Time-frequency analysis of temporomandibular joint (TMJ) clicking sounds using radially Gaussian Kernels.

Temporomandibular joint (TMJ) sounds and motion were recorded during two clinically-derived movements--simple jaw opening and jaw protrusion followed by opening--from ten patients. A new time-frequency method--radially Gaussian kernel distribution--was applied to classify the TMJ clicking sounds into six groups, type I to type VI, based on the time-frequency patterns of energy distribution. The number of clicks and percentage of each type were examined. Relations between the two movements were examined by the prevalence of each type. A detailed classification of TMJ clicking sounds is provided by time-frequency patterns and may provide a better understanding of temporomandibular disorders.

Quantitative description of temporomandibular joint sounds: defining clicking, popping, egg shell crackling and footsteps on gravel.

This study presents a quantitative description of temporomandibular joint (TMJ) sounds provided by a rule-based classification system based on sound classification by three dentists, who listened to and classified the sound recordings as no sound, click, coarse crepitus and fine crepitus. The sounds were recorded with microphones in the ear canal from 126 subjects during vertical opening, digitized at 15 000 Hz, and replayed using a computer sound card and speakers. The dentists' classification of a test set resulted in intra- and inter-tester j values ranging from 0.71 to 0.81 and 0.61-0.73, respectively. Pooled j values for the dentists and the dentists plus the rules were 0.67 and 0.58, respectively, which were not significantly different in terms of the sound features on which the rules were based (P = 0.13). Linear discriminant analysis showed the four TMJ sound types were significantly different (P < 0.001). The performance of the rules was equivalent to the dentists and marginally better than the linear discriminant functions (P = 0.08), establishing the validity of the quantitative descriptions they provide. The recording and rebroadcast methodology produced sounds very similar to those observed in the clinic and could be used to train clinicians in classifying TMJ sounds.

The association between research diagnostic criteria for temporomandibular disorder findings and biting force and endurance in patients with temporomandibular disorders.

OBJECTIVE: This study was designed to evaluate the association between examination findings based on Research Diagnostic Criteria for Temporomandibular Disorders and performances on bite force and endurance tasks. METHODS: Subjects were 126 patients with temporomandibular disorder and 34 pain-free controls. A subset of patients with temporomandibular disorder (n = 56) also were evaluated following a brief conservative 4-week treatment intervention. RESULTS: A multivariate analysis of variance indicated that female patients (P <.001) but not males (P =.17) had lower bite forces than age- and gender-matched controls. Dental examination findings were significantly but modestly predictive of bite task performance (R2 = 0.175), with higher joint pain and smaller maximum unassisted jaw opening associated with lower bite force. The brief treatment interventions resulted in both self-reported and clinically determined improvements. Clinical and self-reported improvement significantly predicted pre-post treatment changes in biting force among female subjects (R2 = 0.237). Specifically, reduction in joint palpation pain and self-reported pain (McGill Pain Questionnaire short form) were the primary predictors of increases in bite force. The improvement in biting force was modest (mean = 7 lb), and the force levels of female patients remained lower than those of control subjects. Treatment did not significantly increase endurance time. DISCUSSION: The brief conservative treatments used resulted in improvements in pain and jaw opening, and 81.8% of patients reported moderate to major improvement. The modest association of the bite task with Research Diagnostic Criteria for Temporomandibular Disorders examination findings and treatment improvement in this heterogeneous sample suggests that the bite and endurance tasks have limited diagnostic utility and sensitivity to treatment effects.

Are all older adults with persistent pain created equal? Preliminary evidence for a multiaxial taxonomy.

