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Mayer TG, Robinson R, Pegues P, Kohles S, Gatchel RJ. Lumbar segmental rigidity: can its identification with facet injections and stretching exercises be useful? Arch Phys Med Rehabil 2000;81:1143-50. Objectives: To describe a method for observing lumbar segmental rigidity and to show how motion measurements and pain/disability questionnaires can be used to evaluate outcomes of combined facet injections and stretching exercises. Design: Preliminary 2-part study: (1) presentation of a technique for identifying lumbar segmental rigidity based on physical observation of the spine's lateral bending; and (2) repeated measures of motion and pain/disability self-report in a chronic lumbar spinal disorder cohort, performed before and after treatment with combined facet injections and stretching exercises. Setting: An outpatient tertiary rehabilitation facility providing interdisciplinary functional restoration for chronic disabling work-related spinal disorders. Patients: Chronically disabled patients with lumbar spinal disorder ( n = 39; mean age, 41yr; 82% male) with segmental rigidity at 1 or more levels on physical examination. Subjects averaged 20 months of disability, and 51% had preinjection spine surgery (average, 1.7 procedures involving up to 3 spinal segments). Thirty-nine percent of the cohort had a fusion at levels 1 or 2. Interventions: Bilateral facet injections were administered under fluoroscopy to all patients, and 2 or 3 levels were performed in 93% of cases (range, levels 1–4). Patients were instructed in an unsupervised stretching program and were reassessed 2 to 4 weeks later. After an intensive supervised resistance exercise training program as part of interdisciplinary functional restoration, a third set of motion, pain, and disability measures were collected. Main Outcome Measures: Changes in true lumbar sagittal and coronal motion (T12-S1), measured with inclinometers, and pain/disability self-report were compared statistically. Results: Patients' mobility improved significantly ( p Conclusions: A simple physical examination technique for assessing lumbar spine segmental rigidity was used in this preliminary study to select patients and levels for combined facet injection and stretching exercise, with resultant improvements in mobility and self-reported pain/disability that may extend beyond the pharmacologic duration of the corticosteroid. The efficacy of either the facet injection or stretching components alone in achieving objective mobility improvements cannot be determined from the present study, but warrants future investigation. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Study design A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients. Objectives To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations. Summary of background data Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations. Methods Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders. Results Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms. Conclusions Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.

A biopsychosocial intervention approach has been found to be effective in the treatment of chronic medical conditions such as temporomandibular disorder (TMD). Recent research has begun to evaluate factors that may predict positive treatment response to such an approach. The present study was designed to assess the ability of two variables (a muscle disorder diagnosis and an elevation of Scale 3 on the MMPI-2) to predict treatment outcomes in a sample of chronic TMD patients. A total of 121 patients with chronic TMD were randomly assigned to one of five different treatment conditions: biofeedback, cognitive-behavioral skills training (CBST), combined CBST/biofeedback, no treatment/random control, or no treatment/not interested in treatment control. All patients were administered the standard Research Diagnostic Criteria (RDC) for TMD at pretreatment. They were reevaluated at posttreatment and 1 year after intervention. There were also four patient classification groups: dual presence of MMPI-2 Scale 3 elevation and an RDC muscle disorder diagnosis; MMPI-2 Scale 3 elevation and no RDC muscle disorder diagnosis; no MMPI-2 Scale 3 elevation and an RDC muscle disorder diagnosis; and no MMPI-2 Scale 3 elevation and no RDC muscle disorder diagnosis. Results revealed that the patient classification group variable significantly affected posttreatment pain levels. Such findings have important treatment implications and also suggest the significant biopsychosocial underpinnings of a chronic medical condition such as TMD.

Interdisciplinary treatment care must address more than the physical pathology. Chronic pain comprises a range of interdependent variables including biologic, cognitive, affective, behavioral, and social factors. This article discusses these psychosocial issues, as well as the four levels of pain management programs, and the characteristics and goals of interdisciplinary treatment. Finally, recent clinical studies demonstrating the efficacy and cost benefits of interdisciplinary pain management programs are reviewed.

