Long-term reliable change of pain scores in individual myogenous TMD patients

A systematic review of temporomandibular disorder diagnostic methods

Objective: To compile the screening tools used to study temporomandibular disorders (TMD), classify and analyze their potential application in the field of physiotherapy.Methods: All gathered data included randomized clinical trials on humans over 18 years of age pulled from three databases up to November 2019.Results: Nineteen articles were retained, in which the subjects included 1095 women and 385 men. The 32 valuation systems reported were classified as follows: direct, requiring observation and/or palpation in situ by a clinician, which can be subdivided into protocols and instrumental systems; and indirect, requiring neither observation nor palpation by a clinician, which can be subdivided into questionnaires and scales.Conclusion: In order to evaluate TMD, the best choice is to combine direct and indirect assessment methodologies. The valuation of pressure pain threshold with an algometer and Fonseca's Anamnestic Index in combination with Anamnestic Questionnaire CMD, respectively, seems to provide the best results.

Focused Evidence Review: Psychometric Properties of Patient-Reported Outcome Measures for Chronic Musculoskeletal Pain

BACKGROUND

Developing successful interventions for chronic musculoskeletal pain requires valid, responsive, and reliable outcome measures. The Minneapolis VA Evidence-based Synthesis Program completed a focused evidence review on key psychometric properties of 17 self-report measures of pain severity and pain-related functional impairment suitable for clinical research on chronic musculoskeletal pain.

METHODS

Pain experts of the VA Pain Measurement Outcomes Workgroup identified 17 pain measures to undergo systematic review. In addition to a MEDLINE search on these 17 measures (1/2000-1/2017), we hand-searched (without publication date limits) the reference lists of all included studies, prior systematic reviews, and-when available-Web sites dedicated to each measure (PROSPERO registration CRD42017056610). Our primary outcome was the measure's minimal important difference (MID). Secondary outcomes included responsiveness, validity, and test-retest reliability. Outcomes were synthesized through evidence mapping and qualitative comparison.

RESULTS

Of 1635 abstracts identified, 331 articles underwent full-text review, and 43 met inclusion criteria. Five measures (Oswestry Disability Index (ODI), Roland-Morris Disability Questionnaire (RMDQ), SF-36 Bodily Pain Scale (SF-36 BPS), Numeric Rating Scale (NRS), and Visual Analog Scale (VAS)) had data reported on MID, responsiveness, validity, and test-retest reliability. Seven measures had data reported on three of the four psychometric outcomes. Eight measures had reported MIDs, though estimation methods differed substantially and often were not clinically anchored.

CONCLUSIONS

In this focused evidence review, the most evidence on key psychometric properties in chronic musculoskeletal pain populations was found for the ODI, RMDQ, SF-36 BPS, NRS, and VAS. Key limitations in the field include substantial variation in methods of estimating psychometric properties, defining chronic musculoskeletal pain, and reporting patient demographics.

TRIAL REGISTRATION

Registered in the PROSPERO database: CRD42017056610.

Grading the intensity of nondental orofacial pain: identification of cutoff points for mild, moderate, and severe pain

Background

When assessing pain in clinical practice, clinicians often label pain as mild, moderate, and severe. However, these categories are not distinctly defined, and are often used arbitrarily. Instruments for pain assessment use more sophisticated scales, such as a 0–10 numerical rating scale, and apart from pain intensity assess pain-related interference and disability. The aim of the study was to identify cutoff points for mild, moderate, and severe nondental orofacial pain using a numerical rating scale, a pain-related interference scale, and a disability measurement.

Materials and methods

A total of 245 patients referred to the Facial Pain Unit in London were included in the study. Intensity and pain-related interference were assessed by the Brief Pain Inventory. Pain-related disability was assessed by the Chronic Graded Pain Scale. Average pain intensity (0–10) was classified into nine schemes with varying cutoff points of mild, moderate, and severe pain. The scheme with the most significant intergroup difference, expressed by multivariate analysis of variance, provided the cutoffs between mild, moderate, and severe pain.

Results

The combination that showed the greatest intergroup differences for all patients was scheme 47 (mild 1–4, moderate 5–7, severe 8–10). The same combination provided the greatest intergroup differences in subgroups of patients with temporomandibular disorder and chronic idiopathic facial pain, respectively. Among the trigeminal neuralgia patients alone, the combination with the highest intergroup differences was scheme 48 (mild 1–4, moderate 5–8, severe 9–10).

Conclusion

The cutoff points established in this study can discriminate in pain intensity categories reasonably well, and showed a significant difference in most of the outcome measures used.

The index 'Treatment Duration Control' for enabling randomized controlled trials with variation in duration of treatment of chronic pain patients

Background

Treatment duration varies with the type of therapy and a patient’s recovery speed. Including such a variation in randomized controlled trials (RCTs) enables comparison of the actual therapeutic potential of different therapies in clinical care. An index, Treatment Duration Control (TDC) of outcome scores was developed to help decide when to end treatment and also to determine treatment outcome by a blinded assessor. In contrast to traditional Routine Outcome Monitoring which considers raw score changes, TDC uses relative change.

Methods

Our theory shows that if a patient with the largest baseline scores in a sample requires a relative decrease by treatment factor T to reach a zone of low score values (functional status), any patient with smaller baselines will attain functional status with T. Furthermore, the end score values are proportional to the baseline. These characteristics concur with findings from the literature that a patient’s assessment of ‘much improved’ following treatment (related to attaining functional status) is associated with a particular relative decrease in pain intensity yielding a final pain intensity that is proportional to the baseline. Regarding the TDC-procedure: those patient’s scores that were related to pronounced signs and symptoms, were selected for adaptive testing (reference scores). A Contrast-value was determined for each reference score between its reference level and a subsequent level, and averaging all Contrast-values yielded TDC. A cut-off point related to factor T for attaining functional status, was the TDC-criterion to end a patient’s treatment as being successful. The use of TDC has been illustrated in RCT data from 118 chronic pain patients with myogenous Temporomandibular Disorders, and the TDC-criterion was validated.

Results

The TDC-criterion of successful/unsuccessful treatment approximated the cut-off separating two patient subgroups in a bimodal post-treatment distribution of TDC-values. Pain intensity decreased to residual levels and Health-Related Quality of Life (HRQoL) increased to normal levels, following successful treatment according to TDC. The post-treatment TDC-values were independent from the baseline values of pain intensity or HRQoL, and thus independent from the patient’s baseline severity of myogenous Temporomandibular Disorders.

Conclusions

TDC enables RCTs that have a variable therapy- and patient-specific duration.