Thesis (M.S.W.) - Carleton University, 2007. / Includes bibliographical references (p. 133-146). Also available in electronic format on the Internet.

Bakgrund: Kronisk smärta är ett globalt fenomen där var femte människa regelbundet upplever måttlig till svår smärta. Otillräcklig förståelse och kunskap om egenvård av kronisk smärta kan vara ett hinder för många äldre personer. Otillräcklig smärtlindring kan medföra onödigt lidande för patienten. Kronisk smärta kan också påverka den äldre personens vardag så väl som deras livskvalité. Syfte: Syftet med studien var att belysa hälso- och sjukvårdspersonalens erfarenhet av omvårdnad hos äldre personer med kronisk smärta. Metod: Denna studie var en litteraturöversikt med induktiv design med 11 kvalitativa artiklar som urval. Resultat: Hälso- och sjukvårdspersonalen uttryckte att det fanns ett ökat behov av kunskap om smärta, eftersom de stundtals tvivlade på sin egen förmåga att bedöma och lindra smärtan hos äldre personer, vilket gav en känsla av maktlöshet. Erfarenheten var att samarbete, tillit och en fungerande kommunikation inom det multi-professionella teamet var viktigt för att patientens smärtlindring skulle bli optimal. Slutsats: För att den äldre patienten med kronisk smärta ska få en god smärtlindring krävs att hälso- och sjukvårdspersonalen har kunskap, samarbetsförmåga och självinsikt. / Background: Chronic pain is a global phenomenon, where every fifth person experiences moderate to severe pain regularly. Insufficient understanding and knowledge of chronic pain can be an obstacle for elderly patients. Pain relief that is insufficient contributes to unnecessary suffering for the individual. Chronic pain can also influence elderly patients' everyday life, as well as their quality of life. Aim: The aim of this study was to describe the health care staffs’ experience of nursing in elderly patients with chronic pain. Method: This study was a literature review with an inductive design in addition to a selection of qualitative articles. Result: The health care staff expressed a need for increasing the knowledge about pain, as they sometimes doubted their ability to assess and alleviate the pain in the elderly, which gave a sense of the staff being powerless. The experience was that collaboration, trust, and a functioning communication within the multi-professional team had an important role for optimal pain relief. Conclusion: In order for the elderly patient with chronic pain to receive sufficient pain relief, the healthcare professionals need abilities such as knowledge, cooperation and self-awareness.

Etude longitudinale comparative de l’efficacité d’un programme cognitivo-comportemental de groupe pour l’autogestion de la fibromyalgie : 112 patients suivis en ambulatoire à l’hôpital, âgés entre 18 et 66 ans, répartis au hasard dans un bras traitement GTCC (8 séances, 2 heures par semaine) ou dans un bras témoin GTEM (1 séance, 2 heures d’information d’éducation thérapeutique) organisés en groupes de 5 à 9 patients. Tous ont répondu à des questionnaires avant l’intervention et ont été réévalués avec des tests cliniques 3, 6 et 12 mois après le traitement. Les résultats montrent : il n’y pas de différences significatives entre GTCC et GTEM. Pour GTCC nous constatons des changements significatifs : amélioration de la motivation au maintien des acquis, de la qualité de vie spécifique à la fibromyalgie, de l’état de santé général ; et diminution du coping dramatisation, de l’intensité de la douleur, de l’anxiété et de la dépressivité. La sévérité de la douleur, reste inchangée. La dépressivité et la douleur peuvent jouer un rôle prédictif du développement de facteurs cliniques. Un programme TCC pour l’autogestion de la fibromyalgie est efficace à court et long terme / A longitudinally comparative study assessed a group self-management CBT program efficacy for 112 fibromyalgia hospital outpatients, aged 18 to 66. They were andomized in treatment group GTCC (8 weekly 2 hours sessions) and reference group GTEM (one 2 hours therapeutic patient education session), both organized with 5 to 9 patients. All patients were submitted a socio-demographic data and clinical questionnaire before intervention and a clinical re-evaluation at 3, 6 and 12 months after treatment. No significant differences between GTCC and GTEM groups were found. GTCC results shows significant short and long-term improvement in motivation to maintain the new strategies, quality of life and health status; and in decreased catastrophizing coping strategies, pain intensity, anxiety and depression propensity. No change in pain severity was found. Depression and pain can predict the development of psychological and clinical factors. A fibromyalgia self-management CBT program is efficient at short and long term.

