Episode #7 - Postoperative Knee Arthroplasty Efficacy & How Australians Practice OMT

Hello everyone and welcome to our seventh episode of the OMM Research Podcast! 

Our panelists for this episode are Dr. Stephen Stacey and Dr. Alfred Amendolara.

In this episode, we are an article titled "Efficacy of Osteopathic Manipulative Treatment for Postoperative Recovery Following Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials" by Oar et al. published in Cureus. The article can be viewed at this link: https://www.cureus.com/articles/442228-efficacy-of-osteopathic-manipulative-treatment-for-postoperative-recovery-following-total-knee-arthroplasty-a-meta-analysis-of-randomized-controlled-trials#!/

We are also looking at an article titled "Therapeutic approaches and conceptions of practice of osteopaths in Australia - a national cross-sectional study and exploratory factor analysis of the Osteo-TAQ" by Thomson et al. published in BMC Health Services Research. The article can be viewed at this link: https://pmc.ncbi.nlm.nih.gov/articles/PMC11529309/

You can also view this podcast episode on the DO-Touch.NET YouTube Channel and see what is happening in the DO-Touch.NET practice-based research network by visiting our website, which are both linked in this sentence.

Hope you enjoy and feel free to reach out to us at dotouchnet@atsu.edu!

Transcript

SPEAKER_02 0:15

Okay, well, hello to you our listeners, the manipulated and the manipulators. Uh, welcome to the OMM Research Podcast. The OMM Research Podcast is produced by Deo Touchnet, a practice-based research network that focuses on osteopathic manipulative medicine research. Dio TouchNet is based out of the AT Still Research Institute, located at AT Still University in Kirksville, Missouri. Please note that the views and opinions of the panelists in this podcast are personal to each panelist and do not reflect the views or opinions of AT Still University. My name is Corey Lubring, and I am the practice-based research coordinator of Deo TouchNet and the host of the OMM Research Podcast. We want to remind our listeners before we get started that this podcast recording has video recorded with it and can be viewed on the Deo TouchNet YouTube channel. As we like to begin all our episodes, we want to start off by introducing our panelists for this episode, starting with Dr. Amendelara.

SPEAKER_00 1:17

My name is Al Amendelara. I'm a PGY1 in neurology at St. Luke's University Health Network in Bethlehem, Pennsylvania. And I'm also an adjunct professor in clinical research at Norda College of Osteopathic Medicine.

SPEAKER_02 1:31

And thanks for being with us back again this month. And then we also want to introduce Dr. Stacy.

SPEAKER_01 1:37

Hi, my name is Steve Stacy. I'm uh Director of Osteopathic Education at the Lacrosse Mayo Family Medicine Residency Program and Associate Professor of Family Medicine at Mayo Clinic.

SPEAKER_02 1:50

And thank you also for being with us again this month. We have a couple exciting articles brought to us. We're going to start off with uh Dr. Abendalara's article that is looking at OMT on uh total knee arthroplasty.

SPEAKER_00 2:06

Yeah, so this article is titled Efficacy of Osteopathic Manipulative Treatment for Postoperative Recovery Following Total Knee Arthroplasty, a meta-analysis of randomized controlled trials by Orr et al. It was published in Curious uh just at the end of 2025. Uh, this is a systematic review and a meta-analysis, as the title implies. Uh, they were looking at specifically the use of OMT to improve pain and range of motion following uh total knee arthroplasty or TKA. They ended up finding three studies that had a approximately a total sample size of about 150. Um, and they did see they saw some positive effects favoring uh the OMT intervention groups, but ultimately they didn't really reach statistical significance. Um and there was some high heterogeneity and and some other kind of caveats that we can talk about. But um overall, uh a nice little study uh that I think answers a useful clinical question, or attempts to answer a useful clinical question.

SPEAKER_02 3:16

And and so what what are you wanting to uh bring to the discussion related to the study? What what what kind of about this article uh did you want to highlight for our listeners and uh discuss here with uh Dr. Stacy?

