Injuries, dislocations, and poor health perceived by older adults to result from vigorous physical activity: implications for active living, health promotion, and gerontology

This study examines older adults' perceptions about their participation in vigorous physical activity (VPA) and the association between VPA and self-related health. A total of 686 older adults responded to self-reported questionnaires, and Pearson's ꭓ2 test and binary logistic regression were used to present findings. About 74% of older adults reported experiencing dislocations, fractures, or/and other forms of injury in intense physical activities lasting 30 minutes or more a day. After controlling for relevant socio-demographic factors, older adults who participated in VPA for 30 or more minutes a day were less likely (OR=0,129; p=0,000) to report good health compared with those who participated in VPA for less than 30 minutes. It is concluded that VPA in older populations can result in casualties that may compel older adults to underrate their health, which can discourage active living habits in older populations and discredit PA/health promotion programs.

Satisfaction with Life in Orofacial Pain Disorders: Associations and Theoretical Implications

AIMS

To test if patients with masticatory myofascial pain, local myalgia, centrally mediated myalgia, disc displacement, capsulitis/synovitis, or continuous neuropathic pain differed in self-reported satisfaction with life. The study also tested if satisfaction with life was similarly predicted by measures of physical, emotional, and social functioning across disorders.

METHODS

Satisfaction with life, fatigue, affective distress, social support, and pain data were extracted from the medical records of 343 patients seeking treatment for chronic orofacial pain. Patients were grouped by primary diagnosis assigned following their initial appointment. Satisfaction with life was compared between disorders, with and without pain intensity entered as a covariate. Disorder-specific linear regression models using physical, emotional, and social predictors of satisfaction with life were computed.

RESULTS

Patients with centrally mediated myalgia reported significantly lower satisfaction with life than did patients with any of the other five disorders. Inclusion of pain intensity as a covariate weakened but did not eliminate the effect. Satisfaction with life was predicted by measures of physical, emotional, and social functioning, but these associations were not consistent across disorders.

CONCLUSIONS

Results suggest that reduced satisfaction with life in patients with centrally mediated myalgia is not due only to pain intensity. There may be other factors that predispose people to both reduced satisfaction with life and centrally mediated myalgia. Furthermore, the results suggest that satisfaction with life is differentially influenced by physical, emotional, and social functioning in different orofacial pain disorders.

Impact of Age on Pain Perception for Typical Painful Diagnoses in the Emergency Department

BACKGROUND

Age-related differences in pain perception have been demonstrated in experimental settings but have been investigated scarcely and without valid scale in the clinical framework.

OBJECTIVES

To examine the effect of age on pain perception for recognized painful diagnoses encountered in the emergency department (ED).

METHODS

A post-hoc analysis of real-time archived data was performed in a tertiary urban and a secondary regional ED. We included all consecutive adult patients (≥18 years) with the following diagnosis at discharge: renal colic, pancreatitis, appendicitis, headache/migraine, dislocation and extremities fractures, and a pain evaluation of ≥1 (0-10, verbal numerical scale) at triage. The primary outcome was to compare for each of these diagnoses the level of pain intensity between four age groups (18-44; 45-64; 65-74; 75+ years).

RESULTS

A total of 15,670 patients (48% women) were triaged with a mean pain intensity of 7.7 (SD=2.0). Women exhibited greater pain scores than men for pancreatitis, headache/migraine, and extremity fracture. Renal colic, pancreatitis, appendicitis, and headache/migraine showed a linear decrease in pain scores with age whereas dislocation and extremity fractures did not present age differences. Mean differences in pain intensity scores between young adults (18-44 years) and patients aged ≥75 years were 0.79 (95% confidence interval [95% CI] 0.5-1.1) for renal colic, 1.1 (95% CI 0.7-1.4) for pancreatitis, 0.70 (95% CI 0.2-1.2) for appendicitis, and 0.86 (95% CI 0.6-1.1) for headache/migraine.

CONCLUSION

Older patients perceive similar pain for dislocation and extremity fractures and less for visceral and headache/migraine pain; however, these age differences may not be clinically important.

