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Tuesday, June 6, 2023

Where does pain science fit, and how does it affect practice?

Brent Brookbush

Brent Brookbush


Panel Discussion: Where does pain science fit, and how does it affect practice?

Pain science has become a popular topic among human movement professionals. More and more research is being published, but how should we use it? What is the practical implications of this relatively new science - how should we change our exercise selection, interventions, treatments and/or approach?

Moderated by Brent Brookbush DPT, PT, MS, PES, CES, CSCS, ACSM H/FS

This discussion started on my personal Facebook page - https://www.facebook.com/brent.brookbush  on Novemeber 22nd, 2014

Scotty Butcher Phd Not an expert on pain, but it really seems like the disconnect between movement science and pain science is finally coming to light.

November 22 at 11:55am

Kathy Benson Zetterberg Personally as a trainer if the pain is outside my expertise I refer clients off to appropriate medical or holistic docs.

November 22 at 11:56am

Scotty Butcher Phd As in, "sometimes people feel pain when they move, but you can't correlate that pain with the way they move." It seems like pain has a more significant effect on movement than the other way around.

November 22 at 11:59am

Mark Jamantoc I generally work with pain prior to strengthening. I do certain exercises to eliminate pain but if pain bothers function, I work on that first using specific manual therapy procedures.

November 22 at 12:00pm

Melinda Reiner Ultimately, the source of the pain needs to be diagnosed prior to addressing. Some systemic or non-orthopedic issues can mask as musculoskeletal pain.

November 22 at 12:09pm

Rick Daigle Pain science is not just "treating pain" rather it's a methodology of treating pain. In my opinion there is only one best practice way to treat- a combo of biomechanical models with pain science models. The issue is see is that there are 2 very distinct grroups/mindsets/etc. Being one sided is not doing right by your patient in my opinion. The human body is an electrical feedback loop with the brain being the circuit and the periphery being what provides constant feedback. The Brain relies on the body and the body relies on the brain.

November 22 at 12:29pm

Brent Brookbush Hey Scotty Butcher Phd,

"sometimes people feel pain when they move, but you can't correlate that pain with the way they move."

I have to disagree 100% with that statement. I have multiple studies in the research corner (https://brentbrookbush.com/online-courses/online-courses/category/research-corner ) that discuss the link between movement and various pathologies, and these pathologies are only known because pain was the precipitating factor that lead to consultation by a medical professional.

Further, this statement implies that my practice is wholly ineffective… now I know you mean no dis-respect, but I use an integrated movement impairment model for all treatment and I am very successful… most often where other PT's and DC's have not been (this is a function of people finding me through my education company, it is rare that I am the first professional they see).

I will say this… movement does not account for all pain, which is where pain science can make an important contribution.

Research Corner | Brent Brookbush

Previous studies have also alluded to delayed activation of GMED resulting in excessive hip adduction and internal…


November 22 at 12:30pm

Brent Brookbush I agree Kathy Benson Zetterberg,

Which is why the talk about the bio psycho social model of pain in fitness and even massage therapy forums has me a little buggered. This is not within the scope of practice of unlicensed professionals, or massage therapists who may be licensed but are not medical professionals… I don't see the point. Pain is a four letter word that should be the domain of licensed medical professionals only.

November 22 at 12:34pm

Brent Brookbush Hey Mark Jamantoc,

Not to call you out, but you mentioned that you "work with pain" first. Can you give me a list of "treatment options" that you would consider interventions for pain specifically?

November 22 at 12:35pm

Mark Jamantoc I Work on eliminating pain by finding out what causes it. Getting to the root of the issue. I also check if it's mechanical in nature and see if I can reproduce it or not. I do a more eclectic approach. No one technique jumps out.

November 22 at 12:42pm

Brent Brookbush Hey Rick Daigle,

I agree 100%, I certainly use pain models and the reading I have done regarding these models to influence my evaluation, communication and education of patients. We must continue to integrate best practices, but… you mentioned this great divide between pain and biomechanical mindsets. My question is this, the Bio Psycho Social and Mature Organism Models are not treatment approaches… what the heck do the pain people do to there patients if they are anti-mechanical… do they talk them out of pain?

November 22 at 12:44pm

Brent Brookbush Hey Mark Jamantoc,

So you are saying that not even you can divide mechanical issues from pain issues… they are intertwined?

November 22 at 12:45pm

Scotty Butcher Phd Hey Brent - no disrespect taken. I think you've misinterpreted my intent. Movement can, of course, cause pain and the way one moves can contribute to this (and, for the record, I spend much of my teaching time discussing and training students appropriate movement to avoid negative consequences of poor movement). I'm simply saying the relationship appears to be not as concrete as many professionals believe. The relatively recent research looking at how pain modifies movement certainly confounds a direct relationship in the other direction. We have much to learn in this area, for sure.

November 22 at 12:53pm

Rick Daigle I don't know if you can talk someone out of pain… We honestly do not truly know/understand pain in my opinion.

November 22 at 12:52pm

Leon Chaitow I'm not entering the deeper discussion here, but will leave a few comments - for once unsupported and based on experience/opinion (biased no doubt). Cognitive Behavioural Therapy (CBT) appears to focus on helping people understand and manage their pain rather than 'treating' it. Results can be surprising;ly good in chronic situations where fear is removed from the equation via education etc…..BUT - and it's a very big BUT….many therapists seem to hide behnd this model and to thereby avoid doing anything remotely practical in terms of modification of pain, restriction or instability….relying on the power of words. My private sense is that some such practitioners are just not very good at managing biomechanically induced or maintained pain - and that CBT and similar approaches are a virtual cop-out. This is not always the case of course, but it does seem that denigrating manual treatment methods and/or functional exercise methods sometimes involves just this mind-set.

November 22 at 12:55pm

Brent Brookbush My point Rick Daigle,

Is there are times when I don't understand what the "Pain People" suggest we do to our patients… When my shoulder impingment/cervical patient walks in on Monday, how do I deal with there issues if not through the use of a integrated movement impairment approach?

November 22 at 12:55pm

Perry Nickelston As Dan John says, 'If someone prescribes a one size fits all approach, I can guarantee one thing: It's wrong.' You don't need a Phd to see how that makes sense. There are many pieces in the pain puzzle.

November 22 at 1:00pm

Brent Brookbush I had a similar thought myself Leon Chaitow, but thought myself to be too inexperienced to make such a bold comment. Glad you said it.

November 22 at 1:04pm

Brent Brookbush Nice point Perry Nickelston - made all the more poignant by your profile pic

November 22 at 1:04pm

Perry Nickelston KISS makeup makes everything better.

November 22 at 1:06pm

Josh Hasenohrl I can tell you all one thing based on my personal experience. The NASM-CES model is the 1 thing that correct my low back and sciatic type pain, I say sciatic type because I went to DCs, DPTs and even got an MRI and analysis done by an Orthopedic Surgeon (which only showed minor stenosis). Movement assessment and continuation of the CES model are the only things that keep it away.

November 22 at 1:58pm

Mark Jamantoc I agree with Perry Nickelston. Wow. Learning a lot from this thread.

November 22 at 1:58pm

Brent Brookbush Hey Josh Hasenohrl,

The NASM CES model is very effective for reducing pain from a variety of orthopedic conditions… after all, the creator is a brilliant PT (Dr. Dr. Mike Clark). I hope to see more research regarding outcomes using the CES model in the future.

