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.

Stress is associated with subsequent pain and disability among men with nonbacterial prostatitis/pelvic pain

BACKGROUND

Nonbacterial prostatitis is a syndrome characterized by persistent pelvic area pain in men with or without voiding symptoms. Its causes are poorly understood, and evidence-based treatments are lacking. Although psychological stress has been proposed as an etiological factor, the literature lacks prospective studies using standardized measures to examine associations between stress and male pelvic pain problems over time.

PURPOSE

This study examined whether perceived stress was associated longitudinally with pain intensity and pain-related disability in a sample of men with nonbacterial prostatitis/pelvic pain.

METHODS

Men (N = 224) completed measures of perceived stress, pain intensity, and pain-related disability 1 month after a health care visit with a new nonbacterial prostatitis/pelvic pain diagnosis and 3, 6, and 12 months later.

RESULTS

Greater perceived stress during the 6 months after the health care visit was associated with greater pain intensity (p = .03) and disability (p = .003) at 12 months, even after controlling for age, symptom duration, and pain and disability during the first 6 months.

CONCLUSIONS

These findings support further research into the associations between stress and male pelvic pain syndromes, as well as the assessment of stress in the evaluation of patients with pelvic pain.

Partner Responses to Pain Behaviors Are Associated With Depression and Activity Interference Among Persons With Chronic Pain and Spinal Cord Injury

This study investigated the extent to which psychosocial factors (partner responses to pain behaviors, social support) are associated with pain-related activity interference and depressive symptom severity among individuals with spinal cord injury (SCI) and chronic pain. Seventy adults (45 men, 25 women) with SCI and pain and 68 partners completed Part II of the West Haven-Yale Multidimensional Pain Inventory, a measure of partner responses to pain behaviors. Individuals with SCI and pain also completed the Social Support Questionnaire-6, a modified Brief Pain Inventory Pain Interference Scale, and the Center for Epidemiological Studies-Depression scale. SCI subject ratings of partner responses to pain behaviors, but not partner ratings, were associated significantly with pain-related activity interference and depressive symptom severity. Negative partner response to pain behaviors explained the most variance in these 2 outcome measures. The results provide preliminary support for the importance of partner responses to pain behaviors in outcomes of individuals with chronic pain and SCI.

PERSPECTIVE

Chronic pain is a significant problem for many persons with spinal cord injury. In this sample of individuals with spinal cord injury and pain, perceived partner negative responses to pain behaviors were associated positively with activity interference and depression. Decreasing negative partner responses to pain behaviors might be a potentially important clinical intervention in this population.

Pain Interference in Persons With Spinal Cord Injury: Classification of Mild, Moderate, and Severe Pain

Pain intensity is commonly measured by patient ratings on numerical rating scales (NRS). However, grouping such ratings into categories may be useful for guiding treatment decisions or interpreting clinical trial outcomes. The purpose of this study was to examine pain intensity classification in 2 samples of persons with spinal cord injuries (SCI) and chronic pain. The first sample (n = 307) rated the average intensity and activity interference of pain in general, and the second sample (n = 174) rated their worst pain problem. Pain intensity was categorized as mild, moderate, or severe using 4 possible classification systems; analyses were performed to determine the classification system that best distinguished the pain intensity groups in terms of activity interference. In both samples, the optimal mild/moderate boundary was lower (mild = 1-3 on a 0-10 NRS scale) than that reported previously for individuals with other pain problems. The possibility that pain may interfere with activity at lower levels for individuals with SCI requires further exploration. The moderate/severe boundary suggested by previous research was confirmed in only one of the samples. Implications for the assessment of pain intensity and functioning in persons with SCI and pain are discussed.

PERSPECTIVE

Although pain in individuals with SCI is common, more research is needed regarding its characteristics and treatment. This study sought to develop an empirically based classification system for mild, moderate, and severe pain that could be useful for applying clinical treatment guidelines and for interpreting the results of much-needed clinical trials.

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.

