Mechanisms of Manual Therapy

in the Treatment of
Musculoskeletal Pain

Scholar: Joel Bialosky, PT, PhD

Lead Mentor: Michael Robinson, PhD
Professional Background
 Musculoskeletal Pain is a Public
Health Problem
• Prevalence
26% low back pain
14% neck pain
52% upper extremity pain
2% physician’s visits in US due to low back
pain
• Cost
193 billion dollars for medical care
61 billion dollars in lost wages
 Manual Therapy Effective
Treatment for MS Pain
• Deyle et al, 2000 • Flynn et al, 2002
• Bronfort et al, 2004 • Childs et al, 2004
• Rozmaryn et al, 1998 • Cleland et al, 2005
• MacDonald et al, 2006 • Fritz et al, 2006
What is Manual Therapy?
How Does Manual Therapy Inhibit
Pain?

Biomechanical Neurophysiological
 How Does Manual Therapy Inhibit
Pain?

Adapted from Bialosky et al, 2008

Associated Responses

Neuromuscular Responses
Motor Neuron Pool
Spinal Cord Afferent Discharge
Muscle activity

Hypoalgesia
Prior Work
 Prior Work
20
18
change in pain perception (NRS)

16
14
15

Change in temporal summation (NRS)

12
10
8
10

6
4 5

2
0 0
Stationary Bike* Lumbar Extension SMT*
-5

-10
Stationary bicycle Lumbar extension SMT*

Healthy Participants Participants with Low Back Pain

What About Here?
Expectation Alters Pain Response

25
Change in temporal summation (C-fiber mediated)

20

15

10

-5

-10

-15

Positive Expectation Neutral Expectation Negative Expectation*

My Research Interests
Placebo
Potential Placebo Effect
Limitations of Current Literature
• Lack of a valid placebo
• Emphasis on an inert placebo
“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.” (Price et al, 2007)
• Magnitude of the placebo effect is not
known
Everything has a placebo effect
What is the magnitude in manual therapy?
 Questions
1. Efficacy of manual therapy in comparison
to a placebo of similar expectations?
2. Effect size of placebo in the clinical
outcomes associated with manual
therapy?
3. Dose response
 Usual instructional set
 Enhanced instructional set
 Questions
1. Efficacy of manual therapy in comparison
to a believable placebo producing similar
expectations?
2. Effect size of placebo in the clinical
outcomes associated with manual
therapy?
3. Dose response
 Usual instructional set
 Enhanced instructional set
Are the Believability and
Expectations for These…
Similar to the Believability and
Expectation for These?
 Manual Therapy Placebo

Neurodynamic Intervention Placebo Intervention

 Outcomes
• Believable 25

 Perceived group 20

assignment 15
Neurodynamic Intervention
Sham

• Similar expectations for 10

pain following the study

5

• Similar clinical outcomes Pain Function

at 3 weeks 15

10
• Group differences in 5 Neurodynamic

experimental pain 0
Intervention
Sham

perception at 3 weeks -5

-10
TS TS*

Baseline 3- weeks
 Questions
1. Efficacy of manual therapy in comparison
to a placebo of similar expectations?
2. Effect size of placebo in the clinical
outcomes associated with manual
therapy?
3. Dose response
 Usual instructional set
 Enhanced instructional set
 Effect Size

Placebo
Response

Manual Placebo Natural

Therapy History
 Questions
1. Efficacy of manual therapy in comparison
to a placebo of similar expectations?
2. Effect size of placebo in the clinical
outcomes associated with manual
therapy?
3. Dose response
 Usual instructional set
 Enhanced instructional set
 Dose Response
• “You will be randomly
assigned to receive
either a manual
therapy technique or a
placebo intervention”
• “You will receive a
manual therapy
technique known to
significantly reduce
pain in some patients”
Vase et al, 2003
 Study Plans
• Placebo for spinal manipulation for low back
pain
 Design
 Assessment of believability
• Effect size
 3 group study design
 Neurodynamic intervention for individuals with carpal tunnel
syndrome
 Spinal manipulation for low back pain
• Dose response for placebo group
 Standard placebo instructional set
 Enhanced placebo instructional set
 Clinical Relevance
• Improved study design
• Magnitude of placebo response can be enhanced
 May allow health care providers to take steps to
optimize this effect
• May provide prognostic benefits through factors
known to affect placebo response
 Expectation
 Desire for pain relief
 Conditioning through prior experience
 Acknowledgements
• Dr Michael Robinson, PhD
• Dr Steven George, PT, PhD
• Rehabilitation Research Career
Development Program (K12-HD055929)