All right.
Well, welcome to our listeners.
Welcome to AOMP Hands On, Hands Off,
where we're exploring these
cutting edge ideas and
trends in orthopedic manual
physical therapy.
And I'm your host.
I have the pleasure to have
Chad Cook on the show,
which I am so excited for.
And for our clinicians and listeners,
what an exciting
opportunity to have you
learn a little bit more
about manual therapy for
better communications with your patients.
And so
For those educators that are listening,
whether you're teaching
entry level or advanced
post-professional clinicians,
Chad's discussion and his
insights always help
prepare the next generation
of physical therapists.
So we're so excited to have
him on the show.
And if you may be living under a rock,
you may not know that Chad
is an internationally
recognized expert with his
four textbooks.
He's taught in over forty
countries and significant
publication numbers.
This is a man who's truly
transforming the way that
we think about manual therapy.
And I think you'll find him
a delight to listen to.
And Chad is not just a researcher.
Believe it or not,
I don't know where he finds
time to do anything else.
But he's super engaged in active life,
which he is a biker and
gets out in the mountain
biking through rough terrain.
So I'm going to bring this a
little bit of an analogy.
Chad,
you've helped navigate some rough
terrains in manual therapy,
some of the swinging pendulum,
whether manual therapy is a good thing,
a bad thing to use it, not to use it.
And yet you are injecting
more knowledge into this
area than anybody else knows.
So we're so excited for you
to help us navigate
a little bit more of these
challenging terrains and
maybe relate to us some of
the frameworks that we can
use either as clinicians or
educators and finding that
perfect balance like you do
on a mountain trail.
So if you're all right,
I'll go ahead and kick us off.
And I would love to know more about this.
So when I first contacted you,
you said you want to
discuss the scaffolding of
manual therapy.
So what does this actually mean?
First of all, thank you for having me on.
And it's wonderful to see you, as always.
And thanks for everything you do for AOMT.
Scaffolding, to me,
it's a term we use in our
NIH U-XXIV about really
building the framework and
the taxonomy around manual therapy.
I think historically,
when you think about manual therapy,
you think about efficacy
and effectiveness studies
or maybe who manual therapy may benefit,
that sort of thing.
But there's a lot more to it.
There are the treatment mechanisms,
what actually happens with
the particular treatment.
There are all these other
disciplines involved in
measuring manual therapy
like biomechanists and
neuroscientists and imaging
specialists and all these folks.
And we're all using
different language and our
assumptions are all different.
So the scaffolding is
essentially structuring a
framework around manual
therapy so that we can all
study it consistently so
that when somebody is
talking about something,
another profession
understands what we're talking about.
It's about building almost a
foundation and then the
scaffolding up one current
study so that it makes sense.
That's great.
So so you were relating this
to your current grant and
work that you're doing.
So is that what led you
towards your most recent
efforts looking at this as
a framework around manual therapy?
Yeah.
So you probably know that.
I mean,
my original manual therapy textbook with
took a crack at trying to
harmonize some terminology
and really talked about all
the different philosophies.
And that's very, I think,
a clinical focus.
What we're doing now has
even a preclinical and a
basic science focus
embedded into it as well.
And if I could use...
If I could use an analogy,
when I presented at NIH in June,
I started off my talk using
the Christian Bible parable,
the Tower of Babel.
And I'm not going to get all the religious,
so don't worry about that.
But in the Tower of Babel,
people think that this is
where all the people got
different languages and
that sort of thing,
because God was angry that
he was building a tower to the heavens.
But in reality, if you read the Bible,
it actually says that this
is God's attempt to confuse people,
confuse the workers so they
could not finish the job.
And that's really what I
mean by this is there's so
much discrepancy, so much confusion.
a lack of harmony around
what we say we do and what
we actually do and how it's
studied and and what people
say to patients and all of
these other things that
that's really what we mean
about around the scaffolding.
It's it's about.
And yes,
it's very much triggered by the
force net grant,
the year twenty four that we had.
But I think it's a
continuation of something
that I was doing a good
eighteen years ago, too.
Yeah.
You know, I think, yeah,
I remember even just teaching with you,
Chad,
and I think one of the biggest
things that you've always said is,
you know, consistency of language.
Like,
what are we actually saying so that
it has meaning and that we can understand,
right, in the written word,
especially in our publications,
like the terminology.