Sobel JB, Sollenberger P, Robinson R, Polatin PB, Gatchel RJ. Cervical nonorganic signs: a new clinical tool to assess abnormal illness behavior in neck pain patients: a pilot study. Arch Phys Med Rehabil 2000;81:170-5. Objective: To develop and assess the reliability of a group of cervical nonorganic physical signs to be used as a simple screening tool for identifying patients with low neck pain who exhibit abnormal illness behavior. Design: Survey, consecutive sample. Data Set: Double masked. Setting: Functional restoration program. Patients: Twenty-six consecutive patients with complaints of chronic neck pain (greater than 4 months duration). Each patient was evaluated by a physician and then again by either a physical or occupational therapist, for the presence of specific cervical nonorganic signs. Both of the evaluations occurred on the same day. Main Outcome Measures: Five categories consisting of eight tests were appraised: (1) tenderness, (2) simulation, (3) range of motion, (4) regional disturbance, and (5) overreaction. Results: The percent agreement between raters ranged from a high of 100% for regional sensory disturbance, to a low of 68% for one of the simulation tests. The average agreement between raters across all of the nonorganic test signs was 84.6%. Likewise, kappa coefficients ranged from 1.00 to.16, reflecting differences in strength of agreement. Conclusion: For many years, the lumbar nonorganic signs (developed by Waddell and colleagues) have been a useful screening tool in the assessment of abnormal illness behavior in the low back pain population. For the first time, a group of cervical nonorganic signs have been developed, standardized, and proven reliable. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

OBJECTIVE The objective of this study was to evaluate whether biopsychosocial functioning differences exist between samples of patients with temporomandibular disorder (TMD) who differ in coping profiles as assessed by the Multidimensional Pain Inventory. METHODS A total of 322 patients who presented with TMD were administered a comprehensive biopsychosocial assessment battery, and the acute or chronic status of their disorder was determined. A follow-up evaluation was conducted 6 months later to determine the status of their pain. RESULTS TMD patients with dysfunctional and interpersonally distressed coping profiles demonstrated more acute and chronic psychosocial difficulties than patients with adaptive coper profiles. The data also suggest that having a dysfunctional/distressed coping profile on the Multidimensional Pain Inventory has some predictive value in determining the likelihood of developing chronicity in the absence of treatment. CONCLUSIONS The presence of a dysfunctional/distressed coping profile in patients with TMD is likely to provide clinicians with important information about the biopsychosocial functioning of those patients, which, in turn, will help to determine the most effective treatment modalities to use with TMD patients.

The purpose of this study was to evaluate the relative efficacy of different biopsychosocial treatment conditions on patients with chronic temporomandibular disorder. Ninety-four patients with chronic temporomandibular disorder were assigned to either a biofeedback treatment group, a cognitive-behavioral skills training (CBST) treatment group, a combined (combination of biofeedback/CBST) treatment group, or a no-treatment control group. Pain scores were analyzed pretreatment and posttreatment to determine group and within-subjects treatment effects. Results demonstrated that, in terms of a self-reported pain score, all three treatment groups had significantly decreased pain scores from pretreatment to posttreatment, while the no-treatment group did not. Moreover, patients in the biofeedback group were the most significantly improved compared to the no-treatment group. Finally, participants in the three treatment groups displayed significant improvement in mood states.

Recent literature indicates that chronic temporomandibular disorders (TMD), as well as other chronic medical conditions, are associated with a high degree of concomitant psycho-pathology. Patients with TMD have been found to evidence a higher distribution of depressive symptoms, as compared with the general population. Moreover, one study examined prevalence rates of psychological disorders for 50 chronic TMD patients and found that 86% of them were diagnosed with at least one Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I disorder; 46% received two or more Axis I diagnoses; and 40% met diagnostic criteria for a personality disorder. These high rates of psychiatric disorders far exceeded those for the general population, with a considerable disparity noted between the prevalence of major depression among TMD patients (74%) and the base rate of this disorder in the general population (5% to 26%).

