The chiropractic profession has a long history of internal conflict. Today, the division is between the ‘evidence-friendly’ faction that focuses on musculoskeletal problems based on a contemporary and evidence-based paradigm, and the ‘traditional’ group that subscribes to concepts such as ‘subluxation’ and the spine as the centre of good health. This difference is becoming increasingly obvious and problematic from both within and outside of the profession in light of the general acceptance of evidence-based practice as the basis for health care.Because this is an issue with many factors to consider, we decided to illustrate it with an analogy. We aimed to examine the chiropractic profession from the perspective of an unhappy marriage by defining key elements in happy and unhappy marriages and by identifying factors that may determine why couples stay together or spilt up.We argue here that the situation within the chiropractic profession corresponds very much to that of an unhappy couple that stays together for reasons that are unconnected with love or even mutual respect. We also contend that the profession could be conceptualised as existing on a spectrum with the ‘evidence-friendly’ and the ‘traditional’ groups inhabiting the end points, with the majority of chiropractors in the middle. This middle group does not appear to be greatly concerned with either faction and seems comfortable taking an approach of ‘you never know who and what will respond to spinal manipulation’. We believe that this ‘silent majority’ makes it possible for groups of chiropractors to practice outside the logical framework of today’s scientific concepts.There is a need to pause and consider if the many reasons for disharmony within the chiropractic profession are, in fact, irreconcilable. It is time to openly debate the issue of a professional split by engaging in formal and courageous discussions. This item should be prioritised on the agendas of national associations, conferences, teaching institutions, and licensing/registration as well as accreditation bodies. However, for this to happen, the middle group of chiropractors will have to become engaged and consider the benefits and risks of respectively staying together or breaking up. Over the past decades, governments, society and patients have an increasing expectation of an evidence-based approach to health care and as the knowlege base has become larger and more widely accepted, the space available for alternative modalities has become smaller –4. This To the public, chiropractors are known to be ‘back pain clinicians’ –12. ThisAs is the case with professions generally, chiropractic has always had subgroups, some further toward the fringe and others closer to mainstream healthcare. Chiropractic arose out of a vitalistic tradition. D.D. Palmer, the founder of chiropractic, declared that 95% of all disease was caused by subluxated vertebrae and that the remaining 5% was caused by slight displacements of bones other than those in the spine . An earlDescribing this division is not simply academic; those aligned with evidence-based ideals have the greatest probability of being further integrated into healthcare systems in the years to come. In contrast, chiropractors, who have traditional ideas of the spine being a source of all or most diseases, are unlikely to make this journey, in the absence of evidence to substantiate their claims. The result is a profession torn between those looking to the future and those wedded to the founding claims of the past. The evidence-friendly chiropractors feel that the claims and activities by the ‘traditionalists’ slows or hinders the development of the profession and there is evidence to substantiate this.In Canada, vitalist practitioners have been shown to be more likely to have anti-vaccination beliefs, and their attitudes about radiographic imaging are inconsistent with current evidence/ guideline-based care . As suchIn Florida, U.S.A., attempts to establish a university-based education in chiropractic were stopped in 2005 because of opposition and lobbying from the traditional group .In 2009 in the UK, a systematic survey of chiropractic websites was done by a group motivated by displeasure at unsupported claims of chiropractors, and formal complaints were lodged with the General Chiropractic Council. Although most chiropractors were found not guilty, thousands of work-hours and much stress was caused , 26. TheIn 2012, the treatment of children based on traditional chiropractic ‘diagnoses’ at the student chiropractic clinics at the Royal Melbourne Institute of Technology in Australia, a university-based chiropractic course, at the time lead by a well-known traditionally-oriented chiropractor, brought down both fury and ridicule on chiropractic. It also resulted in a new movement called ‘Friends of Science’, who wage war on university education involving non-evidence-based alternative medicine, notably chiropractic. This severely threatened at least two chiropractic undergraduate courses , 28.In 2013, attempts to establish a university-based education in chiropractic in Sweden were stopped following a debate that exposed unsupported claims on the websites of some chiropractors .Here are some examples of this problem, as seen from the perspective of the evidence-friendly group:There is also evidence that traditional chiropractors feel aggrieved by the evidence-friendly group, because they think that ‘real’ chiropractic is being denigrated or squandered.Evidence-friendly chiropractors are seen as unfaithful to the traditional tenets of chiropractic .Evidence-friendly chiropractors side with the ‘enemy’, i.e. medical doctors, research scientists, sceptics, etc.And here are some examples of the problem as seen from the perspective of the traditional group:‘Straight [traditional] chiropractors consider the medical diagnosis of disease to be unnecessary because they view these conditions as secondary effects of vertebral subluxations. In essence, they believe that disease symptoms will disappear once the underlying subluxations have been corrected properly. Most straight chiropractors do not wish to have any association with mainstream health care’ .‘Chiropractic’s new normal should look a lot like its old normal. You know, the one centered on our only unique service to mankind: the detection, correction and management of vertebral subluxation’ .‘If you choose the more allopathic path of chiropractic medicine, your practice style will be different. You’ll befriend orthopedists and other medical practitioners, supplying a form of physical medicine. You’ll add various therapies, decompression, orthotics, stretches, exercises, rehab and other adjunctive services to support your spinal manipulations. ……you will be reduced to proper lifting, pillow recommendations and maybe even weight loss’ .Evidence for this is extensive, but a few examples from current chiropractic websites include the following:Given the slates of problems observed by these two groups, the question for the profession to face is, what can be done about it?In response to this division, various chiropractic organisations have since long made great efforts to try to bring the various factions closer together by appreciating and respecting each other’s differences. One such unifying attempt from the European Chipractors’ Union (ECU) was the slogan ‘celebrating diversity’ used in connection for the 2016 ECU conference . HoweverA more recent approach that we are seeing now is that various organisations, who for decades have supported unity between factions at all costs, are now focusing strongly on evidence as the basis for chiropractic practice rather than on unity. One example is the American Chiropractic Association (ACA) that recently adopted the mainstream, broad-consensus ‘Choosing Wisely’ campaign, and the World Federation of Chiropractic (WFC) that recently signaled a policy shift by abandoning attempts at ‘unity’  and focuIn this commentary, we explore another solution to this historic division. One that does not involve uniting both sides, but one that acknowledges that when a division is too great to reconcile, decoupling may be the best way forward for all involved. In this paper, we explore the similarities between couples and professions, examine what happens when they become estranged, and consider how the solutions established by our society for marital disagreement may also be the key to doing what is best for both groups. Uppermost in our minds in this process is what is best for the ‘children’, i.e. patients.Obviously, there are many and varied reasons for making married couples happy and functional. Love, affection, and sex  are impoThese reasons for content marriages are hardly surprising. However, why some couples choose to stay together, when the relationship has gone sour and there is no love left between the parties, is relevant to this discussion.Respect for each other, morality, religion, politics, and business interests may be some reasons for remaining, as well as the wish not to hurt the other partner . Some prAdditionally, when marriages are clearly dysfunctional and the two partners would be better off on their own, it is not uncommon for one of the two to make promises to change  , 44. KinFinally, when things go wrong in a marriage, another strategy is that one partner has too much to lose so they simply tolerate the problem – perhaps this is the closest analogy of where the chiropractic profession has been in the past 25 years. Doubtlessly though, both parts are unhappy with the present arrangement.Instead of choosing to remain in a relationship for any number of reasons, there are obviously many couples who decide to separate , 46. TheThe two main factions in the chiropractic profession still ‘live at the same address’. By this we mean that they present themselves to others under the same family name, have institutions that try to enforce the same international and national Standards of Accreditation of chiropractic programmes for both so that patients are dealt with in fairly standardised ways, and there are regulations for chiropractic educations to ensure a reasonable common level of graduates.Nevertheless, there are definite signs that the situation may be intolerable for many chiropractors on both sides. We have identified reasons for unhappiness, and listed those in Table formal splitting up are visible. Nevertheless, there are many reasons for some marriages to persist despite obvious difficulties and differences. The reasons for the chiropractic profession staying together may be analogous, and, as seen from our viewpoint, some of these are listed in Table Although there are many indications of unhappiness and also great attempts to improve the chiropractic marriage, no obvious signs of a Chiropractors sit on a spectrum, and the majority fall in the middle and practice with a ‘you-never-know who and what will respond to spinal manipulation’ attitude, yet with only some attachments to chiropractic tradition. Chiropractors in this group probably just want to get on with their work, not paying too much attention to the bickering going on. They do not engage politically, they rarely appear at seminars or general assemblies, and they do not take sides. Thus this middle group accepts or at least tolerates much of the statements and activities by the traditionalist groups. Importantly, the middle group does not seem to consider illogical and unsubstantiated claims to be of real danger to the profession and if they are troubled by them, they do not voice this publically, maybe because they think that ‘the more the stronger’ or simply because of apathy.In our opinion, this middle ground is becoming increasingly harder to reconcile and thus difficult to hold, as the marital difficulties inevitably play out more openly, because of the increasing general public interest in chiropractic –54. TherChiropractors are not the only family in the neighbourhood. There are other families i.e., other manual therapeutic professions, who are engaged in ongoing positive positioning, who are willing, able and evidence centred to fill the societal need for conservative approaches to musculoskeletal care. It is likely that this time window of opportunity for chiropractors is limited and closing. Much like climate change perhaps the tipping point has already been breached. The time for action may never be more appropriate than now.We acknowledge that vitalism and other idealistic concepts based on theories and beliefs rather than scientifically accepted logic and evidence have a role to play in the public domain. They are, however, not compatible with the ‘official’ evidence-friendly chiropractic profession, and to accept and protect such an approach, is a serious issue, potentially one of public safety.We have argued that the situation within the chiropractic profession corresponds very much to that of an unhappy couple that stays together for reasons that are unconnected with love or even mutual respect. The current marital disharmony clearly goes beyond the scope of continuing to live unhappily with ‘another person’ of a differing world view. The alternative to this unhappy family structure would be an amicable divorce.Although it might be painful, difficult and unsettling, in the long run it might make it possible for the two main groups to develop their full potentials, as they both deserve a happy professional life. The evidence-friendly group would be free to progress and collaborate in agreement with developing research findings and trends within public health, whereas the traditional groups can flourish in the wellness market, as there is a demand in the public also for more ‘mysterious’ and all-encompassing therapies and movements. For us it appears obvious that stakeholders, public, and the chiropractors would be better off, if the two factions and the middle group clearly stated where they belong. In addition, if patient interests are given true primacy, the arguments for unity, in our opinion, seem less significant than those for divorce.Therefore, chiropractors and chiropractic leaders, regardless of values and persuasion, need to pause and consider, if they are able to live and develop as they would like to in this century-old unhappy marriage.It is hoped that this paper opens a discussion among all parties that can eventually lead to an equitable arrangement for stakeholders and a sustainable future for chiropractic.


