Type 2 diabetes mellitus (T2DM) is a disease affecting approximately 29.1 million people in the United States, and an additional 86 million adults have prediabetes. Diabetes self-management education, a complex health intervention composed of 7 behaviors, is effective at improving self-care behaviors and glycemic control. Studies have employed text messages for education, reminders, and motivational messaging that can serve as “cues to action,” aiming to improve glucose monitoring, self-care behaviors, appointment attendance, and medication adherence.The Text to Move (TTM) study was a 6-month 2-parallel group randomized controlled trial of individuals with T2DM to increase physical activity, measured by a pedometer. The intervention arm received text messages twice daily for 6 months that were tailored to the participant’s stage of behavior change as defined by the transtheoretical model of behavior change.We assessed participants’ attitudes regarding their experience with text messaging, focusing on perceived barriers and facilitators, through two focus groups and telephone interviews. All interviews were audiorecorded, transcribed verbatim, coded, and analyzed using a grounded theory approach.The response rate was 67% (31/46 participants). The average age was 51.4 years and 61% (19/31 participants) were male. The majority of individuals were English speakers and married, had completed at least 12th grade and approximately half of the participants were employed full-time. Overall, participants were satisfied with the TTM program and recalled the text messages as educational, informational, and motivational. Program involvement increased the sense of connection with their health care center. The wearing of pedometers and daily step count information served as motivational reminders and created a sense of accountability through the sentinel effect. However, there was frustration concerning the automation of the text message program, including the repetitiveness, predictability of text time delivery, and lack of customization and interactivity of text message content. Participants recommended personalization of texting frequency as well as more contact time with personnel for a stronger sense of support, including greater surveillance and feedback based on their own results and comparison to other participants.Participants in a theory-based text messaging intervention identified key facilitators and barriers to program efficacy that should be incorporated into future texting interventions to optimize participant satisfaction and outcomes.Clinicaltrials.gov NCT01569243; http://clinicaltrials.gov/ct2/show/NCT01569243 (Archived by Webcite at http://www.webcitation.org/6pfH6yXag) Type 2 diabetes mellitus (T2DM) is a disease affecting approximately 29.1 million people in the United States, and an additional 86 million adults have prediabetes -5.Multiple meta-analyses have demonstrated overall success of mobile-based  interventions with text messaging for glucose self-monitoring and glycemic control while results for long-term physical activity improvement among those with T2DM have been mixed -8. HowevParticipants in the intervention arm were sent two messages a day for a 6-month period. An interdisciplinary team of physicians and health researchers created a bank of over 1000 text messages; subsequently, a behavioral psychologist grouped messages into the stages of behavior change specified by the transtheoretical model of behavior change ,20. The Behavioral interventions should be theory-driven and take into account a participant’s beliefs, preferences, readiness for change, and perceived risks and benefits. Currently, there is a paucity of published studies that assess participants’ experiences with text messaging interventions, hindering the development of successful, patient-centered programs. The purpose of this study was to collect participants’ feedback from the TTM program in order to ascertain the facilitators and barriers to participant engagement. In addition, we inquired about (1) overall satisfaction and perceived effect of participating in the TTM program, (2) knowledge of and barriers to physical activity, (3) perception of text message frequency, content, style, and impact of texts on physical activity, (4) effect of wearing a pedometer, and (5) barriers to intervention efficacy.The study was approved by the Institutional Review Board for the Massachusetts General Hospital and registered at clinicaltrials.gov/ct2/show/NCT01569243. A total of 98 individuals completed the TTM study of which 46 were assigned to the intervention arm and were contacted for poststudy interviews 6 months to 1 year after the study concluded.All English-speaking TTM intervention participants were asked to participate in one of two focus groups held at two health care centers where participants were originally recruited. These focus groups spanned 90 min, were conducted in English and employed an in-depth, semi-structured guide see . ParticiIf an individual did not attend a focus group or was Spanish-speaking, they were contacted for a telephone interview. Interviews were conducted either in English or Spanish by one of two trained researchers using an adapted questionnaire from the focus groups see  to facilAll interviews and focus group sessions were audiorecorded, professionally transcribed verbatim, and then reviewed by team members for accuracy and completeness. Transcripts were analyzed with NVivo 9 . A grounded theory approach was used in data analysis, beginning with two researchers reading three transcripts and identifying main themes . Three aOf the 31 participants, 19 were male, and the average age was 51.4 years  effect of study participation, (2) effect of wearing the pedometer, (3) effect of text messages, and 4) barriers to intervention efficacy. The following are select quotes in conjunction with  barriersEffect of participating in Text to Move (TTM)Increase in daily disease awarenessDiabetes is an everyday part of my life. Insulin, pills, of course exercise. I thought (TTM) was awesome, actually. It kind of reminded me every time I got a text.Program integrated into daily lifeI mean, first describing it, it seems like, “Oh this may be a pain,” but once it’s just like everything else, once you implement it into your lifestyle it becomes second nature and it really wasn’t that bad.Connections arising from participationIncreased connection and sense of support from health care teamI did try to do the best that I could, so that the research could open up more doors or more windows to people to get the job done the right way, to help out others.For me, (the program) did matter because it means that I was doing something that people were putting the time and money into it. Because even if it would have been that I didn’t get anything back, any positive feedback or a reminder, I would have been out. They don’t care. So if they don’t care, why should I care? But just by receiving those text messages on a daily basis and just seeing on the computer how good I was doing, it just kept giving more encouragement for me to do the right stuff.Ambivalence or no change in connection nor sense of support from the health care teamI wanted to believe that there was actually a person who gave a crap about what my data said. It didn’t feel that way.Effect of wearing the pedometer and receiving texts on daily step countMotivational through viewing step count and related textsI’m very much like you where I need that instant—like I need it right now to show me. So with that (pedometer), when I would go home and see the numbers, that would motivate me, when I saw how close I was...I’d go outside at 11:40 (pm) because I knew I had 20 minutes.I was challenging myself to do better and to go farther than previous...I knew what I did the day before and was like, “How do I challenge myself to go a little bit farther, to push myself a little bit hard today?”It was very great to have it working correctly, and synchronized (to the) computer, and you could have the graph to see if you were up by a little, you know, how it worked, or your level, you know, how you were doing. A lot of people are visual. So when you see that visual in front of you, it’s very powerful.Sentinel effect from using the pedometer and receiving step count informationI’d feel guilty if I didn’t reach my goal everyday...I felt bad, like I’m not doing my homework.It made me feel motivated...I would (exercise) because I was afraid they were going to say, “Hey! Get off that sofa!”Evangelizing new technology to others not involved in studyI told all my friends actually, everybody was asking me, “What’s that in your shoes?” Because I put it in my shoes, and I told them that’s to make me move (chuckles).Effect of text messagesText messages as daily remindersI never expected that it was a live person behind. I knew it was kind of like, this is six o’clock. I’m going to get the message, whether it’s the same one that I had before. I just knew it was like a tool and a reminder. I did find it like a reminder.Text messages as informational or useful for idea generation for increasing physical activityThere were some times that, let’s say I didn’t walk. They would be like, “Try to do this type of exercise”...They would give me an example of what other exercises I could have done or stuff like that. So it opens up your mind to see what other things you can do.Barriers to Text to Move (TTM) intervention efficacyTechnical issuesPersonal reasonsLack of investment in the studyComorbidities or physical pain prevented exerciseEnvironmental factorsIt would have been nice, like if it was raining out, we’re all in the same area, “Even though it’s raining out, you can still get active.”Dislike of automation of text messagesText messages were too repetitive and predictableI can tell that they were a can of limited messages that were repeating over and over again. It seemed like it was coming out and it was automated, almost like an alarm clock, that would give you a text. I would almost expect it.Inability to control text frequencyLack of personalizationThe text messages, I thought, were too generic. I thought that they should be specifically more to your accomplishments, and not just the general daily thoughts of the people that are programming it.