The Preface to the Pain Science Revolution with Max Zusman


I have for some time now, been reading articles and scientific papers by physiotherapists Max Zusman. Some of these quotes are from articles, and some are from scientific papers. Max Zusman is one of the lesser known pain experts, but in my opinion he deserves a lot more attention, for the great legacy he leaves behind after his death.

Max Zusman was a true pioneer in pain management, he was the first physiotherapists who started to get physios and other professions to embrace pain, pain physiology, pain philosophy and pain treatment. There are a very few who have changed the direction of physiotherapy, but Max Zusman is unquestionably one of them.

He began his physiotherapy training 1953, and he finished with a Diploma of Physiotherapy. He continued his studies with a Bachelor of Applied Science in 1981, and a Graduate Diploma in Neurology in 1984 and ended it all with a Master of Applied Science in 1988.

Max started his clinical practice 1956 in the field of neurology and worked from 1959 to 1988 in his own private practice. He began teaching at Curtin University in 1988,  supervising students both clinically as well as in research projects.

It is with great sadness that I found out that Max Zusman passed away in 2014. Max Zusman was a world reknowned authority on the physiology of pain and the influence of manual therapy on pain. He published many important papers within this complex field, that is also a highly important aspect of manual therapy. You will be very greatly missed Max. 

His pioneering teaching about pain science and pain management has influenced a generation of physiotherapists and continues to do so.

Without further ado, here are 34 quotes from legendary physiotherapist Max Zusman:

“Research indicates that, despite physiotherapists’ comprehensive training in the basic sciences, manipulative (currently «musculoskeletal») therapy is still dominated in the clinical setting by its original, now obsolete, structure-based «bio-medical» model.

This is further inexplicable in the light of evidence that not only the underlying «philosophy» but also several of the fundamental requirements of the clinical process itself which has the structural-mechanical model as its basis, have been shown to be flawed or at least irrelevant.

The apparent inability of the profession to fully abandon outmoded «concepts» (and embrace the acknowledged science-based «best practice» biopsychosocial model) may have potentially undesirable consequences for both patients and therapists engaged in the management of (chronic) musculoskeletal pain and disability.” Max Zusman

“MPT’s are urged to understand and use pain terminology in conventional terms. They are also asked to appreciate the pathological realities of clinical pain presentation and its attempted classification particularly in relation to ‘manual diagnosis’.” Max Zusman

“Pain is a major cause (and consequence) of functional disability and distress in patients seeking physical treatments for common neuromusculoskeletal pathology. Adequate insight into pain mechanisms, down to the molecular level, is essential for making informed diagnostic and therapeutic decisions with such patients.” Max Zusman

“If the physiotherapy profession wishes to remain a respected provider in the musculoskeletal pain area then it has no choice but to drop the «lip-service» and actually undertake serious philosophical change. To properly secure the clinical freedom and range of benefits the profession has/is seeking in many countries today it needs to abandon its arcane, outmoded empirically-based reasoning and influences” Max Zusman

“As part of the catch-up it also has to take on the responsibility of formerly (albeit superficially) addressing “manageable” psychological issues where this is appropriate [40,48]. To some extent this is beginning to be accepted by the profession with respect to such recognised variables as excessive attention (hypervigilance), exaggerated beliefs/fears (catastrophysing) and unwarrented avoidance of activity” Max Zusman

“The need by patients to have their pain legitimised by the explicit or implicit message that it has some purported pathoanatomical origin is understandable. Among other things, this is necessary in order for them to successfully negotiate the modern compensation system with its structure-based method of impairment rating and disability determination” Max Zusman

“It will be seen that, with both types of pain, the resulting (unaccustomed) barrage of afferent input to the central nervous system results in discrete segments of central sensitization, which can help magnify, and perhaps sustain, clinical pain and disability (chronicity). Also that this input may result in (as yet not fully understood clinically) changes in both function and structure of supraspinal centres involved in the perception and systemic responses to pain/nociception. It will be evident that there are striking similarities between the molecular mechanisms for central sensitisation for pain (at spinal cord level) and those responsible for learning and memory in specific areas of the brain (eg hippocampus).

