Relationship between insomnia and pain in patients with chronic orofacial pain.

OBJECTIVE: Few studies have investigated specific associations between insomnia and orofacial pain (OFP). The aim of this cross-sectional study was to examine relationships of insomnia with pain, mental health, and physical health variables among treatment-seeking patients with chronic OFP. METHODS: OFP diagnosis, demographics, insomnia symptoms, pain intensity, interference, and duration, mental health measures, and number of medical comorbidities were extracted from the medical records of 450 patients receiving an initial appointment at a university-affiliated tertiary OFP clinic. T-tests compared differences between patients with and without insomnia symptomatology, and between patients with different insomnia subtypes (delayed onset/early wakening). RESULTS: Compared to patients without insomnia, those with elevated insomnia symptomatology (45.1%) reported higher pain intensity (60.70 ± 20.61 vs 44.15 ± 21.69; P < .001) and interference (43.81 ± 29.84 vs 18.40 ± 23.43; P < 0.001), depression/anxiety symptomatology (5.53 ± 3.32 vs 2.72 ± 2.66; P < 0.001), dissatisfaction with life (21.63 ± 6.95 vs 26.50 ± 6.21; P < .001), and number of medical comorbidities (6.72 ± 5.37 vs 4.37 ± 4.60; P < .001). Patients with Sleep Onset Latency insomnia (SOL-insomnia) (N = 76) reported higher pain intensity (t = 3.57; P < 0.001), and pain interference (t = 4.46; P < .001) compared to those without SOL-insomnia. Those with Early Morning Awakening insomnia (EMA-insomnia) (N = 71) did not significantly differ from those without EMA-insomnia on any of the variables. Differences remained significant after adjusting for age, sex, primary OFP diagnosis, and pain intensity. CONCLUSIONS: Insomnia is associated with pain outcomes and should be appropriately managed when treating patients with chronic OFP.

A Pilot Study of a Three-Session Heart Rate Variability Biofeedback Intervention for Veterans with Posttraumatic Stress Disorder.

Many veterans do not complete traditional trauma treatments; others may continue to struggle with posttraumatic stress disorder (PTSD) even after completing a full course of therapy (Blasé et al., in Int J Environ Res Public Health 18(7):Article 3329, https://doi.org/10.3390/ijerph18073329 , 2016). Heart rate variability (HRV) biofeedback (HRVB) is a non-invasive, non-pharmacological, breathing-based cardiorespiratory training technique that can reduce trauma symptoms and improve HRV parameters. Prior studies have demonstrated HRVB is well-tolerated by veterans with PTSD symptoms (Tan et al., in Appl Psychophysiol Biofeedback 36(1):27-35, 10.1007/s10484-010-9141-y, 2011; Schuman and Killian, in Appl Psychophysiol Biofeedback 44(1):9-20, https://doi.org/10.1007/s10484-018-9415-3 , 2019). This randomized wait-list controlled pilot study tested a short mobile app-adapted HRVB intervention in combination with treatment as usual for veterans with military-related PTSD to determine if further investigation was warranted. We assessed veterans' military-related PTSD symptoms, depression symptoms, and HRV time and frequency domain measures at baseline, after three clinical sessions, and one month later. This study combined clinical training and home biofeedback with a smartphone app and sensor to reinforce training and validate adherence. In the intervention group, depression and SDNN significantly improved, and we observed marginally significant improvements for PTSD Cluster B (intrusion) symptoms, whereas no significant improvements were observed in the control group. In addition, the brief protocol was acceptable to veterans with PTSD with over 83% of participants completing the study. However, adherence to home practice was low. Findings suggest brief HRVB interventions can decrease comorbid depression and improve overall autonomic function in veterans with PTSD; however, additional research on home biofeedback is necessary to determine the best strategies to increase adherence and which veterans would benefit from brief HRVB interventions.

