Relationship between thoracic, lordotic, and pelvic inclination and craniofacial morphology in adults

Evaluating the Plantar Pressure Loading and Its Correlation to Craniocervical Posture in Subjects With Skeletal Class II Malocclusion Before and After Surgical Mandibular Advancement

Class II malocclusion is one of the most prevalent types of malocclusions following Class I. The most typical postural features observed in Class II patients are extended craniocervical posture, cervical lordosis, and increased forward loading away from the body's centre of mass for compensating the mandibular deficiency and reduced airway. Its treatment involves orthodontic, functional, and orthognathic surgery. The type of treatment regimen opted for depends upon the age, severity of malocclusion, and need of the patient. Thus, appropriate intervention brings about improvement in dentition along with an overall enhancement of the body posture and plantar loading. These variables undergo a significant change whenever there is a change in the maxillomandibular relationship. The main aim of this paper is to correlate the variation in the craniocervical angulation to the plantar pressure distribution during various phases of orthodontic treatment and bilateral sagittal split osteotomy (BSSO) advancement surgery. The craniocervical angulations were determined from the lateral cephalograms of the patients using cephalometric variables and the plantar pressure was estimated using a digital quanpressurometer device (designed and patented in India by Meenakshi Academy of Higher Education and Research; patent number 390136) at each phase, i.e., during pre-treatment, pre-surgery, post-surgery, post-treatment intervals. The outcome of this study indicated that there was a significant change in the craniocervical angulation and the plantar pressure distribution pattern of the subjects before and after orthognathic surgery and it remained constant for six months after orthognathic surgery. The limitation of the study was the limited sample size. This study reveals that there was an improvement in the craniocervical angulation and plantar pressure distribution during the course of orthodontic decompensation and orthognathic surgical treatment, thus bringing about change in the individual's overall body posture and their plantar loading pattern after orthognathic surgery. Therefore, the change in the stomatognathic system by orthodontic and orthognathic treatment influences the overall muscular and functional balance of an individual thereby improving their attitude and lifestyle.

The Association between Masticatory Muscles Activation and Foot Pressure Distribution in Older Female Adults: A Cross-Sectional Study

The association between craniofacial muscles and postural control is well-known because of numerous anatomical connections. However, there are a few conflicting studies that correlated the activity of the masticatory muscles with the distribution of body weight pressure on the feet, which can strongly influence balance. Therefore, the purpose of our study was to evaluate the association between the masseter and temporalis muscle activity and foot pressure distribution. Fifty-two women were recruited, and baropodometric and EMG analyses of the masseter and temporalis baseline activities were analyzed. An ipsilateral association was found between the right temporal muscle activity and the right rearfoot load (r = 0.29, p < 0.05) and right forefoot load (r = -0.29; p < 0.05), as well as the percentage of muscle activation of the right masseter muscles with the percentage of pressure on the right forefoot (r = 0.31, p < 0.05) and right rearfoot (r = -0.31, p < 0.05). While further studies are needed, an ipsilateral association was found between masticatory muscles and foot pressure distribution.

Relationship between Craniocervical Posture and Sagittal Position of the Mandible: A Systematic Review

Changes in craniocervical posture are a critical issue in modern society. Alterations of the mandible position in the anterior-posterior direction in association with head and neck posture are reported. The objective of the present review was to evaluate the relationship between craniocervical posture and sagittal position of the mandible and to evaluate the risk of bias inthe included studies. Electronic databases used to perform the search were PubMed, Wiley Online Library, and Cochrane. Only clinical trials that assessed sagittal craniocervical posture and mandible position in lateral cephalograms were included. Selected inclusion criteria were used to assess the finally selected studies. The upper and lower cervical spine was evaluated by seven and six studies, respectively. The risk of bias in the included studies varied from low to moderate. Literature research identified 438 records from 3 databases. Eventually, seven eligible clinical trials were included in this review. Evaluating the relationship between craniocervical posture and mandible position in the sagittal plane, it can be concluded that increased cervical inclination and head upright position are associated with the posterior position of the mandible. Attention to patients’ craniocervical posture should be paid as a part of clinical evaluation since it might be the reason for the changed mandible position.

Relationship between back posture and early orthodontic treatment in children

Background

The purpose of this study was to analyze the relationship between body posture and sagittal dental overjet in children before and after early orthodontic treatment with removable functional orthodontic appliances.

