Delving into the Complexities of Manual Therapy with Steve George

Welcome to the podcast, Steve.

Thank you, thanks for having me.

You know I really appreciate you spending some time. I know you're busy over there at Duke doing a lot of great things on the research front. I was talking with you before we had in the podcast I had met indirectly Steve through. I was going through Evidence Emotions, Fellowship, gosh. This was about 11 years ago and I was in the midst of my existential crisis that a lot of folks in the manual therapy profession and manual therapy kind of intervention scheme kind of get through where I just didn't know where the complexity of what I was trying to really figure out, what I thought was going to be through my hands, and more complexity of technique and different things. And then Steve, with Joe Bylowski, taught a how manual therapy works course and we some of us who went through that course at the time still reflect back as that being a big stimulus and a big point for us to really have an aha moment of okay, there's a lot more to manual therapy than what's happening at the tissue level underneath our fingers and why. Maybe discriminating some of these like fine dysfunctions maybe that isn't the answer and maybe it's manual therapy can still be effective, but there's a lot more to it than that. So I'm always eternally thankful to Steve for that. But we'll talk into that. But I'd like, Steve, a lot of folks have heard of you but I'd love if you could introduce yourself to the audience a little bit of your background and maybe even how manual therapy was part of that journey.

Sure, and thanks again for having me and I'm, you know, glad that that course was, was helpful. It's always interesting, you know, when you do something and kind of shoot it out into space, which EIM was one of the early adopters of, you know, remote learning, so it's nice to know it landed at least on a few people, probably mostly the stuff Joel taught. But I'll, you know I'll take credit for it. So as, by way of introduction, you know, I'm trained clinically as a physical therapist. I did work for about seven years full time in various practice settings. I kind of settled into outpatient orthopedics and all my practice was in Pittsburgh at the University of Pittsburgh Medical System. That's actually interesting, lee. Where I cross pass with Joel, you already mentioned, he and I were on the same sports medicine team. We also were on the same softball team so, and I did some of my master's training with Joel, which was heavily influenced with manual therapy. At that time Dr Earhard, also known as Dr E, was at Pitt and you know he was doing a lot of instruction. So I was, I was kind of at that point able to, you know, go to a weekend course and then do right away. You know, what we learned that weekend in my practice. So I definitely started off with a very similar background of. You know there's these 30 techniques I learned over the weekend. I better become proficient in all of them and you know that was kind of in the air. So I transitioned from, you know, practice career to research career and that part of that transition was moving to the University of Florida and doing the postdoctoral research fellowship and that was interesting because I was moving from a very like heavy PT rehab community to a pain research community and you know I was very fortunate to make that transition. I always tell people this was, this was before. Anyone thought studying pain for your career was, you know, a slam dunk or an important part. There was the opioid crisis wasn't apparent. Yet this is early 2000s. I moved to Florida in 2002. And I remember a lot of people just saying, oh, that's interesting, I didn't even know there was this pain science or pain pain research. And I got to work with some of the leaders in the field at the time. And there's still the leaders now, people like Mike Robinson who is a clinical psychologist, and Roger Philanjim, and Don Price was there who was a neuroscientist, and you know really, really influential people in pain research, role in STOT as a rheumatologist and notice I'm saying what their kind of clinical or their training was, because none of them were PTs. So it was really unique opportunity to bring a physical therapist perspective to a very, you know, very established pain research group. And one of the things you know that kind of naturally kind of bubbled to the surface was well, what's going on with manual therapy then from a pain, you know, research perspective? And Joel's paper that you know kind of outlined an updated model of manual therapy was really the result of us, meaning people like Joel and I and you know other PTs trying to communicate what we thought manual therapy did to a completely different audience. And that paper was developed for selfish purposes. It was to get us at his dissertation committee on the same ground. Basically, little did we know that a lot of other people, I think. Like you said, we're at this stage where you know what is really going on. So this paper and I don't want to call it a throwaway but it, you know we sent it for review and it got reviewed and it got published. And you know, about three or four years later, all of a sudden people were just very interested in that. You know, in that model and I think it's a good example of kind of. You know, probably the manual therapy crowd had focused a lot on clinical training. I would dare I say a lot of the communication was probably one way. You know, this is how you do it and this is what you should be feeling. And you know, and this was the first time where we had been kind of put on an island and now we're trying to tell, you know, this leading neuroscientist and the psychologist what's going on. And they basically didn't believe that it was all. You know, that interface and they helped us to expand into and really thinking you know what's going on perfectly, what's going on centrally. You know, what does that movement of the joint really do? You know if it's not, if it's not fixing something, you know what is it really doing. So that's kind of where we got to the point. And then you know, when we were doing the thing with evidence and motion, basically it was us getting a chance to practice explaining to physical therapists that model, because we had, you know, now we're in the reverse problem where we could explain it to pain researchers, but for some PTs that was blasphemy. You know that was. We were basically I don't know if you remember, but the initial thing that everybody trains and trains on was like a box and it was. It was like stimulus, you know, a stimulus either to the muscle, the joint or the nerve, and it turns out. You know that's not an underestimation of how you know specific can people be? I think people can be a little more specific than that, but it's a good way to think of it. It's like I'm applying this stimulus manually, I have a target tissue in mind and but then there's all going to be all these other things that potentially happen. And maybe it does matter how I talk to the person about this. Maybe it's. You know, I'm not a surgeon, the person's not anesthetized and I'm not going in there and doing my thing and then leaving. You know the way I'm doing it, their perception of it, their mood that day, all of those things can impact. So so that you know, that's a little bit of expanded version of what was going on in Florida, but really what was also was happening is I was becoming part of the pain research community and then and very thankful for people like Kathleen Sluca, who really was a physical therapist, who, I think in the US, was one of the first people in that space and she was very welcoming with my work, the early work that was kind of getting my C legs, and I was also very lucky that the people at Florida introduced me to, you know, the ISP, the International Association for Study Pain, and the American Pain Society at the time, which is now the United States Association for the Study Pain. So you know it was starting to get get indoctrinated in what pain research was. And then you fast forward, 10 years later, you know, to the IOM report on the blueprint for pain relief and now everybody's admitting this is a chronic pain problem. And then the same people who were patting me on the head and saying, oh that's cute, you're studying pain, you know we're like, oh wow, that was such great foresight of yours and it really wasn't, I was just curious about it. But it was a right time, right place situation for me. So and then you know I worked with some great colleagues Joel we've mentioned Joel a couple of times. He gets a lot of airtime, so I'm going to have to make sure, you know I get some royalties from him and Mark Bishop you know where some of the other PTs and Jason Benichick you said you want to talk about stratified care and Trevor Lenz, who's someone who works with a Duke. You know we just had a really nice group of mostly physical therapists that were interested in their own questions and moving these along. So sorry if I got a little bit, you know, stuck on the menial therapy, but you primed me so I, you know I, stayed there a little bit.