Biopsychosocial factors associated with the subcategories of acute temporomandibular joint disorders

AIMS

To assess the biopsychosocial factors associated with acute temporomandibular disorders (TMD) based on the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD).

METHODS

Participants were assessed in community-based dental clinics and evaluated by trained clinicians using physical and psychosocial measures. A total of 207 subjects were evaluated. Patients' high-risk versus low-risk status for potentially developing chronic TMD was also determined. Analyses of variance and chi square analyses were applied to these data.

RESULTS

Participants' characteristic pain intensity differed among RDC/TMD Axis I diagnoses. They also significantly varied in their self-reported graded chronic pain, depression, somatization (pain inclusive), somatization (pain excluded), and physical well-being. In addition, participants with differing RDC/TMD Axis I diagnoses varied in self-reported pain during their chewing performance. Finally, there were also significant differences in chewing performance between high-risk versus low-risk (for developing chronic TMD) patients.

CONCLUSION

Participants with multiple diagnoses reported higher pain, as well as other symptoms, relative to participants without a TMD diagnosis. For chewing performance, participants with mutual diagnoses reported more pain compared to other participants. Finally, the risk-status of patients significantly affected chewing performance.

The effects of chronic pain on oral health related quality of life in patients with anterior disc displacement with reduction

AIM

The aim of this study was to evaluate the effects of chronic pain on oral health related quality of life (oral QoL) in patients with anterior disc displacement with reduction (DDwR).

MATERIAL AND METHODS

Thirty-seven patients who had disc displacement with reduction (DDwR, F/M: 23/14, median age: 29, range: 23-49) were selected. These patients had chronic pain and had not been undergoing any treatment protocols for the previous six months. Age- and gender-matched healthy subjects healthy control, F/M: 23/14, mean age: 33.0 +/- 15.7 years) were used as a control group. Data were collected by means of a clinical examination and a questionnaire about pain status which included a jaw disability checklist RDC/TMD (Research Diagnostic Criteria for Temporomandibular Disorders). Pain status was scored between 0 (no pain) and 10 (poor pain status) by the patients. Oral health related quality of life (oral QoL) over the previous six months was evaluated by an oral health impact profile-14 (OHIP-14) questionnaire.

RESULTS

OHIP-14 score was significantly higher in patients with DDwR (median:17, min-max:6-39) than healthy controls (9, 0-18) (p = 0.000). The median duration of orofacial pain was 12 (range 7-120) months. Statistically significant correlations were observed between OHIP-14 score and the worst pain intensity in the past six months (7, 0-10) (r = 0.5 p = 0.007) and average pain intensity in the past six months (5.5, 1-10) (r = 0.4 p = 0.018). In addition, an increase in OHIP-14 score was observed in patients experiencing difficulty in smiling/laughing, cleaning their teeth or face, swallowing or talking, according to the jaw disability checklist (p = 0.042, p = 0.001, p = 0.023 and p = 0.007, respectively).

CONCLUSION

Poor oral QoL was related to chronic pain and limitations in jaw function in patients with DDwR.

[Chronic right-sided pain-associated nondermatomal somatosensory deficit following an accident]

We present the case of a 48-year old man who, eight years after an industrial accident, presents with chronic right-sided nondermatomal pain and hypaesthesia to heat and touch. During symmetric peripheral touch functional magnetic resonance imaging revealed hypometabolism in the left thalamus, somatosensory cortex, and anterior cingulate cortex. Pain-associated nondermatomal somatosensory deficits (NDSDs) localizing to one side of the body are a frequent clinical entity, which are often triggered by an accident. The tendency of NDSDs to extend to adjunct ipsilateral body parts and to become chronic points to maladaptive adjustment of pain-processing areas in the central nervous system. Psychological stress prior to or around the triggering event seems an important risk factor for NDSDs.

