Characteristic Pain Intensity Research Articles

Headache Attributed to Temporomandibular Disorders: Axis I and II Findings According to the Diagnostic Criteria for Temporomandibular Disorders.

To analyze Axis I and II findings of patients diagnosed as having painful temporomandibular disorder (TMD) with headache attributed to TMD (HAattrTMD) in order to assess whether HAattrTMD is associated with a specific Axis I and II profile suggestive of the central sensitization process. This retrospective study included 220 patients with painful TMD divided into those with (n = 60) and those without (n = 160) HAattrTMD, and the patients were compared for Axis I and II results according to the Diagnostic Criteria for TMD (DC/TMD). A P value < .05 was considered statistically significant. A total of 27.3% of the patients received a diagnosis of HAattrTMD. Myofascial pain with referral was significantly more common in the HAattrTMD group (P < .001), while local myalgia was significantly more common in the non-HAattrTMD group (P < .001). Characteristic pain intensity was significantly higher in the HAattrTMD group (P = .003), which also showed significantly higher levels of depression (P = .002), nonspecific physical symptoms (P = .004), graded chronic pain (P = .008), and pain catastrophizing (P = .013). Nonspecific physical symptoms were positively associated with HAattrTMD (odds ratio [OR] = 1.098, 95% CI = 1.006 to 1.200, P = .037). Local myalgia was negatively associated with HAattrTMD (OR = .295, 95% CI = 0.098 to 0.887, P = .030). Painful TMD patients who report headache in the temple area and are diagnosed as having local myalgia rather than myofascial pain with referral probably do not have HAattrTMD. The diagnosis of HAattrTMD may point to a central sensitization process and possible current/future chronic TMD conditions.

Treatment responses in chronic temporomandibular patients depending on the treatment modalities and frequency of parafunctional behaviour.

(i) To evaluate the effect of three different interventions on treatment outcomes and (ii) to determine how the frequency of oral parafunction influences the effectiveness of the different therapeutic modalities. Forty-five participants were randomly assigned into three treatment groups [physical therapy (PT), stabilisation splint (SS) and control therapy (CT)]. According to Oral Behavior Checklist score, participants were divided into "high-frequency parafunction" (HFP) and low-frequency parafunction" (LFP) group. Primary (spontaneous pain and characteristic pain intensity) and secondary outcomes (range of mouth opening, anxiety symptoms, quality of life, perceived stress and global functional limitation) were evaluated during six-month treatment period. Participants in PT group showed a significant reduction in characteristic pain intensity (p=.047, η2 =0.243) when compared to SS and CT group, but significant improvement in spontaneous pain was found in all treatment groups. Patients treated with PT and SS exhibited significantly stronger improvement in pain-free mouth opening than patients in CT group (3rd month: p=.037, η2=0.258; 6th month: p=.005, η2 =0.383). Within-group analyses showed significant decrease of perceived stress, anxiety symptoms and global functional limitation only in PT group over a six-month treatment period. Participants with HFP presented significantly greater levels of anxiety (3rd month: p=.009, η2 =0.275; 6th month: p=.041, η2 =0.176) than participants with LFP. Within-group analyses, however, showed significant improvement of anxiety, but also the decrease of perceived stress and improvement of global limitation for the HFP group but not for the LFP group. Although no treatment can be marked as superior in terms of spontaneous pain relief, PT was more effective when observing relief of characteristic pain intensity. In HFP group the reduction of anxiety, stress and functional limitation was present regardless of the applied therapy. ClinicalTrials.gov NCT04694274. Registered on 01/04/2021.

Polymorphisms in the HTR2A and HTR3A Genes Contribute to Pain in TMD Myalgia.

Background: The aim of this study was to investigate if single nucleotide polymorphisms (SNPs) related to monoaminergic neurotransmission, in particular the serotonergic pathway, contribute to pain perception in patients with temporomandibular disorder (TMD) myalgia and if there is a correlation to jaw function as well as psychosocial factors such as stress, anxiety and depression.Materials and Methods: One hundred and seventeen individuals with TMD myalgia were included. A venous blood or saliva sample was taken for genetic analyses and genotyped regarding HTR2A (rs9316233) HTR3A (rs1062613), HTR3B (rs1176744), SERT (5-HTTLPR) and COMT (rs4680). A clinical examination according to Diagnostic Criteria for TMD (DC/TMD) was performed and axis II data (psychosocial factors) were compared between participants with different genotypes for each gene using Kruskall–Wallis test. The characteristic pain intensity (CPI) was tested for correlations to scores for the Perceived Stress Scale, Generalized Anxiety Disorder, and Patient Health Questionnaires using Spearman's rank correlation test with Bonferroni correction for multiple testing. To further explore data factor analysis was performed to identify latent factors associated to the outcome variables.Results: Participants carrying at least one copy of the rare allele of the HTR2A (rs9316233) and HTR3A (rs1062613) had higher CPI compared with the participants with the homozygous common genotype (P = 0.042 and P = 0.024, respectively). Correlation analyses showed several significant positive correlations between CPI on one hand, and self-reported psychosocial distress and jaw function on the other hand for several genotypes that mostly were weak to moderate. The factor analysis identified two latent variables. One was positively correlated to the HTR3B gene, jaw function and self-reported parafunctions, and the other was positively correlated to psychological distress and negatively correlated to SERT.Conclusion: Taken together, the polymorphism rs1062613 in the HTR3A gene contributes to pain intensity in TMD myalgia. This together with positive interactions between pain variables and psychological factors in genotypes strengthens that pain and psychological distress are related. Further research is needed to explore this as well as the influence of gene-to-gene interactions on pain and psychological distress.

