Chiropractic Research Articles

Diagnosing Functional Neurological Disorder through History and Physical Examination: A Case Report

Differentiating between stroke and stroke mimics (i.e., non-vascular conditions) is a major challenge, as they often involve similar presenting symptoms. A common type of stroke mimic is functional neurological disorder (FND), a somatic disorder caused by severe stress, emotional conflict, or a psychiatric disorder usually presenting with one or more neurologic symptoms. This condition is associated with voluntary motor and sensory symptoms that are internally inconsistent with identifiable neurological diseases and lack structural lesions. We describe a 54-year-old female with a history of transient ischemic attack resulting in bilateral blindness and recent social stressors, who presented with right-sided facial and extremity motor and sensory deficits, bilateral diplopia, and dysphagia. Her left upper and lower extremities had 2 out of 5 motor strength, a weak hand squeeze, and a positive Babinski reflex on the contralateral side of her weakness, which resolved the next day. In addition, decreased sensation to light touch and temperature over the right arm and leg were appreciated without a dermatomal pattern. Given the negative stroke work-up, atypical physical exam findings, prior history of blindness, and in the setting of recent psychological stressors, her acute motor and sensory deficits were diagnosed as FND after evaluation by the Neurology service. The current case demonstrates the following important features of making a FND diagnosis: 1) careful history taking in eliciting potential psychological stressors; 2) a comprehensive neurological examination assessing the presence of findings specific for FND (e.g., greater weakness with active rather than passive movements, fluctuating weakness); 3) multidisciplinary collaboration with neurology and psychiatry providers to aid in performing a comprehensive assessment.

How Is Functional Neurological Disorder Managed in Australian Hospitals? A Multi-Site Study Conducted on Acute Inpatient and Inpatient Rehabilitation Wards.

Successful management for functional neurological disorder (FND) requires multidisciplinary involvement starting with providing a definitive diagnosis. To observe clinical management of patients with FND during hospital admission. A prospective observational study was conducted over six Australian hospitals over a 4-month period. Data collected included patient demographics, communication of the diagnosis of FND, access to the multidisciplinary team, hospital length of stay (LOS), and emergency department (ED) presentations. A total of 113 patients were included. Median LOS was 6 (interquartile range, 3-14) days. Thirty-five (31%) presented to ED with 9 (8%) re-presenting two or more times after hospital discharge. Total hospital utilization cost was AUD$3.5million. A new diagnosis was made in 82 (73%) patients. Inpatient referrals were made to neurology (81, 72%), psychology (29, 26%), psychiatry (27, 24%), and physiotherapy (100, 88%). Forty-four (54%) were not told of the diagnosis. Twenty (24%) did not have their diagnosis documented in their medical record. Of the 19 (23%) not reviewed by neurology on non-neurosciences wards, 17 (89%) did not have their diagnosis communicated and 11 (58%) did not have it documented. Twenty-five (42%) referred to neurology were not provided with a diagnosis. Current gaps in service provision during inpatient hospital admissions in Australia include low rates of communication of a diagnosis, particularly when patients are not located on a neurosciences ward, and limited and variable access to inpatient multidisciplinary teams. Specialized services are needed to improve education, clinical pathways, communication, and health outcomes while reducing healthcare system costs.

Neurological Dysfunction in Long COVID Should Not Be Labelled as Functional Neurological Disorder.

There have been suggestions that Long COVID might be purely functional (meaning psychological) in origin. Labelling patients with neurological dysfunction in Long COVID as having functional neurological disorder (FND) in the absence of proper testing may be symptomatic of that line of thought. This practice is problematic for Long COVID patients, as motor and balance symptoms have been reported to occur in Long COVID frequently. FND is characterized by the presentation of symptoms that seem neurological but lack compatibility of the symptom with a neurological substrate. Although diagnostic classification according to the ICD-11 and DSM-5-TR is dependent predominantly on the exclusion of any other medical condition that could account for the symptoms, current neurological practice of FND classification allows for such comorbidity. As a consequence, Long COVID patients with motor and balance symptoms mislabeled as FND have no longer access to Long COVID care, whereas treatment for FND is seldom provided and is ineffective. Research into underlying mechanisms and diagnostic methods should explore how to determine whether motor and balance symptoms currently diagnosed as FND should be considered one part of Long COVID symptoms, in other words, one component of symptomatology, and in which cases they correctly represent FND. Research into rehabilitation models, treatment and integrated care are needed, which should take into account biological underpinnings as well as possible psychological mechanisms and the patient perspective.

