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CHOICES: Perspectives on the Future of PT In this forum you will read interviews conducted in depth with various figures who are making an impact on the profession. NOTE: The forum is fully moderated. All posts need a moderator approval before becoming visible.

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Old 26-12-2008, 08:40 PM   #1
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Default SomaSimple interview with Steven George

Somasimple is very pleased to present Steven George, recent keynote speaker at the 2008 AAOMPT conference in Seattle, as our next guest in Choices.

Steven Z. George, PT, PhD 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. 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. Dr. George’s research has been supported by the University of Florida, the National Institutes of Health, the Department of Defense, and the Foundation for Physical Therapy. His current research projects include: 1) Developing and testing behavioral interventions for patients with low back pain; 2) Investigating the interaction between pain related genetic and psychological factors in the development of post-operative chronic shoulder pain; 3) Investigating the mechanisms and efficacy of manual therapy techniques; and 4) Developing and testing low back pain prevention programs for Soldiers in the United States Army (www.polm.ufl.edu). Dr. George has authored over 45 peer-reviewed publications and has been recognized by the American Physical Therapy Association with the 2007 Eugene Michels New Investigator Award and the American Pain Society with the 2009 John C. Liebeskind Early Career Scholar Award.

See this pubmed query for a list of Dr. George's peer-reviewed publications.
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Old 26-12-2008, 08:55 PM   #2
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SomaSimple:

I’d like to start this interview by thanking Dr. George for taking time out of his busy schedule to participate in this program at SomaSimple.

Your research has approached questions about how manual therapy works and has elucidated mechanisms of effect for some common interventions. This is an area that many researchers of manual therapy do not approach and in fact it’s been argued that too much speculation regarding mechanism already exists, possibly hinting at reasons for the trepidation.

What factors have led you to these research questions and made you feel that answers beyond speculation could be approached?


Steven George:

And I would like to start my response by thanking Jon and Cory for taking an interest in my work and giving me the opportunity to answer some great questions from your forum participants.

There were several factors that led to me being interested in manual therapy mechanisms and they aren’t necessarily mutually exclusive.

First was the decision that I made that manual therapy was an effective treatment for people with musculoskeletal pain (especially when subgroups are used to identify “responders” – but more on that in the second point). That may sound like a trivial issue to make as a manual therapy practitioner; however, once the decision is made that a particular treatment is “effective” it makes sense to then look at what factors make it effective and then if these factors can be modified to enhance effectiveness.

Second was the realization that our profession was going to spend a lot of time and effort on developing (and hopefully eventually validating) clinical prediction rules for manual therapy. I was fortunate enough to be at the University of Pittsburgh working on my PhD when some of the early clinical prediction rule studies were being designed and implemented (the Flynn(1) and Hicks(2) studies). This methodology made a lot of sense to me and I could see how this type of work was going to strongly impact our professional literature. I originally wanted to be part of that, but initially my new environment was not receptive to such studies. When I first came to the University of Florida one of my top priorities was to complete a clinical prediction rule study as a post-doctoral fellow, but this environment was just not ready for it. I would like to point out that this issue was likely not specific to UF, as I would have run into the same issue at any other place I went to in 2002. Clinicians (and most researchers) were just not ready for that methodology because the first manipulation CPR study had not even been published yet. However, there was a benefit to being at UF, and that leads to the third point…

Third was being immersed in an environment that encouraged and valued mechanistic research. For all the strengths of my previous environment at Pitt (emphasis on clinical outcomes research), I had never been exposed to mechanistic models of research. However, during my post-doc experience, that happened and I began to see the value of performing such studies in manual therapy. If manual therapy was effective (and remember I thought it was), then we should be able to determine mechanisms and that is what I set out to do in 2005 (only after failing at my original goal however), by utilizing some of the neurophysiological mechanisms common in pain research.

So to directly answer the question, I think the combination of those three things led me to where I am now, with a fairly well developed line of research on this topic (and lots of work left to do).

