WEBVTT 00:00:02.168 --> 00:00:02.728 All right, 00:00:02.867 --> 00:00:05.528 welcome everyone to the AOMT hands-on, 00:00:05.589 --> 00:00:06.809 hands-off podcast. 00:00:06.849 --> 00:00:07.870 My name is Lina McDaniel. 00:00:07.990 --> 00:00:09.070 I'm a physical therapist. 00:00:09.631 --> 00:00:11.811 I'm a fellow of AOMT and I 00:00:11.852 --> 00:00:13.952 am just thrilled to have 00:00:13.973 --> 00:00:15.173 you all today join us. 00:00:15.212 --> 00:00:17.714 I think it's gonna be a great episode. 00:00:17.754 --> 00:00:19.635 We are so fortunate today to 00:00:19.675 --> 00:00:23.297 have Dr. Kasper Nimm from Denmark. 00:00:23.736 --> 00:00:25.057 He's a chiropractor and 00:00:25.117 --> 00:00:26.318 senior researcher at the 00:00:26.378 --> 00:00:27.919 Spine Center of Southern Denmark. 00:00:28.498 --> 00:00:29.521 He's an assistant professor 00:00:29.561 --> 00:00:31.324 at the University of Southern Denmark, 00:00:31.425 --> 00:00:33.509 where he completed his PhD 00:00:33.670 --> 00:00:34.692 in twenty twenty one. 00:00:35.113 --> 00:00:35.734 Welcome, Casper. 00:00:35.755 --> 00:00:37.539 Thank you. 00:00:38.549 --> 00:00:38.990 Yeah. 00:00:40.131 --> 00:00:41.673 So just to kick off the 00:00:41.692 --> 00:00:42.793 episode a little bit, 00:00:43.695 --> 00:00:44.756 we do want to focus on one 00:00:44.776 --> 00:00:46.618 of your recent publications. 00:00:46.658 --> 00:00:47.999 But before we get into that, 00:00:48.518 --> 00:00:50.000 can you just introduce 00:00:50.021 --> 00:00:50.902 yourself a little bit to 00:00:50.962 --> 00:00:52.523 our audience and tell them 00:00:52.563 --> 00:00:53.344 briefly about your 00:00:53.444 --> 00:00:55.545 background as a clinician, a chiropractor, 00:00:55.606 --> 00:00:58.228 and then as a researcher? 00:00:58.448 --> 00:00:59.210 And what are your 00:00:59.409 --> 00:01:00.530 professional roles right now? 00:01:02.014 --> 00:01:03.075 Yes, absolutely. 00:01:03.395 --> 00:01:04.135 That's not a problem. 00:01:04.335 --> 00:01:05.216 And thank you for having me. 00:01:05.376 --> 00:01:07.358 I really appreciate the invitation. 00:01:07.418 --> 00:01:08.939 It's going to be a lot of fun. 00:01:10.381 --> 00:01:12.442 So you said my clinical background, 00:01:12.462 --> 00:01:13.864 which is actually an interesting story. 00:01:14.605 --> 00:01:15.825 So I'm educated from the 00:01:15.885 --> 00:01:17.066 University of Southern Denmark, 00:01:17.087 --> 00:01:20.890 which is an unorthodox chiro program, 00:01:20.989 --> 00:01:21.469 I would say, 00:01:21.551 --> 00:01:23.091 because it's based one 00:01:23.132 --> 00:01:25.414 hundred percent in a medical faculty. 00:01:25.474 --> 00:01:27.094 So we study alongside medical students, 00:01:27.796 --> 00:01:29.656 which also means that some of the 00:01:30.763 --> 00:01:32.564 raw philosophy of the 00:01:32.625 --> 00:01:33.566 chiropractic profession 00:01:33.585 --> 00:01:34.867 that it has in the background, right? 00:01:35.549 --> 00:01:36.430 We don't really have that in 00:01:36.450 --> 00:01:37.551 there and we're really well 00:01:37.611 --> 00:01:39.373 integrated into the healthcare system. 00:01:40.034 --> 00:01:41.316 So clinically, 00:01:41.415 --> 00:01:42.977 I worked almost my entire 00:01:43.018 --> 00:01:45.960 career at a hospital diagnosing patients. 00:01:46.501 --> 00:01:47.722 So I actually don't have 00:01:48.024 --> 00:01:49.564 that much experience with 00:01:49.706 --> 00:01:50.527 hands-on treatment. 00:01:51.087 --> 00:01:52.067 And it's interesting because 00:01:52.087 --> 00:01:52.888 a lot of my research is 00:01:52.908 --> 00:01:53.668 centered around that. 00:01:54.009 --> 00:01:55.269 So I always get the 00:01:55.289 --> 00:01:56.010 discredit from the 00:01:56.049 --> 00:01:56.969 clinicians that I don't 00:01:56.989 --> 00:01:57.990 understand this because I'm 00:01:58.010 --> 00:01:59.131 not doing it in real life. 00:01:59.191 --> 00:01:59.772 I don't see all the 00:01:59.792 --> 00:02:01.012 potential and stuff like that. 00:02:01.052 --> 00:02:02.972 But I'm always flipping around saying, 00:02:03.013 --> 00:02:03.174 well, 00:02:03.313 --> 00:02:05.734 I always I also don't have that bias, 00:02:06.155 --> 00:02:08.336 you know, that I that I see it works. 00:02:08.376 --> 00:02:09.856 I can be completely, you know, 00:02:09.937 --> 00:02:11.737 objective and just, you know, 00:02:11.777 --> 00:02:13.158 stay within the limits of the data. 00:02:13.199 --> 00:02:14.300 And I do think there's some 00:02:14.479 --> 00:02:15.639 there's some benefits to that, 00:02:15.759 --> 00:02:16.700 although I do appreciate 00:02:17.561 --> 00:02:18.822 clinician researchers as well. 00:02:19.782 --> 00:02:19.923 But 00:02:20.823 --> 00:02:21.843 mostly what I'm doing now 00:02:22.123 --> 00:02:23.044 I'm still doing a lot of 00:02:23.324 --> 00:02:25.146 manual therapy research uh 00:02:25.187 --> 00:02:26.448 different related projects 00:02:26.508 --> 00:02:28.088 but to be honest it's all 00:02:28.408 --> 00:02:29.629 my hobby projects at the 00:02:29.650 --> 00:02:31.132 moment all of my funded 00:02:31.171 --> 00:02:32.413 research is mostly related 00:02:32.453 --> 00:02:33.993 to more healthcare 00:02:34.093 --> 00:02:35.854 utilization and you know 00:02:35.996 --> 00:02:37.336 long-term patient courses 00:02:37.356 --> 00:02:38.437 and mapping those and more 00:02:38.457 --> 00:02:40.218 into the world of epidemiology I'm 00:02:40.579 --> 00:02:41.740 slowly evolving into that. 00:02:42.901 --> 00:02:44.122 But I still love doing the 00:02:44.282 --> 00:02:45.082 manual therapy work, 00:02:45.103 --> 00:02:46.104 and it's a lot of fun. 00:02:46.183 --> 00:02:47.985 And sometimes, you know, 00:02:48.026 --> 00:02:48.586 good stuff happens, 00:02:48.605 --> 00:02:50.087 like the paper we're coming into now, 00:02:50.147 --> 00:02:50.328 right? 00:02:50.348 --> 00:02:51.389 A completely unfunded 00:02:51.408 --> 00:02:52.810 project we just all did in 00:02:52.849 --> 00:02:53.509 our spare time. 00:02:54.170 --> 00:02:56.432 It was a fun and frustrating process, 00:02:56.673 --> 00:02:57.234 to say the least. 00:02:58.823 --> 00:02:59.843 Wow, that's incredible. 00:03:00.044 --> 00:03:01.186 And it's amazing to hear 00:03:01.545 --> 00:03:02.667 that lead off into this 00:03:02.747 --> 00:03:04.830 study because of what a 00:03:04.889 --> 00:03:06.692 massive study was and just 00:03:06.731 --> 00:03:07.472 thinking about all the 00:03:07.592 --> 00:03:08.653 aspects of it and how many 00:03:08.693 --> 00:03:09.474 people were involved. 00:03:09.754 --> 00:03:10.996 So, well, great. 00:03:11.135 --> 00:03:12.137 Well, let's jump into it. 00:03:12.176 --> 00:03:13.218 I want to hear more about 00:03:13.579 --> 00:03:15.501 your perspective on it and 00:03:15.640 --> 00:03:16.762 kind of the background behind it. 00:03:17.543 --> 00:03:18.683 The main publication that we 00:03:18.723 --> 00:03:19.524 do want to highlight and 00:03:19.563 --> 00:03:22.485 talk about today is a recent publication, 00:03:22.545 --> 00:03:23.747 a twenty twenty five 00:03:24.448 --> 00:03:27.330 article in title the 00:03:27.370 --> 00:03:28.971 effectiveness of spinal 00:03:29.010 --> 00:03:30.632 manipulative therapy and 00:03:30.692 --> 00:03:31.953 treating spinal pain does 00:03:31.992 --> 00:03:34.334 not depend on the application procedures, 00:03:34.914 --> 00:03:36.616 a systematic review and 00:03:36.695 --> 00:03:37.997 network meta analysis. 00:03:38.877 --> 00:03:41.177 So this paper that just came out, 00:03:42.138 --> 00:03:44.239 just quite a lot to it and 00:03:44.338 --> 00:03:45.378 really rich with 00:03:45.459 --> 00:03:46.919 opportunity to kind of pull 00:03:47.460 --> 00:03:48.439 some findings from this. 00:03:48.539 --> 00:03:49.840 And we'd love to hear about it. 00:03:49.960 --> 00:03:52.741 Can you briefly describe the study, 00:03:52.760 --> 00:03:55.842 the design and kind of the 00:03:55.882 --> 00:03:57.223 underpinnings of this study for us? 00:03:57.242 --> 00:03:59.103 Yeah, absolutely. 00:03:59.203 --> 00:04:00.623 And if I'm allowed to, 00:04:00.683 --> 00:04:01.924 I'll go a little bit back in time. 00:04:02.806 --> 00:04:03.927 because ever since I was a 00:04:04.008 --> 00:04:06.289 student and I graduated eight years ago, 00:04:06.349 --> 00:04:07.811 so it's, I don't want to admit it, 00:04:07.850 --> 00:04:08.931 but it's a few years ago now, 00:04:09.692 --> 00:04:10.612 but I was always very 00:04:10.932 --> 00:04:12.455 critical of this notion 00:04:12.474 --> 00:04:13.474 that we were taught that 00:04:13.495 --> 00:04:14.656 you could do spinal 00:04:14.716 --> 00:04:16.437 palpation and then feel, you know, 00:04:16.478 --> 00:04:18.298 wherever the dysfunction was, 00:04:18.338 --> 00:04:19.620 and then you could hit, you know, 00:04:19.759 --> 00:04:20.980 exactly at that segment. 00:04:21.000 --> 00:04:22.723 And that would help, you know, 00:04:22.762 --> 00:04:24.204 basically cure people sometimes. 00:04:24.283 --> 00:04:24.463 Right. 00:04:24.543 --> 00:04:25.285 And it's, um, 00:04:26.434 --> 00:04:27.254 And I was really challenged 00:04:27.274 --> 00:04:29.057 then when I got into clinical practice, 00:04:29.076 --> 00:04:30.278 because I have been in 00:04:30.338 --> 00:04:32.139 chiropractic practice for a little bit. 00:04:33.860 --> 00:04:35.783 So I thought that was quite difficult. 00:04:35.822 --> 00:04:37.365 So when I led into my PhD, 00:04:37.404 --> 00:04:38.125 which was actually 00:04:38.853 --> 00:04:40.115 to be honest, when I was young, 00:04:40.134 --> 00:04:41.836 back in twenty sixteen, seventeen, 00:04:42.235 --> 00:04:43.576 we wanted to predict 00:04:43.617 --> 00:04:45.617 responses to to spinal repulation. 