Yeah, no, that's that's. We'll stay there a little bit longer because I think there's some things that maybe unpack a little bit with that publication and kind of you guys discussing you know a lot more than just tissue level type of facts and I definitely would agree it's, you know, a stimulus that we can try to be somewhat targeted, as much as we can be, but that really went against, maybe, the thinking at the time. It was probably a little bit, maybe even controversial for some systems that were still very entrenched in the very specific. I'm wondering did you face any significant blowback or criticisms for that work? I mean, obviously all research gets a little bit of some constructive criticism. I'm just curious what your experience was as you were kind of introducing this to the manual therapy community, and what kind of the response was.

I think it was almost. There's probably three categories. One was people like you who are like this makes sense and almost a liberating feeling. I don't have to have all these elaborate stories that I know maybe have a biomechanical basis but geez, they seem like tall tails and looking back on them that this goes this way, this rotates this way and all of that. I kind of also joke that I always had a hard time with those when I was doing my manual therapy training. Maybe this is just my frustration, the result of my frustration. I struggled with some of those concepts because they kind of assumed everything was happening in a vacuum at that segment. As we know, that's not how it happened. There was a group that I think, like me, kind of found this was liberating. There's a course of group that ignores it because they're just plowing ahead. It's like, hey, I got to treat 15 patients today. That's nice, you published something. I'm not interested. Then there was a group that and no one contacted me directly, but I did hear we at Gainesville were not too far from one of the centers of manual therapy training. I did hear through other people that there were some comments made that this isn't representative of what we're doing. I do think it does threaten the training model because it indirectly suggests you don't need a ton of really focused specific training to be effective at manual therapy. I think the data kind of supports that, to the model's credit. I kind of think of it as three different approaches. I do think through the test of time, I think that paper was published in 2008, and they asked us to do an update about five or six years ago. When we looked at it, largely we thought, yeah, we can update this, but we don't have to. This is not going back to the drawing board type of moment. This is a chance to refine. We talked about the different zones because I think that helps people think about it clinically. The first one, I think, was a little more mechanistic because of who we were talking to. It was also done before. There was as many FMRI studies as there are now and pain. There were some things we could update and maybe be a little more specific of the brain regions that were active and things like that. Largely, it stood up. I think that's what has happened is probably more people have seen this as an opportunity to feel unshackled a little bit. This is, like you said, not to disparage manual therapy at all. It just moves it into a different management model and the way that you can apply it and the way you can use it to benefit people, which is the ultimate goal. The ultimate goal isn't for the provider to have 78 different ways they can move the joint. The ultimate goal is to say I think I'm going to do this, I think it'll give us opportunities for you to be more active later. I think that's the best thing for you to have long-term pain release.

It was interesting just to see, I think, seeing some of the reactions just in my clinical world and folks that I've seen practice. There was this sum and I might even have got a little bit. This is why manual therapy is not and obviously there's the manual therapy sucks and all those different things that were going on online. People took it so far to that, hey, we don't even need to do manual therapy, it's not worthwhile. But you bring up some good points. It just gives us. Manual therapy can still be helpful. We just need to consider the wider context of what's driving some of these outcomes. Again, if it's part of a journey to get someone to active self-management and things, it can definitely still be a valued part of it, especially if patients have found positive experiences and have positive expectations and things. There's nothing.