Since 1986, the percentage of upper-extremity musculoskeletal disorders (UEMSDs) has increased from 1% to 4% of all occupational injury claims, while the average total medical and compensation cost is 80% higher than the average of all other claims. Because chronic disability leads to the highest cost, systematic evaluation of this growing occupational condition is needed. We performed a prospective case-series cohort study of patients (n = 163) with UEMSDs, compared with a matched group of spinal disorder (SD) patients (n = 163) treated with the same protocol. UEMSD patients were subclassified as those with one or more neuropathic diagnoses or those with non-neuropathic diagnoses. The neuropathic UEMSD subgroup had the poorest outcomes, with significantly higher surgery rates, higher health care utilization rates, and lower work retention when compared with the SD group. Rehabilitation outcomes for UEMSDs are similar to those for SDs. However, neuropathic-diagnosis patients are at risk for high-cost injuries and/or poorer prognoses.

This study examined personality pathology in a group of patients with chronic low back pain (CLBP) using both diagnostic interviews and dimensional self-report instruments. A group of CLBP patients (N = 125) was assessed before functional restoration treatment and compared with a matched normal comparison group (N = 75). The CLBP group evidenced broad personality pathology in all assessment modes pretreatment relative to the normal comparison sample. In addition, two subsamples of CLBP patients (n = 49 and n = 56) were assessed after treatment. Reductions in personality pathology between pre- and posttreatment assessments were more pronounced for diagnostic interview than dimensional self-report assessments. These results are discussed in the context of personality assessment and CLBP.

The conceptualization of pain and its progression into chronic disability has evolved from unidimensional models to more integrative, biopsychosocial models that take into account the many biological, psychosocial, social, and economic factors that may significantly contribute to the low back pain experience. This chapter reviews various studies that have demonstrated our growing understanding of these complex, interactive processes in helping to predict those who develop chronic disability as well as those who respond best to treatment attempts. Further, we examine the issue of compensation and how it too is intricately intertwined with the other variables contributing to lower back pain disability.

This study investigated the relationship between chronic low back pain and various psychosocioeconomic factors, especially gender, that have been found significant in previous research. A cohort of 504 acute low back pain patients was initially evaluated and followed via a structured telephone interview at six months and one year after the evaluation in order to assess return-to-work and compensation status. Overall, the results demonstrated that the individuals who did not return to work were more likely to be female, single with children, and who have received compensation for their injury. These findings further document that single working mothers are at greater risk for developing chronic medical problems.

were lost to follow-up. The risk of experiencing TMD after third-molar removal has been acknowledged but not previously quantified, and we hope this information will be of value to our colleagues. The absolute risk is not great and, as Dr. Dodson notes, it is similar in magnitude to the risk of experiencing inferior alveolar or lingual nerve damage. However, due to the frequency of thirdmolar removal, the populationattributable risk is relatively large and should be taken into consideration when recommending prophylactic third-molar removal. Greg J. Huang, DMD, MSD, MPH Assistant Professor Orthodontics

