The Evolution of Physiotherapy: Insights from Chad Cook on Science, Evidence-Based Practice, and the Power of Patient-Driven Approaches

Chad. Welcome to the podcast, Mark. Thanks for having me on. It's great to be here.

Yeah, I really appreciate you. At the time of the recording it is Father's Day weekend and so I appreciate you taking some time on a Saturday morning. We'd spoke before this that some of my recording times are in the evening, which I'm a much bigger fan, as Chad is about the morning recordings. We both evenings are not our most cognitively sharp time of day, So I appreciate you coming on. What I wanted to do. We're going to talk about a lot of topics today in regards to research, but I've always been curious because I've heard Chad on podcast and have a great amount of respect for the research and the work he does over there at Duke University and really helping our profession push some good information out there. But I'd love to hear, Chad, if you can, maybe just introduce yourself of where you're at and what you're up to right now, and then maybe your professional journey Because when you've graduated and what you're upcoming as a PT and how you develop to where you're at today.

Yeah, great, i'll give it a go. Right now I'm a professor at Duke University and I have mostly a research position. I work on three relatively large grants and then I also am the director of the Center of Excellence in Manual and Manipulative Therapy. So I do a lot of research, publish a lot work with a lot of really smart, fun people in research and just enjoy that aspect of academia. I used to be an administration for many years and I'm enjoying the fact that I'm not an administration now, so it's nice. I've been in academia, for I think this is my 24th year and at the time that we're recording I have been a PT for 33 years. So I graduated in 90, studied in the 80s, so I have a bachelor's in PT. Those were the days where it was really difficult to get into PT school. I think at the time it was more difficult to get into PT school than med school because they didn't have very many programs Between you and me. I lucked out. I got in, primarily because somebody had dropped out at the last minute and my mom knew someone and I didn't know much about the profession. but some strings were pulled and I got into a program. It's probably the luckiest thing I've ever done. I've said this before. PT has done so much more for me than I can ever do for it, and just that crack in the door getting in and having an opportunity to be a licensed PT has really made a difference. I practiced for about 10 years primarily orthopedics. I had some leadership positions in that period of time, put together educational programs, was teaching connet, and realized that I actually enjoyed the teaching aspect of things more than the day-to-day clinical grind. So it led me to look at academia and Texas Tech gave me a break to be an assistant professor in 1999, and I've been at Texas Tech, been at Duke twice and taught at Walsh University for about four years.

Nice, nice. I'm curious with your 33 years of your journey as a physio and you've seen the practice evolve over that time. I'm just curious what the biggest shifts you've seen and maybe experienced within your own practice and in your own teaching, as you've kind of see things progress over those 33 years.

I think there have been a lot of shifts. For starters and I shared this recently at a presentation I was that there are 10 times more studies being published on areas of orthopedics, manual therapy, et cetera, than just 1990. So just the growth of science has been pretty terrific and I think it's allowed us to understand things a little bit more than what we thought in the past. I think we had a lot of theory previously and then no evidence, and now evidence is kind of caught up with theory and many of the things that we held very dear and dogmatic to us as practitioners we're starting to let those go. We recognize that the patient plays a bigger role in the recovery than the clinician. We recognize that it's not a one-sided affair right, it's not where if you do the right thing the patient will get better. It takes two to 10 go on in that situation. So that's really opened opportunities on how to manage patients and how to best push those buttons. We've seen I call it the bandwagon effect. We've seen the push of several different types of interventions over the year. We had spinal stabilization, we've had dry needling, we've had psychologically informed practice and it's just stuff goes up, goes down and then the people that kind of sit back and wait are just kind of play things out. They're probably just watching the show and realizing that pretty much the same consistency and things that have worked for the last few decades still work.