(The messages) should specifically target that individual...relating to what you are achieving, or what you’re trying to achieve.Lack of interactivity of text messagesYou should be able to voice your opinion, which you can’t answer them back when they send you a message. That they should let you do.Limited knowledge of recommended physical activityOverall, most respondents reported that participation increased awareness of the daily presence of diabetes in their lives and of their current levels of physical activity.Many participants explained that once they grew accustomed to wearing the pedometer and began to anticipate text messages, the program was incorporated into their daily routine.Several participants exhibited high relationality within the TTM program, noting that their involvement made them feel as if “someone cared.” A focus group participant explained, “It felt like, yea, someone cares what I did today. Even though I have great support from my family, it’s my private, personal, little cheerleader.” Other respondents relayed feelings of “being a part of a team” during participation in the TTM study.Furthermore, when asked if and how the program altered participants’ views of their clinician or health care center, many described developing a more positive outlook. In fact, approximately one-third of participants reported that it was their physician who introduced them to the program and encouraged them to enroll. One individual recollected, “If (doctors) mention it to (patients) in the right way, like my doctor did, you’d want to get involved. I believe my doctor’s the one who really made me feel comfortable about it.”Almost half of the participants demonstrated low relationality during the program. In other words, many felt that their involvement in the TTM program was arbitrary and they did not believe that anyone was monitoring their progress. When asked who they perceived to be sending the text messages, a quarter of respondents had no opinion of the sender. They expressed ambivalence when asked how the program impacted their view of their health care center or physician, stating that their health care provider was not aware of their involvement.For over half of participants, the pedometer proved to be a motivating tool, as step count was perceived as a tangible and realistic target. One female described, “...I would see my numbers and I’m like, ‘I’m so close to this goal.’ I would go out in my backyard and just walk in circles just to get to that next level.”Specifically, “seeing the numbers” represented a goal that participants could attain. Many participants described that knowing the previous day’s step count provided a measure that could be reached or surpassed the following day. The Web-based portal was generally viewed favorably, as several participants noted that it was helpful to track progress longitudinally and observe patterns of physical activity.Over half of participants explained that they felt their performance in the TTM program was being monitored closely and thus they felt motivated to improve their levels of physical activity. This awareness of being monitored and the subsequent adjustment of behavior is known as the “sentinel effect.” For instance, one individual stated, “The majority of the time I was physically active because I knew I was being monitored, and I was trying to challenge myself.”A few individuals were very enthusiastic about sharing the technology with family, friends, and colleagues.Most participants regarded the text messages as daily reminders about physical activity or a diabetes self-care behavior. This perception of the text messages as a functional tool, rather than a source of motivational or educational information, was very common. For example, a participant described, “It reminded me about taking my medication, it reminded me, ‘Yeah, I need to get up and go exercise.’ I always thought it would be good for quitting smoking, too.”A few individuals recalled that the texts provided helpful hints on ways to increase physical activity. One participant recounted, “Instead of parking right next to the door at my work, I parked at the very end of the parking lot and walked. It was one of these things, those little reminders, ‘don’t park so close to your work,’ ‘don’t park so close to the mall entrance,’ ‘park farther away,’ and get in a few more minutes of walking a day.”The most common complaint with the TTM program was malfunctioning of the pedometer or computer software, which led to illogical text messages being sent to participants. Technological issues were a source of frustration with a quarter of respondents. Two participants reported having trouble using their phone keypads to write a text, preventing a response to question-based messages.Individuals often cited reluctance toward physical activity or diabetes self-management as reasons why TTM was not effective. For instance, a couple of participants revealed that they were not emotionally invested in the program. In discussing the text messages, one man said, “They weren’t supportive—they probably would have been supportive if I was willing to do stuff.”About half of respondents explained that comorbidities or pain prevented physical activity. A few participants wished the text messages had taken into account the physical challenge associated with the transition period between a sedentary and active lifestyle. For example, “I kind of ignored (the text messages) because if I was hurting I would do nothing. I would just not pay attention to it.”Many individuals reported that there were external factors inhibiting physical activity such as inclement weather, time constraints, or exhaustion from daily work requirements.Many participants divulged that the text messaging component became predictable, monotonous, and toward the end of the program they would ignore the texts. One male respondent elaborated, “When they’re repetitive, they were nagging because it’s like, ‘I already read this, I need something new’... it’s kind of sad, but at the end of it, it was like really annoying.”A few participants reported that they became weary of the unchanging frequency and timing of the text messages. Although over half of respondents “felt fine” with the number of the texts messages, a few said that there were too many. Several participants expressed interest in controlling the amount and timing of the messages that they received.Important to note, whereas a few participants were dissuaded by the automation of the program, others did not mind the consistency of the text messaging system. One man stated, “To me it didn’t matter, because when you get a text message it’s so impersonal that it doesn’t matter who it comes from, where it comes from. As long as it says the right thing.” In discussing the amount and regularity of the text messages, one man explained, “I would say no, not annoyed. I like the word ‘nagging’ better. It was like motherly love.”There was frustration with the lack of personalization of the text messages. Several participants stated that they would be more likely to read the texts if they contained information specific to their health goals or progress. In addition to addressing activity goals, many participants agreed that they would like the text messages to include a personal touch, such as their name.The lack of interactivity associated with the text messaging system was another source of dissatisfaction, participants often asserting, “there was no way you can respond.”There was a lack of differentiation between physical activity and exercise. When probed during the one-on-one interview, only 4 participants identified the two as separate constructs. When questioned about the recommended level of physical activity for individuals with T2DM, approximately half of individuals said that they were not aware of the guidelines. A few respondents said that they received information on appropriate activity levels from their physician, whereas others said that they knew that physical activity was important, although they were not sure how much was necessary. When asked the most frequent form of physical activity that they partake in, half of participants replied, “walking,” whereas one-third of respondents answered, “use of equipment or weights.”This study reports the perspectives of participants who completed a texting-based physical activity program for individuals with T2DM. TTM was a unique program for three significant reasons: (1) it combined pedometer and text-message components, (2) the text messages were developed based on the transtheoretical model of behavior change, and (3) participants could move between stages of change according to pedometer activity input. There was general participant satisfaction with the program, with over 90% of respondents agreeing that they would recommend the TTM program to a friend with some participants evangelizing the pedometer and TTM to others not involved in study. Yet, several themes reveal sources of frustration among study participants, including a lack of control over program intensity, impersonalization of text messages, and limited feedback from study coordinators. At the same time, we found that participants’ views on TTM were impacted both by social influences and personal reasons.To start, participants varied in their preferences for program intensity stating that they wanted more control over texting frequency. Our finding is consistent with the variable-ratio schedule operant conditioning phenomenon in which a schedule of behavioral learning reinforcement is accomplished through an unpredictable sequence of communication or rewards. This schedule creates a steady and high rate of behavior change compared with a fixed schedule that was used in TTM . Other sIn addition to the frequency pattern of messages, meta-analyses of technology-based studies suggest that personalization of message content can lead to higher participant retention and engagement ,7. Our rImmediate feedback is also considered a cornerstone of a tailored invention as it is used to validate and encourage participants’ progress -36. TTM Identified themes pertaining to preference for increased relationality align with the unified theory of acceptance and use of technology (UTAUT), which outlines several factors influencing technology adoption: effort expectancy (perceived ease of use of the technology); performance expectancy (perceived usefulness of the technology); and social influences . EffortFinally, it is important to recognize that T2DM is a multifaceted condition affected by a range of behavioral and physiological processes. The theme describing text messages as reminders, which while useful to many, reveals that TTM may have been too narrow in scope to promote long-term behavioral change. Unlike interventions aimed at achieving smoking cessation or hand washing, programs that seek to increase physical activity levels may require a more comprehensive approach ,47. SeveDespite study strengths, our results should be interpreted with the following limitations. First, interviews were conducted half a year to one year following closeout of the 6-month TTM program. Therefore, recall and social desirability biases may have impacted participant responses to be more favorable than if collected during or immediately after the intervention. However, we are reassured that the data collected during focus groups and one-on-one interviews, though spaced months apart, revealed common themes. Finally, our results may not be generalizable to other settings because our participants were recruited from community health centers aligned within a large, urban academic health center in Massachusetts. Participants were mostly English-speaking and had high levels of educational attainment and employment.Texting-based interventions have the potential to improve diabetes self-management and enhance physical activity in individuals with type 2 diabetes. Future studies should prioritize participant involvement and input in the design of texting features . In addiAlthough text messaging represents a scalable and cost-effective method of facilitating communication between patients and their health care team , our res


