Dr. Adams' Alabama Headache Blog

Wednesday, March 31, 2010

Effect of Graded Increas in Vertical Dimension on teh Cervical Flexor Strength

The effect of vertical dimension (VD) on maximizing isometric deltoid strength (IDS) has been researched in subjects with deep overbite. However, vertical dimension has been determined in these studies functionally using the Isometric Deltoid Press. In this study vertical dimension of occlusion was increased, 2, 4 and 6 mm using lower acrylic mouthplates. Twenty normal females, mean age 31 years, sat erect in a dental chair and were instructed to bite and either resist to their maximum ability a horizontal force applied to the forehead or a vertical downward force to the wrist of the first one then the other extended arm. This procedure was repeated in normal occlusion and while biting on mouthplates which raised the VD 2, 4 and 6mm. The order of testing was counterbalanced, with one investigator inserting the appliance while another performed the muscle testing. Horizontal and downward pressures were applied by a hand-held stain guage. Peake resistance was measured twice in each condition and averaged to produce a peak isometric strength (PIS). Mean strongest PIS for each site tested was compared to each subject's PIS while biting in habitual occlusion. PIS of cervical flexors with the elevated bite was significantly greater than that for habitual conclusion. PIS for right and left deltoids did not differ but mean deltoid PIS in the elevated condition was significantly greater than biting in habitual occlusion. In the peak condition, cervical flexors increased 24% and deltoids increased 30%. Strength was measures for habitual occlusion after all trialas were administered and were not found to differ from pre-experimental levels indicating that fatigue was not an important factor. In an earlier study, Hart et al was unable to show significant differences when the vertical dimension was raised gradually. However, his dependent variable was isokinetic strength. In earlier publications we have suggested that the strength phenomenon is more salient in isometric strength than isokinetic. Isometric strength of the cervical flexors and deltoids increase significantly when vertical dimension of occlusion is increased in deep overbite subjects.

posted by Dr. Adams at 12:08 PM 0 comments

Tuesday, March 30, 2010

SF-36 Scores of TMD, Chronis Back Pain, Combined Pain Patients and Controls

The SF-36 is a widely used survey to assess health status from the patient's point of view. This patient based, generic health status assessment survey obtains patient's assessments of their functioning and well-being and perception of their general health. It serves as a disability measurement instrument in 29 countries. The dimensions measured 1) Physical Functioning, PF, 2) Role Physical, RP, 3) Body Pain, BP, 4) General Health, GH, 5) Vitality, VT, 6) Social Finctioning, SF, 7)Role Emotional, RE or the effect on usual role due to physical or emotional health, 8) Mental Health, MH. It was of interest to compare the responses of pain patients seeking treatment for TMD, back, and combined TMD and back pain to determine whether their limitations were similar and to compare these scores with those of the asymptomatic controls. The SF-36 scores of four groups of 30 subjects each were analyzed with the Kruskal-Wallis ANOVA by ranks for independent samples. A seperate ANOVA was performed for each of the 8 dimensions. Mann-Whitney U tests were used to compare scores within each dimension. With the exception of VT, control scores were significantly higher, (greater function, least limitation) than those of the other three groups and chronic back pain scores were significantly smaller than all other groups. TMD and combined TMD/back pain scores were both significantly smaller than the scores of controls and significantly greater than those of chronic back pain patients. The difference in the presence of the back pain factor is probably due to the chronicity of the back pain patients who were specifically diagnosed opposed the the TMD being the presenting symptom in the combined pain group. TMD patients tend to suffer impairment in functioning that is intermediate between asymptomatic patietns and chronic back pain patients. The impact of TMD on dimensions of functioning is clearly revelaed I the scores of the SF-36 suggesting is as an importnant diagnostic instrument for disability in the treatmetn of TMD and the assessment of treatment outcome.

posted by Dr. Adams at 11:15 AM 0 comments

Thursday, March 18, 2010

Vertical Dimension and Electromyography of Masseters in Complete Denture Patients

