The Truth About Pain Science & Body Mechanics

The Truth About Pain Science, Exercise, & Movement

Dr. Joel Seedman, Ph.D.



If there’s one thing the field of neuroscience has taught us it is that the mechanisms underlying the sensation of pain are highly complex. Unfortunately, these findings have given way to a troubling trend in the fitness industry which is to overcomplicate the treatment of musculoskeletal derived pain. In other words, the treatment of this type of pain, once considered a simple topic, has now been re-defined by so called “pain experts” and “pain gurus” with such lofty, convoluted, and esoteric logic it’s almost impossible for even a Rhodes scholar to comprehend. On the one hand, yes, the processes leading to the perception of pain, and the factors that modulate pain, including psychological factors such as fear, stress and anxiety, are so complex we may never fully understand them. Yet for anyone who’s ever experienced pain, perception is reality. We can talk in circles, and debate and argue over which physiological, psychological or environmental factors are ultimately responsible for pain, and the systems involved, but in the end, fancy charts and lofty explanations aside, the concept of pain consistently comes down to one key element: the “Ouch Factor”!!! In other words, something hurts – which often means something is inflamed.

In fact, inflammation (the contra-therapeutic, chronic form not the acute beneficial form) and pain are highly correlated. More specifically, the sensation of pain, including chronic pain is often associated with joint and or muscular inflammation, injury, osteoarthritis, myositis, muscle spasticity, joint stress and other common forms of discomfort, all of which are linked to heightened markers of inflammation. Ironically, many pain scientists often ignore or downplay these physiological elements, pointing instead to the psychological or psychosomatic factors. Additionally, they often suggest that therein lies the answer to pain and that many individuals simply have a distorted understanding of pain which drives much of their discomfort, hence the need for pain neuroscience education therapy (PNE). However, quantifiable indicators of inflammation, including blood tests and other biochemical markers, suggest a very strong physiological component that likely plays a key role in most forms of pain, including chronic and/or acute forms.

Pain and Inflammation Research

Back Pain Female.jpg

While it is impossible to narrow pain down to one single component, or even prove that a particular factor is ultimately responsible for causing pain, studies of pain and inflammation suggest that much of the pain individuals experience is likely linked to their musculoskeletal system. Additionally, these studies support the notion that pain is oftentimes a byproduct of one’s movement mechanics and muscle dysfunction, rather than a figment of one’s imagination that elicits a distorted perception of pain. While there are dozens, if not hundreds, of studies that support this concept, for the sake of brevity I’ll simply highlight a small portion of the research.

CRP, Musculoskeletal Pain, and Injury

Multiples studies have shown that musculoskeletal pain including local pain, chronic pain, tenderness, body aches, peripheral nerve irritation, weakness, limited motion, and tension produced from various musculoskeletal-related activities (i.e. repetitive tasks, faulty mechanics, poor postural alignment, and inefficient ergonomics) in otherwise healthy participants, is associated with an increase in pro-inflammatory cytokines and myokines, as well as overall increased levels of systemic inflammation as shown by C-reactive protein levels (CRP) a key marker of inflammation [1-4].

Studies support the notion that pain is oftentimes a byproduct of one’s movement mechanics and muscle dysfunction, rather than a figment of one’s imagination.

In addition, there appears to be a strong correlation between the severity of chronic pain/tenderness and CRP levels, directly linking inflammation to poor musculoskeletal health. Furthermore, as the number of anatomical sites associated with pain increases (i.e. shoulders, neck, knees, hips) etc. the levels of CRP also seem to rise. In fact, in many of these studies the levels of CRP in many of the individuals, particularly those with higher levels of chronic pain, were so elevated that it placed them in “high risk” category of cardiovascular disease. However even “mild pain” that often goes unreported, undetected, or undiagnosed was associated with moderately high levels of systemic inflammation and CRP. These results further support the notion that musculoskeletal pain, discomfort, and injury, produced from faulty mechanics, postural dysfunction, and inefficient movement, are linked to increased inflammation. The fact that the aforementioned studies were carried out on otherwise healthy subjects with no previous incidence of disease or illness, other than the reported work-related musculoskeletal pain and body aches that are oftentimes considered quite normal in society, underscores the fact that inflammation is a very relevant and relatable topic for any and all individuals, as most of the population suffers from varying degrees of musculoskeletal aches and pain.

CRP and Muscle Function

Based on research it appears that muscle function is the key factor that determines whether or not pain, and ultimately inflammation is produced.

Although CRP levels and inflammation have empirically been shown to increase as a result of musculoskeletal pain, it appears that muscle function is the key factor that determines whether or not pain, and ultimately inflammation, is produced in the first place. Several studies have shown a strong relationship between CRP levels and movement/muscle dysfunction including mobility, gait mechanics, grip strength, stability, shoulder mechanics, posture, walking speed, and general fitness issues, with each being strong predictors of CRP levels [5, 6] [3, 7-9]. That is, greater levels of muscular and movement dysfunction are correlated with higher levels of systemic inflammation and CRP.

Musculoskeletal Dysfunction & Low Back Pain

Back Pain Male.jpg

Low back pain is one of the most common forms of physical discomfort and musculoskeletal pain in our society. While there are many factors that contribute to low back pain, one of the most critical yet oftentimes overlooked factors contributing to persistent spinal pain is faulty body mechanics, including poor postural alignment and spinal positioning. In fact, a number of research studies have examined spinal mechanics and posture in relation to low back pain. In many cases a strong relationship appears to exist between back pain and posture/spinal alignment, with more frequent and severe cases of back pain being associated with faulty postural mechanics, while more neutral/proper spinal positions are associated with reduced low back pain [12-15] [16].

It is not inconceivable, therefore, that the many factors that contribute to low back pain are more likely to cause persistent problems and, likewise, the pain associated with these factors is likely to be exacerbated, if spinal mechanics are poor, as even the slightest form of dysfunction may trigger pain and/or an inflammatory response. On the other hand, low back pain associated with these and other factors, can most likely be mitigated, or at least minimized, by optimizing spinal mechanics and muscle function. Significantly, more recent research has shown a positive association between inflammation/CRP levels and low back pain, with increased levels of pain and more extreme low back conditions being associated with higher levels of CRP [17, 18].

Recent research has shown a positive association between inflammation/CRP levels and low back pain.

It should be noted that while many studies have found a strong correlation between low back pain and postural abnormalities, some studies have shown a limited correlation between these factors. Ironically, most of the low back pain studies that failed to find an association between postural aberrations and low back pain involved elderly patients using self-reporting methods. Many authors have remarked on this common scenario noting that much of the pain experienced in the elderly populations oftentimes goes unreported as many older adults simply believe that pain is a normal part of the aging process and don’t report it unless the levels are inordinately high.

Another plausible explanation for this is that elderly individuals, as well as those who live with heightened levels of chronic pain and or inflammation, have desensitized pain receptors, decreased sensitivity to pain, and increased pain threshold [19, 20]. In fact, it is well documented that sensitivity in sensory systems, as well as overall somatosensory feedback, decreases with age due in part to diminished numbers of specialized peripheral receptors combined with a deterioration of supporting tissues. Additionally, peripheral nerves show a reduction of both myelinated and unmyelinated fibers as well as signs of damage and degeneration. Furthermore, The number and size of sensory neurons in dorsal root ganglia decreases with age, thereby impacting age-related changes in nociception [20]. Simply put, just because “pain” isn’t reported with postural abnormalities or structural trauma doesn’t mean there isn’t accompanying inflammation and pathology present that’s impacting the individual’s physiology.

Posture, Neck And Cervical Spinal Pain

Together with low back pain, neck pain has been ranked the 4th leading cause of disability globally, with significant social and economic consequences. While the causes of neck pain are unclear, most uncomplicated neck pain is associated with postural or mechanical factors including sporting related activities, prolonged sitting, faulty body mechanics, environmental factors, occupational activities, neck strain, and cell phone usage [21-23].

Postural abnormalities appear to be associated with increased inflammation as reflected by increased CRP levels.

Although as mentioned earlier poor posture may or may not immediately lead to low back pain, it appears that poor posture has a very direct and almost immediate impact on neck and cervical spinal pain. In fact, many studies have found a strong relationship between postural aberrations such as forward head tilt (associated with tight pectorals and anterior shoulder as well as weak upper back muscles) and cervical neck pain. Other forms of pain including headaches and shoulder pain, have also been linked directly to these same postural abnormalities. [23-27]. Therefore, studies of cervical pain and its relationship to posture give even further credence and validity to the importance of posture and muscle function in injury prevention and overall health.

As is the case with low back pain, neck and cervical spinal pain associated with the postural abnormalities mentioned above also appears to be associated with increased inflammation as reflected by increased CRP levels [1, 3, 4]. Thus, here again, given the link between systemic inflammation and disease, individuals who exhibit faulty posture and its associated pain symptoms (which is a very common occurrence in most of the population) are likely to be more susceptible to the many diseases linked to chronic inflammation and to accelerated aging.

Postural Mechanics, Osteoarthritis, and Inflammation

Back and Shoulder Rear Flex.jpg

Recent studies in the area of osteoarthritis also appear to support the notion that muscle function and postural mechanics have a significant impact on systemic inflammation. While the exact cause of osteoarthritis remains to be elucidated, a number of studies suggest that poor body mechanics and muscular dysfunction may be key contributors to the onset of this very common disease. In fact, several areas of research are now showing such strong correlation between muscular dysfunction and osteoarthritis that it is difficult to deny the impact that body mechanics has on the occurrence of osteoarthritis [28].

