The Elements of Pain Science (and metacognition) with Dr. Jonathan Fass, DPT


I have for several years now, been reading articles and social media posts by Doctor of Physiotherapy Dr. Jonathan Fass. Some of these quotes are from articles and some are from online social media debates. Dr. Jonathan Fass, DPT is one of the lesser known pain experts, but in my opinion he deserves a lot more attention, for the great work and the content that he shares and produces.

Through my work to promoting science and modern pain science, I have for the last 8 years, been fortunate to have the opportunity to participate in a small closed group with pain expert and physiotherapists Dr. Jonathan Fass (DPT, DSc), Dr. Jason Silvernail and a few other experts.

Dr. Fass is the former Private Physical Therapist of His Royal Highness Prince Alwaleed bin Talal, who is a billionaire investor, philanthropist and humanitarian. Dr. Fass graduated from the first Doctoral Class from University of New York’s Physical Therapy program and he attended his Orthopedic Physical Therapy Residency at the University of Delaware, one of the top-ranked physical therapy programs in the United States (U.S.). 

Dr. Fass is currently a Fellow-in-Training in advanced orthopedic manual physical therapy with the NxtGen Institute of Physical Therapy. Dr. Fass has presented at the American Physical Therapy Association’s national convention and was a featured presenter at the 2017 San Diego Pain Summit, and he has has been a guest lecturer at Rutgers University and Drexel University on a number of occasions.

In addition to being a PT, he is a Certified Strength and Conditioning Specialist (CSCS) through the National Strength and Conditioning Association, and a Certified Health & Fitness Specialist (HFS) through the American College of Sports Medicine. Dr. Fass has written for numerous print and online periodicals, including Men’s Health and Men’s Fitness Magazines.

Two very good articles by Dr. Fass are:

The Nocebo Effect: How Your Power of Suggestion May Harm Your Clients (with Matthew Danziger)

How to Analyze Fitness Research

Without further ado, here are 32 quotes from Dr. Jonathan Fass, DPT:

“I wish that we could all learn to separate clinical outcomes from post hoc rationalizations of physiological mechanisms of action. I’m quite confident that she does wonderful things for most but not all of her patients for few of the reasons that she believes…just like all of us. Why can’t we be ok with that?” Dr. Jonathan Fass, DPT

“Telling people to sit less is generally a good idea. Telling them to sit less because of fear-mongering claims based on half-truths and the illusion of evidence is not needed nor helpful.” Dr. Jonathan Fass, DPT

“Telling someone with chronic pain, or disease such as cancer, that it’s “because they sat too much” is as insulting and likely wrong as a vegan running into a cancer ward and screaming “it’s because you ate cheeseburgers!” This can’t happen. It just can’t happen anymore.” Dr. Jonathan Fass, DPT

“Pay less attention to what people say. Pay more attention to what they can back up.” Dr. Jonathan Fass, DPT

“I post a lot about pain and the influence that we as health professionals have – whether you’re a physician, therapist or personal trainer – on people’s experiences and recoveries from pain and injuries. I do this because I feel strongly about the subject and I believe that we as a group of professionals collectively need to do better in educating ourselves and the individuals within our care. We all want to help others, it’s why we do what we do. Nothing makes me more frustrated than seeing misinformation on this topic, because we understand that catastrophizing beliefs and fear-avoidance in behavior and activity can and does cause quantifiable and lasting harm.” Dr. Jonathan Fass, DPT

“We have thirty years of pain science showing us that our approaches and explanations to something as commonplace as back pain and it’s management is misguided at best and potentially causing more harm at worst, and yet very few are even aware of the *field* before running to embrace the simpler outdated and disproven model of biomechanics. “If we waited for science?” More like “If science waited for US” Dr. Jonathan Fass, DPT

“Scientific evidence is a problem. Before the scientific process, anyone’s ideas and beliefs could be real, could have value and validity. The truth of anyone’s beliefs was determined by the ability to argue, not the ability to replicate or to predict. The quality of a thought relied on the agreeability of the listener, not the agreeability to reality.

