In this episode of Hands On, Hands Off, we dive deep into the largest systematic review on SMT to date with researcher and chiropractor Casper Glissmann Nim. What he and his team discovered may shake the very foundation of manual therapy education and clinical practice.
We explore:
- Whether SMT is more effective than placebo or non-recommended therapies
- Why the way you perform SMT might not influence patient outcomes
- How contextual factors and therapeutic alliance play a bigger role than we once thought
- The implications for fellowship training and manual therapy education
- What the future holds for low back pain research and self-management strategies
This is a must-listen for any PT, chiro, educator, or student wrestling with the role of manual therapy in modern practice.
00:00:02 --> 00:00:02 All right,
00:00:02 --> 00:00:05 welcome everyone to the AOMT hands-on,
00:00:05 --> 00:00:06 hands-off podcast.
00:00:06 --> 00:00:07 My name is Lina McDaniel.
00:00:07 --> 00:00:09 I'm a physical therapist.
00:00:09 --> 00:00:11 I'm a fellow of AOMT and I
00:00:11 --> 00:00:13 am just thrilled to have
00:00:13 --> 00:00:15 you all today join us.
00:00:15 --> 00:00:17 I think it's gonna be a great episode.
00:00:17 --> 00:00:19 We are so fortunate today to
00:00:19 --> 00:00:23 have Dr. Kasper Nimm from Denmark.
00:00:23 --> 00:00:25 He's a chiropractor and
00:00:25 --> 00:00:26 senior researcher at the
00:00:26 --> 00:00:27 Spine Center of Southern Denmark.
00:00:28 --> 00:00:29 He's an assistant professor
00:00:29 --> 00:00:31 at the University of Southern Denmark,
00:00:31 --> 00:00:33 where he completed his PhD
00:00:33 --> 00:00:34 in twenty twenty one.
00:00:35 --> 00:00:35 Welcome, Casper.
00:00:35 --> 00:00:37 Thank you.
00:00:38 --> 00:00:38 Yeah.
00:00:40 --> 00:00:41 So just to kick off the
00:00:41 --> 00:00:42 episode a little bit,
00:00:43 --> 00:00:44 we do want to focus on one
00:00:44 --> 00:00:46 of your recent publications.
00:00:46 --> 00:00:47 But before we get into that,
00:00:48 --> 00:00:50 can you just introduce
00:00:50 --> 00:00:50 yourself a little bit to
00:00:50 --> 00:00:52 our audience and tell them
00:00:52 --> 00:00:53 briefly about your
00:00:53 --> 00:00:55 background as a clinician, a chiropractor,
00:00:55 --> 00:00:58 and then as a researcher?
00:00:58 --> 00:00:59 And what are your
00:00:59 --> 00:01:00 professional roles right now?
00:01:02 --> 00:01:03 Yes, absolutely.
00:01:03 --> 00:01:04 That's not a problem.
00:01:04 --> 00:01:05 And thank you for having me.
00:01:05 --> 00:01:07 I really appreciate the invitation.
00:01:07 --> 00:01:08 It's going to be a lot of fun.
00:01:10 --> 00:01:12 So you said my clinical background,
00:01:12 --> 00:01:13 which is actually an interesting story.
00:01:14 --> 00:01:15 So I'm educated from the
00:01:15 --> 00:01:17 University of Southern Denmark,
00:01:17 --> 00:01:20 which is an unorthodox chiro program,
00:01:20 --> 00:01:21 I would say,
00:01:21 --> 00:01:23 because it's based one
00:01:23 --> 00:01:25 hundred percent in a medical faculty.
00:01:25 --> 00:01:27 So we study alongside medical students,
00:01:27 --> 00:01:29 which also means that some of the
00:01:30 --> 00:01:32 raw philosophy of the
00:01:32 --> 00:01:33 chiropractic profession
00:01:33 --> 00:01:34 that it has in the background, right?
00:01:35 --> 00:01:36 We don't really have that in
00:01:36 --> 00:01:37 there and we're really well
00:01:37 --> 00:01:39 integrated into the healthcare system.
00:01:40 --> 00:01:41 So clinically,
00:01:41 --> 00:01:42 I worked almost my entire
00:01:43 --> 00:01:45 career at a hospital diagnosing patients.
00:01:46 --> 00:01:47 So I actually don't have
00:01:48 --> 00:01:49 that much experience with
00:01:49 --> 00:01:50 hands-on treatment.
00:01:51 --> 00:01:52 And it's interesting because
00:01:52 --> 00:01:52 a lot of my research is
00:01:52 --> 00:01:53 centered around that.
00:01:54 --> 00:01:55 So I always get the
00:01:55 --> 00:01:56 discredit from the
00:01:56 --> 00:01:56 clinicians that I don't
00:01:56 --> 00:01:57 understand this because I'm
00:01:58 --> 00:01:59 not doing it in real life.
00:01:59 --> 00:01:59 I don't see all the
00:01:59 --> 00:02:01 potential and stuff like that.
00:02:01 --> 00:02:02 But I'm always flipping around saying,
00:02:03 --> 00:02:03 well,
00:02:03 --> 00:02:05 I always I also don't have that bias,
00:02:06 --> 00:02:08 you know, that I that I see it works.
00:02:08 --> 00:02:09 I can be completely, you know,
00:02:09 --> 00:02:11 objective and just, you know,
00:02:11 --> 00:02:13 stay within the limits of the data.
00:02:13 --> 00:02:14 And I do think there's some
00:02:14 --> 00:02:15 there's some benefits to that,
00:02:15 --> 00:02:16 although I do appreciate
00:02:17 --> 00:02:18 clinician researchers as well.
00:02:19 --> 00:02:19 But
00:02:20 --> 00:02:21 mostly what I'm doing now
00:02:22 --> 00:02:23 I'm still doing a lot of
00:02:23 --> 00:02:25 manual therapy research uh
00:02:25 --> 00:02:26 different related projects
00:02:26 --> 00:02:28 but to be honest it's all
00:02:28 --> 00:02:29 my hobby projects at the
00:02:29 --> 00:02:31 moment all of my funded
00:02:31 --> 00:02:32 research is mostly related
00:02:32 --> 00:02:33 to more healthcare
00:02:34 --> 00:02:35 utilization and you know
00:02:35 --> 00:02:37 long-term patient courses
00:02:37 --> 00:02:38 and mapping those and more
00:02:38 --> 00:02:40 into the world of epidemiology I'm
00:02:40 --> 00:02:41 slowly evolving into that.
00:02:42 --> 00:02:44 But I still love doing the
00:02:44 --> 00:02:45 manual therapy work,
00:02:45 --> 00:02:46 and it's a lot of fun.
00:02:46 --> 00:02:47 And sometimes, you know,
00:02:48 --> 00:02:48 good stuff happens,
00:02:48 --> 00:02:50 like the paper we're coming into now,
00:02:50 --> 00:02:50 right?
00:02:50 --> 00:02:51 A completely unfunded
00:02:51 --> 00:02:52 project we just all did in
00:02:52 --> 00:02:53 our spare time.
00:02:54 --> 00:02:56 It was a fun and frustrating process,
00:02:56 --> 00:02:57 to say the least.
00:02:58 --> 00:02:59 Wow, that's incredible.
00:03:00 --> 00:03:01 And it's amazing to hear
00:03:01 --> 00:03:02 that lead off into this
00:03:02 --> 00:03:04 study because of what a
00:03:04 --> 00:03:06 massive study was and just
00:03:06 --> 00:03:07 thinking about all the
00:03:07 --> 00:03:08 aspects of it and how many
00:03:08 --> 00:03:09 people were involved.
00:03:09 --> 00:03:10 So, well, great.
00:03:11 --> 00:03:12 Well, let's jump into it.
00:03:12 --> 00:03:13 I want to hear more about
00:03:13 --> 00:03:15 your perspective on it and
00:03:15 --> 00:03:16 kind of the background behind it.
00:03:17 --> 00:03:18 The main publication that we
00:03:18 --> 00:03:19 do want to highlight and
00:03:19 --> 00:03:22 talk about today is a recent publication,
00:03:22 --> 00:03:23 a twenty twenty five
00:03:24 --> 00:03:27 article in title the
00:03:27 --> 00:03:28 effectiveness of spinal
00:03:29 --> 00:03:30 manipulative therapy and
00:03:30 --> 00:03:31 treating spinal pain does
00:03:31 --> 00:03:34 not depend on the application procedures,
00:03:34 --> 00:03:36 a systematic review and
00:03:36 --> 00:03:37 network meta analysis.
00:03:38 --> 00:03:41 So this paper that just came out,
00:03:42 --> 00:03:44 just quite a lot to it and
00:03:44 --> 00:03:45 really rich with
00:03:45 --> 00:03:46 opportunity to kind of pull
00:03:47 --> 00:03:48 some findings from this.
00:03:48 --> 00:03:49 And we'd love to hear about it.
00:03:49 --> 00:03:52 Can you briefly describe the study,
00:03:52 --> 00:03:55 the design and kind of the
00:03:55 --> 00:03:57 underpinnings of this study for us?
00:03:57 --> 00:03:59 Yeah, absolutely.
00:03:59 --> 00:04:00 And if I'm allowed to,
00:04:00 --> 00:04:01 I'll go a little bit back in time.
00:04:02 --> 00:04:03 because ever since I was a
00:04:04 --> 00:04:06 student and I graduated eight years ago,
00:04:06 --> 00:04:07 so it's, I don't want to admit it,
00:04:07 --> 00:04:08 but it's a few years ago now,
00:04:09 --> 00:04:10 but I was always very
00:04:10 --> 00:04:12 critical of this notion
00:04:12 --> 00:04:13 that we were taught that
00:04:13 --> 00:04:14 you could do spinal
00:04:14 --> 00:04:16 palpation and then feel, you know,
00:04:16 --> 00:04:18 wherever the dysfunction was,
00:04:18 --> 00:04:19 and then you could hit, you know,
00:04:19 --> 00:04:20 exactly at that segment.
00:04:21 --> 00:04:22 And that would help, you know,
00:04:22 --> 00:04:24 basically cure people sometimes.
00:04:24 --> 00:04:24 Right.
