Psychosocial interventions for the management of chronic orofacial pain

59 Pages·2013·0.51 MB·English

Psychosocial interventions for the management of chronic
orofacial pain (Review)
Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2011,Issue11
http://www.thecochranelibrary.com
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review)
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Analysis1.1.Comparison1Anypsychosocialinterventionversususualcare,Outcome1Painshortterm(3monthsor
less). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Analysis1.2.Comparison1Anypsychosocialinterventionversususualcare,Outcome2Painlongterm(greaterthan3
months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Analysis1.3.Comparison1Anypsychosocialinterventionversususualcare,Outcome3Musclepalpationpainlongterm
(greaterthan3months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Analysis1.4.Comparison1Anypsychosocialinterventionversususualcare,Outcome4Activityinterference/disability
longterm(greaterthan3months). . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Analysis1.5.Comparison1Anypsychosocialinterventionversususualcare,Outcome5Depressionlongterm(greater
than3months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Analysis2.1.Comparison2Habitreversalversuswaitinglistcontrol,Outcome1Painshortterm(lessthan3months). 49
Analysis2.2.Comparison2Habitreversalversuswaitinglistcontrol,Outcome2Lifeinterference. . . . . . . 49
Analysis3.1.Comparison3Cognitivetherapyversusattentionplacebo,Outcome1Painshortterm(3monthsorless). 50
Analysis3.2.Comparison 3Cognitive therapyversusattentionplacebo,Outcome2Painlongterm(greaterthan3
months). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Analysis4.1.Comparison4Hypnosisversusrelaxation,Outcome1Painshortterm. . . . . . . . . . . . 51
Analysis4.2.Comparison4Hypnosisversusrelaxation,Outcome2Depressionshortterm. . . . . . . . . . 51
Analysis4.3.Comparison4Hypnosisversusrelaxation,Outcome3Anxietyshortterm. . . . . . . . . . . 52
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) i
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Psychosocial interventions for the management of chronic
orofacial pain
VishalRAggarwal1,KarinaLovell2,SarahPeters3,HaniehJavidi1,AmyJoughin1,JoannaGoldthorpe1
1OralHealthUnit,SchoolofDentistry,TheUniversityofManchester,Manchester,UK.2SchoolofNursing,MidwiferyandSocial
Work,TheUniversityofManchester,Manchester,UK.3SchoolofPsychologicalSciences,TheUniversityofManchester,Manchester,
UK
Contactaddress:VishalRAggarwal,OralHealthUnit,NationalPrimaryCareResearchandDevelopmentCentre,SchoolofDentistry,
TheUniversityofManchester,HigherCambridgeStreet,Manchester,M156FH,[email protected].
Editorialgroup:CochraneOralHealthGroup.
Publicationstatusanddate:New,publishedinIssue11,2011.
Reviewcontentassessedasup-to-date: 19September2011.
Citation: Aggarwal VR, Lovell K, Peters S, Javidi H, Joughin A, Goldthorpe J. Psychosocial interventions for the man-
agement of chronic orofacial pain. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD008456. DOI:
10.1002/14651858.CD008456.pub2.
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Psychosocialfactorshavearoleintheonsetofchronicorofacialpain.However,currentmanagementinvolvesinvasivetherapieslike
occlusaladjustmentsandsplintswhichlackanevidencebase.
Objectives
Todeterminetheefficacyofnon-pharmacologicpsychosocialinterventionsforchronicorofacialpain.
Searchmethods
Thefollowingelectronicdatabasesweresearched:theCochraneOralHealthGroupTrialsRegister(to25October2010),theCochrane
CentralRegisterofControlledTrials(CENTRAL)(TheCochraneLibrary2010,Issue4),MEDLINEviaOVID(1950to25October
2010), EMBASE via OVID (1980 to 25 October 2010) and PsycINFO via OVID (1950 to 25 October 2010). There were no
restrictionsregardinglanguageordateofpublication.
Selectioncriteria
Randomisedcontrolledtrialswhichincludednon-pharmacological psychosocialinterventionsforadultswithchronicorofacialpain
comparedwithanyotherformoftreatment(e.g.usualcarelikeintraoralsplints,pharmacologicaltreatmentand/orphysiotherapy).