We are experiencing a paradigm shift in today’s world of google and the ability to instantly find answers to our questions, including the knowledge that we do not yet have some of those answers. Opinions are valuable only if they agree with evidence, not necessarily with one another.

You will see strong, passionate arguments that an individual’s ideas are “ahead of the science,” that the speaker is a pioneer that cannot be easily evaluated by the limits of science, but this is a smokescreen to protect the speaker, not the listener. Scientific evidence is a problem, but only for those that refuse its benefits. The ones that it threatens the most are the ones that argue the strongest against it, because without understanding the process of science, that’s all that they can do.” Dr. Jonathan Fass, DPT

“Static posture does not equal dynamic posture. Anyone making that argument needs a refresher in neuro.” Dr. Jonathan Fass, DPT

“For every cherry-picked example of a small and unique approach or technique that is “ahead of the research” (when there really is no such thing, in fact: any technique relies heavily on the knowledge and information accumulated before it, so at best this “new and exciting” approach that has yet to be validated through study is still based on the accumulation of information that preceded it), we have a road paved with the broken ideas that were heralded as “the next advance, ahead of science” only to be invalidated and discarded.

Even worse, when such things *ARE* invalidated, from bosu ball training for strength and power or claims to “affect myofascia” with manual treatments, for instance, it takes the industry *years* to rid itself of this pseudoscience because of practitioners either unwilling to acknowledge this information (as in Nick‘s example) or unaware of it because of scientific illiteracy, which is equally as unacceptable in a science-based field.” Dr. Jonathan Fass, DPT

“What is new and novel to most of us has been studied in-depth for 30 years now, so much for being two years ahead of research…how about 3 decades behind it!” Dr. Jonathan Fass, DPT

“Putting aside the obvious and important issues of consistency and accuracy in data collection,statistics and research reporting for a moment, it still amazes/saddens me when at the exact same time that other scientific fields are making monumental discoveries, such as direct evidence for cosmic inflation – an event that took place *milliseconds* after the Big Bang – personal trainers are still arguing whether or not we can/should “trust” science.

It is like we are arguing whether or not the earth is flat in how absurd such a discussion is: We really need to improve the most basic of scientific literacy and critical reasoning within health & fitness, because it is evident that we don’t have even the slightest clue as a whole. It’s truly horrifying.” Dr. Jonathan Fass, DPT

“The SI joint is a medical garbage term: poor tests, poorly constructed post-hoc reasoning of how pain would occur, etc, etc. can you have pain in the area of the SI joint? Yes, but that doesn’t actually mean that the SI joint, therefore, is responsible for that pain.

As far as PTs and such claiming to move the SI Joint? Wishful thinking on their parts. In the same way that cracking your knuckles feels like something moved/popped (but nothing actually moved), the SI joint can make a sound without the thing moving. And that’s a good thing, too: if the SI joint could be moved from the minimal pressure of a manipulation, then it would blow out any time you stepped off of a curb. It’s just not happening.”  Dr. Jonathan Fass, DPT

“Research is not ‘used in whatever context one wants to.’ We use evidence to guide decision-making, we don’t use it to justify bias.” Dr. Jonathan Fass, DPT

“Janda came up with the Crossed Syndromes theory 35 years ago. We have 35 years of research, discovery and evidence that has invalidated the conceptual framework of this approach, which would only make sense from a cartesian model of nocieception pain response. This has been shown to be flawed and inaccurate. EMG studies are also flawed and inaccurate (well-documented, especially in surface EMG) and newer research indicates that changes in muscle length is *not* a result of altered electrical signaling (see “Increasing Muscle Extensibility: A Matter of Increasing Length or Modifying Sensation?”) – Experimental evidence does not support any of these assertions.” Dr. Jonathan Fass, DPT

“Einstein’s theories are still valid. Sahrmann’s, however, have not been validated. They are not even remotely the same. The BPS model doesn’t “have” it’s place, it “is” the place. BPS incorporates biomedical concepts and therefore anything biomedical is part of the framework. It is a strawman of BPS to assume that it speaks of “psychological” causes of pain: this draws on the stereotype of the “hysterical” (usually) woman whose pain is “all in her head.” BPS recognizes the accuracy of the nature of pain and not an incorrect belief that pain is produced by damaged tissues.