BACKGROUND: Persistent pain is grossly undertreated in older adult sufferers, despite its high prevalence in this age group. Because of its multidimensional impacts, including depression, sleep disruption and physical disability, patients with persistent pain often benefit from interdisciplinary pain clinic treatment. This treatment is expensive, however, and may not be required by all patients. The Multiaxial Assessment of Pain (MAP) has demonstrated value in predicting response to treatment in younger adults with persistent pain. OBJECTIVE: To examine the feasibility of a MAP taxonomy for community-dwelling adults age 65 years or older. PARTICIPANTS AND PROCEDURES: One hundred eight subjects with persistent pain (mean age 73.8 years, SD=8.4 years) were interviewed and data collected on demographics, pain intensity, depressive symptoms, sleep disruption, pain interference with performance of basic and instrumental activities of daily living, frequency of engagement in advanced activities of daily living, cognitive function and comorbidity. A subset of these subjects underwent physical capacities testing, including maximal isometric lift strength, dynamic lifting endurance, timed chair rise and balance. RESULTS: Analyses derived three primary clusters of patients. Cluster 1 (24%) reported less intense pain, less depression and sleep disruption, and higher activity levels. Cluster 3 (30%) suffered from more pain and were more functionally disabled. Cluster 2 (46%) had characteristics of cluster 1 and cluster 3, but with some characteristics that were clearly unique. CONCLUSIONS: While these results are preliminary and require further validation, they indicate that older adults are heterogeneous in their response to persistent pain. Future studies should be performed to examine whether the MAP taxonomy is applicable to older adults regardless of medical diagnosis. Ultimately, this information may have meaning with regard to both treatment prescribing, and the design and interpretation of intervention studies.

Effects of body mechanics training on performance of repetitive lifting.

OBJECTIVE: To measure the efficacy of body mechanics instruction (BMI) in patients with low back pain. METHOD: The effect of BMI was measured in four participants with back injuries using a standardized lifting protocol. Static strength, weight lifted, number of lifts completed, and motion analysis data to describe the body mechanics were measured before and after work hardening to evaluate treatment effects. The participants' performances were compared with 52 controls from an earlier study. RESULTS: Starting postures, characterized by degrees of hip and knee flexion, varied by participant but favored a squat lift in three participants when compared with the controls. Dynamic motion synchrony of the hip and knee joints was similar to controls in three of the four participants. Posttest data revealed significant changes in static strength, dynamic endurance, and lifting speed. CONCLUSION: Intensive instruction in body mechanics provided during the work-hardening treatment produced major changes in lifting styles, in terms of both starting postures and dynamic aspects of repetitive lifting. The computerized measurement procedures used in this study permitted more careful and detailed analyses of body mechanics, particularly dynamic aspects, than is possible with observational methods. This study demonstrated some of the inherent intricacies in isodynamic lifting and suggests additional areas of performance that may be important to address in BMI.

The influence of mandibular movements on joint sounds in patients with temporomandibular disorders.

STATEMENT OF PROBLEM: There are discrepancies among researchers concerning the reliability and use of temporomandibular joint sounds. PURPOSE: This study examined the reliability of mandibular movements and sounds and determined the correlation between movements and sounds. MATERIAL AND METHODS: The mandibular movements of 35 subjects diagnosed with temporomandibular disorders were recorded with 2 CCD cameras, and sounds were recorded bilaterally with Panasonic electret condenser microphones in the ear canal. Subjects performed 3 movements, each repeated 5 times. RESULTS: Reliability of maximum movements across the 5 trials was good to excellent, with Intraclass Correlation Coefficients (ICC) between 0.76 and 0.91 for all movements except protrusion. Temporomandibular sound event counts were reliable for most movements, including vertical opening, protrusion, and right and left laterotrusion (ICCs between 0.41 and 0.81). Most subjects produced sound events either in 100% or in none of the trials. Reliability for sound events was better during protrusion (ICCs between 0.56 and 0.81) than vertical opening (ICCs 0.41 to 0.64). Subjects with sound events during vertical opening (followed by closing) were significantly more likely to have sound events during protrusion (followed immediately by vertical opening and closing) (P <.01). CONCLUSION: Temporomandibular sound events are generally reliable and warrant study regarding their use in classifying and diagnosing patients with temporomandibular disorders. Condylar translation, which occurs during both vertical opening and protrusion, appears to have a strong influence on the production of temporomandibular sound events.

Sore nipples in breast-feeding women: a clinical trial of wound dressings vs conventional care.