It's short-term pain modulation. It's an opportunity for that. I think that there is the danger of over-utilizing it, but I also don't think that means you take it off the board. If someone comes in and they're in a lot of pain and they're an obvious candidate, you know, for a good chunk of these people they're going to feel a lot better. If I do a thrust technique, why would I consciously step back and say they got to figure this out or we got to do something more active? For me it's always been that's a good way. It also helps to build the therapeutic alliance and I think helps to, like you said, now we've built some trust and now it can lead into some other strategies that we know probably are better used for long-term. You don't have to come into clinic to receive. There's some ways to use that to move forward.

Now this is a big question, Of course. You wrote entire papers and did a boatload of research on this. I'm asking you to summarize something that's a bit complex, but I'm wondering if you can discuss where you feel those kind of the mechanisms, maybe the zones of effect of manual therapy, and kind of your view on kind of what's driving some of the change. Obviously, we don't have the perfect ability to perfectly quantify that, but I would love to hear your kind of thoughts on kind of summarizing that.

I mean, I think and a lot of this is driven by the experiments that we've done I think one of the things that we saw that was really interesting and frustrating, but also frustrating Joel did these studies following his dissertation. We were consistently seeing differences in manual therapy and placebo, kind of at the peripheral level we would do some measures of pain sensitivity and the real manual therapy. There was a debate even what is a placebo for manual therapy. We don't need to get into that, but basically we were using techniques that you would see in a textbook and then we were using techniques that were much closer, just to kind of like hands-on. We would see larger changes in the pain sensitivity that were a lot of people thought were more mediated at the spinal cord level. We use some of the temporal summation. I don't want to use too much jargon, but it was really interesting because there was a couple studies where we just there was a difference and it looked like that input was doing something very locally. But then we were either smart or dumb enough to also do the clinical pain ratings. And guess what, when we did the clinical pain ratings, the placebo and the manual therapy were much closer together. So I think that helps us to understand a couple things. One, it's there probably is a difference between the two. So, yes, these the folks who say it's just, I could do anything no, there are some differences between active techniques and just touching your hands, at least at the level where we're measuring with pain sensitivity. Where those folks become a little more correct is now, if I'm measuring the pain outcomes, we will see more similarities and for that that opened up this channel of there's probably multiple avenues for people to improve and I think one of the large ones is that you know the expectation that you've received treatment and it's not like that's the only thing you're going to do, and all of the activities after that, even without that kind of local inhibition, you know the there's all those other pathways in the cortical that are being activated. So you know, I think of it as there's this kind of local potential for hypo-logyseia, pain reduction, whatever you want to call it. We've also seen and others have seen you can probably increase that, you know, by with instructional sets or providing some positive input. But that alone, you know, doesn't push you ahead. You still need to have other things that are going on that engage. You know those, those different zones and I think you know the way we communicate with people is really important. One of the studies that we did as part of Joel's dissertation progression was using different instructional sets and one was a positive, one was a neutral, one was a negative and we couldn't do that in clinic. These were with healthy volunteers but we had we've seen the same responses in healthy and people with pain. So this was a study ethically that would be hard to do in a clinic because you can't randomize someone to get an. I mean you can, but the IRB will have ethical concerns and you'll have to have debriefing. So you know, we're like we'll just study this in healthy people. And it was really interesting because almost all of our studies show that short term pain relief, except for the people who got the negative expectation set. So it shows that even that local part can be, you know, overridden by the other. You know the, the cortical centers, and if you change someone's expectations, that, ooh, we're not sure if this is going to. In fact we think it might make your pain worse. You know that is going to affect the way the pain is perceived.

You know, and it's so resonates just as far as the experience you have in clinic. I remember just coming up as a manual therapy trainer or trainee, I should say and having mentors who, God, I felt like I did the technique in the same way, Like mechanically, I delivered it very similarly yet got diametrically different results. And then I, you know, stepping back and then looking at the 10,000 foot view, Well, and how I look at like a lot of you know very good manual therapy clinicians, they're masters of the ritual of this thing. They can portray it. But, yeah, what are your thoughts on the whole ritualistic components to it?

Well, I think it's important. But I think it also probably led those folks to overestimate the effects of manual therapy because, like you said and again I'm not meeting to, like you know, I learned from them. I learned the techniques but, like you said, it was almost like they had like the professional wrestler mystique, some of them in the like the old days where they would come in, you know, to do a weekend training, you know, take their cape off, and it was just, very, like you said, the ritual part of it and and it's like, give me your hardest person and you know, and then they would get. So I think it was. They were supremely confident. They were better skilled too. I'm not, I'm not saying that my skill level was anywhere close to theirs, but I think the combination of those two if I'm betting on it, you know, I think the big driver was probably their, their overall confidence. And you know, one of the things when we're doing that expectation study, as we realized, those people who've been doing it for so long they never use even a neutral instructional set. They're telling this is exactly what you need. You know this is misaligned with this. You're so lucky you came to see me because I picked this up and you're even luckier because I know exactly what to do to fix it and we're going to do it. Now, take off my cape. You know I'm exaggerating a little bit. You know, hue the fireworks. You know let's get ready to rumble, then it goes. But you know, I'm obviously hopefully for your, for the subscribers, you know, playing this up a little bit, but it's to make the point that you just did that. They, they do, they leaned into that ritual and I wonder if it was because the reinforcement was there. They knew that's going to be part of getting a strong response. Now, contrast it with you and I, who are the poor. You know, we're like shaking and we're like, you know, I hope this works and the person's kind of like is this your first time doing it? And it's like well, do I tell them the truth or do I do you know? so that you know. Those two presentations are very different.