For instance, studies show that poor spinal alignment, faulty gait/walking patterns, and aberrant postural mechanics are strongly associated with osteoarthritis in the knee joint. Biomechanical analysis also shows that such postural aberrations and spinal misalignment issues create additional stress and torque on the knee joints [29, 30]. Thus, while it may be impossible to prove direct causation, it’s likely that the aberrant body mechanics strongly contribute to the onset of osteoarthritis or at least the severity of it.

Furthermore, studies showing a strong relationship between altered biomechanics, pro-inflammatory cytokines, pain, and cartilage degeneration strongly support the notion that poor mechanics and faulty muscle activation lead to, or at least contribute to cartilage degeneration and osteoarthritis, as well as the associated systemic inflammation and oxidative stress, suggesting a complex interplay amongst a number of factors, including biomechanical factors, inflammation, and cartilage degeneration, in the development of osteoarthritis [31].

Foot & Ankle - Treadmill.jpg

Similarly, other studies have concluded that inflammation is one of the key factors leading to the destruction of cartilage in osteoarthritis via a similar inflammatory mechanism as that of rheumatoid arthritis [32]. However, biomechanical stress was also found to be a likely contributor. Similar results were obtained in studies showing a strong relationship between poor foot and ankle alignment (i.e. ankle pronation) and osteoarthritis of the knee as well as other joints. The authors further suggest that foot and ankle mechanics may be a key factor in terms of delaying the onset and/or preventing symptoms of osteoarthritis in various lower body joints [33]. Taken together, these findings, as well as those described in prior sections regarding the impact of poor body mechanics on joint health and inflammation, provide significant evidence in support of the notion that muscular dysfunction and faulty body mechanics may be significant contributors to osteoarthritis and the destruction of joint cartilage.

It is important to note that the impact of biomechanical loading on cartilage and joint health is a complex process. In fact, depending on the mode, magnitude, duration of application, and combination of other biomechanical and physiological factors, it appears that mechanical loading can have either beneficial or detrimental effects on joint health and connective tissue [31]. However, based on the findings discussed in earlier sections, as well as current research on osteoarthritis, it appears that muscle function and body mechanics may be key factors that determine whether or not loading, impact, and tension produce a therapeutic or contra-therapeutic effect on the joints and cartilage.

Proprioception, Muscle Function, And Posture

Foot & Ankle Balance Banner.jpg

Proprioception describes the innate ability of the body to sense the position of its various limb movements in space and make the necessary adjustments to body mechanics and movement. Some also describe this as kinesthetic awareness. The proprioceptive system is a complex system and a vital feature of our nervous system that helps ensure we produce the most efficient movement. When proprioceptive feedback is distorted or impaired movement mechanics and body positioning suffer, ultimately leading to increased joint pain, injury, and potential musculoskeletal trauma. Impaired proprioception therefore, negatively impacts muscle function in much the same way as spinal misalignment.

If as little as 5 minutes of faulty postural alignment is enough to disrupt proprioception, what are the consequences of continuous & consistent postural aberrations?

Many of the studies showing the effect of postural aberrations on body mechanics have also shown a significant effect on proprioceptive function. More specifically, postural aberrations appear to disrupt proprioception and somatosensory feedback, most likely due to poor neural signaling and the short-circuiting of these signals along the spinal pathway as a result of faulty spinal alignment [37-39]. In fact, several studies have shown that assuming faulty postural alignment for as little as 5 minutes is enough to disrupt and distort proprioception [38, 39]. These findings beg the question, if as little as 5 minutes of faulty postural alignment is enough to disrupt proprioception, what are the consequences of continuous and consistent postural aberrations?

Poor proprioception is likely to result in further impairment of body mechanics, kinesthetic awareness and overall muscle function, which are likely to lead to joint pain and associated increases in CRP levels and systemic inflammation. Given the association between musculoskeletal system pain and dysfunction and systemic inflammation and oxidative stress, it follows that impaired proprioception would also increase individuals’ susceptibility to the various pathological issues and physical maladies linked to systemic inflammation, as well accelerate the aging process. Therefore, improving proprioception and kinesthetic awareness, thereby improving body mechanics and movement efficiency, is of critical importance.

Improving Posture

Back, Lat, and Shoulder Stance.jpg

Perhaps the single most eye-opening body of literature regarding the impact of posture on the human body are studies that examine interventions aimed at correcting postural aberrations. Multiple recent investigations have shown that exercise programs aimed at correcting postural aberrations not only improve posture but also help eliminate pain associated with postural aberrations. [11, 23, 43, 44]. It is particularly noteworthy that in several of these studies, the exercise routines were only implemented for a relatively short 4-week period. Given the strong relationship between musculoskeletal pain and systemic inflammation, it’s not unreasonable to speculate that any form of treatment, such as exercise that eliminates or reduces the pain associated with postural aberrations, is also decreasing systemic inflammation and ultimately improving overall health, including a deceleration of the aging process.

Traditional Exercise Programs & Muscle Dysfunction

Bench Press (HD).jpg

Although sound exercise programs that target and aim to improve muscular dysfunction appear to decrease joint pain and may in fact help decrease systemic inflammation, traditional resistance exercise programs may produce the opposite results. In fact, as mentioned earlier, studies have shown that compared to non-lifters, many individuals including recreational lifters, general populations, and even high level athletes who consistently strength train, appear to be at greater risk for musculoskeletal pain and injury due to a higher rate of muscular dysfunction and faulty mechanics associated with their training [45-48]. This is most likely due to the fact that unless properly instructed, most individuals will inevitably resort to the compensation patterns and dysfunctional movements they’ve relied on throughout their lifetime which are only reinforced, and oftentimes made worse, by traditional training. Cervicogenic headaches (CGH), which are frequently associated with poor posture, also appear to be unusually common in weight training populations. This is most likely due to the use of faulty technique that is commonly observed in weight training circles and that degrades optimal mechanics and postural alignment.

Thus, if traditional strength training (or at least the strength training routines performed by most individuals) leads to aberrations in muscle function and increases the risk of musculoskeletal pain and injury, it’s not unreasonable to suggest it also increases the risk of contracting diseases associated with chronic inflammation. Simply put, improper strength training can elicit a pro-inflammatory response that gradually leads to deterioration of the entire body, increased susceptibility to disease and accelerated aging.

Muscle Function in Dancers And Gymnasts

Rings - AHP.jpg

We’ve previously established that faulty body mechanics produce musculoskeletal pain, leading to increased CRP levels and systemic inflammation. However, many activities including those that are often thought of as healthy and physically beneficial such as gymnastics, ballet, and various other forms of dance appear to produce very similar physical maladies to those observed in populations that display dysfunctional movement patterns [49, 50]. In fact, many gymnasts and dancers develop severe low back, hip, knee, foot and ankle issues during their training and competitive years that persist beyond retirement, often becoming chronic in nature [51-53]. This is most likely due to the fact these activities frequently incorporate semi-contortionist-like positions and maneuvers that are aesthetically and visually pleasing, yet most of which are not functional or structurally optimal and oftentimes place the body in biomechanically unsound and faulty positions.

Similar to the effects of improper training mechanics, many gymnasts and dancers develop severe orthopedic issues during their training and competitive years due to dysfunctional movement.

As with other dysfunctional movements and faulty body mechanics, these extreme maneuvers and positions produce joint pain, elevated levels of CRP, and systemic inflammation ultimately culminating in deleterious effects to their overall health, something dancers and gymnasts are all too familiar with both during their competitive years and after retirement. Ironically, dancers and gymnasts in particular are often considered prime examples of strength, coordination, athleticism, and fitness due to their impressive physical abilities, graceful movements, and muscular development. Unfortunately, because much of the strength, skill, and muscle is built on dysfunctional movement patterns, their training actually produces similar, if not more, physiological harm than that observed in individuals who lead semi-sedentary lifestyles.

Having covered some the basics regarding body mechanics and its impact on pain and inflammation, lets now examine what many in the industry consider to be the flipside of this research, namely pain science.

Asymptomatic Spinal Degenerative Disease


A common area of research that “pain scientists” rely on to support the argument that pain is predominantly a matter of perception is found in the literature on asymptomatic spinal degenerative disease. For instance, numerous studies have shown that in many individuals who present without significant pain or injury to their spine there is, actually, significant evidence of spinal degeneration based on MRI, CT, and other imaging findings [36]. While asymptomatic spinal degeneration has been reported in nearly all age groups, the prevalence appears to increase with age, suggesting that spinal degeneration may simply be part of the normal aging process.

Unfortunately, many pain scientists and professionals in the health and fitness industry have largely misinterpreted these results to suggest, therefore, that the basis for much of the pain individuals experience is cognitive and affective in nature rather than physiological. Unfortunately, this could not be further from the truth. In fact, a look at the degenerative changes detected via imaging in asymptomatic individuals may help shed some light on the topic of pain science and support the fact that the perception of pain is not simply affective in nature but rather a byproduct of muscle dysfunction. That being said, there are 5 possible explanations for why spinal degenerative changes can be found on imaging of asymptomatic individuals.

Reason #1
- Test Reliability Issues -

Lab Test.jpg

Perhaps the most plausible explanation is related to the method of analysis. Most, if not all, studies of spinal degeneration in asymptomatic individuals were performed with one key intent – namely to determine whether traditional forms of imaging, such as MRI and CT, are accurate and effective methods for evaluating patients with back pain. However, as shown by many studies [12, 36], MRI and CT findings cannot reliably, effectively, or accurately be used to determine the cause of back pain, as there does not appear to be a strong correlation between degenerative changes on imaging and the presence or degree of low back pain.

In essence, it appears current and traditional forms of imaging in asymptomatic individuals frequently show what could be referred to as ‘false positives’, not in the strict sense of the word, but in the sense that degenerative spine findings would typically be considered reflective of spinal pathology. In other words, MRI and CT findings of spinal degeneration in apparently healthy individuals may be interpreted as signs of injury or trauma where there is none. These results suggest that these methods alone, cannot, and should not, be used for diagnostic purposes in asymptomatic populations but must be interpreted in the context of the patient’s condition.

