- Email: [email protected]
Recent life changes and myofascial pain syndrome
Recent life changes and myofascial pain syndrome Philip M. Moody, Ph.D.,* John T. Kemper, D.M.D.,** Jeffrey P. Okeson, D.M.D.,*** Thomas C. Calhoun, M.A.,**** and Merrill W. Packer, D.D.S., M.S.D.***** University
of Kentucky,
College of Medicine and College of Dentistry,
T
he relationship between recent life changes and myofascial pain-dysfunction (MPD) syndrome has received little attention in the literature. Studies by Rahe et a1.1-4 have indicated that significant increases in life changes act as “stressors” that may account for the occurrence of negative health changes. In these studies, as in the one described here, a Schedule of Recent Experience (SRE) was used.5 The SRE is a self-administered questionnaire which allows respondents to report the occurrence or absence of 42 various life-event items over a given period of their lives. Examples of these life events include marriage, death of a close family member, divorce, change in employment, and change in residence. Studies on life crises and health changes have found that life-change units (LCU) increase significantly during the 6-month onset of illness. Rahe et a1.3 stated that, “Six months is the most useful interval to use in constructing LCU totals . . . the bulk of buildup in life-change intensity was found in the 6-month period prior to illness onset.” A number of studies have identified psychologic factors6-9 in the etiology of MPD syndrome. Furthermore, the literature suggests that anxiety and disturbing life events are associated with mandibular dysfunction problems.‘+‘* Yemm,13 in a review of what type of persons suffer from mandibular dysfunction, stated, “Available evidence, as well as clinical impressions, suggests that temporary states of mind (emotional states) are more likely to be associated with the dysfunction condition . . . the most frequent of which is anxiety. Such findings seem entirely consistent with occupational characteristics of dysfunction patients, with findings of a tendency
*Associate Professor, Department of Behavioral Science. **Assistant Professor, Department of Restorative Dentistry. ***Associate Professor and Director of Occlusion, Department of Restorative Dentistry. ****N.I.M.H., Trainee, Department of Behavioral Science, MN No. 15730-01. *****Dean, College of Dentistry. 328
SEPTEMBER
1982
VOLUME
48
NUMBER
3
Lexington,
Ky.
to develop muscle tension in stress, and with the observation of a close relationship between the onset or exacerbation of dysfunction and specific disruptive or disturbing events in the life of individual patients.” This investigation will focus on comparing recent LCU totals of chronic MPD syndrome patients* with those of other clinical populations. It is assumed that life-change scores from the SRE would significantly increase during the 1 to 6 months before presentation for treatment as compared with the 7 to 12 months before presentation. This assumption is based on previous studies which have found that LCU totals increase significantly during the 6 months before patients seek treatment for a given illness.‘. *. 3. 14-16Within the MPD syndrome group, the study will also compare the number of recent life events during the l- to 6-month time period with those of the 7- to 12-month time period. An increase in recent life events and LCU totals would influence how symptoms are perceived, evalshould be uated, and acted upon. I7 Such information of interest to dentists and other health professionals who are concerned about the relationship of stressful life events and the aberration of MPD syndrome symptoms.
METHODS Data were collected from 19 MPD syndrome patients, 16 women and three men, presenting to the Facial Pain Clinic at the University of Kentucky, College of Dentistry. The mean age of the patients was 29.1 years. All patients reported facial pain of at least 12-month duration. None of the patients had been treated for their symptoms during the 7 to 12 months prior to presentation. Each patient completed the SRE5 for two time periods-the l- to 6-month period and the 7- to 12-month period before presentation. Each of the 42 life-change events was scored as weighted by Holmes *The word “chronic” delineates those MPD syndrome patients with at least a 12-month history of symptoms.
OOZZ-3913/82/090328
+ 03WO.30/00
1982 The C. V. Maby
Co.
