The Case Against Pathologising

By Walt Fritz

How many of these statements have you told your clients?

  • Your forward head posture is so severe
  • You have some of the worst trigger points I’ve ever seen
  • Your muscles are as hard as a rock
  • You have weakness throughout and these muscle groups have completely shut down
  • You have fascial restrictions putting crushing pressures on pain sensitive structures
  • You have a dural tube restriction affecting your cranial rhythm
  • Your spine is out
  • Your pelvis is rotated and one leg is longer than the other
  • Your knots are the cause of your pain
  • Your sacroiliacs are jammed/too mobile
  • Until you let go of those emotions you will never truly heal
  • You have upper crossed syndrome
  • Until you deal with the fascial restrictions you will never address the cause of your pain
  • Your core is weak

I can count quite a few that I’ve told and retold. But what do we base these statements on,, how many do you think are supportable by independent, outside examiners, and what if none of these statements is true?

I used to think that my comments and conclusions on fascial restrictions were based on facts. I’ve made a living as a physical therapist using a derivative of the myofascial release (MFR) I was taught 25 years ago. Over the past 10 years I’ve also been teaching this work. But I have recently become pretty testy about therapists who pathologise their clients without even knowing they are doing it.

The Modality Empire

When choosing which modality or the name of the teacher they will follow, therapists will be required to make decisions on what structure or pathology they wish to view as most important. Most will not realise this until they are entrenched within the umbrella of that modality and all that comes with it.

Committing to a continuing education in most modality-based manual therapy training all but requires you to close your lens to see only the targets that the particular school of therapy sees as important.

The modality empire that I was trained in saw everything as unresolved fascial restrictions and the emotional memories that are trapped within those restrictions. Your targets may be quite different, depending on the empire you’re steeped within. No doubt you feel pretty certain of the existence of your targets and your ability to eradicate those targets from your client’s body. That is the primary purpose of modalities, to rid/reduce/lessen/eliminate, right?

“MFR releases fascial restrictions, allowing you to live a more pain free lifestyle.” – I bet your modality makes similar claims?

We buy into these claims more with every course we take. I have come to believe that taking more “advanced” classes or repeating classes we’ve already taken does little to make us more skilled or learned. It simply drums the stories that we are told into our head; reinforcing the narrative is an important aspect of selling the modality, both to you and to the general public.

What is Pathologising?

To pathologise is to claim that something is abnormal or unhealthy. Pathologising is the practice of seeing a symptom as an indication of a disease or disorder.

The Problem with Pathologising

In my case, I was taught rabbit-hole science, where liberties and exaggerations are made with existing science to form new so-called sciences that can’t withstand critical thinking.

I was quite guilty of succumbing to rabbit-hole science:

  • I picked apart bad posture
  • I looked at patterns of tightness that I thought were fascial restrictions
  • I encouraged patients to root out the emotional holding patterns keeping them back from true healing.

And all in the name of diminishing pathologies of the dreaded fascial restrictions.

The problem was that the stuff I was doing was working.

My guess is that most reading this article could substitute their modality-based beliefs. “But I get great results using (fill in the name of your modality)”. No argument there, I am sure you do get great results. But what about all the other therapists? The ones who believe totally different stories and follow totally different recipes of evaluation and treatment; the ones who believe in totally different pathologies? They are also getting good results.

If all of these problems existed for the reasons we thought; if all of those people are suffering pain due to the causes we find through the recipe of our modality; if our clients are improving due to the reasons we think, can all our claims be true?

Maybe there are simpler reasons, simpler narratives to explain both the problems, as well as the solutions.

Manual therapy is effective but it is quite probably due to reasons that are simpler than we make them out to be or, at least, not so specific that we can selectively and singularly target one tissue, pathology (real or metaphoric) or weakness/inhibition.

Given the uncertainty surrounding the basic tenets of our work, shouldn’t we avoid telling our clients things that may not be accurate? And shouldn’t we avoid making direct references to the things – the pathological states – that we believe our clients are suffering from, and focus on helping them to move and feel better?

As our clients see more and more professionals, they are inoculated with more thoughts of pathologies. Each of us gives them new hope but we often do it by adding to the pile of pathologies they have been given. The load that this over-pathologising creates must be enormous.