November 22 at 2:05pm

Brent Brookbush Hey Scotty Butcher Phd,

I agree that the relationships between pain and movement is certainly less than concrete, and I think many of us have always believed that pain and altered motion have a "chicken and egg" relationship.

Glad you clarified that statement for me.

November 22 at 2:08pm

Jinny McGivern Lots of great discussion on this thread!!! I like to use a lot of the current research into pain as an educational tool to help my patients understand some of the mechanisms that result in pain. I aim to demystify the pain experience for patient and empower them with self management strategies, such as diaphragmatic breathing, positioning, graded movement, etc. As a manual therapist, I use touch as a method of desensitization. If a patient demonstrates a high sensitivity to a very light manual contact in the painful area (even an "Ortho" patient) I apply that same contact to a "non painful" area of the body to demonstrate how sensitized the painful area of the body has become. This is a concrete example that helps the patient understand central sensitization, where the brain is hyper vigilant about generating a pain response to even non noxious stimuli. Explain Pain by David Butler and Taming Pain by Cheryl Wardlaw have been instrumental in helping me as a new physical therapist to understand the pain experience and how to share this information with my patients.

November 22 at 2:13pm

Brent Brookbush Great stuff Jinny McGivern, just the type of practical info I was looking for.

November 22 at 2:17pm

Jason Erickson There have been some good comments so far, but I think we need to understand something: pain science is NOT a method of treating pain, nor does it specifically fall within one scope of practice nor another.

Pain science is the body of knowledge that has been accumulated through decades of study and practice by many, many different health and fitness professionals. That body of knowledge informs us as to the nature of pain, how it develops, how/why it may become persistent/chronic, what things may make it better/worse, etcetera. There are multiple multidisciplinary organizations that focus on the study and treatment of pain, such as the International Association for the Study of Pain (IASP).

The IASP has developed and published a taxonomy of pain and pain-related terminology so that we can all use the same terms with a common understanding of what they mean. This is important to avoid misunderstandings. The IASP taxonomy can be found here:


The IASP also publishes "PAIN" an international peer-reviewed journal.

Any additional comments I make here, I'm sticking to the IASP taxonomy if you want to be clear about the definitions of the terms I use.

IASP Taxonomy - IASP

IASP's pain taxonomy


November 22 at 2:32pm · Like · 2 · Remove Preview

Steven Roffers "Pain is inevitable, suffering is optional."

November 22 at 3:00pm · Unlike · 3

Jason Erickson I also want to address what seems to be a misperception on Brent's part. Pain science is NOT "anti-mechanical".

Brent wrote, "My question is this, the Bio Psycho Social and Mature Organism Models are not treatment approaches… what the heck do the pain people do to there patients if they are anti-mechanical… do they talk them out of pain?"

There are no "pain people". There are, however, many thousands of professionals representing many different professions (MDs, DCs, PTs, PTAs, MTs, ATCs, PhDs, etc.) who are engaged in studying pain science and how to apply it in their work.

Depending on the patients/clients they see and their scope(s) of practice, those professionals use their knowledge of pain science to understand which medications might work better, or how/where/what to inject, to develop client education, to develop professional education, to guide their use of manual/movement therapies, etcetera.

Studying pain science isn't going to stop anyone from using the full range of options that fall within their scope(s) of practice. However, it may provide insights that enable them to use those options to greater effect.

November 22 at 3:25pm

Jason Erickson Brent wrote, "what the heck do the pain people do to there patients if they are anti-mechanical… do they talk them out of pain?"

This is an excellent example of "operator" thinking. An "operator" does things "to" their patients/clients. The locus of control is with the operator, not with the patient. It's essentially a one-way relationship, with the operator doing something to change their patient.

Pain science tells us that helping people in pain is enhanced/harmed by the nature of the interaction(s) between the patient and the professional. The old "operator" mode of thinking is being replaced by an "interactor" mode of thinking.

An interactor doesn't "do" anything to a patient/client. They do things "with" a patient/client. The locus of control is shared, rather than being one-way. The emphasis is on educating the patient/client to understand what they're dealing with, thereby empowering them to better manage their progress.

Here's a letter about the operator and interactor models that was written by a couple of PTs who use manual/movement therapies and patient education:


Therapist as operator or interactor? Moving beyond the technique

We very much enjoyed the excellent article by Bialosky…


November 22 at 3:44pm

Jason Erickson Here is a radio interview about the operator/interactor models with Diane Jacobs and Jason Silvernail, the authors of that letter:


Moving beyond the technique: From Operator to Interactor

Most human commerce involves a contractual nature of…


November 22 at 3:46pm

Brent Brookbush Hey Jason Erickson,

I do not disagree with anything that you have written, but you do seem to have taken one of my statements out of perspective.

1. Yes, "Pain people exist" - who bastardize the science you posted to bash a mechanical, biomechanical, or integrated neuromusculoskeletal approach… FACT

2. My statement, was only pertaining to those individuals. No one else. If you integrate all effective approaches into your treatment WE are on the same page - that most assuredly includes pain science if you are a licensed medical professional.

1. In the case of #1, I am with Leon Chaitow. You should read his post, he makes some great points.

November 22 at 3:51pm

Michelle Langsam I have been seeing a pain medicine and spine physician recently . The only medicine he prescribes are time little exercise movements . At first odd in the approach I did the homework and the results to manage pain has been quite remarkable . His theory is to break down a movement right back to a single plane .i am only allowed to to the movement to the point where there is no stretch and no pain . This is because he believes we do too much too soon moving in and out of comfort zones re injured the comfort zone gets smaller . He wanted me to remain in the comfort zone and take the challenge of the ex to its edges . That is always remaining in the comfort zone and expanding it . I really like his concept and the spine pain is virtually gone in 4 weeks , though now I have hip stuff to work on.

His focus is to unload tension in the joints that is causing pain stress and doing it naturally so the brain can create new ways to fire with the nervous system joints and muscle .

Therefore this concept suggests we may be over training and over paining workouts for injury recovery . I'm liking this concept

November 22 at 6:29pm

Michelle Langsam I missed one extra point that he firmly believes pain and injury degree do not necessarily go hand in hand .

November 22 at 6:31pm

Jason Erickson Okay, I'll concede that there may be people who rely primarily/solely upon cognitive behavioral therapy (CBT). I've never met one, other than possibly a mental health professional who works primarily with pain management.

I have met a few people who believe that the traditional mechanical/biomechanical/postural/structural ways of thinking about and working with people in pain are dead ends. To my knowledge, all of them use manual/movement methods to help their clients. So, it's not so much the methods they use, but rather their conceptual model that shapes their approach to how/when/why those methods are used.

Brent said, "If you integrate all effective approaches into your treatment WE are on the same page - that most assuredly includes pain science if you are a licensed medical professional."

There you go again. That's the second or third time you've seemed to state that only licensed medical professionals should integrate pain science concepts into their work.

That concerns me a bit, because I've been using pain science concepts in my work for over five years, yet I'm not a licensed health professional. Worse, I've taught classes that were attended by licensed health professionals, and some of them have asked me to come teach in their area(s) afterwards. I'm only teaching them what I know and use in my own practice. I must be leading them astray, or something.

However, I may be misunderstanding what you're trying to say, Brent. Please elaborate so that I can completely understand your perspective and not make assumptions.