Medically unexplained symptoms (MUS) are a common yet challenging encounter in primary care. The aim of this study was to explore how general practitioners (GPs) understand and handle MUS.Three focus group interviews were conducted with a total of 23 GPs. Participants with varied clinical experience were purposively recruited. The data were analysed thematically, using the concept of framing as an analytical lens.The GPs alternated between a biomedical frame, centred on disease, and a biopsychosocial frame, centred on the sick person. Each frame shaped the GPs’ understanding and handling of MUS. The biomedical frame emphasised the lack of objective evidence, problematized subjective patient testimony, and manifested feelings of uncertainty, doubt and powerlessness. This in turn complicated patient handling. In contrast, the biopsychosocial frame emphasised clinical experience, turned patient testimony into a valuable source of information, and manifested feelings of confidence and competence. This in turn made them feel empowered. The GPs with the least experience relied more on the biomedical frame, whereas their more seasoned seniors relied mostly on the biopsychosocial frame.The biopsychosocial frame helps GPs to understand and handle MUS better than the biomedical frame does. Medical students should spend more time learning biopsychosocial medicine, and to integrate the clinical knowledge of their peers with their own.The online version of this article (10.1186/s12875-018-0745-2) contains supplementary material, which is available to authorized users. Medically unexplained symptoms (MUS) is an umbrella term used to refer to various symptoms that ‘have no identified organic basis’ , and ‘foframe to explore GPs’ approaches to MUS. Frames are shared ways of ‘organising experience’ . What the patient says and feels, that’s what you have to deal with. And it’s very difficult to assess, say, pain, objectively. Or to assess … sadness, objectively [yes], anxiety, worries. So really, we’re in a situation where we have to listen to the patient, and perhaps sick list based on that. And, when the law says that (…) we have the opportunity to sick list, even when we cannot point to anything specific. Then we have no choice but to trust the patient. And, of course, in principle, the patient decides what he or she wants to say. And then that can be entirely correct, or it could be entirely wrong [in-breath yes]. But often it’s somewhere in between. Those are the difficult sick listing cases, definitely [mhm] ….[T]here are rarely any specific issues with subjective states that there should be a ‘disease, injury or defect’ (a legislative paraphrase) [mhm]. Usually, it’s more of a borderline issue [mhm] (…).I think it’s difficult too, with regards to the legislature. Because it clearly that’s where you’re dependent on what the patient says (…).And some of those sick notes are usually not the ones that last two- or three days. It’s the ones that are a bit longer that are difficult, when it comes to unclear symptom constellations, or how to put it? I think do about it [mhm]. Because, to sick list them … I mean, there’s no disease [mhm]. The way I see it.There are many difficulties with the whole issue of fatigue. Examined, and yet we can’t find anything, and then there are often a lot of burdens in their lives, which leads to the fatigue. And what are we to Mhm. Tremendously difficult. (FG1).the lack of objective evidence. Thus, according to the GPs, ‘there are rarely any specific issues’ with MUS, GPs ‘can’t find anything’, possibly because ‘there’s no disease’ to be found . Some also pointed to the lack of scientific knowledge and explanation. For instance, one regretted not having ‘an explanation for these conditions (MUS) in medical science’ (FG2). When employing the biomedical frame, GPs thus understood and defined MUS negatively, in contrast with “normal” conditions for which evidence is obtainable and medical science has explanations on offer.The excerpt exhibits what was typical and related features of the biomedical framing of MUS. First, the focus throughout is on subjective testimony as a problem. Without objective evidence, GPs ‘have no choice but to trust the patient’ (GP1 excerpt A), i.e. they are ‘dependent on what the patient says’ (GP3 excerpt A). Having to trust the patient was unpopular, as it involved the risk of being misinformed or even deceived. Patient testimony was thus framed as unreliable: it could be ‘entirely correct, or it could be entirely wrong’ (GP1 excerpt A). In other words, subjective testimony was considered a problematic source of knowledge about patients’ conditions. Health insurance policy stipulates that impairment should have disease as its primary cause. Without evidence, the plausible presence of disease must be determined based on testimony. In the biomedical frame, sick listing thus becomes a problem of trust, and this is why some GPs felt it difficult to act responsibly as gatekeepers (see excerpt A).A second feature, and related to the former, is the strong emphasis on negative feelings, such as uncertainty and doubt. Some physicians were afraid that the patient might have a serious undetected problem, as expressed by a participant in FG2: ‘Perhaps there’s something else that I haven’t seen?’ Others emphasised how inability to obtain evidence spawned feelings of uncertainty, doubt and powerlessness. Consider excerpt B:Third, related to both lacking evidence and the low epistemic value attributed to testimony were frequent references to grab a hold of these things. We can’t do any blood tests, we can’t scan them or anything. And then we begin to doubt a little. (FG2).(…) we start to doubt how sick the patient is. Because we can’t quite objectively The GP explicitly ties his doubt to the inability to ‘objectively grab a hold’ of MUS. It is because he ‘can’t do any blood tests’ or the likes that he begins ‘to doubt how sick the patient is’. It is noteworthy that lack of evidence results in doubts in patients rather than doubt in medical knowledge. Some voiced suspicion of malingering. For instance, a participant in FG3 talked about two cases concerning young men with back pains. She ‘couldn’t find anything wrong’ with their backs and concluded that they were unhappy with their jobs and wanted sick notes for their ‘supposed back pains’. Some also complained about feeling powerless. Consider excerpt C:counsel, and I can suggest that we try and up the workload in accordance with what is considered medically appropriate. But, in the end, when she says ‘No, I actually cannot work more (…) I have no choice but to trust the patient, and I really feel forced into doing what she wants . (FG1).I can urge, or give medical feel powerless; their powers are no more restricted here than they are with biologically verifiable diseases like hyperthyroidism . But with MUS, GPs feel inhibited. Note also that the participant believes the patient to be healthier than the patient does. The GP’s problem, then, is the lack of authoritative warrants. Without evidence to back him, he feels that he cannot (or should not) force or sway the patient.We emphasise that GPs The biomedical frame thus accentuated the lack of objective evidence, the problem of trust and subjective testimony, and various troubling emotions. For those reasons, the frame also brought up frequent references to how MUS made GPs’ work difficult. Because the symptoms are ‘difficult to assess’, sick listing becomes difficult (‘what are we to do about it?’), elevating the risk of going into what one GP called ‘a stalemate’, i.e. an unfruitful therapeutic situation (FG1).nice aspect of being a GP is getting to know people over time. And I’m thinking of my patient list a bit like my flock. I‘m looking out for them, over time, to get the most out of it. They’re going to be as comfortable as possible, so they can go to work, make money, pay taxes. And that means that you get to know people, and you can tell ‘Will it pay off to invest in a small sick note? Be a little proactive about it [mhm]?’ So that they’ll return to work quicker? Almost like a preventive measure [mhm]. And I do have quite a few ‘good girls’ and a few ‘good boys’, who will at times stretch the rubber band a bit too far [M: mhm]. And then, some people need a little sick leave. So you’ve got to be watchful (…). (FG3).A In contrast to the biomedical frame, the biopsychosocial frame accentuated what is present, and opportunities that flow from this presence. Thus, when talking about MUS in the biopsychosocial frame, the GPs emphasised understanding, confidence and competence. Consider excerpt D:understanding of the condition of patients he characterises as ‘good girls’ and ‘good boys’ – Norwegian slang for dutiful persons who tend to exert themselves too far. He also explains the condition by way of metaphor, saying such patients ‘will at times stretch the rubber band a bit too far’ – i.e. the body’s ability to recuperate (elasticity), is lost. In other words, he (feels that he) knows what is troubling his patient. Other patient types were suggested, such as ‘the double-labouring woman’, ‘between 37 and 43 years old, with three kids (…) and a job in the care services’, whose conditions were understandable to the participants: ‘It’s in the entire system, the entire body, and the burden becomes too heavy’ (FG2). This was typical of the biopsychosocial frame: MUS were discussed in terms of patient types the participants understood and could accept.Excerpt D exhibits several prominent accents of the biopsychosocial frame. First, the participant expresses an confident about how to handle these patients. He ‘can tell’ when a brief sick leave ‘will pay off’, and so he is ‘watchful’. In other words, he (believes that he) knows what to do. As a result, he does not seem worried about sick listing patients with MUS. In his experience with these patients, using sick notes for the present condition can work ‘like a preventive measure’ for a later longer, and possibly irreversible illness trajectory. Understanding MUS in terms of patient types thus seems clinically efficacious. The contrast with the biomedical framing of MUS in this regard is striking.Second, because the participant in excerpt D feels confident that he understands, he also seems clinical experience: it is because he gets ‘to know people over time’ that he ‘can tell’ what is wrong. This, we suggest, is a seminal effect of the biopsychosocial frame: it invites GPs to draw on their clinical experience to make sense of MUS. It is not simply that GPs come to trust what their patients say. By drawing on their extensive clinical experience, GPs can acquire a holistic understanding of the sick person, enabling them to act with confidence. Note that ‘understanding’ does not imply veracity – the GP could have the wrong idea. What is implied is rather that the patient’s complaint is rendered meaningful in a clinically helpful way. Moreover, because GPs get ‘to know people over time’, trust is not (as much of) an issue. The credibility of patients’ suffering is not called into question. Consider excerpt E:Third, the participant in excerpt D ties his understanding with his see them over time, you have to get to know people, so you can sense-, or form a picture, over time. Is it real? Do they have these troubles, these impairments they claim to have? That you don’t have instruments to measure. And I’m thinking this is where being a doctor is exciting [Yes]! This is where the art of medicine comes in! And where people knowledge comes in! Whereas with these other conditions, if a leg is broken or you’ve seen a heart attack on EKG. Alright then  that’s technique. But its not much of an art of medicine. (…).You have to know the patient, like (GP1) says, over a quite extended period of time, I think most of us would agree that … the suffering is there. I think one feels that quite well, that there is no doubt that these patients suffer, and are sick. (FG2).I think that when you rather a lot of patients, without having to use what I learnt in medical school, like academic or scientific (training). It’s more like … ‘yes, mhm, yes I understand, mhm’ (pretending to answer a patient). I mean, that’s what we spend our time doing. (FG1).(…) I feel that, in the course of an ordinary day, I can see The emphasis on clinical experience (‘people knowledge’) and ‘the art of medicine’ was at times coupled with a distancing from scientific medicine and medical training, as in excerpt F:Thus, in the biopsychosocial frame, MUS concerns what they do know, instead of what they do not. Rather than worrying about the lack of objective signs of disease and evidence based treatment, talking about MUS in the biopsychosocial frame meant relying on clinical experience , informal explanatory models and interpretation. In the biopsychosocial frame, MUS thus become (more) tangible.The use of frames differed across the focus groups. The group with specialists in training (FG1) relied heavily (though not entirely) on the biomedical frame. In contrast, the group of experienced specialists (FG3) relied almost exclusively on the biopsychosocial frame for discussing MUS. FG2, the group with the most variation in clinical experience, slightly emphasised the biopsychosocial frame. Similarly, outspoken preference for biomarkers (‘the more objective (…) the more we like it’) was frequently expressed in FG1 (the juniors), less frequently in FG2 (mixed group), and not once in FG3 (the seniors). Moreover, expressions of insecurity and frustration regarding patient management was frequently expressed in FG1, in contrast to FG3, whose members seemed confident about themselves and their own judgement. When the seniors in FG3 and FG2 voiced their frustration, it typically concerned bureaucrats and consulting physicians who did not accept the GPs’ clinical judgement and instead instigated ‘the burden of evidence’ on them.Our analysis has shown how two medical frames shaped GPs’ understanding of MUS, and how this affected them and their approach to handling patients. Biomedical framing emphasised what is missing (objective evidence), made what is present (patient testimony) problematic, and manifested feelings of uncertainty, doubt and powerlessness. By comparison, biopsychosocial framing seemed to lessen and even solve some of those problems. In particular, it made the conditions understandable and turned patient testimony into a valuable source of information, which in turn made GPs more comfortable and confident. A main reason for these differences, we suggest, is that whereas the biomedical frame invites GPs to draw on formal and scientific knowledge (of little use with MUS), the biopsychosocial frame invites GPs to draw on their clinical experience to make sense of their patients’ problems. This enables them to make clinically efficacious distinctions between patients with MUS that give direction to clinical judgement.In terms of patient handling, biomedical framing centred on what the patient has (disease or not). Since this is precisely what cannot be biomedically determined, handling (such as sick listing) became problematic. In contrast, biopsychosocial framing centred on how to improve the patient’s condition. For instance, the GPs suggested that short-term sick listing can alleviate stress and prevent long-term absence from work, and that being compassionate and supportive can help patients cope with their situation. Paraphrasing Stone , the bioFinally, the GPs with the most experience tended mostly to employ the biopsychosocial frame, whereas those with the least experience tended to rely more on the biomedical frame.don’t like are conditions where you have zero objective findings (…)’ (FG1). GPs are thus part of a culture that values objective evidence and unambiguous disease  should feel makes sense’ (FG2). For these reasons, framing is not simply a matter of choice.The biopsychosocial model is at home in primary health care, and seems better suited for handling MUS. So why was biomedical framing a prominent feature in the FGs? In short, because framing is not simply a matter of personal choice. For one, GPs’ framing practices are subject to external pressure: there is a strong institutional emphasis on the biomedical model of disease. Formally speaking, health related benefits are contingent on a biomedical account , 22. Whemedicine ). There Our study is small, and the findings cannot be generalized to all GPs. However, although few studies have explored the effect of medical frames, our findings and their theoretical underpinnings are supported by – and shed light on tensions within – existing research literature.how biomedical framing makes MUS problematic. Our findings thus help tie frequently reported problems of MUS to the biomedical model of disease: it is against such a background that trust in patient testimony, and lacking objective evidence and scientific explanations, become problematic.First, regarding the negative effects of biomedical framing of MUS, studies typically report that GPs experience negative emotions when working with MUS, such as uncertainty, fear, frustration and powerlessness , 37–41. Second, our finding regarding the positive effects of biopsychosocial framing also finds support in the literature. Although rarely highlighted, several studies reporting negative emotions also show examples of GPs feeling confident about their ability to understand and handle MUS. And typically, this is when they depart from a biomedical frame. For instance, Wileman et al.  reports The work of Mik-Meyer , 49 apprless strict gatekeepers than their experienced peers [biopsychosocial practice builds confidence. More research is needed, and in that regard we note that experience is not limited to number of years – the type of experience (e.g. feeling that you succeed) likely matters most.Third, regarding our finding that the junior GPs relied the most on biomedical framing and expressed more insecurity and frustration than the seniors, the literature indicates that this is not coincidental. Studies suggest that understanding and handling MUS is more problematic for inexperienced GPs , 55, 56.ed peers . One posWe suggest that biopsychosocial framing, combined with clinical experience, enables GPs to understand and handle MUS better than biomedical framing does. However, that does not necessarily imply that biopsychosocially minded GPs benefit patients and society. Although similarities between MUS have been found , it remaThe strength of qualitative studies, such as focus-group interviews, is their ability to provide experience-based knowledge and insight, rather than a quantitative ranking of importance or the proportional distribution of opinions , 67. Incclinical knowledge [If biopsychosocial thinking and clinical experience are central to GPs’ understanding and handling of MUS, than this should be reflected in research, teaching and practice. What is needed is an emphasis on the role of nowledge , 69. Clinowledge , 70, 71.nowledge . Yet notnowledge , 74–76. nowledge . In linenowledge , 78.Additional file 1:Translated interview guide. English translation of the semi-structured interview guide. (DOCX 13 kb)Additional file 2:The OPR reports. (ZIP 65 kb)