STUDY DESIGN A prospective cohort design with two groups of patients representing short-term or long-term disability (n = 497) who were selected from a larger cohort (n = 938) of consecutively treated spinal disorder patients with chronic compensation injuries. OBJECTIVES To prospectively evaluate the impact of length of spinal disability on socioeconomic outcomes of medically directed rehabilitation. SUMMARY OF BACKGROUND DATA Despite an increasing tendency of managed care organizations to limit rehabilitation services for disabled workers with chronic spinal disorders, there has been a surprising lack of prospective research evaluating the impact of length of disability on objective socioeconomic treatment outcomes. Although only approximately 10% of all patients with spinal disorders are disabled beyond 4 months, they account for nearly 80% of all workers' compensation expenditures. Little is known about whether relatively early intervention improves outcomes after chronicity has been established or whether any predictors distinguish between these groups. METHODS Two comparison groups of functional restoration tertiary treatment graduates were identified from the same community referral pool. The "long-term disabled" group involved a minimum of 18 months of disability (n = 252). This group was compared with a "short-term disabled" group (n = 245), no more than 8 months since injury, but chronic based on a minimum of 4 months after injury. The long-term disabled group showed significantly higher rates of pretreatment surgery than the short-term disabled group (P < 0.001). All patients were evaluated prospectively with specific physical, psychological, and occupational measurements. They also underwent a structured interview 1 year after treatment evaluating work status, health care use, and recurrent injury. RESULTS The short-term disabled group showed statistically higher return to work (P < 0.001) and work retention (P < 0.05) relative to the long-term disabled group. However, health care use and recurrent lost time injury claims were low in both groups and did not differ significantly. No predictors of outcome were found among the prospectively collected physical performance or psychosocial variables. CONCLUSIONS This study suggests that early tertiary nonoperative care, once patients with chronic spinal disorders are identified as having potentially high-cost chronic pain and disability, is efficacious in achieving goals of better work return and work retention. Such early rehabilitation may also prevent significant indemnity expense, as well as some late surgical interventions sought by progressively more desperate patients. However, individuals with long-term disability achieve respectable work return and retention rates, while faring no worse on other socioeconomic outcomes that represent major "cost drivers" to the workers' compensation system. Early intervention is not a panacea or a necessary condition for the successful rehabilitation of workers with disabling chronic spinal disorders.

Previous research has linked cognitive distortion, perceived interference with instrumental activities, and self-control to depression in chronic pain patients, though to date no study has examined all three variables concurrently. The present study investigated these three cognitive mediators in a comprehensive model to determine whether each variable represented an independent dimension in the pain-depression relationship. Results in a sample of 74 chronic low back pain patients revealed that a regression model containing all three cognitive variables had the strongest association with depressive symptoms. Consistent with a cognitive mediational model of the pain-depression relation, when self-control, cognitive distortion, and interference were held constant, pain and disability did not have a significant association with self-reported depression. These findings indicate that a comprehensive cognitive model of depression and chronic pain will need to incorporate all three cognitive variables.

W eisberg and Keefe provide an excellent review of literature that supports their contention that a concerted focus on personality disorders (POs) may lead to important advances in the ability to more heuristically understand and effectively manage patients with chronic pain (CP). Research has clearly revealed the high prevalence of POs in CP patients. I also want to amplify their clinically appropriate caution that diagnoses of PO should be pursued only when "it will provide structure and s.ubstance to the treatment plan." Indeed, the inappropnate use and overuse of PO diagnoses can lead to a detrimental "labeling" effect that can stigmatize a patient within a treatment facility, as well as permanently "follow" that patient after treatment in a case file. This is a potential hazard of which any ethical mentalhealth professional needs to be acutely aware whenever making psychological diagnoses of patients. Appropriate psychological-personality assessment conducted in order to help guide a treatment program is appropriate; routine use of it when not essential for treatment is inappropriate. In this Commentary, I would like to highlight some of the important issues in personality assessment not discussed by Weisberg and Keefe.Moreover, I propose the potentially greater importance and utility of a more dimensional trait approach to personality assessment rather than following currently available categorical approaches to POs.

In the present study, 107 patients (72 males and 35 females) completed self-report measures of depression, distortion, disability, and pain intensity at three points during their rehabilitation: (1) admission to a 3-week comprehensive functional restoration program, (2) discharge from the comprehensive phase, and (3) 4–6 weeks later at their first post-program evaluation. Various range-of-motion measures were also collected at these same times using inclinometry. Results demonstrated significant improvements on all measures which were maintained into follow-up. Patients were also subsequently grouped into depressed and non-depressed at admission, and both groups demonstrated significant improvement across time. Additionally, patients were divided into high and low distortion groups. High general cognitive distortion patients did not show improvement on 3 of the 5 range of motion, or pain intensity scores, although they did improve on their depression, distortion, and disability scores. Findings also suggested thatlow back pain-related cognitive distortion may be considered a state or situational factor, whereasgeneral cognitive distortion appears to be more of a trait characteristic.

