If you are a regular reader of exercise biology, you ought to have read some of my posts about the functional movement screen and about pain treatments. My interest in physical therapy dates back to my early personal training years and to my own struggles with low back pain. Anyway, I have been hearing a lot about Kelly Starrett who seems to have taken the crossfit and strength & conditioning field by storm. So finally checked out his national bestseller book Becoming a Supple Leopard.
From his blog: Kelly Starrett is a coach, physical therapist, author, speaker, and creator of this blog, which has revolutionized how athletes think about human movement and athletic performance.
Again, nothing new besides the terminologies. Rule 1 means just make sure have a stable core/neutral spine and don’t round/extend your back. All good I think. Then Kelly Starr starts talking about sitting and standing position. Kelly writes”
After reading this part, I honestly didn’t want to read anymore. This was one of the best examples of fear mongering and bad science that I have read. He is literally taking your hand and walking you back to the dark ages of physical therapy of the 1950’s, when we used to believe pain comes from joint, tissues, bad posture and movement. . I wrote an article back in 2005 about the myth of posture and pain and ended the article saying “Now close your eyes, take a deep breath, slowly slump – and savor the freedom of movement”. That time I thought this would be common knowledge in a couple of years. It is 2013 and we are worse off.
| Sun August 18, 2013
Great points Anoop… I would prefer a humble leopard and not a supple leopard but Kelly has passed the red line this time.
Especially the toes pointing in front during the squat movement is so silly and shows that Kelly Starret in accordance with the neo-fanatic, low-technique people of the crossfit community, knows nothing about lifting and strength training.
Or he is beggining or starting to learn.
| Sun August 18, 2013
Very thorough review, with a lot of valid points, but i think you’re missing the point. It sounds like you were expecting Starrett to revolutionize the practice of physical therapy - for physical therapists. The goal is to get a lot of people, many of which having no previous knowledge about biomechanics whatsoever, moving better and understanding the pitfalls when performing under physical stress. It’s kinda a safety-net. And he is changing something - a lot of people have read his book, and has gotten great results using his methods.
And “Coach Zero”
It’s so sad that people have to bash crossfit generally, saying all of the involved parts are uneducated meatheads. It’s some pretty serious claims: “knows nothing about lifting and strength training”. That would be like me saying: everybody in commercial gyms are on rhoids, and is only there for cosmetic gains”
Have you ever interacted with the crossfit community, or are you making you mind up after seeing some bulls*¨t compilation video on youtube, showing the worst cases of bad technique(which clearly happens - i’m not refuding that!) Crossfit is getting people who would maybe never end up being more active than you average person, to engage in “high level” gymnastics, olympic weightlifting and powerlifting. If you saw on a daily basis, the progress soccermoms go through, getting to know the own bodies, learning to adjust complex movements, and generally just feeling awesome about themselves, i would hope you statement would be a little more nuanced.
All in all - thanks for the review - it has made me wiser, and i will definitely research what you writing about pain/posture theme.
| Sun August 18, 2013
Excellent review. Eyal Lederman commented in a recent interview that the stability concept is a business not science and isn’t going to disappear. It’s here to stay unfortunately.
I too feel that despite the information being out there is largely ignored in the pursuit of profit rather that appropriate education and intervention for people with pain. Very sad.
| Sun August 18, 2013
Nice review Anoop. What is interesting within the PT community is that many will discuss pain (this is in his title for gosh sakes) without having a complete understanding of what “pain” is.
Anoop | Mon August 19, 2013
Thanks Coach Zero!
Thanks Esben. I didn’t say it is “revolutionary”. The book synopsis says it and I quote him too. Yep if the goal is show people how to lift properly, I would have no problem and wrote that too in the article. Here since you skipped it “I would have been happy if the book stayed within the realm of athletic, lifting injuries and proper form and stayed far away from treatment of pain or preventing pain”. And please read what is the harm part too. Also check the article I wrote about pain.
Thanks Duncan! i read his excellent article about core stability and the biomechanical model.
Thanks Joe! Great point! If you are a bodybuilder, study more about muscle. If you are powerlifter, study more strength. If you a physical therapist, study more about PAIN! Is that too much to ask to a PT?
I cannot watch his videos where he is giving advice to laymen about how to live better. One of remarks made by a lady after the show was “now she knows how 80% of the americans are moving wrong!” He even scolds people when people get up from the chair and have had their feet turned out! http://www.youtube.com/watch?v=3WOpb8PrrSc. Maybe you can write a post.
| Tue August 20, 2013
Thanks for the review Anoop, having had a quick read of some of the book it does seem to have more of a nocebo tone than placebo tone.
If ‘The goal is to get a lot of people, many of which having no previous knowledge about biomechanics whatsoever, moving better and understanding the pitfalls when performing under physical stress.’ then why is the understanding not understandable? It’s not hard to differentiate between biomechanics and neurophysiology or physics and psychology and yet a lot of the book seems to confuse the distinct but overlapping areas instead of clearing it up.
Anoop | Tue August 20, 2013
Look, there is no ideal way to move. Nobody has yet to show there is an ideal way to move and if there is if it lowers injury /prevent pain. And we have been fucking studying this for over 30-50 years! 30-50 years! I have a better idea, why not just move.
Are there some basic guidelines when we lift heavy weights? Yes. Don’t round your low back and maybe stay from loading at end range of motion and maintain healthy joint range of motion. . Outside these basic guidelines, there isn’t anything out there in biomechanics that predicts injuries in lifting. Your job as an author is to somehow stretch it to 400 pages. Even those are a maybe since we often see people lifting with rounded back or squatting ass to the ground and still doing fine. So when someone keeps on nitpicking about form for almost 100 exercise, it is just unbearable. Some of stuff is just too silly, like if you lean forward in dips, you are making an over extension fault; If you cross your legs, your lats turn off blah blah. And it’s all fine. I think any advice on form is always better.
What about performance? And this is just too vague. It just depends on what expert you are listening. Ask Glen Pendlay or Rippettoe and they will say squat with toe turned out. Ask Kelly he will say, if you squat with toes out, you will soon be in injury or pain and lack performance. And I am using the toe out because that’s the only time people about Kelly when it comes to lifting technique. Rippettoe head down squat technique will be a total no-no from Kelly because that’s breaking his one-joint rule. When it comes to the simplest of sport like running fast in a straight line - the most primitive movement I guess, we got no clue how biomechanics will influence. Heck, experts thought Usain bolt was not made for sprinting because of his biomechanics (6,5 height) and he is the fastest ever on the planet! What does it tell you about biomechanics??
Now when you come to just movement without any loading or performance, there is almost zero evidence to show how to move or sit or stand. Kelly think you should pick up a pencil like you deadlift. And he thinks that is one reason why there are so many low back pain problems. What we have instead is plenty of evidence going against the advice of emphasizing too much about ideal movement and posture in pain persistence.
If he had the book with just exercises and proper form for lifting, his book would be just another lifting book with 2-3 reviews and not a national best seller. And his shot of fame was all the mobility exercises with bands which improves pain and ROM. That is what made him pretty popular and that maybe helpful for people.
| Tue August 20, 2013
“Kelly think you should pick up a pencil like you deadlift.” How do you think that a person should pick up a pencil? Round their back and bend forward? Stuart McGill has actually shown a lot of proof that one of the best ways to have disc herniation is to do enough flexion movement in the spine. The pencil doesn’t weigh much but if you do it enough times it can hurt you, consider how many times a week, month, year people bend over the wrong way and have bad backs. So i really don’t see how you can make a statement about science showing that we shouldn’t have a good form when picking things up?
It’s like saying that it’s ok to let the knees buckle in when walking up a stair, rising up from a chair etc, how would that not affect the tissues in you knee? Because ideal posture/movement isn’t important in your opinion.
| Tue August 20, 2013
‘Stuart McGill has actually shown a lot of proof that one of the best ways to have disc herniation is to do enough flexion movement in the spine.’
I completely agree that taking dead tissue (without an intact and working neuro/immune system that repairs and adapts it to stressors) and applying repeated physical stress to it will create disc hernitation, the only problem is that it doesn’t then correspond well to living tissue in conscious cognitively able sentient humans. I have no troubles with applying mechanical forces to an inert lifeless tissue and the results. I have difficulties when the results from an experimental system with a particular set of properties are conflated to another signficantly different system with a myriad of properties, only some of which correspond to the initial experimental system.
It also doesn’t explain those people who have been shown to have disc herniation and no report of pain or function loss.
My only qualm Anoop (and it is a quibble amongst a way larger set of qualms) is that pain and certain pathologies (ACL ruptures etc) could possibly indicate that a particular person in a particular movement has fallen outside of THEIR particular ideal. So the exception to the rule of ‘there is no ideal way to move’ is possibly (interesting philosophical debate) when they experience pain or create tissue pathology. There are always exceptions to the exception to the exception (I lift a car off my daughter and rip all the muscles off my arm in doing so but save her life - i’d say i’d moved ideally even though i’d created tissue pathology).