Methods

Angle Class II patients (mean age 8.2 ± 1.2 years; 29 males and 25 females) with a distinctly enlarged overjet (> 9 mm) were retrospectively examined regarding body posture parameters before and after early orthodontic treatment. In addition, changes in overjet were investigated with the aid of plaster models. Forms of transverse dysgnathism (crossbite, lateral malocclusions) and open bite cases were excluded. Body posture parameters kyphosis, lordosis, surface rotation, pelvic tilt, pelvic torsion and trunk imbalance were analyzed by means of rasterstereographical photogrammetry to determine, if the orthodontic overjet correction is associated with specific changes in posture patterns.

Results

In nearly all patients an overjet correction and an improvement regarding all body posture and back parameters could be noted after early orthodontic treatment. Overjet reduction (− 3.9 mm ± 2.1 mm) and pelvic torsion (− 1.28° ± 0,44°) were significantly (p < 0.05) and moderately correlated (R = 0.338) with no significant associations found for the other posture and back parameters (p > 0.05).

Conclusion

Overjet reduction during early orthodontic treatment may be associated with a detectable effect on pelvic torsion.

Relationship between foot posture and dental malocclusions in children aged 6 to 9 years: A cross-sectional study

The aim of this study was to determine the association, if any, between foot posture and dental malocclusions in the anteroposterior plane, in children.The study population consisted of 189 children (95 boys and 94 girls) aged 6 to 9 years. In every case, previous informed consent was requested and obtained from the parent/guardian and the study was approved by the Ethics Committee of the University of Málaga (CEUMA 26/2015H).This observational, descriptive, cross-sectional analysis is based on a study population (STROBE). Qualified personnel conducted a podiatric and dental examination of each child, recording the Clarke angle and the foot posture index (FPI) as an outcomes measure in the feet, and also dental malocclusions, according to Angle classification.A significant correlation was observed for the FPI scores (for right foot) as well as the Clarke angle (for right foot), in relation to dental malocclusions as determined by Angle classification (P < .001). Of all the supinated feet analyzed, 38.46% were Class II according to Angle classification, and none were Class III. Of the pronated feet, 48.57% were Class III, 42.85% were Class I, and 8.57% were Class II.The Clarke angle decreases with the progression from Class I to III, whereas the FPI increases with that from Class I to III. These findings suggest there is a relation between the Clarke angle and FPI, on the one hand, and dental malocclusion on the other.

Effect of Treatment with Twin-Block Appliances on Body Posture in Class II Malocclusion Subjects: A Prospective Clinical Study

Background

There is strong evidence that malocclusion and body posture are interdependent. The relationship between improvement of nasopharyngeal airway, correction of malocclusion by orthodontic treatment or orthognathic surgery, and changes in body posture were evaluated in several studies. The purpose of the present study was to analyze the effect of the orthodontic treatment with Twin-block appliance on body posture.

Material/Methods

The study group consisted of 23 children (mean age 12.45 (1.06) years). They were orthopedically (back shape analysis) and orthodontically (cephalometric radiograph analysis) examined before the treatment with Twin-block appliance and 10–14 months after the beginning of treatment.

Results

Treatment with Twin-block appliance caused mandibular protrusion as SNB increased by 0.91°, distance Ar-B increased by 4.9 mm, ANB decreased by 0.15°; and increase of face height. Oropharynx airway increased by 1.54 mm and deep pharynx airway by 1.08 mm. The decrease in kyphotic, lordotic, craniocervical angles, upper thoracic, pelvic, and trunk inclinations was found to be statistically significant. When comparing orthopedic measurements between study and control groups, no differences were detected. The control group also showed reduction of all measured angles. Although the decrease of kyphotic angle, upper thoracic inclination, trunk inclination, and craniocervical angle were more pronounced in the study group, the differences were not significant.

Conclusions

Based on these results, the body posture changes during treatment with Twin-block appliance were an expression of the physiological growth, not a response to improvement in occlusion.

Can different occlusal positions instantaneously impact spine and body posture? : A pilot study using rasterstereography for a three-dimensional evaluation

PURPOSE

Orthodontists influence dental occlusion directly. To suggest any link between dental occlusion and body posture is highly contentious, as evidenced by the literature. Rasterstereography, an optical technique that enables three-dimensional (3D) body measurements to be collected, has not yet been used to impartially examine whether different occlusal positions could instantaneously alter spine and body posture. We therefore set out to use this technique to nonsubjectively evaluate this question under static conditions.