However, MSTS does not seem to improve routine traditional sampling in detecting tumor budding, extramural venous invasion, and perineural invasion. We conclude that (1) MSTS is the best method for tumor sampling to detect ITH balancing high performance and sustainable cost, (2) MSTS must be adapted to tumor shape and tumor location for an optimal performance.Current sampling protocols of neoplasms along the digestive tract and in the urinary bladder have to be updated, as they do not respond to the necessities of modern personalized medicine. We show here that an adapted version of multisite tumor sampling (MSTS) is a sustainable model to overcome current deficiencies in digestive and bladder tumors when they are large enough so as to make unaffordable a total sampling. The new method is based on the divide-and-conquer algorithm and includes a slight modification of the MSTS, which proved to be useful very recently in clear cell renal cell carcinoma. This  Neoplasia has been proposed as a model of intracellular metabolic shift , where cMany big tumors are in practice far away for being totally analyzed. In these situations, pathologists  partly sample such big tumors under the assumption that the selected samples are good representatives of the whole neoplasm. In other words, pathologists decide which parts of the tumors will be selected for histological and molecular analysis and which parts will not . For such a purpose, classic handling and routine sampling protocols (RP) are available for different tumor topographies in referential textbooks . HoweverRecent literature shows many examples of controversial results (sometimes contradictory) in molecular analyses of the same tumor types and, even more important, deep disagreements in the performance of some expensive therapies. In this specific scenario, basic researchers, oncologists, and pathologists should first wonder how many of these apparent inconsistencies might be simply due to incomplete tumor samplings.Representativeness of the tumor sample is an important issue in modern oncology, particularly in those cases in which therapeutic decisions are made with small core biopsies. In these cases, liquid biopsy appears in the next horizon as a promising alternative in detecting tumor heterogeneity and in identifying mutations associated with tumor aggressiveness. Furthermore, liquid biopsy could be regarded as a complementary sample to surgical specimens for the application of massive sequencing tools.An efficient sampling of a large tumor must ensure properly ITH detection without incurring extra costs, and such a method has not yet been established in modern pathology. We have recently suggested a novel method called multisite tumor sampling (MSTS)  that makMultisite tumor sampling is based on the divide-and-conquer (DAC) algorithm . DAC is Multisite tumor sampling was shown to be an efficient method to sample large tumors for neoplasms growing in solid organs, i.e., kidney . HoweverSome carcinomas, however, do grow with different shapes in the mucosa , not like simple spheroids, and their growth is different depending on the axis considered, i.e., vertical or horizontal. This tumor category is represented, for instance, by carcinomas along the digestive tract and in the urinary bladder.Gastric adenocarcinomas (GACs), colorectal adenocarcinomas (CRCs), and urothelial cell carcinomas (UCC) of the urinary bladder are substantially different neoplasms developing in similar topographic sites, since the digestive tract and the urinary bladder are hollow viscera with similar walls that include mucosa, submucosa, muscularis propria, and serosa. A significant subset of UCC and many GACs and CRCs are plaque-like shaped neoplasms having two main components of growth: superficial  and vertical (deep invasion). Due to the specific characteristics of the local environment, it is likely that a substantial part of the relevant information for these neoplasms such as biological aggressiveness and prognosis are located in the invasion front –18. HoweUrothelial cell carcinomas of the urinary bladder are common neoplasms in Western countries. Over new 76,000 cases will occur in USA in 2016 . A relatHelicobacter pylori and changes in lifestyle  there is no official answer to this question at this time, we have recently proposed a method to increase the number of samples in CCRCC while keeping the same cost fixed . We showanalysis , method analysis , and clianalysis ] that a in silico approach to the problem with colon cancer as an example. On the one hand, the modeling takes into account both microsatellite stable and unstable tumor categories in CRC. On the other hand, different densities of tumor budding, extramural venous invasion, and perineural invasion at the tumor front of invasion have also been considered in the analysis.Here, we have adapted our method to the topographic peculiarities of stomach, large bowel, and urinary bladder, respectively, and have performed a similar The goal of MSTS is the recruitment of many tumor samples for analysis, but the procedure must be adapted to specific tumor shape. Excavated and plaque-like neoplasms can be sampled with full-thickness bars of tumor tissue including the lower invasion front. Next, six to eight of these bars are placed in the same cassette for study Figure . A thoroSince obtaining a large amount of these full-thickness tissue bars along several tumor slices may be perceived as too laborious by pathologists, we propose here the use of a multi-wheel rolling pasta cutter (or any similar device) Figure  to get sOur accumulated experience with MSTS points to this method as the most affordable sampling strategy in large tumors to guarantee a proper ITH detection without increasing cost. It seems, however, that MSTS must be adapted to the tumor shape, on the one hand, and to the tumor topography, on the other hand. Tumors growing as 3D spheroids like those arising in the kidney, liver, lung, breast, and soft tissues, for example, are not confined by anatomical barriers and are well sampled with tissue cubes, as recently shown . HoweverL. So, the ITH modeling is similar to the previous one  and j = 1, …, L (indicating column). The 0 value models homogeneity, while the 1 value models the presence of ITH at tumor position . Tumor budding  is represented by a different matrix (θ)ij ≡ {0,1}, where the 0 and 1 values represent, respectively, absence or presence of budding in position .We extended here the modeling approach we performed in our previous paper , but nowious one  and is rh = 1, …, H steps and where the initial condition was for all the cases γ = 0. At each step h, a 2D position  is chosen at random and a value of (γ)ij = 1 is assigned. After the H steps, the γ matrix is fixed and defines the tumor ITH configuration. The percentage of ITH density associated with a given tumor is defined as x-axis in Figure Similar to our previous approach , two clai,j), with no constraints for i and j, and this occurred for all the H steps. By contrast, for regITH, only at the first iteration (h = 1), the value of γ was assigned at position  with no constraints for i and j (using the same procedure as for ranITH), but for the following iterations (h ≥ 2), either the new chosen i or the new j was constrained to be necessarily a neighbor index of any of all the previously chosen i or j.For the ranITH situation, the matrix elements of γ were randomly generated at position (i = 1 (modeling the tumor invasion front). Budding was simulated using an iterative method with b = 1, …, B steps and where the initial condition was for all the cases θ = 0. At each step b, a random position j = 1, …, L was chosen and a value of (θ)1j = 1 was assigned. After the B steps, the θ matrix is fixed and defines the configuration of tumor budding. The percentage of budding density associated with a given tumor is defined as Budding was present only in tumor row of N times (and separately) two different strategies: routine protocol  and our alternative, the DAC strategy. For each repetition and strategy, we calculated the number of successfully detected ITH and budding sites. Results were averaged across the N repetitions and also across M different tumors (each one with different ITH and budding configurations)  Figure .Multisite tumor sampling is the best method for tumor sampling to detect ITH balancing high performance and sustainable cost. MSTS must be adapted to tumor shape and tumor location for an optimal performance.JL and GP exposed the problem and provided an affordable solution; JC implemented the modeling approach; JL, GP, and JC wrote the final version of the manuscript and agreed with this submission.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Young children spend considerable time in educational settings, in which traditionally, their primary occupation is play. A playful preschool environment has been related to better cognitive, social and emotional development. Although it is assumed that teachers’ playful behaviors are important in creating a playful school environment, empirical knowledge on this subject is lacking. The current study pilot examines the relation between teachers’ and children’s playfulness. Thirty-one teacher–child dyads participated. The teachers were asked to complete the Adult Playfulness Scale (APS). Thirty-minute videotapes of teacher–child play interactions were used to evaluate the child’s playfulness using the Test of Playfulness. A positive relation was found between two of the APS subscales (spontaneity and silliness) and child playfulness. Teacher silliness mediated the relation between children’s age and playfulness. This study is the first to show that teachers’ playfulness aspects are related to higher playfulness in children. Promoting teachers’ playful behaviors can be related to better teacher–child playful interactions, thereby enhancing children’s playfulness. Young children spend considerable time in educational settings, in which traditionally, their primary occupation is play . Play anThe current study is part of a broader research project on play interactions between children and adults at home and in educational settings. Specifically, it aims to examine the relation between aspects of teachers’ perceived playfulness  and children’s observed playfulness in ECE settings.Over the years, several attempts have been made to understand the role of play in ECE, based on extensive theoretical and empirical literature supporting its significance for young children’s development and well-being . Four girls and 27 boys participated . The children were all from mid-upper socioeconomic