Boston Sports Medicine and Performance Group, LLC Blog

Painful Education for Physical Therapists

Posted by Boston Sports Medicine and Performance Group on Mon, Sep 17, 2012 @ 07:09 AM


by Chris Joyce, DPT


athlete back pain 


Pain. A word that ignites a cascade of thoughts and emotions in a person, often formulating as questions that are specific and situational to the individual. For example:

Clinician: Joint or muscle? Disc or neural tension? Movement patterns or structural lesion?

Athlete: Season ending? Same thing as teammate’s/professional athlete’s? Scholarship jeopardized?

Patient: Copay cost and insurance coverage? Time off from work? Old age?


The answers to these questions undoubtedly play a role in the success or failure of an individual’s rehabilitation, and as such it becomes paramount that the clinician considers any and all physical or mental restrictions. With the growing accessibility of diagnostic tests, diagnostic websites, and diagnostic friends/family, the practitioner faces the challenge of not only delivering successful interventions, but also guiding the patient’s cognitive state as they become overwhelmed with input. Fortunately, in the last 20-30 years we have seen an increased availability of information that can facilitate this type of high quality comprehensive patient care that encompasses both physical and psychological medicine.  It is my personal belief that education in academia, in conjunction with numerous resources for continued knowledge, equips the AT/PT/Chiro/etc, with almost all the necessary physical skills to treat someone in pain.  However in regards to formal education, the same thing cannot be said about the required understanding of the neurophysiology of pain, including it’s psychosocial contributions. Now, it is WAY outside my scope to attempt to educate my colleagues in the complexities of neuroscience and pain modulation. Rather, my goal is to highlight the importance of pain education within our professional development, and within our everyday patient interactions.


Surely we have all heard of the phenomenon “phantom pain,” where a person with a recent (or chronic) limb amputation continues to experience pain in the absence of his extremity. And surely we have heard of the opposite phenomenon, where a person takes significant physical damage to their body yet reports no symptoms at the time of insult.  From these two examples, we can convincingly agree that pain is not simply an input from peripheral structures, but rather an output of a central processor (Melzack 2001).  Scientific evidence that dispels structural pathologies as definitive pain sources is a study done in 2007, when images were taken of tennis players who have disc herniations, spondylolisthesis and stress reactions, yet were asymptomatic (Alyas 2007).   Looking conversely, I’m sure we could all provide cases where patients complained of significant pain, were sent out for imagining and returned with normal findings. This does not mean the person is not experiencing pain, but rather that it is unlikely the source of the pain is an anatomical or even biomechanical dysfunction.   


With this established, we know we have to consider the other factors that may affect the brain’s processing of pain, such as thoughts, beliefs and emotions.   As illustrated in the introduction, these may differ greatly in an athlete or a patient, so they must be identified and addressed specific to each individual. One way proven to effectively mitigate pain and its associated impact is simply by providing education as an intervention.  In various studies, neuroscience education has had immediate effect in pain thresholds during physical tasks (Mosely 2004), improved outcomes of therapeutic exercise (Mosely 2002), and decreased fear in a patient’s perception of his pain. The methods used for transferring this information can vary greatly, but the underlying concept is fundamental: people who understand why they may feel pain can manage their pain more effectively. Therefore, the patient/athlete education we provide is a critical component in rehabilitation.  The clinician must become versed in the complex process of pain neurophysiology to be able to succinctly articulate the phenomenon.


We’re in the midst of an exciting shift in our orthopedic assessments to show greater respect to the neuromuscular system.  Failing to incorporate current concepts of pain physiology would be detrimental to our vision of global movement and function.  An excellent place to start is by reading the book Explain Pain, downloading the recently published article A neuroscience approach to managing athletes with low back pain, or attending the BSMPG course in May that will feature renown expert, Adriaan Louw.


Register for the 2013 BSMPG  Summer Seminar Today


Chris Joyce is a physical therapist at a sports orthopedic clinic in Boston. He’s currently completing a Sports Residency at Northeastern University, and can be reached at


Alyas, F. Turner, M. Connell, D. (2007). MRI findings in the lumbar spines of asymptomatic, adolescent, elite tennis players. British Journal of Sports Medicine 41(11), 836-841.