Les recherches actuelles ne permettent pas de connaître le rôle de certaines manifestations de la gestion émotionnelle (stratégies cognitives de régulation émotionnelle ou la suppression expressive), chez les personnes atteintes de fibromyalgie. Objectif : l’objectif principal de cette recherche est de déterminer les relations existantes entre gestion émotionnelle (alexithymie, stratégies cognitives, suppression émotionnelle), détresse émotionnelle provoquée par la douleur (irritabilité, anxiété, dépression) et handicap. Méthodologies : cette étude fait appel à deux démarches méthodologiques différentes et complémentaires : (1) une démarche quantitative, qui s'appuie sur un échantillon total de 417 participants ayant complété des questionnaires (TAS-20, CERQ, ERQ, PCS-CF, HADS, CHIP, MPI, FIQ) ; (2) une démarche qualitative, qui repose sur un échantillon de 10 participants ayant participé à un entretien semi-directif. Résultats : les résultats quantitatifs de cette étude montrent qu'il existe un effet de la détresse émotionnelle provoquée par la douleur sur le handicap, médiatisé par la gestion émotionnelle. L'approche qualitative montre que le recours à des stratégies de gestion émotionnelle habituellement associées au mal-être (anxiété/dépression) varie, en fonction du contexte personnel des participants Elle permet également d'apprendre que certains participants ignorent comment ils gèrent leurs émotions et que la détresse émotionnelle provoquée par la douleur ne leur permet pas d'être disponibles (que ce soit sur le plan attentionnel ou émotionnel) pour gérer d'autres évènements émotionnels. Conclusion : les résultats de cette étude peuvent avoir des implications sur le plan psychothérapeutique. Notamment, il serait souhaitable de mettre l'accent sur la gestion de la douleur dans un premier temps, puis de proposer aux patients, dans un second temps, une approche psycho-éducative et psychothérapeutique de la gestion émotionnelle. / Research does not provide information about the role of some manifestations of emotional management such as cognitive strategies of emotional regulation and emotional suppression, in fibromyalgia. Objective: the main objective of this study is to determine the links between emotional management, emotional distress (irritability, anxiety and depression) caused by pain and disability. Methods: this study is based on two different and complementary methodological approaches: (1) a quantitative approach, with a total sample of 417 participants who replied to questionnaires (TAS-20, CERQ, ERQ, PCS-CF, HADS, CHIP, MPI, FIQ) ; (2) a qualitative approach, with a sample of 10 participants who was subject to a semi-directive interview. Results: Quantitative results of this study show that there is an effect of pain emotional distress caused by pain on disability, mediated by emotional management. Qualitative approach enhances a better understanding of processes involved, through the recounting of participants. Indeed, some of them not know how they manage their emotions. Moreover, emotional distress caused by pain does not allow them to be able to manage other emotional event. Conclusion: Results of this study can have psychotherapeutic implications. Notably, it would be beneficial to work on pain management, in the first time, and subsequently to provide patients a psycho-educational and psychotherapeutic approach of emotional management (explain that we can manage emotions, how and what are the consequences).

