Establishing the content validity of palpatory examination for the assessment of the lumbar spine using ultrasonography: a pilot study.

CONTEXT: Practitioners of manipulative medicine have long sought to prove the intra- and interexaminer reliability of palpatory examinations in assessing somatic dysfunction. However, decades of research have yet to achieve the level of reproducibility needed to satisfy evidence-based criteria. OBJECTIVES: To examine the content validity of segmental motion evaluations using ultrasonographic measurements and to investigate the implication of these results for understanding the effects of an osteopathic manipulative treatment technique--high-velocity, low-amplitude (HVLA)--applied to somatic dysfunction in the lumbar spine. METHODS: A repeated-measures design was used, with the ultrasonographer blinded to the findings for each participant. The study was divided into 2 phases: (1) palpatory and ultrasonographic examination with no treatment and (2) palpatory and ultrasonographic examination with HVLA treatment. During phase 1, measurements were taken of tissue depth corresponding to bony landmarks of the dysfunctional vertebrae. Dysfunction was identified by means of palpatory examination and captured in sequential (ie, test-retest) ultrasonographic images. Content validity of somatic dysfunction was addressed by comparing palpatory examination with ultrasonographic data. During phase 2, the same protocol for tissue depth measurements was applied to the pre- and posttreatment images for comparison. RESULTS: Twelve young, healthy, asymptomatic students with no contraindications to HVLA treatment were recruited at Kansas City University of Medicine and Biosciences. The test-retest reliability, as determined by a Pearson correlation coefficient, was 0.997. For all participants, objectively identified side of dysfunction correlated with palpatory evaluation of segmental motion. A within-subjects analysis of variance was performed on the raw data, corrected for lumbar lordosis, showing statistical significance for main effect for side of measurement (P<.001) and interaction of side and time (P<.001), and showed no statistically significant effect for time (P=.259). CONCLUSION: Ultrasonography is a reliable instrument for the assessment of somatic dysfunction of the lumbar spine. The data also establish the content validity of palpatory examinations. In addition, this study provides the first objective evidence, to our knowledge, of the effect of a thrusting manipulative treatment on dysfunctional lumbar vertebrae.

Short-term hematologic and hemodynamic effects of osteopathic lymphatic techniques: a pilot crossover trial.

CONTEXT: Research into the physiologic effects of osteopathic lymphatic techniques has been somewhat limited. OBJECTIVE: To assess the short-term hematologic and hemodynamic effects of a comprehensive lymphatic treatment protocol. METHODS: Randomized crossover design that included 10-minute lymphatic treatment and rest (control) protocols delivered 1 week apart for a small pilot group of healthy men (N=15). At baseline, albumin, hematocrit, hemoglobin and platelet count , total protein, and white blood cell count were measured, as were systolic and diastolic blood pressure. All measures were repeated 20, 50, and 80 minutes after baseline data were gathered. RESULTS: Significant condition x time interaction effects were observed, indicating a decrease in platelet counts and an increase in diastolic blood pressure after the lymphatic treatment protocol [corrected]. Statistically significant differences by time were observed in all hemotologic measures and in systolic blood pressure. No adverse events or complications from the treatment protocol were observed in this population. CONCLUSION: Lymphatic techniques may decrease platelet counts and increase diastolic blood pressure during the first hour after treatment.

Temporomandibular disorders and facial pain: a psychophysiological perspective.

This article presents a psychophysiological perspective on temporomandibular muscle and joint disorders (TMJD) and facial pain. After a brief introduction to TMJD, the article presents data, largely derived from work carried out in my laboratory, that address four questions: (1) What are the consequences of parafunctional activities? (2) Do TMJD patients engage in parafunctional activities? (3) Why are TMJD patients unaware of these activities? and (4) What are the implications of these findings for treatment? The findings suggest that low-level parafunctions increase pain in otherwise pain-free individuals and can produce symptoms sufficiently severe to meet the diagnostic criteria for TMJD diagnoses of myofascial pain and/or arthralgia. Patients with certain forms of TMJD report very high levels of parafunctional tooth contact. Their lack of awareness of these behaviors may arise from uncertain definitions of the term "clenching", from proprioceptive deficits, or from the presence of adjunctive behaviors. Preliminary work shows that reduction in tooth contact via habit reversal techniques may be a promising mechanism for reducing pain in these patients.

