Daily pain coping among patients with chronic temporomandibular disorder pain: an electronic diary study.

AIMS: To describe patients' daily coping with the pain of chronic temporomandibular disorders (TMD), the conservative treatment received, and the self-care strategies used, and to examine the relationships between these strategies and daily pain intensity, activity interference, and jaw use limitations. METHODS: TMD clinic patients (n = 137, 88% women) completed electronic diary measures of pain, interference, jaw use limitations, and use of 20 strategies 3 times daily for 2 weeks. RESULTS: Reliability and validity were demonstrated for 4 scales of related coping items: cognitive coping, relaxation, activity reduction, and emotional support. Average scores were higher on the relaxation and activity reduction scales than on the cognitive coping and emotional support scales. Among the coping items not included in the scales, "did something to try to reduce pain" (direct action) was endorsed most frequently (reported in a median of 74% of interviews). Heat, cold, and seeking spiritual support were used least (< or = 5%). At times of increased pain, patients were more likely to use almost all types of strategies. Pain intensity was associated strongly with concurrent activity interference and jaw use limitations. When the design controlled for pain intensity, activity reduction and seeking emotional support were associated positively within-subjects with interference and jaw use limitations. CONCLUSION: TMD clinic patients use a variety of treatment, self-care, and coping strategies to contend with daily pain. Inquiring about a broad range of strategies might help clinicians better understand how individual patients approach pain management. Research is needed to examine whether decreasing activity reduction and emotional support coping results in improved outcomes.

Self-efficacy is associated with pain, functioning, and coping in patients with chronic temporomandibular disorder pain.

AIMS: To examine the psychometric characteristics of a measure of self-efficacy for managing temporomandibular disorders (TMD) and to determine whether scores on this measure were related to pain, disability, and psychological distress in patients with chronic TMD pain. METHODS: Patients seeking treatment for chronic TMD pain (n = 156, 87% female, mean age = 37 years) completed measures assessing pain, disability, mental health, pain-coping strategies, and self-efficacy for managing their pain. RESULTS: The self-efficacy measure, which was adapted from arthritis research, demonstrated good psychometric characteristics (Cronbach's alpha = 0.91, minimal floor and ceiling effects, and validity). Greater self-efficacy was associated with significantly (P < .05) lower levels of pain, disability, and psychological distress. Self-efficacy remained significantly associated with disability and mental health measures even after controlling for demographic variables and pain intensity. In addition, patients with higher self-efficacy reported significantly (P < .05) greater use of an active, adaptive chronic pain-coping strategy (task persistence) and less use of a passive, maladaptive chronic pain-coping strategy (rest). CONCLUSION: Self-efficacy for managing pain appears to be important in the adjustment of patients with chronic TMD pain. Research is needed to determine whether treatments designed to increase self-efficacy improve TMD patient outcomes.

Short- and long-term efficacy of brief cognitive-behavioral therapy for patients with chronic temporomandibular disorder pain: a randomized, controlled trial.

We evaluated the short- and long-term efficacy of a brief cognitive-behavioral therapy (CBT) for chronic temporomandibular disorder (TMD) pain in a randomized controlled trial. TMD clinic patients were assigned randomly to four sessions of either CBT (n=79) or an education/attention control condition (n=79). Participants completed outcome (pain, activity interference, jaw function, and depression) and process (pain beliefs, catastrophizing, and coping) measures before randomization, and 3 (post-treatment), 6, and 12 months later. As compared with the control group, the CBT group showed significantly greater improvement across the follow-ups on each outcome, belief, and catastrophizing measure (intent-to-treat analyses). The CBT group also showed a greater increase in use of relaxation techniques to cope with pain, but not in use of other coping strategies assessed. On the primary outcome measure, activity interference, the proportion of patients who reported no interference at 12 months was nearly three times higher in the CBT group (35%) than in the control group (13%) (P=0.004). In addition, more CBT than control group patients had clinically meaningful improvement in pain intensity (50% versus 29% showed > or =50% decrease, P=0.01), masticatory jaw function (P<0.001), and depression (P=0.016) at 12 months (intent-to-treat analyses). The two groups improved equivalently on a measure of TMD knowledge. A brief CBT intervention improves one-year clinical outcomes of TMD clinic patients and these effects appear to result from specific ingredients of the CBT.