The Seventy-first World Health Assembly in 2018 approved the World Health Organization’s (WHO’s) thirteenth general programme of work, which is mostly based on the sustainable development goals (SDGs).To meet these goals, policy-makers and programme managers strive to make evidence-informed decisions for strategies and interventions, while dealing with competing sectoral priorities and constrained resources. Policy-makers need to consider the efficacy and safety of clinical interventions as well as information addressing health-system and health promotion strategies. Programme managers are interested in understanding how interventions interact with and can bring about wider changes in the health system as a whole.Current evidence synthesis and guideline development methods can be enhanced to respond to these needs. Developers of evidence-informed guidance, including WHO, often apply processes and methods grounded in linear models of cause and effect–Several international groups are actively working to advance the methods for assessing and synthesizing evidence and formulating recommendations on complex interventions.WHO has a unique position as a science- and evidence-based organization that sets global norms and standards.The supplement introduces the new WHO-INTEGRATE evidence-to-decision framework,Work is ongoing to translate the findings of this series into pragmatic guidance for WHO guideline developers. We look forward to further collaboration with academics, researchers, programme implementers and other end-users to continue to apply and improve these methods. This will ensure that WHO guidelines remain updated and relevant, and most importantly, provide the much-needed normative guidance to support countries to achieve their goals for social transformation and improved health of their populations.


The objective of the current study was to explore the potential of full weight-bearing clinical computed tomography (CT) to evaluate the helical axis and centre of rotation of the subtalar joint during inversion and eversion motion. A subject specific methodology was proposed for the definition of the subtalar joint motion combining three-dimensional (3D) weight-bearing imaging at different joint positions with digital volume correlation (DVC). The computed subtalar joint helical axis parameters showed consistency across all healthy subjects and in line with previous data under simulated loads. A sphere fitting approach was introduced for the computation of subtalar joint centre of rotation, which allows to demonstrate that this centre of rotation is located in the middle facet of the subtalar joint. Some translation along the helical axis was also observed, reflecting the elasticity of the soft-tissue restraints. This study showed a novel technique for non-invasive quantitative analysis of bone-to-bone motion under full weight-bearing of the hindfoot. Identifying different joint kinematics in patients with ligamentous laxity and instability, or in the presence of stiffness and arthritis, could help clinicians to define optimal patient-specific treatments.Accurate  The talus comprises of three facets  that articulate with the mating facets on the calcaneus at the subtalar joint. The bones are connected by a complex of ligamentous structures that connect the talus to the calcaneus and both structures to the adjacent navicular bone, which is intricately involved in hindfoot and midfoot motion Fig. . The sub2, preventing participation in sports and normal daily activities. Common pathologies affecting the joint include instability following ligamentous injury3, and painful flat feet in children and adults. In addition, end stage ankle and hindfoot arthritis is a major problem that has been shown to affect quality of life as much as end stage heart disease5. Although the incidence of subtalar joint arthritis is unknown, approximately 3.4% of the population aged over 50 has radiographic hindfoot arthritis, which is more than 300,000 people in the UK6. The most common cause of subtalar joint arthritis is posttraumatic, occurring in almost all patients following a talar body or calcaneal fracture8. Other non-traumatic causes include longstanding flat feet, tendon dysfunction and inflammatory conditions such as rheumatoid arthritis9. Following failure of non-operative management which includes the use of painkillers, ankle supports, and activity modification, the gold standard treatment for end stage subtalar joint arthritis at present consists in the removal of the subtalar joint and fusion of the talus to the calcaneus  using metalwork. In this situation the talocalcaneal and or talonavicular motion is obliterated and the hindfoot moves as one structure. Fusion causes transmission of abnormal stresses to adjacent joints13, leading to their increased risk of wear and tear. Although subtalar joint replacement has been attempted, early failure rates greater than 50% within the first year14 led to the abandonment of the procedure. The creation of a subtalar joint replacement, that is as functionally effective and as reliable as other joint (i.e. hip and knee) replacements, is inhibited by the higher complexity of the subtalar joint as well as due to lack of understanding of the mechanics of the joint.Problems associated to the subtalar joint can have a significant impact on function15. In general, subtalar joint motion has been described using a finite helical axis. At each moment in time, motion of the subtalar joint can be broken down into a rotation about, and a translation along the helical axis, although it has been shown that the physiological axis cannot be described that simplistically18. Subtalar joint helical axis is directed obliquely from posterior-lateral-plantar to anterior-medial-dorsal, piercing the talus anteriorly at the superior aspect of the talar neck20. During weight-bearing motion, the foot has been proposed to behave as a rigid unit with all the bones of the foot rotating around the central pivot of the talus at the subtalar joint axis19. The ability to accurately determine the centre of rotation  of human joints is particularly important in the field of orthopaedics, where treatments involve the replacement of joints that need to replicate the native kinematics. Whilst considerable attention has been given to the determination of the centre of rotation of the hip joint22, knee joint24 and ankle joint26, the location of the centre of rotation of the subtalar joint has not been previously identified.Motion of the subtalar joint is complex. Due to the convex posterior facet of the calcaneus and corresponding concave facet of the talus, subtalar joint movement can be described as rotation, translation or a combination of bothin vivo. External surface markers28, dual fluoroscopic imaging31 and three-dimensional (3D) imaging methods (i.e. computed tomography (CT) and magnetic resonance imaging (MRI))35 have been proposed to address subject-specific subtalar joint biomechanics. Although camera registration techniques provide subtalar joint kinematics during stance and walking, the lack of external landmarks of the talus hinder rotation and translation measurements. Conversely, imaging methods directly measure helical axis of rotation, providing more accurate measurements in vivo35. Fluoroscopic imaging overcomes some of these challenges in using external marker-based models, and when coupled with a CT or MRI it can provide 3D information of the joint motion. However, its application for the evaluation of subtalar joint helical axis has not been reported. Recent studies have shown the potential of four-dimensional (4D) CT to evaluate subtalar joint kinematics and detect changes between healthy and pathological subjects both ex vivo36 and in vivo37. However, all previous literature reports images acquired with subjects placed in the CT scanner table in a supine position and, although custom-built ankle loading devices are commonly used, images acquired are not in a weight-bearing configuration.Tracking subtalar joint motion is technically challenging, thus several methodologies have been proposed to study subtalar joint kinematics 19. Consequently, motion and bone position of the subtalar joint may not be accurately defined with traditional non-weight-bearing imaging techniques. Recently, full weight-bearing standing CT devices such as PedCAT  have been developed, allowing more functional diagnosis of foot problems39 as well as more accurate measurements of bone alignment43. PedCAT dual scanning modality  in combination with the advancements of image-based analysis such as digital volume correlation (DVC)44 can be exploited to analyse subtalar joint movement in vivo. DVC is a 3D image registration technique able to provide full-field displacement throughout the interior of materials subjected to incremental loading whilst simultaneously imaged (i.e. via CT) and it has been widely used in bone biomechanics47. The fundamentals of DVC method rely on the measurement of a discrete displacement vector field by correlation of 3D images in different deformation states, based on the natural variations in image grey-level intensity, which are given by the internal material texture of the sample. Thus, a 3D image-based patient specific procedure can be defined to describe subtalar joint motion under full weight-bearing by computing 3D full-field displacement of the subtalar joint from inversion to eversion position.During weight-bearing, the combination of tensile loading of the ligaments and compression loading of all the joints of the foot creates a more tightly joined and stable architecture when compared to a non-weight-bearing situationTherefore, the aim of this study is two-fold. Firstly, a novel method enabling the quantification of inversion-eversion at the subtalar joint based on 3D imaging with full weight-bearing in combination with 3D full-field DVC-computed displacement is introduced. Under the hypothesis that there is a single axis of rotation of the posterior facet of the subtalar joint in normal healthy individuals the second aim of this study is to establish whether there is a centre of rotation of the subtalar joint, effectively a central pivot of the talus along the helical axis.Motion of the subtalar joint was captured from weight-bearing clinical CT images acquired in three different positions: inversion, neutral and eversion. The position of the talus relative to the fixed calcaneus in such poses after segmentation of both bones and rigid registration of the calcaneus demonstrates the lateral opening of sinus tarsi in the inverted foot and closing in the everted foot as shown in Fig. The helical axes representing the range of motion of the subtalar joint between inversion and eversion positions were consistent in the group of eight subjects for both feet Fig. , with a The calculated centres of rotation of the relative motion of the talus around the calcaneus showed good agreement for all subjects Fig. . These wA comparison of the shift of the calculated centre of rotation from the neutral to the rotated positions and the total range of talus displacement computed using DVC is shown in Fig. The outliers identified in the computation of helical axis Fig. , centre in vivo and proved to be robust, showing consistency of the helical axis parameters for the subtalar joint among subjects in different foot positions.This is the first study to use weight-bearing clinical CT to evaluate subtalar joint helical axis from inversion to eversion positions in healthy standing subjects. This novel approach combined 3D images to measure displacements of the