Professional Musicians with Craniomandibular Dysfunctions Treated with Oral Splints

Abstract

Craniomandibular dysfunction (CMD) symptoms occur frequently in violin/viola and wind players and can be associated with pain in the neck, shoulders and arm. In the current study, the effect of oral splint treatment of CMD on reducing pain and symptoms especially in these areas was investigated. Thirty (30) musicians undergoing CMD treatment with oral splints participated in this study. They completed a questionnaire that addressed CMD symptoms, localization of pain, and subjective changes in symptoms. Pain in the shoulder and/or upper extremity was the most frequent symptom reported by 83% of subjects, followed by neck pain (80%) and pain in the teeth/TMJ regions (63%). Treatment with oral splints contributed to a significant decrease in neck pain in 91%, teeth/TMJ pain in 83%, and shoulder and upper extremity pain in 76% of the musicians. Eighty percent (80%) of the patients reported improvement of their predominant symptoms. CMD can be a potential cause for pain in the neck, shoulders, and upper extremities of musicians. It is paramount that musicians with musculoskeletal problems be examined for CMD symptoms. Treatment with oral splints seems to be valuable. Further prospective, randomized controlled studies are necessary to confirm efficacy of oral splint treatment in CMD-associated pain and problems in the neck, shoulder, and the upper extremities in musicians.     

Multidimensional evaluation of craniomandibular dysfunction. II: Pain assessment

To standardize clinical history taking, a comprehensive anamnestic questionnaire was developed (Screen). Screen includes questions about: (i) pain, (ii) other symptoms of craniomandibular dysfuntion (CMD), (iii) correlates of CMD, (iv) pychosocial factors, and (v) general health. The current study focuses on variables in Screen concerning pain reported somewhere in the head, neck and/or shoulders. This study was performed to assess whether subgroups of patients with signs and symptoms of CMD and a control group of dental patients with and without signs and symptoms of CMD can be characterized by differences in areas reported to be painful, in quantitative and qualitative characteristics of pain, and in factors exacerbating pain. Results indicate that several characteristics of pain as measured in Screen can be used to discriminate between: (i) subgroups of subjects with signs and/or symptoms of CMD and controls without signs or symptoms of CMD, (ii) subgroups of clinical cases and controls with signs or symptoms of CMD, and (iii) patients with CMD with mainly a myogenous component and patients with CMD with mainly an arthrogenous component. The results of logistic regression analysis indicate that four adverbs describing pain correctly classified 75% of patients with CMD-myo and patients with CMD-arthro. Differences between patients and controls are interpreted with regard to the correct classification of patients with CMD with a mainly myogenous component and patients with CMD with a mainly arthrogenous component and the subjective treatment need for CMD. Implications for further research are discussed.     

Cervical pain and discomfort among dentists. Epidemiological, clinical and therapeutic aspects. Part 1. A survey of pain and discomfort

The aim of the investigation was to study the frequency of pain, ache and discomfort in the musculoskeletal system among dentists, above all concerning headache, cervical and shoulder pain and further, to find possible correlations between these symptoms and various working positions and different working actions. A questionnaire was answered by 359 dentists (90.8%). Of those who answered the questionnaire 72% had pain and discomfort from either the neck, shoulders or headaches. Only 60 dentists had no pain or discomfort. Concerning the male dentists, the investigation revealed that younger dentists had pain and discomfort in the neck, shoulders and headaches to a greater extent than the older dentists. Younger female dentists had a significantly higher frequency of pain and discomfort in the neck and headaches than older colleagues. The results showed that dentist who positioned the patient carefully so that a direct view gained had a significantly lower frequency of headaches. Of the 359 dentists 55% mostly used the mirror to facilitate a direct view. From the answers it was clear that those dentists who did not have discomfort in the upper locomotor system used the mirror more often than those who did suffer discomfort.     

Sex differences in signs and symptoms from masticatory and other muscles in 19-year-old individuals

Pain and tenderness of masticatory muscles are often related to muscle tenderness elsewhere in the body. It has been shown that women are more prone to musculoskeletal disorders than men. We sought to determine whether sex differences of muscular symptoms were established by the age of 19. The subjects comprised 51 boys and girls who received a questionnaire regarding the function of their masticatory system, frequency of headache, and neck, shoulder and low back pain. Their masticatory system was examined, and neck and shoulders were palpated. For all variables in the questionnaire girls reported symptoms more often than the boys. Of the subjects 50% had tender chewing muscles upon palpation. Again the girls had the most. There was good correlation between reports of pain in one area as compared to others. The number of clinically tender neck and shoulder muscles correlated with the number of tender masticatory muscles. It was concluded that girls presented more muscular symptoms than boys.     

