Let's Talk About OMM Research! Episode 3: Journal Club
Good morning, everyone! We're glad to have you with us this morning for our third episode of the Let's Talk about OMM Research! series. Today's episode is is a journal club. It's our first journal club uh uh episode, uh session, however we want to word it. And uh so um I hope you all had the opportunity to to read the article. And uh so uh our presenter will be Dr Brian Degenhardt. And after he presents... we'll ... the article, uh we're we're going to have hopefully a lively discussion about about the article and what it said. And and uh uh so I am going to share my screen now. So um just some quick uh business. So as I said, this is our research journal club uh program today. We will have a discussion forum available on the website um as soon as I can get that posted when we're done. uh so um For for those of you who are uh um requesting CME credits uh we have these learning objectives for the entire Let's Talk about OMM Research! series. uh So if you want to get your continuing education credits you have to complete three steps. uh The first is that you must in the Zoom chat uh put your first and last name so that we can verify that you're here. uh You will receive a physician attestation form and you will receive a evaluation survey. And despite the fact that this says the instructions were sent to the email you provided, they haven't been sent yet. So I will send that as soon as the meeting is done. Just about the program, it's accredited by the uh American Osteopathic Association... ATSU is accredited by the American Osteopathic Association. Disclosure policies... We will disclose any conflicts of interest. And each presenter will do so as well. And the steering committee has no conflicts of interest. If you have any questions uh about the continuing education, you're welcome to to contact me about this particular program. uh And if you have any questions about the continuing education in general, uh you can contact Jan Baum at A.
T. Still University. So without further ado, I'm going to turn the time over to Brian Degenhardt who's going to talk about "Short-term Effect"... the article "Short-term Effect of Osteopathic Manual Techniques on Respiratory Function in Healthy Individuals". Brian, you're muted. Tt wouldn't be a Zoom session if someone wasn't muted on the panel. Okay, how about now? Much better! Perfect okay very good one more ... turn that off okay. So once again, good morning! And I want to welcome everybody to our first journal club. One of the important parts of this journal club, because we're not sure how many people have had a chance to participate in a journal club before, is to help everybody understand the process of doing a journal club because we're hoping that our future journal clubs are going to be run by by everybody who's on the program this morning and those that will be joining us in the future. uh We'll have the opportunity for people to sign up uh for uh future uh uh to present for future journal clubs. uh That's part of how we want certainly our our network to continue to develop its skill set. We'll go on to the next slide. Okay All right so I I don't have anything um to disclose uh in regards to um conflicts of interest with with this presentation this morning. Okay so um we're gonna go back a slide to uh um there we go okay. So um the purpose of a journal club, there are three. First is to teach and to develop critical appraisal skills and that's for all of us. And it's something that is not just occurs at any particular time during one's career. This is something that's just an ongoing process and a journal club is really helpful in developing and improving our critical appraisal skills. It is, also the journal club is to increase our exposure to a rapidly evolving medical literature. The amount of of literature that is uh being um disseminated now is is beyond comprehension. And for us to to stay on top of all of that, it's just not realistic.
And certainly we're not expecting that this journal club is going to make a significant impact on that because in the end we are only going to be having about four of these journal clubs a year. But this does uh help us to to highlight some of the most important articles that are coming up coming out that are most relevant for the work that we are doing. And then once again uh help us to get a greater understanding of of how that research was done, to be able to critically appraise it. And then from that information uh develop more informed clinical practice. Since that's really our primary function uh as in our our careers and our involvement in the practice-based research work research network that we have is our clinical practice. Okay so journal clubs are designed to help facilitate better knowledge and literature awareness through group discussion with peers. And so our discussion is going to be really important. So uh feel free to uh unmute or or to post something in the chat if you have a question as the discussion or as a presentation uh occurs. All right go to the next slide. So as the presenter, my goal, and for those that will become presenters in the future, our goal will be to communicate the essential information about the study in a concise, mostly standardized format that is easily digested by the listener. So that is what I hope will be able to be accomplished this morning. And the citation on the bottom of this slide is a really good summary of how a journal club should be performed. Okay we'll move to the next slide. So the format for the journal club... So first is to describe what attracted you to the paper. uh Every person who's the presenter has the um the luxury of of determining which paper they are going to present. You want to then explain how you came across the article. So what was your your your search method to find it because that will also help us develop our skills as a group to be able to find relevant literature.
Then it is looking at what type of question was asked, the type of study that was done, and where it was done. And then to state the research question and why you feel that it was important. We'll then look at a brief background and then details on the patients, the intervention, the comparison, and the outcomes. And that's the mnemonic of PICO is a very commonly one used in the development of grants, making sure that a grant is is uh well constructed. It's also very important in in manuscripts. And then in the present presentation of the manuscripts in a journal club. After presenting the PICO, then we look at summarizing the primary results. It doesn't necessarily require all of the results to be presented; primarily those that are are relevant in answering the research question and that seem most relevant to you as as the presenter. Then um you will then evaluate the article for its basic validity. uh And then make have discussion on whether or not the results uh can be applied uh to our patients within our clinical practice. So that's the overall um process that a journal club is designed to do. And so I'm going to go ahead and begin to present this week's journal. Is this a time to address any questions? Are there any questions about the overall purpose and the presentation of a journal club before we head into this? Okay very good thank you Geof. All right so um I um ended up choosing this article from uh PLOS, the "Short-term Effects of Osteopathic Manual Techniques on Respiratory uh Function in Healthy Individuals". These researchers come out of Poland. They are DO/PT's there. And going on to the next slide... So why did I choose this study? First of all it was uh just recently published. uh It was it also was hopefully was easily accessible. I think that's one thing that's really important for for future presenters to make sure that when you choose a study that it's something that everybody can get access to online.
So to have open access article is important. It's a uh this study was a very common format for uh osteopathic research, uh applying a technique or a series of techniques to a a particular population to see if that technique had any particular results. And I can say that this is also in an area of my personal interest. I've certainly published with collaborators in the area of pulmonary function tests and this is an area of work that we're going to be uh expanding at A.T. Still Research Institute as well. So that's why I ended up choosing choosing this study. Okay so why is this study significant? Well certainly everybody knows that breathing is the the most vital biological function of the body. When we stop breathing for a very short time there are significant consequences. So so to be able to breathe and to optimize breathing is important. uh It is the sixth uh holds the sixth place among the most common causes of death in the world. These are the various diseases that influence our ability to breathe. And it is expected by 2030 that that will be the the third uh highest cause common cause of death. uh There are many uh types of symptoms that are also associated with pulmonary diseases. And those not only include shortness of breath and coughing but also exhaustion pain uh depression and anxiety. And and so these are things that are commonly presented by the patients by the clients that we see in our office. And so once again it's it's it's really a relevant area for us to look at. Now um we can look at just uh outside of what they reviewed in in that effective a therapy and a respiratory system clearly has global significance. As we're dealing with the the current pandemic and as a respiratory generally a respiratory system disease, effective therapy is certainly obviously critical.