Datacollectionandanalysis
Datawereindependentlyextractedinduplicate.Trialauthorswerecontactedfordetailsofrandomisationandlosstofollow-up,and
alsotoprovide meansandstandard deviations foroutcome measureswherethesewerenot available.Risk of biaswas assessedand
disagreementsbetweenreviewauthorswerediscussedandanotherreviewauthorinvolvedwherenecessary.
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 1
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Mainresults
Seventeentrialswereeligibleforinclusionintothereview.Psychosocialinterventionsimprovedlong-termpainintensity(standardised
meandifference(SMD)-0.34,95%confidenceinterval(CI)-0.50to-0.18)anddepression(SMD-0.35,95%CI-0.54to-0.16).
However,theriskofbiaswashighforalmostallstudies.Asubgroupanalysisrevealedthatcognitivebehaviouraltherapy(CBT)either
aloneorincombinationwithbiofeedbackimprovedlong-termpainintensity,activityinterferenceanddepression.Howeverthestudies
pooledhadhighriskofbiasandwerefewinnumber.Thepooledtrialswereallrelatedtotemporomandibulardisorder(TMD).
Authors’conclusions
Thereisweakevidencetosupporttheuseofpsychosocialinterventionsforchronicorofacialpain.Althoughsignificanteffectswere
observedforoutcomemeasureswherepoolingwaspossible,thestudieswerefewinnumberandhadhighriskofbias.However,given
thenon-invasive natureofsuchinterventions theyshouldbeusedinpreferencetootherinvasive andirreversibletreatmentswhich
alsohavelimitedornoefficacy.Furtherhighqualitytrialsareneededtoexploretheeffectsofpsychosocialinterventionsonchronic
orofacialpain.
PLAIN LANGUAGE SUMMARY
Psychosocialinterventionsforthemanagementofchronicorofacialpain
Studiesindicatethatpsychologicalfactorsareassociatedwithchronicpainintheface,mouthorjaws.However,currentmanagement,
particularlyindentistry,doesnottargetthesefactors.Thisreviewthereforeexploredwhetherbehaviouralinterventionslikecognitive
behaviouraltherapy(CBT),biofeedbackandpostureregulationcomparedwithusualcarecouldimproveoutcomesforpatientswith
chronicorofacialpain.Wefoundthatsuchinterventionsimprovedlong-termpainintensity,paininterferencewithdailylifeactivities
anddepression.However,thequalityofthestudieswaspoorandtherewerefewstudiesfromwhichwecouldcombineresults.We
thereforerecommendfurtherhighqualitytrialsareneededtosupporttheuseofsuchinterventionsforchronicorofacialpain.
BACKGROUND andthathasbeenpresentfor3monthsorlonger.Theresultsof
thisresearchsupportspreviousfindingsandshowedthatchronic
orofacial pain thusdefinedhad distinct characteristics based on
paindescriptors,patternsandcomorbiditiesthatdistinguishedit
Descriptionofthecondition fromother commonly reported dental pains (Aggarwal 2008a).
Thisworknotonlyprovidesevidencethatchronicorofacialpain
Therearefourrecognisablesymptomcomplexesofchronicoro-
encompassesagroupofdistinctconditions, butalsoshowsthat
facial pain that may coexist: temporomandibular disorder (my-
chronicorofacialpainco-occurswithotherfrequentlyunexplained
ofacial face pain); atypical facial pain (atypical facial neuralgia);
syndromeslikechronicwidespreadpain,irritablebowelsyndrome
atypical odontalgia (phantom tooth pain); and burning mouth
andchronicfatigue,andthatitsharescommonpsychosocialfac-
(oraldysaesthesia,glossodynia,glossopyrosis).Thesechronicoro-
torswiththesesyndromes(Aggarwal2006),andmaythereforebe
facial pain conditions have been considered as medically unex-
partofawiderspectrumofchronicpaindisorders.
