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  • Tip Discussion of Steven George interview

    The interview with Steven George has been posted. I've opened this thread for any discussion that may ensue.

    What are the initial thoughts?
    Cory Blickenstaff, PT, OCS

    Pain Science and Sensibility Podcast
    Leaps and Bounds Blog
    My youtube channel

  • #2
    Excellent interview, Cory and Jon. I'm going to copy and send the pdf version to my colleagues with the subject heading "Required Reading."

    George is just the kind of "rubber meets the road" researcher that PT needs right now, which is very encouraging. I was particular taken by this statement in his answer to the first question:

    Historically, where the manual therapy profession falls short is that we have many more speculators about how manual therapy works in comparison to people that are willing to properly test the speculation. It is much more immediately gratifying to speculate about how a particular technique works, and in the past that speculation (also known as a theory) was sufficient to teach the skill to others.
    He's so right that the "speculation" of manual therapy's mechanisms is driven by "immediate gratification." He's fairly diplomatic and restrained in his language, as a research scientist probably should be. I suppose he'll leave it to us to speculate on what the motives for immediate gratification might be.

    I think there's two sides to that coin: the speculators and the "speculatees". The motive of the former is easy: $$$. The latter is a little more complicated, but in a word, "laziness" comes to mind.
    John Ware, PT
    Fellow of the American Academy of Orthopedic Manual Physical Therapists
    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

    Comment


    • #3
      John-
      I don't disagree with you, but personally I'm always a bit cautious when imputing intent to others. I think a large number of those on both sides of your coin just want to be competent providers of care and were taken in both by the biomechanical memes that undergird our profession and fell into the empiricist trap (it works).

      Regardless, those who still propagate such biomechanical rationales have fewer and fewer places to hide.
      I call this "OMT of the gaps" - they use their flawed biomechanical rationale for function but they are able to use it fewer and fewer places as the research comes out. I look forward especially to the POLM trial results in a few years, and just about anything that Dr George does, since I really like this line of research.
      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist


      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

      Comment


      • #4
        I am also printing out the pdf to pass out -at the very least to encourage people to think outside the box a bit and stimulate some thought.

        I am looking forward to his next piece of research!

        Thanks Cory for great job!
        Erica

        Comment


        • #5
          Originally posted by Jason Silvernail View Post
          John-
          I don't disagree with you, but personally I'm always a bit cautious when imputing intent to others. I think a large number of those on both sides of your coin just want to be competent providers of care and were taken in both by the biomechanical memes that undergird our profession and fell into the empiricist trap (it works).
          Very well put.
          Rod Henderson, PT, ScD, OCS
          It is useless to attempt to reason a man out of a thing he was never reasoned into. — Jonathan Swift

          Comment


          • #6
            Jason,
            Your point is well-taken. I suppose I should have described the "speculation" on a continuum rather than using the dichotomous "coin" metaphor. Certainly, the PTs I work with are good people who mean well, but have fallen into the "empiricist trap" that you describe.

            However, at what point do good intentions and "I do it because it works" fall into the category of "lame excuses" for not getting up to speed with the latest science relevant to one's profession?

            I've been sending to my colleagues articles by Moselely, Shacklock and others, the "Current Consensus on Pain" from SS and my own work on pain and neurodynamics for over a year. So far, the only response I've gotten was at the company Christmas party when one of my colleagues asked, "So are you saying that everything we do is a farce?" This was her response to the Bialosky article.

            I'm less forgiving of those who continue to speculate using biomechanical theories for the underpinning of the continuing education or residency courses they teach. People who teach techniques to treat people in pain should have a current understanding of pain. Yet, either they choose to exploit the ignorance of the clinicians who sign up for their courses, or they still believe in these outdated biomechanical constructs. Either way, the onus is on professional educators to update their knowledge so that it's consistent with what we currently know.