bones via digital volume correlation (DVC) under various loaded states 48. This may result from the subject-specific talus-based coordinate system, defined differently from previous studies, in which the helical axis was defined based on the anatomical planes of the foot1. A coordinate system based on the geometric principal axis minimise inaccuracies related to the manual selection of anatomical landmarks based on 2D projections of MRI, CT or X-rays32 to define the anatomical planes of the foot and, consequently, the variability among subjects is reduced.It was shown that the helical axis of the subtalar joint runs from postero-lateral-inferior to antero-medial-superior Fig. , with an16 to 37.3° ± 5.9°35. Difference may reflect the more accurate measurement of subtalar rotation in subjects that were weight-bearing, whereby the combination of tensile loading of the plantar ligaments and compression loading of all the joints of the feet creates a more tightly joined and stable architecture when compared to non-weight-bearing conditions19.The current results have shown that the average range of motion of the subtalar joint amounts to 13.9° ± 3.5° during inversion-eversion motion of the foot. Other studies that have estimated subtalar rotation using a simulated load bearing scan have shown rotations ranging from 15.1° ± 9.7°50. Here, DVC was introduced for the first time to quantify, in vivo, subtalar joint displacements in weight-bearing conditions. Not only the definition of the helical axis parameters  could be defined but, in addition, the 3D full-field displacement of the talus motion around the calcaneus . This can be explained by the need to manually define calcaneal and sustentaculum facets, which unavoidably introduce operator-dependent variability. Similar values were found by rigidly registering the obtained CT images . The advantage of using DVC before a rigid registration procedure relies on its ability to track the displacement of the internal bone structure. Therefore, the local displacements can be quantified instead of the global rotation and translation. Furthermore, not just the boundary of the bones35 (whose definition may be subjected to segmentation errors) is considered in the matching procedure between two different foot positions, but the inner bone structure can be analysed. This shows the large potential of DVC to better understand foot and ankle motion in vivo when combined with weight-bearing clinical CT. Although not the objective of the present work, full-field strain distribution in bone could be quantified, allowing a novel diagnostic tool for foot and ankle deformities.The use of DVC with images from clinical CT remains partially unexplored53. However, fusion of hindfoot joints has been shown to transfer the stresses to adjacent joints leading to progressive arthritis and symptoms in these joints13. Any previous attempts to replace rather than fuse the subtalar joint have been based on two conforming surfaces that allowed sliding and translation and failed to replicate the somewhat constrained rotation of the talus on the calcaneus that is seen in vivo14. In all cases the patients had pain and probable clinical instability, leading to abandonment of the procedure14.In conditions such as post-traumatic arthritis, or symptomatic talocalcaneal coalition, posterior tibial tendon dysfunction, isolated subtalar joint instability or inflammatory arthritis, surgical fusion of the subtalar joint is currently the gold standard treatment25 or dual fluoroscopic imaging23; however, the calculation of the centre of rotation for the subtalar joint has never been addressed, which can be partially explained by the difficulties in tracking subtalar joint motion in vivo. A subject-specific method of locating the centre of rotation based on a sphere fitting approach of the centre of mass of the talus has been herein proposed and it was shown that the centre or cluster of centres appears to be in the region of the middle facet of the subtalar joint  used 4D CT to assess differences in talus/calcaneus relative angles and distances during motion in the non-weight-bearing setting between healthy individuals and patients with subtalar joint stiffness and instability. They mainly looked at relative kinematic measurements of the talus and calcaneus in the virtual reconstructed radiographs (2D) from conventional clinical CT images37. However, 3D motion (i.e. rotation and translation) of the subtalar joint was not addressed. The potential of 3D volumetric data was also not exploited, as it has been performed in the present study.The reconstruction of the rotational motion of the talus around the calcaneus  participated in the experiment; therefore, generalisation and extrapolation of the location of the centre of rotation of the subtalar joint in healthy individuals warrants further analysis. Nevertheless, high consistency has been shown among subjects. Another limitation is related to the use of standardised wedges to image inversion and eversion positions for all subjects. Even though each subject was asked to place their feet on the wedges so that they felt it was the maximal inversion or eversion they could achieve, this may not represent the total range of motion of the subtalar joint. Last, this study quantified subtalar joint rotation and translation from static weight-bearing CT images acquired at different degrees of rotation. This acted as a surrogate for motion, but the dynamic motion between the talus and calcaneus was not addressed. While 4D CT or the combination of dual fluoroscopic imaging with CT can provide dynamic information of subtalar joint movement, motion artefacts occurring during imaging acquisition could affect 3D image reconstruction and consequently, DVC computation. In addition, it may be difficult to obtain ethical approval given the much greater radiation doses that this would involve. Nonetheless, coupling weight-bearing static and dynamic CT for the evaluation of subtalar joint kinematic could lead to a better identification and description of subtalar joint pathologies.Further research will be needed to establish how the normal subtalar motion changes under load, when the soft tissue restraints are pathological such as following ligamentous injury or in patients with lax ligaments, or indeed in the presence of arthritis and stiffness. The methodology described in this paper could also be used to assess hindfoot motion after surgery paving the way for an improved understanding of the outcomes of surgery which hitherto have been next to impossible to evaluate in the clinical setting.in vivo but also to give a better understanding of the relative motion at the subtalar joint under physiological loading. It was determined that the helical axis of the subtalar joint runs from postero-lateral-inferior to antero-medial-superior with an average angle of inclination of 42.6° and a deviation of 6.1° in a full weight-bearing position. It has also been shown that the centre of rotation is located in the region of the middle facet of the subtalar joint with on average up to 11% translation in normal subjects reflecting the viscoelasticity of the normal subtalar ligaments. It is hypothesised that the translational component is likely to be greater in patients with ligamentous disruption and hypermobility. Any joint replacement developed to replace this joint will need to replicate normal motion and incorporate appropriate constraints to prevent clinical instability. 4D image-based analysis shows promise to assess changes in motion and kinematics in normal and pathological cases, helping to direct better clinical understanding and future treatments.In conclusion, this study demonstrated the feasibility of a 4D image-based patient-specific procedure to evaluate subtalar joint motion with full weight-bearing clinical CT in healthy subjects. The quantification of the 3D full-field displacement of the subtalar joint during inversion-eversion motion using DVC provided a novel tool not only to measure the helical axis 55.The study received ethical approval from the London Ethics Committee (16/LO/025) and all methods were performed in accordance with the relevant guidelines and regulations. Eight healthy asymptomatic volunteers  participated in this study following receipt of informed consent. Each subject walked into a PedCAT  standing CT scanner and positioned into the centre of two rings on a baseplate Fig. . AlthougImage post-processing prior to quantitative analysis of subtalar joint kinematics was performed according to a fixed workflow Fig. . Bone se56) to align the calcaneus in inversion and eversion positions with the neutral reference configuration . Both translation and rotation parameters for each bone were computed in order to find an optimal fit in the three dimensions . The positive major principal axis (X-axis) was directed anteriorly, the positive second principal axis (Y-axis) medially and the positive third principal axis (Z-axis) proximally.For quantitative analysis of the subtalar joint kinematics, the motion of the talus relative to the calcaneus between neutral-inversion and neutral-eversion positions were computed. Firstly, a rigid registration was performed , reached via successive (predictor) passes using sub-volumes of 40, 32, 24 and 16 voxels. To quantify the level of uncertainties of the DVC measurements, which is associated to imaging conditions, image post-processing and sub-volume size of the rigidly registered calcaneus images were used. In an ideal repeated CT image, the displacements could be considered null; however, in this real experiment the actual displacements were affected by the actual motion of the joint in the different positions and the registration procedure. Therefore, the accuracy of the computed displacement  could not be evaluated and only the precision (standard deviation) was assessed60. Precision of the DVC-computed displacements ranged from 0.25 to 0.02 mm (0.66 to 0.07 voxels) among all pair of images analysed. Only sub-volumes fully included within the talus or calcaneus were considered for the displacement field calculation to avoid inaccuracies in the segmentation procedure that may affect the surface of both talus and calcaneus. In addition, a threshold for the correlation coefficient was set to 0.5 and just sub-volumes exceeding such threshold were analysed.Digital volume correlation  was used to compute the displacement field of both talus and calcaneus from neutral to inversion and neutral to eversion positions. DVC is a cross-correlation method operating on the intensity values  of the 3D reconstructed CT images. In essence, the measurement volume is divided into smaller sub-volumes and the contrast  pattern is then tracked from reference  to deformed (inversion/eversion position) state as a discrete function of the grey-levels. The operating principles of DVC methods have been extensively reported elsewheret = 0 to inversion/eversion position at time t were then computed 3\documeFinally, the ratio of translation of the centre of rotation relative to the total range of talus displacement was evaluated and defined as a shift motion.α = 0.05) in Matlab software.Quantitative variables are reported as mean ± standard deviation and represented as median, range, 95% confidence intervals (CIs) and outliers on boxplots . The asymmetry between the left and right foot helical axis parameters and centre of rotation as well as differences between neutral-inversion and neutral-eversion displacement were compared using a two-side Wilcoxon signed rank test (Supplementary Information.Video S1.Video S2.