METHODS

Optical body scans were collected for 44 subjects, using the Diers formetric 4D system, for seven different mandible positions. In total, ten spinal and body posture parameters were assessed (trunk inclination, trunk imbalance, pelvic tilt, pelvic torsion, fleche cervicale, fleche lombaire, kyphotic angle, lordotic angle, surface rotation, and lateral deviation) for each mandible position and compared with scans performed with habitual intercuspation (HIC).

RESULTS

Significant body posture deviations were found for the fleche cervicale (position of the mandible: right eccentrically), fleche lombaire (positions of the mandible: physiologic rest position, cotton rolls on both sides, bite elevation 1 mm), and the kyphotic angle (positions of the mandible: cotton rolls on both sides, right eccentrically). No other significant differences were detected.

CONCLUSIONS

Data for the parameters that varied with different dental occlusions generated high standard deviations. Therefore, within the limitations of this pilot study, we could not conclusively associate dental occlusion to an instantaneous impact on the tested parameters. The posture changes that we detected could also have arisen from individual neuromuscular compensation; a possibility that must now be ruled-in, or out, by further research studies with a higher number of subjects.

Evaluation of validity and reliability of a methodology for measuring human postural attitude and its relation to temporomandibular joint disorders

INTRODUCTION

Temporomandibular joint disorders (TMJDs) are caused by several factors such as anatomical, neuromuscular and psychological alterations. A relationship has been established between TMJDs and postural alterations, a type of anatomical alteration. An anterior position of the head requires hyperactivity of the posterior neck region and shoulder muscles to prevent the head from falling forward. This compensatory muscular function may cause fatigue, discomfort and trigger point activation. To our knowledge, a method for assessing human postural attitude in more than one plane has not been reported. Thus, the aim of this study was to design a methodology to measure the external human postural attitude in frontal and sagittal planes, with proper validity and reliability analyses.

METHODS

The variable postures of 78 subjects (36 men, 42 women; age 18-24 years) were evaluated. The postural attitudes of the subjects were measured in the frontal and sagittal planes, using an acromiopelvimeter, grid panel and Fox plane.

RESULTS

The method we designed for measuring postural attitudes had adequate reliability and validity, both qualitatively and quantitatively, based on Cohen's Kappa coefficient (> 0.87) and Pearson's correlation coefficient (r = 0.824, > 80%).

CONCLUSION

This method exhibits adequate metrical properties and can therefore be used in further research on the association of human body posture with skeletal types and TMJDs.

Relationships between Malocclusion, Body Posture, and Nasopharyngeal Pathology in Pre-Orthodontic Children

BACKGROUND

Malocclusion, body posture, and breathing pattern may be correlated, but this issue is still controversial. The aim of the study was to examine the relationship between the type of malocclusion, body posture, and nasopharyngeal obstruction in children aged 7-14 years.

MATERIAL AND METHODS

The study group comprised 94 patients aged 7-14 years (mean±SD: 11.9±2.1 years); 44 (46.8%) males and 50 (53.2%) females. All patients passed an examination performed by the same orthodontist (study model and cephalometric radiograph analysis), orthopedic surgeon (body posture examined from the front, side, and back), and otorhinolaryngologist (anterior and posterior rhinoscopy and pharyngoscopy) in a blind manner.

RESULTS

Postural disorders were observed in 72 (76.6%) patients. Hypertrophy of the adenoids was diagnosed in 54 (57.4%) patients, hypertrophy of the tonsils in 85 (90.3%), nasal septum deviation in 51 (54.3%), and allergic rhinitis in 19 (20.2%) patients. There was a statistically significant correlation between presence of kyphotic posture and a reduction in the SNB angle, representing sagittal position of the mandible. Also, there was a statistically significant association between kyphotic posture and nasopharyngeal obstruction (54.1% of patients with nasopharyngeal obstruction were kyphotic, compared with 25% of patients with no nasopharyngeal obstruction; p=0.02). Kyphotic posture and reduced SNB angle were more common among males.

