The aim of this essay is to clarify principles that guide a “movement

based” approach to orthopedic conditions. Additionally, I hope to

explain and illustrate how the contemporary Pain Science movement

may be misrepresenting and misappropriating sound research, while at

the same time discounting and disregarding decades of useful clinical

experience and expertise. This comes in direct response to the deluge of

propaganda that is being produced and spread by the psycho-social,

evidence-based community who have taken an extremely controversial

stance on the relationship between pain and the foundational aspects of

musculoskeletal medicine like posture, stabilization, and movement,

which up to this point, have been assumed to be etiologic factors for

orthopedic conditions.

While I appreciate that novel perspectives and innovative insights can be

gained from credible research, the skepticism undertaken by the Pain

Science practitioners in regards to a “movement based” approach is

rising to the level of Descartes, where every bit of minutia is questioned

to the point of complete uncertainty and therefore, nothing seems to

actually contribute to our patient’s symptoms except for the psycho-

emotional or psycho-social aspects of pain! I hope to articulate that

while the cause of pain is multifactorial and extremely complex,

eliminating components such as posture and movement from the

contributory spectrum seems to be a bit rash and clinically unfounded.

Let me first begin by discussing what I feel are invaluable insights that

Pain Science has afforded clinical practitioners. Obviously, the role of

perception and cognitive experience cannot be denied in attempting to

understand our patient’s symptomatic pain, and must be considered in

the treatment of all painful conditions. Appreciating how pain can

sensitize our tissue, movement, and more generally, our nervous system,

is essential to a broad conception of our patient’s experience of his or

her symptoms, and that appreciation must be taken into consideration

when dealing with a person in pain. Without question, the science of

Pain cannot be underestimated or undervalued, and is integral to a truly

holistic approach.

The role, effectiveness, and mechanism of various manual therapy

techniques that utilize skilled palpation has also been questioned,

directly and indirectly, by the Pain Science community. The research

seems to show that, in most cases, it is practically impossible to feel what

we are attempting to feel (e.g. minuscule joint motions) and that most

of our techniques including manipulation, fascial mobilization,

active/passive stretching, etc., do not, in fact, do what we think they do;

in some cases, cannot do what we intend them to do. As this research

continues to pile up, manual therapists must alter their perspective and

approach if they are to remain honest with their patients and

themselves. Personally, I have always been skeptical of the ability and

effectiveness of palpation, as well as manual therapy, and applaud

quality research that will hone our practices. However, we must not

discount the value of palpation and movement-based strategies that

have provided practitioners with clinical success for many years. There

is a significant difference between research that enhances our approach

and understanding of manual therapy and evidence that utterly debunks

the utility of any form of hands-on therapy. There is no need to throw

out the DNS baby with the bathwater!

Not that I believe this community is actually suggesting such a thing, but

the manner and tone in which they discuss the validity of manual therapy

and palpation seems to advocate scrapping all forms of “hands on”

treatment. Essentially, the Pain Science crowd seems to be saying that

the use of manual therapy and palpation is, at best, ineffective, and at

worst, a complete waste of time! What I would argue is that we ought

to use the knowledge gleaned from contemporary research to re-

conceptualize and hone our approach to manual medicine, and elucidate

its truly useful effects, rather than simply acting to debunk decades of

clinical experience. I am hardly the first one, but I would propose that

what the research actually seems to show is that certain manual therapy

techniques can have beneficial effects, which ought to be defined by

observable, measurable changes in the functioning of the nervous

system via provocative testing and assessment. This provides healthcare

practitioners with a new perspective regarding the mechanisms, effects,

and utility of manual therapy, as well as a useful window that allows for

optimal and more effective training.

Furthermore, I also believe that the current focus of the Pain Science

movement, which heavily emphasizes the psychosocial and emotional

aspects to therapy, has erroneously mischaracterized the “movement-

based” approach and limited the outlook of practitioners due to the

following claims:

-since research shows that people move in a variety of ways, there is no

“right” or “ideal” way to move

-since we all have different physical anatomy and cognitive experience,

there can be no standard way to move

-deviation from a supposed “optimal” movement strategy does not

cause pain…or another way of putting it is, even if we do move

“optimally”, we still experience pain

While I agree that in some instances, there may be a variety in the way

in which humans move, and that variety can be due to pain, joint

dysfunction, experience, anatomy, or voluntary control, among

countless other reasons. These facts do not preclude an ideal way to

move…they simply imply that humans can veer from ideal in a variety of

ways, consciously or unconsciously. The variations in movement and

stabilization strategies that clinicians observe on a daily basis say nothing

other than give us a representation of the current status of this patient’s

nervous system; whether these strategies are “good” or “bad” has yet to

be determined. Therefore, is it suspect to believe there is a chance that

pain can be experienced when a human seems to veer from ideal?

Of course it is true that some of our anatomy and experience may differ,

but motor programs engrained in our central nervous system are, in fact,

shared amongst the entire human population. This is not a controversial

statement…infantile motor development, or Developmental Kinesiology,

provides the standard for optimal movement of all humans. The

principles expounded by development of movement, posture, and

stabilization of the infant is what allows us to objectively determine

“better” from “worse” motor strategies. For those in Pain Science that

do not accept any form of ideal, standard, or optimal movement

strategy, I suggest they pick up any textbook on pediatric development

of movement and they will see that there are definite rules, guidelines,

and milestones that every child follows which describe and define ideal,

normal development. When those movement milestones are skipped or

delayed, central coordination disorders that range from mild postural

abnormalities to those as serious as cerebral palsy can result.