00:04:24 --> 00:04:25 And it's, um,
00:04:26 --> 00:04:27 And I was really challenged
00:04:27 --> 00:04:29 then when I got into clinical practice,
00:04:29 --> 00:04:30 because I have been in
00:04:30 --> 00:04:32 chiropractic practice for a little bit.
00:04:33 --> 00:04:35 So I thought that was quite difficult.
00:04:35 --> 00:04:37 So when I led into my PhD,
00:04:37 --> 00:04:38 which was actually
00:04:38 --> 00:04:40 to be honest, when I was young,
00:04:40 --> 00:04:41 back in twenty sixteen, seventeen,
00:04:42 --> 00:04:43 we wanted to predict
00:04:43 --> 00:04:45 responses to to spinal repulation.
00:04:45 --> 00:04:46 I'm just going to call it SMT.
00:04:47 --> 00:04:48 We wanted to predict
00:04:48 --> 00:04:50 responses of SMT using pain
00:04:50 --> 00:04:51 sensitivity and spinal
00:04:52 --> 00:04:52 stiffness as like
00:04:53 --> 00:04:55 biomarkers on where to get the treatment.
00:04:55 --> 00:04:56 And what we really noticed
00:04:56 --> 00:04:57 when we looked at the data
00:04:57 --> 00:04:58 was that it was like
00:04:59 --> 00:05:00 the participants in our
00:05:00 --> 00:05:02 study got the exact same treatment.
00:05:02 --> 00:05:04 They completely changed
00:05:04 --> 00:05:06 identical of each other, those two groups,
00:05:06 --> 00:05:08 as in completely identical,
00:05:08 --> 00:05:09 as it was the complete same
00:05:09 --> 00:05:10 treatment we gave them.
00:05:10 --> 00:05:12 And that really opened up
00:05:12 --> 00:05:13 the door of looking more into that.
00:05:13 --> 00:05:16 So we did the first original
00:05:16 --> 00:05:17 review as part of my PhD
00:05:17 --> 00:05:18 back in twenty twenty,
00:05:18 --> 00:05:20 which was published in Scientific Reports,
00:05:21 --> 00:05:22 where we looked at the
00:05:22 --> 00:05:23 target site and didn't see
00:05:23 --> 00:05:24 any differences.
00:05:24 --> 00:05:25 And when we published that, we had a
00:05:27 --> 00:05:30 like a huge critique from a
00:05:30 --> 00:05:31 lot of clinicians,
00:05:31 --> 00:05:33 both physios and chiros.
00:05:33 --> 00:05:35 Everyone kind of hated me a little bit,
00:05:36 --> 00:05:37 you know, at least in public.
00:05:37 --> 00:05:38 Private, I got a lot of positive feedback,
00:05:39 --> 00:05:39 but in public,
00:05:39 --> 00:05:40 everyone disliked the study.
00:05:42 --> 00:05:45 So some of the critique
00:05:45 --> 00:05:46 points that we got there,
00:05:46 --> 00:05:48 we did in another JOSPT
00:05:48 --> 00:05:49 review that we published in
00:05:49 --> 00:05:50 in twenty twenty three,
00:05:50 --> 00:05:51 where we looked at it,
00:05:51 --> 00:05:53 we removed some of the
00:05:53 --> 00:05:54 heterogeneity from the
00:05:54 --> 00:05:55 original study and then
00:05:55 --> 00:05:57 focused a little bit more
00:05:57 --> 00:05:59 on a certain population and
00:05:59 --> 00:06:00 found the exact same thing again.
00:06:02 --> 00:06:03 But we were still only
00:06:03 --> 00:06:04 looking at one aspect of it,
00:06:05 --> 00:06:06 which was the target selection.
00:06:07 --> 00:06:10 So over the last couple of years,
00:06:10 --> 00:06:11 this network meta-analysis
00:06:12 --> 00:06:13 approach really came up and
00:06:14 --> 00:06:14 there has been a lot of
00:06:14 --> 00:06:15 network meta-analysis.
00:06:16 --> 00:06:17 I think like almost...
00:06:18 --> 00:06:20 I think in it was something
00:06:20 --> 00:06:22 from to there was almost
00:06:22 --> 00:06:23 four hundred network
00:06:23 --> 00:06:25 meta-analysis published on MSK research.
00:06:26 --> 00:06:28 So it exploded all of a
00:06:28 --> 00:06:29 sudden and it does allow
00:06:30 --> 00:06:31 mathematically that you can
00:06:31 --> 00:06:33 actually compare two
00:06:33 --> 00:06:34 different interventions
00:06:34 --> 00:06:36 that are not being directly
00:06:36 --> 00:06:38 compared within the same study.
00:06:38 --> 00:06:40 So that's the indirect evidence.
00:06:40 --> 00:06:41 There's a whole bunch of
00:06:41 --> 00:06:43 statistics that goes behind that,
00:06:43 --> 00:06:44 which I won't get into too
00:06:44 --> 00:06:45 much here today.
00:06:45 --> 00:06:47 But this did allow us to
00:06:47 --> 00:06:49 actually classify all of
00:06:49 --> 00:06:52 the different SMTs that
00:06:52 --> 00:06:53 were delivered in studies
00:06:53 --> 00:06:54 and then compare those
00:06:54 --> 00:06:56 classifications to each other,
00:06:56 --> 00:06:57 which meant that we could
00:06:57 --> 00:06:58 look at other things now
00:06:58 --> 00:06:59 than just target selection.
00:07:00 --> 00:07:01 We could also look at the thrust specifics,
00:07:02 --> 00:07:02 and we could even look at
00:07:02 --> 00:07:04 the region where it was provided.
00:07:04 --> 00:07:04 And those were the three
00:07:04 --> 00:07:05 things we went with.
00:07:08 --> 00:07:10 So we took, we basically, we wanted to,
00:07:11 --> 00:07:11 yeah, sorry.
00:07:11 --> 00:07:12 Casper, I think all that's great.
00:07:13 --> 00:07:14 I just want to interrupt you
00:07:14 --> 00:07:17 briefly because in reading this study,
00:07:17 --> 00:07:18 I'm familiar with some of
00:07:18 --> 00:07:19 these terms that you're using,
00:07:19 --> 00:07:21 but just for our listeners
00:07:21 --> 00:07:23 who may be less familiar,
00:07:23 --> 00:07:26 could you briefly define SMT for us?
00:07:26 --> 00:07:28 And then can you briefly
00:07:28 --> 00:07:28 define the target?
00:07:28 --> 00:07:30 What do you mean when you say target?
00:07:31 --> 00:07:32 Yes, of course.
00:07:32 --> 00:07:32 Sorry.
00:07:33 --> 00:07:34 Yeah, no, SMT, we define,
00:07:36 --> 00:07:36 I don't think there's a
00:07:36 --> 00:07:37 quite clear definition,
00:07:38 --> 00:07:39 but basically it's the
00:07:39 --> 00:07:41 cracking manual therapy.
00:07:41 --> 00:07:42 So it's the manual therapy
00:07:42 --> 00:07:43 that has a high thrust and
00:07:43 --> 00:07:44 a low amplitude.
00:07:45 --> 00:07:46 sorry, high velocity, low amplitude.
00:07:47 --> 00:07:49 And it often results in a cracking sound.
00:07:50 --> 00:07:51 So we actually, in this study,
00:07:51 --> 00:07:53 excluded like other types
00:07:53 --> 00:07:54 of mobilization.
00:07:54 --> 00:07:56 If you follow the Maitland criteria,
00:07:56 --> 00:07:56 maybe the listeners are
00:07:56 --> 00:07:57 more familiar with that.
00:07:57 --> 00:07:59 This will be a grade five mobilization.
00:08:00 --> 00:08:03 So it was only the popping
00:08:03 --> 00:08:05 manual therapy that we use
00:08:05 --> 00:08:06 for this SMT definition.
00:08:07 --> 00:08:08 Sometimes mobilizations are
00:08:08 --> 00:08:09 being put in there, but for our study,
00:08:09 --> 00:08:13 we just looked at the cracking therapies,
00:08:13 --> 00:08:14 so to speak.
00:08:15 --> 00:08:18 um and and when I say target
00:08:18 --> 00:08:19 and thrust what I mean is
00:08:19 --> 00:08:21 by target I mean where
00:08:22 --> 00:08:23 where do you decide on
00:08:24 --> 00:08:25 where to give the treatment
00:08:25 --> 00:08:27 so there's a like this huge
00:08:28 --> 00:08:30 literature and even
00:08:30 --> 00:08:32 profession specific debate
00:08:32 --> 00:08:34 about where to do it and it
00:08:34 --> 00:08:35 can go with like the
00:08:35 --> 00:08:36 classic thing at least in
00:08:36 --> 00:08:37 chiro practice is that you
00:08:37 --> 00:08:38 palpate the spine and then
00:08:38 --> 00:08:40 you find these dysfunctions
00:08:40 --> 00:08:43 that the fixed joints or the
00:08:43 --> 00:08:45 lock joints typically around the facet,
00:08:45 --> 00:08:47 and then you manipulate it,
00:08:47 --> 00:08:48 you make it go the little cracking sound,
00:08:48 --> 00:08:50 you get the first of the
00:08:50 --> 00:08:51 bubble and those theories
00:08:52 --> 00:08:53 that we can get into if you
00:08:53 --> 00:08:53 really want to,
00:08:54 --> 00:08:55 and that improves the patients.
00:08:57 --> 00:08:58 And you have to deliver it
00:08:58 --> 00:08:59 at the exact right spot, right?
00:08:59 --> 00:09:00 Because everyone can make
00:09:00 --> 00:09:01 their back say crack,
00:09:01 --> 00:09:03 but it's not in the right spot.
00:09:04 --> 00:09:05 That's the whole theoretical
00:09:05 --> 00:09:06 foundation around it.
00:09:07 --> 00:09:08 So when I say target, that's what I mean.
00:09:08 --> 00:09:09 That's basically where
00:09:09 --> 00:09:11 exactly is the intervention?
00:09:11 --> 00:09:13 Where is SMT being targeted on the spine?
00:09:15 --> 00:09:17 And, and if you go with thrust,
00:09:18 --> 00:09:19 which we also looked at,
00:09:19 --> 00:09:20 that could be like,
00:09:20 --> 00:09:21 was it a specific thrust?
00:09:21 --> 00:09:23 Do you try to hit a single
00:09:23 --> 00:09:25 vertebral segment or was it
00:09:25 --> 00:09:26 more of a generalized thrust?
