Questions to Dr Joel Bialosky

**Jason Silvernail** · 22-10-2010, 06:02 PM

Attached please find the handout from Dr Bialosky's 2010 AAOMPT presentation on manual therapy responses.

Feel free to ask questions of him in this thread.

Jon Newman · 22-10-2010, 11:49 PM

I'm excited about this. Thanks Jason and Joel. I've got a number of questions. Over what sort time frame do you hope to generate questions? (That wasn't one of my questions.)

Q1: What is the K12 Rehabilitation Research Career Development Program and how does one get accepted into it?

Jon Newman · 23-10-2010, 05:30 PM

Q2: The word "placebo" is used differently by different people. 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?

Jon Newman · 23-10-2010, 05:34 PM

Q3: 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?

**Jason Silvernail** · 23-10-2010, 07:04 PM

At the AAOMPT lecture, 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. Could you elaborate on this topic further and discuss study designs and processes that might answer some of these questions?

We have a thread here called "More than Placebo" in which we discussed some of those issues and that our readers (and perhaps Dr Bialosky) would like to review:
More Than Placebo

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?

**Jason Silvernail** · 24-10-2010, 02:59 AM

We've sent this offer to the Neuroscience Facebook page also, so hope to bring in some questions that way as well.

**Frédéric** · 24-10-2010, 04:35 AM

Thanks Dr Bialosky, I simply want to start by saying I look forward to reading most of your research. They keep me motivated.

Sorry, my Q1 is long.
Q1 : Placebo has, in part, an opioid mechanism. In the late 90' and beguining of the 2K period, studies on SMT 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 this month's 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 this month's PAIN article, they used a higher dose of naloxone and successfully blocked the immediate TENS alagesia by doing so. They hypothethized TENS works, at least in part, through a delta-opioid receptor mechanism.

Finally, my questions are : 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?

**Frédéric** · 24-10-2010, 04:41 AM

Q2 : 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?

**Frédéric** · 24-10-2010, 04:59 AM

Q3 : how much of the biomechanical model do you think should be salvaged ?

Q4 : Despite the fact the biomechanical models has many flaws, most of the research still focuses on treatment technics or applications directly derived from this model. It's just that the focus is now on the neurophysiological mechanisms behind these traditionnally biomechanically oriented treatments.

Should'nt we try to find better/new ways to achieve these, and superior, neurophysiological effects instead of constantly revisiting the same ones, actually invented along the lines of a biomechanical paradigm?

Q5 : Do you think, these mechanically oriented treatments maintain their popularity because they fit nicely in the patients and therapists' default belief system?

**John W** · 24-10-2010, 04:15 PM

My thanks also to Dr. Bialosky for taking the time to indulge us with his participation in this interview.

I have two questions for now- one is about a specific construct for conceptualizing assessment and treatment of MSK pain problems, and the other is a general question about the future of the physical therapy profession.

1. In our previous interview here with your mentor, Dr. Steven George, he made this statement:

Quote:

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?

2. 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?

**Jason Silvernail** · 25-10-2010, 12:32 AM

I read with interest your paper on spinal manipulation efficacy and expectation.
How do we go about validating a tool such as that?
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?

**Jason Silvernail** · 27-10-2010, 01:48 AM

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

weni888 · 27-10-2010, 03:37 AM

Hi, Dr. Bialosky,

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 too be misled by the result of any research?

In you experience, which following will bring about more placebo effect when the client comes to see us? The physio's reputation, dress, interpersonal communication skills, clinical reasoing skills, manual skills... anything else.....??/
Thank you

Regards,

weni

**zimney3pt** · 27-10-2010, 06:45 AM

Hi and thank you for your time Dr. Bialosky,

My question is in regards to your Guest Editorial in JOSPT, June 2008. 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?

**Jason Silvernail** · 27-10-2010, 11:53 PM

In a thread here about manual therapy and placebo, one therapist stated essentially that there were no specific effects of manual therapy and that they were all placebo mediated responses. What would response to that concept be?

**Frédéric** · 28-10-2010, 05:04 AM

To complete Jason's previous question, I would ask as I asked prior :

Are those specific effects, if any, related to outcome, and how much?