It's very important that I know where you're coming from before I dive into the many, many ways that pain science informs the way I work as a massage therapist, as a personal trainer, as a mentor to other therapists and trainers, and as a teacher.

Don't hold back on your concerns. Let's be completely frank.

November 23 at 12:36am

Leon Chaitow Michelle what your physician is doing has strong echoes of the McKenzie rehab approach in which all movements that provoke pain are avoided and those that are pain-free/easy are encouraged. This is a well-validated approach that it would be hard to argue against.

November 23 at 1:28am

Jim Horn Great discussion Brent. I was just curious if this was initiated in part based on the long back-and-forth threads found on the "Evidence Based Physical Therapy" LinkedIn forum? Very interesting discussions over the past couple of years. While often heated at times, it's been a great sharing of information and ideas. At the end of the day, it's these "debates" that will hopefully lead to better outcomes for our patients/clients. Keep up the great work!

November 23 at 7:44am

Brent Brookbush Hey Jason Erickson,

So you are probably well aware that I am both a Physical Therapist and a Trainer. And…. I teach human movement professionals from many different professions, but the majority of my students at live workshops are personal trainers. I often get asked how I make the distinction (separation in scope) between physical therapists (as well as, ATC's and DC's) and personal trainer's when I am teaching my versions of the postural dysfunction models and the corrective exercise/ther ex. that comprise the "Advancements in Exercise Selection" workshops. My answer has always been - "A personal trainers scope ends where manual techniques and pain begin."

Now, LMT's are a bit of an in-between - They have licence to touch, and muscle soreness and "aches" are seemingly the drive for an individual to see a massage therapist, but LMT's do not get enough training for differential diagnosis and the treatment of various orthopedic pathologies - So an LMT's scope is somewhere in the realm of "a liscence to touch, but not to treat."

So how does this relate to this discussion:

If you are a personal trainer and potentially if you are an LMT - I do not think you should be responsible for any information pertaining to diagnosis, treatment or management of pain, including the more recent research showing the complex interactions between biomechanical, psychological and social factors relating to pain.

If you are a personal trainer you have huge amounts of information that are more relevant to your practice like periodization, exercise progression, cuing and form, routine design, corrective exercise, functional anatomy, exercise physiology, behavior modification, and of course, how to drive a successful business in a competitive industry. If you start thinking about the BPS, MOM or even the Gate Theory of pain… you have gone too far and need to refer out.

If you are a massage therapist, you are stuck in the middle, you need to decide how far you are willing to tread into the grey area of your scope… but… chances are if you are developing treatment plans for a diagnosed injury you have crossed the line. If an LMT finds a patients "achiness" stubborn, consistent without change overtime, and/or your treatment seemingly worsens the condition… again, refer out. If you do find yourself using the information that is discussed in this forum, it almost certainly be under the supervision of a medical professional.

If you are a PT, DC or ATC, well… we are responsible for continuing our development toward evidence-based practice. Having a working knowledge of the work by Butler in regard to the nervous system and pain is probably a good minimum standard, and if you are working with more chronic pain patients than the topic of this discussion needs to be your wheelhouse. "Pain" is our profession; however, we are also clinical - MANUAL practitioners. In the case of this model we need more research that shows the effectiveness of the manual application of pain science, and/or a better understanding of how this refines our differential diagnosis. So far the only practical suggestion in this thread (I believe, sorry if I forgot anyone) was given by Jinny McGivern.

I am sure I missed something, but the discussion is far from over

November 23 at 10:08am

Brent Brookbush Hey Jim Horn,

There are so many debates going on, I couldn't say if that group was the singular impetus… but if I was on it… I am sure it played a role

Honestly, my impetus for this discussion was to have a debate about pain with an over-all positive vibe. I have never been part of, or read a debate about pain (on social media that is) that has not descended into some incredibly disrespectful rhetoric and unwillingness of anyone to try and find the common ground.

Although there have always been disagreements in my panel discussions, I hope that everyone on this forum would agree that the gross majority of the time professionals are made to feet comfortable, happy and supported.

November 23 at 10:14am

Brent Brookbush Hey Michelle Langsam,

Depending on the level of pain and what the "working diagnosis" is, I think your physician is effectively using the pain science we are aware of with a model that has been shown to be effective over & over again as Leon Chaitow mentioned.

But… after you are done with this approach, and you are starting to feel better don't forget to start re-conditioning before you jump into your highest intensity activity. This little gap between rehab and sport (even recreational) can be a very challenging time. One of the weaknesses in the current rehab model (at least in the US) is progression from pain free during normal daily activity to pain free during high intensity activity. Progressing exercise and reestablishing a neuromusculoskeletal system that can mitigate the loads of your highest intensity activity is the key to you not being re-injured.

November 23 at 10:19am

Brent Brookbush This has been a great discussion so far, but I would like to see more PRACTICAL.

Check out Jinny McGivern's example (originally from Butler's text), where she uses a very simple teaching technique to help a patient differentiate between a sensitized painful area and normal.

I would love more little "clinical gems" like this. It can be anything from a story about one of your patients, a new question you added to your assessment forms, or an idea you have for an additional technique. Thank you in advance, Jason Erickson, Jim Horn, Leon Chaitow, Michelle Langsam, Steven Roffers, Mark Jamantoc, Perry Nickelston, Rick Daigle, Scotty Butcher Phd, Kathy Benson Zetterberg, Josh Hasenohrl and Melinda Reiner

November 23 at 10:54am · Edited · Like · 1

Jim Horn Brent, I have shared this clip with many patients over the past several years and have found it to be a useful tool in education. Just a PART of my treatment though.


Understanding Pain What to do about it in less than five minutes


November 23 at 11:06am

Robert Gazso I had found myself getting too mechanical in my practice and am transitioning from operator to interactor as Jason Erickson writes about. In my experience many cases have an emotional component to the pain. I agree with Rick Daigle that "there is only…See More

Jack with Peter O'Sullivan

Jack describes to Prof Peter O'Sullivan about how he had chronic back pain. He was told he had a back of a 70…


November 23 at 11:11am

Brent Brookbush Nice video Jim Horn,

I like how they go back to an integrated approach to well-being and stick with a more conservative approach to treatment. Good stuff.

November 23 at 11:16am

Brent Brookbush Hey Robert Gazso,

We have to be careful here… Peter O'Sullivan did not talk this patient out of pain. He combined some education, with a variety of relaxation techniques and neuromuscular re-education. Yes, the approach may be "more advanced" than Ice, heat, or E-stim, but this is not a purely cognitive approach.

To add to Rick Daigle's statement "There is only one best practice way to treat - a combo of biomechanical models with pain science models" - it is important to add - "we do our part in an integrated model of treatment, and know when to refer out." For example, the two posted videos have now mentioned, or at least hinted at, "psychology." - My guess is that no one on this thread has gone to school for psychology. Just as we would be appalled by a psychologist or psychiatrist doing a lumbar manipulation, we should not be doing "heavy digging" into someones psychology. If all you did is talk to your patient for an hour about their pain, and billed them for personal training, physical therapy, chiropractic, etc… in essence you over-charged them for a psychiatry session with an individual who is in-experienced, under- qualified and less effective.

When you say "your approach has become too mechanical," - the connotation of that phrase concerns me. Yes we have to educate and accurately assess pain… but… mechanical is what you do. You don't "do" pharmacology, or behavioral therapy, or hypnotize for that matter.