00:04:45.677 --> 00:04:46.959 I'm just going to call it SMT. 00:04:47.418 --> 00:04:48.180 We wanted to predict 00:04:48.220 --> 00:04:50.800 responses of SMT using pain 00:04:50.821 --> 00:04:51.982 sensitivity and spinal 00:04:52.002 --> 00:04:52.961 stiffness as like 00:04:53.002 --> 00:04:55.124 biomarkers on where to get the treatment. 00:04:55.723 --> 00:04:56.785 And what we really noticed 00:04:56.944 --> 00:04:57.884 when we looked at the data 00:04:57.944 --> 00:04:58.745 was that it was like 00:04:59.870 --> 00:05:00.951 the participants in our 00:05:00.971 --> 00:05:02.572 study got the exact same treatment. 00:05:02.672 --> 00:05:04.572 They completely changed 00:05:04.872 --> 00:05:06.512 identical of each other, those two groups, 00:05:06.872 --> 00:05:08.014 as in completely identical, 00:05:08.533 --> 00:05:09.973 as it was the complete same 00:05:09.994 --> 00:05:10.713 treatment we gave them. 00:05:10.754 --> 00:05:12.154 And that really opened up 00:05:12.175 --> 00:05:13.495 the door of looking more into that. 00:05:13.995 --> 00:05:16.295 So we did the first original 00:05:16.375 --> 00:05:17.735 review as part of my PhD 00:05:17.776 --> 00:05:18.697 back in twenty twenty, 00:05:18.737 --> 00:05:20.377 which was published in Scientific Reports, 00:05:21.216 --> 00:05:22.257 where we looked at the 00:05:22.317 --> 00:05:23.517 target site and didn't see 00:05:23.557 --> 00:05:24.158 any differences. 00:05:24.197 --> 00:05:25.358 And when we published that, we had a 00:05:27.588 --> 00:05:30.452 like a huge critique from a 00:05:30.492 --> 00:05:31.374 lot of clinicians, 00:05:31.673 --> 00:05:33.115 both physios and chiros. 00:05:33.156 --> 00:05:35.119 Everyone kind of hated me a little bit, 00:05:36.160 --> 00:05:37.161 you know, at least in public. 00:05:37.362 --> 00:05:38.983 Private, I got a lot of positive feedback, 00:05:39.024 --> 00:05:39.644 but in public, 00:05:39.685 --> 00:05:40.826 everyone disliked the study. 00:05:42.288 --> 00:05:45.088 So some of the critique 00:05:45.129 --> 00:05:46.048 points that we got there, 00:05:46.389 --> 00:05:48.410 we did in another JOSPT 00:05:48.629 --> 00:05:49.670 review that we published in 00:05:49.911 --> 00:05:50.651 in twenty twenty three, 00:05:50.670 --> 00:05:51.350 where we looked at it, 00:05:51.932 --> 00:05:53.031 we removed some of the 00:05:53.112 --> 00:05:54.172 heterogeneity from the 00:05:54.211 --> 00:05:55.192 original study and then 00:05:55.273 --> 00:05:57.012 focused a little bit more 00:05:57.293 --> 00:05:59.033 on a certain population and 00:05:59.053 --> 00:06:00.314 found the exact same thing again. 00:06:02.574 --> 00:06:03.735 But we were still only 00:06:03.755 --> 00:06:04.935 looking at one aspect of it, 00:06:05.096 --> 00:06:06.297 which was the target selection. 00:06:07.218 --> 00:06:10.382 So over the last couple of years, 00:06:10.423 --> 00:06:11.963 this network meta-analysis 00:06:12.004 --> 00:06:13.625 approach really came up and 00:06:14.005 --> 00:06:14.927 there has been a lot of 00:06:14.987 --> 00:06:15.949 network meta-analysis. 00:06:16.009 --> 00:06:17.569 I think like almost... 00:06:18.422 --> 00:06:20.603 I think in it was something 00:06:20.644 --> 00:06:22.446 from to there was almost 00:06:22.505 --> 00:06:23.507 four hundred network 00:06:23.547 --> 00:06:25.889 meta-analysis published on MSK research. 00:06:26.370 --> 00:06:28.192 So it exploded all of a 00:06:28.211 --> 00:06:29.754 sudden and it does allow 00:06:30.014 --> 00:06:31.696 mathematically that you can 00:06:31.755 --> 00:06:33.538 actually compare two 00:06:33.577 --> 00:06:34.559 different interventions 00:06:34.978 --> 00:06:36.761 that are not being directly 00:06:36.781 --> 00:06:38.122 compared within the same study. 00:06:38.862 --> 00:06:40.343 So that's the indirect evidence. 00:06:40.403 --> 00:06:41.463 There's a whole bunch of 00:06:41.704 --> 00:06:43.223 statistics that goes behind that, 00:06:43.603 --> 00:06:44.904 which I won't get into too 00:06:44.944 --> 00:06:45.524 much here today. 00:06:45.564 --> 00:06:47.064 But this did allow us to 00:06:47.144 --> 00:06:49.466 actually classify all of 00:06:49.485 --> 00:06:52.086 the different SMTs that 00:06:52.107 --> 00:06:53.206 were delivered in studies 00:06:53.666 --> 00:06:54.747 and then compare those 00:06:54.766 --> 00:06:56.348 classifications to each other, 00:06:56.668 --> 00:06:57.348 which meant that we could 00:06:57.367 --> 00:06:58.288 look at other things now 00:06:58.307 --> 00:06:59.468 than just target selection. 00:07:00.028 --> 00:07:01.749 We could also look at the thrust specifics, 00:07:02.108 --> 00:07:02.829 and we could even look at 00:07:02.850 --> 00:07:04.050 the region where it was provided. 00:07:04.069 --> 00:07:04.769 And those were the three 00:07:04.790 --> 00:07:05.629 things we went with. 00:07:08.262 --> 00:07:10.843 So we took, we basically, we wanted to, 00:07:11.163 --> 00:07:11.564 yeah, sorry. 00:07:11.625 --> 00:07:12.925 Casper, I think all that's great. 00:07:13.545 --> 00:07:14.485 I just want to interrupt you 00:07:14.526 --> 00:07:17.406 briefly because in reading this study, 00:07:17.507 --> 00:07:18.367 I'm familiar with some of 00:07:18.387 --> 00:07:19.848 these terms that you're using, 00:07:19.889 --> 00:07:21.149 but just for our listeners 00:07:21.209 --> 00:07:23.209 who may be less familiar, 00:07:23.290 --> 00:07:26.552 could you briefly define SMT for us? 00:07:26.632 --> 00:07:28.012 And then can you briefly 00:07:28.052 --> 00:07:28.913 define the target? 00:07:28.952 --> 00:07:30.853 What do you mean when you say target? 00:07:31.814 --> 00:07:32.454 Yes, of course. 00:07:32.475 --> 00:07:32.694 Sorry. 00:07:33.035 --> 00:07:34.956 Yeah, no, SMT, we define, 00:07:36.052 --> 00:07:36.634 I don't think there's a 00:07:36.913 --> 00:07:37.997 quite clear definition, 00:07:38.076 --> 00:07:39.862 but basically it's the 00:07:39.901 --> 00:07:41.004 cracking manual therapy. 00:07:41.125 --> 00:07:42.108 So it's the manual therapy 00:07:42.127 --> 00:07:43.271 that has a high thrust and 00:07:43.310 --> 00:07:44.213 a low amplitude. 00:07:45.108 --> 00:07:46.529 sorry, high velocity, low amplitude. 00:07:47.329 --> 00:07:49.651 And it often results in a cracking sound. 00:07:50.252 --> 00:07:51.392 So we actually, in this study, 00:07:51.812 --> 00:07:53.454 excluded like other types 00:07:53.494 --> 00:07:54.334 of mobilization. 00:07:54.574 --> 00:07:56.036 If you follow the Maitland criteria, 00:07:56.076 --> 00:07:56.755 maybe the listeners are 00:07:56.776 --> 00:07:57.536 more familiar with that. 00:07:57.857 --> 00:07:59.838 This will be a grade five mobilization. 00:08:00.538 --> 00:08:03.579 So it was only the popping 00:08:03.600 --> 00:08:05.180 manual therapy that we use 00:08:05.521 --> 00:08:06.781 for this SMT definition. 00:08:07.242 --> 00:08:08.502 Sometimes mobilizations are 00:08:08.523 --> 00:08:09.944 being put in there, but for our study, 00:08:09.963 --> 00:08:13.065 we just looked at the cracking therapies, 00:08:13.706 --> 00:08:14.146 so to speak. 00:08:15.127 --> 00:08:18.468 um and and when I say target 00:08:18.509 --> 00:08:19.629 and thrust what I mean is 00:08:19.689 --> 00:08:21.350 by target I mean where 00:08:22.129 --> 00:08:23.951 where do you decide on 00:08:24.031 --> 00:08:25.151 where to give the treatment 00:08:25.672 --> 00:08:27.992 so there's a like this huge 00:08:28.353 --> 00:08:30.634 literature and even 00:08:30.673 --> 00:08:32.075 profession specific debate 00:08:32.115 --> 00:08:34.576 about where to do it and it 00:08:34.596 --> 00:08:35.537 can go with like the 00:08:35.557 --> 00:08:36.517 classic thing at least in 00:08:36.557 --> 00:08:37.918 chiro practice is that you 00:08:37.957 --> 00:08:38.977 palpate the spine and then 00:08:38.998 --> 00:08:40.259 you find these dysfunctions 00:08:40.947 --> 00:08:43.227 that the fixed joints or the 00:08:43.268 --> 00:08:45.490 lock joints typically around the facet, 00:08:45.549 --> 00:08:47.009 and then you manipulate it, 00:08:47.029 --> 00:08:48.650 you make it go the little cracking sound, 00:08:48.671 --> 00:08:50.072 you get the first of the 00:08:50.111 --> 00:08:51.993 bubble and those theories 00:08:52.013 --> 00:08:53.254 that we can get into if you 00:08:53.274 --> 00:08:53.714 really want to, 00:08:54.654 --> 00:08:55.735 and that improves the patients. 00:08:57.275 --> 00:08:58.155 And you have to deliver it 00:08:58.176 --> 00:08:59.856 at the exact right spot, right? 00:08:59.876 --> 00:09:00.677 Because everyone can make 00:09:00.697 --> 00:09:01.817 their back say crack, 00:09:01.857 --> 00:09:03.678 but it's not in the right spot. 00:09:04.479 --> 00:09:05.799 That's the whole theoretical 00:09:05.820 --> 00:09:06.780 foundation around it. 00:09:07.081 --> 00:09:08.360 So when I say target, that's what I mean. 00:09:08.400 --> 00:09:09.741 That's basically where 00:09:09.782 --> 00:09:11.582 exactly is the intervention? 00:09:11.663 --> 00:09:13.884 Where is SMT being targeted on the spine? 00:09:15.480 --> 00:09:17.982 And, and if you go with thrust, 00:09:18.043 --> 00:09:19.124 which we also looked at, 00:09:19.244 --> 00:09:20.484 that could be like, 00:09:20.524 --> 00:09:21.825 was it a specific thrust? 00:09:21.845 --> 00:09:23.365 Do you try to hit a single 00:09:23.647 --> 00:09:25.288 vertebral segment or was it 00:09:25.327 --> 00:09:26.408 more of a generalized thrust? 00:09:26.448 --> 00:09:26.989 Like you wanted to, 00:09:27.408 --> 00:09:29.490 to manipulate an entire lumbar region, 00:09:29.530 --> 00:09:29.910 for instance. 00:09:31.020 --> 00:09:32.360 And the region, I think it's, 00:09:32.802 --> 00:09:35.162 we split it up into the region of pain. 00:09:35.402 --> 00:09:36.442 So that could be low back 00:09:36.482 --> 00:09:37.883 pain patients with, you know, 00:09:37.923 --> 00:09:39.663 manipulated at the lumbar spine. 