MRI and CT should not be used to asses injury but rather to confirm injury in patients who present with low back pain or report an injury

Additionally, it appears that patient self-reported levels of pain and disability, or lack thereof, are significantly more reliable than MRI and CT as evidence of actual injury, particularly in asymptomatic individuals. In other words, in the absence of pain or obvious trauma, regardless of MRI or CT findings, it is unlikely the patient has suffered a significant injury and therefore, does not need to be clinically treated. Furthermore, it is also unlikely the incidental finding of spinal degeneration by MRI or CT in an asymptomatic patient reflects the fact that the patient was somehow injured yet feels no pain. What is more likely is they were not injured in the first place and the degree of degeneration is not as extreme as the imaging tests may suggest. However, it does appear that MRI and CT may be an accurate means of confirming injury, trauma, and degeneration in patients that report feeling pain and discomfort, or present symptoms following an injury. Simply put, MRI and CT should not be used to asses injury but rather to confirm injury in patients who present with low back pain or report an injury.

Reason #2
- Severity of Degenerative Changes -

Back and DNA.jpg

A second plausible explanation may be related to the severity of injury. In other words, the fact that MRI and CT can more accurately confirm rather than evaluate an injury may be explained by another key factor that many pain scientists tend to ignore, namely, that imaging findings in most, if not all, studies are not stratified or reported by the degree of severity but rather “occurrence vs. non-occurrence”. In fact, the authors of the meta analysis described above postulate that it is possible that asymptomatic individuals have less severe degenerative changes than those with symptoms. Simply put, it’s likely that the discrepancy observed between imaging findings and the presence or absence of symptoms is often due to the fact that the magnitude or severity of structural injury/trauma is not reported. If the severity of injury were reported it’s likely we may see a significant difference in terms of imaging findings when comparing asymptomatic vs. symptomatic patients, with symptomatic patients most likely showing more severe degeneration.

This is consistent with the fact that while signs of spinal degeneration have been detected by MRI and CT in asymptomatic individuals, the prevalence of degenerative spine findings in this population is not as high as that observed in symptomatic individuals. In fact, one meta analysis showed that spinal degeneration and spinal injuries are more prevalent in individuals who report back pain compared with asymptomatic individuals. This further supports the notion that the pain associated with these findings is likely a result of actual injury and structural trauma and not simply a matter of perception or mental state [12].

Reason #3
- Timescale of Degenerative Changes -

Spinal degeneration in asymptomatic individuals could represent red flags and warning signs of future issues that, if left untreated, could eventually become problematic

Another factor that may contribute to some of the findings observed in asymptomatic populations is related to the timescale of development of spinal degeneration. As previously discussed, some individuals who show signs of significant spinal degeneration don’t necessarily report feeling pain at the time of their MRI or CT evaluation. However, a recent review describes a unique trend across multiple studies showing that in asymptomatic individuals, the development of various forms of spinal stenosis over a 10-year period was associated with future development of neck pain [54]. Simply put, the fact that a person shows signs of spinal degeneration, or even injury, yet is asymptomatic does not mean they won’t experience future issues. In other words, spinal degeneration in asymptomatic individuals could represent red flags and warning signs of future issues that, if left untreated, could eventually become problematic. Significantly, preliminary investigations and anecdotal data suggest that spinal stenosis may be strongly related to posture, further reinforcing the notion that treating postural aberrations via proper exercise selection, execution and neuromuscular re-education techniques may play a key role in preventing pain associated with spinal stenosis.

Reason #4
- Pain Desensitization -

Knee Pain.jpg

Yet another plausible explanation as to why evidence of spinal degenerative changes can be found in asymptomatic patients may relate to pain desensitization. As previously mentioned, pain desensitization is not ideal yet it is, in fact, a common problem amongst aging individuals who, as a result, fail to heed the proper warning signs and symptoms of a potential threat of injury. Thus, individuals who experience pain desensitization may be more prone to extreme injuries and catastrophic trauma. Perhaps not surprisingly, the prevalence of spinal degenerative changes in asymptomatic individuals appears to increase significantly with age suggesting that pain desensitization may be a key factor contributing to these findings. Although pain desensitization occurs more frequently and strongly in aging populations, such an undesirable physiological phenomenon can easily occur in individuals of any age if their bodies are forced to adapt to enough inflammation, trauma, and injury.

Reason #5
- Individual variability and the role of musculoskeletal and neuromuscular factors -

Bodybuilder and DNA.jpg

As previously shown, many forms of spinal degeneration do not cause pain. However, many forms of spinal pain are associated with and linked to spinal degeneration. It’s likely that the severity of the injuries, as well as the magnitude of injury/degeneration needed to eventually manifest as pain differs from person to person.

Factors that may contribute to this individual variability and likely play a key role in determining how much a given level of degeneration causes pain include musculoskeletal and neuromuscular factors, such as the level of muscular strength, mobility, stability, and function around the injured areas (e.g. resting length of the muscles around the spine). That is, spinal degeneration in the presence of weak core muscles, poor low back strength, muscle dysfunction, as well as suboptimal length of associated muscle fibers (i.e. spastic or hypertonic muscles) may be associated with pain more often.

In contrast, spinal degeneration present in individuals with relatively greater levels of core strength and optimal muscle function may be less frequently associated with pain. Simply put, the muscles that surround the injured or degenerating regions may play a more pivotal role than the injury itself when it comes to experiencing pain. With this in mind, optimal muscle function and body mechanics becomes even more paramount in the discussion of pain management.

The muscles that surround the injured or degenerating regions may play a more pivotal role than the injury itself when it comes to experiencing pain.

Finally, just as asymptomatic individuals may show signs of spinal degeneration on imaging, some individuals who manifest pain may not show signs of injury or structural damage upon MRI and CT evaluation. This is likely due to the fact that not all pain is structural, spinal, or joint related but can often be of a muscular nature such as spastic muscles. In fact, muscular injury and muscular inflammation can cause and contribute to pain just as much as spinal injuries and joint trauma. However, consistent and repeated muscular injuries may eventually result in structural trauma and injury to the associated regions particularly if unaddressed.

Misinterpretation of Neuroscience Pain Education

The key takeaway from NPE research is that maintaining physical activity, and simply moving the body via light to moderate activities is critical during pain management.

There’s no doubt that an individual’s perception and experience of pain can have a significant impact on their quality of life as, among other things, it can either promote or prevent physical activity. In fact, this is perhaps the single most critical finding reported by the field of pain science and, more specifically, the field of NPE or neuroscience pain education, which aims to educate individuals on pain-related biology as a means of changing their understanding of pain. In essence, it has helped individuals understand the importance of remaining physically active, rather than avoid physical activity, by reducing their pain-related and activity-related fear, allowing them to participate in physical activities even if they’re experiencing pain. This is in contrast to the decades- and centuries-old recommendation by well respected physicians to rest, immobilize, and minimize (if not altogether eliminate) physical activity when battling bodily pain, discomfort, fatigue, and injury, one of the most ineffective and quite frankly counterproductive treatments ever suggested by the medical field and physicians.

Abs and DNA Strand.jpg

Many individuals who struggle with pain, injuries, inflammation, fatigue, and other medical issues fear physical activity and believe being physically active will only worsen their conditions. Advocating inactivity and body immobilization reinforces their fear of physical activity, and it is this lack of activity that oftentimes worsens their condition. Fortunately, over the last decade the field of neuroscience pain education (NPE), as well as other areas of research, have shown that maintaining physical activity, and simply moving the body via light to moderate activities (i.e. walking, shopping, gardening, cleaning, hiking, light cardio etc.) is one of the healthiest and most beneficial treatments for this population, not to mention most human beings.

Unfortunately, many trainers, strength coaches, fitness experts, and "pain gurus' have misunderstood NPE, and completely misinterpreted and distorted these findings. As a result they have erroneously applied what are common misconceptions of NPE to the fields of biomechanics and neuromuscular physiology as they relate to strength training, athletics, high intensity physical activity, high impact movements, weightlifting, and high level sports performance. This has done unprecedented, and in many ways irreparable, damage to the field of kinesiology, as it's perpetuated the fallacious notion that body mechanics, technique, form, and joint positioning during high force and high impact activities are essentially irrelevant or relatively unimportant since each person can and should move the way he or she desires with no ramifications and consequences.

Essentially, many of these "pain experts" have entirely misconstrued the results of NPE studies and suggested that there's no such thing as wrong or right ways to move, or good or bad mechanics, as each person will have their own unique method of movement. Furthermore, the thought in the pain science community is that, if pain does exist, these individuals simply need to be educated about pain through neuroscience pain education therapy (NPE) via learning modules, discussions, and educational sessions, so as to change their perception of pain. In addition to the studies discussed earlier that highlight the relationship between pain and body mechanics, there are several additional flaws in this misconstrued NPE ideology highlighted most notably by pain science research itself.

The Truth About Neuroscience Pain Education

DNA and Molecule Structure.jpg

Over the last decade, the topic of pain neuroscience education (PNE), neurophysiological pain education (NPE) therapy, and its impact on pain, have been extensively studied. Although the results vary, the general consensus based on studies, literature reviews, and meta analyses is that NPE, as a standalone therapy, is only mildly effective at best. For instance, a recent study demonstrated that PNE did not reduce the levels of pain in individuals with chronic spinal pain [55]. However, secondary outcomes such as perceived threat of movement (catastrophizing) and fear of movement causing pain (kinesiophobia) were reduced. Simply put, PNE did positively shift the study subjects’ mindset in regards to staying physically active, although the level of pain and disability from the treatment remained unchanged. However, it could be argued that increasing activity levels in and of itself, by going from a relatively sedentary state, as is common for many patients with chronic pain, to a physically active state, may constitute an important ingredient when it comes to helping reduce pain and improve overall health.