And effective therapy on the respiratory system has really been key to osteopathic history. uh Early on in in the profession in 1918 the whole flu pandemic at that time in the use of OMT to treat those patients really for a century became a focal point for demonstrating how the use of the hands can influence the physiology of an organ system. And so once again I think all of these reasons are are why this particular study is important for us to look at today. So what was their research question? The research question was to assess the influence of osteopathic techniques on breathing. And so in some respects it it wasn't a question it was you know more of an observatory uh type of of a purpose for their study. um When when you're using doing research it's often really important to evaluate to have hypotheses as part of your study. So that was one thing I did not see in this particular article. If you want to go ahead and forward... there you go. um And and they certainly very easily could have made a statement that if the use of osteopathic techniques would improve um spirometric uh parameters and be specific regarding what those parameters were. They didn't also have a very thorough review of the literature. They missed several osteopathic studies that used pulmonary function tests, spirometric measurements, as outcome indicators for for OMT. And so we certainly uh when we are disseminating our work we we want to make sure we are certainly um acknowledging the work that has been done before and how that is how you are building upon that in this current study. And then lastly there was no consideration of the osteopathic manipulative therapy model with pulmonary physiology. So in addition to the hypothesis, which was missing which was kind of um um implied that the use of OMT was going to improve these various outcome measures, that should then be followed by some type of physiologic rationale for that that you're really testing.
And so those were some limitations in this study's uh outline of their research question. Okay so next we're going to look at at the PICO, looking at the population, the interventions, uh outcomes, and so forth. And so they had 30 healthy adult volunteers uh equal number male and females uh from the age of 48, sorry 18 to um i believe it was 48. Sorry that that's missing on this slide. 15 individuals were randomly assigned to an experimental group and 15 to the placebo group. So the the experimental group had experienced three types of techniques. One were thoracic thrust techniques which were manipulations focused to the vertebral joints and ribs. The next technique was a sternal pump technique. And then lastly was a technique involving the stretching of the diaphragm. So that was the experimental control group, experimental group. The control group, they had their patients uh their their volunteers lying supine um and they performed soft tissue uh to the masseter muscle, to the the cheeks of the face. And they gave um a rationale to the volunteers in that group so that there was uh some you know potential uh placebo impact that could help to maybe augment the outcomes. So in the end they chose a population that were healthy, that were asymptomatic, and... But there was really no indication regarding somatic dysfunction and I think in general there could be an assumption that uh based off of the healthy population that we would have considered that the level of somatic dysfunction uh with whatever was present would would be subclinical and not very important. Okay so we'll go on to the next slide and look at then spirometry. So what we're going to do is, I'm not sure how many people have seen spirometry. So we're going to see we have a very short video just so you can all make sure that you understand what that's all about. Joan today we're going to assess how your lungs are working.
To do that test we'll be using this equipment called a spirometer. What we're going to measure is how much air you can blow out and how fast you can blow it out. So I'll be encouraging you to do some very big breaths in and out today. To do the test sometimes it can make you feel a bit dizzy or light-headed so we'll be doing it sitting down in the chair with your back nice and straight and your feet flat on the ground. We'll also be using a nose peg on your nose and that will just ensure that all the air is coming out through your mouth to be measured. I'll get you to hold this mouthpiece there. You'll have when you place it in your mouth, you put the teeth and the lips over the end a good firm seal with your lips. So I'll ask you to have a really big breath in, pop the mouthpiece in, and then blow out with all your might as hard and fast as you possibly can for as long as you can. Then I'll ask you still with the mouthpiece in to have a big breath in. I have criteria that I have to meet to ensure that we're going to get accurate results. So we'll need to do at least three blows. And as long as I've got two blows that are repeatable or consistent with each other, we'll be able to accept those results. Now before I start I need to ask you if you had any of your puffers today. No, that's great. We can do go ahead and do the test. If you had had that we just need to make a note of the time that you last took it. So Joan we just need to pop this nose peg on your nose. A bit uncomfortable. You're right there? Good. And if you just hold the mouthpiece there. And when you're ready I want you to have the biggest breath in you possibly can. And mouthpiece in and go, push push push push push, keep going keep going keep going keep going, That's fantastic. All the way, all the way, biggest breath in. And relax. Well done. Good effort. That's looking good thank you. So we need to do another breath now.
.. Okay so you can see that it was it's a very simple piece of equipment. It's something that can very easily be done in a clinical setting. um So uh it has you know relevance for for a practice-based research network to uh to be aware of the spirometry. um So as we saw in the video spirometry is used to measure how much air that you can inhale, how much you can exhale, and how quickly you can exhale that hair... air. And so it generates a variety of outcome measures and one is called the force forced expiratory volume. So the FEC is is pretty much how much air can you push out uh over a certain period of time. And so that can be done at different periods. So that the force expiratory volume subscript one, which is our our second measure there, is how much air the person was able to push out within one second. And there's FEV2 and 3. So it can be done at different time frames looking at the forced expiratory volume over time. When we have the person as we saw in the video completely blow out all the air that they have in their lungs, that's the forced vital capacity or FVC. The peak expiratory flow that means that's the fastest you can blow air out in that whole cycle of of of expiration. Generally that occurs within the first 200 milliseconds so very early on as we push that air out. That's where that peak expiratory flow is measured. And we'll... that's one of the measurements that's critical in our our article today so I'll make sure that people understand that. And then lastly is the total lung capacity, how much air is in the lungs. And that's we get that information in that very big deep inhalation that the patient did at the end of the video. Okay so here is is what the data will look like um that this spirometer will produce. And so the blue line here is is the the amount of uh volume in liters of air that has been blown out over time and so that's what the line shows. And in a healthy normal patient which is what we are working with within this study we see a very sharp um increase or a large amount of volume going out of the lungs very early on, where we see the the peak expiratory flow being measured.
We see the uh forced expiratory volume at one second. And then we can see that it begins to it peaks out around two to three seconds and it remains kind of stable out to a six second time frame. When doing spirometry we really want to paste a person to blow out at least six seconds to have a good uh valid test. In this other graph we're looking at a person with obstructive lung disease. So this could have been a smoker over the... And this is how their spirometry measurements have changed. We can say that the airflow is significantly slowed down, that by the that there's not a very rapid explosion of air coming out uh that would be part of the their peak expiratory flow. We see that within one second of time their forced expiratory volume is significantly reduced from four liters down to un less than two liters. And so this is how we're seeing that the air is not coming out as easily or as smoothly as possible so there's obstruction within that pulmonary system. So this is what spirometry allows us to to see. So in their um study design actually I I misspoke earlier. I said that they had equal number of males and females. No, in this particular study they only had healthy women as part of their study design. So you can see all of the things that they ruled out to make sure that these volunteers were um were healthy, that they had no no pulmonary problems whatsoever. Okay. Okay. So what was their protocol. So as I mentioned earlier there were three uh parts to their protocol. One was spinal uh thoracic thrust of of which um I felt uh was really poorly described. And in the modern world even though uh a lot of people might know what that is just because of their training, in the world of science there are a lot of fields that are going to be interested in in the outcomes that we have and so we have to be descriptive of what is being done.
