An examination of the psychometric structure of the Multidimensional Pain Inventory in temporomandibular disorder patients: a confirmatory factor analysis

Patient-Reported Outcome Measures Used in Temporomandibular Disorders: A Review of the Literature

AIMS

To identify the range of patient-reported outcome measures (PROMs) used in TMD studies, summarize the available evidence for their psychometric properties, and provide guidance for the selection of such measures.

METHODS

A comprehensive search was conducted to retrieve articles published between 2009 and 2018 containing a patient-reported measure of the effects of TMDs. Three databases were searched: MEDLINE, Embase, and Web of Science.

RESULTS

A total of 517 articles containing at least one PROM were included in the review, and 57 additional studies were also located describing the psychometric properties of some tools in a TMD population. A total of 106 PROMs were identified and fell into the following categories: PROMs describing the severity of symptoms; PROMs describing psychologic status; and PROMs describing quality of life and general health. The most commonly used PROM was the visual analog scale. However, a wide range of verbal descriptors was employed. The Oral Health Impact Profile-14 and Beck Depression Inventory were the most commonly used PROMs describing the effect of TMDs on quality of life and psychologic status, respectively. Additionally, the Oral Health Impact Profile (various versions) and the Research Diagnostic Criteria Axis ll questionnaires were the instruments most repeatedly tested in a TMD population, and these instruments have undergone cross-cultural validation in several languages.

CONCLUSION

A wide range of PROMs have been used to describe the impact of TMDs on patients. Such variability may limit the ability of researchers and clinicians to evaluate the efficacy of different treatments and make meaningful comparisons.

Psychological therapies for temporomandibular disorders (TMDs)

BACKGROUND

Temporomandibular disorders (TMDs) are a group of musculoskeletal disorders affecting the jaw. They are frequently associated with pain that can be difficult to manage and may become persistent (chronic). Psychological therapies aim to support people with TMDs to manage their pain, leading to reduced pain, disability and distress.

OBJECTIVES

To assess the effects of psychological therapies in people (aged 12 years and over) with painful TMD lasting 3 months or longer.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched six bibliographic databases up to 21 October 2021 and used additional search methods to identify published, unpublished and ongoing studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of any psychological therapy (e.g. cognitive behaviour therapy (CBT), behaviour therapy (BT), acceptance and commitment therapy (ACT), mindfulness) for the management of painful TMD. We compared these against control or alternative treatment (e.g. oral appliance, medication, physiotherapy).

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We reported outcome data immediately after treatment and at the longest available follow-up. We used the Cochrane RoB 1 tool to assess the risk of bias in included studies. Two review authors independently assessed each included study for any risk of bias in sequence generation, allocation concealment, blinding of outcome assessors, incomplete outcome data, selective reporting of outcomes, and other issues. We judged the certainty of the evidence for each key comparison and outcome as high, moderate, low or very low according to GRADE criteria.