Intensive Short-Term Dynamic Psychotherapy (ISTDP) associated with healthcare reductions in patients with functional seizures

Intensive Short-Term Psychodynamic Therapy (ISTDP) has demonstrated promising evidence for the treatment of Functional Neurological Disorders (FND) including functional seizures.This paper aimed to further examine the therapeutic effects of a 3-session course of this treatment focusing on its potential to maintain reduced healthcare utility within a group of patients with complex difficulties, across an extended time period, post-therapy.The original study followed a mixed methods case series design and recruited 18 patients from secondary adult mental health care and specialist neurology services. Seventeen participants completed the intervention and attendance rates were very high (95%). In this follow-up study, which was solely focused on the utilization of healthcare resources, results showed decreases when comparing 12 months prior and 12 months post three sessions of ISTDP.The results provide further support for the use of ISTDP in this group of participants with complex clinical presentations, specifically, its capacity to reduce healthcare usage over 12 months post-therapy. Further evidence from controlled and randomized studies with larger sample sizes is warranted.

Functional neurological disorder: Clinical manifestations and comorbidities; an online survey

Functional Neurological Disorder (FND) is common and is often accompanied by multiple comorbid symptoms and conditions. There have been no large-scale studies exploring the change of its clinical manifestations and comorbidities.We used an online survey to assess FND patient characteristics, changes to fatigue, sleep and pain and comorbid symptoms and diagnoses, as well as treatment strategies. The survey was shared via the charities FND Action and FND Hope.527 participants were included in the analysis. Most (97.3%) reported experiencing more than one core FND symptom. Many respondents reported associated pain (78.1%), fatigue (78.0%) and sleep disturbances (46.7%) before FND diagnosis which often increased thereafter. Rates of obesity were higher (36.9%) than in the general population. Obesity was associated with increased pain, fatigue and sleep difficulties. There was frequent weight gain after diagnosis. 50.0% of participants reported having other diagnoses prior to FND, while in 43.3% new comorbidities arise after FND diagnosis. Many respondents reported being dissatisfied with their care, expressing a wish for further follow-up from mental health (32.7%) and/or neurological services (44.3%).This large online survey further supports the phenotypic complexity of FND. High rates of pain, fatigue and sleep disturbance exist before diagnosis but monitoring for change is worthwhile. Our study identified major gaps in service provision; we highlight the importance of an open mind regarding change in symptoms; this could aid the early identification and management of co-morbidities, including obesity and migraine, which possibly have a negative impact on FND.

Chiropractic Care in a Multidisciplinary Sports Health Care Environment: A Survey of Canadian National Team Athletes

ObjectiveThe purpose of this study was to describe the utilization of health team practitioners among national-level athletes and report their injury profile as well as access to and knowledge of chiropractic care. MethodsThis study was a retrospective analysis of non-identifiable, cross-sectional survey data that were previously collected from members of the AthletesCAN organization who voluntarily completed a web-based, bilingual survey in July or August 2017. The sport of the athlete, number of years on a national team, number and type of injuries, health care practitioners visited, and specific details on chiropractic care were collected. Descriptive statistics were performed to summarize the responses in terms of frequencies and percentages. ResultsThere was an 11% response rate (198/1733), with 67 unique sports identified (21 winter sports [50 athletes] and 46 summer sports [148 athletes]). Athletics and swimming were the sports with the most respondents. Fewer than half (43.9%) of the 198 respondents were members of AthletesCAN for 2 to 5 years. Seventy percent reported 1 to 5 injuries over their career, with ankle, low back, and shoulder the most likely body parts affected. A majority of athletes (93.4%) reported visiting multiple practitioners, including medical physicians, physiotherapists, athletic therapists, massage therapists, and chiropractors. Two-thirds (67%) of athletes sought chiropractic treatment, most typically for neck or back pain (81.3%), despite nearly half (45.7%) being unsure about access to chiropractic care. ConclusionThis sample of Canadian national team athletes who experience an injury may seek care from multiple types of health care providers and include chiropractic as part of their approach to health care.