In their methods section there was no description of where it was being done, just that it was to the in the thoracic area. In their discussion they did have one sentence that indicated that it was focused from T1 to T5 only. But it didn't say whether they did every single vertebral level, whether it was just based off of what they localized as being dysfunctional segments, and that would also then be true for uh rib angles because they they did say that this was kind of trying to address both intervertebral dysfunctions as well as effects of ribs uh into the articulations with the uh thoracic vertebra. With the sternal thrust I found this interesting because this is certainly not a a technique that is commonly um taught within the American osteopathic system. Here they had a patient that was supine. The patient... the clinician step stood above them with their hands overlapped directly on the sternum. So more like doing CPR versus when we do thoracic or pumps in the United States it's really more out on the ribs themselves not on the sternum. And so they applied force on the sternum. It was unclear what level of force that they were applying. uh And they applied that force during exhalation, so basically trying to augment um the the air going out of the lungs through the pressure on the sternum. They performed it five times and at the last two times they did it they uh did recoil. So I'm not sure they didn't really describe what recoil meant. I'm assuming that means that as a person breathed in they they removed their hands that allowed for a certain amount of recoil from inhalation. But I uh that is only assumption on my part. The last technique technique they did was a diaphragmatic stretch. And here they placed their hands um underneath the lower part of the costal borders of the ribcage.
And with inhalation they augmented the mo... movement of the ribs and then with exhalation they they inhibit or stopped rib motion during exhalation. So there was definitely building up a tension in that lower ribcage and diaphragm in hoping to produce some type of therapeutic effect. And that was repeated several times at different points along that thoracic uh or rib border. So that was the the uh intervention um their OMT protocol. For the control group they had the patients supine. They identified the masseter muscle. And while the therapist the clinician was at the head of the table they performed rubbing techniques along that the masseter muscle, both longitudinal and and friction directions along the masseter, until tenderness and local spasm was decreased. And I thought that was kind of interesting because um first of all as I do it on myself there's no tenderness or spasm present. And if these are our healthy normals as they screened in their in their uh um recruitment then having tenderness and local spasm would not have from my perspective had been expected. So how could they have determined that as a time for stopping that particular aspect of their protocol. Okay. So on to the outcome measure. As a they first did a basic spirometry as we had just seen to evaluate um the the various spirometric measures. They had uh three tests done uh they rep... so that they were uh repeated repeatable uh uh to make sure that they were valid uh assessment. And then this participant's best single um trial those measurements were the ones that were used for analysis. So here are the results. In Table 1 this is looking at the baseline measurements. And in here we can see that there were no differences in the forced uh vital capacity, the forced expiratory volume at one second, or the peak expiratory flow. These were the three measures that they uh reported in their study.
And we can see uh looking at experimental and placebo groups that the the p values were 0.18 or higher. The positive expiratory flow is the one that was certainly lowest. The other two were around a point p value of 0.5 or better. Now if we then look at Table 2 which looks at the comparing before and after within group. So looking at the OMT group before versus after and the placebo group before and after. We see that in first of all we'll talk about the placebo group first. We can see that there were no statistical significance between them. There was certainly a bit of a change with the uh forced expiratory volume uh one but once again not close to a .05 level whatsoever. So everything would would indicate that there were no changes as a result of the placebo intervention. When we look at the experimental group we can see that the forced vital capacity was at a .0... .07 which does not meet the criteria for statistical significance. um um We see with the forced expiratory volume at one second that that was a 0.14. And then for the peak expiratory flow a highly significant change between baseline and the post manipulative therapy. When we move then to the third table where they're comparing the um placebo versus the experimental group um here we can see that there was no change uh between those groups uh after the intervention. And so that that is kind of um interesting and may may seem kind of confusing how you can have you know no differences at baseline, you see differences occurring before and after treatment within a group, but then afterwards you don't see any difference between the groups as well. And so Jane Johnson produced our next slide to help us understand what's going on here con... statistically. So here when we we um... The this is called a box plot and uh with the box plot the majority of of the data falls within the box and the line goes out to you know the the the least and the greatest, the maximum value for that particular area.
And and so here we're looking purely at the um a peak expiratory flow measurement where they saw the statistical significance. And we can see within the experimental group that before treatment and after treatment there was the statistical significance. But we can see that there's significant overlap between the data within that group from before versus after the OMT. When we look at before versus after in the placebo group we see that there's really you know no uh change in the box plot whatsoever. And when we look at the uh after boxes for the experimental versus the placebo group once again they they look very very similar some slight changes regarding the median and the minimum value. But once again we're seeing really very little change going on between the placebo group and the experimental group although they did report a statistically significant change in the peak expiratory flow measurement. So their one of their conclusions was um or their purpose was to obtain a significant positive effect, a combination of manipulative techniques such as manipulations of the intervertebral joints and costo vertebral joints combined with soft tissue techniques that included a diaphragm stretch, releasing myofascial of the cervical and thoracic regions, and a sternal thump pump or visceral manipulation should be used. And so this was their conclusion based off of the data that we just saw. And I think that this is really significantly exceeding the both the research question, the design, as well as the results that are associated uh with this article. And we will engage this in discussion in a moment. And so what what are the limitations that I've identified and and certainly some of these they identified as well. So first of all a major limitation is that there was no proposed mechanism up front as to why they would think that the peak expiratory flow would be expected.
They had no proposed mechanisms for how changing uh ribcage biomechanics would impact change, whether it's just due to these the somatic system or through a neurogenic regulatory changes uh associated with uh autonomic uh factors that we typically attribute to these types of techniques. Another limitation, and I think we will need to discuss this, is that they only used um they only they chose to only use normal healthy adults and they did not report any examination of somatic dysfunction to determine or to demonstrate whether the techniques that were performed were relevant for those particular patients. And so once again I think when we talk about osteopathic manipulative treatment versus osteopathic manipulative therapy, one being more potentially a recipe driven protocol versus one that is specific for patient findings, I think this may be a factor that that brings out limitations for this particular study. They recommended that in the future that they wanted a larger population but one of the advantages of this particular study is that they there is now data that could allow us to do some power analysis for these particular outcome measures. So so it is the outcome is beneficial for future research. uh They wanted better definition of overall the cohort and and sub cohorts. um I think um as I mentioned better establishment of hypotheses uh that uh hopefully maybe with the study they they might be able to develop a better definition of the techniques. And um I think one thing that often we neglect within osteopathic research is to bring in somebody that is a content expert within the the measure, within the instrumentation that are being used, or within the field of the physiologic parameter that's being done. And so here having somebody that was a pulmonologist somebody that has expertise with spirometry would have been very helpful to guide the methodology and interpretation for this particular study.
So from their conclusion that they said that there was an uh indicated that peak expiratory flow may be considered a reliable marker for measuring the effects of osteopathic manipulative treatments targeting the respiratory system. From the review that we did, I'm hoping that you would would be critical of that particular conclusion. First of all this is not a study of of reliability uh the um and that the results were really really quite slim to determine um uh changes uh before and after treatment. So I think that conclusion is not very supported by by the outcomes. From my perspective this was not a study of reliability but to demonstrate that a test may be sensitive enough to identify biomechanical changes of the ribcage and or the neurologic or neurogenic regulatory changes of lung physiology that could be secondary to OMT. So that is my presentation of of our first uh article for the for DO-Touch.NET's journal club. I'd like to now open up a time for discussion. And these are some evidence-based references that you can look at as well for uh further review. You do have uh two questions right now in the Q&A pod here we've got. To which of the five columns of outcomes do the p values refer? Okay um so I think we um go back to one of the tables. I'm assuming that's in regards to the table. um I can just answer that if you'd like. Okay please do. They refer to the median, so comparing the medians, uh whether the uh whether the medians were different. um The the within group comparisons look at the median change from pre to post. The between group comparisons just compares the two groups on the median. Okay and we've got another question here. They say that included they included 30 male and females whereas later the exclusion criteria they explicitly excluded males. Did they not find any male participants or did they only find unhealthy men. No this is a sign of an incompetent presenter.