MAIN RESULTS

We identified 22 RCTs (2001 participants), carried out between 1967 and 2021. We were able to include 12 of these studies in meta-analyses. The risk of bias was high across studies, and we judged the certainty of the evidence to be low to very low overall; further research may change the findings. Our key outcomes of interest were: pain intensity, disability caused by pain, adverse events and psychological distress. Treatments varied in length, with the shortest being 4 weeks. The follow-up time ranged from 3 months to 12 months. Most studies evaluated CBT.   At treatment completion, there was no evidence of a benefit of CBT on pain intensity when measured against alternative treatment (standardised mean difference (SMD) 0.03, confidence interval (CI) -0.21 to 0.28; P = 0.79; 5 studies, 509 participants) or control (SMD -0.09, CI -0.30 to 0.12; P = 0.41; 6 studies, 577 participants). At follow-up, there was evidence of a small benefit of CBT for reducing pain intensity compared to alternative treatment (SMD -0.29, 95% CI -0.50 to -0.08; 5 studies, 475 participants) and control (SMD -0.30, CI -0.51 to -0.09; 6 studies, 639 participants). At treatment completion, there was no evidence of a difference in disability outcomes (interference in activities caused by pain) between CBT and alternative treatment (SMD 0.15, CI -0.40 to 0.10; P = 0.25; 3 studies, 245 participants), or between CBT and control/usual care (SMD 0.02, CI -0.21 to 0.24; P = 0.88; 3 studies, 315 participants). Nor was there evidence of a difference at follow-up (CBT versus alternative treatment: SMD -0.15, CI -0.42 to 0.12; 3 studies, 245 participants; CBT versus control: SMD 0.01 CI - 0.61 to 0.64; 2 studies, 240 participants). There were very few data on adverse events. From the data available, adverse effects associated with psychological treatment tended to be minor and to occur less often than in alternative treatment groups. There were, however, insufficient data available to draw firm conclusions. CBT showed a small benefit in terms of reducing psychological distress at treatment completion compared to alternative treatment (SMD -0.32, 95% CI -0.50 to -0.15; 6 studies, 553 participants), which was maintained at follow-up (SMD -0.32, 95% CI -0.51 to -0.13; 6 studies, 516 participants). For CBT versus control, only one study reported results for distress and did not find evidence of a difference between groups at treatment completion (mean difference (MD) 2.36, 95% CI -1.17 to 5.89; 101 participants) or follow-up (MD -1.02, 95% CI -4.02 to 1.98; 101 participants). We assessed the certainty of the evidence to be low or very low for all comparisons and outcomes. The data were insufficient to draw any reliable conclusions about psychological therapies other than CBT.

AUTHORS' CONCLUSIONS

We found mixed evidence for the effects of psychological therapies on painful temporomandibular disorders (TMDs). There is low-certainty evidence that CBT may reduce pain intensity more than alternative treatments or control when measured at longest follow-up,  but not at treatment completion. There is low-certainty evidence that CBT may be better than alternative treatments, but not control, for reducing psychological distress at treatment completion and follow-up. There is low-certainty evidence that CBT may not be better than other treatments or control for pain disability outcomes.  There is insufficient evidence to draw conclusions about alternative psychological therapeutic approaches, and there are insufficient data to be clear about adverse effects that may be associated with psychological therapies for painful TMD.  Overall, we found insufficient evidence on which to base a reliable judgement about the efficacy of psychological therapies for painful TMD. Further research is needed to determine whether or not psychological therapies are effective, the most effective type of therapy and delivery method, and how it can best be targeted. In particular, high-quality RCTs conducted in primary care and community settings are required, which evaluate a range of psychological approaches against alternative treatments or usual care, involve both adults and adolescents, and collect measures of pain intensity, pain disability and psychological distress until at least 12 months post-treatment.

DEEP Study: Utility of the multidimensional pain inventory in persistent oro-facial pain

BACKGROUND

Persistent oro-facial pain (POFP) is disabling, and patients' treatment outcomes are difficult to predict; psychosocial factors play a role. The West Haven-Yale Multidimensional Pain Inventory (MPI) is a self-report measure, which to our knowledge, has not been studied across primary and secondary care in heterogeneous POFP.

OBJECTIVE

Assess the MPI's ability to predict clinical outcome in POFP patients across primary and secondary care settings receiving usual care.

METHODS

About 146 patients receiving usual care for POFP were recruited from primary and secondary care medical and dental practices in north-east England. Participants completed the MPI (v3) and Graded Chronic Pain Scale (GCPS) at recruitment, and after 6, 12, 18 and 24 months. The Patient Health Questionnaire-4 (PHQ-4) was completed at recruitment, 12, and 24 months. 'Good' and 'poor' outcome status was assigned to participants based on their mode dichotomised GCPS score across timepoints. Logistic regression was used with overall GCPS outcome (good/poor) as the dependent variable and MPI subscale scores, demographic variables, and PHQ-4 scores as predictors.

RESULTS

110 participants had a 'good', and 36 had a 'poor' outcome. In the 'poor' outcome group, age, mean income, and life control scores were lower; deprivation, months in pain, PHQ-4, pain severity, interference, and affective distress scores were higher. In the 'good' group, MPI scores improved over time. Interference was the only consistent predictor of 'poor' outcome in the logistic regression model (OR: 1.14-1.98, p < 0.05).