Screening Survey of Pain Intensity in Patients with Temporomandibular Disorders

Objective: Pain tends to be the chief complaint in patients suffering temporomandibular disorders (TMD). Previous studies on pain and psychosocial factors have reported on the relationship between presence of pain and mental disorders. To date, however, few studies have addressed the relationship between intensity of pain and psychosocial factors. In this study, we investigated the relationship between intensity of pain and age, gender, palpation scores (PPS), tendencies toward depression, anxiety, and somatization, and oral parafunctional habits. Methods: This screening survey encompassed 104 patients (70 women and 34 men; mean age of 46.1 ± 19.3) who visited our clinic. We gathered the following data: age; gender; PPS included in Axis I diagnosis; and characteristic pain intensity (CPI), depression, anxiety, somatization, and oral parafunctional habits (assessed by the Oral Behavior Checklist) included in Axis II diagnosis. Based on the results of CPI, we divided patients into two groups: those experiencing low pain intensity (LP group) and those experiencing high pain intensity (HP group). The statistically significant level was set to below 5%. IBM SPSS Statistics V25 was used to perform all statistical analyses. Results: We observed no gender differences between LP and HP groups. The HP group included significantly more patients with higher scores for depression, anxiety, somatization, and oral parafunctional habits than the LP group. While no gender differences were observed in CPI, depression, anxiety, somatization, and oral parafunctional habits were significantly more common in women than in men. We observed no differences in age or PPS between the LP and HP groups. However, scores for depression, anxiety, somatization, and oral parafunctional habits were significantly higher in the HP group than in the LP group. We performed multiple regression analysis using the CPI score as the dependent variable and scores for depression, anxiety, somatization, and oral parafunctional habits as independent variables in both the LP and the HP groups. We identified no significant predictors for the LP group, but extracted depression as a significant predictor in the HP group. On evaluating the correlation of PPS with depression, anxiety, somatization, and oral parafunctional habits in both the LP and the HP groups, we found no correlation between the PPS and the seven-item generalized anxiety disorder (GAD-7) scale in the LP group but identified a significant correlation between the PPS and GAD-7 scores in the HP group. Moreover, the correlation coefficient between the patient health questionnaire (PHQ)-9 and GAD-7 scores was higher in the HP group than in the LP group. Conclusion: In those reporting more intense pain, we found a stronger correlation among psychological factors in patients diagnosed with TMD. Greater tendency toward depression was directly associated with pain intensity. The results point to the need to consider differences in psychosocial factors associated with pain intensity when treating TMD.

Screening Survey of Pain Intensity in Patients with Temporomandibular Disorders

Objective: Pain tends to be the chief complaint in patients suffering temporomandibular disorders (TMD). Previous studies on pain and psychosocial factors have reported on the relationship between presence of pain and mental disorders. To date, however, few studies have addressed the relationship between intensity of pain and psychosocial factors. In this study, we investigated the relationship between intensity of pain and age, gender, palpation scores (PPS), tendencies toward depression, anxiety, and somatization, and oral parafunctional habits. Methods: This screening survey encompassed 104 patients (70 women and 34 men; mean age of 46.1 ± 19.3) who visited our clinic. We gathered the following data: age; gender; PPS included in Axis I diagnosis; and characteristic pain intensity (CPI), depression, anxiety, somatization, and oral parafunctional habits (assessed by the Oral Behavior Checklist) included in Axis II diagnosis. Based on the results of CPI, we divided patients into two groups: those experiencing low pain intensity (LP group) and those experiencing high pain intensity (HP group). The statistically significant level was set to below 5%. IBM SPSS Statistics V25 was used to perform all statistical analyses. Results: We observed no gender differences between LP and HP groups. The HP group included significantly more patients with higher scores for depression, anxiety, somatization, and oral parafunctional habits than the LP group. While no gender differences were observed in CPI, depression, anxiety, somatization, and oral parafunctional habits were significantly more common in women than in men. We observed no differences in age or PPS between the LP and HP groups. However, scores for depression, anxiety, somatization, and oral parafunctional habits were significantly higher in the HP group than in the LP group. We performed multiple regression analysis using the CPI score as the dependent variable and scores for depression, anxiety, somatization, and oral parafunctional habits as independent variables in both the LP and the HP groups. We identified no significant predictors for the LP group, but extracted depression as a significant predictor in the HP group. On evaluating the correlation of PPS with depression, anxiety, somatization, and oral parafunctional habits in both the LP and the HP groups, we found no correlation between the PPS and the seven-item generalized anxiety disorder (GAD-7) scale in the LP group but identified a significant correlation between the PPS and GAD-7 scores in the HP group. Moreover, the correlation coefficient between the patient health questionnaire (PHQ)-9 and GAD-7 scores was higher in the HP group than in the LP group. Conclusion: In those reporting more intense pain, we found a stronger correlation among psychological factors in patients diagnosed with TMD. Greater tendency toward depression was directly associated with pain intensity. The results point to the need to consider differences in psychosocial factors associated with pain intensity when treating TMD.