Catastrophizing is associated with clinical examination findings, activity interference, and health care use among patients with temporomandibular disorders.

AIMS: To examine whether catastrophizing is associated with clinical examination findings, pain-related activity interference, and health care use among patients with pain related to temporomandibular disorders (TMD). METHODS: Patients with TMD (n = 338; 87% female; mean age, 37 years) completed measures of pain, pain-related activity interference, health care use, and depression, and received a Research Diagnostic Criteria/ Temporomandibular Disorders (RDC/TMD) clinical examination from an oral medicine specialist. RESULTS: Catastrophizing was not significantly associated with the more objective clinical examination measures of maximum assisted jaw opening and jaw-joint sounds, but it was associated with the more subjective examination measures (unassisted opening without pain, extraoral muscle site palpation pain severity, joint site palpation pain severity) and with increased TMD-related activity interference and number of health care visits (P values for all < .01). Even after controlling for demographic variables, pain duration, and depression severity, catastrophizing remained significantly associated with extraoral muscle and joint site palpation pain severity and with activity interference and number of health care visits. CONCLUSION: TMD patients who catastrophize have higher scores on clinical examination measures reflecting more widely dispersed and severe pain upon palpation of TMD-related facial muscle and joint sites, as well as greater TMD-related activity interference and health care use. Clinicians should consider screening patients with moderate or greater TMD pain and activity interference for catastrophizing. Cognitive-behavioral interventions may help reduce pain, disability, and health care use of patients who catastrophize.

Brief cognitive-behavioral therapy for temporomandibular disorder pain: effects on daily electronic outcome and process measures.

We used patient daily electronic ratings of outcome (activity interference, pain intensity, jaw use limitations, negative mood) and process (pain-related beliefs, catastrophizing, and coping) variables to evaluate a brief cognitive-behavioral (CB) treatment for chronic temporomandibular disorder (TMD) pain. TMD clinic patients (N=158) were assigned randomly to four biweekly sessions of either CB pain management training (PMT) or an education/attention control condition [self-care management (SCM)] and were asked to complete electronic interviews three times daily for the 8-week treatment. We analyzed diary data from 126 participants who completed >50% of requested interviews for >6 weeks. Multilevel regression analyses indicated no statistically significant difference between the study groups in rate of within-subject change over time on the daily outcome measures, but consistently greater within-subject improvement in the PMT group on the daily process measures. Significantly (P<0.05) greater proportions of PMT than of SCM patients showed clinically important (>50%) improvement from weeks 1 to 8 in daily activity interference and jaw use limitations. This study is novel in its application of electronic diary methods for assessing outcome and process variables in a chronic pain treatment trial, and supports the feasibility and utility of such methods. The brief CB treatment was efficacious in decreasing catastrophizing and increasing perceived control over pain, and in improving activity interference and jaw use limitations for a subgroup of patients. Longer-term follow-ups are ongoing to determine if there is an impact on outcomes over time.

Electronic diary assessment of pain-related variables: is reactivity a problem?