CONCLUSION

The MPI interference subscale may help to identify patients with POFP who are likely to have consistent pain-related disability over time; it may therefore be useful clinically to identify patients likely to need early intervention.

BEEP-Bodily and Emotional Perception of Pain. A Questionnaire to Measure Reaction to Pain in Chronic Pain Disorders

Background: The assessment of pain and its impact on quality of life is central to the evaluation of chronic pain syndromes. However, most available tools focus on the nociceptive experience of pain, and at best only consider the occurrence of anxious, depressive, or cognitive problems. Here is a new questionnaire aimed at measuring the multifaceted impact of pain in chronic pain syndromes, the Bodily and Emotional pErception of Pain (BEEP).

Methods: All consecutive patients who accessed a center for the treatment of pain were invited to take part in the study. The sample included 222 participants (51 with fibromyalgia, 84 with low back pain; 87 with other chronic pain syndromes). Women were 77% of the sample, the mean age was 61 ± 15. Participants completed the BEEP, the Patient Health Questionnaire-9 (PHQ-9), and the Mood Disorder Questionnaire (MDQ).

Results: Reliability was good for all questionnaires. The expected three dimensions of the BEEP were confirmed by confirmatory factor analysis, and a bifactor model with three orthogonal factors showed a good fit as well. Participants diagnosed with fibromyalgia showed higher scores on the BEEP than the participants who had been diagnosed with low back pain or other chronic pain syndromes. The prevalence of probable cases of major depression and bipolar disorder in the sample was higher than expected for non-clinical samples. Levels of depression, as measured by the PHQ-9, were associated with the three dimensions of the BEEP and with the intensity of pain.

Conclusions: The BEEP is a promising measure of the impact of pain in daily life and differentiates fibromyalgia from other chronic pain syndromes. The BEEP may be helpful to evaluate the patient's response to the treatment over time and may favor the identification of unmet needs in patients' personal, social, and daily functioning.

Association between headache and temporomandibular disorder

Headaches are one of the most common conditions associated with temporomandibular disorder (TMD). In the present paper, we evaluated the relationship between headache and TMD, determined whether headache influences the symptoms of TMD, and reported two cases of TMD accompanied by headache. Our practical experience and a review of the literature suggested that headache increases the frequency and intensity of pain parameters, thus complicating dysfunctional diseases in both diagnostic and treatment phases. Therefore, early and multidisciplinary treatment of TMD is necessary to avoid the overlap of painful events that could result in pain chronicity.

Do Correlates of Pain-Related Stoicism and Cautiousness Differ in Younger and Older People With Advanced Cancer?

Age differences are not evident in pain-related stoicism and cautiousness in people with cancer pain. Little is known about the factors associated with these pain-related attitudes or age-related patterns in these associations. The present cross-sectional study investigated the biopsychosocial correlates of the attitudes in younger and older patients with advanced cancer. Pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) were assessed using the Pain Attitudes Questionnaire-Revised (PAQ-R). Participants, 155 younger (younger than 60 years old) and 114 older (60 years old or older) patients with advanced cancer completed the PAQ-R and measures of sociodemographic and medical characteristics, pain intensity, cognitive-affective pain-related responses, physical functioning, psychological distress and well-being, and psychosocial functioning. Backwards regression analyses identified correlates for each PAQ-R factor separately for younger and older patients. Activity engagement was a frequent correlate, but its relationship with concealment was the only association common to both age groups. Younger and older patients exhibited different avoidance-related constructs suggesting relational challenges in the former group (avoidant attachment) and intrapersonal fear in the latter (cognitive avoidance). Medical correlates also showed age differences: younger patients showed symptom-focused correlates, whereas older patients showed aging-related correlates. Findings support a biopsychosocial framework of cancer-pain adaptation incorporating a lifespan-developmental perspective.