Comparison of occlusal discomfort in patients with temporomandibular disorders between myofascial pain and disc displacement

We compared occlusal discomfort in patients with temporomandibular disorders (TMD) between myofascial pain (MFP) and disc displacement (DD) using a database created from Sep, 2003 to Aug, 2005. We selected 71 patients with MFP and 170 patients with DD to construct a null model of structural equation modeling (SEM) in which anxiety influenced depressive mood, depressive mood aggravated occlusal discomfort and sleep complaints, and sleep complaints or an onset event caused by another person aggravated occlusal discomfort. We performed a simultaneous analysis of patients with MFP and DD. The estimated parameter of the path from depressive mood to occlusal discomfort was significant for patients with MFP, but not for patients with DD. The path from an onset event caused by another person, such as dental treatment to occlusal discomfort was significant in patients with MFP and those with DD. The Goodness of Fit Index (=0.909), The Adjusted Goodness of Fit Index (=0.867), and The Root Mean Square Error of Approximation (=0.039) indicated good acceptability. These results suggested that an increase in depressive mood may aggravate occlusal discomfort in patients with MFP, and an onset event caused by another person, such as dental treatment, also may aggravate occlusal discomfort in patients with MFP and those with DD.

Role of psychosocial factors in the etiology of temporomandibular disorders: relevance of a biaxial diagnosis

AIM

The prevalence of temporomandibular disorders (TMD) is higher among women than men, indicating a multifactorial role for gender-related differences in the etiology of TMD: physiological hormonal differences, inflammatory response to stress, and sociocultural differences in response to pain. The aim of this study was to draw a biobehavioral picture of the TMD patient based on Research Diagnostic Criteria for TMD (RDC/TM) Axis II diagnosis and analysis of gender-related differences.

METHODS

Between January 2006 and January 2008, 362 subjects were consecutively enrolled from patients who presented at the Clinic for Temporomandibular Disorders, School of Dental Medicine, University of Pavia, because of orofacial pain, limitation or joint sounds on mandibular movement. Of the 362 subjects evaluated, 308 met the inclusion criteria.

RESULTS

The average age of the study population was 41 years; the female: male ratio was 4:1. When stratified according to chronic pain intensity grade and gender, 26% of the women had grade I, 36.4% grade II, 17% grade III, and 9.7% grade IV; 34.4% of the men had grade I, 32.8% grade II, 6.5% grade III, and 3.3% grade IV. Depression was moderate in 35 women and in 6 men and severe in 138 women and in 24 men; somatization was moderate in 59 women and in 20 men and severe in 143 women and in 19 men.

CONCLUSIONS

Gender-related differences may be considered risk factors for TMD; psychological characteristics, including somatization, depression, and anxiety related to gender, appear to have a significant impact on the prevalence of TMD.

Oral health-related quality of life in patients with temporomandibular disorders

AIMS

To characterize the level of impairment of oral health-related quality of life (OHRQoL) in a temporomandibular disorder (TMD) patient population.

METHODS

OHRQoL was measured using the German version of the Oral Health Impact Profile (OHIP-G) in a consecutive sample of 416 patients seeking treatment for their complaints in the masticatory muscles and temporomandibular joints and with at least 1 diagnosis according to the German version of the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). The level of impairment of OHRQoL was characterized by the OHIP summary score mean and its 95% confidence interval. OHRQoL was described for each of the 8 RDC/TMD diagnoses (Axis I) and the RDC/TMD Axis II measures (Graded Chronic Pain Scale [GCPS], jaw disability list, depression, and somatization). These findings were compared with the level of impairment of OHRQoL in the adult general population derived from a national sample (n = 2,026).

RESULTS

Among the RDC/TMD Axis I measures, all diagnoses were correlated with much higher impacts compared to the normal population (means for all diagnoses were 32.8 to 53.7 versus 15.8 in the general population). All diagnoses had a similar level of impact except for disc displacement with reduction (which had a lower impact). There were larger differences in mean OHIP-G scores among subgroups of RDC/TMD Axis II measures than among subgroups of RDC/TMD Axis I characteristics. The strongest association was with GCPS, with mean OHIP scores of 33.3 for grade I, 48.1 for grade II, 71.7 for grade III, and 88.5 for grade IV.

CONCLUSION

OHRQoL was markedly impaired in TMD patients. The level of OHRQoL varied across diagnostic categories but more across Axis II, ie, the psychosocial axis; the variation was reflected especially in their level of graded chronic pain.

