Works of Illness and the Challenges of Social Risk and the Specter of Pain in the Lived Experience of TMD

A meta-ethnography of how children and young people with chronic non-cancer pain and their families experience and understand their condition, pain services, and treatments

BACKGROUND

Chronic non-cancer pain in childhood is widespread, affecting 20% to 35% of children and young people worldwide. For a sizeable number of children, chronic non-cancer pain has considerable negative impacts on their lives and quality of life, and leads to increased use of healthcare services and medication. In many countries, there are few services for managing children's chronic non-cancer pain, with many services being inadequate. Fourteen Cochrane Reviews assessing the effects of pharmacological, psychological, psychosocial, dietary or physical activity interventions for managing children's chronic non-cancer pain identified a lack of high-quality evidence to inform pain management. To design and deliver services and interventions that meet the needs of patients and their families, we need to understand how children with chronic non-cancer pain and their families experience pain, their views of services and treatments for chronic pain, and which outcomes are important to them.

OBJECTIVES

1. To synthesise qualitative studies that examine the experiences and perceptions of children with chronic non-cancer pain and their families regarding chronic non-cancer pain, treatments and services to inform the design and delivery of health and social care services, interventions and future research. 2. To explore whether our review findings help to explain the results of Cochrane Reviews of intervention effects of treatments for children's chronic non-cancer pain. 3. To determine if programme theories and outcomes of interventions match children and their families' views of desired treatments and outcomes. 4. To use our findings to inform the selection and design of patient-reported outcome measures for use in chronic non-cancer pain studies and interventions and care provision to children and their families. The review questions are: 1. How do children with chronic non-cancer pain and their families conceptualise chronic pain? 2. How do children with chronic non-cancer pain and their families live with chronic pain? 3. What do children with chronic non-cancer pain and their families think of how health and social care services respond to and manage their child's chronic pain? 4. What do children with chronic non-cancer pain and their families conceptualise as 'good' chronic pain management and what do they want to achieve from chronic pain management interventions and services?

SEARCH METHODS

Review strategy: we comprehensively searched 12 bibliographic databases including MEDLINE, CINAHL, PsycInfo and grey literature sources, and conducted supplementary searches in 2020. We updated the database searches in September 2022.

SELECTION CRITERIA

To identify published and unpublished qualitative research with children aged 3 months to 18 years with chronic non-cancer pain and their families focusing on their perceptions, experiences and views of chronic pain, services and treatments. The final inclusion criteria were agreed with a patient and public involvement group of children and young people with chronic non-cancer pain and their families.

DATA COLLECTION AND ANALYSIS

We conducted a qualitative evidence synthesis using meta-ethnography, a seven-phase, systematic, interpretive, inductive methodology that takes into account the contexts and meanings of the original studies. We assessed the richness of eligible studies and purposively sampled rich studies ensuring they addressed the review questions. Cochrane Qualitative Methods Implementation Group guidance guided sampling. We assessed the methodological limitations of studies using the Critical Appraisal Skills Programme tool. We extracted data on study aims, focus, characteristics and conceptual findings from study reports using NVivo software. We compared these study data to determine how the studies related to one another and grouped studies by pain conditions for synthesis. We used meta-ethnography to synthesise each group of studies separately before synthesising them all together. Analysis and interpretation of studies involved children with chronic non-cancer pain and their families and has resulted in theory to inform service design and delivery. Sampling, organising studies for synthesis, and analysis and interpretation involved our patient and public involvement group who contributed throughout the conduct of the review. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We used a matrix approach to integrate our findings with existing Cochrane Reviews on treatment effectiveness for children's chronic non-cancer pain.