La douleur chronique (DC) est un trouble sensoriel complexe caractérisé par des changements structurels, c'est-à-dire par des réarrangements anatomiques sévères du cortex somatosensoriel et des changements fonctionnels, à savoir des anomalies dans la connectivité fonctionnelle du réseau et la transmission de l'information au niveau du circuit thalamo-cortical. Structurellement, dans chaque module cortical, une unité morpho-fonctionnelle peut être reconnue, appelée unité neuro-gliale-vasculaire, où les cellules gliales représentent les structures de pontage permettant le transfert de métabolites et d'oxygène aux neurones. La dépendance fonctionnelle entre les éléments neuronaux et vasculaires, explorée en grande partie par microscopies confocale 3D et biphotonique a élargi le concept de l'espace synaptique en une forme plus complexe, appelé «synapse tripartite», où malgré la présence de neurones pré et post-synaptiques, un composant glial est ajouté face au contexte microvasculaire. Il semble donc correct d'analyser les effets microscopiques corticaux de l'image macroscopique. Des études récentes de notre groupe ont traité de l'origine et l'évolution de la DC dans des modèles expérimentaux de rat DC (Seltzer) grâce à des analyses microstructurales et fonctionnelles axées sur le substrat neuronal corticale et les propriétés micromorphologiques et vasculodynamiques du sang. La microarchitecture du réseau vasculaire cortical a été révélée via la microtomographie par rayonnement X synchrotron aux lignes ID17 et ID16A (ESRF, Grenoble) ainsi qu’à la ligne TOMCAT (SLS, Villigen). S’en est suivi une analyse morphométrique du réseau vasculaire 3D par squelettisation et transformation du graphe spatial. Ensuite, une étude comparative "Neuropathique vs Contrôle", basée sur les propriétés du réseau vasculaire (nombre de vaisseaux, points de branche, segments de squelette et diamètre du vaisseau) a montré des changements évidents dans les compartiments microvasculaires corticaux: une augmentation généralisée des micro-vaisseaux et des capillaires sanguins dans les régions étudiées (cortex somatosensoriel SS1) caractérisent tous les rats DC. Parallèlement, une réduction du diamètre moyen des vaisseaux des rats DC prouve que les capillaires et les microvaisseaux ont une affinité prédominante pour ces événements angiogénétiques. L'évolution de la néogénèse est très présente dès la première étape de la neuropathie (2 semaines), puis diminue mais persiste durant la dernière étape considérée (6 mois). En outre, un flux sanguin maximal accru a été trouvé dans l'état de DC, indiquant que les réseaux vasculaires DC sont compatibles avec un flux enrichi soutenu par l'angiogenèse. Ces résultats provenant de la micro et nanotomographie ont été confirmés via microscopie en immunofluorescence: les échantillons DC ont montré la positivité à trois marqueurs de néogénèse vasculaire (VEGFR1, VEGFR2 et VWF). En parallèle, pour analyser fonctionnellement la genèse et l'évolution des circuits thalamo-corticaux dans les conditions de DC, l'activité neurale a été enregistrée par une matrice de 32 microélectrodes implantée dans le cerveau, recevant simultanément des signaux du noyau thalamique VPL et du cortex SS1. Tous les rats DC montrent des troubles de connectivité révélés aussi par l'évolution de la topologie du réseau de «Modules et Hubs» à une organisation «aléatoire» où les connexions fonctionnelles intra et intercommunautaires diminuent. Ces résultats confirment comment la dynamique neuronale est liée à l'activité vasculaire: les événements néo-génétiques des microvaisseaux corticaux dans la DC sont fortement corrélés aux anomalies fonctionnelles de la dynamique des réseaux neuronaux. L'implication microvasculaire dans la DC ouvre une nouvelle façon de l’interpréter, non seulement reconnue comme pathologie sensorielle, mais aussi comme une maladie neurologique où les réseaux de connectivité neuronale et vasculaire sont largement impliqués dans le système. / Chronic pain (CP) is a complex sensory disorder characterized by structural changes, i.e. severe anatomical rearrangements of somatosensory cortex, and functional changes, i.e. anomalies in network functional connectivity and in information transmission at the level of thalamo-cortical circuit. From the structural point of view, within each cortical module, a morpho-functional unit can be recognized, also called neuro-glial-vascular unit, where the glial cells represent the bridging structures allowing for the transfer of metabolites and oxygen to neurons. Namely, the functional dependency between neuronal and vascular elements, largely explored by 3D confocal microscopy and two photon microscopy, has expanded the concept of synaptic space to a more complex form, indicated as “tripartite synapse”, where besides the presence of the pre- and post- synaptic neurons, a glial component is added facing on the microvascular context. Due to this dependency it appears, thus, correct to analyse the cortical microscopical effects of the macroscopical picture. Novel studies by our group have recently investigated CP origin and evolution