Some studies have reported mild improvements in the levels of pain. Unfortunately, the degree of improvement as well as the long-term effects appear to be quite small. In fact, in a recent study PNE appeared to slightly reduce the levels of pain in individuals with chronic neck pain [56]. However, the effects did not reach statistical significance, thus minimizing the usefulness of PNE in practical settings.

Another recent study demonstrated that PNE treatment had no significant effect on perceived disability due to pain (Pain Disability Index) yet, as has been reported by others, a positive effect on kinesiophobia and several subscales regarding perception of pain, including the negative consequences of movement, were observed. However, the effect sizes were again relatively small, leading the authors to conclude that clinical utilization of PNE may be limited. The authors further suggested that PNE should not be used as the sole treatment modality for pain but should be combined with other treatment strategies.

Even more noteworthy are two very recent literature reviews and meta-analyses. The study results described in one of the reviews indicate there is low to moderate evidence that the addition of PNE to usual physiotherapy intervention in patients with low back pain improves disability in the short-term [57]. However, this meta-analysis failed to show evidence of any long-term improvement on pain or disability. Therefore, once again, the usefulness of PNE as an effective treatment is limited.

At best it appears NPE treatment may have a relatively small impact on the level of pain in the short-term, but less of an impact long term.

Perhaps the most promising findings in support of NPE therapy were reported in a recent review by Tegner et al. [58]. In this case studies found moderate evidence that NPE has a small to moderate effect on pain, and low evidence of a small to moderate effect on disability immediately after the intervention. Additionally, NPE was shown to have a small to moderate effect on pain and disability at 3 months follow-up. So what can we conclude from all these studies? At best, it appears NPE may have a relatively small, positive impact on the level of pain in the short-term, but less of an impact in the long term. However, there does appear to be greater evidence in support of the notion that NPE may help reduce fear of movement in individuals with pain, yet the actual impact on disability appears to be minimal at best.

The Real Reason NPE Works

Back Injury.jpg

With that being said, let’s examine the most likely explanation as to why NPE may provide a slight degree of pain relief. In essence, NPE appears to help individuals who are inactive and sedentary minimize their fear of pain and understand the importance of staying physically active. Simply put, adding in light physical activity and resuming a moderately active life style is a surefire method to improve almost any and all forms of physical disability and maladies, not just pain related issues. However, few, if any of the studies on NPE/PNE mention anything about engaging in high force, high impact, and high intensity physical activity such as sports, weightlifting, jumping, sprinting, strength training etc. nor do they suggest that biomechanics are irrelevant. They simply highlight the importance of staying physically active (i.e. walking, cleaning, hiking, moving, shopping, etc.).

However, even in terms of staying physically active, these studies are quite inconclusive, showing that NPE techniques are only mildly effective at best, and mainly effective in the short term. In reality, the true long-term solution is to improve body mechanics, technique, muscle activation, body alignment, and movement efficiency. Educating individuals on the importance of movement and the need to stay active is simply the first step in the right direction, but by no means represents the end goal, or the final step in reaching the desired resolution.

Obvious Conclusions About Pain Science, Body Mechanics & NPE

Given that most studies show that the effectiveness of NPE appears to be moderate at best, the question becomes how, in fact, did the existing pain science trend in the fitness industry become so popular? To best answer this question requires a brief history of the industry.

Error Leads to More Error

The popularization of the misguided modern day “pain science” theory currently perpetuated in the fitness industry, which suggests that most pain is a matter of perception and there is, in fact, no such thing as wrong or right ways to move, can be traced back to 2 primary factors, namely 1) the failure of the functional fitness trend and 2) attempts to justify this failure by incompetent and/or uneducated trainers.

To fully grasp the significance of these issues it’s important to first take a step back and define what I refer to as the 3 major trends in the fitness industry: 1) the bigger, stronger, faster trend, 2) the functional fitness trend, and 3) the pain science trend.

Bench Press and Spotter.jpg

The bigger, stronger, faster trend spanned an approximately 20-year time period, from the early 80’s to the early 2000’s, essentially representing the first major trend in the field of exercise science. This trend relied primarily on a combination of old school strength methods, bodybuilding, powerlifting, and Olympic lifting techniques. While athletes did, in fact, become bigger, faster, and stronger than they had in prior decades, there also seemed to be a relatively high incidence of injuries including lifting related injuries.

This paved the way for the functional fitness trend as it allowed professionals in the industry to provide a potential solution by suggesting that these injuries and aches and pains were not par for the course when it came to training, but simply a matter of improper application of training principles, including the failure to address various forms of muscle dysfunction and movement aberrations. The functional fitness trend, which began with a powerful surge in the mid 2000’s, utilized a variety of training methods ranging from muscle assessment, corrective exercises, stabilization drills, mobility exercises, soft tissue work, motor control techniques, biomechanical manipulations, and more.

Unfortunately, the functional fitness trend represents one of the most heart breaking stories in the fitness industry. On the one hand its inception brought excitement to the field, as it appeared to provide a potential rationale and explanation, as well as a solution, to the pain, various injuries, and inflammation brought on by the bigger stronger faster trend. However, despite some slight improvements in terms of injury prevention, the functional fitness trend began to gradually decline around 2014 as the results never lived up to expectations and the predicted outcomes never materialized.

Squat Male.jpg

Like many trends in the fitness industry, the functional fitness trend’s disappointing results were not so much a matter of flawed concept but a matter of faulty implementation of scientific principles as they applied to the practical setting. That is, the idea that individuals need to improve their body mechanics, eliminate dysfunction, master their technique, and enhance muscle function in order to minimize injuries and maximize health, fitness, and performance was, in fact, the necessary mindset, particularly given the issues produced by the bigger, faster, stronger trend.

Unfortunately, the fitness industry failed to precisely define what proper movement and body mechanics entailed, therefore, the ability to “improve body mechanics”, eliminate dysfunction, and minimize injuries could be taken only so far. As a result, many trainers, practitioners, kinesiologists, coaches, and therapists alike began to gradually jump off the functional fitness band wagon in favor of a more tantalizing theory, promoted by the pain science fad, which suggested that the reason they could not eliminate many of the injuries and associated pain had less to do with body mechanics and more to do with people’s mental perception of pain. For many in this field, such a theory was both convenient and appealing, as it represented a legitimate way to rationalize many of the failed attempts of the functional fitness trend, as well as their own failed attempts at eliminating pain and injuries in their, and their clients’ bodies.

As the pain science fad continued to evolve many trainers and practitioners, particularly those that rely heavily on the modern day “pain science” argument, compounded this misguided philosophy by taking it to the extreme, suggesting that "there is no such thing as proper or improper technique, "good or bad mechanics", or "proper or improper posture". Although the fitness industry as a whole is partly to blame for such a fallacious doctrine, this simply became a way for uneducated trainers and incompetent practitioners to justify their inability to help clients eliminate pain and dysfunction, not to mention their inability to properly coach movements.

A competent trainer will take the time to learn his or her craft, meticulously implement their knowledge then, inevitably, come to the realization that while there may be subtle individual differences, there is in, fact, an optimal and proper method of performing most movements that happens to be quite similar from person to person. When applied properly these protocols help eliminate most of the pain felt by their athletes and clients, as well as themselves. Unfortunately, the ideology espoused by the “pain science” fad has attempted to nullify this approach and in many ways has done irreparable damage to the fitness industry.

Dangerous Advice Leads To Dire Consequences

The worst advice we can give an athlete or individual engaging in physically demanding, high-force activities such as strength training, sprinting, running, jumping, etc. is that body mechanics and technique aren't that important. The notion that we need to empower/encourage people to workout and train without fear of biomechanical-related injuries, rather than instruct them on how improve their body mechanics, is analogous to telling someone who chooses to snort cocaine that we support their decision to self-medicate, and we want to empower them to make their own choices, rather than warn them about the long term consequences of their illicit drug use.

As professionals in this field it’s our responsibility to educate people on proper mechanics, not empower them to make unsafe decisions by telling them to train through pain without worrying about negative repercussions

As professionals in this field it's our job and responsibility to educate people on proper mechanics, not encourage them to make unsafe decisions by telling them to train through pain, without worrying about the negative repercussions. For example, an athlete who repeatedly injures their ACL due to constant valgus knee and valgus ankle collapse needs to be educated and trained to eliminate such movement aberrations. The worst thing we can do is encourage them to keep working through these forms of dysfunction by suggesting that the pain is predominantly in their mind.

Another classic example is that of individuals with poor postural and pressing mechanics who perform bench press movements while experiencing continual shoulder issues, pain, and inflammation. Advising them to continue working through their discomfort by suggesting it's all in their mind and is simply a pain mechanism they need to learn to tune out, represents a philosophy that’s setting these individuals up for disaster and recurring injuries, with each injury oftentimes becoming worse and worse. In reality, what would provide the necessary solution for their pain and inflammation is addressing shoulder mechanics, posture, technique, and muscle activation.

Empowering people to work through injuries and significant pain by suggesting it's all in their mind will actually promote the recurrence of pain and injury, the end result being they become even more afraid to workout until eventually they cease to engage in that form of physical activity altogether. Unfortunately, the very thing the "pain experts" are attempting to avoid (fear of movement) is the very thing they end up promoting with their flawed and misconstrued philosophies. Educating individuals on how to move correctly is essentially what “frees them up”, as they'll notice how movements which once caused pain, injury, and inflammation, can actually be performed without negative consequences, provided they keep their body mechanics in check. This is how we successfully empower individuals to reach their health, fitness, and performance goals.

