Referred pain is frequently associated with misdiagnosis and unnecessary therapy directed to the pain location instead of its origin. When craniofacial pain is the sole symptom of myocardial ischemia, failure to recognize its cardiac source can endanger the patient. In particular, patients with acute myocardial infarction (AMI) who do not experience chest pain run a very high risk of misdiagnosis and death. Pain that is limited to the craniofacial region during myocardial ischemia has so far been described only in case reports and its overall prevalence is unknown. Experimental research in animals suggests a vagal involvement in the pathological mechanisms of cardiac pain referred to the face. The aim of this study was to gain knowledge about the prevalence, clinical characteristics and possible mechanisms of craniofacial pain of cardiac origin, in order to improve the clinician’s ability to make a correct diagnosis. It was hypothesized that the quality of craniofacial pain from cardiac versus dental origin would differ, implying a high diagnostic validity. It was also hypothesized that craniofacial pain can be the sole symptom of a prodromal (pre-infarction) angina episode and that this pain location would be especially associated with cardiac ischemia in the areas more densely innervated by vagal afferent fibres. The study group was comprised of consecutive patients who experienced craniofacial pain of a verified cardiac (n=326) or dental (n=359) origin. Demographic details on age, gender and pain characteristics (location, quality and intensity) were assessed in both groups. Cardiovascular risk factors, cardiac diagnosis and ECG signs of ischemia were also assessed in the cardiac pain group. Ethics approval and informed consent for each patient was obtained. Craniofacial pain was found to be the sole symptom of myocardial ischemia in 6% of patients and was the sole symptom of an AMI in 4% of patients; this craniofacial pain was more prevalent in women (p=0.031). In those patients without chest pain, it was the most frequent pain location and was the only symptom of prodromal angina in 5% of AMI patients. The craniofacial pain included the throat, the jaws, the temporomandibular joints/ears and the teeth, mainly bilaterally. The pain quality descriptors “pressure” and “burning” were statistically associated with pain of cardiac origin, while “throbbing” and “aching” were associated with an odontogenic cause (p<0.001). In myocardial ischemia patients, the occurrence of craniofacial pain was associated with an inferior localization of ischemia in the heart (p<0.001). In conclusion, this study showed that pain in the craniofacial region could be the sole symptom of cardiac ischemia and AMI, particularly in women. Craniofacial pain of cardiac origin was commonly bilateral, with the quality pain descriptors “pressure” and “burning”, and pain provocation with physical activity and pain relief at rest. The association between the presence of craniofacial pain and inferior wall ischemia suggests a vagal involvement in the mechanisms of cardiac pain referred to the craniofacial region. Since the possibility of misdiagnosis and death in this group of patients is high, awareness of this clinical presentation needs to be brought to the attention of researchers, clinicians and the general public.

Syfte. Studiens syfte var att retrospektivt undersöka vilka kliniska variabler, bedömda under specialistundersökning av orofacial smärta, som kan förutsäga närvaro av en störd central smärtmodulering (DCPM). Material och metod. DC/TMD-data hämtades ur patientjournaler från 86 patienter som undersökts på Orofaciala smärtenheten på Malmö Universitet under perioden september 2012 till och med december 2013. Undersökta variabler omfattade smärtintensitet, smärtutbredning, smärtrelaterad nedsatthet, psykosociala variabler, refererad smärta samt kliniska fynd under somatosensoriska undersökningar. Baserat på denna data delades patienterna upp i en DCPM-grupp och en grupp utan DCPM. Allodyni, hyperalgesi, dysestesi, wind-up, regional/generell smärtutbredning samt eftersensation ansågs vara markörer för DCPM. Icke-parametriska statistiska analyser användes och en sannolikhetsnivå på P<0,05 ansågs vara signifikant. Resultat. Graden av ospecifika fysiska symptom och antalet refererande smärtor var signifikant högre i DCPM-gruppen. Den multivariata logistiska regressionen visade att ospecifika fysiska symptom, stress, smärtduration, smärtintensitet, smärtrelaterad nedsatthet, antalet