Yeah, no, completely agree it. It and again, it liberates a lot of the young trainees of like you know that it's some sort of I know for me I falsely went on this diet. Well, I just got to go on the JIT I pursued man, I got to figure this thing out through my fingertips and maybe I just can't discriminate those millimeters. And then, stepping back your research, and others say, hey, it still has a place, again, not to, we're not throwing things out, but it's just we need to. We need to pump the brakes on. You know, some of the mechanisms and some of the theorizing of what we can do with our hands, but putting it in a perspective that if it again, if it moves a person in a positive direction, it can be part of the journey. But yeah, the, the wrestling analogy, I like it. I'm gonna have to have to use that very early clinical experiences.

Before I was gonna you know, before I even knew I was going to do research went to a Maitland course and we they used to bring people in very well known people in to pit and they would train everyone instead of sending people out. So they were like you know what? It's more efficient, let's bring in the best and then we'll have weekend courses. So I was exposed to a lot and I don't even remember the instructor, it's not important, just that they were. They were all in on Maitland and we spent the first like four hours doing grade one mobilizations and the only feedback this person would give was grade one is strong enough to bend the needs of a fly. And I, I heard that enough and I finally just said what does that mean? Like, tell me, like, how hard is that? Like is it a big flies at a little fly? And he looked at me and he said it's just what you need to bend the needs of a fly. And that, like that's the perfect answer for Jedi, right? Because now I'm supposed to go and think about this. But I had spent four hours doing grade one mobilizations, which sure as hell didn't see much different than the grade of one mobilizations and I just left. I just couldn't take it anymore. But that's like you said, that for some people they're gonna, and I don't think it's their fault, I think you know, here's this person, they're revered, they're brought in, but I just I had a bad reaction to that and again, that might have been something. But you know, I guess I was hoping for a little more guidance than bending the knees of a fly. And when I asked for it as a learner and didn't get it, it, it it was dissatisfied.

Yeah, I've had similar sour taste in my mouth from from some of the explanatory models look begging for depth and some more logical explanatory models and and then sometimes it just fallen flat in that effect. But again, I think you know we're looking big picture. We're seeing some of the contextual, ritualistic things which aren't necessarily bad. It's just recognized, they're part of the gig and it's part of why your, your mentors and things are having these great outcomes. Doesn't mean you're deficient as a clinician. I mean I I was at the point where I was ready to quit, like I just can't do this thing. I'm just I can't. I can't just like have been in flies knees and making things magically improve. It made no sense to me.

And I will say, like Dr Earhart, you know he was to me, was a kind of a hybrid. He was fluent in all of the the prior language, but he understood. A new kind of approach was needed, because even he, you know, when we would talk to him he would kind of give us the traditional and then he would kind of give his little spin on it. So that definitely, you know, we could see his. His mind was kind of in both, both worlds. And you know, joel and I have talked about that, that, that it was nice, that he was at least open minded enough to let us peek behind the curtain every now and then and even for him to say you know, I know we taught you seven techniques to do the upper cervical, but this, these are the two that I really mostly do and I can't tell you, you know why this, you know why we don't need the other five. So I do think he was, he was definitely in that transition zone where you know, like I said, kind of grateful for that. But he also knew, you know he knew the traditional part too, because that's what, that's how he was trained and you know he was revered. So he was in, he was in that kind of you know, wrestling persona for some people, for us he was just Dr E. I mean, we had everyday access to him and you know not that we abuse that, but we, we we had a lot of conversations with him, you know, in clinics and things like that. He would let you he had a spine clinic If you had a patient you're having trouble with, you know, he would let you because it was the same health system refer the patient to him and then you could come and watch and talk to him about it and that. That's. That was pretty cool, you know, for someone two years out of PT school to be able to do that.

Yeah, no, that's a, you know, that's awesome experience, you know one, that that mentorship piece like that, and then having somebody to help translate the past to the present. You know, okay, this is what we're saying in the past, but and let's, let's translate to what science is saying and kind of being able to, you know, give you a good perspective on both, maybe the traditional view and maybe you know he'd be in on the right forefront of of seeing. Okay, we got to look bigger picture. You know, I need to kind of update my explanatory models of what's going on here. So, yeah, great to have folks like that in your world clinically to maybe get your feet a little bit more stable on the ground as it kind of constantly gets questioned and different things as you're trying to figure things out. But I'd like to switch gears a little bit because we had talked before about touching upon stratified care. There was the initial, you know, start back in Jonathan Hill's group where there were some pretty promising results of like the start back tool where we would go from low to medium to high risk and stratified care based on, you know, those ratings on the start back, where you know high levels of distress, you know the high categorization where there's. You know we needed psychos, so you know psychology or behavioral health services along with PT and things. And then you know low risk folks would you know, maybe just need traditional PT on its own and then the research trying to replicate it. I know you were part of Dan Rohn's study that recently came out in JAMA. You published a commentary in pain and we'll link all this stuff in the show now so you all can take a peek at those. But I'm wondering maybe if you can kind of give us a little bit of a rundown of kind of the journey of stratified care from where it started to maybe where it's at now with some of these recent studies and some of your commentaries on it.