Men With Pelvic Pain: Perceived Helpfulness of Medical and Self-Management Strategies

OBJECTIVE

To assess the frequency of use of different treatments and pain management strategies and their perceived helpfulness in male patients with pelvic pain.

METHODS

Approximately 1 month after a health maintenance organization visit for pelvic pain, 286 men (mean age 46.7 years) completed telephone interviews about their symptoms and treatments and pain management strategies used in the past year. Participants rated the helpfulness of each treatment and strategy used on 0 to 10 scales.

RESULTS

Even though men with identified bacterial etiology were excluded from the study, antibiotic medication was the most commonly reported treatment (67% of patients) and rated as the second most helpful treatment [mean (SD)=6.3 (3.6)]. Opiates were rated as the most helpful treatment on average [mean (SD)=7.9 (2.1)], but were used by only 12% of patients. Substantial minorities of patients reported several behaviors as helpful, including urinating (reported as helpful by 26%), taking warm baths (23%), and drinking water (23%), although patterns of effects differed for men with versus without urinary symptoms. Activities most commonly reported as worsening symptoms were sitting (42%), walking/jogging (27%), and sexual activity (25%).

DISCUSSION

Patients with male pelvic pain syndrome are commonly prescribed antibiotics, which they perceive as moderately helpful, despite the lack of scientific evidence of efficacy. Clinicians may find it useful to support patient use of safe, inexpensive, self-management approaches, especially warm baths, increased water intake, and avoidance of prolonged sitting.

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.

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.

Clinically Significant Change in Pain Intensity Ratings in Persons With Spinal Cord Injury or Amputation

OBJECTIVE

To examine the clinical significance of changes in chronic pain in 2 disability groups: spinal cord injury and lower limb amputation.

METHODS

A reanalysis of 2 controlled clinical trials for pain in persons with disabilities. Eighty-two persons with spinal cord injuries and 34 persons with amputations provided pretreatment and posttreatment ratings of pain intensity on 0 to 10 numerical rating scales. After treatment, participants also rated the meaningfulness of any changes in pain they experienced.

RESULTS

An average decrease of 1.80 points on the 0 to 10 numerical rating scales and percent decreases of about 36% corresponded to reports of a meaningful change in pain. There was no significant difference between samples, and also no differences due to gender or treatment condition. Age and pretreatment pain, however, were associated with the amount of pain decrease rated as meaningful. The change in pain intensity rated as meaningful was greater for older participants and participants with higher levels of pretreatment pain. Consistent with previous research, percent change scores were less biased by pretreatment pain than were absolute change scores.

DISCUSSION

These findings are generally consistent with similar findings in other pain populations, and, in light of previous research, support an approximate 33% decrease in pain as a reasonable standard for meaningful change across chronic pain conditions. Percent change scores may be more useful for comparing the effects of pain treatments across samples or conditions because they are less biased by pretreatment pain level.

A descriptive study of older adults with persistent pain: use and perceived effectiveness of pain management strategies [ISRCTN11899548]

BACKGROUND

Persistent pain is a common, often debilitating, problem in older adults; however, few studies have focused on the experiences of older adults in managing their pain. The objective of this study was to describe the use and perceived effectiveness of pain management strategies in a sample of older adults and to explore the associations of these variables with demographic and psychosocial characteristics.

METHODS

Adults >or= 65 years old and living in retirement facilities who reported persistent pain (N = 235, mean age = 82 years, 84% female, 94% white) completed measures of demographics, pain, depression, self-efficacy for managing pain, and a Pain Management Strategies Survey. Participants identified current and previous-year use of 42 pain management strategies and rated helpfulness of each on a 5-point scale.

RESULTS

Acetaminophen, regular exercise, prayer, and heat and cold were the most frequently used pain management strategies (61%, 58%, 53%, and 48%, respectively). Strategies used by >25% of the sample that were rated moderately or more helpful (i.e., >2 on a 0 to 4 scale) were prayer [mean (SD) = 2.9 (0.9)], opioids [2.6 (0.8)], regular exercise [2.5 (1.0)], heat/cold [2.5 (1.0)], nonsteroidal anti-inflammatory drugs [2.4 (1.0)], and acetaminophen [2.3 (1.0)]. Young-old (65-74 years) study participants reported use of more strategies than did old-old (85+ years) participants (p = .03). Perceived helpfulness of strategy use was significantly associated with pain intensity (r = -.14, p < .0001), self-efficacy (r = .28, p < .0001), and depression (r = -.20, p = .003).