refererande smärtpunkter, maximal gapning med och utan smärta, ångest samt antalet smärtinducerande käkrörelser var signifikanta marörer för DCPM (LR Chi2 = 26.89, p = 0.003, Pseudo R2 = 0.29). Slutsats. Denna studie indikerar att stress, ångest, smärtduration, smärtintensitet, smärtrelaterad nedsatthet, antalet refererande smärtpunkter, maximal gapning med och utan smärta samt antalet smärtinducerande käkrörelser är associerat med DCPM hos patienter med orofacial smärta. / Objective. To retrospectively investigate clinical variables that can predict the presence of disturbed central pain modulation (DCPM). Material and methods Medical records of 86 patients examined at the Orofacial Pain Unit at Malmö University from September 2012 to December 2013 were examined regarding pain intensity, pain distribution, pain-related disability, psychosocial variables, referred pain as well as somatosensory changes. Based on these variables, the patients were divided into a disturbed central pain modulation (DCPM) group and a non-DCPM group. Allodynia, hyperalgesia, dysesthesia, increased wind-up, regional/general pain distribution and aftersensation were considered as markers for DCPM. Non-parametric statistics were used and a probability level of P<0.05 was considered as significant. Results. The degree of unspecific physical symptoms and the number of sites eliciting pain referral were significantly higher in the DCPM group. In the multivariate regression model, the independent variables physical symptoms, stress, pain duration, characteristic pain intensity, pain-related disability, number of sites with referred pain, maximum mouth opening with and without pain, anxiety, and number of pain eliciting jaw movements significantly predicted DCPM (LR Chi2 = 26.89, p = 0.003, Pseudo R2 = 0.29). Conclusion. This study indicates that stress, anxiety, orofacial pain and its consequences, unspecific physical symptoms and jaw dysfunction are clinical signs of DCPM in patients with orofacial pain. Also, high number of palpations sites with referred pain over the masseter and temporal muscles and the TMJ indicate presence of DCPM.

Objectives: To explore the pain mechanism and the origin of the pain and to evaluate a short-term pain relief treatment in women suffering from CPP persisting after childbirth in order to enable physiotherapeutic intervention. Material and methods: Thirty-six parous women with chronic pelvic pain persisting after childbirth were recruited at the Department of Physiotherapy, SundsvallHospital and by advertisements in newspapers and 29 parous women without chronic pelvic pain were recruited from an organized gynaecological screening at a midwifery surgery. All women were provoked by intra-pelvic palpation of 13 predetermined intra-pelvic landmarks. The provoked pain distribution was expressed in pain drawings and the pain intensity verbally on a Likert scale.Also, in a randomised controlled trial the 36 women with chronic pelvic pain were allocated to bilateral injection treatment with either triamcinolone or saline solutions, given once on the ischial spine with follow-up after four weeks. Results: Referred pain provoked on intra-pelvic landmarks follows a specific pattern. In general, pain provoked by palpation of the posterior intra-pelvic landmarks was mostly referred to the sacral region and pain provoked by palpation of the ischial and pubic bones was mostly referred to the groin and pubic regions. In women with chronic pelvic pain the provoked pain distribution area and pain intensity were magnified as compared to women without chronic pelvic pain. In the clinical trial decreased pain intensity, decreased distribution of pain and improved physical function was achieved among the triamcinolone treatment group as compared to the saline treatment group. Also, a positive correlation was shown between reduced pain intensity and improved function. Conclusions: Referred pain patterns provoked on intra-pelvic landmarks in women with chronic pelvic pain persisting after childbirth are consistent with sclerotomal sensory innervations and indicates allodynia and central sensitisation. This suggests that pain mapping can be used to evaluate and confirm the pain experience and contribute to diagnosis. Also, the pain intensity provoked by stimulation of the intra-pelvic landmarks is suggested to be useful to differentiate women with chronic pelvic pain from those without. Corticosteroid treatment to the ischial spine resulted in decreased pain and increased function.