plained symptoms affecting the region of the mouth and face
(Madland2001;Wessely1999),aspathologicalchangesfailtoex-
plaintheassociatedsymptoms.Recentresearchhasalsoshownthat
theseconditionssharecommoncharacteristicsandclustertogether
into a single group based on theseshared characteristics (Woda
Descriptionoftheintervention
2005).Epidemiologicalresearchhastakenthisevidenceforward
by ’lumping’ these conditions together and collectivelyterming Psychosocial interventions targeted towards changing thoughts,
themaschronicorofacialpain,definedaspainintheface,mouth behaviours and/or feelings that may exacerbate pain symptoms
orjawsthathasbeenpresentforadayorlongerinthepastmonth, throughaviciouscycle.
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 2
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Howtheinterventionmightwork ician assessing them and therefore tends to follow the current
biomedicalmodelwhichfocusesonidentifyingunderlyingabnor-
Psychosocial interventions may assume two possible models for
malpathologyforreportedsymptoms.Patientsarethereforesub-
chronicorofacialpain.
jectedtomultipletestsandtreatmentsinsearchforsuchacause.
1. Inactivity-wherepersistentphysicalsymptomsofpainlead
Pfaffenrath1993showedthatpatientswithatypicalfacialpainhad
topatientslearningtoavoidphysicalactivityduetofearof
consultedonaverage7.5(range1to20)differentdoctorsperpa-
exacerbatingtheircondition.Inturn,thesenegativecognitive
tient:91%dentists,80%physicians,66%neurologists,63%ear,
andbehaviouralresponsesprolongandintensifysymptoms
noseandthroatsurgeons,31%eachorthopaedicsandmaxillofa-
(Gheldof2006).Theinterventionwouldtargetthisfear-
cialsurgeons,23%psychiatrists,14%neurosurgeonsand6%each
avoidancebehaviourtoalleviatesymptomsbyareturntonormal
ophthalmologistsanddermatologists(n=30).Thisresultedina
functioning.Thismechanismconsiderscentralpainprocessing
range of treatmentsvaryingfromsurgery (60%), antidepressant
mechanisms.
drugs(69%),analgesics(69%),andarangeofphysicaltherapies.
2. Overactivity-emotionalstress(anxiety,depression,anger)
Nopatientsconsideredanyformofsurgerytobehelpfuland,in
mayincreasepainbyprecipitatingactivityinpsychophysiological
many,thepainwasmadeworse.Recentresearchhasalsoexposed
systemsthatarealsoactivatedbynoxiouseventsandprovoke
this pattern of multiple consultations and lack of agreement in
substantialautonomic,visceralandskeletalactivity.The
terminologyandmanagementofthesepatients(Aggarwal2008a;
interactionsamongthesebiologicalsystemsarewellillustrated
Elrasheed2004).Thisimposesahugeburdenonalreadystretched
bythe’anxiety-pain-tension’cyclethathasbeenproposedto
healthcareresources.
accountforsomeformsofchronicpain(Wall1999).This
Evidence from systematic reviews has also shown no beneficial
viciouscycleisfrequentlyencounteredinchronicorofacialpain
effectsoftherapiessuchasirreversibleocclusaladjustments(Koh
conditionsliketemporomandibularpaindysfunctionwhereby
2003) and splints (Al-Ani 2004) that are targeted towards the
psychosocialfactorslikelifestressandanxietyprovokegrinding
correctionofmechanicalfactorswithwhichtemporomandibular
ofteethandsustainedcontractionofmusclesoftheface.This
jointpain(oneoftheentitiesthatconstitutechronicorofacialpain)
producespainwhichprovokesfurtheranxiety,whichinturn
is thoughtto be associated. Epidemiological investigations have
producesprolongedmusclespasmattriggerpoints,aswellas
alsoshownthatsuchmechanicalfactorsthoughttobeassociated
vasoconstriction,ischaemiaandreleaseofpainproducing
withchronicorofacialpainrepresentheightenedawarenessofbody
substances.Thiswillthenfurtherreducephysicalactivity,and
symptomsgenerallyandarenotspecifictochronicorofacialpain
consequentlymuscleflexibility,muscletone,strengthand
(Aggarwal2008b).