            It's no less incumbent on the clinicians who spend their money on these courses/residencies to ask if the material is consistent with current pain theory.
            John Ware, PT
            Fellow of the American Academy of Orthopedic Manual Physical Therapists
            "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
            “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
            be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

            Comment


            • #7
              "So are you saying that everything we do is a farce?" This was her response to the Bialosky article.
              Seems like her response could have easily been "This shows that what we do isn't a farce!" followed by enthusiatic smiles and high fives. Oh how I love dream world.

              It seems that we've got some growing pains to experience. However, perhaps growing pains is a progression from fingers in the ears and stomping of feet. I'm curious of what doors people believe Dr. George's research will open for our progression?
              Cory Blickenstaff, PT, OCS

              Pain Science and Sensibility Podcast
              Leaps and Bounds Blog
              My youtube channel

              Comment


              • #8
                Originally posted by John W View Post
                So far, the only response I've gotten was at the company Christmas party when one of my colleagues asked, "So are you saying that everything we do is a farce?" This was her response to the Bialosky article.

                I'm less forgiving of those who continue to speculate using biomechanical theories for the underpinning of the continuing education or residency courses they teach. People who teach techniques to treat people in pain should have a current understanding of pain.
                :clap1::clap1::clap1:
                It is the mark of an educated mind to be able to entertain a thought without accepting it. ~Aristotle
                Healthskills

                Comment


                • #9
                  Fantastic Interview.

                  Dr George said the following about manual therapy:
                  I think there is, because the “bottom-up” approach facilitates mechano-receptors, muscle spindles, Golgi tendon organs, etc. These structures provide valuable afferent information to the central nervous system, and this afferent input has the potential to inhibit pain without descending inhibition.
                  Dr George, could you review the mechanisms here other than descending inhibition? For example, is the gating mechanism part of this equation, and if so, how has our understanding of that changed recently?
                  Thanks.
                  Jason Silvernail DPT, DSc, FAAOMPT
                  Board-Certified in Orthopedic Physical Therapy
                  Fellowship-Trained in Orthopedic Manual Therapy

                  Certified Strength and Conditioning Specialist


                  The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                  Comment


                  • #10
                    I re-read the George interview and was thinking about this quote:
                    The sufficient scenarios then are when pain is more prominent than the observed impairment. An easy example is the chronic pain patient, who has physical impairment, but it may not be as obvious in the previous scenario. In this situation manual therapy is probably sufficient to elicit the responses, but there is less need for peripheral afferent input (most people believe chronic pain is not only a peripheral problem), and descending inhibition may be adequate. The clinical evidence is supportive of this as it suggests manual therapy is equally as effective as other approaches that incorporate a “top-down” approach, like cognitive-behavioral therapy, for chronic pain.
                    I highlighted in red that phrase in parentheses because I thought everyone who researches or knows anything about chronic pain believes it's not only a peripheral problem. Is he aware of some who don't?

                    Also, I'm wondering about the implication then that acute pain is a predominantly peripheral event. How does this view jive with neuromatrix theory? Can we say that this is true of all acute pain? What about acute exacerbations or recurring acute pain?
                    John Ware, PT
                    Fellow of the American Academy of Orthopedic Manual Physical Therapists
                    "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                    “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                    be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                    Comment


                    • #11
                      John, good catch.

                      I really think we should never consider anything like this: "acute pain is a predominantly peripheral event".
                      The inclusion of the word pain immediately makes it a central event.

                      Pain is never peripheral - pain-preceding events may be peripheral, but the genesis of pain occurs in the brain.
                      I know you know this, but I think our language with regards to pain needs to be scrupulously tidy.....
                      We don't see things as they are, we see things as WE are - Anais Nin

                      I suppose it's easier to believe something than it is to understand it.
                      Cmdr. Chris Hadfield on rise of poor / pseudo science

                      Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                      We don't need a body to feel a body. Ronald Melzack

                      Comment


                      • #12
                        Yes John, you’re right in pointing this out.

                        The fact is many therapists don’t see painful problems as anything more than a peripheral event and most don’t know pain is an output because they are completely unfamiliar with Melzack’s model – and I mean completely. See Gradient for more on this. When questioned, a therapist will always say, “Of course the brain’s important” but they understand so little of today’s neuroscience that this comment is essentially meaningless.