00:09:26 --> 00:09:26 Like you wanted to,
00:09:27 --> 00:09:29 to manipulate an entire lumbar region,
00:09:29 --> 00:09:29 for instance.
00:09:31 --> 00:09:32 And the region, I think it's,
00:09:32 --> 00:09:35 we split it up into the region of pain.
00:09:35 --> 00:09:36 So that could be low back
00:09:36 --> 00:09:37 pain patients with, you know,
00:09:37 --> 00:09:39 manipulated at the lumbar spine.
00:09:40 --> 00:09:41 But it could also be, let's say,
00:09:41 --> 00:09:42 patients with cervical,
00:09:43 --> 00:09:44 like neck pain who were
00:09:44 --> 00:09:46 treated in the thoracic spine.
00:09:46 --> 00:09:48 That could be the non-symptomatic region.
00:09:48 --> 00:09:50 So that's how we define regions.
00:09:50 --> 00:09:51 So those are the three
00:09:51 --> 00:09:52 things that we wanted to
00:09:52 --> 00:09:54 assess in this review here,
00:09:54 --> 00:09:55 where we could only look at
00:09:55 --> 00:09:58 the target earlier.
00:09:58 --> 00:09:58 Great.
00:09:58 --> 00:09:59 Thank you.
00:09:59 --> 00:10:00 I think that really helps.
00:10:01 --> 00:10:02 Can you speak a little bit
00:10:02 --> 00:10:04 more about how this study
00:10:04 --> 00:10:05 then came about?
00:10:05 --> 00:10:06 I kind of got you off track,
00:10:06 --> 00:10:07 but thanks for those
00:10:08 --> 00:10:09 definitions to kind of clarify.
00:10:09 --> 00:10:12 Yeah, you're welcome.
00:10:12 --> 00:10:13 Yeah, it's always when you, you know,
00:10:13 --> 00:10:15 you got to speak to a broad audience.
00:10:15 --> 00:10:16 Sometimes everybody doesn't
00:10:16 --> 00:10:17 really understand what SMT is.
00:10:17 --> 00:10:20 I mean, sometimes we can't even define it.
00:10:20 --> 00:10:21 So it's a good point.
00:10:23 --> 00:10:26 Um, so the study came, came about in,
00:10:26 --> 00:10:27 I believe,
00:10:27 --> 00:10:32 I had the idea about doing this.
00:10:32 --> 00:10:35 And then I, um, I engaged Carson Yule,
00:10:35 --> 00:10:36 who's a professor at the
00:10:36 --> 00:10:37 university of Southern Denmark.
00:10:37 --> 00:10:38 He's also a physio.
00:10:39 --> 00:10:40 He has done a lot of systematic reviews.
00:10:40 --> 00:10:43 He's like an expert on systematic reviews.
00:10:43 --> 00:10:44 And I told him about the
00:10:44 --> 00:10:46 idea and he really liked it.
00:10:46 --> 00:10:49 And then we pretty much got going.
00:10:49 --> 00:10:51 Then we got a senior team together.
00:10:51 --> 00:10:51 So we got Chad Cook,
00:10:51 --> 00:10:53 who I'm sure most of your
00:10:53 --> 00:10:54 listeners are familiar with.
00:10:54 --> 00:10:55 We got Chad involved in it.
00:10:55 --> 00:10:57 And then we got Jan Hartwiesen,
00:10:57 --> 00:10:58 who's a professor also at
00:10:58 --> 00:10:59 the University of Southern
00:10:59 --> 00:11:00 Denmark at Cairo.
00:11:00 --> 00:11:02 He has done extensive work
00:11:02 --> 00:11:03 in the low back pain field.
00:11:03 --> 00:11:05 He was an author on the Lancet series,
00:11:05 --> 00:11:05 for instance.
00:11:06 --> 00:11:07 So a very good guy.
00:11:08 --> 00:11:10 And then we also included Steven Pearl,
00:11:10 --> 00:11:11 which I think your
00:11:11 --> 00:11:12 listeners probably won't know.
00:11:12 --> 00:11:14 He's also a chiro by
00:11:14 --> 00:11:16 training and he's retired now, but
00:11:17 --> 00:11:19 he has a, he has a mind of his own.
00:11:19 --> 00:11:22 Like he knows every theory,
00:11:22 --> 00:11:23 every treatment.
00:11:23 --> 00:11:25 He is just, he, he's a sponge.
00:11:25 --> 00:11:26 He remembers everything.
00:11:26 --> 00:11:29 So we included him as well in the, as,
00:11:29 --> 00:11:30 as the senior team.
00:11:30 --> 00:11:32 And then we had to find, you know,
00:11:32 --> 00:11:33 people to actually do the work.
00:11:33 --> 00:11:33 Cause we all know that
00:11:33 --> 00:11:35 professors don't really do a lot of work.
00:11:35 --> 00:11:38 So, so we had to get a huge review team.
00:11:38 --> 00:11:39 And originally I was,
00:11:40 --> 00:11:41 I know another reason,
00:11:41 --> 00:11:43 but I'm a part of the car fellowship,
00:11:43 --> 00:11:46 which is like, um, international, uh,
00:11:46 --> 00:11:46 like,
00:11:49 --> 00:11:50 uh I want to say research
00:11:50 --> 00:11:50 and leadership
00:11:51 --> 00:11:52 international cairo program
00:11:52 --> 00:11:55 so we had we were fourteen
00:11:55 --> 00:11:56 people in the program so we
00:11:56 --> 00:11:57 got a bunch of them in and
00:11:57 --> 00:11:59 then we realized holy moly
00:11:59 --> 00:12:00 this is going to be a lot
00:12:00 --> 00:12:00 more work than we
00:12:00 --> 00:12:02 anticipated so we got more
00:12:02 --> 00:12:04 people involved in it and
00:12:04 --> 00:12:04 that's where megan
00:12:04 --> 00:12:05 donaldson came in for
00:12:05 --> 00:12:08 instance uh also with a armed um
00:12:09 --> 00:12:10 And at every point,
00:12:10 --> 00:12:11 we wanted to keep it very
00:12:11 --> 00:12:13 interdisciplinary.
00:12:13 --> 00:12:14 That was very important for
00:12:14 --> 00:12:15 us because some of the
00:12:15 --> 00:12:16 critique that we got,
00:12:16 --> 00:12:17 especially from Kairos from
00:12:17 --> 00:12:19 our prior reviews, was that, well,
00:12:19 --> 00:12:21 all of this work was done by physios.
00:12:22 --> 00:12:23 which was actually most of
00:12:24 --> 00:12:25 the other studies that we included.
00:12:26 --> 00:12:26 But here we had a
00:12:26 --> 00:12:28 possibility to include from
00:12:29 --> 00:12:30 all types of different
00:12:30 --> 00:12:31 professions because we
00:12:31 --> 00:12:32 looked at it more broadly.
00:12:33 --> 00:12:33 So we also wanted to make
00:12:34 --> 00:12:35 sure that we had a very
00:12:35 --> 00:12:36 broad and interdisciplinary
00:12:37 --> 00:12:38 and international team as well.
00:12:39 --> 00:12:40 So we also had a sports science guy.
00:12:41 --> 00:12:42 We had a lot of, like you said,
00:12:42 --> 00:12:44 I think we were eighteen authors.
00:12:44 --> 00:12:45 So we had a lot of different
00:12:45 --> 00:12:46 people in there.
00:12:46 --> 00:12:48 That's really what it took to get it done.
00:12:48 --> 00:12:51 It was a huge process when
00:12:51 --> 00:12:51 we got it going.
00:12:52 --> 00:12:54 The search was big and then
00:12:54 --> 00:12:56 the data extraction was
00:12:56 --> 00:12:57 enormous because we had to
00:12:57 --> 00:12:59 extract a lot of things to
00:13:00 --> 00:13:01 classify these different
00:13:01 --> 00:13:02 SMT interventions.
00:13:03 --> 00:13:04 So yes,
00:13:04 --> 00:13:07 a lot of process that I think we
00:13:07 --> 00:13:09 worked on it maybe a year
00:13:09 --> 00:13:11 and a half before we
00:13:11 --> 00:13:12 attempted to submit it somewhere.
00:13:12 --> 00:13:15 So it was quite a lot of
00:13:15 --> 00:13:16 work to get it done.
00:13:18 --> 00:13:19 Yeah, it's amazing.
00:13:19 --> 00:13:20 Just an enormous data set.
00:13:20 --> 00:13:22 So going through kind of the
00:13:22 --> 00:13:24 introduction there were.
00:13:24 --> 00:13:26 I believe in your final sample,
00:13:26 --> 00:13:29 a hundred and sixty one total studies.
00:13:29 --> 00:13:31 Eleven little over eleven
00:13:31 --> 00:13:33 thousand total subjects included in this.
00:13:34 --> 00:13:37 Um, can you speak to how you.
00:13:39 --> 00:13:40 Managed that large of a data
00:13:41 --> 00:13:42 set and your choices of
00:13:42 --> 00:13:44 some of these statistical
00:13:44 --> 00:13:45 methods to analyze the data.
00:13:46 --> 00:13:47 And then I think you
00:13:47 --> 00:13:48 mentioned some of the
00:13:48 --> 00:13:49 variables that you were studying.
00:13:50 --> 00:13:51 But what were your main outcomes?
00:13:53 --> 00:13:54 As we're looking at,
00:13:54 --> 00:13:56 as a result of these procedures.
00:13:57 --> 00:14:00 Yeah, let's start from the beginning.
00:14:00 --> 00:14:01 How do we manage it?
00:14:01 --> 00:14:02 Luckily,
00:14:02 --> 00:14:04 I'm a quite organized and
00:14:04 --> 00:14:05 structured guy when it
00:14:05 --> 00:14:07 comes to data management.
00:14:07 --> 00:14:08 I'm also pretty sufficient
00:14:08 --> 00:14:11 with the statistical
00:14:11 --> 00:14:12 software program that we used.
00:14:13 --> 00:14:15 But it was really, really difficult.
00:14:15 --> 00:14:17 And it was reported in just
00:14:17 --> 00:14:19 a number of different ways.
00:14:19 --> 00:14:21 So there was a lot to keep
00:14:21 --> 00:14:22 track on when we actually got the data.