The Murmur of Everything Moving

The Murmur of Everything Moving Maureen Stanton (bio) On a quiet Saturday afternoon in May, while Steve napped on the couch and I sat in the La-Z-Boy watching television, I heard a tinny knock on our screen door. Joey, Steve's childhood friend, stood on our veranda. "Hey, Joe," I said, and welcomed him in. I'd met Joey two years earlier, after a Sunday dinner at Steve's parents' house in his hometown of Jackson, Michigan. Joey had noticed Steve's truck in the driveway and stopped by to say hello. As Joey and Steve shot pool in the basement, I studied Joey—the dirty jeans, the beat-up leather jacket on his slight frame. He was bald on top with a ring of brown hair brushing his shoulders. He reminded me of the townies I'd known growing up in Walpole, Massachusetts—former high-school athletes still hanging around the center square, looking for parties. Or small-time drug dealers who'd never left, only the high-school girls they enticed into their cars changing year after year. Joey worried me; perhaps I didn't really know Steve if he had friends like Joey. We'd met in New York, both of us working [End Page 253] temporary jobs. I fell in love with him quickly, and after two months, I moved with him to Michigan. That afternoon in Jackson, we perused their high-school yearbook, Joey and I flanking Steve on the couch as we scanned the rows of black-and-white portraits. They'd graduated in 1974, and so everyone's hair was mashed down. In spite of his mutton-chop sideburns and rippled bangs plastered across his forehead, Steve looked handsome, with his blond curls and sleepy blue eyes, his creamy complexion. Back then, Joey had a full head of hair; the monochrome photography smoothed his acne-pitted skin. They looked so hopeful, all these teenagers, the way the photographer positioned them looking up to the camera, guileless and naive, their dreams and aspirations recorded in the yearbook. Steve touched the headshots of his classmates, pronouncing life sentences. "Divorced … divorced … in jail … dead." Ten years had passed since they graduated and people's fortunes could be told. ________ Steve sat up to greet Joey, which took some effort as he was still sick and weak from the most recent round of chemotherapy. We were excited about a visitor, someone to take our attention away from each other—a live person, not like the television shows or movies we watched for hours each day, an escape from Steve's dreary circumstances. "I saw your mother at Motor Vehicles," Joey said. He looked scruffy in his leather jacket and shaggy hair. "She told me about the cancer. Man, I couldn't believe it." Joey sat in the recliner, leaning forward toward Steve. "How you feeling, buddy?" "Pretty good," Steve said. "I was supposed to be dead by now." [End Page 254] Steve's bluntness seemed to me a brave front for his friend. He recounted his history, the back pain which had begun six months earlier, the chiropractic care that hadn't helped, his diagnosis by an oncologist at St. Joseph's hospital in Ypsilanti, a gleaming, six-story facility, where the doctors had given him two weeks to live (two months at the outside). He described the alternative hospital we'd found, a six-hour drive away, in Zion, Illinois, the experimental therapy that Steve would have there, whole-body hyperthermia, at four thousand dollars per treatment, which his insurance refused to cover. Joey was quiet. I'd never heard him speak much anyway. I'd only seen him a few times in the couple of years since I had first met him, though often enough to have my impression of him alter from wariness to the kind of affection one has for the runt of the litter. Joey didn't seem to have much going for him. He worked at Hoyt's junkyard in the industrial zone of his and Steve's hometown, where flat-roofed, corrugated-tin warehouses stretched for blocks. A few months before Steve fell ill, he and I had...

Changes in the Rate of Emergency Presentation in Patients with Functional Neurological Disorder Attending a Long-term Community Care Program for FND