Lower Back Complaints in Adolescent Competitive Alpine Skiers: A Cross-Sectional Study

Background: Little is known about lower back complaints in adolescent competitive alpine skiers. This study assessed their prevalence and severity (i.e., intensity and disability) with respect to sex, category, discipline preference, and training attributes. Methods: 188 competitive skiers aged 15 to 18 years volunteered in this study. Data collection included (i) questions on participants’ demographics, sports exposure, discipline preferences, and other sports-related practices; (ii) the Nordic Musculoskeletal Questionnaire on lower back complaints; and (iii) the Graded Chronic Pain Scale. Results: As many as 80.3% and 50.0% of all skiers suffered from lower back complaints during the last 12 months and 7 days, respectively. A total of 50.7% reported their complaints to be attributable to slalom skiing, and 26% to giant slalom. The majority of complaints were classified as low intensity/low disability (Grade I, 57.4%) and high intensity/low disability complaints (Grade II, 21.8%). The Characteristic Pain Intensity was found to be significantly related to the skiers’ years of sports participation, number of competitions/season, and number of skiing days/season. Conclusion: This study further supports the relatively high magnitudes of lower back-related pain in adolescent competitive alpine skiers, with a considerable amount of high intensity (but low disability) complaints, and training attributes being a key driver.

Internet-Based Multimodal Pain Program With Telephone Support for Adults With Chronic Temporomandibular Disorder Pain: Randomized Controlled Pilot Trial.

BackgroundChronic pain from temporomandibular disorders remains an undertreated condition with debate regarding the most effective treatment modalities.ObjectiveThe aim of the study was to investigate the treatment effect of an internet-based multimodal pain program on chronic temporomandibular disorder pain and evaluate the feasibility of a larger randomized controlled trial.MethodsAn unblinded randomized controlled pilot trial was conducted with 43 participants (34 females, 9 males; median age 27, IQR 23-37 years) with chronic temporomandibular pain. Participants were recruited within the Public Dental Health Service and randomized to intervention (n=20) or active control (n=23). The intervention comprised a dentist-assisted internet-based multimodal pain program with 7 modules based on cognitive behavior therapy and self-management principles. The control group received conventional occlusal splint therapy. Primary outcomes included characteristic pain intensity, pain-related disability, and jaw functional limitation. Secondary outcomes were depression, anxiety, catastrophizing, and stress. Outcomes were self-assessed through questionnaires sent by mail at 3 and 6 months after treatment start. Feasibility evaluation included testing the study protocol and estimation of recruitment and attrition rates in the current research setting.ResultsOnly 49% of participants (21/43) provided data at the 6-month follow-up (internet-based multimodal pain program: n=7; control: n=14). Of the 20 participants randomized to the internet-based multimodal pain program, 14 started treatment and 8 completed all 7 modules of the program. Between-group analysis showed no significant difference for any outcome measure at 3- or 6-month follow-up—characteristic pain intensity (3 months: P=.58; 6 months: P=.41), pain-related disability (3 months: P=.51; 6 months: P=.12), jaw functional limitation (3 months: P=.45; 6 months: P=.90), degree of depression (3 months: P=.64; 6 months: P=.65), anxiety (3 months: P=.93; 6 months: P=.31), stress (3 months: P=.66; 6 months: P=.74), or catastrophizing (3 months: P=.86; 6 months: P=.85). Within-group analysis in the internet-based multimodal pain program group showed a significant reduction in jaw functional limitation score at the 6-month follow-up compared to baseline (Friedman: χ2=10.2, P=.04; Wilcoxon: z=–2.3, P=.02). In the occlusal splint group, jaw function limitation was also reduced at the 6-month follow-up (Friedman: χ2=20.0, P=.045; Wilcoxon: z=–2.3, P=.02), and there was a reduction in characteristic pain intensity at the 3- and 6-month follow-up (Friedman: χ2=25.1, P=.01; Wilcoxon 3 months: z=–3.0, P=.003; Wilcoxon 6 months: z=-3.3, P=.001).ConclusionsThis study was not able to demonstrate a difference in treatment outcome between an internet-based multimodal pain program and occlusal splint therapy in patients with chronic temporomandibular pain. However, the findings suggested that the internet-based multimodal pain program improves jaw function. The results also confirmed the treatment effect of occlusal splint therapy for chronic temporomandibular pain. Furthermore, because of the high attrition rate, this pilot study showed that a randomized controlled trial with this design is not feasible.Trial RegistrationClinicalTrials.gov NCT04363762; https://clinicaltrials.gov/show/NCT04363762

Motor Control Stabilisation Exercise for Patients with Non-Specific Low Back Pain: A Prospective Meta-Analysis with Multilevel Meta-Regressions on Intervention Effects.