And so I love that that's
come back even eighteen
years later and you're
putting more to it.
And it's really part of the
grant that you've had.
So I think that that's wonderful.
How does this challenge
traditional teaching
methods maybe that
clinicians or educators
have followed for years?
And maybe you can kind of
highlight some of those
discrepancy areas that have
caused some concern.
I mean, that's a great question.
You know, you and I spoke together,
I think, at CSM earlier this year.
And one of the things that I
had mentioned was that
science really started to catch up,
I think,
with the theories around manual
therapy in nineteen ninety
so that we had enough
sophistication in the
science to actually explore
some of these concepts, terms,
assumptions that you saw
with many of the
philosophies around manual therapy.
And unfortunately,
the science actually
identified some areas where
we were flat out wrong.
We had these vanguards,
manual therapy philosophers
who they saw something in the clinic.
They knew it was meaningful.
And what they did is they
tried to backfill it with these ideas.
And unfortunately, those ideas,
many of those haven't
really stood up over time in science.
The challenge, I think, comes when
in the educational classroom
or postgraduate or whatever,
when we're still using
outdated taxonomies or
terminologies to try to
train individuals or try to
apply a philosophy that
really doesn't fit.
on to that patient that's in front of you.
So we're running kind of
butting into some of these
concepts with with what
we're identifying within
the force that you're
twenty four with some of
the publications that we're
putting together.
But we're also
Butting heads with some
basic science research, too, as well,
that suggests that certain things happen.
And because they happened in
a mouse in a controlled environment,
that it means it's going to
transfer to a clinical environment.
You know,
there are all kinds of areas that
need tightening up and need
the appropriate scaffolding
for us to actually build
upon that and move forward.
So, you know, already with this,
this grant,
you're describing basically
all these professions or disciplines,
I should say,
coming together and finding out, you know,
debunking some of the ideas
or the myths or the
theories or the approaches, right.
And understanding some of that language.
So I think language is super important.
How does that relate a
little bit more maybe to
the clinician and how would
it refine maybe clinical
reasoning or treatment planning?
How does it have a direct
impact on then maybe our
listeners or who are in the
clinics today?
I think it has a lot of different ways.
You know, to me,
in one of the ways that we,
we look at clinicians as
another form of expert, right?
So around manual therapy.
So they have a domain of expertise,
just as an imaging
specialist has a domain of expertise,
as a neuroscientist has a domain.
Everybody has these different domains.
And when the cogs start
working together and everything,
everybody is communicating,
everybody agrees on something,
then we have a common language.
We have a common statement
so that policymakers
understand what we're doing,
so that the patients get a
real story behind what this is.
The challenge is when we're
independent of one another.
And right now, it's fairly independent.
This weekend, we had a summit.
And in the summit,
we had all of these
different professions.
And we were intentional
about inviting people that
had a foot in the space of
force-based manipulations
or manual therapy,
but didn't necessarily
collaborate with any of these areas.
We had clinicians talk.
We had imaging specialists talk.
We had biomechanists talk.
We had neuroscientists talk.
We even had a basic
scientist who worked only
with mouse studies talk.
to tell you all the things
that are wrong with mouse studies.
We even had a psychologist,
a person who had a
psychological background.
It was the most dynamic
meeting of all these people
interacting with one another.
How can it influence a clinician?
there are such a rich amount
of knowledge in these other
fields that could influence
our interactions with our
patients so that clinicians
can learn from these individuals,
just like these individuals
learn from clinicians.
And our goal is to get that
optimal connection,
harmonize it the best we can,
and then be able to
you know,
better improve the way that we
manage our patients,
understand better when to
use manual therapy in the
patient process and really tease out,
is it,
is manual therapy doing what we
think it's doing?
Basically, I mean,
you're asking in clinicians,
it's challenging right
there in the day to day.
So to reframe some of this
mindset or ideas, right?
Season clinicians may have
had practices for a long time.
And, you know,
new clinicians are coming
out from maybe entry level
may not have been exposed to that.
So where would be some
places that you know,
how could some of our
audience gain insight to
some of those different perspectives?
Where are some resources
that they should lean into?
I think the first thing they
need to do is be willing to
go outside their narrow
band of knowledge or
training and learn from
these some of these other
professions who specialize
in different areas.
