Biofeedback in the treatment of long-term temporomandibular joint pain: an outcome study

The forehead lift, with interruption of the continuity of the frontalis muscle, has been an effective method in our hands for improving the appearance of the upper third of the face. It can be done independently, or combined with a facial rhytidectomy, a blepharoplasty, and/or other ancillary procedures. In some cases of apparent upper lid redundancy, it can eliminate the need for an upper lid blepharoplasty. The results are pleasing and seem to be lasting, while the complications have been few and mild. We describe the operation and discuss its indications, contraindications, advantages, and disadvantages.     

Etiologic factors in temporomandibular joint disorders and pain

Parallel to the construction of better classifications and the identification of subgroups of temporomandibular disorders, an important development has taken place in research concerning its etiology. The etiological factors implied in muscle problems refer to more generalised disorders as myofascial pain syndrome and fibromyalgia. The role of occlusal and articular factors has been brought down to realistic proportions, indicating a minor contribution. Similarly, doubt has arisen concerning the existence of a vicious cycle of pain/spasm/pain. With regard to internal derangements, emphasis has been put on the high prevalence in an otherwise normal population and the fluctuating character of the symptom. Also here, developments point towards constitutional and systemic factors, more than local influences. Trauma, however, seems to play an increasing role. The development of osteoarthrosis has been studied more in depth revealing local processes of inflammation, neurogenic inflammation and the existence of specific markers which might be important in the future. The relationship between disc derangement and the development of osteoarthrosis remains unclear.     

Electronic thermography for the assessment of acute temporomandibular joint pain

Electronic thermography (ET) has the potential to be a nonionizing, noninvasive, low-cost diagnostic alternative for evaluating temporomandibular joint (TMJ) disorders. This study was designed to evaluate the use of ET as a diagnostic aid in the assessment of patients with acute TMJ pain. Computer measurements made using facial thermography were able to distinguish normal patient populations from symptomatic patients with acute TMJ pain. Additional studies are needed before thermographic diagnosis of TMJ disorders will be clinically accepted.     

Biofeedback and relaxation training for chronic headache: A controlled comparison of booster treatments and regular contacts for long-term maintenance.

Assigned 55 adult Ss, successfully treated by 2 of the present authors in behavioral treatment for chronic headaches, to 1 of 2 follow-up conditions: (1) regular contact or (2) booster treatment. Ss assigned to regular contact were asked to continue daily monitoring of headache activity and home practice and were seen for a brief visit (10–25 min) on a monthly basis for 6 mo. Ss assigned to booster treatments received full sessions during their 6 monthly visits. Results show that at 1-yr follow-up diary records and interviews with Ss and significant others revealed no major differences between groups. Although Ss attributed a number of positive side effects to treatment, it is suggested that regular contact may be an efficient procedure for maintaining treatment gains. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting parent and child outcomes of a filial therapy program.

The present study investigated parent and child factors that predict outcome in a filial therapy program for parents (N = 27) and young children (ages 2–10). Higher levels of parent distress and poorer child regulation of emotion at pretest were predictive of greater reductions in child behavior problems; poorer parent regulation of emotion at pretest was predictive of greater increases in parent acceptance; and less parent satisfaction with social support from family and friends at pretest was predictive of greater increases in parent communication of acceptance in parent–child play. Implications and directions for future research are discussed. (PsycINFO Database Record (c) 2011 APA, all rights reserved)     

Comorbidity of depression with chronic facial pain and temporomandibular disorders

OBJECTIVE: The objective of this study was to examine the comorbidity of depressive disorders in patients with chronic facial pain presenting to a multidisciplinary facial pain clinic. STUDY DESIGN: Data were collected from 72 consecutive patients with chronic facial pain who had received a maltidisciplinary evaluation including a psychiatric examination for the presence of depressive disorders. RESULTS: Twenty-eight percent of patients met criteria of the latest Diagnostic and Statistical Manual of Mental Disorders for major depression, and 25% met the criteria for minor depression. A further 22% reported subsyndromal depressive symptoms. Temporomandibular disorders were demonstrable in 71% of these patients, but the remaining 29% had no objective physical findings. There was no statistical difference in comorbidity of depressive disorders in patients with temporomandibular disorders compared with patients without temporomandibular disorders. CONCLUSION: Screening for symptoms of depression should be an integral part of the evaluation of all patients with chronic facial pain, even when masticatory muscle or temporomandibular joint disorders are identified.     

