Search

The present study aimed to investigate mandibular asymmetry as a possible etiopathologic factor in temporomandibular disorder (TMD). A prospective cross-sectional study of patients with dentofacial deformities seeking corrective orthognathic surgery was conducted. The pre-operative prevalence of TMD in patients with mandibular asymmetry and other dentofacial deformities was assessed using the Diagnostic Criteria for TMD (DC/TMD) Axis I protocol. A total of 134 patients were recruited – 82 with mandibular asymmetry and 52 without. There was a significantly higher prevalence of TMD in those with mandibular asymmetry (67.1%; 95% CI 59 to 75%) compared to those without (40.4%; 95% CI 32 to 49%, p = 0.002). The overall pre-operative prevalence of TMD in this population of patients was 56.7% (95% CI 48 to 65%). Pain disorder only was present in 9.7%, TMJ disorder only in 29.9%, and both pain and TMJ disorders in 17.2%. The most prevalent type of TMD is disc displacement with reduction (77.6%), followed by myalgia (35.5%) and arthralgia (21.1%). The prevalence of TMD in those with mandibular asymmetry was significantly higher than those without, suggesting that mandibular asymmetry could be a possible etiopathologic factor in TMD. The significantly higher prevalence of temporomandibular disorder in those with mandibular asymmetry suggests that we need to be especially cognizant of this condition in our pre-operative, surgical, and post-operative management of this group of orthognathic patients.

Background Headache is the most common pain disorder, affecting around 66% of the global population. This study aimed to investigate the efficacy of high-frequency repetitive transcranial magnetic stimulation (rTMS) in treating patients with primary chronic daily headaches (chronic tension-type headache and chronic migraine). Methods Twenty-seven patients participated in the study, divided into 2 groups: a study group (16 patients) and a control group (11 patients). Treatment consisted of 12 high-frequency (5 Hz) real rTMS sessions, delivered over the left dorsolateral prefrontal cortex (DLPFC), whereas sham rTMS was used for the control group. Results Patients of the study group, after real rTMS stimulation, showed a high statistically significant reduction of the measured headache parameters compared to the control group (P value < 0.001), and the percentage of improvement was 94.5%. No significant reduction of headache parameters, after sham rTMS stimulation, was observed in the control group (P value > 0.05) and the percentage of improvement was 7.9%. Conclusion High-frequency rTMS is effective in reducing chronic tension headaches and chronic migraines. This finding runs with the approval of the suggested role of DLPFC in pain control. This might open opinions for new treatment strategies in tension-type headache and migraine prevention.

Fibromyalgia syndrome (FMS) is a chronic pain syndrome. Previous analyses of untargeted metabolomics data indicated altered metabolic profile in FMS patients. We report a semi-targeted explorative metabolomics study on the urinary metabolite profile of FMS patients; exploring the potential of urinary metabolite information to augment existing medical diagnosis. All cases were females. Patients had a medical history of persistent FMS (n = 18). Control groups were first-generation family members of the patients (n = 11), age-related individuals without indications of FMS (n = 10), and healthy, young (18–22 years) individuals (n = 41). The biofluid investigated was early morning urine samples. Data generation was done through gas chromatography–mass spectrometry (GC–MS) analysis and data processing and analyses were performed using Matlab, R, SPSS and SAS software. Quantitative analysis revealed the presence of 196 metabolites. Unsupervised and supervised multivariate analyses distinguished all three control groups and the FMS patients, which could be related to 14 significantly increased metabolites. These metabolites are associated with energy metabolism, digestion and metabolism of carbohydrates and other host and gut metabolites. Overall, urinary metabolite profiles in the FMS patients suggest: (1) energy utilization is a central aspect of this pain disorder, (2) dysbiosis seems to prevail in FMS patients, indicated by disrupted microbiota metabolites, supporting the model that microbiota may alter brain function through the gut-brain axis, with the gut being a gateway to generalized pain, and (3) screening of urine from FMS is an avenue to explore for adding non-invasive clinical information for diagnosis and treatment of FMS.