Melzack, R. (2001) Pain and the neuromatrix of the brain. Journal of Dental Education, 65(12), 1378-1382.

Mosely, G.L., Nicholas, M.K., Hodges, P.W. (2004). A randomized controlled trail of intenseive neurophysiology education in chronic low back pain. Clinical Journal of Pain, 20(5), 324-330.

Mosely, G.L. (2002). Combined physical therapy and education if efficacious for chronic low back pain. Australian Journal of Phyisiotherapy, 45(4) 297-302.

Mosely (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130-14.

Topics: Adriaan Louw, BSMPG Summer Seminar

Adriaan Louw - Course Description - 2013 BSMPG Summer Seminar

Posted by Boston Sports Medicine and Performance Group on Wed, Aug 29, 2012 @ 07:08 AM

Adriaan Louw

BSMPG Summer Seminar


A Neuroscience Approach to Low Back Pain in Athletes

Adriaan Louw, PT, PhD (c), M.App.Sc (Physio)

Course Description:

Low back pain (LBP) is common in athletes. Most therapeutic interventions focus on structural issues such and instability or hypermobility and result in treatment associated with spinal stabilization. This presentation, however, is designed to updated attendees on the brain’s processing of LBP in athletes, with an emphasis on LBP, brain processing and its potential effect on sports performance. New research into the brain’s processing of pain has shown that not only sensory areas of the brain processes pain, but key areas associated with sports performance, such as the motor, pre-motor, amygdala and more are significantly active when LBP is experienced. Given the brain’s priority of processing pain, many of these key areas associated with optimum performance is less likely to contribute to the athletes recovery and may play a significant role in potential performance loss and re-injury. The neuromatrix view of LBP is a true bio-psycho-social view of pain and essential for physical therapists treating athletes. Clinicians need to realize that addressing issues such as fear, anxiety, expectations and pain itself, are all important in delivering optimal recovery in athletes with LBP. This presentation will include discussion of motor control, endocrine system, and immune system and more, all in relation to a brain’s processing of pain in athletes.



Upon completion of this educational session the participants will be able to:


1. Understand how the brain processes low back pain

2. Understand how an athlete dealing with pain, ultimately utilizes areas of the brain associated with sports performance, thus impacting their recovery

3. Identify bio-psycho-social factors associated with the development of LBP in athletes

4. Develop strategies, based on the neuromatrix, on how the manage athletes with LBP

5. Apply the information from the educational session into clinical practice


Register for the 2013 BSMPG  Summer Seminar Today


Selected References:

  1. Baron R, Janig W. The role of the sympathetic nervous system in pain processing. In Villanueva L, Dickenson A, Ollat H eds. The Pain System in Normal and Patological States: A Primer for Clinicians. Seattle: IASP Press, 2004.
  2. Bono CM. Low-back pain in athletes. J Bone Joint Surg Am 2004;86-A:382-96.
  3. Butler D, Moseley G. Explain Pain.ed. Adelaide: Noigroup, 2003.
  4. d'Hemecourt PA, Gerbino PG, 2nd, Micheli LJ. Back injuries in the young athlete. Clin Sports Med 2000;19:663-79.
  5. George SZ, Delitto A. Management of the athlete with low back pain. Clin Sports Med 2002;21:105-20.
  6. George SZ, Dover GC, Fillingim RB. Fear of pain influences outcomes after exercise-induced delayed onset muscle soreness at the shoulder. Clin J Pain 2007;23:76-84.
  7. Hangai M, Kaneoka K, Hinotsu S, et al. Lumbar intervertebral disk degeneration in athletes. Am J Sports Med 2009;37:149-55.
  8. Hides JA, Stanton WR, McMahon S, et al. Effect of stabilization training on multifidus muscle cross-sectional area among young elite cricketers with low back pain. J Orthop Sports PhysTher 2008;38:101-8.
  9. Hind K, Truscott JG, Evans JA. Low lumbar spine bone mineral density in both male and female endurance runners. Bone 2006;39:880-5.
  10. Hodges PW, Moseley GL. Pain and motor control of the lumbopelvic region: effect and possible mechanisms. J ElectromyogrKinesiol 2003;13:361-70.
  11. Hodges PW, Moseley GL, Gabrielsson A, et al. Experimental muscle pain changes feedforward postural responses of the trunk muscles. Exp Brain Res 2003;151:262-71.
  12. Janig W, Chapman CR, Green PG. Pain and body protection: sensory, autonomic, neuroendocrine and behavioural mechanisms in control of inflammation and hyperalgesia. In Flor H, Kalso E, Dostrovsky JO eds. Proceedings of the 11th World Congress on Pain. Seattle: IASP Press, 2006.
  13. Kraft DE. Low back pain in the adolescent athlete. PediatrClin North Am 2002;49:643-53.
  14. Larsson SE, Cai H, Zhang Q, et al. Microcirculation in the upper trapezius muscle during sustained shoulder load in healthy women--an endurance study using percutaneous laser-Doppler flowmetry and surface electromyography. Eur J ApplPhysiolOccupPhysiol 1995;70:451-6.
  15. Lundin O, Hellstrom M, Nilsson I, et al. Back pain and radiological changes in the thoraco-lumbar spine of athletes. A long-term follow-up. Scand J Med Sci Sports 2001;11:103-9.
  16. MacDonald DA, Moseley GL, Hodges PW. The lumbar multifidus: does the evidence support clinical beliefs? Man Ther 2006;11:254-63.
  17. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain 2004;8:39-45.
  18. Moseley GL. A pain neuromatrix approach to patients with chronic pain. Man Ther 2003;8:130-40.
  19. Moseley GL. Widespread brain activity during an abdominal task markedly reduced after pain physiology education: fMRI evaluation of a single patient with chronic low back pain. Aust J Physiother 2005;51:49-52.
  20. Moseley GL, Brhyn L, Ilowiecki M, et al. The threat of predictable and unpredictable pain: differential effects on central nervous system processing? Aust J Physiother 2003;49:263-7.
  21. Moseley GL, Hodges PW, Gandevia SC. Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine 2002;27:E29-36.
  22. Moseley GL, Nicholas MK, Hodges PW. Does anticipation of back pain predispose to back trouble? Brain 2004;127:2339-47.
  23. Nadler SF, Malanga GA, Bartoli LA, et al. Hip muscle imbalance and low back pain in athletes: influence of core strengthening. Med Sci Sports Exerc 2002;34:9-16.
  24. Nadler SF, Malanga GA, Feinberg JH, et al. Functional performance deficits in athletes with previous lower extremity injury. Clin J Sport Med 2002;12:73-8.
  25. Nadler SF, Moley P, Malanga GA, et al. Functional deficits in athletes with a history of low back pain: a pilot study. Arch Phys Med Rehabil 2002;83:1753-8.
  26. Ong A, Anderson J, Roche J. A pilot study of the prevalence of lumbar disc degeneration in elite athletes with lower back pain at the Sydney 2000 Olympic Games. Br J Sports Med 2003;37:263-6.
  27. Peyron R, Laurent B, Garcia-Larrea L. Functional imaging of brain responses to pain. A review and meta- analysis (2000). NeurophysiolClin 2000;30:263-88.
  28. Richardson C, Hodges P, Hides J. Therapeutic Exercise For Lumbopelvic Stabilization. Second ed. London: Churchill Livingstone, 2004.
  29. Standaert CJ, Herring SA, Pratt TW. Rehabilitation of the athlete with low back pain. Curr Sports Med Rep 2004;3:35-40.
  30. Takemitsu M, El Rassi G, Woratanarat P, et al. Low back pain in pediatric athletes with unilateral tracer uptake at the pars interarticularis on single photon emission computed tomography. Spine 2006;31:909-14.
  31. Trainor TJ, Wiesel SW. Epidemiology of back pain in the athlete. Clin Sports Med 2002;21:93-103.
  32. Watkins LR, Maier SF. Beyond neurons: evidence that immune and glial cells contribute to pathological pain states. Physiological Reviews 2002;82:981-1011.
  33. Watkins LR, Milligan ED, Maier SF. Immune and glial involvement in physiological and pathological exaggerated pain states. In Dostrovsky JO, Carr DB, Kolzenburg M eds. Progress in Pain Research and Management. Seattle: IASP Press, 2003:369-86.