Just before this particular podcast,
I was listening to the
University of North
Carolina had a seminar
series and they brought in
a speaker from the
University of Delaware.
And she was an imaging
specialist who has a bond
mechanist background.
And she was talking about
the three different tendons
affiliated with the Achilles.
And so a couple of things with that.
All right.
First of all,
I didn't know there were
three tendons in the Achilles.
I didn't know that until last weekend.
And then secondly,
I learned a lot about fail
rates across those,
about how age influences that,
about how prior injury influences that,
and all these other elements.
This is somebody outside of
my profession that gave a
talk that is going to be
meaningful for me moving
forward when looking at that.
So the first thing definitely is
you know,
be open in the way that you learn
and learn from people who
you think may not actually contribute.
I think we've done that
really well as a profession
for psychologists and
really looking at that part for
Pain science specialist,
I think we've been very open on that,
but I think we've ignored
maybe some areas that can
be really beneficial,
like imaging and then biomechanics.
We've kind of poo-pooed
biomechanics and pushed it
off to the side,
but there's actually more
there than I think people recognize.
The second thing I think we
can do is really challenge
ourselves on some of these
traditional paradigms that
we learned from.
I mean,
everybody essentially has some
background or they've
learned from some philosophy.
Mine is Maitland.
So I learned very much a test.
A test.
retest philosophy and ignoring, you know,
ignoring the complexity and
then going toward more of the simple,
you know, this is what we found,
so we're going to move with it.
I think it's okay to have
that as a foundation,
but to recognize that those
have major gaps and to try
to fill those gaps with as
much science as we can tackle.
I,
without paralyzing ourselves and trying
to find a single answer, I really,
I spoke to a, at IFOMPT,
I spoke to someone who I
really respect and we just
kind of ran into each other
and the person said, you know,
I appreciate what you're
doing with mechanisms,
but I'm not a hundred
percent sure that we're
ever going to fully
understand how manual therapy works.
And I said, I agree,
but the journey is a
wonderful experience.
And learning from that as we go along is,
I think,
going to make us all better clinicians.
Right.
And so you may have this
huge amount of knowledge.
You may still use the same
frameworks to go through in
a clinical practice time, test, retest,
right?
Because if you're still
using patient response,
you might find something there.
But maybe at a point where
we're not finding the right
information or the patient
is not responding,
certainly requires us to
step back reframe and think
again about what are we
missing or what might else
be going on here because
certainly that's been some
of the challenges that you
know we have a great amount
of who responds and then we
have these non-responders
and and so maybe it's worth
that exploration I think
you give a great
perspective you gotta step
back and like look at maybe
what else could be going on
there maybe something you
haven't thought of and uh a
little bit bigger maybe
biomechanics or something
else and you know something
you bring up is that
I think it was a different group.
It's mainly out of
osteoarthritis that we
really learned that people
respond differently to even
efficacious treatment.
So even a really good treatment approach,
if you have a spectrum of
maybe twenty people,
you're going to get a
variability in response with that.
And that's just normal human nature.
Even with drugs like
pharmacological agents,
you'll see variability in response.
Knowing that is a tremendous asset,
I think, as a clinician,
that you have to be
adaptable and recognize
there isn't one thing
that's going to help everybody.
And we learn that from a
different discipline, basically.
But I think we can learn a
lot from other areas.
Yeah, that's great.
So, Chad, you know,
you speak to the concept
that you've been exposed, right,
in so many different areas
and seeing so many different
professionals and
disciplines and the way
they're approaching things
from basic scientists to biomechanics,
right,
and imaging and all of these things.
And I would even think with
your extensive teaching in
over forty different countries, you know,
what international
perspective has also
influenced maybe your
scaffolding and how could
this have a global
educational approach to, you know,
orthopedic manual therapy
as we're thinking about this framework?
and its relevance, you know,
across not just maybe the
US and our listeners,
but maybe across the world.
So I'll first start by saying, well,
I'm gonna answer it two ways.
The first way is that
regardless of where I'm at,
and I have been very
blessed to speak in many countries,
very fortunate, is a PT is a PT is a PT.
You can pick a physio out
across the road and say, that's a physio.
I can tell by the way they stand,
the way they look,
and how very observational they are,
the way they interact with people.