The vertical dimension of occlusion (VDO) which achieves the highest isometric strength of sternocleidomastoid muscles (SCMs) has been determined in complete denture patients. The purpose of the present day study was to investigate the effect of this VDO on electromyographic (EMG) activity of the masseters in complete denture patients using the Davicon M44 Dual EMG. Seventeen complete denture patients with complete upper and lower dentures for at least one year, no history of physical trauma to the head and neck, no untreated chronic illness and no cervical symptoms require treatment in the past 5 years were selected for this study. Patients were seated in an upright position and instructed to resist a horizontally transmitted force applied until resistance failed. The load was recorded under five conditions: rest position, biting on existing denture, bting on wooden blocks (2, 6 &10 mm) increasing the VDO 2mm) increasing the VDO 2 mm, 6mm and 10 mm respectively. On the second visit, bilateral electrodes were applied to the masseter muscles with 2 active electrodes in parallel with the muscle fibers. The subjects were instructed to bite as hard as possible on the existing denture and peak EMG activity was recorded in microvolts. An acyrlic resin layer was then fitted over the lower denture of each subject to add height on the existing denture. This height was determined from the maximum isometric strenth of the SCM muscle. The data was analyzed using the student's t-test. The results showed a statistically significant difference in the mean EMG activity or the right masseter muscle between the maximum clench on existing denture and maximum possible clench on the increased VDO which achieved peak isometric of the SCM muscle. The mean EMG activity of the left masseter maximum clench on an increased which achieved peak isometric strength of the masseter muscle. In conclusion, the vertical dimension of the occlusion which achieved maximum isometirc strength of the SCM muscles has a significant effect on the electromyo-graphic activity of the masseter muscles in complete denture patients.

posted by Dr. Adams at 1:22 PM 0 comments

Wednesday, March 17, 2010

Coping Strategies, SF-36, SCL-90 in Mild and Severe TMD Pain

Coping strategies are self generated cognitive maneuvers used by chronic pain patients to deal with their stress. In this study, the pain level, duration and coping strategies of 49 female TMD patients as measured by the Coping Strategies Questionnaire-Revised (CSQ-R) were compared with psychological status (SCL-90 scores) and degree of disability (SF-36 Health Status.) High intensity reported pain was found to be associated with more frequent use of Catastrophizing Coping Self Statements, Distraction and Praying than low intensity pain. While individual dimensions of the SCL-90 (Anxiety, Depression, Somatization, and General Stress Index) showed no statistical difference, all dimensions were higher in the high pain patients. High pain were more disabled than low pain patients (Mann-Whitney U analysis of SF-36, z -3.26, p=0.001). When long term pain (2-50 yrs) was compared with short term pain responses (1 month-1.5 yrs), long term patients used Distancing and Ignoring more than short term patients. Degree of disability was the same between long and short-term pain. When patients used three coping strategies (Catastrophizing, Distraction, and Praying), significantly higher levels of anxiety, depression, somatization and general stress were reported. Patients who used Distancing more often reported higher levels of anxiety and general stress. Patients using a wide variety of coping strategies (flexibilty) reported higher levels of pain, more psychological distress and greater disability. Using a diversity of coping strategies was not related to long duration of pain. The use of the combination of three strategies, Catastrophizing, Distraction, and Praying are associated with elevated psychological scores abd greater disability. Intensity, not duration of pain appears to determine which coping strategies are used by patients. Some of these strategies may be maladaptive.

posted by Dr. Adams at 12:48 PM 0 comments

Tuesday, March 16, 2010

Active Resistance Exercise for TMD Related Tension Pain

Rocobado and Kraus have proposed exercises to relieve muscle tension pain related to TMD and craniocervical dysfunction. The Profile Toner (Tasmark, Inc. N. Easton, MA) is an ective resisted motion device originally designed for toning muscles of the neck to elimanated double chin. It is a polyurethane foam ball 5 inches in diameter. The purpose of this experiment was to examine the effect of active resisted motion exercise of the cervical flexors on pain reported in 10 body sites and neck mobility. Thirty female TMD patients (mean age 35.6 yr., range 24-48) were selected in order of appearance for treatment at a TMD center. They were assigned at random to either Experimental (E) or Control (C) groups of 15 each. For 8 weeks E subjects performed flexing exercises, bending the neck so as to compress the ball between the chin and chest (as a nut cracker) and a second set opening the mandible pushed into the ball. C subjects performed the same number of exercises compressing the ball at the elbow joint. Pain levels were recorded on 10, 10 point visual analogue scales pre and post experimentally. Rotation, bending and flexion were recorded on a protractor. The pain points of both groups pre-experimentally did not differ but the mean reduction of the E group (14.3,43.7%) was significantly greater than that of the C group (2.6, 10%), t=3.9. TMJ pain reduction tended toward significance for the E group (p=0.058) as did headache (p=0.07) and face pain (p=0.08). Neck pain reduced significantly for the E group. A significant increase in right and left bending of the neck (7.0 degrees vs 0.28 degrees and 7.5 degrees vs 0.9 degrees) as well as flexion (3.7 degrees vs -2.6 degrees0 occured in the E group. Neck exercises may be an effective adjunct to the MPD treatment, reducing pain and increasing mobility of the neck.

posted by Dr. Adams at 12:07 PM 0 comments

Monday, March 15, 2010

Relationship Between TMDs Pain, Somatization, Depression and SF-36 Scores.

