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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 22-10-2010, 05:59 PM   #1
Jason Silvernail
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Default SomaSimple Interview with Joel Bialosky

SomaSimple is proud to announce the interview with Dr Joel Bialosky.

You can find his bio page here.

Quote:
Joel Bialosky, PT, PhD, FAAOMPT, OCS has over 14 years of clinical experience primarily in orthopedic and musculoskeletal physical therapy. He is a board certified clinical specialist in Orthopedics and a fellow in the American Academy of Orthopedic Manual Physical Therapists. He received a bachelor’s degree in physical therapy from Ithaca College in 1990 and a master’s degree in musculoskeletal physical therapy from the University of Pittsburgh in 1998. He graduated from the University of Florida with a PhD in Rehabilitation Science in 2008 with his research interests focused on the mechanisms of manual therapy in the treatment of musculoskeletal pain. He is currently supported by the K12 Rehabilitation Research Career Development Program with a research program focused on 1) placebo mechanisms of manual therapy and 2) neuroplastic changes in pain associated with musculoskeletal disorders and their response to common rehabilitation interventions.
Please post questions to Dr Bialosky in the questions thread, and we'll bring him here for the interview.
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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.

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Old 05-11-2010, 11:23 PM   #2
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Default Dr Bialosky's Interview

Thank you Dr Bialosky for participating in our interview and sharing your knowledge and experience with us. We realize you're not available for further forum discussion but appreciate you answering our questions.

Quote:

Dr Bialosky:
I would like to thank everyone submitting a question and/or reading the responses and the moderators of this forum for the invitation to participate. I am very fortunate to have stumbled into a career in academics studying a topic that I love and which fascinates me. My answers provide my thoughts and insight based on both my clinical and research experience in this area. Within the scope of the forum I have tried to provide references when appropriate; however, as this is a “discussion”, I have also liberally included my own impressions (again, based upon my own experiences and years spent reading other people’s work). Thanks again for your interest and participation.


SomaSimple:
How did you become interested in neuroscience and the mechanisms of manual therapy?
What is the K12 Rehabilitation Research Career Development Program and how does one get accepted into it?

Dr Bialosky:
I would say that I have unknowingly always been interested in neuroscience. I worked as a physical therapy clinician for fourteen years primarily in orthopedic outpatient physical therapy settings. I identified myself as a physical therapist specializing in the treatment of individuals with orthopedic injuries or musculoskeletal pain. Subsequently, I was very interested in the biomechanical basis of the physical therapy examination and treatment. i.e. identifying and stretching tight structures and strengthening weak structures. When I started the PhD program in Rehabilitation Science (RSD) at the University of Florida I was the only RSD student with an interest in orthopedics. Many of the other students were interested in what I considered neuroscience such as the rehabilitation of individuals following stroke or spinal cord injuries and I considered my background and interests vastly different than theirs. As I interacted with pain researchers from other disciplines such as medicine, dentistry, and psychology, I slowly realized musculoskeletal pain has a vast neurophysiological influence. Additionally, as I listened to the research interests and finding of the other RSD students and their mentors regarding “true” neuroscience, I began to see similarities in changes in processing that occur in response to stroke and spinal cord injury and the corresponding rehabilitation and those that accompany musculoskeletal pain conditions. In hindsight, a neuroscience component of pain should not be surprising; however, as a clinician focused on identifying physical impairments and “correcting” them, the role of neuroscience within our treatments and outcomes was a bit of a revelation for me personally. My interest in the mechanisms of manual therapy came from both my clinical background and research opportunities. We have decent evidence that at least a subgroup of individuals respond positively to manual therapy (particularly individuals with low back pain receiving spinal manipulation). Clinically I saw some of my own patients respond to my manual therapy interventions and those of my colleagues respond (at times) to vastly different approaches. Some of which were not necessarily evidence based. I was always curious as to why certain people responded and frequently very dramatically to our varying approaches to manual therapy. I was very fortunate to have the opportunity to come to the University of Florida as a PhD student with Steve George as my mentor when he was beginning his research agenda into the mechanisms of manual therapy.