As for the idea that suboptimal movement strategies do not cause pain,

I must confess that I am confused. What am I to believe when a runner

with an extreme, unilateral genu valgum and pes planus who also

happens to be complaining of ipsilateral (same-sided) anterior hip pain

presents to my office? While a complete history and physical

examination is obviously required, in my limited clinical experience (just

about 10 years of practice), I have observed a correlation between what

I would define as an abnormal loading strategy of the lower extremity

(based on the principles of development), use of specific corrective

exercise and manual therapy treatment strategies based on my findings,

followed by symptom reduction, and functional improvement. It seems

that the Pain Science practitioners want me to totally discount doubt

that entire rationale, in favor of what they believe to be evidently

nothing more than a large scale example of confirmation bias and

placebo effect. This is a complete upheaval of the scientific principles of

a practitioner who uses clinical experience in addition to reproducible

results in their practice.

I find the idea that “bad movements do not cause pain” to be similar to

the misrepresentation and “bad name” given to the current state of

imaging. While no one is under the impression that MRI findings are the

Gold Standard for diagnosis and treatment (nobody relevant needs to be

reminded of the statistics), I ask again what ought you believe when you

take a clinical history that includes a report of sudden “electric shock

like” pain down the leg, followed by burning and paresthesia radiating

into that extremity; physical examination findings consistent with sciatic

nerve impingement and irritation, followed by an MRI showing a large,

local disc herniation that just happens to correlate specifically with the

findings of your assessment? Is this another example of runaway

confirmation bias propagated by my confused beliefs about the

importance of structure and function?

Obviously, the results of an MRI should be thought of in the same way

you treat any other sign produced or visualized on a physical

examination, and I am including in these “results” the findings of a

postural assessment or manual muscle test…the skillful clinician will

attempt to correlate all his or her data to create a reasonable hypothesis

regarding the cause of their patient’s symptoms, as well as a realistic

projection of recovery. Yet again though, it seems that the Pain Science

community is calling for a complete disregard of all findings except for

pyscho-social and emotional factors, since research shows that there is

a statistical discrepancy between things like “abnormal” postural

findings and pain.

There are some additional arguments from the Pain Science community

that have also been expressed over the past couple years that I would

like to address, and hopefully some clarification can be made.

The idea that even if your patient who presented with pain describes a

decrease in symptoms following your corrective exercise and

stabilization intervention, then this does not necessarily prove that what

you prescribed did what you thought it did. I am not exactly sure what

this implies other than remind yourself that complete certainty is never

really a possibility. Again, this hypersensitive sense of scrutiny may be

somewhat useful in a rigorous research setting, where each variable is

attempting to be laboriously assessed, controlled, and analyzed, but to

introduce this level of skepticism into everyday practice where you

continually question all the basic, foundational assumptions of your

treatment approach is practically absurd. While complete and utter

certainty in every aspect of your treatment is undoubtedly foolish and

those who practice in this way should be mistrusted, not giving any

credence to your rationale, even after positive results are reproducibly

observed, is equally ridiculous. Again, when a practitioner successfully

treats many patients of similar presentation over many years, due to

their reliance on clinical observations based on a physical examination

that is grounded in some form of anatomical and functional ideals, then

it is reasonable for that practitioner to acquire some level of confidence

that his or her rationale is somewhat accurate and useful.

Another criticism of the movement-based approach being leveled by the

Pain Science community is that our exercise prescriptions are too rigid

and structured; that movement needs to be varied, novel, challenging,

and fun. I honestly don’t believe that any practitioner who has thought

seriously about movement doesn’t believe in the necessity of variability,

innovation, and intention, so to assert that is to state the obvious, but

there must be some objective standard to measure your patient’s

abilities against or else there is no logic to what you are attempting to

do.

The faction of healthcare providers who adhere to a more evidence-

based, psycho-social, Pain Science approach to neuromusculoskeletal

medicine have, in my opinion, made a primary, foundational mistake:

they have dis-integrated pain from the other outputs of the central

nervous system, and have given it too much priority. In doing so, they

view pain as something categorically different than every other sign and

symptom of the brain and spinal cord.

Specific pieces of testable and reproducible data like the Bicipital reflex,

Tibialis Anterior strength, or more general impressions like Thoracic

spine posture and iliac crest height, are all reflections of the collective

functioning of the nervous system, and while the experience of pain is

important, it should not be viewed any differently than if you were to

observe hyper-reflexia, muscle inhibition, or hyperkyphosis. All are

classified as atypical, or abnormal, and should be considered

appropriately as you move through your assessment. Analyzing all the

information, rather than being preoccupied with pain, is what allows us

to identify predictable patterns of dysfunction, as well as formulate

rational, effective treatment plans. Therefore, assessing the nervous

system in a more provocative way where attention is paid to all clinical

signs, not just pain, is vital.

Basing your standard of measurement on Pain, which is but one output

of the central nervous system, is just not acceptable. As previously

discussed, this is where the ideal patterns of movement and stabilization

governed by developmental kinesiology serve their crucial purpose.

Rather, if you choose to use Pain as your primary guide for movement

prescription, then I believe you are doing a major disservice to most

patients in your clinic.

As stated at the beginning of this piece, my intention was to describe the

movement-based approach within the context of contemporary

neuroscience, while at the same time articulate why I feel that the more

controversial arguments raised by the Pain Science community are at

times confused, and sometimes outright fatuous. Hopefully, the topics

discussed here will clear up some of the mischaracterizations, and

generate more clarity regarding both the application of movement

fundamentals and Pain Science to clinical practice.

Dr. Bill Tortoriello, D.C., Cert. DNS Practitioner

*I would like to thank my colleague, friend, and mentor, Robert Lardner,

for his contributions to this discussion