UNLABELLED: Reactive measures (measures that change the phenomenon assessed) cause problems in interpreting any changes observed. This study examined whether electronic daily diary measures of pain, activity interference, mood, and pain beliefs were reactive in terms of both observable data and patient-reported effects. Patients with chronic temporomandibular disorder pain (N = 71, 86% female) completed electronic diaries 3 times daily for approximately 2 weeks and subsequently reported perceived effects on symptom-related variables. Seventy-three percent of patients reported that the assessment affected their pain, whereas 51%, 45%, and 39% thought that it affected their daily activities, mood, and beliefs, respectively. In contrast, there was little objective evidence of reactivity as observed in the electronic diary ratings; changes over 14 days were small (eg, predicted changes on 0 to 10 scales: positive mood, .1; pain, -.3; perceived control, -.5) and not statistically significant. Subjective reactivity was generally not significantly related to objective reactivity. The data suggest that patients view daily assessment as having positive and negative effects on pain-related variables, but pain-related measures do not show reactive effects. PERSPECTIVE: Electronic daily diary assessment methods hold the potential to increase knowledge concerning patients' experiences with pain and sequential relations between pain-related variables, but only if the measurement process is nonreactive. This study provides evidence that electronic diary assessment of pain-related variables is nonreactive.

Short-term clinical outcomes and patient compliance with temporomandibular disorder treatment recommendations.

AIMS: To evaluate short-term patient compliance with 5 conservative temporomandibular disorder (TMD) treatments (jaw relaxation, jaw stretching, heat application, cold application, and occlusal splint use) and the association of compliance with changes in pain intensity, pain-related activity interference, and jaw use limitations. METHODS: Eighty-one TMD patients were given 1 to 5 treatment recommendations as part of usual care in a TMD specialty clinic. Compliance with each recommendation and pain, pain-related activity interference, and jaw use limitation measures were calculated from electronic interviews conducted 3 times daily for 2 weeks. RESULTS: Median compliance with individual treatment modalities ranged from 7.7% for heat application to 92.7% for jaw relaxation; median overall compliance was 54.8%. Participants with higher initial pain intensity and jaw use limitations were significantly more compliant with their recommended treatment regimen (P < .05). The authors controlled for age, gender, education, and initial jaw use limitations. Overall compliance was associated significantly and positively with 2-week jaw use limitations (P = .03). A trend toward a statistically significant positive association was found between compliance and 2-week pain intensity (P = .09). CONCLUSION: Compliance varied widely across patients and therapies. Patients with higher initial pain and jaw use limitation levels were more compliant with treatment recommendations. Although compliance was associated with slight increases in pain and jaw use limitations in this preliminary study, further research is needed to evaluate the longer-term effects of compliance with recommended therapies.

Pain-related catastrophizing: a daily process study.

Little is known about the extent to which individuals vary versus remain stable in their pain-related catastrophizing, or to which catastrophizing is associated with pain and related problems on a daily basis. We used daily electronic interviews to examine the: (1) reliability and validity of a brief daily catastrophizing measure; (2) stability of catastrophizing; (3) patient characteristics associated with catastrophizing; (4) associations between catastrophizing and concurrent and subsequent outcomes (pain, activity interference, jaw use limitations, and negative mood), between and within patients; and (5) associations between pain and subsequent catastrophizing. One hundred patients with chronic temporomandibular disorder pain completed electronic interviews three times a day for 2 weeks [mean (SD) number of interviews=46 (15)]. The catastrophizing scale had high internal consistency (Cronbach's alpha = 0.95) and validity (r = 0.65 with the Coping Strategy Questionnaire Catastrophizing scale), and catastrophizing was stable (ICC=0.72) over time. Younger age and greater baseline depression, pain, and disability predicted greater daily catastrophizing. Daily catastrophizing was associated significantly with concurrent outcomes, between- and within-subjects (P < 0.001); however, associations with same-day subsequent outcomes were greatly attenuated after adjusting for prior outcome levels. Similarly, daily pain was associated significantly with subsequent catastrophizing, but this association was no longer statistically significant after adjusting for prior catastrophizing. The data indicate that catastrophizing is stable over short periods of time in the absence of substantial change in pain, and that within patients, times of greater catastrophizing are associated with worse pain, disability, and mood.

Reasons for missing interviews in the daily electronic assessment of pain, mood, and stress.