Telehealth Increases Access to Brief Behavioral Interventions in an Orofacial Pain Clinic During the COVID-19 Pandemic: A Retrospective Study.

OBJECTIVE: The aim of the study was to test whether patients with orofacial pain were more likely to start and complete a brief psychological intervention for managing certain chronic orofacial pain conditions (physical self-regulation [PSR]) via telehealth (during the COVID-19 pandemic) vs. in-person (before the COVID-19 pandemic). The exploratory aim was to describe demographic factors that could influence patients' likelihood of starting and completing PSR. METHODS: Retrospective medical charts of all patients seen at a university-affiliated tertiary orofacial pain clinic between July-December 2019 (in-person; before the pandemic) and July-December 2020 (telehealth; during the pandemic) were reviewed. Charts were examined for demographic information and to compare the number of patients who started and completed PSR during each study period (chi-squared test). RESULTS: Of 248 new patients seen in the clinic during the 2019 period, 25 started PSR in-person (10.08%). Of 252 new patients seen during the 2020 period, 53 started PSR via telehealth (21.03%). Patients were more likely to start PSR (odds ratio = 6.21, p < 0.001, 95% confidence interval = 2.499 to 15.435) and more likely to complete all three sessions of PSR (odds ratio = 5.69, p < 0.001, 95% confidence interval = 2.352 to 13.794) when it was offered via telehealth than when it was offered in-person. Among those who started PSR via telehealth, patients from metropolitan areas were more likely to start the intervention than those from non-metropolitan areas (p = 0.045). CONCLUSIONS: Offering brief psychological pain interventions via telehealth in tertiary orofacial pain clinics has demonstrated feasibility and may improve patients' willingness to participate in psychological treatments. Results need to be replicated with prospective data, as modality was confounded with the pandemic in the present study.

Expected Estimation Errors in Studies of the Cortisol Awakening Response: A Simulation.

OBJECTIVE: Misestimation as a consequence of small sample sizes, small effect sizes, and noisy measurement may be particularly problematic in biomarker studies, the cost of which can adversely affect design decisions. This simulation study used real study designs reported in a meta-analysis of psychosocial correlates of the cortisol awakening response to investigate the probability that the results of these designs would yield misestimates in a cross-sectional study. METHODS: For each of the 212 designs, 100,000 simulated data sets were produced and the percentages of effects that were in the wrong direction and/or that differed by more than 0.10 from the true effect (b = 0.10) were calculated. RESULTS: As expected, small samples (n < 100) and noisy measurement contributed to higher probability of errors. The average probability of an effect being in the wrong direction was around 20%, with some designs reaching 40%; misestimation probabilities were around 40%, with some designs reaching 80%. This was true for all studies as well as those reporting statistically significant effects. CONCLUSION: Results call for better study designs, and this article provides suggestions for how to achieve more accurate estimates.

Cross-Sectional Associations of Fatigue Subtypes with Pain Interference in Younger, Middle-Aged, and Older Adults with Chronic Orofacial Pain.

OBJECTIVE: Mental, emotional, physical, and general fatigue, as well as vigor, have each been associated with pain interference-defined as pain-related disruption of social, recreational, and work-related activities-in patients with chronic orofacial pain (COFP). The objectives of the current study were to compare levels of these fatigue subtypes across younger, middle-aged, and older patients with COFP and test the associations between fatigue subtypes and pain interference in these age groups. DESIGN: A cross-sectional cohort design was used. SETTING: Participants self-reported fatigue subtypes (Multidimensional Fatigue Symptom Inventory-Short Form), pain interference (West Haven-Yale Multidimensional Pain Inventory), pain intensity (visual analog scale), pain duration (months), depression (Symptom Checklist 90-Revised), and sleep quality (Pittsburgh Sleep Quality Index) at their initial appointment at a tertiary orofacial pain clinic. SUBJECTS: Sixty younger (age 18-39), 134 middle-aged (age 40-59), and 51 older (age 60-79) COFP patients provided data for the study. METHODS: Analysis of variance was used to compare levels of fatigue subtypes between the age groups. Regression with dummy-coding was used to test if the relationship between fatigue subtypes and pain interference varied by age. RESULTS: Older COFP patients reported less general fatigue and more vigor than younger or middle-aged adults. Fatigue subtypes were each associated with greater pain interference, but associations became nonsignificant after controlling for depression, sleep, and pain intensity/duration. Age group-by-fatigue subtype interactions were not observed. CONCLUSIONS: Managing fatigue may be important to reduce pain interference in COFP populations and may be accomplished in part by improving depression and sleep.