00:09:40.203 --> 00:09:41.465 But it could also be, let's say, 00:09:41.524 --> 00:09:42.625 patients with cervical, 00:09:43.865 --> 00:09:44.846 like neck pain who were 00:09:44.865 --> 00:09:46.546 treated in the thoracic spine. 00:09:46.586 --> 00:09:48.287 That could be the non-symptomatic region. 00:09:48.966 --> 00:09:50.687 So that's how we define regions. 00:09:50.807 --> 00:09:51.567 So those are the three 00:09:51.607 --> 00:09:52.788 things that we wanted to 00:09:52.847 --> 00:09:54.269 assess in this review here, 00:09:54.948 --> 00:09:55.788 where we could only look at 00:09:55.828 --> 00:09:58.610 the target earlier. 00:09:58.649 --> 00:09:58.889 Great. 00:09:58.950 --> 00:09:59.309 Thank you. 00:09:59.510 --> 00:10:00.410 I think that really helps. 00:10:01.620 --> 00:10:02.761 Can you speak a little bit 00:10:02.822 --> 00:10:04.544 more about how this study 00:10:04.585 --> 00:10:05.586 then came about? 00:10:05.666 --> 00:10:06.807 I kind of got you off track, 00:10:06.826 --> 00:10:07.648 but thanks for those 00:10:08.168 --> 00:10:09.610 definitions to kind of clarify. 00:10:09.629 --> 00:10:12.234 Yeah, you're welcome. 00:10:12.254 --> 00:10:13.695 Yeah, it's always when you, you know, 00:10:13.794 --> 00:10:15.256 you got to speak to a broad audience. 00:10:15.376 --> 00:10:16.578 Sometimes everybody doesn't 00:10:16.599 --> 00:10:17.519 really understand what SMT is. 00:10:17.539 --> 00:10:20.082 I mean, sometimes we can't even define it. 00:10:20.102 --> 00:10:21.443 So it's a good point. 00:10:23.384 --> 00:10:26.268 Um, so the study came, came about in, 00:10:26.849 --> 00:10:27.188 I believe, 00:10:27.570 --> 00:10:32.056 I had the idea about doing this. 00:10:32.616 --> 00:10:35.740 And then I, um, I engaged Carson Yule, 00:10:35.780 --> 00:10:36.822 who's a professor at the 00:10:36.883 --> 00:10:37.803 university of Southern Denmark. 00:10:37.823 --> 00:10:38.804 He's also a physio. 00:10:39.426 --> 00:10:40.888 He has done a lot of systematic reviews. 00:10:40.947 --> 00:10:43.490 He's like an expert on systematic reviews. 00:10:43.890 --> 00:10:44.792 And I told him about the 00:10:44.871 --> 00:10:46.212 idea and he really liked it. 00:10:46.933 --> 00:10:49.375 And then we pretty much got going. 00:10:49.475 --> 00:10:51.018 Then we got a senior team together. 00:10:51.057 --> 00:10:51.918 So we got Chad Cook, 00:10:51.958 --> 00:10:53.220 who I'm sure most of your 00:10:53.240 --> 00:10:54.280 listeners are familiar with. 00:10:54.341 --> 00:10:55.482 We got Chad involved in it. 00:10:55.562 --> 00:10:57.083 And then we got Jan Hartwiesen, 00:10:57.104 --> 00:10:58.666 who's a professor also at 00:10:58.686 --> 00:10:59.427 the University of Southern 00:10:59.447 --> 00:11:00.187 Denmark at Cairo. 00:11:00.922 --> 00:11:02.182 He has done extensive work 00:11:02.202 --> 00:11:03.644 in the low back pain field. 00:11:03.804 --> 00:11:05.287 He was an author on the Lancet series, 00:11:05.307 --> 00:11:05.706 for instance. 00:11:06.067 --> 00:11:07.808 So a very good guy. 00:11:08.490 --> 00:11:10.392 And then we also included Steven Pearl, 00:11:10.432 --> 00:11:11.432 which I think your 00:11:11.452 --> 00:11:12.594 listeners probably won't know. 00:11:12.673 --> 00:11:14.917 He's also a chiro by 00:11:14.976 --> 00:11:16.477 training and he's retired now, but 00:11:17.698 --> 00:11:19.600 he has a, he has a mind of his own. 00:11:19.659 --> 00:11:22.321 Like he knows every theory, 00:11:22.721 --> 00:11:23.681 every treatment. 00:11:23.802 --> 00:11:25.802 He is just, he, he's a sponge. 00:11:25.822 --> 00:11:26.743 He remembers everything. 00:11:26.822 --> 00:11:29.124 So we included him as well in the, as, 00:11:29.244 --> 00:11:30.283 as the senior team. 00:11:30.864 --> 00:11:32.264 And then we had to find, you know, 00:11:32.284 --> 00:11:33.225 people to actually do the work. 00:11:33.245 --> 00:11:33.826 Cause we all know that 00:11:33.846 --> 00:11:35.206 professors don't really do a lot of work. 00:11:35.725 --> 00:11:38.508 So, so we had to get a huge review team. 00:11:38.707 --> 00:11:39.788 And originally I was, 00:11:40.467 --> 00:11:41.149 I know another reason, 00:11:41.168 --> 00:11:43.549 but I'm a part of the car fellowship, 00:11:43.570 --> 00:11:46.770 which is like, um, international, uh, 00:11:46.811 --> 00:11:46.951 like, 00:11:49.243 --> 00:11:50.124 uh I want to say research 00:11:50.163 --> 00:11:50.784 and leadership 00:11:51.365 --> 00:11:52.746 international cairo program 00:11:52.986 --> 00:11:55.149 so we had we were fourteen 00:11:55.169 --> 00:11:56.211 people in the program so we 00:11:56.230 --> 00:11:57.111 got a bunch of them in and 00:11:57.131 --> 00:11:59.494 then we realized holy moly 00:11:59.654 --> 00:12:00.355 this is going to be a lot 00:12:00.375 --> 00:12:00.936 more work than we 00:12:00.956 --> 00:12:02.697 anticipated so we got more 00:12:02.717 --> 00:12:04.159 people involved in it and 00:12:04.179 --> 00:12:04.679 that's where megan 00:12:04.740 --> 00:12:05.721 donaldson came in for 00:12:05.760 --> 00:12:08.264 instance uh also with a armed um 00:12:09.524 --> 00:12:10.326 And at every point, 00:12:10.366 --> 00:12:11.789 we wanted to keep it very 00:12:11.830 --> 00:12:13.231 interdisciplinary. 00:12:13.251 --> 00:12:14.153 That was very important for 00:12:14.193 --> 00:12:15.937 us because some of the 00:12:15.957 --> 00:12:16.719 critique that we got, 00:12:16.759 --> 00:12:17.860 especially from Kairos from 00:12:17.900 --> 00:12:19.224 our prior reviews, was that, well, 00:12:19.283 --> 00:12:21.327 all of this work was done by physios. 00:12:22.393 --> 00:12:23.994 which was actually most of 00:12:24.014 --> 00:12:25.335 the other studies that we included. 00:12:26.275 --> 00:12:26.816 But here we had a 00:12:26.855 --> 00:12:28.977 possibility to include from 00:12:29.038 --> 00:12:30.118 all types of different 00:12:30.158 --> 00:12:31.019 professions because we 00:12:31.038 --> 00:12:32.179 looked at it more broadly. 00:12:33.059 --> 00:12:33.961 So we also wanted to make 00:12:34.000 --> 00:12:35.542 sure that we had a very 00:12:35.581 --> 00:12:36.682 broad and interdisciplinary 00:12:37.202 --> 00:12:38.803 and international team as well. 00:12:39.183 --> 00:12:40.725 So we also had a sports science guy. 00:12:41.745 --> 00:12:42.886 We had a lot of, like you said, 00:12:42.927 --> 00:12:44.768 I think we were eighteen authors. 00:12:44.888 --> 00:12:45.808 So we had a lot of different 00:12:45.828 --> 00:12:46.870 people in there. 00:12:46.889 --> 00:12:48.309 That's really what it took to get it done. 00:12:48.870 --> 00:12:51.172 It was a huge process when 00:12:51.211 --> 00:12:51.913 we got it going. 00:12:52.994 --> 00:12:54.735 The search was big and then 00:12:54.914 --> 00:12:56.056 the data extraction was 00:12:56.096 --> 00:12:57.317 enormous because we had to 00:12:57.376 --> 00:12:59.957 extract a lot of things to 00:13:00.399 --> 00:13:01.599 classify these different 00:13:01.700 --> 00:13:02.960 SMT interventions. 00:13:03.980 --> 00:13:04.301 So yes, 00:13:04.360 --> 00:13:07.023 a lot of process that I think we 00:13:07.082 --> 00:13:09.605 worked on it maybe a year 00:13:09.625 --> 00:13:11.605 and a half before we 00:13:11.666 --> 00:13:12.807 attempted to submit it somewhere. 00:13:12.986 --> 00:13:15.149 So it was quite a lot of 00:13:15.168 --> 00:13:16.950 work to get it done. 00:13:18.583 --> 00:13:19.485 Yeah, it's amazing. 00:13:19.565 --> 00:13:20.764 Just an enormous data set. 00:13:20.885 --> 00:13:22.767 So going through kind of the 00:13:22.807 --> 00:13:24.288 introduction there were. 00:13:24.927 --> 00:13:26.688 I believe in your final sample, 00:13:26.708 --> 00:13:29.010 a hundred and sixty one total studies. 00:13:29.691 --> 00:13:31.331 Eleven little over eleven 00:13:31.371 --> 00:13:33.813 thousand total subjects included in this. 00:13:34.634 --> 00:13:37.616 Um, can you speak to how you. 00:13:39.238 --> 00:13:40.960 Managed that large of a data 00:13:41.039 --> 00:13:42.702 set and your choices of 00:13:42.822 --> 00:13:44.043 some of these statistical 00:13:44.083 --> 00:13:45.846 methods to analyze the data. 00:13:46.366 --> 00:13:47.008 And then I think you 00:13:47.048 --> 00:13:48.089 mentioned some of the 00:13:48.109 --> 00:13:49.610 variables that you were studying. 00:13:50.032 --> 00:13:51.874 But what were your main outcomes? 00:13:53.154 --> 00:13:54.317 As we're looking at, 00:13:54.356 --> 00:13:56.679 as a result of these procedures. 00:13:57.898 --> 00:14:00.600 Yeah, let's start from the beginning. 00:14:00.620 --> 00:14:01.421 How do we manage it? 00:14:01.961 --> 00:14:02.301 Luckily, 00:14:02.360 --> 00:14:04.322 I'm a quite organized and 00:14:04.342 --> 00:14:05.303 structured guy when it 00:14:05.344 --> 00:14:07.184 comes to data management. 00:14:07.225 --> 00:14:08.466 I'm also pretty sufficient 00:14:08.546 --> 00:14:11.187 with the statistical 00:14:11.207 --> 00:14:12.428 software program that we used. 00:14:13.610 --> 00:14:15.412 But it was really, really difficult. 00:14:15.652 --> 00:14:17.913 And it was reported in just 00:14:17.953 --> 00:14:19.174 a number of different ways. 00:14:19.855 --> 00:14:21.636 So there was a lot to keep 00:14:21.677 --> 00:14:22.957 track on when we actually got the data. 00:14:23.458 --> 00:14:25.980 It took some time to prepare 00:14:26.020 --> 00:14:27.001 the data for analysis. 00:14:27.402 --> 00:14:28.442 And then the analysis itself 00:14:28.482 --> 00:14:29.504 took maybe ten seconds. 00:14:30.004 --> 00:14:31.647 So that was kind of a bummer, 00:14:31.687 --> 00:14:32.687 but probably took two 00:14:32.727 --> 00:14:33.427 months to get there. 