CONCLUSION

On average, older adults view the strategies they use for persistent pain as only moderately helpful. The associations between perceived helpfulness and self-efficacy and depression suggest avenues of pain management that are focused less on specific treatments and more on how persons with persistent pain think about their pain.

Policy-relevant research: when does it matter?

Evidence-based medicine is most meaningful to policy makers when research questions are clearly informed by strategic health policy questions. In Washington State workers' compensation, key structural characteristics allow for the conduct of effective policy-relevant research. These include clear authority and a stable funding stream, a formal relationship between a policy agency and a University, development of appropriate research capacity, development of research questions related to strategic goals, and a robust data source. The research conducted relies on computerized medical bills and work disability records, medical records, structured telephone surveys to collect data on pain, functional status, quality of life, and computerized data on employment status. The types of policy-relevant research include identification of factors leading to preventable disability, outcomes research of specific procedures, technology assessment, and "real-time" research that addresses rapidly emerging questions. Health policy changes implemented from research have been substantial in Washington State workers' compensation, including: 1) noncoverage or partial coverage decisions for emerging technologies not proven to be of value to injured workers, 2) formal treatment guidelines and utilization review criteria for invasive, expensive, or marginally effective procedures, 3) disability prevention efforts, and 4) relatively rapid changes in policy as emerging patterns suggest harmful outcomes from existing treatments (e.g., schedule II opioids). Key structural characteristics must be in place to conduct policy-relevant research effectively. The workers' compensation system in Washington State is a single-payer system with other unique properties that have allowed the emergence of these structural characteristics and the conduct of research linked to the strategic goals of policy makers.

Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002

BACKGROUND

The use of opioids for chronic non-cancer pain has increased in the United States since state laws were relaxed in the late 1990s. These policy changes occurred despite scanty scientific evidence that chronic use of opioids was safe and effective.

METHODS

We examined opiate prescriptions and dosing patterns (from computerized databases, 1996 to 2002), and accidental poisoning deaths attributable to opioid use (from death certificates, 1995 to 2002), in the Washington State workers' compensation system.

RESULTS

Opioid prescriptions increased only modestly between 1996 and 2002. However, prescriptions for the most potent opioids (Schedule II), as a percentage of all scheduled opioid prescriptions (II, III, and IV), increased from 19.3% in 1996 to 37.2% in 2002. Among long-acting opioids, the average daily morphine equivalent dose increased by 50%, to 132 mg/day. Thirty-two deaths were definitely or probably related to accidental overdose of opioids. The majority of deaths involved men (84%) and smokers (69%).

CONCLUSIONS

The reasons for escalating doses of the most potent opioids are unknown, but it is possible that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain. Opioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain.

Self-Efficacy for Managing Pain Is Associated With Disability, Depression, and Pain Coping Among Retirement Community Residents With Chronic Pain

Little is known about cognitive and behavioral factors that influence older adults' adjustment to chronic pain. The objective of this study was to investigate the relationship of self-efficacy for managing pain to reports of pain intensity, pain-related disability, depressive symptoms, and pain coping strategy use among 140 retirement community residents (88% female; age mean = 81.7, range 66-99 years) with chronic pain. The 8-item Arthritis Self-Efficacy Scale, modified to specify pain rather than arthritis, demonstrated good psychometric characteristics (Cronbach alpha = .89, minimal floor and ceiling effects, and validity) in this sample. Controlling for age, gender, and pain intensity, self-efficacy was associated significantly and negatively with pain-related disability and depressive symptoms (P values < .001), and positively with use of pain coping strategies previously found to be associated with better outcomes (task persistence, exercise/stretch, coping self-statements, activity pacing; P values < .05). Self-efficacy for managing pain appears to be important in the adjustment of older adults with pain. Research is needed to determine whether interventions designed to increase self-efficacy improve quality of life and prevent functional declines in this population.