Low-to-moderate quality meta-analytic evidence shows that motor control stabilisation exercise (MCE) is an effective treatment of non-specific low back pain. A possible approach to overcome the weaknesses of traditional meta-analyses would be that of a prospective meta-analyses. The aim of the present analysis was to generate high-quality evidence to support the view that motor control stabilisation exercises (MCE) lead to a reduction in pain intensity and disability in non-specific low back pain patients when compared to a control group. In this prospective meta-analysis and sensitivity multilevel meta-regression within the MiSpEx-Network, 18 randomized controlled study arms were included. Participants with non-specific low back pain were allocated to an intervention (individualized MCE, 12 weeks) or a control group (no additive exercise intervention). From each study site/arm, outcomes at baseline, 3 weeks, 12 weeks, and 6 months were pooled. The outcomes were current pain (NRS or VAS, 11 points scale), characteristic pain intensity, and subjective disability. A random effects meta-analysis model for continuous outcomes to display standardized mean differences between intervention and control was performed, followed by sensitivity multilevel meta-regressions. Overall, 2391 patients were randomized; 1976 (3 weeks, short-term), 1740 (12 weeks, intermediate), and 1560 (6 months, sustainability) participants were included in the meta-analyses. In the short-term, intermediate and sustainability, moderate-to-high quality evidence indicated that MCE has a larger effect on current pain (SMD = −0.15, −0.15, −0.19), pain intensity (SMD = −0.19, −0.26, −0.26) and disability (SMD = −0.15, −0.27, −0.25) compared with no exercise intervention. Low-quality evidence suggested that those patients with comparably intermediate current pain and older patients may profit the most from MCE. Motor control stabilisation exercise is an effective treatment for non-specific low back pain. Sub-clinical intermediate pain and middle-aged patients may profit the most from this intervention.

The impact of fascia iliaca compartment block on chronic postsurgical pain in patients undergoing hip fracture repair

Study objectiveChronic postsurgical pain (CPSP), i.e. pain persisting >3 months, may appear after any type of surgery. There is a paucity of literature addressing CPSP development after hip fracture repair and the impact of any analgesic intervention on the development of CPSP in patients after hip fracture surgery. This study is the first aiming to examine the impact of ultrasound-guided fascia iliaca compartment block (USG FICB) on the development of CPSP after hip fracture repair. DesignProspective randomized study. SettingOperating room. Patients182 patients scheduled for hip fracture surgery. InterventionsPatients were randomized to receive a USG FICB (FICB group) or a sham saline injection (sham FICB group), twenty minutes before positioning for spinal anesthesia. MeasurementsThe hip – related characteristic pain intensity (CPI) at 3- months post-surgery was the primary outcome measure. Presence and severity of hip-related pain at 3- and 6-months post-surgery, numeric rating pain scale (NRS) scores at 6, 24, 36, 48 postoperative hours, total 24-hour tramadol PCA administration and timing of the first tramadol dose, were documented as well. Main resultsFICB group presented with lower CPI scores 3- months postoperatively (p < 0.01), as well as lower percentage of patients with high-grade CPSP, 3 and 6 months postoperatively (p < 0.001). FICB group also showed significantly lower NRS scores in all instances, lower total 24 – hour tramadol consumption and higher mean time to first tramadol dose (p < 0.05). The overall sample of 182 patients reported a considerably high incidence of hip –related CPSP (60% at 3 months, 45% at 6 months). ConclusionsUSG FICB in the perioperative setting may reduce the incidence, intensity and severity of CPSP at 3 and 6 months after hip fracture surgery, providing safe and effective postoperative analgesia.

Comparison of acupuncture on specific and non-specific points for the treatment of painful temporomandibular disorders: A randomised controlled trial.