00:14:33.508 --> 00:14:35.590 That's the thing about data 00:14:35.629 --> 00:14:37.611 cleaning that as non researchers, 00:14:37.631 --> 00:14:38.673 you often don't appreciate 00:14:38.712 --> 00:14:40.195 as much because you're like, oh, 00:14:41.056 --> 00:14:41.716 You get the results, 00:14:41.755 --> 00:14:42.657 but sometimes the results 00:14:42.697 --> 00:14:44.719 take months to even get to 00:14:44.778 --> 00:14:46.159 a point where you can analyze the data. 00:14:46.799 --> 00:14:48.701 So that took quite a lot of work. 00:14:48.761 --> 00:14:50.082 I also had to really 00:14:50.123 --> 00:14:51.403 understand this network 00:14:51.423 --> 00:14:53.326 meta-analysis thing, 00:14:53.346 --> 00:14:55.947 which is quite different 00:14:55.967 --> 00:14:57.389 than a normal meta-analysis 00:14:58.850 --> 00:14:59.831 from a math standpoint. 00:14:59.850 --> 00:15:01.812 So I had to put my head into that as well. 00:15:02.273 --> 00:15:04.335 So that really did take a lot of time. 00:15:05.490 --> 00:15:05.649 Yes. 00:15:05.669 --> 00:15:07.451 And then we extracted, like I said, 00:15:07.552 --> 00:15:08.472 a bunch of information. 00:15:08.592 --> 00:15:09.754 And for outcomes, 00:15:09.994 --> 00:15:12.775 we decided quite early on that, you know, 00:15:13.196 --> 00:15:13.897 because we knew we were 00:15:13.917 --> 00:15:15.378 going to end up with a broad, 00:15:15.678 --> 00:15:18.821 very heterogeneity kind of 00:15:19.201 --> 00:15:20.022 study sample here. 00:15:20.062 --> 00:15:21.322 So we went with the two 00:15:21.403 --> 00:15:22.923 outcomes that we had at 00:15:22.964 --> 00:15:24.125 least knew that probably 00:15:24.164 --> 00:15:26.067 the majority would publish, 00:15:26.106 --> 00:15:27.207 which would be pain 00:15:27.248 --> 00:15:28.989 intensity and some kind of 00:15:29.028 --> 00:15:29.929 disability measure. 00:15:30.410 --> 00:15:31.631 So that was the two outcomes 00:15:31.652 --> 00:15:32.371 that we selected. 00:15:32.572 --> 00:15:33.113 And then we were 00:15:34.260 --> 00:15:36.000 strategic and saying that we 00:15:36.020 --> 00:15:37.761 will only look at right 00:15:37.822 --> 00:15:38.562 after the treatment. 00:15:39.221 --> 00:15:40.182 So right after the treatment, 00:15:40.763 --> 00:15:41.503 like the intervention, 00:15:41.822 --> 00:15:42.883 if it was twelve sessions, 00:15:42.923 --> 00:15:44.024 it would be after that twelve sessions, 00:15:44.043 --> 00:15:45.244 that would be the short-term outcomes. 00:15:45.663 --> 00:15:47.085 And then we had the long-term outcomes, 00:15:47.125 --> 00:15:48.524 which was the closest thing 00:15:48.544 --> 00:15:49.284 to twelve months. 00:15:51.145 --> 00:15:52.466 So those were the outcomes 00:15:52.505 --> 00:15:53.846 that we selected, 00:15:54.466 --> 00:15:55.287 which meant that we had to 00:15:55.307 --> 00:15:56.846 do a lot of analyses 00:15:57.506 --> 00:15:58.628 because we did a lot of 00:15:58.687 --> 00:15:59.788 networks and each network 00:15:59.807 --> 00:16:00.988 had to be repeated for 00:16:01.028 --> 00:16:01.769 different outcomes at 00:16:01.808 --> 00:16:02.609 different time points. 00:16:03.373 --> 00:16:04.355 Which is why the study got 00:16:04.394 --> 00:16:06.277 so all the paper got so 00:16:06.317 --> 00:16:06.958 enormous as it did. 00:16:06.979 --> 00:16:07.078 Right. 00:16:07.099 --> 00:16:09.822 Yeah, absolutely. 00:16:10.423 --> 00:16:11.625 So after all of that, 00:16:11.826 --> 00:16:13.408 after collecting all of that data, 00:16:14.089 --> 00:16:14.990 what did you all find? 00:16:18.567 --> 00:16:20.509 Well, I think we found a number of things. 00:16:20.788 --> 00:16:22.190 The first thing that kind of 00:16:22.470 --> 00:16:26.033 pops up is that we mirrored 00:16:26.113 --> 00:16:27.714 what the other systematic 00:16:27.754 --> 00:16:28.414 reviews have found, 00:16:28.495 --> 00:16:29.475 which was really positive 00:16:29.515 --> 00:16:30.897 because our systematic 00:16:30.917 --> 00:16:33.139 review here was more broad than, 00:16:33.578 --> 00:16:34.940 let's say, Sidney Rubenstein, 00:16:34.980 --> 00:16:36.381 who published a systematic 00:16:36.402 --> 00:16:37.442 review on chronic low back 00:16:37.461 --> 00:16:39.043 pain back in twenty twenty nineteen. 00:16:39.063 --> 00:16:39.683 That was probably the 00:16:39.724 --> 00:16:40.924 biggest or that probably 00:16:41.144 --> 00:16:42.626 that was the biggest review 00:16:42.647 --> 00:16:44.187 to date published in BMJ 00:16:44.248 --> 00:16:44.989 back in twenty nineteen. 00:16:45.708 --> 00:16:48.029 And that was a little bit more concrete. 00:16:48.370 --> 00:16:50.571 Ours included, you know, different regions, 00:16:51.511 --> 00:16:53.212 a lot of different techniques, different, 00:16:54.052 --> 00:16:55.374 you know, durations of pain. 00:16:55.653 --> 00:16:56.533 We had both acute and 00:16:56.573 --> 00:16:57.514 chronic pain in there. 00:16:57.554 --> 00:16:59.216 So that's why we ended up 00:16:59.255 --> 00:17:00.355 with so many studies and so 00:17:00.395 --> 00:17:01.196 many participants. 00:17:01.596 --> 00:17:03.076 So we were happy to see, first of all, 00:17:03.116 --> 00:17:05.699 that all results actually mimicked, 00:17:06.138 --> 00:17:06.298 sorry, 00:17:06.719 --> 00:17:08.340 mirrored what they found, 00:17:08.800 --> 00:17:10.282 which is that SMT seemed to 00:17:10.323 --> 00:17:13.065 be as effective as other interventions, 00:17:13.286 --> 00:17:14.346 recommended interventions, 00:17:14.727 --> 00:17:16.188 such as exercise and other 00:17:16.228 --> 00:17:16.909 manual therapies. 00:17:16.929 --> 00:17:18.190 There was no real difference there. 00:17:18.790 --> 00:17:19.832 And also that SMT was, you know, 00:17:19.892 --> 00:17:22.413 a little bit more effective 00:17:22.473 --> 00:17:24.496 than non-recommended therapies, like say, 00:17:24.636 --> 00:17:26.659 putting yourself in traction or... 00:17:28.250 --> 00:17:30.712 uh like ultrasound for 00:17:30.752 --> 00:17:31.773 instance and like stuff 00:17:31.794 --> 00:17:32.595 that is no longer being 00:17:32.634 --> 00:17:33.556 recommended in clinical 00:17:33.596 --> 00:17:34.916 guidelines what we did 00:17:34.938 --> 00:17:35.778 found that was different 00:17:35.817 --> 00:17:36.538 from a lot of the other 00:17:36.558 --> 00:17:37.680 reviews was that when we 00:17:37.720 --> 00:17:39.942 compared to sham treatment 00:17:40.343 --> 00:17:41.483 we actually found quite a 00:17:41.523 --> 00:17:43.025 larger effect of smt 00:17:43.065 --> 00:17:44.145 compared to other studies 00:17:45.017 --> 00:17:47.278 And I think part of that is due to the, 00:17:47.417 --> 00:17:48.718 we had to pool some 00:17:48.758 --> 00:17:50.798 different placebo studies together. 00:17:51.378 --> 00:17:53.838 So one could be a real setup 00:17:54.079 --> 00:17:55.579 where you completely mimic 00:17:55.640 --> 00:17:56.619 the intervention. 00:17:56.660 --> 00:17:57.380 And the other one could be 00:17:57.420 --> 00:17:58.641 like a detune ultrasound 00:17:58.780 --> 00:18:00.080 thing that you just put on patients. 00:18:00.661 --> 00:18:02.221 And from a contextual standpoint, 00:18:02.301 --> 00:18:03.422 which we'll talk more about later, 00:18:03.741 --> 00:18:04.761 those are very different. 00:18:04.821 --> 00:18:06.563 And we also know that from a 00:18:06.782 --> 00:18:08.222 paper published in pain last year, 00:18:08.624 --> 00:18:09.344 that there's quite a big 00:18:09.384 --> 00:18:10.124 difference in the effect 00:18:10.144 --> 00:18:11.284 sizes between those two 00:18:11.304 --> 00:18:12.224 different placebos. 00:18:12.944 --> 00:18:13.065 So. 00:18:14.109 --> 00:18:15.171 That's probably why we found 00:18:15.211 --> 00:18:15.790 those results. 00:18:15.951 --> 00:18:17.271 So that was the first thing we found. 00:18:17.932 --> 00:18:18.732 And then we looked at, 00:18:19.653 --> 00:18:21.295 we basically used different 00:18:21.315 --> 00:18:24.057 ways of categorizing the target, 00:18:24.116 --> 00:18:25.258 the thrust and the region. 00:18:25.278 --> 00:18:26.298 And then we compared all of 00:18:26.338 --> 00:18:28.339 those with each other based 00:18:28.420 --> 00:18:30.862 on this advanced and complex statistics. 00:18:31.781 --> 00:18:32.982 So we got a result out and 00:18:33.103 --> 00:18:34.144 that result was very clear. 00:18:34.503 --> 00:18:36.705 Like it worked and it really 00:18:36.726 --> 00:18:38.106 didn't matter how you used it. 00:18:39.106 --> 00:18:40.748 Like there were no real 00:18:40.968 --> 00:18:42.989 differences between any of 00:18:43.028 --> 00:18:44.309 the SMT interventions. 00:18:45.750 --> 00:18:46.611 It reached statistical 00:18:46.631 --> 00:18:48.132 significance a couple of times, 00:18:48.152 --> 00:18:49.112 but it was still a somewhat 00:18:49.172 --> 00:18:50.113 small effect size. 00:18:50.992 --> 00:18:52.953 So basically saying that SMT 00:18:52.993 --> 00:18:54.234 seems to work as well as 00:18:54.295 --> 00:18:55.315 other recommended therapies, 00:18:55.595 --> 00:18:56.516 but how you do it. 00:18:57.569 --> 00:18:58.990 It didn't explain any of the 00:18:59.010 --> 00:19:00.790 variation in the outcome data. 00:19:01.171 --> 00:19:02.372 So there was no difference whether, 00:19:03.531 --> 00:19:04.291 let's take an example, 00:19:04.311 --> 00:19:04.971 whether you used a 00:19:05.011 --> 00:19:05.952 completely generalized 00:19:05.972 --> 00:19:06.893 thrust or whether you were 00:19:06.992 --> 00:19:07.992 trying to be like sniper 00:19:08.012 --> 00:19:09.614 specific on that vertebral segment, 00:19:09.913 --> 00:19:10.493 didn't matter. 00:19:10.973 --> 00:19:11.913 Even if you did it in the 00:19:12.134 --> 00:19:13.474 region where people came in, 00:19:13.714 --> 00:19:15.414 like let's say a neck patient came in, 00:19:15.434 --> 00:19:16.955 you manipulated the neck or 00:19:16.976 --> 00:19:18.435 you manipulated their thoracic spine. 00:19:18.455 --> 00:19:19.696 There was a lot of studies that did that. 00:19:19.997 --> 00:19:22.057 Also no difference in neck 00:19:22.076 --> 00:19:23.238 pain outcomes or neck 00:19:23.258 --> 00:19:24.238 disability outcomes. 