RECENT
LIFE CHANGES
AND
MPD
Table I. Comparison of LCU totals for l- to 6-month time period and 7- to la-month to illness onset obtained in the current study with those reported by others
LCU mean score
Research design
*dy Rahe and Romo19
Description
Retrospective
Prospective
Rahe and Lind”
Retrospective
Rahe et al.16
Prospective
Retrospective
Current study
of sample
Table II. LCU totals for 19 chronic MPD syndrome patients for I- to 6-month and 7to I.&month time periods to facial pain clinic
No.
Patients with coronary heart disease Survivors of myocardial infarction Sudden death due to myocardial infarction Patients with disease of the cardiovascular system Smokers Nonsmokers Former smokers Healthy US Navy officers and crew prior to illness onset Healthy US Navy and Marine corps personnel prior to illness onset Swedish coronary heart disease patients No HX With HX Healthy US Navy officers and enlisted men Prior to illness onset Illness period (LCU = 175) After illness Chronic MPD syndrome patients
Retrospective
Rahe”
before
Mean Z difference
presentation
the data for the l- to 6-month
time
period with that of the 7- to 12-month time period, it can be ascertained whether the patients’ life crises were increasing, remaining stable, or declining. The reliability correlations for the SRE questionnaire have ranged from as high as 0.90 to as low as 0.26, depending on the time elapsing between occurrence of the events and the time of the questionnaire. The 0.90 test-retest correlation was for a 2-week interval and the 0.26 for a 2-year interval.” OF PROSTHETIC
DENTISTRY
65
77
80 43 26
81 64 68
68 39 50
174
125
100
50
164
10 29
165 108
83 97
125 -
IO0 .._ 130
2,900
19
120 216
Mean 7.5 R difference = 2.7; SE difference df = 18; p < .Ol
139.6
= 31; t = 2.47;
and Rahe,5 and a total was given for each of the two time periods. Additionally, the total number of events for each time period was determined. By
THE JOURNAL
74
l- to B-month time period before presentation
df = 18; p < .05
comparing
113
140
Number of life events
7- to X&month time period before presentation
216.4
= 76.8; SE difference
7 to 12 months
lto6months
Table III. Number of life events for 19 chronic MPD syndrome patients for time periods before presentation to facial pain clinic
LCU totals l- to 6-month time period before pmwmtation
time period prior
7- to l&month time period bdort! peesentation 4.8
= .97; t = 2.80.
RESULTS LCU totals for the time periods 1 to 6 months and 7 to 12 months prior to illness onset found in this study are compared to those reported by other researchers in Table I. The chronic MPD syndrome patients have a mean value of 216 for the I- to 6-month time period prior to seeking treatment. This LCU total was higher than that of any study reviewed. The LCU total of 140 for the 7- to 12-month time period was also higher than that of any of the other studies. Data for the changes in LCU totals for the two time periods are reported in Tables II and III and 329
MOODY
indicate that the MPD syndrome patients had an increase in life changes preceding presentation for treatment. The life-change totals for the l- to 6month time period are significantly greater than for the 7- to 12-month time period (x difference = 76.8; t = 2.47; p < .05) (Table II). Additionally, the data from Table III indicate that the number of lifechange events was significantly greater for the l- to 6-month time period than for the 7- to 12-month time period (X difference = 2.7; t = 2.80; p < .Ol). DISCUSSION The data presented in this study suggest that patients suffering from MPD syndrome have higher LCU totals than patients with other illnesses. It should be noted that in this study LCU totals for the MPD syndrome patients were obtained at the time the patient presented for treatment rather than at the time of illness onset as with the other studies. The influence of this variation in time of administration of the SRE is unknown. There are a number of possible explanations as to why MPD syndrome patients have higher LCU totals. One explanation may be that as the number of life changes being experienced by a patient increases so does the psychologic stress. This stress is considered to be an etiologic factor in MPD syndrome.8 Another explanation may be that as life changes increase, the patient’s ability to cope with existing symptoms decreases. In either case, the symptoms are accentuated and the patient seeks professional help. Life change in patients suffering from MPD syndrome should be more completely investigated. Perhaps further studies may reveal LCU totals to be helpful in the selection of treatment for MPD syndrome patients.
