By Alexander Bell-Moratto
Fitness Realm And Pain Science
There is an overwhelming amount of information in the health and fitness realm about pain science. Blogs about how pain is ‘in the brain’, videos ‘explaining pain’, and many other resources getting the message out there. From my experience, they are usually met with one of two reactions:
#1 This is BS. Some random internet guy is trying to tell me that my XXXX technique doesn’t work. I have tons of satisfied clients that say otherwise. I have SEEN my method work with my own two eyes!
#2 I think I could get on board with some of this. I mean, they do make some good points. But does this mean posture doesn’t matter at all? What the hell are we supposed to do to prevent or help injury?
There is a masterful video, titled Crossing The Chasm by Dr. Jason Silvernail, which outlines a rebuttal to a lot of these concerns. This is one of the biggest messages that don't get across in many introductory ‘how pain actually works’ type resources out there. There are a lot of effective modalities where the reasons for why it works, has not shifted in concert with what the body of research is telling us.
So part of the answer to ‘What the hell do I do now?’ is just what you were doing before but without any misinformation. Using debunked rationales for methods can have negative effects: most notably nocebo (the flip side of placebo, where symptoms get worse due to expectations) (1 2) .
Here is an attempt at some ‘learn Sunday, apply Monday’ type information. This is how I have retrofitted my sessions given the current literature:
Warm Up & Preventative or ‘Corrective Exercises’
● Used to discuss all the flaws in posture and how each movement is going to fix each problem.
● Since we are more concerned with global neurological mechanisms rather than specific changes in the tissue, I focus a lot more on moving in a relaxed, mindful way during each warm-up movement (3).
● I try to extinguish any fears as much as I can. For example: If the client is afraid of crepitus or any sound their joint make, I will explain how it is natural and not a cause for concern (4 5). I preface pretty much any concern with a statement like ‘Serious issues are pretty rare…’ to put their worries into context.
● If there is an injury or pain, I can use my favorite ‘correctives’ to give some movement variability, novel stimulus, and/or progressively load the tissue. Functional Anatomy Seminars is an example of an evidence-based mobility certification.
Self Myofascial Release aka foam rolling, lacrosse balls, smashing, etc:
● As discussed above, it’s more about relaxation and mindfulness. For example, if side lying and foam rolling the TFL, sometimes I will have the client put their top foot under their bottom knee to take some pressure off.
● You can probably guess my opinion on anything called ‘smashing’…
● Again, I no longer try to change resting posture.
● Still, teach good form when lifting heavy things, and many times there can be performance benefits to changing posture (for example 100m sprinters). I am just very careful not to perpetuate the myths that:
○ there is an ideal posture
● I don’t use movement screens anymore. If you choose to, just be cognizant of how you discuss them with clients.
● If you want to use specific exercises to target what you perceive to be ‘deficits’ (which may just be normal variation) then go right ahead. But while you are ‘injury-proofing’ their body, also inoculate their mind from the dangers of a frail/weak mindset.
● If you deal with someone struggling with psychosocial issues, encourage them to get back to doing pleasurable activities (this can be lacking in the life of depressed people) (16). You are not a psychologist, but the ‘stuff’ you give them to do outside of sessions does not have to be a strict workout plan, you could just encourage things like hiking or gardening.
Giving Advice on Pain *Soapbox Alert*
● Unfortunately, many (most) personal trainers out there think they know a lot more about injury than they do. They go off what they know about good lifting form and try to apply it to injury.
● Personal trainers are usually not taught anything about pain science or any red flags of serious injury. Many things they do learn about rehabilitation are either from questionable sources, old sources, or self-taught out of context (when first starting, I was guilty of reading a few textbooks on methods outside of my realm).
● Do not abuse your scope of practice. You are not qualified to assess or treat anything. Anterior pelvic tilt, upper/lower cross syndrome, scoliosis, forward head posture, and many others are routinely addressed by trainers with no training and who do not read research on these topics. Side note: looking at 2 abstracts that agree with your position does not count as ‘reading the research’.
● If a trainer is overly confident in their competency in treating injury, this is a telltale sign of being unfamiliar with the research. If they were even moderately familiar with how little we know about many of these subjects, they would not speak so confidently.
● Long story short, admit when you are not sure. Even the sliding filament theory has holes in it (17)!
● Therapist's 5 R's of Rehab by Ben Cormack is a great application checklist for therapists, but still has a lot of relevance for trainers who are part of a rehab team.
Tips For Finding Referrals
● Find evidence-based practitioners to refer to. Their treatment doesn’t matter. Instead of saying ‘you have to try XXXX method, it will fix all back pain’, just find an evidence-based practitioner.
● Look for people with Ph.D.’s, research fellows, or refer to local or national pain organizations. This sounds cut and dry, but in practice, it can be like trying to find Foie gras on a Hard Rock Cafe menu. Opening this can of worms will have to wait for another time...
The reason there are not many applicable techniques on pain out there is that it’s not something you take out of your tool box, use, then put it back in. It is infused in how you talk to people, and is as much about what you don’t do, as it is what you do. Don’t stop doing everything you used to, but...
● Under promise, over deliver.
● Don’t spread misinformation. Many times, structure is not relevant, which gives a lot of freedom in picking exercises.
● Say things that are going to empower and reassure clients in pain, rather than potentially do harm.
Alexander Bell-Moratto has been a personal trainer for 6 years working with all sorts of populations, in many instances working as part of a rehabilitation team. Alex also works as a kinesiologist in a neuro rehabilitation clinic in Canada called Synaptic Health, and writes for the European Institute of Sports Physiotherapy
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