The functional restoration approach to treating chronic spinal disability consists of a medically directed, interdisciplinary team approach to physical reconditioning and a cognitive-behavioral “crisis intervention” procedure for dealing with related psychosocial problems. One- and two-year follow-up studies have demonstrated the clinical efficacy of this approach. The present article describes this approach and summarizes the research documenting its success in treating patients with chronic spinal disability. This article also highlights the pitfalls in misunderstanding and misrepresenting the components of the functional restoration approach when evaluating treatment efficacy.

This study assessed the prevalence rates of psychopathology in acute carpal tunnel syndrome (CTS) and acute low back pain (LBP) patients. Psychopathology was assessed with the Structured Clinical Interview for the DSM-III-R (SCID). The results showed that the CTS patients had significantly higher rates of anxiety disorders, both current and lifetime, than the LBP patients. However, LBP patients had significantly higher rates of lifetime substance abuse than the CTS patients. In regard to other types of psychopathology, such as depression, current substance abuse, and somatoform pain disorders, CTS patients had similar rates as the LBP patients. It was concluded that anxiety disorders may be a concomitant of carpal tunnel syndrome, and that treating psychological problems along with physical aspects of the syndrome may increase the patient's chance of a successful therapeutic outcome.

In this paper, we present a system which is able to interact through natural dialogue, with PTSD patients, as well as to guide the conversation aiming to elicit enough information to make an assessment of their condition, in a manner similar to a self assessment test. Our system is able to adapt to each individual patient and can operate in two modes: one that stores information about previous sessions with a patient to provide a sense of trust and relationship; and one that does not store information to preserve anonymity.

According to American Academy of Orofacial Pain, 75% of the U.S. population experiences painful symptoms of temporo-mandibular joint and muscle disorder (TMJMD) during their lifetime. Thus, objective assessment of pain is crucial for efficient pain management. We used near infrared spectroscopy (NIRS) as a tool to explore hemodynamic responses in the frontal cortex to noxious thermal stimulation of temporomadibular joint (TMJ). NIRS experiments were performed on 9 healthy volunteers under both low pain stimulation (LPS) and high pain stimulation (HPS), using a temperature-controlled thermal stimulator. To induce thermal pain, a 16X16 mm 2 thermode was strapped onto the right TMJ of each subject. Initially, subjects were asked to rate perceived pain on a scale of 0 to 10 for the temperatures from 41°C to 47°C. For the NIRS measurement, two magnitudes of temperatures, one rated as 3 and another rated as 7, were chosen as LPS and HPS, respectively. By analyzing the temporal profiles of changes in oxy-hemoglobin concentration (HbO) using cluster-based statistical tests, we were able to identify several regions of interest (ROI), (e.g., secondary somatosensory cortex and prefrontal cortex), where significant differences (p

Purpose We studied the efficacy of osteopathic manual treatment (OMT) and ultrasound therapy (UST) for chronic low back pain. Methods A randomized, double-blind, sham-controlled, 2 × 2 factorial design was used to study OMT and UST for short-term relief of nonspecific chronic low back pain. The 455 patients were randomized to OMT (n = 230) or sham OMT (n = 225) main effects groups, and to UST (n = 233) or sham UST (n = 222) main effects groups. Six treatment sessions were provided over 8 weeks. Intention-to-treat analysis was performed to measure moderate and substantial improvements in low back pain at week 12 (30% or greater and 50% or greater pain reductions from baseline, respectively). Five secondary outcomes, safety, and treatment adherence were also assessed. Results There was no statistical interaction between OMT and UST. Patients receiving OMT were more likely than patients receiving sham OMT to achieve moderate (response ratio [RR] = 1.38; 95% CI, 1.16-1.64; P Conclusions The OMT regimen met or exceeded the Cochrane Back Review Group criterion for a medium effect size in relieving chronic low back pain. It was safe, parsimonious, and well accepted by patients.