Scales of Movement Intensity

The idea that there's no such thing as a right or wrong technique needs to be examined on a scale of movement. Although highly debatable, one could make an argument that there is no such things as "right or wrong" posture or "good or bad" mechanics when it comes to low force and low intensity activity as well as resting states. This isn't to suggest that body mechanics are irrelevant during such activities, only that they are not as critical. However, the greater the magnitude of the forces involved, the more urgent it is to reconsider and revise this ideology as there are, in fact, optimal body mechanics both for producing and absorbing high level forces and impact. Based on various principles of neurophysiology, biomechanics, osteokinematics, and muscle physiology, optimal body mechanics during high force scenarios can be narrowed down to such precise parameters that optimal human movement should and will, in fact, look quite similar from human to human when performed correctly.

The greater the magnitude of the forces involved, the more body mechanics and technique matter.

For instance, the topic of joint centration, as simple and as elementary as it seems, simply highlights the notion that when tension and forces are equally and properly distributed across the entire joint, as well as across the various joints, muscles, and connective tissue that are involved, the risk of injury and inflammation is markedly reduced. Such an outcome can only be achieved through optimal biomechanics and proper muscle activation, as it's ultimately the muscles that determine whether or not the joints and connective tissue are in their proper position to amply absorb, distribute, and disperse these forces. When activation and recruitment are amiss, more tension is placed across a particular area of a joint, or excessively on one specific joint rather than across all the involved joints, structures, or regions of the body. In other words, the consequences of faulty movement is much more severe under high force scenarios as compared to low force activities.

Unfortunately, many athletes have neither maximized their genetic potential in terms of performance, nor minimized their risk for injury, as most of them simply don't move with proper mechanics. However, this in no way implies that it’s unnecessary to train for optimal body mechanics. We may never achieve perfect mechanics, but at least by training for it we can come as close to it, and maximize our God-given genetic potential as much as is humanly possible. Additionally, just because some athletes can perform well using faulty mechanics in no way suggests that these movement aberrations are optimal. It may take weeks, months, years and sometimes decades, but faulty mechanics and muscle dysfunction will eventually produce physiological consequences and adverse health effects.

So lets recap the main takeaway points about Neuroscience Pain Education.

Takeaway 1

NPE alone is, at best, only mildly effective for reducing pain or associated symptoms of pain. Furthermore, any benefit appears to be short-term with little if any carryover in the long-term alleviation of the pain.

Takeaway 2

The mild and limited findings from NPE studies highlight the importance of staying physically active via low intensity activities (i.e. walking, gardening, hiking, shopping cleaning, etc.)

Takeaway 3

Studies of NPE were never intended to minimize the importance of body mechanics and its impact on injury and pain. In fact, studies clearly show that poor body mechanics are strongly associated with increased pain, injury, and inflammation.

Takeaway 4

Trainers, as well as many segments of the fitness industry, have misconstrued these in an attempt to rationalize and justify their own failures at applying "proper body mechanics" and technique to their own training and that of their athletes.

The Obvious Solution

Although it may be obvious at this point, the solution for treating a majority of injuries, pain, and inflammation is quite simple: teach people to move properly by eliminating their muscle dysfunction and enhancing their body mechanics. This requires first and foremost that we analyze, define, and specify exactly what is meant by proper movement. Such a complex, yet paramount subject matter, however, is a topic for another article and is in fact what I recently wrote in my book, Movement Redefined (see HERE and below). That being said, I believe there’s one final element to highlight that many readers may find interesting as it provides additional support for the aforementioned solution based on my own 15+ years of experience in the industry.

My Own Anecdotal Experience

I realize highlighting my own personal experience and anecdotal rationale is only mildly persuasive at best, as it simply represents numerous examples of n=1. And while I’m a strong believer in scientific investigation, I’m also a strong advocate for analyzing experiential evidence and personal examples, particularly when the number of repeated occurrences is high and they are further bolstered by the scientific literature.

Although I’ve been training clients and athletes for over 15 years, the last 7 years have been quite unique as I’ve created a niche in my training business by helping individuals resolve pain, injuries, and inflammation that they were unable to resolve using other methods and therapeutic modalities. These individuals range from pro athletes, bodybuilders, high school athletes, fitness enthusiasts, and every day business men and women seeking a remedy for their pain. It’s also worth noting that my services are oftentimes a last resort and final attempt to find relief for their pain. That’s because my services are not covered by insurance companies since they only cover costs provide by licensed physical therapists, not muscle physiologists. Therefore, I often work with clients who’ve tried a wide range of therapies and medical treatments for months, if not years, with little if any relief.

Teach the person how to move properly and the pain not only greatly dissipates, in many cases it ceases altogether, regardless of the severity, history, frequency, and/or form of injury.

Throughout the past 7 years I’ve literally seen this scenario repeat itself in an almost daily fashion. That is, teach the person how to move properly and the pain not only greatly dissipates, in many cases it ceases altogether, regardless of the severity, history, frequency, and/or form of injury. In other words, it almost always comes down to whether or not the muscles are performing their job correctly. When movement mechanics and activation patterns are proper, the muscles are able to absorb incoming forces and impact rather than having a majority of those forces go to the joints and connective tissue. When mechanics are amiss, and the individual is not in a position where the muscles can absorb the incoming forces, then trauma, inflammation, and ultimately pain signals inevitably occur.

Yes, this is a very simple and archaic way of explaining movement and pain, both of which are obviously much more complex than this, but from a practical standpoint, this is exactly what happens. For example, if the various muscles surrounding the hip joint are not performing their roles correctly (i.e. absorbing force and producing biomechanically sound movement), stress will inevitably be placed on the hip joint and surrounding connective tissue. Over time this leads to capsular issues, soft tissue abnormalities, osteoarthritis, and overall joint degeneration. While a physician may label this as “overuse” or genetically predisposed structural deficiencies, “improper use” is more accurate.

The body’s joints and connective tissue are incredibly resilient as long as appropriate muscles are performing their roles correctly and absorbing impact. Proper muscle function not only prevents joint and tissue trauma, it can help individuals with even the most severe of injuries including tears, osteoarthritis and joint degeneration, to avoid surgery and eliminate most if not all associated pain and other symptoms, although structurally the injuries may still exist.

If this has not been your experience as a coach, trainer, or practitioner in this field, then you likely need to re-evaluate your coaching skills and gain a better grasp of proper movement mechanics.

For example, an individual with a significant rotator cuff injury could avoid surgery and medical treatment almost indefinitely, regardless of whether or not the injury structurally healed on its own, if, in fact, that individual’s neuromuscular system could be properly re-programmed to recruit surrounding muscles to essentially absorb incoming forces and torque, thereby alleviating most if not all tension from the injured site. In essence, this individual could continue to play their sport, move efficiently, and maintain high functionality of the upper extremities with little if any discomfort. Although there are extreme and rare cases where surgery and medical treatment are the only viable options, most injuries can be overcome by re-educating the nervous system and instilling optimal muscle function.

If this has not been your experience as a coach, trainer, or practitioner in this field, then you likely need to re-evaluate your coaching skills and gain a better grasp of proper movement mechanics. Having worked hands on with athletes and clients for over 15 years, I can tell you undoubtedly this is how movement and pain works, plain and simple, as I see it occur daily in my own clientele.

The fact is few, if any, forms of pain start off purely as a mental perception, although the mental component can oftentimes compound the physical. For example, many individuals who suffer from chronic low back pain exhibit extreme guarding and are consciously aware of the feeling of pain in their low back, though oftentimes they perceive the pain to be worse than it is. However, their perception of pain did not arise spontaneously out of thin air. At some point in time they began to feel significant physical discomfort in their back that was real, not a randomly fabricated figment of their imagination. In fact, it is likely that in nearly every single one of these cases the pain was triggered by a physiological event such as faulty postural mechanics, poor spinal alignment, dysfunctional movement, lack of mobility, aberrations in body mechanics, impaired core activation, or general back weakness. So yes, the physical preceded the mental component, however, the mind oftentimes compounds the physical. Furthermore the mind will never be fully free from pain without the body adapting first.

One’s perception of pain did not arise spontaneously out of thin air. It began with some physiological component likely related to muscle function

We can attempt to convince these individuals until we’re blue in the face that they can free their mind and use their body and spine like a “normal person”. And yes, perhaps this will reduce the pain or the perception of pain slightly as the mind is a powerful tool. But until we teach them to move properly by re-educating their CNS with appropriate activation patterns, in most cases those signals of discomfort, pain and potential danger, will not allow them to move in an uninhibited and/or pain free manner. Teach them step by step how to properly position their spine, fire their core, stabilize their spine, hinge at their hips, activate their feet, adjust their extremities, and control their body mechanics, and over time these signals not only lessen, the sensation of pain is altogether eliminated. That’s because the movements being performed are no longer perceived as a threat to the body. In other words, by eliminating dysfunctional movement patterns and correcting their body mechanics these positions and movements become therapeutic rather than contra therapeutic.

No doubt there are a myriad factors that impact “pain”, but the one that we have the most control over, and the one I believe from experience has the most significant impact on the mechanisms underlying pain, is body mechanics and muscle function. Teaching someone how to move properly may not eliminate all of the pain and inflammation in the body but it will eliminate a large part of it, or at least eliminate the part that is, in fact, reversible. Attempting to eliminate pain by simply training the mind is, in effect, treating only the symptoms, as the pain was not just magically conjured up by individuals to have something interesting to dwell on throughout their busy and tumultuous days. No, the pain actually stems from inflammation, and that inflammation is a direct result of dysfunctional movement and aberrant activation patterns. In fact, getting an individual to tune out the pain when there is a strong degree of inflammation present amounts to simply masking the discomfort while continuing to induce further damage on those particular regions and is the worst thing one can do.