However science is always going to be a set of statistics and a theoretical model (simplified way of viewing) that can be applied to a unique set of circumstances (reality). It’s when reality is meant to be subservient to a simplified theoretical model that I get concerned. Science can tell us the scope of how the universe and us works, it can’t tell us where an inidividual falls within that system. same way that when a client walks into my room and says they have LBP I can’t simply say it must be disc or z joint or illiopsoas or ...
And overall it doesn’t detract from an excellant review.
Many thanks for your work.
Anoop | Wed August 21, 2013
Thanks for the comment. It is good to know you re questioning. And i hope it doesn’t stop. I have read all the posture and movement stuff. Even own Cook’s video tapes and corresponded with Sahrmann. I was one time very concerned about my clients posture and movement.
Regarding your point: ‘Stuart McGill has actually shown a lot of proof that one of the best ways to have disc herniation is to do enough flexion movement in the spine”. As Joe Brenece wote in the previous comment, if you want to get rid of pain, study pain, not biomechanics. do you know why the American College of Physicians have come forward with clinical guidelines saying” Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”. Bcos we clearly now know that abnormal findings on the x-ray and MRI ( like disc herniations, bulging disk, degenerating joints and so on) are clearly NOT related to the onset, severity, prognosis, or duration of low back pain.
And flexion of the spine is a basic fundamental movement just like extension,adduction and so forth.
Anoop | Wed August 21, 2013
Almost acute injuries have one thing in common: extreme loading at end range of motion. What are the strategies for preventing ACL injuries: minimize loading (landing softly, making a 3 step stop than one), don’t let knees buckle in (prevent loading at the end range of motion). In essence, most injuries are due to extreme loading at end range of motion of a joint. This is the reason why you don’t see an ACL tear in a gym though they are end range of motion, the loading is way less that running or jumping. Is that revolutionary? I can assume end range of motion without loading and be fine. So even the wide margin for error for movement is also dependent on the load on it.
Pain is very complex. You can have injuries and no pain. You can have no discernible injury and have pain. So it is better to talk about movement errors and margin of erros to acute injuries.
Thank you for the comments Mark. And it ok to question me. That is the purpose of the site. It helps me think critically too.
| Thu August 22, 2013
Enjoyed this review. I am planning on reading this book soon so I’m glad I’ll be able to look at it with a more critical eye when I do.
I’ve been reading more about pain recently and the idea that its cause is really not what we would think it is. This concept does give me some confusion so hopefully I can articulate what I’m missing:
I know that for me personally, and many people I’ve worked with, fixing movement patterns and strengthening certain muscle groups have done a lot in pain reduction. For instance, I fractured my spine and had immediate pain and consequences for years following. I didn’t even know at the time what exactly I had done. I was unable to visit a doctor until 2 years later. After following PT guidelines and smart strength training, I have very few problems.
For certain clients I work with (I’m a personal trainer), fixing movement patterns such as learning to properly hip hinge in a squat / deadlift have greatly reduced knee pain.
So what is happening in these instances? I am not questioning that there is much more to pain than we think. Is it that in some cases there are cut and dry causes and solutions and in others there are more psychological underpinnings that must be addressed?
I have certainly had clients where I fixed movement patterns / biomechanical issues and still had them experience pain. I always figured I was doing something wrong and was missing the root cause.
Anoop | Thu August 22, 2013
Thanks for the comment and glad to know that you are questioning concepts and results.
I would have you read this: http://www.exercisebiology.com/index.php/site/articles/a_revolution_in_the_understanding_of_pain_and_treatment_of_pain/ . I have also some podcast and videos in the recommended reading list at the end of the article. You would have a better idea of pain and why some of your clients and you felt better.
After reading it, let me know what your thoughts are. if you have more questions, ask me.
| Thu August 22, 2013
This was pretty bad to be honest and with due respect. So many grammatical errors, many with words just missing from the sentence. The whole article looks like it was written by someone who barely speaks English. After investigating his credentials the guy is known as “the ass guy” writes blogs for volume and pop-ups with gimmicky demands for your e-mail address.
If you took 5 minutes to actually learn about Kelly then you would know that he has never claimed to be bringing anything new to the table, ever. He tries to package things in a way anyone can understand and literally states that, “a physical therapist should not stand between you and understanding how to move.” In fact, the whole point is to deliver a system everyone can use with minimal cost. This book has thousands of dollars of information in it for $20. Rather than pay someone $200 an hour to teach you things that should be taught in elementary school for free, and should be tested for mastery before graduation from high school for free (his words not mine and I completely agree). It is absurd that you can graduate high school and have no clue what a squat is, how to prioritize your spine, or how to walk and run properly. People simply having this information from a young age would solve the vast majority of injuries in many fields. Competitive sports and injury go hand in hand but for the average man this stuff is life saving.
Before you attack this book which has myriad benefits for the average person, you should keep in mind what doctors are charging for this same information. I think all of this information is excellent. Just because a CSCS pursuing a PhD does not find it useful, does not mean that hundreds of millions of people who have no clue about any of this stuff would not find it beneficial if not life saving. His system has changed my life and taught me how to move when there was nowhere else to turn to learn these things. Millions of us do not even have health insurance and can not see a physio or doctor. My everyday pain has gone way way down regardless of your “do what you wanna do it does not make a difference” attitude says, and my posture and flexibility have improved dramatically.
To me this review does a disservice to any average person who wants to learn to resolve pain and increase mobility. This stuff does work, very quickly. Much better than any pills or prescriptions a doctor has offered me, and much better than being told not to worry about it because amputees don’t have pain by some random article.
| Thu August 22, 2013
I do not think it is that hard to explain to people how their brain sends out an output to make a movement, based on what it believes to be it’s current environmental demands and what it believes to be the bodys current state of beingn, the same nervous system is at the same time bringing in the sensation of movement and all it’s other sensations, and the brain adapts and changes it’s movement patterns. I did it in a sentence, I do it all day long with clients. I don’t dumb it down and miss steps, I just take small steps and go through the WHOLE process.
Why teach someone only 1/2 the alphabet and call it literacy?
I agree there is some great information in Kelly’s book, my qualm is why is there not other great information to help contextualise it more appropriately based on modern science, not pain science or neuroscience, it’s all just science.
And as soon as you add the word ‘properly’ into a sentence about movement it becomes debatable. Science isn’t about ‘properness’, properness is an interpretation of science and that’s a different kettle(bell) of fish. It’s a little like me looking at someone else and saying you’re ugly because you’re not symmetrical and science says that symmetry is beauty.
On the plus side it’s great to hear that you are feeling better and have noticed an improvement in your movement. Anoop’s http://www.exercisebiology.com/index.php/site/articles/a_revolution_in_the_understanding_of_pain_and_treatment_of_pain/ is a good simple read of some of the underlying mechanisms that occured, based on some very sound and exciting science.
Anoop | Fri August 23, 2013
It is absurd that you can graduate high school and have no clue what a squat is, how to prioritize your spine, or how to walk and run properly.
I think your above comment shows me you haven’t understood the the biopsychosocial model of pain or where the current pain science is heading towards. As Mark wrote, read the article I posted in Brett’s site - the ass man you call. And then come back and vent.
his stuff does work, very quickly. Much better than any pills or prescriptions a doctor has offered me, and much better than being told not to worry about it because amputees don’t have pain by some random article.
And this is the problem. 99% of the people are impressed if you lose weight, gain muscle, get rid of pain in 6 weeks. That’s how 99% of the quacks in the industry make money. There are people who lose 30lbs on a cabbage diet in six weeks. And since it worked for them, they are convinced that is THE diet. They don’t stop to think about the long term or the harm.
And of course, anybody who questions the cabbage diet - the best seller- is doing a disservice to average people who wants to lose weight and to humanity!
| Fri August 23, 2013
It is easy if you do not like the review, stop reading it…
This website is devoted to bring some scientific data to the fitness world which is filled with market gimmicks. It is not meant to be a soap box for arguing
If I don’t like a particular food I do not keep trying to eat it to see if I like it. I don’t mean to be rude but this website is about scientific methods and it is good to always challenge idea’s.
Anoop | Wed September 11, 2013
Here is one of the best interviews you will hear about pain:
Jason Silvernail & Bret Contreras talks about common misconceptions about pain, how biomechanics, posture, movement can or cannot influence pain positively and negatively. A very complex topic, but Jason makes it so simple.
Can someone send this to Kelly Starr please
| Thu September 12, 2013
Don’t care much about the book. The biopsychosocial model however I find very interesting.