A 33-year-old male patient came to our observation for a slight discomfort in the left side of the tongue. The patient reported good general health and that he have sometimes taken benzodiazepine in periods of stress. The dental abrasion showed the presence of bruxism. On an objective examination we could notice the simultaneous presence of a "toothed tongue" and a slightly area of erosion on the left side of the dorsal tongue, with an irregular white halo around it. This lesion, appeared from some days, is symptomatic. The diagnosis is compatible for benign migratory glossitis. The patient claimed to have never suffered of skin diseases strongly related to migratory glossitis. It is possible that the bruxism may have determined the presence of that lateral tongue shape and that stress may be the main cause of the appearance of migratory glossitis. The simultaneous presence of the two conditions has never been documented in the scientific literature and we do not exclude that there may be a correlation to the genesis of both lesions. Sometimes the presence of a tongue with this morphology could be the result of a trauma or a surgery. The lingual erosion can be placed in differential diagnosis with a heat burn or a chemical burn.


Although modifying diets, by thickening liquids and modifying the texture of foods, to reduce the risk of aspiration has become central to the current management of dysphagia, the effectiveness of this intervention has been questioned. This narrative review examines, and discusses possible reasons for, the apparent discrepancy between the widespread use of modified diets in current clinical practice and the limited evidence base regarding the benefits and risks of this approach.There is no good evidence to date that thickening liquids reduces pneumonia in dysphagia and this intervention may be associated with reduced fluid intake. Texture-modified foods may contribute to undernutrition in those with dysphagia. Modified diets worsen the quality of life of those with dysphagia, and non-compliance is common. There is substantial variability in terminology and standards for modified diets, in the recommendations of individual therapists, and in the consistency of diets prepared by healthcare staff for consumption. Although use of modified diets might appear to have a rational pathophysiological basis in dysphagia, the relationship between aspiration and pneumonia is not clear-cut. Clinical experience may be a more important determinant of everyday practice than research evidence and patient preferences. There are situations in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust evidence. Nevertheless, there is a significant discrepancy between the paucity of the evidence base supporting use of modified diets and the beliefs and practices of practitioners.The disconnect between the limited evidence base and the widespread use of modified diets suggests the need for more careful consideration as to when modified diets might be recommended to patients. Patients (or their representatives) have a choice whether or not to accept a modified diet and must receive adequate information, about the potential risks and impact on quality of life as well as the possible benefits, to make that choice. There is an urgent need for better quality evidence regarding this intervention. Oropharyngeal dysphagia is common in older people and in those with neurological and neurodegenerative diseases –6. DysphTo summarise the evidence regarding the potential benefits and hazards of modified diets in dysphagia;To examine whether current practice regarding modified diets reflects and is supported by the current evidence base;To explore the reasons for any disconnect between evidence and practice; andTo provide recommendations and suggestions regarding the appropriate use of modified diets.The clinical effects of modified diets in adults with dysphagia, or in selected subgroups, have been examined in multiple high-quality systematic reviews in recent years –24. ThesOverall, there is no convincing evidence to suggest that texture modified foods and thickened fluids benefit adults with dysphagia by preventing pneumonia and its consequences –28. Therp < 0.001 or more). Honey-thickened liquids were significantly less likely to prevent aspiration when presented last than when presented first in the sequence of trials, which may reflect the effects of fatigue.The best evidence  regp = 0.05). Urinary tract infection and fever were also more common in the thickened liquid groups. Ultimately, the trial ended early after a futility analysis concluded that enrolling additional participants would not change the results. The authors concluded that no definitive conclusions about the superiority of any of the tested interventions could be made.In a follow-up study, Robbins et al. randomised 504 subjects who had done equally well  or poorly (no intervention eliminated aspiration) to continue with one of the three interventions . The cumOther studies provide indirect evidence regarding the effects of thickened fluids. In ‘free water protocols’, selected patients who aspirate thin fluids are allowed to drink water, often under supervision and after meticulous oral hygiene, in addition to thickened fluids. A recent meta-analysis of data from inpatient rehabilitation units concluded that there was low-quality evidence that this approach did not increase the risk of lung complications and may increase fluid intake and patient satisfaction . ProspecPoor hydration is common in frail older people and, in particular, in nursing home residents where up to a half of residents in several studies have current or impending water-loss dehydration  –41. SomeFewer studies to date have examined the relationship between modified diets and biochemical indices of dehydration. In a retrospective study of acute stroke patients, any modification of solid diets or thickened liquids resulted in significantly elevated blood urea nitrogen/creatinine values at discharge compared with those not having that intervention ; these bThe use of modified-texture foods, particularly pureed diets, contributes to the high prevalence of malnutrition in those with dysphagia, especially in long-term care residents , 49–52. Even a minimal increase in viscosity can delay medication dissolution and disintegration and hence bioavailability and this delay becomes greater with increasing viscosity , 53. AbsHalf to two thirds of dysphagia patients are non-compliant with recommendations to take a modified diet; some are completely non-compliant, while others ‘cheat’ or ‘sneak’ proper food and drinks –57. The A recent systematic review of studies confirmed that modified diets worsen health-related quality of life significantly . PatientCarers’ beliefs that modified diets are unpalatable also contribute to non-compliance. In a recent study of staff perceptions of pureed food, most had a negative view describing such food with terms like ‘tasteless’ and ‘mush’; positive comments such as ‘tasty’ and ‘aromatic’ mainly came from allied health professionals and dietary-nutrition staff .Healthcare professionals and non-dysphagic patients who have sampled them report a strong dislike for thickened fluids, especially those of higher viscosity –68. Gorha modest reduction in pneumonia incidence would (my emphasis) produce an enormous economic benefit and increased survival, justifying management of dysphagia’. [In the USA, the total monthly costs for thickened liquids for a person have been estimated to be in the range of $174 to $289 , 69 In Ephagia’.  However,phagia’.  and fromUsual clinical practice with regard to modified diets is characterised by a startling inconsistency at all levels: inconsistencies in national standards and practices; inconsistencies in how carers and professionals apply those standards that do exist; and inconsistencies in the recommendations and practices of individual therapists.An international convention on terminology and definitions for texture-modified foods and thickened liquids has recently been agreed . NationaEven experienced SLTs are unable to reliably produce liquids to desired levels of thickness and have only moderate success in their ability to replicate those levels of thickness in later attempts . There iThe use of different modified diets among SLTs vary greatly , 76–78. While conducting their RCT, Logemann et al. noted that some patients were receiving thickened fluids although they did not have any aspiration of thin liquids during the VFSS . A failuThe lack of evidence supporting the use of modified diets to reduce pneumonia is widely acknowledged in the dysphagia literature, and several writers have expressed unease at how widely they are used in everyday practice despite the lack of evidence , 81–83. Modifying diets is a rational approach to reducing aspiration, and this, irrespective of any paucity of long-term evidence, may justify their use , 71. StuAspiration pneumonia is not a direct and inevitable consequence of aspiration: not all who aspirate develop pneumonia, and many who develop pneumonia are not aspirators –95. DyspAn instrumental swallowing assessment bears little resemblance to eating in real life and fluids used during videofluoroscopy do not provide an accurate indication of swallowing ability at mealtime . There rAlthough the risk of aspiration in instrumental studies is reduced with liquids with increasing degrees of thickness, higher viscosity liquids also result in increased pharyngeal residue after swallowing with the potential for increased aspiration risk . The samThis argument sounds plausible, but it is only a hypothesis; many widely-used interventions in medicine that should have benefited patients, based on pathophysiological reasoning, ultimately were shown to have no benefit, or even to cause harm , 91. TheOther writers have criticised the over-emphasis on (the lack of) RCT evidence regarding dysphagia interventions , 86. ManThese are strong arguments. Practitioners faced with a patient with troublesome dysphagia must often make pragmatic recommendations even if based on imperfect evidence. It is also true, however, that the absence of robust evidence has a more detrimental effect on decision making if an intervention, as with modified diets, is intrusive and carries significant potential hazards as well as benefits , 103.Surveys of practicing SLTs suggest a strong consensus supporting modified diets based primarily on therapists’ training and experience , 8, 87. As with other healthcare interventions, the person or, if he or she lacks capacity to decide, their representative should decide - and accept responsibility for the consequences of that decision - whether to take a modified diet after receiving adequate information about the risks and benefits of their use , 105. ThGiven the lack of robust evidence, most recommendations to modify diets should come hedged with ‘maybe’s’ and with acknowledgements of uncertainty rather than with ‘must’s’. However, the strong belief of some practitioners that modified diets are essential and beneficial might influence how they educate patients  about modified diets , 87. UllSome reports regarding those who are non-compliant with recommendations to modify diets raise questions about how voluntarily people give consent. Non-compliance may cause ‘moral unease or distress’ to staff; some may refuse to participate