CONCLUSIONS

We concluded that: 1) there was a significant association between the sagittal position of the mandible (SNB angle) and a kyphotic posture; 2) kyphotic posture was significantly more common among patients with nasopharyngeal obstruction.

The effect of complex rehabilitation training for 12 weeks on trunk muscle function and spine deformation of patients with SCI

[Purpose] It is important for patients with incomplete spinal cord injury (SCI) to strengthen their muscle strength and return to the work force one of the ultimate objectives of rehabilitation. This study reports how a single patient with SCI became stabilized in terms of abdominal muscles and back extension muscles, as well as returning the back to the neutral position from spinal deformation, as result of complex exercises performed for 12 weeks. [Subjects] The degree of damage of the subject was rated as C grade. The subject of this study had unstable posture due to paralysis in the lower extremities of the left side after removal of a malignant tumor by surgical operation, and tilting and torsion in the pelvis increased followed by increase of kyphosis in the thoracolumbar spine. The subject was more than two years since diagnosis of incomplete SCI after surgery. [Methods] Using isokinetic lumbar muscle strength measurement equipment, peak torque/weight, total work and average power in flexion and extension of the lumbar region were measured. A trunk measurement system (Formetric 4D, DIERS, Germany), which is a 3D image processing apparatus with high resolution for vertebrae, was used in order to measure 3D vertebrae and pelvis deformation as well as static balance abilities. As an exercise method, a foam roller was used to conduct fascia relaxation massage for warming-up, and postural kyphosis was changed into postural lordosis by lat pull-down using equipment, performed in 5 sets of 15 times preset at 60% intensity of 1RM 4 set of 10 crunch exercises per set using Togu's were done while sitting at the end of Balance pad, and 4 sets of 15 bridge exercises. [Results] All angular speed tests showed a gradual increase in muscle strength. Flexion and extension showed 10% and 3% improvements, respectively. The spine deformation test showed that isokinetic exercise and lat pull-down exercise for 12 weeks resulted in improved spinal shape. [Conclusion] In this study, core stability exercise for deep muscle training and lat pull-down exercise had positive effects on lower extremity muscle strength and the spinal shape of a patient with SCI.

The effect of power nordic walking on spine deformation and visual analog pain scale in elderly women with low back pain

[Purpose] The purpose of this study was to examine whether Nordic walking exercise can relieve low back pain and change the spine shape in elderly women. [Subjects] Sixteen elderly women with chronic low back pain from N University in Chungcheong-do, South Korea, were enrolled. [Methods] The participants were asked to walk in an upright posture, with the head upright and looking forward. The Nordic poles were held close to the body. When a foot was moved forward, the arm on the other side lifted the Nordic pole and moved it forward. The participants were using the Nordic pole when walked on the track with their arms lifted above their shoulders. The type of shoes worn during walking was not considered. [Results] One-way analysis of variance was used to determine the presence of significant differences between the measures of spine deformation and VAS. [Conclusion] Chronic low back pain, a complaint often received from elderly women, was reduced by pole-induced power walking reduction on the balance of the spine and back of this important exercise program is presented as a guideline.

Craniofacial and cervical morphology related to sagittal spinal posture in children and adolescents

Studies on the relationship between body posture and craniofacial parameters often focus on the cervical spine. Thus, less attention has been paid to the morphology of the vertebra C2 that serves as both a structural and functional link between the craniofacial area and the other part of the spine. The objective of this study was to assess the relation of craniofacial features to certain morphological and positional characteristics of the cervical vertebrae and the spine during growth. We determined body posture indices for 69 children and adolescents by means of a radiation-free method (rasterstereography). The morphological and positional analysis of the craniofacial area and the cervical vertebrae was based on standardized lateral X-ray cephalograms. Medium to strong correlations were found between body posture, C2 morphology, and craniofacial parameters. We found significant correlations between the C2 dens axis height and maxillary indices as well as between the C2 dens axis inclination and cephalometrical values of the mandibular area. Similarly the correlation between the C2 dens axis inclination and the postural index flèche cervicale was highly significant (P < 0.05, r = 0.333). These results suggest that morphological features of the odontoid process may serve as valuable predictive markers in interdisciplinary orthopedic-orthodontic diagnostics.