Anoop | Fri September 13, 2013
Check out the podcast I posted in the previous comment. It goes through everything very well. And the article I linked to.
| Thu September 26, 2013
I am no expert, which is how I happen upon sites like yours to read up about the topic, but your logic is false here, “There are 1000’s of people who have bad posture and have no pain. There are 1000’s of athletes running around with bad movement and no pain. There are 1000’s of cerebral palsy and polio patients walking around with the worst movement and posture and no pain. ” Just because people move poorly without having pain does not mean that for the people in pain, posture and form etc. was not the root cause or a strong contributor.
I plan on reading the book and what you say provides some context and information as I delve into it. Fitness and wellness is a lifelong journey, and with that comes not spoon feeding but a combing and cobbling together advice and best practices as we continue on the journey. This books sounds like it will function well in that context.
Anoop | Thu September 26, 2013
Thanks for the comment.
I am no expert either, but I have done a lot of reading on this topic and corresponded with most of the researchers in this field.
It is a good point. The reason I have those questions is because these are the same questions which seriously questioned the old biomechanical model of pain which says pain is linearly related to injury.If pain is closely related to injury, how can someone walk around with a herniated disc and not have pain even for a day? Can you guess?
Or are these genetic mutants who don’t get pain? Studies have looked at the prognosis of people developing pain too and have found no relation to disc herniation, stenosis and such. And this is not something new. Very very smart people people have studied this for 30-40 years and then came up with the neuromatrix theory of pain. This is not my opinion. This is the actual biology of pain.
And read the article I posted too. I explained pretty well the problems with the old model and the new model and the new approach to pain.
| Thu September 26, 2013
Thanks. Surely I can guess, not all herniations, tears etc are equal. I have two herniated discs from an accident which have been very painful twice in my life due to the way the discs bulge into the nerve. On a daily basis, I manage the issue by doing exercises which keep the herniation from actually impacting the nerve. It is not the herniation itself but rather the impact the herniation has which can cause problems. Surely people have various types of herniations, tears and the like which impact them differently.
You have shifted to a topic I didn’t raise and didn’t address the one I did raise, which is that poor movement can be the root caues of pain for some people. Just because 1000’s can move poorly pain free, does not mean that for the 1000’s in pain poor movement was a contributor. Just like 1000’s can eat cheeseburgers, nachos and maintain a horrible diet while never having high blood pressure, cholesterol or obesity, for the ones with those afflictions, sure diet is a contributor.
I am not certain what I think about the pain theory you address. Certainly the way the mind creates pain for a limb which is not longer there (or sensation in general) is amazing, but because the mind creates a false experience for a limb which doesn’t exist doesn’t mean that the pain felt for a limb which does exist is strictly manufactured pain. In addition, you reference a Neuromatrix Theory but you also discuss it as actual biology. I have begun reading about the theory, but it must be noted that a theory is just that, a theory, nothing proven yet. It is not really accurate to proport theories as actual facts or assumed science.
All in all, the tidbit that seems to make the most sense was written by Jason Silvernail in the comments section of your pain article, “I do what I can to help them manage what’s going on in their body through movement and manual therapy, I reinforce their physician’s appropriate medication prescription (both addressing the tissues), and I help them understand why they hurt and what they can do about it so they understand it better (addressing the brain). That’s addressing both the brain and the body, while acknowledging the patient’s pain is real and getting at the root of the problem. That’s how clinicians can put this information into practice, and how fitness professionals can help their clients understand pain and its treatment better.”
In that context, it seems to make sense to apply a varied approach to pain management and pain prevention. If addressing the body can help heal, then why not address the body to prevent injury, along with the mental aspects you address?
| Thu September 26, 2013
Got the book. Lots of simple easy to follow, clearly illustrated instructions (unlike Rippotoes rather tedious, long winded tome on which the editor was very lazy).
I felt pain in my shoulder and foot, used techniques for myofascial relief decsrbibed in the book, pain has gone, mobility back. So theorise as musch as you want about pain, but i’m a layman, i want to be able to train and manage pain and no Dr or PT has ever mentioned Myofascial Release to me before or that i could treat it myself. Well if i know i could treat it myself why would i go back for a £60 session. I wouldn’t.
Starretts cult of personailty will help relieve more ‘pain’ and give more mobility probably to more people than anyone one person has ever done. He keeps it simple and precise. If it’s nothing new technique wise it doesnt matter, it’s the package and the personailty that does and the scale of people who are paying attention is something new. Will those poeple be better off or worse? Time will tell.
| Thu September 26, 2013
@Paul - You have shifted to a topic I didn’t raise and didn’t address the one I did raise, which is that poor movement can be the root caues of pain for some people.
I don’t think anyone will deny that there can be a relationship between movement and pain (and to those that don’t just ask them to repeatedly poke themselves in the eye until they get the point). However in terms of ‘cause’ of pain a lot of what was earlier assumed to be a cause of pain is not clearcut or stereotypical. So the ‘you have knee pain because of flatfeet’ (1/ to 1/6 population characteristic) type statements are now shown via studies to be as relatable as ‘you have knee pain because of blue eyes’ type statement, you can have kneepain and blue eyes, you can have kneepain and flatfeet but it doesn’t mean that the one causes the other. You can have movement and have pain but does the way the brain produce movement when it’s in a pain state cause the ‘poor’ness of the movement or does the movement cause the pain? Because it’s a continually proactive and reactive little beast I’d say sometimes it may be one or the other or both.
There’s a good article by paul hodges and kylie tucker called moving differently in pain that is out on the internet that discusses this.
So maybe ‘poor’ movement isn’t the root cause of pain so much as a contributing factor and one factor that the person in pain can address along with others. I notice Anoop isn’t advocating do nothing and stay still!
The neuromatrix is a model.
| Fri September 27, 2013
@ Mark H, I didn’t address you at all, at least I wasn’t intending too, so really no topic to shift from.
Anoop | Fri September 27, 2013
Nope .We clearly know that these herniations bulges and spinal stenosis, and complete lack of cartilage between joints should be painful, but are not in lots of people. And there are people who show lot more pain but not much on their MRI’s. These were all the studies which showed us the failure of the structure -pathology model of pain. In fact the same reason why doctors are told not to scan for low back pain unless they have some serious red flags.
About your theory comment: ‘A scientific theory is a well-substantiated explanation of some aspect of the world, based on knowledge that has been repeatedly confirmed through observation and experimentation’. The same is true for theory of gravitation and cell theory or theory of evolution.
I shifted it to disc herniation just to show that there are people walking around with herniations with no pain when we know clearly they should be crying out in pain. Then should we worry about posture? Since you asked for it, here you go:
Roffey DM, Wai EK, Bishop P. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. The Spine Journal 2010: 10; 89-99.
Edmondston SJ, Chan HY, Ngai GC, et al. Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture, and cervicothoracic kinaesthesia. Manual Therapy 2007: 12; 363-371.
Youdas JW, Garrett TR, Egan KS, et al. Lumbar Lordosis and Pelvic Inclination in Adults With Chronic Low Back Pain. Physical Therapy2000: 80; 261-275.
Basically shows no/weak association between posture and pain. And we have been fuckin studying this for 30-40 years and still people can’t believe it!
I wrote about the bottom up approach and top down approach in my article. Unfortunately, we don’t have anything to show that can prevent injury or pain. If there is, I would do it right now!
And people who are very smart have studied this topic for 30-40 years before coming up with these pain theories. Just reading it for 10 minutes and then jumping on your intuitions doesn’t sound very good. I have a lot of reading material in that article.
here is a good read for you: http://www.bettermovement.org/2010/five-misconceptions-about-posture/
Anoop | Fri September 27, 2013
And here is a famous study. Are structural abnormalities or psychosocial variables more important for predicting serious low back pain? Check the conclusion.
Spine J. 2005 Jan-Feb;5(1):24-35.
Discographic, MRI and psychosocial determinants of low back pain disability and remission: a prospective study in subjects with benign persistent back pain.
Carragee EJ, Alamin TF, Miller JL, Carragee JM.
BACKGROUND CONTEXT:A range of morphologic and psychosocial variables has been suggested as risk factors for serious low back pain (LBP) illness. Although the relative contributions of structural and psychosocial variables are intensely debated, the validity of differing hypotheses has proven difficult to test because the incidence of serious disabling LBP illness is low in healthy subjects. These factors dictate the requirement for large sample sizes, extensive structural imaging and extended longitudinal study. Previous studies included either small cohorts with intensive imaging testing or large population studies that do not establish a detailed morphologic baseline.
PURPOSE:To establish, using a strict patient sample design, the relative contribution of structural and psychosocial determinants of serious LBP illness among subjects with no previous LBP disability or clinical LBP illness.