Endometriosis is a chronic disease of women during their reproductive age. The most typical symptoms are dysmenorrhoea, dyspareunia, dysuria, cyclical and acyclical pelvic pain, bleeding disorders and infertility. These symptoms lead to significant impairment of the quality of life and economic burden. The prevalence is estimated to be 2-20 % of all women in this age and due to this fact, it is one of the most frequently benign gynecological diseases. Not all women suffer from severe symptoms, but more than 50 % require ongoing treatment. Beside the severe physical impairment due to the pain, the high recurrence rate of 50-80 % also after surgical and/or hormonal treatment is problematic. The interval between onset of symptoms and diagnosis is approximately 6-8 years. These problems are a consequence of lack of knowledge about the pathogenesis of the disease and the pain mechanisms as well as the lack of awareness of physicians in this field.

BackgroundFibromyalgia (FM) is a chronic, debilitating pain disorder. Dissatisfaction with conventional medicine can lead people with FM to turn to complementary and alternative medicine (CAM). Two previous overviews of systematic reviews of CAM for FM have been published, but they did not assessed for risk of bias in the review process.MethodsFive databases Medline, Embase, AMED (via OVID), Web of Science and Central were searched from their inception to December 2015. Reference lists were hand-searched. We had two aims: the first was to provide an up-to-date and rigorously conducted synthesis of systematic reviews of CAM literature on FM; the second was to evaluate the quality of the available systematic review evidence using two different tools: AMSTAR (Shea et al. BMC Med Res Methodol 15; 7:10, 2007) and a more recently developed tool ROBIS (Whiting et al. J Clin Epidemiol 69:225-34, 2016) specifically designed to assess risk of bias in systematic reviews. Any review that assessed one of eight CAM therapies for participants diagnosed with FM was considered. The individual studies had to be randomised controlled trials where the intervention was compared to placebo, treatment as usual or waitlist controls to be included. The primary outcome measure was pain, and the secondary outcome measure was adverse events.ResultsWe identified 15 reviews that met inclusion criteria. There was low-quality evidence that acupuncture improves pain compared to no treatment or standard treatment, but good evidence that it is no better than sham acupuncture. The evidence for homoeopathy, spinal manipulation and herbal medicine was limited.ConclusionsOverall, five reviews scored 6 or above using the AMSTAR scale and the inter-rater agreement was good (83.6%), whereas seven reviews achieved a low risk of bias rating using ROBIS and the inter-rater agreement was fair (60.0%). No firm conclusions were drawn for efficacy of either spinal manipulation or homoeopathy for FM. There is limited evidence for topical Capsicum, but further research is required. There is some evidence to support the effectiveness of acupuncture for FM, but further high-quality trials are needed to investigate its benefits, harms and mechanisms of action, compared with no or standard treatment.Systematic review registrationPROSPERO CRD42016035846.

Fibromyalgia is a pain disorder associated with frequent comorbid mood, anxiety, and sleep disorders. Despite the frequent use of a complex, poly-drug pharmacotherapy, treatment for fibromyalgia is of limited efficacy. Oxytocin has been reported to reduce the severity of pain, anxiety, and depression, and improve the quality of sleep, suggesting that it may be useful to treat fibromyalgia. To evaluate this hypothesis, 14 women affected by fibromyalgia and comorbid disorders, assuming a complex pharmacotherapy, were enrolled in a double-blind, crossover, randomized trial to receive oxytocin and placebo nasal spray daily for 3 weeks for each treatment. Order of treatment (placebo-oxytocin or oxytocin-placebo) was randomly assigned. Patients were visited once a week. At each visit, the following instruments were administered: an adverse drug reaction record card, Visual Analog Scale of Pain Intensity, Spielberger State Anxiety Inventory, Zung Self-rating Depression Scale, and SF-12. Women self-registered painkiller assumption, pain severity, and quality of sleep in a diary. Unlikely, oxytocin nasal spray (80 IU a day) did not induce positive therapeutic effects but resulted to be safe, devoid of toxicity, and easy to handle.