Your practice should be mechanically based in a frame work of pain science, or… if you truly believe this is not the right approach its time to "suck it up" and go back to school for the licencing that will allow you to do what you need to do.

That's what I did with PT school after being a personal trainer for 12 years… I know that sounds tough, but doing the right thing is not always easy.

November 23 at 11:49am

Robert Gazso I appreciate your comments Brent. I will take some time to think about what you wrote here.

November 23 at 12:02pm

Brent Brookbush Take all the time you need brother - Robert Gazso,

You know I appreciate the participation

November 23 at 12:22pm

Steven Roffers "What this study adds• To our knowledge, this is the first study that has assessed a large population of mixed sources of pain in order to understand the characteristics of patient populations that might contribute to increased risks for complications when making medication pre- scribing decisions.• This analysis highlights a breadth of pain management variables evaluated in a single population of patients, as opposed to analyses that have examined single variables.• This study documents treatments for a range of patients with neck and back pain diagnoses for whom clinicians might have to make pain management decisions."


November 23 at 2:43pm

Jason Erickson Thank you for clarifying your position, Brent. That's very helpful.

Brent said, "My answer has always been - "A personal trainers scope ends where manual techniques and pain begin.""


If a personal training client is experiencing soreness, what then? What about clients that are transitioning from rehab back into (re)conditioning? If they are not completely pain free, should a trainer refuse to work with them? Also, what about assisted stretching? It seems impractical to say that we trainers should only work with clients that are completely pain-free, and never use any methods that include a manual component. I would argue that familiarity with pain science increases a personal trainer's ability to understand where their scope of practice truly ends, and enables them to work more effectively within their scope.

Brent said, "Now, LMT's are a bit of an in-between - They have licence to touch, and muscle soreness and "aches" are seemingly the drive for an individual to see a massage therapist, but LMT's do not get enough training for differential diagnosis and the treatment of various orthopedic pathologies - So an LMT's scope is somewhere in the realm of "a liscence to touch, but not to treat.""


Massage therapists don't diagnose, but we often don't have the luxury of a differential diagnosis to work with. Lacking a diagnosis, what shall we do with clients in pain? Many of my clients are referred to me by licensed medical professionals (MDs, PTs, DCs, etc.) for help with their pain. Some come with diagnoses, but many have eluded formal diagnosis - they just have lots of information about what is NOT causing the problem. Many other MTs also specialize in working with clients in pain, with referrals from medical professionals. The expectation is that the MT's work will have a positive influence on the client's pain. It definitely places us in a gray area - and I would argue that familiarity with pain science facilitates our ability to work effectively within our scope of practice and to coordinate our work with that of other health/fitness professionals.

Brent said, "So how does this relate to this discussion:

If you are a personal trainer and potentially if you are an LMT - I do not think you should be responsible for any information pertaining to diagnosis, treatment or management of pain, including the more recent research showing the complex interactions between biomechanical, psychological and social factors relating to pain."


I agree that personal trainers and massage therapists are generally not expected to be responsible for those things, but I think that's a poor reason to argue that they should not learn about those things.

Brent said, "If you are a personal trainer you have huge amounts of information that are more relevant to your practice like periodization, exercise progression, cuing and form, routine design, corrective exercise, functional anatomy, exercise physiology, behavior modification, and of course, how to drive a successful business in a competitive industry. If you start thinking about the BPS, MOM or even the Gate Theory of pain… you have gone too far and need to refer out.""


When a client presents with some discomfort, how does a personal trainer deal with that? The NASM CES program suggests a number of ways that a trainer might work with that, but here you're suggesting that a trainer should refer out? What about foam rolling? Again, I argue that pain science provides conceptual tools that will help trainers understand how to safely work with clients that have some discomfort and know when to refer out, whether or not to use foam rolling, whether or not to use assisted stretching, etcetera. Pain science also provides useful insights into progressions, cuing and form, routine design, corrective exercise, behavior modification, client motivation, etc.- and all of that can contribute to building a successful practice.

Brent said, "If you are a massage therapist, you are stuck in the middle, you need to decide how far you are willing to tread into the grey area of your scope… but… chances are if you are developing treatment plans for a diagnosed injury you have crossed the line. If an LMT finds a patients "achiness" stubborn, consistent without change overtime, and/or your treatment seemingly worsens the condition… again, refer out. If you do find yourself using the information that is discussed in this forum, it almost certainly be under the supervision of a medical professional."


As I stated above, many medical professionals refer their patients to massage therapists for help with pain, even when no diagnosis is available. In almost all cases, those medical professionals choose not to provide any supervision whatsoever unless the MT works within the same practice/clinic/facility. It is impractical to suggest that MTs work without any sort of plan, regardless of the circumstances. Pain science provides insights that enable massage therapists to work appropriately with a wide range of pain conditions, and also the knowledge of when to refer clients out for medical treatment - even if the client was referred to them by a medical professional.

In future posts, I will shift my focus to discussing how pain science knowledge is practical for personal trainers and for massage therapists. I suspect that will be of great interest to many.

November 23 at 4:55pm

Ryan Crandall Excellent points Jason Erickson. I have found learning about pain science has not only helped my patients (especially the chronic pain patients) but also helped me deal with off and on pains. I think LAY PEOPLE should be taught about pain education(yes, my mom your mom, everyones mom)…that is why they call it pain education and why IPSI uses metaphors to describe and help a patient understand. This is commonsense information that is helpful for all including the gym trainer, therapists, and Uncle John. And I agree, by knowing this there is a more clear delineation as to what the scope is (well there should be)For example, we all learn countless things in school that have very little to no purpose in our profession, but knowing basic mechanisms can't hurt…and knowing a bit more about pain science, a proverbial tool in the tool box, then movement folks can have the advantage of knowing when to refer out. Finally, I'm not for throwing the baby out with the bath water, but I've found explaining pain to my patients (and we get upwards of 80/day) goes a LONG way to shortening visits which insurance companies love. I for one look to learn more about pain science as well as other great practical things (I'm a therapist) from the McKenzie institute, Tai Chi, Yoga, strength coaches, and whoever else can add tools to my toolbox. Cheers.

November 23 at 5:18pm

Brent Brookbush Hey Jason Erickson,

We're getting closer

To your first point, or roughly the first 4 paragraphs. As long as you are dealing with a patient who has received an exam by a medical professional, and that medical professional has decided that massage therapy would be beneficial, I am with you, and would defend you if necessary. I am sorry if you thought that by " they I expected a medical professional to be standing of your shoulder.. not my intention. All I hope for is the responsible use of a skill set. The question we are alluding to in this discussion is one of "autonomy" and as you mentioned "differential diagnosis". LMT's do not have enough education to do a differential diagnosis, and therefore should not seek-out "pain patients" without clearance from a medical professional. For example, if you started boasting as an "expert in pain science" I might have to recommend further education before using this to attract clientele.

That is not to say that physical therapists diagnose either, but we are well prepared to screen for non-orthopedic pain.

For example, of why clearance from a medical professional is important, think about the case study below and answer the question (I humbly ask that you appease me on this one… I have no intention of being condescending)

A patient walks in with unremitting low-back pain that has become progressively worse over the last 3 months. Movement is painful in all directions, flexion slightly worse than other directions - what do you do next?

To the next several paragraphs,

November 23 at 7:50pm

Brent Brookbush I am glad you brought up the NASM CES model Jason Erickson,

Although I use a version of this model in my treatment of patients, the version taught to personal trainers is not a pain management model. It is an assessment, and techniques to improve neuromuscular efficiency and optimize movement.

