Top 5 Fridays! 5 Outdated Pain Explanations or Why You Cannot Dabble in Pain Science Education | Modern Manual Therapy Blog

Top 5 Fridays! 5 Outdated Pain Explanations or Why You Cannot Dabble in Pain Science Education

Thankfully, many blogs like mine, Zac Cupples, The Hybrid Perspective, Eat, Run, Rehab, and more have exposed many readers to Pain Science Education.

This is not a topic however, that you can "sometimes use" or just save it for "chronic pain patients." If you really mean to be a Modern Manual Therapist, you need to give up the following things

1) Using Pathoanatomy to explain why someone is in pain
  • this includes structural explanations that happen insidiously (as in not acute physical trauma), using imaging to explain why someone is in pain (degeneration, spurs, pinched nerves)
  • you can't say, pain is an output in response to perceived threat on one low back pain patient, and then the next one say it's from a rotated innominate or weak core
  • i.e., rotated pelvis, muscle imbalance, slipped or buldging discs, locked facets, trigger points, scar tissue, tissue adhesions
  • even if a patient is stuck on any of the above concepts, I tell them the reality of it, and still say, these self treatments will help your "insert pathoanatomical cause here" - but I try my best to de-emphasize
  • an example of changing association - change "slipped disc with pinched nerve" to "forward bending/sitting being a threat to your brain, walking and standing is not"
  • emphasizing the not is important as they realiize the picture of what their spine looks like when they are lying in a tube is constant, but the perception of threat is different depending on movements/positions

2) Thinking it is ok to regularly cause pain or discomfort during the evaluation, manual treatment or exercises
  • on true chronic pain patients, this may be unavoidable, if they have constant pain, but in the least, this should not increase during any intervention as much as possible
  • mash on painful/tender points hoping they go away - caveat - you tried everything else pain free, and the only thing that helped was a painful technique that the patient has positive expectation of benefit
  • if you regularly tell patients, this might hurt, or you may be sore after treatment, you're using too much force, over stimulating the nervous system, or mashing too hard

3) Using a lot of passive treatments that the patient cannot replicate
  • part of being a Modern Clinician is to educate the patient on the transient effects of passive treatments
  • they must be educated on self assessment for baselines and self treatments to keep the nervous system vigilance low
  • you should start with the least amount of treatments, and force possible
  • the first line of treatment being positional relief or repeated motions in the directional preference is empowering to the patient since they can do the same treatment at home
  • manual treatments should be used if they cannot get to end range, only with the expectation that it is to help them perform self treatment
  • we're just gaining range faster than if the patient kept trying to convince their own nervous system that the movement was ok, but it's not needed, and the patient must understand that

4) Acting like the patient needs your hands or treatments regularly to stay better
  • sure treatments require reinforcement to keep the positive benefits going, but these can be easily extended with the right education, mindset, and self treatments
  • since going cash based, I have reduced frequency from the typical 2 times a week for 1-2 weeks, to 1 time a week for 2 weeks, then 1 time every other week, and most patients are done by that time

5) Blame pain on a "weak core"
  • motor control is one thing, but that is also altered when in pain
  • once the nervous system is reset or pain/stretch is modulated, movements that previously tested "weak" are often strong and painless
  • if the core was "weak" doing any number of strengthening exercises would not yield rapid benefit, as true tissue hypertrophy takes time
  • the rapid changes are neurophysiologic, meaning, restoration of motor control and/or disassociation of pain with a particular movement/position

Sure, after taking one of the first Explain Courses ever offered in the US in 2002, I "dabbled" in Pain Science, and slowly integrated it into my practice and daily interactions with patients. Now, it's the only way I explain pain, movement, and treatments to patients. It's liberating, and if you go all in, you are providing patients with true solutions, not focusing on physical problems that cannot be or do not need to be changed.

Keeping it Eclectic...


  1. I've done some PRI and SFMA cont ed and I'm really interested in using pain Science education more. But I have a couple of questions,
    We can't forget the bio part of biopsychosocial, right? Some patients have physiological reasons for pain, otherwise surgery would never help pain. Sometimes someone needs a hip or knee replacement, right? I think you are right for a large majority of people, but I'm not sure it's for 100%.
    what do you think about PRI in respect to the above? Seems like it regularly violates 1 and 4 above, 1 much more than 4. I've also started to think that SFMA is less important vs pain Science, I am feeling it's much less important to get people to FN than getting them thinking about pain differently. Thoughts?

  2. There is no 100%, and that is for 100% sure! Yes, even Lorimer Moseley says we cannot forget the bio, and I professionally dislike the term biopsychosocial, because of the tendency to forget the bio, even though it comes first. In terms of PRI, I have only taken the home courses, but not sure if Zac puts the neuro spin on it more than the instructors do, but yes, that along with traditional OMPT and osteopathic courses are way too structural. The good thing about Pain Science is it can neatly integrate into any method you use, but it's all about practicing and perfecting your ability to scale your language up and down depending on the level of patient comprehension. That is the art. Saying what they need to hear to alleviate their anxiety and disassociate pain with movement. Changing their framework and negative thoughts about pain is paramount, but manual therapy and exercise are still very important in most cases. Some combination of all of those concepts is how I practice, sometimes using more of one than the other depending on patient need and response.

    We cannot predict why anatomy matters for some and not the other. But still, the best predictor of long term success after TKA is not ROM, strength, prior function, it was fear avoidance.

  3. I'm really intrigued by your last statement and I was wondering if you could refer me where that information is coming from, I would like to integrate it when I discuss it with my patients but I'd like to read up on how that conclusion was met. Thanks.

  4. You mean the entire last point or the neurophysiologic changes statement? Either way start here

  5. Sorry, should have been more specific, the part about the TKA and fear avoidance vs strength. Thanks!

  6. Jason, sorry! I replied, but it didn't seem to save! In terms of the bio, even Moseley says we can't forget about the bio in biopsychosocial. Sure the periphery matters and nothing for sure is 100%. However, part of being a modern therapist is to embrace what Pain Science tells us and to change the way we explain concepts, treatments, and pain to our patients. PRI is rooted in pathoanatomy and for the wrong patient, that promotes anxiety and the thinking that their pelvis/rib cage is rotated. Even though we cannot predict why pain happens in some cases of "degeneration" and most it does not, still to ensure better post surgical outcomes, patients need to have their fear avoidance lowered as that is the best predictor of long term outcomes.