BACKGROUND: Sore nipples in breast-feeding mothers are a common cause of premature weaning, and are difficult to treat owing to recurrent trauma and exposure to the infant's oral flora. OBJECTIVE: To compare the safety and efficacy of a hydrogel moist wound dressing (Elasto-gel, Southwest Technologies Inc, Baltimore, Md) with the use of breast shells and lanolin cream in the treatment of maternal sore nipples associated with breast-feeding. DESIGN: Randomized controlled trial comparing the above treatments for sore nipples. Patients were seen for a maximum of 3 follow-up visits within 10 days, or until the resolution of symptoms. SETTING: The Maternal-Infant Lactation Center at the Mercy Hospital of Pittsburgh, Pittsburgh, Pa, a tertiary care teaching hospital in inner-city Pittsburgh. PATIENTS: A referred sample of 42 breast-feeding women who presented to the Maternal-Infant Lactation Center for the treatment of sore nipples. All patients with breast infection or chronic unrelated pain conditions were excluded from the study. INTERVENTION: After informed consent, patients were randomized to receive either a hydrogel wound dressing or breast shells and lanolin. All patients underwent a history, physical examination of the infant and the mother's breasts, assessment of breast-feeding technique, and breast-feeding instruction. MAIN OUTCOME MEASURES: The degree of pain on self-report questionnaires and the change in scores for physical examination, breast-feeding technique, and pain behaviors during breast-feeding. RESULTS: Although both treatments, in association with instruction in breast-feeding technique, were effective, greater improvement was seen in the group using breast shells and lanolin. This reached statistical significance for physician-rated healing (P<.01) and self-reported pain (P<.05). There were significantly more infections in the dressing group (P<.05), which resulted in early discontinuation of the study. CONCLUSIONS: Prevention of sore nipples by teaching proper technique on the initiation of breast-feeding should be instituted. For those cases in which sore nipples do develop, breast shells and lanolin in association with instruction in breast-feeding technique are more effective than moist wound dressings. Lanolin and shells should remain first-line therapy.

Shoulder and elbow motion during two speeds of wheelchair propulsion: a description using a local coordinate system.

Individuals who propel wheelchairs have a high prevalence of upper extremity injuries. To better understand the mechanism behind these injuries this study investigates the motion of the shoulder and elbow during wheelchair propulsion. The objectives of this study are: (1) To describe the motion occurring at the shoulder and elbow in anatomical terms during wheelchair propulsion; (2) to obtain variables that characterize shoulder and elbow motion and are statistically stable; (3) to determine how these variables change with speed. The participants in the study were a convenience sample of Paralympic athletes who use manual wheelchairs for mobility and have unimpaired arm function. Each subject propelled an ultralight wheelchair on a dynamometer at 1.3 and 2.2 meters per second (m/s). Biomechanical data was obtained using a force and moment sensing pushrim and a motion analysis system. The main outcome measures investigated were: maximum and minimum angles while in contact with the pushrim, range of motion during the entire stroke and peak accelerations. All of the measures were found to be stable at both speeds (Cronbach's alpha > 0.8). The following measures were found to differ with speed (data format: measure at 1.3 m/s +/- SD; measure at 2.2 m/s +/- SD): minimum shoulder abduction angle during propulsion (24.5 degrees +/- 6.7, 21.6 degrees +/- 7.2), range of motion during the entire stroke in elbow flexion/extension (54.0 degrees +/- 9.9, 58.1 degrees +/- 10.4) and shoulder sagittal flexion/extension (74.8 degrees +/- 9.4, 82.6 degrees +/- 8.5), and peak acceleration in shoulder sagittal flexion/extension (4044 degrees/s2 +/- 946, 7146 degrees/s2 +/- 1705), abduction/adduction (2678 degrees/s2 +/- 767, 4928 degrees/s2 +/- 1311), and elbow flexion/extension (9355 degrees/s2 +/- 4120, 12889 degrees/s2 +/- 5572). This study described the motion occurring at the shoulder and elbow using a local coordinate system. Stable parameters that characterize the propulsive stroke and differed with speed were found. In the future these same parameters may provide insight into the cause and prevention of shoulder and elbow injuries in manual wheelchair.

Spinal cord stimulation revisited.