SPEAKER_00 3:29

Yeah, I think there's a couple things that this study did well that I just want to call out. I think there's like a reasonable clinical question that they're trying to answer, which is always a good start for a meta-analysis like this. Uh, there's some sort of logical basis for doing a manual therapy after a procedure like this, um, to try and help pain and range of motion and essentially help with these patient outcomes, patient kind of patient-focused outcomes. Um, so I think that's good. And I think their reporting is is pretty good as well. It looks like they put thought into what they were doing. Um, and really what I wanted to kind of talk about is a little bit of about the methodology and some of the things they did right and some of the things they did wrong, and maybe how you could go about or how we would go about doing this study a little bit differently. Because really, I think meta-analyses and systematic reviews are uh very alluring. Um, but when you really start to get into them, into the weeds with them, they're really a lot more complicated and there's a lot of moving parts. Uh, and this paper, I think, does a is a is a good case study for you know, maybe what to do and what not to do in some of those situations.

SPEAKER_02 4:41

Sure. All right, so so what kind of methodology did you want to point out to our listeners?

SPEAKER_00 4:47

So, you know, right off the top, I think they have a a reasonable research question, but it's it's kind of broad. They ask, you know, what are the significant differences in post-operative pain or range of motion when used in the acute post-operative period following a TKA, but they don't really give any other specifics for it. Um, you know, usually we try and frame these as like a PICO kind of uh style. So your population, your intervention, your control, your outcome. And that's sort of missing here. And I think that leads into the major problem of the study that hopefully will become clear as we we kind of talk a little bit more about things like the inclusion and exclusion criteria, um, which I think is is what we can hit on now. Um, they only include randomized controlled trials, which I think is good. If if your intent is to try and do a meta-analysis, uh really the only thing worth doing, in my opinion, is with randomized controlled trials, unless you have a really strong argument to look at observational or retrospective studies, if there's not enough evidence um or there's there's just not the work out there. Um but they really have kind of a loose inclusion and exclusion criteria. They include randomized controlled trials, they have to be in English, they have to be in 2010, and then they do mention some kind of vague requirements for adequate follow-up or and then reporting, of course, their primary outcomes, which was pain or range of motion, specifically inflection.

SPEAKER_02 6:26

Like specifically, the study had to be done just in 2010, no like range of motion.

SPEAKER_00 6:31

But sorry, um, uh no studies prior to 2020.

SPEAKER_02 6:33

Oh, prior to, okay, sorry.

SPEAKER_00 6:37

Yeah, an attempt to keep it recent. So within the past approximately uh 15 years. Gotcha. Um from publication of this study, which I think is a good choice. Um although I don't know, given their small the small number of studies they ended up finding, which was only three, I would think that would have been a good argument to expand that a little bit and to to try and find more evidence. You know, truthfully, uh, with so little evidence, if we're gonna try and ask this clinical question, um I think we want additional data. And and I can't say whether or not that data exists because they didn't really include that in their search. And there's certainly an argument for only including recent data. Obviously, surgical techniques change, post-operative care changes, guidelines change, um, but they don't really go into that. There's not a lot of justification for why they're making a lot of these decisions. So on a positive front, they they talk about it, but then a lot of it's not justified. Um, their search strategy, their search term is pretty simple. I don't think it needs to be overly complex, but it leaves me wondering, you know, do did they miss out on things essentially? Or are we missing potentially important or useful studies here? And then, you know, they they go on to describe their data extraction and their quality assessments um using the NIH study quality assessment tool. I'm not sure why they didn't use Cochrane's risk of bias here. Um they're using randomized controlled trials. That's a pretty standard tool to uh to use for that, and I would argue probably a better measure of bias than the NIH um quality assessment tools, which are really advantageous when you're using when you're looking at studies that aren't randomized controlled trials and don't fit into the risk of bias purview. Um and then they go into their statistical analysis and their assessment of the results and stuff, and all of this was reasonable. But you know, the the big problem that maybe I haven't been quite clear enough about is that there's only three studies in this, and their total sample size ended up being something like 154 patients or so. And we see a a pretty a pretty notable um uh effect size favoring the intervention. So the using a random effects model, the mean difference was a little bit under one favoring OMT for uh essentially reduction in pain scores. And then it was a little bit under approximately like eight or nine, um, again, favoring the the OMT intervention for range of motion. So we got some good uh a good effect size that looks like there could be something going on here, but the confidence intervals are huge. Uh, there's no way to say for certain whether or not this is a statistical kind of aberration because of low samples and whether we're getting uh really probably a type two error here. Um so it's hard to interpret this. And so at the end of the day, we have this study that really I think was put together at least with good intentions and reasonably competently, but at the end of at the end of it, we just are back where we started saying, well, we really don't know if this is an effective treatment, and there should be more research on it, and and that's about it. Um, and that's really, I guess, what I'm kind of building up towards is I think one of the most important parts of going into a systematic review or any sort of um meta study design is really picking a question that's clinically relevant, which they did, but then also picking a question where there's enough data to actually answer your clinical question. And this is something that I think we run into a lot with osteopathic research. Um, I know I think that we've all kind of fallen into this trap of having this question we really, really want to answer and just finding out that there's not quite enough evidence to answer it. Um and in their case, they they went through the motions, they did the meta-analysis. There's nothing egregiously wrong with any of this, but the the end recommendation is is not particularly reliable, it's not particularly robust. We haven't gained any information from this study. Um, so even more so than just the reporting and the the nitty-gritty of the methodology. It's the it's building an entire research question that's actually answerable.