The K12 Rehabilitation Research Career Development Program is a funding source for early career researchers providing salary support for protected research time along with continued mentoring. I participate through a grant awarded to the University of Florida and the University of Texas Medical Branch in Galveston.

http://www.sahs.utmb.edu/k12/default.asp

Another K12 grant has been awarded through the University of Pittsburgh, the University of Delaware, and Washington University in St. Louis

http://www.corrt.pitt.edu/



SomaSimple:
Different people use the word “placebo” differently. Some suggest that placebo is that which has no effect. I never liked that sort of definition because if there is no effect, then it's senseless to speak of a placebo response or a placebo effect. How do you define placebo?

Dr Bialosky:
I agree that by definition, a placebo effect or response is indicative of an active agent. With this in mind, defining placebo as inert or “nothing” is contradictory. One of my favorite descriptions of placebo comes from a paper written by Price et al. (Annu. Rev. Psychol. 2008. 59:565–90). “The focus has shifted from the “inert” content of the placebo agent (e.g., starch capsules) to the concept of a simulation of an active therapy within a psychosocial context.” Due to the robust effect placebo can have on pain and the numerous neurophysiological responses which accompany placebo related pain reduction, we consider placebo as a neurophysiological mechanism of pain inhibition likely related to supraspinal control.



SomaSimple:
Placebo has, in part, an opioid mechanism. In the late 90s and beginning of the 2000s, studies on SMT (spinal manipulative therapy) have tried to see if SMT had an opioid mechanism. In these studies, naloxone failed to block immediate SMT analgesia and SMT did not seem to show tolerance to repeated administration. These studies led the researchers to conclude SMT did not have an opioid analgesic mechanism to achieve the immediate effect on pain thresholds. TENS had also failed to see its effect blocked by naloxone in past studies until a recent article in PAIN. It seems prior studies used an insufficient dosage of naloxone which did not block all the opioid receptors. That would have prevented the blocking of delta-opioid receptors. In that recent PAIN article, they used a higher dose of naloxone and successfully blocked the immediate TENS analgesia by doing so. They hypothesized TENS works, at least in part, through a delta-opioid receptor mechanism. Do you think, provided the right dosage of naloxone is used, SMT's initial analgesic effect could be blocked with naloxone? Would that demonstrate SMT works through an opioid mechanism? If so, is this effect reflecting mostly the placebo response or a specific mechanism?

Dr Bialosky:
Placebo related pain reduction appears to be mediated by the opioid system and numerous studies have observed the placebo response (i.e. pain reduction) can be eliminated if the opioid pathway is blocked through a means such as the use of the opioid antagonist naloxone. This is not always the case as a study by Vase et al, Pain 115 (2005) 338–347 has observed placebo related pain reduction not naloxone reversible and conditioning protocols using non- opioid drugs may produce non- naloxone reversible placebo related pain inhibition. (Amanzio and Benedetti J. Neurosci., January 1, 1999, 19(1):484–494). So, while placebo related pain inhibition is certainly linked to an opioid pathway, other mechanisms may also be relevant. Preliminary studies have suggested a non opioid mediated mechanism of manual therapy in pain inhibition; however, this has not been studied extensively or in light of more recent knowledge regarding factors such as the dose of naloxone. I can not speculate on whether higher doses of naloxone would block a pain inhibitory effect of SMT. Such as finding would suggest an opioid mediated response as one mechanism of SMT related pain inhibition. Such as finding would not necessarily implicate SMT related pain inhibition as a placebo response, but could suggest either some of the observed clinical responses to SMT are due to a placebo mechanism or could suggest both placebo and SMT are active interventions capable of producing pain inhibition through similar mechanisms.


SomaSimple:
My question for you is that it seems difficult not to avoid any placebo effect when doing research. How are we as readers, not researchers, not to be misled by this when interpreting research?
In your experience, which following will bring about a stronger placebo effect when the client comes to see us? Might it be the provider’s reputation, dress, interpersonal communication skills, clinical reasoning skills, manual skills, anything else?

