On 2015 Feb 12, Brian Clark commented:

We (Brian C. Clark and Jack Blazyk) published an opinion article in the “In My View” section of the August 2014 issue of The Journal of The American Osteopathic Association (JAOA) titled “Research in the Osteopathic Medical Profession: Roadmap to Recovery.” Four of our clinical colleagues in the Department of Osteopathic Manipulative Medicine (OMM) at our home institution, the Ohio University Heritage College of Osteopathic Medicine, responded to our article with the letter-to-the-editor indexed above. As stated in the “Editor’s Note” at the end of their letter-to-the-editor, "The JAOA declined to publish the response submitted by Drs. Clark and Blazyk.”

Since the JAOA denied us the opportunity to reply to the letter in print, we are posting our response here on PubMed Commons (see follow-up post below). When the journal editors attempted to alter our reply, we stated that "we are not willing to make any further changes to our response. Since our article was clearly defined as an opinion piece, we feel that we are entitled to state our opinion, particularly with regard to our response to Walkowski et al.'s letter-to-the-editor. Is it the JAOA's intent to edit or censor their letter? If not, we believe that we should be afforded the opportunity to reply according to our beliefs and principles. If the decision is not to publish our response, we request a brief statement that the authors and the journal were unable to agree on an acceptable response.”

On 2015 Feb 12, Brian Clark commented:

We welcome the correspondence from Walkowski and colleagues submitted in response to our article titled “Research in the Osteopathic Medical Profession: Roadmap to Recovery.” We address their questions and criticisms as follows:

Use of NIH Funding Data to Compare Research by Institutional Type

While it might be useful to compare different disciplines according to the number of institutional research FTE, these data are not easily obtainable nor publicly available. It seems highly unlikely, though, that any normalization procedure would reveal serious research strength within osteopathic medical schools in this regard, as our NIH funding levels are negligible. Is not this criticism by the correspondents an admission of the unfortunate reality that our osteopathic medical schools lack sufficient numbers of faculty trained in and committed to research?

We recognize that there are many impactful research findings arising from non-NIH funded studies and did not mean to imply, that for research to be valued, it must be funded by NIH. We simply chose this metric because the NIH peer-review process is rigorous and respected, and NIH funding is the typical standard by which medical schools as well as other health professional schools are compared for stature in research and scholarly activity.

OMM & EBM

Due to word limitations we were unable to provide more examples of unsubstantiated applications of osteopathic manipulation. We agree that there is clearly growing evidence for the efficacy of OMM to treat certain conditions, particularly low back pain, and that more work needs to be done. An example of the tension between reliance on historical tradition vs. evidence-based practice, however, is the intense training that many osteopathic medical schools offer in the use of diagnostic palpatory tests. For more than three decades, scientists and clinicians have investigated the reliability of many diagnostic tests, with systematic reviews of the literature finding that motion and landmark location diagnostic tests have poor inter-rater reliability [1-3]. Even the most rigorous reliability studies fail to demonstrate acceptable reliability rates for most diagnostic palpatory tests [4]. In light of the poor inter-rater reliability of palpatory diagnosis, validity cannot possibly be addressed. This raises the question of why so much time and effort is invested in palpatory diagnosis training and in promoting its value in osteopathic clinical decision-making. We simply provide this as one example to support our argument.

Why hold OMM to a different standard than other fields of medicine?

We did not intend to single out OMM as the only area that lacks a sufficient evidence base to warrant acceptance as a medical standard of care. The following example was included in our original manuscript, but was excised by the JAOA editors. The AOA recognizes a specialty college in ‘Prolotherapy Regenerative Medicine’ despite the lack of evidence of its efficacy for the treatment of musculoskeletal pain (e.g., to our knowledge, all MedLine-indexed systematic reviews or meta-analysis reports suggest that prolotherapy is either ineffective or inconclusive, at best) [5-13]. Since the osteopathic profession is ideally positioned and has an inherent responsibility to take the lead in musculoskeletal research, examining the utility of interventions such as prolotherapy by an objective, systematic approach is certainly reasonable. Whether or not physicians should be using prolotherapy to treat their patients may be debatable, but is it appropriate for the AOA itself to recognize Prolotherapy Regenerative Medicine as a specialty college? We strongly encourage the AOA, as well as osteopathic medical schools, to examine the balance between creating a unique identity versus the importance of accepting and assimilating scientific and clinical evidence that must ultimately determine best treatments and advances in healthcare.