Yeah, i'm always. When I got really into psychologically informed care and a lot of the pain science stuff, i was fortunate to get to chat with some groups clinicians at healthcare systems and I thought I was on the cutting edge. And then I would see some older clinicians who had been seasoned and been out practicing for a while and especially in the women's health arena. Then I would get the opportunity to chat with some OTs too and they're like this stuff isn't all that new. We've been kind of doing this for a bit. It's a little bit more new as far as maybe new names and things behind it. But it's always interesting how, like you said, those bandwagons jump up and down and with our social media culture that we're in, it definitely can catch fire and different things. But we had it more in Hohe on the other day or other week and he talks about having a purposeful skepticism of the research and Matt Lowe talks about having a purposeful skepticism as far as when the new things come out, not bad to learn them and not bad to maybe have them as a possible intervention, but as opposed to throwing everything else away the whole baby with the bathwater discussion maybe we need to just hold our ground, have some good clinical discussions in a good clinical community of some good mentors and see where it sits in the long term versus jumping hook line and sinker in the short term. So yeah, definitely I'm with you on that. One topic I wanted to make sure we chatted about today because it's one that was really a big shifter for me when I was kind of when I got into Evidence and Motions Fellowship it's been a great program was transform my practice, my clinical reasoning, critical thinking can't thank them enough for that journey that they took me on. Took a lot of humbling and ego swallowing for me to realize that it's a lot more than just how expert you are of a manual therapist. And the equipoise research was the one topic you really came out with and kind of changed my thought process because it became I became frustrated with manual therapy that dang it. I'm not fixing these people because that was the mindset of me where it's just I need to be more complex with manual because it's just maybe I can't sense this facet dysfunction enough. Maybe I just need to develop my hands more and more. And that was the complexity I thought I was missing in my practice. And then you had some studies around equipoise that came out because I jumped. Then when I got so frustrated with manual therapy I was like, well, the research is gonna answer it. Then it's just gonna be if I can figure. All of these clinical practice guidelines and then clinical prediction rules had their big heyday. Thankfully they've kind of been put into perspective at this point. But equipoise really kind of said, okay, maybe we need to be mindful of what other factors in the research study can play a role. So I'm wondering if you can just chat a little bit to the clinical personal, equipoise that you've discussed and some studies and kind of where you see and how it fits in the grand scheme of what we need to be considering.

Yeah, i'm happy to and thanks for bringing that up. By the way, when we first tested that in one of our randomized trials, it was purely out of curiosity on whether or not the thoughts of a clinician could influence a patient's outcomes. And if you think of that, it seems like, well, i doubt that could actually happen. But I'll give you some context behind why we explored it. At the time I was doing a lot of analyses on the back end of a lot of surgical studies and we were finding that the sponsored studies, the devices that were sponsored, were having a fact that was greater than the comparator. And my thought was I said well, tell me about this device what's really different about it? I mean, why are we seeing a difference in clinical outcomes, which is quite a complex topic right Function and a person's pain experience, specifically pain intensity. How in the world is that influenced by a device type? And then we realized that it probably wasn't that and we looked into the literature and there have been people talking about equipoise for some time and the clinical equipoise piece. This is where, if you do a randomized trial, you really should have two groups or two comparators that one isn't known to be different than the other. You expect the two to be very similar. If you go into a study expecting one to be markedly different, then you are going to have bias toward that which will improve it. And the other one was the biggest one and it was based on a lot of the studies at the time that were going on where people were comparing manipulation versus mobilization and they were big advocates of manipulation and they didn't believe in mobilization. Or it was McKenzie versus non-McKenzie and that people were huge advocates of McKenzie and the comparison was some garbage intervention And that is a lack of personal equipoise. So the clinician basically has an assumption going in that one is going to be better. So what we did is we measured it in our study. We had 18 PTs that actually delivered the care in the RCT And before the study began we actually found out where they were on a spectrum Are you pro mobilization or are you pro manipulation And if so, what is the effect? How strong are you pro or con on that? And then we calculated that versus the outcomes at discharge And we actually found it was a pretty noticeable effect that those who were pro manipulation actually had outcomes that were better with manipulation because they did both interventions And then those that were pro mobilization had better outcomes with mobilization than manipulation And it was an eye-opener And I thought, okay, maybe this is an anomaly. And then Mark Bishop's group out of University of Florida did a follow-up study, because I remember meeting him in a It was at a bar but we weren't drinking, we were just talking about the study and he said I think I'm going to embed that in my study And he found the exact same thing. So it was wonderful to see, you know externally, somebody else find that, found that I think it's part of that whole contextual component, right, contextual factors, all of those extra therapy elements that are really hard to measure but we know influence outcomes quite a bit. They can either add or subtract from the specific effect of a treatment. So the clinician themselves can actually influence outcomes based on their delivery of the care process, whether they You know a lot of people said they must be sabotaging the other side. I don't think that actually happened. I think it was probably an unconscious promotion of the care process they thought was better.

