 You're listening to This Week in Chiropractic. Here are the headlines for the week of May 7th, 2021. In news, a new Kickstarter campaign has raised over $1.6 million for the first Bionic knee. The E-Knee claims to be an intelligent knee support solution and features compression a 28-hour battery and a control box. The device will retail for $469 per pair. A new chiropractic school is coming to Kentucky according to Dynamic Chiropractic. A private Christian University, Campbell's Bill University in Kentucky, plans to accept students during the 2021-22 academic year as reported by Dennis Short, Dean of Chiropractic Operations. In events, the World Federation of Chiropractic has announced their biannual congress to be held September 23-25, 2021. The event with a tagline Chiropractic for a new normal will be 100% virtual this year due to the uncertainty around the COVID pandemic. In research, rubber pillows and spring pillows may have better performance than feather pillows for neck pain according to a systematic review and meta-analysis from clinical biomechanics. Authors identified clinical trials assessing the effects of different types of pillows on neck pain, waking symptoms, neck disability, sleep quality and spinal alignment. The meta-analysis revealed significant differences favoring the use of rubber pillows to reduce neck pain, reduce waking pain and neck disability, and enhance the satisfaction rate. Pillow designs did not appear to influence sleep quality in patients with chronic neck pain. A meta-analysis failed to identify any moderators that would enable clinicians to identify which patients are likely to benefit more from spinal manipulative therapy. The study looked at individual participant data from 21 randomized control trials to analyze 23 potential patient moderators, things like duration of back pain, smoking, previous exposure to spinal manipulative therapy. The results showed small effects that did not represent minimally relevant differences. A new systematic review reports an association between back pain and mortality in women and adults with more severe back pain. Eric Rosine et al. looked at 11 studies with over 80,000 participants. The presence of back pain in itself was not associated with an increase in mortality. However, back pain was associated with a modest increase in all-cause mortality in studies of women and among adults with more severe back pain. Two conflicting papers have been published regarding the Global Summit on Manipulation for Non-Musculoskeletal Disorders. A large majority of participants in the Global Summit, which took place in September of 2019, published their findings in an open-access systematic review in chiropractic and manual therapies. The authors concluded that they found no evidence of an effect for SMT for the management of non-musculoskeletal disorders and recommended that governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies and considering reimbursement for treatment. Following that publication, four participants in the Global Summit, who declined authorship, published another paper in the Journal of Manipulative and Physiological Therapeutics. The article in press shares concerns that the authors of the systematic review were extrapolating beyond the data and making sweeping policy implications based on weak scientific evidence. Those are the headlines for this week in chiropractic, May 7th, 2021. For links to these stories and more, go to thisweekinchiropractic.com. Well, let us take a look at some of these papers and some of these stories. There's a lot of research recently with many of the publications coming out around this time of the quarter. Before we get to the research, let's talk about this Kickstarter campaign for the E-NE, your Customized Intelligent Knee Support Solution. Now, I think we probably most of us agree that external supports aren't ideal. I mean, there's cases when you want to use them, but we have seen these exoskeletons in the news at least. They're doing a research and testing in the military for full-body exoskeletons. And of course, what was the Matt Damon movie? Elysium came out that featured not just exoskeletons, but jetpacks and things. There's another one with Tom Cruise like that. But this is kind of the first consumer targeted at least and probably consumer available exoskeleton-like device. And it's a knee brace. It's got, I'm not sure exactly how it works. It's not very clear. There's these red coils, which apparently provide some added support. It is a compression sleeve, much like what you would just find at your drugstore. But it does have a battery and a control box. And so it's got to be adding some type of mechanical support. In Hong Kong dollars, they've raised over 1.6 million. That is equivalent to roughly $200,000 US. The thing with these Kickstarter campaigns is that a good percentage of them never actually make it to production. And so if you put your money in and the product doesn't ever come out, you're kind of at a loss. I mean, the creators of it could opt for a fund you, but usually what these funds are used for are pre-production, machining, finding a factory. And so that money is used. It's just that there's always, almost always barriers to actually getting them out into the market. So it'll be cool to see if these come out. I would play with one, but I probably will not buy one. If you got an early enough, they weren't too expensive, but they are going for MSRP of $480 for a pair, I believe. Maybe it's just a little bit less than that. What are your thoughts on new chiropractic schools being created? This is a story and dynamic chiropractic from the beginning of April that some chiropractors in Kentucky are planning on accepting students for a new program at Private Christian University in Campbell'sville, Kentucky. Now, there's other programs that have come up recently, one in Florida, part of a medical school. There are talks about University of Pittsburgh fundraising to create one. And they, of course, are hosting the primary spine practitioner seminars once or twice a year, which is a certification you can get. And that's Michael Schneider. That's the PSP program is Michael Schneider, Don Murphy, John Blinking on his name, but a number of people who are doing the PSP program, which probably has shown, you know, viability for chiropractic program at Pittsburgh. Now, Kentucky is a much smaller state, much less populated. I just, I worry based on the data on market demand, more for PTs, and the data there is more clear. There's over 200 physical therapy programs, most of them at public universities, and over 40 in development right now. But a letter from the College of Academic