Norman Kettner - Academia.edu (original) (raw)

Papers by Norman Kettner

NeuroImage, Sep 1, 2009

Acupuncture-induced sensations have historically been associated with clinical efficacy. These se... more Acupuncture-induced sensations have historically been associated with clinical efficacy. These sensations are atypical, arising from sub-dermal receptors, and their neural encoding is not well known. In this fMRI study, subjects were stimulated at acupoint PC-6, while rating sensation with a custom-built, MR-compatible potentiometer. Separate runs included real (ACUP) and sham (SHAM) acupuncture, the latter characterized by non-insertive, cutaneous stimulation. FMRI data analysis was guided by the on-line rating timeseries, thereby localizing brain correlates of acupuncture sensation. Sensation ratings correlated with stimulation more (p<0.001) for SHAM (r=0.63) than for ACUP (r=0.32). ACUP induced stronger and more varied sensations with significant persistence into no-stimulation blocks, leading to more runtime spent rating low and moderate sensations compared to SHAM. ACUP sensation correlated with activation in regions associated with sensorimotor (SII, insula) and cognitive (dorsomedial prefrontal cortex (dmPFC)) processing, and deactivation in default-mode network (DMN) regions (posterior cingulate, precuneus). Compared to SHAM, ACUP yielded greater activity in both anterior and posterior dmPFC and dlPFC. In contrast, SHAM produced greater activation in sensorimotor (SI, SII, insula) and greater deactivation in DMN regions. Thus, brain encoding of ACUP sensation (more persistent and varied, leading to increased cognitive load) demonstrated greater activity in both cognitive/evaluative (posterior dmPFC) and emotional/ interoceptive (anterior dmPFC) cortical regions. Increased cognitive load and dmPFC activity may be a salient component of acupuncture analgesia-sensations focus attention and accentuate bodily awareness, contributing to enhanced top-down modulation of any nociceptive afference and central pain networks. Hence, acupuncture may function as a somatosensory-guided mind-body therapy.

Journal of Manipulative and Physiological Therapeutics, Sep 1, 2006

Objective: The aim of this study was to describe the appearance of a rare occurrence of a spicula... more Objective: The aim of this study was to describe the appearance of a rare occurrence of a spiculated periosteal reaction caused by stress injury and the subsequent diagnostic assessments. A proposed mechanism for the etiology of stressinduced periosteal reactions in this case is offered. Clinical Features: A 54-year-old female had ankle pain for 1 year. Radiographs revealed a spiculated periosteal reaction of the distal fibula. In light of the clinical history of prior breast carcinoma, the possibility of metastatic disease was entertained. Intervention and Outcome: Scintigraphy and magnetic resonance imaging were used in the diagnostic evaluation of this patient. Malignancy was ruled out on the basis of the magnetic resonance imaging findings, and an etiology of a stress reaction was proposed based on the scintigraphic findings. Conclusion: Stress-induced spiculated periosteal reactions are a rare occurrence. This case illustrates the role that advanced imaging plays in the assessment of a suspicious periosteal reaction.

Journal of Manipulative and Physiological Therapeutics, Mar 1, 2007

Objective: This case report describes and discusses the clinical presentation, diagnosis, and man... more Objective: This case report describes and discusses the clinical presentation, diagnosis, and management of a patient with a sacral fatigue fracture. Clinical Features: A 26-year-old female long-distance runner presented with nonspecific low-back and buttock pain that prevented her from training. Intervention and Outcome: Radiographic findings on the patient's lumbar spine and pelvis were interpreted as normal. Single-photon emission computed tomography and magnetic resonance imaging were performed, revealing a fatigue fracture of the left sacral ala. The patient discontinued training for 6 months and gradually returned to running. Conclusions: A high index of suspicion should prompt investigation with skeletal scintigraphy, computed tomography, or magnetic resonance imaging. Sacral stress fractures may respond well to conservative measures if diagnosed in a timely fashion. (