Dr Bialosky:
I agree that avoidance of a placebo effect for something like manual therapy is next to impossible. I am not sure of the context of your first question exactly, so I will answer based on my initial impression and hope this touches on what you are getting at. As a clinician reading clinical trials, I would not worry about being misled and instead accept the findings (particularly if beneficial) at face value regardless of whether they may be attributed to a mechanism specific to the studied intervention or a placebo mechanism. Placebo mechanisms are likely present to some extent in all interventions for pain and that is not a bad thing. Unfortunately, most studies are not designed to allow us to determine how much of the outcome can be attributed to placebo. What you should consider from a 2 group placebo controlled trial (i.e. studied intervention compared to placebo) is you have no way of knowing the size of the placebo effect from such a design. All you can conclude is that the studied intervention did better than placebo in regards to a specific outcome or was the equivalent of placebo. Keep in mind that a studied intervention doing no better than placebo may not be a bad thing if both groups did significantly better than people who received nothing (a natural history group). Without a natural history group, you have no way of knowing which portion of an observed outcome from placebo (or the studied intervention for that matter) is the result of factors such as natural history or regression to the mean. In a 3 group design (studied intervention, placebo control, and no treatment control), the outcome in response to placebo can be compared to the outcome in response to receiving nothing at all. The difference between the outcome observed in response to natural history and that observed in response to placebo is the magnitude of your placebo effect.

In response to your second question, I think all of the above influence a placebo response to our interventions. A placebo responder has not been identified. That is, studies have not been able to identify specific attributes of an individual likely to experience a placebo response. What is known is a placebo response is dependent upon factors related to expectation (i.e. what a person think will occur), conditioning and learning (i.e. individual prior experiences), and psychological factors such as those related to fear and anxiety. Everyone is likely a placebo responder; however, the stimulus to which we experience a placebo response if probably highly variable between individuals. So all of the factors you listed likely play a role in our ability to enhance the placebo aspect of our interventions; however, their relevance probably differs from patient to patient.



SomaSimple:
It has been shown that SMT and manual therapies have an immediate analgesic effect on pain. Do you think this immediate effect is related to outcomes? That is, would eliminating this effect actually block the positive effects on outcomes?

Dr Bialosky:
You ask a great question. A number of studies and research groups have observed immediate hypoalgesia in response to manual therapy. We currently don’t know the relevance of these findings to clinical outcomes. Hypoalgesia in response to manual therapy can take two forms. One is diminished clinical pain such as a person reports 6/10 pain in the low back prior to an intervention and 2/10 immediately following the intervention. Preliminary evidence suggests a relationship between within session changes in clinical pain and longitudinal outcomes (Hahne et al. Aust J Physiother 2004;50(1):17-23, Tuttle N. Aust J Physiother 2005;51(1):43-48.) In addition to changes in clinical pain, hypoalgesia is also observed in pain sensitivity. These changes are seen in response to external stimuli such as pressure and heat. For example, a person may report 6/10 pain to 4 kilograms of pressure applied by an algometer to the low back immediately prior to an intervention and 2/10 pain to the same 4 kilograms applied to the same location immediately following the intervention. People with chronic pain often demonstrate greater sensitivity to painful stimuli (such as pressure and heat) than people not in pain suggesting a potential target for manual therapy (i.e. attenuation of heightened pain sensitivity). Fairly substantial evidence exists that immediate hypoalgesia is associated with manual therapy. The focus now needs to shift to the significance of this finding to longer term clinical outcomes.


SomaSimple:
Spinal manipulation has received quite a lot of attention from the research community and I've heard it described as "low hanging fruit" for researchers due to its popularity within the culture and evidence base. What would you consider to be high hanging fruit for physical therapists?

Dr Bialosky:
I'm not sure.


SomaSimple:
My question is in regards to your Guest Editorial in JOSPT, June 2008 (Why ask why?). What negative effects do you see could come about in the delivery of Spinal Manipulative therapy without proper and accurate (at least to the best of our current knowledge) education to the patient of why it works?