Physical Therapies came out recently saying that in 2030, by 2030, there will be an oversupply of 25,000 PTs. And I can't imagine it would be very much different for chiropractic. Now, our utilization rate is only what average 10% across the nation, low back pain, neck pain, musculoskeletal disorders, and other things that we can potentially help with are prevalent. And so there's certainly a need if we can penetrate the market. The question is, can we do that by opening new schools? Or do we need to make some reform to the ones that are already out there? Interesting to see. Certainly will be fun to follow this and see how it goes if they actually do make it to launch and make it to accreditation and then make it to graduating the first class. Well, the World Federation Biennial Congress is coming up in September. It'll be 100 percent virtual, which is going to be great, because I've not been able to go. I was really hoping to go in Berlin a couple years ago. So virtual would be great. Now, I'm going to be curious to see how they do it. I participated in the Carloquium a couple months ago, which used a platform called Verbello, which is this second life fortnightish virtual world that you actually walked around through. They the WFC says they are partnering with the best in the business, as well as Parker seminars to develop a worldwide reputation for delivering outstanding online events. I did not participate in Parker seminars, unfortunately, but it looked like a much better implementation than Carloquium. Carloquium wasn't bad. They're really great pros to it. But on the whole, I personally don't think that's the way to do virtual conferences. Something more like what I think Parker seminars did, I can get behind that. We'll see what they're they're going to do. Production values got to be high, right? They got to invest in more than a webcam and air pods, right? You've got to have good quality audio number one, good camera and lighting number two, and then, you know, some good production. So, hey, WFC, if you want some help, I sort of am figuring this stuff out. I don't really know what I'm doing yet, but I'd love to make sure that this conference, at least the production side of it, is a hit. Alright, lots of research over the past few weeks. It's kind of that time of the quarter when multiple journals pre publish their papers online, at least. And so I've only included a few, but there's quite a bit to go through. So we'll be quick on the first few. I really want to spend time on the global summit. I've been having, you know, discomfort at night with my half down half feather pillow. So this, this paper caught my eye, the effects of pillow designs on neck pain, waking symptoms, neck disability, sleep quality and spinal alignment in adults, systematic review and meta analysis. I've yet to read through it all, but the conclusions are that rubber pillows and spring pillows may have better performance than feather pillows. This kind of makes sense to me. I mean, at least for those of us who've grown up using pillows and having slight flexion at night or at least laying on the side, you've got to have some support to that. Now you can make the argument that it's better to just lie flat. You know, Katie Bowman, if any of you have read her stuff, nutritiousmovement.com, makes the argument for just laying on the ground. They've gotten rid of all furniture in their house. And that's, that's something to aspire to. But, you know, pillows like memory foams or the purple pillow, I've got a purple mattress have not tried their rubber pillow seem to be better, according to this study. So I thought that was pretty interesting to look at. I need to get a new pillow. So if you have a recommendation dropping in the comments, if you have a pillow you love other than sorry to get political the my pillow one, I don't think I'm going to support that. Moving on though, moderators of the effect of spinal manipulative therapy on pain relief and function in patients with chronic low back pain. So the authors took individual participant data from what was it I said about 11 studies. So they were actually able to get the individual data to do this meta analysis. And what they're trying to find is, are there any moderators that can tell us who's going to respond to spinal manipulative therapy? This currently is somewhat of a holy grail right now in research with Greg Kochak doing the the biomechanical, you know, this engineered device that looks at stiffness. And then another study they did that looked at just who responds and it's the people who respond like that's they don't know how to tell who will respond until you actually try the adjustment and measure their response. And if they respond well, then continue if they don't respond, try something else. And then they looked at the stiffness of the spine to see if that would change anything. These authors are looking for a number of other things, whether they're smokers, whether it's chronic, how long have they had it less than a year, longer than a year, have they had spinal manipulation in the past 23 different moderators, I think are what they evaluated. And for the most part, nothing, nothing really worked. There were some small, small effects with smoking and previous exposure and duration of low back pain, but not enough to make to be clinically significant. So the hunt continues for moderators that will allow you to tell who will respond or not. I really liked this paper by Eric Racine and others. We know that back pain is the most common cause of disability in the world. 80% of people experience it throughout their life. And the economic burden, the burden of disability from low back pain and neck pain is higher than really just about any other condition, even the big bad ugliest, the cancers, the HIV malaria in the economic burden, right, loss of work, loss of pay, inability to just get up and move around during the day, right. These are measures of disability. There's all these metrics like years lived with disability, a disability adjusted life years, quality adjusted life years, all these ways to try to quantify the impact. But what we know, we know that back pain doesn't really cause death, like a lot of these big bad ugliest do, right. People die from HIV and AIDS, people die from cancer, people die from malaria. And so from that perspective, low back pain is not that big of a deal, even though economically it is a bigger burden. But it turns out there might be an association. And so if you look at people with low back pain, and it turns out particularly women who are disproportionately affected by back pain, at least when considering disability, when you look