The aim of this single-centre, two-arm, parallel-group, double-blinded, randomised controlled trial was to investigate the disputed specific effectiveness of acupuncture by comparing acupuncture on specific and non-specific points among patients with non-chronic, painful TMDs. Following predefined eligibility criteria, 49 consecutive patients of both sexes were recruited to the study. All subjects were diagnosed with a non-chronic (Graded Chronic Pain Scale grade <3) painful TMD, as assessed using the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD). Patients were randomly assigned to group A (acupuncture on specific points) or group B (acupuncture on non-specific points) after the initial examination (T0). Both acupuncture treatment sessions were conducted by a trained dentist once a week for four weeks. The examination was repeated five weeks (T5) after T0 by one calibrated examiner who was unaware of the study groups. Characteristic pain intensity (CPI) was evaluated as the main outcome criterion and compared between times and treatment groups by means of non-parametric tests (significance level set at P=.05). Secondary outcomes comprised the maximum corrected active mouth-opening without pain (MAO); patients' expectations regarding acupuncture treatment and pain development; depressivity; and oral health-related quality of life (OHRQoL). A total of 41 patients (38 female) successfully completed the study (mean age: 40.17±16.61). The two groups did not differ significantly at any time in terms of age and CPI. However, CPI was significantly (P<.05) lower at T5 than at T0 for both groups (29.66 and 30.35% lower in group A and group B, respectively). An increase in MAO was observed at T5 for both groups but was significant for group B only (P=.016). All patients had positive expectations of acupuncture therapy, and the two groups did not differ significantly at T5 with regard to the extent to which their expectations had been fulfilled by the treatment (P=.717). Comparison of T0 and T5 showed a statistically significant reduction of depressivity for group A (P=.0205), but no significant change for group B (P=.329). At T5, OHRQoL had improved significantly for both groups (group A, P=.018; group B, P<.001) compared with at T0. Acupuncture on both specific and non-specific points reduces the non-dysfunctional pain of TMD patients. The effect of acupuncture on painful TMD cannot be attributed to the specific point selection.

&lt;p&gt;Stress and Self-Efficacy as Long-Term Predictors for Chronic Low Back Pain: A Prospective Longitudinal Study&lt;/p&gt;

PurposePsychosocial variables are known risk factors for the development and chronification of low back pain (LBP). Psychosocial stress is one of these risk factors. Therefore, this study aims to identify the most important types of stress predicting LBP. Self-efficacy was included as a potential protective factor related to both, stress and pain.Participants and MethodsThis prospective observational study assessed n = 1071 subjects with low back pain over 2 years. Psychosocial stress was evaluated in a broad manner using instruments assessing perceived stress, stress experiences in work and social contexts, vital exhaustion and life-event stress. Further, self-efficacy and pain (characteristic pain intensity and disability) were assessed. Using least absolute shrinkage selection operator regression, important predictors of characteristic pain intensity and pain-related disability at 1-year and 2-years follow-up were analyzed.ResultsThe final sample for the statistic procedure consisted of 588 subjects (age: 39.2 (±13.4) years; baseline pain intensity: 27.8 (±18.4); disability: 14.3 (±17.9)). In the 1-year follow-up, the stress types “tendency to worry”, “social isolation”, “work discontent” as well as vital exhaustion and negative life events were identified as risk factors for both pain intensity and pain-related disability. Within the 2-years follow-up, Lasso models identified the stress types “tendency to worry”, “social isolation”, “social conflicts”, and “perceived long-term stress” as potential risk factors for both pain intensity and disability. Furthermore, “self-efficacy” (“internality”, “self-concept”) and “social externality” play a role in reducing pain-related disability.ConclusionStress experiences in social and work-related contexts were identified as important risk factors for LBP 1 or 2 years in the future, even in subjects with low initial pain levels. Self-efficacy turned out to be a protective factor for pain development, especially in the long-term follow-up. Results suggest a differentiation of stress types in addressing psychosocial factors in research, prevention and therapy approaches.

Oral splints for patients with temporomandibular disorders or bruxism: a systematic review and economic evaluation

Splints are a non-invasive, reversible management option for temporomandibular disorders or bruxism. The clinical effectiveness and cost-effectiveness of splints remain uncertain. The objectives were to evaluate the clinical effectiveness and cost-effectiveness of splints for patients with temporomandibular disorders or bruxism. This evidence synthesis compared (1) all types of splint versus no/minimal treatment/control splints and (2) prefabricated versus custom-made splints, for the primary outcomes, which were pain (temporomandibular disorders) and tooth wear (bruxism). Four databases, including MEDLINE and EMBASE, were searched from inception until 1 October 2018 for randomised clinical trials. The searches were conducted on 1 October 2018. Cochrane review methods (including risk of bias) were used for the systematic review. Standardised mean differences were pooled for the primary outcome of pain, using random-effects models in temporomandibular disorder patients. A Markov cohort, state-transition model, populated using current pain and Characteristic Pain Intensity data, was used to estimate the incremental cost-effectiveness ratio for splints compared with no splint, from an NHS perspective over a lifetime horizon. A value-of-information analysis identified future research priorities. Fifty-two trials were included in the systematic review. The evidence identified was of very low quality with unclear reporting by temporomandibular disorder subtype. When all subtypes were pooled into one global temporomandibular disorder group, there was no evidence that splints reduced pain [standardised mean difference (at up to 3 months) -0.18, 95% confidence interval -0.42 to 0.06; substantial heterogeneity] when compared with no splints or a minimal intervention. There was no evidence that other outcomes, including temporomandibular joint noises, decreased mouth-opening, and quality of life, improved when using splints. Adverse events were generally not reported, but seemed infrequent when reported. The most plausible base-case incremental cost-effectiveness ratio was uncertain and driven by the lack of clinical effectiveness evidence. The cost-effectiveness acceptability curve showed splints becoming more cost-effective at a willingness-to-pay threshold of ≈£6000, but the probability never exceeded 60% at higher levels of willingness to pay. Results were sensitive to longer-term extrapolation assumptions. A value-of-information analysis indicated that further research is required. There were no studies measuring tooth wear in patients with bruxism. One small study looked at pain and found a reduction in the splint group [mean difference (0-10 scale) -2.01, 95% CI -1.40 to -2.62; very low-quality evidence]. As there was no evidence of a difference between splints and no splints, the second objective became irrelevant. There was a large variation in the diagnostic criteria, splint types and outcome measures used and reported. Sensitivity analyses based on these limitations did not indicate a reduction in pain. The very low-quality evidence identified did not demonstrate that splints reduced pain in temporomandibular disorders as a group of conditions. There is insufficient evidence to determine whether or not splints reduce tooth wear in patients with bruxism. There remains substantial uncertainty surrounding the most plausible incremental cost-effectiveness ratio. There is a need for well-conducted trials to determine the clinical effectiveness and cost-effectiveness of splints in patients with carefully diagnosed and subtyped temporomandibular disorders, and patients with bruxism, using agreed measures of pain and tooth wear. This study is registered as PROSPERO CRD42017068512. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 7. See the NIHR Journals Library website for further project information.