MAIN RESULTS

We synthesised 43 studies sampled from 170 eligible studies reported in 182 publications. Included studies involved 633 participants. GRADE-CERQual assessments of findings were mostly high (n = 21, 58%) or moderate (n = 12, 33%) confidence with three (8%) low or very low confidence. Poorly managed, moderate or severe chronic non-cancer pain had profound adverse impacts on family dynamics and relationships; family members' emotions, well-being, autonomy and sense of self-identity; parenting strategies; friendships and socialising; children's education and future employment prospects; and parental employment. Most children and parents understood chronic non-cancer pain as having an underlying biological cause and wanted curative treatment. However, families had difficulties seeking and obtaining support from health services to manage their child's pain and its impacts. Children and parents felt that healthcare professionals did not always listen to their experiences and expertise, or believe the child's pain. Some families repeatedly visited health services seeking a diagnosis and cure. Over time, some children and families gave up hope of effective treatment. Outcomes measured within trials and Cochrane Reviews of intervention effects did not include some outcomes of importance to children and families, including impacts of pain on the whole family and absence of pain. Cochrane Reviews have mainly neglected a holistic biopsychosocial approach, which specifies the interrelatedness of biological, psychological and social aspects of illness, when selecting outcome measures and considering how chronic pain management interventions work.

AUTHORS' CONCLUSIONS

We had high or moderate confidence in the evidence contributing to most review findings. Further research, especially into families' experiences of treatments and services, could strengthen the evidence for low or very low confidence findings. Future research should also explore families' experiences in low- to middle-income contexts; of pain treatments including opioid use in children, which remains controversial; and of social care services. We need development and testing of family-centred interventions and services acceptable to families. Future trials of children's chronic non-cancer pain interventions should include family-centred outcomes.

"It's All in Your Head": A Meta-Synthesis of Qualitative Research About Disenfranchising Talk Experienced by Female Patients with Chronic Overlapping Pain Conditions

Interactions between female patients with chronic pain and their medical providers in which providers question or contest the "realness" or nature of their illness experience (e.g. "It's all in your head") have been reported extensively in the extant qualitative literature, particularly for poorly understood ("contested") chronic pain syndromes. Many terms have been offered to describe this talk (e.g. invalidating, dismissive), resulting in conceptual fragmentation and isolated silos of research which together report about one communicative phenomenon. To rectify this fragmentation, the present study offers a meta-synthesis which explores, analyzes, and integrates the findings of 82 qualitative interview studies representing the patient-provider communication experiences of 2,434 female patients living with one or more of 10 chronic overlapping pain conditions (COPCs). COPCs are costly, gendered, and poorly understood. From the meta-synthesis, three key concepts are identified: (1) Functions of disenfranchising talk: Discrediting, silencing, and stereotyping; (2) Effects of disenfranchising talk: Harmed agency, credibility; access to care, support, and resources; and perception of patient-provider relationship; and (3) Responses to disenfranchising talk: Submission, critique, and resistance. Findings confirm the centrality of gender in the experience of disenfranchising talk, underscore the need to adopt an intersectional approach to the study of this talk along additional axes of race and class, and offer heuristic value toward conceptually unifying research about female COPC patients' experiences of disenfranchising talk from providers.

Healthcare priorities in patients with chronic facial pain of temporomandibular disorders

OBJECTIVES

To explore the experiences of patients with temporomandibular disorders (TMDs) with the National Health Service and to discover their healthcare priorities when seeking treatment.

METHODS

Semi-structured interviews were used. They were directed using a topic guide covering subjects such as initial visits in primary care, referrals to secondary care, and the effect on symptoms. The discussions were audiotaped and transcribed verbatim. Thematic analysis was utilised to analyse the data.

RESULTS

In total, 15 participants took part in three focus groups. Six themes were identified: "access to appropriate care", "organised and coordinated care", "receiving a diagnosis and enough information", "interaction with the clinical staff", "treatment strategies and having an 'action plan'" and "support and social networks".

CONCLUSIONS

The participants gave accounts of the difficulties encountered in healthcare in general terms and specific to TMD. Most notable was the struggle to access appropriate care, receive a diagnosis and be understood. Our findings suggest that delays in delivering appointments with people of expertise may have caused the worsening of symptoms. However, when a pleasant experience was encountered, access to care was fast, the clinician was understanding and communication with the clinical team was good. These provided positive experiences and were appreciated by the patients.

