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The authors address several points including alleged missing LBP inclusion criteria, misinterpretation of eligibility and index-date temporal alignment, and failure to apply imposed date-range restrictions. They argue the replication logic could introduce prior or recurrent LBP and older data, inflating cohort sizes without invalidating results.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/response-to-query-design-logic-in-trinetx-studies-letter-to-the-editor/432383/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/response-to-query-design-logic-in-trinetx-studies-letter-to-the-editor/432383.png","ImageObject",300,407,{"name":92,"@type":93},"Elsa","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-30","2026-09-29",true,{"@type":102,"interactionType":103,"userInteractionCount":44},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the main purpose of this letter?","Question",{"text":112,"@type":113},"To respond point by point to critiques of the original study’s query design and inclusion logic regarding SMT for low back pain and opioid use disorder.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How did the authors define inclusion for low back pain patients?",{"text":117,"@type":113},"They included adults receiving care for a new LBP episode with or without sciatica using ICD-10 codes M54.4 or M54.5, as described in the methods.",{"name":119,"@type":110,"acceptedAnswer":120},"Why do the authors argue that the replication query may have produced different cohorts?",{"text":121,"@type":113},"Because it omitted imposed temporal constraints and used more flexible timing (e.g., allowing SMT on or after the first instance of LBP), which could capture prior/recurrent cases and older data than the 2015–2023 restriction.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},432383,1791271010,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":44,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24,"preview_page_count":4},137455077381,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Health Science Reports   \nLETTER TO THE EDITOR   \nResponse to: Query Design Logic in TriNetX Studies  \nRobert J. Trager1,2,3  | Zachary A. Cupler4  | Jordan A. Gliedt5  | Ryan A. Fischer6 | Roshini Srinivasan7 | Hannah Thorfinnson8  \n1Connor Whole Health, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA | 2Department of Family Medicine and Community Health,School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA | 3Department of Biostatistics and Bioinformatics Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina, USA | 4Physical Medicine & Rehabilitative Services, Butler VA Health Care System, Butler, Pennsylvania, USA | 5Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA | 6Section of General Internal Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA | 7Duke University Department of Medicine, Duke University Hospital, Durham, North Carolina, USA | 8Butler VA Medical Center, Butler VA Health Care System, Butler, Pennsylvania, USA  \nCorrespondence: Robert J. Trager ([Robert.Trager@case.edu](Robert.Trager@case.edu))  \nReceived: 7 November 2025 | Revised: 7 November 2025 | Accepted: 18 December 2025  \n1 | Introduction  \nWe thank the author(s) for their interest in our study examining the association between spinal manipulative therapy (SMT) for low back pain (LBP) and opioid use disorder [1] and for their efforts to replicate our query. However, several key aspects of our design and inclusion logic were misinterpreted, leading to incorrect conclusions in their Letter.  \n2 | Point‐by‐Point Response  \n2.1 | Inclusion of Low Back Pain Patients  \nA central argument of the Letter that an “inclusion criterion for LBP was missing” from our methods is incorrect. As stated in our article, we included adults “receiving care for a new LBP episode with or without sciatica (ICD‐10: M54.4 or M54.5)”(Methods, section 2.2) . Therefore, the suggestion that LBP diagnoses were not required is factually inaccurate and misrepresents our methods.  \n2.2 | Misinterpretation of Eligibility Criteria and Index Date Alignment  \nThe Letter misinterprets our handling of temporal logic and inclusion criteria. The authors suggest that we should have required “any LBP code before or on the same day as the patients′ index SMT event” or ibuprofen prescription. This does  \nnot align with our study′s objective or design. Our analysis focused specifically on new episodes of LBP, as stated in the abstract, methods, and supporting materials. We excluded prior LBP and radiculopathy episodes from −91 to −1 days before the index date (see Supporting Information: Table S1), ensuring that included patients were experiencing a new episode of LBP.  \nIllustratively, the Letter′s attempted replication query allowed SMT to occur “on or after the first instance” of LBP. This flexible logic could include patients with longstanding or recurrent LBP, testing a different clinical question altogether. Our approach, which required SMT to occur on the same date as the new episode of LBP diagnosis, ensured that the treatment corresponded to the index episode under study. Accordingly, the critique that some patients “were not diagnosed with LBP at study entry” is unfounded.  \n2.3 | Failure to Apply Temporal Constraints  \nIn attempting to reproduce our query, the author omitted the date range restrictions we imposed. Their supplemental file includes the phrase “the terms in this group occurred at anytime,” whereas our study restricted inclusion to encounters between 2015 and 2023 (Abstract and section 2. 1) . Their omission could inflate cohort sizes and introduce older data that may not reflect contemporary opioid prescribing trends. In TriNetX, it is possible to obtain data from 20 years before the query date, such that their query likely captured data from 2005 to present, rather t","cbCaigQ1q9DcI7cs","https://ap.wps.com/l/cbCaigQ1q9DcI7cs","pdf",243727,"English","# Introduction\n# Point-by-Point Response\n## Inclusion of Low Back Pain Patients\n## Misinterpretation of Eligibility Criteria and Index Date Alignment\n## Failure to Apply Temporal Constraints\n## Database Growth Does Not Imply Invalidation\n# Conclusions","[{\"question\":\"What is the main purpose of this letter?\",\"answer\":\"To respond point by point to critiques of the original study’s query design and inclusion logic regarding SMT for low back pain and opioid use disorder.\"},{\"question\":\"How did the authors define inclusion for low back pain patients?\",\"answer\":\"They included adults receiving care for a new LBP episode with or without sciatica using ICD-10 codes M54.4 or M54.5, as described in the methods.\"},{\"question\":\"Why do the authors argue that the replication query may have produced different cohorts?\",\"answer\":\"Because it omitted imposed temporal constraints and used more flexible timing (e.g., allowing SMT on or after the first instance of LBP), which could capture prior/recurrent cases and older data than the 2015–2023 restriction.\"}]","Response to: Query Design Logic in TriNetX Studies - Letter to the Editor | PDF",1790659404]