00:14:23 --> 00:14:25 It took some time to prepare
00:14:26 --> 00:14:27 the data for analysis.
00:14:27 --> 00:14:28 And then the analysis itself
00:14:28 --> 00:14:29 took maybe ten seconds.
00:14:30 --> 00:14:31 So that was kind of a bummer,
00:14:31 --> 00:14:32 but probably took two
00:14:32 --> 00:14:33 months to get there.
00:14:33 --> 00:14:35 That's the thing about data
00:14:35 --> 00:14:37 cleaning that as non researchers,
00:14:37 --> 00:14:38 you often don't appreciate
00:14:38 --> 00:14:40 as much because you're like, oh,
00:14:41 --> 00:14:41 You get the results,
00:14:41 --> 00:14:42 but sometimes the results
00:14:42 --> 00:14:44 take months to even get to
00:14:44 --> 00:14:46 a point where you can analyze the data.
00:14:46 --> 00:14:48 So that took quite a lot of work.
00:14:48 --> 00:14:50 I also had to really
00:14:50 --> 00:14:51 understand this network
00:14:51 --> 00:14:53 meta-analysis thing,
00:14:53 --> 00:14:55 which is quite different
00:14:55 --> 00:14:57 than a normal meta-analysis
00:14:58 --> 00:14:59 from a math standpoint.
00:14:59 --> 00:15:01 So I had to put my head into that as well.
00:15:02 --> 00:15:04 So that really did take a lot of time.
00:15:05 --> 00:15:05 Yes.
00:15:05 --> 00:15:07 And then we extracted, like I said,
00:15:07 --> 00:15:08 a bunch of information.
00:15:08 --> 00:15:09 And for outcomes,
00:15:09 --> 00:15:12 we decided quite early on that, you know,
00:15:13 --> 00:15:13 because we knew we were
00:15:13 --> 00:15:15 going to end up with a broad,
00:15:15 --> 00:15:18 very heterogeneity kind of
00:15:19 --> 00:15:20 study sample here.
00:15:20 --> 00:15:21 So we went with the two
00:15:21 --> 00:15:22 outcomes that we had at
00:15:22 --> 00:15:24 least knew that probably
00:15:24 --> 00:15:26 the majority would publish,
00:15:26 --> 00:15:27 which would be pain
00:15:27 --> 00:15:28 intensity and some kind of
00:15:29 --> 00:15:29 disability measure.
00:15:30 --> 00:15:31 So that was the two outcomes
00:15:31 --> 00:15:32 that we selected.
00:15:32 --> 00:15:33 And then we were
00:15:34 --> 00:15:36 strategic and saying that we
00:15:36 --> 00:15:37 will only look at right
00:15:37 --> 00:15:38 after the treatment.
00:15:39 --> 00:15:40 So right after the treatment,
00:15:40 --> 00:15:41 like the intervention,
00:15:41 --> 00:15:42 if it was twelve sessions,
00:15:42 --> 00:15:44 it would be after that twelve sessions,
00:15:44 --> 00:15:45 that would be the short-term outcomes.
00:15:45 --> 00:15:47 And then we had the long-term outcomes,
00:15:47 --> 00:15:48 which was the closest thing
00:15:48 --> 00:15:49 to twelve months.
00:15:51 --> 00:15:52 So those were the outcomes
00:15:52 --> 00:15:53 that we selected,
00:15:54 --> 00:15:55 which meant that we had to
00:15:55 --> 00:15:56 do a lot of analyses
00:15:57 --> 00:15:58 because we did a lot of
00:15:58 --> 00:15:59 networks and each network
00:15:59 --> 00:16:00 had to be repeated for
00:16:01 --> 00:16:01 different outcomes at
00:16:01 --> 00:16:02 different time points.
00:16:03 --> 00:16:04 Which is why the study got
00:16:04 --> 00:16:06 so all the paper got so
00:16:06 --> 00:16:06 enormous as it did.
00:16:06 --> 00:16:07 Right.
00:16:07 --> 00:16:09 Yeah, absolutely.
00:16:10 --> 00:16:11 So after all of that,
00:16:11 --> 00:16:13 after collecting all of that data,
00:16:14 --> 00:16:14 what did you all find?
00:16:18 --> 00:16:20 Well, I think we found a number of things.
00:16:20 --> 00:16:22 The first thing that kind of
00:16:22 --> 00:16:26 pops up is that we mirrored
00:16:26 --> 00:16:27 what the other systematic
00:16:27 --> 00:16:28 reviews have found,
00:16:28 --> 00:16:29 which was really positive
00:16:29 --> 00:16:30 because our systematic
00:16:30 --> 00:16:33 review here was more broad than,
00:16:33 --> 00:16:34 let's say, Sidney Rubenstein,
00:16:34 --> 00:16:36 who published a systematic
00:16:36 --> 00:16:37 review on chronic low back
00:16:37 --> 00:16:39 pain back in twenty twenty nineteen.
00:16:39 --> 00:16:39 That was probably the
00:16:39 --> 00:16:40 biggest or that probably
00:16:41 --> 00:16:42 that was the biggest review
00:16:42 --> 00:16:44 to date published in BMJ
00:16:44 --> 00:16:44 back in twenty nineteen.
00:16:45 --> 00:16:48 And that was a little bit more concrete.
00:16:48 --> 00:16:50 Ours included, you know, different regions,
00:16:51 --> 00:16:53 a lot of different techniques, different,
00:16:54 --> 00:16:55 you know, durations of pain.
00:16:55 --> 00:16:56 We had both acute and
00:16:56 --> 00:16:57 chronic pain in there.
00:16:57 --> 00:16:59 So that's why we ended up
00:16:59 --> 00:17:00 with so many studies and so
00:17:00 --> 00:17:01 many participants.
00:17:01 --> 00:17:03 So we were happy to see, first of all,
00:17:03 --> 00:17:05 that all results actually mimicked,
00:17:06 --> 00:17:06 sorry,
00:17:06 --> 00:17:08 mirrored what they found,
00:17:08 --> 00:17:10 which is that SMT seemed to
00:17:10 --> 00:17:13 be as effective as other interventions,
00:17:13 --> 00:17:14 recommended interventions,
00:17:14 --> 00:17:16 such as exercise and other
00:17:16 --> 00:17:16 manual therapies.
00:17:16 --> 00:17:18 There was no real difference there.
00:17:18 --> 00:17:19 And also that SMT was, you know,
00:17:19 --> 00:17:22 a little bit more effective
00:17:22 --> 00:17:24 than non-recommended therapies, like say,
00:17:24 --> 00:17:26 putting yourself in traction or...
00:17:28 --> 00:17:30 uh like ultrasound for
00:17:30 --> 00:17:31 instance and like stuff
00:17:31 --> 00:17:32 that is no longer being
00:17:32 --> 00:17:33 recommended in clinical
00:17:33 --> 00:17:34 guidelines what we did
00:17:34 --> 00:17:35 found that was different
00:17:35 --> 00:17:36 from a lot of the other
00:17:36 --> 00:17:37 reviews was that when we
00:17:37 --> 00:17:39 compared to sham treatment
00:17:40 --> 00:17:41 we actually found quite a
00:17:41 --> 00:17:43 larger effect of smt
00:17:43 --> 00:17:44 compared to other studies
00:17:45 --> 00:17:47 And I think part of that is due to the,
00:17:47 --> 00:17:48 we had to pool some
00:17:48 --> 00:17:50 different placebo studies together.
00:17:51 --> 00:17:53 So one could be a real setup
00:17:54 --> 00:17:55 where you completely mimic
00:17:55 --> 00:17:56 the intervention.
00:17:56 --> 00:17:57 And the other one could be
00:17:57 --> 00:17:58 like a detune ultrasound
00:17:58 --> 00:18:00 thing that you just put on patients.
00:18:00 --> 00:18:02 And from a contextual standpoint,
00:18:02 --> 00:18:03 which we'll talk more about later,
00:18:03 --> 00:18:04 those are very different.
00:18:04 --> 00:18:06 And we also know that from a
00:18:06 --> 00:18:08 paper published in pain last year,
00:18:08 --> 00:18:09 that there's quite a big
00:18:09 --> 00:18:10 difference in the effect
00:18:10 --> 00:18:11 sizes between those two
00:18:11 --> 00:18:12 different placebos.
00:18:12 --> 00:18:13 So.
00:18:14 --> 00:18:15 That's probably why we found
00:18:15 --> 00:18:15 those results.
00:18:15 --> 00:18:17 So that was the first thing we found.
00:18:17 --> 00:18:18 And then we looked at,
00:18:19 --> 00:18:21 we basically used different
00:18:21 --> 00:18:24 ways of categorizing the target,
00:18:24 --> 00:18:25 the thrust and the region.
00:18:25 --> 00:18:26 And then we compared all of
00:18:26 --> 00:18:28 those with each other based
00:18:28 --> 00:18:30 on this advanced and complex statistics.
00:18:31 --> 00:18:32 So we got a result out and
00:18:33 --> 00:18:34 that result was very clear.
00:18:34 --> 00:18:36 Like it worked and it really
00:18:36 --> 00:18:38 didn't matter how you used it.
00:18:39 --> 00:18:40 Like there were no real
00:18:40 --> 00:18:42 differences between any of
00:18:43 --> 00:18:44 the SMT interventions.
00:18:45 --> 00:18:46 It reached statistical
00:18:46 --> 00:18:48 significance a couple of times,
00:18:48 --> 00:18:49 but it was still a somewhat
00:18:49 --> 00:18:50 small effect size.
00:18:50 --> 00:18:52 So basically saying that SMT
00:18:52 --> 00:18:54 seems to work as well as
00:18:54 --> 00:18:55 other recommended therapies,
00:18:55 --> 00:18:56 but how you do it.
00:18:57 --> 00:18:58 It didn't explain any of the
00:18:59 --> 00:19:00 variation in the outcome data.
00:19:01 --> 00:19:02 So there was no difference whether,
00:19:03 --> 00:19:04 let's take an example,
00:19:04 --> 00:19:04 whether you used a
00:19:05 --> 00:19:05 completely generalized
00:19:05 --> 00:19:06 thrust or whether you were
00:19:06 --> 00:19:07 trying to be like sniper
00:19:08 --> 00:19:09 specific on that vertebral segment,
00:19:09 --> 00:19:10 didn't matter.