Maintenance of affective wellbeing following acute pain in healthy older and younger adults.

Over 70% of older adults report chronic or acute pain, and pain threatens affective wellbeing. The strategies older adults use to maintain affective wellbeing following acute pain remain unknown. Specific strategies that can be used to manage pain include recalling, recognizing, and responding to positive stimuli and prioritizing close over knowledgeable social partners. The study tested whether older adults used positivity-enhancing strategies and maintained affective wellbeing following acute pain better than younger adults. Fifty older (ages 65-85) and 50 younger (ages 18-30) pain-free adults experienced a control and a pain condition and were given the chance to employ positivity-enhancing strategies. Older and younger adults similarly used positivity-enhancing strategies following pain. Younger adults demonstrated reduced preference for knowledgeable social partners after experiencing pain. Pain-related affective changes were similar between age groups. Older and younger adults may cope with acute pain similarly, highlighting future directions for exploring age differences in pain coping.

Associations of Pain Intensity and Frequency With Loneliness, Hostility, and Social Functioning: Cross-Sectional, Longitudinal, and Within-Person Relationships.

BACKGROUND: The current studies investigated associations between pain intensity and pain frequency with loneliness, hostility, and social functioning using cross-sectional, longitudinal, and within-person data from community-dwelling adults with varying levels of pain. METHOD: Secondary analysis of preexisting data was conducted. Study 1 investigated cross-sectional (baseline data: n = 741) and longitudinal (follow-up data: n = 549, observed range between baseline and follow-up: 6-53 months) associations. Study 2 tested within-person associations using daily diaries across 30 days from a subset of the participants in Study 1 (n = 69). RESULTS: Cross-sectionally, pain intensity and frequency were associated with higher loneliness (ßintensity = 0.16, ßfrequency = 0.17) and worse social functioning (ßintensity = - 0.40, ßfrequency = - 0.34). Intensity was also associated with higher hostility (ß = 0.11). Longitudinally, pain intensity at baseline predicted hostility (ß = 0.19) and social functioning (ß = - 0.20) at follow-up, whereas pain frequency only predicted social functioning (ß = - 0.21). Within people, participants reported higher hostility (γ = 0.002) and worse social functioning (γ = - 0.013) on days with higher pain, and a significant average pain by daily pain interaction was found for loneliness. Pain intensity did not predict social well-being variables on the following day. CONCLUSION: Pain intensity and frequency were associated with social well-being, although the effects were dependent on the social well-being outcome and the time course being examined.

Endogenous Cortisol Exposure and Declarative Verbal Memory: A Longitudinal Study of Healthy Older Adults.

OBJECTIVE: Exposure to endogenous cortisol is associated with hippocampal degeneration and may contribute to problems with declarative memory, but effects of persistent versus phasic cortisol elevations have not been established. The present longitudinal investigation examined persistent individual differences and phasic changes in cortisol as they related to verbal memory, executive functions, and subjective cognitive function. METHODS: Older adults (n = 132, aged 60-93 years) were followed up for up to 5 years. They were assessed annually for verbal memory and every 6 months for executive functions, subjective cognitive function, and cortisol area under the curve (averaged over 3 days). RESULTS: In multilevel models, persistently but not phasically higher cortisol was associated with worse verbal memory in both learning (t(181) = 2.99, p = .003) and recall (t(280) = 3.10, p = .002). This effect withstood adjustment for stress, depression, metabolic health, and age. There was evidence for attenuated primacy in learning with higher persistent cortisol. Phasic increases in cortisol were not associated with changes in memory, and cortisol was not related to executive functions or subjective cognitive function. CONCLUSIONS: Higher secretion of cortisol may, over time, contribute to memory dysfunction in older adults.