Relationships Between Pain, Life Stress, Sociodemographics, and Cortisol: Contributions of Pain Intensity and Financial Satisfaction

Objective The relationship between psychosocial stress and chronic pain is bidirectional. An improved understanding regarding the relationships among chronic pain, life stress, and ethnicity/race will inform identification of factors contributing to health disparities in chronic pain and improve health outcomes. This study aims to assess relationships between measures of clinical pain, life stress, sociodemographics, and salivary cortisol levels. Methods A cross-sectional analysis involving data from 105 non-Hispanic White (NHW) and non-Hispanic Black (NHB) participants aged 45–85 years old with or at risk for knee osteoarthritis. Data included sociodemographics, clinical pain, psychosocial stress, and salivary cortisol across five time points over an approximate 12-hour period. Non-parametric correlation analysis, sociodemographic group comparisons, and regression analyses were performed. Results Clinical pain and psychosocial stress were associated with salivary cortisol levels, particularly morning waking and the evening to morning awakening slope. With the inclusion of recognized explanatory variables, the Graded Chronic Pain Scale characteristic pain intensity and financial satisfaction were identified as the primary pain and psychosocial measures associated with cortisol levels. Sociodemographic group differences were indicated such that NHB participants reported higher pain-related disability, higher levels of discrimination, lower financial and material satisfaction, and showed higher evening salivary cortisol levels compared to NHW participants. In combined pain and psychosocial stress analyses, greater financial satisfaction, lower pain intensity, and lower depression were associated with higher morning waking saliva cortisol levels while greater financial satisfaction was the only variable associated with greater evening to morning awakening slope. Conclusion Our findings show relationships among clinical pain, psychosocial stress, sociodemographic factors, and salivary cortisol levels. Importantly, with inclusion of recognized explanatory variables, financial satisfaction remained the primary factor accounting for differences in morning waking cortisol and evening to morning awakening cortisol slope in an ethnic/racially diverse group of middle aged and older adults with or at risk for knee osteoarthritis.

Long-term Effectiveness of Occlusal Splint Therapy Compared to Placebo in Patients with Chronic Temporomandibular Disorders.

PurposeThe aim of this study was to compare long-term effectiveness of stabilization splint (SS) with that of placebo splint (PS) in chronic TMD patients and to investigate differences in treatment outcomes based on diagnostic subgroups [disc displacement (DD)/myofascial pain (MP)].Materials and MethodsThirty-four female participants, diagnosed with chronic TMD, were classified in groups: one provided with SS and other with PS and were followed for six months. Treatment outcomes included spontaneous pain [visual analogue scale (VAS)], self-perceived quality of life (OHIP-14), pain-free maximal mouth opening (MCO), maximal mouth opening (MMO), level of perceived stress (PSS), characteristic pain intensity [graded chronic pain scale (GCPS)], and functional jaw limitation [jaw functional limitation scale (JFLS)].ResultsBaseline characteristics did not differ significantly between the two groups (p>0.05). After six months of treatment the changes in spontaneous pain and OHIP-14 scores differed significantly between treatment groups (p=0.004, p=0.02 respectively), with greater reduction in SS compared to the PS group. Pain-free maximal mouth opening did not change significantly over time, however MCO values differed significantly between the two treatment groups, with greater overall values in the SS compared to the PS group (p= 0.046), as well as between TMD subgroups, with greater overall values in MP compared to DD patients (p= 0.03). In the SS group, significant difference in JFLS categories was found between baseline and after 6 months of treatment in all except emotional and verbal expression (mastication p=0.00015; vertical jaw mobility p=0.00018). No such changes in JFLS categories were observed in the PS group.ConclusionsDuring 6-month period, SS was more effective than PS in reducing spontaneous pain and improving self-perceived quality of life and functional limitations of the lower jaw. Moreover, significantely higher values of pain-free mouth opening were observed in patients treated with stabilization splint. While placebo might be partly responsible for improving the symptoms of TMD, it seems that itcannot maintain a continual long-term positive therapeutic effect.