00:19:10 --> 00:19:11 Even if you did it in the
00:19:12 --> 00:19:13 region where people came in,
00:19:13 --> 00:19:15 like let's say a neck patient came in,
00:19:15 --> 00:19:16 you manipulated the neck or
00:19:16 --> 00:19:18 you manipulated their thoracic spine.
00:19:18 --> 00:19:19 There was a lot of studies that did that.
00:19:19 --> 00:19:22 Also no difference in neck
00:19:22 --> 00:19:23 pain outcomes or neck
00:19:23 --> 00:19:24 disability outcomes.
00:19:25 --> 00:19:25 And we actually found,
00:19:25 --> 00:19:27 but that's not what we want to conclude,
00:19:27 --> 00:19:29 because I'll get to that in a second.
00:19:29 --> 00:19:31 But we actually found that a
00:19:31 --> 00:19:33 completely nonspecific approach,
00:19:33 --> 00:19:36 a generalized thrust to the
00:19:36 --> 00:19:37 non-symptomatic region
00:19:37 --> 00:19:38 actually appeared to be the
00:19:38 --> 00:19:41 most effective way of doing it.
00:19:42 --> 00:19:43 But because of the way that
00:19:43 --> 00:19:44 the study was set up,
00:19:45 --> 00:19:47 we said that clinicians,
00:19:47 --> 00:19:48 and that's the main takeaway,
00:19:48 --> 00:19:49 that clinicians can
00:19:49 --> 00:19:51 basically do whatever they
00:19:51 --> 00:19:52 want to and expect to get
00:19:52 --> 00:19:53 the same results.
00:19:53 --> 00:19:56 So we shouldn't dive into
00:19:56 --> 00:19:58 the different philosophies
00:19:58 --> 00:19:59 or theoretical frameworks
00:19:59 --> 00:20:02 for this type or this type.
00:20:02 --> 00:20:03 At least on average,
00:20:03 --> 00:20:04 it seems to be that there
00:20:05 --> 00:20:06 is no real difference.
00:20:06 --> 00:20:07 And we found one last thing,
00:20:07 --> 00:20:08 which I might add,
00:20:08 --> 00:20:10 which was that as expected,
00:20:10 --> 00:20:13 because normally in systematic review,
00:20:13 --> 00:20:13 you should do a great
00:20:13 --> 00:20:15 approach to assess the
00:20:15 --> 00:20:16 certainty of the evidence.
00:20:17 --> 00:20:17 And normally,
00:20:17 --> 00:20:19 you want to get high certainty evidence.
00:20:19 --> 00:20:20 That's what's going to
00:20:20 --> 00:20:21 change clinical practice.
00:20:22 --> 00:20:24 basically which rarely
00:20:24 --> 00:20:25 happens in spine research
00:20:26 --> 00:20:28 unfortunately and it also
00:20:28 --> 00:20:28 didn't happen here we
00:20:28 --> 00:20:31 actually got low certainty
00:20:31 --> 00:20:32 evidence more or less all
00:20:32 --> 00:20:35 the way through and that it
00:20:35 --> 00:20:36 is really explained by a
00:20:36 --> 00:20:37 few things first of all we
00:20:37 --> 00:20:39 used you always assist risk
00:20:39 --> 00:20:41 of bias in these randomized
00:20:41 --> 00:20:43 trials that we included and
00:20:43 --> 00:20:44 here we were very stringent
00:20:44 --> 00:20:46 we used cochran's which is
00:20:46 --> 00:20:47 the recommended tool and we
00:20:47 --> 00:20:48 were quite hard so we used
00:20:49 --> 00:20:51 cochran's way of doing it and cochrane is
00:20:53 --> 00:20:54 It's like the guidebook on
00:20:54 --> 00:20:56 how to do reviews, basically,
00:20:57 --> 00:20:58 which meant that almost all
00:20:58 --> 00:20:59 of the studies were
00:20:59 --> 00:21:00 categorized as having a
00:21:00 --> 00:21:03 high risk of bias just
00:21:03 --> 00:21:05 because you cannot really blind it.
00:21:05 --> 00:21:06 And all the outcomes we
00:21:06 --> 00:21:07 looked at were subjective.
00:21:07 --> 00:21:08 So I would say,
00:21:09 --> 00:21:11 my pain is now three out of
00:21:12 --> 00:21:13 ten instead of five out of
00:21:13 --> 00:21:13 ten or whatever.
00:21:14 --> 00:21:15 And that's all a subjective
00:21:15 --> 00:21:17 opinion that can be biased
00:21:17 --> 00:21:18 by a lot of different things.
00:21:18 --> 00:21:19 It kind of makes sense, right?
00:21:21 --> 00:21:23 So that pumped the certainty
00:21:24 --> 00:21:24 of the evidence.
00:21:25 --> 00:21:26 It downgraded it, I would say.
00:21:26 --> 00:21:29 And then we also saw some inconsistencies.
00:21:29 --> 00:21:30 So there were some
00:21:31 --> 00:21:32 comparisons that we did.
00:21:32 --> 00:21:33 And I don't want to get too technical here,
00:21:33 --> 00:21:35 where we had a study that
00:21:36 --> 00:21:37 did a direct comparison.
00:21:37 --> 00:21:38 So let's say an RCT that
00:21:38 --> 00:21:41 compared SMT to exercise, for instance.
00:21:42 --> 00:21:43 And that would show one result.
00:21:43 --> 00:21:44 And then based on all these
00:21:44 --> 00:21:45 advanced mathematics,
00:21:46 --> 00:21:48 when we looked at the indirect evidence,
00:21:48 --> 00:21:49 so that would be if we
00:21:50 --> 00:21:51 took what the computer
00:21:51 --> 00:21:53 decided is probably the
00:21:53 --> 00:21:56 effect of manipulation over exercise.
00:21:56 --> 00:21:57 Those two could differ a bit.
00:21:58 --> 00:22:00 So that's what we call inconsistency.
00:22:00 --> 00:22:01 And we also had a little bit of that.
00:22:01 --> 00:22:03 And it was mostly related to
00:22:03 --> 00:22:05 when we compared SMT to
00:22:06 --> 00:22:07 other interventions.
00:22:09 --> 00:22:09 So again,
00:22:10 --> 00:22:11 basically saying that the
00:22:11 --> 00:22:13 outcomes we looked at are
00:22:13 --> 00:22:14 all over the place,
00:22:15 --> 00:22:16 which did impact the
00:22:16 --> 00:22:18 certainty of our evidence.
00:22:18 --> 00:22:19 But we still,
00:22:19 --> 00:22:20 and I don't know if you want
00:22:20 --> 00:22:21 to ask about this later,
00:22:21 --> 00:22:23 but we actually still conclude that,
00:22:23 --> 00:22:24 and we just wrote a blog to
00:22:24 --> 00:22:25 JOSBT about this,
00:22:25 --> 00:22:26 where we explained this,
00:22:27 --> 00:22:28 in in more detail which
00:22:28 --> 00:22:29 didn't fit into the
00:22:29 --> 00:22:31 original paper we still
00:22:31 --> 00:22:32 believe that this has an
00:22:32 --> 00:22:33 impact on education
00:22:33 --> 00:22:34 specifically and also on
00:22:35 --> 00:22:36 clinical practice because
00:22:36 --> 00:22:37 it's not only this paper
00:22:37 --> 00:22:38 that says that we had the
00:22:38 --> 00:22:39 other reviews we have
00:22:39 --> 00:22:40 individual trials we have
00:22:40 --> 00:22:42 mechanistic research saying
00:22:42 --> 00:22:43 that you can't really
00:22:43 --> 00:22:45 control forces or at least
00:22:45 --> 00:22:47 control where where the
00:22:47 --> 00:22:48 forces are delivered like
00:22:48 --> 00:22:50 for instance if you were to
00:22:50 --> 00:22:51 quantify where the popping
00:22:51 --> 00:22:52 sounds occur they occur all
00:22:52 --> 00:22:53 over the spine even
00:22:54 --> 00:22:55 multiple places away and
00:22:55 --> 00:22:56 only like half the time
00:22:56 --> 00:22:57 they actually occur on this
00:22:57 --> 00:23:01 segment um so so this this
00:23:01 --> 00:23:02 aligns really well with
00:23:03 --> 00:23:04 with mechanistic research
00:23:04 --> 00:23:05 with other reviews with
00:23:05 --> 00:23:07 individual trials and also
00:23:08 --> 00:23:10 to be honest with a more
00:23:10 --> 00:23:12 modern understanding of
00:23:12 --> 00:23:15 pain science and how back
00:23:15 --> 00:23:19 pain is fluctuating and how
00:23:19 --> 00:23:20 complex pain really is.
00:23:21 --> 00:23:22 It also goes along really well with that.
00:23:22 --> 00:23:23 So we still think that our
00:23:23 --> 00:23:25 conclusions holds a lot of
00:23:25 --> 00:23:26 recommendations that we
00:23:26 --> 00:23:28 hope will be implemented different places,
00:23:28 --> 00:23:30 despite the low certainty
00:23:30 --> 00:23:31 evidence from a more
00:23:31 --> 00:23:32 statistical standpoint,
00:23:32 --> 00:23:32 if that makes sense.
00:23:32 --> 00:23:35 Yeah, I think so.
00:23:35 --> 00:23:35 Thank you for the
00:23:36 --> 00:23:37 explanation and description of results.
00:23:38 --> 00:23:40 The first thing that kind of comes to mind,
00:23:41 --> 00:23:43 and I don't mean this in a negative way,
00:23:43 --> 00:23:45 but being a fellowship
00:23:45 --> 00:23:47 trained in AOMT and just
00:23:47 --> 00:23:48 having some conversations
00:23:48 --> 00:23:50 with colleagues about these
00:23:50 --> 00:23:50 sorts of things,
00:23:52 --> 00:23:53 we like to think that our
00:23:53 --> 00:23:54 training allows us to
00:23:56 --> 00:23:58 deliver maybe different
00:23:58 --> 00:23:59 levels of manual therapy
00:23:59 --> 00:24:02 skills than colleagues who
00:24:02 --> 00:24:03 maybe didn't go through
00:24:03 --> 00:24:04 residency training or
00:24:04 --> 00:24:05 fellowship training or just
00:24:05 --> 00:24:07 don't have the experience.