physicalendurance.Alltheaboveleadtothecommonlyobserved
Thereisalsostrongevidencetoshowthatchronicorofacialpainis
physicalsymptomsoftemporomandibularpaindysfunctionsuch
associatedwithpsychologicalfactors(Aggarwal2006;Macfarlane
aslimitedmouthopeningandthefeelingthatteetharenot
2001; Macfarlane 2002; Macfarlane 2004) and co-occurs with
fittingproperly.Fearavoidanceandconsequentdisabilitydueto
other medically unexplained symptoms (Aggarwal 2006). Fur-
disusehasbeendescribedinotherchronicpainconditions
ther,thereisgrowingevidencefromrandomisedcontrolledtrials
(Gheldof2006).Psychologicalfactorsalsomodulatepain
(Gatchel2006;Turner2006)thatearlybiopsychologicalinterven-
responsesandthelimbicsystemthatisresponsibleforemotional
tionslikecognitivebehavioural therapy(CBT)andbiofeedback
responsesinhibitspainstimuliviadescendingpathways(Wall
mechanismscanimproveoutcomeinpatientswithchronicoro-
1999).Analterationofthissystemasencounteredinemotional
facialpainconditionsliketemporomandibularpain.Giventhese
disturbances(anxiety,depression,anger,etc)willleadtoreduced
strongpsychologicalassociationsandlackofassociationswithme-
inhibitionviathedescendingpathwaysandthusanincreasein
chanicalfactors,theuseofextensiveinvasivetherapyintheman-
pain(Wall1999).Psychosocialinterventionshavethepotential
agementofchronicorofacialpaindoesnotappeartobejustified.
totargetthesenegativethoughts,behavioursand/orfeelingsthat
EarlyinterventionwithpsychosocialtherapiessuchasCBTshould
mayexacerbatepainsymptomsandthereforeshouldbea
beapriorityforinvestigationasithasthepotentialtotargetnega-
priorityforinvestigation.Theinterventionwouldtargetthe
tivethoughts,behavioursand/orfeelingsthatmayexacerbatepain
underlyingstressorresponsibleforoveractivityandinducea
symptomsthroughaviciouscycle.
returntonormalfunctioning.Thismechanismislikelytowork
throughchangesinperipheralnociception.
Whyitisimportanttodothisreview
OBJECTIVES
Although patients with chronic orofacial pain do not have un-
derlyingorganicabnormalitiesforreportedsymptoms,theirman- Todeterminetheefficacyofpsychosocialinterventionsintheman-
agement tends to be influenced by the background of the clin- agementofchronicorofacialpain.
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 3
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
METHODS Searchmethodsforidentificationofstudies
For the identification of studies included or considered for this
review,detailedsearchstrategiesweredevelopedforeachdatabase
Criteriaforconsideringstudiesforthisreview searched.Thesewerebasedonthesearchstrategydevelopedfor
MEDLINE(OVID)butrevisedappropriatelyforeachdatabase.
Thesearchstrategyusedacombinationofcontrolledvocabulary
andfreetexttermsandwaslinkedwiththeCochraneHighlySen-
Typesofstudies
sitiveSearchStrategy(CHSSS)foridentifyingrandomisedtrials
Randomisedcontrolledtrials(RCTs)whichincludepsychosocial inMEDLINE:sensitivitymaximisingversion(2009revision)as
interventionsforchronicorofacialpaincomparedwithanyother referencedin Chapter6.4.11.1 anddetailedin box6.4.c of the
form of treatment such as surgery, usual care, pharmacological CochraneHandbookforSystematicReviewsofInterventionsVersion
treatmentand/orwaitinglistcontrols. 5.1.0(updatedMarch2011)(Higgins2011).DetailsoftheMED-
LINE search are providedin Appendix1. Thesearchesof EM-
BASEandPsycINFOwerelinkedtotheCochraneOralHealth
Typesofparticipants GroupfiltersforidentifyingRCTs.
Therewerenorestrictionsregardinglanguage.