Should OPP (osteopathic principles and practices) research be encouraged and supported?

While we concur that OPP research should be encouraged and supported, we questioned whether the AOA Council on Research should focus all of its attention and resources on OPP-related research at the expense all other areas of research critical to advancing human health, particularly related to the delivery of primary care.

Other thoughts:

• We did not intend for this article to be perceived as divisive or territorial (as stated by Walkowski and colleagues). In fact, one of our peer reviewers in the JAOA review process noted that “…every critical statement is substantiated with data and cannot possibly be taken as mean-spirited or as an attack on the profession. On the contrary, the tone of this paper is one of genuine concern for the DO profession, attempting to help in a positive way to shape the future research agenda.” To be explicitly clear, our goal in publishing this paper was not only to point out the relative lack of scholarly activity and research focus in osteopathic medical schools, but to offer specific steps to improve this situation.

• The AOA Commission on Osteopathic College Accreditation (COCA) must begin to enforce its research accreditation standards. Many of the existing osteopathic medical schools have little or no infrastructure to support research. Moreover, there are an additional 13 proposed osteopathic medical schools on the drawing board (as of 17-June-2014, 13 entities that have requested ‘Applicant status’, which is the first step in seeking accreditation). Will COCA continue to approve new schools, as well as renew accreditation to existing schools, that do not significantly contribute to developing new knowledge and improving healthcare through scientific inquiry, as mandated by COCA Standard Seven? The time is long overdue for the leadership of the osteopathic profession to act by putting teeth into its accreditation standards.

• Lastly, we agree wholeheartedly with Walkowski and colleagues that a team-based approach that synthesizes the respective expertise of clinicians and scientists is critical to impactful health-related research; however, we strongly disagree with their suggestion that: “We are first osteopathic, and it is that quality that serves to primarily employ and support our basic science faculty. To that end, it is the job of each researcher in our colleges to support the philosophy and practice of osteopathic medicine by actively designing and engaging in studies that support or refute the current science around that practice.” The notion that non-physician researchers at osteopathic institutions should confine their research to the philosophy and practice of osteopathic medicine is antithetical to free and unfettered scientific inquiry and discovery. As we stated in our article, “this approach marginalizes our profession by ceding new developments in the vast panoply of modern health care not only to MDs but also to all other research-driven health care professionals.” We argue that the job of folks like us (i.e., PhD researchers) is not to support any particular philosophy, but rather to constructively criticize and question the rational basis underlying any area of medical practice that might advance medical care. This is what medically-oriented PhD scientists, like ourselves, are trained to do.

Are osteopathic medical schools, the AOA, and COCA ready and willing to take the first steps toward improving our stature in research and scholarly activity in order to elevate our standing among our healthcare colleagues and the general public? Now is the time for action.

Brian C. Clark, PhD and Jack Blazyk, PhD Ohio University

On 2015 Feb 12, Brian Clark commented:

REFERENCES

1.Seffinger et al. Spine, 2004. 29(19): p. E413-25.

2.Stochkendahl et al. J Manip Physiol Thera, 2006. 29(6): p. 475-85, 485 e1-10.

3.van der Wurff et al. Manual Therapy, 2000. 5(1): p. 30-6.

4.Degenhardt et al. J Am Osteo Assoc, 2010. 110(10): p. 579-86.

5.Chou et al. Spine, 2009. 34(10): p. 1078-93.

6.Dagenais et al. Spine J, 2005. 5(3): p. 310-28.

7.Dagenais et al. Spine J, 2008. 8(1): p. 203-12.

8.Krogh et al. Am J Sports Med, 2012.

9.Rabago et al. Clin J Sport Med, 2005. 15(5): p. 376-80.

10.Rabago et al. Br J Sports Med, 2009. 43(7): p. 471-81.

11.Staal et al. Cochrane Rev, 2008(3): p. CD001824.

12.Staal et al. Spine, 2009. 34(1): p. 49-59.

13.Yelland et al. Spine, 2004. 29(19): p. 2126-33.