Dr Bialosky:
The negative effects that I see from inadequate understanding of the mechanisms of manual therapy are in our clinical outcomes rather than from inadvertently misinforming our patients. I would argue that we currently provide manual therapy clinically in one of two ways. Either as 1.) a misconception (i.e. implying a strictly biomechanical mechanism) or 2.) as a blind faith approach (clinical prediction rules). Manual therapy is frequently applied clinically with a dependence upon evaluative techniques to locate and identify a misaligned or hypo mobile tissue necessitating a specific manual therapy intervention to restore the proper position or mobility. The literature does not support 1.) that we can accurately locate these dysfunction, 2.) that our techniques are specific to the site of dysfunction, 3.) that lasting changes in position occur, or 4.) that this matters to the observed outcomes. Subsequently, a specific and independent biomechanical mechanism is unlikely. On the other hand, clinical prediction rules may be helpful in identifying individuals likely to respond positively to manual therapy but with no knowledge of why. Additionally, many of the clinical prediction rules have recently been criticized as indicative of a likely general positive prognosis rather than a positive prognosis for a specific intervention. I would argue that without an understanding for why manual therapy works; we cannot maximally identify individuals likely to experience a positive response. So if we determine manual therapy works through diminishing pain sensitivity in patients presenting in pain, we can find clinical ways to identify our patients presenting with heightened pain sensitivity as likely responders. If manual therapy is found to work primarily through a biomechanical mechanism such as restoring movement to a hypo- mobile segment, we can work on more reliable ways to clinically identify individuals presenting with a hypo- mobile segment likely to respond. Additionally, knowledge of the mechanisms would allow us to monitor pertinent clinical changes to ascertain adequate dose and response to a treatment.



SomaSimple:
Given the research to date, do you feel there is support for the position taken by some in the manual therapy community, that there are some specific effects of particular manual therapy methods beyond placebo or nonspecific mechanisms?
In a thread here about manual therapy and placebo, one therapist stated essentially that there were no specific effects of manual therapy and that any effects were all placebo-mediated responses. What would your response to that position be? Are the specific effects, if any, related to outcome, and is there an indication of how much?

Dr Bialosky:
My personal feeling is placebo is one of several mechanisms through which manual therapy helps our patients. Placebo likely plays a role in all interventions for pain and manual therapy is no exception. The problem, not specific to manual therapy, is we don’t currently know how large of a role placebo plays in our outcomes. The only way we can determine the magnitude of placebo is to design studies including not only a placebo comparison, but also a no treatment control group. The size of an outcome in the placebo group above that which occurs in the natural history group represents the placebo effect size. Outcomes in manual therapy above and beyond placebo can then be considered as resulting from mechanisms “specific” to the manual therapy intervention. I would guess that these types of study designs would observe placebo to account for some, but not all of the treatment effect of manual therapy and the additional effect could be attributed to other “specific” mechanisms. As a side note, we frequently refer to placebo responses as “non- specific” effects of manual therapy. An important consideration is that placebo related pain inhibition is heavily dependent upon expectation. High expectation specific to a manual therapy intervention may enhance the associated placebo response. For example, in a study comparing a manual therapy intervention to a sham ultrasound (placebo) if expectation for the manual therapy was significantly higher than the sham ultrasound, the findings of the manual therapy group having significantly better clinical outcomes than the sham ultrasound group COULD be at least in part attributed to a placebo response related to enhanced expectation specific to the manual therapy intervention. Subsequently, non- specific responses are potentially specific to an intervention.



SomaSimple:
Despite the fact the biomechanical models has many flaws, most of the research still focuses on treatment techniques or applications directly derived from this model. It's just that the focus is now on the neurophysiologic mechanisms behind these traditionally biomechanically oriented treatments.
Shouldn’t we try to find better/new ways to achieve these, and superior, neurophysiologic effects instead of constantly revisiting the same ones, actually invented along the lines of a biomechanical paradigm? Do you think these mechanically oriented treatments maintain their popularity because they fit nicely in the patients and therapists' default belief system?
How much of the biomechanical model of manual therapy do you think should be salvaged?