It doesn't matter where you're at.
They're stamped out of the same mold,
basically.
Probably the biggest thing
that has influenced me from
my international experiences is that,
and this is not a shot
toward North America,
but I think other countries
are more curious.
And it's probably self,
it's a selection bias
because they're usually
coming to my courses or at
the conference or something like that.
But they're very,
very curious on what is happening here?
Why does it work?
What do I need to know?
What's the right thing to
say to a patient?
What happens if somebody
doesn't get better?
What does that typically mean?
What could be some of the
reasons for that?
That part has been fuel for
me to continue to look for that,
to look for those answers
and to be able to actually
give those and say,
here's some of the things
that it could mean.
And I think if there's anything...
you know,
the pain science revolution has
brought us is an
understanding that there
will be differences in your
outcomes and people are
going to respond
differently and having an
underlying understanding of
why that might be the case.
So the big one for me
internationally is the curiosity piece.
It's just that part has been
very rejuvenating for me, I think.
Yeah, and I'm curious, like, why?
Like, what is it that, you know,
what stems their curiosity
differently maybe than the U.S.?
Is it the time?
Is it productivity?
What's the modeling that I
think about factors?
Why would you see such a difference?
Do you have any idea?
You brought it up, so now I'm asking.
I think it's a lot of different things.
I think part of it is the
payment systems are different.
So in many cases, in social environments,
they're not incentivized to
necessarily see more people
or anything like that.
They're more incentivized by
their own passions to just do a good job.
In other environments,
it is very much fee for
service and they have to
deliver a superior product
or that person is going to
go a couple doors down and
go to a different place
because most of the places
are privately owned and
they hang their shingle out
and hope that they can have
a strong base with that.
In other cases too,
physio is a young
profession in some of these countries.
So it's very much in the growing phase.
I would argue that it's
similar to what we were
like in the eighties and nineties.
When everybody went to Conahead,
you would go to five or six
different major Conahead
courses in a year and you
had your employers would
pay for it because they
wanted you to grow as a clinician.
So I see those parallels,
but obviously I don't know
the actual answer,
but that's kind of what I think.
Yeah, that's a great point.
Great point.
So now I'm going to
transition back to the U.S.
and the education side on our side,
because I think we've hit
some concepts around the clinical side,
right?
Curiosity, you know,
it stems from somewhere.
They've had some training,
some basic training.
So before students leave, like,
so let's go back to that
maybe entry level education.
How do you envision some of
the work that you're doing
now or that you anticipate
doing and hopefully some of
the outcomes from that?
How do you see that shaping or,
I would say,
helping to reframe maybe
entry-level curricula or
even early post-professional curricula?
So whether it's fellowship
level or even as students
are kind of in those
certificate courses before
they go into fellowships.
Well,
I would hope it has a blueprint
that's similar to exercise
science and that you have
these exercise prescription.
This is what we know,
what happens with exercise.
Here are the mechanisms.
Here's what it can actually
influence in a person's
disease mechanisms.
Here's how its role during
an inflammatory process, et cetera.
So providing a framework,
providing a taxonomy around
application of how you would use it
That's my goal.
If if there's that and then
that could be part of that
educational process and so
that there's everybody's
kind of on common ground, then the
treatment part of it,
the application part of it
can take whatever flavor
the educator wants.
My concern right now is that
when I look at manual therapy,
especially in an entry level requirement,
it's a lot of techniques
and it's not a lot of
structure or understanding
on when and how to use it.
Yeah, that's a great point.
And I think that's something
that we could go further on.
if they were to do, right?
We all teach orthopedics or
musculoskeletal, right?
And so there's a desire for
students to know how to do
things with their hands.
And I think what you've said
is that it's just as
important to really
understand some of the
understanding of the
mechanisms that we
understand and how it may
work in that clinical approach.
So the reasoning pieces to
that may be helpful.
Is there anything else that
beyond reasoning that you
feel like that really
should be a focus of these
entry level programs?
Well,
I think we need to understand where
the manual therapies
actually fit within the
health care paradigm.
And I teach a health
services course at Duke.
And in the health services course,
we talk about the different approaches.
One of them is stepped care.
I'm a firm believer that
safe interventions, low cost interventions,
non-invasive interventions
like the manual therapies, exercise,
et cetera.