It will be seen that ‘desensitising’, and reversing ‘pain memory’ with suitable patients using physical (in particular movement-based) treatments requires graduated ‘safe’ exposure to mechanical stimuli. This involves identification and resolution of peripheral (‘bottom-up’) and supraspinal (‘top-down’) sources of pain-associated, ‘memory’-reinforcing sensory activity.” Max Zusman

“Reduction in pain provides MPT’s with a window of opportunity in which to introduce, and progress, the necessary active treatment. Importantly, the passive modalities are intended to facilitate voluntary movement. As stand-alone treatments it has been difficult to justify either their clinical or cost effectiveness. Moreover used unwisely some may encourage dependency along with a tendency to absolve musculoskeletal pain patients from taking a necessarily active role in their own rehabilitation. These unintended but nonetheless detrimental consequences were highlighted by the cost-explosive 20th century health care ‘disaster’, low back pain. Forced to abandon long-held structure-based causes of pain for the overwhelming majority of cases (‘non-specific’), it became apparent to all from the evidence that prolonged rest and passive intervention were not particularly helpful.” Max Zusman

“As the evidence clearly demonstrates, patients pay an undeservedly high price in return for structure-oriented diagnoses and treatment of their back pain.” Max Zusman

“To a MPT world long accustomed to viewing clinical musculoskeletal pain in structural-biomechanical terms, the relatively recent move into neurological events in the central nervous system has inevitably been somewhat fragmented and independent. On the one hand there is the reluctance to fully abandon original clinical reasoning associated with various ‘concepts’ of passive movement. On the upside it has aroused a profound interest in pain mechanisms right down to the molecular level – something deemed largely unnecessary in the past.” Max Zusman

“Thus it is generally recognised that the term nociception refers to everyday mechanically and thermal- ly evoked pain that falls short of actual tissue damage. Nociceptive pain is therefore always evoked (not spontaneous), localised (doesn’t spread), is temporary (doesn’t linger) and requires a suprathreshold stimulus (doesn’t sensitise). It may be superimposed, deliberately or unintentionally, upon existing inflammatory or neuropathic pain. However, it is not a pathological clinical entity in its own rite and should not be used in this regard.” Max Zusman

“With inflammatory pain peripheral thresholds for thermal or mechanical evoked pain are dramatically lowered. Pain with suprathreshold stimuli is greatly magnified. Importantly pain may be produced by normally inadequate (subthreshold) peripheral stimuli. Pain also occurs spontaneously and may persist in the absence of any additional peripheral stimulus. It has a tendency to spread (be perceived) beyond the area of actual tissue damage. Obviously all of the above makes tissue damage pain quite different from nociception” Max Zusman

“Central sensitisation – at least in the experimental setting – denotes a peripheral nociceptive activity-initiated increase in the excitability of spinal dorsal horn neurons. The peripheral activity- (and later transcription-) dependent increases in the excitability of dorsal horn neurons results in their expanding their receptive fields, and responding to subsequent stimuli/incoming information in an exaggerated and ‘ab- normal’ manner. Clinically this manifests as patients heightened perception of peripheral mechanical stimuli applied to normal tissue surrounding the pathological site. “  Max Zusman

“It is not difficult to appreciate how such structure-oriented beliefs could have detrimental consequences.” Max Zusman

“The medical profession previously viewed low back pain as being the result of tissue pathology involving structural, anatomical, and biomechanical factors (SAB model). Hence it was commonly treated surgically or with often lengthy deconditioning pain-dictated bed rest. Alternative providers, including a subspecialty of the physiotherapy profession, also embraced the SAB model, but favored noninvasive fault correction, and were more concerned with structurally flawed passive (and active) movement than with either pain mechanisms or pathology” Max Zusman

“So, the dogma behind the trial and error formulae that have dominated learning and clinical practice of thera- peutic passive movement for decades is gradually being discredited. Even recommended guidelines and rationale for the once all important “selection of technique” appear to lack validity and reliability.” Max Zusman

“After all, apart from implied alterations in structure, what the research mainly disputes are simply empirically based dictates of the various founding fathers. It may be argued that many of these were “conceptualised” and dominated teaching and practice a long time ago, and that the early literature cited here has little relevance to the current situation.” Max Zusman

“Historically, the incidence and prevalence of back pain appear to have been relatively stable (Fordyce 1995). In other words it has been difficult to attribute this modern epidemic to some inexplicable dramatic increase in the generally recognised “specific” diagnoses. Nor have proposals attributing back pain to everyday lifestyle factors been particularly convincing.” Max Zusman 

The profound interest in pain mechanisms currently being shown by musculoskeletal (formerly manipulative) physiotherapy worldwide is a key example. Though by no means the only example, this focus on pain at the molecular level is particularly significant. It is certainly a far cry from the earlier world of manipulative physiotherapy where ritualised passive movement was king and pain was seen as essentially an “inconvenience” to its optimal delivery. Pain was to be either palliated (sub)acutely (“irritable”/“chemical”), or resolved chronically as a result of the “correction” of its purported mechanical (movement-related) basis” Max Zusman

“There is now increasing recognition of the critical role that patients’ beliefs play in the cause, prognosis and management of back pain” Max Zusman

“Therapeutic rest and both invasive and non-invasive correction of structure are largely the result of anatomical and imaging-driven opinions as to an injury/tissue damage and struc~rall biomechanical basis for back pain. However, this structurally- based view has been challenged for the overwhelming majority (approximately 80 per cent) of cases, which are now labelled non-specific back pain” Max Zusman