Dr Bialosky:
I agree the biomechanical model has a number of significant flaws; however, I would not completely discount the biomechanical influence. Hypomobility of a lumbar segment is a component of the clinical prediction rule for spinal manipulation and some evidence suggests neurophysiological responses to manual therapy may differ by the biomechanical parameters. For example, greater effects with higher speed, more forceful application. (Colloca et al. Clin.Biomech.2006; 21:254-262; McLean et al. Clin.Biomech.2002; 17:304-308; Pickar et al. Spine J. 2007; 7:583-595.) There is likely a biomechanical component to the mechanisms through which manual therapy inhibits musculoskeletal pain and we have tried to indicate this with our theoretical model for the mechanisms of manual therapy (Bialosky et al, Man Ther. 2009 Oct;14(5):531-8.) I would argue that the biomechanical mechanism is not specific or the primary mechanism, but rather, as indicated by the model, initiates the potentially more pertinent neurophysiological mechanisms. My concern for the biomechanical model is the influence on practicing clinicians (myself included). Manual therapy and particularly spinal manipulation was not considered an entry level skill when I graduated with my entry level physical therapy degree. The thought was these interventions required advanced continuing education much of which focused on learning to identify numerous biomechanical faults and then becoming competent in numerous and specific manual therapy interventions to correct what we found. Speaking for myself, there was a hesitancy initially to use these techniques on patients due to not being comfortable in my ability to find the specific fault or with the specific intervention necessary to correct the fault I believed I had found. In fact, the literature supports some people respond very favorably to manual therapy; however, this does not appear dependent upon our ability to accurately locate a dysfunctional segment, our ability to localize our techniques to a specific level, lasting change in position caused by our techniques, or even necessarily which specific technique we use. I believe the beauty of a neurophysiological approach to manual therapy is that it demystifies much of what we do and allows more widespread use of these interventions. The first consideration is whether manual therapy is contraindicated. If not, then the therapist can determine whether the patient fits a pattern supported by the literature as likely to respond to manual therapy or can apply manual therapy with the intention of producing a known neurophysiological response (such as hypoalgesia). Rather than requiring an evaluative finding of a specific biomechanical dysfunction and the application of a specific technique, the therapist can be comfortable and proficient with a few techniques of their choosing and use these on appropriate patients. Maximal responses may require specific types of techniques (such as thrust manipulation rather than less forceful and lower velocity mobilization techniques); however, the thrust technique used could be one of the therapists (and/or patient’s) choosing and not dictated by an impairment of questionable importance.



SomaSimple:
Given the depth of understanding that you and your research partners have gained as a result of the research you've undertaken in manual therapy mechanisms, how confident are you that the profession of physical therapy will embrace these findings and modify its traditional roots in the orthopedic/biomechanical model? And as a follow up, what do you think will be the consequences if we don't?

Dr Bialosky:
Translating research findings into a change in common clinical practice is difficult under any circumstance. I believe we have already seen a change in physical therapist’s use of manual therapy from the conventional biomechanical model to an emphasis on the identification of manual therapy “responders”. There is no intervention to which all patients respond and manual therapy is not an exception. The trick is to identify at an early stage individuals likely to respond to a given intervention so they may be treated appropriately. Good or bad, our profession has been inundated with clinical prediction rules in an attempt to identify people with various types of musculoskeletal pain likely to respond positively and quickly to manual therapy interventions. Caution must be taken with this approach as many of these studies have not been validated; however, the point is we are moving beyond simply identifying a misaligned or hypo mobile joint as an indicator of when to use manual therapy. Sufficient literature exists to make us question the biomechanical model as an independent and specific mechanism through which manual therapy produces clinical outcomes. The pain literature is very clear regarding the neurophysiological mechanisms of pain and manual therapy studies are providing insight into changes in the neuroplasticity of pain associated with manual therapy. I think there is potential for clinical practice to change to where manual therapists may rely on tools such as pressure algometry or responses to thermal pain stimuli rather than strictly palpation and passive motion assessment to assist them in determining who should receive manual therapy and for immediate feedback whether an adequate and/or successful dose was applied. Certainly, much more research is needed into these areas before we are comfortable recommending changes and can expect practicing clinicians to heed such recommendations.


SomaSimple:
What changes, if any, do you feel should be made to modern entry level physical therapy training programs as a result of the neurobiologic revolution in the understanding of pain mechanisms? Should there be any changes in manual therapy fellowship training? Did you do your Fellowship training before or after your shift in understanding as to the mechanisms of manual therapy and how did it affect your thoughts on the training process?