The effect of sacroiliac joint mobilization on pelvic deformation and the static balance ability of female university students with si joint dysfunction

[Purpose] The present study aimed to determine the effect of an 8-week program of joint mobilization on changes in pelvic obliquity and pain level in seventeen female university students aged in their 20’s with sacroiliac joint dysfunction by dividing them into two groups: a joint mobilization group (MWM) and a control group. [Subjects] Seventeen subjects were selected from female university students aged in their 20’s attending N University in Cheon-An City, Korea, The subjects had sacroiliac joint syndrome, but experienced no problems with daily living and had no previous experience of joint mobilization exercise. The subjects were randomly assigned to a joint mobilization group of eight and a control group of nine who performed joint mobilization exercise. [Methods] Body fat and lean body mass were measured using InBody 7.0 (Biospace, Korea). The Direct Segmental Multi-frequency Bioelectrical Impedance Analysis Method (DSM-BIA) was used for body composition measurement. A pressure footstool (Pedoscan, DIERS, Germany) and a trunk measurement system (Formetric 4D, DIERS, Germany), a 3D image processing apparatus with high resolution for vertebrae, were used to measure 3D trunk images of the vertebrae and pelvis obliquity, as well as static balance ability. [Result] The MWM group showed a significantly better Balance than the control group. In addition, the results of the left/right and the front/rear balance abilities were significantly better than those of the control group. [Conclusion] This study proved that a combination of mobilization with movement and functional training was effective in reducing pelvis malposition and pain, and improving static stability control.

Neuromuscular dentistry: Occlusal diseases and posture

Neuromuscular dentistry has been a controversial topic in the field of dentistry and still remains debatable. The issue of good occlusion and sound health has been repeatedly discussed. Sometimes we get complains of sensitive teeth and sometimes of tired facial muscles on getting up in the morning. Owing to the intimate relation of masticatory apparatus with the cranium and cervico-scapular muscular system, the disorders in any system, draw attention from concerned clinicians involved in management, to develop an integrated treatment protocol for the suffering patients. There may be patients reporting to the dental clinics after an occlusal restoration or extraction, having pain in or around the temporomandibular joint, headache or neck pain. Although their esthetic demands must not be undermined during the course of treatment plan, whenever dental treatment of any sort is planned, occlusion/bite should be given prime importance. Very few dentist are able to diagnose the occlusal disease and of those who diagnose many people resort to aggressive treatment modalities. This paper aims to report the signs of occlusal disease, and discuss their association with TMDs and posture.

Clinical association between teeth malocclusions, wrong posture and ocular convergence disorders: an epidemiological investigation on primary school children

Background

As the various systems in the body are inter-connected to form a single structural unit, a pathological condition in one area can also affect other areas. There are many known correlations between the visual and motor system. The importance of visual function, particularly the paracentral peripheral field of view, in motor coordination, ambulation and the maintenance of balance has been amply demonstrated.

In line with current medical principles, which are moving towards a more holistic view of the human body, this study aims to investigate, in an interdisciplinary manner, the incidence of dental malocclusions together with posture and eye convergence disorders.

Methods

Six hundred and five children attending at the 3^rd, 4^th and 5^th years of seven Genoa primary schools were examined. Each child underwent the following examinations: (i) dental/occlusal; (ii) orthoptic; and (iii) postural. Occlusal data concerned the presence of cross-bite, midline deviation with a mandibular shift, bad habits and deep or open bite.

Postural assessment involved frontal and lateral inspection, investigation during trunk flexion and ambulation, and note of any asymmetry in the lower limbs. The recorded orthoptic data included those pertaining to ocular dominance, a cover test, convergence and the Brock string test.

Results

A prevalence of cases with an unphysiological gait was found in patients with overjet (14.70%) or overbite (14.87%), while the percentage of patients with normal occlusion that showed an unphysiological gait was 13.08%. Also, about 93.8%–94.2% of children showed normal legs without dysmetry, with no difference in respect to the type of occlusion. Subjects with an open bite or deep bite showed a slightly different distribution of right or left dominant eyes.

Conclusion

About 13% of children showed a pathological gait and, among them, vertical anomalies of occlusion (deep bite or open bite) were prevalent with respect to the other occlusal defects. The vertical dimension of occlusion revealed a slight relationship with the proper dominant eye. Postural, orthoptic, osteopathic and occlusal variables were often clinically associated, and therefore these disorders appear to request a multidisciplinary medical approach for their treatment.