“Costly erroneous and dysfunctional structure-oriented beliefs emerged as the only variable to consistently predict return to work in the study by LaCroix et al (1990). Patients entering the study with .the belief that hack pain was the product of a “disintegrating” spine for example, were far less likely to have resumed working when reassessed one year later.” Max Zusman

“These structure-oriented beliefs were found to have quite specific backgrounds and consequences, involving the cause of pain, attitude to activity/work, choice of treatment and opinion of providers” Max Zusman

“Regardless of how rationalised, the biomechanical model for passive movement has always suffered from the fact that positive outcomes may sometimes be obtained by treatment applied “elsewhere”. This is highly suggestive of a “neurological” rather than mechanical effect. Namely, facilitation of movement through (endogenous) inhibition of pain” Max Zusman

“The key finding was that clinicians’ beliefs (“worldview”) concerning the cause of patients’ (chronic) pain and disability were still dominated by the outmoded, structure-oriented “biomedical” model. This in turn reflected therapists’ “explanation” to patients, indication for the type and duration of treatment em- ployed, judgemental attitude toward some patients, and outcome expectations. It is especially troubling that a structural perspective informed clinical reasoning even for patients who presented with obvious psychosocial “overlay” (sic). The only distinction made was that some patients were likely to be “good” (responsive to physical treatment) while other were classified as “difficult” (un-responsive—also dependent, uncooperative, “demanding”, in other words all health care professionals least preferred pain patient)” Max Zusman

“Difficult patients tended to be either “written off” rather quickly with referral back to the pain service. Presumably this was because their “make-up” did not fit easily with physiotherapists structure-oriented biomedical model” Max Zusman

“The physiotherapy profession as a whole has the vital (and difficult) clinical role of helping to get people mov- ing following a wide variety of health-related “set-backs”. In order to achieve this goal it employs a selection of treatment modalities from its repertoire, one of which is passive movement. Given the widely available evidence it would seem no longer acceptable to imply that some or other “concept” of passive movement might be a rehabilitative end in its own right. The profession needs to be seen to be taking the mature stance afforded by its modern science-based training and put this (or for that matter any other) modality into its proper perspective” Max Zusman

“Central sensitisation has been defined as ‘increased responsiveness of nociceptive neurons in the central nervous system (CNS) to their normal [nociceptive] afferent input’.20 It is important to emphasise that varying degrees and duration of sensitisation of spinal and supraspinal nociceptive pathway neurones is a common and relatively rapid consequence of peripheral tissue insult” Max Zusman

“Central sensitisation occurs following intense peripheral noxious stimuli, tissue injury or nerve damage. Clinically, it contributes to pain ‘hyper- sensitivity’ in skin, muscles, joints and viscera.” Max Zusman

“In this paradigm, inhibitory learning is the result of graduated (‘safe’) exposure to the feared stimulus. Without this experience, the nervous system is unable to learn that it is overestimating the outcome when it predicts that afferent input produced by (therapeutically modified) everyday movement is invariably (and severely) painful. This is one clinically relevant example of inhibitory learning through ‘violation of (sensory) expectation’.40 In this situation, it is hypothesised that the graduated physical exposure strategies employed by MP can effectively restore an original ‘uncontaminated’ pattern of proprioceptive afferent input.” Max Zusman

“In most respects, acute ‘non-specific’ back pain would seem to be no different from any other type of short- lived regional musculoskeletal pain. It is probably initiated by inflammatory chemicals (however pre- sent), with varying degrees and duration of peripheral and central sensitisation. Pain, along with its behavioural consequences, would be expected to subside steadily as these spontaneously resolve. Indeed, this appears to be the typical history of most episodes of back pain across the globe, for which no treatment is usually sought (or is available/ affordable).” Max Zusman

“To conclude, neither purely biomechanical nor psychological ‘susceptibility’ to episodic or chronic non-specific back pain fully account for still mystify- ing structural and functional inconsistencies seen both between and within symptomatic and asymptomatic individuals. Mechanisms of an associatively learned memory for pain along with its potential for extinction with physical exposure-desensitisation protocols, is another perhaps more ‘encompassing’ explanation.” Max Zusman

“Constant mechanical stimulation is fundamental to the homeostasis of the musculoskeletal system. Appropriate response to mechanical forces such as gravity and muscle contraction (movement) is a major function of connective tissues. Significant connective tissue deterioration and impaired healing found with the ‘weightlessness’ studies reflects a breakdown in the normal interplay between transmembrane force and its everyday homeostatic consequences. Even in a normal (gravity-based) environment prolonged regional immobilisation and deprivation of active movement can have serious negative consequences for connective (and other) tissue.” Max Zusman

“There are probably several understandable reasons why clinicians do not always follow clinical best practice guidelines. With hands-on providers, it is simply because these guidelines are fundamentally incompatible with their professional raison d’être.” Max Zusman