in feeding a non-compliant patient; patients who remains determined to make what is seen as an unduly risky choice may be threatened with premature discharge . Non-comSituations do arise in the management of dysphagia where common sense and the necessity of intervention will clearly outweigh any lack of evidence or when application of evidence-based principles can enable good decision making despite the absence of robust RCT evidence.It seems obvious that assessment and intervention is needed if there is immediate and significant distress related to feeding or a high risk of asphyxiation. (‘Immediate’ and ‘significant’ are highlighted: the distress that might result from developing pneumonia or occurrence of non-severe symptoms such as a wet voice or a clearing cough should not be used as a justification for widespread intervention). People with severe aspiration or chewing problems may be fearful of taking thin liquids and a normal diet . They maThere is some evidence of benefit from swallow rehabilitation programs, and intensive swallow therapy reduces chest infections in dysphagic acute stroke patients , 30. PatEven in the absence of high quality evidence, a ‘carefully controlled single patient treatment trial’ to evaluate the effect of an intervention is justified if an intervention is logical for that patient, there is a reasonable expectation of benefit and the patient agrees . This seThere is little good evidence of benefit from modified diets and there is the potential for harm including as adverse impact on quality of life. This does not mean that use of modified diets should be abandoned. It does suggest the need for careful consideration as to when modified diets might be recommended to patients and how discussions about modified diets should be conducted and informed consent sought.It is likely that practitioners will have to continue to consider the appropriateness of modified diets for patients with dysphagia without the benefit of RCT evidence for the foreseeable future.  shows no registered trial dealing with this topic). It has been argued persuasively that, even in these circumstances, application of the principles of evidence-based practice can lead to practitioners and their patients making reasonable decisions about this intervention , 111. InWhile there are no doubt many settings where such good practices are followed, some studies raise concerns about whether everyday practice and attitudes towards modified diets does reflect an evidence-based approach. These include studies showing an overreliance of some practitioners on clinical experience and training to guide practice and the provision of modified diets, perhaps particularly in long-stay units, without appropriate assessment, communication, implementation and review. It is true that some such practices are outside the control of clinicians ; neverthThe tone of the discussions between clinicians and patients and the strength of recommendations of the former should be highly dependent on the quality of the evidence. There should be, in effect, a sliding scale of how strongly clinicians should recommend modified diets from, for example, urging or pleading with a reluctant or non-compliant patient to accept some modification of food texture if their risk of an asphyxial death is high to, at most, a tentative suggestion of a trial of therapy if there might be sufficient benefit from a thick fluid consistency to offset the risks of dehydration and impact on quality of life. Ultimately, the patient must understand that, irrespective of the view of the clinician, he or she has a choice.Clinician recommendations and patient decisions are based on their relative assessments of whether the potential benefits of modified diets (or other interventions) will outweigh the potential risks . It is for the patient to decide how he or she would judge that balance. In order to make that decision the patient needs and is entitled to information, not only about the potential for reducing aspiration pneumonia, but about possible risks and hazards, including underhydration and nutrition and the impact on quality of life . UncertaQuality of life is as or more important than quantity of life for many people , 113–116Modified diets are a more intrusive intervention than any medication and are widely used in the absence of a high-quality evidence base. Individual patient trials may be the best that can be achieved at present but are no substitute for having RCT evidence to guide practice. Such trials are even more important if widespread screening of those who do not present with worrying symptoms directly suggestive of aspiration problems is to be recommended . There i


Legal theorists have characterized physical evidence of brain dysfunction as a double-edged sword, wherein the very quality that reduces the defendant’s responsibility for his transgression could simultaneously increase motivations to punish him by virtue of his apparently increased dangerousness. However, empirical evidence of this pattern has been elusive, perhaps owing to a heavy reliance on singular measures that fail to distinguish between plural, often competing internal motivations for punishment. The present study employed a test of the theorized double-edge pattern using a novel approach designed to separate such motivations. We asked a large sample of participants (N = 330) to render criminal sentencing judgments under varying conditions of the defendant’s mental health status  and the disorder’s treatability . As predicted, neurobiological evidence simultaneously elicited shorter prison sentences  and longer terms of involuntary hospitalization  than equivalent psychological evidence. However, these effects were not well explained by motivations to restore treatable defendants to health or to protect society from dangerous persons but instead by deontological motivations pertaining to the defendant’s level of deservingness and possible obligation to provide medical care. This is the first study of its kind to quantitatively demonstrate the paradoxical effect of neuroscientific trial evidence and raises implications for how such evidence is presented and evaluated. Neuroscience is playing an increasing role in criminal trials. While it is unfeasible to estimate the prevalence of neurobiological evidence in lower courts, their rates in murder trials may exceed five percent, as indicated by the subset of cases documented at the appellate level . But braAccording to recent research, ordinary people have considerable preconceptions about the explanatory power of neurobiological evidence. Weisberg, Taylor, and Hopkins , for exaIf people perceive evidence to be stronger when it is dressed up in neuroscientific garb, to what extent does this tendency impact legal judgments? In a study of trial court judges, Aspinwall, Brown, and Tabery , found tOne explanation for the apparent “seductive allure” of neurobiological evidence is that people assume that physical causes of behavior, such as genetic or neurological causes, indicate that the behavior is outside the agent’s ability to make free choices or to control their behavior and therefore outside their scope of responsibility. Thus, when physical causes are more salient than other causes, judgments should be more lenient. Consistent with this theory, Greene and Cohen  have argOther scholars have argued that the tendency to excuse a person of responsibility simply because that behavior has identifiable physical causes is fallacious because, in reality, all actions are ultimately physically determined. Morse  names thFallacious or not, the inference that physical causes of a defendant’s behavior render that behavior outside his control carries another risk. Though such inferences can reduce attributions of responsibility, scholars have warned that they can potentially increase perceptions that the defendant is dangerous and in need of greater institutional supervision. For instance, Berryessa  found thDespite the growing number of studies on this topic, evidence of the double-edged nature of biological evidence has been elusive. Though biological evidence has tended to mitigate guilt and punishment in the aforementioned studies , 8, otheYet other mock trial studies have reported null effects of biological explanations. For example, neurobiological evidence of psychopathic or anti-social tendencies in criminal offenders had no effect on participant’s recommended prison sentence lengths compared to psychological or behavioral evidence , 23. SimDespite expectations that neurobiological evidence cuts both ways, no single study has quantitatively demonstrated both mitigating and aggravating effects side by side. One reason could be that different studies have ignored potential attitudes about the disorder’s amenability to treatment. Highly treatable disorders tend to reduce perceptions that the defendant continues to be a danger to others. So if a biological disorder is portrayed as treatable, punishments should be lenient because the defendant will be perceived as low in both responsibility and dangerousness. But if the same disorder is portrayed as untreatable, this may evoke concerns that the defendant is dangerous even if he is less morally responsible for the crime. To our knowledge, no previous studies have considered the potentially moderating role of treatability.Another possible reason for the inconsistent findings is that the dependent measures used across studies fail to capture distinct, sometimes competing, punitive motives within the same individual. Most quantitative studies, for instance, included only a single punishment measure, along the lines of: “How long should the offender be sentenced to prison?” or “How much should the offender be punished?”