Pathologising Avoidance

When I ask my clients what they’ve previously been told by other practitioners, they can tick off a list of real pathologies: disc bulges, scar tissue and sprains, as well as metaphoric pathologies: fascial restrictions, trigger points, knots and cranial lesions. I refer to these as metaphoric pathologies because it is difficult to prove or disprove their existence even though therapists view them as real.

These clients are looking to me to figure them out, to help them improve. They’re usually expecting yet another pathology to be pronounced. I don’t aim to add more layers and burdens of pathologies upon them. As I move through my evaluation, my greatest goal is to get clients to relate the experience of their pain/dysfunction with me but framed in their own experience, not mine. I try to avoid assigning my beliefs onto them but, if pressed, I will mirror the question back onto them – “What have others told you? What do you think?”

If they grab me by the shirt and insist that I tell them what I think is the problem, my preference is to frame my reply from the context of pain science: that there may possibly be nothing wrong with them, that there may be no damage and no nefarious creatures under their skin that other professionals have named as the culprits. I frame my reply from a basic understanding of neurology, mechanoreceptor action and neurodynamic technique.

I cannot rule out contextual factors, ones that may benefit the relationship since they came to see a pain specialist. But I want them to feel heard. I might say, “well, it might be the trigger points that your last therapist said it was, or the fascial restrictions that the therapist before that told you, but all I know is that when I touch you in this way, you tell me I’ve replicated a familiar aspect of that pain. Does this stretch/pressure/contact feel like it might be helpful? If so, let’s just hold this engagement until you feel a change”. Sound too simple?

I believe in patient-directed approaches to manual therapy, as opposed to pathology driven models.

Avoid pathologising. Reducing your reliance on older proprietary models of manual care and moving into more plausible (but often less slick and specific) ones is not easy but it is worthwhile.

About the Author

Walt Fritz is a US-based physical therapist who teaches a simple, science-informed version of myofascial release. Walt will be presenting workshops in Sydney, Brisbane and Melbourne in February 2018. Full details on these workshops, and more information on Walt’s treatment philosophy may be found on Walt’s website. Walt operates a clinic in Rochester, New York.


Images in this article have been sourced from Pixabay, Wikipedia Commons and the author

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  1. My sentiments exactly. And on all fronts here.
    Here’s to effective treatment.

  2. Hans A. Quistorff, LMP
    16/01/2018 - 7:06 am

    Your body has been doing the best it can under the circumstances.
    Pain is your body’s message to your conscious mind that you have to do something different because it can’t cope with what is happening. I propose we explore what you can do differently. Please tell me what makes you feel more comfortable or more uncomfortable and where.

  3. Amen!
    Massage therapy education needs to change. We are ‘taught’ an inordinate amount of crap from the beginning. Trigger points, adhesions, syndromes which haven’t stood the test of science, etc. All of this baloney operates under the premise that we can change the structure of someone’s tissue in their body with our hands from the outside of their body. I often tell my clients that if I could do that, I would not be working in a little clinic in Ryde. I’d be working for the best athletes in the world and charging a motsa.
    If you are making your clients feel good by the way you touch them and they keep coming back then I would say keep doing it but change the narrative because words matter. Telling people they have trigger points that you are busting up or fascial restrictions that you are releasing is incorrect. This is not how the human body works and words matter. Learn basic neuroscience. Pay attention to the neurophysiology of what we do. Stop hurting people. There is no place for amateurism in health care – keep up to date with current evidence. Treat your client’s skin and nervous system with respect.
    Pain is far more complex than ‘push real hard here’ or ‘rub this out’. A whole human with beliefs, expectations, past pain memories, fear, worry, walks into our hands. A human in pain asking for help.

    • Sharon Livingstone
      26/02/2019 - 9:44 am

      Thanks for reading Leah. Walt’s wisdom hopefully gets massage therapists thinking about the how and why of what they’re doing. I hope you caught Aran Bright’s article on “Does Poor Function Always Cause Pain” from 20 February.

      • Yes I did! Great work Aran. I see Aran a fair bit over on the Exploring Pain Science Fb page so I’m familiar with his work.

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