Working postures of dentists and dental hygienists

A joint study was conducted by a manufacturer of dental stools in the Midwest of the United States and Marquette University to measure the occupational postures of dentists and dental hygienists. The postures of 10 dentists and 10 dental hygienists were assessed using work sampling and video techniques. Postural data of the neck, shoulders and lower back were recorded from video and categorized into 30-degree intervals: o (neutral posture of respective joint), 30, 60 and 90 degrees. Each subject's postures were observed while they were treating patients during a four-hour period, during which 100 observations of postures were recorded at random times. Compared to standing, dentists and dental hygienists were seated 78 percent and 66 percent of the time, respectively. Dentists and dental hygienists flexed their trunk at least 30 degrees more than 50 percent of the time. They flexed their neck at least 30 degrees 85 percent of the time during the four-hour duration, and their shoulders were elevated to the side of their trunk (abducted) at least 30 degrees more half of the time. The postures of the trunk, shoulders, and neck were primarily static. This database of postures can be used by dental professionals and ergonomists to assess the risk dentists and dental hygienists are exposed to musculoskeletal disorders, such as low back pain or shoulder tenosynovitis, from deviated joint postures. They could use these data to select dental furniture or dental devices that promote good body posture, i.e., reduce the magnitude and duration of deviated joint postures, which, in theory, would decrease the risk of musculoskeletal disorders.     

Is there a relationship between head posture and craniomandibular pain?

An often-suggested factor in the aetiology of craniomandibular disorders (CMD) is an anteroposition of the head. However, the results of clinical studies to the relationship between CMD and head posture are contradictory. Therefore, the first aim of this study was to determine differences in head posture between well-defined CMD pain patients with or without a painful cervical spine disorder and healthy controls. The second aim was to determine differences in head posture between myogenous and arthrogenous CMD pain patients and controls. Two hundred and fifty persons entered the study. From each person, a standardized oral history was taken and blind physical examinations of the masticatory system and of the neck were performed. The participants were only included into one of the subgroups when the presence or absence of their symptoms was confirmed by the results of the physical examination. Head posture was quantified using lateral photographs and a lateral radiograph of the head and the cervical spine. After correction for age and gender effects, no difference in head posture was found between any of the patient and non-patient groups (P > 0.27). Therefore, this study does not support the suggestion that painful craniomandibular disorders, with or without a painful cervical spine disorder, are related to head posture.     

Reported symptoms and clinical findings in a group of subjects with longstanding bruxing behaviour

summary Signs and symptoms of craniomandibular dysfunction (CMD) and social medical history were reported in 29 subjects, aged 23–68 years, with longstanding (5 years or more) bruxing behaviour. The subjects were selected from answers to an advertisement in the local newspaper. The subjects presented many symptoms of a general character including somatic and psycho-social problems, sleep disorders (72%), and pain (86%). More than half of the subjects (55%) had symptoms every day. Frequent aches in the neck, back, throat or shoulders were reported by 69% and frequent headache by 48% of the subjects. The most common symptoms of CMD were pain in the face or jaws (48%), stiffness in the jaws in the morning (44%), temporo-mandibular joint (TMJ) sounds (34%) and fatigue in the jaws during chewing (38%) and the most common clinical signs were more than three muscles tender on palpation (76%), TMJ-sounds (55%) and tenderness of TMJ on lateral palpation (66%). There was a statistically significant correlation between frequent tooth clenching and headache, pain in the neck, back, throat or shoulders, sleep disorders and high scores of the clinical dysfunction index (Di). The frequent clenchers had higher score values than the 'non-clenchers' for pain in the face and the jaws; headache; pain in the neck, back, throat or shoulders and the clinical dysfunction index (Di). These findings indicate a causal relationship between frequent tooth clenching and signs and symptoms of CMD. including headache and pain in the neck, back, throat or shoulders and high pathogenicity for frequent clenching. However, the material in this study is small and some precaution must be taken prior to generalized conclusions. More studies are required, especially sleep laboratory investigations, which could perhaps give answers to some of the numerous questions in this unexplored field of odontology.     