STUDY DESIGN/SETTING:A prospective, longitudinal study of subjects with high risk factors for serious LBP as determined by structural and psychosocial characteristics.
PATIENT SAMPLE:One hundred subjects with known mild persistent low back pain and a 2:1 ratio of chronic (non-lumbar) pain syndrome were recruited from a study population with a predisposition to disc degenerative disease, to undergo baseline examination, testing and 5-year follow-up.
OUTCOME MEASURES:Observations were made at 6-month intervals over 4 to 6 years (mean, 5.3) for the after primary outcomes measures: episodes of serious back pain (visual analogue scale [VAS] > or =6), episodes of occupational disability less than 1 week, episodes of occupational disability for 1 week, remission episodes of all back pain symptoms at least 6 months and medical visits primarily for LBP evaluation and treatment.
METHODS:Lumbar magnetic resonance imaging (MRI), lumbar provocative discography (in psychometrically normal subjects), physical examinations, medical and work histories and psychometric testing were performed at baseline. Imaging and psychometric testing were graded by blinded examiners. A scripted interview was conducted every 6 months during follow-up by independent research assistants who also were blinded to patient baseline data. The interview covered interval medical, occupational and accident or injury histories.
RESULTS: Psychosocial variables strongly predicted both long- and short-term disability events, duration and health-care visits for LBP problems (p<0.0001-0.004). The likelihood of a sustained remission from the baseline persistent (subclinical) LBP appeared to be linked to occupation factors (leaving a heavy labor occupation; p=0.0001), neurophysiologic variables (chronic nonlumbar pain; p=0.0002) and psychometric profiles at baseline (DRAM and FABQ-PA; p=0.003-0.002). Of the structural findings measured only moderate or severe Modic changes of the vertebral end plate were weakly associated with an adverse outcome. A positive provocative discogram at baseline did not predict any future adverse event.
CONCLUSION:The development of serious LBP disability in a cohort of subjects with both structural and psychosocial risk factors was strongly predicted by baseline psychosocial variables. Structural variables on both MRI and discography testing at baseline had only weak association with back pain episodes and no association with disability or future medical care.
| Tue November 05, 2013
” Are there some basic guidelines when we lift heavy weights? Yes. Don’t round your low back and maybe stay from loading at end range of motion and maintain healthy joint range of motion. . Outside these basic guidelines, there isn’t anything out there in biomechanics that predicts injuries in lifting.”
I’m sorry but my knees disagree with you, I did poorly in a set of push-presses using the knees first not engaging my posterior-chain enough because of weak lumbar.
AND GUESS WHAT!! I burned my knees as PREDICTED and warmly warned by many lifting couches and Kelly, so poor biomechanics can cause pain and injury and can PREDICT injuries. After correcting the execution I can perform push-presses pain free.
My understanding is that you are missing the point of the Kelly’s book, people are trying to move ( as you clearly are in favor ), and are reaching problems when they try to execute complex movements because of lack of ROM, this kind of people are using Kelly’s book to get rid of the problems and execute with efficiency the movements.
| Thu November 14, 2013
I feel like we have to use the 80/20 with any defined program. There is validity I that for 80%, a program will be beneficial and 20% will be the exception rate. We must remember that function is a spectrum influenced by adaptability. Pain is a spectrum influenced by sensitization, among other things. I get frustrated any time anyone makes sweeping claims. That being said, Starrett’s work is a good resource for the 80%. I dont yet go along with the neutral foot squat. I feel the external rotation deloads the developmental internal rotation of the myotomes and puts the lower extremity in the open pack position, reducing natural eccentric tension. I am still in the butt wink camp, as I feel the pelvic flexion facilitates improvement in the mechanical advantage of the glutes and hamstrings. Not to mention, there’s no such thing as one joint in a live person.
We all need to avoid any “absolute” terminology. Nothing is absolute, and this is why healthcare will always have an “art"component equal to its science component (despite what the research model will drill into your brain).
I appreciate starrett for the resource. I don’t blame him for seeking compensation for his time and information packaging. (It’s true that in the wiki age, all the information is on the internet, but the value comes in the packaging of it into digestible chunks.) I also appreciate intelligent discourse from varying viewpoints. I just hope everyone can keep from emotional reactions, because it compromises the integrity of the discussion.
| Wed November 20, 2013
“For the newcomers. Pain has very little do with your posture and how well you move. There are 1000’s of people who have bad posture and have no pain. There are 1000’s of athletes running around with bad movement and no pain. “
“Cancer has very little do with how much you smoke. There are 1000’s of people who have smoked for years and don’t have cancer.” I stopped reading here FYI.
I really am interested in hearing solid, intelligent criticisms of Kelly and others but every negative review that I’ve read of this book was written by a fool. Srs.
Anoop | Wed November 20, 2013
Thanks for the comment.
Your question is a genuine one and most people make this mistake. Here is your answer in 2 lines:
Smoking has shown in studies to be very strong risk factor in cancer.
Posture and gait has shown in studies to be not even a risk factor in pain.
So your analogy is like comparing peanuts to coconuts.
| Wed November 20, 2013
Have you actually talked to Kelly about his research/findings? He has called you out numerous times on this review (Barbell Shrugged Podcast, London Real Interview) - perhaps you should sit down and talk to him about his viewpoints and why he believes this?
Since you are still pursuing your Ph.D in this field and Kelly has already obtained his, I would put forth that perhaps some of his rationale is based on actual evidence that he has seen within his practice as a licensed Physio and Chiro?
Just wanted to stimulate some conversation as apposed to saying yes or no…
Anoop | Wed November 20, 2013
I skipped though one of them and heard he talked about me and how I was wrong about posture not causing pain. And what his retort? “Does he know how many people have low back pan, stenosis, and so forth”. Means he does’t have anything.
And Kelly didn’t came up with anything so why should he be so bothered? Posture and stuff came about in 1980’s from Kendall. Even his Vodoo stuff that he claimed to came up with is just directly from Mullgan’s book.
Kelly doesn’t have a Ph.D. He has a DPT in Physical Therapy. It is similar to Master’s program with more clinical hours.
I wrote my Posture article- Correcting Posture: Myth or Reality back in 2005. Long before anyone heard about Kelly!
And read the article I linked to and the podcast. I have given enough rationale and evidence in those articles. And this is not my theory or anything. it is the biology of pain and most well educated PT’s know this.
Maybe I will re-write a posture article!
| Sun November 24, 2013
Well, have fun getting traffic on your website Hopefully most of the comments won’t be of the emotional variety but bring great questions. If they are emotional troll like comments, god help them be funny ones. Cause laughing is good for us all. Peace
| Mon November 25, 2013
Anoop are you interested in actually having a dialogue with Kelly or just criticizing from afar? Why don’t you send him this? Would be more beneficial than to just create a trash talking platform for other people
| Tue November 26, 2013
I suspect some of those commenting need to understand the difference between:
a. Critiquing ideas/content
b. Critiquing an individual
Kelly has expressed his ideas in a public forum, through the release of this book. Because of this, his ideas are fair game for scrutiny (as are any of those provided by us who publish information).
As Anoop has pointed out, some of the ideas taught in this book are not the best-evidenced. The “ideas” (again this critique of ideas; not Kelly) are based off of an older theoretical model of “pain”(developed in 1965), which it’s own originator, Ronald Melzack, has altered (back in 1998). For years, it was suspected that pain information was carried to the brain, from Ad and C nociceptive fibers. Again, the guy who theoretically developed this model realized, “pain is not carried from the tissues to the brain” and instead understood that several forms of input can cause the brain to become defensive (resulting in an output of pain/altered action programming). It was also theorized that an “input” was not truly necessary for an “output” to occur (ie. phantom limb pain).
Along with pain, altered action programming/motor control, was discovered to likely be a “defensive” output. This is important. We move differently when a threat has occured (ie. lifting a foot off of a nail, after making contact), or is suspected (ie. walking cautiously through a haunted house). This program is top-down. For those who don’t understand where I am going: People move and sit certain ways that are biologically advantageous. We move differently due to outputs. We have research to support this. It is less plausabile to argue that defective tissues lead to pain (research has indicated that large % of asymptomatic individuals have defective structures).
Anoop | Tue November 26, 2013
Thanks! There are a few. But it just aknee jerk response because all this pain science goes against what people beleive. so I dont expect people to just agree without a bit of reading.
If you read the comment above me, you will see that Kelly has already talked about in his 2 videos this month. He just said ” I was a hater and should be crushed and there are a lot of herniations”. I wish he would have read the books and articles I gave the link and gave an educated opinion. I posted the video on my facebook.
Thanks for the comment. Your comments are always welcomed. Very important point about the cause or consequence. In the recent review even Hodges even says it is mainly a consequence than cause.