The FASEB Journal, 2020

The vagus nerve plays an important role in both sensory and motor aspects of gastric physiology. ... more The vagus nerve plays an important role in both sensory and motor aspects of gastric physiology. Both animal and human studies suggest that accommodation reflex consists of a vagovagal reflex pathway. Thus, modulating vagal efference may be promising to increase gastric hypomotility for gastroparesis or functional dyspepsia.Transcutaneous vagus nerve stimulation (tVNS) of the auricular branch of the vagus nerve is a promising non‐invasive neuromodulatory therapy for numerous disorders. We have demonstrated that tVNS targets nucleus tractus solitarii, and medullary efferent parasympathetic (vagal) nuclei (Sclocco et al. 2019). Our group showed that neural target‐engagement can be enhanced by gating stimulation to the exhalation phase of respiration, via Respiratory‐gated Auricular Vagal Afferent Nerve Stimulation (RAVANS).In this ongoing study, we evaluate nine (9) functional dyspepsia (FD) patients with both brain fMRI and 4D cine MRI of the stomach during a test meal challenge and ...

Journal of Ultrasound, Mar 12, 2019

PurposeUlnar nerve instability (UNI) in the cubital tunnel is defined as ulnar nerve subluxation ... more PurposeUlnar nerve instability (UNI) in the cubital tunnel is defined as ulnar nerve subluxation or dislocation. It is a common disorder that may be noted in patients with neuropathy or in the asymptomatic. Our prospective, single-site study utilized high-resolution ultrasonography (US) to evaluate the ulnar nerve for cross-sectional area (CSA) and measures of shear-wave elastography (SWE). Mechanical algometry was obtained from the ulnar nerve in the cubital tunnel to assess pressure pain threshold (PPT).MethodsForty-two asymptomatic subjects (n = 84 elbows) (25 males, 17 females) aged 22–40 were evaluated. Two chiropractic radiologists, both with 4 years of ultrasound experience performed the evaluation. Ulnar nerves in the cubital tunnel were sampled bilaterally in three different elbow positions utilizing US, SWE, and algometry. Descriptive statistics, two-way ANOVA, and rater reliability were utilized for data analysis with p ≤ 0.05.ResultsFifty-six percent of our subjects demonstrated UNI. There was a significant increase in CSA in subjects with UNI (subluxation: 0.066 mm2 ± 0.024, p = 0.027; dislocation: 0.067 mm2 ± 0.024, p = 0.003) compared to controls (0.057 mm2 ± 0.017) in all three elbow positions. There were no significant group differences in SWE or algometry. Inter- and intra-observer agreements for CSA of the ulnar nerves within the cubital tunnel were assessed using intraclass correlation coefficient (ICC) and demonstrated moderate (ICC 0.54) and excellent (ICC 0.94) reliability.ConclusionsMost of the asymptomatic volunteers demonstrated UNI. There was a significant increase in CSA associated with UNI implicating it as a risk factor for ulnar neuropathy in the cubital tunnel. There were no significant changes in ulnar nerve SWE and PPT. Intra-rater agreement was excellent for the CSA assessment of the ulnar nerve in the cubital tunnel. High-resolution US could be utilized to assess UNI and monitor for progression to ulnar neuropathy.

SN Comprehensive Clinical Medicine, Aug 28, 2019

Variant sciatic nerve anatomy in the thigh occurs in about 4% of cadaveric specimens. Its signifi... more Variant sciatic nerve anatomy in the thigh occurs in about 4% of cadaveric specimens. Its significance is relevant in both clinical and surgical settings. This case describes a rare asymptomatic split with reunification of the sciatic nerve in the thigh utilizing sonography. A 27-year old male presented as a participant in a sonography research study (in preparation for publication). He was a healthy control subject without low back pain or radicular symptoms. A bilateral sonographic examination was performed to assess the sciatic nerve in the long (sagittal) and short (axial) planes. Incidentally demonstrated was a split of the sciatic nerve occurring approximately 8 cm distal to the ischial tuberosity. The finding was symmetric and bilateral. The split was maintained for 12 cm with a perpendicular epineural bridge connecting the two branches, reuniting proximal to the sciatic nerve bifurcation. Sciatic nerve variants are often described at the level of the piriformis. In contrast, there are few studies that describe variant anatomy of the sciatic nerve in the mid-thigh. Sonography provides a safe, easy, and available resource for depicting anatomic morphology of the sciatic nerve. This article is part of the Topical Collection on Imaging