A maioria dos pacientes que têm dor de origem dentária pulpar ou periapical tem dor referida, e algumas características da dor parecem influenciar este fenômeno. Por meio do preenchimento de fichas clínicas, com informações sobre as características da dor, investigamos, em 60 voluntários, a distribuição topográfica de áreas de dor referida de origem dentária. Por meio de métodos psicofísicos, comparamos a resolução espacial da dor com a resolução espacial de outras modalidades somestésicas (mecânica e térmica). Nossos resultados indicam que a intensidade da dor favorece o fenômeno da dor referida e interfere na sua dispersão topográfica. Dentes algógenos com polpa viva influenciam um maior espalhamento da dor. A organização hodológica do núcleo espinal do trigêmeo e mecanismos fisiológicos de integração neural podem explicar de maneira satisfatória várias características da dor referida. Além disso, observamos que a resolução espacial na localização da dor é maior que a resolução espacial da localização de outros estímulos somestésicos nos elementos dentários. / The majority of patients who suffer from toothache report referred pain to other sites in the head and neck. Thus, the aim of this study was to investigate the clinical and psychophysical characteristics of referred pain in the orofacial region and how factors such as intensity, duration and nature of odontogenic pain might modulate them. We employed psychophysical and clinical methods to correlate pain perception with the anatomy and physiology of the trigeminal system. Sixty patients reporting primary toothache were investigated as to the clinical and psychophysical aspects of their pains symptoms and signals (intensity, duration, location and state of the pulp inflammatory process). Pain intensity and state of irreversible pulp inflammation were found to significantly affect facilitate the incidence of referred pain and its spread across vertical laminations. Considering these results, we proposed a physiological model based on both neuronal integration (spatial and temporal summation) and the topographic organization of the trigeminal system, which is able to explain the observed characteristics of referred dental pain.

A maioria dos pacientes que têm dor de origem dentária pulpar ou periapical tem dor referida, e algumas características da dor parecem influenciar este fenômeno. Por meio do preenchimento de fichas clínicas, com informações sobre as características da dor, investigamos, em 60 voluntários, a distribuição topográfica de áreas de dor referida de origem dentária. Por meio de métodos psicofísicos, comparamos a resolução espacial da dor com a resolução espacial de outras modalidades somestésicas (mecânica e térmica). Nossos resultados indicam que a intensidade da dor favorece o fenômeno da dor referida e interfere na sua dispersão topográfica. Dentes algógenos com polpa viva influenciam um maior espalhamento da dor. A organização hodológica do núcleo espinal do trigêmeo e mecanismos fisiológicos de integração neural podem explicar de maneira satisfatória várias características da dor referida. Além disso, observamos que a resolução espacial na localização da dor é maior que a resolução espacial da localização de outros estímulos somestésicos nos elementos dentários. / The majority of patients who suffer from toothache report referred pain to other sites in the head and neck. Thus, the aim of this study was to investigate the clinical and psychophysical characteristics of referred pain in the orofacial region and how factors such as intensity, duration and nature of odontogenic pain might modulate them. We employed psychophysical and clinical methods to correlate pain perception with the anatomy and physiology of the trigeminal system. Sixty patients reporting primary toothache were investigated as to the clinical and psychophysical aspects of their pains symptoms and signals (intensity, duration, location and state of the pulp inflammatory process). Pain intensity and state of irreversible pulp inflammation were found to significantly affect facilitate the incidence of referred pain and its spread across vertical laminations. Considering these results, we proposed a physiological model based on both neuronal integration (spatial and temporal summation) and the topographic organization of the trigeminal system, which is able to explain the observed characteristics of referred dental pain.

Pain and movement are intimately connected and nearly universal human experiences. However, our understanding of the extent, significance, and mechanisms of pain-movement relationships is limited. While pain is a normal, protective response to injury and potentially harmful stimuli, prolonged or dysfunctional neuromuscular adaptions in response to pain can contribute to a variety of pain conditions. Alternatively, movement (in the form of global physical activity, individual exercise programs, and/or specific motor learning/functional tasks) is often prescribed to help decrease pain and improve function. While attempts have been made to show an effect of movement on pain or to better understand altered movement strategies in response to pain, much of the research has been limited to animal models or to those with specific persistent or chronic pain conditions limiting generalizability and interpretability. Therefore, this research sought to advance current understanding of the relationships between physical activity and normal variability in centrally- and peripherally-mediated pain in healthy adults. Additionally, we sought to characterize changes in reflexive motor responses in the upper extremity to an endogenous, naturally-occurring, long-lasting acute muscle pain. The results of these investigations indicate that greater, self-reported intense (i.e. vigorous) and leisure activity are more strongly associated with decreased pain sensitivity than is pain modulation or measured activity (via accelerometry). Future research is needed to determine directionality of these relationships. Further, reflexive motor responses to endogenous, acute muscle pain in the upper extremity were not significantly altered indicating that changes in pain-related, movement strategies may be more strongly influenced by supraspinal adaptations. These results may have value in improving understanding of pain-related, movement sequelae and directing future research in this area.