Sagittal back contour and craniofacial morphology in preadolescents

The aim of this study was to analyze the correlation ratios between the sagittal back contour (flèche cervicale and lombaire, trunk inclination) and selected parameters of craniofacial morphology in children. The patient sample consisted of 66 healthy children with a mean age of 11.2 years (SD 1.6 years), of which 34 were male (mean age 11.5 years, SD 1.3 years) and 32 were females (mean age 10.9 years, SD 1.9 years). The children were recruited during the preparation of the initial orthodontic treatment records. Craniofacial morphology was analyzed by six angular measurements: facial axis, mandibular plane angle, inner gonial angle, lower facial height, facial depth and maxilla position. Rasterstereography was used for reconstruction of the spinal back sagittal profile. From the profile flèche cervicale, flèche lombaire and trunk inclination were determined and the correlations with the craniofacial morphology were calculated (Pearson and Mann-Whitney U test). Significant correlations were found with respect to the inner gonial angle and the flèche cervicale, the mandibular plane angle and the flèche lombaire, the inner gonial angle and the flèche lombaire, and the angular lower facial height and the flèche lombaire, as well as the inner gonial angle and the trunk inclination. The craniofacial vertical growth pattern, presented by mandibular plane angle, inner gonial angle and the angular lower facial height, and the correlation to flèche cervicale and lombaire as well as trunk inclination reveal correlations between growth pattern and sagittal back contour.

The relationship between the stomatognathic system and body posture

In recent years, many researchers have investigated the various factors that can influence body posture: mood states, anxiety, head and neck positions, oral functions (respiration, swallowing), oculomotor and visual systems, and the inner ear. Recent studies indicate a role for trigeminal afferents on body posture, but this has not yet been demonstrated conclusively. The present study aims to review the papers that have shown a relationship between the stomatognathic system and body posture. These studies suggest that tension in the stomatognathic system can contribute to impaired neural control of posture. Numerous anatomical connections between the stomatognathic system's proprioceptive inputs and nervous structures are implicated in posture (cerebellum, vestibular and oculomotor nuclei, superior colliculus). If the proprioceptive information of the stomatognathic system is inaccurate, then head control and body position may be affected. In addition, the present review discusses the role the myofascial system plays in posture. If confirmed by further research, these considerations can improve our understanding and treatment of muscular-skeletal disorders that are associated with temporomandibular joint disorders, occlusal changes, and tooth loss.

Craniofacial features of children with spinal deformities

Background

The objective of this epidemiological study is to map the dentofacial anomalies that can be correlated to the two most frequent spinal diseases responsible for postural abnormalities and that can be clinically identified by the orthodontic examination.

Methods

Twenty-three children with Scheuermann's disease participated in the study (mean age: 14Y8M; SD: 1Y8M), 28 with Scoliosis (mean age: 14Y7M; SD: 2Y3M) and a control group of 68 orthopedically healthy children (mean age: 14Y8M; SD: 0Y11M). Standardized orthodontic screening protocols were used to map the occlusal relations in the sagittal, vertical, and transversal dimensions, space relations of the maxillary and mandibular frontal segment, and the TMJ status and function. The examinations for the children with orthopedic disorders were supplemented by the evaluation of routine orthodontic radiograms – lateral cephalograms and panoramic X-rays.

Results

The majority of the dentofacial features examined revealed more and greater abnormalities among patients in the Scheuermann's disease group than in the scoliosis group. In the latter group the proportion of the TMJ symptoms and the consecutive functional deviations were greater. When comparing the values of the two spinal-disorder groups and the control group, statistically significant differences (p < .05) occurred for the following measurements: frequency of unilateral Cl.II. molar occlusion, overjet and extreme overjet mean value (Scheuermann's disease group), as well as the frequency of TMJ pathological symptoms (scoliosis group). The evaluation of the panoramic X-rays showed significant differences among the mandibular measurements of the two spinal-disorder groups. Within the framework of the evaluation of the cephalograms significant differences (p < .05) were found only in the case of dental relations. However, several values differed significantly from the Ricketts' norms, none of the indices strictly characterized any of the groups with spinal disorders.

Conclusion

The more extended treatment of the malocclusions closely correlated to postural disorders draws attention to the indicators of a higher frequency and severity occurring in the case of the dentofacial deviations in the patients of the MSCH group who had previously been less examined.