519 subjects were selected at random from a pool of 5,000 patients attending a multidisciplinary facial pain center. Pain was measured by a pain scored questionnaire composed of 20 Visual Analogue Scales (VAS). Ten pain sites were monitored, each by a VAS for the right and left sides. Possible scores were 0-10 for each VAS and 0-20 for each site with left and right scores combined. A global pain score for each site was obtained by adding scores of all ten sites yielding a maximum possible score of 200. The purpose of the study was to determine the relationship between reported pain and three dimensions of the SCL-90 (somatization, anxiety, and depression) and the globak score of the SF-36. Although pain was significantly correlated with Somatization (r=0.52), Anxiety (r=0.31) and Depression (r=0.36), the coefficient of determination was relatively weak for each (r=27), 0.10, and 0.11 respectively). Pain was not correlated the SF-36 global score (r=0.015). On the other hand, Somatization scores were significantly correlated to Anxiety (r=0.66, r=0.44), Depression (r=0.71, r=50) and Anxiety significantly correlated with Depression (r=0.82, r=0.67) with strong coefficients of determination. In order to ascertain whether high pain patients responded differently than low pain patients, patients were divided into two groups: total pain scores of less than 50 were placed in the Moderate pain group (mean 28.5) and total pain scores of => 50 were placed in the Severe pain group (mean 83.9). In all three measures of the SCL-90, the Severe pain patients scored significantly higher than the Moderate pain patients (p< 0.0001) but in all eight dimensions of the SF-36 there was no difference between Severe and Moderate pain responses. The scores of the three dimensions of the SCL-90, Somatization, Anxiety, and Depression, suggested by Dworkin et al. are sensitive to differences in pain intensity while none of the dimensions of the SF-36 are. In addition, scores of the 3 SCL-90 scales are strongly intercorrelated.

posted by Dr. Adams at 9:39 AM 0 comments

Friday, March 12, 2010

The Effectiveness of Multi-faceted Treatment of TMDs

In this retrospective study, 519 subjects were selected at random from a pool of 5000 patients who had completed treatment of attended at least three treatment sessions before terminating treatment. Treatment consisted of intraoral appliances: a soft upper for sleep and a mandibular repositioning device for daytime and a self administered home program for muscle relaxation. When indicated physical therapy was prescribed. Prior to treatment, on the next to last treatment and on the last treatment day, patients filled out a pain score sheet composed of 20 Visual Analogue Scales(VAS). Ten pain sites were monitored, each by a VAS for the right and left sides. Possible scores were 0-1-for each site and 0-2- for each site when left and right scores combined. A global pain score for each site was obtained by adding scores of all ten sites yielding a maximum possible score of 200. Pre-treatment mean pain was 54.6, next to last visit was 29.9 and last visit mean was 24.9. Each mean was significantly from the pretreatment baseline. Only subjects reporting pain in a site were studied. Each of the ten sites showed a significant reduction from a range of means 7.2-10 to 2.5-4.6. The post-treatment means of the five major diagnostic sites for TMDs (TMJ Pain, Clicking, Headache, Face Pain, and Neck Pain) were compared to scores of 220 dental students as a control. The pain levels of the two groups were almost identical (means ranging from 3.8 to 4.2) Overall, 92% of patients showed improvement and 8% were worse. An interesting finding of this research is that Neck, Upper Back, and Lower Back pain decreased significantly with a treatment of the oral condition. This lends support to the view that TMD treatment may affect areas outside the stomatognathic system. It was concluded that multidimensional treatment of TMDs is effective, reducing pain in 10 sites and in five sites to levels of dental student controls.