On 2015 Feb 12, Brian Clark commented:

None

On 2015 Feb 12, Brian Clark commented:

None

On 2015 Feb 12, Brian Clark commented:

None

On 2015 Feb 12, Brian Clark commented:

None

On 2015 Feb 12, Brian Clark commented:

REFERENCES

1.Seffinger et al. Spine, 2004. 29(19): p. E413-25.

2.Stochkendahl et al. J Manip Physiol Thera, 2006. 29(6): p. 475-85, 485 e1-10.

3.van der Wurff et al. Manual Therapy, 2000. 5(1): p. 30-6.

4.Degenhardt et al. J Am Osteo Assoc, 2010. 110(10): p. 579-86.

5.Chou et al. Spine, 2009. 34(10): p. 1078-93.

6.Dagenais et al. Spine J, 2005. 5(3): p. 310-28.

7.Dagenais et al. Spine J, 2008. 8(1): p. 203-12.

8.Krogh et al. Am J Sports Med, 2012.

9.Rabago et al. Clin J Sport Med, 2005. 15(5): p. 376-80.

10.Rabago et al. Br J Sports Med, 2009. 43(7): p. 471-81.

11.Staal et al. Cochrane Rev, 2008(3): p. CD001824.

12.Staal et al. Spine, 2009. 34(1): p. 49-59.

13.Yelland et al. Spine, 2004. 29(19): p. 2126-33.

On 2015 Feb 12, Brian Clark commented:

We welcome the correspondence from Walkowski and colleagues submitted in response to our article titled “Research in the Osteopathic Medical Profession: Roadmap to Recovery.” We address their questions and criticisms as follows:

Use of NIH Funding Data to Compare Research by Institutional Type

While it might be useful to compare different disciplines according to the number of institutional research FTE, these data are not easily obtainable nor publicly available. It seems highly unlikely, though, that any normalization procedure would reveal serious research strength within osteopathic medical schools in this regard, as our NIH funding levels are negligible. Is not this criticism by the correspondents an admission of the unfortunate reality that our osteopathic medical schools lack sufficient numbers of faculty trained in and committed to research?

We recognize that there are many impactful research findings arising from non-NIH funded studies and did not mean to imply, that for research to be valued, it must be funded by NIH. We simply chose this metric because the NIH peer-review process is rigorous and respected, and NIH funding is the typical standard by which medical schools as well as other health professional schools are compared for stature in research and scholarly activity.

OMM & EBM

Due to word limitations we were unable to provide more examples of unsubstantiated applications of osteopathic manipulation. We agree that there is clearly growing evidence for the efficacy of OMM to treat certain conditions, particularly low back pain, and that more work needs to be done. An example of the tension between reliance on historical tradition vs. evidence-based practice, however, is the intense training that many osteopathic medical schools offer in the use of diagnostic palpatory tests. For more than three decades, scientists and clinicians have investigated the reliability of many diagnostic tests, with systematic reviews of the literature finding that motion and landmark location diagnostic tests have poor inter-rater reliability [1-3]. Even the most rigorous reliability studies fail to demonstrate acceptable reliability rates for most diagnostic palpatory tests [4]. In light of the poor inter-rater reliability of palpatory diagnosis, validity cannot possibly be addressed. This raises the question of why so much time and effort is invested in palpatory diagnosis training and in promoting its value in osteopathic clinical decision-making. We simply provide this as one example to support our argument.

Why hold OMM to a different standard than other fields of medicine?

We did not intend to single out OMM as the only area that lacks a sufficient evidence base to warrant acceptance as a medical standard of care. The following example was included in our original manuscript, but was excised by the JAOA editors. The AOA recognizes a specialty college in ‘Prolotherapy Regenerative Medicine’ despite the lack of evidence of its efficacy for the treatment of musculoskeletal pain (e.g., to our knowledge, all MedLine-indexed systematic reviews or meta-analysis reports suggest that prolotherapy is either ineffective or inconclusive, at best) [5-13]. Since the osteopathic profession is ideally positioned and has an inherent responsibility to take the lead in musculoskeletal research, examining the utility of interventions such as prolotherapy by an objective, systematic approach is certainly reasonable. Whether or not physicians should be using prolotherapy to treat their patients may be debatable, but is it appropriate for the AOA itself to recognize Prolotherapy Regenerative Medicine as a specialty college? We strongly encourage the AOA, as well as osteopathic medical schools, to examine the balance between creating a unique identity versus the importance of accepting and assimilating scientific and clinical evidence that must ultimately determine best treatments and advances in healthcare.