Psychologic status in patients with temporomandibular disorders

PURPOSE

The aim of this study was to investigate diferrences in the prevalence of depression and somatization scores in temporomandibular disorder (TMD) patients.

MATERIALS AND METHODS

One hundred fifty-four patients with single and/or multiple RDC/TMD diagnoses were classified into 7 groups based on Axis I criteria. Somatization and depression scores from the Symptom Checklist-90 were compared between groups.

RESULTS

The results of this investigation indicate that patients with myofascial pain and arthralgia psychologically differed from those with disc displacement. These results were in accordance with findings that support the notion that the pain induces psychologic sequelae, at least in relation to depression and somatization.

CONCLUSION

It was concluded that psychologic factors play an important role in etiopathogenesis of TMD, as demonstrated by an increase in levels of depression and somatization in TMD patients.

The role of parafunctions, emotions and stress in predicting facial pain

BACKGROUND

The authors conducted a study to examine the degree to which parafunctions and emotional states predicted jaw pain in subjects with temporomandibular disorder (TMD) and control subjects.

METHODS

Ninety-six subjects diagnosed with myofascial pain, myofascial pain and arthralgia, disk displacement or no TMD symptoms participated. The authors used experience sampling methodology to collect data on pain, behaviors and emotions. They paged subjects approximately every two hours, but not during sleep. When paged, subjects completed a brief questionnaire containing rating scales of jaw pain, masticatory muscle tension, time and intensity of tooth contact, mood and stress level.

RESULTS

Analyses of variance showed that groups differed significantly (P < .05) in terms of pain; masticatory muscle tension; and a composite variable measuring time and intensity of contact; mood; and stress. The two myofascial pain groups scored higher on these measures than did the group with disk displacement and the control group. The authors used masticatory muscle tension, the composite variable, mood and stress to predict jaw pain using linear regression. The model was significant and accounted for 69 percent of the variance in jaw pain. Because tension was so highly correlated with jaw pain, the authors removed this variable and re-ran the analysis. The second model also was significant and accounted for 46 percent of the variance in jaw pain.

CONCLUSIONS

Parafunctional behaviors, especially those that increase muscle tension, and emotional states are good predictors of jaw pain levels in patients with TMD and healthy control subjects.

CLINICAL IMPLICATIONS

Treatment that helps patients reduce parafunctions, excess masticatory muscle tension, stress and emotional distress should be effective in reducing TMD pain.

Chronic myofascial pain, disk displacement with reduction and psychosocial factors in Finnish non-patients

This study aimed to determine chronic groups of myofascial pain and chronic disk displacement with reduction over a 1-year period, and to study the relationship between psychological status and these chronic subgroups of temporomandibular disorders (TMD) in non-patients. A total of 211 subjects (males 47%, mean age 46 years; standard deviation 6) attended examinations in 1999 and 2000 performed according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Chronic myofascial pain was found in 7% and chronic disk displacement with reduction in 11% of subjects; new diagnoses were made in only 4% and 1% of the subjects, respectively. An increase in the level of somatization by 1 step increased the probability of having chronic myofascial pain by over 3 times (P = 0.006). Myofascial pain and disk displacement with reduction seem to be relatively common and fluctuating in nature in non-patients. As somatization associated significantly with myofascial pain, this should be borne in mind in the management of TMD. The results strengthen the rationale of the biopsychosocial orientation in health care.

Functional outcome (SF-36) of patients with displaced calcaneal fractures compared to SF-36 normative data

BACKGROUND

The purpose of this study was to demonstrate the general health status after treatment of displaced intraarticular calcaneal fractures compared to normative data, other orthopaedic procedures, and other medical conditions.

METHODS

Three hundred and twelve patients between 25 and 64 years of age were treated for displaced intraarticular calcaneal fractures at a Level I trauma center. Followup ranged from 2 to 8 years. The Short Form 36 Health Status Survey (SF-36) was used for outcome measurement.