I would like to directly answer the speculation part, because I do think it is an important point that is sometimes missed in our “evidence-based” world. There is nothing wrong with speculating about how a particular treatment works. In fact, it is an important part of the scientific process. Speculation leads to testable hypotheses, which leads to well designed experiments, and all of this helps move a field forward (scientifically). 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. For example, not too long ago I could have suggested that manual therapy inhibits pain due to inhibition of temporal summation with NO supporting data. It would have been seen as credible because it was neurophysiologically possible. Currently, however, data is valued and that led to the experiments.

So I actually did not feel much trepidation, as I just saw this as an opportunity to collect data and test if this particular line of speculation had any value.

References:
1) Flynn T, Fritz JM, Whitman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine. 2002 Dec 15;27(24):2835-43.

2) Hicks GE, Fritz JM, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients will respond to a stabilzation exercise program. Arch Phys Med Rehabil. 2005 Sep;86(9):1753-62.

Last edited by BB; 26-12-2008 at 09:37 PM.
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Old 26-12-2008, 09:05 PM   #3
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Somasimple:

Does your research indicate separate distinct mechanisms at play in effective manual therapy? If so is there any indication of one or more effects being more important or prominent than others?

And an immediate follow up: Are these effects able to be generalized beyond manipulation?


Steven George:

Currently our research has focused on temporal summation (a neurophysiological mechanism related to magnification of nociceptive input at the dorsal horn) and how expectation affects temporal summation. So those are the primary 2 factors that we have been focusing on in studies to date. Obviously there are many, many more potential mechanisms at play and we hope to expand on those 2 factors. Our current conceptual model(3) was developed with help from one of my doctoral students, Joel Bialosky and is now available on epub ahead of time through Pub Med (Manual Therapy PMID: 19027342). This model outlines some of the other promising areas of mechanistic research for manual therapy and pain inhibition, as well as ways to measure these factors. Clearly, it is a more complex system than we (and others) have been studying and this model attempts to highlight the complexity, as well as to hopefully motivate investigators to consider more simultaneous factors in their studies.

See attached below Figure 1 from Bialosky et al 2008 Manual Therapy xxx (2008) 1-8, depicting the above mentioned conceptual model

The question about which effects being more prominent is difficult to answer right now, because so many studies only include limited effects (it is most common to only include 1 effect in a study) and in studies that include more than 1, the criterion to determine which is more important is not clear. For example, is it the effect that is “largest” or the effect that is associated with clinical outcomes or the effect that is consistently observed across different studies? These issues have not been addressed, but should be in future mechanistic studies of manual therapy. One route we will take is to see if changes in proposed pain inhibitory mechanisms (like temporal summation) are correlated with improvements in clinical status, like pain VAS ratings.

I am not sure the specific effects, like suppression of temporal summation, can be generalized past manipulation. There is some interesting data from our lab suggesting similar effects on temporal summation are observed following neural mobilization techniques, so there may be some potential of this phenomenon being generalized across different manual therapy techniques, but I don’t think that assumption should be made until more data are available. Also, we have not investigated non-thrust techniques yet (i.e. mobilization), so again, I am hesitant to generalize these effects to non-thrust techniques.

Reference:

3) Bialosky JE, Bishop MD, Price DD, Robinson ME, Geroge SZ. The mechanisms of manual therapy in the treatment of musculskeletal pain: a comprehensive model. (In Press) Manual Therapy 2008 xxx: 1-8
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Old 26-12-2008, 09:19 PM   #4
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SomaSimple:

I won’t be going out on too big of a limb to state that we will all be anxiously awaiting the evolution of this research in the directions you mention.

The following quote comes from the paper cited above, and is describing the conceptual model:

Quote:
Subsequently, we suggest, that as illustrated by the model, a mechanical
force is necessary to initiate a chain of neurophysiological responses
which produce the outcomes associated with MT.(3)
While this model is meant to address the impact of manual therapy only, is it not plausible that such a chain of events could also be initiated by non-mechanical stimuli, such as education?