The just-published psychiatric diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), American Psychiatric Association (2013), has been lauded by its organizers (e.g., Regier, Kuhl, and Kupfer in World Psychiatry 12, pp. 92–98, 2013), but has been criticized on multiple grounds, as well. Several of its major diagnostic categories concern the area of psychological injury and law (e.g., tort cases involving posttraumatic stress disorder (PTSD), chronic pain, and traumatic brain injury (TBI)). The one for chronic pain seems the one most greatly changed. The approach to chronic pain in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (American Psychiatric Association 2000) and the DSM-5 are compared, leading to an alternative diagnostic criteria list partly based on the changes in the DSM-5. The DSM-5 should be used with caution in forensic assessments. This applies especially to the psychological injury patient, including the pain one, given the high stakes involved and the need for accuracy in assessment based on a reliable and valid diagnostic system. Future iterations of the manual should be improved in both these regards.

The Diagnostic and Statistical Manual, DSM-IV-TR (American Psychiatric Association 2000) includes the diagnosis of pain disorder, and it has been revised in major ways in the DSM-5 draft (American Psychiatric Association 2010). Pain disorder has been relegated as a specifier of the new diagnosis of complex somatic symptom disorder. It cannot be diagnosed prior to 6 months of the pain’s onset. Also, there are still the pejorative connotations with which the disorder is associated. In terms of treatment, it might be more difficult to get treatment plans accepted as a result of the changes, and in terms of the legal arena, it might prove more difficult to have the disorder serve as the basis of action in legal proceedings.

Female sexual dysfunctions are common in the general population and remain a multifaceted problem that continues to be under recognized and under treated. This article reports a descriptive analytic study to assess prevalence of female sexual dysfunction and related factors for under treatment. In this cross sectional study, 1054 married women age 18–59 years were randomly selected from rural and urban health centers of Bushehr province. Data was collected by a questionnaire for demographic characteristic and Female Sexual Function Index for assessment of sexual dysfunction. For data analysis descriptive analytic tests were used. A total of 71.1% of subjects reported desire disorder. Prevalence of arousal, lubricating, orgasmic and pain disorders were 66.4, 38, 34.8 and 38.4%, respectively. Desire and arousal disorder were significantly interrelated with age, educational level, economic and marital status, smoking behavior of subjects and age, educational level, occupation and marital status of their husbands. Lubricating disorder was interrelated with age, educational level, occupation, smoking behavior and economic status of subjects and age, educational level, occupation of their husbands. Orgasmic disorder was significantly interrelated with age, educational level, occupation, economic status and smoking behavior of subjects and age, educational level and occupation of their husbands. There was a significant relationship between pain disorder with age, smoking, economic status of subjects and age, educational level and occupation of their husbands. 47.1 percent of subjects agreed that they had a problem. Only 9.2% of them reported going for treatment. Most of participants reported that they were ashamed of talking about these problems. Female sexual dysfunction is prevalent in Bushehr province but treatment rate is very low. Screening for sexual disorder, initiating dialogue by professionals and establishing a counseling plan may provide the opportunity to improve their sexual health.

The purpose of this study was to describe a new treatment strategy for children with both chronic pain and severe emotional distress, the “pain provocation technique” (PPT), and report on its utilization in a 15-year-old boy with both pain and adjustment disorder. The PPT is a treatment method including graded exposure and bilateral stimulation to increases in pain intensity and the use of pain coping strategies and bilateral stimulation to decreases in pain intensity. Core outcome variables (pain intensity, disability, school absence, emotional distress) were assessed at admission, and 3, 6, and 12 months post treatment. Results indicated a decrease in pain intensity and emotional distress. The single case design limits interpreting the results. Therefore, further studies are warranted.