in experimental CP rat models (Seltzer) through microstructural and functional analyses focused both on the cortical neuronal substrate and the blood micromorphological and vasculodynamic properties. The 3D microarchitecture of cortical vascular network has been revealed by means of synchrotron X-ray micro Computed Tomography (CT) at the ID17 and ID16A beamlines (ESRF, Grenoble) and the TOMCAT beamline (SLS, Villigen). A subsequent morphometric analysis of the 3D vascular network has been implemented by means of skeletonization and spatial graph transformation. Then, a comparative study “Neuropathic vs Control”, based on the estimated vascular network properties (number of vessels, branch points, skeleton segments and vessel diameter), showed evident changes in cortical microvascular compartments: a widespread increase of blood microvessels and capillaries in the investigated regions (the somatosensory [SSI] cortical area) has been found in all CP rats. In parallel, a reduced mean value of vessel diameter in all CP rats prove that capillaries and small microvessels are predominantly interested by these angiogenetic events. By investigating the time evolution of the neogenesis, it appears strongly present since the first stage of the neuropathy (2 weeks), fading away, but still present, during the last time stage considered (6 months). In addition, an increased maximum blood flow, sustained by the vascular network, has been found in CP condition, indicating that CP vascular networks are compatible with an enriched blood flow sustained by the promoted novel angiogenesis. These results from micro- and nano-tomography have been further confirmed also by immunofluorescence microscopy analysis: CP samples have shown the positivity to three markers of vascular neo-genesis (VEGFR1, VEGFR2 and VWF). In parallel, to functionally analyse the genesis and the evolution of the thalamo-cortical circuits in CP conditions, the neural activity has been recorded by means of 32-microelectrode matrices implanted in the brain, simultaneously receiving signals from the VPL thalamic nucleus and the SS1 cortex. All the CP groups show connectivity disorders exhibited also by the evolution of the network topology from “Modules and Hubs” to a “random” network organisation where the intra-community and inter-community functional connections decrease. These results clearly confirm how the neuronal dynamics is strictly linked to the vascular activity: the cortical microvessel neo-genetic events in CP are strongly correlated to the functional anomalies in neuronal network dynamic. The microvascular involvement in CP opens a new way of interpretation of CP disease, not only recognized as sensory pathology, but also as a neurological disease where neuronal and vascular connectivity networks are extensively involved in the whole system.

abstract: "Too often, people in pain are stuck in limbo. With no diagnosis there is no prognosis. They feel that without knowing what is wrong, there is no way to make it right" (Lewandowski, 2006, p. ix). Research has shown that environmental factors, such as views of nature, positive distractions and natural light can reduce anxiety and pain (Ulrich, 1984). Patients with chronic, painful diseases are often worried, anxious and tired. Doctor's appointments for those with a chronic pain diagnosis can be devastating (Gilron, Peter, Watson, Cahill, & Moulin, 2006). The research question explored in this study is: Does the layout, seating and elements of positive distraction in the pain center waiting room relate to the patients experience of pain and distress? This study utilized a mixed-method approach. A purposive sample of 39 individuals participated in the study. The study employed the Positive and Negative Affect Schedule (PANAS), the Lewandowski Pain Scale (LPS) and a researcher developed Spatial Perception Instrument (SPI) rating the appearance and comfort of a pain center waiting room in a large metropolitan area. Results indicated that there were no significant correlations between pain, distress and the waiting room environment. It is intended that this study will provide a framework for future research in the area of chronic pain and distress in order to advance the understanding of research in the waiting area environment and the effect it may have on the patient. / Dissertation/Thesis / M.S.D. Design 2012

This investigation utilized a novel, self-help, multi-element psychological program to manage chronic low back pain. A literature review indicated that this disorder was costly and prevalent, yet a large percentage of chronic low back pain patients did not respond to traditional treatment. Recent research has demonstrated that numerous psychological difficulties have been associated with this disorder, including depression and anxiety. It was hypothesized that these psychological concomitants of chronic low back pain maintain and promote further pain, as part of a vicious cycle. Self-help treatment attempted to break this tension-pain-anxiety cycle using various stress reduction, and cognitive and behavioral management strategies.