Improving the quality of human movement not only has a positive impact on performance, but reduces the risk of injury - which are two great reasons to use the CES model. I can post several studies that I have reviewed on BrentBrookbush.com if you would like…. But, you really need to look no further than the athletic play of the Phoenix Suns, and the fact that they have had the lowest occurrence of injury among starters in the NBA for almost a decade - they are in fact an NASM partner. I know that isn't research, but that is a timeline and trend that cannot be explained by luck alone.

There is grey area here too of course. Nearly every client over the age of 30 who starts with a personal trainer, regardless of the goal, will likely have joint aches and pains. If the personal trainer assesses movement using the Overhead Squat Assessment and mitigates some of those issues by using that assessment to assemble a corrective exercise routine that improves the quality of movement- well, awesome. But, at no point did the personal trainer actually have to address the pain specifically (which if we really want to start a deep conversation, we could start talking about how the new pain science actually favors a movement impairment approach over a pain provocation approach). If corrective exercise does not mitigate these minor joint aches and pains then its time to refer out.

Brent Brookbush | Integrated Education Platform

Live Workshop Schedule Posted on October 1, 2014 by…


November 23 at 8:01pm

Kathy Benson Zetterberg Exactly Brent Brookbush .. That was the point my post from earlier was making

November 23 at 8:07pm

Brent Brookbush To your last point Jason Erickson,

There is a difference between a "plan" and a "treatment plan". I know this sounds like I am dicing words, but here me out.

A treatment plan includes a working diagnosis, a prognosis, a timeline, techniques to address the specific issues, a home exercise program, and objective measures to monitor progress.

My guess is that is not what you are doing in your practice. A treatment plan assumes that you are readily working to "cure" or "treat" a diagnosed issue. If you have a plan to help your client using massage, I am again, without a doubt, on your side. Too many individuals in all human movement professionals take a shotgun approach every time someone walks in the door. In essence, consistent success is dependent on you having a plan.

To sum up this portion of our discussion.

Everyone can benefit from knowing something about pain science, from personal trainer all the way to licensed medical professional. What I am trying to convey is a balance between nice to know, need to know, and responsible practice. You know where I get testy regarding pain science. The are professionals out there using pain models to disenfranchise, demean and condescend. It is not a trainers responsibility to know the biopsychosocial model of pain, anymore than it is a massage therapists responsibility to know special tests, or a physical therapists responsibility to have a knowledge of pharmaceuticals that would allow for prescription. We need to be humble, and realize that people have been successful treating various injuries and working toward various goals without this information. If there are practical applications of this model for every human movement professional than more should be done to provide those practical suggestions and far less criticism of other approaches standing on a pedestal of pain science. We still have yet to have a single outcome study comparing a pain model approach to manual therapy approach that gives evidence that this approach is better. Not saying that it cannot improve our practice, but lets not throw the baby out with the bath water. Keep what works and add what is promising.

November 23 at 8:14pm

Brent Brookbush My use of the biopsychosocial model of pain:

A patient is referred to me by a personal trainer for neck pain. It has become increasingly problematic and she blames this on one of the toughest emotional issues any of us can face - she's losing her father.

After thorough evaluation I note a thoracic kyphosis, pain in flexion, extension and left rotation and marked decrease in range. She has been going to massage but the pain returns within 48 hours of a treatment. She is emotional and is worried that she is going to have to deal with this for the entire time her father loses the battle to cancer. Her husband and friends are supportive, but no one close to her can specifically empathize with the loss of a parent and because of this she feels she has no one to "truly" talk to.

Now, we have a relatively strong emotional component, an orthopedic component, and an "emptiness" in the social component.

What do I do:

I explain that stress is a systemic process and that if the stress alone was causing her pain, that the pain would not be solely in her neck. After all, why not her knee, shoulder, low back or ankle? - increased stress and sympathetic activity results in hormone production (blood born) which may result in changes in everything from internal organ function to well… any tissue with receptors for these hormones who receive nutrients via the blood.

However, emotional stress can be a magnifier. An undamaged (facilitated) nerve is unlikely to respond from increase caticholimine production, as the receptors for these hormones are not present. But once a nerve becomes facilitated, receptors literally grow, the nerve becomes bathed with prostaglandin and bradykinin, and now a nerve that once had a very specific purpose can be triggered by a variety of stressors. So, although her social situation is magnifying the problem, we have an opportunity to change her situation - her emotional situation is triggering a nerve that was likely originally damaged by acute and chronic trauma to her neck - there is an orthopedic root to this problem.

I asked her to consider that her father was not the cause of her neck pain only a little fuel on the fire - in essence changing the psychology of her pain, I recommended she see a therapist so she had someone to talk to about her problem with her therapist and learn how to better communicate her feelings with those close to her, and I treated her neck.

She regained 80 percent of her lost range and her pain had subsided to a 2 out of 10 (from a 7). I gave her a home program including therapeutic exercise, changes to her pillows and sitting posture, and a suggestion to speak to her doctor about an anti-inflammatory. I recommended heat or ice if the pain got intense, and assured her that we could get her neck under control. The home exercise program was not just a treatment, but a way for her to take control of the pain… I could go into to detail about how this is related to the "Interactor" model Jason Erickson described, but that would require I dictate the entire conversation (this model is very similar to Ryan and Deci's "Self-Determination Theory - and the fundamental need of "Autonomy).

The patient is doing great, was pain free in 3 sessions (10 days), and continues to see me as she beats herself up with boxing, silks, resistance training, and a myriad of other activities.

I hope that aids a few in the practical application of this model, and where I think we fit in this discussion as human movement professionals.

Oh ya,

Last thing… why didn't massage therapy work… I needed to throw that in their to show that sometimes it is not chronic pain, but a deeper issue. The pain she was feeling was not solely soft tissue and had a high correlation to what we know of as facet joint pain. Mobilizations and manipulations brought her the greatest relief.

November 23 at 8:47pm

Melinda Reiner Basic history and physical and expand on that based on the patient's responses. Everyone is a unique human being and one cannot set a model that applies to all. These days no one takes a proper history and many barely do physical exam, focused at best.

November 23 at 11:03pm

Robert Gazso Hey Brent - I see that the pain came back because manipulations and mobilizations were necessary to address the facet pain. It may go the other way also. Practitioners that do manipulations and mobilizations often do not do soft tissue work and we also see the pain coming back. It is interesting to me how many clients come in that may have done a substantial amount of therapy but they have not received any soft tissue work. One previous client of mine comes to mind who had been hit head on by a drunk driver who was driving a full size van. She was riding a motorcycle. She had received a substantial amount of rehab and even had 2 surgeries to remove scar tissue in the muscles in her upper arm. She said none of the practitioners she worked with had done any soft tissue work. She showed me she had 30 degrees of motion in abduction and said it had been like this for two years. Soon after beginning some soft tissue work we were seeing increased ROM and decreased pain.

November 24 at 12:08pm

Nick Chertock Just from observing conversations online over the last few years it appears the idea that "pain alters movement" is now more and more expanded to mean "poor biomechanics don't directly lead to pain", much of the shift being led by evidenced based PTs based on published research.