5.
Holmes, T. H., and Rahe, R. H.: The social rating scale. J Psychosom Res 11:213, 1967.
6.
Schwartz, L. L.: Disorders of the Temporomandibular joint. Philadelphia, 1959, W. B. Saunders Co. Laskin, D. M.: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969. Okeson, J. P.: The etiology and treatment of occlusal pathosis and associated facial pain. J PROSTHET DENT 45:199, 1981. Heiberg, A. N., Heloe, B., and Krogstad, B. S.: The myofascial pain-dysfunction: Dental symptoms and psychological and muscular function. An overview. Psychother Psychosom 30:81, 1978. Marbach, J. J., Lipton, J. A., Lund, P. B., Delahanty, F., and Blank, R. T.: Facial pain and anxiety levels: Consideration for treatment. J PROSTHET DENT 40:434, 1978. Rugh, J. D.: A behavioral approach to diagnosis and treatment of functional oral disorders: Biofeedback and self-control techniques. In Rugh, J. D., Perlis, D. B., and Disraeli, R. I., editors: Biofeedback in Dentistry. Phoenix, 1977, Semantodotics, chap 19. Rugh, J. D., and Solberg, W. K.: Psychological implications in temporomandibular pain and dysfunction. Oral Sci Rev 7:3, 1976. Yemm, R.: Causes and effects of hyperactivity of jaw muscles. In Bryant, P., Gale, E., and Rug-h, J., editors: Oral Motor Behavior: Impact on Oral Conditions and Dental Treatment. HEW, PHS, NIH. Publication No. 79-1845, 1979, pp 138-156. Rahe, R. H.: Subjects’ recent life changes and their nearfuture illness reports. Ann Clin Res 4:250, 1972. Rahe, R. H., and Lind, E.: Psychosocial factors and sudden
7. 8.
9.
10.
11.
12.
13.
14. 15.
cardiac 1971. 16.
17.
2.
3.
4.
330
A
pilot
study.
J
Psychosom
Res
15:19,
Rahe, R. H., Bennett, L. K., Romo, M., Siltanen, P., and Arthur, R. J.: Subjects’ recent life changes and coronary heart disease, in Finland. Am J Psychiatry 130:1222, 1973. Mechanic, D.: Medical Sociology, ed 2. New York, 1978, Free Press. Rahe, R. H.: The pathway between subjects’ recent life changes and their near-future illness reports: Representative results and methodological issues. In Dohrenwend, B., and Dohrenwend, B. P., editors: Stressful Life Events: Their Nature and Effects. New York 1974, John Wiley and Sons, Inc., pp 73-85.
19.
Rahe, R. H., and Romo, M.: Recent life changes and the onset of myocardial infarction and coronary death in Helsinki. In Gundersen E. K. E., and Rahe, R. H., editors: Life Stress and Illness. Springfield, 1969, Charles C Thomas, Publisher, pp 92-125.
20.
Moody, P. M.: Effect of smoking and recent life changes upon onset of diseases of the circulatory system. Pub Health Rep 93:443, 1978.
Rahe, R. H.: Life crisis and health change, In May, P. R. A., and Wittenbom, Jr., J. R., editors: Psychotropic Drug Response: Advances in Prediction. Springfield, Ill., 1969, Charles C Thomas, Publisher, pp 92-125. Rahe, R. H., and Arthur, R. J.: Life-change patterns surrounding illness experience. J Psychosom Res 11:341, 1968. Rahe, R. H., McKean, J., and Arthur, R. J.: A longitudinal study of life-change and illness patterns. J Psychosom Res 10:355, 1967. Rahe, R. H., FUistad, I., Bergan, T., Ringdal, R., Gerhardt, R., Gunderson, E. K. E., and Arthur, R. J.: A model for life changes and illness research. Arch Gen Psychiatry 31:172, 1974.
death:
readjustment
18.
REFERENCES 1.
ET AL
Reprint requsts to: PHILIP M. MOODY UNIVERSITY OF KEVITKXY COLLEGE OF MEDICINE ROOM MN-652 LEXINGTON, KY 40536 h.