Are there scenarios in which you see manual therapy as necessary vs. sufficient?


Steven George:

Yes, I do think that the chain of events could be initiated by non-mechanical stimuli, like education or a classical operant conditioning response or a placebo response. However, there are some important distinctions to make here for these non-mechanical stimuli and manual therapy. In those previous examples it would be viewed as a “top-down” initiated response, and then the only options for pain inhibition would be associated with pathways involved descending inhibition. Contrast that with manual therapy which is a “bottom-up” approach that is originated in the periphery, must travel into the central nervous system AND THEN initiate descending inhibition processes.

When it is sketched out that way, you can see then, that the difference is whether you think there is any value in eliciting anything before descending inhibition processes are initiated. 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 (or more likely in combination with descending inhibition).

And that is why we conceptualized the model as starting with that type of input. While technically you could start some of the processes highlighted in the model with a “top-down” approach, manual therapy is a “bottom-up” approach because of the peripheral nervous system to central nervous system connection. This is the way manual therapy must be conceptualized (in my humble opinion), unless you view it purely as a non-specific effect (which I don’t). While I think there are non-specific factors that enhance the effect of manual therapy (like patient expectation), I still think an actual stimulus is necessary to elicit the optimal response.

And to add a little more on the “necessary vs. sufficient” scenarios – I do think there are situations where in the presence of obvious physical impairment and pain (i.e. classic hypomobility with acute spine pain) manual therapy is “necessary”. While there are other “bottom-up” interventions used by physical therapists (TENS, US, massage, etc.) for musculoskeletal pain, there seems to be stronger evidence for manual therapy (especially manipulation). I can only speculate that one of the reasons that manual therapy is more effective is it does a better job eliciting a wide range of peripheral afferent inputs, in comparison to those other “bottom up” interventions like TENS.

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.

Reference:

3) Bialosky JE, Bishop MD, Price DD, Robinson ME, Geroge SZ. The mechanisms of manual therapy in the treatment of musculskeletal pain: a comprehensive model. (In Press) Manual Therapy 2008 xxx: 1-8
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Old 26-12-2008, 09:24 PM   #5
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Somasimple:

Your group has recently demonstrated that temporal summation responses following manipulation can be significantly modified by verbally influencing a subject's expectations of manipulation. (4)

What is the plausible extent of this interaction in terms of its clinical implications?

Do you think that the interaction between manipulation and expectation might also occur in the opposite direction; that is, can manipulation itself influence subject expectation?


Steven George:

The role that expectation has on patient outcomes has broad implications, and not just for manual therapy. In our line of research we essentially wanted to determine if expectation could alter manual therapy outcomes. In our opinion there is a high potential for this affecting the clinical outcomes received with manual therapy, because most practitioners of manual therapy provide positive expectations of pain relief.

In our research so far it seems that the extent of this interaction could potentially be far-reaching, although to be fair our data is only in our experimental model involving healthy subjects and induced pain. In this model we observed an INCREASE in pain following negative expectations.

See the attachment below for Figure 2 from Bialosky et al, BMC Muskuloskeletal disorders (2008) Feb 11; 9:19

This was really quite telling for us, because we expected all subjects to have decreased pain, but the folks getting the negative expectation to have less of a decrease, or possibly no decrease. Instead, they had an actual increase of pain, which is not typical. All published studies of manual therapy show group changes of decreased pain in response to standard stimulus (to the best of my knowledge). The unexpected nature of this finding demonstrated to us the potential power of expectation, by reversing what would be the expected response. Of course, the clinical parallel to that is hard to do, and I am not sure of the exact clinical implications, but it does show the extent of patient expectation in a controlled setting.