Recently, there has been a substantial amount of interest directed at investigating temporomandibular disorder (TMD)1. The motivation to better understand this pain condition was stimulated by many studies demonstrating the apparent overlap of physical symptoms among TMD and other comorbid disorders, such as fibromyalgia (FM), chronic fatigue syndrome (CFS), and chronic headaches, etc 2. Symptoms involving aches and pains in the muscles and joints, cognitive problems, gastrointestinal disturbances, and changes in the quantity or quality of sleep are commonly observed among those with TMD, FM, and CFS. Indeed, 75% of those with FM can also be diagnosed with TMD using the Research Diagnostic Criteria for TMD (RDC/TMD), whereas 35% to 70% of those with CFS meet the criteria for FM3. Yunus4 discusses the implications of the terms that have been used to classify these disorders. He explains that, traditionally, the polysymptomatic patient would have been given a “wastebasket” diagnosis, such as “somatoform disorder,” or “multiple symptoms disorder.” Such terms potentially complicate patient-physician relationships as they imply, at some level, that the symptoms are purely psychological, and, therefore, “not real.” Moreover, as the etiology is poorly understood, such phenomenology possesses certain connotations that are not conducive to effective treatment strategies. With more research demonstrating the possibility that these disorders could result from similar underlying mechanisms involving central sensitization (CS), the term central sensitization syndrome (CSS) has been introduced in an attempt to provide more validity in searching for some underlying etiology than was previously offered by terms used in the past4. Although there is yet no conclusive evidence that CS is a common etiological factor of TMD and comorbid CSS, several studies have made a convincing argument in favor of such an etiology5. In many cases, CS is the basis of chronic pain, “or pain that persists beyond a normal time of healing”6. It is characterized by hyperexcitability in the dorsal horn neurons in the spinal cord, which ascend through the spino-thalamic tract7. In addition, it is promoted and maintained by neural activity among key regions in the brain involved in pain processing. The general assumption is that the central nervous system is altered in ways that amplify pain processing. Consistent with the idea that CS may be involved in the pathogenesis of TMD, the Orofacial Pain: Prospective Evaluation of Risk-Assessment (OPPERA) study was funded to investigate the biopsychosocial factors of TMD8. The general hope among the collaborators was that important risk factors or mechanisms would be elucidated, which might provide some insight for other musculoskeletal pain conditions. Among the studies, Greenspan and colleagues9 identified increased pain sensitivity to different types of experimental pain at multiple body sites beyond the orofacial region. Genetic risk-factors were also identified among those with TMD, which have demonstrated to be important in pain transmission10. Specifically, they found that polymorphisms on the genes, that encode for dopamine and serotonin, were positively correlated with pain severity, suggesting a genetic basis for the hypersensitivity experienced among those with TMD. Moreover, the dysregulation among neuroendocrine and neurotransmitter systems observed within the TMD population is highly related to the dysregulation of the hypothalamic pituitary adrenal (HPA) axis10. Dysfunction of the HPA axis has been consistently demonstrated to be involved in TMD and other comorbid pain conditions11. The HPA axis serves as an important intermediary among neuroendocrine, neurotransmitter, and neuroimmune systems, all of which have been suggested to be imbalanced among those with TMD and CSS. In fact, Maixner and colleagues12 identified altered function among those with TMD at rest, and in response to physical and psychosocial stressors. Specifically, they investigated indirect measures of HPA axis function, including heart rate, heart rate variability, baroflex sensitivity, and blood pressure. Ohrbach and McCall 13 also proposed that prolonged stress exposure plays a more direct role in TMD pathogenesis, causing sustained increases in stress hormones that promote tonic muscle contraction and consequential orofacial pain. However, many others have suggested that emotional distress is a consequence of pain, while the majority support a view involving dynamic interactions among these factors14-15. The indirect influence of emotional distress can be observed in pain behaviors and cognitions common among these patients15-16. For example, it is typical for individuals to seek treatment when they experience pain. However, there is a sub-population of individuals who do not respond adaptively in this regard. The somatic amplification hypothesis suggests that some individuals become hypersensitive and hyperreactive to pain, benign somatic sensations, and stressful events16. Hyperreactivity often manifests itself in a highly catastrophic manner owing to the common tendency for these individuals to misinterpret their symptoms as indicators of serious illness when, in fact, there is none 16. For this reason, treatment-seeking is more common among those with CSSs, although these individuals are usually resistant to reassurance from physicians. A common concern among these individuals is that something important has been overlooked. In trying to convince physicians that there is “something wrong,” they reinforce their invalid beliefs that they have a serious medical disease that, in turn, engenders more emotional distress16. The influence of daily stressors is reflected in increases in the prevalence of somatic complaints, as well as the severity of symptoms during times of greater psychosocial stress (e.g., work load, interpersonal problems) 18-19. Subsequent increases in stress hormones and inflammatory factors in response to prolonged stress exposure has been linked to illness behavior, including changes in diet and exercise habits, activity level, and other maladaptive coping strategies that pose challenges for treatment 20. Also, studies have shown that having a muscle disorder and elevation on the Minnesota Multiphasic Personality Inventory (MMPI) Scale-2, which is considered a good indicator of psychosocial function, was predictive of poor treatment outcomes 20. More recent studies have demonstrated a pattern of elevation on the MMPI-2 (known as the “Disability Profile”) to be particularly problematic and resistant to treatment responsiveness 21. While the relationship between TMD and symptoms of CSS is becoming readily established, there still remains the need to identify what accounts for this relationship2. The current study was therefore designed to investigate the prevalence of comorbid symptoms across the various groups of TMD disorders (i.e., Axis I RDC/TMD Group I Muscle Disorders, Group II Disc Displacements, and Group III Bone Deficiencies). The importance of investigating the influence of emotional distress with respect to these disorders stems from the clinical observation that TMD and CSS are related4. Moreover, emotional distress is thought to play both a direct and indirect role in these disorders through the physiological mechanisms previously discussed, and through its ability to exacerbate the condition and hinder pain rehabilitation and management. Thus, the current study examines the contribution of emotional distress on the prevalence of comorbid symptoms of CSS, as well as in self-report of pain and pain-related disability. On the basis of previous research demonstrating indices of CS among those with TMD Muscle Disorders, it was predicted that those with an RDC/TMD Group I Muscle Disorder, and those with more than one diagnosis, would have more comorbid symptoms of CSS, as well as higher reports of pain and pain-related disability22. Additionally, it was expected that emotional distress would account for a significant amount of variance of symptoms of CSS, pain, and pain-related disability. Furthermore, it was predicted that all group comparisons would be mediated by emotional distress23.