And no, posture itself will not produce a pain response, and postural deviations in patient populations is a result of, not a cause of pain. These single-cause full-stop “explanations” of pain experience and inaccurate appeals to “preventative” training through mechanistic-only explanations is simply wrong.” Dr. Jonathan Fass, DPT

“When someone says that “science needs to catch up,” to their current practice or technique, or that they practice “ahead of the science,” they are stating that they have “discovered” something in their gyms that researchers have not thought of or validated.

It is the Americana narrative of the lone genius inventor that is so far ahead of the rest of the world that he alone discovers truths while the “scientists” are in their labs doing the mundane and the ordinary: It’s the fabled mythology of Einstein the patent clerk developing Relativity and becoming an instant superstar while the rest of the physics world had to “catch up.

It’s largely a myth. Maybe I’m biased, but I don’t think that the next Einstein will be wearing Under Armor and shouting out rep counts…just saying.” Dr. Jonathan Fass, DPT

“It took me a year of being an orthopedic resident: when everything that you say and do is “wrong,” you learn very quickly the value of disassociating yourself with your clinical beliefs” Dr. Jonathan Fass, DPT

“Is this a lone voice speaking an opinion that remains the minority, or is this view representative of a larger portion of MTs, either directly or along similar lines of “logic” – if it’s not palpating cranial nerves and moving the bones of the skull, it’s moving energy in Reiki, or palpating “energy meridians” in acupuncture? This hardly appears to be a “lone wolf” issue on this board and on many, many others: based in the numerous posts made proclaiming nonsense as plausible reality and harsh, immediately defensive pushback to valid, plausible and falsifiable evidence to its contrary, I would personally say that this conversation is *very* needed and necessary to show anyone else reading along that the “alt-med” emperor is wearing no clothes. The patients and clients in our charge deserve better.” Dr. Jonathan Fass, DPT

“If personal training is to be respected as a field of health – and I believe that it should be, as regular exercise is unquestionably linked to improved health and longevity – then we must purge ourselves of charlatans such as that, with “it’s true only if it agrees with my beliefs” Guru tribalisms.”Dr. Jonathan Fass, DPT

“Scientific evidence is a problem, but only for those that refuse its benefits. The ones that it threatens the most are the ones that argue the strongest against it, because without understanding the process of science, that’s all that they can do.” Dr. Jonathan Fass, DPT

“Unless the client wants to specifically address a postural issue for the sake of appearance (which is entirely legit), I probably couldn’t care less. No matter what you might find, you’ve still got to confirm it through dynamic movement and loaded movement, and the best way to bias yourself to see something that isn’t really there is to prime yourself to believing that you *will* find something before you look for it.  Waste of time in most cases.” Dr. Jonathan Fass, DPT

“If everyone in the industry had a basic respect and understanding of the scientific process and the basic body of knowledge, a post such as this might be useful and provide reasonable context to develop discussion; however, given the alarming amount of pseudoscience taken as fact, of implausible and illogical beliefs parroted from trainer to trainer on a regular basis, and misguided beliefs that can cause true harm to those that we are intended to help, a post like this only serves as confirmation bias to anyone that would prefer to believe in fairytales over systematic, controlled evidence.