Journal of Chiropractic Medicine, Jun 1, 2016

The purpose of this case report is to describe the features of an unusual presentation of fibrous... more The purpose of this case report is to describe the features of an unusual presentation of fibrous dysplasia. Clinical Features: A 53-year-old woman had low back pain and numbness in the anterior upper left thigh that started 3 years earlier after a fall. She experienced pain during active lumbar flexion and extension range of motion. Radiographic examination demonstrated an oval geographic osteolytic lesion in the left ilium and abnormal trabecular architecture with variable-sized osteolytic lesions and both ill-defined and well-defined borders along the sacroiliac joint margin. Intervention and Outcome: Because of the aggressive osteolytic appearance, magnetic resonance imaging of the pelvis with gadolinium contrast was obtained for additional characterization of the lesions. There were 3 additional mixed signal lesions located within the left femoral neck and extending to the greater trochanter that enhanced with contrast. Because of the suspicion of malignancy, needle biopsy was performed. The pathologic findings in combination with the radiographic appearance confirmed the diagnosis of polyostotic fibrous dysplasia. Conclusion: This case demonstrated a rare aggressive appearance of polyostotic fibrous dysplasia located in the left innominate and the left proximal femur that prompted a diagnostic imaging workup and biopsy for suspected skeletal malignancy. These lesions may require careful evaluation by an experienced team of physicians, radiologists, and pathologists to ensure proper diagnosis and treatment.

Ultrasound in Medicine and Biology, Apr 1, 2015

Journal of Chiropractic Medicine, Dec 1, 2021

ObjectiveThe purpose of this report is to describe the clinical, radiographic, and diagnostic ult... more ObjectiveThe purpose of this report is to describe the clinical, radiographic, and diagnostic ultrasound findings in a patient who sustained a type III Salter-Harris fracture of the first proximal phalanx.Clinical FeaturesA 14-year-old male baseball player presented to a chiropractic clinic with a 2-day history of proximal thumb pain, which began following a forceful hyperabduction injury while sliding into base. Thenar swelling was evident on clinical examination, and both active and passive thumb motions were painful in all directions. Radiography revealed a type III Salter-Harris fracture of the first proximal phalangeal base. Additionally, diagnostic ultrasonography demonstrated a probable high-grade ulnar collateral ligament sprain. No further displacement of the fracture fragment was visualized with radial deviation stress.Intervention and OutcomeThe patient was referred to a pediatric hand orthopedic specialist for consultation and treatment.ConclusionSalter-Harris III fractures of the thumb base warrant special attention to various clinical and imaging features, which may affect patient outcomes. Fracture characterization with radiography is essential in determining the proper management. Ultrasonography and magnetic resonance imaging may be useful in the evaluation of concomitant soft tissue injuries, as demonstrated in this case report.

Journal of Chiropractic Medicine, Jun 1, 2018

Objective: The purpose of this report is to describe a patient with scapholunate advanced collaps... more Objective: The purpose of this report is to describe a patient with scapholunate advanced collapse (SLAC) of the wrist. Clinical Features: A 38-year-old man presented to a chiropractic teaching clinic with right wrist pain after falling off of the tailgate of a truck 7 years prior. The mechanism of injury was a fall on an outstretched hand. Ultrasonography and radiography were performed, which demonstrated abnormal lunate kinematics and scapholunate interval diastasis associated with a clenched-fist maneuver. These findings were consistent with SLAC. Intervention and Outcome: Following the diagnosis of SLAC, the wrist was splinted. Conservative care consisting of physical therapy included paraffin dips, therapeutic ultrasound, and stretching. The patient received only minimal alleviation of pain, and a surgical consultation was obtained. The patient elected surgical intervention, utilizing the proximal row carpectomy procedure. Conclusion: This case demonstrates a patient with chronic wrist pain, with progression to carpal instability, which ultimately manifested as SLAC. We demonstrate, utilizing multiple imaging modalities, both preoperative and postoperative findings. To our knowledge, this is the first case to describe the use of diagnostic ultrasonography in the evaluation of the proximal row carpectomy procedure.