. If a participant has both deontological concerns  and consequentialist concerns , she is forced to use a single measure to voice both types of concerns. When participants are forced to use prison time as a “one-stop shop” to capture their diverse punitive motives, these separate motives could interact or cancel out in unknown ways.The present study was designed to address these limitations in a contrastive vignette experiment involving the diagnosis of an impulse control disorder following a sexual assault. A sexual assault crime was selected because it is one of the more plausible charges used to justify commitment to involuntary hospitalization in many U.S. states. By explicitly manipulating whether the neurobiological or psychological disorder is deemed treatable or untreatable, we control for the possible dependency of neurobiological descriptions on perceived treatability . And, bA supplemental goal of this project was to explore whether the predicted effects are associated with individual differences in cognitive functioning. Individual differences in legal settings are important because they can serve as sources of differential treatment of offenders. Leading theories suggest that many context effects are caused by a tendency to attend to the salient attributes and activate confirmatory associations in memory . If so, This study investigated the effect of brain-based evidence of an impulse control disorder on lay sentencing judgments in a large Internet-based sample. The use of lay samples to study judicial decision making is indirect at best. But lay samples are valuable for at least two other reasons: They are scientifically important to the extent that they help illuminate general patterns of human cognition, and they are legally important in that legal policy often relies on public opinion, as expressed through vehicles like the election of judges and legislators and the endorsement of ballot propositions and referenda. So, understanding punitive judgment formation among laypeople can help inform criminal punishment policies and practices even if these decisions don't necessarily generalize to judicial decision making.The overarching rationale of this study was that if a neurobiological explanation of an impulse control disorder, more so than a psychological one, primes people to believe the defendant lacked control of his actions and should therefore be held less responsible for his crime, then such an explanation should result in reduced prison sentences. However, in this view, the same evidence should increase support for non-punitive custody  because a defendant who lacks control will also be perceived as more dangerous. This latter effect should be especially apparent when the defendant’s disorder is rendered untreatable. We thus tested the following hypotheses:H1. Neurobiological evidence of a disorder will decrease prison sentences relative to psychological evidence and to no evidence.H2. The H1 effect will be greater when the disorder is seen as treatable versus untreatable.H3. Neurobiological evidence will increase involuntary hospitalization terms relative to psychological evidence and to no evidence.H4. The H3 effect will be greater when the disorder is seen as untreatable.H5. (a) The H1 effect will be best accounted for by a reduction in deontological concerns, and (b) the H3 effect will be accounted for by increased consequentialist concerns.EH1. Individuals who score lower in executive functioning  will exhibit decreases in punishment and involuntary hospitalization relative to higher scoring individuals.SD = 11.38, range = 19–71). Median annual household income was $25,000-$49,999. Political party affiliation was 43.9% democratic, 29.0% independent, 15.5% republican, and 15.6% other. Human subject research was authorized by the Georgia State University institutional review board: H16349. Written consent was obtained from all participants.Three hundred sixty nine adults residing in the U.S.  were recruited from Amazon Mechanical Turk (MTurk) in November 2017 and paid $3.00 for participating. Thirty nine respondents were omitted for incomplete data, missed attention checks , or for spending too little time on the survey , resulting in a final sample size of 330. The average age was 36.0 years  and treatability status (treatable vs. untreatable) on recommended punishment, assuming that the probability of obtaining a false positive is α = 0.05. Under this assumption, a sample of 327 participants provides 95% power to detect a significant interaction in this design where the effect size is f = 0.20 . Change in prison sentence recommendation was calculated as the within-subject change from baseline—the difference between their baseline and revised prison sentence recommendation. In order to account for individual-level variation in punishment judgments, a composite punishment score was constructed, defined as the individual's revised sentence divided by his/her baseline punishment recommendation, yielding a percentage change score for each participant. Exploratory measures were designed to check and clarify the results of our hypothesis tests. These consisted of Likert-type ratings (from (1) “Strongly Disagree” to (7) “Strongly Agree”) for various statements regarding the defendant’s moral responsibility, blameworthiness, desert of punishment, free will, ability to stop himself, trustworthiness, danger to society, likelihood of reoffense, the degree to which the crime was an expression of his character, the perceived efficacy of treatment, and the perceived impact and importance of the evidence on their punishment decision.The study used a 3  x 2 (Treatability Status) incomplete factorial design with random assignment to conditions. Mental health status varied whether the defendant was described as having an impulse control disorder of neurobiological origins, of psychological origins, or was healthy. Treatability status varied whether the impulse control disorder was seen to be completely treatable or untreatable, but only for the neurobiological and psychological conditions, not the healthy condition. The primary dependent measures consisted of a preliminary, baseline prison sentence recommendation made before exposure to the manipulations, a revised prison sentence recommendation after the presentation of manipulations, and the amount of time the defendant should involuntarily spend in an inpatient hospital The case summary described an instance of sexual assault in which an adult male was found guilty of assaulting an adult female neighbor.  scale is used to assess the ability to reason counterfactually, as well as a measure of perspective switching and open mindedness—For example: “My beliefs would not have been very different if I had been raised by a different set of parents” . The DifParticipants were asked to complete the survey privately on their personal devices. After providing consent, they were instructed to read carefully through a summary of a criminal court case, and to imagine as if they were the judge overseeing the trial. After the case summary, the dependent measures were presented followed by several manipulation checks, validated inventories, and supplemental questions. Finally, participants provided demographic information including age, gender, political affiliation, and income.F = 13.07, p < .001, ηp2 = .056,  than when psychological evidence was given . The same pattern of results was found using the change in prison recommendation, F = 6.18, p = .014, ηp2 = .027, as well as when subjected to a one-way ANOVA including the healthy condition, F = 33.64, p < .001, η2 = .171. Pairwise comparisons (Fisher’s LSD) showed that, as predicted, the recommended prison sentence was significantly shorter when the defendant had a disorder supported by neurobiological evidence  or psychological evidence , than when the defendant was healthy . Similarly, the disorder supported by neurobiological evidence garnered significantly shorter prison sentences than the disorder supported by psychological evidence, p < .001. To assess whether the introduction of any health related information altered prison sentences, a two-tailed paired t-test was conducted within the healthy condition before and after disclosure that the defendant was, in fact, in good mental health. As anticipated, there was a null effect, t(106) = 1.46, p = .15, indicating that participants likely assumed that the defendant was of sound mental health, by default, before any evidence was presented.Revised prison sentence recommendations were subjected to a two-way Analysis of Variance with two mental health status conditions  and two treatability status conditions . There was a main effect of mental health status on prison sentencing, chardson : .0588 ≤F = 7.18, p = .008, ηp2 = .032, indicating that when participants were told the defendant’s disorder was treatable, they recommended significantly shorter prison sentences  than when participants were told the disorder was untreatable . However, there was no significant interaction between the mental health status presented and the treatability of the disorder, F < 0.001, p = .99, ηp2 < .001. The same pattern of results was found using the change in prison recommendation, F = 13.95, p < .001, ηp2 = .060 and F = 0.073, p = .79, ηp2 < .001, respectively. As a whole, these results were consistent with H1 but not H2. See As expected, there was a main effect of treatability status on prison sentencing, F = 4.07, p = .045, ηp2 = .018, indicating, as predicted, that when neurobiological evidence was given as an explanation for the defendant’s underlying disorder, participants recommended significantly longer recommended involuntary hospitalization terms , than when psychological evidence was given . Participants’ change in prison sentence and involuntary hospitalization terms were negatively correlated, r(223) = -.38, p < .001, suggesting a perceived trade off between these decision outcomes. The same pattern of results was found when recommended involuntary hospitalization terms were subjected to a one-way ANOVA, including the healthy condition, F = 42.99, p < .001, η2 = .208. Pairwise comparisons showed that, as predicted, the recommended involuntary hospitalization term was significantly longer when the defendant’s disorder was described neurobiologically  as well as when the evidence was described psychologically, , than when the defendant was healthy, . Similarly, neurobiological evidence garnered significantly longer recommended involuntary hospitalization terms than psychological evidence, p = .040.Recommended involuntary hospitalization terms were subjected to a two-way Analysis of Variance with two mental health status conditions  and two treatability status conditions . There was a main effect of mental health status on recommended involuntary hospitalization terms, F = 31.97, p < .001, ηp2 = .127, indicating that when participants were told the defendant’s disorder was untreatable, they recommended significantly longer involuntary hospitalization terms  than when participants were told the disorder was treatable . However, there was no significant interaction between the mental health status presented and the treatability of the disorder, F = 1.69, p = .20, ηp2 = .008. These results were consistent with H3 but not H4. See As expected, there was also a main effect of treatability status on recommended involuntary hospitalization terms, a priori grouping and explained 66.24% of the variance. We then used an ordinary least squares path analysis to examine whether these two types of concerns could account for, the observed effect of mental health status  on prison sentence term. The two composites were entered into a parallel regression model in order to compare their relative impact.We clustered the above items  into two categories in accordance with jurisprudence theories of punishment: deontological concerns  and consequentialist concerns . Items comprising the deontological factor were: the offender’s moral wrongness, moral responsibility, blameworthiness, desert of punishment, control of action, and free will (Cronbach’s α = .86). Items comprising the consequentialist factor were: the defendant’s dangerousness to society and likelihood of committing future crimes (α = .77). These clusters were confirmed in a two-factor solution identified by a principal components analysis of all items with varimax rotation, resulting in two independent factors  that matched our R2 = .33). The mitigating effect of neurobiological evidence was fully accounted for by deontological concerns . The direct effect of mental health status on prison sentence was not significant, b = -0.30, SE = 0.17, p = .081. An identical pattern was observed for the effect of mental health status on the change in a participant’s prison sentence recommendation pre- and post-mental health status manipulation.One third of the variance in recommended prison sentence length was explained by our parallel model , indicating that consequentialist concerns did