class families. The teachers – all women – were aged 24 to 57 . All teachers had a degree in education and a teaching certificate. All children learned in urban public preschools and kindergartens supervised by of the Israeli Ministry of Education. All teachers knew the children they were playing with at least 3 months before data collection.Thirty-one teacher–child dyads participated in the study. The children were all typically developed and their ages ranged between 40 and 72 months .In order to make sure all children were typically developed, they passed a developmental assessment using the Mullen Scales of Early Learning MSEL;  or the WTeachers were asked to complete a background questionnaire as well as the Adult Playfulness Scale APS; , 1993. Trarely or never, 3 = almost always); (2) Intensity ; and (3) Skill . In our study, one of the items  was eliminated because it was inappropriate for dyadic play. A complete list of ToP items and examples may be found in The Test of Playfulness ToP;  was usedScoring the ToP utilizes a test-specific keyform, which plots the relative difficulty of each item against the means and standard deviations for all items, and produces a total score ranging from 7 to -7, subsequently translated into a 0–3 score .In addition, Rasch analysis was performed using a “fit-the-model” methodology . Rasch aAll videotapes were coded by three trained and reliable coders. Inter-coder reliability was established for 15% of the videotapes using inter-class correlations , and ranAs mentioned, the data were collected as part of a larger study that investigated play interactions of children with and without ASD at home and educational settings. The study was approved by the Ethics Committee of the Hebrew University of Jerusalem and the Israel Ministry of Education.First, the research team contacted teachers in preschools and kindergartens for typically developed children that are supervised by the ministry. Teachers who agreed to participate were asked to write to all the parents in the preschool or kindergarten, explaining about the research and asking their permission for their children to participate. The children who were permitted to participate and who met our age and gender criteria were included in this study. Each teacher was paired to the first child/ two children from her classroom included in the study.Data were collected during the second and third quarters of the school year, in order to let the teachers get to know the children and establish their relationship before the research. A certified psychologist administered the developmental assessment to each child at their home. Parent who were interested in getting the test result, could receive a formal report and meet with the head psychologist for discussion. Each child–teacher dyad was videotaped in a 30-min play interaction at school, playing “as you usually do.” The dyad was offered to play with developmentally appropriate and attractive toys  provided by the researchers. Finally, teachers were asked to complete a demographic questionnaire and the APS.First, descriptive statistics and bivariate Pearson’s correlations between research variables were calculated. Next, a mediation model was tested to investigate the indirect link between children’s chronological age (CA) and playfulness as mediated by teachers’ playfulness aspects. The mediation analysis was conducted using PROCESS macro for SPSS . No relationship was found between children’s chronological or mental age (CA/MA) and their level of playfulness . However, a negative correlation was found between children’s CA and teachers’ perceived silliness , indicating that teachers of younger children perceived themselves as more “silly.” A positive relation was found between two of the APS subscales and children’s playfulness. Specifically, teachers’ spontaneity and silliness were both positively related to higher levels of child playfulness . No significant relation was found with the expressive, fun and creative subscales. A positive, non- significant, correlation was found between the teachers’ overall APS score and child playfulness .SE = 0.12; 95% confidence interval: LLCI = -0.054, ULCI = -0.003). Thus, the relationships between a child’s age and playfulness was mediated by teacher’s silliness.Given the correlation found between children’s age and teachers’ silliness, as well as between teachers’ silliness and children’s playfulness, a mediation model was run to examine whether the relationship between children’s age (independent variable) and playfulness (dependent variable) was mediated by teachers’ silliness (mediator variable). According to This pilot study is one of the first to demonstrate that aspects of teachers’ playfulness are positively related to higher levels of children’s playfulness. The study showed that teacher spontaneity and silliness were positively related to child playfulness. In addition, the relation between teachers’ overall playfulness and children’s playfulness was close to significant, and should be reexamined on a bigger sample. Those results are some of the first that empirically support the hypothesis that aspects of teachers’ playfulness in ECE, and specifically in teacher–child play interactions, are related to higher level of child playfulness. Note, however that this relation can be bidirectional nature, and that children’s classroom behavior can also affect teachers’ playfulness.Our findings confirm The other teacher behavior found in the present study to be significantly related to child playfulness, silliness – defined as childlike behavior  – and haIn the current study, the mediation model showed that teachers’ silliness was higher when children were younger, so that younger children would be more playful given higher levels of teachers’ silliness. No direct correction was found between children’s age and playfulness level. However, it seems that age did have a role in teacher playfulness, so that it was indirectly related to children’s playfulness. This may be explained by the fact that in recent years, play is sidelined by early learning standards and assessment of academic attainments ; thus, tKnowing the benefits of play and playfulness in ECE  and theiAlthough playfulness is usually considered a personal trait, playful behaviors such as silliness may also be seen as skills that can be acquired and honed. Using silliness, spontaneity and other play behaviors for pedagogical purposes is easier when one has mastered play-based assessment and communication techniques . Unfortuafter the play-interaction had been videotaped. The play interaction could thus have affected the way they completed the survey. Finally, despite its advantages, the APS, was criticized for poor theoretical background, psychometrics and validity. Therefore, future research should consider using alternative measurements of adult playfulness (such as provided by The current study is a pilot study, and despite its interesting findings, its limitations must be taken into consideration. First, its sample is small and not fully representative. For example, all the teachers in the sample were female. Although ECE teachers in Israel are females, it is important to include male teachers in research and to investigate gender differences. Future research should continue this investigation using larger and more representative samples. Second, longitudinal research should be conducted in order to determine causality. Third, teachers’ playfulness was measured using a self-report questionnaire, since, to the best of our knowledge, no observational measurement for adult playfulness exists. However, in order to gain deeper understanding of how teachers use playful behaviors in play interaction in ECE, observational measurement should be considered. Furthermore, all teachers have complete the APS In addition, further research should investigate additional child and teacher characteristics that can be related to those findings, for example, by looking into the variability among teachers in their play understanding and practices. Promoting teachers’ playfulness and playful ECE environment can eventually lead to better classrooms and play experiences for children. As part of a broader research project that investigated play interactions between and children adults at home and educational settings, it will be interesting to look at differentness in playfulness between parent and teachers and its relations to child’s playfulness. Finally, in is important to remember that one-on-one teacher–child play interactions are not common in today’s ECE settings. Future studies can examine group play interactions with teachers, as well as whether improved teacher–child play interactions also lead to improved child–child play and other interactions.The author was responsible for research design, data collection, data analysis, and writing the paper.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Research. The disorders temporomandibular dysfunction and the synonymous craniomandibular dysfunction are still being discussed intensely in the literature. Traditionally, attention is mostly devoted to occlusion and its relationship with these disorders. The conclusions reached are often contradictory. Considering the definitions of temporomandibular and craniomandibular dysfunctions/disorders and “occlusion,” a possible explanation for this controversy can be found in the subsequent methodological problems of the studies. Based on a Medline search of these terms over the past 40 years related to contemporary terms such as “Evidence Based Dentistry” and “Pyramid of Evidence,” these methodological aspects are examined, resulting in recommendations for future research and TMD-occlusal therapy. Management. To assist the dental practitioner in his/her daily routine to meet the modern standards of best practice, 7 guidelines are formulated that are explained and accompanied with clinical examples for an evidence-based treatment of patients with this disorder in general dental practices.By analogy with the journal's title Pain Research and Management, this review describes TMD Research and Management. More specific are the (1) research aspects of “occlusion,” still one of the most controversial topics in TMD, and (2) as much as possible evidence-based management aspects of “TMD” for the dental practitioner.  