at women, and when you look at those with a more severe back pain, there is an association again, no causation can be inferred, but there is an association with all cause mortality, meaning that well, it could mean a lot of things, right. People who are more likely to have severe back pain, including women, oftentimes are also the people who are more likely to be in poverty, more likely to just be unhealthy in other ways. And this comes back to probably, I'm making some assumptions here. This is not necessarily what the paper said, but it comes back to the social determinants of health, right, these things that we can't affect as healthcare practitioners directly, the environment, the education, the demographics, the region that you grow up, are social determinants of health, and will determine how healthy you are, access to healthcare as well. So it's not too surprising that there's an association. But to my knowledge, this study has never been done before. And I think it's important now, when you're talking about disability to keep in mind, yeah, actually, it also is associated with mortality. Well, the global summit on, oh, I've got the wrong paper here, by the way. No wonder I made a mistake here. So let's see if I can pull it up while I'm talking about this, but the global summit happened in September of 2019. And 50, count them 50, researchers with experience, you know, well known researchers like Jan Hardfix and Pierre Cote, so many that you would know went to Toronto, following a multiple months long research, and pulling up lots of different papers and randomized control trials that look at non musculoskeletal conditions, right? This is a claim that's existed ever since chiropractic started that we can cure diabetes and cancer and bedwetting and infantile colic, all of these things that just up till now don't have great support. They looked at these did a systematic review. And the conclusion was, yeah, there's really no evidence of an effect of SMT for the management of non musculoskeletal disorders. And these authors kind of voted on, yeah, do we do we agree with a statement for each of these conditions? And as a whole, and it was over 80%. For some, it was 190, 94% agreed. But, but there were four authors, again, respected researchers who you would know. Christine Gertz, Eric Hurwitz, Bernadette Murphy, and Ian Coulter, names that anybody who follows chiropractic research would recognize at least, who said, well, no, wait a minute, wait a minute, they declined to author this systematic review that was the result of the global summit and said, none of you guys are taking this too far. They didn't necessarily disagree with many of the statements, but some of the kind of implications, the conclusions, they say they were extrapolating beyond the data and making sweeping policy implications based on weak scientific evidence. So again, that original systematic review from the global summit of 38 plus authors, in their conclusion, recommended that governments, payers, regulators, educators, and clinicians should consider this evidence when developing policies or in other words, the lack of evidence when developing policies and considering reimbursement for chiropractic, for infantile colic, for asthma, for, you know, all of these non-musculoskeletal conditions. When I read that, I was, I also was a bit concerned. You're saying that there's a lack of evidence to support or refute, the original paper says support or refute any benefit, any efficacy, effectiveness of chiropractic adjustments for these non-musculoskeletal disorders. But then you're saying that governments and payers should consider this when making decisions. I mean, I don't know for sure, but my impression is that medicare and the government, they want to pay as little as they possibly can. They want to limit the amount of money they spend on treatments, even if there is pretty good evidence, unless it shows them that they will save more money later on. And so to suggest that they take this paper to inform their policy decisions, to me, was a bit of a reach. And that's really what Christine Gertz and the other authors felt now. That said, this paper on extrapolating beyond the data from my reading had some misquotes and misstatements about the original systematic review. I read through it and they're trying to say that the authors were lumping these conditions all together and saying all of these conditions like asthma, like bedwetting, like infantile colic, all of these things are just one thing. But when you really look through their systematic review, they did break them out and they assess the quality and the quantity of evidence for each. The second paper also states that, let's see if I can find it here, that they said that SMT was not effective and should not be studied further, but they didn't. They clearly said that, albeit in just one sentence, but they said that further research needs to be done. And so it's just interesting to me from an outsider, someone who isn't really involved in publishing research, but to see this type of discussion and debate back and forth. I think it's healthy. I think it's good, but I think it's important for us to take the time to evaluate on both sides each of these claims that they're making about the others. And I'm very curious if there's any hard feelings here. I'd love to get the corresponding authors on a podcast to discuss these. I think it'd be very valuable to get more details on this. So I think, as many others have said, that we should keep abreast of this literature. So the links to all of these are in the show notes. Just head into this week in chiropractic.com and look for May 7th and the links to these papers will be right there in the show notes. You can get them hopefully the full paper, although it is interesting to note that this reply from Gertz et al. was published behind a paywall in JNPT. But I encourage you to go take a look at these articles as well as others that I will tweet out and share. And hopefully next week and the next two weeks do another show with many of the other research papers that have come out. In the meantime, please let me know if there's any stories I missed. Tell me what your thoughts are on new chiropractic programs coming and being developed. And also send me a message to let me know if there's something that you'd like to hear or someone you'd like to hear on the show. I'd love to bring in co-hosts to have more of a discussion rather than just my opinion, get some more informed people into this show. So thank you very much for watching. This has been This Week in Chiropractic for May 7th, 2021. I'm Dr. Nathan Cashin, and I'll see you in the next one.