I believe pain definitely alters movement patterns and CERTAIN movement pathologies lead to pain in CERTAIN people while others do not. I also believe many of the studies are flawed in that they don't do enough to account for the fact that the best way to avoid pain in the short and even intermediate term is to be sedentary. People who move better engage in more activities that could cause injury, people who move poorly will tend to not even try the kind of training that can lead to injury.

Stu McGill mentioned the phenomenon in his debate with Gray--the better athlete will get more playing time and this alone is a risk factor. If it's not properly accounted for the results of a study may be slanted toward the conclusion that the guys who move less efficiently are no more likely to get injured.

How this is taken into account, I am unsure. I am told it is factored into results but haven't seen the supporting details.

November 24 at 12:27pm

Brent Brookbush Hey Nick Chertock,

Rule #1 of Research: Just because you have not seen the study, does not mean the study does not exist.

I have several studies that link poor movement and/or altered muscle recruitment to an increased risk of injury and pain.

November 24 at 12:42pm

Leon Chaitow Jim Horn --- I looked at the neat little video on pain and of course it's persuasive. BUT - around the middle it includes one statement that deserves cosnideration….I am paraphrasing, but it goes something like this…"By the time you've had pain for 4 or 5 months there is no longer any tissue involvement in the pain process, it's all down to a sensitized nervous system and the brain". BUT THIS IS SIMPLY NOT TRUE IN MANY INSTANCES. I'll personalise this. Some years ago I underwent a surgical procedure for kidney stones that involved being suspended - inverted - for 2 to 3 hours - held aloft by stirrups in what is known as the lithotomy position. The compression of the mid and lower calf area for that length of time resulted in an immediate (next day) inability to walk more than 20 yards without acute cramp-like pain …Over the past 7 years I have been able to increasingly 'walk through the pain' so that I can now manage miles….but with constant discomfort transitioning into pain as the damaged superficial fascial structures impinge on normal function in my legs. The condition has been greatly helped by carefully applied manual and mechanical methods that enhance the functional potential of these structures - e.g. connective tissue massage ('skin rolling') and mechanically induced. deep tissue vibration .. The fact though is that tissue changes have occurred, and the pain while obviously in my brain, would be far worse without manual or mechanical interventions, as described. What I take from this saga and countless parallel experiences with patients, is that the pain story needs to take account of the peripheral tissues that may be key to persistent problems….as well of course as the brain/CNS…etc

November 24 at 12:54pm

Brent Brookbush Hey Robert Gazso,

Your example is perfectly suited for the point I was making… Chronic centralized pain is a special issue which is relatively rare based on my personal experience. Although we may make the argument that all pain has a component of centralization, it would be a leap to say that this is the primary cause of pain in a large percentage of the population. IMHO chronic pain is most often caused from tissues being left behind the could use some additional work. The human movement system cannot be separated into parts for any reason outside of teaching and organization. All dysfunction will involve some level of muscular, articular, fascial and neural adaptations. This is why an integrated approach is so important, including the pain models that are the topic of this discussion.

November 24 at 7:43pm

Brent Brookbush Leon Chaitow,

My understanding of those who are at the forefront pain science is that an understanding of the integration between central and peripheral structures is the goal. In Butler's text he discusses a classification for the types pain that may be generated from peripheral structures and integrates the processing of pain as a piece of patient education - I am wondering if your view is similar?

November 24 at 7:47pm

Leon Chaitow I'm not sure this requires much thought Brent Brookbush - it is obvious from research evidence (see a few citations below) and from the clinical experience of anyone who cares to test the idea, that modification of peripheral pain generators reduces the overall pain experience in chronic situations…so while pain may be in the brain…it can often be modulated or arguably eliminated by attention to the periphery.

Affaitati G et al 2011 Effects of treatment of peripheral pain generators in fibromyalgia patients. European Journal of Pain 15(1):61-69

Kobesova A et al 2007 Twenty-year-old pathogenic ‘‘active’’ postsurgical scar: a case study of a patient with persistent right lower quadrant pain J Manipulative Physiol Ther 30:234-238

Kraft K et al 2011 Reducing of pain in patients with fibromyalgia syndrome by applying a vibration massage device. European Journal of Pain. Supplement 5:15–29

Niddam D et al 2008. Central representation of hyperalgesia from myofascial trigger point. Neuroimage 39:1299–1306

November 24 at 8:01pm

Brent Brookbush Always bringing the research Leon Chaitow… love it.

Really appreciate the years of experience and how you frame your points within a perspective that includes so many sources of information - an ability "to see the forest from the trees" so to speak.

November 24 at 9:07pm

Jim Horn Thank you for your personalized story and for bringing up that very important point, Leon. I just took another look at the video. What it says is that "MOST things in the body are healed as well as they can be by 3-6 months" and that in the case of chronic pain, it is "less about structural changes in the body and more about the sensitivity of the nervous system." I would agree with you had the video stated that ALL things in the body are healed by 3-6 months, rather than most. There are obviously exceptions to everything, as your personal story indicates. I do think that patients begin to trust themselves to move more once they're given some peace of mind that they won't harm themselves more. When they introduce graded movement, take some control of the process, and begin to trust in the healing process, good things generally happen.

I am glad to hear that you have finally found some relief after all these years.

November 25 at 7:59am

Leon Chaitow Interesting Jim that I heard what I expected to hear - or rather recalled what I thought I had heard……but even that 'most' qualification requires a stretched credibility, particularly when - as I am - it means dealing with an older population, where my experience is that 'most' (or at least 'many') chronic symptoms involve biomechanical features that can be improved…with consequent modulation of chronic pain, and as in my earlier response to Brent Brookbush (above) there is mounting evidence that this is the case in that most bizarre example of sensitization - fibromyalgia (see Affaitati et al study)

November 25 at 10:03am

Robert Gazso It's interesting that Leon Chaitow mentioned that part of the where it said "MOST things in the body are healed as well as they can be by 3-6 months" since this jumped out at me also when I heard the video. My thought when I heard this was that while it may be true that the injured tissues may be healed that the source of the pain may still be biomechanical factors. Pain occurs whether or not there is tissue damage. For example the woman that I mentioned above had knee pain. It had been years since her motorcycle accident so it is likely that the pain was not from tissue damage. My thought was that if I could get better activation of the Gmax that this would allow for better biomechanics at the knee. I was able to get better activation of her Gmax which did in fact alleviate her knee pain. Why? Because improved biomechanics changes the forces at the knee which changed the info being sent by mechanoreceptors and nociceptors which decreased the threat of something in the knee being injured. So it appeared that it was the threat of injury that was causing the pain. That being said my experience is that there may also be emotional factors that are responsible for some or all of the pain. Fear of reinjury or a fear that they may need surgery may also be the cause of the pain the individual is experiencing. This fear may be a good thing but also may be irrational. Practitioners may say things that create nonsensical levels of fear. Pain is a produced by the brain and it signals that there is danger to one's survival. As pointed out by Moseley in this video the pain that someone is experiencing may occur with no injury whatsoever. https://www.youtube.com/watch?v=gwd-wLdIHjs

TEDxAdelaide - Lorimer Moseley - Why Things Hurt

Why do we hurt? Do we actually experience pain, or is…


November 25 at 12:28pm

Jason Erickson Please accept my apologies for the delay in responding to this conversation. I will present some examples demonstrating how knowledge of pain science has been practical and beneficial in my work as a personal trainer.