Adultsover18yearsofagewithchronicorofacialpaindefinedas
thosediagnosedwiththefollowingconditions:temporomandibu-
lar disorders (TMDs), atypical facial pain, atypical odontalgia, Electronicsearches
burningmouthsyndrome.Othertermsusedtodescribethesecon-
Thefollowingelectronicdatabasesweresearched.
ditionswillalsobeincludedinthesearchstrategye.g.myofacial
• CochraneOralHealthGroup’sTrialsRegister(to25
pain,myofascialpainrelatedtothefacialregion,craniomandibu-
October2010)(seeAppendix2).
lar/oromandibular dysfunction, mandibular stresssyndrome,fa-
• TheCochraneCentralRegisterofControlledTrials
cialarthromyalgia,masticatorymuscledisorder,masticatorymyal-
(CENTRAL)(TheCochraneLibrary,2010,Issue4)
gia,temporomandibularjointsyndrome,stomatodynia.
(seeAppendix3).
• MEDLINEviaOVID(1950to25October2010)
(seeAppendix1).
Typesofinterventions • EMBASEviaOVID(1980to25October2010)
Psychosocial interventions targeted towards changing thoughts, (seeAppendix4).
behaviours and/or feelings that may exacerbate pain symptoms • PsycINFOviaOVID(1950to25October2010)
throughaviciouscycle. (seeAppendix5).
Searchingotherresources
Typesofoutcomemeasures
Thereferencelistsofalleligibletrialswerecheckedforadditional
studies. Where these had not already been searched as part of
the Cochrane Journal Handsearching Programme, the journals
Primaryoutcomes
werehandsearchedbythereviewauthorsifelectroniccopieswere
1. Painintensity(shortand/orlongterm)measuredusinga notavailable.Thesearchattemptedtoidentifyallrelevantstudies
visualanaloguescaleoravalidatedcategoricalscale. irrespectiveoflanguage.Translatedcopiesofnon-Englishpapers
2. Painseverity-impact(activityinterference,functionand/or were obtained. The principal review author is a member of the
distress)scoresmeasuredusingvalidatedscales(e.g.briefpain International Association for Studies on Pain (IASP) Orofacial
inventory,multidimensionalpaininventory,hospitalanxietyand Pain SpecialInterest Groupand contacted key membersof this
depressionscale). grouptoascertainwhethertheyknewofanyunpublishedmaterial.
3. Satisfactionwithpainrelief.
4. Qualityoflife.
Datacollectionandanalysis
Secondaryoutcomes
1. Serviceuse-numberofconsultationstoclinicians. Selectionofstudies
Compliancewiththeinterventionwasalsotoberecordedwhere Thetitleandabstracts ofarticlesandreportsresultingfromthe
reported. searchstrategywerescreenedindependentlyandinduplicateby
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 4
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
tworeviewauthors.Fullreportswereobtainedwheretrialsmetthe • Randomsequencegeneration(selectionbias).
inclusioncriteriaorwhereacleardecisioncouldnotbemadefrom • Allocationconcealment(selectionbias).
thetitleorabstract. Disagreements wereresolvedby discussion. • Blindingofparticipants/caregivers(wherefeasible)and
Studiesrejectedatthisorsubsequentstageswererecordedinthe outcomeassessors(performancebiasanddetectionbias).
’Characteristicsofexcludedstudies’tablealongwithreasonsfor • Incompleteoutcomedata(attritionbias).
exclusion. • Selectivereporting(attritionbias).
• Otherbias.
Dataextractionandmanagement
Eachdomaininthetoolincludesoneormorespecificentriesin
Datawasextracted,independentlyandinduplicate,usingapre- a‘Riskofbias’table.Withineachentry,thefirstpartofthetool
viously prepared data extraction form which included thechar- describes what was reported to have happened in the study, in
acteristicsoftrialparticipants,interventions,controlgroupsand sufficientdetailtosupportajudgementabouttheriskofbias.The
outcomes. Characteristics of included and excluded studies are secondpartofthetoolassignsajudgementrelatingtotheriskof
presentedintheirrespectivetables(seeCharacteristicsofincluded biasforthatentry.Thisisachievedbyassigning ajudgementof
studiesandCharacteristicsofexcludedstudies).Anydifferences ‘Lowrisk’ofbias,‘Highrisk’ofbias,or‘Unclearrisk’ofbias.