not account for the effect of mental health status on prison sentence recommendation, consistent with our prediction. The observed regression model indicates that the mitigating effect of neurobiological evidence on prison sentence length can be explained by changes in deontological concerns—namely that the defendant was seen as less responsible for his criminal act.Consequentialist concerns also significantly predicted prison sentences, (H5b) A test of the effect of deontological and consequentialist concerns on the relationship between mental health evidence and recommended involuntary hospitalization was not justified because no direct effect of evidence type on recommended involuntary hospitalization was observed.F = 3.29, p = .071, ηp2 = .018, and no interaction, F = 1.42, p = .23, ηp2 = .008, indicating that the effect of mental health status on prison sentence length did not depend on a participants’ tendency to reason counterfactually.Change in prison sentence recommendation was subjected to a two-way Analysis of Variance with two mental health status conditions  and two counterfactual reasoning levels  as determined by a median split. A median split was performed to circumvent problems of multicollinearity observed using a more conventional, linear regression method. Contrary to expectation, there was no main effect of counterfactual reasoning level, F = 0.01, p = .93, ηp2 < .001, and no interaction, F = 0.26, p = .61, ηp2 = .001, indicating that the effect of mental health status on prison sentence length did not depend on a participants’ ability to regulate their emotions.Similarly, change in prison sentence recommendation was subjected to a two-way Analysis of Variance with two mental health status conditions  and two emotional regulation ability levels  as determined by a median split. Again, there was no main effect of emotional regulation level, Several exploratory measures were examined to help contextualize and explain the results of our hypothesis tests.We theorized that any mitigating effect of neurobiological explanation on prison sentences would be driven primarily by deontological sentiments that the defendant should be held less morally responsible for the crime. If so, then participants presented with neurobiological evidence should likewise rate that defendant lower on measures of responsibility, blameworthiness, deservingness of punishment, free will, ability to stop himself from performing the crime, and higher on measures of trustworthiness. In this view, participants presented with neurobiological evidence should also perceive the crime as less characteristic of the defendant. All of these predictions were supported.F = 16.13, p < .001, ηp2 = .069, his blameworthiness, F = 15.09, p < .001, ηp2 = .064, his deservingness of punishment, F = 12.26, p = .001, ηp2 = .053, free will, F = 21.89, p < .001, ηp2 = .091, ability to stop himself from committing the crime, F = 10.58, p = .001, ηp2 = .046, his trustworthiness, F = 7.82, p = .006, ηp2 = .034, and the perception that the defendant’s action was an expression of his essential character , F = 20.91, p < .001, ηp2 = .087. Those in the neurobiological condition saw the defendant as less morally responsible  = 14.63, p < .001, ηp2 = .063, such that when the defendant’s disorder was treatable he was perceived as more trustworthy than when the disorder was untreatable. Similarly, there was no interaction effect between mental health status and treatability on any measure besides trustworthiness, F = 6.82, p = .010, ηp2 = .030, such that the positive effect of treatability on trustworthiness was larger in the neurobiological condition, p < .001, ηp2 = .063. As might be expected, this effect did not extend to the condition in which the disorder was described as untreatable, p = .90, ηp2 < .001.In contrast, there was no main effect of treatability status on any of these measures except trustworthiness, F = 4.05, p = .045, ηp2 = .018, indicated that participants presented with neurobiological evidence found the defendant less dangerous than those presented with psychological evidence. This effect was further supported by an interaction, F = 6.22, p = .013, ηp2 = .028, in which the mitigating effect of treatability, F = 75.23, p < .001, ηp2 = .256, on perceived dangerousness was larger when the evidence was described as neurobiological compared to psychological, p = .002, ηp2 = .045. Pairwise differences were not found between neurobiological and psychological evidence in the untreatable condition, p = .74, ηp2 = .001. One interpretation of these counter-intuitive results is that participants perceived involuntary hospitalization not as a way to incapacitate morally culpable people that pose a danger to society but as a way to provide medical attention to those most in need of it, including, potentially, those who pose a danger to themselves—a distinction that our dangerousness measure may not have captured.We theorized that any aggravating effect of the neurobiological explanation on involuntary hospitalization would be motivated primarily by concerns of the defendant’s future danger to society. If so, then participants presented with neurobiological evidence should characterize that defendant as more dangerous. However, this prediction was not supported. Instead, a main effect of mental health status on the defendant’s dangerousness, F = 9.64, p = .002, ηp2 = .042, such that participants presented with neurobiological evidence of a treatable disorder expressed stronger belief in the efficacy of the treatment than those presented with psychological evidence of a treatable disorder, p = .003, ηp2 = .040. As might be expected, this effect did not extend to the condition in which the disorder was described as untreatable, p = .17, ηp2 = .009. Moreover, there was no main effect of mental health status on the efficacy of the defendant’s treatment, F = 1.28, p = .26, ηp2 = .006.If the aggravating effect of neurobiological explanation on recommended involuntary hospitalization term was not due to perceptions of increased dangerousness, perhaps it could be due to a perception that neurobiological disorders are more treatable than psychological disorders, at least in inpatient contexts. If so, then people should rate the treatment of the neurobiological disorder as more efficacious. We observed partial support for this hypothesis. There was a significant interaction between mental health status and treatability, Next we examined whether participants expressed explicit attitudes consistent with the mitigating effect of neurobiological evidence on punishment. If so, this would support the interpretation that participants were consciously aware of the reasons driving their decision. To address this question, participants indicated the extent to which they thought the evidence of the defendant’s condition “decreases, increases, or has no effect on” their initial punishment. They were also asked how important the exam results were to their punishment decision.F = 12.42, p = .001, ηp2 = .054; F = 21.78, p < .001, ηp2 = .090. Similarly, participants told that the disorder was treatable reported the evidence as more mitigating and important than those told the disorder was untreatable, F = 20.62, p < .001, ηp2 = .086; F = 5.87, p = .016, ηp2 = .026. There were no significant interactions, F = 0.35, p = .56, ηp2 = .002; F = 0.23, p = .64, ηp2 = .001.As expected, participants given neurobiological evidence reported the evidence as more mitigating and more important than those given psychological evidence, The purpose of this project was to investigate the effect of brain-based evidence of an impulse control disorder on lay sentencing judgments. We observed three key findings: (1) Both brain evidence and psychological evidence had mitigating effects on prison sentences, but the mitigating effect of brain evidence was stronger. (2) Yet that same brain evidence evoked relative increases in involuntary hospitalization terms. (3) The variation in sentencing judgments was best explained by deontological considerations pertaining to moral culpability.These findings suggest that lay people assign more importance to mental health evidence whose causes are described in neurobiological terms than in psychological terms. As predicted, this evidence seems to both favor or disfavor the defendant depending on the decision type: Although evidence of a neurobiological cause of a disorder may mitigate prison punishment, the same evidence can place the defendant at an increased risk of involuntary hospitalization. Though the effect sizes of our primary hypotheses were not large, they are still potentially relevant to the law, where punishment practices and policies can have far-reaching consequences for society when deployed over large temporal and geographic scales.One plausible explanation for this effect is that neurobiological evidence primes fact-finders to preferentially attend to the distinctly physical causes of behavior, and this feeds their intuitions that the behavior is outside the defendant's control. Perceptions of reduced control may, in turn, reduce attributions of responsibility while potentially increasing the belief that the defendant requires medical intervention (see ).obligation to provide care, regardless of treatment prospects. Our manipulation checks did not make such fine distinctions. If these interpretations are confirmed in future research, they would be compatible with “moral education theory,” the idea that punishments may be justified, or perhaps even obligatory, to the extent that they benefit to the person being punished [The mitigation effect is consistent with the operation of a deontological motive for punishment, namely that punishment should be proportionate to the offender’s moral culpability. The reason for the aggravating effect of neurobiological evidence on recommended involuntary hospitalization term is less clear. “Double edge” theories would explain this increase using consequentialist reasons such as a desire to protect society from danger or a desire to provide treatment to those who would most benefit from it, but the neurobiologically disordered defendant was rated as no more dangerous or treatable than the other disordered defendant. This leaves open the question of exactly why people assigned more hospitalization time to the neurobiologically disordered defendant. We speculate that the answer hinges on how people interpret the specific purpose of involuntary hospitalization. Perhaps, for instance, people considered involuntary hospitalization more justified for long-term disease management, even if their treatment prospects are low. Similarly, people in this condition might have felt a greater punished . Alternapunished –40. In sThis study is the first to quantitatively dissociate the divergent effects of neurobiological evidence on sentencing decisions . In a similar vein, research by Aspinwall et al.  and FussAs with all studies, our findings are necessarily limited by our procedural choices. We included an alternative measure to prison punishment  to distill the nature of participants punitive motives. Even so, involuntary hospitalization itself can be used for a variety of purposes that we could not disentangle, such as treatment, incapacitation, or possibly even punishment. Efforts to understand participants motivations for such decisions should consider a wider