This ignorant meme of “if you’re truly EBP, you’re five years behind” is pure fantasy, and for every single finding of a practitioner that has a truly unique and valid idea that has not been investigated yet, we have tens and hundreds of now outdated and invalidated “ahead of the research” concepts that continue to flourish out of ignorance and defiance. I’m sorry, this is not a helpful post, unless your intention is to justify the wide-spread health/fitness community practice of science denial and selective reasoning.” Dr. Jonathan Fass, DPT

“People have questioned why I will tend to be critical of certain approaches – whether that’s the FMS and “pure” biomechanical approaches, alternative medicine approaches, anything from “The Strength Sensei,” etc, etc. They have labelled me as a hater, cursed me out, or made other such accusations that all I wish to do is to destroy, not to build because I don’t “offer alternative solutions” (apparently, they don’t read the 10:1 number of articles and papers that I post that show such things, of course).

Why do I do this? Because these kinds of problems in our industries of health and healthcare – the “philosophy as fact” and guru belief systems approaches – to me aren’t just wrong, it’s immoral to deceive people who are responsible for others’ welfare and well-being. I get protective about it after seeing too many people get harmed by well-meaning but entirely incorrect approaches, which includes how I myself worked as a new PT. I remember the face of every patient that I couldn’t help because I had been sold a bag of goods that wasn’t worth the bag that it came in. I owed those people better than i gave them. That’s not ok.

I’m not perfect, but I’m trying to improve. I don’t mind alternative viewpoints: they are the backbone of scientific exploration. What I *do* mind is the kind of thinking that is put forwards in defense of these approaches by the collective, that being critical is hating, that to question is akin to trolling. Nothing has ever been discovered without first recognizing problems in current systems of thought and practice. If you think that your approach is beyond criticism, you are part of the problem.” Dr. Jonathan Fass, DPT

“Putting aside the obvious and important issues of consistency and accuracy in data collection,statistics and research reporting for a moment, it still amazes/saddens me when at the exact same time that other scientific fields are making monumental discoveries, such as direct evidence for cosmic inflation – an event that took place *milliseconds* after the Big Bang – personal trainers are still arguing whether or not we can/should “trust” science.

It is like we are arguing whether or not the earth is flat in how absurd such a discussion is: We really need to improve the most basic of scientific literacy and critical reasoning within health & fitness, because it is evident that we don’t have even the slightest clue as a whole. It’s truly horrifying.” Dr. Jonathan Fass, DPT

“There are numerous confounders and endogenous influencers in anything – nutrition, strength training, weightloss, or anything else. We have to maintain the same critical approach to anything, within the reality of our capabilities (particle physicists can run thousands upon thousands of experiments of the same phenomenon, so we can’t apply the same criteria between disciplines sometimes, but saying that nutrition needs a lab but exercise only needs knowledgeable trainers and their observations isn’t a reasonable comparison unless we can definitely demonstrate why our ability to observe and report data is superior in one vs the other – and in truth, we know that it’s not).

Anecdotal evidence isn’t useless, it’s only useless for anyone other than the individual directly experiencing the results. Now, I could listen to your experience and I could decide to try the approach myself, but without systematic evidence, I absolutely cannot expect to see the same response, nor can either of us assume that any response is true cause and effect. We would *never* accept a cause-and-effect conclusion from a correlational study design, even if it had many times the participants with far greater controls.

We can’t decide just because *we* observed the results from our experience (without any control of bias, statistical insight and analysis, etc) that our findings are reproducible or applicable to anyone else. If we allow that for ourselves, we must allow that for everyone else, and that would effectively negate the need or use of the scientific process, because everyone’s claims based on personal observations would be legitimate. This is ultimately the problem” Dr. Jonathan Fass, DPT

“The problem with this argument, as I see it, is that we do not have an agreement of terms and definitions. The idea that someone “cannot be 100% evidenced” is false; by definition, evidence of one kind or another – even if it’s by use of someone else’s opinions or simply n=1 observance of patient/client response is using evidence.