As always i didn’t come up with any of these nor this is my pet theory. this all based on the current science of pain and where the treatment of pain is heading towards. Most people who critique this article are doing it because:
1. They haven’t read anything about recent developments and research in pain so just ignorant about the how pain is triggered and maintained.So just lack of knowledge.
2. They had some pain and it got better with Kelly’s work.So it should be right.
And these EXACTLY THE TWO reasons why even homeopathy/cleansing/energy healing… and all other non-evidenced based treatments/advice prosper out there.
| Tue December 03, 2013
Ahhhhh Anoop don’t be so cynical. The time effort and angst you put into this blog could have been far better spent.
I agree preaching a practice in the defiance of evidence is elementary, but so is hanging your hat purely on the evidence. As you’ve outlined what we know about the human body is limited at best, therefore to practice purely evidence based is self limiting.
Let the evidence guide your clinical judgement but not define it and don’t worry so much about what others do as it is your own decisions and actions in life that effect you so personally.
Thanks for the material on pain, a poorly understood element of our practice.
Keep up the good work
| Sat February 01, 2014
When anyone begins by criticizing someone’s grammar and spelling, he/she immediately loses credibility with me. In almost every case what follows is an ego-driven diatribe. I have no patience with those types. I love Anoop’s writing style because it isn’t “dressed to impress”.
| Wed February 05, 2014
Dear Anoop—I’ve been reading this blog and related debates closely in recent weeks. Thank you for your analysis and thoughtfulness. You obviously care about helping people and deriving the truth. I appreciate that.
I am a layperson—no degrees or clinical experience in this subject matter. I was open to many of Starrett’s ideas because over a period of a few months of implementing them, I did notice some improvements in ROM as well as strength gains in smaller supporting/stabilizing muscle groups. I’m not in a position to determine whether those improvements were beneficial, detrimental, or neutral, though.
I had two questions I was hoping you could answer.
1. In the discussion forum below your article, you write: “Don’t round your low back and maybe stay away from loading at end range of motion,” as two basic guidelines to follow to avoid injury/pain. I was wondering if you could explain what exactly you mean by avoiding loading at end range of motion? Does that mean I shouldn’t do a squat to full depth, or that I shouldn’t lock my elbows out at the bottom of a pull up? How far short of end range of motion is it advisable to stop? I just wasn’t sure how to apply that piece of advice to specific exercises.
2. The second question is in regards to the body of knowledge that we’re dealing with (epistemology). Regarding Starrett’s book, you write: “The problem here is that these recommendations which are re-enforcing people’s belief that the pain comes from bad movement and posture are just exactly what modern pain science has shown to be the problem. The more you talk about biomechanics, joints and movements, the more you are raising the threat level in the brain and making the pain chronic.” This seems to imply that there’s a kind of Pavlovian conditioning going on: we create in our minds a linkage between bad movement and injury/pain, and then, psychosomatically, we feel pain by talking about it; so, therefore, the more we talk about bad movement as a cause of injury/pain, the more likely we are to experience pain. I’m curious how this linkage developed in the first place? If there really is no correlation between bad movement and injury/pain, how have we become socially conditioned as a society to the point where mere discussion of bad movement can induce pain? In Pavlov’s scenario, the dogs came to associate the bell with food, precisely because there was such a strong correlation (at least initially). If there had been no correlation between bell and food, the now famous Pavlovian reaction never would have developed. (I realize that there is no causal relation between bell and food, and perhaps that is your point—third factors, not the bell, determined whether there was food. I’m just curious how we as a society came to make this association in our minds in the first place, since you seem to imply that, causation aside, there isn’t even correlation: that tons of people experience pain with no sign of “injury,” and that tons of people with “injury” experience no pain.)
Thanks again for your time and research, and for entertaining so many of our questions here. Best regards.
Anoop | Thu February 06, 2014
Thanks for the comment.
1. Just a common sense advice. Generally acute injuries tend to happen when you are at the end range of motion when your connective tissue is bearing the brunt of the weight. For example, landing on side of your foot when it is twisted and at the extreme end of its normal ROM. I am talking about acute injuries not the type when you feel pain oneday in your knees and such. The stuff like deep squats and such, as long as your progress gradually and do it in a controlled manner, you should be fine. I wrote an article about deep squats an injury.
2. Good question, and I know most people who read the review didn’t really understand that concept. The very reason I wrote the latest article: http://www.exercisebiology.com/index.php/site/articles/what_should_fitness_professionals_understand_about_pain_and_injury/
Hope that helps. An you can join the forum if you wanna ask more.
| Wed February 19, 2014
After reading the book and watching some of his videos, I can say that there are some concepts that I don’t fully agree with. However, based on personal experience, the majority of the material does work.
I’ve been a soccer player my whole life and have been strength training, researching, and testing theories for the last 8 or so years. Pain was always something I didn’t have a firm grasp on and was something that would plague me from time to time as an athlete. It wasn’t until coming across Kelly’s material that I’ve been able to train relatively pain free. This was a result of a change in thinking for rehab techniques as well as movement positioning. Can you move and train using bad positions pain free? Sure! Does it work well for long term or high load situations? Probably not.
The material he has is a starting point for people to figure out how their body works (whether or not he advertises it as such). Everyone should take what they read with a grain of salt and test what works for them personally so as to know what they should really be doing (each athlete is a different case and should be treated as such). Kelly’s book and and site and whatever he has besides that is a good resource and it’s just that, a resource.
As an athlete with flat feet (working on it) and a bad case of Osgood Schlatter’s disease (not much I can do there), I have to be very careful how I train. I can easily debilitate myself by merely squatting with bad form (no weight, mind you). There are plenty of athletes that have varying degrees of “good/bad” form and have no pain (not saying that my form is amazing but it’s what works best so far [which hopefully continues to evolve and get better]). With that, I’m sensitive to movement patterns.
Anyway, all in all, your review was good and picked at some of the sketchier portions of his thinking. People should think for themselves. Some of Kelly’s stuff is good and some of it is not so good. He does tend to come across as little abrasive at times it would seem but that’s his personality from what I can tell. Use what works and leave the rest, as should be applied to most aspects of training (which takes time for personalized approaches). Test and re-test (as Kelly likes to say).
Anoop | Thu February 20, 2014
Thanks for the comment. I don’t think anyone wrote you should throw good technique and good form out of the window. Besides a few general tips, there isn’t anything new when it comes to lifting. If you wanna hear or see good form minus the blown up terminology, fear mongering, and over-exaggeration, check out Mark Rippetoe or Dan Jones.
And it is not as simple as take what works and leave the rest. We practiced bloodletting for 2500 years thinking it worked! And sure it worked for a lot of people. Hope you get my point.
And check the new article I wrote about pain. You may find it interesting and it explains why some of Kelly’s stuff is just plain wrong.
| Sun February 23, 2014
Anoop, Where do I buy your book?
| Sun February 23, 2014
I haven’t yet had a chance to read the book, yet I have watched a lot of Kelly’s videos on mobility and injury prevention, and they are good.
From what I have heard from others their mobility and flexibility have improved a lot since following steps in the book.
It’s common sense that improved mobility and flexibility would naturally lead to better movement patterns, provided you implemented correct technique, and therefore fewer injuries.
I have never known him to continually harp on about PAIN, which is all you seemed to focus on in this ENTIRE REVIEW. PAIN PAIN PAIN PAIN PAIN. You act like therapists have been incorporating some great techniques in their therapy for decades, what a load of bullshit. 99% of therapists look solely at the area a patient complains about and hardly look at anything related to full movement pattern involved, what Gray Cook has been doing is ‘new’ in terms of the typical approach to physical therapy.
I am not sure why you bash his book so much, as no one needs to know about some 1950’s blah blah blah who gives a shit, to know what makes sense.
Better range of motion, will allow anyone to put themselves in better positions when performing movements, and will thus reduce chance of injury.
You bash his foot stance, yet provide no reference for any argument you make that claims it’s bullshit, he explains quite simply how torque is generated, and learning to open up your hips and ankles through a movement like a squat will help generate better torque.
Have you ever seen anyone do very high box jumps? NO ONE stands with their feet rotating at like 40degrees and proceeds to jump.
Honestly I wonder what if any understanding of the body you have?
But not knowing much about you, you come across as one of those nerds, who has read a few books and thinks he has a clue.
I can at least respect someone who can display good technique to me.
I’d be surprised if you have ever lifted a weight in your lift or performed in compound movement.
I’ve dealt with many PT’s like you before, who are not athletes, never achieved anything with their bodies, and I must expect them to try tell me about the mechanics of a movement they have never performed in their life?
Anoop | Sun February 23, 2014
His whole book is based on his belief that injury and pain treatment/prevention are synonymous. Most people in the gym don’t just get acute injuries like in sports. Ever heard about the most common knee injury - ACL injury - in the gym? What people complain and worry about lifting is about pain -knee pain, low back pain, shoulder pain and so forth.