Sensory Neuron-TRPV4 Modulates Temporomandibular Disorder Pain Via CGRP in Mice

Temporomandibular disorder (TMD) pain that involves inflammation and injury in the temporomandibular joint (TMJ) and/or masticatory muscle is the most common form of orofacial pain. We recently found that transient receptor potential vanilloid-4 (TRPV4) in trigeminal ganglion (TG) neurons is upregulated after TMJ inflammation, and TRPV4 coexpresses with calcitonin gene-related peptide (CGRP) in TMJ-innervating TG neurons. Here, we extended these findings to determine the specific contribution of TRPV4 in TG neurons to TMD pain, and examine whether sensory neuron-TRPV4 modulates TMD pain via CGRP. In mouse models of TMJ inflammation or masseter muscle injury, sensory neuron-Trpv4 conditional knockout (cKO) mice displayed reduced pain. Coexpression of TRPV4 and CGRP in TMJ- or masseter muscle-innervating TG neurons was increased after TMJ inflammation and masseter muscle injury, respectively. Activation of TRPV4-expressing TG neurons triggered secretion of CGRP, which was associated with increased levels of CGRP in peri-TMJ tissues, masseter muscle, spinal trigeminal nucleus, and plasma in both models. Local injection of CGRP into the TMJ or masseter muscle evoked acute pain in naïve mice, while blockade of CGRP receptor attenuated pain in mouse models of TMD. These results suggest that TRPV4 in TG neurons contributes to TMD pain by potentiating CGRP secretion. PERSPECTIVE: This study demonstrates that activation of TRPV4 in TG sensory neurons drives pain by potentiating the release of pain mediator CGRP in mouse models of TMJ inflammation and masseter muscle injury. Targeting TRPV4 and CGRP may be of clinical potential in alleviating TMD pain.

A Meta-Synthesis of the Experience of Chronic Temporomandibular Disorder Patients Within Health Care Services

Aims: To systematically review the qualitative evidence related to experiences of patients with temporomandibular disorders (TMD) and to explore their journeys within health care services. Methods: A systematic search of the following databases was conducted: MEDLINE, Embase, PsycINFO, Web of Science, CINAHL Complete, and the Cochrane database. Thematic synthesis was used to analyze and synthesize the data from qualitative studies that explored the journeys of TMD patients within health care services. The Critical Appraisal Skills Programme (CASP) tool was used to critically appraise the quality of the included studies. Results: The search strategies yielded 4,563 articles across all databases, and 18 articles were eventually included. Six themes were derived: care-seeking attitudes; expectations and health care experience; the patient-clinician interaction; diagnosis as a stepping stone for improvement; management; and social support. Conclusion: The journey within health care services may play a valuable role in the ability to cope with chronic TMDs. Receiving a diagnosis, being listened to, and being believed are among the most important elements making for a positive clinical experience.

"What if it doesn't unlock?": A qualitative study into the lived experiences of adults with persistent intra-articular temporomandibular disorders

BACKGROUND

Temporomandibular disorders (TMD) are associated with increased self-reported disability and psychosocial issues, although little is known about those who specifically experience mechanical signs and symptoms such as clicking and locking. Understanding the lived experiences of individuals with persistent intra-articular TMD is an important first step to gaining insight into specific domains of self-reported disability associated with these conditions. This information can be helpful to improve clinical management of this subgroup.

OBJECTIVES

To explore the lived experiences of adults with persistent intra-articular TMD, including its impact on activity, participation and psychological wellbeing, and the influence of contextual factors on disability.

DESIGN

Qualitative study.

METHODS

Semi-structured interviews explored the lived experiences of adults with persistent intra-articular TMD, and data were analysed using thematic analysis. Participants were recruited via convenience sampling from private physiotherapy and dental practices, and the community.