unknown 11:10

Dr.

SPEAKER_02 11:10

Sacey, is there anything you want to chime in?

SPEAKER_01 11:14

Yeah. Um a systematic review stands or falls on the methodology, like he said. And one of the first questions really comes down to what is their inclusion criteria and whether they found the correct studies. You know, once the studies were found, I think their methodology was fine, but a lot hinges on that one particular moment. And looking through their methods, uh, it doesn't, it seems potentially a little bit exclusive. They don't say exactly how they used the Boolean operators, whether it was ands or ors. And so it could potentially have been much too narrow if all of the different things were and. I don't know if if um you you read this article more closely than I did, Al. Is that am I speaking truth here?

SPEAKER_00 12:09

No, I I did not see any obvious like supplemental material that includes a full um full search term that may be more complicated. So I have to assume that what they have in their methods is more or less their search term, and and you're exactly right. There's no indication of the and or you know how they're structuring this, how it was changed for PubMed, whether or not they were using um uh database specific terms. You know, they include things like Google Scholar Research Gate in their list of databases, but there's really no way to effectively search and return results from databases like that or download them in bulk. So it does make me question well, how were these actually collected? Yeah, how were they screened at this initial search search stage?

SPEAKER_01 13:02

And that ends up being really important because you do worry if they missed important articles. So um, you know, for example, there was already an article three years ago by Zhu et al. titled Inhibiting the Musculoskeletal Pathological Process and Post-Knee Replacement Surgery with Osteopathic Manipulative Treatment, a systematic review, which by the title seems to cover a lot of the same things. Reading through the abstract of that article, it's more of a narrative review rather than a meta-analysis. And you know, in both cases, a systematic review, again, is where you publish the process by which you obtained the articles that you're looking at. But what you do with those articles once you find them can be different. So in the case of a meta-analysis, they're trying to pull them statistically, versus if you're doing a simple narrative review, you're you're looking at the evidence maybe a little bit more qualitatively. Um and so there is potentially a difference there, but the fact that it wasn't even referenced or noted, you know, you you really do want to comment on why you're doing a systematic review on the same topic three years later. Um, and then I also found another um another article with just simple search about pre-operative osteopathic manipulative therapy, improves postoperative pain and reduced opioid consumption after total knee arthroplasty, a prospective comparative study. Um and this was just with a simple PubMed search, and that wasn't included in their systematic review. And I don't really see why it wouldn't be necessarily. Uh, you know, maybe if I read through them both in more detail you'd get to that. But um if a simple search yields obviously effective and helpful articles that are not included in the review, um you know, you you're just left wondering if they found the right articles, and they didn't give me enough in the report here to to make me convinced that they did.

SPEAKER_00 15:12

Right, exactly. And I I think that for me, that is the the big problem with the article. We're left with the the technical aspects of it are really not particularly bad. Like you mentioned, once they kind of have their selection of articles, I think the meta-analysis is fine. I think what they're concluding based on what they've done is reasonable. There's nothing egregiously wrong, but it's it's in the setup and development of this where things kind of fall apart. And I think it's it's particularly notable and important in systematic reviews and meta-analyses, which is kind of why I picked a systematic review and meta-analysis. But I think it's also relevant in other kinds of primary research. Um, this idea that when as we go through to either conduct research ourselves or to read others' research, especially in osteopathic medicine, a lot of the deficiencies are in the initial planning stage and in the setup of the experiments and in the experimental design. And then things may be done competently after the fact, but it's it's a bit of um, you know, garbage in, garbage out with uh, you know, a calculator. So even if you do a really good job reporting and on the technical aspects of things, I think really more attention and probably more research education and teaching needs to be dedicated to developing the good research questions from the top down.