Yeah, and I think there's probably a lot more practiced. You know rituals around their more favored intervention too. Like if you're very well-versed in manipulation, you kind of learn how to portray it, how to explain it, even the context and all the different things, and it's always been fascinating. I've never really. I guess I tend to be more mobilization. If I was just looking, if I still manipulate, i don't. Just, maybe this is a little more selective And that's just my bias. Of course there's clinicians doing various ways of that, but it's interesting to see those debates And it definitely makes sense to me because I've seen both clinicians who are very more manipulation heavy get great outcomes And I've seen mobilization folks who are very much more pro-mobilization get great outcomes. And I think that study just made a lot of sense of maybe it's not the intervention being massively superior to one another. It's maybe that those intervention contextual effects of the deliverer of the intervention who brings those, maybe those intangibles or hard to measure things to those interventions. So it was a really great study And I really appreciated your work on that for sure, And it's nice to see it's been replicated by Mark Bishop and his group as well.

Yeah, I appreciate that, you know. There are a couple of things I want to add to that. First of all, in the study we looked at mobilization versus manipulation for low back And we did not find the difference between those two interventions. We had gone in expecting probably manipulation to have a stronger effect And that was because in the mechanisms literature, like the preclinical basic science literature, there's a little bit more of a physiological effect. With manipulation It's a little bit more robust, not a ton. Certainly we need to use caution in translating mechanisms research to clinical practice because sometimes done on animals or asymptomatic individuals. And the second piece I get and I get this question all the time and I honestly don't know how to answer it And people say you know, we talk about the negativity of the ritual and these individuals who go into Like there's no other bigger ritual to me than dry needling, right, i mean that is a big old ritual, you know a whole lot going on. You got needles, you've got your sterile field, and people say, well, you know, should I downplay the ritual if it actually has an effect, if it has, you know, a positive placebo effect? Should I downplay it or should I just go with it? And I don't know. You know, i mean, if it's something that boosts the outcomes and it doesn't hurt anyone and you're not lying about what it does and you've, you know, like manual therapy, if you've given all of the potential risks and adverse events. I don't know the answer to that one. I think it's an interesting quandary, though.

Yeah, no, it's interesting even just from an ethics discussion and different things around that of like you know, should you be, you know knowingly incorporating placebo. But I don't think you can ever escape it. I think you know, for the pre-celled benedetism works always fascinating in a lot of the doctor-patient relationship. I dug deep into that at different times of my development And it's just, i think, being implicitly aware of it and just being able to kind of understand that hey, there's probably more to my intervention and its effects than you know strictly the mechanistic. You know things around, you know proposed mechanisms of some of these interventions. I would agree with you, i think dry kneeling comes with a massive ritual behind it. Not saying I think there's still work to be done as far as hashing out mechanisms and unique things that are unique to dry kneeling, but I think knowing those things is definitely helpful for sure.

Hey, fun fact, i shared a taxi. My wife and I shared a taxi with Benedetti in Italy one time, so that's the one time I've met them.

Oh jealous, I would love to have been in the ride with you guys. He's I've actually just reached out to him. Whether he comes on the podcast or not, I always swing big and if I miss big deal. I was lucky enough to get you out and others, So I'm happy if I get that even a 250 batting average. But yeah, I'm hoping to get him on. He's been a huge influence as far as just kind of really thinking about what's more to the effects of what we do than just in some of the just evolutionary ways we are wired to seek a healer, and we can get deep into that discussion. But we'll maybe say that for a later date. But I'd love to hear too You, you, you've shot me a study and I hadn't read it yet but I thought it was fascinating around believability and you looked at some interesting variables that influence believability from clinicians in regard to different, you know, categories of intervention. I'd love for you to kind of maybe chat with that for the audience, because I thought there were some interesting things you found in that study that you know definitely makes sense with the world we're living in Twitter and in YouTube, where you all might be watching this. I'd love to hear your thoughts on that study, maybe summarize it or give folks a little bit of a view of what you did.