Effects of Head and Neck Inclination on Bilateral Sternocleidomastoid EMG Activity in Healthy Subjects and in Patients with Myogenic Cranio-Cervical-Mandibular Dysfunction

This study was conducted in order to determine the effect of head and neck position on bilateral electromyographic (EMG) activity of the sternocleidomastoid muscles. The study was performed on 16 patients with myogenic cranio-cervical-mandibular dysfunction (CMD) and 16 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the right and left sternocleidomastoid muscles. EMG activity was recorded in the left lateral decubitus position, in a darkened room and with the individual's eyes closed, under the following experimental conditions: 1. Head, neck, and body horizontally aligned; 2. Head and neck upwardly inclined with respect to the body, simulating the effect of a thick pillow, 3. Head and neck downwardly inclined with respect to the body, simulating the effect of a thin pillow. Variation of head and neck positions was determined by measuring the distance from the angle of neck and shoulder and the apex of the shoulder (SND = shoulder—neck distance) of each individual. Then, head and neck were forward or downwardly inclined with respect to the body at one-third of SND. A significantly higher contralateral EMG activity and a more asymmetric EMG activity were observed in the CMD group than in the healthy subjects (Kruskal-Wallis Test).These results suggest a different behavior of bilateral sternocleidomastoid EMG activity in CMD patients than in healthy subjects depending on the positioning of the head and neck.     

Musculoskeletal symptoms among dental personnel; - lack of association with mercury and selenium status, overweight and smoking

Our objective was to describe the occurrence of musculoskeletal symptoms and how they affect the daily life of three different occupational groups of dental personnel. A cross sectional-study was performed among 268 dental staff members and 111 referents. Female dental hygienists and female dentists showed, compared with their referents, higher prevalence of symptoms during the past 12 months from neck, shoulders and hands/wrists. Both dental groups also had higher frequencies of combined symptoms from these body regions, as well as longer duration of symptoms in neck and shoulders during the past 12-month period. Male dentists had higher frequencies of neck and shoulder symptoms compared with their referents. Female dental assistants did not deviate from their referents. The symptoms from each single body region, or the occurrence of symptoms from multiple regions in a subject, did not show any statistically significant association with mercury (whole blood and urinary levels) or selenium (plasma level) status, neither with smoking habits nor overweight (Body Mass Index). The high frequency of musculoskeletal disorders probably reflects the specific work load in dentistry, with high demands on vision and precision and fine manipulative hand movements and work with unsupported, elevated arms. The symptoms might impair work capacity and the future possibility to stay in the profession. Further studies are needed to verify this.     

Psychosocial aspects of craniomandibular dysfunction. An assessment of clinical and community findings

This study was performed to assess whether subgroups of patients with signs and symptoms of craniomandibular dysfunction (CMD) and a control group of dental patients with and without signs of CMD can be characterized by psychosocial variables, and whether there is evidence of stress-induced muscle hyperactivity as a contributing factor in the development of signs and symptoms of CMD. A group of 127 care-seeking patients and a control group of 158 dental patients completed a Questionnaire Battery (QB) designed to measure external stressors, stress-related emotional reactions (anxiety and depression) and personal factors such as coping styles, health locus of control and personality. Patients with CMD with both a myogenous and an arthrogenous component reported more stress and stronger stress-related emotional reactions than patients with either an arthrogenous or a myogenous CMD. However, patients with arthrogenous CMD did not differ on psychosocial variables from patients with myogenous CMD. In contrast to expectations, controls with signs of CMD reported more stress than patients with CMD. Compared with controls, CMD-patients experienced less personal control over their health and they considered health to be determined by chance or fate. CMD-patients also reported to cope differently with stress than controls. Analyses of covariance showed that the results were not influenced by differences in age, sex or pain reported in the head, neck and/or shoulders. Results were interpreted with regard to the psychophysiological theory of the development of signs and symptoms of CMD as a consequence of the progression of stress-induced muscle hyperactivity. Differences between patients and controls in personal factors were interpreted with regard to treatment need for CMD.     