SPEAKER_02 16:36

So what what would you do? You mentioned you like uh uh about exploring or talking about some of the changes that you would have made if you would have done the study or if you were to repeat it and everything. Uh so what kind of changes would you make to the study?

SPEAKER_00 16:51

Yeah, I think there's two different directions you could kind of branch off in. I on one hand, you know, and it's hard to say from their methodology in the the study selection initial search. I didn't do that search, so I don't know. Um, but I think there has to be a decision point where you say either there's not enough data out there, you know, we have done a truly comprehensive search, or we're confident in our methodology, and there's just not enough data out there to do a useful meta-analysis or do a new systematic review when maybe someone has just published one, um, and pivot and either broaden your scope or change your research question or or in some way move from your initial plan. On the other side of things, I think if you go in the other direction, you could say, well, maybe their early planning and development of the research methodology wasn't quite as robust. And in that case, I think there's room to say, well, a little bit more attention to the inclusion and exclusion criteria, which databases you're searching, why you're choosing to include certain papers and not others. You know, why did we go necessarily with a meta-analysis and exclude everything that wasn't a randomized control trial? Like I think then you start to ask these questions and ultimately probably bring in librarians, bring in other senior researchers who have done this a million times, and and then kind of say, okay, how do we shore up our methodology to to get to our end goal? So it's kind of a a bit of a why. I think it depends on it depends on where you are boots on the ground. But those would be my two options. Either you you have to pivot overall or you have to shore up some of the the that initial methodology that the rest of the paper is built on. You agree with that, uh, Dr.

SPEAKER_02 18:47

Stacy?

SPEAKER_01 18:48

Yeah, for sure. I think summed up well.

SPEAKER_02 18:53

Well, thank you for that wonderful article this month and everything. Before we move on to our second article, we uh do want to remind our listeners that we do have video uh recorded with this on our YouTube channel. Uh smash that follow and subscribe button, whether it's on YouTube or it's on your uh podcast uh platform of choice, and to be able to follow along with things that we are talking about here with the OMM Research Podcast. And um you can always check out things that are happening as well on the Dio TouchNet website. Our second article, brought here by Dr. Stacy, is looking at uh how osteopaths practice in Australia.

SPEAKER_01 19:34

Yes, the title of the article is Therapeutic Approaches and Conceptions of Practice in Osteopaths in Australia, a national cross-sectional study and exploratory factor analysis of the osteotech by uh Thompson et al. Published November 1st, 2024 in the journal BMC Health Services Research. They tried to answer the question: Can the osteopaths therapeutic approaches questionnaire, abbreviated osteotech, T-A-Q, demonstrate supportive evidence of internal structure and reliability in an Australian osteopathic population? They wanted to see if it could help provide evidence about therapeutic orientation and conceptions to practice. So basically saying, can we tell how different people think about their practice based off of this test? And their conclusion is that it did provide um initial um internal structure and content evidence for the for the uh questionnaire.

SPEAKER_02 20:41

Gotcha. So, what kind of jump down to you related to this article that made you want to bring it to us this month?

SPEAKER_01 20:48

There are really um there are a lot of really cool things that they did that set up some uh some science in uh very systematic ways, and then some other ways that they maybe deviated from it a little bit in important ways that I think we can learn from. Um one of the main things that this assesses here is this idea of whether something is valid. And we hear this phrase often enough where somebody will say, Oh, this is a validated test, as though that is an award that can be given to uh an instrument and say, like, now that it has been validated, we're free to use it however we want. Um validated is is a little bit like saying a drug is effective. So, number one, that conclusion may or may not be true. But then number two, even if it is true, it really depends on what it is that you're saying the drug is effective for, right? So saying aspirin is effective is fine if you're talking about secondary prevention uh, you know, to prevent hospitalization for repeat MI. It is not True, if you're going to say aspirin is effective as primary treatment for peptic ulcer disease, in which case it would be the opposite of true. And so to say a measurement tool is valid, again, really needs context. And that context has been fleshed out in really modern thinking puts it around five different validity evidence domains. And they explored a couple of them here.

SPEAKER_02 22:28

So can you give us some more information about the validity validity domains that they explored and uh the ones that they didn't? Could you you dive a little deeper into that for our listeners?