PERSPECTIVE

To our knowledge, this article is the first to identify biopsychosocial correlates of stoic and cautious attitudes toward cancer pain in younger and older patients with advanced cancer. Findings highlight possible age-related motivations for greater pain-related stoicism or cautiousness and can potentially inform interventions addressing challenges in cancer-pain adaptation in advanced cancer.

Temporomandibular Disorder Diagnostic Groups Affect Outcomes Independently of Treatment in Patients at Risk for Developing Chronicity: A 2-Year Follow-Up Study

AIMS

To evaluate whether a biobehavioral intervention would be more effective than a self-care intervention or no intervention in reducing psychosocial distress, reducing pain, and improving functioning in patients with an acute myofascial temporomandibular disorder (m-TMD).

METHODS

Participants (n = 435) were from community dental clinics in the Dallas-Fort Worth Metroplex who were seeking treatment for their acute TMD symptoms and were recruited between 2008 and 2013. The participants were diagnosed using the Research Diagnostic Criteria for TMD (RDC/TMD) and assigned to a biobehavioral intervention, self-care intervention, or no intervention. Three outcomes were assessed: psychosocial distress, pain, and functioning; and treatment effectiveness was assessed according to TMD diagnosis. Outcome evaluations were conducted immediately postintervention as well as at 1 and 2 years postintervention. Analyses were conducted using two-level hierarchical multilevel linear models (MLMs).

RESULTS

Contrary to expectations, patients did not respond differently to the intervention based on their TMD diagnosis. Acute m-TMD patients, especially those with other comorbid TMD diagnoses, reported the highest levels of pain and pain-related symptoms and disability. They also exhibited poorer jaw functioning, especially if they were at high risk for chronic TMD.

CONCLUSION

This study indicates that acute m-TMD tends to result in more severe symptom presentations, particularly if diagnosed in combination with other TMD comorbidities. Additionally, patients do not appear to respond better to biobehavioral or self-care intervention on the basis of their TMD diagnosis.

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.

Pain Intensity Moderates the Relationship Between Age and Pain Interference in Chronic Orofacial Pain Patients

BACKGROUND/STUDY CONTEXT: Chronic pain is associated with increased interference in daily functioning that becomes more pronounced as pain intensity increases. Based on previous research showing that older adults maintain well-being in the face of pain as well as or better than their younger counterparts, the current study examined the interaction of age and pain intensity on interference in a sample of chronic orofacial pain patients.

METHODS

Data were obtained from the records of 508 chronic orofacial pain patients being seen for an initial evaluation from 2008 to 2012. Collected data included age (range: 18-78) and self-reported measures of pain intensity and pain interference. Bivariate correlations and regression models were used to assess for statistical interactions.

RESULTS

Regression analyses revealed that pain intensity positively predicted pain interference (R(2) = .35, B = 10.40, SE = 0.62, t(507) = 16.70, p < .001). A significant interaction supported the primary hypothesis that aging was associated with reduced interference at high levels of pain intensity (ΔR(2) = .01, B = -1.31, SE = 0.63, t(505) = -2.90, p = .04).

CONCLUSION

At high levels of pain intensity, interference decreased with age, although the age by pain intensity interaction effect was small. This evidence converges with aging theories, including socioemotional selectivity theory, which posits that as people age, they become more motivated to maximize positive emotions and minimize negative ones. The results highlight the importance of studying the mechanisms older adults use to successfully cope with pain.

Somatosensory and affective contributions to emotional, social, and daily functioning in chronic pain patients

OBJECTIVE

The present study tested the independent and interactive contributions of the somatosensory component of pain (pain intensity) and the affective component of pain (pain unpleasantness) on emotional, social, and daily functioning in chronic pain patients.

SUBJECTS

Participants were 472 patients seeking treatment for chronic orofacial pain. Mean age of the sample was 46.0 years (standard deviation [SD] = 14.67, range 18-78), with 82.2% female. Average pain duration at the time of initial appointment was 75.7 months (SD = 106.66).