The aetiology of chronic whiplash associated disorder (WAD) is unclear and the condition has been perceived both as a chronic pain disorder, based on the injury to the neck, and as a functional somatic disorder. Based on the hypothesis that chronic WAD should be perceived as a functional somatic syndrome, we compared the symptom profile of persons with chronic WAD with the profile of persons with a functional somatic disorder, and with the profile of persons with an organic pain disorder. A sample of 55,046 persons participating in a Norwegian population-based health study (HUNT 2) was divided into four study groups: chronic WAD, fibromyalgia, rheumatoid arthritis, and controls (none of these disorders). Symptoms were categorized as pain and stiffness, cardiopulmonary and gastrointestinal symptoms, and mental disorders. Odds ratios (ORs) with 95% confidence intervals (CIs) from logistic regression were used to compare the prevalence of symptoms among the groups. The chronic WAD group had a significantly higher prevalence of symptoms from all body parts, across organ systems and also mental symptoms, compared to the control group. The fibromyalgia group had an even higher prevalence of all symptoms, while the rheumatoid arthritis group showed an increase in the prevalence of particularly pain and stiffness symptoms and also a minor increase in the prevalence of other symptoms compared to the control group. We conclude that this study provide evidence in favour of the hypothesis that chronic WAD should be perceived as a functional somatic syndrome. Persons with chronic WAD had a symptom profile more similar to people with a functional somatic disorder than an organic pain disorder, consisting of a wide array of symptoms, not only predominantly pain symptoms.

Objectives. In this investigation we studied the relationships between different psychological relevant subgroups and the presence of different psychosomatic symptoms in a sample of chronic pain patients, testing the accuracy of the DSM- and ICD classification systems. Results. We found no evidence for a “pure” pain syndrome according to the DSM- and ICD systems. On the contrary, we found highly significant evidence of a mixed psychosomatic condition. Conclusion. The results suggest a broad somatoform classification, with subgroups based on personality characteristics taking a stress—coping model into account, including interpersonal attachment behaviour. An alternative model of a diagnostic approach is presented.

The series of articles in this special topic on the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) draft (American Psychiatric Association 2010), which is preparatory to publication of the DSM-5, deals with issues and disorders and conditions pertinent to the field of psychological injury and law. The articles describe and critique the changes anticipated for the diagnoses of posttraumatic stress disorder, pain disorder, and neurocognitive disorder, in particular. Further, changes suggested in the draft for personality disorder are analyzed with a critical eye. In addition, the articles examine the lack of change for dealing with malingering and the general lack of consideration of group differences such as for race, in areas pertinent to psychological injury and law. This summary of the articles concludes that some of the changes in the DSM-5 draft are premature, and it calls for continued research and evidence-informed bases for recommended changes for the DSM-V.

Although the feeling or sensation that we call pain is usually uncomfortable and unpleasant, it is actually a great asset in many situations in general medicine, especially when we think of children and older people. Were it not for a persistent complaint or expression of pain, family members or others might not realize that a small child or older person has suffered a significant injury or is ill. Indeed, at any age, the symptom of pain may be an important indication that a disease may be present. For young children, the sensation of pain can also be a learning experience, teaching them to take extra care with such items as hot stoves or broken glass. All those situations in which injury, disease, or something of a physical nature has caused pain are universally understood without any disagreement. We see in them a logical sequence of cause and effect. The focus of this article is on those patients who complain of pain for a long period of time but in whom no physical disease has ever been found.

Physicians and other clinicians who treat patients with chronic pain have doubtless recognized the interplay of various psychological and somatic variables in their patients' pain. Notwithstanding, there continues to be primary emphasis on the somatic factors, and continued neglect of the psychological. This article asserts that pain disorder and somatization disorder are indeed valid diagnostic entities, and that their respective incidence and prevalence are quite high both in patients with chronic pain and in the primary care setting. These diagnoses are compared and contrasted, along with the related diagnosis of the psychological factors affecting physical condition. Guidelines for assessment of these conditions are provided, as are recommendations as to when to refer patients for further psychological and psychiatric assessment and treatment.