The opposite is 100% not evidenced, which would essentially be making something up without any pre-learned information (“I think that the best way to treat CLBP is to sprinkle fairy dust from Martian Pixies on a patch of grass outside of the patient’s driveway” would be an example of the use of zero evidence, perhaps). So rather, what is being discussed here is a misunderstanding of what evidence is and how it should be used according to the Sackett definition. We are not able to base a good amount of practice on 100% *high-quality* evidence, but we can absolutely base our practice on 100% evidence of some kind using varying levels of quality (and in fact, we do). Even the pseudoscientists, anti-vaxxer movements, global warming deniers, etc, etc are basing their beliefs in evidence, just low-level, highly biased, and incomplete evidence relative to the body of knowledge.

What this post, in its original statement is really addressing is *claims* based on low-level evidence. We cannot make definitive statements with evidence that is not itself definitive. “Dr. Jonathan Fass, DPT

“Be consistent. Be intellectually honest. If you think that Dr. Oz is a scammer – and you’d be correct – then why haven’t you held other concepts to the same level?” Dr. Jonathan Fass, DPT

“This, to me, is the real issue here: people make objectionable claims which are then challenged with either requests of evidence to support the claims, or evidence that directly contradicts those claims. If the original person making these claims either denies the worth of the evidence, or over-inflates the value of their own evidence (observational, or opinion-based, or otherwise correlational), they are in the wrong. It’s as simple as that.

Being “100% evidence based” is 100% possible, and in fact is how just about anyone would actually practice. Understanding what that actually means, and not understanding the limitations of any form of evidence and how to use these concepts within best-practice by individuals making extraordinary claims and then being frustrated when those claims are challenged is the real issue here, imo. “ Dr. Jonathan Fass, DPT

“Research can be flawed, but we can’t appeal to unscientific opinion > scientific findings, unless those findings are evidenced to be flawed in those specific cases. Researchers do not and cannot prove anything: they can only provide evidence for or against a concept, which may or may not be rooted in anecdotal observations” Dr. Jonathan Fass, DPT

Anecdotal evidence is not fact, I’m afraid. You have no way, in any shape, of determining if the “dangerous technique” would have led to injury, nor do you know if your stretching was what prevented the bad technique, or if it was a combination of the strength training and neuromuscular training that came with it while correcting the form. The evidence is quite clear here. Continue with the stretching if you’d like to, I personally have no qualms with that…but if you make claim to “evidence” where none exists, you are being intellectually dishonest, and this is an anecdotal evidence fallacy in fact. Dr. Jonathan Fass, DPT

“Stretching does not appear to actually lengthen muscle physiologically (at least, not for the average person with “two sets of 30 second holds,” and the result of stretching may actually be entirely neural, essentially conditioning the neuromuscular system to achieve greater ranges before automatic “safety” mechanisms kick in to prevent further range. Because of this, stretching, to our current knowledge, does not and cannot prevent exercise-related injuries”  Dr. Jonathan Fass, DPT

“The issue here is that (I think) that many of you are confusing “facts” and “evidence.” An expert’s opinion IS evidence (which also brings up another version of the “appeal to authority” – when an individual claims expertise or is consulted as a topic expert but is, in fact, not. Think of the medical doctor that consults his/her patients that squatting is bad for the knees when they are not educated in orthopedics or exercise), but it the lowest form of acceptable evidence (and not always included depending on the scale referenced, FYI).

However, no single study’s conclusions/findings are “fact,” either. We need multiple confirmations to consider that these findings might be considered a fact. The difference between a study and an opinion, even when that opinion is provided by an expert weighing the evidence, is the potential for bias, for any individual’s preconceived opinions to cloud the data and lead to a conclusion that I reflects that bias.Studies can be flawed as well, but if they are properly blinded, recorded and reported, the chance of any single experimenter’s bias causing invalid conclusions is substantially lowered vs simply “taking someone’s word for it.” So in this sense, ALL things must be confirmed, but some sources are more suspect than others, because of the very likely chance for human error and interpretation” Dr. Jonathan Fass, DPT