So you know, stratified care I was first introduced to it and, again, right place, right time theme permeates Now, you know, need something to do in my spare time other than manual therapy. So I was, I guess, lucky enough to review the first start back paper. That was the prognostic paper and I had been using the Fairboyd Speliefs questionnaire and actually published a trial in 2008 where we, you know, we were looking at people with high and low beliefs and whether they did better with graded exposure, and one of the people reviewing the trial said you really should be using the start back tool. And you know our response was that's great. You know it wasn't available when we were planning the trial. So then I got a chance to review the paper and it was a very you know, I can see why it took off, even in reviewing that paper. So one of the things I thought is we need to study this and had another PT who was doing his PhD with PE, jason Benichick, who, by the way, came in and really wanted to do some manual therapy stuff and but he was also getting an MPH. So he and I sat down one day and just talked and I said you know, if you're getting an MPH, you might want to think a little more. You know broadly about what your dissertation is. Here's this new tool that's going to be published, what do you think? So he, over at Brooks and Jacksonville, started collecting some of the first start back data in the US, as best I can tell. So we looked at it and, sure enough, you know it had good prognostic abilities. So we started thinking like how do we apply this in treatment? And we did an early trial over at Brooks where we trained some PTs and then monitored their patient outcomes. And lo and behold, the PTs that we trained in risk stratified care, their patients did have better outcomes, especially for disability, so that that matched the start back trial. So we, you know, we're like maybe this is the way to go. Now what has happened since is? You know I was lucky enough to be part of the target trial team. You know that trial did not find results. There was another trial in the US, the match trial. That didn't. That that had part of the Kiel team to help training and it didn't find any positive results. Then the Danes you know there was a. There was a SIST study in the day Excuse me in Denmark's health system didn't find differences. And, dan, you know, all along Dan had been running Dan Rohn, as you mentioned, he's the lead of that. He brought in Jason and I to do the training for the military study. And the military study I was really interested in because the military has a lot of resources for behavioral health. So it's not like when you do these in the private setting where you know you have to get a referral date. They have a lot of resources and, dan, you know, part of the study was making sure the high risk folks had, you know, good access to those. And then you know that study ended up being all the commentary was a stratified care study in whiplash and it was null. So, yeah, you know, yeah, I think my thoughts on stratified care have changed a little bit. But maybe, instead of changing, maybe they've been distilled where, prognostically definitely you'll see differences based on high, medium, low and that's kind of the shooting fish in the barrel part. You know we've known that for a long time. But that tool is a very concise and effective way to see that stratification, the response to the treatment. We have seen a few proof of concepts but you know the ability to propagate that is challenging and then it boils down to and what I tried to talk about in the commentary it really boils down to the training burden. It's surprisingly hard for health systems sometimes to get the right patient to the right person at the right time. So you know, you have this. What sounds simple on paper of like, well, I'm screening someone at primary care, the high risk people need to go to PTs who have received additional training to deliver psychologically informed care. Well, that I mean for a health, for you know, for the same kind of universe that created a COVID vaccine in record time, that seems like we should be able to do that. It's surprisingly challenging when you get in there and start doing these especially pragmatic trials. And then what do you do when half the therapist you train change jobs in a year, you know. And then what do you do when the other half of the therapists are saying you don't need to do this stuff? You know there's. So you know, I don't know that I would say it's dead, but I do think it. The the efficacy, effectiveness contrast in risk stratified care is larger than you see in some other things and I think it's due to the challenges of, like I said, it's a multi step and then the intervention you apply. It's not an easy intervention to apply and oh, by the way, the high risk patients also, you know, are more likely not to show their, you know it's. These are not the types of patients that are really giddy to get their 18 pt visits in. So and and rightfully so, I mean, these are people that the health system hasn't helped, you know they have pain, their beliefs about pain there's. So, you know, I tried to get for the people are listening. This probably is an incentive to read the commentary, but, trust me, it's a lot more concise the thoughts. But I do think it is. You know, if, if, if, we really like that model, it has to be done in a way where it's fully embraced, and I think that's why the first trial worked. I mean, jonathan, you know they, they had it was in an integrated health system very strong support, an excellent training model, you know. So I think that's hard been harder to get in in the follow up trials and maybe, maybe, they underestimated you know people like me underestimated what that training burden was going to be like. I will say, in Dan's trial, you know, the other thing is well, are you even applying the treatment. You know, in Dan's trial we did not see differences in the primary endpoints, but there was some evidence in his trial that the risk stratified care was applied because we did see some decreases in psychological distress. So we didn't have that in the target trial. So, you know, it did seem like we were getting some of the treatments to them. And then the other thing I wonder and I mentioned this briefly in the commentary maybe, maybe unbeknownst to us. You know, maybe usual care is getting better, maybe people are paying attention to these guidelines. You know, the start back trial was published in 2011. We're 12 years later. You know, the American College of Physicians, really, the guidelines that change things were published in 2009. Like, when I say change things, they were the ones who kind of really leaned into, you know, frontline, non-pharma and stuff like that, and it's been about 15 years. Maybe, maybe usual care is getting better, maybe that's something as researchers, you know, we've always kind of been able to assume usual care is not good. But maybe, maybe people are paying attention to those practice guidelines. And that's something, you know, as I was thinking about, and you know I don't know how to test that, but you know that could be the other possibility.