Base teórica: A dor crônica decorre de alterações estruturais e funcionais mal adaptativas que influenciam a resposta ao estímulo ou que sustentam os processos de excitabilidade. Um dos sintomas que permeia grande número de pacientes com dor crônica é a catastrofização, cujas características são um conjunto de pensamentos negativos, deseperança e magnificação do sintoma ou condição. Este sintoma é mensurado por meio de uma escala de catastrofização usada em vários países. No entanto não dispomos deste instrumento validado para o português.Objetivos: Validar para o português do Brasil (B) a PCS e verificar suas propriedades psicométricas. Verificar a consistência interna, estrutura fatorial, e sua capacidade de discriminar pacientes com condições específicas de dor crônica como cefaleia tensional crônica (CTC) (International Headache Society) e fibromialgia de acordo com os critérios do American College of Rheumatology. Avaliar os possíveis mecanismos neurobiológicos correlacionados com o nível de sintomas catastróficos, através de dosagens de cortisol e TNF em uma amostra de pacientes com CTC. Métodos: 384 sujeitos com idades entre 18-79 anos com dor crônica de origem músculo-esquelética participaram deste estudo transversal. A versão da B-PCS foi aplicada, assim como a intensidade da dor, interferência da dor na capacidade funcional, no humor e um questionário sócio-demográfico. A capacidade discriminatória da B-PCS foi avaliada numa sub-amostra de pacientes com cefaléia tensional crônica (CTC) de acordo com os critérios da International Headache Society (n = 19), e em outro com diagnóstico de fibromialgia segundo os critérios do American College of Rheumatology (n = 50). Após a validação a B-PCS foi aplicada num grupo de pacientes com CTC. Foi avaliado o impacto da cefaleia usando o Short-Form Headache Impact Test (HIT-6), coletadas amostras de cortisol salivar às 08:00; 16:00 e 22:00 e dosado o TNF sérico. Resultados: Observou-se boa consistência interna [valores α de Cronbach de 0,91 para o total da BR-PCS. Para os subdomínios 0,93 (desesperança), 0,88 (magnificação), 0,86 (ruminação)]. Os coeficientes de correlação item-total variaram 0,91-0,94. Análise fatorial confirmatória apoiou os três fatores de estrutura, com o índice de ajuste comparativo = 0,98, a raiz quadrada média do erro de aproximação = 0,09, e índice de ajuste normalizado = 0,98. Foram encontradas correlações significativas para a intensidade da dor, interferência da dor e humor do paciente (coeficientes de correlação variaram 0,48-0,66, P <0,01). Nas comparações entre grupo controle (pacientes com escores de dor na VAS igual ou inferior a 40 mm na maior parte do dia nos últimos seis meses), e pacientes com condições dolorosas específicas observou-se pontuações mais baixas de catastrofização no grupo controle. No grupo com CTC a relação entre a curva de cortisol salivar, obtida em três pontos do dia (08:00, 16:00 e 22:00 horas) e a catastrofização de acordo com os grupos de catastrofização ( escores B-PCS) estratificados em níveis alto e baixo (alto> Q75 = 42 ou baixo Q75 < 42 ), utilizou-se análise de variância de medidas repetidas (ANOVA), com teste post hoc de Bonferroni. Pacientes com altos escores de catastrofismo apresentaram supressão da secreção de cortisol às 08:00 (p <0,05). Usando modelo multivariado de regressão linear, os fatores correlacionados positivamente com a variável dependente (escores da B-PCS) foram os fatores independentes: níveis séricos de TNF, pontuação no HIT6 e idade (p <0,05). O uso de antidepressivos reduziu em 21% o incremento nos escores da B-PCS. Conclusão: Nossos resultados suportam a validade e confiabilidade da B-PCS. A escala mostrou propriedades psicométricas satisfatórias. A estrutura de três fatores apresentou boas propriedades discriminatórias na comparação de pensamentos catastróficos de sujeitos controles, fibromiálgicos e CTC. A B-PCS mostrou-se instrumento com perfil satisfatório para uso em pesquisa e clínica no Brasil. Também, observamos que a catastrofização está correlacionada com o impacto da CTH, menor oscilação circadiana na secreção de cortisol salivar e níveis séricos de TNF. Isto sugere que o comportamento catastrófico possui substrato biológico que indica sua associação