Deutsche Zeitschrift für Akupunktur, 2011

Journal of Chiropractic Medicine, Dec 1, 2017

Objective: This report describes chiropractic management for 3 cases of inactive ankylosing spond... more Objective: This report describes chiropractic management for 3 cases of inactive ankylosing spondylitis (AS). Clinical Features: A 25-year-old woman presented with chronic, mechanical neck pain and stiffness that was ultimately diagnosed as AS. A 23-year-old man presented with chronic low back and left hip pain that was diagnosed as AS. A 31-year-old man with low back pain presented with a known diagnosis of AS. Physical examination in 2 cases failed to identify systemic findings associated with AS. In the third case, examination revealed a history of ulcerative colitis. Laboratory examination of case 2 yielded a positive HLA-B27, but cases 1 and 3 were HLA-B27 negative. The acute reactants were negative in all 3 patients, indicating an inactive phase of disease. All 3 patients underwent spinal imaging including sacroiliac joint radiography. In case 3, magnetic resonance imaging of the sacroiliac joints was performed. All 3 imaging examinations revealed bilateral, symmetric sacroiliitis. Interventions and Outcome: Patients were managed by both a medical rheumatologist and a doctor of chiropractic. Chiropractic care ranged from instrument-assisted spinal manipulation to diversified spinal and soft tissue manipulation and Cox flexion-distraction. Patients were given home stretches and rehabilitation exercises. All 3 patients experienced some relief of their symptoms including pain reduction and improved activities of daily living. Conclusion: These 3 patients displayed differences and commonalities in clinical, laboratory, and imaging features. Chiropractic manipulation and rehabilitation seemed to be beneficial in reducing symptomatology and improving musculoskeletal function for these 3 patients. These findings suggest the potential for collaborative or integrative management in similar cases.

Journal of Manipulative and Physiological Therapeutics, Jul 1, 2002

To discuss a case involving a 55-year-old diabetic woman with neuropathic osteoarthropathy initia... more To discuss a case involving a 55-year-old diabetic woman with neuropathic osteoarthropathy initiated by a fall. The patient fell into a hole, injuring her left foot. Because of the anesthesia associated with her diabetic peripheral neuropathy, she did not notice the ensuing plantar puncture wound. The patient assumed that her swelling was a result of a sprain. Mild dislocation and osseous fragmentation was noted within the midfoot on radiographs. The neuropathic osteoarthropathy progressed until the patient was later casted. Plain films taken at the time of cast removal demonstrated resorption and consolidation of fragmentation, but the dislocation was unaltered. The patient was scheduled for surgery and wound debridement. However, before surgery, complications of a burn sustained on the contralateral foot required fifth ray amputation. Surgery of the left foot has been postponed until adequate postsurgical healing has occurred at the right foot amputation site. This article provides tools for the timely diagnosis and treatment of neuropathic osteoarthropathy. An increased understanding of this entity will help lead to a reduction in the incidence of delayed treatment resulting from misdiagnosis.

Journal of Ultrasound, Dec 8, 2016

The purpose of this case report is to describe the value of musculoskeletal ultrasound (US) in di... more The purpose of this case report is to describe the value of musculoskeletal ultrasound (US) in diagnosing both distal intersection syndrome (DIS) and rupture of the extensor pollicis longus (EPL) tendon in the same patient. A 38-year-old female presented for evaluation of a painful bump of unknown etiology on the dorsolateral aspect of her non-dominant wrist. US demonstrated tenosynovitis distal to Lister's tubercle of the EPL and extensor carpi radialis tendon sheaths, consistent with DIS. Immobilization therapy was employed, during which time the patient suffered rupture of the EPL tendon. Follow-up US examination confirmed this additional diagnosis. Characteristic US findings of DIS and EPL tendon rupture were observed. Surgical intervention was required and the patient recovered without complication. Although EPL rupture is relatively common in the literature, DIS is rare. This is the first known case of imaging-proven DIS progressing to EPL tendon rupture. This case underscores the value of US as a widely available, cost effective, and dynamic imaging modality for evaluation of wrist complaints. Keywords Ultrasonography Á Wrist Á Tendons Á Tenosynovitis Á Overuse syndrome Á Intersection syndrome Sommario Lo scopo di questo caso clinico è quello di descrivere l'utilità dell'ecografia (US) muscolo-scheletrica nella diagnosi della sindrome da intersezione distale (DIS) e della rottura del tendine estensore lungo del pollice (EPL) in uno stesso paziente. Il caso riguarda una donna di 38 anni, valutatain merito ad una tumefazione dolente di eziologia sconosciuta sulla superficie dorsolaterale del polso non dominante. L'ecografia dimostrava una tenosinovite distale al tubercolo di Lister della EPL e delle guaine tendinee dell'estensore radiale del carpo, coerente con la diagnosi di DIS. Tale lesione è stata trattata con immobilizzazione dell'arto, durante il quale la paziente ha subito rottura del tendine EPL. L'esame ecografico di follow-up ha confermato questa ulteriore diagnosi. L'ecografia ha quindi evidenziato reperti caratteristici della DIS e di rottura del tendine EPL, sulla base dei quali la paziente è stata sottoposta ad intervento chirurgico che è stato effettuato senza complicazioni, permettendo il recupero funzionale dell'arto. Anche se la rottura del EPL è relativamente comune nella letteratura, la DIS è rara. Questo è il primo caso a noi noto di imagingche dimostra la DIS con progressione verso rottura del tendine del EPL. Questo caso sottolinea il valore dell'ecografia come modalità di diagnostica di imaging dinamico,ampiamente disponibile ed economica per valutare le lesioni del polso.