RESULTS

Sixteen participants were interviewed. Four themes emerged from the data: i) The challenge of living with intra-articular TMD, ii) Living with uncertainty, iii) Seeking control, and iv) Learning to live with it. Novel findings included the impact of persistent intra-articular TMD on dreams, work, intimacy and socialising; and the role of non-pain symptoms (e.g. locking) in disability.

CONCLUSIONS

Persistent intra-articular TMD are associated with numerous activity limitations, participation restrictions and psychological issues. Disability is complex and multi-directional, and influenced by various contextual factors including individuals' thoughts, beliefs and support networks. These findings emphasise the need for biopsychosocial and person-centred care in clinical practice.

Chronic pain experience and health inequities during the COVID-19 pandemic in Canada: qualitative findings from the chronic pain & COVID-19 pan-Canadian study

BACKGROUND

Chronic pain affects about 20 % of the Canadian population and can lead to physical, psychological and social vulnerabilities. However, this condition remains poorly recognized and undertreated. During 2020, as the COVID-19 pandemic disrupted daily living and health care systems, the situation of people with chronic pain has drawn little public attention.

METHODS

This qualitative study was part of a pan-Canadian mixed-methods project and aimed to understand the experiences and challenges of people living with chronic pain during the COVID-19 pandemic in Canada. Between May and August 2020, we conducted in-depth semi-structured interviews with 22 individuals living with chronic pain across the country. We used reflexive thematic analysis to interpret data.

RESULTS

Our findings underscored four dimensions of the chronic pain experience during the pandemic: (1) Reinforced vulnerability due to uncertainties regarding pain and its management; (2) Social network as a determinant of pain and psychological condition; (3) Increasing systemic inequities intermingling with the chronic pain experience; (4) More viable living conditions due to confinement measures. Though several participants reported improvements in their quality of life and reduced social pressure in the context of stay-at-home orders, participants from socio-economically deprived groups and minorities reported more challenges in accessing pain relief, health care services, and psychosocial support.

CONCLUSIONS

The COVID-19 pandemic has revealed and intensified pre-existing disparities and challenges among people living with chronic pain in terms of material resources, psychosocial condition, social support, and access to care. In post-pandemic times, it will be essential to address flaws in health and welfare policies to foster equity and social inclusiveness of people with chronic pain.

The Stressful Characteristics of Pain That Drive You NUTS: A Qualitative Exploration of a Stress Model to Understand the Chronic Pain Experience

OBJECTIVE

Despite decades of research on the identification of specific characteristics of situations that trigger a physiological stress response (novelty, unpredictability, threat to the ego, and sense of low control [NUTS]), no integrative research has examined the validity of this framework applied to pain experiences. This study aimed to 1) explore the stressful characteristics of pain among individuals living with chronic pain and 2) examine whether the NUTS framework comprehensively captures the stressful nature of pain.

SUBJECTS

Participants were 41 adult participants living with chronic pain.

METHODS

Interviews in six focus groups were conducted in French using a semistructured interview guide. Participants first discussed how pain is stressful. Then, they were introduced to the NUTS framework and commented on the extent to which it captured their experience. The verbatim transcriptions of interviews were reviewed using reflexive thematic analysis. Analyses were conducted in French; quotes and themes were translated into English by a professional translator.

RESULTS

The pain-NUTS framework adequately captured participants' experiences. Multiple aspects of pain (pain intensity fluctuations, pain flare-up duration, pain quality and location, functional limitations, diagnosis and treatment) were associated with one or more stress-inducing characteristics. In addition, a second layer of meaning emerged in the context of chronic pain that provided contextual information regarding when, how, and why pain became more or less stressful.

CONCLUSIONS

The NUTS characteristics seem to offer a comprehensive framework to understand how pain and its context of chronicity can be a source of stress. This study provides preliminary support for the pain-NUTS framework to allow the formal integration of pain and stress research.