Lumbar flexion-relaxation (FR) is a well-known phenomenon that can reliably be seen in normal subjects but not in most chronic low back pain (CLBP) patients. The purpose of this study was to determine which surface electromyographic (SEMG) measures of FR best distinguish CLBP patients from pain-free control subjects. Standing SEMG and lumbar flexion range of motion (ROM) were also evaluated.A cohort of 218 CLBP patients, who were admitted to a functional restoration program, received a standardized SEMG and ROM assessment during standing trunk flexion and reextension. An asymptomatic control group of 30 nonpatients received an identical assessment. Both groups were compared on 8 separate SEMG and 3 flexion ROM measures.A receiver operating characteristic curve analysis was used to determine how well each measure distinguished between the CLBP patients and the pain-free control subjects. All SEMG measures of FR performed acceptably. Between 79% and 82% of patients, and 83% and 100% of controls were correctly classified. Standing SEMG performed less well. Gross flexion ROM was the best single classification measure tested, correctly classifying 88% of patients and 83% of controls. A series of discriminant analyses found that certain combinations of SEMG and ROM performed slightly better than gross ROM alone for correctly classifying the 2 subjects groups.Because all SEMG measures of FR performed acceptably, the determination of which SEMG measure of FR is "best" is largely dependent on one's specific purpose. In addition, ROM measures were found to be important components of the FR assessment.