To date, over 22,000 papers are published concerning the disorders temporomandibular dysfunction and the synonymous craniomandibular dysfunction. In this paper, the term “Temporomandibular Disorders,” henceforth “TMD,” is used to present a collection of the 4 studied terms and its abbreviations: temporomandibular disorders, temporomandibular dysfunction (TMD) and craniomandibular disorders, and craniomandibular dysfunction (CMD).Recently, a paradigm shift regarding “TMD” has occurred from the biomedical model, more specifically from occlusion, to a biopsychosocial model of disease. The biopsychosocial model was introduced in medicine in 1977 and published in 1978 by Engel . The modIn this study, a two-track scientific approach was followed. Literature searches were executed focusing on 1) randomized controlled trials, the highest level in the pyramid of evidence, and all trials and 2) the search terms “evidence based dentistry,” “biopsychosocial model,” and “occlusion.” Web of Science searches in the Medline database were executed over, respectively, a 67-year period for the data in Tables  randomiz the searSearch terms and topics were Craniomandibular Disorders, Craniomandibular Dysfunction, Temporomandibular Disorders, Temporomandibular Dysfunction, CMD, TMD, Occlusion, Biopsychosocial Model, Evidence Based Medicine, Evidence Based Dentistry, and Pyramid of Evidence. Results were further filtered by the type of the study  and/or sorted by the year of publication and frequency of citation. The results of the “occlusion” searches are presented in 3 tables, 2 figures, and an eight-point summary.During the recent 67-year period, there are only 35 papers published concerning the biopsychosocial model and “TMD,” 86 different trials, of which 52 randomized controlled trials  3–54] a a54] andIt is almost impossible to abstract an extensive RCT into single keywords regarding the results of the study. Nevertheless, the combination of the columns “characteristics of the trial” and “effect/result” is an attempt to realize this. Further explanations of the study results are presented in Discussion. Researchers are invited to further scan, screen, and study the collected papers by themselves to verify the presented conclusions.“The reviews are not meant to stand alone but are intended to inform the interested reader about what has been discovered in the past year. The readers are then invited to go to the source if they wish more detail.” On one hand, this selection is most probably beneficial for the dental practitioner. On the other hand, a researcher following this advice is directed to only 0.5% of the preselected TMD papers and misses the other 99.5%. Also, the Luther study [Without underestimating the value of papers that will not be addressed in further detail here, the search, presented in er study  might haFinally, 5 of the selected papers in this search are letters or comments, with 4 of them disputing the Rinchuse 2005 orthodontic-orientated TMD papers. All of the letters and comments concerned about orthodontic-related TMD aspects.In the period 1977–2017, a total of 20,340 “TMD” papers were published, starting with 160 papers in 1977 to almost a thousand (903) in 2016. The “TMD” refined with “occlusion” curve does not follow the curve of evidence-based dentistry papers. However, the number of EBD papers did increase in line with the total number of “TMD” papers. In the recent decade, EBD papers also increased substantially to approximately 180 papers yearly. It might be prudently concluded from these data that apart from the 21 papers presented in A clear discrepancy is visible between the periods of increased activity in the number of papers of the topics “TMD” + “occlusion” and the EBD curve, whereas the curves of “TMD” + EBD and the trial curves of “TMD” + “occlusion” are fluctuating more or less constantly over the 40-year period .n=86) and the “TMD”-related EBD (n=58). Regarding the 11-year period of increased attention to the “occlusion” and “TMD” topics from 1982 to 1992, all 14 exclusively “occlusion”-oriented RCTs were published. This is the same number of RCTs as that in the 22-year period from 1993 to 2015.The increase of the number of EBD studies is not followed by a progression of both the studies of “TMD” + occlusion   trials appeared to be present. Refined with the keywords “Evidence Based Dentistry,” 417 studies could be selected. A further refining with “occlusion” resulted in 8 studies.“Evidence-based clinical practice guideline for the use of pit-and-fissure sealants” by Wright et al. “Does altering the occlusal vertical dimension produce temporomandibular disorders? A literature review” by Moreno and Okeson “Is there enough evidence to regularly apply bone screws for intermaxillary fixation in mandibular fractures?” by Bins et al. “Occlusion on oral implants: current clinical guidelines” by Koyano and Esaki “Bilateral balanced articulation: science or dogma?” by Farias-Neto and Carreiro “Complete denture occlusion: an evidence-based approach” by Farias-Neto and Carreiro “Critical appraisal of methods used in randomized controlled trials of treatments for temporomandibular disorders” by Fricton et al. “Association between orthopedic and dental findings: what level of evidence is available?” by Hanke et al. A summary of all trials in the Medline database in the period 1950–2017 refined with the search terms Evidence Based Dentistry and Occlusion:As a result of this search, only 2 papers addressing the “occlusion” topic of our study were found: the Moreno/Okeson study and the Fricton study. After replacing “occlusion” by “TMD” in the second refining step of the same EBD search, this revealed only 3 studies: the Keenan 2015 study , the ForDespite the substantial number (2419) of published papers about “TMD” and “occlusion,” there are still controversy and contradictory opinions on the interaction between “occlusion” and “temporomandibular disorders.”What could be an explanation for the still ongoing discussion? Why has the scientific world not yet reached consensus? For a one-to-one link between a disorder and a factor, the 2419 occlusion papers, or otherwise, the 52 RCTs, the highest level of research in the pyramid of evidence , should A possible explanation for the ongoing controversy about “occlusion” and “temporomandibular disorders” is definition-based.Ever since Goodfriend described functional disturbances of the stomatognathic system in the Dental Cosmos of 1932 , severalConsidering the topic “occlusion” in the dental literature, this term is used for 4 different entities: (1) the anatomic or “orthodontic” jaw relation: the Angle classification, (2) static contact between the teeth of the upper and lower jaws, (3) dynamic contact between the teeth of the upper and lower jaws, for example, cuspid guidance versus group function, articulation, and occlusal interferences, and (4) the prosthetic classifications, more specifically, the complete/incomplete dentition versus complete dentitions and the presence of fixed/removable prosthetics.4 = 10,000 different possibilities for research and RCT studies .Based on purely statistical fundamentals, there are at least 10It can be concluded that due to the phenomenon of the multiple catch-all or container concepts of both “occlusion” and “TMD,” there are many different options to research. In addition, considering the etiology, the cause and effect relation, and vice versa, there are almost inexhaustible possibilities.In summary, the 52 RCTs of the Medline database over the period 1977–2017 only represent approximately 0.5% of these 10,000 possible study options. In addition, there are also RCTs in this 52-RCT search collection dealing with other topics than exclusively “occlusion.” This is a consequence of the generally accepted multifactorial and multicausal character of “TMD.”Considering the multifactorial character, 40 years ago, in 1979, De Boever  describeThis is in line with the “biopsychosocial” theory published in 1987 by Marbach and Lipton, “Biopsychosocial factors of the temporomandibular pain dysfunction syndrome. Relevance to restorative dentistry” . More re“The mandibular articulation undergoes functional adaptation” [Considering the adaptation capacity, already in the early years of dental literature in 1932, 85 years ago, Goodfriend stated the following in his concluding remarks: ptation”  .“TMD” fluctuates over time.Adaptation is an important quality of the human being; in this respect, it is more specific of the stomatognathic system.Focusing on the aim and the subject of this paper—research about the contradictory role of “occlusion” in relation to “TMD”—the following conclusions about “occlusion” in relation to “TMD” can be abstracted after a more in-depth study of the 52 selected RCTs and the results of the other described searches:The still existing confusion and contradiction in the dental literature about the role of “occlusion” in “TMD” is probably caused by the approach of some mainly American gnathologists/researchers who maintain that since occlusal interferences affect TMD, all occlusal varieties and “abnormalities” cause TMD signs or symptoms and therefore have to be treated preventively. Such an approach to patients does not account for the interindividual variation, as present all over the world and in this context as described by Ramfjord and Ash , 94.Since it will take about a generation to fundamentally change treatment strategies and opinions , the proWith respect to the possible role of “occlusion” in the etiology of “TMD,” the scientific world has to accept that it will most probably never ever be more elucidated than it is at present. In all probability, there will never be an ethics commission approving “occlusal experiments” in healthy young people to study the onset or incidence of “TMD” signs or symptoms over time.The only possibility to make any progress is to study in detail the available studies and to respect and implement practitioners' experiences.It is one of the challenging and obliging tasks of universities, researchers, and dental societies to achieve this progress by performing an objective, accurate, and critical study of the existing literature. This will then result in studies with a sound methodological standard. Accurate reviewing of submitted papers in peer-reviewed journals is also important to achieve this aim. All this might result in less “scientific” papers and consequently less  granting, but on the other hand, also in a higher level, standard and quality of the published papers.It will create an achievable way for practitioners