Attempting to induce some psycho-analytic trance or pre-hypnotic self efficacy therapy to convince individuals the pain is all in their mind is not the answer.

So no, attempting to induce some psycho-analytic trance or pre-hypnotic self efficacy therapy to convince individuals the pain is all in their mind is not the answer. What I’m talking about is actually eliminating the root cause of the pain and getting to the heart of the problem once and for all by addressing the very thing that caused that “pain “ to register in the person’s mind to begin with – i.e. faulty mechanics and muscle dysfunction. And yes, it’s that simple, but it does require that the coach understand and teach what proper mechanics entails as well as what constitutes dysfunctional mechanics and aberrant movement. If the coach is unable to do this then yes, they’re probably better off going down the “psycho hypnotic “and “mental trance” route.

With that said, I want to highlight one final example I’ve observed countless times in my clients and athletes as a last effort to drive this concept home. As previously mentioned, I often work with individuals who come to me as a last resort after years of therapy and other forms of traditional treatment that did little if anything to resolve their pain and injuries. Not surprisingly, many of these folks are quite skeptical as they’ve been mentally and psychologically conditioned to expect minimal relief. Simply put, they expect to feel pain during our sessions due to their prior history. For instance, if an individual has knee, hip, or low back pain they’ve struggled with for years, particularly on movements such as squats, hinges, and lunges, they expect to feel pain and discomfort in the associated areas whenever performing these movements.

The level of pain and inflammation produced by a movement is directly related to the degree to which one deviates from proper mechanics.

In fact, when I first have them attempt the movement, most individuals visibly grimace and wince in fear as they begin the movement, expecting the pain to kick in any second. However, as long as I take the necessary time beforehand (typically 2-5 minutes per drill) to properly teach and coach them on the proper lower body mechanics for basic movements such as squats (using eccentric isometric protocols), not only are they able to perform the movement without pain and discomfort, their overall levels of pain and inflammation begin to dissipate, and oftentimes fully subside after 2-8 weeks of consistent training. It’s actually quite entertaining to watch their facial expressions and the extreme and visible sense of shock, surprise, awe, and excitement they feel when they’re “miraculously” able to perform a previously debilitating movement in a pain free manner. This is often followed by a verbal expression such as “wow, that’s crazy, I didn’t feel any pain”.

Now, in some instances the individual feels exceptionally less pain and discomfort but not always full relief during the movement. In fact I’ve noticed time and again that the level of pain and inflammation produced by a movement is directly related to the degree to which one deviates from proper mechanics. However, once the individual is provided with a few additional cues and coached to make any adjustments they feel are necessary to eliminate the pain (i.e. self-correction via sensory feedback using eccentric isometrics), the discomfort almost always dissipates. Ironically, the position and biomechanics that resolve the pain end up being nearly identical from person to person, not just in the case of a handful of exercises but for every movement pattern.

Initially this observation baffled me, as I expected unique differences in movement mechanics based on individual anthropometrics. However, after further studying the neurophysiology, biomechanics, and structural physiology of human movement, it became less surprising and, in fact, quite obvious that such an occurrence was not only likely but inevitable, as proper movement and proper body mechanics are nearly identical from human to human. It’s these very mechanics that provide all the necessary therapy, treatment, and healing an individual needs to maximize their fitness, health, and performance, while simultaneously minimizing pain, inflammation, and injuries. At this point you’re probably asking what exactly constitutes proper movement mechanics?? Well that, my friends, is a topic for another discussion. In the mean time, you’ll likely find my article on eccentric isometrics and even more so in my book, Movement Redefined (see HERE and below) an appropriate starting point.

Final Key Takeaways

- Key Points, Random Thoughts, & Personal Rants -

  • Not all musculoskeletal issues produce immediate pain. However most forms of pain can be traced back to musculoskeletal related dysfunction and faulty mechanics.

  • By teaching someone to move properly we can eliminate much of the pain and inflammation they experience.

  • The degree to which we exhibit proper muscle function and body mechanics significantly determines the degree of inflammation and pain we experience in our bodies.

  • Not all pain is due to faulty muscle activation and body mechanics but much of it is, and that which is not is in most cases, unfortunately, out of our control.

  • I’ve worked with hundreds of individuals with pain and inflammation, both chronic and acute, whom doctors did not know how to deal with nor had been able to help. Teaching them to move correctly eliminated the pain and inflammation 99% of the time. Unfortunately, the other 1% is oftentimes untreatable.

  • Our body perceives poor movement as a substantial threat that, if continued, will inevitably produce injuries. Therefore, what the sensation of pain or threat of danger is essentially telling us is to stop moving in this manner and adjust our body mechanics. This is one of the most important survival mechanisms for human beings. What I’m referring to here is not the pain that is associated with diseases that will take researchers an entire lifetime to figure out. I’m referring to the daily pain, both chronic and acute, that everyone has to deal with on a consistent basis such as back pain, knee pain, shoulder pain, hip pain, neck pain etc. It’s here that body mechanics play a critical role. And yes, while biomechanics isn’t the only factor, it’s the most critical one, and the one we have the most control over.

  • Many “pain scientists” get caught up in semantics and the jargon associated with pain mechanisms and lose sight of the practical applications and long-term solutions.

  • When it comes to pain keep it simple: treat the cause, and watch the “ouch factor” disappear.

  • No one is denying that “pain experts” do in fact take into consideration body mechanics. The problem is they underestimate its impact, while overestimating the effects of other less relevant factors.

  • If you’re not able to eliminate a majority of pain and inflammation via proper movement re-education and elimination of muscular dysfunction, then you’re ability to properly coach body mechanics and movement patterns needs to be re-evaluated.

  • Yes, there are many factors that affect pain and inflammation such as diet, sleep patterns, preexisting trauma or injuries, environmental factors, pollution, beliefs, mindsets, emotions, and of course movement mechanics. In the end, movement mechanics is what you can impact the most, followed very closely by diet and lifestyle factors.

  • Trainers, coaches, or therapists who overcomplicate the root cause of pain do so because they can find no other explanation for the pain and are likely unaware of the fact that their methods are what may, in fact, have contributed to the pain and inflammation in their clients in the first place.

  • To understand the value of proper movement you have to first experience it. Trainers, coaches, or therapists that downplay the importance of using correct biomechanics have most likely never applied proper mechanics to their own training or to that of the clients. Oftentimes, they themselves display numerous forms of dysfunction and movement aberrations in even the most foundational of movement patterns. As a result they don’t fully comprehend the power of proper movement, have no understanding of how damaging faulty movement can be, nor understand how therapeutic proper movement is for the body. They are, therefore, inclined to blame their pain and that of their clients on some unexplainable esoteric reasoning, instead of realizing that most of the pain is related to their muscle dysfunction.

  • Poor mechanics is like smoking. It can take anywhere from months to decades before the consequences are felt. Eventually it does affect your health and quality of life. It’s just a matter of time.

  • To say that our sitting, standing, and walking posture don’t matter is an illogical approach to body mechanics. The more we engage in high-level force activities, the more important posture becomes. How we sit impacts how we stand, and how we stand impacts our gait, which ultimately seeps into our training mechanics, including high force activities. This can make us more or less prone to injury depending on how functional or dysfunctional our movement and posture is.

  • After working with clients on a consistent basis for months and sometimes years, I can tell, within the first several minutes of training, when they've been sitting or standing with slouched posture as it shows up immediately. When this occurs we typically allocate several minutes to reeducate their nervous systems on proper alignment before we proceed to more intense activities.

  • Pain is not the only negative ramification of poor movement mechanics. Faulty mechanics can throw off our proprioception, breathing patterns, balance, digestion, immune function, autonomic nervous system function, circulation, hormones, biochemistry, and more. For instance, poor posture causes breathing issues due to a lack of oxygen intake and oxygen utilization. This causes sympathetic overdrive and dysfunctions in the autonomic nervous system, which can contribute to digestive issues and increased acidity. Ironically, these are all linked to increased inflammation, which has also been shown to accelerate aging, as well as many diseases, not to mention cause anxiety and other psychological disorders. So yes, posture definitely matters.

  • Even if faulty posture doesn’t immediately cause pain, it short-circuits neural signaling through the spine pathway. This causes reflexive and neuromuscular hiccups, involuntary twitches, spastic movements, lack of neuromuscular coordination, faulty recruitment patterns, balance and stability issues, proprioceptive dysfunction, increased risk of falling, mobility restrictions, and other muscular issues. Ultimately, these can lead to various injuries not to mention decreased quality of life.

  • Proper posture might not guarantee an injury-free training experience, but it will sure turn the odds in your favor.

  • While most pain comes from faulty body mechanics, there are some forms of pain we can't fully explain or completely eliminate. For instance, over the years, I've probably done irreparable damage to my spine by experimenting on myself as a human guinea pig, and as a result of using poor mechanics during my early years of training. Every once in a while I’ll experience very mild pain (i.e. 1-2 on a scale of 1-10) regardless of how careful I am with my body mechanics. However, had I not perfected my mechanics and mastered my form, that pain would probably be at a 6 or above, and on many days would likely be incapacitating. Such a scenario, which used to occur on a very frequent basis in my body, no longer occurs. That’s because I’ve learned to minimize the levels of pain and inflammation despite trace elements of injuries and irreparable structural damage that are beyond my ability to fully understand or eliminate. So yes, there may be a small percentage of pain we’ll never understand or eliminate, but we can still optimize our levels of pain and minimize it by mastering our mechanics. For many individuals this will result in the complete elimination of pain while for others it may only be 80% eliminated. However, that is far better than had we not mastered our mechanics or simply ignored it.

  • Strength training has both the power to heal the body or incapacitate it. The difference lies in the technique, form, and execution of the movements.