Electronic diary assessment methods offer the potential to accurately characterize pain and other daily experiences. However, the frequent assessment of experiences over time often results in missing data. It is important to identify systematic reasons for missing data because such a pattern may bias study results and interpretations. We examined the reasons for missing electronic interviews, comparing self-report and data derived from electronic diary responses. Sixty-two patients with temporomandibular disorders were asked to rate pain intensity, pain-related activity interference, jaw use limitations, mood, and perceived stress three times a day for 8 weeks on palmtop computers. Participants also were asked the number of and reason(s) for missing electronic interviews. The average electronic diary completion rate was 91%. The correspondence between self-report and electronic data was high for the overall number of missed electronic interviews (Spearman correlation=0.77, P < 0.0001). The most common self-reported reasons for missing interviews were failure to hear the computer alarm (49%) and inconvenient time (21%). Although there was some suggestion that persistent negative mood and stress were associated with missing electronic interviews in a subgroup of patients, on the whole, the patient demographic and clinical characteristics, treatment, and daily fluctuations in pain, activity interference, mood, and stress were not associated significantly with missing daily electronic interviews. The results provide further support for the use of electronic diary methodology in pain research.

Chronic diffuse musculoskeletal pain, fibromyalgia and co-morbid unexplained clinical conditions.

This chapter reviews our current knowledge on the presence of overlapping syndromes in one form of chronic diffuse pain, fibromyalgia. Patients with fibromyalgia often present with signs and symptoms of other unexplained clinical conditions, including chronic fatigue syndrome, irritable bowel syndrome, temporomandibular disorders, and multiple chemical sensitivities. The high prevalence, impact on function and opportunities for treatment underscore the need for clinicians and researchers to screen routinely for co-morbid unexplained clinical conditions among persons with fibromyalgia. We, therefore, describe a simple approach to screening for such conditions in accordance with published criteria. Interventions should directly address both fibromyalgia symptoms and co-morbid unexplained clinical conditions, as well as the multiple factors that propagate pain, fatigue and limitations in function.

Health and functional status of twins with chronic regional and widespread pain.

OBJECTIVE: To examine the independent effects of chronic regional and widespread pain syndromes on health and functional status after accounting for comorbid chronic fatigue using a co-twin control design. METHODS: We identified 95 twin pairs discordant for pain in which one twin had chronic regional or widespread pain and the other denied chronic pain. Demographic data, functional and psychological status, health behaviors, and symptoms based on the 1994 criteria for chronic fatigue syndrome (CFS) were assessed by questionnaire. Psychiatric diagnoses were based on structured interview. Random effects regression modeling estimated associations between chronic regional and widespread pain and each health measure with and without adjustment for CFS. RESULTS: Significant differences (p

Coping strategies predict disability in patients with primary fibromyalgia.

We administered the Coping Strategies Questionnaire (CSQ) to 80 patients with fibromyalgia (FM) to determine the relationship between coping strategies and functional disability. A principal components factor analysis revealed two dimensions of patients' CSQ responses: Coping Attempts and Catastrophizing. Coping Attempts consists of five scales: Reinterpreting Pain, Ignoring Pain Sensations, Diverting Attention, Coping Self-Statements and Increasing Activity Level. Catastrophizing is comprised solely of the CSQ Catastrophizing scale. Both coping strategy dimensions were significantly related to patients' disability scores on the Sickness Impact Profile even after controlling for demographic and clinical variables as well as neuroticism. Coping Attempts was associated with higher levels of Physical (P < 0.05) and Total Disability (P < 0.01), and lower levels of Psychosocial Disability (P < 0.05). Catastrophizing was associated with higher levels of Total Disability (P < 0.01). These relationships suggest that investigators should attempt to identify Coping Attempts strategies that best reduce patients' psychological distress in the laboratory. It then may be possible to teach patients to use these strategies to reduce distress in their home and work environments.