The Nature of Self-Regulatory Fatigue and "Ego Depletion": Lessons From Physical Fatigue.

Self-regulation requires overriding a dominant response and leads to temporary self-regulatory fatigue. Existing theories of the nature and causes of self-regulatory fatigue highlight physiological substrates such as glucose, or psychological processes such as motivation, but these explanations are incomplete on their own. Historically, theories of physical fatigue demonstrate a similar pattern of useful but incomplete explanations, as recent views of physical fatigue emphasize the roles of both physiological and psychological factors. In addition to accounting for multiple inputs, these newer views also explain how fatigue can occur even in the presence of sufficient resources. Examining these newer theories of physical fatigue can serve as a foundation on which to build a more comprehensive understanding of self-regulatory fatigue that integrates possible neurobiological underpinnings of physical and self-regulatory fatigue, and suggests the possible function of self-regulatory fatigue.

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.

Neural and behavioral bases of age differences in perceptions of trust.

Older adults are disproportionately vulnerable to fraud, and federal agencies have speculated that excessive trust explains their greater vulnerability. Two studies, one behavioral and one using neuroimaging methodology, identified age differences in trust and their neural underpinnings. Older and younger adults rated faces high in trust cues similarly, but older adults perceived faces with cues to untrustworthiness to be significantly more trustworthy and approachable than younger adults. This age-related pattern was mirrored in neural activation to cues of trustworthiness. Whereas younger adults showed greater anterior insula activation to untrustworthy versus trustworthy faces, older adults showed muted activation of the anterior insula to untrustworthy faces. The insula has been shown to support interoceptive awareness that forms the basis of "gut feelings," which represent expected risk and predict risk-avoidant behavior. Thus, a diminished "gut" response to cues of untrustworthiness may partially underlie older adults' vulnerability to fraud.

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

UNLABELLED: 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.

Social health in young women with chronic pain.

Introduction: Chronic pain may negatively affect social functioning, but no study to date has examined the specific social impact of different chronic pain conditions in young women, and whether living with multiple chronic overlapping pain conditions (COPCs) differently influences social domains. Objectives: This study aimed to assess social functioning (social isolation, hostility, informational support satisfaction, social roles, emotional support, friendships, and family relationships) among young women with chronic pain compared with pain-free controls and to test whether the number of COPCs influenced the extent of social burden. Methods: Participants aged 18 to 30 years with a physician-confirmed diagnoses of migraine, fibromyalgia, or temporomandibular disorder (TMD) and pain-free controls were invited to participate from across the United States. After confirming eligibility, participants completed a 1-hour REDCap online questionnaire assessing social functioning. Results: One hundred four participants (mean age 24.54 ± 3.35 years) were included (n = 26 with TMD, n = 25 with fibromyalgia, n = 25 with migraine, and n = 28 controls). All 3 chronic pain groups combined reported worse functioning than controls on friendship (P = 0.038), social isolation (P = 0.002), and social roles (P < 0.001). There were no differences on social variables between the 3 chronic pain groups (all P's > 0.05). Compared with those with 3 COPCs, participants with 1 condition reported better family relationships (P = 0.024). Conclusions: Experience of chronic pain-regardless of the specific pain condition-may negatively affect some areas of social functioning in young women.

Occupations associated with treatment seeking and biopsychosocial functioning at a tertiary orofacial pain clinic: A cross-sectional study.