Sure, yeah. So it was an international survey and it was an international team of authors too, which was really great to work with them. We translated the survey into five different languages and really used social media in a good way to reach out to individuals to provide their thoughts around believability. So our hypothesis was, just as you mentioned, that the way that people gather information is going to alter what they believe in certain topics like, for example, exercise or psychological informed practice or manual therapy or modalities or research around sports and sports performance, and with the assumption that some of these areas, which are attacked quite heavily on social media, would probably have a decreased believability. And we did a zero to five score, five being I completely believe the information that I read or hear and zero being I don't believe anything that I read or hear. So we had two that were notably different than the other scores. One, which we hypothesized, was manual therapy Most people did not believe what they read or heard And the other was modalities. Actually, the lowest belief was around modalities and, surprisingly, sports performance, i thought, because that's pretty conflicting among researchers They seem to never find the same thing twice but that was had high levels of believability. I will say this, most of them, most of the categories, had really high levels of believability. We also captured additional information to really tease out what tended to be related to that level of believability, and a big one was the person, the character of the person, the researcher, their reputation. That seemed to elevate things quite a bit. In fact, that was one of the strongest areas for the with respect to being associated to a level of believability. But it was nice to do, i mean it. Really, i had concerns that some of the misinformation that you hear on social media and there's a lot And, by the way, i'm a big fan of social media. I believe it's a great way to disseminate work. In fact, i use Twitter all the time to push any publications I get. It's a nice way for me to toss things out for people who have an interest in reading something new. I find a lot of articles that I wasn't aware of by people who do pushing, so I'm a big fan. I'm also a complete believer in free speech. I believe people should say what they want. Nonetheless, i had some concerns that it had been influencing the misinformation had been influencing what people thought, which could potentially influence clinical practice.

Yeah, i think we've seen it influence clinical practice pretty significantly. The, you know, manual therapy debate has been a hot one and it seems the more the voice that seems to be loudest on social media is around. You know the bad things about manual therapy And you know, as with any intervention, all intervention deserves good critique. I think there's, but there's also some strengths to it. It just seems like the voice around manual therapy hasn't really been all that strong as the. You know. The cons have definitely been out there in full. You know volume, but it doesn't seem there's been, and I think you've. I remember watching you're in Adam Meakin's I was debating. Was this going to be like a steel cage match from WWE days or is it? it was a very respectful. I really enjoyed the conversation. You both made some great points. As with any intervention, i don't think you know manual therapy, it's not a panacea, but it can definitely be a helpful part of a treatment program to move somebody forward for the right patient at the right time. That's why you learn good clinical reasoning and critical thinking skills. But yeah, it's. It's interesting. I to to we had spoke about this a little bit before we went on and I'm curious what your thoughts are, And I don't know if there's a perfect answer to this There's probably not but with this social media world and I love the fact too Twitter is like the most free connet area that you can have out there, where you're getting like all of these researchers, like Chad cooks and you know Jill cooks and other folks that are doing amazing like leaders in their field. You can see what's going on, what their thought process is, get to interact with them. You get to message these folks about hey, what did you think this? Why did you do this in the study? What was the purpose of this? And often I've had such great interactions with a lot of researchers including you, chad, over some of these topics. But with all this said, I and I know some research journals are doing some more work on the social media things, mainly just again, maybe pushing article citations out when they publish things. And I know like maybe British Journal of Sports Medicine is pretty active and they do some more event-based stuff. But I'm curious what your thoughts are on how we can make sure maybe from this you know traditional research journal and you know which is great because we need, you know, peer review and all these things to make sure we're putting the best information out there. But then there's social media where you know you can wake up one day with a thought and opinion and push it out there to hundreds of thousands of viewers And unfortunately, you know, sometimes patients don't have that And most patients, or most folks who might be pruseness information, don't have the peer review thought process or have invented information or have a critical process to say, hey, where's this coming from? I'm just curious what you think we can do as researchers, as clinicians, to help maybe meet the times where they're at versus. I just sometimes wonder if the traditional research journal world is maybe at risk of getting left behind with the multimedia in your, you know, instant gratification world that we're in.