com o estresse crônico e resposta inflamatória. / Theoretical basis: Chronic pain is due to structural and functional changes that influence the maladaptive response to stimuli or processes that underlie excitability. One of the symptoms that permeates large number of patients with chronic pain is the catastrophizing, whose characteristics are a set of negative thoughts, holplessness and magnification of the symptom or condition. This symptom is measured through a catastrophizing scale used in several countries. However, we do not have this instrument for the Portuguese. Objectives: To validate the PCS for Brazil’s Portuguese (B) and verify its psychometric properties. Check the internal consistency, factor structure, and its ability to discriminate patients with specific conditions of chronic pain chronic such as chronic tension type headache (CTH) in accordance with International Headache Society and fibromyalgia according to the criteria of the American College of Rheumatology. To evaluate the possible neurobiological mechanisms correlated with the level of catastrophic symptoms through Cortisol and TNF dosages in a sample of patients with CTH. Methods: 384 subjects aged 18-79 years with chronic musculoskeletal pain participated in this cross-sectional study. The version of the B-PCS was applied as well as pain intensity, pain interference in functional ability, mood and a socio-demographic questionnaire. The discriminatory capacity of B-PCS was assessed in a subsample of patients with chronic tension type headaches (CTH) in accordance with the criteria of the International Headache Society (n = 19), and another with a diagnosis of fibromyalgia according to the criteria of the American College of Rheumatology (n = 50). After the validation the B-PCS was applied in a group of patients with CTH. The impact of headache were evaluated using the Short-Form Headache Impact Test (HIT-6), salivary cortisol samples collected at 08:00, 16:00 and 22:00 and serum TNF. Results: There was good internal consistency [Cronbach's α values of 0.91 for the total PCS-BR. For subdomains 0.93 (holplessness), 0.88 (magnification), 0.86 (rumination)].The coefficients of item-total correlation ranged from .91 to .94. Confirmatory factor analysis supported the three factor structure, with the comparative fit index = 0.98, root mean square error of approximation = 0.09, standard setting and the index of = 0.98. Significant correlations were found for pain intensity, pain interference and mood of the patient (correlation coefficients ranged from .48 to .66, P <0.01). Comparisons between the control group (patients with VAS pain scores at or below 40 mm in most of the day in the last six months), and patients with specific pain conditions were observed lower catastrophizing scores in the control group. In the group with CTH the relationship between the salivary cortisol curve, obtained at three points of the day (08:00, 16:00 and 22:00 hours) and catastrophizing according catastrophizing groups (B-PCS scores) stratified into low and high level (high>Q75=42 or low Q75<42), we used analysis of variance for repeated measures (ANOVA) with Bonferroni post hoc test. Patients with high scores of catastrophism had suppression of cortisol secretion at 08:00 (p <0.05). Using a multivariate linear regression model, the factors positively correlated with the dependent variable (scores of B-PCS) were the independent factors: serum levels of TNF, HIT6 score and age (p <0.05). The use of antidepressants decreased by 21% the increase in scores of B-PCS. Conclusion: Our results support the validity and reliability of the B-PCS. The scale showed satisfactory psychometric properties. The three-factor structure showed good discriminatory properties in comparison to control subjects, fibromyalgia, and HSC catastrophic thoughts. The B-PCS showed to be an instrument with a profile suitable for use in research and clinical practice in Brazil. Also, we found that catastrophizing is correlated with the impact of CTH, lower circadian oscillation in the secretion of salivary cortisol and serum levels of TNF. This suggests that the catastrophic behavior has biological substrate indicating its association with chronic stress and inflammatory response.