PERSPECTIVE

Among retirement community residents (mean age of 82 years) with chronic pain, higher self-efficacy for managing pain is associated with less disability and depression and with the use of pain coping strategies related to better adjustment. This suggests the potential value of interventions to increase self-efficacy in this population.

A prospective cohort study of surgical treatment for back pain with degenerated discs; study protocol

Background

The diagnosis of discogenic back pain often leads to spinal fusion surgery and may partly explain the recent rapid increase in lumbar fusion operations in the United States. Little is known about how patients undergoing lumbar fusion compare in preoperative physical and psychological function to patients who have degenerative discs, but receive only non-surgical care.

Methods

Our group is implementing a multi-center prospective cohort study to compare patients with presumed discogenic pain who undergo lumbar fusion with those who have non-surgical care. We identify patients with predominant low back pain lasting at least six months, one or two-level disc degeneration confirmed by imaging, and a normal neurological exam. Patients are classified as surgical or non-surgical based on the treatment they receive during the six months following study enrollment.

Results

Three hundred patients discogenic low back pain will be followed in a prospective cohort study for two years. The primary outcome measure is the Modified Roland-Morris Disability Questionnaire at 24-months. We also evaluate several other dimensions of outcome, including pain, functional status, psychological distress, general well-being, and role disability.

Conclusion

The primary aim of this prospective cohort study is to better define the outcomes of lumbar fusion for discogenic back pain as it is practiced in the United States. We additionally aim to identify characteristics that result in better patient selection for surgery. Potential predictors include demographics, work and disability compensation status, initial symptom severity and duration, imaging results, functional status, and psychological distress.

The association between pain and disability

A clearer understanding of how pain intensity relates to disability could have important implications for pain treatment goals and definitions of treatment success. The objectives of this study were to determine the optimal pain intensity rating (0-10 scale) cutpoints for discriminating disability levels among individuals with work-related carpal tunnel syndrome (CTS) and low back (LB) injuries, whether these cutpoints differed for these conditions and for different disability measures, and whether the relationship between pain intensity and disability was linear in each injury group. Approximately 3 weeks after filing work injury claims, 2183 workers (1059 CTS; 1124 LB) who still had pain completed pain and disability measures. In the LB group, pain intensity rating categories of 1-4, 5-6, and 7-10 optimally discriminated disability levels for all four disability measures examined. In the CTS group, no pain intensity rating categorization scheme proved superior across all disability measures. For all disability measures examined, the relationship between pain intensity and disability level was linear in the CTS group, but nonlinear in the LB group. Among study participants with work-related back injuries, when pain level was 1-4, a decrease in pain of more than 1-point corresponded to clinically meaningful improvement in functioning, but when pain was rated as 5-10, a 2-point decrease was necessary for clinically meaningful improvement in functioning. The findings indicate that classifying numerical pain ratings into categories corresponding to levels of disability may be useful in establishing treatment goals, but that classification schemes must be validated separately for different pain conditions.

A trial of an activating intervention for chronic back pain in primary care and physical therapy settings

In primary care and physical therapy settings, we evaluated an intervention for chronic back pain patients which incorporated fear reducing and activating techniques. Primary care patients seen for back pain in primary care were screened to identify persons with significant activity limitations 8-10 weeks after their visit. Eligible and willing patients were randomized (N=240). A brief, individualized program to reduce fear and increase activity levels was delivered by a psychologist and physical therapists. Over a 2 year follow-up period, intervention patients reported greater reductions in pain-related fear (P<0.01), average pain (P<0.01) and activity limitations due to back pain (P<0.01) relative to control patients. The percent with greater than a one-third reduction in Roland Disability Questionnaire scores at 6 months was 42% among Intervention patients and 24% among control patients (P<0.01). Over the 2 year follow-up, fewer intervention patients reported 30 or more days unable to carry out usual activities in the prior 3 months (P<0.01). The adjusted mean difference in activity limitation days was 4.5 days at 6 months, 2.8 days at 12 months, and 6.9 days at 24 months. No differences were observed in the percent unemployed or the percent receiving worker's compensation or disability benefits, but these outcomes were relatively uncommon. We conclude that an intervention integrating fear reducing and activating interventions into care for chronic back pain patients produced sustained reductions in patient fears, common activity limitations related to back pain, and days missed from usual activities due to back pain.