Journal of Ultrasound, Jun 23, 2015

This case report describes the use of diagnostic ultrasound to diagnose a Stener lesion in a pati... more This case report describes the use of diagnostic ultrasound to diagnose a Stener lesion in a patient who presented for conservative care of thumb pain following a fall on an outstretched hand. Conventional radiographic images demonstrated an avulsion fracture at the ulnar aspect of the base of the first proximal phalanx. Diagnostic ultrasound revealed a torn ulnar collateral ligament of the thumb that was displaced proximal to the adductor aponeurosis, consistent with a Stener lesion. Dynamic imaging with ultrasound confirmed displacement of the fully torn ligament. Surgical repair followed the diagnosis. Diagnostic ultrasound in this case provided an accurate diagnosis obviating further imaging. This allowed an optimal outcome due to early intervention. Keywords Stener lesion Á Ulnar collateral ligament Á Thumb Á Adductor aponeurosis Á Ultrasonography Sommario Il caso che presentiamo descrive l'uso dell'ecografia nella valutazione della lesione di Stener in un paziente che si è presentato con pollice dolorante, a seguito di caduta a mano tesa. Le immagini radiografiche convenzionali avevano mostrato una frattura da avulsione dell lato ulnare della base della falange prossimale. La diagnosi ecografica ha rivelato una rottura completa del legamento collaterale ulnare metacarpo-falangeo del pollice, ribaltato sull' aponeurosi dell'adduttore (lesione di Stener). L'imaging dinamico con ecografia ha confermato il ribaltamento del legamento lacerato. In seguito alla diagnosi è stata eseguita riparazione chirurgica. In questo caso la valutazione ecografica si è rivelata utile per una diagnosi accurata, evitando ulteriori indagini ed ha permesso di ottenere un risultato ottimale con l'intervento immediato.

Pm&r, Nov 10, 2015

BackgroundNo detailed reports exist describing the methodology of ultrasound image acquisition of... more BackgroundNo detailed reports exist describing the methodology of ultrasound image acquisition of the deep external rotator muscles of the hip. Because gluteal pain and sciatica are common, ultrasound may be a useful dynamic imaging adjunct in the evaluation of these patients.ObjectiveTo describe dynamic ultrasonography of the deep external rotator muscles of the hip for diagnostic purposes.DesignDescriptive.SettingUniversity radiology department.ParticipantsParticipants (n = 25; 14 male) without gluteal pain or sciatica were enrolled (mean age 27.6 ± 4.7 years; mean body mass index 26.0 ± 4.1 kg/m2).MethodsUltrasonographic cine clips oriented to the long axis of each deep external rotator muscle were captured. In addition, cine clips of the piriformis tendon and obturator internus tendon were obtained. Cine clips were analyzed approximately 1 week after completion of image acquisition independently by 2 blinded raters.Main Outcome MeasuresA 5‐point Likert scale to evaluate the diagnostic utility of the ultrasound image.ResultsThe modal Likert scores for rater 1 were as follows: piriformis muscle = 4; piriformis tendon = 4; superior gemellus muscle = 3; obturator internus muscle = 4; obturator internus tendon = 4; inferior gemellus muscle = 4; quadratus femoris muscle = 4. The modal scores for rater 2 were: piriformis muscle = 4; piriformis tendon = 3; superior gemellus muscle = 4; obturator internus muscle = 3; obturator internus tendon = 4; inferior gemellus muscle = 3; quadratus femoris muscle = 4.ConclusionDynamic ultrasonography may be useful to image the hip deep external rotator musculature for diagnostic purposes and therefore aid in the evaluation of gluteal pain and sciatica. Future work should investigate the reliability and validity of ultrasonography in the evaluation of pathology of these muscles.

