Craniofacial pain syndromes that mimic temporomandibular joint disorders

Undiagnosed pain in the face, head and neck is very frustrating to all parties involved: the patient, the family of the patient, and the clinician. Simple pains may be treated with ease; however, chronic pain is a different matter. Often, patients consult numerous doctors, clinics, and hospitals in their search of pain relief. The patient may then undergo extensive and at times, unnecessary invasive treatment with the hope that the relentless agony of their suffering will be relieved. The purpose of this article is primarily one of education. Physicians and dentists alike encounter these unfortunate sufferers and yet, are confounded by the multitude of symptoms and complaints. Therefore, it was felt that an article such as this was needed. Many concepts presented within are either new or revised. It will be interesting to the reader just how similar many of these pain syndromes appear. Yet, when a systematic diagnostic approach is attempted, it will become clear just how different these syndromes are as well.     

Hepatic angiomyolipoma: a clinicopathologic study of 30 cases and delineation of unusual morphologic variants

Posttraumatic headache can be a very difficult syndrome to manage, especially if chronic. As with most other types of headache, medications are the primary treatment modality, although there is very limited evidence-based data to support any given approach. A number of physical interventions also are available to be used in conjunction with medication, particularly for headaches with a musculoskeletal component. This article will review the general principles of pharmacological treatment for headache and the physical approach to treatment of headaches and head and facial pain. The major categories of medications commonly used for treatment of many varieties of headache will be discussed. In addition, the problems encountered in diagnosing and treating chronic daily headache and analgesic rebound headache are addressed. The approach to treatment of such syndromes as myofascial pain, cervico-zygapophyseal joint pain, neuritic pain, and craniocervical somatic pain are outlined.     

Establishing a research agenda for investigating alternative medical interventions for chronic pain

This article describes the University of Maryland School of Medicine's Center for Complementary Medicine Research approach to developing an agenda for investigating alternative medical treatments for chronic pain syndromes. This agenda includes conducting extensive literature searches and analyses to form a knowledge base for making clinical decisions on which chronic pain syndromes are in greatest need of better therapies, as well as which alternative medical therapies offer the greatest therapeutic promise for these specific chronic pain syndromes. To date, the Center has identified back pain, arthritis, and fibromyalgia as the chronic pain syndromes that contribute the greatest clinical and economic burden to overall chronic pain statistics. Not coincidentally, patients with these diagnoses are the greatest users of alternative therapies. The Center has identified acupuncture, homeopathy, manual/manipulative therapies, and mind-body therapies as the alternative medical therapies offering the greatest clinical potential for these three general chronic pain diagnoses. Preliminary data from the Center's ongoing clinical trials programs are presented.     

Overlooked physical diagnoses in chronic pain patients involved in litigation, Part 2. The addition of MRI, nerve blocks, 3-D CT, and qualitative flow meter

This study followed 120 chronic pain patients referred to a multidisciplinary pain center. The referral diagnosis for many patients, such as "chronic pain," "psychogenic pain," or "lumbar strain," was frequently found to be incomplete or inaccurate (40%) following a multidisciplinary evaluation that used appropriate diagnostic studies, including magnetic resonance imaging, computed tomography, nerve blocks, and qualitative flowmeter. Significant abnormalities were discovered in 76% of the diagnostic tests. An organic origin for pain was found in 98% of these patients. The patients were discharged with objective verification of diagnoses including facet disease, nerve entrapment, temporomandibular joint disease, thoracic outlet syndrome, and herniated discs.     

Changes in beliefs, catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment.

To examine the associations between changes in cognitions and coping and multidisciplinary pain treatment outcomes, the authors had 141 patients with chronic pain complete measures of adjustment, beliefs, catastrophizing, and coping; in addition, their significant others rated patient physical functioning at pretreatment, posttreatment, and 6- and 12-month follow-ups. Decreases in guarding and resting and in the belief that pain signals damage were associated with decreases in patient disability. Increases in perceived control over pain and decreases in catastrophizing and in the belief that one is disabled were associated with decreases in self-reported patient disability, pain intensity, and depression. The results are consistent with the hypothesis, derived from cognitive-behavioral models of chronic pain, that the outcomes of multidisciplinary pain treatment are associated with changes in patient cognitions and coping responses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pharmacokinetics of SPECT radiopharmaceuticals for imaging hypoxic tissues

Low back pain (LBP), a common illness that may progress to chronic disability, costs many billions for care, lost work, and compensation. Conventional medicine does not effectively restore chronic LBP patients to work; multidisciplinary rehabilitation does, but limited or delayed access risks unnecessary costs, additional morbidity, and permanent disability. The authors examine costs of delayed treatment for 23 disabled LBP patients in a rehabilitation program. Compensation costs average $26,159 per patient, a sum covering treatment for 3 patients. Additional medical and societal costs are estimated. Factors causing delay, such as economic incentives and ignorance about pain, and policies to remediate these problems, are discussed.     