So that's a big question And I'm going to try to unpack it and cover it in a lot of different areas. So for starters, i think about the lay clinician that's grinding away 50 hours a week with patients and then documentation at home. They're not going to have the time to do traditional journal scouring to stay up to date with evidence. That said, there are probably 40,000 articles a year on low back. You know there are estimates that there are 2.4 million biomedical journals articles published every year. I don't think it's reasonable to assume that somebody's going to stay on top of that. And I do a lot of low back pain research and I will go and I'll be speaking somewhere and someone will say, did you read this particular paper? And I said no, i missed that one. And they kind of look aghast Like how can you miss that paper? Well, there are 40,000 a year. You know it's pretty easy to miss a lot. So I think the traditional way of gathering information I think most people recognize, including publishing companies, editors. I think they realize that I can't just publish a paper and expect it to be read. You know I've read where 50% of papers that are published are never read beyond what the reviewer and the author did. It's just a lot of dead work out there. So I think it's incumbent upon the authors, it's incumbent upon journals to be active on social media and to actually push their work and present it in a way where a clinician has an understanding how to use it And so you know, like a Monday morning use, and I think those people tend to be the most successful people. And you had, i think, peter O'Sullivan on And you know I'm a big fan of Peter. I think he's just a magnetic person And he does a really exceptional job on social media in pairing down things that are important in his work and how this can be applied in clinical practice. So that you don't lose that much if you don't read his paper Still recommend reading the paper, but you gather the highlights of it. I've seen patient infographics being used or just regular infographics which describe a study. Yannique Tousignan Leflin, the guy that I wrote the Low Back Pain and Disability Drivers paper with Brilliant guy, really fantastic with infographics. He tells a story in a one-page picture, basically says this is what the study says. I think that's a real quick takeaway for individuals who are consuming literature. I think what you're doing here podcast are a great way to get into the nuts and bolts of a particular topic. Yeah, i definitely think we are in a place now where we're thinking of doing things differently. Seth Peterson's viewpoint in JoA's PT actually talked about the fact that it's about 10% of people get their evidence from journal articles And the rest is from something else, and his emphasis in that paper was it's a lot of con-ed, which is like. Con-ed to me is like a gas station sushi It's pretty dangerous from what you get, it's not very well-controlled And you can really get some weird stuff. But that's an alternative way to learn too. If you find a con-ed provider that is reputable, that is grounded in evidence, i think they can make a difference in clinical practice. So even as a person who publishes a lot and at the time of this podcast I have a 350 publications I 100% know that I can't live alone on that. If I want my work read, if I want my work recognized, then I've got to find other ways to get it out there.

Yeah, yeah, and you mentioned some of the work you do on Twitter And I agree Peter does a great job And some of the infographic work, like with your papers and others, definitely is a nice way to summarize in a more bite-size at lunch maybe between documentation and things for some of those folks you mentioned who are on the grind, because we definitely talked that there's some clinicians who are really and there's some challenges systemically that make it hard for clinicians to find time. So we're living in some challenging times when it comes to having clinicians who have the amount of time that would be necessary. So it's good to have these mediums to help folks more rapidly imbibe some of this information. For sure, with the research, there's another topic we had touched upon before we went on. There is this trustworthiness, and you were on a paper with Sean Riley on trustworthiness, kind of developing a protocol around systematic reviews. I think you all identified some of the issues with systematic reviews and some of the information that gets pulled into them, maybe the garbage in, garbage out type thought process with it. Maybe you can chat with the audience about that study and some of the challenges that we have, because I think sometimes you see, it's the top of the food chain on the evidence-based practice pyramid, so it must be. If it has SR by it, it's got to be the best thing And I'm just going to take that information and run with it because it's a systematic review or meta-analysis. I'd love if you can talk about that protocol and some of the issues that you guys have we're trying to work against with development of that protocol.