                        We’re talking about therapists who hear virtually every patient they see complain first and foremost about the pain they have experienced.

                        It occurs to me that in Elaine Scarry’s seminal work The Body in Pain: The Making and Unmaking of the World (quoted here) dysfunction in the form of restricted mobility and preferred expression precedes pain and is not in and of itself painful. The output of pain follows stimulation after that restriction and relief from the restriction does not necessarily insure relief from the pain.

                        There’s an important lesson in there for all of us, and it confirms the central nature of the experience of pain.

                        I think Scarry’s book should be required reading in every therapy clinic.
                        Barrett L. Dorko

                        Comment


                        • #13
                          Quick reply

                          Hello all, just cruising through reading some of the comments from the interview, and had a minute to reply.

                          1. Sorry about the sloppy language with regards to acute pain perception. Of course all pain has a cortical component, but with acute pain the link to the periphery/inflammatory response/precipitating event is more direct. This link is not as strong with chronic pain syndromes.

                          2. I think it is safe to think of some of the "bottom up" approaches as consistent with classic gate theory, with the relevant updates since the. For example, instead of the gate either being "open or closed", it is a dynamic, adaptable system that is modifiable (neuroplasticity). I am sorry I can't review specific pathways here, and to be honest I am not sure it is even necessary because they are difficult to distinguish in human studies.

                          Thanks for all the kind words and I am glad some of you found our research meaningful.

                          Comment


                          • #14
                            Just chiming in for a congratulations

                            Thanks again for taking the time to join us at SS!

                            John C. Liebeskind Early Career Scholar Award
                            Steven George, PhD PT

                            Steven Z. George, PhD PT, received his bachelor's degree in physical therapy from West Virginia University (summa cum laude) in 1994. He received a master's degree in orthopedic physical therapy and a doctoral degree in rehabilitation science from the University of Pittsburgh in 1997 and 2002, respectively. Dr. George completed a post-doctoral fellowship in the Center for Pain Research and Behavioral Health at the University of Florida, under the mentorship of Michael E. Robinson in 2004. After that, he joined the faculty at the University of Florida as an assistant professor in the department of physical therapy.

                            Dr. George's primary research interests involve the utilization of biopsychosocial models for the prevention and treatment of chronic musculoskeletal pain disorders. His current research projects include: (a) developing and testing behavioral interventions for patients with low back pain; b) investigating the interaction between pain related genetic and psychological factors in the development of post-operative chronic shoulder pain; (c) investigating the mechanisms and efficacy of manual therapy techniques; and (d) developing and testing low back pain prevention programs for soldiers in the United States Army.
                            The John C. Liebeskind Early Career Scholar Award was named in 1998 to honor the memory of John C. Liebeskind, PhD, an APS past president who was a noted pain researcher, scientist, and teacher. The Early Career Scholar Award recognizes early career achievements that have made outstanding contributions to pain scholarship.
                            Last edited by Jon Newman; 16-01-2009, 01:13 AM.
                            "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

                            Comment


                            • #15
                              Originally posted by szgeorge View Post
                              I think it is safe to think of some of the "bottom up" approaches as consistent with classic gate theory, with the relevant updates since the. For example, instead of the gate either being "open or closed", it is a dynamic, adaptable system that is modifiable (neuroplasticity). I am sorry I can't review specific pathways here, and to be honest I am not sure it is even necessary because they are difficult to distinguish in human studies.
                              Dr George-
                              Congratulations on the Liebeskind Award!

                              I can appreciate that you don't want to get into the specific pathways here. For those of us interested, can you recommend an accessible source for those of us who are interested in the more specific pathways? Thanks!
                              Jason Silvernail DPT, DSc, FAAOMPT
                              Board-Certified in Orthopedic Physical Therapy
                              Fellowship-Trained in Orthopedic Manual Therapy

                              Certified Strength and Conditioning Specialist


                              The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                              Comment

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