Uh I I I was incorrect in that earlier slide that talked about uh men. It was... this study was designed for only females and so that was my um... I am I am just um... In in study designs in general if you're only going to focus on a particular uh component of the population, you need to have a good rationale. It's important to have a rationale for why you're excluding people uh and so I just made an assumption that they they they used both uh both sexes and it was uh so that I I never changed that that earlier slide so my apologies. But it does say in the abstract that they had 30 healthy males and females. Well thank you! I knew there had to have been a better reason. I'm going to accept the outright you know... bit for that but it was not addressed in the article about men. They just talked about the exclusion criteria and men being one of the exclusion criteria... male. Okay and we have uh Markus here with his hand up. Let me pop... there you go. Hi, hello! Yeah that's that's just what I wanted to say that you did not do anything wrong. It says it right here so thanks Jane for for cleaning it up. But while I'm unmuted um... Do you... what what would you think like isn't it usually... isn't that a peer-reviewed uh journal where they published? Shouldn't like different people pick up the things you just mentioned and keep them from publishing um not because they are generally bad people or this is generally bad research but maybe this is questionable research or does not contribute any value to our um profession. So so so i don't know maybe this is a little bit of off topic but maybe you can shed some light on on how this process usually works. Because it really like I read this for I think five or ten minutes and immediately took up my phone and and wrote to Jane. Because I thought like did am I doing something wrong because I think this article, and I don't I mean no offense to the authors, but it doesn't seem really good.
Yeah thank you and um for bringing that up. This wasn't my initial choice. um I I was going to the one that I had originally thought of was one that um I know would have been very much a premier article. um But a lot of times our our work gets into you know uh lower level peer-reviewed journals. And right now there are so many places where peer-reviewed journals exist but they are really you know part of a a you know a way of of uh making money. And so the the review process is not as stringent as what is really um uh driven by the scientific community versus just a publication you know this uh dispersal community. um So so as we choose our articles in the future this is an important point that we need to look at. One, we have to be able to have access to it and and there are many highly regarded rigorous periodicals that have that we can choose from. But once again if if you see something from the very beginning that says wow the reviewers didn't obviously review it quite well, that's just an indication that that's a level of of a peer-reviewed process that really we should probably avoid in in our our work here. Thank you. Okay so we have um another question here. uh More of an observation. This was going to be underpowered from the get-go osteopathic intervention in an asymptomatic population would be anticipated to show limited changes. Yeah, so this is an issue I'm going to let Jane talk cause she has she has seen many studies through her 20-plus year career um as a as a a statistician and methodologist within this field. So uh we have already talked about it but I'm gonna let Jane address that. So so I told Brian in in my uh professional medical opinion as a statistician, it is curious to me there seems to be a lot of of research done on healthy populations in the osteopathic profession. And and my uh simple analogy is if you give an aspirin to someone who doesn't have a fever, you don't expect their body temperature to reduce.
And so if you're doing osteopathic manipulation on people who don't have somatic dysfunction, then do you really expect there to be a change. So that was just you know... Yeah so in this case you know, do we expect that OMT is going to allow the balloon of our lungs to expand you know a bit more and is going to change the forces of expelling that air when once again their their their body is is healthy and normal. uh And so once again that's a recurrent design issue that I think we need to screen out with our as we choose future articles and as we prepare our future research studies that once again that we are choosing the right population for the question that we're asking. And you got an absolutely agree with you Jane in the Q&A pod there. um I another one here is... I find it interesting that smoking wasn't included as an exclusion. However having been in Poland they might not have had any participants given how many folks smoke. Another one here... fully concur that the clinical significance of the hypothesis was in question and I couldn't answer the question as to why the paper was important enough to publish. ... Followed up by... OMT doesn't change us into supermen or women. I think that was following up on your last comment there. And I have looks like Dr Brooks with a hand up here so here we go. I have a couple comments. First of all Brian thank you for an excellent review and a great start to this process. I too was distressed by this paper but I think perhaps the problem isn't so much that it was a study that shouldn't have been published but it should have been so critically reviewed that the conclusions and the speculations and the discussion should have been eliminated. In other words there's probably very little data that isn't worth reporting. The problem I find is what people do with the data. And so there might have been some data that was worthwhile here but it should have been very very very much more narrowly interpreted I think.
And so that was one comment. The other comment is I've been interested in chest compliance for some time although not I'm not up to date on the literature. And in the pulmonary medicine world there's basically the assumption that the mechanics of chest wall are a fixed variable... in other words they're not a variable. And so I I appreciate your slide although it was non-committal one of your concluding slides... well it could be mechanical or it could be pulmonary. And the fact is that when we breathe it is a both and situation. In other words you have to have a healthy lung and a healthy mechanical system. I think it's an a great opportunity for our profession to start to raise consciousness about this and start to tease this out. And even in a setting like I'm guessing these physical therapists were uh working in which probably didn't have you know the kinds of resources that we would ex we would hope they'd have for um more sophisticated outcome measures. But the simple act of of measuring chest expansion with a cloth measuring tape is a way to start to discriminate the mechanical properties of breathing from the total pulmonary function that's then measured with spirometry. So I know you are working on much more sophisticated tools at Kirksville but I think it's something that others could consider. And is really uh foundational in addition to all the other critiques you appropriately offered for us to be able to say there's actually a biomechanical change or not, that might then be mechanistically linked to what actually happens when you breathe. So those are my two comments. Thank you. Okay we have um one other hand up. Sergio, I think we got you unmuted there. Sergio, you might unmute yourself. Sorry, yes, it was the case. Thank you, sorry guys. um I have a few comments.
First um congratulations Dr Brian Degenhardt for your great presentation about this uh article. And as I'm I am living in Europe I know the European uh mentality from the osteopaths who are studying osteopathy in Europe. Most of them are physical therapists at a basis. Some are doctors but most of them are physical therapists. And they are they are using only techniques without the background the scientific background. And they you they think that if we uh we use a technique we can implement the system. Because maybe they read some books of Dr Still. But Dr Still was using that the osteopathic techniques of on a sick person who has lung problems and not a person who are healthy. If you want to to start a discussion about what are the the osteopathic technique um doing on the physiology then we need to do it maybe first on healthy people and then to see if we do it on on healthy people what can we expect about it. But it's true if we if we do it on healthy people we have to always to have a comparison and a control group who says if I don't move this rib and I ask only the patient to breathe to do a big inspiration it won't it will fix it fix it on its own. Who knows that if it is the case or not. That we don't we we when we practice that uh osteopathic medicine on our patient or manipulative treatment we know what we want to to reach. But as Jane said we don't cannot practice osteoporotic medicine on healthy people without uh somatic dysfunction. It's like taking an aspirin for someone who has uh no headache or fever. Okay, thank you... Sorry, um last point. No one no surgeon would do an operation to see what is it if I do a surgery on that if uh on that I don't take off an appendix for someone who has no appendicitis. No me sorry you have understood me you know um I don't take um surgery for someone who has no um a bowel problem and abdomen very pain in the abdomen uh like in appendix. I don't think I'll take the appendix away because I want to test surgery about this appendix.