Journal of Clinical Ultrasound, 2010

Background. To use sonography to measure the cross-sectional area (CSA) of the greater occipital ... more Background. To use sonography to measure the cross-sectional area (CSA) of the greater occipital nerve (GON) and the adjacent obliquus capitis inferior muscle (OCI) in normal subjects. Methods. Data from 30 asymptomatic subjects between the ages of 22 and 35 were collected. CSA and circumference of the GON and CSA of OCI were measured using sonography. Interexaminer reliability analysis was performed using the intraclass correlation coefficient. Results. The CSA of the GON and OCI were 2 mm 2 6 1 mm 2 and 1.86 cm 2 6 0.51 cm 2 , respectively. The average circumference of the GON was 4.8 mm 6 1.3 mm. The interexaminer reliability of the measurements was excellent with intraclass correlation coefficient coefficients of 0.91, 0.84, and 0.73 for the GON CSA, GON circumference, and OCI CSA, respectively. Conclusion. We report the normal values of the CSA of the GON and OCI. Knowledge of these normal values may facilitate the diagnosis of GON entrapment and provide outcome measures in therapeutic interventions. V V

Journal of Clinical Ultrasound, Jun 8, 2011

We present a case of a solitary plantar fibroma with unique sonographic features with MRI and pat... more We present a case of a solitary plantar fibroma with unique sonographic features with MRI and pathologic correlation. A 25‐year‐old woman presented with a left foot mass that interfered with her gait. Sonography demonstrated a well‐circumscribed, 32 mm × 27 mm × 14 mm subcutaneous mass with heterogeneous echogenicity. Unique sonographic characteristics included posterior acoustic enhancement, cystic components, and mild intratumoral hypervascularity. MRI confirmed the sonographic findings. Surgical excision was performed without complication. A pathologic diagnosis of fibroma with myxoid degeneration and cyst formation was made. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound 40:114–112, 2012

Journal of chiropractic medicine, 2019

Objective Spondylolysis is 1 of the most common sources of low back pain in children and adolesce... more Objective Spondylolysis is 1 of the most common sources of low back pain in children and adolescents; however, there is still a great deal of confusion in regard to etiology, clinical presentation, and diagnostic imaging findings. It is imperative for clinicians to recognize that persistent low back pain is strongly indicative of spondylolysis, especially in high-performance athletes. This case series demonstrates a comprehensive diagnostic spectrum of spondylolysis and its treatment in 2 competitive adolescent cheerleaders. Clinical Features In case 1, a 12-year-old female competitive cheerleader presented with a gradual onset of subacute low back pain. Comprehensive clinical examination indicated imaging studies that identified bilateral L5 grade 1 stress reaction, consisting of neural arch bone marrow edema (BME). Treatment included spinal adjustments, rehabilitation, and myofascial therapy. In case 2, 15-year-old female competitive cheerleader presented with insidious chronic lo...

Neurogastroenterology & Motility, 2021

BackgroundAssessment of gastric function in humans has relied on modalities with varying degrees ... more BackgroundAssessment of gastric function in humans has relied on modalities with varying degrees of invasiveness, which are usually limited to the evaluation of single aspects of gastric function, thus requiring patients to undergo a number of often invasive tests for a full clinical understanding. Therefore, the development of a non‐invasive tool able to concurrently assess multiple aspects of gastric function is highly desirable for both research and clinical assessments of gastrointestinal (GI) function. Recently, technological advances in magnetic resonance imaging (MRI) have provided new tools for dynamic (or “cine”) body imaging. Such approaches can be extended to GI applications.MethodsIn the present work, we propose a non‐invasive assessment of gastric function using a four‐dimensional (4D, volumetric cine imaging), free‐breathing MRI sequence with gadolinium‐free contrast enhancement achieved through a food‐based meal. In healthy subjects, we successfully estimated multiple...