Moderators of Mindfulness Meditation, Cognitive Therapy, and Mindfulness-Based Cognitive Therapy for Chronic Low Back Pain: A Test of the Limit, Activate, and Enhance Model

This study examined psychosocial pain treatment moderation in a secondary analysis of a trial that compared cognitive therapy (CT), mindfulness-meditation (MM), and mindfulness-based cognitive therapy (MBCT) for chronic low back pain (CLBP). The Limit, Activate, and Enhance (LA&E) model of moderation provided a framework for testing a priori hypotheses. Adult participants (N = 69) with CLBP completed a pretreatment assessment of hypothesized moderators: pain catastrophizing, brain state as assessed by electroencephalogram, mindful observing, and nonreactivity. Outcomes were pain interference, characteristic pain intensity, physical function, and depression, assessed at pre- and post-treatment. Moderation analyses found significant interaction effects, specifically: 1) higher and lower baseline pain catastrophizing was associated with greater improvement in pain intensity in MM and MBCT, respectively; 2) higher baseline theta power was associated with greater improvement in depression in MBCT and interfered with response to CT; 3) lower baseline nonreactivity was associated with greater improvement in physical function in MM while higher nonreactivity was associated with greater improvement in MBCT. The findings support the possibility that different patients are more or less likely to benefit from various treatments. Theory-driven moderation research has the capacity to inform the development of patient-treatment matching algorithms to optimize outcome. PerspectiveThis study presents preliminary findings from theory-driven tests of the moderators of mindfulness meditation, cognitive therapy, and mindfulness-based cognitive therapy for chronic low back pain. The results of such analyses may inform the understanding of for whom various evidence-based psychosocial pain treatments may engender the most meaningful benefits.

(218) Resilience Factors may Buffer Cellular Aging in Individuals with and without Knee Pain

Telomere length, a measure of cellular aging, is negatively associated with chronic pain severity and serves as an indicator of overall system functioning. While psychological resilience factors such as optimism, acceptance, positive affect and active coping have been associated with lower levels of clinical pain and greater physical functioning, it is unknown whether resilience may buffer against telomere shortening in individuals with chronic pain. Additionally, a broader conceptualization of resilience that includes biobehavioral and social factors may improve our understanding of the relationship between resilience, chronic pain, and health outcomes. We hypothesized that: 1) psychological resilience factors would be associated with longer telomere length, and 2) a combined biobehavioral/psychosocial composite would strengthen the association. A total of 79 individuals (34% Male, 66% Female) with/without knee pain completed psychological/psychosocial resilience (optimism, affect, active coping, perceived stress and social support) and biobehavioral measures (smoking status, and waist/hip ratio). Clinical cut points for each measure were established based on previously published normative data or means where applicable and used to create summative psychological (optimism, affect, coping, perceived stress) and biobehavioral/psychosocial (psychological resilience + social support, smoking, waist/hip ratio), resilience composites. Blood samples were collected and telomere length determined. Regression analyses were completed with sex, race, age, and GCPS characteristic pain intensity as additional predictors. A positive relationship emerged such that greater psychological resilience and biobehavioral/psychosocial resilience were associated with longer telomeres (p = .0295 and p = .0116, respectively). When compared with psychological resilience alone, the biobehavioral/psychosocial composite was significantly more predictive of telomere length than the psychological resilience composite (p

Resilience factors may buffer cellular aging in individuals with and without chronic knee pain.

Telomere length, a measure of cellular aging, is inversely associated with chronic pain severity. While psychological resilience factors (e.g., optimism, acceptance, positive affect, and active coping) are associated with lower levels of clinical pain and greater physical functioning, it is unknown whether resilience may buffer against telomere shortening in individuals with chronic pain. Additionally, a broader conceptualization of resilience that includes social and biobehavioral factors may improve our understanding of the relationship between resilience, chronic pain, and health outcomes. In individuals with and without chronic knee pain, we investigated whether (1) psychological resilience would be positively associated with telomere length and if (2) a broader conceptualization of resilience including social and biobehavioral factors would strengthen the association. Seventy-nine adults, 45 to 85 years of age, with and without knee pain completed demographic, health, clinical pain, psychological, social, and biobehavioral questionnaires. Resilience levels were determined by summing the total number of measures indicating resilience based on published clinical ranges and norms. Blood samples were collected, and telomere length was determined. In regression analyses controlling for sex, race, age, and characteristic pain intensity, greater psychological resilience and psychosocial/biobehavioral resilience were associated with longer telomeres (p = .0295 and p = .0116, respectively). When compared, psychosocial/biobehavioral resilience was significantly more predictive of telomere length than psychological resilience (p < .0001). Findings are promising and encourage further investigations to enhance understanding of the biological interface of psychosocial and biobehavioral resilience factors in individuals with musculoskeletal chronic pain conditions.