.. about the colon. So um there are some... okay we have to ask ourself what we want to reach. uh we need Dr Still did a lot of wonderful techniques. But they don't they don't have been um but they have then now they have been improved during the years. But we don't have search because only based on the somatic dysfunction but never on what can cause on the physiology these manipulative techniques. Thank you. I know it was a lot, sorry. Thank you so much. um I I I'm afraid our time is up uh for for live discussion but I I really hope that we are able to to continue this this discussion about this article on our uh website forum. uh I I hope to have that open and ready for discussion this afternoon. So so um and and I'll just thank Brian for for his presentation. And uh uh let remind you of our next uh Let's Talk about Research... OMM Research! episode which is scheduled for January 15th. And that will be a a director update about the activities of uh DO-Touch.NET and what we're doing. uh There will not be continuing education credits for that session. But back when we're back in February with our webinar, we will have that available then. So thank you so much!.
T. Still University. So without further ado, I'm going to turn the time over to Brian Degenhardt who's going to talk about "Short-term Effect"... the article "Short-term Effect of Osteopathic Manual Techniques on Respiratory Function in Healthy Individuals". Brian, you're muted. Tt wouldn't be a Zoom session if someone wasn't muted on the panel. Okay, how about now? Much better! Perfect okay very good one more ... turn that off okay. So once again, good morning! And I want to welcome everybody to our first journal club. One of the important parts of this journal club, because we're not sure how many people have had a chance to participate in a journal club before, is to help everybody understand the process of doing a journal club because we're hoping that our future journal clubs are going to be run by by everybody who's on the program this morning and those that will be joining us in the future. uh We'll have the opportunity for people to sign up uh for uh future uh uh to present for future journal clubs. uh That's part of how we want certainly our our network to continue to develop its skill set. We'll go on to the next slide. Okay All right so I I don't have anything um to disclose uh in regards to um conflicts of interest with with this presentation this morning. Okay so um we're gonna go back a slide to uh um there we go okay. So um the purpose of a journal club, there are three. First is to teach and to develop critical appraisal skills and that's for all of us. And it's something that is not just occurs at any particular time during one's career. This is something that's just an ongoing process and a journal club is really helpful in developing and improving our critical appraisal skills. It is, also the journal club is to increase our exposure to a rapidly evolving medical literature. The amount of of literature that is uh being um disseminated now is is beyond comprehension. And for us to to stay on top of all of that, it's just not realistic.
And certainly we're not expecting that this journal club is going to make a significant impact on that because in the end we are only going to be having about four of these journal clubs a year. But this does uh help us to to highlight some of the most important articles that are coming up coming out that are most relevant for the work that we are doing. And then once again uh help us to get a greater understanding of of how that research was done, to be able to critically appraise it. And then from that information uh develop more informed clinical practice. Since that's really our primary function uh as in our our careers and our involvement in the practice-based research work research network that we have is our clinical practice. Okay so journal clubs are designed to help facilitate better knowledge and literature awareness through group discussion with peers. And so our discussion is going to be really important. So uh feel free to uh unmute or or to post something in the chat if you have a question as the discussion or as a presentation uh occurs. All right go to the next slide. So as the presenter, my goal, and for those that will become presenters in the future, our goal will be to communicate the essential information about the study in a concise, mostly standardized format that is easily digested by the listener. So that is what I hope will be able to be accomplished this morning. And the citation on the bottom of this slide is a really good summary of how a journal club should be performed. Okay we'll move to the next slide. So the format for the journal club... So first is to describe what attracted you to the paper. uh Every person who's the presenter has the um the luxury of of determining which paper they are going to present. You want to then explain how you came across the article. So what was your your your search method to find it because that will also help us develop our skills as a group to be able to find relevant literature.
Then it is looking at what type of question was asked, the type of study that was done, and where it was done. And then to state the research question and why you feel that it was important. We'll then look at a brief background and then details on the patients, the intervention, the comparison, and the outcomes. And that's the mnemonic of PICO is a very commonly one used in the development of grants, making sure that a grant is is uh well constructed. It's also very important in in manuscripts. And then in the present presentation of the manuscripts in a journal club. After presenting the PICO, then we look at summarizing the primary results. It doesn't necessarily require all of the results to be presented; primarily those that are are relevant in answering the research question and that seem most relevant to you as as the presenter. Then um you will then evaluate the article for its basic validity. uh And then make have discussion on whether or not the results uh can be applied uh to our patients within our clinical practice. So that's the overall um process that a journal club is designed to do. And so I'm going to go ahead and begin to present this week's journal. Is this a time to address any questions? Are there any questions about the overall purpose and the presentation of a journal club before we head into this? Okay very good thank you Geof. All right so um I um ended up choosing this article from uh PLOS, the "Short-term Effects of Osteopathic Manual Techniques on Respiratory uh Function in Healthy Individuals". These researchers come out of Poland. They are DO/PT's there. And going on to the next slide... So why did I choose this study? First of all it was uh just recently published. uh It was it also was hopefully was easily accessible. I think that's one thing that's really important for for future presenters to make sure that when you choose a study that it's something that everybody can get access to online.
So to have open access article is important. It's a uh this study was a very common format for uh osteopathic research, uh applying a technique or a series of techniques to a a particular population to see if that technique had any particular results. And I can say that this is also in an area of my personal interest. I've certainly published with collaborators in the area of pulmonary function tests and this is an area of work that we're going to be uh expanding at A.T. Still Research Institute as well. So that's why I ended up choosing choosing this study. Okay so why is this study significant? Well certainly everybody knows that breathing is the the most vital biological function of the body. When we stop breathing for a very short time there are significant consequences. So so to be able to breathe and to optimize breathing is important. uh It is the sixth uh holds the sixth place among the most common causes of death in the world. These are the various diseases that influence our ability to breathe. And it is expected by 2030 that that will be the the third uh highest cause common cause of death. uh There are many uh types of symptoms that are also associated with pulmonary diseases. And those not only include shortness of breath and coughing but also exhaustion pain uh depression and anxiety. And and so these are things that are commonly presented by the patients by the clients that we see in our office. And so once again it's it's it's really a relevant area for us to look at. Now um we can look at just uh outside of what they reviewed in in that effective a therapy and a respiratory system clearly has global significance. As we're dealing with the the current pandemic and as a respiratory generally a respiratory system disease, effective therapy is certainly obviously critical.
And effective therapy on the respiratory system has really been key to osteopathic history. uh Early on in in the profession in 1918 the whole flu pandemic at that time in the use of OMT to treat those patients really for a century became a focal point for demonstrating how the use of the hands can influence the physiology of an organ system. And so once again I think all of these reasons are are why this particular study is important for us to look at today. So what was their research question? The research question was to assess the influence of osteopathic techniques on breathing. And so in some respects it it wasn't a question it was you know more of an observatory uh type of of a purpose for their study. um When when you're using doing research it's often really important to evaluate to have hypotheses as part of your study. So that was one thing I did not see in this particular article. If you want to go ahead and forward... there you go. um And and they certainly very easily could have made a statement that if the use of osteopathic techniques would improve um spirometric uh parameters and be specific regarding what those parameters were. They didn't also have a very thorough review of the literature. They missed several osteopathic studies that used pulmonary function tests, spirometric measurements, as outcome indicators for for OMT. And so we certainly uh when we are disseminating our work we we want to make sure we are certainly um acknowledging the work that has been done before and how that is how you are building upon that in this current study. And then lastly there was no consideration of the osteopathic manipulative therapy model with pulmonary physiology. So in addition to the hypothesis, which was missing which was kind of um um implied that the use of OMT was going to improve these various outcome measures, that should then be followed by some type of physiologic rationale for that that you're really testing.