Generalized pain and pain sensitivity in community subjects with facial pain: a case-control study

AIMS: To investigate the existence of pain outside the facial area as well as pain sensitivity in a population-based sample of 34-year-old subjects with facial pain. METHODS: Fifty-two facial pain cases (10 men, 42 women) and 52 pain-free controls (10 men, 42 women) included in the Northern Finland Birth Cohort of 1966 underwent a clinical musculoskeletal examination. Pain outside the facial area during the week prior to the examination was defined by means of a pain drawing. Eighteen fibromyalgia points were palpated in response to digital palpation with an algometer. Pressure pain thresholds were measured from the dorsal side of the wrist and from the highest points of the temporalis muscles. RESULTS: Compared to controls, pain cases reported significantly more pain in areas outside the face, with the exception of the shoulder and lower back. The number of painful fibromyalgia points was significantly higher in cases than in controls. Mean pressure pain thresholds were slightly lower in cases than in controls; the difference was significant in the left wrist. CONCLUSION: Subjects with facial pain reported more pain and had more mascular tenderness outside the facial area compared to controls. Pain symptoms outside the facial area should be assessed in patients seeking treatment for facial pain, and they should be taken into account when treatment is planned.     

Effects of head and neck inclination on bilateral sternocleidomastoid EMG activity in healthy subjects and in patients with myogenic cranio-cervical-mandibular dysfunction

This study was conducted in order to determine the effect of head and neck position on bilateral electromyographic (EMG) activity of the sternocleidomastoid muscles. The study was performed on 16 patients with myogenic cranio-cervical-mandibular dysfunction (CMD) and 16 healthy subjects. EMG recordings at rest and during swallowing of saliva and maximal voluntary clenching were performed by placing surface electrodes on the right and left sternocleidomastoid muscles. EMG activity was recorded in the left lateral decubitus position, in a darkened room and with the individual's eyes closed, under the following experimental conditions: 1. Head, neck, and body horizontally aligned; 2. Head and neck upwardly inclined with respect to the body, simulating the effect of a thick pillow, 3. Head and neck downwardly inclined with respect to the body, simulating the effect of a thin pillow. Variation of head and neck positions was determined by measuring the distance from the angle of neck and shoulder and the apex of the shoulder (SND = shoulder-neck distance) of each individual. Then, head and neck were forward or downwardly inclined with respect to the body at one-third of SND. A significantly higher contralateral EMG activity and a more asymmetric EMG activity were observed in the CMD group than in the healthy subjects (Kruskal-Wallis Test). These results suggest a different behavior of bilateral sternocleidomastoid EMG activity in CMD patients than in healthy subjects depending on the positioning of the head and neck.     

Reports of body pain in a dental student population

BACKGROUND: Dentists experience more neck, shoulder and lower back pain than do practitioners in other occupational groups. The authors examined the prevalence of musculoskeletal pain in dental students, by sex. METHODS: The authors investigated the body distribution and severity of reported musculoskeletal pain in a population of dental students, considering increased exposure to clinical experience with years in dental school. A total of 271 dental students in all four school years completed a questionnaire focusing on pain reported in five general body regions. RESULTS: Forty-six to 71 percent of students reported body pain, with the percentage generally increasing with years in dental school. Women reported having the worst pain in their neck/shoulder region (chi2, P = .004); men reported having the worst pain in their mid- to lower back regions (chi2, P = .015). Frequency and daily duration of the worst pain were higher in the third year of dental school than in the first year (Bonferroni test, P = .014 and P = .001, respectively), as was the persistence (in months) of the most symptomatic body pain (P = .001). Pain intensity was higher for women than for men (two-way analysis of variance, P < .05). The perception of how performance of dental procedures affects pain increased significantly with number of years in dental school (P = .001). CONCLUSIONS: Chronic musculoskeletal pain appears early in dental careers, with more than 70 percent of dental students of both sexes reporting pain by their third year. CLINICAL IMPLICATIONS: Musculoskeletal pain is a common complaint of dental professionals that may lead to serious physical disability. Since this type of pain occurs early in dental training, dentistry is obligated to further examine the mental, physical and ergonomic factors that may be contributory.     