Topics: Adriaan Louw, BSMPG Summer Seminar

BSMPG Summer Seminar Highlights - Chris Powers

Posted by Boston Sports Medicine and Performance Group on Mon, Aug 27, 2012 @ 07:08 AM

Click below to see highlights from our 2012 BSMPG Summer Seminar featuring Keynote Speaker, Chris Powers.

More highlights are set to come in the next few weeks so stay tuned!



Save the date for the 2013 BSMPG Summer Seminar - May 17th & 18th in Boston MA.


Keynote Speakers include: Dr. Stuart McGill, Dr. Marco Cardinale, Fergus Connolly, Adriann Louw and Marvin Chun.  Individual learning track speakers will be announced shortly. 


Register for the 2013 BSMPG  Summer Seminar Today 


This is sure to be the biggest Sports Medicine and Sports Performance Seminar to date!

A special thanks again to our SPONSORS!




Topics: Stu McGill, Adriaan Louw, Marco Cardinale, Marvin Chun, Fergus Connolly, Rob Butler, Chris Powers

World Pain Expert, Adriaan Louw Joins BSMPG 2013 Summer Seminar Keynote Speaker Set

Posted by Boston Sports Medicine and Performance Group on Mon, Aug 13, 2012 @ 06:08 AM

BSMPG is proud to announce Ariaan Louw as a keynote speaker at the 2013 BSMPG Summer Seminar - May 17th and 18th, 2013!  Adriaan joins keynote speakers, Dr. Stuart McGill, Marco Cardinale, Fergus Connolly and Marvin Chun for this weekend event.  With the most thorough and integrated speaker line-up ever assembled, the 2013 BSMPG Summer Seminar will be the WORLD'S most sought after Sports Medicine & Performance Seminar to date!!

We are expecting the largest crowd in the history of BSMPG events with speakers and attendees traveling the globe to be in Boston in May of 2013, and thus have already made plans to move our main lecture hall to a newly renovated multi-tier auditorium.

Be sure to save the date now - hotels will fill fast with this event along with normal Boston traffic so start making plans now!

See you in Boston next May!!!


Adriaan Louw


BSMPG Summer Seminar


ADRIAAN LOUW, PT, PhD (c), M.App.Sc (physio), GCRM, CSMT

International Spine and Pain Institute

Adriaan Louw attended the University of Stellenbosch in Cape Town, South Africa, where he graduated in 1992 from an extensive physiotherapy program, including a very stringent manual therapy based training. Adriaan is an adjunct faculty member at Rockhurst University in Kansas City, where he teaches spinal manipulative therapy. Adriaan maintains clinical practice and is a co-owner, part-time clinician and spine specialist at The Ortho Spine and Pain Clinic in Story City, Iowa. Adriaan has been teaching postgraduate spinal manual therapy and pain science classes throughout the US and internationally since 1996. Adriaan completed his Graduate Certificate in Research Methodology from the University of South Australia, followed by his Masters degree in research into spinal surgery rehabilitation at his alma mater, Stellenbosch University. Adriaan is a Certified Spinal Manual Therapist through International Spine and Pain Institute. Adriaan is in the final stages of his PhD, focusing on therapeutic neuroscience education and spinal disorders. Adriaan has presented at numerous national and international manual therapy, pain science and medical conferences and has authored and co-authored numerous articles and book chapters related to spinal disorders and pain science.


Save the Date: May 17 & 18th, 2013 - Boston MA.  This will be one conference that you will not want to miss!!

Topics: Art Horne, Brian McCormick, basketball conference, Craig Liebenson, Chronic Pain, Adriaan Louw, BSMPG Summer Seminar, Cal Dietz, Marco Cardinale, Stuart McGill