And so those were some limitations in this study's uh outline of their research question. Okay so next we're going to look at at the PICO, looking at the population, the interventions, uh outcomes, and so forth. And so they had 30 healthy adult volunteers uh equal number male and females uh from the age of 48, sorry 18 to um i believe it was 48. Sorry that that's missing on this slide. 15 individuals were randomly assigned to an experimental group and 15 to the placebo group. So the the experimental group had experienced three types of techniques. One were thoracic thrust techniques which were manipulations focused to the vertebral joints and ribs. The next technique was a sternal pump technique. And then lastly was a technique involving the stretching of the diaphragm. So that was the experimental control group, experimental group. The control group, they had their patients uh their their volunteers lying supine um and they performed soft tissue uh to the masseter muscle, to the the cheeks of the face. And they gave um a rationale to the volunteers in that group so that there was uh some you know potential uh placebo impact that could help to maybe augment the outcomes. So in the end they chose a population that were healthy, that were asymptomatic, and... But there was really no indication regarding somatic dysfunction and I think in general there could be an assumption that uh based off of the healthy population that we would have considered that the level of somatic dysfunction uh with whatever was present would would be subclinical and not very important. Okay so we'll go on to the next slide and look at then spirometry. So what we're going to do is, I'm not sure how many people have seen spirometry. So we're going to see we have a very short video just so you can all make sure that you understand what that's all about. Joan today we're going to assess how your lungs are working.
To do that test we'll be using this equipment called a spirometer. What we're going to measure is how much air you can blow out and how fast you can blow it out. So I'll be encouraging you to do some very big breaths in and out today. To do the test sometimes it can make you feel a bit dizzy or light-headed so we'll be doing it sitting down in the chair with your back nice and straight and your feet flat on the ground. We'll also be using a nose peg on your nose and that will just ensure that all the air is coming out through your mouth to be measured. I'll get you to hold this mouthpiece there. You'll have when you place it in your mouth, you put the teeth and the lips over the end a good firm seal with your lips. So I'll ask you to have a really big breath in, pop the mouthpiece in, and then blow out with all your might as hard and fast as you possibly can for as long as you can. Then I'll ask you still with the mouthpiece in to have a big breath in. I have criteria that I have to meet to ensure that we're going to get accurate results. So we'll need to do at least three blows. And as long as I've got two blows that are repeatable or consistent with each other, we'll be able to accept those results. Now before I start I need to ask you if you had any of your puffers today. No, that's great. We can do go ahead and do the test. If you had had that we just need to make a note of the time that you last took it. So Joan we just need to pop this nose peg on your nose. A bit uncomfortable. You're right there? Good. And if you just hold the mouthpiece there. And when you're ready I want you to have the biggest breath in you possibly can. And mouthpiece in and go, push push push push push, keep going keep going keep going keep going, That's fantastic. All the way, all the way, biggest breath in. And relax. Well done. Good effort. That's looking good thank you. So we need to do another breath now.
.. Okay so you can see that it was it's a very simple piece of equipment. It's something that can very easily be done in a clinical setting. um So uh it has you know relevance for for a practice-based research network to uh to be aware of the spirometry. um So as we saw in the video spirometry is used to measure how much air that you can inhale, how much you can exhale, and how quickly you can exhale that hair... air. And so it generates a variety of outcome measures and one is called the force forced expiratory volume. So the FEC is is pretty much how much air can you push out uh over a certain period of time. And so that can be done at different periods. So that the force expiratory volume subscript one, which is our our second measure there, is how much air the person was able to push out within one second. And there's FEV2 and 3. So it can be done at different time frames looking at the forced expiratory volume over time. When we have the person as we saw in the video completely blow out all the air that they have in their lungs, that's the forced vital capacity or FVC. The peak expiratory flow that means that's the fastest you can blow air out in that whole cycle of of of expiration. Generally that occurs within the first 200 milliseconds so very early on as we push that air out. That's where that peak expiratory flow is measured. And we'll... that's one of the measurements that's critical in our our article today so I'll make sure that people understand that. And then lastly is the total lung capacity, how much air is in the lungs. And that's we get that information in that very big deep inhalation that the patient did at the end of the video. Okay so here is is what the data will look like um that this spirometer will produce. And so the blue line here is is the the amount of uh volume in liters of air that has been blown out over time and so that's what the line shows. And in a healthy normal patient which is what we are working with within this study we see a very sharp um increase or a large amount of volume going out of the lungs very early on, where we see the the peak expiratory flow being measured.
We see the uh forced expiratory volume at one second. And then we can see that it begins to it peaks out around two to three seconds and it remains kind of stable out to a six second time frame. When doing spirometry we really want to paste a person to blow out at least six seconds to have a good uh valid test. In this other graph we're looking at a person with obstructive lung disease. So this could have been a smoker over the... And this is how their spirometry measurements have changed. We can say that the airflow is significantly slowed down, that by the that there's not a very rapid explosion of air coming out uh that would be part of the their peak expiratory flow. We see that within one second of time their forced expiratory volume is significantly reduced from four liters down to un less than two liters. And so this is how we're seeing that the air is not coming out as easily or as smoothly as possible so there's obstruction within that pulmonary system. So this is what spirometry allows us to to see. So in their um study design actually I I misspoke earlier. I said that they had equal number of males and females. No, in this particular study they only had healthy women as part of their study design. So you can see all of the things that they ruled out to make sure that these volunteers were um were healthy, that they had no no pulmonary problems whatsoever. Okay. Okay. So what was their protocol. So as I mentioned earlier there were three uh parts to their protocol. One was spinal uh thoracic thrust of of which um I felt uh was really poorly described. And in the modern world even though uh a lot of people might know what that is just because of their training, in the world of science there are a lot of fields that are going to be interested in in the outcomes that we have and so we have to be descriptive of what is being done.
In their methods section there was no description of where it was being done, just that it was to the in the thoracic area. In their discussion they did have one sentence that indicated that it was focused from T1 to T5 only. But it didn't say whether they did every single vertebral level, whether it was just based off of what they localized as being dysfunctional segments, and that would also then be true for uh rib angles because they they did say that this was kind of trying to address both intervertebral dysfunctions as well as effects of ribs uh into the articulations with the uh thoracic vertebra. With the sternal thrust I found this interesting because this is certainly not a a technique that is commonly um taught within the American osteopathic system. Here they had a patient that was supine. The patient... the clinician step stood above them with their hands overlapped directly on the sternum. So more like doing CPR versus when we do thoracic or pumps in the United States it's really more out on the ribs themselves not on the sternum. And so they applied force on the sternum. It was unclear what level of force that they were applying. uh And they applied that force during exhalation, so basically trying to augment um the the air going out of the lungs through the pressure on the sternum. They performed it five times and at the last two times they did it they uh did recoil. So I'm not sure they didn't really describe what recoil meant. I'm assuming that means that as a person breathed in they they removed their hands that allowed for a certain amount of recoil from inhalation. But I uh that is only assumption on my part. The last technique technique they did was a diaphragmatic stretch. And here they placed their hands um underneath the lower part of the costal borders of the ribcage.