This article reviews the AMA guidelines for judging impairment that involves anatomic or physiologic deficits and should be evaluated objectively based upon current biomedical knowledge. Disability, in contrast, is a biopsychosocioeconomic phenomena based upon many nonmedical demands. Chronic pain syndrome is examined as a disabiling condition best conceptualized and treated with such a multisystems model, while the underlying impairment needs to be assessed and rated by a biomedical model.The wide range of "central processes" relevant to chronic pain are reviewed. It argues that patients should not be viewed as reaching MMI unless they have been treated at a comprehensive chronic pain rehabilitation program, or are unable or unwilling to do so. A balanced, direct yet compassionate approach is recommended in treating these patients: the source of pain and that it will not cause harm is carefully explained and a clear expecatation that the patient’s condition is not disabling and that he or she can return to work is conveyed.The need to change the compensation and disability systems so that they encourage early intervention with incentives toward rehabilitation and return to work is emphasized.

Chronic soft tissue pain disorders are not well understood from a pathophysiologic standpoint. Psychologic difficulties are common, clinical signs incompatible with conventional understanding of the nervous system are often present, and these disorders usually fail to respond to medical intervention.When this constellation of factors is combined with unresolved litigation-compensation issues, it is not surprising that chronic pain disorders are often misdiagnosed as hysteria or malingering. Unfortunately, these diagnoses may have significant negative consequences that are not often appreciated and may compromise treatment.

Chronic pain is a major public health problem that inflicts not only tremendous personal suffering but also huge economic loss to individuals and society. This article discusses the psychiatric aspects of chronic pain and disability. Topics covered include chronic pain and psychiatric illness (eg. somatization disorder, conversion disorder, hypochondriasis, and so on), the interrelationship between pain and depression, and psychodynamics and psychotherapy.

Objectives Alexithymia is highly prevalent among chronic pain patients. Pain is a remarkable cause for high levels of chronic anxiety. The purpose of this study was to investigate the prevalence of alexithymia and to determine anxiety levels among DSM-IV somatoform pain disorder (chronic pain) female patients and to examine the relationship between alexithymia and the self-reporting of pain. Methods Thirty adult females (mean age: 34,63 ± 10,62 years), who applied to the outpatient psychiatry clinic at a public hospital with the diagnosis of chronic pain disorder (DSM-IV), were included in the study. Thirty seven healthy females (mean age: 34,46 ± 7,43 years), who matched for sociodemographic features with the patient group, consisted the control group. A sociodemographic data form, 26-item Toronto Alexithymia Scale (TAS-26), Spielberger Trait Anxiety Inventory (STAI) were administered to each subject and information was obtained on several aspects of the patients' pain, including intensity (measured by VAS), and duration. Results Chronic pain patients were found significantly more alexithymic than controls. There was a positive correlation between TAS-26 scores and the duration of pain. The alexithymic and nonalexithymic group did not differ in their perception of pain. Neither positive correlation nor significant difference was found between alexithymia and trait anxiety in pain patients. Discussion Alexithymia may be important in addressing the diversity of subjective factors involved in pain. The conceptualization of alexithymia as a personality trait as well as a secondary state reaction is underlined by our data.

