20 unpopular opinions… a guest blog by Lars Avemarie

So I’m pleased to give you another belter of a guest blog, this time from a good friend of mine who is a walking, talking pain science encyclopaedia. Lars is a man after my own heart as he isn’t afraid to question and challenge many things, including me, and this can at times make him unpopular. As someone who is also unpopular for many things, mostly my views on shitty manual therapy and other passive treatments, I’m glad Lars has done this blog on his most unpopular opinions as they are mostly mine as well. So without further ado, it’s over to Lars…


I hold many science-based opinions, but most of them are unpopular because they go against the old dogmatic views that are within the pain management and physiotherapy profession.

As noted by Barradell 2017 physiotherapy (like other industries) has a tendency to be tied to specific ways of seeing the world and these are passed down from old generations of physiotherapists to new physiotherapy graduates. This dogmatic way of training and teaching is one of the major reasons that is holding the physiotherapy profession back from taking a more modern and science-based view of pain management.

It is like we look at the horizon through binoculars, only focusing on a small part of it, making us blind to all the other things we could discover. We are putting our head in the sand to the last 30 years of research, for example, research that has shown us that there are many factors influencing pain and that pain is a multi-factorial experience.

The real losers in this sad situation are our clients. Because when we choose to only focus on one single point on the horizon we are choosing to be blind to all of the other possible solutions for our patient’s problem.

Here are my 20 unpopular opinions:

No 1 – Pain is modulated by emotional, mental, and sensory mechanisms, and our treatments should reflect this.

No 2 – Most health professionals lack a comprehensive scientific perspective on pain, and are often scientific illiterate.

No 3 – Often it is our education tradition and historical continuity that maintains most assumptions about what we do and learn, it is not the repeated assessment of the validity of these assumptions (adapted from Edward DeBono)

No 4 – The ‘toolbox’ approach to pain management does not provide optimal treatment and typically its results rely on non-plausible and non-scientific therapeutic modalities.

No 5 – A barrier to a more scientific approach to pain management is the old dogmatic way of viewing the body that is still being taught to health professionals, these ways are passed down to new generations from the past generations.

No 6 – Pain is multidimensional experience produced by multiple influences, and our treatments should reflect this.

No 7 – Pain management is suboptimal when done with a purely biomedical ideology.

No 8 – Pain (both acute or chronic) is always a biopsychosocial experience and will, therefore, be influenced by patient’s goals, beliefs, experiences and predictions, our treatments should reflect this (thanks, Dr Bronnie Lennox Thompson for that one).

No 9 – Pain felt in the body is not a “thing” but many therapeutic modalities have conceptualised pain as something in the body like a kidney or a patella. Pain is not a somatic entity. This erroneous belief leads therapist to try and attack this “thing” called pain forgetting that it is an experience. This is like going to Norway and viewing aurora borealis (an experience) to staying at home trying to find aurora in your own knee. (Thanks to Dr John Quintner for that one).

No 10 – Health professionals talk a lot about the quality of care and making healthcare better for the future. However, you don’t increase quality by saying “yes” all the time and being overly positive towards every type of treatment, part of getting higher quality care is by saying NO to low-quality treatments.

No 11 – It is often assumed that an error in a movement will cause an injury, tissue damage and/or pain. But most health professionals forget the specificity principle, and that an adaptation could also be a result of this.

No 12 – A problem in pain management right now, is that there is an epidemic of bad reasoning. This is a pandemic of “broscience” and non-scientific thinking and dysrationalia. In debates, when people are faced with an argument and/or evidence that goes against their belief, the common answer is “but I know it works”, or “I have seen it work”.

No 13 – Structure and biomechanics are not destiny, most findings on imaging are also common in asymptomatic individuals.

No 14 – Finding “errors” in people like bad posture, tilted pelvises, weak cores, sacroiliac joints “out”, “tight” muscles, imbalances, faulty movement patterns or any other bio-“mechanical” problems are not single causal factors for pain, and are also common in people without pain.

No 15 – Human movement and the human body exhibit unique individual characteristics much like fingerprints. Finding “errors” in gait, running, and movement is problematic due to the high variability. This puts a big hole in the theory about assessment, it is very difficult to know what is a “dysfunction” (hate that word) or a normal variation.

No 16 – Personal anecdotes and “clinical experience” are unreliable and therefore we cannot make any reliable and sound assumptions based upon them.

No 17 – I’ve seen it “work” is not an argument a health professional that provides care for another human being should make, we have to do better, “With great power comes great responsibility.”

No 18 – The placebo effect does not justify “magical” pseudo-scientific non-plausible treatments with only dubious evidence.

No 19 – Most advice on ergonomic sitting (and to some degree lifting) is based on old data, and makes the faulty assumption that “stress” leads to injury or pain. This assumption goes against the S.A.I.D principle. People will adapt to increased load like a deadlift, but then to say this does not apply to sitting with their head a little bit forward is just not logical.

No 20 – Psychological factors like depression, fear-avoidance or pain-related fear are often more important to the influence and development of chronic pain than most biomechanical or biomedical factors.

Thanks to Brian Rutledge for the idea of this post.


About Lars

Lars Avemarie is a personal trainer and 3rd-year physiotherapy student. Lars has a unique blend of knowledge about pain science, neuroscience, physiotherapy, evidence-based practice, exercise science, rehabilitation, sleep research and critical thinking. He has worked almost a decade full-time in the healthcare industry.  He has specialised in the training of clients with injuries and chronic pain.

3 thoughts on “20 unpopular opinions… a guest blog by Lars Avemarie

  1. With No 4 – The ‘toolbox’ approach to pain management does not provide optimal treatment and typically its results rely on non-plausible and non-scientific therapeutic modalities.

    Can you please explain a bit more about it?

    If we are aware of the psychological effect on pain, would this statement changed?

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