And with inhalation they augmented the mo... movement of the ribs and then with exhalation they they inhibit or stopped rib motion during exhalation. So there was definitely building up a tension in that lower ribcage and diaphragm in hoping to produce some type of therapeutic effect. And that was repeated several times at different points along that thoracic uh or rib border. So that was the the uh intervention um their OMT protocol. For the control group they had the patients supine. They identified the masseter muscle. And while the therapist the clinician was at the head of the table they performed rubbing techniques along that the masseter muscle, both longitudinal and and friction directions along the masseter, until tenderness and local spasm was decreased. And I thought that was kind of interesting because um first of all as I do it on myself there's no tenderness or spasm present. And if these are our healthy normals as they screened in their in their uh um recruitment then having tenderness and local spasm would not have from my perspective had been expected. So how could they have determined that as a time for stopping that particular aspect of their protocol. Okay. So on to the outcome measure. As a they first did a basic spirometry as we had just seen to evaluate um the the various spirometric measures. They had uh three tests done uh they rep... so that they were uh repeated repeatable uh uh to make sure that they were valid uh assessment. And then this participant's best single um trial those measurements were the ones that were used for analysis. So here are the results. In Table 1 this is looking at the baseline measurements. And in here we can see that there were no differences in the forced uh vital capacity, the forced expiratory volume at one second, or the peak expiratory flow. These were the three measures that they uh reported in their study.
And we can see uh looking at experimental and placebo groups that the the p values were 0.18 or higher. The positive expiratory flow is the one that was certainly lowest. The other two were around a point p value of 0.5 or better. Now if we then look at Table 2 which looks at the comparing before and after within group. So looking at the OMT group before versus after and the placebo group before and after. We see that in first of all we'll talk about the placebo group first. We can see that there were no statistical significance between them. There was certainly a bit of a change with the uh forced expiratory volume uh one but once again not close to a .05 level whatsoever. So everything would would indicate that there were no changes as a result of the placebo intervention. When we look at the experimental group we can see that the forced vital capacity was at a .0... .07 which does not meet the criteria for statistical significance. um um We see with the forced expiratory volume at one second that that was a 0.14. And then for the peak expiratory flow a highly significant change between baseline and the post manipulative therapy. When we move then to the third table where they're comparing the um placebo versus the experimental group um here we can see that there was no change uh between those groups uh after the intervention. And so that that is kind of um interesting and may may seem kind of confusing how you can have you know no differences at baseline, you see differences occurring before and after treatment within a group, but then afterwards you don't see any difference between the groups as well. And so Jane Johnson produced our next slide to help us understand what's going on here con... statistically. So here when we we um... The this is called a box plot and uh with the box plot the majority of of the data falls within the box and the line goes out to you know the the the least and the greatest, the maximum value for that particular area.
And and so here we're looking purely at the um a peak expiratory flow measurement where they saw the statistical significance. And we can see within the experimental group that before treatment and after treatment there was the statistical significance. But we can see that there's significant overlap between the data within that group from before versus after the OMT. When we look at before versus after in the placebo group we see that there's really you know no uh change in the box plot whatsoever. And when we look at the uh after boxes for the experimental versus the placebo group once again they they look very very similar some slight changes regarding the median and the minimum value. But once again we're seeing really very little change going on between the placebo group and the experimental group although they did report a statistically significant change in the peak expiratory flow measurement. So their one of their conclusions was um or their purpose was to obtain a significant positive effect, a combination of manipulative techniques such as manipulations of the intervertebral joints and costo vertebral joints combined with soft tissue techniques that included a diaphragm stretch, releasing myofascial of the cervical and thoracic regions, and a sternal thump pump or visceral manipulation should be used. And so this was their conclusion based off of the data that we just saw. And I think that this is really significantly exceeding the both the research question, the design, as well as the results that are associated uh with this article. And we will engage this in discussion in a moment. And so what what are the limitations that I've identified and and certainly some of these they identified as well. So first of all a major limitation is that there was no proposed mechanism up front as to why they would think that the peak expiratory flow would be expected.
They had no proposed mechanisms for how changing uh ribcage biomechanics would impact change, whether it's just due to these the somatic system or through a neurogenic regulatory changes uh associated with uh autonomic uh factors that we typically attribute to these types of techniques. Another limitation, and I think we will need to discuss this, is that they only used um they only they chose to only use normal healthy adults and they did not report any examination of somatic dysfunction to determine or to demonstrate whether the techniques that were performed were relevant for those particular patients. And so once again I think when we talk about osteopathic manipulative treatment versus osteopathic manipulative therapy, one being more potentially a recipe driven protocol versus one that is specific for patient findings, I think this may be a factor that that brings out limitations for this particular study. They recommended that in the future that they wanted a larger population but one of the advantages of this particular study is that they there is now data that could allow us to do some power analysis for these particular outcome measures. So so it is the outcome is beneficial for future research. uh They wanted better definition of overall the cohort and and sub cohorts. um I think um as I mentioned better establishment of hypotheses uh that uh hopefully maybe with the study they they might be able to develop a better definition of the techniques. And um I think one thing that often we neglect within osteopathic research is to bring in somebody that is a content expert within the the measure, within the instrumentation that are being used, or within the field of the physiologic parameter that's being done. And so here having somebody that was a pulmonologist somebody that has expertise with spirometry would have been very helpful to guide the methodology and interpretation for this particular study.
So from their conclusion that they said that there was an uh indicated that peak expiratory flow may be considered a reliable marker for measuring the effects of osteopathic manipulative treatments targeting the respiratory system. From the review that we did, I'm hoping that you would would be critical of that particular conclusion. First of all this is not a study of of reliability uh the um and that the results were really really quite slim to determine um uh changes uh before and after treatment. So I think that conclusion is not very supported by by the outcomes. From my perspective this was not a study of reliability but to demonstrate that a test may be sensitive enough to identify biomechanical changes of the ribcage and or the neurologic or neurogenic regulatory changes of lung physiology that could be secondary to OMT. So that is my presentation of of our first uh article for the for DO-Touch.NET's journal club. I'd like to now open up a time for discussion. And these are some evidence-based references that you can look at as well for uh further review. You do have uh two questions right now in the Q&A pod here we've got. To which of the five columns of outcomes do the p values refer? Okay um so I think we um go back to one of the tables. I'm assuming that's in regards to the table. um I can just answer that if you'd like. Okay please do. They refer to the median, so comparing the medians, uh whether the uh whether the medians were different. um The the within group comparisons look at the median change from pre to post. The between group comparisons just compares the two groups on the median. Okay and we've got another question here. They say that included they included 30 male and females whereas later the exclusion criteria they explicitly excluded males. Did they not find any male participants or did they only find unhealthy men. No this is a sign of an incompetent presenter.