The proportion of patients with intractable pain successfully managed with spinal cord stimulation (SCS) remains disputed. We analyze 27 consecutive patients with intractable pain treated with SCS using identical hardware (Itrel II System; Medtronic Neurological, Inc Minneapolis, MN, USA) by a single satisfactory diagnosis 1992 through 1995. A rigid selection protocol was used: 1. A satisfactory diagnosis of the pathologic process resulting in pain was made. 2. A corrective surgical procedure was judged not feasible by surgeons experienced in the particular pathology, e.g., vascular peripheral nerve, spine. 3. Lack of satisfactory response to noninterventional pain management modalities by an interdisciplinary pain clinic. 4. Independent psychological evaluation, including a structured interview was performed by a psychologist specialized in chronic pain management. In the last eight cases, a battery of self-report tests designed to assess psychosocial and behavioral consequences of the chronic pain problem were administered as well. All cases were of nonmalignant pain, except for one patient. Thirteen cases were diagnosed with failed back surgery syndrome (FBSS), one older patient with lumbosacral radiculopathy who refused decompression, one cervical radiculopathy and Klippel-Feil syndrome, six with reflex sympathetic dystrophy (RSD), two with peripheral vascular ischemic disease, one with post-thoracotomy pain syndrome, one with leg pain following resection of angiolipoma, one with traumatic superficial peroneal neuropathy, and one with Pancoast's tumor. Fifteen patients were female and twelve were male. All were Caucasian. Their ages ranged from 27 to 84 years (mean:48). The average follow-up was 21 months (range: 48-6). All patients underwent a three day trial screening with Pisces-Quad/Resume epidural leads connected to a temporary external stimulator. An Itrel II System pulse-generator was internalized in each of the 24 patients who had successful trial (three cervical and twenty-one thoracic-lumbar). There was no morbidity. Pain reduction was sustained in 22 out of the 24 patients who continue to use the stimulator. The same number would choose to receive in an electrical stimulator again. Normalization or improvement in Quantitative Sudomotor Axon Reflex Test (Q-SART) and Thermography was documented in the patients with RSD. We conclude that rigid selection protocol can maximize the proportion of patients with intractable pain who are successfully treated with SCS. Strict neurosurgical technique eliminates infection risk. Hardware selection minimizes incidence of malfunction.

A comparison of the effect of different occlusal forms in mandibular implant overdentures.

STATEMENT OF PROBLEM: Posterior tooth form selection for implant overdentures is made according to personal preference and experience using the concepts of conventional complete denture prosthodontics. PURPOSE: This study (1) compared the masticatory efficiency of three occlusal forms, 0 degrees, 30 degrees, and lingual contact (lingualized occlusion), in subjects with mandibular implant overdentures, and (2) determined their effects on the implant supporting tissues. MATERIAL AND METHODS: Eight patients who had four root form implants in the mandibular symphysis area connected with a Hader bar were selected. Maxillary and mandibular dentures were constructed for each patient with interchangeable posterior segments and the three occlusal forms were tested. The masticatory efficiency for each posterior tooth form was assessed with objective food tests and a subjective patient preference questionnaire. Periodic evaluation of implant-supporting tissues also was performed. RESULTS: Reliability analysis showed that all R1 coefficients were > or =0.80 (<0.001), indicating high subject consistency between multiple chewing efficiency trials. MANOVA analysis indicated a significant difference in chewing efficiency among the three occlusal forms (p < 0.001). The 0 degree occlusal form was associated with a significantly higher number of chewing strokes compared with 30 degrees or lingualized occlusal forms. The different occlusal forms were not found to have a clinically detrimental effect on the peri-implant soft or hard tissues. CONCLUSION: Chewing efficiency tests and patient preference ratings showed that 30 degree teeth and lingual contact provided better chewing efficiency than 0 degree teeth. None of the tested occlusal forms showed any clinical or radiographic detrimental effect on the implant-supporting tissues.

Early inpatient rehabilitation after elective hip and knee arthroplasty.

CONTEXT: Inpatient rehabilitation after elective hip and knee arthroplasty is often necessary for patients who cannot function at home soon after surgery, but how soon after surgery inpatient rehabilitation can be initiated has not been studied. OBJECTIVE: To test the hypothesis that high-risk patients undergoing elective hip and knee arthroplasty would incur less total cost and experience more rapid functional improvement if inpatient rehabilitation began on postoperative day 3 rather than day 7, without adverse consequences to the patients. DESIGN: Randomized controlled trial conducted from 1994 to 1996. SETTING: Tertiary care center. PARTICIPANTS: A total of 86 patients undergoing elective hip or knee arthroplasty and who met the following criteria for being high risk: 70 years of age or older and living alone, 70 years of age or older with 2 or more comorbid conditions, or any age with 3 or more comorbid conditions. Of the 86 patients, 71 completed the study. INTERVENTIONS: Random assignment to begin inpatient rehabilitation on postoperative day 3 vs postoperative day 7. MAIN OUTCOME MEASURES: Total length of stay and cost from orthopedic and rehabilitation hospital admissions, functional performance in hospitals using a subset of the functional independence measure, and 4-month follow-up assessment using the RAND 36-item health survey I and the functional status index. RESULTS: Patients who completed the study and began inpatient rehabilitation on postoperative day 3 exhibited shorter mean (+/-SD) total length of stay (11.7+/-2.3 days vs 14.5+/-1.9, P<.001), lower mean (+/-SD) total cost ($25891+/-$3648 vs $27762+/-$3626, P<.03), more rapid attainment of short-term functional milestones between days 6 and 10 (36.2+/-14.4 m ambulated vs 21.4+/-13.3 m, P<.001; 4.8+/-0.8 mean transfer functional independence measure score vs 4.3+/-0.7, P<.01), and equivalent functional outcome at 4-month follow-up. CONCLUSION: These data showed that high-risk individuals were able to tolerate early intensive rehabilitation, and this intervention yielded faster attainment of short-term functional milestones in fewer days using less total cost.