Perceived efficacy, indications, and information sources for medically indigent patients and their healthcare providers regarding dietary supplements.

BACKGROUND: Evidence exists that medically indigent and minority patients use dietary supplements at rates as high or higher than that of the general population. Safety concerns regarding the use of dietary supplements are further exacerbated by a suboptimal level of patient disclosure and provider inquiry. OBJECTIVE: To determine dietary supplement use, indications, perceived efficacy, and information sources of patients and providers using a pilot study in a clinic for the medically indigent. METHODS: Five hundred self-administered patient surveys and 50 healthcare provider surveys were made available to any patient at a free health clinic in Kansas City, MO. Surveys were collected and descriptive analyses were performed. RESULTS: Three hundred eleven patient surveys were returned. Of the 37.3% (116/311) of respondents who had used dietary supplements, 13.8% (n = 16) had 10 comorbid conditions. Ninety-six dietary supplements were used for 8 medical condition categories. The 9 agents most frequently reported used were garlic (n = 32), aloe/green tea (n = 27 each), chamomile/echinacea (n = 24 each), St. John's wort (n = 22), ginseng (n = 18), and cranberry/Ginkgo biloba (n = 17 each). Patients reported a broad range of indications for taking dietary supplements. Patients reported (mean +/- SD) 2.37 +/- 4.23 agents as effective and 0.78 +/- 1.73 as ineffective or harmful. Provider surveys revealed that 60% (21/35) and 74% (26/35) were currently or had ever used dietary supplements, respectively. Fifty-seven percent (20/35) of providers reported attending educational programs on dietary supplements, and providers perceived patient supplement use to be most influenced by advertisements (40%) and friends (40%). CONCLUSIONS: The medically indigent population uses a wide variety of dietary supplements. There is little consistency in perceived indications, which may prevent clinicians from accurately predicting specific herbal use rationale given any individual's or population's set of comorbid conditions. Clinicians are encouraged to accurately determine their individual practice setting's use pattern.

Efficacy of biofeedback-based treatments for temporomandibular disorders.

Bibliographic searches identified 14 controlled and uncontrolled outcome evaluations of biofeedback-based treatments for temporomandibular disorders published since 1978. This literature includes two randomized controlled trials (RCTs) of each of three types of biofeedback treatment: (1) surface electromyographic (SEMG) training of the masticatory muscles, (2) SEMG training combined with adjunctive cognitive-behavioral therapy (CBT) techniques, and (3) biofeedback-assisted relaxation training (BART). A detailed review of these six RCTs, supplemented with information from non-RCT findings, was conducted to determine the extent to which each type of intervention met treatment efficacy criteria promulgated by the Association for Applied Psychophysiology and Biofeedback (AAPB). We conclude that SEMG training with adjunctive CBT is an efficacious treatment for temporomandibular disorders and that both SEMG training as the sole intervention and BART are probably efficacious treatments. We discuss guidelines for designing and reporting research in this area and suggest possible directions for future studies.

Parafunctional clenching, pain, and effort in temporomandibular disorders.

This study tested the hypotheses that (1) parafunctional clenching increases pain and can lead to a diagnosis of temporomandibular disorder (TMD) pain and (2) electromyographic (EMG) activity during parafunctional clenching is significantly and positively correlated with reports of pain. Fourteen individuals without TMD participated in 5 consecutive days of 20-min long EMG biofeedback training sessions of the left and right temporalis and masseter muscles. Subjects were randomly assigned to either a Decrease or Increase group and were instructed to maintain EMG activity below 2 microV or above 10 microV during training, respectively. Two Increase subjects and no Decrease subjects were diagnosed, by a blinded examiner, with TMD pain following training. Self-reported pain posttraining was significantly higher for the Increase group. Masseter EMG activity was strongly correlated with pain. Parafunctional clenching increases pain and can lead to a diagnosis of TMD in otherwise pain-free individuals. Pain reports are positively correlated with the activity of the masseter muscle.