00:19:25.134 --> 00:19:25.834 And we actually found, 00:19:25.854 --> 00:19:27.974 but that's not what we want to conclude, 00:19:27.994 --> 00:19:29.576 because I'll get to that in a second. 00:19:29.635 --> 00:19:31.656 But we actually found that a 00:19:31.717 --> 00:19:33.537 completely nonspecific approach, 00:19:33.676 --> 00:19:36.038 a generalized thrust to the 00:19:36.137 --> 00:19:37.259 non-symptomatic region 00:19:37.479 --> 00:19:38.739 actually appeared to be the 00:19:38.818 --> 00:19:41.160 most effective way of doing it. 00:19:42.000 --> 00:19:43.580 But because of the way that 00:19:43.961 --> 00:19:44.821 the study was set up, 00:19:45.362 --> 00:19:47.061 we said that clinicians, 00:19:47.383 --> 00:19:48.383 and that's the main takeaway, 00:19:48.722 --> 00:19:49.482 that clinicians can 00:19:49.522 --> 00:19:51.344 basically do whatever they 00:19:51.403 --> 00:19:52.605 want to and expect to get 00:19:52.644 --> 00:19:53.345 the same results. 00:19:53.944 --> 00:19:56.125 So we shouldn't dive into 00:19:56.385 --> 00:19:58.105 the different philosophies 00:19:58.326 --> 00:19:59.746 or theoretical frameworks 00:19:59.786 --> 00:20:02.247 for this type or this type. 00:20:02.287 --> 00:20:03.186 At least on average, 00:20:03.346 --> 00:20:04.728 it seems to be that there 00:20:05.087 --> 00:20:06.028 is no real difference. 00:20:06.567 --> 00:20:07.448 And we found one last thing, 00:20:07.468 --> 00:20:08.127 which I might add, 00:20:08.528 --> 00:20:10.249 which was that as expected, 00:20:10.729 --> 00:20:13.089 because normally in systematic review, 00:20:13.109 --> 00:20:13.950 you should do a great 00:20:13.990 --> 00:20:15.190 approach to assess the 00:20:15.430 --> 00:20:16.671 certainty of the evidence. 00:20:17.270 --> 00:20:17.671 And normally, 00:20:17.691 --> 00:20:19.911 you want to get high certainty evidence. 00:20:19.951 --> 00:20:20.632 That's what's going to 00:20:20.672 --> 00:20:21.692 change clinical practice. 00:20:22.551 --> 00:20:24.153 basically which rarely 00:20:24.192 --> 00:20:25.732 happens in spine research 00:20:26.433 --> 00:20:28.214 unfortunately and it also 00:20:28.234 --> 00:20:28.894 didn't happen here we 00:20:28.974 --> 00:20:31.155 actually got low certainty 00:20:31.195 --> 00:20:32.336 evidence more or less all 00:20:32.355 --> 00:20:35.077 the way through and that it 00:20:35.157 --> 00:20:36.438 is really explained by a 00:20:36.478 --> 00:20:37.818 few things first of all we 00:20:37.959 --> 00:20:39.599 used you always assist risk 00:20:39.640 --> 00:20:41.861 of bias in these randomized 00:20:41.881 --> 00:20:43.601 trials that we included and 00:20:43.641 --> 00:20:44.862 here we were very stringent 00:20:44.961 --> 00:20:46.082 we used cochran's which is 00:20:46.102 --> 00:20:47.363 the recommended tool and we 00:20:47.383 --> 00:20:48.864 were quite hard so we used 00:20:49.364 --> 00:20:51.565 cochran's way of doing it and cochrane is 00:20:53.934 --> 00:20:54.875 It's like the guidebook on 00:20:54.894 --> 00:20:56.134 how to do reviews, basically, 00:20:57.135 --> 00:20:58.276 which meant that almost all 00:20:58.296 --> 00:20:59.217 of the studies were 00:20:59.277 --> 00:21:00.217 categorized as having a 00:21:00.336 --> 00:21:03.538 high risk of bias just 00:21:03.577 --> 00:21:05.298 because you cannot really blind it. 00:21:05.638 --> 00:21:06.819 And all the outcomes we 00:21:06.839 --> 00:21:07.920 looked at were subjective. 00:21:07.960 --> 00:21:08.640 So I would say, 00:21:09.641 --> 00:21:11.981 my pain is now three out of 00:21:12.021 --> 00:21:13.301 ten instead of five out of 00:21:13.321 --> 00:21:13.801 ten or whatever. 00:21:14.063 --> 00:21:15.222 And that's all a subjective 00:21:15.482 --> 00:21:17.403 opinion that can be biased 00:21:17.423 --> 00:21:18.284 by a lot of different things. 00:21:18.344 --> 00:21:19.484 It kind of makes sense, right? 00:21:21.336 --> 00:21:23.958 So that pumped the certainty 00:21:24.018 --> 00:21:24.979 of the evidence. 00:21:25.459 --> 00:21:26.799 It downgraded it, I would say. 00:21:26.839 --> 00:21:29.442 And then we also saw some inconsistencies. 00:21:29.481 --> 00:21:30.162 So there were some 00:21:31.123 --> 00:21:32.243 comparisons that we did. 00:21:32.263 --> 00:21:33.605 And I don't want to get too technical here, 00:21:33.664 --> 00:21:35.806 where we had a study that 00:21:36.105 --> 00:21:37.186 did a direct comparison. 00:21:37.287 --> 00:21:38.768 So let's say an RCT that 00:21:38.807 --> 00:21:41.730 compared SMT to exercise, for instance. 00:21:42.150 --> 00:21:43.431 And that would show one result. 00:21:43.510 --> 00:21:44.751 And then based on all these 00:21:44.771 --> 00:21:45.893 advanced mathematics, 00:21:46.272 --> 00:21:48.054 when we looked at the indirect evidence, 00:21:48.453 --> 00:21:49.494 so that would be if we 00:21:50.950 --> 00:21:51.809 took what the computer 00:21:51.829 --> 00:21:53.631 decided is probably the 00:21:53.671 --> 00:21:56.211 effect of manipulation over exercise. 00:21:56.352 --> 00:21:57.472 Those two could differ a bit. 00:21:58.573 --> 00:22:00.013 So that's what we call inconsistency. 00:22:00.054 --> 00:22:01.394 And we also had a little bit of that. 00:22:01.933 --> 00:22:03.934 And it was mostly related to 00:22:03.954 --> 00:22:05.215 when we compared SMT to 00:22:06.816 --> 00:22:07.856 other interventions. 00:22:09.130 --> 00:22:09.589 So again, 00:22:10.310 --> 00:22:11.432 basically saying that the 00:22:11.551 --> 00:22:13.113 outcomes we looked at are 00:22:13.232 --> 00:22:14.054 all over the place, 00:22:15.355 --> 00:22:16.736 which did impact the 00:22:16.796 --> 00:22:18.037 certainty of our evidence. 00:22:18.537 --> 00:22:19.518 But we still, 00:22:19.617 --> 00:22:20.358 and I don't know if you want 00:22:20.378 --> 00:22:21.179 to ask about this later, 00:22:21.199 --> 00:22:23.260 but we actually still conclude that, 00:22:23.361 --> 00:22:24.741 and we just wrote a blog to 00:22:24.801 --> 00:22:25.843 JOSBT about this, 00:22:25.863 --> 00:22:26.723 where we explained this, 00:22:27.243 --> 00:22:28.724 in in more detail which 00:22:28.884 --> 00:22:29.645 didn't fit into the 00:22:29.685 --> 00:22:31.247 original paper we still 00:22:31.267 --> 00:22:32.548 believe that this has an 00:22:32.587 --> 00:22:33.769 impact on education 00:22:33.788 --> 00:22:34.989 specifically and also on 00:22:35.009 --> 00:22:36.089 clinical practice because 00:22:36.109 --> 00:22:37.570 it's not only this paper 00:22:37.611 --> 00:22:38.632 that says that we had the 00:22:38.692 --> 00:22:39.573 other reviews we have 00:22:39.613 --> 00:22:40.773 individual trials we have 00:22:40.814 --> 00:22:42.134 mechanistic research saying 00:22:42.174 --> 00:22:43.494 that you can't really 00:22:43.715 --> 00:22:45.297 control forces or at least 00:22:45.936 --> 00:22:47.057 control where where the 00:22:47.116 --> 00:22:48.637 forces are delivered like 00:22:48.657 --> 00:22:50.018 for instance if you were to 00:22:50.057 --> 00:22:51.138 quantify where the popping 00:22:51.179 --> 00:22:52.939 sounds occur they occur all 00:22:52.999 --> 00:22:53.960 over the spine even 00:22:54.119 --> 00:22:55.480 multiple places away and 00:22:55.539 --> 00:22:56.480 only like half the time 00:22:56.519 --> 00:22:57.701 they actually occur on this 00:22:57.740 --> 00:23:01.241 segment um so so this this 00:23:01.261 --> 00:23:02.821 aligns really well with 00:23:03.363 --> 00:23:04.563 with mechanistic research 00:23:04.603 --> 00:23:05.742 with other reviews with 00:23:05.782 --> 00:23:07.423 individual trials and also 00:23:08.919 --> 00:23:10.779 to be honest with a more 00:23:10.839 --> 00:23:12.000 modern understanding of 00:23:12.540 --> 00:23:15.142 pain science and how back 00:23:15.162 --> 00:23:19.183 pain is fluctuating and how 00:23:19.223 --> 00:23:20.463 complex pain really is. 00:23:21.025 --> 00:23:22.464 It also goes along really well with that. 00:23:22.484 --> 00:23:23.346 So we still think that our 00:23:23.365 --> 00:23:25.326 conclusions holds a lot of 00:23:25.386 --> 00:23:26.446 recommendations that we 00:23:26.487 --> 00:23:28.307 hope will be implemented different places, 00:23:28.708 --> 00:23:30.288 despite the low certainty 00:23:30.328 --> 00:23:31.289 evidence from a more 00:23:31.329 --> 00:23:32.329 statistical standpoint, 00:23:32.369 --> 00:23:32.750 if that makes sense. 00:23:32.769 --> 00:23:35.010 Yeah, I think so. 00:23:35.050 --> 00:23:35.791 Thank you for the 00:23:36.071 --> 00:23:37.853 explanation and description of results. 00:23:38.891 --> 00:23:40.991 The first thing that kind of comes to mind, 00:23:41.332 --> 00:23:43.472 and I don't mean this in a negative way, 00:23:43.532 --> 00:23:45.854 but being a fellowship 00:23:45.874 --> 00:23:47.253 trained in AOMT and just 00:23:47.854 --> 00:23:48.934 having some conversations 00:23:48.974 --> 00:23:50.055 with colleagues about these 00:23:50.095 --> 00:23:50.736 sorts of things, 00:23:52.195 --> 00:23:53.336 we like to think that our 00:23:53.396 --> 00:23:54.656 training allows us to 00:23:56.617 --> 00:23:58.417 deliver maybe different 00:23:58.578 --> 00:23:59.959 levels of manual therapy 00:23:59.999 --> 00:24:02.200 skills than colleagues who 00:24:02.279 --> 00:24:03.180 maybe didn't go through 00:24:03.240 --> 00:24:04.161 residency training or 00:24:04.201 --> 00:24:05.601 fellowship training or just 00:24:05.641 --> 00:24:07.162 don't have the experience. 00:24:08.387 --> 00:24:09.648 What are your thoughts on 00:24:10.068 --> 00:24:13.771 the potential impact or implications of, 00:24:14.252 --> 00:24:15.453 as you yourself mentioned, 00:24:15.473 --> 00:24:16.974 just the large data set and 00:24:17.035 --> 00:24:17.615 potentially the 00:24:17.655 --> 00:24:19.297 heterogeneity of the 00:24:19.317 --> 00:24:20.998 different studies that were included? 