wereresolvedbydiscussion.Priortodataextractiontheformwas Aftertakingintoaccounttheadditionalinformationprovidedby
pilotedusing threestudies andallreview authors extracting the the authors of the trials, studies weregraded into the following
dataparticipatedinthepilotingsothattheywereclearaboutthe categories.
extractionprocess.Theformwasmodifiedforeaseofusefollow- • Lowriskofbias:lowriskofbiasforallkeydomains.
ingthepilotextractions. • Unclearriskofbias:unclearriskofbiasforoneormorekey
domains.
• Highriskofbias:highriskofbiasforoneormorekey
Assessmentofriskofbiasinincludedstudies
domains.
Theassessmentofriskofbiasintheincludedtrialswasundertaken
independentlyandinduplicateaspartofthedataextractionpro- A risk of bias table was completed for each included study (see
cess,asdescribedabove,andinaccordancewiththeapproachde- Characteristicsofincludedstudies).Resultsarepresentedgraph-
scribedinChapter8oftheCochraneHandbook(Higgins2011). icallybystudy(Figure1)andbydomainoverallstudies(Figure
Thisisatwo-parttooladdressingsixspecificdomainsasfollows. 2).
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 5
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Figure1. Riskofbiassummary:reviewauthors’judgementsabouteachriskofbiasitemforeachincluded
study.
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 6
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Figure2. Riskofbiasgraph:reviewauthors’judgementsabouteachriskofbiasitempresentedas
percentagesacrossallincludedstudies.
Assessmentofreportingbiases
Measuresoftreatmenteffect
Thestrengthandgeneralisabilityoftheevidencewasassessedby
For dichotomous outcomes, treatment effectswere expressed as taking into account issues around publication bias and internal
risk ratios with 95% confidence intervals whilst for continuous andexternalvalidity.
outcomes mean differenceswith 95% confidence intervalswere
used. All analyses were performed using RevMan 5 software (
RevMan2011). Datasynthesis
Meta-analyseswasonlycarriedoutiftrialswereofsimilarcom-
parisonsreportingthesameoutcomemeasures.Estimatesofeffect
werecombinedusingarandom-effectsmodelifthreeormoretri-
Dealingwithmissingdata
alswereavailableforanalysis,otherwisethefixed-effectmodelwas
Trialauthorswerecontactedtoretrievemissingdatawhereneces- tobeused.Riskratioswerecombinedfordichotomousoutcomes,
sary. and mean differences for continuous outcomes or standardised
Theanalysesgenerallyincludedonlytheavailabledata(ignoring mean differences where the same outcome was measured using
missingdata),howevermethodsforestimatingmissingstandard differentscales.
deviationsinChapter7.7.3oftheCochraneHandbook(Higgins
2011)weretobe usedifrequired. Noimputations or statistical
methodstoallowformissingdatawereused. Subgroupanalysisandinvestigationofheterogeneity
Subgroupanalysiswasintendedonthetypeofchronicorofacial
pain investigated. However, all studies included were based on
TMDpainandthiswasthereforenotpossible.
Assessmentofheterogeneity
Clinicalheterogeneitywasassessedbyexaminingtheparticipants,
Sensitivityanalysis
interventions and outcome measures included inthe trials. Sta-
tisticalheterogeneitywasassessedbymeansofCochran’stestfor Wewereunabletoundertakethisduetoinsufficientdata.Data
heterogeneityandquantifiedbytheI2statistic. permitting,wewouldhaveusedsensitivityanalysestoexaminethe
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 7
Copyright©2011TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
effect of allocation concealment, intention-to-treat analysis and long-term changes. Therefore, based on the information avail-
blindoutcomeassessmentontheoverallestimatesofeffect. able from the included trials, psychological interventions were
groupedintothefollowing:cognitivebehaviouraltherapy(CBT)
alone,biofeedbackalone,combinationofCBTandbiofeedback
andphysicalself-regulationwhichwasusedbyonetrial(Carlson
2001).Outcomemeasuresincludedshort-term(3monthsorless)
RESULTS
and long-term (more than 3 months) pain intensity and long-
termmeasuresformusclepalpationpain,activityinterferenceand
Descriptionofstudies depression.