Should OPP (osteopathic principles and practices) research be encouraged and supported?

While we concur that OPP research should be encouraged and supported, we questioned whether the AOA Council on Research should focus all of its attention and resources on OPP-related research at the expense all other areas of research critical to advancing human health, particularly related to the delivery of primary care.

Other thoughts:

• We did not intend for this article to be perceived as divisive or territorial (as stated by Walkowski and colleagues). In fact, one of our peer reviewers in the JAOA review process noted that “…every critical statement is substantiated with data and cannot possibly be taken as mean-spirited or as an attack on the profession. On the contrary, the tone of this paper is one of genuine concern for the DO profession, attempting to help in a positive way to shape the future research agenda.” To be explicitly clear, our goal in publishing this paper was not only to point out the relative lack of scholarly activity and research focus in osteopathic medical schools, but to offer specific steps to improve this situation.

• The AOA Commission on Osteopathic College Accreditation (COCA) must begin to enforce its research accreditation standards. Many of the existing osteopathic medical schools have little or no infrastructure to support research. Moreover, there are an additional 13 proposed osteopathic medical schools on the drawing board (as of 17-June-2014, 13 entities that have requested ‘Applicant status’, which is the first step in seeking accreditation). Will COCA continue to approve new schools, as well as renew accreditation to existing schools, that do not significantly contribute to developing new knowledge and improving healthcare through scientific inquiry, as mandated by COCA Standard Seven? The time is long overdue for the leadership of the osteopathic profession to act by putting teeth into its accreditation standards.

• Lastly, we agree wholeheartedly with Walkowski and colleagues that a team-based approach that synthesizes the respective expertise of clinicians and scientists is critical to impactful health-related research; however, we strongly disagree with their suggestion that: “We are first osteopathic, and it is that quality that serves to primarily employ and support our basic science faculty. To that end, it is the job of each researcher in our colleges to support the philosophy and practice of osteopathic medicine by actively designing and engaging in studies that support or refute the current science around that practice.” The notion that non-physician researchers at osteopathic institutions should confine their research to the philosophy and practice of osteopathic medicine is antithetical to free and unfettered scientific inquiry and discovery. As we stated in our article, “this approach marginalizes our profession by ceding new developments in the vast panoply of modern health care not only to MDs but also to all other research-driven health care professionals.” We argue that the job of folks like us (i.e., PhD researchers) is not to support any particular philosophy, but rather to constructively criticize and question the rational basis underlying any area of medical practice that might advance medical care. This is what medically-oriented PhD scientists, like ourselves, are trained to do.

Are osteopathic medical schools, the AOA, and COCA ready and willing to take the first steps toward improving our stature in research and scholarly activity in order to elevate our standing among our healthcare colleagues and the general public? Now is the time for action.

Brian C. Clark, PhD and Jack Blazyk, PhD Ohio University

On 2015 Feb 12, Brian Clark commented:

We (Brian C. Clark and Jack Blazyk) published an opinion article in the “In My View” section of the August 2014 issue of The Journal of The American Osteopathic Association (JAOA) titled “Research in the Osteopathic Medical Profession: Roadmap to Recovery.” Four of our clinical colleagues in the Department of Osteopathic Manipulative Medicine (OMM) at our home institution, the Ohio University Heritage College of Osteopathic Medicine, responded to our article with the letter-to-the-editor indexed above. As stated in the “Editor’s Note” at the end of their letter-to-the-editor, "The JAOA declined to publish the response submitted by Drs. Clark and Blazyk.”

Since the JAOA denied us the opportunity to reply to the letter in print, we are posting our response here on PubMed Commons (see follow-up post below). When the journal editors attempted to alter our reply, we stated that "we are not willing to make any further changes to our response. Since our article was clearly defined as an opinion piece, we feel that we are entitled to state our opinion, particularly with regard to our response to Walkowski et al.'s letter-to-the-editor. Is it the JAOA's intent to edit or censor their letter? If not, we believe that we should be afforded the opportunity to reply according to our beliefs and principles. If the decision is not to publish our response, we request a brief statement that the authors and the journal were unable to agree on an acceptable response.”