Yeah, no good points. You bring up the training burden. We had Peter O'Sullivan on and Peter Kent of the Restore Back Trial a few episodes ago and they have a very intense training. I mean 40 hours I think it was, which is impressive, but it'll be interesting to see. Obviously there are more geared towards helping that medium to high-risk group. We navigate things a little bit more effectively. And then, you know, can we? Because, I agree, I think there's a lot of systemic barriers to where you have a system where it's not that nice neat identification and get to. I used to practice at the Mayo Clinic and it's an amazing place. Some of the amazing world's best, you know, biomedical innovations have happened there and we're grateful for it. But it is a very long, winding path. Of all of us you can see there at Mayo, where it's not maybe this nice, with a lot of differing opinions and differing labels on what's going on, all private pathologizing, the same forest but with their unique tree, look at it. But yeah, so you bring up some good points on that for sure I think.

Yeah, wouldn't it be interesting if, like CFT works in Australia and risk stratified care works in the UK? You know, and maybe some of these things are like much more system dependent and the willingness you know to accept training For the target trial we wanted to train longer, but the funding agency wanted it to be pragmatic so they wanted it to fit in a traditional one day CEU course. If Pete was on here, peter Selden, he'd say that's completely insufficient and I would say you're probably right, but we don't have the models in the US to give people, you know, 40 hours of training if they're and I'm not saying one is right or wrong, but I'm just saying that you know that is that's an issue.

Yeah, just a reality of what we're facing. I mean, they had, you know, mentors. They had sessions, like you had with Dr Eve, where they could have trouble with patients, and then they had, you know, direct supervision of folks watching their encounters and helping them in the midst of it, which I would. I told Peter that I, you know, I want to be in that, that camp, that trial, just for the sure learning opportunity, let alone, obviously, being better able to help patients with some of the stuff. So, yeah, there are definite challenges and I agree it would be fascinating to see what are the, what are the approaches that might best fit the system, versus maybe thinking one approach works across all systems, because we're seeing that challenge and it's not really materializing.

And each of those countries have different cultures too and thoughts, you know, and you know, I think, for things like back pain that may matter. I mean, that's kind of it's hard sometimes to fathom because people think, oh, back pain in Australia. But there may be some differences that you know. We are just kind of becoming aware of.

No, 100%. I mean, I just remember reading some of the studies of when Western medicine was introduced to some of these populations indigenous, or populations where you know, I think it was Aboriginal, if I remember when I first read some of the research, and how back pain got way worse once Western medicine things came about. So, yeah, there's definitive cultural components to that experience, and how we define it and how we kind of look at it culturally is definitely an impact for sure. I wanted to talk a little bit. I really enjoyed your lecture in 2017, the Mealy lecture really was a good one to kind of talk about some of the pain management, the roadmap to revolution, and we'll link it in the show notes. You can watch it, I think it's on YouTube, and then there's a, I think, a dictation of it online as well. I'm wondering your thoughts, maybe kind of looking at that roadmap that you were talking about in 2017 and you've been a big part of. You know physios journey, you know improving our journey and maybe better you know, help informing our journey, as we're better trying to understand pain and where does it fit and, as we've talked today, within the context of a manual therapy intervention. How does this all kind of come together. I'm curious if you can maybe discuss kind of that, your roadmap view and where you think we're at and where you'd like to see us go, and maybe if you think we're following a good roadmap at the moment.