00:24:08 --> 00:24:09 What are your thoughts on
00:24:10 --> 00:24:13 the potential impact or implications of,
00:24:14 --> 00:24:15 as you yourself mentioned,
00:24:15 --> 00:24:16 just the large data set and
00:24:17 --> 00:24:17 potentially the
00:24:17 --> 00:24:19 heterogeneity of the
00:24:19 --> 00:24:20 different studies that were included?
00:24:21 --> 00:24:22 Was there any way that you
00:24:22 --> 00:24:26 were able to control for or account for.
00:24:27 --> 00:24:29 The type of treatment delivered,
00:24:29 --> 00:24:31 whether it was from a trained clinician,
00:24:32 --> 00:24:33 and then can you speak to
00:24:33 --> 00:24:34 maybe the breakdown of.
00:24:35 --> 00:24:37 Different applications of
00:24:37 --> 00:24:39 these treatments from a chiropractic.
00:24:40 --> 00:24:42 Standpoint is probably your your lens,
00:24:43 --> 00:24:44 but also the chiro
00:24:44 --> 00:24:46 philosophy versus physical therapy.
00:24:46 --> 00:24:46 Do you think that.
00:24:47 --> 00:24:50 Made a difference and I again.
00:24:51 --> 00:24:52 Acknowledging that,
00:24:53 --> 00:24:56 including both of those professions,
00:24:56 --> 00:24:57 because we both utilize
00:24:57 --> 00:24:58 that as a treatment
00:24:58 --> 00:24:59 technique and trying to
00:25:00 --> 00:25:02 span conclusions from
00:25:03 --> 00:25:03 application of this
00:25:03 --> 00:25:05 treatment is important.
00:25:06 --> 00:25:07 But do you think that
00:25:07 --> 00:25:08 limited your ability to
00:25:09 --> 00:25:11 conclude definitively
00:25:13 --> 00:25:14 things based across the board?
00:25:15 --> 00:25:16 I don't know.
00:25:17 --> 00:25:18 Yeah, no, I know what you mean.
00:25:18 --> 00:25:19 There were two really
00:25:19 --> 00:25:20 important questions there.
00:25:20 --> 00:25:22 One about the AOM training
00:25:22 --> 00:25:23 and all that stuff,
00:25:23 --> 00:25:27 like to get those qualifications.
00:25:27 --> 00:25:28 Let's get back to that a
00:25:28 --> 00:25:28 little bit because I do
00:25:28 --> 00:25:29 want to answer that.
00:25:30 --> 00:25:31 We can take the study first.
00:25:31 --> 00:25:32 Obviously,
00:25:32 --> 00:25:33 the effects that we see here are
00:25:33 --> 00:25:34 all average defects.
00:25:35 --> 00:25:37 So it might be that there
00:25:37 --> 00:25:39 are certain outliers where
00:25:39 --> 00:25:41 this matters a whole lot
00:25:41 --> 00:25:43 and other outliers where it
00:25:43 --> 00:25:44 really doesn't matter at all.
00:25:45 --> 00:25:46 but on average,
00:25:47 --> 00:25:48 there was no real difference in it.
00:25:48 --> 00:25:50 And that's currently the
00:25:50 --> 00:25:51 only way that we can look
00:25:51 --> 00:25:54 at it is using the average data.
00:25:55 --> 00:25:56 And then you asked about,
00:25:57 --> 00:25:59 I would say we, first of all,
00:25:59 --> 00:25:59 our study was,
00:26:00 --> 00:26:01 despite the large number of studies,
00:26:01 --> 00:26:03 was not really powered to
00:26:03 --> 00:26:05 look at whether different
00:26:05 --> 00:26:07 professions differed or
00:26:07 --> 00:26:08 whether the experience of
00:26:08 --> 00:26:09 different professions,
00:26:11 --> 00:26:12 if that mattered for outcomes.
00:26:13 --> 00:26:13 There were some other
00:26:13 --> 00:26:14 studies out there where
00:26:14 --> 00:26:16 they look at the experience
00:26:16 --> 00:26:17 of people and how that matters,
00:26:17 --> 00:26:18 and it doesn't seem to
00:26:18 --> 00:26:20 matter a great deal,
00:26:21 --> 00:26:22 which also boils down to
00:26:22 --> 00:26:23 the complexity of measuring
00:26:23 --> 00:26:24 pain in real life.
00:26:25 --> 00:26:26 It is quite complex.
00:26:27 --> 00:26:28 And even just to understand
00:26:28 --> 00:26:30 that and interpret it as a
00:26:30 --> 00:26:32 research participant, very difficult.
00:26:34 --> 00:26:36 And then I would say we
00:26:36 --> 00:26:37 deliberately also didn't
00:26:37 --> 00:26:39 want to compare clinicians
00:26:39 --> 00:26:41 against each other because
00:26:41 --> 00:26:42 there are a lot of other
00:26:42 --> 00:26:45 factors that are involved
00:26:45 --> 00:26:47 here into the effect of these studies.
00:26:48 --> 00:26:49 So let's say like the
00:26:49 --> 00:26:51 smaller sample sizes of some studies,
00:26:51 --> 00:26:52 for instance,
00:26:52 --> 00:26:53 that's something that probably matters.
00:26:54 --> 00:26:55 Risk of bias may matter as well.
00:26:56 --> 00:26:57 But we did,
00:26:57 --> 00:26:59 and I haven't talked about this yet,
00:26:59 --> 00:27:01 but the paper is about a couple of pages.
00:27:01 --> 00:27:03 But then our supplementary material,
00:27:03 --> 00:27:04 our appendix,
00:27:04 --> 00:27:05 is actually three hundred
00:27:05 --> 00:27:06 and forty pages.
00:27:06 --> 00:27:08 So we did we did numerous
00:27:09 --> 00:27:11 additional analyses kind of
00:27:11 --> 00:27:12 to validate or verify some
00:27:12 --> 00:27:13 of these findings.
00:27:13 --> 00:27:14 And some of the things that
00:27:14 --> 00:27:16 we looked at that didn't matter was,
00:27:16 --> 00:27:16 you know,
00:27:16 --> 00:27:18 where did the patient have pain?
00:27:18 --> 00:27:20 What was the pain duration?
00:27:20 --> 00:27:21 But it was all more patient
00:27:21 --> 00:27:22 specific criteria.
00:27:22 --> 00:27:23 We didn't really look at the
00:27:24 --> 00:27:26 at the, at the clinician itself, but
00:27:28 --> 00:27:29 And I kind of don't want to do it,
00:27:29 --> 00:27:29 to be honest,
00:27:29 --> 00:27:31 because I don't want to set
00:27:31 --> 00:27:32 Kairos up against physios.
00:27:32 --> 00:27:33 I don't think that makes any sense.
00:27:33 --> 00:27:35 We should probably be better
00:27:35 --> 00:27:36 at collaborating than
00:27:36 --> 00:27:36 fighting each other.
00:27:37 --> 00:27:41 And it doesn't really have any impact,
00:27:41 --> 00:27:41 I would say,
00:27:41 --> 00:27:42 on clinical practice because
00:27:42 --> 00:27:45 we all know on an everyday basis,
00:27:46 --> 00:27:48 if patients, they like to go to Kairos,
00:27:48 --> 00:27:49 they'll go to Kairos.
00:27:49 --> 00:27:50 If they want to go to physios,
00:27:50 --> 00:27:51 they'll go to physios.
00:27:52 --> 00:27:53 And if one thing doesn't work for them,
00:27:53 --> 00:27:54 maybe they'll switch.
00:27:54 --> 00:27:54 But
00:27:55 --> 00:27:57 The risk of going back to a
00:27:57 --> 00:27:58 provider is who you see first,
00:27:59 --> 00:28:00 most likely.
00:28:00 --> 00:28:04 So I would kind of hate
00:28:04 --> 00:28:06 doing research like that,
00:28:06 --> 00:28:08 especially on this type of database.
00:28:09 --> 00:28:10 And when I say all this,
00:28:10 --> 00:28:12 and I get back to your first question,
00:28:12 --> 00:28:13 which I thought was really
00:28:13 --> 00:28:15 good about the AOMD
00:28:15 --> 00:28:16 classification and
00:28:16 --> 00:28:17 postgraduate education and all that,
00:28:18 --> 00:28:19 I do think that matters greatly.
00:28:20 --> 00:28:22 So there are two points in
00:28:22 --> 00:28:23 all of this that we haven't
00:28:23 --> 00:28:24 been able to assess.
00:28:25 --> 00:28:25 And one,
00:28:25 --> 00:28:26 if you want to start with the
00:28:26 --> 00:28:30 biomechanics, is false modulation skills.
00:28:31 --> 00:28:33 So for instance, the more trained you are,
00:28:33 --> 00:28:34 you would understand that
00:28:35 --> 00:28:37 some patients need a little bit more push,
00:28:37 --> 00:28:39 some patient needs a little less push,
00:28:40 --> 00:28:41 some patients maybe don't
00:28:41 --> 00:28:42 want to be pushed at all.
00:28:42 --> 00:28:44 So that controlling of forces,
00:28:45 --> 00:28:46 and I don't mean where
00:28:46 --> 00:28:47 right now where it's being delivered,
00:28:47 --> 00:28:49 but by hand forces, how much
00:28:49 --> 00:28:51 you know, how much of your mass,
00:28:51 --> 00:28:52 your body mass you use when
00:28:52 --> 00:28:53 you deliver the treatment.
00:28:53 --> 00:28:55 I think that matters some,
00:28:55 --> 00:28:56 maybe not for clinical outcomes,
00:28:57 --> 00:28:58 but it definitely matters for safety.
00:28:59 --> 00:29:00 And I think it matters for
00:29:00 --> 00:29:01 patient comfort as well.
00:29:01 --> 00:29:03 And also for participant comfort,
00:29:03 --> 00:29:05 not provider comfort.
00:29:05 --> 00:29:07 And that's the next thing to go into here,
00:29:07 --> 00:29:08 because I think a lot of
00:29:08 --> 00:29:10 this is being driven by
00:29:10 --> 00:29:12 contextual factors, to be honest,
00:29:12 --> 00:29:13 where manual therapy in
00:29:13 --> 00:29:15 general is a very powerful
00:29:15 --> 00:29:16 contextual factor.