Use and misuse of intra-articular corticosteroids in treatment of temporomandibular joint pain

In certain cases of intractable pain in the temporomandibular joint after conservative treatments have been unsuccessful, a single intra-articular injection of up to 40 mg of prednisolone trimethylacetate has been shown to be useful for permanent relief. This treatment has most success in patients over the age of 30 years; the older the patient the greater likelihood of clinical improvement. It is not to be recommended in the younger age groups. There is no evidence that a single intra-articular injection of any such corticosteroid causes damage that can be detected radiographically to an apparently sound articular surface. But it is still possible that multiple injections can cause damage, and they should not be used for any age group. In some cases where there is radiographic evidence of articular erosion before treatment, an advance of the lesion with reduction of the size of the mandibular condyle can be expected but is consistent with a reduction of the symptoms. The final result may be said to resemble a pharmacologically-achieved arthroplasty. Judgment of the success of the treatment by symptomatic assessment has proved to be entirely satisfactory, since the majority of patients have been grateful for the initial and continued relief of their pain and dysfunction. They have, in fact, avoided surgery to their joints and have no untoward side-effects.     

Biofeedback as therapy: Some theoretical and practical issues.

Gives examples of the use of biofeedback in individual therapy from basic research on self-regulation of blood pressure and heart rate and from clinical research on essential hypertension and Raynaud's disease. Patient motivation is a critical variable, since its absence may hamper long-term success in therapy, as indicated by case histories. The use of cognitive and somatic mediators as an aid to self-regulation, both with and without feedback, is illustrated. It is concluded that biofeedback, in conjunction with other medical and psychological techniques, may prove effective for a selected group of motivated patients having acute rather than chronic organ damage. A combined behavioral-biological model, emphasizing (a) the natural relations between responses; (b) the exact manner in which the feedback and reward is given; and (c) biological, cognitive, and environmental constraints, is offered as a potential means of predicting whether biofeedback training will be clinically significant for a given patient. (31 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Knowledge and beliefs of dentists regarding temporomandibular disorders and chronic pain

To assess the knowledge and beliefs of practicing dentists regarding temporomandibular disorders and chronic pain, a random sample of dentists in the Kansas City metropolitan area was surveyed. A survey instrument examining knowledge and beliefs in four domains (psychophysiological, psychiatric disorders, chronic pain, and pathophysiology) was used. The responses of the practicing dentists were compared to the responses of panels of experts. Results indicated that dentists generally agreed with experts in the psychophysiological and psychiatric disorders domains but disagreed with the experts in the chronic pain and pathophysiology domains. Specialists and general dentists did not differ from one another in their responses. The findings partially replicate an earlier, similar survey of dentists in the Seattle, Washington, area. The findings suggest that the role of psychiatric disorders and psychophysiologic factors in the etiology of temporomandibular disorders is widely acknowledged by practicing dentists. However, there is considerable discrepancy between practicing dentists and temporomandibular disorder experts on the pathophysiology of temporomandibular disorders and how best to diagnose and treat these chronic conditions.     

Biofeedback/relaxation training and exercise interventions for fibromyalgia: a prospective trial

OBJECTIVE: To compare the effectiveness of biofeedback/relaxation, exercise, and a combined program for the treatment of fibromyalgia. METHODS: Subjects (n = 119) were randomly assigned to one of 4 groups: 1) biofeedback/relaxation training, 2) exercise training, 3) a combination treatment, or 4) an educational/attention control program. RESULTS: All 3 treatment groups produced improvements in self-efficacy for function relative to the control condition. In addition, all treatment groups were significantly different from the control group on tender point index scores, reflecting a modest deterioration by the attention control group rather than improvements by the treatment groups. The exercise and combination groups also resulted in modest improvements on a physical activity measure. The combination group best maintained benefits across the 2-year period. CONCLUSION: This study demonstrates that these 3 treatment interventions result in improved self-efficacy for physical function which was best maintained by the combination group.     

Age analysis of cognitive-behavioral group therapy for chronic pain outpatients.