Health Concerns of Patients With Nonbacterial Prostatitis/Pelvic Pain

BACKGROUND

Heightened awareness of patients' reasons for physician visits for male pelvic pain (nonbacterial prostatitis) and symptom concerns may increase patient satisfaction with care and help guide better management of this syndrome, for which evidence-based treatment is lacking.

METHODS

We interviewed men with recent health maintenance organization visits for new episodes of nonbacterial prostatitis (N = 286; mean age, 46.7 years) and again 3, 6, and 12 months later. We inquired about their reasons for the visit and, at each interview, symptom concerns. We used Poisson regression to examine the association between baseline symptom worry and health care utilization during the 14 months after the index visit.

RESULTS

Most patients reported concern at the index visit that they might have an infection (73%) or cancer (68%). One year later, 43% reported prostatitis symptoms in the past month. Among these, many were still concerned that their symptoms would worsen if untreated (71%), that they had cancer (46%) or an infection (45%), and that they might need surgery (44%). Controlling for patient age and baseline symptom severity, we found that baseline symptom worry predicted prostatitis-related health care visits over the 14 months after the index visit (P = .005).

CONCLUSIONS

Despite symptom improvement following a health care visit for a new episode of pelvic pain/nonbacterial prostatitis, continued patient concerns about cancer, infection, and symptom worsening without treatment were common, even 1 year later. Patient worry may be associated with increased health care utilization.

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

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.

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.

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.

A communitywide intervention to improve outcomes and reduce disability among injured workers in Washington State

One pressing challenge facing the U.S. health care system is the development of effective policies and clinical management strategies to address deficiencies in health care quality. In collaboration with researchers at the University of Washington, the Washington State Department of Labor and Industries has created a communitywide delivery system intervention to improve health outcomes and reduce disability among injured workers. This intervention is currently being tested in two sites in western and eastern Washington. So far, it appears to be possible to engage physicians and health care institutions in quality improvement initiatives and to form effective public-private partnerships for this purpose. Furthermore, collaborating with university researchers may help enhance the scientific rigor of the quality improvement initiative and create more opportunities for a successful evaluation.

Changes in readiness to self-manage pain are associated with improvement in multidisciplinary pain treatment and pain coping

A patient's readiness to adopt a self-management approach to pain has been hypothesized to increase during multidisciplinary pain treatment and to impact pain coping responses. The Pain Stages of Change Questionnaire (PSOCQ; [J Pain (1997) 227]) was designed to assess four components of readiness to self-manage pain: pre-contemplation, contemplation, action, and maintenance. We tested three hypotheses concerning this construct in two different samples of patients with chronic pain: (1) readiness to self-manage pain, as assessed by the PSOCQ, would increase from pre-multidisciplinary pain treatment to post-treatment and follow-up; (2) changes in readiness to self-manage pain measured pre-treatment to post-treatment and follow-up would be associated with changes in the use of pain coping strategies; and (3) increases in readiness to self-manage pain would be associated with improvement in multidisciplinary pain treatment. The findings supported all three hypotheses. We discuss the implications of the findings for understanding motivational issues in the self-management of pain.

Prognosis of patients with new prostatitis/pelvic pain syndrome episodes

PURPOSE

Little is known about the natural history of nonbacterial prostatitis/male pelvic pain syndrome, the transition from acute to chronic pelvic pain and risk factors for chronicity. In this study we determined the course of symptoms after physician visits for new nonbacterial prostatitis/pelvic pain syndrome episodes, and determined predictors of symptom persistence 1 year later.