IntroductionPatients with Functional Neurological Disorder have a high return rate to Emergency Rooms.ObjectivesTo assess possible changes in Emergency Room presentation rates in patients with Functional Neurological Disorder following their attendance of specialized long-term multidisciplinary treatment and rehabilitation program.MethodsSeventy-two adult patients with Functional Neurological Disorder were included. These patients were consecutive referrals accepted for ongoing specialist FND treatment.The total number of Emergency Room presentations in the year prior to program admission was obtained from central health records. Patients were provided ongoing treatment for one year, during which the number of ER presentations was monitored. Patients received one or more of the following treatment modalities: psychoeducation, psychological therapy, psychologically informed physical and occupational rehabilitation and psychopharmacological treatments.We subsequently compared high and low emergency service users. Low ER users are those with pre-treatment Emergency Room presentations of less than 3 per year. High emergency service users are those who presented to the emergency room 3 or more times per year before the start of their treatment.ResultsThe mean emergency room presentation per year in the year leading to patients referral was 2.6 per patient, SD 9.4; dropped to 1.2 emergency room presentations per year, with a standard deviation of 4.4 in the year following the start of treatment. The difference was statistically significant (p= 0.02).There was a strong positive correlation between the pre and post-treatment number of presentations with a Pearson Correlation Coefficient of 0.976 (95% Confidence Interval 0.962 to 0.985).The reduction in emergency room presentations in both high and low-emergency service user groups was significant, with a mean difference of 12 ER visits a year in high-frequency emergency service users (p= 0.04) and a mean difference of 0.5 visits a year in low-frequency emergency service users (p < 0.001).ConclusionsOngoing specialist treatment and rehabilitation of patients with Functional Neurological Disorder significantly reduce their need for emergency room presentation, regardless of the treatment modality.Disclosure of InterestNone Declared

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder.

• Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions. Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.

Implications for Nursing and Multidisciplinary Collaboration in the Management of Gastroparesis Patients Receiving Chiropractic Care: A Case Series

Background: Gastroparesis, partial paralysis of the stomach, is a chronic and sometimes disabling neuromuscular disorder diagnosed by delayed emptying of solid food in the absence of a mechanical obstruction. The management of gastroparesis is less than optimal because the pathogenesis has not been clearly defined. Significance: With gastroparesis becoming an increasing concern, nurses need to communicate, collaborate and educate providers and patients regarding complementary therapies that can alleviate patient symptoms and suffering, improve outcomes and quality of life, and decrease inappropriate healthcare system use. Methodology: Through a case series presentation, two case reports describe the successful outcome of chiropractic treatment and implications for nursing care as part of a multidisciplinary team model, for the symptom management of gastroparesis. Results: Both cases were treated for musculoskeletal complaints of cervical, thoracic, and lumbar segmental dysfunction with myofascial involvement and expressed improvements in their musculoskeletal complaints and gastroparesis symptoms following treatments. The improvement of gastroparesis is thought to be a side effect of the treatment. Conclusion and Recommendations: This case series provides evidence that incorporating nurses and chiropractors as part of a multidisciplinary team model offers a unique approach to patient care, symptom management, and improved patient outcomes.

Intersex Differences in Functional Neurological Disorders

Letter to the Editor

Psychogenic non-epileptic seizures and functional motor disorders in developmental age: A comparison of clinical and psychopathological features

BackgroundPsychogenic Non-Epileptic Seizures (PNES) and Functional Motor Disorders (FMDs) commonly represent the main clinical manifestations of Functional Neurological Disorders (FNDs). Despite their high prevalence in pediatric neurological services, literature on this topic is still spare for this population.The present study aimed to deepen the clinical knowledge of a pediatric FNDs sample through a demographic and clinical characterization of the most recurrent clinical patterns during the pediatric age. Moreover, a comparison of neuropsychological and psychopathological profiles of PNES and FMD patients was carried out to identify specific vulnerabilities and therapeutic targets linked with these different clinical manifestations. Materials and methodsA total of 43 FNDs patients (age range 7–17 years old) were retrospectively included in our study, enrolled in two subgroups: 20 with FMDs and 23 with PNES diagnosis. They were inpatients and outpatients referred over a period of 5 years and a standardized neurological, neuropsychological (WISC-IV/WAIS-IV), and psychiatric (CDI-2, MASC-2, ADES, DIS-Q, PID-5) evaluation was assessed. ResultsIn PNES patients the most common clinical phenotypes were functional tonic-clonic (52%) and atonic (32%) manifestations while in the FMDs group were gait alterations (60%), functional myoclonus (35%), and tremor (35%). A higher frequency of cognitive impairment was reported in PNES patients with higher anxiety-depressive symptom rates than FMDs patients. ConclusionsNotably, specific neurocognitive and psychopathological profiles were described in PNES and FMDs, highlighting higher cognitive and psychiatric vulnerabilities in PNES, suggesting as well different strategy for therapeutic approaches.