posted by Dr. Adams at 8:58 AM 0 comments

Thursday, March 11, 2010

Effect of Splint Design on Head Posture and Cervical Symptoms

This study compared the effect of two types of occlusal appliances on head posture, cervical symptoms and cervical range of motion in temporomandibular disorders (TMDs) patients. Twenty-two subjects diagnosed with TMDs (Research Diagnostic Criteria) were randomly assigned to two equal groups: Group-I received a three-dimensionally balanced mandibular occlusal splint, while group-II received a mandibular occlusal splint, which maintained mandibular position. Head posture and cervical range of motion (CRM) were measured using the Cervical Range of Motion Instrument (Performance Attainment Associates, St. Paul, MN). Cervical symptoms were assessed using a 10-point Visual Analogue Scale (VAS). Measurements were recorded pre-insertion, 10 minutes post-insertion and two weeks post-insertion. A T-test showed that there was a significant change in head posture from pre-insertion to 2 weeks post-insertion in group-I (mean=4.7°, t df=10=3.34, p=0.007) while there was no change in group-II (mean=0.41°, t df=10=0.36, p>0.05). ANOVA showed that there was a significant effect for time in cervical symptoms in group-I F df=3=9.95, >0.05, (mean=452.2 to 447.3 p>0.05). An ANOVA of CRM data showed a main effect for group-I, F df=3=5.87, p=0.002 (mean=8.6 to 10.6, t=4.8, p>0.05 (mean=8.7 to 9.1, p>0.05). It was concluded that different splints affect TMDs patients differently. The three dimensionally balanced splint reduced forward head posture and improved cervical symptoms and CRM significantly.

posted by Dr. Adams at 8:34 AM 0 comments

Monday, March 8, 2010

Activation and Expression in the Synovial Membrane After Induced Synovitis

NF-kB plays a pivotal role in pathogenesis in general arthritis. However, the participation of NF-kB in inflammation of the temporomandibular joint (TMJ) is poorly understood. We examined NF-kB expression in rat TMJs with synovitis induced by condyle hypermobility. By immunohistochemistry, NF-kB immunoreactivity was found mainly in the cytoplasm, not the nucleus, of the synovial lining cells of induced synovitis and control TMJs. Southwestern histochemistry, a new method for detecting transcription factors, showed greater NF-kB expression in the nucleus of the synovial lining in the hypertrophic synovium than in the control synovium. Increased levels of the synovial lining cells with immunoreactivity for inducible nitric oxide synthase (iNOS), which is transcriptionally regulated by NF-kB, were also seen in the inflamed synovium. These findings indicated that excess mechanical stress increases NF-kB activation in the TMJ and suggest that active NF-kB is incolved in the progression of the TMJ inflammation.

posted by Dr. Adams at 9:36 AM 0 comments

Tuesday, March 2, 2010

Radiographic Signs of Bone Destruction in the Arthritic Temporomandibular Joint

To investigate the progression of radiographic changes of the temporomandibular joint (TMJ) with the reference to plasma levels of interleukin-1B (IL-1B), C-reactive protien (CRP) and disease duration.

Twenty-one patients with chronic inflammatory joint disease and TMJ involvement were included. Individualized tomography of the TMJ was performed twice with an interval of at least 12 months.

Significant progression of the overall grade of radiographic changes occurred during the observation period, whereas erosions showed great interindividual variability. Progression of TMJ bone loss was correlated to raised levels of CRP and, in patients with a diagnosis of rheumatoid arthritis, or with a shorter duration, also to a plasma IL. Progression of an overall grade of radiographic changes in the TMJ occurs in patients with chronic inflammatory joint disease. Raised levels of serum CRP are associated with progression of TMJ bone lpss.

posted by Dr. Adams at 9:11 AM 0 comments

Monday, March 1, 2010

TMJ and Juvenile Arthritis

This study assessed the temporomandibular joint (TMJ) abnormalities in juvenile idiopathic arthritis (JIA) by longitudinal radiographic examinations from childhood to adulthood. Radiographic TMJ evaluations of 60 JIA patients were obtained at baseline (mean age 8.6 years, mean disease duration 3.2 years) and 1 to 3 times thereafter, with the final examination on verage 27 years after baseline. A radiographic grading system for severity of TMJ abnormality was applied. Cumulative radiographic TMJ abnormalities increased from baseline to final examination (42% to 75%, P<.001), as did bilateral TMJ involvement (60% to 82%, P<.001). Of patients with abnormalities, 53% showed progression, and 16% revealed signs of improvement. TMJ abnormalities were associated with physical limitations at baseline and reduced well-being and more extensive jiont involvement at the final examination. The frequency of TMJ abnormalities in JIA was high and increased from childhood to adulthood. Although progression of TMJ abnormalities was the general rule, near normalization also occurred on occasion.

posted by Dr. Adams at 6:23 AM 0 comments

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