Thanks. I think you know it'll be interesting to see. Is that ages, if it, you know, if it stands up. But I've had a few people say, you know, they still use at least parts of it. The tattoo artist always seems to be an interesting one. But you know, I think my view of the roadmap is a little different, so that that lecture and looking back was really kind of the book, the bookends I mentioned. You know I'm introduced to the Pain Research Committee in 2002 and then 2016,. 17 get a chance to do this lecture and that was kind of the bookends of my pain research time at Florida because then I moved up to Duke shortly after that and I think it encapsulates, like you said, that during that time there was a change in PT's physios from being interested in it to, you know, participating in it to now it was like the expectation is we know, you know we want to be a legitimate kind of player in this pain management space, especially the non-pharma. So you know my view on the roadmap now is in a parallel is what we talked about with risk stratified care. There's enough content out there, you know. There's enough of people that have models. You know, pain neuroscience education really took off. Like you said, the CFT approach. What I see kind of lacking when we go and do we try to do like embedded pragmatic trials, is it still is not trickled down, you know, to everyday practice in a way that you know. If I randomly picked, did a survey of 100 people who received PT today, I think it's probably better than it would have been 10 years ago with some of the things, but I don't think it's where, like the APTA markets, you know how we do with pain. So in a way it's encouraging because I think it's moving in the right direction. But I do think, as a researcher, constantly reminded of the limited reach of our work. That's why it's nice to come and talk to people who are willing to help disseminate this information in different ways and forms. This is a researcher, you know. I'm not trained to think of this. You know disseminating my information the same way you are. So it's nice to be able to talk to someone who has an understanding of what we've done but also has a much broader audience and reach than I ever could have. So I think, you know, part of the next part of that roadmap would be, I think, to be more maybe strategic about some of those plans. I do get a little frustrated that as physios, especially in the US, we tend to reinvent the wheel. I do get a little frustrated that there's not more understanding and appreciation and partnership with organizations like ISP, like why do we have to recreate our own pain tool kits when they've been available for 10 years and we're developed by international physios? Like why does the US have to develop their own you know and kits? I worry sometimes too that we're recreating some of the problems in the past by creating some of our own lingo around pain instead of again kind of embracing the international approaches to things. But overall I think, and I do think the academic programs have done a good job. A lot of them have found room in their curricula to have more dedicated education. I don't see that happening as much like with physicians and other. So I do think you know this. When I talk to DPT students now, which is in as much as I did when in Florida, like before they're going out to practice, they know a lot about pain, pain science and I'd like to think that's an advantage. Where it becomes a problem is when they bump into their clinical mentor who maybe doesn't, and we know that, unfortunately, the clinical mentoring tends to override the didactic. So you know, I think giving the new trainees the confidence that you know this is relatively new material and you know, not all CIs are going to keep up. You know not all the clinical instructors are going to keep up on things. So I think, you know, I think some progress has been made. I think it would be fun to revisit that maybe in 10 years and see, like, where we need to go. One of my goals which hasn't happened is also to get in the US. The way, and you know, the way like the APTA thinks about things is in its academies they used to be sections and I really think they're things that should cut across and pain is one of them because ortho you know the ortho academy really they put a lot of time and resources into pain and but that kind of creates the impression that, a only orthopedic patients have pain, which we know is just wrong, and, b, that you know that it's not something that's in the wheelhouse of every physical therapist. So you know, one of my goals would be let's not just think of pain as like a special interest group, like why isn't pain considered in cardiovascular? Do people have chest pain? Yes, does it sometimes indicate, you know, a serious problem? Yes, but it also a lot of times just, you know there's a lot of interesting things with visceral pain and cardiac pain. You know I have an emergency room colleague and that that would be a really fascinating research project is helping people understand, you know, when chest pain is truly benign. Pts could have a role in that. You know neuro pain, you know people understand stroke, spinal cord injury, so you can see it kind of cutting across. But we tend to partition it and it. And you know I've had conversations with people like how can on one hand we say choose first, and then when we look structurally at our, you know, professional society, that thing we're choosing first is the special interest group of one academy, like how is that installing? You know, how's that kind of showing that our structure reflects that choose first part? So maybe, you know, maybe there'll be some opportunities to align that a little bit better.

Yeah, no, I completely agree. I think pain is not an ortho section only or ortho academy only issue it. You know, haven't my wife's a cardiovascular specialist or CCS and through the APTA and definitely deals with some pain and different things in that realm and we're trying to at Midwestern University, trying to incorporate throughout curriculum as far as yeah, it's because it is, it's not just a unique, I think neuro geriatric there's just so many, you know applications and it exists across. It doesn't just coordinate pain, doesn't coordinate itself off to one one body section or yeah.

And the way the APTA would suggest we handle that now is each of those components have like a SIG and each of them would have their own little meetings and they would talk and but you know, really it needs to be, you know, going more horizontal than than just straight that way. So but I, you know I, so that those are the things I think about, you know, reflecting on the, the melee lecture, which was, you know, an incredible opportunity. I had a great team help me put it together. As you can hopefully tell, we had some fun with it, but you know, it also a lot of it's resonated with a lot of people and we've received positive feedback from that. And that's, you know, for a lot of people. That's still, for me, if you're one looking for one, stop shopping. That's not a bad place to go.

Yeah, yeah, it's packed full of good resources and a good talk and, like I said, we'll link it in the show notes so people can watch it. One last question as a researcher and with your experience, with all the great things you've been talking about so far in the podcast today, what are the biggest questions you think that linger out there? I know we've spoke to some about, you know, Manure Therapy, Stratified Care. Maybe those are the questions that we haven't discussed yet, that you're thinking about, but what questions do you think we need to ask and hopefully answer to better help? You know, pain care, be it physio or maybe across health systems?

Yeah, I think you know one of the things each kind of field has, you know their holy grail questions. And the one that is really intriguing to me is the acute to chronic pain transition. I think you know, I think I've been part of a group that has helped to understand, like what the psychological part of that is, but it's not the only part. So I'm really interested to see you know what's going on and how can we take what we know with the psychological and now do we add, like, what are going to be the biologic contributors, what are going to be the social determinant contributors, and can we really put that together? And one of our colleagues here at Duke, adam Good, you know he's been working a lot on that acute to chronic transition and really I think has some interesting directions that maybe we'll go looking at some of the biologic parts of it. You know the biomarkers and things and that's really an area I'm intrigued because, like I said, I've spent a lot of my time in that psychological realm. So I think you know that is one area that I'm really interested in. And then, I think you know, can we get to the point where we can truly kind of individualize either someone's prognosis or you know their pain profile for like what are things you will respond? Like, what are the things you're likely to respond well to, what are the things that maybe you should avoid? You know, right now we kind of do that by trial and error but it would be nice to have you know people have done that nutrition. They've done that in exercise. You know people take a lot of different. You know you, the elite athletes now they get a blood test, they see what they're lactate. You know there's, there's a lot of things where is in the past it was and I feel like where. That's where we are still in pain a little bit, where you know you find out when you've exercised too much, when you exercise too much.