Prevalence of autistic traits in functional neurological disorder and relationship to alexithymia and psychiatric comorbidity

IntroductionIn a cohort of adults with Functional Neurological Disorder (FND), we aim to:1)Report the prevalence of autistic traits and alexithymia.2)Report psychiatric comorbidity associated with autistic traits and alexithymia.3)Explore whether alexithymia mediates the association between autistic traits and comorbidity. Methods91 patients participating in a FND 5-week outpatient program completed baseline self-report questionnaires for total phobia, somatic symptom severity, attention deficit hyperactivity disorder (ADHD) and dyslexia. Patients were grouped by Autism Spectrum Quotient (AQ-10) score of <6 or ≥ 6 and compared for significant differences in tested variables. This analysis was repeated with patients grouped by alexithymia status. Simple effects were tested using pairwise comparisons. Multistep regression models tested direct relationships between autistic traits and psychiatric comorbidity scores, and mediation by alexithymia. Results36 patients (40%) were AQ-10 positive (scoring ≥6 on AQ-10). A further 36 patients (across AQ-10 positive and AQ-10 negative groups) (40%) screened positive for alexithymia. AQ-10 positive patients scored significantly higher for alexithymia, depression, generalised anxiety, social phobia, ADHD, and dyslexia. Alexithymia positive patients scored significantly higher for generalised anxiety, depression, somatic symptoms severity, social phobia, and dyslexia. Alexithymia score was found to mediate the relationship between autistic trait and depression scores. ConclusionWe demonstrate a high proportion of autistic and alexithymic traits, in adults with FND. A higher prevalence of autistic traits may highlight a need for specialised communication approaches in FND management. Mechanistic conclusions are limited. Future research could explore links with interoceptive data.

Safety and Feasibility of Robot-assisted Gait Training in Adults with Cerebral Palsy in an Inpatient Setting – an Observational Study

Background: To investigate the safety and feasibility of six sessions of Hybrid Assistive Limb (HAL) robot-assisted gait training (RAGT) integrated into an inpatient therapy concept and their influence on walking speed and gait parameters in adult CP patients. Methods: Eleven subjects (male = 8, female = 3, mean age: 23 years and 2 months, ± 4.5 years) with spastic CP underwent six 20-minute RAGT sessions with the HAL during an 11-day hospital stay. Additionally, physiotherapy, physician-performed manual medicine, massage and exercise therapy were provided. Pre- (T1) and post- (T2) intervention assessments were: 10-metre walking test (10MWT), 6-minute walking test (6MWT), Gross Motor Function Measure (GMFM-88) and lower extremities passive range of motion (pROM). Results: All subjects completed the study. No adverse events were noted. Walking speed in the 10MWT test increased from 32.5 s (± 24.5 s) at T1 to 27.5 s (± 21.4 s) at T2, without significance. Slight, but non-significant improvements were detected in the 6MWT, GMFM and pROM. Confounding factors did not significantly affect the results. Conclusion: Intensive therapy including HAL training leads to non-significant improvements. Further studies with more patients and longer intervention time could provide further insights into the RAGT therapy of adult patients with CP. Registration DRKS-ID: DRKS00020275.

The spinal manipulation / chiropractic care neurophysiological function and immune markers

The spinal manipulation / chiropractic care neurophysiological function and immune markers

РАЗМЫШЛЕНИЯ О ВНУТРИЧЕРЕПНОЙ ГИПЕРТЕНЗИИ С ТОЧКИ ЗРЕНИЯ ОСТЕОПАТИЧЕСКОЙ И МАНУАЛЬНОЙ МЕДИЦИНЫ

In article value of somatic dysfunctions in pathogenesis of intracranial hypertensia is proved and results of application osteopathic and manual medicine for their correction at 215 patients are presented. Rationality and efficiency of these methods is shown at intracranial hypertensia.

A two-year follow-up: Twitter activity regarding misinformation about spinal manipulation, chiropractic care and boosting immunity during the COVID-19 pandemic