1: Middle-aged man I met at the gym. He was warming up before his workout and I noticed him wince a bit with some basic unweighted knee flexion-extension movements. I inquired, concerned he might be about to work out with a fresh injury. We sat down to chat and he said his left knee had sharp pains around the patella on any extension movement - the worst was pressing the clutch pedal when driving. He had had it checked out by multiple physicians, x-rays, MRI, medications… they couldn't find a cause and their suggested interventions (steroid injections and pain meds) didn't help. His experience with physical therapy focused solely on several months of strengthening exercises that didn't help. At each step, each medical professional told him he might be stuck with the pain for the rest of his life if their approach didn't work for him.

14 years after his knee pain started, he was talking to me about it. I asked him if anyone had ever explained what pain is and how it works. No one had. So, we started by talking a little about the nature of what pain is and how it's an output of the brain in response to perceived threat and can be present even in the absence of any tissue damage. I also explained that pain science indicated that sometimes a simple non-nociceptive sensory input could potentially change the brain's perception of what was happening in that area, and that could result in a positive change.

I asked if he'd be willing to try something to see if it made any difference. At this point, he was looking hopeful and curious. He consented. I used one hand to gently cup the back of his left knee, then used that palm to gather the skin behind his knee, placing a small lateral stretch on the skin. After about five minutes, I released his knee.

I asked him to try some simple unloaded knee flexion-extension movements, and he did. Cautiously, at first, but then with enthusiasm because he felt no pain. We then tried some bodyweight squats and lunges. They had been painful for 14 years, and now he was doing them with correct form and zero pain.

After that, he was raring to test the limits. I suggested some caution but otherwise encouraged him to start with everyday activities and go from there. I also told him not to be surprised if some discomfort returned, and not to worry much, either. "Most people don't experience permanent relief from just a few minutes of skin stretching, so just pay attention to it and see how things go."

Six years later, his knee pain has never returned. Not once. He has referred people to me for personal training, and also for massage therapy.

November 26 at 3:46am

Jason Erickson #2: Middle-aged woman, active in race walking, history of knee pain that forced her to stop running years before. She was training with me to get stronger and leaner. Loaded knee flexion (squats, lunges, etc.) often resulted in pain - the heavier the load, the more knee pain she felt. Medical evaluation resulted in a diagnosis of osteoarthritis with badly worn menisci.

We talked about her medical history, the medical evaluations, and the diagnosis. We discussed her goals and her accomplishments in race walking. She was doing well, overall. Then I gave her a brief explanation of pain neurology and how we were going to tailor her training to miminize discomfort while building up strength and conditioning.

Over the next few months, she made rapid progress. As she became stronger and saw her body transforming, she also experienced much less knee pain under loaded flexion. Though her bodyweight didn't change much, she eventually gained the ability to squat more than her own bodyweight below parallel without pain for sets.

Now and then, during bench presses, her right shoulder started to protract. I'd have her rack the bar and sit up. With her sitting up, I'd gently stretch the skin of her shoulder for a minute or so. This would give her some rest and some non-nociceptive sensory input for the anterior shoulder, which was underperforming and for which the protraction was an obvious compensation. Afterward, she could press normally again. Once she learned to go through a simple dynamic ROM routine to loosen up before upper body workouts, she made faster progress in her bench presses without having to stop in the middle of a set.

Here's the routine I taught her, which has also been helpful for many other people over the last eight years. It's not so much about stretching, and more about exploring pain-free ROM. For most people, it's a form of novel movement, which the CNS seems to like.


Bar Routine for Upper Body Mobility

This simple routine can be done with a dowel, broomstick, or similar implement. Over the seven years prior to…


November 26 at 4:27am

Jason Erickson For more on novel movement, Cory Blickenstaff has provided many excellent examples.


However, it's not critical to understand Cory's work to make use of novel movement with clients. If you understand the basic neurology of pain, you can pull "novel movement" from all kinds of movement patterns/traditions.

Forward Motion PT

Forward Motion is your home for Edgework, Novel Movement, and other physical therapy demonstrations for pain and other movement issues. See examples of our u…


November 26 at 4:32am

Jason Erickson Many exercise videos provide excellent material for "novel movements" that can be used with clients. For example the "Intu-Flow" DVD by Scott Sonnon has good stuff from head to toe. He has made the Beginner level of his DVD available on YouTube, here:


So, while you can certainly make use of this material without a grasp of pain science, the pain science makes it much easier to understand how/when/why it might be appropriate to try novel movements.

Scott Sonnon Intuflow Joint Mobility Beginner Part 1

http://www.YourPainFreeMobility.comScott Sonnon,…


November 26 at 4:37am

Jason Erickson A grasp of pain science implies a basic grasp of practical neurology. Even with a limited grasp, it's possible to have useful insights. For example, here's a video posted by Will Stewart from a personal training session he did a few years ago. In it, it shows how he applied some common fitness tools and training concepts with what he knew of pain science to provide results for a client.


Dermoneuromodulation - based Training

Bobby complained of having "clumsy" feet and not being able to move on the athletic field as well, so we came…


November 26 at 4:42am

Jason Erickson Here's an example of a "novel movement" that can be further adapted for conditioning once the technique is mastered. It was inspired by my experience as a former yoga instructor.

Jason Erickson's photo.

November 26 at 4:57am

Jason Erickson Here's the client with "bad knees" from Example #2 doing step-ups after a year of training and a little education in basic pain science. She was carrying 15 pound dumbbells as she did these for long sets. She was pain-free during and afterward.

She has also referred many people to me for personal training and/or massage therapy.

Jason Erickson's photo.

November 26 at 5:11am

Jason Erickson That's enough for now. I will add more thoughts later.

November 26 at 5:10am

Leon Chaitow An article that we will be publishing in JBMT next year is now through the review process and is - to use a publishing phrase, is - IN PRESS - awaiting publication. This addresses some of the themes in this thread: >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

Tellez-Garcı´a M et al Neuroscience education in addition to

trigger point dry needling for the management of patients with mechanical chronic low back pain: A preliminary clinical

trial. Journal of Bodywork & Movement Therapies (2014)>>>>>> >>>>>>>>>>>>>>>>>

Summary The objective of the current study was to determine the short-term effects of trigger point dry needling (TrP-DN) alone or combined with neuroscience education on pain,

disability, kinesiophobia and widespread pressure sensitivity in patients with mechanical low

back pain (LBP). Twelve patients with LBP were randomly assigned to receive either TrP-DN

(TrP-DN) or TrP-DN plus neuroscience education (TrP-DN fl EDU). Pain intensity (Numerical Pain

Rating Scale, 0e10), disability (RolandeMorris Disability Questionnaire-RMQ-, Oswestry Low

Back Pain Disability Index-ODI), kinesiophobia (Tampa Scale of Kinesiophobia-TSK), and pressure

pain thresholds (PPT) over the C5eC6 zygapophyseal joint, transverse process of L3

vertebra, second metacarpal, and tibialis anterior muscle were collected at baseline and 1-week after

the intervention. Patients treated with TrP-DN fl EDU experienced a significantly

greater reduction of kinesiophobia (P Z 0.008) and greater increases in PPT over the transverse

process of L3 (P Z 0.049) than those patients treated only with TrP-DN. Both groups

experienced similar decreases in pain, ODI and RMQ, and similar increases in PPT over the

C5/C6 joint, second metacarpal, and tibialis anterior after the intervention (all, P > 0.05).