The use of SPECT bone scans to evaluate patients with idiopathic jaw pain

OBJECTIVE: The purpose of this study was to investigate the potential usefulness of single photon emission computed tomography (SPECT) bone scanning with technetium-99m methylene diphosphonate (Tc-99m MDP) in the diagnosis of idiopathic jaw pain. Unlike planar bone scanning, SPECT uses tomographic technology to provide 3-dimensional images, which are more useful in localizing small lesions.Study Design: Twenty patients, each with a diagnosis of chronic idiopathic jaw pain, were compared after SPECT bone scanning with 20 age-matched and gender-matched normal controls. Uptake was identified and compared in sites with previously detected jaw pathoses and jaw pain. RESULTS: Nineteen of 20 patients with jaw pain evaluated with SPECT had positive scans, in contrast with 12 of 20 control subjects (P <.04). Positive scans were correlated with painful sites in 15 of 20 patients, with the remaining 5 patients demonstrating no uptake in painful locations. Patients with jaw pain demonstrated 37 of 80 mouth quadrants with positive scans, in contrast with 21 of 80 mouth quadrants in the controls (P <.01). Nineteen of 24 painful mouth quadrants had uptake in the pain group. Of the 21 quadrants positive in the controls, 17 were correlated with previously detected jaw pathoses. The sensitivity and specificity for detecting painful sites were 0.79 and 0.68, respectively. The sensitivity and specificity for detecting previously identified pathoses in the jaws of normal controls were 0. 80 and 0.93, respectively. CONCLUSION: Patients with idiopathic jaw pain had a significantly greater frequency of positive SPECT bone scans when compared with normal controls. However, the sensitivity and specificity of SPECT bone scans in detecting painful sites were low. These findings suggest that SPECT bone scanning with Tc-99m MDP is not indicated as a routine imaging procedure for the detection of jaw pathoses, but may be considered as a potential research tool in the future study of chronic idiopathic jaw pain.     

Increased pain sensitivity of the upper extremities of TMD patients with myalgia to experimentally-evoked noxious stimulation: possibility of worsened endogenous opioid systems

The purpose of this study was to examine whether or not temporomandibular disorder (TMD) patients with chronic masticatory myalgia have increased pain sensitivity at remote sites outside of the head and neck region, and to evaluate whether the endogenous pain inhibitory systems triggered ischemic pain functions favorably in those patients. Twenty female TMD patients with chronic myalgia and 20 controls participated in this study. Ischemic pain was produced to activate endogenous opioids. The pain threshold time, pain tolerance time, pain intensity and pain unpleasantness were compared between the TMD patients and controls. The pressure pain thresholds in the hand were also compared before, between, and immediately after the ischemic pain. The TMD patients showed higher severe pain intensity and unpleasantness values and had lower pressure pain thresholds in the hand. Although both groups showed an increase in the pressure pain threshold, there was less of an increase in the pressure pain threshold in the TMD patients than in the controls. These findings indicate that TMD patients have increased pain sensitivity at remote sites, and also indicate additional evidence that the endogenous opioid systems may become impaired in TMD patients with chronic masticatory myalgia.     

Shoulder complaints after neck dissection; is the spinal accessory nerve involved?

The purpose of the current study was to investigate the relation between shoulder morbidity (pain and range of motion), and the function of the spinal accessory nerve after neck dissection. Identifying dysfunction of the nerve gives insight in the mechanisms of post-operative shoulder complaints. In total 112 patients after neck dissection (73 males/39 females), mean (SD) age 61 (13) years, participated in the study. The mean duration of follow up was 3 (2) years. Five patients had radical, 43 modified radical, 48 supraomohyoid, and 16 posterolateral neck dissection. Thirty-nine complained of shoulder pain of whom 20 (51%) had dysfunction of the spinal accessory nerve, and 19 (49%) did not. In total 29 patients (26%) had dysfunction of the spinal accessory nerve of whom 20 (69%) had shoulder pain. Shoulder pain was significantly related to dysfunction of the nerve (P < 0.001). Twenty-three patients had a difference in active range of motion in shoulder abduction of > or =40 degrees, of whom 22 (96%) had dysfunction of the nerve. A difference in active shoulder abduction of > or =40 degrees was significantly related to loss of function of the spinal accessory nerve (P < 0.001). CONCLUSION: Shoulder pain after neck dissection can only be attributed to dysfunction of the spinal accessory nerve in about 50%. If patients experience shoulder pain after neck dissection examination of the trapezius muscle and active bilateral abduction of the shoulder should be made to find out if the spinal accessory nerve is involved.     