BACKGROUND: The aim of this study was to describe whether certain occupations were over- or underrepresented and to compare biopsychosocial functioning by types of occupation and employment status among adults seeking orofacial pain (OFP) treatment. METHODS: The authors extracted self-reported employment status, occupation, and biopsychosocial functioning from initial appointment records of 444 treatment-seeking adults at a university-affiliated OFP clinic. The authors categorized occupations in major and minor occupational groups according to the 2018 Standard Occupational Classification. The authors compared proportions between their sample and the corresponding state level, using a ratio and 95% CI (1.00 = equal representation in sample vs state, < 1.00 = underrepresentation, > 1.00 = overrepresentation). RESULTS: Among major occupational categories, health care practitioners and technical occupations were the most common in the study sample (22.4%) and the second most overrepresented (ratio, 3.20; 95% CI, 2.59 to 3.97) after the arts, design, entertainment, sports, and media occupations (ratio, 3.95; 95% CI, 2.15 to 7.26). Among minor occupational categories, teachers and instructors were the most common in the study sample (11.2%) and the most overrepresented (ratio, 90.71; 95% CI, 65.67 to 125.30), followed by managers (ratio, 43.87; 95% CI, 29.61 to 64.99) and photographers (ratio, 40.89; 95% CI, 10.23 to 163.4). No differences were observed in biopsychosocial functioning between major occupational categories. However, those not working due to health reasons or disability had worse biopsychosocial functioning (insomnia, anxiety and depression, life satisfaction, sleep health, pain intensity, pain-related interference; all P < .034) than those who were employed. CONCLUSIONS: Several occupations are strongly over- and underrepresented among adults seeking OFP treatment. Differences were not explained by biopsychosocial functioning. PRACTICAL IMPLICATIONS: Future research should attempt to identify and address the underlying mechanisms of association between occupation and seeking care for OFP.

The impact of the COVID-19 pandemic on orofacial pain practice: Perceptions from a convenience sample of orofacial pain practitioners.

BACKGROUND: COVID-19 has had a substantial impact on people's lives. Increasing evidence indicates that patients with chronic pain particularly are being affected; however, few articles have examined how the pandemic has affected the care or clinical presentation of patients with orofacial pain. The aim of this study was to describe COVID-19-related changes in referral patterns and numbers, in patient demographics, in patients' seeking treatment for problems, and in administrative procedures in 3 orofacial pain clinical settings. METHODS: Practitioners participating in the American Academy of Orofacial Pain webinar titled "Practicing Orofacial Pain, Headache, and Sleep Care During the COVID-19 Pandemic" completed a voluntary anonymous online survey. Survey respondents completed general questions related to their orofacial pain practices and about perceptions of their patients' symptoms. For statistical analysis, the authors calculated frequencies and used analysis of variance for continuous variables or Likert scale variables and the χ2 test for dichotomous or categorical variables. Statistical significance was set at P value of .05 or below. RESULTS: Practitioners noted an increase in new patients with orofacial pain. Of the participants, 33% indicated the onset of their patients' pain was often or extremely often related to COVID-19. The 5 most common symptoms that providers felt were aggravated in their patients were masticatory muscle myalgia, anxiety, tension-type headache, bruxism, and insomnia or fragmented sleep. CONCLUSION: The COVID-19 pandemic has resulted in a marked increase in the number of patients seeking consultation for orofacial pain and associated symptoms. PRACTICAL IMPLICATIONS: Because of the COVID-19 pandemic, orofacial pain practitioners have noticed an increase in orofacial pain symptoms across practice settings.

Weak Relationships Between Psychological Factors and Experimental Pain Outcomes in Pain-Free Individuals: An Aggregate Analysis of 8 Studies.