RESULTS

The scores in eight SF-36 categories in patients with displaced intraarticular calcaneal fractures differed by more than five points from the population norms. This suggests that there is clinical and social relevance to this injury. Outcomes in patients with displaced intraarticular calcaneal fractures were not as good across most SF-36 categories as were outcomes of patients with other orthopaedic conditions. Outcomes in patients with intraarticular calcaneal fractures also were worse across most categories than outcomes in patients who had organ transplants or myocardial infarctions.

CONCLUSION

By comparing treatment for displaced intraarticular calcaneal fractures with treatment for orthopaedic problems or other disease processes, we concluded that intraarticular calcaneal fractures are serious life-changing events.

The association between subtalar joint motion and outcome satisfaction in patients with displaced intraarticular calcaneal fractures

BACKGROUND

There is a paucity of literature on the effect of calcaneal fractures on subtalar joint motion and patient satisfaction. The objective of this study was to determine the relationship between subtalar joint motion and outcome satisfaction in patients who had displaced intraarticular calcaneal fractures. The design of this study was a retrospective analysis from a randomized, controlled clinical trial. The setting was a Level I trauma center.

METHODS

Of the 332 displaced intraarticular calcaneal fractures entered into the clinical trial and managed by the senior author, 244 fractures had subtalar joint motion measurements taken at least 12 weeks after fracture, and patient-oriented outcomes were reviewed at 2 years. Nonoperative treatment consisted of ice, elevation, and rest without closed reduction. In the operative group, an extended lateral approach was used with subchondral fixation, plating, and bone grafting when necessary. The Short Form 36 (SF-36), a validated visual analogue scale (VAS), and a gait analogue score measured patient satisfaction. Subtalar joint motion was recorded as percentages of the uninjured limb and grouped into quartiles.

RESULTS

The VAS, SF-36 (p <.0001), and the gait satisfaction score (p <.05) all increased significantly with increasing subtalar joint motion. Satisfaction on the VAS and SF-36 was significantly related to subtalar joint motion for men (p <.0001) and in the age groups 30 to 39 (p <.001) and 40 to 49 years (p <0.05). In non-Workman Compensation Board (WCB) clients, higher subtalar joint motion was significantly related to improved satisfaction on VAS and SF-36 (p <.005). Patient satisfaction was significantly related to subtalar joint motion as measured by the VAS when patients reported pre-injury workloads of moderate (p <.05) or heavy (p <.01) regardless of whether they were treated operatively (p <.05) or nonoperatively (p <.0005).

CONCLUSIONS

The amount of subtalar joint motion at least 12 weeks after displaced intraarticular calcaneal fracture is significantly related to patient satisfaction at 2 years regardless of the method of treatment.

Depression in older people after fall-related injuries: a prospective study

BACKGROUND

objectives of the study were i) to describe changes in depression in independently living people aged 57 or older with fall-related injuries, and ii) to examine the effect of incomplete recovery of physical functions on depression one year post-injury.

METHOD

prospective cohort-study, including a pre-injury baseline and post-injury assessments at 8 weeks, 5 months and one year. The sample consisted of 159 patients who sustained various kinds of fall-related injuries to the limbs. Physical functioning was measured by the Groningen Activity Restriction Scale, depression by the Hospital Anxiety and Depression Scale. Additional variables in the study were age, gender, chronic medical conditions and severity of the injury (three level-groups). Pre- and post-injury levels of depression were compared by using Student's t-test and effect size indices. Hierarchical multivariate regression analysis was used to examine the contribution of change in physical functioning between baseline and one year post-injury to depression one year post-injury.

RESULTS

severity of the injury was not associated with depression. Mean depression levels of all patients remained stable until 5 months post-injury but increased between 5 months and one year. Physical functioning decreased between baseline and 8 weeks post-injury, increased between 8 weeks and 5 months but did not change after 5 months. One year post-injury, both disability and depression were higher than at baseline. Change in physical functioning between baseline and one year post-injury accounted for 19% of the variance in depression explained by the regression model.

CONCLUSIONS

depressive reactions did not occur as long as patients experienced improvement in physical functioning but became manifest as recovery appeared to stagnate. No significant differences in this respect were found between hip fracture patients and patients with other injuries.