Management of patient-controlled analgesia: a comparison of primary surgeons and a dedicated pain service.

Although Patient-Controlled Analgesia (PCA) is routinely available in most hospitals in the United States, there appears to be little standardization regarding who provides this valuable service to postoperative patients. This study evaluates the differences in PCA management practices and patient outcomes between primary service (PS) physicians and acute pain service (APS) physicians. Over a 3-mo period, 40 patients prescribed PCA by PS physicians were prospectively studied without the knowledge of the physicians or nurses involved in PCA management. After collecting PS data, a proportionate stratified random sampling procedure was used to select 40 APS patients matched for gender, age, and type of surgery. Data regarding patient demographics, PCA prescription, changes in PCA orders, opioid consumption, reason for discontinuation of PCA, verbal analog scale pain scores, side effects, and post-PCA pain management were analyzed. Although pain scores were not different between groups, APS patients had fewer side effects, were more likely to receive a loading dose, had their PCA settings adjusted more often (P < 0.05), and used more opioid. PS patients were more likely to receive intramuscular medications after PCA discontinuation (P < 0.05). This study demonstrates potentially important PCA management differences between APS and PS physicians.

Wrist biomechanics during two speeds of wheelchair propulsion: an analysis using a local coordinate system.

OBJECTIVE: To describe motion, forces, and moments occurring at the wrist in anatomic terms during wheelchair propulsion; to obtain variables that characterize wrist function during propulsion and are statistically stable; and to determine how these variables change with speed. DESIGN: Case series. SETTING: Biomechanics laboratory. PARTICIPANTS: Convenience sample of Paralympic athletes (n = 6) who use manual wheelchairs for mobility and have unimpaired arm function. INTERVENTION: Subjects propelled a standard wheelchair on a dynamometer at 1.3m/sec and 2.2m/sec. Biomechanical data were obtained using a force and moment sensing pushrim and a motion analysis system. MAIN OUTCOME MEASURES: Maximum angles, forces, and moments in a local, wrist coordinate system. Each variable was evaluated for stability using Cronbach's alpha. Measures found to be stable (infinity > .8) at each speed were then compared to look for differences associated with speed. RESULTS: The following measures were stable at both speeds: maximum wrist flexion, ulnar deviation, and radial deviation angles, peak moments acting to cause wrist flexion, extension, and ulnar deviation, peak shear forces acting between the radial and ulnar styloids, and peak axial force acting at the wrist. Of these measures, the following measures differed (p < .05) between speeds (+/-SD): maximum radial deviation (1.3m/sec, 25.1 degrees +/- 9.0; 2.2m/sec, 21.4 degrees +/- 6.9), peak flexion moment (1.3m/ sec, 3.4N.m +/- 3.0; 2.2m/sec, 5.2N.m +/- 3.7), peak extension moment (1.3m/sec, 10.4N.m +/- 4.8; 2.2m/sec, 13.6N.m +/- 5.1), peak shear acting from the ulnar styloid to the radial styloid (1.3m/sec, 2.3N +/- 2.7, 2.2m/sec, 8.3N +/- 7.5) and maximum axial force (1.3m/sec, 50.9N +/- 18.2; 2.2m/sec, 65.9N +/- 27.6). CONCLUSION: This study found stable parameters that characterize wrist biomechanics during wheelchair propulsion and varied with speed. Ultimately these parameters may provide insight into the cause and prevention of wrist injuries in manual wheelchair users.