  • The more we clean up our body mechanics the more everyone's form starts to look the same.

  • The idea that there's no such thing as "right or wrong form" is simply a way for incompetent and/or uneducated trainers to rationalize their inability to properly coach foundational movement patterns, as well as their failure to eliminate pain and dysfunction in their own body and that of their clients.

  • The time scale looks different for each individual as everyone has a different threshold at which point things begin to break down. For some individuals faulty mechanics can produce immediate negative ramifications in as little as days, whereas for others it can take months, years, and in rare cases decades. But eventually, everyone hits a breaking point. The consequences are oftentimes most extreme in individuals who take longer to manifest problems, as the issues tend to pile up before they suddenly break. In contrast, individuals who are more sensitive not only experience negative ramifications sooner, oftentimes they are less extreme, thanks to the fact that their bodies send early warning signs before they suffer more extreme consequences.

  • Many pain scientists" tend to underplay the importance of proper body mechanics and muscle function while simultaneously overemphasizing the impact of other factors related to perception, beliefs, mindset, emotions, fear, environmental factors, habits, pollution, stress etc. This is often a direct result of their inability to properly coach and grasp what proper movement entails therefore they're unable to reap the incredibly powerful benefits associated with proper movement. As a result they feel compelled to concoct other explanations for the pain in their bodies and that of their clients. Yes other factors such as those listed above obviously play a role in pain but when muscle function is dialed in, these other factors have minimal impact and oftentimes represent a form of minutia in comparison to mastering one's movement. I've seen this time and again over my 15 years of training and research. When a client's mechanics and muscle function are amiss then even the smallest outside element (perception, emotions, stress, environment) tend to be the final straw as the person is living on the edge physiologically and anything can push them over that edge. In other words even the smallest level of stress can produce heightened pain and tension throughout their body. In contrast when muscle function is proper then even a multitude of these other factors have little impact on their musculoskeletal pain. In other words stress factors add only to stress without compounding effects or producing musculoskeletal pain as the person is not living on the edge physiologically. Instead their bodies are functioning as they should and therefor can handle a myriad of other elements without breaking down.

  • Many of the injuries and associated pain we see in the weight room as a result of intense training involve hardcore fitness enthusiasts and strength training fanatics who oftentimes have to be convinced to dial back their training. In other words, their pain has nothing to do with fear of movement (until it gets to the point that it occurs repeatedly). These aren’t the mental weaklings that “pain experts” suggest they are. On the contrary, they are mentally some of the toughest individuals who have gone through extraordinary levels of pain, and trained through levels of body discomfort and injury that would incapacitate most folks. When these folks experience pain it’s not in their head. Suggesting the pain is in their head and they simply need to push through it is the worst thing we could do to these individuals as it sets them up for continued injury not to mention eventual “fear of movement”.

  • I currently (and probably always will) have multiple injuries that will never be structurally eliminated. The difference in terms of whether or not they produce pain or movement limitations almost always comes down to my mechanics. Had you assessed me 10 years ago I would have been categorized as a “symptomatic” injured person, with injuries that caused tremendous pain. I still have the same injuries (as many of them never healed structurally), but I’m now an “asymptomatic” injured person (provided I move correctly). Once again, it all comes down to proper body mechanics, technique, and muscle activation patterns. A majority of my clients fall under same category. Furthermore, the only time the pain ever comes back is if they gravitate back to old compensation patterns and prior bad movement habits.

  • Being afraid to be physically active is never healthy. However, being afraid to perform intense forms of training because you know there is a high chance of injury is actually your body's way of telling you that your muscle function is amiss.

  • Mild levels of pain that occur infrequently and last less than 48 hours are oftentimes benign and not related to anything other than the natural, cyclical nature of inflammation. However, moderate to large levels of pain, or recurring pain is almost always related to some form of muscle dysfunction and misuse.

  • Everyone operates on their own scale or range of muscle function. Some blessed and genetically-resilient individuals can operate within very low ranges of muscle function, e.g. 4-5 on a scale of 1-10, while others must be very particular about their form and mechanics and must function at an 8 or better in order to not feel pain. Simply, everyone manifests pain differently and at varying levels of dysfunction. However, improving their dysfunction almost always greatly reduces, if not fully, eliminates the pain.

  • A common misconception is that you need excessive stretch combined with high loads to build up tendon and connective tissue strength. This is completely false and in no way substantiated by any form of research. In reality, you don't need extreme range of motion (ROM) or exaggerated stretch to strengthen the tendons, ligaments, and connective tissue, as proper ROM will produce a similar and, in fact, superior effect by allowing the movement to be more effectively overloaded. Additionally, this will occur without the negative ramifications associated with excessive stretching and exaggerated ROM.

  • If we saw an individual perform a basic movement such as pushups with blatantly obvious form aberrations such as excessive lumbar extension, sagging hips, forward head tilt, rounded shoulders, extreme elbow flare, and poor motor control, we would obviously conclude they need to improve their body mechanics, muscle function, and technique. In contrast, the modern-day fitness industry “pain science” approach would suggest that we not alter this person’s technique or form because it represents the method the individual naturally gravitates to, and since there's no such thing as right or wrong form, or good or bad posture mechanics, this person should simply be empowered to keep up with their training regimen, and encouraged to forge ahead and stick to the status quo. Ironically, many “pain experts” would agree that such form aberrations should be remedied, thereby nullifying the very theories they vehemently support.

  • We want to increase pain sensitivity while decreasing our pain threshold. Unfortunately, most forms of training produce the opposite effect and most “pain science experts” advocate for this by recommending we live in a state of decreased pain sensitivity with an increased pain threshold.

  • Hip replacements in middle aged women have risen significantly over the last decade. Ironically, the two forms of exercise that have gained the most popularity with this group during that time are yoga and Pilates. Coincidence? I think not. Given the extreme contortionistic positions, excessive range of motion, exaggerated stretching, faulty biomechanics, and dysfunctional movements commonly employed by these methods, it's likely they have contributed significantly to the early onset of hip osteoarthritis as well as damage to other joints. Sure, there are some obvious benefits to these training methods just as there are with any training protocol. However, there are other options that provide similar, if not better, benefits without the same side effects.

  • When it comes to adapting to faulty biomechanics, temporary adaptation can be quite misleading. For instance, with proper training, dancers, gymnasts, and ballet dancers can adapt to their training so that they can perform their art with less risk of acute injury. Unfortunately, they’re sacrificing long-term joint health for short-term adaptations and temporary success, as noted by the high prevalence of joint issues and musculoskeletal pain dancers eventually struggle with.

  • Yes, our tissues adapt to whatever stimulus we expose them too. However, with biomechanically faulty positions our tissues break down faster than they adapt. For instance, with biomechanically faulty positions such as those advocated in dance, gymnastics, and ballet, tissues adapt to a degree but the level of inflammation, injury, structural trauma, and degeneration to the joints, muscles, and connective tissues, appears to occur at a faster rate than tissue adaptation response. This is noted by the frequent and repeated trend of injuries and pain that most if not all dancers, gymnasts, figure skaters, and ballet artists inevitably encounter during and after their careers. Simply put, their bodies don’t fully adapt - they revolt and rebel. The same is true of any form of training and/or exercise that employs faulty body mechanics.

  • If you experience pain and inflammation from movement or exercise, the worst thing you can do is to blunt that response and dull the pain sensation without addressing the root cause. In fact, if not for the psychological and mental hardships associated with pain, it would actually be more beneficial to temporarily increase the sensation of pain and discomfort associated with faulty movement, as this would give greater sensory feedback about that movement, thereby aiding the neurophysiological process involved in mastering body mechanics and eliminating dysfunction. If you’re moving improperly, the best thing that can happen is for the body to produce pain signals notifying you your mechanics are amiss. Then it’s your job to take that sensory feedback and continue to fine-tune and modify the movement until there isn’t pain. This is movement mastery in a nutshell.

  • High levels of pain and inflammation that result from improper movement are always a blessing in disguise, as it gives us more feedback than any coach or trainer can give regarding the quality of our movement. In essence, pain is your friend. To try and remove or mask these symptoms by stretching, foam rolling, icing, massaging, incorporating frequent chiropractic adjustments, prolonged warm-ups, dry needling, or the latest and greatest soft tissue modality is simply putting a band aid on a larger, continuous, and never-ending self-induced wound. Instead of masking the symptoms, determine what’s causing the issue and get to the root of the problem. In this case the root cause is faulty movement patterns and muscular dysfunction, the wound is the resulting inflammation and pain, the band-aid is the aforementioned therapeutic modalities, and the cure-all is proper movement mechanics.


1. Riondino, S., et al., Functional impairment in video terminal operators is related to low-grade inflammation. Int Arch Occup Environ Health, 2011. 84(7): p. 745-51.

2. Pritchett, J.W., C-reactive protein levels determine the severity of soft-tissue injuries. Am J Orthop (Belle Mead NJ), 1996. 25(11): p. 759-61.

3. Carp, S.J., et al., Inflammatory biomarkers increase with severity of upper-extremity overuse disorders. Clin Sci (Lond), 2007. 112(5): p. 305-14.

4. Matute Wilander, A., et al., Inflammatory biomarkers in serum in subjects with and without work related neck/shoulder complaints. BMC Musculoskelet Disord, 2014. 15: p. 103.

5. Verghese, J., et al., High-sensitivity C-reactive protein and mobility disability in older adults. Age Ageing, 2012. 41(4): p. 541-5.

6. Kositsawat, J., L.C. Barry, and G.A. Kuchel, C-reactive protein, vitamin D deficiency, and slow gait speed. J Am Geriatr Soc, 2013. 61(9): p. 1574-9.

7. Bautmans, I., et al., Circulating acute phase mediators and skeletal muscle performance in hospitalized geriatric patients. J Gerontol A Biol Sci Med Sci, 2005. 60(3): p. 361-7.