Depression and somatization in patients with temporomandibular disorders

STATEMENT OF PROBLEM

Psychological and behavioral traits may be important for the diagnosis and management of orofacial pain.

PURPOSE

This study compared the levels of depression and somatization in patients in single and multiple research diagnostic criteria for temporomandibular disorders (RDC/TMD) diagnostic groups.

MATERIAL AND METHODS

The RDC/TMD was established to allow standardization and replication of research into the most common forms of muscle- and joint-related research and is divided into 2 axes: axis I, clinical TMD, and axis II, pain-related disability and psychological status. One hundred seventeen patients (28 male and 89 female; mean age, 33.3 +/- 10.3 years) with RDC/TMD-defined clinical TMD were selected. The RDC/TMD history questionnaire and examination forms were input directly into computers with the use of a software program developed at the National University of Singapore (NUS TMDv1.1 software). Axis I and II variables were generated online and automatically archived for statistical analysis. Patients were subsequently classified into 7 groups based on the presence of the various RDC/TMD axis I diagnostic groups: group A, myofascial pain only (group I); group B, disk displacement only (group II); group C, other joint conditions such as arthralgia, osteoarthritis, and osteoarthrosis only (group III); group D, myofascial pain and disk displacement (groups I and II); group E, myofascial pain and other joint conditions (groups I and III); group F, disk displacement and other joint conditions (groups II and III); and group G, myofascial pain, disk displacement, and other joint conditions (groups I, II, and III). Differences in mean Symptom Checklist-90 scores between groups were compared by analysis of variance/Scheffé tests to contrast depression and somatization levels between the various axis I diagnostic groups (alpha=.05).

RESULTS

The frequencies of the different groups were as follows: group A, 26.5%; group B, 29.9%; group C, 12.8%; group D, 6.0%; group E, 13.7%; group F, 4.3%; and group G, 6.8%. Approximately 39% of patients were clinically depressed, and 55% had moderate to severe somatization. Differences in mean depression and somatization with pain item scores were significant between groups (P<.05).

CONCLUSION

Within the limitations of this study, patients diagnosed with myofascial pain and other joint conditions (group E) had significantly higher levels of depression (P=.03) and somatization (P=.03) than patients diagnosed with only disk displacements (group B).

A case-control study of temporomandibular disorders: symptomatic disc displacement

This case-control study was designed to investigate the risk factors for disc displacement (DD) without myofascial pain (MFP). The study population included 59 cases with DD without MFP, selected in two hospital dental clinics, and 100 concurrent controls selected in one of these clinics. The association with DD was evaluated for bruxism, head-neck trauma, orthodontic treatment, and sociodemographic characteristics by using unconditional logistic regression. In the multivariate analysis, excluding psychological factors, an association was found between DD and clenching-grinding (OR=3.57; 95% CI: 1.27-9.98). This association persisted when anxiety (OR=3.07; 95% CI: 1.08-8.70) or depression (OR=4.02; 95% CI: 1.43-11.31) was included in the model. A positive association was noted between orthodontic treatment and DD (OR=3.10; 95% CI: 1.06-9.65). The effect between orthodontic treatment and DD remained and increased with the inclusion of anxiety (OR=3.65; 95% CI: 1.15-11.61) or depression (OR=3.20; 95% CI: 1.06-9.65). A high level of anxiety (OR=2.40; 95% CI: 1.01-5.73), was positively related to DD. We concluded that clenching combined with grinding, and orthodontic treatment are factors related to DD. The interpretation of these associations, however, requires caution because of the inclusion of prevalent cases.

Etiology, pathogenesis and treatment of habitual dislocations of the T.M. Joints [original work]

Definite treatment of any pathological condition, is based on the understanding of its correct pathogenesis and etiology. Without this basic understanding correct and lasting treatment is not possible. When there is no knowledge of exact pathogenesis and etiology, various theories and treatments are suggested by various workers. This is what exactly happened in the case of habitual dislocations of the T.M. Joints. This in term has happened because the dental surgeons and so called oral surgeons, never expanded their vision, beyond their restricted field of 20 deciduous teeth and 32 permanent teeth. Lack of understanding of basic physiological functions, of various tissues in the body and their effects on various systems as a whole was neglected. For this study four patients were selected from many, who could visit my clinic regularly and co-operate to follow all the instructions over a period of at least 5 years. The analysis of their symptoms and signs, had a different story to tell than what was described in the literature so far.