As far as the other way around, I think there is great potential for a “positive feedback” loop to occur, where in the clinical setting good outcomes are associated with continued positive expectations. This is similar to the conditioning that occurs to placebo response, so although it has not been studied specifically for manual therapy, there is a scientific precedent out there. Patient expectation can be a difficult thing to study, because typically it is assessed at one point in time (if it is assessed at all) and that one point is usually at the beginning. However, some of our preliminary work (in chronic pain patients not receiving manual therapy) suggests expectations change over course of treatment, so it is really a dynamic system, and one that needs more clarification. For example, patients may have one threshold for pain relief that is their expectation at baseline, but as the treatment progresses, that threshold may change, depending on their response to the treatment. We just don’t have a good grasp on how treatment response affects patient expectations just yet, but those studies will hopefully be forthcoming.

References:

4) Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of
expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskelet Disord 2008;9:19.
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Old 26-12-2008, 09:29 PM   #6
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Somasimple:

Traditionally, most physical therapists have considered anything that is not within the realm of biomechanics and pathophysiology to be outside their scope of practice. How valid is this concern given your research? In what ways do you feel that these findings can and should impact this perception?


Steven George:

I have run into this contention quite a bit given that I cut my research teeth by investigating psychosocial influences on pain perception. I was constantly amazed with some PT’s attitudes towards this topic, it was something along the lines of – “I don’t deal with that, I focus on the physical part of the rehabilitation”. I always thought this attitude was incredibly short sighted, because even if you didn’t directly deal with the psychosocial issues, they were an important factor in the patient rehabilitation. It wasn’t like the patients were going to be able to compartmentalize their musculoskeletal pain complaints into “physical” and “psychosocial” categories, so why did the therapist get such a luxury?

I can see some similar issues being present for the research we are doing in manual therapy. Most of us (including myself) were trained on strict biomechanical application of manual therapy. Now, it seems that the biomechanical part of manual therapy may not be as important as originally thought. There is a fairly strong line of research with contributions from many groups that indicates there is the potential for neurophysiological mechanisms to be a primary “active” agent in manual therapy.

Taken together, these findings should make it fairly clear that any profession that deals with patient well being should not look to compartmentalize their efforts. I think it just limits the profession and its potential scope. Instead, the profession should be flexible enough to incorporate these research findings, instead of being resistant to them. I am also not saying the profession needs to abandon the traditional parts of biomechanics and pathophysiology, but the profession should consider their relevance and role by, spending the appropriate amount of time on each of those.

This is not just PT that is being challenged like this either. What we are seeing now is a shift from the “clinician centered biomedical” model (again in which the bulk of us were trained) to a more “patient centered biopsychosocial” model of health care. We cannot just be seen as practitioners of biomechanics and pathophysiology, instead we are those that deal with all issues related to musculoskeletal pain, and that means broadening your scope (assuming the goal is to provide optimal patient care).
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Old 26-12-2008, 09:31 PM   #7
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Somasimple:

Your research has broad implications not only for physical therapy but for manual therapy in general. It challenges many long held beliefs on mechanisms of action that remain firmly entrenched within the culture of manual therapy as well as incorporating a much needed up to date pain science perspective. How do you see the traditional manners in which we as manual therapists think about our craft and about pain evolving in the future and what, if any, roadblocks to this transition do you foresee?


Steven George:

This is a good question, and I would like to state before I answer it that I am going to speculate on this with the assumption that what we, and others, are finding is that the neurophysiological effects are a primary effect for manual therapy. I think there are some favorable trends in this area, but it is not a done deal. The biomechanical explanations seems to be a rapidly sinking ship, but there is still time to reverse that trend. However, I am going to answer this question like it is a done deal because it is more fun than taking the “safe” answer of “only time will tell”.

So… I think the biggest way this research will change manual therapy craft (and we have already seen convergence of this from the clinical literature) is that there does not need to be so much emphasis on the specific anatomical application of manual therapy. In other words we can probably spend less time worrying about identifying specific anatomical lesions and applying the manual therapy to exactly correct that lesion. We can worry less about whether the student really rotated and flexed the segment in the right direction, things like that. We can re-examine what it means to be an “expert” manual therapist – perhaps it is not based solely on the psychomotor application of manual therapy?