Although psychological factors such as anxiety, depression, and pain catastrophizing are known to influence pain outcomes in chronic pain populations, there are mixed results regarding whether they influence experimental pain outcomes in pain-free individuals. The objectives of this study were to determine the associations between psychological factors and experimental pain outcomes in pain-free adolescents and adults. Relationships between anxiety, depression, and pain catastrophizing and experimental pain outcomes across 8 different studies (total N = 595) were examined in different populations of pain-free adult and adolescent participants. Analyses were conducted with and without controlling for sex, age, and race. Studies were analyzed separately and as part of an aggregate analysis. Individual study analyses resulted in 136 regression models. Of these, only 8 models revealed a significant association between psychological factors and pain outcomes. The significant results were small and likely due to Type 1 error. Controlling for demographic factors had minimal effect on the results. The aggregate analyses revealed weak relationships between anxiety and pressure pain threshold (Fisher's z = -.10 [-.19, -.01]), anxiety and cold pain intensity ratings (Fisher's z = .18 [.04, .32]), and pain catastrophizing and pressure pain threshold (Fisher's z = -.14 [-.26, -.02]). Sample size calculations based on the aggregate analyses indicated that several hundred participants would be required to detect true relationships between these psychological factors and pain measures. The overall negative findings suggest that in pain-free individuals, anxiety, depression, and pain catastrophizing are not meaningfully related to experimental pain outcomes. PERSPECTIVE: Psychological variables have been shown to predict pain outcomes in chronic pain populations but these relationships may not generalize to pain-free populations. An analysis of 595 pain-free individuals across 8 studies in our lab revealed that anxiety, depression, and pain catastrophizing were not meaningfully related to experimental pain outcomes.

Fatigue in Adults with Chronic Arthralgia/Myalgia in the Temporomandibular Region: Associations with Poor Sleep Quality, Depression, Pain Intensity, and Future Pain Interference.

AIMS: To examine associations between fatigue and poor sleep quality, depression symptoms, and pain intensity in an adult population with chronic arthralgia/myalgia in the temporomandibular region and to test whether fatigue predicted future pain-related interference above and beyond these other constructs. METHODS: The sample included 40 participants with chronic arthralgia and/or myalgia in the temporomandibular region and 21 healthy controls. Participants self-reported fatigue (PROMIS fatigue score), sleep quality (PSQI), depression symptoms (PROMIS depression score), and average pain intensity and completed four weekly surveys of pain-related interference with daily activities. RESULTS: The chronic arthralgia/myalgia group reported greater fatigue than healthy controls (t = 4.85, P < .001). Fatigue was significantly correlated with poor sleep quality (r = .46), higher depression symptoms (r = .41), and higher pain intensity (r = .46) in the chronic arthralgia/myalgia group, and these three variables together explained 39% of variance in fatigue. Greater fatigue-above and beyond sleep quality, depression symptoms, and average pain intensity-was associated with a higher average level of pain-related interference (ß = 0.56, t score = 3.30, P = .002) over the following month. Depression symptoms, poor sleep quality, and pain intensity did not significantly predict pain interference above and beyond fatigue (all P > .05). CONCLUSION: The results suggest that fatigue is a clinically relevant symptom distinct from depression, poor sleep quality, or pain intensity and may be related to worse pain outcomes over the following month in adults with chronic temporomandibular arthralgia/myalgia. Clinicians should assess, monitor, and treat fatigue to the best of their abilities when working with this population.

Characterizing Fatigue Subtypes in Adolescents with Chronic Musculoskeletal Pain and Pain-Free Controls.