And it is NOT common sense that improved mobility and flexibility will reduce injuries. In fact, it is pretty much known that stretching to improve ROM doesn’t do anything to prevent injuries. We have studies this to death. Gymnasts have probably the best movement patterns - stability, mobility, flexibility- but the injury rate rivals even contact sports. So your repeated shouting of how improved ROM will prevent injuries is just wrong. Won’t blame you considering you get everything from Kelly.
And there is nothing new when it comes to lifting technique. It isn’t rocket science and the book clearly makes it that way. There are lot of good books which shows proper lifting form without the overblown terminologies, unnecessary & complicated recommendations, and fear mongering. For example, Dan John or Mark Rippettoe.
thanks for the comment.
| Fri February 28, 2014
I believe I read somewhere on the Soma Simple site a very succinct view of what pain is and how to reduce it: 1) Pain is a threat response. 2) To reduce pain, reduce the threat. Anoop, have you read/heard that? I think that was put up by Diane who is a Soma Superstar.
If that’s the case (just thinking here) could it be that IF someone sees relief from one of Kelly’s techniques (or the techniques of Gray Cook, Gary Gray, Eric Cobb, ANYONE) THEN it’s a result of one of those techniques reducing the brain’s perception of threat?
I could be completely wrong here… Thanks for all this great info though! I find all this pain science enormously interesting.
Anoop | Fri February 28, 2014
Thanks for the comment.
I am guessing you haven’t read much of what I have written about pain. Check the latest article I wrote about for fitness professionals. Explains the whole thing and what Kelly got it wrong:
And what you wrote is 100% right.
| Tue April 01, 2014
Have you ever thought the two systems could live together?
Treating soft tissues restriction, respecting fascia lines and treatments like A.R.T, massage therapy, Rolfing, etc. Working on proper joint mechanics, movement technique to keep joint in neutral position and reduce stress on the joints and tissues. OF COURSE there is gonna be some differences from one person to another, but the same logic behind.
All that, while keeping a biopsychosocial themed speech with the patient about what is happening with his brain and over-stimulated nociceptors and how he needs to remove his scheme of movement = pain and catastrophism, etc. Mobilise him, work on aerobic system also which has been shown to reduce sympathetic tone (which can be assessed with correlation with HRV, search OmegaWave or Heart Rate Variability in PubMed) and increase pain tolerance (that too, on PubMed).
Less stress on joints, more fluid movements, less fear, more active patient, less sympathetic tone (normal nervous system), better hormonal profile and biomarkers. Ain’t that what we all looking for?
I believe they can co-exist.
Just my two cents. (first time reader!
| Wed April 02, 2014
As soon as we start creating a dichotomy of two systems we’ve lost the point. Can you mix scientific statements and nonscientific or pseudoscientific statements ... sure, it’s possible but does that then make a good HEALTH PROFESSIONAL ... No.
Are there some ideas out there that may not have been investigated that once done so will show some validity in construct, sure. Does that mean that a person can use those untested ideas as a basis for the belief that forms their action and then consequently treatments/therapy actions? Sure ... but in doing so then that person, if a professional, is moving outside of their professional boundaries.
All logic starts from somewhere (a belief) and follows a path based upon other beliefs. If one of those beliefs is not valid then the issue isn’t with logic but with the belief that informs the logic.
If you’re only going to put a biopsychosocial theme into your speech actions but not your therapeutic intervention then surely something is asunder. There is bio in BPS but it’s a different bio to that in biomechanics.
| Fri April 04, 2014
I understand what you are saying.
I know it is a different BIO. If I understand it right, it would stand for:
- Immune response
- Physiological response
- Sympathetic response
- Maybe genetics
If an acute injury that isn’t treated, it is going to result in chronic pain, overstimulation of the nociceptors/nervous system and more. Yes, psychotherapy, reactivation and whatever you use within the BPS will help. But if there is ALSO un-treated soft-tissue restriction, capsular tightness/restriction and more underlying problems that remains + an overreactive nervous system that doesn’t know how to treat or manage pain. Wouldn’t addressing both accelerate the process instead of just addressing the BPS associated pain symptoms when looking for reduced pain, more function, return to work/activity/sport?
Lots of people is saying that his methods are reducing pain, yes, but also enhancing mobility and movement. Is the pain reducing comes from taking care of their own problem, empowering the patient with tools to help them, confidence level going up, MOBILISING patients in doing something constructive about their health. Maybe. Most certainly that’s a big part of what’s helping them. Endorphins secreted because of somewhat painful mobilisation technique of the soft tissues. Maybe.
As you stated earlier, it is not that much ‘anecdotal’ techniques, it is basically some self-use of Mulligan, A.R.T, Rolfing, PNF, Sahrmann, Cook and the like’s movement approach and the sort. The author isn’t to my knowledge taking credit on new concept. But being accessible in everybody’s home in a cheap and easy way, is what he calls revolutionary and that is debatable.
The laws of torque is nothing new and is more geared towards performance, muscle activation, stability maybe reducing chances of acute injuries (like FMS demonstrated in reducing chances of injury) than treatment of pain, so to me, that point is irrelevant.
Personally, I am more interested in why it HELPS people than trying to blame the guy. It is not unethical, it is based of evidence based techniques. Maybe not evidence based on treating CHRONIC PAIN.
Not trying to sound like all Biomechanical and no BPS. I deeply believe in both systems and to me, it is more multifactorial (BPS and Biomechanical systems) than a dichotomy.
Thanks for taking the time to repond!
P.S If some stuff is incomprensible, french is my mothertongue.
Anoop | Tue April 08, 2014
Check this article I wrote:
Good question about combining both approaches. I talk about it in this article. You can do it , but that requires a sea change in your understanding of pain and pain treatment.
| Tue April 15, 2014
Anoop you are using very generalised terms and explaninations when bashing Kelly Starets approach. Your explanations of pain are within chronic centralisation. Pain is very much linked to how you move, and compromised posture and has been shown to be an indicator of pain.
Gross measures of flexibility, range of movement and strength are NOT predictors of injury…any decent therapist can tell you that and Kelly does not make those claims.
‘Pain has very little do with your posture and how well you move’....you are incorrect.
Research clearly demonstrates that subjects with pain present with aberrant movement patterns, and adopt patterns of movement that would usually be used for high load tasks for low load function. Scientific literature demonstrates that uncontrolled movement is linked to pain (e.g. back pain, knee pain, shoulder pain, and neck pain etc), disability (functional ability), and recurrence of symptoms.
But if you look at broad simplistic measures of strength flexibility, range of movement etc you should not be suprised with lack of evidence of any intervention. (for example lumping everyone with non-specific low back pain into the same group)
I get the impression that you beleive the biopsychosocial model is THE answer to pain and is somehow a seperate entity to mecahical pain?
I will read and respond to your pain artical seperately
| Mon April 28, 2014
I have had tennis elbow for 9 months I have been a powerlifter for 5 years I started getting signs of tennis elbow ignored the pain continued lifting weights and getting cortizone shots after the cortizone wore off it was horrible pain couldnt grip any barbells or dumbbells or hold onto them I seen a sports medicine physical therapist he gave me a bunch of different excercizes it helped a bit but I am a truck driver that drives in town all day so at work 12hrs a day non stop shifting with my bad arm thought it would never get better havent been able to lift for 6 months started doing the band thing 7 days ago while not being at work my arm has zero pain feel like I could jump right back in the gym I notice though when I use my arm alot pain will come back a bit but extremely better over 7 days cant believe it I have tried everything and read almost everything I am not just a normal weight lifter I am a die hard not being able to work out has put a huge void in my life wojld just like to thank kelly starrett for helping me get my life back ive tried everything and this I can honestly say works awesome…
| Thu May 08, 2014
Kelly is trying to reach the masses with his book not re write a medical paper, he has collated a lot of yes previous studies into a well written book. Your average person is not going to delve into research papers to find out this. And stating “nothing new to most lifters” is a bit vague. Lifters get taught by who ever they bump into at the gym. Nowadays like myself people prefer to train at home in the park woods etc and don’t enter a gym where I think most are more interested in their appearance than often technique and quite a few substitute with steriods (yes not all but quite a problem in my neck of the woods). This book is not necessarily aimed at just lifters it is for life in general even lifting the shopping or your kids etc.
I have tried a few of the ball and roller techniques and various joint stretches to resolve some of my back and neck pain which saved me a fortune on physio bills. I personally think his articles are a excellent knowledge base to quickly try out and see if it works.
| Fri May 16, 2014
I read your review and your article on pain (as you advise every post to do it) - and still can’t understand your position.
1. While being so concerned with studies on pain you constantly state examples that are only subjective belief and “broscience”.