It should be an early option
for people with musculoskeletal problems.
So understanding where it
fits in that care process
For the bulk of our patients
with musculoskeletal problems,
that should be an essential teach,
I think, in entry-level programs,
but also reinforced in
postgraduate programs that
we really have a role and, you know,
I would argue a
responsibility to make sure
that everybody was
following those preferred paradigms.
And right now, stepped care, I think,
is probably the best option
within that framework.
That's great.
So let me ask you kind of a
wrapping up question.
Where do we learn more?
And I mean,
you've said listening maybe to
different authors or going
outside of our own comfort
zones a little bit and
maybe listening to others
that may have interest.
Obviously,
ForceNet is a group and you guys
have some podcasts that go
or not podcasts,
but some different speakers
that come on to your
your group that you do,
where else can our audience
and listeners gain more information,
things that you would recommend,
maybe next steps from them
beyond today's talk?
Well, the first step, I think,
is keep an eye on some of
our publications that will
be coming out pretty soon.
We have two in review and plus one.
We have another one in the
International Journal of
Osteopathic Medicine,
and then two more that
we'll be submitting very
soon that are really built
around this concept of
here's the scaffolding of
what you need to know.
ForceNet is a great place to start.
We have a number of free
webinars that are online
that you can listen to.
We throw so many different
educators in those webinars.
They're absolutely outstanding.
That's actually been one of
our best pieces, I think, of ForceNet.
We actually have an online
manual therapy conference in February,
February the twenty second,
two thousand twenty five.
It's called Converge twenty twenty five.
And in this conference,
we have invited all
different disciplines that
work with it's called force
based manipulations,
but it's manual therapy.
So this would go run the gamut from.
the basic scientist who
works in mouse studies,
all the way to the
clinician who has a full
schedule of patients that
they use manual therapy with.
And we will have different tracks.
But keep an eye on that.
It's on our ForceNet website.
We'll be advertising for that very soon.
I think that'll be really interesting.
The tracks are going to be imaging.
They're going to be the
clinician and mechanisms.
There's going to be a
neuroscientist track.
And then there's actually
going to be a modeling track, too.
Oh, that's very cool.
Very cool.
Well, Chad,
I think you just accomplished
all that in one week.
I mean,
what are you going to do next week
at this point?
So, I mean,
you're going to have like eight
papers in one week already.
So you're one of the most productive,
productive scholar
researchers I've ever met.
You're exaggerating.
Oh, I am not.
I am not.
Listeners,
you all know I will not lie to you,
but I so appreciate your time, Chad.
And thank you for just
making some time to have
conversation about all the
cool stuff you're doing.
Introducing our listeners to scaffolding,
right?
Ways to navigate these
trails and trials and
challenges and orthopedic manual PT,
as we know,
it's about finding the right balance,
right?
And I think this relates to
your biking and navigating
the trails that you have
navigated for us because
you truly are a pioneer in what we do.
And so thank you for all of
your dedication to the
profession and hard work.
being inspired by our young
our young attendees at
conferences or continuing ed courses,
challenging you to learn
more and then help educate us more.
And so we're grateful that
you do that work.
You know,
I think that there is a perfect
understanding that we do
have to find balance
between theory and practice.
I don't think there's just
the right one right size.
And I really appreciate you
giving us some insight into other ways,
other areas and ways that
we can get more information,
be thoughtful about other
disciplines as we we grow.
as our understanding about
how we can be better at
manual therapy and its application.
So thank you for that today.
Appreciate it.
Well, thank you for having me.
Always.
So Chad, we're grateful that you are here.
We are grateful that we get
to see you in our upcoming
conference at AOM.
So yeah,
I get to put that AOM chat on and say,
I get to see you soon.
And we're presenting together again.
So that will be very fun.
And I look forward to having
you in Orlando and listen,
so many of our listeners
are going to show up there too.
So we're really excited for that.
And for those who aren't there,
Chad gave you another
opportunity to catch up on
the ForestNet website and
see when their conference
is coming up in February.
So you can learn more about
those manipulation
opportunities and learn how
you might broaden your
horizons a little bit further.
So thank you for your time today.
And we will catch you on our next podcast.
And again, remember,
hands on or hands off.
We'll figure it out.
All right.
Thanks so much, guys.
Have a good one.