Syfte. Att retrospektivt undersöka relationen mellan central sensitisering i det orofacialaområdet och refererad smärta, som kliniskt fynd, samt psykosociala faktorer hos patienter medDC/TMD-muskeldiagnosen myofasciell smärta med refererad smärta (MPR). Studien syftadeäven till att undersöka skillnader gällande psykosociala faktorer mellan patienter somdiagnostiserats med DC/TMD muskeldiagnoserna myofasciell smärta med refererad smärta(MPR), lokal myalgi (LM) och patienter med orofacial smärta eller käkdysfunktion men ejkäkmuskeldiagnos (WMD) som kontrollgrupper.Material och metod. Information från 85 patienters DC/TMD-undersökning utförd påOrofaciala smärtenheten vid Malmö högskola mellan september 2012 till årsslutet 2013insamlades retrospektivt. Undersökta variabler inkluderade smärtintensitet, smärt-relateraddysfunktion, psykosociala faktorer (depression, ångest och stress) samt refererad smärta.Patienterna indelades i grupper baserade på muskeldiagnos enligt DC/TMD samt utbredning avsmärta. Non-parametrisk statistik användes och P < 0,05 betraktades som signifikant.Resultat. Patienter med MPR uppvisade en signifikant korrelation mellan totala antaletrefererade smärtlokalisationer och smärt-relaterad dysfunktion (rs = 0,43, n = 49, p = 0,002),depression (rs = 0,32, n = 49, p = 0,023) och stress (rs = 0,39, n = 49, p = 0,006). Patienter meden generell smärtutbredning uppvisade en signifikant högre grad av stress (p = 0,020) samt flerantal refererade smärtlokalisationer (p = 0,019) jämfört med patienter med lokal och/ellerregional orofacial smärta.Konklusion. Studien indikerar att grad av central sensitisering kan bedömas med hjälp avutbredningen av refererad smärta, undersökt enligt DC/TMD, hos patienter med diagnosenmyofasciell smärta med refererad smärta i det orofaciala området. Studien kunde inte påvisaskillnader gällande psykosociala faktorer mellan de undersökta grupperna. / Objective. The aim of this study was to retrospectively investigate the relation between referredpain, as a clinical finding, and psychosocial factors versus central sensitization in patients withmyofascial pain with referral (MPR) as assessed according to DC/TMD. The study also aimedto investigate differences regarding psychosocial factors between patients demonstratingmyofascial pain with referral (MPR) and patients diagnosed with the DC/TMD muscle diagnoselocal myalgia (LM) as well as OFP/TMD patients without masticatory muscular diagnose(WMD) as control patients.Material and methods. Patients’ medical records of 85 patients examined at the Orofacial PainUnit at Malmö University during September 2012 till the end of 2013 were retrospectivelyexamined for DC/TMD data. Examined variables included pain intensity, pain-related disability,psychosocial factors (depression, anxiety and stress) and referred pain. The patients weredivided into groups based on DC/TMD muscle diagnosis as well as extension of pain. Nonparametricstatistics were used and a probability level of P < 0.05 was considered as significant.Results. Patients with MPR demonstrated significant correlations between the total number ofreferred pain sites and disability score (rs = 0.43, n = 49, p = 0.002), depression (rs = 0.32, n =49, p = 0.023) as well as stress (rs = 0.39, n = 49, p = 0.006). Patients with generalized paindistribution demonstrated a significantly higher degree of stress (p = 0.020) as well as highernumber of referred pain sites (p = 0.019) than patients with local and/or regional orofacial pain.Conclusion. This study indicates that the degree of central sensitization can be estimated bythe extent of referred pain, as assessed according to DC/TMD, in patients with myofascial painwith referred pain in the orofacial region. This study could not detect a difference inpsychosocial factors between the three groups, myofascial pain with referral (MPR), localmyalgia (LM) and no masticatory muscle diagnosis (WMD).