We can focus more on determining who the responders to manual therapy will be, and what makes them responders to manual therapy. We can focus on using the “new” science of pain to manage the patient from a broad perspective that has scientific support, instead of following a specific manual therapy philosophy that may or may not have any scientific support. We can also focus on ensuring that patients get adequate doses of manual therapy to maximize their chances of reducing acute pain, and preventing transition to chronic pain. We can also worry less about acquiring additional manual therapy techniques in our “toolbox” because there does not seem to be a clear indication of which techniques are “superior”. There will be some basic questions answered, such as is thrust better than mobilization, is neural tension a legitimate technique, etc. However, we can worry less about whether Guru A’s version of manual therapy is better than Guru B’s.

I think the roadblocks to changing these beliefs are all the usual suspects – professional inertia, unwilling to change entrenched practices, those who teach manual therapy for a living may be very skeptical, etc. I do think there is hope, however. There seems to be a solid group of manual therapy practitioners who have accepted clinical prediction rules. These clinical prediction rules are very consistent with what we are finding. As acceptance of those rules grows, so should some of these alternate methods of explaining how manual therapy works. Also, I am always pleasantly surprised with how many manual therapists are current on pain research and exploring ways to incorporate such work in their clinical practice.

A good analogy may be (sorry to revisit this again) the psychosocial work I started with. Ten years ago it was quite rare and novel for therapists to screen for yellow flags. Now, it is more common for physical therapists I talk with to use screening tools like the fear-avoidance beliefs questionnaire and now clinical practice guidelines recommend their use. The transition didn’t happen immediately, but it did happen and I can see a similar thing happening manual therapy.
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Old 26-12-2008, 09:33 PM   #8
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SomaSimple:

Is there anything on the horizon of your research that you would be willing to share with those of us who will be anxiously awaiting its arrival?


Steven George:

Well, I don’t like to get too far ahead of what we are doing, and of course like any good poker player I don’t want to give away my hand… but I can share some things that we will likely be publishing over the next 12 months. We have finished recruiting a study looking at the same mechanistic outcomes (temporal summation) for neural tension techniques in healthy subjects and patients with carpal tunnel syndrome. The healthy subjects paper should be published first (it is already in review with JOSPT), followed by the carpal tunnel syndrome paper (very close to being completed and planned to submit to JOSPT). There are some interesting findings in those papers that Jason and Joel presented at AAOMPT this year and these findings parallel what we have found in spinal manipulation. We will also be publishing a study on spinal manipulation with patients that have low back pain to supplement our earlier paper on healthy subjects (very close to being completed and plan on submitting that to PTJ). Last, we are working on finishing a project looking at these mechanistic outcomes in thoracic manipulation, so we can see if these neurophysiological effects transfer from other areas of the body.

In the future I think we will start comparing different manual therapy techniques to see if the neurophysiological effects differ, and I think that is very interesting and will parallel some of the clinic work recently presented at AAOMPT by Josh Cleland. Also I expect that Joel will be developing our line of research looking at the non-specific effects of manual therapy and comparisons to manual therapy placebos. I think that is where we are headed over the next few years. There is lots to do, and we are looking forward to it…
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Old 26-12-2008, 09:35 PM   #9
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SomaSimple:

To close I would like to once again thank Dr. George for taking the time to participate in this interview, especially considering it was conducted at the end of the semester. We will be following your work closely and with much anticipation while looking forward to the discussions it will foster.


Steven George:

I really don’t have any closing remarks, except to say that all of these responses are time dependent and based on my interpretation of the literature at this time. This is a dynamic area, and it is very enjoyable to be part of this evolving process. I also would like to thank you again for providing me an opportunity to expand my thoughts and highlight my research. Sometimes we get so focused on what we are doing, don’t have time to reflect, and this was a good chance to do that. I hope your readers find this exchange informative.
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Old 27-12-2008, 05:43 PM   #10
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Here is a pdf of the entire interview.
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Old 27-12-2008, 07:40 PM   #11
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If this interview helped you or generated questions please post your comments and questions in this thread.

Thanks Cory and Steve. Great job.
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