SEPTEMBER
1982
VOLUME
48
NUMBER
3
of Kentucky,
College of Medicine and College of Dentistry,
T
he relationship between recent life changes and myofascial pain-dysfunction (MPD) syndrome has received little attention in the literature. Studies by Rahe et a1.1-4 have indicated that significant increases in life changes act as “stressors” that may account for the occurrence of negative health changes. In these studies, as in the one described here, a Schedule of Recent Experience (SRE) was used.5 The SRE is a self-administered questionnaire which allows respondents to report the occurrence or absence of 42 various life-event items over a given period of their lives. Examples of these life events include marriage, death of a close family member, divorce, change in employment, and change in residence. Studies on life crises and health changes have found that life-change units (LCU) increase significantly during the 6-month onset of illness. Rahe et a1.3 stated that, “Six months is the most useful interval to use in constructing LCU totals . . . the bulk of buildup in life-change intensity was found in the 6-month period prior to illness onset.” A number of studies have identified psychologic factors6-9 in the etiology of MPD syndrome. Furthermore, the literature suggests that anxiety and disturbing life events are associated with mandibular dysfunction problems.‘+‘* Yemm,13 in a review of what type of persons suffer from mandibular dysfunction, stated, “Available evidence, as well as clinical impressions, suggests that temporary states of mind (emotional states) are more likely to be associated with the dysfunction condition . . . the most frequent of which is anxiety. Such findings seem entirely consistent with occupational characteristics of dysfunction patients, with findings of a tendency
*Associate Professor, Department of Behavioral Science. **Assistant Professor, Department of Restorative Dentistry. ***Associate Professor and Director of Occlusion, Department of Restorative Dentistry. ****N.I.M.H., Trainee, Department of Behavioral Science, MN No. 15730-01. *****Dean, College of Dentistry. 328
SEPTEMBER
1982
VOLUME
48
NUMBER
3
Lexington,
Ky.
to develop muscle tension in stress, and with the observation of a close relationship between the onset or exacerbation of dysfunction and specific disruptive or disturbing events in the life of individual patients.” This investigation will focus on comparing recent LCU totals of chronic MPD syndrome patients* with those of other clinical populations. It is assumed that life-change scores from the SRE would significantly increase during the 1 to 6 months before presentation for treatment as compared with the 7 to 12 months before presentation. This assumption is based on previous studies which have found that LCU totals increase significantly during the 6 months before patients seek treatment for a given illness.‘. *. 3. 14-16Within the MPD syndrome group, the study will also compare the number of recent life events during the l- to 6-month time period with those of the 7- to 12-month time period. An increase in recent life events and LCU totals would influence how symptoms are perceived, evalshould be uated, and acted upon. I7 Such information of interest to dentists and other health professionals who are concerned about the relationship of stressful life events and the aberration of MPD syndrome symptoms.
METHODS Data were collected from 19 MPD syndrome patients, 16 women and three men, presenting to the Facial Pain Clinic at the University of Kentucky, College of Dentistry. The mean age of the patients was 29.1 years. All patients reported facial pain of at least 12-month duration. None of the patients had been treated for their symptoms during the 7 to 12 months prior to presentation. Each patient completed the SRE5 for two time periods-the l- to 6-month period and the 7- to 12-month period before presentation. Each of the 42 life-change events was scored as weighted by Holmes *The word “chronic” delineates those MPD syndrome patients with at least a 12-month history of symptoms.
OOZZ-3913/82/090328
+ 03WO.30/00
1982 The C. V. Maby
Co.
RECENT
LIFE CHANGES
AND
MPD
Table I. Comparison of LCU totals for l- to 6-month time period and 7- to la-month to illness onset obtained in the current study with those reported by others
LCU mean score
Research design
*dy Rahe and Romo19
Description
Retrospective
Prospective
Rahe and Lind”
Retrospective
Rahe et al.16
Prospective
Retrospective
Current study
of sample
Table II. LCU totals for 19 chronic MPD syndrome patients for I- to 6-month and 7to I.&month time periods to facial pain clinic
No.