O primeiro objetivo deste estudo foi determinar, no nosso meio, a validade dos Critérios de Diagnóstico de Pesquisa das Desordens Temporomandibulares RDC/TMD como fator de diagnóstico em pacientes com desordens temporomandibulares. Sessenta e nove pacientes com DTM e 70 pessoas do grupo-controle, todas do gênero feminino, foram submetidas aos Critérios de Diagnóstico de Pesquisa das Desordens Temporomandibulares (RDC/TMD) e comparados em um estudo caso-controle. O segundo objetivo foi o de verificar a validade prognóstica do RDC/TMD através de um estudo longitudinal tipo resultado de tratamento. As pacientes com DTM foram submetidas a tratamento por meio de dispositivos - placas de mordida e/ou ajuste oclusal, etc., da maneira que o clínico responsável julgou necessário, o qual foi “cego” a todos os resultados do RDC/TMD. Estas pacientes foram chamadas seis meses após o tratamento realizado para a reavaliação da intensidade de dor orofacial. O critério de melhora clínica para que as pacientes com DTM pudessem ser incluídas no grupo de respondentes ao tratamento (rDTM), foi uma redução de 30% na intensidade da dor sobre a avaliação de dor em repouso no início do tratamento, utilizando-se escalas visuais análogas (VAS). Os resultados foram comparados com a auto-avaliação da paciente (melhor/igual/pior) para determinar o grau de confiabilidade dos resultados. As pacientes que melhoraram foram incluídas no Grupo 1a (rDTM). Aquelas que não melhoraram fizeram parte do Grupo 1b (nrDTM) e os assintomáticos foram incluídos no Grupo 2. A base de dados e a análise estatística foram realizadas no programa SPSS versão 11.5 para Windows®. As variáveis foram ambas categóricas/recodificadas e contínuas; portanto, tanto testes não-paramétricos (Pearson’s Chi-Square, Fisher’s exact test, two-sided test, P<0.05) quanto paramétricos (Student’s t test, two-sided test, ANOVA, P<0.05) foram empregados. Os resultados comparativos entre pacientes com DTM e controle mostraram que 57,1 % das pacientes do grupo-teste foram diagnosticadas com desordem miofascial. O deslocamento de disco com redução ocorreu em 24,3 % das articulações do lado esquerdo e em 18,6 % das articulações no lado direito. O diagnóstico de artralgia foi estabelecido em 61,4% nas articulações do lado esquerdo e em 62,9 % nas articulações do direito. O grau de dor crônica foi de média intensidade para 60,9 %, a incapacidade por dor crônica foi em média de 66,9 para o grupoteste e de 0,01 para o grupo-controle. A incapacidade foi moderada para 20 % do grupo-teste. A depressão média foi de 1,02 no grupo-teste e de 0,56 no grupo-controle. A depressão foi moderada para 40 % das pacientes do grupo-teste e para 22,9 % no grupo-controle. A somatização com dor foi em média de 1,25 no grupo-teste e de 0,44% no grupo-controle. Ela foi moderada para 30 % das pacientes do grupo-teste e 27,5 % no grupo-controle. A somatização sem dor foi em média de 1,12 no grupo-teste e de 0,35 no grupo-controle. A somatização moderada ocorreu em 25,7 % das pacientes do grupo-teste e em 24,3 % no grupo-controle. Os resultados apresentaram diferenças estatísticamente significativas entre os grupos teste e controle. Ao comparar as pacientes respondentes e não respondentes ao tratamento da DTM não foram evidenciadas diferenças estatísticamente significantes para qualquer um dos ítens estudados. Portanto, concluiu-se que a validade de diagnóstico foi positiva, mas a validade prognostica foi negativa. / The primary objective of this study was to determine, in our cultural background, the validity of the RDC/TMD (Research Diagnostic Criteria for Temporomandibular Disorders) as a diagnostic tool for patients with temporomandibular disorders. Sixty nine patients with TMD and 70 subjects from the