8. Enright, P.L., et al., The 6-min walk test: a quick measure of functional status in elderly adults. Chest, 2003. 123(2): p. 387-98.

9. Hamer, M. and G.J. Molloy, Association of C-reactive protein and muscle strength in the English Longitudinal Study of Ageing. Age (Dordr), 2009. 31(3): p. 171-7.

10. Gerling, M.E. and S.H. Brown, Architectural analysis and predicted functional capability of the human latissimus dorsi muscle. J Anat, 2013. 223(2): p. 112-22.

11. Jeong, U.C., et al., The effects of gluteus muscle strengthening exercise and lumbar stabilization exercise on lumbar muscle strength and balance in chronic low back pain patients. J Phys Ther Sci, 2015. 27(12): p. 3813-6.

12. Brinjikji, W., et al., MRI Findings of Disc Degeneration are More Prevalent in Adults with Low Back Pain than in Asymptomatic Controls: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol, 2015. 36(12): p. 2394-9.

13. Chaleat-Valayer, E., et al., Sagittal spino-pelvic alignment in chronic low back pain. Eur Spine J, 2011. 20 Suppl 5: p. 634-40.

14. Jackson, R.P. and A.C. McManus, Radiographic analysis of sagittal plane alignment and balance in standing volunteers and patients with low back pain matched for age, sex, and size. A prospective controlled clinical study. Spine (Phila Pa 1976), 1994. 19(14): p. 1611-8.

15. Rajnics, P., et al., The importance of spinopelvic parameters in patients with lumbar disc lesions. Int Orthop, 2002. 26(2): p. 104-8.

16. Sheeran, L., et al., Spinal position sense and trunk muscle activity during sitting and standing in nonspecific chronic low back pain: classification analysis. Spine (Phila Pa 1976), 2012. 37(8): p. E486-95.

17. Rathod, T.N., et al., High sensitive C-reactive protein-Effective tool in determining postoperative recovery in lumbar disc disease. Indian J Orthop, 2014. 48(4): p. 354-9.

18. Le Gars, L., et al., Systemic inflammatory response with plasma C-reactive protein elevation in disk-related lumbosciatic syndrome. Joint Bone Spine, 2000. 67(5): p. 452-5.

19. Kaye, A.D., A. Baluch, and J.T. Scott, Pain management in the elderly population: a review. Ochsner J, 2010. 10(3): p. 179-87.

20. Yezierski, R.P., The effects of age on pain sensitivity: preclinical studies. Pain Med, 2012. 13 Suppl 2: p. S27-36.

21. Watson, D.H. and P.H. Trott, Cervical headache: an investigation of natural head posture and upper cervical flexor muscle performance. Cephalalgia, 1993. 13(4): p. 272-84; discussion 232.

22. Phage, P., CERVICOGENIC HEADACHES: AN EVIDENCE-LED APPROACH TO CLINICAL MANAGEMENT. Internaltion Journal of Sports and Physical Therapy, 2011. Volume 6(3); Sep 2011.

23. Kong, Y.S., Y.M. Kim, and J.M. Shim, The effect of modified cervical exercise on smartphone users with forward head posture. J Phys Ther Sci, 2017. 29(2): p. 328-331.

24. Binder, A.I., Cervical spondylosis and neck pain. BMJ, 2007. 334(7592): p. 527-31.

25. Fredriksson, K., et al., Work environment and neck and shoulder pain: the influence of exposure time. Results from a population based case-control study. Occup Environ Med, 2002. 59(3): p. 182-8.

26. Kim, B.B., et al., Effects of suboccipital release with craniocervical flexion exercise on craniocervical alignment and extrinsic cervical muscle activity in subjects with forward head posture. J Electromyogr Kinesiol, 2016. 30: p. 31-7.

27. Macovei, L.A. and E. Rezus, CERVICAL SPINE LESIONS IN RHEUMATOID ARTHRITIS PATIENTS. Rev Med Chir Soc Med Nat Iasi, 2016. 120(1): p. 70-6.

28. Duffell, L.D., et al., Balance and gait adaptations in patients with early knee osteoarthritis. Gait Posture, 2014. 39(4): p. 1057-61.

29. Tauchi, R., et al., Influence of spinal imbalance on knee osteoarthritis in community-living elderly adults. Nagoya J Med Sci, 2015. 77(3): p. 329-37.

30. Favre, J. and B.M. Jolles, Gait analysis of patients with knee osteoarthritis highlights a pathological mechanical pathway and provides a basis for therapeutic interventions. EFORT Open Rev, 2016. 1(10): p. 368-374.

31. Sanchez-Adams, J., et al., The mechanobiology of articular cartilage: bearing the burden of osteoarthritis. Curr Rheumatol Rep, 2014. 16(10): p. 451.

32. Kim, J.R., J.J. Yoo, and H.A. Kim, Therapeutics in Osteoarthritis Based on an Understanding of Its Molecular Pathogenesis. Int J Mol Sci, 2018. 19(3).

33. F, E.A., et al., A positive association between foot posture index and medial compartment knee osteoarthritis in moroccan people. Open Rheumatol J, 2014. 8: p. 96-9.

34. Al-Khazraji, B.K., et al., Osteoarthritis, cerebrovascular dysfunction and the common denominator of inflammation: a narrative review. Osteoarthritis Cartilage, 2018.

35. Burke, A.D., et al., The threat of behavioral changes in dementia. Prim Care Companion CNS Disord, 2013. 15(1).

36. Brinjikji, W., et al., Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol, 2015. 36(4): p. 811-6.

37. Lee, J. and K. Seo, The comparison of cervical repositioning errors according to smartphone addiction grades. J Phys Ther Sci, 2014. 26(4): p. 595-8.

38. Dolan, K.J. and A. Green, Lumbar spine reposition sense: the effect of a 'slouched' posture. Man Ther, 2006. 11(3): p. 202-7.

39. Kim., Y.-G., et al., Influence of the Duration of Smartphone Usage on Flexion Angles of the Cervical and Lumbar Spine and on Reposition Error in the Cervical Spine. 2013.

40. Carney, D.R., A.J. Cuddy, and A.J. Yap, Power posing: brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychol Sci, 2010. 21(10): p. 1363-8.

41. Dainese, R., et al., Influence of body posture on intestinal transit of gas. Gut, 2003. 52(7): p. 971-4.

42. Verpillot, A. Can your posture affect your digestion? 2014; Available from: https://

43. Im, B., et al., Effects of scapular stabilization exercise on neck posture and muscle activation in individuals with neck pain and forward head posture. J Phys Ther Sci, 2016. 28(3): p. 951-5.

44. Kim, D., et al., Effect of an exercise program for posture correction on musculoskeletal pain. J Phys Ther Sci, 2015. 27(6): p. 1791-4.

45. Kolber, M.J., et al., Shoulder Joint and Muscle Characteristics in the Recreational Weight Training Population. The Journal of Strength & Conditioning Research, 2009. 23(1): p. 148-157 10.1519/JSC.0b013e31818eafb4.

46. Chorba, R.S., et al., Use of a functional movement screening tool to determine injury risk in female collegiate athletes. N Am J Sports Phys Ther, 2010. 5(2): p. 47-54.

47. Laudner, K.G., Upper Extremity Sensorimotor Control Among Collegiate Football Players. The Journal of Strength & Conditioning Research, 2012. 26(3): p. 672-676 10.1519/JSC.0b013e31822a69c8.

48. Kiesel, K., P.J. Plisky, and M.L. Voight, Can Serious Injury in Professional Football be Predicted by a Preseason Functional Movement Screen? N Am J Sports Phys Ther, 2007. 2(3): p. 147-58.

49. Backhouse, K. The Knee For Dance or Disaster. The Imperial Society of Teachers of Dancing (ISTD) 2013; Available from:

50. Bennett, D.L., L. Nassar, and M.C. DeLano, Lumbar spine MRI in the elite-level female gymnast with low back pain. Skeletal Radiol, 2006. 35(7): p. 503-9.

51. Smith, T.O., et al., National survey to evaluate musuloskeletal health in retired professional ballet dancers in the United Kingdom. Phys Ther Sport, 2017. 23: p. 82-85.

52. Smith, J., Moving beyond the neutral spine: stabilizing the dancer with lumbar extension dysfunction. J Dance Med Sci, 2009. 13(3): p. 73-82.

53. Standaert, C.J., New strategies in the management of low back injuries in gymnasts. Curr Sports Med Rep, 2002. 1(5): p. 293-300.

54. Hill, L., et al., Do findings identified on magnetic resonance imaging predict future neck pain? A systematic review. Spine J, 2018. 18(5): p. 880-891.

55. Malfliet, A., et al., Patients With Chronic Spinal Pain Benefit From Pain Neuroscience Education Regardless the Self-Reported Signs of Central Sensitization: Secondary Analysis of a Randomized Controlled Multicenter Trial. PM R, 2018.

56. Andias, R., M. Neto, and A.G. Silva, The effects of pain neuroscience education and exercise on pain, muscle endurance, catastrophizing and anxiety in adolescents with chronic idiopathic neck pain: a school-based pilot, randomized and controlled study. Physiother Theory Pract, 2018. 34(9): p. 682-691.

57. Wood, L. and P. Hendrick, A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: short- and long-term outcomes of pain and disability. Eur J Pain, 2018.

58. Tegner, H., et al., Neurophysiological Pain Education for Patients With Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Clin J Pain, 2018. 34(8): p. 778-786.

59. Moseley, G., Butler, D., Fifteen Years of Explaining Pain: The Past, Present, and Future: Critical Review. The Journal of Pain, Vol 16, No 9 (September), 2015: pp 807-813