00:24:21.038 --> 00:24:22.318 Was there any way that you 00:24:22.759 --> 00:24:26.303 were able to control for or account for. 00:24:27.642 --> 00:24:29.423 The type of treatment delivered, 00:24:29.463 --> 00:24:31.965 whether it was from a trained clinician, 00:24:32.506 --> 00:24:33.846 and then can you speak to 00:24:33.886 --> 00:24:34.948 maybe the breakdown of. 00:24:35.788 --> 00:24:37.951 Different applications of 00:24:37.971 --> 00:24:39.833 these treatments from a chiropractic. 00:24:40.353 --> 00:24:42.974 Standpoint is probably your your lens, 00:24:43.015 --> 00:24:44.517 but also the chiro 00:24:44.537 --> 00:24:46.218 philosophy versus physical therapy. 00:24:46.238 --> 00:24:46.939 Do you think that. 00:24:47.419 --> 00:24:50.260 Made a difference and I again. 00:24:51.400 --> 00:24:52.540 Acknowledging that, 00:24:53.801 --> 00:24:56.144 including both of those professions, 00:24:56.183 --> 00:24:57.444 because we both utilize 00:24:57.464 --> 00:24:58.125 that as a treatment 00:24:58.164 --> 00:24:59.526 technique and trying to 00:25:00.287 --> 00:25:02.929 span conclusions from 00:25:03.068 --> 00:25:03.829 application of this 00:25:03.869 --> 00:25:05.891 treatment is important. 00:25:06.132 --> 00:25:07.112 But do you think that 00:25:07.292 --> 00:25:08.733 limited your ability to 00:25:09.554 --> 00:25:11.836 conclude definitively 00:25:13.237 --> 00:25:14.877 things based across the board? 00:25:15.459 --> 00:25:16.038 I don't know. 00:25:17.087 --> 00:25:18.167 Yeah, no, I know what you mean. 00:25:18.669 --> 00:25:19.229 There were two really 00:25:19.269 --> 00:25:20.169 important questions there. 00:25:20.269 --> 00:25:22.670 One about the AOM training 00:25:22.710 --> 00:25:23.309 and all that stuff, 00:25:23.509 --> 00:25:27.131 like to get those qualifications. 00:25:27.391 --> 00:25:28.152 Let's get back to that a 00:25:28.172 --> 00:25:28.971 little bit because I do 00:25:28.991 --> 00:25:29.612 want to answer that. 00:25:30.011 --> 00:25:31.153 We can take the study first. 00:25:31.813 --> 00:25:32.232 Obviously, 00:25:32.272 --> 00:25:33.813 the effects that we see here are 00:25:33.833 --> 00:25:34.913 all average defects. 00:25:35.773 --> 00:25:37.734 So it might be that there 00:25:37.855 --> 00:25:39.394 are certain outliers where 00:25:39.434 --> 00:25:41.096 this matters a whole lot 00:25:41.796 --> 00:25:43.296 and other outliers where it 00:25:43.375 --> 00:25:44.537 really doesn't matter at all. 00:25:45.592 --> 00:25:46.574 but on average, 00:25:47.115 --> 00:25:48.718 there was no real difference in it. 00:25:48.917 --> 00:25:50.500 And that's currently the 00:25:50.580 --> 00:25:51.803 only way that we can look 00:25:51.863 --> 00:25:54.327 at it is using the average data. 00:25:55.490 --> 00:25:56.391 And then you asked about, 00:25:57.563 --> 00:25:59.423 I would say we, first of all, 00:25:59.463 --> 00:25:59.944 our study was, 00:26:00.105 --> 00:26:01.486 despite the large number of studies, 00:26:01.526 --> 00:26:03.627 was not really powered to 00:26:03.688 --> 00:26:05.528 look at whether different 00:26:05.568 --> 00:26:07.309 professions differed or 00:26:07.369 --> 00:26:08.691 whether the experience of 00:26:08.750 --> 00:26:09.692 different professions, 00:26:11.212 --> 00:26:12.634 if that mattered for outcomes. 00:26:13.015 --> 00:26:13.634 There were some other 00:26:13.654 --> 00:26:14.615 studies out there where 00:26:14.635 --> 00:26:16.237 they look at the experience 00:26:16.257 --> 00:26:17.597 of people and how that matters, 00:26:17.637 --> 00:26:18.459 and it doesn't seem to 00:26:18.499 --> 00:26:20.039 matter a great deal, 00:26:21.020 --> 00:26:22.442 which also boils down to 00:26:22.481 --> 00:26:23.923 the complexity of measuring 00:26:23.962 --> 00:26:24.763 pain in real life. 00:26:25.644 --> 00:26:26.505 It is quite complex. 00:26:27.286 --> 00:26:28.346 And even just to understand 00:26:28.366 --> 00:26:30.167 that and interpret it as a 00:26:30.228 --> 00:26:32.130 research participant, very difficult. 00:26:34.491 --> 00:26:36.193 And then I would say we 00:26:36.253 --> 00:26:37.615 deliberately also didn't 00:26:37.654 --> 00:26:39.195 want to compare clinicians 00:26:39.236 --> 00:26:41.117 against each other because 00:26:41.538 --> 00:26:42.699 there are a lot of other 00:26:42.759 --> 00:26:45.281 factors that are involved 00:26:45.342 --> 00:26:47.503 here into the effect of these studies. 00:26:48.310 --> 00:26:49.833 So let's say like the 00:26:49.873 --> 00:26:51.875 smaller sample sizes of some studies, 00:26:51.895 --> 00:26:52.236 for instance, 00:26:52.256 --> 00:26:53.778 that's something that probably matters. 00:26:54.159 --> 00:26:55.680 Risk of bias may matter as well. 00:26:56.499 --> 00:26:57.358 But we did, 00:26:57.940 --> 00:26:59.200 and I haven't talked about this yet, 00:26:59.220 --> 00:27:01.540 but the paper is about a couple of pages. 00:27:01.881 --> 00:27:03.781 But then our supplementary material, 00:27:03.862 --> 00:27:04.321 our appendix, 00:27:04.342 --> 00:27:05.461 is actually three hundred 00:27:05.501 --> 00:27:06.282 and forty pages. 00:27:06.843 --> 00:27:08.763 So we did we did numerous 00:27:09.104 --> 00:27:11.044 additional analyses kind of 00:27:11.064 --> 00:27:12.464 to validate or verify some 00:27:12.505 --> 00:27:13.184 of these findings. 00:27:13.744 --> 00:27:14.385 And some of the things that 00:27:14.425 --> 00:27:16.125 we looked at that didn't matter was, 00:27:16.145 --> 00:27:16.445 you know, 00:27:16.705 --> 00:27:18.346 where did the patient have pain? 00:27:18.807 --> 00:27:20.167 What was the pain duration? 00:27:20.188 --> 00:27:21.288 But it was all more patient 00:27:21.327 --> 00:27:22.347 specific criteria. 00:27:22.409 --> 00:27:23.388 We didn't really look at the 00:27:24.680 --> 00:27:26.712 at the, at the clinician itself, but 00:27:28.023 --> 00:27:29.025 And I kind of don't want to do it, 00:27:29.065 --> 00:27:29.625 to be honest, 00:27:29.786 --> 00:27:31.086 because I don't want to set 00:27:31.207 --> 00:27:32.428 Kairos up against physios. 00:27:32.488 --> 00:27:33.749 I don't think that makes any sense. 00:27:33.788 --> 00:27:35.109 We should probably be better 00:27:35.130 --> 00:27:36.250 at collaborating than 00:27:36.290 --> 00:27:36.971 fighting each other. 00:27:37.692 --> 00:27:41.153 And it doesn't really have any impact, 00:27:41.213 --> 00:27:41.595 I would say, 00:27:41.634 --> 00:27:42.875 on clinical practice because 00:27:42.895 --> 00:27:45.376 we all know on an everyday basis, 00:27:46.238 --> 00:27:48.380 if patients, they like to go to Kairos, 00:27:48.660 --> 00:27:49.520 they'll go to Kairos. 00:27:49.560 --> 00:27:50.602 If they want to go to physios, 00:27:50.781 --> 00:27:51.781 they'll go to physios. 00:27:52.242 --> 00:27:53.584 And if one thing doesn't work for them, 00:27:53.644 --> 00:27:54.505 maybe they'll switch. 00:27:54.545 --> 00:27:54.684 But 00:27:55.919 --> 00:27:57.220 The risk of going back to a 00:27:57.259 --> 00:27:58.980 provider is who you see first, 00:27:59.619 --> 00:28:00.161 most likely. 00:28:00.701 --> 00:28:04.442 So I would kind of hate 00:28:04.883 --> 00:28:06.222 doing research like that, 00:28:06.262 --> 00:28:08.284 especially on this type of database. 00:28:09.732 --> 00:28:10.773 And when I say all this, 00:28:10.834 --> 00:28:12.634 and I get back to your first question, 00:28:12.653 --> 00:28:13.413 which I thought was really 00:28:13.453 --> 00:28:15.214 good about the AOMD 00:28:15.275 --> 00:28:16.174 classification and 00:28:16.315 --> 00:28:17.996 postgraduate education and all that, 00:28:18.355 --> 00:28:19.715 I do think that matters greatly. 00:28:20.497 --> 00:28:22.396 So there are two points in 00:28:22.436 --> 00:28:23.778 all of this that we haven't 00:28:23.798 --> 00:28:24.718 been able to assess. 00:28:25.417 --> 00:28:25.798 And one, 00:28:25.837 --> 00:28:26.878 if you want to start with the 00:28:26.898 --> 00:28:30.140 biomechanics, is false modulation skills. 00:28:31.092 --> 00:28:33.474 So for instance, the more trained you are, 00:28:33.734 --> 00:28:34.836 you would understand that 00:28:35.237 --> 00:28:37.259 some patients need a little bit more push, 00:28:37.660 --> 00:28:39.662 some patient needs a little less push, 00:28:40.403 --> 00:28:41.423 some patients maybe don't 00:28:41.443 --> 00:28:42.486 want to be pushed at all. 00:28:42.945 --> 00:28:44.909 So that controlling of forces, 00:28:45.128 --> 00:28:46.569 and I don't mean where 00:28:46.590 --> 00:28:47.652 right now where it's being delivered, 00:28:47.731 --> 00:28:49.314 but by hand forces, how much 00:28:49.713 --> 00:28:51.153 you know, how much of your mass, 00:28:51.193 --> 00:28:52.535 your body mass you use when 00:28:52.555 --> 00:28:53.535 you deliver the treatment. 00:28:53.875 --> 00:28:55.055 I think that matters some, 00:28:55.434 --> 00:28:56.934 maybe not for clinical outcomes, 00:28:57.275 --> 00:28:58.976 but it definitely matters for safety. 00:28:59.296 --> 00:29:00.115 And I think it matters for 00:29:00.155 --> 00:29:01.316 patient comfort as well. 00:29:01.836 --> 00:29:03.817 And also for participant comfort, 00:29:03.836 --> 00:29:05.057 not provider comfort. 00:29:05.356 --> 00:29:07.356 And that's the next thing to go into here, 00:29:07.797 --> 00:29:08.798 because I think a lot of 00:29:08.817 --> 00:29:10.137 this is being driven by 00:29:10.377 --> 00:29:12.117 contextual factors, to be honest, 00:29:12.478 --> 00:29:13.538 where manual therapy in 00:29:13.637 --> 00:29:15.699 general is a very powerful 00:29:15.739 --> 00:29:16.598 contextual factor. 00:29:17.159 --> 00:29:18.460 Like you you lay down, 00:29:18.500 --> 00:29:19.759 you're being examined and 00:29:19.819 --> 00:29:21.560 you something is being done 00:29:21.601 --> 00:29:22.300 and the patient can 00:29:22.421 --> 00:29:23.740 obviously hear and feel 00:29:23.760 --> 00:29:24.602 that something happens. 