General health factors and denture function in patients with burning mouth syndrome and matched control subjects

summary A total of 30 denture-wearing patients with burning mouth syndrome (BMS) referred to a Pain Clinic Unit and 26 age- and sex-matched control subjects were examined and compared with respect to general health factors and denture function. The study demonstrated a significantly higher frequency of multiple chronic diseases, psychosocial stress factors, and tenderness/pain in masticatory, neck, shoulder, and suprahyoid muscles in patients with BMS. Denture function differed also between the two groups as patients with BMS had significantly less daily use of dentures, reduced tongue space, incorrect placement of occlusal table and increased vertical dimension. Pain interview with the use of the McGill Pain Questionnaire demonstrated that pain in parts of the body other than the oral cavity were reported more frequently and that the intensity of past pain experiences was not rated higher except for pain in the head in patients with BMS. The results suggested a complex interaction between several general health factors, psychosocial stressors and denture dysfunction in order to explain an idiopathic burning pain in the anterior part of the oral cavity. The existence of demonstrable load factors does not seem to support the suggestion that BMS is primarily a psychogenic disorder.     

Occupational cervico-brachial disorders among dentists. Analysis of ergonomics and locomotor functions

The aim of the investigation was to compare dentists with and without occupational cervicobrachial disorders with regard to the mobility of the neck and shoulders and the static endurance of the shoulder muscles. Further, differences in working position and the task performance on a stimulated case were to be analysed. The investigation was carried out during a visit to the workplace of 143 dental officers in the Public Dental Service in Malm?hus District and the Municipality of Malm?. Of these dentists, 96 had signs of cervico-brachial disorders and discomfort while 47 had not. The ergonomic examination showed, that significantly more dentists without symptoms of pain applied a wedge cushion under the upper part of the back of the patient to get an optimum view (p less than 0.05). It was also found that significantly more dentists without symptoms were aware of and utilised the naturally arising pauses in their work than dentists with pain and discomfort. Further dentists with cervico-brachial disorders kept their head sidebent and rotated to a greater extent than dentists without symptoms (p less than 0.01). No significant difference was found between the two groups concerning mobility of the neck and shoulders. Significant differences were found between women with and without cervico-brachial systems.     

Pain and discomfort in the musculoskeletal system among dentists. A prospective study.

The aim of this prospective study was to follow the pain and discomfort among dentists in the Public Dental Service in Malm?hus District and the Municipality of Malm?. In this investigation 311 dentists, who had answered questionnaires in 1987 and in 1990, took part. The prevalence of musculoskeletal pain and discomfort had increased, except the lower back pain and headache. However, the only significant difference was found with respect to the shoulders. As in 1987, female dentists had also in 1990 a higher prevalence of pain and discomfort in the neck and shoulders than their male colleagues. Of the 311 dentists, 262 had symptoms both in 1987 and in 1990. In 1987 forty-nine dentists were free of symptoms, while 24 of them reported symptoms in the locomotor system in 1990. Of the 262 dentists with symptoms in 1987 twenty-four were without symptoms at the follow-up in 1990. The aim of the investigation was also to study the influence of some ergonomic factors on the course of symptoms. However, these ergonomic variables showed a low predictive value for recovery or for the development of pain and discomfort in the locomotor system.     

Differenzielle und gemeinsame Merkmale bei Patienten mit atypischem Gesichtsschmerz und kraniomandibularer Dysfunktion

Background

Craniomandibular disorders (CMD) and atypical facial pain (AFP) represent a clinical challenge. Whereas CMD patients respond to somatic approaches, somatization should be strictly avoided in AFP. The aim of this study was to establish prognostic criteria to identify an aggravated risk of a chronic course in CMD and AFP.

Method

A total of 124 consecutive patients with CMD (n=108) or AFP (n=16) were examined by two interdisciplinary academic pain centers. Psychometric evaluation was conducted with standardized questionnaires (SCL-90R, STAXI, modified SBAS-IV). All patients were clinically assessed by a maxillofacial surgeon or specialized dentist.

Results

The following variables proved to be significant: age (risk for AFP vs CMD increased by 6% p.a.), decreased dysfunction index (13% higher risk for AFP vs CMD), and low scores concerning outwardly directed anger (12% higher risk for AFP vs CMD). There was no correlation between initial pain intensity and somatic parameters of disease as assessed by the standardized clinical examination. Low educational status proved to be the best predictor (p<0.001) for patients presenting high initial pain with a marked discrepancy between somatic findings and subjective status.

Conclusions

CMD patients differ from AFP patients regarding age, psychosocial isolation, outwardly directed anger, and a decreased dysfunction index. Additionally, initial pain intensity in patients presenting indistinct CMD/AFP can be considered as a valid predictor for a chronic course in pain.