METHODS

Participants completed self-report measures of pain intensity, unpleasantness, and functional outcomes at the time of their first appointment. These data were later extracted from participant's de-identified medical records. Multivariate linear regression was used to test the interaction of pain intensity and unpleasantness on outcome measures of emotional, social, and daily functioning.

RESULTS

Results revealed that pain intensity contributed to poorer functional outcomes but higher levels of social support even after controlling for pain unpleasantness. After controlling for pain intensity, unpleasantness was associated with higher pain interference and affective distress. There was also pain intensity by unpleasantness interaction on pain interference. Specifically, at lower levels of pain unpleasantness, changes in pain intensity produced greater changes in pain interference than they did at higher levels of pain unpleasantness.

CONCLUSIONS

Results suggest that both intensity and unpleasantness contribute unique variance to functional outcomes. The results highlight the importance of interventions that not only try to reduce pain levels but also reduce levels of pain unpleasantness.

A preliminary study of cigarette smoking in female orofacial pain patients

The relationship between behavior (eg, diet, exercise, substance use) and the functioning of chronic-pain patients, including orofacial-pain patients, is poorly understood. This preliminary study examined cigarette smoking and both pain-related and psychological functioning in female orofacial-pain patients. Correlates of intentions to quit smoking were also explored. There were 48 participants in this cross-sectional study. Smokers reported significantly less self-control over pain (d = .66), lower general activity levels (d = .52), more fatigue (d = .80), and poorer sleep quality (d = .53) than non-smokers. The mean effect size for all dependent variables was .49 (range, .33-.80) with the smallest and largest effect found for negative mood and fatigue, respectively. More positive attitudes toward smoking cessation independently predicted stronger intentions to quit (β = .52, p = .03). Findings suggest smoking is significantly associated with pain-related and psychological functioning in female orofacial-pain patients. Smoking-cessation treatment for these patients should include motivational interviewing techniques directed toward attitudinal change.

Enhancing the efficacy of treatment for temporomandibular patients with muscular diagnosis through cognitive-behavioral intervention, including hypnosis: a randomized study

OBJECTIVE

This study evaluated the efficacy of a cognitive-behavioral therapy (CBT), including hypnosis, in patients with temporomandibular disorders (TMDs) with muscular diagnosis.

STUDY DESIGN

Seventy-two patients (65 women and 7 men with an average age of 39 years) were selected according to the Research Diagnostic Criteria for TMD, and assigned to the experimental group (n = 41), receiving the 6-session CBT program, and the control group (n = 31). All patients received conservative standard treatment for TMD. The assessment included pain variables and psychologic distress.

RESULTS

There were significant differences between the groups, the experimental group showing a higher improvement in the variables evaluated. Specifically, 90% of the patients under CBT reported a significant reduction in frequency of pain and 70% in emotional distress. The improvement was stable over time, with no significant differences between posttreatment and 9-month follow-up.

CONCLUSIONS

CBT, including hypnosis, significantly improved conservative standard treatment outcome in TMD patients.

Disaggregating the relationship between posttraumatic stress disorder symptom clusters and chronic orofacial pain: implications for the prediction of health outcomes with PTSD symptom clusters

BACKGROUND

Research has established a significant relationship between posttraumatic stress disorder (PTSD) symptoms and pain; however, very little research has examined the differential role of PTSD symptom clusters on pain outcomes.

PURPOSE

(a) To confirm the most appropriate PTSD symptom factor structure for an orofacial pain population and (b) to test a model of prediction of pain outcomes with PTSD symptom clusters.

METHODS

The study was a cross-sectional, retrospective case series of 411 female patients with orofacial pain (mean 41.0 years, SD 13.1). A series of structural equation modeling analyses were conducted to examine five competing models of PTSD symptom clusters.

RESULTS

Two four-factor models of PTSD symptom clusters fit the data reasonably well, and differing PTSD symptom clusters predicted different components of pain.

CONCLUSIONS

To increase predictive utility for pain and for a wide range of health disorders, researchers should examine the unique predictive power of PTSD symptom clusters rather than examining a one-factor model of PTSD symptoms.