MATERIALS AND METHODS

A total of 286 male health maintenance organization enrollees (87% white, mean age 46.7 years, 83% completed the 12-month followup) with recent physician visits for new prostatitis/pelvic pain episodes completed baseline, and 3, 6 and 12-month followup telephone interviews, including the National Institutes of Health Chronic Prostatitis Symptom Index in a prospective longitudinal inception cohort study.

RESULTS

On average symptoms improved substantially during months 1 to 3, modestly from months 3 to 6 and then remained unchanged. At each followup outcomes were better for men whose initial visit was for a first lifetime episode compared with a recurrent prostatitis/pelvic pain episode. Patients with more severe symptoms (Wald chi-square 11.27, p = 0.0008) and whose episode was recurrent (OR 2.2, 95% CI 1.16 to 4.06) at baseline were significantly more likely to report symptoms 1 year later.

CONCLUSIONS

Most men who make physician visits for new nonbacterial prostatitis/pelvic pain episodes experience symptom improvement during the next 6 months. However, chronic, mild, persistent or recurrent symptoms are common. Patients with previous episodes and more severe symptoms are at higher risk for chronic pelvic pain.

Screening for psychosocial risk factors in patients with chronic orofacial pain

BACKGROUND

The authors compiled information about recent advances in screening for psychosocial risk factors considered to be yellow flags for potentially poor outcomes among patients with chronic orofacial pain (most commonly temporomandibular disorders).

TYPES OF STUDIES REVIEWED

The authors conducted MEDLINE searches for the period 1995 through 2002 using the terms "temporomandibular disorders," "assessment" and "psychological," as well as "primary care," "screening" and "psychological disorders." They also searched personal files for relevant articles.

RESULTS

Psychosocial dysfunction is prevalent among patients with chronic orofacial pain. Yellow flags include high levels of disability; psychological disorders; and prolonged or excessive use of opiates, benzodiazepines, alcohol or other drugs. The authors identified several reliable, valid and brief patient self-administered questionnaires that can be used to screen for these yellow flags. Some of these are the Research Diagnostic Criteria/ Temporomandibular Disorders Axis II, Alcohol Use Disorders Identification Test and Patient Health Questionnaire.

CLINICAL IMPLICATIONS

Dentists can improve the quality of care for patients with chronic orofacial pain by screening for psychosocial risk factors and by referring patients with risk factors for psychological or psychiatric assessment and treatment.

Patient satisfaction, treatment experience, and disability outcomes in a population-based cohort of injured workers in Washington State: implications for quality improvement

OBJECTIVE

To determine what aspects of patient satisfaction are most important in explaining the variance in patients' overall treatment experience and to evaluate the relationship between treatment experience and subsequent outcomes.

DATA SOURCES AND SETTING

Data from a population-based survey of 804 randomly selected injured workers in Washington State filing a workers' compensation claim between November 1999 and February 2000 were combined with insurance claims data indicating whether survey respondents were receiving disability compensation payments for being out of work at 6 or 12 months after claim filing.

STUDY DESIGN

We conducted a two-step analysis. In the first step, we tested a multiple linear regression model to assess the relationship of satisfaction measures to patients' overall treatment experience. In the second step, we used logistic regression to assess the relationship of treatment experience to subsequent outcomes.

PRINCIPAL FINDINGS

Among injured workers who had ongoing follow-up care after their initial treatment (n = 681), satisfaction with interpersonal and technical aspects of care and with care coordination was strongly and positively associated with overall treatment experience (p < 0.001). As a group, the satisfaction measures explained 38 percent of the variance in treatment experience after controlling for demographics, satisfaction with medical care prior to injury, job satisfaction, type of injury, and provider type. Injured workers who reported less-favorable treatment experience were 3.54 times as likely (95 percent confidence interval, 1.20-10.95, p = .021) to be receiving time-loss compensation for inability to work due to injury 6 or 12 months after filing a claim, compared to patients whose treatment experience was more positive.