In these examples a clinician can clearly see you don’t have any experience or understanding of these pathologies.
Disc herniations are your contstant example trying to underline that tissue stress/dysfunction has no real correlation to pain.
Every clinician has a grasp why some people walk around with herniations without pain, some not. You never account for the etiology, the anatomical differences and systemic factors that greatly influence pain in disc herniations, osteoarthritis etc.
The subjective intensity of pain is of course dependent on biopsychologicial factors, but even then your example of people without pain with severe injuries is not science ! It shows different coping mechanisms and evironments/circumstances that influence the experience of pain, as the brain has protective mechanisms.
2. Although “hard” evidence is not easy to find with the bad posture -> still no pain argument of yours again clinicians can see the consequences of bad posture / biomechanical deviation every single day.
Your example: People with palsy that walk inhumanly wrong. Interesting we have to treat these people every day because of their joint pain much earlier in life than regular patients because of their POSTURE. You can find these examples in many occupational journals or by being involved in clinic work. You can often predict the diagnosis by looking at a patients posture, and the tissue dysfunction causing pain could have been avoided by not being in this posture before.
Lack of studies for some illnesses, especially lower back pain is mostly because of the diverse etiology and confounding co-factors.
So all in all - your information about the “top-down” approach that is already teached in med-schools is right, but your application seems too dominant in my opinion.
In contrast, Kelly’s book is an excellent resource probably preventing injuries and also pain in long-term (believe it or not).
Have you ever lifted a serious amount of weight and spent enough years “under the bar”?
Have you even seen or talked to Kelly about the things you accuse him (foot stance - a thing he has talked about much longer than in his book) ?
Don’t think so.
| Fri May 16, 2014
Couldn’t agree more!
Lower Back Pain as a constant example is so undefined and diverse - we will never have a “result” or treatment advise when looking at the broad population. And the biopsychological model won’t cure all patients but again only a few selected patients showing the diversity we both know of.
Anoop | Sat May 17, 2014
Hi TJ Hunt,
It is not MY position. This is what the current pain science says and where the whole of PT profession is moving towards. And I used to think like you 15 years back.
I would advice you to make a thread in somasimple if you want to learn more. Or you will just wallow in your cognitive biases. And Kelly knows about this and has talked about it.
| Sat May 17, 2014
thanks for answering but it is condescending of you to accuse me of wallowing in my biases, as you have yours and are far from understanding everything completely (like everyone else including me).
You have a position on the current pain science, because if you ask different professors, there will be enough that will come to different conclusions. Your interpretation and evaluation of the current aviable science is your position.
My whole point is that you seem to totally abolisch the biomechanical model with the biopsychosocial model, that is still far from being complete.
There is far from enough evidence to do so. Your article on pain (although nothing “new” as this model is already teached in this way today, at least in the medical field) is correct factwise, but the consequences and interpretations you assume differ from mine.
Probably because if you know more about the pathologies you mention you get a clearer picture that there are indeed a lot of times when the tissue is the problem (although of course still the experience and magnitutde of pain is different) - which you can treat and resolve.
Both you and Kelly will not have enough evidence to see if posture will cause pain in specific scenarios because I will yet see the study that has enough patients with a specific postural problem that is monitored correctly over enough years.
But if you look at a patient with 2 valgus knees, one operated at young age, the other side not - after 20 years you see one knee that is finished and a biomechanical aligned knee after an operation that looks as healthy as it gets.
That is why I value good biomechanical alignment because although I believe in the same pain model as you do, in my today not scientifically proven opinion there are biomechanical deviations that will predispose one to otherwise avoidable pain or degeneration (knowing that still I might be almost pain free in the best case, but seeing otherwise everyday).
Even if according to you I have no pain at all with dysfunctional tissue/movement, there will still be a functional difference - that has been proven if you look at specific problems.
Your inability to accept that the biomechanical model is outdated but in a lot of cases still an important theorem in pain and results in evidence-based treatment strategies is again your maybe even more “stubborn” position than mine.
| Sat May 17, 2014
I do have to disagree with your statement:
“That is why I value good biomechanical alignment because although I believe in the same pain model as you do, in my today not scientifically proven opinion there are biomechanical deviations that will predispose one to otherwise avoidable pain or degeneration”
As a Physical Therapist, I wish I could agree with this statement. It would truly make my job much easier (if there were truly reliable ways to assess this). But unfortunately evidence has pointed to the contrary.
For example, a 2010 systematic review assessing the relationship between awkward occupational postures and low back pain found that there is strong evidence to support there is no relationship between the two. This article included the review of eight high-quality studies that assessed individuals who worked in professions that forced them to assume prolonged, static postures. These professions included scaffolding, nursing, retail sales, podiatry, firefighting, etc. It would be expected that individuals with these professions would have higher incidences of low back pain but statistically , they did not.
•Roffey DM, Wai EK, Bishop P. Causal assessment of awkward occupational postures and low back pain: results of a systematic review. The Spine Journal 2010: 10; 89-99.
In addition, a 2007 article published in Manual Therapy assessed the relationship between sustained static posturing and postural neck pain. Similar to the systematic review, the authors found that neck pain was not associated with the individuals habitual postures or kinesthetic sensibility. The study came to this conclusion after assessing the habitual sitting posture, perception of good posture and postural repositioning error in symptomatic and asymptomatic individuals.
•Edmondston SJ, Chan HY, Ngai GC, et al. Postural neck pain: An investigation of habitual sitting posture, perception of ‘good’ posture, and cervicothoracic kinaesthesia. Manual Therapy 2007: 12; 363-371.
While I truly do appreciate the studies of biomechanics and kinesiology, there is so much variation of the human condition to truly build predictive models, let alone normative data. I think we make less errors in reasoning by simply telling someone “the next movement is the best movement” (ie. If something hurts, lets try moving as whole differently).
Do you mind sharing a bit of your background, T. Hunt?
| Sun May 18, 2014
@joe: Although not important my background is orth. surgery/powerlifting.
I think two problems will hinder an agreement between Anoop/You and Me:
1) I see problems of prolonged bad posture after decades in a way more specific context - the thing I’m trying to show you that it is hard to get evidence for this because the steady example of just “low back pain” is just too broad or the follow-up time is too long. In a specific context you will find this evidence (e.g. shoulder pain in regards to thoracic spine/scapular dysfunction) or if you wait long enough.
2) Regarding the scientific context both Anoop/You are so very sure about the interpretation although many way more experienced individuals than you and me disagree:
Commentary in the lancet:
“This far-reaching conclusion is based on reviews of published
epidemiological studies and on the relation between evidence of tissue injury on imaging and low back pain. In terms of epidemiology, Balagué and colleagues base their conclusion
on a series of reviews by Wai, Roﬀ ey, Bishop, Kwon, and Dagenais. These reviews have been criticised for several reasons.2,3 First, they rely on application of the Bradford-Hill criteria to single epidemiological studies, whereas these criteria were proposed to help assess the evidence for causality across studies from diﬀ erent disciplines. Second, other reviews4 have reached contrasting conclusions. Third, in the studies on which the reviews were based, exposure to mechanical loading was incomplete—ie, not encompassing
intensity, frequency, and duration—and was based on inaccurate proxy measures. Where exposure has been better characterised, strong relations are seen.5 Balagué and colleagues furthermore
use the lack of a one-to-one relation between back pain and structural damage to the spine as an argument against the relevance of mechanical injury in the origin of low back pain.
Such an argument could be used similarly to deny the relation between smoking and lung cancer.Neglect of occupational, mechanical loading as a causal factor in low back pain is not based on evidence and might seriously hamper eﬀ ective prevention and management.”
Maybe you will now understand that your conclusion of scientific studies is not guaranteed to be right and Your/Anoop’s statement far from being “evidence-based”.
Evidence-based would be to say that in current literature there was no strong association found between low back pain and posture in a observational context, but a causual relationship cannot be denied with our existing literature. More specific research is needed to examine the role of posture/work/load and low back pain.
Until the evidence is conclusive, I can also rely on experience on top of evidence-based treatments, being a good biomechanical alignment next to just being active (Agreeing with you on that)
| Sun May 18, 2014
Thank you for the reply and attempt to find middle ground.
Here are a few additional thoughts which may hinder our ability to agree:
1. The current model of pain indicates nociception is not sufficient, nor necessary, in the experience of pain. While biomechanics may be quite important for the functionality of a joint, they are unfortunately not predictive in the experience of pain. I understand limitations in epidemiological research, but in absence of this, we must fall upon our best understanding of the current physiology.
2. I appreciate the comments by Dieen et al, but this is a clinical commentary, which we can equate to our discussion and analyses here. You state they may be far more experienced than us, but this line of reasoning leads to a genetic fallacy (I could use this line of reasoning to state that Ronald Melzack, who developed the neuromatrix model has more experience than Dieen et. therefore we should instead listen to him…).