array of punishment measures designed to fulfill distinct aims or should devise additional manipulations that achieve this effect.It is also unclear why participant’s individual differences  did not explain individual susceptibility to change in prison sentence. It is possible that this was a consequence of weak construct validity. However, these results are consistent with previous literature showing that those high in cognitive ability are no less susceptible to cognitive biases  than those low in cognitive ability . Future This study investigated punishment judgments in an Internet-based lay sample and do not necessarily generalize to legal samples such as judges and jurors or to the broader U.S. population. Future research on lay samples should aspire to full randomization across key dimensions including geography and political party affiliation. Likewise, this research should be extended to legal samples in attempt to replicate these effects among groups whose judgments are directly consequential for criminal defendants, such as trial court judges. Lastly, it would be helpful to move beyond experimental survey methods and into more realistic presentation modalities, such as mock trials, to establish greater ecological validity.Our study design did not permit investigation of potential interactive relationships between psychological and neurobiological evidence. In real criminal trials, both types of evidence might be presented together. Inclusion of a combined condition would address whether their joint presentation might have multiplicative, or perhaps antagonistic, effects on attributions of responsibility and punishment.Finally, interpretation of evidence likely depends on the type of crime and mental health condition portrayed. Our vignettes described a sexual assault in order to increase the plausibility of the use of involuntary hospitalization, but this choice departs from other studies in this body of literature. Likewise, the defendant’s mental condition was defined as an “impulse control disorder.” This decision was made to minimize unknown preconceptions about culturally loaded labels such as psychopathy, schizophrenia, and psychosis, thus differentiating this study from others of its kind , 8, 21. pro forma by information about its potentially biasing effects? Should it be accompanied by information about the defendant’s amenability to treatment? When may neuroscience evidence stand alone, and when must it be accompanied by corresponding behavioral evidence? Should judges be required to receive legal education on neuroscience evidence? Should jurors be entitled (or required?) to review the treatment options or mandates that would apply if the defendant is excused on grounds of mental illness? Additional scholarship is needed to examine these and other practical applications of this research.Limitations notwithstanding, these findings are important for criminal law procedure, and particularly for policy makers, because they highlight a potential contextual effect that has not been examined in previous research. Specifically, policy makers must confront the question of how to manage the effects that we observed. For example, when neuroscientific evidence is introduced to support mental illness arguments, should it be accompanied S1 Appendix(DOCX)Click here for additional data file.S1 Dataset(CSV)Click here for additional data file.


Health Res Policy Syst 15:93, 2017) have suggested that these inconsistencies are primarily due to processes, statistical methodologies and technical capacity varying between regulatory agencies. They go on to name specific individuals involved in the evaluation of this anti-influenza medicine and imply that differences in the judgements of these individuals has affected public policy concerning the market access of this medicine.Decisions regarding the regulation of individual medicines differ from country to country. In the case of Relenza, Mulinari and Davis (This Commentary argues that what may appear as inconsistent decision-making may in fact be due to differences in the applicability of the evidence base to the local population and health system for which each regulator has responsibility. If health technology assessors are providing nuanced judgements on the effectiveness of a medicine for the local population, differences in regulation and reimbursement decisions are to be expected. Health technologies encompass medicines, devices, medical tests, programmes and procedures – basically any form of health intervention. Whenever a new health technology is brought to market it invariably undergoes a process of assessment. Health technology assessment (HTA) occurs over the lifecycle of each new health technology. It is used to inform pre-market horizon scanning, regulatory decision-making, public funding decision-making (reimbursement), clinical practice guideline development, and disinvestment decision-making.Health Research Policy and Systems critiqued the apparent inconsistent decision-making between European and United States regulators regarding the marketing and labelling of an anti-influenza medicine, Relenza [Within the regulatory domain, the 2017 article by Mulinari and Davis in globalises the evidence and localises the decision” [Inconsistent decision-making is expected in HTA. In fact, it is common knowledge that HTA “ecision” . Differeecision”  explain This heterogeneity, or difference in results between studies, is common, and makes the decision to pool the results of studies in a meta-analysis a matter of judgement. In fact, Ioannidis et al.  found thThe FDA was appropriately cautious about allowing Relenza to be marketed given the lack of clinical benefit observed in the American trial population. The situation was reversed for the MPA as a clinical benefit was observed in the European trial population. Because of differences in the applicability of the trial evidence to each regulatory agency’s local circumstances, it would appear that they also held different views as to whether the findings from each of the trials should be meta-analysed. According to Mulinari and Davis , the FDAConversely, the Swedish MPA did accept a meta-analysis of the trial results and, in their context, this is also reasonable. The European trial found a median time reduction of 2.5 days to symptom improvement in influenza-positive patients receiving Relenza; therefore, by allowing the meta-analysis of the trials, the pooled result dropped to 1.5 days, which is a more conservative estimate of the treatment effect for the European population and in accordance with the variability in results observed among all the trials.Each regulatory agency appears to have appropriately interpreted the evidence supplied to them in the context of their own population and health system.Particular individuals from both regulatory agencies were named in the article by Mulinari and Davis . In LettHowever, often the work of HTA assessors is de-identified to protect them from the large, vested interests associated with the technologies they are assessing; otherwise, there would be a large power imbalance. Similar to government public servants, for HTA assessors, the body responsible for the technology assessment and subsequent decisions is the agency, not the individual. The HTA team evaluates the medicine on behalf of the agency. As decisions informed by that evaluation can have multi-million-dollar impacts, the agency handles any associated media and legal ramifications and is ultimately responsible for the quality and credibility of the evaluation.What is clear from the Mulinari and Davis  analysisThe identity of the MPA assessor in the paper by Mulinari and Davis  was obtaThe large FDA assessment team responsible for the assessment of Relenza is a matter of public record but, being a large team, the accountability is shared. Although Mulinari and Davis  lament tHTA assessments are performed by a team, with the HTA agency being ultimately responsible for the technology evaluation and ensuing recommendations. The analysis from Mulinari and Davis  would ha


A commentary by Stefania Papatheodorou provided an overview and guidance about umbrella reviews and why they are needed . We woulp value , number of cases (cut-off by 1000 cases), the p-value of the largest component study (p < 0.05), 95% prediction intervals , absence of large heterogeneity (I2 < 50%), no evidence of small study effects (p > 0.1), and no evidence of excessive significance (p > 0.1). The author highly recommended to use the criteria to ensure objectivity and standardized classification across umbrella reviews. But so far, there is no consensus that these criteria are the method of choice. Most of these criteria are categorized according to arbitrary cut-offs. For example, the p-value is not a good option to evaluate the clinical relevance of the findings from a study [2 has been criticised because it does not present an adequate measure of heterogeneity between studies [We read with great interest the commentary, however we have major concerns regarding the grading of the certainty of evidence. Papatheodorou recommended for umbrella reviews to classify the certainty of evidence in four categories  association, no association or inconclusive association (insufficient evidence)) according to the following criteria: the geneity I < 50%, n studies . Additio studies . We belithe risk of bias in the studies accounting for limitations in the study design and methods, by applying the Cochrane tools e.g. the revised Cochrane risk-of-bias tool for randomized trials (RoB 2) , or the Inconsistency between study results (heterogeneity),Indirectness: Considers the applicability of the single study to the study question of interest with respect to the participants, intervention, comparator and outcome (PICO),Imprecision: Precision of the overall effect estimate considering the 95% confidence interval as well as total sample size,Small study effect (publication bias),Other: Large effect size, dose-response association, absence of confounding.While the first five categories might be possible reasons for a down grading, the last category may lead to rating up of the certainty of evidence.In this context, there is a well-established tool available that consider these latter factors. The GRADE  working group has developed a systematic, sensible and transparent approach to grade the certainty of evidence and its strength of recommendations, which are adopted from considerations arising from the Bradford Hill criteria for causation . There iThe main challenge of the GRADE tool might be the evaluation of risk of bias from the primary studies included in the meta-analysis, by using the tools suggested by Cochrane , 6. So fp-values) should not be the way forward, and further aspects such as the risk of bias need to be considered to judge the certainty of evidence.In conclusion, umbrella reviews provide a comprehensive overview of a specific research topic and are very helpful tools to evaluate the certainty of evidence. These systematic overviews are helpful for the translation of research findings into recommendations, and also for identifying new research directions. We agree that for comparability, standardized procedures, especially regarding the evaluation of the certainty of evidence, are needed. However, the reliance solely on “statistical significance” (expressed mainly as