Jon Newman · 31-10-2010, 08:01 PM

Will Dr. Bialosky be participating in a post-interview discussion here?

**Jason Silvernail** · 31-10-2010, 08:34 PM

I think that depends on his time schedule. He may just respond to our questions, we'll see.
The invitation has been extended.

**Diane** · 29-01-2012, 02:42 AM

Open public access to the paper, The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model, from 2009 (Joel E Bialosky, PT, MS, Mark D Bishop, PT, PhD, Don D Price, PhD, Michael E Robinson, PhD, and Steven Z George, PT, PhD).

Link to Jason's interview in 2010 with Bialosky.

22-10-2010, 11:49 PM	#2
Jon Newman Enjoy a moment of whimsy Join Date: Dec 2005 Posts: 9,024 Thanks: 5 Thanked 55 Times in 41 Posts	I'm excited about this. Thanks Jason and Joel. I've got a number of questions. Over what sort time frame do you hope to generate questions? (That wasn't one of my questions.) Q1: What is the K12 Rehabilitation Research Career Development Program and how does one get accepted into it? __________________ "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

23-10-2010, 05:30 PM	#3
Jon Newman Enjoy a moment of whimsy Join Date: Dec 2005 Posts: 9,024 Thanks: 5 Thanked 55 Times in 41 Posts	Q2: The word "placebo" is used differently by different people. 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? __________________ "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

23-10-2010, 05:34 PM	#4
Jon Newman Enjoy a moment of whimsy Join Date: Dec 2005 Posts: 9,024 Thanks: 5 Thanked 55 Times in 41 Posts	Q3: 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? __________________ "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

23-10-2010, 07:04 PM	#5
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	At the AAOMPT lecture, 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. Could you elaborate on this topic further and discuss study designs and processes that might answer some of these questions? We have a thread here called "More than Placebo" in which we discussed some of those issues and that our readers (and perhaps Dr Bialosky) would like to review: More Than Placebo 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? __________________ 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.

24-10-2010, 02:59 AM	#6
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	We've sent this offer to the Neuroscience Facebook page also, so hope to bring in some questions that way as well. __________________ 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.

24-10-2010, 04:35 AM	#7
Frédéric Swaying against the breeze Join Date: Sep 2008 Location: Prévost Québec Age: 37 Posts: 1,880 Thanks: 92 Thanked 122 Times in 57 Posts	Thanks Dr Bialosky, I simply want to start by saying I look forward to reading most of your research. They keep me motivated. Sorry, my Q1 is long. Q1 : Placebo has, in part, an opioid mechanism. In the late 90' and beguining of the 2K period, studies on SMT 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 this month's 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 this month's PAIN article, they used a higher dose of naloxone and successfully blocked the immediate TENS alagesia by doing so. They hypothethized TENS works, at least in part, through a delta-opioid receptor mechanism. Finally, my questions are : 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? __________________ Frédéric Wellens, pht «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.» «Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate. » Friedrich Nietzsche www.physioaxis.ca chroniquesdedouleur blog Last edited by Frédéric; 24-10-2010 at 05:01 AM.

24-10-2010, 04:41 AM	#8
Frédéric Swaying against the breeze Join Date: Sep 2008 Location: Prévost Québec Age: 37 Posts: 1,880 Thanks: 92 Thanked 122 Times in 57 Posts	Q2 : 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? __________________ Frédéric Wellens, pht «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.» «Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate. » Friedrich Nietzsche www.physioaxis.ca chroniquesdedouleur blog

24-10-2010, 04:59 AM	#9
Frédéric Swaying against the breeze Join Date: Sep 2008 Location: Prévost Québec Age: 37 Posts: 1,880 Thanks: 92 Thanked 122 Times in 57 Posts	Q3 : how much of the biomechanical model do you think should be salvaged ? Q4 : Despite the fact the biomechanical models has many flaws, most of the research still focuses on treatment technics or applications directly derived from this model. It's just that the focus is now on the neurophysiological mechanisms behind these traditionnally biomechanically oriented treatments. Should'nt we try to find better/new ways to achieve these, and superior, neurophysiological effects instead of constantly revisiting the same ones, actually invented along the lines of a biomechanical paradigm? Q5 : Do you think, these mechanically oriented treatments maintain their popularity because they fit nicely in the patients and therapists' default belief system? __________________ Frédéric Wellens, pht «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.» «Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate. » Friedrich Nietzsche www.physioaxis.ca chroniquesdedouleur blog

25-10-2010, 12:32 AM	#11
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	I read with interest your paper on spinal manipulation efficacy and expectation. How do we go about validating a tool such as that? 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? __________________ 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.