3. I am curious how you are applying evidence-based treatment if the current evidence is inconclusive? I am assuming you are basing your interventions upon your patients values, in combination with your expertise (following Sacketts definition)? Here are some of my thoughts on this subject: http://forwardthinkingpt.com/2014/03/30/evidence-based-practice-a-proposal-for-an-updated-definition-of-clinical-expertise/
I am not recommending anyone completely stops doing what they are doing. I am recommending adapting the reasoning models on why it may work. We are ALL susceptible to post-hoc-ergo-propter-hoc, otherwise…
I am curious what lead you to believe I am “very sure”? I actually utilize Occam’s Razor within my own clinical reasoning and want to clarify that I am often unsure why my patients may have gotten better. I accept that there are a ton of inputs (variables) which may confound or influence an outcome. I simply attempt to understand and manipulate them (no pun intended) and assess for in- or between-session change.
Anoop | Mon May 19, 2014
Hi TJ hunt,
Here is your crux of the argument:
If I get this right, according to you the lack of association between posture and pain in scientific studies for the past 30 years is due to confounding and diverse etiology and such. However, your anecdotal observation of valgus knee in a kid and a few of your treatments were VERY STRONG AND UNBIASED evidence to you to show that posture matters! Do you see the serious disconnect here?
I would still advise you to make thread in somasimple. I sill work on posture, but don’t make any claims as I used to.
| Tue May 20, 2014
Why do you still work on posture, fascia, imbalances if it has NOTHING to do with pain. If you don’t believe in it having a positive impact, how do you explain it to your patient and what is your reasoning behind it?
There seem to be a disconnect with what you believe in (evidence-based, bio-psycho-social) and what you actually do with your clients?
Biomechanical model can be used to assess predictability of acute injuries (like using FMS and Y-Balance test. Un-resolved acute injuries or being treated poorly can result in chronic pain. Has a relationship been studied between the two models using different variables? Wouldn’t that bombard nociceptors and amplify the pain signal sent by the brain and play a key role in kinesiophobia/catastrophisation of the patient?
Again I am more interested about why stuff works and the best approach for my patients.
Anoop | Tue May 20, 2014
Pleas read the pain I article I wrote recently. I have talked about posture and such. Also talked about the relation of injury and pain. I do personal training. I am not a physical therapist.
If you are a therapist and want to learn the why and how, register in somasimple.
| Thu June 05, 2014
I am a fan of Kelly so I am bit disturbed with such strong negative reaction to his book.
I did not give the marketing term “revolutionary approach” much relevance, as his book is just another resource for me to learn more about moving better, and I was not under the impression that he made new revolutionary discoveries.
You obviously are annoyed with all the folks around claiming to have the Holly Grail for pain, and I can understand why.
I believe that ignoring biomechanics will bring you damage. My conclusion from listening Kelly and other folks pointing out to good posture is: “Why practice good shape few hours in the gym just to fuck it up rest of the time when not in the gym”
Herniating a disc is not a good thing to do, and being pain free is not the failure of good/bad posture approach, but failure of our body to notify us this is happening. The disc itself does not hurt, it hurts when such dysfunction damages something else that then hurts or presses a nerve causing pain elsewhere.
Pain is good and I agree with you that no posture can fix the pain. I do believe posture is related to injury, but injury does not have to cause pain, so your point that posture is not related to pain is true, still injury is there, and I blame lack of pain for this and not posture.
When body is not giving us the right amount of pain (too much or too little) the pain research comes in to try to understand why and how to fix it.
| Fri June 06, 2014
I read it and nor posture and biopsychosocial model is news to me. I still think both models fit together. It is complex, it is multifactorial. I am not making the assumption that bad posture or causes pain or anything. I stil believe in efficiency of movement and descreased joint tension (McGill’s studies on lumbar shear force and such)
I’ll go take a look at somasimple even if I am not a physical therapist out of curiosity!
Still, good job on fighting for this because I think BPS model is really not mainstream and should be part of every health professionnal’s common knowledge!
| Wed August 20, 2014
Maybe you should look at the conversation between Kelly and Gray Cook and how they have the same basic philosophy on movement. Or how Kelly promoted the FMS as Gray promotes Kelly’s teaching of motor control and mobility. Don"t use one one expert to refute another when they are in agreement with each others philosophy.
| Tue August 26, 2014
2 thumbs down, this article was a waste to read and obviously the author has no real life experience.
| Sat August 30, 2014
One point you seem to reiterate is that poor posture, biomechanical alterations and movement dysfunctions are not necessarily causative of PAIN. So what?
Pain is not the problem.Pain is a functional response to dysfunctional stress and inflammation. Pain, as far as your brain is concerned, is the solution. Too much additional stress (physical, chemical and emotional) adds to the neurological burden which causes unwanted neuroplastic adaptations.
The idea of chasing pain is old world thinking and needs to be abandoned for the functional model. Most disease and dysfunction is silent before (if ever) it becomes symptomatic. Kelly’s model is one of daily maintenance of the human frame and is similar to the idea brushing one’s teeth in it’s approach. In my opinion more good than harm would occur if people did daily mobility work.
Anoop | Fri September 05, 2014
Thanks for the comment. Where did I use Gray Cook to refute Kelly? I have written about Gray cooks stuff long back. And they even posted on the FMS site, even though it wasn’t really ‘praising’ about FMS.
I only let your negative comment through is because I do let positive comments through without any content. Next time do write a bit more.
First, it is clearly not Kelly’ model. We have looked at all this posture and movement for more than 30 years without much evidence or results. And people who are familiar with this topic know this very well.
Second, about your ‘dysfunction is silent until it becomes symptomatic’ comment. We clearly know that 40-50% of people who have no pain whatsoever do have some serious disc herniations/degenerations/abnormalities. And guess what? Studies clearly have shown these herniations and degeneration are NOT related to the onset, severity, prognosis, or duration of low back pain. Hence American College of Physicians have come forward with clinical guidelines saying” Clinicians should not routinely obtain imaging or other diagnostic tests in patients with nonspecific low back pain”. So basically they remain ‘silent’. And if there is evidence to show that certain modalities indeed prevent injuries, I will be the first one to do it. But that’s not the case here and infact we now CLEARLY know these advises are more harmful than helpful. So there is no excuse for someone keep on promoting them!
Please do read the pain article I wrote.
| Mon October 20, 2014
The BSP model of pain still has a large mechanical component to it (the B in BSP) And I find Kelly`s book to be very valuable to the lay person for improving their technique, form and improving their joint ROM through the self mobilizations and lacrosse ball / foam rolling. Even for clinicians I believe it is a good reference tool for ideas for interventions.
Could the language he uses in his book be more in line with the BSP approach? Sure.
To me it seems you are too preoccupied with the psychological and social aspect of pain and almost all but ignore the biological (mechanical)
With the patient population I work with, I still stress good body mechanics and form…I just try to say things in a non threatening way based on my understanding of pain science. Otherwise, I would be more of a psychologist vs a physical therapist lol
Anoop | Sat October 25, 2014
His book is good for lifting technique and in terms of athletic/lifting injuries. I even wrote that in bold. He does seem to complicate lifting technique to the extreme which is unnecessary and just fear mongering. If you are a layperson/beginner, get a book from Mark Rippettoe or Dan Johns. Lifting isn’t rocket science mind you.
There is more to BSP than language. And Kelly is one person who is at the exact opposite end of the BSP model.Do sign up at somasimple.com when you get a chance
Sure. Nobody is saying you should lift with horrible form. And good form is a loose term. And I talk about all that in the pain article. Please read it when you get a chance.
| Wed January 27, 2016
Is there any science on the specific mobility techniques advised in the book?
- Banded flossing
- Smash & floss
I have restricted mobility in my hip from an ancient injury preventing me from sitting cross-legged and short hamstrings from sitting my whole life. I’m interested in the best way to improve.
Anoop | Sat January 30, 2016
Almost all his mobility techniques are Mulliigans: http://www.physio-pedia.com/Mulligan_Concept. In fact, even his voodoo band is from Mulligans.
If it is improving mobility, sure they will help and ‘may’ help with pain. Any sort of movement is always good for pain.
I hope you read this article: http://www.exercisebiology.com/index.php/site/articles/what_should_fitness_professionals_understand_about_pain_and_injury/
| Tue March 01, 2016
Thanks for the response. I have read our posts about pain, they were very informative and I’m looking for further opportunities in that area.
For mobility improvement, some advocate avoiding discomfort and relaxing into stretches, while Kelly talks about covering up your pain face. Do you have any insight on this?
I’m also wondering if there’s a mobility resource you’d recommend for laypeople.