Emotional factors in temporomandibular joint disorders

The chronic pain of many temporomandibular disorders is associated with multiple changes in emotional function and activities of daily living. Temporomandibular disorders (TMD) are similar to other chronic pain disorders in their impact on patients. Depression is probably the most common emotional state associated with chronic pain, although anxiety disorders also can be associated with TMD. The probability of emotional problems appears to be greatest in those individuals diagnosed with myofascial pain and least in those with disk displacement. Dental practitioners are encouraged to seek professional liaisons with mental health professionals who can assist them in managing chronic pain patients.

'Everybody looks at my pubic bone'--a case report of an adolescent patient with body dysmorphic disorder

OBJECTIVE

Body dysmorphic disorder (BDD) was described for the first time more than 100 years ago, but it is still unknown to many clinicians. Although the onset usually occurs during adolescence, BDD has received little attention in the adolescent psychiatric literature.

METHOD

The case and treatment of a 16-year-old female patient is described.

RESULTS

The patient, suffering from the overvalued belief of a dislocated pubic bone, a comorbid mild depressive episode, BDD associated rituals and social avoidance, was treated successfully with a combination of exposure and response prevention and 125 mg/day of doxepine.

CONCLUSION

If BDD is diagnosed early in the course and treated appropriately, it is possible to obtain a satisfying outcome.

Cognitive-behavioral profiles among different categories of orofacial pain patients: diagnostic and treatment implications

Psychological homogeneity in temporomandibular disorders (TMD) is not conclusive. The multidimensional pain inventory (MPI) has previously identified 3 cognitive-behavioral profiles in TMD and chronic pain patients. Our aims were to replicate these findings in another cultural setting and relate the profiles to the diagnosis and to the treatment demand and outcome. The MPI was administered to 112 referrals comprising 6 categories of patients diagnosed with TMD or intractable orofacial pain. Dysfunctional profiles (high in pain and distress) were most common in patients with orofacial pain of obscure origin and more common in myofascial pain patients than in patients with other TMD diagnoses. Interpersonally-distressed profiles were found in all categories. Among patients with disk displacement, the 3rd profile (adaptive copers with low pain and distress and high control and activity) was most common in earlier successfully diskectomized patients and least common in those about to undergo invasive interventions. A dysfunctional profile was associated with treatment failure, conservative or surgical, and with the demand for radical therapy. Some support for a cyclical causality between pain and psychological factors was found. It is concluded that the robustness of the MPI as a relevant assessment instrument was further strengthened.

Voluntary scapulothoracic subluxation: a case report

Dislocation of the scapula is a rare event, usually associated with massive trauma and injury. We report a case of a patient for whom dislocation was the sole presentation. The possibility of voluntary dislocation for secondary gain was suspected, but because of perceived progressive brachial plexus involvement, urgent closed reduction was undertaken and led to resolution of the neurologic symptoms. The patient returned 1 year later with similar complaints and findings, but declined another closed reduction attempt when offered only an interscalene regional block as pain relief. The diagnosis of voluntary dislocation should be considered in a patient presenting with superior and lateral migration of the scapula, without a history of trauma.

Emergency treatment of acute temporomandibular disorders: Part II

In this, the second part of a presentation on the emergency treatment of an acute temporomandibular disorder, we will address the problems of joint sounds, open and closed locking and psychological considerations. The management of pain and muscle spasm was considered in the previous paper.