The results suggest that TrP-DN was effective for improving pain, disability, kinesiophobia and widespread pressure sensitivity in patients with mechanical LBP at short-term. The inclusion of a neuroscience educational program resulted in a greater improvement in kinesiophobia.

November 26 at 5:41am

Brent Brookbush I want to try to some this up, but not over-simplify Jason Erickson, Leon Chaitow, Robert Gazso, Scotty Butcher Phd, Rick Daigle, Mark Jamantoc, Perry Nickelston and Steven Roffers…

The practical application of pain science is the addition of a pain education component to our physical interventions (manual and/or exercise). Looking at all examples, no patients were treated with a cognitive approach alone, nor does pain science imply that there should be a change in the way we physically treat pain.

What do you think?

November 26 at 8:24am

Jason Erickson Actually, pain science does imply that how/when/why we use physical interventions is more variable than the old biomechanistic model of treatment would suggest.

I've been away from this discussion for a bit, but it seems there is much more for us to talk about.


Jason Erickson The concept of dermoneuromodulation is based on modern pain science. Applications of the concept in manual therapy and personal training sometimes lead to unusual interventions that seem to work well.

Here's an article I wrote about DNM concepts, with some examples of simple applications. The pain science discussion was very light due to the publication it appeared in, and there was no room for me to cite sources. Even with those limitations, you'll find the applications easy to understand and employ.



Leon Chaitow Jason Erickson I am at a loss to understand - based on the examples in the article to which you provided a link - how DNM is other than a version of what in the USA is called Myofascial Release and in Europe Myofascial Induction. They are certainly not the same, but similar. Clearly there is far more focus on the skin in DNM - but in the 'myofascial induction' model that's about all that is taken to a first barrier while changes are awaited. There are other methodological differences, but they do seem similar…apart from the DNM name, which is compellingly more appropriate. Thanks for the introduction.


Jason Erickson Leon, you are correct that the examples in the article are very similar to various "myofascial" methods. You will also find positional release concepts employed, often in conjunction with skin stretching.

In my experience, learning DNM concepts and applications is a big paradigm change for many, even when the physical applications appear quite similar. I have found the writings of Walt Fritz PT about his experiences in transitioning from being fascia-oriented towards a model based on pain science to be very enlightening. His blog atwww.WaltFritzSeminars.com is very good.

The thought process behind how/when/why to use positioning, skin stretch, movement, taping, or other physical interventions varies based on one's preferred explanatory model of mechanisms.

Foundations in Myofascial Release Seminars

What makes Foundations in Myofascial Release…



Jason Erickson Here is a short video demonstrating some DNM applications. The camera angles could be better, but you can see a variety of examples.


Dermoneuromodulation (DNM) - some concepts and applications

This demonstration explains some important DNM…



Jason Erickson This post by Walt Fritz PT is a good place to start:


Frozen Chicken and Myofascial Release/Manual Therapy

What is the Deal With the Frozen Chicken?Using…



Leon Chaitow thank you Jason Erickson. Yes I did note some positional release similrities in the descriptions. And I am familiar with Walt Fritz's writings. I will insert a thought that for me adds a different - yes fascial - dimension. It is inconceivable that movement of skin does not also involve movement (let's call it load) - however minimal, of the subcutaneous, superficial fascia including the extra cellular matrix of those tissues. Mechanotransduction effects would immediately be inititiated leading to biochemical responses from affected cells - unrelated from neural influence. Some of the most compelling evidence from this will be published in 2015, in the Journal of the American Osteopathic Association. The lead author is Paul Standley from The University of Arizona Medical School.The study involves bioengineeed tendon - constructed by growing an artificial tendon in a lab using bovine collagen and human fibroblasts. The 'tendon' was deliberately damaged and the healing process of the injury was closely observed and monitored during a variety of scenarios - for example: under 1% 3% 5% 9% etc degrees of 'stretch (load)…for varying amounts of time - 1 minute - 3 minutes etc etc. The outcomes showed that 'healing' of the wound by fibroblasts (remember this is with no blood supply and no nerves) started within seconds (mechanotransduction influences…with fibroblasts doing what they are programmed to do when there is tissue injury) - and this process of 'healing was seen to be more rapid under light degrees of load, for several minutes, but to be diminished under greater degrees of load for longer periods. If I recall the detail (presented in Rome in September at an osteopathic conference on Biological Mechanisms) - the greatest influence was 3 to 5 minutes at 5 to 9% of load, with greater load, for longer periods, retarding healing, and lighter load (1%) doing nothing to speed up what was a process that began directly after the artificial trauma of an artificial tendon…containing real fibroblasts. It of course 'proves' nothing, but suggests that load applied superficially has effects unrelated to nerve supply ---so it may be that DNM will need to be revised as DFNM - dermofibroneuromodulation? Mechanotransduction involving fascial cells cannot be ignored - just as neural features cannot be ignored in the human body. I find the DNM model very interesting and in time look forward to its evolution.


Jason Erickson Thank you for that, Leon. I agree that mechanotransduction is an important factor to consider. Since I can't touch nerves directly, it's logical that the physical application of DNM concepts is dependent upon more than just nerve manipulation. There has been some excellent discussion of this on the Dermoneuromodulation page. The bit I've posted here is quite lacking in details of underlying mechanisms.

I look forward to seeing the publication of that study on tissue regeneration!


Leon Chaitow I watched the video Jason and my comment would be that while you are speaking of 'skin', you are really working on the superficial fascia to which it attaches. There is no way whatever that moving, or putting tension into, or stretching, the skin - is not also doing the same to the superficial or areola fascia - which is itself richly supplied with receptors of all sorts. I remain at a loss as to why proponents of the work you are doing remain antagonistic to accepting that fascia is just as much, or more, the focus of their attention? Also that as well as modifying pain neurally there are likely to be alterations in production of hyaluronic acid and therefore enhanced sliding potential between subdermal layers of tissue.


Kennet Waale I would like to add to this dissuasion as a trainer working mostly with post injury rehab and chronic pain clients. As a coach, Working in conjunction with therapists of various aspects and dimensions is of course vital, however - it's come to my attention over many years of practice that educating clients on the multifactorial aspects of understanding pain (latest pain research) has been very effective. They often then understand and can gauge why they feel what they're feeling and that pain isn't just physical. We, in this way, clear many correlations of pain and provide long term improvements.

Great discussion Brent !

Jason Erickson Leon, I won't be an apologist for others; I understand what you are asking.To me, the significance of what I've mentioned so far is rooted in the fact that the neurological aspects of pain and dysfunction have been largely ignored in favor of biomechanistic factors such as mechanotransduction and potential changes in fascial tissues. Now we are seeing a "correction" in that manual and movement therapists are starting to become acquainted to the neurological aspects and how those might impact clinical reasoning and treatment/training decisions.The DNM concepts and applications mentioned so far are just one aspect of how pain science is being applied. For personal trainers and physical therapists, movement-based methods may seem easier to incorporate in practice.

For example, the "novel movements" and "Edgework" concepts promoted by Cory Blickenstaff of Forward Motion PT represent a very different way of applying pain science in practice. Many videos are available on YouTube, here:


Forward Motion PT

Forward Motion is your home for Edgework, Novel Movement, and other physical therapy demonstrations…


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Jason Erickson For those familiar with Feldenkrais concepts, the work of Barrett L. Dorko presents an accessible way of incorporating pain science. There are some good lectures and demonstrations here:


barret dorko - YouTube

© 2014 Brent Brookbush

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