Patients with coronary heart disease Survivors of myocardial infarction Sudden death due to myocardial infarction Patients with disease of the cardiovascular system Smokers Nonsmokers Former smokers Healthy US Navy officers and crew prior to illness onset Healthy US Navy and Marine corps personnel prior to illness onset Swedish coronary heart disease patients No HX With HX Healthy US Navy officers and enlisted men Prior to illness onset Illness period (LCU = 175) After illness Chronic MPD syndrome patients
Retrospective
Rahe”
before
Mean Z difference
presentation
the data for the l- to 6-month
time
period with that of the 7- to 12-month time period, it can be ascertained whether the patients’ life crises were increasing, remaining stable, or declining. The reliability correlations for the SRE questionnaire have ranged from as high as 0.90 to as low as 0.26, depending on the time elapsing between occurrence of the events and the time of the questionnaire. The 0.90 test-retest correlation was for a 2-week interval and the 0.26 for a 2-year interval.” OF PROSTHETIC
DENTISTRY
65
77
80 43 26
81 64 68
68 39 50
174
125
100
50
164
10 29
165 108
83 97
125 -
IO0 .._ 130
2,900
19
120 216
Mean 7.5 R difference = 2.7; SE difference df = 18; p < .Ol
139.6
= 31; t = 2.47;
and Rahe,5 and a total was given for each of the two time periods. Additionally, the total number of events for each time period was determined. By
THE JOURNAL
74
l- to B-month time period before presentation
df = 18; p < .05
comparing
113
140
Number of life events
7- to X&month time period before presentation
216.4
= 76.8; SE difference
7 to 12 months
lto6months
Table III. Number of life events for 19 chronic MPD syndrome patients for time periods before presentation to facial pain clinic
LCU totals l- to 6-month time period before pmwmtation
time period prior
7- to l&month time period bdort! peesentation 4.8
= .97; t = 2.80.
RESULTS LCU totals for the time periods 1 to 6 months and 7 to 12 months prior to illness onset found in this study are compared to those reported by other researchers in Table I. The chronic MPD syndrome patients have a mean value of 216 for the I- to 6-month time period prior to seeking treatment. This LCU total was higher than that of any study reviewed. The LCU total of 140 for the 7- to 12-month time period was also higher than that of any of the other studies. Data for the changes in LCU totals for the two time periods are reported in Tables II and III and 329
MOODY
indicate that the MPD syndrome patients had an increase in life changes preceding presentation for treatment. The life-change totals for the l- to 6month time period are significantly greater than for the 7- to 12-month time period (x difference = 76.8; t = 2.47; p < .05) (Table II). Additionally, the data from Table III indicate that the number of lifechange events was significantly greater for the l- to 6-month time period than for the 7- to 12-month time period (X difference = 2.7; t = 2.80; p < .Ol). DISCUSSION The data presented in this study suggest that patients suffering from MPD syndrome have higher LCU totals than patients with other illnesses. It should be noted that in this study LCU totals for the MPD syndrome patients were obtained at the time the patient presented for treatment rather than at the time of illness onset as with the other studies. The influence of this variation in time of administration of the SRE is unknown. There are a number of possible explanations as to why MPD syndrome patients have higher LCU totals. One explanation may be that as the number of life changes being experienced by a patient increases so does the psychologic stress. This stress is considered to be an etiologic factor in MPD syndrome.8 Another explanation may be that as life changes increase, the patient’s ability to cope with existing symptoms decreases. In either case, the symptoms are accentuated and the patient seeks professional help. Life change in patients suffering from MPD syndrome should be more completely investigated. Perhaps further studies may reveal LCU totals to be helpful in the selection of treatment for MPD syndrome patients.
5.
Holmes, T. H., and Rahe, R. H.: The social rating scale. J Psychosom Res 11:213, 1967.
6.