This study explored the effectiveness, in terms of age of the client, of a 10-week cognitive–behavioral group therapy (stress inoculation training) for chronic pain. A total of 69 outpatients between the ages of 27 and 80 (M?=?52.74 years, SD?=?14.40) with diverse types of chronic pain were assigned randomly to immediate or wait-list-delayed therapy. Self-report measures of pain, activities, coping, and the use of medications and other physical pain control techniques were obtained at baseline, during therapy, and at 1- and 6-month follow-up. Treatment decreased the degree to which pain interfered with activity, increased ability to cope with pain, and decreased use of some medications and other physical treatments. It had little effect on perceived pain intensity. Gains were maintained through 6-month follow-up. Age was unrelated to outcome. Stress inoculation training appears to be an effective method of ameliorating the interference of chronic pain with the daily activities of life for adults of all ages. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting the outcome of social therapy with chronic psychotics.

A group of 69 male, long-hospitalized chronic psychotics in an experimental rehabilitation unit was tested on a new device, the Hunter problem box, prior to their treatment by 1 or 3 variants of social therapy. A summary score, the Hunter Process Index, was developed to relate to patients' postprogram adjustment on completion of a social therapy program. The index reflects changes in the degree of problem solving rigidity displayed by the patient as he moves from a simple, 2-light, single alternation problem to a more complex, 4-light, double alternation problem. The Hunter Process Index was validated with a group of 71 long-hospitalized, female psychotics who also had been exposed to the social therapy approach of the rehabilitation unit, and again with a group of 48 male chronic psychotics who had received some slight variation in the program. The index scores were predictive of the outcome of patients in these groups. Clinical judgments failed to predict outcomes. A normal control group in a separate study earned better Hunter index scores than did either the released or hospitalized groups of male chronic psychotics. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Effectiveness of behavioral therapy for chronic low back pain: A component analysis.

The effects of outpatient group behavioral therapy including aerobic exercise (BE), behavioral therapy only (B), and aerobic exercise only (E) on pain and physical and psychosocial disability were evaluated and compared in a group of mildy disabled chronic low-back-pain patients. Ninety-six Ss were randomly assigned to the 3 treatments and a waiting-list control (WL) condition and assessed on a variety of patient self-report, spouse-rated, and direct observational measures at pretreatment, posttreatment, and 6- and 12-month follow-ups. Patients in the BE condition, but not the B or E conditions, improved significantly more pretreatment to posttreatment than did WL patients on the patient self-report and observer-rated measures. At both follow-ups, all 3 treatment groups remained significantly improved from pretreatment, with no significant differences among treatments. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Opioid therapy for chronic noncancer back pain. A randomized prospective study

STUDY DESIGN: A randomized, open, long-term, repeated-dose comparison of an anti-inflammatory drug and two opioid regimens in 36 patients with back pain. OBJECTIVES: To examine the long-term safety and efficacy of chronic opioid therapy in a randomized trial of patients with back pain. METHODS: All participants underwent a 4-week washout period of no opioid medication before being randomly assigned to one of three treatment regimens for 16 weeks: 1) naproxen only, 2) set-dose oxycodone, or 3) titrated-dose oxycodone and sustained-release morphine sulfate. All patients then were assigned to a titrated dose of opioids for 16 weeks and then gradually tapered off their medication for 12 weeks. Finally, all participants were monitored for a 1-month posttreatment washout period. Each patient was called once a week for a report on pain, activity, mood, medication, hours awake, and adverse effects and was monitored carefully for signs of abuse and noncompliance. RESULTS: Weekly reports during the experimental phase showed the titrated-dose group to have less pain (P < 0.001) and less emotional distress (P < 0.001) than the other two groups. Both opioid groups were significantly different from the naproxen-only group. During the titration phase, patients also reported significantly less pain and improved mood. Few differences were found in activity or hours asleep, or between average pretreatment and posttreatment phone-interview and questionnaire variables. No adverse events occurred, and only one participant showed signs of abuse behavior. CONCLUSIONS: The results suggest that opioid therapy has a positive effect on pain and mood but little effect on activity and sleep. Opioid therapy for chronic back pain was used without significant risk of abuse. However, tapered-off opioid treatment is palliative and without long-term benefit.     