00:29:24.682 --> 00:29:25.521 And, you know, 00:29:25.662 --> 00:29:27.462 if it says at least in Cairo 00:29:27.502 --> 00:29:28.563 field and I guess also in 00:29:28.603 --> 00:29:29.483 physios from some of the 00:29:29.503 --> 00:29:30.263 conversations I had, 00:29:30.544 --> 00:29:31.923 whenever it says that popping sound, 00:29:31.963 --> 00:29:32.984 you always get a little bit. 00:29:33.204 --> 00:29:34.305 Yes, that was really good. 00:29:34.345 --> 00:29:34.464 Right. 00:29:34.484 --> 00:29:35.425 You got a good response. 00:29:36.423 --> 00:29:37.482 And that response, 00:29:38.523 --> 00:29:39.884 that rubs off on the patient. 00:29:39.983 --> 00:29:41.164 Obviously, it does. 00:29:41.285 --> 00:29:42.644 And they will get up and say, yeah, 00:29:42.724 --> 00:29:44.185 I can feel I move much better now. 00:29:44.586 --> 00:29:46.747 And all of that probably has 00:29:46.826 --> 00:29:47.926 more to do with context 00:29:48.007 --> 00:29:48.967 than what actually happens 00:29:49.106 --> 00:29:49.968 inside the spine. 00:29:52.248 --> 00:29:53.328 And that is something that 00:29:55.429 --> 00:29:58.730 is being portrayed better by, 00:29:58.750 --> 00:30:00.351 and this is just me. 00:30:00.431 --> 00:30:01.371 I don't have any data on this. 00:30:01.391 --> 00:30:02.352 This is just me speculating. 00:30:03.257 --> 00:30:04.757 But I would say that is 00:30:04.896 --> 00:30:06.298 easier to sell if you are 00:30:06.317 --> 00:30:07.557 an experienced clinician 00:30:07.617 --> 00:30:08.738 who trained this and has a 00:30:08.877 --> 00:30:09.778 high confidence. 00:30:10.239 --> 00:30:11.358 You can easily build up this 00:30:11.398 --> 00:30:12.479 therapeutic alliance. 00:30:12.798 --> 00:30:15.039 You can more easily wrangle 00:30:15.160 --> 00:30:16.220 your different techniques, 00:30:16.339 --> 00:30:17.960 your force modulation skills, 00:30:18.359 --> 00:30:18.901 and all of that. 00:30:19.201 --> 00:30:22.201 I think that matters to a certain degree. 00:30:24.041 --> 00:30:25.142 And stuff like that is just 00:30:25.182 --> 00:30:26.602 difficult to learn because 00:30:26.622 --> 00:30:28.323 you need to be comfortable 00:30:28.383 --> 00:30:29.722 doing it and confident doing it. 00:30:30.539 --> 00:30:31.661 That way, you know, 00:30:31.681 --> 00:30:32.701 patients will also be 00:30:32.780 --> 00:30:33.781 confident and comfortable 00:30:33.842 --> 00:30:34.461 in you doing it. 00:30:34.682 --> 00:30:36.242 And that will lead to better outcomes. 00:30:36.863 --> 00:30:38.624 But again, that has nothing to do with, 00:30:39.003 --> 00:30:40.164 you know, the way you do it, 00:30:41.226 --> 00:30:42.246 which is why we make the 00:30:42.286 --> 00:30:43.826 argument that clinicians, 00:30:44.686 --> 00:30:46.048 experienced clinicians such as yourself, 00:30:46.428 --> 00:30:47.769 you can go out, you know, 00:30:47.808 --> 00:30:49.490 practicing tomorrow or next 00:30:49.529 --> 00:30:50.830 Monday and you can do whatever you want. 00:30:51.490 --> 00:30:52.932 probably won't matter a whole lot. 00:30:53.011 --> 00:30:54.313 You can try to be as 00:30:54.353 --> 00:30:56.054 specific and as concrete as you want, 00:30:56.473 --> 00:30:57.375 whether you're a physio or 00:30:57.394 --> 00:30:58.515 a chiro or whatever it is. 00:30:58.974 --> 00:31:00.536 But for the future clinicians, 00:31:00.977 --> 00:31:03.758 I think we are basically 00:31:03.817 --> 00:31:04.898 looking into a major 00:31:04.939 --> 00:31:06.460 paradigm shift of the way 00:31:06.500 --> 00:31:09.521 that we teach manual therapy. 00:31:10.467 --> 00:31:12.887 into an approach where we 00:31:12.928 --> 00:31:13.928 have to look at it, 00:31:14.147 --> 00:31:15.667 I want to say the word holistically, 00:31:15.768 --> 00:31:16.769 even though I hate that word, 00:31:16.788 --> 00:31:18.509 because there's so many 00:31:19.489 --> 00:31:20.769 negative associations with it, 00:31:21.029 --> 00:31:22.250 but we have to see the whole person. 00:31:22.349 --> 00:31:23.390 We have to understand how 00:31:23.430 --> 00:31:24.611 these contextual factors 00:31:25.191 --> 00:31:26.171 impact the patient, 00:31:26.211 --> 00:31:27.451 how it impacts our treatment. 00:31:27.971 --> 00:31:28.951 And then we have to learn, 00:31:30.011 --> 00:31:31.792 we still have to learn like motor skills, 00:31:31.932 --> 00:31:33.492 how to modulate forces. 00:31:33.873 --> 00:31:34.452 We still have to be 00:31:34.512 --> 00:31:36.173 confident in the way that we do it. 00:31:37.082 --> 00:31:38.482 I still think like palpation, 00:31:38.623 --> 00:31:40.143 it has an effect on people 00:31:40.182 --> 00:31:42.443 just like palpating, you know, feeling, 00:31:42.463 --> 00:31:44.265 getting a sense of the 00:31:44.325 --> 00:31:45.724 structure and tissue and 00:31:45.785 --> 00:31:46.865 texture of the patient. 00:31:46.885 --> 00:31:48.946 Like, is this someone who I need to be, 00:31:49.207 --> 00:31:49.406 you know, 00:31:49.507 --> 00:31:50.727 put a little bit more mass into 00:31:50.807 --> 00:31:52.087 or should I back off a little bit? 00:31:52.867 --> 00:31:53.528 Some of those things are 00:31:53.548 --> 00:31:54.869 still very important to teach, 00:31:55.289 --> 00:31:56.570 but teaching stuff like, oh, 00:31:56.590 --> 00:31:57.451 you want to move the bone 00:31:57.471 --> 00:31:58.373 this way or that way, 00:31:58.492 --> 00:31:59.513 or you want to hit this 00:31:59.693 --> 00:32:00.934 angle because then you will hit the, 00:32:01.315 --> 00:32:02.415 you will impact the disc 00:32:02.915 --> 00:32:04.317 rather than the facet joints. 00:32:04.778 --> 00:32:06.479 That is all just outdated information. 00:32:06.519 --> 00:32:08.101 And we need to update that across, 00:32:08.840 --> 00:32:10.182 I would say like worldwide 00:32:10.242 --> 00:32:12.344 across all institutions 00:32:12.384 --> 00:32:14.185 that teach rather undergrad 00:32:14.425 --> 00:32:16.387 or post-grad that teach 00:32:16.448 --> 00:32:17.428 manual therapy skills, 00:32:17.488 --> 00:32:18.588 at least when it comes to 00:32:19.029 --> 00:32:20.411 this popping sound that we 00:32:20.431 --> 00:32:21.211 investigated SMT. 00:32:22.625 --> 00:32:24.286 So that would be my very 00:32:24.326 --> 00:32:25.467 long answer to your two 00:32:25.708 --> 00:32:26.989 slightly complicated questions, 00:32:27.368 --> 00:32:28.089 if that makes sense. 00:32:28.289 --> 00:32:29.971 And I don't know if you agree or not, 00:32:30.010 --> 00:32:32.532 but it's my point, at least, 00:32:32.553 --> 00:32:33.733 based on all this data that 00:32:34.134 --> 00:32:35.336 I have looked at over the last, 00:32:35.836 --> 00:32:36.656 I want to say, ten years. 00:32:38.205 --> 00:32:38.385 Yeah, 00:32:38.586 --> 00:32:39.945 definitely follow what you're 00:32:40.125 --> 00:32:43.047 describing and excellent answers, Casper. 00:32:43.666 --> 00:32:44.487 I think also, 00:32:44.847 --> 00:32:47.488 and this is not different 00:32:47.528 --> 00:32:48.667 than I think a lot of the 00:32:48.708 --> 00:32:49.709 philosophy that our 00:32:49.808 --> 00:32:51.888 listeners or the listeners 00:32:51.929 --> 00:32:53.529 are familiar with this podcast. 00:32:55.049 --> 00:32:55.609 In fact, 00:32:55.650 --> 00:32:57.730 a more recent publication on the 00:32:57.770 --> 00:32:58.951 definition of orthopedic 00:32:59.010 --> 00:33:00.770 manual physical therapy and 00:33:00.790 --> 00:33:01.791 that paper was recently 00:33:01.832 --> 00:33:03.771 published and I believe 00:33:03.791 --> 00:33:05.132 Jason Silvernail was on for 00:33:05.172 --> 00:33:07.232 an interview to discuss that and how 00:33:08.321 --> 00:33:10.962 So OMPT is exactly what you're saying, 00:33:11.123 --> 00:33:13.103 not just the application of 00:33:13.163 --> 00:33:14.163 the hands-on technique, 00:33:14.183 --> 00:33:15.084 but it's all these other 00:33:15.104 --> 00:33:15.903 things that go into it. 00:33:15.943 --> 00:33:17.085 It's the clinical reasoning. 00:33:17.605 --> 00:33:18.964 It's the choice of technique. 00:33:18.984 --> 00:33:20.405 It's the contextual factors. 00:33:20.486 --> 00:33:21.806 It's setting it up for the 00:33:21.846 --> 00:33:23.987 patient and what you do before, 00:33:24.027 --> 00:33:24.826 what you do after, 00:33:24.866 --> 00:33:25.807 how you weave it into your 00:33:25.826 --> 00:33:26.867 treatment and plan of care. 00:33:28.682 --> 00:33:30.343 I think that that is really, 00:33:30.423 --> 00:33:33.285 really important and great 00:33:33.305 --> 00:33:34.526 thing to bring up as we're 00:33:34.566 --> 00:33:35.426 trying to integrate that 00:33:35.487 --> 00:33:37.228 into our educational 00:33:37.248 --> 00:33:40.130 settings just to increase 00:33:40.651 --> 00:33:42.172 the skill of our clinicians 00:33:42.192 --> 00:33:43.492 that we have coming out of those. 00:33:44.272 --> 00:33:46.094 That's great. 00:33:46.335 --> 00:33:46.954 Can I add one thing? 00:33:47.234 --> 00:33:47.474 Sorry. 00:33:47.654 --> 00:33:50.517 Yeah, please do. 00:33:50.557 --> 00:33:51.637 We're looking into a world 00:33:51.657 --> 00:33:52.759 now where we understand the 00:33:52.798 --> 00:33:54.380 complexity of low back pain a lot better. 00:33:54.440 --> 00:33:54.960 We've done a lot of 00:33:54.980 --> 00:33:56.642 trajectory research over these last 00:33:57.494 --> 00:33:58.154 I want to say, twenty, 00:33:58.174 --> 00:34:00.076 maybe thirty years to see 00:34:00.457 --> 00:34:01.557 how much it actually varies 00:34:01.596 --> 00:34:04.137 over time and how, you know, 00:34:04.178 --> 00:34:05.538 back in the day we had this definition, 00:34:05.618 --> 00:34:06.680 acute and chronic low back 00:34:06.720 --> 00:34:08.139 pain doesn't really make sense anymore. 