The third therapeutic revolution: behavioral medicine.

Behavioral medicine--and one of its progenitors, biofeedback--are expanding as the Third Therapeutic Revolution, supplementing surgery and pharmacology in treating human illnesses. Parallel development of nonscience-based therapies is a part of the same revolution. Labeling their positive results as "placebo effects" hides a greater truth: faith and trust play an enormous role in therapy. The successes of both behavioral medicine and unorthodox complementary medicine are the result of the debonafide effect (my Latin for "from good faith"). Readers are urged to adopt this better definition of the "unexplicable" and substantial good results of both the placebos in research and the ministration of unorthodox treatments.

Use of the Halstead Category Test as a cognitive predictor of functional recovery in the hemiplegic upper limb: a cross-validation study.

Current motor learning theory suggests that recovery in the hemiplegic upper limb partially depends on the client's cognitive ability to maximize sensory feedback in order to activate appropriate efferent motor pathways. Study 1 investigated the use of the Category Test as a predictor of functional recovery. Initial scores on the Upper Extremity Function Test and the Category Test explained 81% of the variance of the discharge Upper Extremity Function score (N = 29). Psychological factors such as the client's attitude and motivation were less significant than more direct measures of the biological event. Study 2 (N = 16) confirmed these results and also found that stroke survivors who made fewer errors on the Category Test performed better on a functional disability test. Survivors making the fewest errors on the Category Test also showed the greatest amount of change in arm and hand function. The results are discussed in terms of the role of cognitive and biological factors that might influence recovery.

Agonist and antagonist activity during voluntary upper-limb movement in patients with stroke.

Forty-four patients with hemiplegia following stroke and 10 nondisabled subjects were studied to examine the contributions inadequate motor unit recruitment and co-contraction attributable to impaired antagonist inhibition play in the movement disorder of the hemiplegic arm. Electromyographic data were recorded from agonist and antagonist muscles while subjects attempted six specified tasks. Data from subjects who could complete the tasks were compared with those who could not complete the tasks. Differences between the two groups were found in the electromyographic data obtained from the agonist muscles. Electromyographic values were consistently and significantly lower in patients who were unable to complete the tasks than in patients who were able to complete the tasks. In the antagonist muscles, a significant difference was noted only once; in this case, the EMG values were again lower in the group of patients who were unable to complete the task. Inadequate recruitment of agonists, not increased activity in the antagonists, was a consistent finding in patients who were unable to carry out the movement tasks. This study theoretically supports aiming treatment efforts at improving motoneuron recruitment rather than reducing activity in antagonists while retraining arm function.

Electromyography of pronators and supinators in great apes.

We obtained electromyographic recordings from the supinator, biceps brachii, pronator quadratus, and pronator teres muscles of a chimpanzee and a gorilla and from the supinator, pronator quadratus, and biceps brachii muscles of an orangutan as they stood and walked quadrupedally on horizontal and inclined surfaces, engaged in suspensory behavior, reached overhead, and manipulated a variety of foods and artifacts. In Pan troglodytes and Pan gorilla, as in Homo sapiens, the supinator muscle is the prime supinator, with the biceps brachii muscle serving to augment speed or force of supination. Primary of the pronator quadratus muscle over the pronator teres muscle during pronation is less clear in the African apes than in humans. Possibly, pongid radial curvature or forelimb elongation or both factors are related to the somewhat different patterns of activity that we observed in the pronator muscles of Pan versus those reported for Homo sapiens. In Pongo pygmaeus, as in P. troglodytes and P. gorilla, the pronator quadratus muscle acts as a pronator and the supinator muscle acts to supinate the hand at the radioulnar joints. The biceps brachii muscle is active at low levels as the orangutan supinates its hand with the elbow flexed.

Special considerations for research with pharmacologic agents.

As physical medicine and rehabilitation becomes more and more complicated, the medical rehabilitation research teams are often bewildered by the sweeping changes occurring in the application of therapeutic drugs for rehabilitation. Society, through the instrument of governmental regulations, dictates that all new treatments must be efficacious before "release."

Acute back pain and spasm. A controlled multicenter trial of combined analgesic and antispasm agents.

A double-blind, 18-center, balanced trial of diflunisal vs. cyclobenzaprine HCl vs. these two drugs combined vs. placebo produced complete results from 175 patients. They had sought treatment at the cooperating centers for acute painful spasms of the back within a day or two of trauma or strain. Global results over the 7 to 10 days of observations revealed a clinically and statistically significant superiority of the combined therapy by Day 4 (P = 0.006) and almost all patients recovered within a week to 10 days. A combination therapy with an effective safe analgesic and a true muscle relaxant for less than a week appears to be an excellent relief measure for acute back problems.

Therapeutic exercise in the management of rheumatic diseases.

In spite of the wide use of therapeutic exercise in the management of musculoskeletal diseases such as chronic arthritis, there are few controlled studies that establish its effectiveness. Only active contraction can increase muscle strength. Exercises in the horizontal plane or of limbs supported by the buoyancy of water can be carried out with relative ease by people with weak muscles or painful joints. The benefits of exercise programs can be classified as improving general fitness, increasing joint mobility and reconditioning. Whether the large amount of money currently being spent on exercise programs is truly cost-effective is an important question relating to health policy that requires an answer.

Stroke treatment: comparison of integrated behavioral-physical therapy vs traditional physical therapy programs.

This was a controlled study of the efficacy of two forms of therapy on upper limb functions of hemiparetic patients--one heavily behavioral and the other based on Bobath therapeutic exercises. It arose from an earlier pilot study comparing EMG biofeedback with physical therapy from which it was concluded that both the elapsed time since the acute stroke and the severity of residual disability were particularly important factors. Of 29 patients included and randomly assigned to one or the other heavily systematized therapies, 18 were classified as having early-severe and 11 as late-mild conditions. Multiple function tests by a "blinded" special technician in another location revealed that overall both forms of therapy obtained worthwhile clinical and statistical improvement, which was maintained at nine-month recheck testing; but there was no statistically significant superiority of one therapy over the other under the very specific circumstances of the research design. Ease of delivering care and other socioeconomic considerations become important factors in choosing either or both of these methods.

Muscle relaxants in multiple sclerosis.

Spasticity is an important cause of physical impediment in multiple sclerosis. Only drug therapy offers useful (but not universal) relief. Dantrolene sodium and/or baclofen are the drugs of choice, being both effective and clinically suitable in over half of cases when carefully titrated and monitored.

Ketazolam once daily for spasticity: double-blind cross-over study.

This double-blind cross-over study of 14 severely spastic inpatients with chronic multiple sclerosis reveals that once-daily doses of ketazolam, a new drug, are effective in reducing spasticity in a significant proportion of patients without significant side-effects. Added to the similar findings of an earlier double-blind controlled study of divided doses, the results suggest that this special feature of ketazolam provides a unique flexibility that may be exploited in individual cases.

Electrodiagnostic model for motor unit action potential (MUAP) generation.

The paper presents the development of inverse analysis of EMG, in terms of a Linear Prediction Coding (LPC) model and its parametric simulation of recorded single motor-unit action potential, for electrodiagnosis of neuromuscular disorders due to motor neuron degeneration, regeneration after lesion, myopathy, etc.