Pain unit director: Role issues for health psychologists.

The increasing involvement of psychologists in the treatment of chronic pain has led to the emergence of psychologists as directors of multidisciplinary pain treatment programs. Although the role of pain unit director offers many opportunities to psychologists, several potential problems exist. Relationships with physicians must be carefully addressed; adequate administrative support must be secured; and the requisite clinical privileges must be sanctioned. Without such interprofessional and administrative groundwork, psychologists will have difficulty functioning within a medically dominated health care system. (16 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Multidisciplinary treatment of chronic low back pain: A review.

Presents an overview of the general theoretical viewpoint of a multidisciplinary treatment of chronic low-back pain. Results from a number of multidisciplinary pain clinics are summarized, and major treatment modalities utilized by this approach are critically reviewed. (39 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Behavioral concepts in the analysis of chronic pain syndromes.

Discusses behavioral and psychological concepts applied to the assessment and treatment of a variety of chronic pain syndromes. Operant conditioning principles are commonly used to analyze and modify maladaptive overt behavior patterns such as excessive dependence on narcotics, bedrest, or on family or health-care professionals. Psychophysiologic concepts that are widely used include the stress-pain hypothesis, the pain-muscle spasm-pain cycle, and the neuromuscular pain model. Interventions for pain based on these concepts include relaxation and biofeedback training. Concepts from cognitive psychology are increasingly being used to evaluate subjective responses to persistent pain. The advantages and disadvantages of these concepts are discussed. (65 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Changes in crystallinity by sterilization and processing of ultrahigh molecular polyethylene used in endoprosthetics]

Research in animals shows that the levels of neuropathic pain expression is genetically associated with a characteristic response profile to sensory stimuli. The aim of the present investigation was to examine if pressure algometry can identify a specific pain sensitivity profile in patients with complex regional pain syndrome, Type I (reflex sympathetic dystrophy), and to distinguish complex regional pain syndromes from other chronic pain dysfunction syndromes. Pressure pain threshold and pain tolerance measured at the sternum in 17 patients with complex regional pain syndrome, Type I (reflex sympathetic dystrophy), were compared with values obtained in 13 patients suffering from other chronic pain dysfunction syndromes and in a control group of 24 pain-free volunteers. The pressure algometer consisted of a force displacement transducer with a 0.25 cm2 tip connected to a recorder. The rate of force application was 1 kg/0.25 cm2/s. The difference between threshold and tolerance was defined as the pain sensitivity range. Young patients with complex regional pain syndrome (<40 yr) demonstrated a significantly higher mean pain sensitivity range compared with young subjects who had chronic pain or who were pain-free. Mean threshold and tolerance values were significantly lower in patients with complex regional pain syndrome (2.7+/-1.0 kg (mean +/- standard deviation) and 5.4+/-2.0 kg, respectively) and in patients suffering from other chronic pain syndromes (2.6+/-1.1 and 4.6+/-1.7 kg) than in healthy subjects (5.4+/-2.3 and 8.4+/-2.6 kg). Women in the chronic pain group exhibited a significantly lower pressure pain threshold than all other subgroups. Regardless of group, women exhibited lower pressure pain tolerance than men. In conclusion, the study contained herein shows a specific pain sensitivity profile to experimental stimuli behavior in young patients with complex regional pain syndrome expressed by a large pressure pain sensitivity range, at a location away from the painful area. However, one single pressure pain measurement over the sternum is insufficient for differentiation of patients with complex regional pain syndrome from those with chronic pain because of intersubject variation.     

Renal failure associated with hepatitis C virus infection. Improvement in renal function after treatment with interferon-alpha

Hepatitis C virus infection can result in mixed cryoglobulinemia and associated clinical syndromes including membranoproliferative glomerulonephritis. Reports regarding the efficacy of interferon-alpha (IFN-alpha) in the treatment of patients with membranoproliferative glomerulonephritis and chronic hepatitis C infection have been inconclusive regarding improvement of renal function. We describe two patients with chronic hepatitis secondary to hepatitis C virus complicated by mixed cryoglobulinemia and membranoproliferative glomerulonephritis who developed severe renal failure which resolved after treatment with standard doses of IFN-alpha 2b.     