Sure. So Sean Patrick Riley, he has been the biggest push behind this And he's the type of guy that'll text you at 3 AM and said I've got this idea And you're like you're in a different universe, sean, and the way that you think and do things. But he is such a good critical researcher in looking at the quality of the work that's out there. So it's a lot of fun to work with him. We were concerned, just as you mentioned, that the systematic reviews were publishing really low-quality work and then making a decision based on that low quality And it isn't just risk-abias. That's only one measure you would look at in a systematic review. I mean there's applicability. There is whether this information is transferrable to your patient population. I mean there are 1,000 different points that one needs to consider for you to take information from a systematic review and feel that it's trustworthy, that it's something that you think has longevity and meaning in clinical practice. And we had noticed after looking at several systematic reviews, we had major concerns that they were coming to a conclusion based on just really questionable work that was included. So Sean was the driver behind this. He's kind of dragged me along And he's part of Duke Center of Excellence in Manual Manipulative Therapy And he has taken on the living reviews piece of that at CMAT with an idea that we need to keep updating these things, don't let them get stale, but make sure that we look at high-quality work. He has tackled, i think, three of these now. I think two were in review, one that was published And we're finding probably a fourth of the papers that well, out of all the papers that would normally go in a systematic review, maybe a fourth are trustworthy enough that the quality is there, that it is impactful And if you think of that, that is pretty remarkable. It really makes you question systematic reviews And I've been very vocal in my concern about systematic reviews. First of all, there are too many And there are some areas in rehab where there's more systematic reviews and there are randomized trials. I wrote a blog one time that said I hate systematic reviews And I just list all the reasons why I really don't like them And I don't even like to do them. I find the work to be excruciatingly boring And I just have concerns. So Sean's the real champion of that one. I believe in what he's doing. It just shows that a lot of the evidence out there not to the fault of the author just by virtue of how the study was done, where it was done, how much funding they had and just natural challenges with research, a lot of the research out there. It's very questionable.

Yeah, Yeah, And it's great to know that we have these critical processes going on in the research to help clinicians recognize that these issues, Because sometimes I just think we just take these things at face value without really digging deep to, OK, what went into the conclusions of this systematic review? I think we tend to just see, like I said, systematic review and make assumptions that there's some gold standard quality that accompanies these And a lot of these things enter into clinical practice guidelines and things too. I mean, obviously that process is maybe slightly different, of course, But it's just. I think we need to just be again a little bit skeptical purposely skeptical of all research, so we can make sure we check some of these factors out before we maybe take the conclusions too much to heart.

So you've pulled other skeptics on your podcast. You can put me on that list too. I am very much purposely skeptical On the Rogers Innovation Curve. I'm near the end. I don't buy, even on technology products. I don't buy the new stuff. I kind of wait and see what's coming. But with research I very much sit back and wait. There's a, there's something called the Proteus Phenomenon. You may have heard of this and that's where new research, when it's first published, it, tends to have a large effect and there's a pretty big difference between two groups And it's partly related to the you know, the interest in it and the clinicians probably have a lack of personal equal pose. They're really pushing for a particular outcome But over time subsequent studies really don't find the same level of an effect. We see that in pharmacy studies, we see it in surgical studies, we see it in rehab And a classic example is the clinical prediction rule for low back pain, which you know the original effect was what about 1.0, which is astronomical. And then subsequent studies didn't even find significant differences between groups And that's and I don't believe that the authors I mean these are stellar authors that were in the first publication. I don't think it has anything to do with nefarious research. I just think that's a natural phenomenon that you see in research. So if you wait that out a little bit, you'll get to a better estimate of what the truth probably is.

Yeah yeah, that's a good strategy for us Excuse me, all they use as far as really having some purposeful skepticism in a good way to just let. Let's let the research kind of accumulate before we make, you know, big assumptions or big conclusions on on some of the studies that we initially see out there, on some of these interventions. I think there's definitely some interventions out there that still need to have maybe the dust settle and see where things stand as we move forward. One other topic I was hoping we could talk about today is this and I had mentioned in my email when I reached out to you is you know we're big and I think you know talking to Peter O'Sullivan and you know David Polter from Twitter and different things and and a lot of clinicians who we've recognized and the research has pointed to bio. You know psychosocial factors and psychologically informed care and things And a lot of that comes around like this narrative based practice, this, this ability to take into account the patient's narrative, the patient's story that that brings comes into our treatment room. I just wonder sometimes, like with traditional research methods, when it's very empirical, quantitative, you were trying to resolve it to groups and means, and for good reason. There's, there's good purpose for that study, those studies. They serve a great role in our understandings of things. But the argument's been like well, what? what about the patient voice? You know there's obviously qualitative research, there's mixed methods which I have understood. I don't do a ton of research of of, but I know that's not an easy task to put some of these studies together. I'd love to hear your perspective on where you think we can do better on a research methods or push information out that would encourage clinicians to recognize that patient voice and other ways we can capture it. That would best help us, you know, and clinicians especially who don't want to get caught up into. I'm just going to treat based on a CPR of a few you know variables. I want to treat it unique to the human in front of me where I really take those patient values, part of that stool and really apply it. Well, because we see that that I think that part of the stool we thought it was a lot shorter than it really is There's a lot to the patient values, part of what we do. I'd love to see, from a researcher's perspective, how do you think we can better capture that and incorporate that into our, you know clinical practice and clinical research.