27-10-2010, 01:48 AM	#12
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	Are there any projects you are currently working on that you can share with us? __________________ 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.

27-10-2010, 03:37 AM	#13
weni888 Senior Member Join Date: Aug 2008 Location: Adelaide, South Australia Posts: 160 Thanks: 124 Thanked 110 Times in 25 Posts	Another Dr. Dr. Bialosky's article about expectation Hi, Dr. Bialosky, 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 too be misled by the result of any research? In you experience, which following will bring about more placebo effect when the client comes to see us? The physio's reputation, dress, interpersonal communication skills, clinical reasoing skills, manual skills... anything else.....??/ Thank you Regards, weni Last edited by John W; 27-10-2010 at 04:58 AM.

27-10-2010, 06:45 AM	#14
zimney3pt life long learner, clinician, and instructor Join Date: Dec 2009 Location: Sioux City, IA Age: 43 Posts: 1,902 Thanks: 149 Thanked 677 Times in 265 Posts	Hi and thank you for your time Dr. Bialosky, My question is in regards to your Guest Editorial in JOSPT, June 2008. 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? __________________ Kory Zimney, PT, DPT http://koryzimney.blogspot.com "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei

27-10-2010, 11:53 PM	#15
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	In a thread here about manual therapy and placebo, one therapist stated essentially that there were no specific effects of manual therapy and that they were all placebo mediated responses. What would response to that concept be? __________________ 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.

28-10-2010, 05:04 AM	#16
Frédéric Swaying against the breeze Join Date: Sep 2008 Location: Prévost Québec Age: 37 Posts: 1,880 Thanks: 92 Thanked 122 Times in 57 Posts	To complete Jason's previous question, I would ask as I asked prior : Are those specific effects, if any, related to outcome, and how much? __________________ Frédéric Wellens, pht «We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.» «Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate. » Friedrich Nietzsche www.physioaxis.ca chroniquesdedouleur blog

31-10-2010, 08:01 PM	#17
Jon Newman Enjoy a moment of whimsy Join Date: Dec 2005 Posts: 9,024 Thanks: 5 Thanked 55 Times in 41 Posts	A question for the mods Will Dr. Bialosky be participating in a post-interview discussion here? __________________ "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

31-10-2010, 08:34 PM	#18
Jason Silvernail Clinician and Researcher Join Date: Dec 2005 Location: Kandahar Province, Afghanistan Age: 39 Posts: 4,078 Thanks: 111 Thanked 536 Times in 182 Posts	I think that depends on his time schedule. He may just respond to our questions, we'll see. The invitation has been extended. __________________ 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.

29-01-2012, 02:42 AM	#19
Diane Human Primate Social Groomer and Neuroelastician Join Date: Mar 2004 Location: Weyburn Sask. Posts: 19,670 Thanks: 1,486 Thanked 3,189 Times in 1,567 Posts	Open public access to the paper, The Mechanisms of Manual Therapy in the Treatment of Musculoskeletal Pain: A Comprehensive Model, from 2009 (Joel E Bialosky, PT, MS, Mark D Bishop, PT, PhD, Don D Price, PhD, Michael E Robinson, PhD, and Steven Z George, PT, PhD). Link to Jason's interview in 2010 with Bialosky. __________________ Diane www.dermoneuromodulation.com SensibleSolutionsPhysiotherapy HumanAntiGravitySuit blog Neurotonics PT Teamblog Diane Jacobs.com (personal website) Canadian Physiotherapy Pain Science Division (Archived newsletters) Canadian Physiotherapy Association Pain Science Division Facebook page @PainPhysiosCan WCPT PhysiotherapyPainNetwork on Facebook @WCPTPTPN Neuroscience and Pain Science for Manual PTs Facebook page @dfjpt SomaSimple on Facebook @somasimple "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

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