The evolving MR appearance of structures in the internal auditory canal after removal of an acoustic neuroma.

PURPOSE: To identify patterns of enhancement in the internal auditory canal (IAC) on MR studies after removal of an acoustic neuroma, including changes in those patterns with time; to evaluate signal and enhancement of the labyrinth; to differentiate normal postoperative findings from those suggesting residual tumor; and to describe MR hallmarks of surgical approaches. METHODS: We reviewed the postoperative MR studies obtained in 36 patients who had had surgery for acoustic neuroma (101 images total). Four patterns of IAC enhancement were evaluated, as was labyrinthine signal intensity before and after contrast administration, changes in findings over time, and anatomic alterations caused by surgery. RESULTS: All patients had enhancement of the IAC on the first postoperative study. In 30 patients, IAC enhancement remained the same or decreased over time. Seventeen patients had hyperintense cochlear signal and 15 had cochlear enhancement that decreased with time. Effects of retrosigmoid craniotomy, a translabyrinthine surgical approach, and middle fossa craniotomy were recognizable. CONCLUSION: Linear enhancement in the IAC is probably normal after surgery. Nodular and masslike enhancement and any progressive enhancement may require close follow-up to monitor growth of residual tumor. Labyrinthine hyperintensity may reflect blood metabolites. An MR protocol is suggested for following up patients in the years after surgery.

Traumatic onset of temporomandibular disorders: positive effects of a standardized conservative treatment program.

OBJECTIVE: To compare presenting problems and response to treatment of chronic temporomandibular (TMD) patients who perceive the onset of their symptoms to be related to trauma with those who report symptoms of unknown origin. DESIGN: Prospective treatment outcome study. SETTING: Outpatient multidisciplinary pain treatment center at a university medical center. PATIENTS: A total of 361 were evaluated initially, including 103 who perceived traumatic onset of symptoms and 258 who did not perceive onset to be related to trauma. Two hundred thirty-three (59 trauma and 174 nontrauma) returned for follow-up evaluation 6 months after the conclusion of treatment. INTERVENTIONS: Standardized six-session treatment program consisting of intraoral appliance, biofeedback, and stress management training. OUTCOME MEASURES: Clinical changes in muscle pain, temporomandibular joint pain, and mandibular opening. Self-report of change in perceived pain severity (MPQ--short form), depressive symptoms (BDI), catastrophizing about pain (CSQ--catastrophizing scale), MPI--interference scale, oral parafunctional habits, global evaluation of improvement, and use of pain medications at follow-up. RESULTS AND CONCLUSIONS: Regression of onset type on pretreatment variables indicated that a small but statistically significant proportion of pretreatment variability (8.7%) could be accounted for by onset. Both traumatic and nontraumatic onset groups showed positive outcomes following treatment. No significant differences between groups were found for any of the clinical or self-reported outcome measures with the exception that a significantly higher percentage of the trauma group reported using pain medication at follow-up. These findings are in contrast with previous suggestions that post-traumatic TMD patients show poorer response to treatment than nontrauma TMD patients.

Elongated styloid process in a temporomandibular disorder sample: prevalence and treatment outcome.

An elongated styloid process is an anatomic anomaly present in 2% to 30% of adults; it is occasionally associated with pain. Its prevalence among patients with classic temporomandibular disorder pain symptoms is unknown. The effect of conservative treatment on patients who have symptoms of temporomandibular disorders and an elongated styloid process is also unknown. The objectives of this study were to determine the prevalence of the elongated styloid process in a sample of patients with temporomandibular disorders and to compare patients with and without the elongated styloid process on initial presenting signs and symptoms and treatment outcome. A total of 100 panoramic radiographs of patients with symptomatic temporomandibular disorders were examined to ascertain the presence or absence of an elongated styloid process. All patients participated in a conservative treatment program of biofeedback and stress management and a flat-plane intraoral appliance. Initial symptoms and treatment outcome of patients with and without an elongated styloid process were compared by use of multivariate analysis of variance on several oral-paraoral and psychosocial-behavioral methods. The prevalence of an elongated styloid process in this clinic sample of temporomandibular disorders was 27%. The patients with or without an elongated styloid process were not significantly different in pretreatment symptoms, and both groups exhibited substantial treatment gains. However, patients with an elongated styloid process showed significantly less improvement on unassisted mandibular opening without pain than did patients who did not have an elongated styloid process. This suggests that an elongated styloid process may place structural limitations on pain-free maximum mandibular opening. The results support conservative management of patients with symptoms of temporomandibular disorders when an elongated styloid process is present.