SPEAKER_01 22:41

Yeah. So when we talk about something being quote unquote valid, really probably a better way to phrase it would be to say you're going to make uh an argument in support of a certain instrument being useful somehow. And the different domains, so one is um called content evidence or evidence of content validity. Um, so it's really saying, does the item adequately represent the intended thing that it's meant to measure? So if we were to compare it to, say, the COMLEX test, for example, to say that the COMLEX has content validity would be to say it is testing what we are teaching in osteopathic medical school. Um, response process validity is or evidence based on response process is another domain. And so that's saying really, are the respondents interpreting and answering the items as intended? And so for that one, you would say, you know, you'd look at the entire um process used around how the test is taken and interpreted, and and you'd say, okay, well, I thought we were asking this question, but really we were asking that question. So for example, maybe we're asking the question, how much do people know off the top of their head? But we aren't um we aren't monitoring the situation and people are ending up being able to use their phones, which ends up answering a different question, which is what can people find out with access to the internet? And both can be important questions, but if the response process doesn't work out the way you want, it doesn't actually assess the domain that you wanted it to. Um another one is uh internal structure. So that's really um, you know, do the relationships among the items represent a coherent internal structure? So that would be saying, um, you know, so we have people know about things like interrater reliability, which is to say different people using the test to rate would come up to the same score. Intrarator would be somebody using the instrument multiple times would come with the same score. Um and they they did these first two in this study, right? Where they they looked on content and they surveyed a whole bunch of osteopaths in Australia, giving them this osteotac tool. And the osteotac was previously developed in the UK, and they wanted to say, does this make sense in a population of Australian osteopaths? So they give them the test and um they do something called exploratory factor analysis, where they look to see whether the the domains statistically group together the way that um the in some way that might be able to be predictive. Um you could argue that they maybe should have done confirmatory factor analysis since this had already been derived, but then again, it was derived in kind of a different population, so they wanted to.

SPEAKER_00 25:59

So that's um that's probably deeper than we need a slice here, but at the bottom that was gonna be where I would head with that, and yeah, that might be too into the weeds with this.

SPEAKER_01 26:08

Yeah. Um at the end of the day, I will say their their decision of the methods was justifiable and how they um how they went out and analyzing it um was uh from what I can tell, pretty appropriate, right? They did answer the question, you know, does this represent how osteopaths in Australia think about osteopathic medicine? So for example, they would ask questions about like, how much do you, how much do you put your hands on patients versus how much do you talk with them versus how much do you kind of tell them what you do versus get them involved in the discussion process, because they had these three domains that they thought it would follow under educator, communicator, and treater? And they wanted to try and sort people into one of those categories, which gets to um the the last two validity pieces that is where this study loses me a little bit. Um, one is um evidence based on relation to other variables. So basically, you know, does a score on this test correlate with some other external variable, like a like the theory might predict? And then the other one is evidence based on the consequence of testing. So again, if we look at something like the COMLEX and we say, you know, there's a certain cutoff that's going to be pass fail on Comlex one. And so the the consequence evidence would be to say, do people who fail, um, are they less likely to graduate medical school or do they do worse in residency, or are they you're more likely to get sued as a physician, right? So you'd say, okay, the judgment that we are making, well, some of that is also relation to other variables, but um, but if you look at you know what the consequence is, are they are they consequences that make sense based off of um of what you have determined from this test? So again, let's come back to the osteo osteotach, right? Um the authors don't really clearly define what decision the osteotach is really intended to support. So we're we're left asking, how is this tool actually going to change practice or patient care or training or administration or research?

SPEAKER_00 28:30

Um I'm glad you're mentioning that because I I think that's my as we're you know, I'm sitting here listening to you and have read this study, that's the big question that comes to mind. Um, is is what are we doing with this exactly? Because I think the discussion on validity is important for other clinical tools we use and and probably osteopathic philosophy in general. Um, for sure. For this in particular, I'm lost a little bit about what we're what we're doing with this.