Predicting attendance and expectations for group therapy.

Inconsistent membership is one of the leading problems in groups. Group therapy participants (N=310) from 2 university counseling centers were studied over a period of 7 years to examine interpersonal style, expectations, and attendance in group therapy. The Group Therapy Questionnaire (R. R. MacNair & J. Corazzini, 1994; R. R. MacNair-Semands, 1996, 1997, 2001) assessed client goals, substance use, and interpersonal problems in relation to expectations for group and attendance. A discriminant analysis demonstrated that angry hostility and social inhibition were predictive of low attendance. Additionally, clients with previous therapy reported more positive expectations about group, whereas those reporting greater substance use and more somatic symptoms had fewer positive expectations about group. Implications for treatment decisions are discussed. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Biofeedback and relaxation training with three kinds of headache: Treatment effects and their prediction.

After a 4-wk baseline period during which daily ratings of headache activity were made and all participants took several psychological tests, 91 18–68 yr old patients with chronic headache (tension, migraine, and combined tension and migraine) were given a 10-session relaxation-training regimen. Ss who did not show substantial reductions in headache activity from the relaxation therapy were given a 12-session regimen of biofeedback (thermal biofeedback for vascular headaches and frontal EMG biofeedback for tension headaches). Relaxation therapy alone led to significant improvement for all groups, with a trend for the tension headache group to respond the most favorably. Biofeedback therapy led to further significant reduction in headache activity for all who received it, with a trend for combined migraine and tension headache patients to respond the most favorably. Multiple regression analyses revealed that approximately 32% of the variance in end-of-treatment headache diary scores could be predicted after relaxation and that 44% of the variance after biofeedback could be predicted using standard psychological tests. (34 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting rehabilitation outcomes: The twisted pear revisited.

Prediction of rehabilitation outcome occurs with few unifying theories or practices. The authors propose J. Fisher's (1959) neglected twisted pear model as central to understanding perplexing problems such as somatoform disorders, mild traumatic brain injury, likelihood of therapeutic benefit from rehabilitation interventions, and assessment of driving competence. Fisher argued that many psychological and biological behaviors were predictable in only one segment of the distribution. The 2?×?2 twisted pear matrix demonstrates this nonuniform scatter (heteroscedasticity), limiting acceptable classification accuracy to individuals with poor-impaired predictor scores. Outcomes become increasingly variable as scores improve to average or better. Examples from clinical practice support the conclusion that the twisted pear model is a useful paradigm for rehabilitation professionals. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Predicting outcome of chronic back pain using clinical predictors of psychopathology: A prospective analysis.

This study evaluated whether a comprehensive assessment of psychosocial measures is useful in characterizing those acute low back pain patients who subsequently develop chronic pain disability problems. A cohort of 324 patients was evaluated, with all patients being administered a standard battery of psychological assessment tests. A structured telephone interview was conducted 6 months after the psychological assessment to evaluate return-to-work status. Analyses, conducted to differentiate between those patients who were back at work at 6 months versus those who were not because of the original back injury, revealed the importance of 3 measures: self-reported pain and disability, the presence of a personality disorder, and scores on Scale 3 of the Minnesota Multiphasic Personality Inventory. These results demonstrate the presence of a psychosocial disability variable that is associated with those injured workers who are likely to develop chronic disability problems. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Evaluation of acupuncture and occlusal splint therapy in the treatment of temporomandibular joint disorders

One hundred patients showed signs and symptoms of temporomandibular joint disorder, were participated in a one year follow up study. The patients were randomly divided into four groups: Acuhealth treatment (group A), occlusal splint therapy (group B), Acuhealth and occlusal splint therapy (group C), and control (group D). Each group comprised 25 patients. The patients were examined before and 3, 6, and 12 months after treatment. At the three month evaluation, the patients who were not satisfied with the treatment outcome were offered additional treatment. The result showed that 87% of the patients treated by Acuhealth unit, 77.3% of the patients treated with occlusal splint therapy, and 91.3% of the patients received Acuhealth and occlusal splint therapy were improved subjectively and clinically after 3 months follow-up. The patients who responded well to treatment initially also responded well in the long run. The study showed that the Acuhealth unit proved to be an ideal early therapy for TMD, and complemented later with occlusal splint.