BackgroundSpinal manipulative therapy (SMT) is offered by many health professions, most often by chiropractors. While SMT can be effective for some musculoskeletal disorders, there is no evidence that SMT improves human immunity in a clinically meaningful way. Despite this, we showed previously that Twitter misinformation about chiropractic/SMT improving immunity increased sharply at the start of the COVID-19 pandemic. Here, we perform a two-year follow-up.MethodsWe previously employed specialized software (i.e. Talkwalker) to search the entirety of Twitter activity in the months before and after the COVID-19 pandemic was declared (March 11, 2020). In this paper, we conducted follow-up searches over two successive 12 month periods using terms related to SMT, immunity and chiropractic. The resulting tweets were then coded into those promoting/refuting a relation between SMT and immunity (tone) and messaging about chiropractic/interventions (content). Further analyses were performed to subcategorize tweet content, tally likes, retweets and followers, and evaluate refuting tweets and the country of origin. Finally, we created a chronology of Twitter activity superimposed with dates of promoting or refuting activities undertaken by chiropractic organizations.ResultsOver the 27 month study period, Twitter activity peaked on March 31, 2020 then declined continuously. As in our first paper, our follow-up data showed that (1) the ratio of refuting/promoting tweets remained constant and (2) tweets that refuted a relationship between SMT and immunity were substantially more liked, retweeted and followed than those promoting. We also observed that promoting tweets suggesting that SMT improves immunity decreased more rapidly. Overwhelmingly, promoting tweets originated in the USA while refuting tweets originated in Canada, Europe and Australia. The timing of the decline in peak Twitter activity, together with a parallel decline in tweets claiming that SMT improves immunity, was coincident with initiatives by chiropractic organizations and regulators targeting misinformation.ConclusionOverwhelmingly, Twitter activity during the COVID-19 pandemic focussed on refuting a relation between chiropractic/SMT and immunity. A decline in Twitter activity promoting a relation between SMT and immunity was observed to coincide with initiatives from chiropractic organizations and regulators to refute these claims. The majority of misinformation about this topic is generated in the United States.

Mark Hallett, MD, Leader in Study of Functional Neurological Disorders, On Future Challenges of the Field

Mark Hallett, MD, Leader in Study of Functional Neurological Disorders, On Future Challenges of the Field

Pediatric Functional Neurological Symptoms Disorder: Walking Ability and Perceived Exertion Post-Pediatric Rehabilitation.

Adolescents with functional neurological symptoms disorder (FNSD) commonly present walking abnormalities. Walking is influenced by 'objective' (e.g., fitness) and 'subjective' (e.g., fear) components. Rate of perceived exertion (RPE) reflects the interaction between these two components. This study compared the walking ability and RPE before and after rehabilitation of adolescents with FNSD to adolescents with moderate-to-severe traumatic brain injury (TBI). Factors predicting walking and RPE were also examined. Adolescents with FNSD (n = 31) and adolescents with moderate-to-severe TBI (n = 28) aged 6 to 18 years participated in the study. Participants received a multidisciplinary rehabilitation program. Six-minute walk test (6MWT) and RPE were assessed before and after rehabilitation. At pre-test, the TBI group presented lower RPE than the FNSD group (3.38 ± 2.49 and 6.25 ± 2.71, respectively). In the FNSD group, pre-test 6MWT was a significant predictor of post-test 6MWT (adjusted R2 = 0.17; p = 0.01). In the TBI group, post-test 6MWT was significantly predicted by both the pre-test 6MWT and age (adjusted R2 = 0.16; p = 0.04). Prior to the intervention, adolescents with FNSD perceived walking as a more difficult activity than adolescents with TBI. Post-intervention, although the intervention was effective in terms of changes in 6MWT and RPE, the 'subjective' component still contributed to the elevated RPE of the FNSD group.

Enabling health potential: exploring nonlinear and complex results of osteopathic manual medicine through complex systems theory.

Osteopathic medicine is a holistic, patient-specific approach. Explaining the impact of osteopathic manipulative medicine (OMM) has been problematic because many of its effects are nonlinear. Complex systems theory (CST) is explored as a mechanism of understanding the interplay of the body's anatomy and physiology, an illness process, and the effects of OMM. Tensegrity is discussed as an example of an emergent property of the body's systems that affects notonly biomechanics but also pathophysiology. Previous explanations of osteopathic philosophy are reviewed. The Host+Disease=Illness paradigm is a way to think through the impact of host and disease factors on an illness state, and how targeted interventions may affect the illness. The Osteopathic 5 Models are another way to view the body's complexity. The area of greatest restriction (AGR) screen can be understood to direct OMM in a way that respects complexity and enables asymmetric and nonlocal results torealize health potential. The impact of this framework isin coherently explaining the impact of osteopathic philosophy and OMM and exploring new approaches to research.