00:34:08.581 --> 00:34:09.601 It's either episodic low 00:34:09.641 --> 00:34:10.641 back pain or recurrent low 00:34:10.661 --> 00:34:11.541 back pain or simply 00:34:11.581 --> 00:34:12.623 persistent low back pain. 00:34:13.043 --> 00:34:13.362 But, you know, 00:34:13.822 --> 00:34:14.744 back pain is never like this, 00:34:14.784 --> 00:34:16.043 just high all the time. 00:34:16.385 --> 00:34:17.545 It fluctuates up and down, 00:34:18.045 --> 00:34:18.846 which means that we are 00:34:18.885 --> 00:34:20.507 looking into a way that 00:34:20.586 --> 00:34:22.467 people need to learn how to self-manage. 00:34:23.288 --> 00:34:24.509 And we have to shift our 00:34:24.789 --> 00:34:26.128 education and research and 00:34:26.168 --> 00:34:27.110 clinical reasoning into 00:34:27.170 --> 00:34:28.590 understanding how can we 00:34:28.630 --> 00:34:30.010 take this apparently 00:34:30.130 --> 00:34:31.291 effective intervention? 00:34:31.891 --> 00:34:33.992 And that is that is, you know, 00:34:34.012 --> 00:34:35.074 probably in the way that 00:34:35.114 --> 00:34:35.934 most people understand it 00:34:36.014 --> 00:34:36.954 is pretty far away from 00:34:37.014 --> 00:34:38.135 self-management strategies 00:34:38.514 --> 00:34:39.735 and implement that into a 00:34:39.795 --> 00:34:41.257 way where we can use it as 00:34:41.277 --> 00:34:42.376 a self-management strategy, 00:34:42.416 --> 00:34:44.418 where we can reduce the flares, 00:34:44.577 --> 00:34:45.938 maybe the pain flare ups. 00:34:46.518 --> 00:34:47.440 Something like that. 00:34:47.500 --> 00:34:48.860 And we don't really have a 00:34:48.880 --> 00:34:49.860 great understanding of that 00:34:49.880 --> 00:34:50.400 at the moment. 00:34:50.820 --> 00:34:51.762 And I think that's 00:34:51.802 --> 00:34:55.264 definitely where we need to move ahead. 00:34:55.463 --> 00:34:56.503 We have to understand that 00:34:56.543 --> 00:34:57.425 better because we are 00:34:57.445 --> 00:34:58.826 looking into a world where 00:34:59.206 --> 00:35:00.387 back pain is growing more 00:35:00.407 --> 00:35:02.688 and more and people have to 00:35:02.728 --> 00:35:03.967 learn how to self-manage it 00:35:03.987 --> 00:35:04.969 because we cannot cure it. 00:35:07.425 --> 00:35:08.487 Yeah, I think that's excellent. 00:35:08.527 --> 00:35:10.648 So it leads into my last question. 00:35:10.708 --> 00:35:11.628 I can talk to you all day. 00:35:11.648 --> 00:35:12.728 I think this is fascinating, 00:35:12.789 --> 00:35:14.570 but last question for you 00:35:14.590 --> 00:35:15.710 is kind of looking ahead 00:35:16.331 --> 00:35:18.072 and based on the findings 00:35:18.112 --> 00:35:19.333 from this study that we 00:35:19.373 --> 00:35:20.632 spent a lot of time talking about, 00:35:21.273 --> 00:35:22.273 but then also based on the 00:35:22.313 --> 00:35:23.855 other research that you're involved in, 00:35:24.014 --> 00:35:25.815 what do you see really now 00:35:25.896 --> 00:35:27.056 as some of the gaps in the 00:35:27.077 --> 00:35:29.657 literature and where we 00:35:29.697 --> 00:35:34.300 need to focus future research efforts? 00:35:34.400 --> 00:35:34.800 If you talk, 00:35:35.342 --> 00:35:36.362 SMT specifically, 00:35:36.583 --> 00:35:37.443 I would say there are gaps 00:35:37.623 --> 00:35:38.284 all over the place. 00:35:38.324 --> 00:35:39.726 There's a huge area of 00:35:39.766 --> 00:35:40.967 simply research waste, 00:35:41.007 --> 00:35:44.829 a lot of bad trials, underpowered trials. 00:35:45.391 --> 00:35:46.731 There's very low funding to 00:35:46.751 --> 00:35:48.032 the area as well. 00:35:49.628 --> 00:35:51.909 So that's probably the reason. 00:35:51.949 --> 00:35:53.349 So I think gaps, we could talk. 00:35:54.088 --> 00:35:54.768 I could say anything, 00:35:54.789 --> 00:35:55.889 and there would be a gap in it. 00:35:56.429 --> 00:35:57.210 Like, let's say, for instance, 00:35:57.230 --> 00:35:58.090 if you really wanted to 00:35:58.130 --> 00:35:59.050 conclude whether it 00:35:59.110 --> 00:36:01.471 mattered to be highly specific or not, 00:36:01.771 --> 00:36:03.371 we would need a really 00:36:03.452 --> 00:36:05.693 high-powered trial with 00:36:06.273 --> 00:36:07.512 hundreds of people in it to 00:36:07.532 --> 00:36:08.853 really estimate whether 00:36:08.893 --> 00:36:10.233 those two things were the same. 00:36:10.893 --> 00:36:13.614 But based on all of this research, 00:36:13.755 --> 00:36:14.815 I would say that's not 00:36:14.855 --> 00:36:15.914 something that we should do, 00:36:15.974 --> 00:36:17.215 and we shouldn't fund that either. 00:36:18.134 --> 00:36:19.755 Because we have to look at 00:36:19.894 --> 00:36:22.476 SMT more as having a widespread effect. 00:36:23.197 --> 00:36:24.077 That's probably the best way 00:36:24.117 --> 00:36:24.818 to describe it. 00:36:25.199 --> 00:36:26.099 So even though that's a gap, 00:36:26.119 --> 00:36:27.159 that's not a gap that I 00:36:27.179 --> 00:36:28.320 would recommend people to 00:36:28.360 --> 00:36:29.282 follow because it will be 00:36:29.422 --> 00:36:30.001 more of the same. 00:36:30.481 --> 00:36:32.764 If you do it properly, 00:36:34.465 --> 00:36:35.266 the two outcomes will be 00:36:35.286 --> 00:36:36.266 the same for the two groups. 00:36:36.487 --> 00:36:38.407 That's just the way it'll 00:36:38.447 --> 00:36:40.128 work in nine out of ten times. 00:36:42.574 --> 00:36:44.315 And then, like I said before, 00:36:44.355 --> 00:36:45.554 how to implement this into 00:36:45.675 --> 00:36:46.735 self-management strategy, 00:36:46.795 --> 00:36:47.996 long-term care plans, 00:36:49.536 --> 00:36:52.137 how to better provide treatment for, 00:36:52.257 --> 00:36:52.599 I would say, 00:36:52.619 --> 00:36:53.778 the elderly as well is 00:36:53.818 --> 00:36:54.478 something that's going to 00:36:54.498 --> 00:36:55.380 be really interesting over 00:36:55.400 --> 00:36:56.539 this next couple of years here. 00:36:57.001 --> 00:36:58.440 As the population grows older, 00:36:59.001 --> 00:36:59.681 like a lot of 00:37:00.777 --> 00:37:02.039 And also, to be honest, 00:37:02.378 --> 00:37:03.159 at least in Denmark, 00:37:03.179 --> 00:37:05.340 and I assume it's the same all around, 00:37:05.840 --> 00:37:07.442 that all the people, 00:37:07.681 --> 00:37:08.501 they want to do more. 00:37:08.541 --> 00:37:09.422 They have more money. 00:37:09.483 --> 00:37:10.643 They have more resources. 00:37:10.762 --> 00:37:12.264 So they want to live their 00:37:12.304 --> 00:37:13.525 life to the fullest when 00:37:13.545 --> 00:37:14.405 they retire even. 00:37:15.045 --> 00:37:15.646 So there's going to be a 00:37:15.706 --> 00:37:17.407 high demand on how to 00:37:18.146 --> 00:37:19.987 make these patients, not patients, 00:37:20.007 --> 00:37:21.728 but these elderly citizens, 00:37:22.088 --> 00:37:23.108 how to make them function 00:37:23.128 --> 00:37:24.110 in a day-to-day basis. 00:37:24.230 --> 00:37:25.150 I think that's going to be 00:37:25.250 --> 00:37:26.050 super interesting and 00:37:26.070 --> 00:37:26.931 something that we really do 00:37:26.951 --> 00:37:27.670 need to research. 00:37:28.371 --> 00:37:29.152 And I would still say, 00:37:29.771 --> 00:37:31.413 specifically for SMT mechanisms, 00:37:31.452 --> 00:37:31.932 it's still really 00:37:31.952 --> 00:37:34.233 interesting and we need 00:37:34.813 --> 00:37:36.474 more and we need better research, 00:37:36.655 --> 00:37:38.054 simply put, on it. 00:37:38.496 --> 00:37:39.076 And we need to 00:37:40.224 --> 00:37:42.030 know follow a string where 00:37:42.050 --> 00:37:43.614 we you know find something 00:37:44.416 --> 00:37:45.398 experimentally like 00:37:45.458 --> 00:37:46.320 biomechanically or 00:37:46.342 --> 00:37:47.925 neurophysiological and then test that 00:37:49.938 --> 00:37:51.900 all the way to a clinical population. 00:37:51.960 --> 00:37:53.820 We need programs that does this. 00:37:55.061 --> 00:37:56.041 And it's probably not to 00:37:56.101 --> 00:37:58.041 understand how to give the treatment, 00:37:58.081 --> 00:37:59.762 but more like who is the 00:37:59.802 --> 00:38:01.001 responders of the treatment? 00:38:01.302 --> 00:38:02.202 Who should we provide this 00:38:02.242 --> 00:38:03.262 to and who should we do 00:38:03.322 --> 00:38:04.182 something different to? 00:38:04.663 --> 00:38:06.304 I think that's going to be 00:38:06.344 --> 00:38:07.583 some of the main things 00:38:07.603 --> 00:38:08.603 that we have to work on 00:38:08.684 --> 00:38:09.804 over these next couple of years. 00:38:11.385 --> 00:38:14.047 Maybe my entire career, who knows? 00:38:15.309 --> 00:38:16.130 But that's definitely 00:38:16.150 --> 00:38:17.170 something that we need to look at, 00:38:17.190 --> 00:38:18.391 which we at the moment 00:38:18.452 --> 00:38:19.773 don't really have any idea of. 00:38:20.152 --> 00:38:22.215 And not just related to this, 00:38:22.235 --> 00:38:23.315 you could look at exercise, 00:38:23.717 --> 00:38:24.777 which is much more research 00:38:24.797 --> 00:38:25.757 than manual therapy. 00:38:26.298 --> 00:38:27.579 They also struggle to come 00:38:27.639 --> 00:38:30.001 up with definitions of 00:38:30.782 --> 00:38:33.664 trying to predict responders, basically. 00:38:33.704 --> 00:38:34.246 Very difficult. 00:38:36.014 --> 00:38:37.257 Great. 00:38:37.277 --> 00:38:37.998 Well, Casper, again, 00:38:38.018 --> 00:38:38.858 thank you so much for 00:38:38.918 --> 00:38:40.521 joining us on the Hands On, 00:38:40.581 --> 00:38:41.782 Hands Off podcast. 00:38:42.164 --> 00:38:44.327 It's been a joy listening to you, 00:38:44.387 --> 00:38:45.188 learning from you, 00:38:45.407 --> 00:38:46.550 and we will definitely be 00:38:46.630 --> 00:38:48.391 following your future work. 00:38:48.612 --> 00:38:50.554 So thanks so much. 00:38:50.594 --> 00:38:51.135 I appreciate it. 00:38:51.175 --> 00:38:52.717 Thank you for having me. 00:38:52.757 --> 00:38:53.239 Absolutely.