So I mean, first of all, your spot on. A randomized controlled trial is not the way to get the patient's voice and to identify the impact to the individual patient And people think well, wait a minute, it's way up there in the top of the pyramid, just below the systematic review. It's just not designed to do that. It's a group effects measure And that's great that. That helps us detect whether we're dealing with snake oil treatment or something else, and there's value in that. But that individualized patient voice is the next great frontier and being able to really understand that And I'm just going to kind of toss a few things out there. I haven't figured it out yet. I'm just going to say that I wish I knew of a particular design. You know I'm getting into qualitative research because I'm. I believe it's very powerful And when it's done correctly it'll identify things that you would have never thought about. So one of the things that I thought was really valuable about the pain science revolution, as I've heard that term used, is an understanding that no two people's patient pain experience is the same. And I'm getting into more mechanisms based research, which is more the biology or physiology of what happens with interventions And what's really imperative to recognize to and this is from the impact group is that no two people respond the same way, even to an efficacious intervention. So if I give you an NSAID which has shown to have an effect, the way your body processes that may be completely different to me, and how it influences your pain mechanisms that are responsible for your pain experience is also markedly different. So this suggests that people are going to respond differently to the same efficacious intervention, and knowing that on the clinic side of things, as a clinician, has been an eye opener for me. We also know that there are all these mediating factors that influence a person. You know, i've heard people use the term meeting the patient where they're at and meaning their social components, the psychological components and other contextual components. All of these factors will mediate the effectiveness of your treatment, either enhance it or make it worse, and we need to recognize those. And that's the only way you're going to recognize those is by communicating with your patient and finding out where they're at. We can attempt to quantify that. We've done that. We've I mean we've done a number of social risk studies where we've created a social risk measure to see how much it influences overall outcomes, and it does a lot. There are many that have used psychological variables, whether it's psychological distress, you know, with an OSPRO or any tool that you can think of, those certainly do mediate outcomes as well. I'm not sure how to do it all and to get that patient voice and to maybe help drive the right treatment for that particular patient without just noticing that that person in front of you is the most important person and that the care they receive will be based on the interaction between you and them, not a particular tool. That tool is going to guide you, not a clinical practice guideline That provides guide rails, right, but what that patient needs is going to be what that patient needs, and that's where the really good clinicians will tease it out. Some people will say, well, you should do an N of one study, or you know other studies where you're looking primarily within subjects, designs, those have flaws when you're looking at them. So I'm not sure what. I don't know how to answer that, other than it's imperative and between you and me, it's what makes, as a researcher, it makes our job interesting. If we can start figuring things out better, it's going to be revolutionary.

Yeah, yeah, i know some of my digging into the philosophy of science and just some of the rooting of how we research and consider knowledge and what's true objectivity and the whole demarcation of subjective and objective, which likely isn't as demarcated as we think it is. It's a fascinating topic to talk about. I wish there was a perfect answer. It's just people are darn complex and pain is darn complex And to me it's. What makes the clinic so fun is because you get that N equals one, i guess you could say chance to see what's the unique components of that unique individual's experience, what's the unique story they bring to the table which you can kind of see, you know, using those guardrails of clinical practice guidelines and being informed by the controlled trials and all these different things to see, okay, how does that all come together? Because it's a lot to be bringing in, there's a lot of factors and variables, and that's where you see the master clinicians who can kind of take all that data together and form a coherent kind of treatment approach and a narrative that you co-create with the patient, which again, i would love to see. I think you know, i just think of the qualitative and then having these stories out there of like, i think, multimedia with like YouTube and being able to have patients and I love what, like Peter O'Sullivan and others have done, where they're actually having patients kind of you know, have their narrative put up of like their experience with these studies or their experience with these treatment approaches, because you sometimes hear things maybe you didn't expect that they thought about this intervention scheme and it's a fascinating place to go. I think that's kind of one of our passions is to see how we can get that story best, you know, incorporated into clinical practice, at least giving it a stage, because I think you probably wouldn't disagree that healthcare, i think physio, we're doing better. You know, i think initially we might have been not as good, you know, maybe two decades ago, but there's still a lot of healthcare where patient voices aren't really, even if they even get a chance to talk, it's not very much and often interrupted and all these different things.