SPEAKER_01 29:00

Right. So at the end of the day, what they did is they have uh a really strong argument that this represents some underlying thing that can be measured that is a thing that they want to measure, right? And so that's where we're talking about good um content validity and um and even internal structure validity, though maybe that is a little bit less robust for this for reasons we could get into, but again, that's maybe getting a little into the weeds. The the main thing again is that the the modern validity framework wasn't really fully operationalized here. They they make the claim now that it is validated, but it it feels more like they're talking about the content validity, which some people call face validity, which isn't really a thing in modern validity practice. So they, you know, people that are really into this don't really use the term face validity. Um but again, it has has theoretical value, but they it's really on the authors to help explain to us what is the practical value of this, right? So as it's operationalized, how how can it help support some decisions? Like we really need to be thinking forward about um relation to other variables and consequences of testing. And if you're gonna go through this whole process laying the foundation without getting to the end, it's kind of like going through this whole thing with a drug and being like, okay, does it bind to the receptor? Um, does it uh, you know, do patients know how to take it? But you didn't actually go through the question to say, what are the benefits versus harms of actually prescribing the drug? Or not even thinking about like how might I use the drug?

SPEAKER_02 30:53

Gotcha.

SPEAKER_00 30:54

So if if we're kind of if we have this kind of open question with specifically the osteoattack, maybe my question is like as a researcher, what do I do with this validity information? Do I is it, you know, am I looking for this in other things? Or I mean, obviously, we kind of want to make sure that whatever scales and metrics we're using are validated, but that gets tossed around, like you're saying, kind of as a a rubber stamp to say, okay, my metric is validated. But what are the implications of that? And then if I want to go out and look for something, or or if I have something that I want to validate, how am I doing it differently?

SPEAKER_01 31:33

No, that's a that's a good question. So let's think about other types of heuristics or or tests that we might use in osteopathic manipulative medicine and say Fryet's laws that would say um, you know, a spine moves in a certain way. So if I feel this um this spinal element, you know, this transverse process is posterior on the right compared to the left, it's anterior. I'm going to use that to make a judgment based off of that heuristic uh about, you know, saying that something is rotated right, right? And then I'm going to think through, okay, so if it's rotated right, that's going to mean something else about side bending, flexion. Um, and so now if we look at content, right, does what we're teaching reflect what is actually going on within the spine, or does it reflect how osteopathic physicians conceptualize treatment? And at this point, it's a bit of a circular argument because, you know, since that's what we teach, then yes, it represents how we think about things. So, but then if you were to look at it based off of internal structure and you say, would multiple osteopathic physicians get the same diagnosis from the spa same spinal segment on the same patient, or would that same osteopathic physician going back to the patient make the same diagnosis positionally using the heuristic of Fryett's laws? Right. So for you to say that this is that Fryett's laws are validated in that sense would be simplistic. You could say you could make an argument that it is useful for a certain purpose, but then you'd have to say again, okay, how does it relate to other variables? So if we look at externally, how does it relate to how other specialties or professions conceptualize spinal movement? Or if you were to look at say, um I I don't mean I'm just gonna interrupt you there.

SPEAKER_00 33:29

You mentioned external valid validity, that's not something they really address in this paper, though, right? Or they they touch on it maybe with their they mention, they mention another um other measures of practice. I think they mention another PAVS PT, um, but they don't really do much comparison to the body of the paper that I see.

SPEAKER_01 33:53

No, so it really gets down to as we're looking at different types of assessment tools that we use, saying, How is this being how is it how does it function in real life? What purpose does it serve? And do we have evidence that this is a good purpose and that it's really doing what it claims to do? Rather than saying it is validated or not validated, you look at again, how is it actually being used? Because again, the same test, right? So if you're going to use the Complex to make a decision about who can graduate from osteopathic medical school, it may be suited to that task, but it may not be suited to the task of determining who gets into medical school in the first place, where the MCAT may be better suited to that task.

SPEAKER_02 34:46

This might have to be a topic that we dive further into in some later episodes, but I do have to ask before we end the conversation on this article: do Australian osteopaths practice differently differently from other osteopaths?

SPEAKER_01 35:02

Uh well, I guess you could use the osteotact to answer that question.

SPEAKER_02 35:08

Wonderful. Well, thank you. It's been validated. It's been validated. That's right. Well, thank you both for uh these awesome articles this month and for uh joining us on this episode. We do want to remind our listeners uh that if you want to find out more that's happening within Dio TouchNet, you can go to our website, which is do-to-c h dot n e t to find out more that's happening within the network. Join and become a member or follow up on uh past episodes that we've done. Um again, make sure to smash those follow subscribe buttons on whatever platform you're on to continue to follow along.

unknown 35:44

Dr.

SPEAKER_02 35:45

Abandelara, Dr. Stacy, thank you both for being with us again this month. And we'll see you all next time. Hey, thanks. Thank you.