[Prediction of recovery from dislocation of the cervical vertebrae (whiplash injury of the cervical vertebrae) with initial assessment of psychosocial variables]

The purpose of the present study was to investigate the predictive relationship between psychosocial factors and the course of recovery in patients with whiplash injury. A non-selected sample of 117 subjects satisfying to a clear definition of the syndrome was assessed early after trauma (mean 7.4 +/- 4.2 days) and again at 3, 6, and 12 months. Initial evaluation included subjective complaints (including timing of symptom onset and initial pain intensity) and a large number of psychosocial factors (e.g., self-ratings of well-being, personal and family history, personality traits, and cognitive functioning). Rate of recovery was assessed at follow-ups. One year after initial trauma patients were divided in two groups (recovered and still symptomatic) and compared with regard to initial findings. Finally, a regression analysis was performed with all baseline variables, employing groups (recovered vs symptomatic) as factor variables. Patients who remained symptomatic at 1 year had significantly higher ratings of initial neck pain and headache, displayed a greater variety of subjective complaints, higher scores on the scale "nervousness" from the personality inventory, worse well-being score and poorer performance with regard to focussed attention. According to the regression analysis the following set of initial variables was in significant relationship with poor recovery at 1 year: higher age, complaint of sleep disturbances at initial investigation, and higher intensity of initial neck pain and headache.

Major skeletal injuries in the obtunded blunt trauma patient: a case for routine radiologic survey

Trauma patients obtunded as a result of head injury, hypotension, alcohol, or drugs have an unreliable physical examination which may lead to errors or delays in diagnosis. To define the extent of routine radiologic survey needed in patients with a depressed level of consciousness, the records of 789 adults with blunt injuries and a Glasgow Coma Score (GCS) of 10 or less on admission were reviewed. Major skeletal injury (MSI), was defined as one or more fractures or dislocations of the axial spine, pelvis, hip, or long bones of the lower extremity. The overall incidence of MSI was 31%. Injuries to the axial spine were present in 14% of patients, while 10% sustained pelvic fractures or hip dislocations and 15% sustained femur or tibia-fibula fractures. Patients who sustained MSI had lower admission CRAMS, Trauma Score, GCS, and admission blood pressure compared to non-MSI patients (p less than 0.002). An analysis of mechanisms of injury showed that pedestrians struck by a motor vehicle (57%), and victims of motorcycle accidents (40%) had increased incidences of MSI (p less than 0.05). Patients suffering falls (18%) and assaults (2%) had a decreased incidence of MSI (p less than 0.01). The high incidence of potentially occult MSI in obtunded patients after blunt trauma demonstrated by this data suggests the need for routine radiologic survey including the axial spine, pelvis and long bones of the lower extremity. Mechanism of injury, CRAMS, TS, and GCS may be useful in the early identification of a particularly high-risk group.

Patient response to surgical and nonsurgical treatment for internal derangement of the temporomandibular joint

One hundred thirty-six patients who had been diagnosed as having internal derangements of the temporomandibular joint by history, clinical examination, and arthrotomography were retrospectively evaluated. Fifty-two patients had been treated by nonsurgical and 84 by surgical methods. A case review was conducted and a self-administered survey was distributed to patients to assess response to treatment. The results indicated that for a majority of the patients surgery had significantly reduced TMJ symptoms. Patients who had been treated nonsurgically also reported fewer symptoms following treatment, but the improvement was not as great as that of the surgical group.

Psychometric profiles and facial pain

The myofacial pain-dysfunction syndrome and atypical facial pain are the most prevalent chronic pain disorders of the facial region. Previously, the myofacial pain-dysfunction syndrome included all TMJ/masticatory muscle pain, jaw dysfunction, and joint clicking. We have segregated two major subgroups subsumed within this diagnostic classification and have assigned them to a myogenic facial pain (MFP) group and a TMJ internal derangement (TMJID) group. Significant age and personality differences were uncovered when these subpopulations were compared to subjects with atypical facial pain (AFP). Both MFP and TMJID groups are relatively homologous, involving younger persons than AFP subjects. Alternatively, when MFP, TMJID, and AFP subjects were compared for differences in MMPI psychometric scales, MFP and AFP subjects exhibited significantly higher scores, particularly for hypochondriasis, depression, and hysteria, than did TMJID subjects. It is concluded that subcategorization of myofascial pain-dysfunction patients into a myogenic pain group and a TMJ internal derangement group is justified on the basis of psychometric differences. Furthermore, psychopathologic factors are more significant among MFP and AFP subjects than among TMJID patients.