to stay up-to-date with the literature to the application of evidence-based dentistry in their daily dental practice and not be overwhelmed by an ocean of conflicting information and endless discussions about scientific topics.The conclusion of this review is to stop trying to find the exact etiologic role of “occlusion” in the perspective of “TMD” and concentrate on a critical study of the available scientific and clinical information and integrate them.Each patient is unique.Respect the biological variation in form/appearance and (the coherent) function.Adaptation is possible within defined biologic limits and contains a time factor or aspect.Be alert to recent  treatments or events that might interrelate with the onset of the complaints or problems.Try to differentiate and diagnose the different entities of TMD and adjust your treatment modality accordingly.Be reluctant with irreversible treatment options and direct the treatment as much as possible to a predictable, reliable, and proven result with a known determined prognosis.Consider and take into account the opinion or idea of the patient about the possible cause of the complaint or problem.Based on the available “TMD” papers and experiences from the daily dental practice, first, some general elementary starting issues are detailed below to provide the general practitioner some support and clues for the treatment of TMD patients. Subsequently, practical clinical examples and tips of each issue are presented:Observe and consider that not only the anatomy and morphology of each individual diverge but also the regular everyday use of the stomatognathic system differs from one another. The biologic variation is huge, even within distinguished ethnic groups. The functions of the stomatognathic system: communicating , eating (biting and chewing), supporting , stress processing , and aesthetics, differ significantly between individuals. There may be clues present between the complaints and the observed problems with the functions of the stomatognathic system of the patient in question. The patient's age and gender also affect the prevalence of TMD  intrusion of the concerning tooth occurs as a possible mechanism of compensation or adaptation. This tooth also apparently does not abide the overall biological, natural, and functional wear of the other adjacent teeth. Subsequently, as a mechanism of adaptation, their mobility increases slightly. These patients indicate most of the time that the tooth is feeling a little bit higher and more sensitive. Based on clinical experience, these, a little more than physiologic mobile teeth, show most often interferences at chewing movements, at articulation, and not in the static occlusal contact position. These are mostly indirect restorations such as (solitaire/single) crowns, abutment teeth for removable casted partial prosthetics, or the occlusal clasps of removable partial dentures. These so-called “iatrogenic occlusal interferences” will manifest only over time. It is advisable to eliminate the disturbance by selective grinding and reshaping and adjusting the contour of these restored teeth or clasps. The recently developed device “Tekscan®” may be a useful aid to substantiate this, also in the treatment of “occlusion-sensitive” subjects .Exceeding the adaptation capacity might also occur in a specific and limited period of time, during the eruption of the wisdom molars, more specifically, the eruption of the 3rd mandibular molars. Although the eruption pattern of the 3rd molars shows a wide range, the majority erupts between the age of 17 and 26 years , 101. EsThe distal interference causes tilting of the concerning TMJ and might initiate grinding and wear of the contralateral cuspids in a short period of time, as a parafunction, mostly unconsciously at night. In combination with the mostly irritated operculum, patients compensate for this with an unnatural, divergent chewing pattern. This unnatural chewing pattern occurs in unnatural positions within the TMJs and the articular discs, resulting in dislocation, joint sounds, and pain in and around the TMJs. Counseling, information, advice about extraction, or preferably the extraction procedure itself is desirable. Some adaptation time after the extraction of the third molar, the affected and worn top of the cuspid might be restored using the composite etch technique. If, for any reason, the third molar will not be extracted, treatment of the painful operculum is recommended. Both the further eruption of the third molar and the occlusal condition have to be monitored or treated.With respect to the onset of TMD or TMD-related complaints, it is advised to be alert to recent dental procedures or events that might be associated with the complaints. This includes extractions, particularly extractions of mandibular teeth. Damaging or even luxation of the TMJs might have occurred. Also, long-lasting dental treatment procedures when the patient had to have the mouth opened extremely wide and for a long time may have this effect. Equally, the intubation procedures for general anesthesia/surgical interventions are notorious and suspected. As a result, the TMJs might have been extremely strained and stretched, and the musculature might have been traumatized and injured. Recovery of these attacks on the TMJ tissues requires time and has to be treated by getting as much rest as possible. This means no excessive function, temporary use of soft or liquid foods, and/or temporary medication for pain relief.Recently inserted prosthetic devices also might provoke complaints of a TMD character such as tenderness of the chewing muscles, biting on the cheek or lips during chewing, joint sounds, or even pain in or around the TMJs and the masticatory muscles. In case, after accurate inspection, no shortcomings or imperfections of the prosthetic provisions and no deviations in the static and active dynamic occlusion can be determined, the adaptation capacity has to be appealed. The patient has to be informed and counseled and explained that more time is necessary to adapt to the new situation. Not infrequently, the patient is not convinced of this approach and appears to be unhappy with the aesthetics or comfort of the new devices. The patient explains and interprets this by a lack of the support function and the presence of chewing problems.Frequently, the patient's interpretation of those shortcomings is gratefully strengthened by the treatment and repetitive corrections of the occlusion by the general practitioner. A treatment not addressing the real cause or problem will never ever be successful. In extreme cases, placebo adjustments might be applied to address and permeate this problem.From a historical perspective, TMD patients show different, nowadays better distinguished functional disorders. It is important for the dental practitioner to assess the most possible specific diagnosis. If the diagnosis is correct, a conforming, matching therapy and treatment is available. If the treatment was successful, then the diagnosis was the right one. Crucial for this is a good and complete examination of the patient. Anamnesis and clinical examinations, not only intraoral but also from the head and neck region, are very important and indispensable.Important signs might be observed as nonverbal expressions such as the overall body posture, the position of the head in relation to the chest, shoulders up or down, and patients' handshake with a firm or soft hand. How does the patient communicate? How clearly does he or she express himself or herself? Is there a (recent) trauma in his or her history? How many different professionals have previously been consulted? Is the location of the pain clearly pointed to with one finger, for instance, the joint, or do the patient's hands encircle the entire head? Are other joint problems present such as hypermobility of knees, ankles, wrists, or elbows? Is there a history of rheumatic diseases?All this information is important to assess a correct and specific diagnosis.Whenever the general practitioner is not able to reach a right circumscribed diagnosis, other experts have to be consulted before any treatment is proposed. The advice of a specialized gnathologist might be required, or a physiotherapist specialized in TMJ problems might be consulted mainly for muscular problems, or a  psychologist.There is plenty of literature available describing the patient's anamnesis and clinical examination protocols , 103.Occasionally, even after intensive examinations and interdisciplinary consultation, a general practitioner might not be convinced of a right treatment approach of the specific TMD. In that situation, it is advised to be cautious with (irreversible) treatment options. One has to treat as predictably as possible. In progressive bruxism cases, preventive occlusal splints are necessary. The application of occlusal appliances is also recommended as indispensable reversible tools to test, restore, and establish a physiologically accepted natural and healthy comfortable balance in the stomatognathic system.Whenever a patient is not aware of a TMD problem, but the dental practitioner recognizes signs of TMD at the regular checkups of the patient, it is important to find out whether the patient himself or herself has any idea or assumption about the cause or the existence of the assessed TMD phenomenon . If not,This study at the end of the professional career of the first author is the final spin-off from the PhD thesis: Prevalence and Etiology of Craniomandibular Dysfunction. An Epidemiological Study of the Dutch Adult Population . In this“More emphasis should be placed on patient-centred criteria of what is perceived to be important to patients' function, satisfaction, and needs, as well as dentists' views of what is significant for improvement in dental health” Ash [lth” Ash .It is clear, that even without a role in TMD etiology, the occlusion retains an important role in most aspects of dental practice” [A final comment of Klineberg to the Forssell Paper  about evractice” .“In a longer perspective, many of today's “truths” will be questioned, and dogmas that lack strong evidence will eventually be abandoned. But to achieve this goal it is necessary for open-minded educators and researchers to question and analyse current practice methods in all areas of clinical dentistry.”And last, but certainly not least, also the most recent statement of these 3 from Carlsson is the following : “In a l