Uh I I I was incorrect in that earlier slide that talked about uh men. It was... this study was designed for only females and so that was my um... I am I am just um... In in study designs in general if you're only going to focus on a particular uh component of the population, you need to have a good rationale. It's important to have a rationale for why you're excluding people uh and so I just made an assumption that they they they used both uh both sexes and it was uh so that I I never changed that that earlier slide so my apologies. But it does say in the abstract that they had 30 healthy males and females. Well thank you! I knew there had to have been a better reason. I'm going to accept the outright you know... bit for that but it was not addressed in the article about men. They just talked about the exclusion criteria and men being one of the exclusion criteria... male. Okay and we have uh Markus here with his hand up. Let me pop... there you go. Hi, hello! Yeah that's that's just what I wanted to say that you did not do anything wrong. It says it right here so thanks Jane for for cleaning it up. But while I'm unmuted um... Do you... what what would you think like isn't it usually... isn't that a peer-reviewed uh journal where they published? Shouldn't like different people pick up the things you just mentioned and keep them from publishing um not because they are generally bad people or this is generally bad research but maybe this is questionable research or does not contribute any value to our um profession. So so so i don't know maybe this is a little bit of off topic but maybe you can shed some light on on how this process usually works. Because it really like I read this for I think five or ten minutes and immediately took up my phone and and wrote to Jane. Because I thought like did am I doing something wrong because I think this article, and I don't I mean no offense to the authors, but it doesn't seem really good.
Yeah thank you and um for bringing that up. This wasn't my initial choice. um I I was going to the one that I had originally thought of was one that um I know would have been very much a premier article. um But a lot of times our our work gets into you know uh lower level peer-reviewed journals. And right now there are so many places where peer-reviewed journals exist but they are really you know part of a a you know a way of of uh making money. And so the the review process is not as stringent as what is really um uh driven by the scientific community versus just a publication you know this uh dispersal community. um So so as we choose our articles in the future this is an important point that we need to look at. One, we have to be able to have access to it and and there are many highly regarded rigorous periodicals that have that we can choose from. But once again if if you see something from the very beginning that says wow the reviewers didn't obviously review it quite well, that's just an indication that that's a level of of a peer-reviewed process that really we should probably avoid in in our our work here. Thank you. Okay so we have um another question here. uh More of an observation. This was going to be underpowered from the get-go osteopathic intervention in an asymptomatic population would be anticipated to show limited changes. Yeah, so this is an issue I'm going to let Jane talk cause she has she has seen many studies through her 20-plus year career um as a as a a statistician and methodologist within this field. So uh we have already talked about it but I'm gonna let Jane address that. So so I told Brian in in my uh professional medical opinion as a statistician, it is curious to me there seems to be a lot of of research done on healthy populations in the osteopathic profession. And and my uh simple analogy is if you give an aspirin to someone who doesn't have a fever, you don't expect their body temperature to reduce.
And so if you're doing osteopathic manipulation on people who don't have somatic dysfunction, then do you really expect there to be a change. So that was just you know... Yeah so in this case you know, do we expect that OMT is going to allow the balloon of our lungs to expand you know a bit more and is going to change the forces of expelling that air when once again their their their body is is healthy and normal. uh And so once again that's a recurrent design issue that I think we need to screen out with our as we choose future articles and as we prepare our future research studies that once again that we are choosing the right population for the question that we're asking. And you got an absolutely agree with you Jane in the Q&A pod there. um I another one here is... I find it interesting that smoking wasn't included as an exclusion. However having been in Poland they might not have had any participants given how many folks smoke. Another one here... fully concur that the clinical significance of the hypothesis was in question and I couldn't answer the question as to why the paper was important enough to publish. ... Followed up by... OMT doesn't change us into supermen or women. I think that was following up on your last comment there. And I have looks like Dr Brooks with a hand up here so here we go. I have a couple comments. First of all Brian thank you for an excellent review and a great start to this process. I too was distressed by this paper but I think perhaps the problem isn't so much that it was a study that shouldn't have been published but it should have been so critically reviewed that the conclusions and the speculations and the discussion should have been eliminated. In other words there's probably very little data that isn't worth reporting. The problem I find is what people do with the data. And so there might have been some data that was worthwhile here but it should have been very very very much more narrowly interpreted I think.
And so that was one comment. The other comment is I've been interested in chest compliance for some time although not I'm not up to date on the literature. And in the pulmonary medicine world there's basically the assumption that the mechanics of chest wall are a fixed variable... in other words they're not a variable. And so I I appreciate your slide although it was non-committal one of your concluding slides... well it could be mechanical or it could be pulmonary. And the fact is that when we breathe it is a both and situation. In other words you have to have a healthy lung and a healthy mechanical system. I think it's an a great opportunity for our profession to start to raise consciousness about this and start to tease this out. And even in a setting like I'm guessing these physical therapists were uh working in which probably didn't have you know the kinds of resources that we would ex we would hope they'd have for um more sophisticated outcome measures. But the simple act of of measuring chest expansion with a cloth measuring tape is a way to start to discriminate the mechanical properties of breathing from the total pulmonary function that's then measured with spirometry. So I know you are working on much more sophisticated tools at Kirksville but I think it's something that others could consider. And is really uh foundational in addition to all the other critiques you appropriately offered for us to be able to say there's actually a biomechanical change or not, that might then be mechanistically linked to what actually happens when you breathe. So those are my two comments. Thank you. Okay we have um one other hand up. Sergio, I think we got you unmuted there. Sergio, you might unmute yourself. Sorry, yes, it was the case. Thank you, sorry guys. um I have a few comments.
First um congratulations Dr Brian Degenhardt for your great presentation about this uh article. And as I'm I am living in Europe I know the European uh mentality from the osteopaths who are studying osteopathy in Europe. Most of them are physical therapists at a basis. Some are doctors but most of them are physical therapists. And they are they are using only techniques without the background the scientific background. And they you they think that if we uh we use a technique we can implement the system. Because maybe they read some books of Dr Still. But Dr Still was using that the osteopathic techniques of on a sick person who has lung problems and not a person who are healthy. If you want to to start a discussion about what are the the osteopathic technique um doing on the physiology then we need to do it maybe first on healthy people and then to see if we do it on on healthy people what can we expect about it. But it's true if we if we do it on healthy people we have to always to have a comparison and a control group who says if I don't move this rib and I ask only the patient to breathe to do a big inspiration it won't it will fix it fix it on its own. Who knows that if it is the case or not. That we don't we we when we practice that uh osteopathic medicine on our patient or manipulative treatment we know what we want to to reach. But as Jane said we don't cannot practice osteoporotic medicine on healthy people without uh somatic dysfunction. It's like taking an aspirin for someone who has uh no headache or fever. Okay, thank you... Sorry, um last point. No one no surgeon would do an operation to see what is it if I do a surgery on that if uh on that I don't take off an appendix for someone who has no appendicitis. No me sorry you have understood me you know um I don't take um surgery for someone who has no um a bowel problem and abdomen very pain in the abdomen uh like in appendix. I don't think I'll take the appendix away because I want to test surgery about this appendix.
.. about the colon. So um there are some... okay we have to ask ourself what we want to reach. uh we need Dr Still did a lot of wonderful techniques. But they don't they don't have been um but they have then now they have been improved during the years. But we don't have search because only based on the somatic dysfunction but never on what can cause on the physiology these manipulative techniques. Thank you. I know it was a lot, sorry. Thank you so much. um I I I'm afraid our time is up uh for for live discussion but I I really hope that we are able to to continue this this discussion about this article on our uh website forum. uh I I hope to have that open and ready for discussion this afternoon. So so um and and I'll just thank Brian for for his presentation. And uh uh let remind you of our next uh Let's Talk about Research... OMM Research! episode which is scheduled for January 15th. And that will be a a director update about the activities of uh DO-Touch.NET and what we're doing. uh There will not be continuing education credits for that session. But back when we're back in February with our webinar, we will have that available then. So thank you so much!.