Transient Receptor Potential (TRP) Ion Channels in Orofacial Pain

Orofacial pain, including temporomandibular joint disorders pain, trigeminal neuralgia, dental pain, and debilitating headaches, affects millions of Americans each year with significant population health impact. Despite the existence of a large body of information on the subject, the molecular underpinnings of orofacial pain remain elusive. Two decades of research has identified that transient receptor potential (TRP) ion channels play a crucial role in pathological pain. A number of TRP ion channels are clearly expressed in the trigeminal sensory system and have critical functions in the transduction and pathogenesis of orofacial pain. Although there are many similarities, the orofacial sensory system shows some distinct peripheral and central pain processing and different sensitivities from the spinal sensory system. Relative to the extensive review on TRPs in spinally-mediated pain, the summary of TRPs in trigeminally-mediated pain has not been well-documented. This review focuses on the current experimental evidence involving TRP ion channels, particularly TRPV1, TRPA1, TRPV4, and TRPM8 in orofacial pain, and discusses their possible cellular and molecular mechanisms.

Persons with Complex Regional Pain Syndrome Renegotiate Social Roles and Intimacy: A Qualitative Study

Objective

Persons with complex regional pain syndrome often experience allodynia, where touch is painful. Allodynia is associated with poor prognosis, but the impacts on roles, activities, social relationships, and intimacy remain unclear. There is a need to examine intimacy in complex regional pain syndrome from a lived experience perspective.

Methods

We conducted a secondary analysis of cognitive debriefing interview data from 44 persons with complex regional pain syndrome who completed a patient-reported questionnaire. Using interpretive description and thematic analysis, we analyzed items and responses addressing allodynia, relationships, and intimacy.

Results

Two themes were developed to understand intimacy related to the pain experience: a renegotiated social identity and participation and a reinvented intimate self. These themes included elements of a) loss of control, b) loss of shared experiences, c) feeling that their condition was misunderstood, d) a need for self-preservation, e) altered self-concept, and e) the concept of intimacy is broader than sexuality. Our findings suggest that complex regional pain syndrome has pervasive impacts on relationships and intimacy that merit discussion with their health care team.

Conclusions

Persons with persistent pain need to be supported in roles and activities that allow them to express intimacy in their everyday lives.

Broadening measures of success: results of a behavioral health translational research training program

Background

While some research training programs have considered the importance of mentoring in inspiring professionals to engage in translational research, most evaluations emphasize outcomes specific to academic productivity as primary measures of training program success. The impact of such training or mentoring programs on stakeholders and local community organizations engaged in translational research efforts has received little attention. The purpose of this evaluation is to explore outcomes other than traditional academic productivity in a translational research graduate certificate program designed to pair graduate students and behavioral health professionals in collaborative service-learning projects.

Methods

Semi-structured qualitative interviews with scholars, community mentors, and academic mentors were conducted regarding a translational research program to identify programmatic impacts. Interviews were transcribed and coded by the research team to identify salient themes related to programmatic outcomes.

Results

Results are framed using the Translational Research Impact Scale which is organized into three overarching domains of potential impact: (1) research-related impacts, (2) translational impacts, and (3) societal impacts. This evaluation demonstrates the program’s impact in all three domains of the TRIS evaluation framework. Graduate certificate participants (scholars) reported that gaining experience in applied behavioral health settings added useful skills and expertise to their present careers and increased their interest in pursuing translational research. Scholars also described benefits resulting from networks gained through participation in the program, including valuable ties between the university and community behavioral health organizations.

Conclusions

This evaluation of the outcomes of a graduate certificate program providing training in translational research highlights the need for more community-oriented and practice-based measures of success. Encouraging practitioner involvement in translational research is vital to translate knowledge into practice and to enable practice-based needs to inform research and policy. A more flexible approach to measuring programmatic success in research training programs can help bridge the knowledge translation gap.