Evidence-based management of chronic pelvic pain

Diagnosis and management of chronic pelvic pain are greatly facilitated by a multidisciplinary approach integrating medical intervention with identification and management of socioenvironmental problems, cognitive-behavioral pain strategies, and treatment of concurrent psychological morbidity. Available evidence suggests that outcomes, including pain severity, general health and functional status, and disability are more significantly improved after this approach than after isolated medical or surgical interventions. Because of the chronic nature of many of the underlying psychological and social factors predisposing to chronic symptom formation and maintenance, care of the patient with chronic pelvic pain must be continuous and longitudinal if recurrent adverse sequelae, including disability, inappropriate healthcare utilization, and recurrent depression, are to be prevented.     

Do changes in cognitive factors influence outcome following multidisciplinary treatment for chronic pain? A cross-lagged panel analysis.

Changes in maladaptive cognitions may constitute therapeutic processes of multidisciplinary pain programs. A cross-lagged panel design was used to determine whether (a) early-treatment cognitive change predicted late-treatment outcome index change, but not vice versa; and (b) these effects remained significant with depression change controlled. Ninety chronic pain patients, in a 4-week multidisciplinary program, completed measures of catastrophizing, pain helplessness, depression, pain, interference, and activity level at pre-, mid-, and posttreatment. With depression changes controlled, early-treatment catastrophizing and pain helplessness changes predicted late-treatment outcome index changes, but not vice versa; early-treatment depression changes predicted late-treatment activity changes, but not vice versa. Findings advance understanding of pain treatment process and suggest that negative cognition changes may indeed affect improvements in treatment outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Pain in gynecologic practice

This paper has given a general discussion of the spectrum of pain complaints presented to the gynecologist. Specific information about pain sensation and localization has been reviewed together with the gynecologic causes of acute abdominal pain. Chronic pain has been classified as episodic or continuous, and the causes, mechanisms, diagnosis and treatment of episodic and chronic pelvic pain have been presented. The concluding remarks have outlined some diagnostic considerations for the patient with chronic pain. (The interested reader will find more extensive information on these subjects in the articles listed in the bibliography.).     

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.     

Current principles of multidisciplinary treatment of pain in orthopedic clinics

Differentiated strategy of treating patients with acute and chronic pain is developed. Preemptive analgesia is a priority trend in the treatment of acute postoperative pain. The most prevalent method of postoperative analgesia is prolonged opioid epidural analgesia carried out in intensive care wards and other wards by an acute pain management team. For treating patients with chronic painful syndromes, protocols of initial clinical and diagnostic evaluation are developed, permitting the choice of individual treatment strategy. Differentiated complex drug therapy planned with consideration for individual course of the painful syndrome is the basis of treating patients with phantom pain syndrome. Algorithms of differentiated therapy of radicular and spondylogenic pain are designed. Stage-by-stage analysis of treatment efficacy is carried out using modern electrophysiological methods. Realization of the proposed organization principles improved the efficacy of postoperative analgesia to 88.2%, prevented the development of postoperative painful syndrome in 35.6% cases, decreased the incidence of phantom pain syndrome after amputation of the limb from 63.3 to 31.6% and increased the efficacy of this syndrome treatment to 70.1%, and increased the efficacy of treating vertebrogenic painful syndromes to 82.3%.     

Psychosomatic aspects of chronic pain syndromes. An introduction to diagnosis and therapy

The approach to chronic pain syndromes must be an interdisciplinary one. Thereby the psychiatrist plays an important part. He participates in the diagnostic process and undertakes special therapeutic tasks. He must identify the focus of the chronic pain syndrome, diagnose psychiatric disorders and describe the context of the pain symptoms. The treatment of the psychiatric disorders and the effort to cope in a good way may positively influence the development of the chronic pain syndrome.     

Mind/body dualism in medicine: The case of chronic pelvic pain without organic pathology: a critical review of the literature

Chronic pelvic pain in the absence of organic pathology identifiable in medical terms is considered one of the most perplexing conditions that gynecologists confront. A critical analysis of the medical, psychiatric, and psychological literature on chronic pelvic pain without organic pathology reveals that the dichotomous construct of mind and body underpinning medical research and understanding is a barrier to the successful diagnosis and treatment of this condition, and indeed to the productive engagement of the health professional with the patient. The strict duality of the condition's etiology being understood in either physiological or psychogenic terms has been questioned at times over the last 40 years, but only recently has an "integrative model" been proposed. However, it is argued here that although the development of a multidisciplinary approach is important, only a radical deconstruction of the medical paradigm will truly address the problem and enable a real change in practice.