00:29:17 --> 00:29:18 Like you you lay down,
00:29:18 --> 00:29:19 you're being examined and
00:29:19 --> 00:29:21 you something is being done
00:29:21 --> 00:29:22 and the patient can
00:29:22 --> 00:29:23 obviously hear and feel
00:29:23 --> 00:29:24 that something happens.
00:29:24 --> 00:29:25 And, you know,
00:29:25 --> 00:29:27 if it says at least in Cairo
00:29:27 --> 00:29:28 field and I guess also in
00:29:28 --> 00:29:29 physios from some of the
00:29:29 --> 00:29:30 conversations I had,
00:29:30 --> 00:29:31 whenever it says that popping sound,
00:29:31 --> 00:29:32 you always get a little bit.
00:29:33 --> 00:29:34 Yes, that was really good.
00:29:34 --> 00:29:34 Right.
00:29:34 --> 00:29:35 You got a good response.
00:29:36 --> 00:29:37 And that response,
00:29:38 --> 00:29:39 that rubs off on the patient.
00:29:39 --> 00:29:41 Obviously, it does.
00:29:41 --> 00:29:42 And they will get up and say, yeah,
00:29:42 --> 00:29:44 I can feel I move much better now.
00:29:44 --> 00:29:46 And all of that probably has
00:29:46 --> 00:29:47 more to do with context
00:29:48 --> 00:29:48 than what actually happens
00:29:49 --> 00:29:49 inside the spine.
00:29:52 --> 00:29:53 And that is something that
00:29:55 --> 00:29:58 is being portrayed better by,
00:29:58 --> 00:30:00 and this is just me.
00:30:00 --> 00:30:01 I don't have any data on this.
00:30:01 --> 00:30:02 This is just me speculating.
00:30:03 --> 00:30:04 But I would say that is
00:30:04 --> 00:30:06 easier to sell if you are
00:30:06 --> 00:30:07 an experienced clinician
00:30:07 --> 00:30:08 who trained this and has a
00:30:08 --> 00:30:09 high confidence.
00:30:10 --> 00:30:11 You can easily build up this
00:30:11 --> 00:30:12 therapeutic alliance.
00:30:12 --> 00:30:15 You can more easily wrangle
00:30:15 --> 00:30:16 your different techniques,
00:30:16 --> 00:30:17 your force modulation skills,
00:30:18 --> 00:30:18 and all of that.
00:30:19 --> 00:30:22 I think that matters to a certain degree.
00:30:24 --> 00:30:25 And stuff like that is just
00:30:25 --> 00:30:26 difficult to learn because
00:30:26 --> 00:30:28 you need to be comfortable
00:30:28 --> 00:30:29 doing it and confident doing it.
00:30:30 --> 00:30:31 That way, you know,
00:30:31 --> 00:30:32 patients will also be
00:30:32 --> 00:30:33 confident and comfortable
00:30:33 --> 00:30:34 in you doing it.
00:30:34 --> 00:30:36 And that will lead to better outcomes.
00:30:36 --> 00:30:38 But again, that has nothing to do with,
00:30:39 --> 00:30:40 you know, the way you do it,
00:30:41 --> 00:30:42 which is why we make the
00:30:42 --> 00:30:43 argument that clinicians,
00:30:44 --> 00:30:46 experienced clinicians such as yourself,
00:30:46 --> 00:30:47 you can go out, you know,
00:30:47 --> 00:30:49 practicing tomorrow or next
00:30:49 --> 00:30:50 Monday and you can do whatever you want.
00:30:51 --> 00:30:52 probably won't matter a whole lot.
00:30:53 --> 00:30:54 You can try to be as
00:30:54 --> 00:30:56 specific and as concrete as you want,
00:30:56 --> 00:30:57 whether you're a physio or
00:30:57 --> 00:30:58 a chiro or whatever it is.
00:30:58 --> 00:31:00 But for the future clinicians,
00:31:00 --> 00:31:03 I think we are basically
00:31:03 --> 00:31:04 looking into a major
00:31:04 --> 00:31:06 paradigm shift of the way
00:31:06 --> 00:31:09 that we teach manual therapy.
00:31:10 --> 00:31:12 into an approach where we
00:31:12 --> 00:31:13 have to look at it,
00:31:14 --> 00:31:15 I want to say the word holistically,
00:31:15 --> 00:31:16 even though I hate that word,
00:31:16 --> 00:31:18 because there's so many
00:31:19 --> 00:31:20 negative associations with it,
00:31:21 --> 00:31:22 but we have to see the whole person.
00:31:22 --> 00:31:23 We have to understand how
00:31:23 --> 00:31:24 these contextual factors
00:31:25 --> 00:31:26 impact the patient,
00:31:26 --> 00:31:27 how it impacts our treatment.
00:31:27 --> 00:31:28 And then we have to learn,
00:31:30 --> 00:31:31 we still have to learn like motor skills,
00:31:31 --> 00:31:33 how to modulate forces.
00:31:33 --> 00:31:34 We still have to be
00:31:34 --> 00:31:36 confident in the way that we do it.
00:31:37 --> 00:31:38 I still think like palpation,
00:31:38 --> 00:31:40 it has an effect on people
00:31:40 --> 00:31:42 just like palpating, you know, feeling,
00:31:42 --> 00:31:44 getting a sense of the
00:31:44 --> 00:31:45 structure and tissue and
00:31:45 --> 00:31:46 texture of the patient.
00:31:46 --> 00:31:48 Like, is this someone who I need to be,
00:31:49 --> 00:31:49 you know,
00:31:49 --> 00:31:50 put a little bit more mass into
00:31:50 --> 00:31:52 or should I back off a little bit?
00:31:52 --> 00:31:53 Some of those things are
00:31:53 --> 00:31:54 still very important to teach,
00:31:55 --> 00:31:56 but teaching stuff like, oh,
00:31:56 --> 00:31:57 you want to move the bone
00:31:57 --> 00:31:58 this way or that way,
00:31:58 --> 00:31:59 or you want to hit this
00:31:59 --> 00:32:00 angle because then you will hit the,
00:32:01 --> 00:32:02 you will impact the disc
00:32:02 --> 00:32:04 rather than the facet joints.
00:32:04 --> 00:32:06 That is all just outdated information.
00:32:06 --> 00:32:08 And we need to update that across,
00:32:08 --> 00:32:10 I would say like worldwide
00:32:10 --> 00:32:12 across all institutions
00:32:12 --> 00:32:14 that teach rather undergrad
00:32:14 --> 00:32:16 or post-grad that teach
00:32:16 --> 00:32:17 manual therapy skills,
00:32:17 --> 00:32:18 at least when it comes to
00:32:19 --> 00:32:20 this popping sound that we
00:32:20 --> 00:32:21 investigated SMT.
00:32:22 --> 00:32:24 So that would be my very
00:32:24 --> 00:32:25 long answer to your two
00:32:25 --> 00:32:26 slightly complicated questions,
00:32:27 --> 00:32:28 if that makes sense.
00:32:28 --> 00:32:29 And I don't know if you agree or not,
00:32:30 --> 00:32:32 but it's my point, at least,
00:32:32 --> 00:32:33 based on all this data that
00:32:34 --> 00:32:35 I have looked at over the last,
00:32:35 --> 00:32:36 I want to say, ten years.
00:32:38 --> 00:32:38 Yeah,
00:32:38 --> 00:32:39 definitely follow what you're
00:32:40 --> 00:32:43 describing and excellent answers, Casper.
00:32:43 --> 00:32:44 I think also,
00:32:44 --> 00:32:47 and this is not different
00:32:47 --> 00:32:48 than I think a lot of the
00:32:48 --> 00:32:49 philosophy that our
00:32:49 --> 00:32:51 listeners or the listeners
00:32:51 --> 00:32:53 are familiar with this podcast.
00:32:55 --> 00:32:55 In fact,
00:32:55 --> 00:32:57 a more recent publication on the
00:32:57 --> 00:32:58 definition of orthopedic
00:32:59 --> 00:33:00 manual physical therapy and
00:33:00 --> 00:33:01 that paper was recently
00:33:01 --> 00:33:03 published and I believe
00:33:03 --> 00:33:05 Jason Silvernail was on for
00:33:05 --> 00:33:07 an interview to discuss that and how
00:33:08 --> 00:33:10 So OMPT is exactly what you're saying,
00:33:11 --> 00:33:13 not just the application of
00:33:13 --> 00:33:14 the hands-on technique,
00:33:14 --> 00:33:15 but it's all these other
00:33:15 --> 00:33:15 things that go into it.
00:33:15 --> 00:33:17 It's the clinical reasoning.
00:33:17 --> 00:33:18 It's the choice of technique.
00:33:18 --> 00:33:20 It's the contextual factors.
00:33:20 --> 00:33:21 It's setting it up for the
00:33:21 --> 00:33:23 patient and what you do before,
00:33:24 --> 00:33:24 what you do after,
00:33:24 --> 00:33:25 how you weave it into your
00:33:25 --> 00:33:26 treatment and plan of care.
00:33:28 --> 00:33:30 I think that that is really,
00:33:30 --> 00:33:33 really important and great
00:33:33 --> 00:33:34 thing to bring up as we're
00:33:34 --> 00:33:35 trying to integrate that
00:33:35 --> 00:33:37 into our educational
00:33:37 --> 00:33:40 settings just to increase
00:33:40 --> 00:33:42 the skill of our clinicians
00:33:42 --> 00:33:43 that we have coming out of those.
00:33:44 --> 00:33:46 That's great.
00:33:46 --> 00:33:46 Can I add one thing?
00:33:47 --> 00:33:47 Sorry.
00:33:47 --> 00:33:50 Yeah, please do.
00:33:50 --> 00:33:51 We're looking into a world
00:33:51 --> 00:33:52 now where we understand the
00:33:52 --> 00:33:54 complexity of low back pain a lot better.
00:33:54 --> 00:33:54 We've done a lot of
00:33:54 --> 00:33:56 trajectory research over these last
00:33:57 --> 00:33:58 I want to say, twenty,
00:33:58 --> 00:34:00 maybe thirty years to see
00:34:00 --> 00:34:01 how much it actually varies
00:34:01 --> 00:34:04 over time and how, you know,
00:34:04 --> 00:34:05 back in the day we had this definition,
00:34:05 --> 00:34:06 acute and chronic low back
00:34:06 --> 00:34:08 pain doesn't really make sense anymore.