Dr Bialosky:
I did my Fellowship training while working as a clinician at Centers for Rehabilitation Services (affiliated with the University of Pittsburgh). I was very fortunate to learn from people like Tony Delitto, Dick Erhard, Rick Bowling, and many other very skilled manual therapists. Like many others, my introduction to manual therapy was through a biomechanical emphasis upon examination and treatment. I had many moments of self doubt while practicing in this manner for example, not feeling the same vertebral movement dysfunction that a co- worker insisted was present and frantically looking up a specific technique for a specific dysfunction when I was much more comfortable with another technique. Despite these limitations, I still experienced relatively good results in many of my patients on whom I used manual therapy interventions. John Childs has told this story about Dick Erhard before and I too experienced this firsthand. Dick taught a number of our courses in the advanced masters degree program at the University of Pittsburgh and provided a number of continuing education courses. During these he would teach us numerous techniques to correct numerous, specific dysfunctions. However, when you watched Dick in clinical practice he tended to use the same one or two techniques on the vast majority of his patients. So, to answer your question, I did not fully appreciate the potential for non mechanical mechanisms of manual therapy while undergoing my fellowship training; however, I had doubts about the usefulness of a strictly mechanical model and was certainly very happy to consider other potential mechanisms. To address the first part of your question, I am surprised at how little of the pain research comes from physical therapists. There are exceptions such as Kathy Sluka from the University of Iowa and Steve George from here at Florida, but for a profession that (I believe rightfully) considers itself the experts in the management of musculoskeletal pain conditions, we have contributed less to this line of research than might be expected. Clinically, we sometimes disregard pain also. I have often heard physical therapists dismiss their patient’s reports of pain with the explanation that we treat dysfunction and not pain. As physical therapists we are a profession uniquely suited to addressing both the sensory and emotional component of pain. We certainly have numerous tools at our disposal to lessen pain and are becoming more adept at interpreting the results of psychological factors on our outcomes and altering our interventions in response to relevant psychological findings. I don’t believe our entry level programs are generally quite where we should be in terms of teaching our students the most up to date information about pain; however, I feel we are improving in this regard. For our profession to succeed as a primary provider for pain conditions, it will be important that our students are provided (and clinicians incorporate) a solid, current understanding of the multiple dimensions of pain, reliable and valid ways to measure pain, the neuroplastic changes that accompany and may lead to chronic pain, and the influence of our interventions upon the multiple dimensions of pain.



SomaSimple:
At the AAOMPT keynote lecture in 2010, I recall you suggesting that the total effects of improvement after manual therapy could be attributed to a combination of natural history, placebo mechanisms, and then other mechanisms. I think you suggested that a three-arm trial might be necessary to sort these effects. Could you elaborate on this topic further and discuss study designs and processes that might answer some of these questions?

Dr Bialosky:
Numerous factors likely play a role in the outcomes associated with our interventions. For an excellent commentary on this, read an article by John Whyte and Tessa Hart, It’s More Than a Black Box; It’s a Russian Doll
Defining Rehabilitation Treatments. Am. J. Phys. Med. Rehabil. Vol. 82, No. 8. The problem with most placebo controlled studies is they compare the studied intervention to a placebo. This design allows the determination of the efficacy of the intervention in comparison to placebo; however, does not allow for the determination of the placebo effect. Changes in the placebo group (and the studied intervention for that matter) may be due to factors such as the natural history of the condition, regression to the mean, etc. A study including a manual therapy intervention, a placebo control, and a no treatment control allows comparison between the placebo and the no treatment control group for a given outcome (for example, pain). Simply put, the change in pain seen in placebo greater than the change seen in natural history is indicative of the placebo effect. For example, if the placebo group experiences a 4/10 reduction in pain and the natural history group a 2/10 reduction in pain, then the placebo effect is the equivalent of a 2/10 reduction as the other half can be accounted for by natural history. If the manual therapy group experiences a 6/10 change, then we can say that likely 2/10 of that change is indicative of changes over the time of the study (natural history), 2/10 may be attributed to placebo mechanisms, and the remaining 2/10 may be due to other mechanisms “specific” to the manual therapy intervention.



SomaSimple:
In our previous interview here with Dr. Steven George, he made this statement:
“There is some interesting data from our lab suggesting similar effects [to SMT] 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…”
Have you looked at this more closely in the lab, and what role do you see for neurodynamics as both an intervention and explanatory model in manual therapy?

Dr Bialosky:
We looked at the influence of a neurodynamic intervention on temporal summation in both healthy individuals and those with carpal tunnel syndrome. The results in healthy individuals have been published in a manuscript with Jason Beneciuk as the lead author

http://www.ncbi.nlm.nih.gov/pubmed/19487826

The results in individuals with carpal tunnel syndrome were published in a manuscript with myself as the lead author

http://www.pubmedcentral.gov/article...?artid=2864088


SomaSimple:
I read with interest your paper on spinal manipulation efficacy and expectation.
How do we go about validating a tool to measure expectation?
Do you feel this is a response mediator variable such that future trials of manual therapy should collect this and report it between groups to attempt to control for its influence?