Migraine is probably the second most common pain disorder next to tension-type headache. The majority of migraineurs have episodic attacks, but a small minority have chronic migraine [1, 2]. Treatment options for chronic migraine are sparse. Thus, clinical trials investigating new treatment options are therefore endorsed in order to provide evidence-based data. Two double-blind, randomized, placebo-controlled clinical trials for the treatment of chronic migraine with onabotulinumtoxinA, the Phase III REarch Evaluating Migraine Prophylaxis Therapy (PREEMPT) 1 and 2 as well as the pooled data from the two trials were recently published [3–5]. The introduction of the three onabotulinumtoxinA papers describes the definition of chronic migraine according to the criteria of the International Classification of Headache Disorders II (ICHD II) [6, 7]. The PREEMPT inclusion criteria for chronic migraine were: Migraine according to the ICHD II excluding hemiplegic migraine, basilar-type migraine, ophthalmoplegic migraine and migrainous infarction. ≥15 headache days within 28 days at baseline, with each day consisting of ≥4 h of continuous headache and with ≥50% of days being migraine or probable migraine days. Two of the PREEMPT exclusions criteria were: Diagnosis of other primary or secondary headache disorders. Use of prophylactic medication within 28 days before start of baseline. At a first glance it seems that chronic migraine in the PREEMPT studies adhere to criteria of the ICHD II, as other primary and secondary headache disorders were excluded. However, the latter was not specified in details and also lacked a reference, although one might get the impression that the criteria of the ICHD II were applied, since this classification is mentioned in the beginning of the study participants section [3, 4]. However, Table 1 in the results section shows that approximately 2/3 of all PREEMPT 1 and 2 included participants with chronic migraine had overused acute headache pain medication at baseline [3, 4]. The pooled data publication do not include this information in Table 1, but the result section mention that most patients overused acute pain medication at baseline and 1.7% had opioid overuse [5]. The mean years since onset of chronic migraine varied between 17.6 and 20.6 years [3, 4]. Thus, it is reasonable to assume that the medication overuse had persisted for at least 3 months in the majority of the included participants with medication overuse at baseline. According to the criteria of the ICHD II chronic migraine is classified only if there is no medication overuse (criteria D) [6, 7]. Thus, the 2/3 of the PREEMPT 1 and 2 included participants with chronic migraine and medication overuse should be classified medication overuse headache and not chronic migraine [6–8]. This leaves only approximately 1/3 of PREEMPT 1 and 2 participants included with a ICHD II diagnosis of chronic migraine. In fact it might be less, since the ICHD II definition of chronic migraine only includes migraine without aura and not migraine with aura. No doubt classification on chronic migraine and medication overuse headache has been a challenge within the last two decades, since the ICHD I from 1988 did not include chronic migraine, and the ICHD II from 2004 was soon revised [6–9]. This has been described in details elsewhere [10]. However, the description of different chronic migraine criteria in different part of the three onabotulinumtoxinA papers are confusing and misleading, especially since medication overuse is not explicit mentioned in the methods section (study participants sections) [3–5]. The heterogeneity of the study participants raise questions in relation to efficacy of onabotulinumtoxinA on the primary and secondary end point defined in the PREEMPT 1 and 2. Firstly, what is the efficacy of onabotulinumtoxinA in those with medication overuse headache (chronic migraine without aura and medication overuse headache)? Secondly, what is the efficacy of onabotulinumtoxinA in those with chronic migraine (chronic migraine without aura without medication overuse)? Furthermore, how do factors such as migraine with aura, gender, race and previously used prophylactic medication influence on the efficacy of onabotulinumtoxinA? Such evidence-based data are warranted for those treating chronic migraine and medication overuse headache. Data on those whom had medication overuse headache and those whom had previously tried prophylactic medication are especially important. Short information to people with chronic headache (≥15 days/month for at least 3 months) and medication overuse about the possible role of medication overuse in headache chronification, and no further contact before follow-up approximately 1½ years later, reduced mean medication days from 22 to 6 days/month, and 42% no longer had chronic headache [11]. Fifty-three percentage of the participants had co-occurrence of migraine, but only a few had chronic migraine. Since enrollment of the PREEMPT 1 and 2 required that prophylactic medication was not taken 28 days prior to the baseline data collection, it is likely to assume that those enrolled had none or only a modest effect of previous tried prophylactic medications. This is important in the light that 79% (−6.6/−8.4) of the reduction of headache days (primary efficacy variable) was due to placebo response [5]. Hopefully, future publication on onabotulinumtoxinA will enlighten us regarding the efficacy of onabotulinumtoxinA for the treatment of chronic migraine and medication overuse headache among others.