The behavioral inhibition and activation systems and function in patients with chronic pain

BackgroundThe behavioral inhibition system (BIS) and behavioral activation system (BAS) are two neuropsychological systems hypothesized to underlie response to cues signaling potential reward and punishment, respectively, also in patient responses to chronic pain. ObjectivesThe aim of this study was to test these hypotheses by evaluating the relative contributions of BIS and BAS to the prediction of function in sample individuals with chronic musculoskeletal pain. Methods253 participants were administered a battery of questionnaires. Two linear regression analyses were performed to evaluate the contributions of BIS and BAS to the prediction of impairment and psychological function, and to determine if either or both moderated the effects of pain intensity on function. ResultsAfter controlling for demographic factors, pain diagnosis, and characteristic pain intensity, BIS contributed significantly and independently to the prediction of pain-related physical impairment and psychological function. BAS activity had a significant and direct effect on psychological function only. No moderating effects of BIS or BAS on the association between pain intensity and function were identified. DiscussionThe findings are generally consistent with a BIS-BAS 2-factor model of chronic pain, suggesting BIS and BAS activity as potential targets for chronic pain treatment.

Specific occlusal scheme for partially edentulous patients with TMD signs-preliminary report

BackgroundThe purpose of this study was to ascertain a specific occlusal scheme to reduce temporomandibular disorder signs and symptoms in the therapy of partially edentulous patients with removable partial acrylic dentures. MethodologyThirty-four partially edentulous patients who had unilateral free-end saddle in the mandible along with a history of TMD signs and symptoms were prosthodontically treated, fitting them with new removable acrylic partial dentures (NRAPD) for their lower jaws. The new and specific occlusal scheme was established with tendencies to restrict mandibular functional movements partly; this proved somewhat awkward, but had the benefit of allowing continued unrestricted occlusal contacts in grinding and functional movements. RDC-TMD clinical examinations and answers to questionnaires were provided for the old dentures, and nine weeks after delivery of NRAPD. ResultsAfter the NRAPD treatment, the patients’ painful symptoms were reduced and their mandibular movements were corrected. Statistically significant changes were obtained for the opening pattern (Pearson Chi2=18.609; P=0001), the maximum unassisted opening (F=3.507; P=0.052), the maximum assisted opening (F=4.299; P=0.042), and the corrected position of midline (F=5.893; P=0.018) before and after the NRAPD treatment. Additionally, significant changes were seen for questions on changes in facial pain to ability to work (Pearson Chi2=26.921; P=0.00), jaws click or pop when they open, close, or chew (Pearson Chi2=6.227; P=0.013), jaws make a grating or grinding noise when they open, close, or chew (Pearson Chi2=9.273; P=0.002), and bites feel unusual (Pearson Chi2=13.170; P=0.000). Characteristic pain intensity (F=19.311; P=0.000), points for disability score (F=9.830; P=0.003), disability points (F=10.208; P=0.002), and chronic pain grade (F=7.961; P=0.006) were significantly different in terms of the effects of the NRAPD therapy. ConclusionSpecific occlusal scheme in NPARD promoted improvement in the therapy.

Predictors of Long-Term Temporomandibular Disorder Pain Intensity: An 8-Year Cohort Study.

To investigate, in individuals with pain-related temporomandibular disorder (TMD), the association of long-term pain intensity with baseline health-related quality of life (HRQoL) and jaw functional limitation. Of 513 cases with baseline pain-related TMD (masticatory muscle and/or temporomandibular joint [TMJ] pain), 273 were reevaluated after 8 years, and 258 of them had complete baseline data for Jaw Functional Limitation Scale (JFLS) scores and HRQoL measured by the Physical Component Summary (PCS) and Mental Component Summary (MCS) scores of the 12-item Short Form Health Survey and follow-up data for Characteristic Pain Intensity (CPI) from the Graded Chronic Pain Scale. Secondary analyses of existing data quantified the effects of primary (PCS, MCS) and secondary (JFLS) predictors on follow-up CPI by using multivariable linear regression. Sensitivity analyses considered differences between the included participants (n = 258) and those who were not included (n = 255) by using inverse probability weighting. Interactions of baseline predictors with age, sex, and baseline CPI were evaluated using multivariable linear regression. The score for baseline PCS, but not MCS or JFLS, was associated with follow-up CPI (P = .012). One standard deviation (SD = 9.0)-higher baseline PCS score predicted an overall 3.2-point-lower follow-up CPI (95% confidence interval -5.8 to -0.7) after adjusting for age, sex, MCS, JFLS, and baseline CPI scores. However, the effect of PCS score was not uniform: the association between PCS and follow-up CPI scores was statistically significant for participants with baseline CPI ≥ 51.3/100 and clinically significant for participants with baseline CPI ≥ 68.7/100. Adjustment for TMD treatments and sensitivity analyses had negligible effect. In participants with moderate to severe baseline TMD pain intensity, higher baseline physical HRQoL predicted lower TMD pain intensity at 8 years follow-up. PCS score could contribute to a multifactorial long-term TMD pain prediction model.