Social risk, stigma and space: key concepts for understanding HIV vulnerability among black men who have sex with men in New York City

Black men who have sex with men in the USA face disproportionate incidence rates of HIV. This paper presents findings from an ethnographic study conducted in New York City that explored the structural and socio-cultural factors shaping men's sexual relationships with the goal of furthering understandings of their HIV-related vulnerability. Methods included participant observation and in-depth interviews with 31 Black men who have sex with men (three times each) and 17 key informants. We found that HIV vulnerability is perceived as produced through structural inequalities including economic insecurity, housing instability, and stigma and discrimination. The theoretical concepts of social risk, intersectional stigma, and the social production of space are offered as lenses through which to analyse how structural inequalities shape HIV vulnerability. We found that social risk shaped HIV vulnerability by influencing men's decisions in four domains: 1) where to find sexual partners, 2) where to engage in sexual relationships, 3) what kinds of relationships to seek, and 4) whether to carry and to use condoms. Advancing conceptualisations of social risk, we show that intersectional stigma and the social production of space are key processes through which social risk generates HIV vulnerability among Black men who have sex with men.

Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain

In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response.

Medical Judgments Across the Range of Reported Pain Severity: Clinician and Lay Perspectives

BACKGROUND

While increasing evidence suggests that observers discount high-severity chronic pain, factors that occasion such discounting are poorly understood, particularly regarding health provider vs lay perspectives.

OBJECTIVE

This study examined the effects of supporting medical evidence and comorbid psychological distress (pain behavior) on medical student and lay clinical judgments of increasingly severe patient pain reports.

DESIGN

In a 2 × 2 × 2 × (7) mixed between- and within-subject design, participants (medical students vs lay) made clinical judgments after reading vignettes describing a hypothetical patient that varied in levels of medical evidence and pain behavior (low vs high) and pain severity (4/10-10/10).

SUBJECTS

Fourth-year medical students (N = 115) and lay persons in the community (N = 300) participated in this research.

RESULTS

While both medical student and lay judgments plateaued at high levels of pain severity, judgments regarding cause (medical vs psychological), treatment (opioid prescription), and disability showed growing divergence as levels of reported pain severity increased. Divergence relative to medical and psychological causes of pain was found irrespective of the level of supporting medical evidence; divergence relative to opioid treatment and support for a disability claim was found when supporting medical evidence was low.

CONCLUSIONS

The results indicate differing expectations of chronic pain treatment for health care providers relative to the lay public that could impact clinical care, especially at high pain severity levels, where lay expectations diverge significantly from those of health professionals.

"Just Advil": Harm reduction and identity construction in the consumption of over-the-counter medication for chronic pain

Direct-to-consumer marketing has sparked ongoing debate concerning whether ads empower consumers to be agents of their own care or shift greater control to the pharmaceutical industry. Ads for over-the-counter (OTC) medications in particular portend to offer simple, harmless solutions for meeting the demands of social life. Rather than join the longstanding debate between consumer agency and social control in pharmaceutical advertising, I approach self-medication with over-the-counter (OTC) analgesics using Harm Reduction as a framework. From this perspective, consumption of OTC analgesics by chronic pain sufferers is a means of seeking some level of relief while also avoiding the stigma associated with prescription pain medication. Qualitative methods are used to analyze data from two sources: (1) semi-structured qualitative interviews with 95 participants in a trial examining the effectiveness of Traditional Chinese Medicine for Temporomandibular Disorders (TMD) from 2006 to 2011 in Tucson, AZ and Portland, OR; and (2) print, online, and television advertisements for three major brands of OTC pain medication. Participants described their use of OTC medications as minimal, responsible, and justified by the severity of their pain. OTC medication advertising, while ostensibly ambiguous and targeting all forms of pain, effectively lends support to the consumption of these medications as part of the self-projects of chronic pain sufferers, allowing them to reconcile conflicting demands for pain relief while being stoic and maintaining a positive moral identity. Describing OTC medication as "just over-the-counter" or "not real pain medication," sufferers engage in ideological harm reduction, distinguishing themselves from "those people who like taking pain medication" while still seeking relief. Justifying one's use of OTC medication as minimal and "normal," regardless of intake, avoids association with the addictive potential of prescription pain medications and aligns the identity of the chronic pain sufferer with a culturally sanctioned identity as stoic bearer of pain.