So what are your thoughts on AI, possibly contributing to this? You know I've talked to other clinicians are talking to. Could those models help us maybe gather and make sense of all these complex data points? My concern is, like you're never going to substitute the unique human relationship in those nonspecific contextuals that an AI interface may not be able to provide to somebody. But what are your thoughts on maybe with that? Do you think that's seen as you see that being helpful at all, or is it something you've considered or seen considered?

I think it'll be helpful, but maybe not in the ways that people think. You know I I've been exposed to AI more on a conceptual level. There's a lot of interest, obviously everywhere. Duke has a strong like AI health science team, and they, you know, there's the folks that are working on the math part of it, and that part I don't pretend to understand. There's a small part of me that was like I was decent in math in high school. It's like it would be fun to go back, but then it's like no, it wouldn't. But conceptually, you know, ai is best when it can get a lot of convergence right. So when, as an example, we're working with an AI health fellow who's she's developing like deep learning for measuring hip knee angle pre and post arthroplasty, so that would be something that right now, you know the surgeons have to do. Excuse me, we have an arthroplasty team, and you know she's part of it, and this would be a big help and it probably would be more accurate. It was something that could be done, which would allow the surgeons to either spend more time with the patients, see more, you know. The nice thing about that, though, is it's a closed system, a lot of convergence. When I see some of the things that we've been talking about, you know, this kind of links to my very high variability. Like AI is not is going to be as good with that, because it it's going to have trouble with the learning because it would not like that. You know, when I take a 47 degrees Celsius temperature threshold, you know, and put it on your arm, which is what we've done tons of times, my understanding, and at least in this generation of AI, is that would be trained to expect a certain response. Well, I know I'm going to get zero to 100 ratings because I've done it and other people have done it and that's one of the things, by the way, that is the same in Australia, europe, you know, uk and the US. Is that that variability and that pain rating? I don't know. You know, conceptually, I don't think that's the best fit for AI right now. So, you know, if it's AI looking a lot like automating, scoring of questionnaires, you know, getting standard information and consolidating a profile, like I do, I think AI would be great for red flag screening. Yeah, I do, because I think you can ask the same set of questions. There's probably a certain set that indicates this person needs, you know, to be considered at higher risk, but do I think AI is going to say, well, this person needs four sessions of manual therapy, follow, you know, I think it actually can tell you that, but I, like you said, I don't think. I don't think that's it, that's not how it's trained, because it's going to be so divergent. So that's, you know, my long way of saying I think this generation of AI, the learning that's occurring, is going to be best suited for, you know, things that converge and that's how would be my guidance. So, for clinicians that are looking to jump on it, and things like note writing, yeah, you know I would always want to have a section that I can personalize it, but, yeah, there's parts of the note that probably voice to text, the AI would knock it out and would be better note than I would write, but I'm going to make sure I always read it and be you know, I want to have some areas that, like you said, when it's outside of what the algorithm thinks, you know that I have the opportunity to update that.

The APDA just had, I think, the Health Innovation Summit. One of our clinicians at Midwestern just went to it and the AI was a big topic and discussion, especially on the documentation front, which I will freely admit it is not the most enjoyed part of my day. Most clinicians I don't think it's the most enjoyed part of their day.

I'm a compliant documenter but begrudgingly with all the yeah, I mean you'd be an account accountant, right, if that was the most. There are people that enjoy that documentation part, but most of them, I don't think, drift towards PT as a profession.

Yeah, that would not be their chosen craft for sure. Well, steve, I wanted to thank you again for your time today. I really appreciate it and also just thank you for all the work you've been doing and helping us better understand this thing.

So let's not wait ten years to interface again. You know that let's make sure we cross pass.

Absolutely, we'll have to. I know I'll be at some conferences. I know you're always at the APTA conferences, so I'll have to grab a coffee or something and chat.

Yeah, february and Boston coffee sounds good. You know it won't be warm, that's for sure. The coffee will be warm. The weather may not be warm.

Yeah, that's always my. I wish the APTA would stay self, but you know I get it. We gotta go up to other, spread our wings and let other folks parts of the country get a little bit of the pub, but I sure don't mind when it's in San Diego and other places, although last year was brutal weather. But you know what are you gonna do? For those of you listening, we'd love if you could subscribe on your podcast listening a vendor and also, if you're watching on YouTube, if you could subscribe there. That'll help us get the information out to more people. But until next time, we'll talk to you next episode.

This has been another episode of the Modern Pain Podcast with Dr Mark Cargilla. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modernpaincarecom. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs. Changing the story around pain this is the Modern Pain Podcast.