficacy of classification-specific treatment and adherence on outcomes in people with chronic low back pain. A one-year follow-up, prospective, randomized, controlled clinical trial. Man Ther. 2016 August ; 24: 52–64

Timmons, Mark K, Chuck A Thigpen, Amee L Seitz, Andrew R Karduna, Brent L Arnold, and Lori A Michener. 2012. “Scapular Kinematics and Subacromial-Impingement Syndrome: A Meta-Analysis.” Journal of Sport Rehabilitation 21 (4). United States: 354–70.

Ratcliffe, Elizabeth, Sharon Pickering, Sionnadh McLean, and Jeremy Lewis. 2014. “Is There a Relationship between Subacromial Impingement Syndrome and Scapular Orientation? A Systematic Review.” British Journal of Sports Medicine 48 (16): 1251–56.

Struyf, F., J. Nijs, S. Mollekens, I. Jeurissen, S. Truijen, S. Mottram, and R. Meeusen. 2013. “Scapular-Focused Treatment in Patients with Shoulder Impingement Syndrome: A Randomized Clinical Trial.” Clinical Rheumatology 32 (1). Springer-Verlag: 73–85.

Camargo, Paula R, Francisco Alburquerque-Sendin, Mariana A Avila, Melina N Haik, Amilton Vieira, and Tania F Salvini. 2015. “Effects of Stretching and Strengthening Exercises, With and Without Manual Therapy, on Scapular Kinematics, Function, and Pain in Individuals With Shoulder Impingement: A Randomized Controlled Trial.” The Journal of Orthopaedic and Sports Physical Therapy 45 (12). United States: 984–97.

McClure, Philip W, Jason Bialker, Nancy Neff, Gerald Williams, and Andrew Karduna. 2004. “Shoulder Function and 3-Dimensional Kinematics in People with Shoulder Impingement Syndrome before and after a 6-Week Exercise Program.” Physical Therapy 84 (9). United States: 832–48.

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