So yeah, Yeah, we're starting to see more patients being part of the original design, which I think is gonna have some value as well, because it'll give you a different perspective. It's not just a researcher thinking about. We're starting to get input from patients on what outcomes measures should actually, what should be the composition of outcome measures. For example, the promise was co-created with patients, whereas most of the legacy skills we use, like you know, the ODI and the NDI and the LEFs they were created by researchers. So in many cases you're gonna see a difference in the type of question that's asked. I think that's gonna be a value. So I would definitely recommend the promise. I even think you know, as we move forward, having some sort of design that allows a patient-driven approach early, that is filtered into different levels, maybe to see if that improves overall outcomes. I mean, i think that would be an interest. There are some study. Well, there's one study Martin Underwood study that suggested if you just provide an all-account you know here are all the different treatments, they all have similar outcomes to the patient You actually get worse outcomes if you do that. So there still needs to be that engagement between the provider. The provider needs to provide their input and their recommendations. So there's a it's 4D chess, right, mark? I mean it's complicated. It's somebody, probably by the, will be long retired by the time they figure this stuff out, or maybe they never will. Yeah.

I mean, it's been an issue for a while and it will be continued. I think you know the world we live in only gets more complex by the day, so it's interesting to think about. I wanna respect your time today, chad. I really appreciate you spending it with us. I'd love to just hear kind of maybe what you got going on right now or maybe what you see is I mean, you've already talked about the next frontier of, like you know, getting this patient voice and then having some ways to kind of really incorporate that and better account for it in our research methods. So it can be less of maybe a confounding factor and more of like a counter for factor. I'm curious what you think or what you're up to now, anything coming down the pipeline that you can share, and then maybe some thoughts of where you think we need to head to best maybe grow as a profession.

Yeah, we're always brewing something. So we, for starters, we have a. We have a harmonized definition of contextual factors that will be coming out in frontiers and psychology, and this was an international nominal group technique that we did. So now, instead of this nebulous, what is a contextual factor? we actually have a true definition for it, which I think is gonna be really meaningful for patients, clinicians, policymakers and researchers. We have a manual therapy framework study. That also an international study, nine different countries, 16 pain and manual therapy experts, and what we've done is we've taken the IASP categories of pain nociception, neuroplastic, nocicep excuse me, neuropathic and then nocoplastic, and we've basically, with expert, consensus-based methods, we've identified what should the manual therapy treatment look like for each of these different pain mechanisms. And it's completely different, which was what we thought, but it was wonderful to see the international expert group of about 100 experts actually validate that. We have a grant that Amy McDubbitt, brian O'Halloran and Frank Keith, who is a clinical psychologist. We have a grant where we're actually looking at a comparison between manual therapy and exercise for people with chronic neck pain And we are measuring both specific mechanisms and shared mechanisms, and specific mechanisms should be different between. I mean, people would argue they do two different things, they should have different specific mechanisms. Our hypothesis is most likely the biggest reasons for the outcome change will be the shared mechanisms, that's things such as reduction of fear, therapeutic alliance, psychological distress, all of those components that the change in those will probably be greater than the specific mechanisms. So those are three of the big things that and I've always got other things boiling, but that comes to mind.

Yeah, there's never a shortage of research questions to ask, and the more you ask, the more that arise afterwards. So no, i think I can speak for our audience that we're really thankful for folks like yourself who are doing that work. I will definitely say my strong suit is not in the research game. This is where I like to disseminate the knowledge and hopefully push it out to the masses and interview smart people like yourself who can kind of share your expertise and your research. So thank you for your time today and thank you for all the work you're doing for our profession.

Mark, thanks for having me on. I was very pleased when you contacted me, so thanks again for reaching out. Yeah, no, problem.

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