Schwartz, L. L.: Disorders of the Temporomandibular joint. Philadelphia, 1959, W. B. Saunders Co. Laskin, D. M.: Etiology of the pain-dysfunction syndrome. J Am Dent Assoc 79:147, 1969. Okeson, J. P.: The etiology and treatment of occlusal pathosis and associated facial pain. J PROSTHET DENT 45:199, 1981. Heiberg, A. N., Heloe, B., and Krogstad, B. S.: The myofascial pain-dysfunction: Dental symptoms and psychological and muscular function. An overview. Psychother Psychosom 30:81, 1978. Marbach, J. J., Lipton, J. A., Lund, P. B., Delahanty, F., and Blank, R. T.: Facial pain and anxiety levels: Consideration for treatment. J PROSTHET DENT 40:434, 1978. Rugh, J. D.: A behavioral approach to diagnosis and treatment of functional oral disorders: Biofeedback and self-control techniques. In Rugh, J. D., Perlis, D. B., and Disraeli, R. I., editors: Biofeedback in Dentistry. Phoenix, 1977, Semantodotics, chap 19. Rugh, J. D., and Solberg, W. K.: Psychological implications in temporomandibular pain and dysfunction. Oral Sci Rev 7:3, 1976. Yemm, R.: Causes and effects of hyperactivity of jaw muscles. In Bryant, P., Gale, E., and Rug-h, J., editors: Oral Motor Behavior: Impact on Oral Conditions and Dental Treatment. HEW, PHS, NIH. Publication No. 79-1845, 1979, pp 138-156. Rahe, R. H.: Subjects’ recent life changes and their nearfuture illness reports. Ann Clin Res 4:250, 1972. Rahe, R. H., and Lind, E.: Psychosocial factors and sudden
7. 8.
9.
10.
11.
12.
13.
14. 15.
cardiac 1971. 16.
17.
2.
3.
4.
330
A
pilot
study.
J
Psychosom
Res
15:19,
Rahe, R. H., Bennett, L. K., Romo, M., Siltanen, P., and Arthur, R. J.: Subjects’ recent life changes and coronary heart disease, in Finland. Am J Psychiatry 130:1222, 1973. Mechanic, D.: Medical Sociology, ed 2. New York, 1978, Free Press. Rahe, R. H.: The pathway between subjects’ recent life changes and their near-future illness reports: Representative results and methodological issues. In Dohrenwend, B., and Dohrenwend, B. P., editors: Stressful Life Events: Their Nature and Effects. New York 1974, John Wiley and Sons, Inc., pp 73-85.
19.
Rahe, R. H., and Romo, M.: Recent life changes and the onset of myocardial infarction and coronary death in Helsinki. In Gundersen E. K. E., and Rahe, R. H., editors: Life Stress and Illness. Springfield, 1969, Charles C Thomas, Publisher, pp 92-125.
20.
Moody, P. M.: Effect of smoking and recent life changes upon onset of diseases of the circulatory system. Pub Health Rep 93:443, 1978.
Rahe, R. H.: Life crisis and health change, In May, P. R. A., and Wittenbom, Jr., J. R., editors: Psychotropic Drug Response: Advances in Prediction. Springfield, Ill., 1969, Charles C Thomas, Publisher, pp 92-125. Rahe, R. H., and Arthur, R. J.: Life-change patterns surrounding illness experience. J Psychosom Res 11:341, 1968. Rahe, R. H., McKean, J., and Arthur, R. J.: A longitudinal study of life-change and illness patterns. J Psychosom Res 10:355, 1967. Rahe, R. H., FUistad, I., Bergan, T., Ringdal, R., Gerhardt, R., Gunderson, E. K. E., and Arthur, R. J.: A model for life changes and illness research. Arch Gen Psychiatry 31:172, 1974.
death:
readjustment
18.
REFERENCES 1.
ET AL
Reprint requsts to: PHILIP M. MOODY UNIVERSITY OF KEVITKXY COLLEGE OF MEDICINE ROOM MN-652 LEXINGTON, KY 40536 h.
SEPTEMBER
1982
VOLUME
48
NUMBER
3