00:34:08 --> 00:34:09 It's either episodic low
00:34:09 --> 00:34:10 back pain or recurrent low
00:34:10 --> 00:34:11 back pain or simply
00:34:11 --> 00:34:12 persistent low back pain.
00:34:13 --> 00:34:13 But, you know,
00:34:13 --> 00:34:14 back pain is never like this,
00:34:14 --> 00:34:16 just high all the time.
00:34:16 --> 00:34:17 It fluctuates up and down,
00:34:18 --> 00:34:18 which means that we are
00:34:18 --> 00:34:20 looking into a way that
00:34:20 --> 00:34:22 people need to learn how to self-manage.
00:34:23 --> 00:34:24 And we have to shift our
00:34:24 --> 00:34:26 education and research and
00:34:26 --> 00:34:27 clinical reasoning into
00:34:27 --> 00:34:28 understanding how can we
00:34:28 --> 00:34:30 take this apparently
00:34:30 --> 00:34:31 effective intervention?
00:34:31 --> 00:34:33 And that is that is, you know,
00:34:34 --> 00:34:35 probably in the way that
00:34:35 --> 00:34:35 most people understand it
00:34:36 --> 00:34:36 is pretty far away from
00:34:37 --> 00:34:38 self-management strategies
00:34:38 --> 00:34:39 and implement that into a
00:34:39 --> 00:34:41 way where we can use it as
00:34:41 --> 00:34:42 a self-management strategy,
00:34:42 --> 00:34:44 where we can reduce the flares,
00:34:44 --> 00:34:45 maybe the pain flare ups.
00:34:46 --> 00:34:47 Something like that.
00:34:47 --> 00:34:48 And we don't really have a
00:34:48 --> 00:34:49 great understanding of that
00:34:49 --> 00:34:50 at the moment.
00:34:50 --> 00:34:51 And I think that's
00:34:51 --> 00:34:55 definitely where we need to move ahead.
00:34:55 --> 00:34:56 We have to understand that
00:34:56 --> 00:34:57 better because we are
00:34:57 --> 00:34:58 looking into a world where
00:34:59 --> 00:35:00 back pain is growing more
00:35:00 --> 00:35:02 and more and people have to
00:35:02 --> 00:35:03 learn how to self-manage it
00:35:03 --> 00:35:04 because we cannot cure it.
00:35:07 --> 00:35:08 Yeah, I think that's excellent.
00:35:08 --> 00:35:10 So it leads into my last question.
00:35:10 --> 00:35:11 I can talk to you all day.
00:35:11 --> 00:35:12 I think this is fascinating,
00:35:12 --> 00:35:14 but last question for you
00:35:14 --> 00:35:15 is kind of looking ahead
00:35:16 --> 00:35:18 and based on the findings
00:35:18 --> 00:35:19 from this study that we
00:35:19 --> 00:35:20 spent a lot of time talking about,
00:35:21 --> 00:35:22 but then also based on the
00:35:22 --> 00:35:23 other research that you're involved in,
00:35:24 --> 00:35:25 what do you see really now
00:35:25 --> 00:35:27 as some of the gaps in the
00:35:27 --> 00:35:29 literature and where we
00:35:29 --> 00:35:34 need to focus future research efforts?
00:35:34 --> 00:35:34 If you talk,
00:35:35 --> 00:35:36 SMT specifically,
00:35:36 --> 00:35:37 I would say there are gaps
00:35:37 --> 00:35:38 all over the place.
00:35:38 --> 00:35:39 There's a huge area of
00:35:39 --> 00:35:40 simply research waste,
00:35:41 --> 00:35:44 a lot of bad trials, underpowered trials.
00:35:45 --> 00:35:46 There's very low funding to
00:35:46 --> 00:35:48 the area as well.
00:35:49 --> 00:35:51 So that's probably the reason.
00:35:51 --> 00:35:53 So I think gaps, we could talk.
00:35:54 --> 00:35:54 I could say anything,
00:35:54 --> 00:35:55 and there would be a gap in it.
00:35:56 --> 00:35:57 Like, let's say, for instance,
00:35:57 --> 00:35:58 if you really wanted to
00:35:58 --> 00:35:59 conclude whether it
00:35:59 --> 00:36:01 mattered to be highly specific or not,
00:36:01 --> 00:36:03 we would need a really
00:36:03 --> 00:36:05 high-powered trial with
00:36:06 --> 00:36:07 hundreds of people in it to
00:36:07 --> 00:36:08 really estimate whether
00:36:08 --> 00:36:10 those two things were the same.
00:36:10 --> 00:36:13 But based on all of this research,
00:36:13 --> 00:36:14 I would say that's not
00:36:14 --> 00:36:15 something that we should do,
00:36:15 --> 00:36:17 and we shouldn't fund that either.
00:36:18 --> 00:36:19 Because we have to look at
00:36:19 --> 00:36:22 SMT more as having a widespread effect.
00:36:23 --> 00:36:24 That's probably the best way
00:36:24 --> 00:36:24 to describe it.
00:36:25 --> 00:36:26 So even though that's a gap,
00:36:26 --> 00:36:27 that's not a gap that I
00:36:27 --> 00:36:28 would recommend people to
00:36:28 --> 00:36:29 follow because it will be
00:36:29 --> 00:36:30 more of the same.
00:36:30 --> 00:36:32 If you do it properly,
00:36:34 --> 00:36:35 the two outcomes will be
00:36:35 --> 00:36:36 the same for the two groups.
00:36:36 --> 00:36:38 That's just the way it'll
00:36:38 --> 00:36:40 work in nine out of ten times.
00:36:42 --> 00:36:44 And then, like I said before,
00:36:44 --> 00:36:45 how to implement this into
00:36:45 --> 00:36:46 self-management strategy,
00:36:46 --> 00:36:47 long-term care plans,
00:36:49 --> 00:36:52 how to better provide treatment for,
00:36:52 --> 00:36:52 I would say,
00:36:52 --> 00:36:53 the elderly as well is
00:36:53 --> 00:36:54 something that's going to
00:36:54 --> 00:36:55 be really interesting over
00:36:55 --> 00:36:56 this next couple of years here.
00:36:57 --> 00:36:58 As the population grows older,
00:36:59 --> 00:36:59 like a lot of
00:37:00 --> 00:37:02 And also, to be honest,
00:37:02 --> 00:37:03 at least in Denmark,
00:37:03 --> 00:37:05 and I assume it's the same all around,
00:37:05 --> 00:37:07 that all the people,
00:37:07 --> 00:37:08 they want to do more.
00:37:08 --> 00:37:09 They have more money.
00:37:09 --> 00:37:10 They have more resources.
00:37:10 --> 00:37:12 So they want to live their
00:37:12 --> 00:37:13 life to the fullest when
00:37:13 --> 00:37:14 they retire even.
00:37:15 --> 00:37:15 So there's going to be a
00:37:15 --> 00:37:17 high demand on how to
00:37:18 --> 00:37:19 make these patients, not patients,
00:37:20 --> 00:37:21 but these elderly citizens,
00:37:22 --> 00:37:23 how to make them function
00:37:23 --> 00:37:24 in a day-to-day basis.
00:37:24 --> 00:37:25 I think that's going to be
00:37:25 --> 00:37:26 super interesting and
00:37:26 --> 00:37:26 something that we really do
00:37:26 --> 00:37:27 need to research.
00:37:28 --> 00:37:29 And I would still say,
00:37:29 --> 00:37:31 specifically for SMT mechanisms,
00:37:31 --> 00:37:31 it's still really
00:37:31 --> 00:37:34 interesting and we need
00:37:34 --> 00:37:36 more and we need better research,
00:37:36 --> 00:37:38 simply put, on it.
00:37:38 --> 00:37:39 And we need to
00:37:40 --> 00:37:42 know follow a string where
00:37:42 --> 00:37:43 we you know find something
00:37:44 --> 00:37:45 experimentally like
00:37:45 --> 00:37:46 biomechanically or
00:37:46 --> 00:37:47 neurophysiological and then test that
00:37:49 --> 00:37:51 all the way to a clinical population.
00:37:51 --> 00:37:53 We need programs that does this.
00:37:55 --> 00:37:56 And it's probably not to
00:37:56 --> 00:37:58 understand how to give the treatment,
00:37:58 --> 00:37:59 but more like who is the
00:37:59 --> 00:38:01 responders of the treatment?
00:38:01 --> 00:38:02 Who should we provide this
00:38:02 --> 00:38:03 to and who should we do
00:38:03 --> 00:38:04 something different to?
00:38:04 --> 00:38:06 I think that's going to be
00:38:06 --> 00:38:07 some of the main things
00:38:07 --> 00:38:08 that we have to work on
00:38:08 --> 00:38:09 over these next couple of years.
00:38:11 --> 00:38:14 Maybe my entire career, who knows?
00:38:15 --> 00:38:16 But that's definitely
00:38:16 --> 00:38:17 something that we need to look at,
00:38:17 --> 00:38:18 which we at the moment
00:38:18 --> 00:38:19 don't really have any idea of.
00:38:20 --> 00:38:22 And not just related to this,
00:38:22 --> 00:38:23 you could look at exercise,
00:38:23 --> 00:38:24 which is much more research
00:38:24 --> 00:38:25 than manual therapy.
00:38:26 --> 00:38:27 They also struggle to come
00:38:27 --> 00:38:30 up with definitions of
00:38:30 --> 00:38:33 trying to predict responders, basically.
00:38:33 --> 00:38:34 Very difficult.
00:38:36 --> 00:38:37 Great.
00:38:37 --> 00:38:37 Well, Casper, again,
00:38:38 --> 00:38:38 thank you so much for
00:38:38 --> 00:38:40 joining us on the Hands On,
00:38:40 --> 00:38:41 Hands Off podcast.
00:38:42 --> 00:38:44 It's been a joy listening to you,
00:38:44 --> 00:38:45 learning from you,
00:38:45 --> 00:38:46 and we will definitely be
00:38:46 --> 00:38:48 following your future work.
00:38:48 --> 00:38:50 So thanks so much.
00:38:50 --> 00:38:51 I appreciate it.
00:38:51 --> 00:38:52 Thank you for having me.
00:38:52 --> 00:38:53 Absolutely.