Context: General fatigue, sleep-related fatigue, and cognitive fatigue are prevalent and disruptive in adults with chronic musculoskeletal (MSK) pain, but little is known about these fatigue subtypes in pediatric musculoskeletal pain. Objective: To compare fatigue and its subtypes between adolescents with chronic MSK pain and pain-free controls and to test if fatigue subtypes were associated with concurrent pain and its impact (pain intensity, number of pain sites, pain interference, and functional disability) or experimental pain (intensity and tolerance) in adolescents with chronic MSK pain. Finally, we sought to explore adolescents' qualitative characterizations of their fatigue. Methods: Adolescents with chronic MSK pain (12-17 y.o., n = 26) and pain-free controls (n = 26) completed validated self-report measures of fatigue, pain, and functional disability, underwent an experimental pain tolerance task (cold water immersion of the hand), and provided qualitative descriptions of their fatigue (pain group only). Results: Adolescents with chronic MSK pain reported significantly greater general, sleep-related, and cognitive fatigue than pain-free controls (all p's < 0.001). In adolescents with chronic MSK pain, fatigue subtypes were associated with clinical pain and pain impact (r's = 0.43-0.84) but not experimental pain measures (p's > 0.05). Adolescents with chronic MSK pain qualitatively described the negative implications of the different fatigue subtypes, particularly when perceived as long-lasting. Conclusion: This preliminary study suggests that fatigue subtypes are prevalent and impactful in pediatric patients with chronic MSK pain. When planning multi-disciplinary treatment for pediatric MSK pain, providers should recognize fatigue as another disabling symptom.

Pediatric Chronic Orofacial Pain: A Narrative Review of Biopsychosocial Associations and Treatment Approaches.

Pediatric chronic orofacial pain (OFP) is an umbrella term which refers to pain associated with the hard and soft tissues of the head, face, and neck lasting >3 months in patients younger than 18 years of age. Common chronic pediatric OFP diagnoses include temporomandibular disorder, headaches, and neuropathic pain. Chronic OFP can adversely affect youth's daily functioning and development in many areas of well-being, and may be associated with emotional stress, depression, functional avoidance, and poor sleep, among other negative outcomes. In this mini-review, we will discuss common psychological comorbidities and familial factors that often accompany chronic pediatric OFP conditions. We will also discuss traditional management approaches for pediatric orofacial pain including education, occlusal appliances, and psychological treatments such as relaxation, mindfulness-based interventions, and cognitive-behavioral treatments. Finally, we highlight avenues for future research, as a better understanding of chronic OFP comorbidities in childhood has the potential to prevent long-term pain-related disability in adulthood.

Preliminary evidence for conserved transcriptional response to adversity in adults with temporomandibular disorder.

Temporomandibular disorder (TMD) is one of the most common orofacial pain conditions. Alteration in immune functioning is one promising biological mechanism underlying pain in TMD. However, there is a gap in the understanding of molecular bases contributing to altered immune functioning in these patients. OBJECTIVES: In the current study, we investigated whether individuals with TMD would exhibit differential activity of 3 specific transcription factors involved in inflammatory (nuclear factor-kappa B, NF-kB), antiviral (interferon-regulatory factors, IRF), and sympathetic (cAMP response element-binding protein, CREB) processes using a promoter-based bioinformatics analysis, which is characterized as the "Conserved Transcriptional Response to Adversity." METHODS: Adults with TMD (n = 19) and without (n = 17) underwent a standardized clinical examination for TMD. A blood sample was collected for genome-wide transcriptional RNA profiling. Bioinformatic analyses tested for differential prevalence of proinflammatory and antiviral transcription factor activity in core promoter sequences from all genes showing >1.2-fold differential expression in TMD vs controls. RESULTS: Promoter-based bioinformatic analyses of genome-wide transcriptome profiles confirmed upregulation of genes bearing response elements for proinflammatory transcription factor (NF-kB, P = 0.002) and downregulation of genes with response elements for IRF (P = 0.037) in patients with TMD relative to controls. Results also indicated upregulated activity of CREB in patients with TMD (P = 0.08), consistent with increased activity of the sympathetic nervous system. CONCLUSION: These results provide initial support that the regulation of immune pathways is altered in individuals with TMD. A shift of transcriptional resources to a proinflammatory state may be driven by psychosocial stress and contributes to symptoms associated with TMD.