See:Characteristicsofincludedstudies;Characteristicsofexcluded
studies.
Detaileddescriptionsofthestudiesareinthe’Characteristicsof Excludedstudies
includedstudies’and’Characteristicsofexcludedstudies’tables.
From the 38 manuscripts identified for detailed extraction, 15
studieswereexcludedastheywerenotrandomisedcontrolledtrials
orhadthewrongdiseasedefinitionand/orpatientgroup.
Resultsofthesearch
Theinitialsearchstrategyyielded525referenceswhichwereas-
sessedblindandindependentlybytworeviewauthors,andbased
on the abstracts and titles these were reduced to 38 relevant
Riskofbiasinincludedstudies
manuscripts.Mainreasonsforexclusionwerethatalargepropor-
tionofstudieswerenottrialsandotherswerenotonchronicoro- RiskofbiasplotsaredisplayedinFigure1andFigure2;theformer
facialpain. showingtheoverallriskofbiasandthelatterindividualplotsfor
All the 38 manuscripts identified were data extracted by the eachstudy.
leadauthor.Dataextractionwasduplicatedbysharingblindand
independently between the other review authors. Twenty-three
manuscriptswererelevantforinclusionandrepresented17studies Allocation
(sixpaperswerefollow-upstudiesofthesametrial).
Thiswasreportedby onlyone study (Turner 2006)andoverall
theriskofbiasinthisareawasthereforehigh.
Includedstudies
Of the 17 included trials, 15 were on temporomandibular dis-
orders(TMDs) and two trials investigated burning mouth syn- Blinding
drome. Twelve of the TMD trials included comparable control
It is notable that due to the nature of the intervention, blind-
groupsthathadusualtreatmentwhichinvolvedconservativetreat-
ing was difficultwhere the intervention and controls were con-
ment composed of education, counselling and an intraoral flat
cerned.However,itwaspossibleforoutcomeassessmentandfor
planeappliance.However,thetrialsonburningmouthsyndrome
thepurposesofthisreviewweevaluatedwhetherincludedstudies
usedanattentionplaceboandplacebopillsascontrols(Bergdahl
hadblindedoutcomemeasurement.Thiswaspoorwithonlyfour
1995;Miziara2009)whilsttheTownsend2001andTurk1993
oftheincludedstudies(Carlson2001;Dworkin1994;Dworkin
studiesusedwaitinglistcontrols.AsTurk1993hadanintraoral
2002b;Turner2006)adequatelyreportingblindingforassessing
appliancecomparison,thiswasusedasausualtreatmentcompar-
outcomemeasures.
isonandthisstudyincludedinthemaincomparison.
However, of the 12 studies eligible for pooling, Dworkin’s two
studies(Dworkin2002a;Dworkin2002b)andKomiyama’sstudy
Incompleteoutcomedata
(Komiyama 1999) displayed results graphically and we did not
havemeansandstandarddeviations(SDs)topoolthesestudies. Onlysevenofthe17trialsincludedreportedonmissingoutcome
Trial authors were contacted to obtain data but only provided dataandwereassessedasbeingatlowriskofbiasforthisdomain.
meanswithnoSDsordidnotrespond.Thesethreestudiescould
thereforenotbeincludedinthemeta-analysis.Overall,therefore,
nineTMDtrialswereeligibleforpooling.Evenwithinthesenine
Selectivereporting
studies, there was much heterogeneity whereby studies did not
usethesameintervention,didnotmeasuresimilaroutcomesand Nineofthe17includedtrialswereassessedasbeingatlowriskof
somereportedonlyshort-termchangeswhilstothersreportedonly biasforselectivereporting.
Psychosocialinterventionsforthemanagementofchronicorofacialpain(Review) 8
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