control group, all females, underwent the RDC/TMD and were compared in a case-control study. The second objective was to verify the prognostic validity of the RDC/TMD in a longitudinal treatment outcome study. Patients with TMD underwent conservative treatments (bite-splints and occlusal adjustment, etc.) according to the treating clinician, who was blind to all RDC/TMD results. These patients were recalled after six months for a re-evaluation of orofacial pain intensity. The improvement criteria for patients to be included in the responding group (rTMD) was a 30% reduction in pain intensity at rest as compared to baseline using Visual Analogue Scales (VAS). The results were also compared to a patient’s self-assessment scale (better/same/worse) to determine the degree of reliability. Patients who improved were included in Group I (rTMD). Those who did not improve (nonresponding TMD) were part of Group II (nrTMD). Asymptomatic controls were included in Group III. The database and statistical analyses were made in the SPSS version 11.5 for Windows. The variables were both categorical/recoded as well as continuous; therefore, both parametric (Student’s t test, two-sided test, ANOVA, P<0.05) and non-parametric (Pearson’s Chi-Square, Fisher’s exact test, two-sided test, P<0.05) tests were used. The results comparing TMD patients versus controls have shown that 57.1 % of patients in the test group were diagnosed with miofascial pain. Disk intereference with reduction was observed in 24.3 % of temporomandibular joints on the left side and in 18.6 % of those on the right side. The diagnosis of arthralgia was identified in 61.4% of joints on the left side as well as in 62,9 % of those on the right side. The Chronic Pain Grade was of mild intensity for 60.9% of patients, and the Chronic Pain Intensity was 66.9 on average for the test group and 0.01 for controls. The Disability Points was moderate for 20% of the test group. The average depression score was 1.02 in the test group and 0.56 in the control one. Depression was moderate for 40% of patients as well as for 22.9% in controls. Somatization with pain was 1.25 on average for TMD patients and 0.44 in controls. Moderate somatization with pain was found in 30% of TMD patients and 27.5% in controls. Somatization without pain was 1.12 on average for the test group and 0.35 in the control group. Moderate somatization without pain was observed in 25.7 % in patients and 24.3 % in controls. The results have shown statistically significant difference between TMD patients and controls. However, when we compare responding versus non-responding TMD patients, no significant difference was observed for any of the items studied. Therefore, it is concluded that the diagnostic validity was positive, but not the prognostic one.

Chronic pain sufferers are frequently misunderstood and stigmatised. The aim of this investigation was to provide a description of the lifewor1d of people with chronic low back pain, using the phenomenological method. Themes which emerged were that the persistent nature of chronic pain makes it particularly difficult to endure, arousing a profound fear of the future. It causes a disruption in the relationship between the person and the body, in which the person is forced to function within the constraints of pain. Sufferers are unable to fulfil social roles as expected and are forced to revise their goals and activities. The distress of their experience is mediated by the ability to make sense of their condition, finding meaning in the pain itself. The study highlights the value of the phenomenological method in health psychology. Recommendations are made which may be of benefit to people with chronic pain and their families. / Psychology / M. Sc. (Psychology)