Dysfunctional patients with temporomandibular disorders: evaluating the efficacy of a tailored treatment protocol.

Forty-eight dysfunctional patients (i.e., high levels of pain, interference, and affective distress and low levels of perceived control) with temporomandibular disorders (TMDs) were randomly assigned either to a treatment consisting of an intraoral appliance (IA) and stress management with biofeedback (SM) plus nondirective, supportive counseling (SC) -- IA + SM + SC -- or to a customized treatment that included cognitive therapy (CT) with the IA and SM--IA + SM + CT. Both treatment groups reported statistically significant reductions on a set of physical, psychosocial, and behavioral measures posttreatment and at a 6-month follow-up. However, the intervention that included CT demonstrated significantly greater reductions in pain, depression, and medication use. Only the groups receiving the treatment that included the CT demonstrated continued improvements to the follow-up on pain associated with muscle palpation, self-reported pain severity, depression, and use of medications. These results support the efficacy of the tailored treatment for dysfunctional TMD.

Functional capacity assessment: Influence of behavioral and environmental factors.

The environment surrounding the functional capacity evaluation (FCA) is complex and determined by both external factors as well as those specific to the testing situation. In this paper we (1) briefly review existing models of pain, (2) highlight how current FCAs of pain patients adhere in general to behavioral conceptualizations of chronic pain, (3) review some inadequacies of current conceptualizations of FCA when it applies to chronic pain, (4) review the many internal and external environmental factors that can significantly influence FCAs, and (5) consider some psychosocial factors that play an important role in patients' performances. We conclude that not only should evaluators more carefully consider the central influences of psychosocial factors when interpreting the results of FCAs, but that an alternate conceptual model that emphasizes both environmental and psychological factors is also needed to more adequately describe the physical performances obtained during FCAs.

Body motion patterns during a novel repetitive wheel-rotation task. A comparative study of healthy subjects and patients with low back pain.

STUDY DESIGN: This study evaluated performance differences between patients with chronic low back pain and a control group during their performance of a novel functional capacity task. OBJECTIVE: To 1) evaluated strength and endurance differences between patients and control subjects, 2) test for movement pattern differences between these groups, and 3) evaluate how these patterns changed with repetitive performance of the wheel-turning task. SUMMARY OF BACKGROUND DATA: Despite increased emphasis on quantifying functional capacities, few well-controlled studies comparing the performances of patients with low back pain with those of control subjects have appeared in the literature, particularly for movement patterns. METHODS: Forty patients with low back pain and 40 control subjects performed a sustained isodynamic wheel turning task. This task was selected because it simultaneously combined several common pain-related movements. A set of kinematic measures to characterize the basic movement patterns during this task were developed. RESULTS: Control subjects produced significantly higher levels of static torque and completed significantly more wheel-turning repetitions. Patients with low back pain exhibited significantly less upper torso and pelvic motion, upper torso rotation, and lateral trunk flexion than those in the control group. CONCLUSION: The dissimilar movement strategies found between the patient and control groups suggests that factors beyond more global physical explanations (e.g., deconditioning) may be important in accounting for the large discrepancy between these groups regarding the amount of work performed. These findings, along with the basic kinematic patterns developed in this study, may have important implications for determining the efficacy of instruction in body mechanics and treatment outcome for patients with chronic low back pain.

Measuring treatment effects on repetitive lifting for patients with chronic low back pain: speed, style, and coordination.

The purpose of this study was to determine changes in the amount of work performed and lifting speed, style, and coordination during a repetitive dynamic-lifting task for patients with chronic low back pain (CLBP) after an intensive 3 1/2-week pain rehabilitation program. Subjects included 57 CLBP patients and an age- and gender-matched control group (n = 57). Patients' work indices increased by 71%, but remained significantly less than those observed for controls. Similarly, their lifting speed also increased significantly after treatment, but remained slower than the lifting speed of controls. Patients' posttreatment coordination indices, however, were not significantly different from those of controls. This finding suggests that treatment effectively normalized the dynamic lifting motion used by the patients. These findings, along with the basic kinematic patterns developed in this study, have important implications for determining improvements in functional capacity in the treatment of patients with CLBP.