Dr Bialosky:
One of the first issues with measuring expectation is to come to a consensus on the definition of expectation. Thompson and Sunol

http://www.ncbi.nlm.nih.gov/pubmed/7655809

have provided a model for expectation which, while intended to explain patient satisfaction, likely has merit as a starting point for clinical outcomes such as pain. Thompson and Sunol describe 4 types of expectation

Predicted (what the person believes will occur)
Ideal (what the person wants to occur)
Normative (what the person believes should occur)
Unformed (lack of a preconceived notion)

So a person presenting with low back pain rated as 8/10 may have predicted expectation achieving a pain level of 5/10 following 4 weeks of therapy; however, the person may desire (ideal expectation) 0/10 pain following 4 weeks of therapy. Additionally, the person may have undergone physical therapy for low back pain several years ago during which they received heat, ultrasound, and massage. Normative expectation may be that they will receive the same interventions for this course of rehabilitation. All of these expectations and whether or not they are met following rehabilitation have potential to affect both patient outcomes and satisfaction with treatment. This is just one model of expectation; however, it underscores the point that expectation may be multifaceted and a measurement tool may need to differentiate the constructs. Currently despite the lack of a standard definition and the use of numerous measurement tools, expectation has a fairly strong association with outcomes related to musculoskeletal pain. The variability becomes problematic in comparing the results across different trials having used different measures of expectation. I do believe expectation has a role as a response mediator for which we should account. Many of the neurophysiological effects observed in response to manual therapy are also observed in placebo studies in which expectation is manipulated. For example, a participant is provided with a placebo with the instructions the agent you are receiving has been shown to be a potent pain killer for some people. In this type of study, significant pain reduction is frequently observed in response to the placebo and similar neurophysiological responses to those observed following manual therapy have also been observed. As a result studies of the mechanisms of manual therapy which frequently use neurophysiological responses as outcome measures (such as changes in motor neuron pool excitability, changes in EMG activity, hypoalgesia) should also consider expectation as a mediator of these findings. The same is true for efficacy studies of manual therapy where differences in expectation for the studied manual therapy intervention and the comparative intervention are a potential mediator of outcomes. This may have particular pertinence in placebo controlled studies of manual therapy. A validated placebo for manual therapy does not exist and many comparative “placebos” have been included such as light touch and de- tuned modalities. Placebo related pain inhibition is particularly dependent upon expectation for the placebo. Difference in outcomes between a manual therapy intervention and a placebo de- tuned ultrasound may be mediated by differences in expectation for each intervention. Measuring expectation for competing interventions as part of our study designs will allow us to account for this potential mediator and provide valuable information regarding factors such as expectation as a potential contributory mechanism of manual therapy.


SomaSimple:
Are there any projects you are currently working on that you can share with us?

Dr Bialosky:
A benefit of working at the University of Florida is the tremendous resources and the opportunity to work with people such as Steve George and Mark Bishop who have done and continue to do some really fascinating work in the field of the mechanisms of manual therapy. We currently have 3 PhD students working with us who are all FAAOMPT plus several other PhD students with strong interests in manual therapy. We have a somewhat unique opportunity also of having established close research collaborations with pain researchers from the departments of clinical and health psychology, dentistry, and medicine. These individuals continue to provide tremendous outside insight into our sometimes narrow physical therapy/manual therapist study designs and interpretation of our findings. My current interests are primarily in placebo/expectation as a mechanism of manual therapy and I have an ongoing study looking at this. More to come in the not too distant future if recruitment continues to go well.
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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.
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Old 06-11-2010, 03:50 AM   #3
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WOW!!!

That was a fantastic read. A great thank you to Jason and Dr. Bialosky for the great question and answers. I personally will need to read those answers many times to fully digest the content fully.

Thanks again!!!

Gary
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Old 06-11-2010, 08:26 AM   #4
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Here is the file.
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Simplicity is the ultimate sophistication. L VINCI
We are to admit no more causes of natural things than such as are both true and sufficient to explain their appearances. I NEWTON

Everything should be made as simple as possible, but not a bit simpler.
If you can't explain it simply, you don't understand it well enough. Albert Einstein
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