Temporomandibular disorders (TMD) are a significant public health problem affecting approximately 5% to 12% of the population.1 TMD is the second most common musculoskeletal condition (after chronic low back pain) resulting in pain and disability.1 Pain-related TMD can impact the individual's daily activities, psychosocial functioning, and quality of life. Overall, the annual TMD management cost in the USA, not including imaging, has doubled in the last decade to $4 billion.1

Patients often seek consultation with dentists for their TMD, especially for pain-related TMD. Diagnostic criteria for TMD with simple, clear, reliable, and valid operational definitions for the history, examination, and imaging procedures are needed to render physical diagnoses in both clinical and research settings. In addition, biobehavioral assessment of pain-related behavior and psychosocial functioning—an essential part of the diagnostic process—is required and provides the minimal information whereby one can determine whether the patient's pain disorder, especially when chronic, warrants further multidisciplinary assessment. Taken together, a new dual-axis Diagnostic Criteria for TMD (DC/TMD) will provide evidence-based criteria for the clinician to use when assessing patients, and will facilitate communication regarding consultations, referrals, and prognosis.2

The research community benefits from the ability to use well-defined and clinically relevant characteristics associated with the phenotype in order to facilitate more generalizable research. When clinicians and researchers use the same criteria, taxonomy, and nomenclature, then clinical questions and experience can be more easily transferred into relevant research questions, and research findings are more accessible to clinicians to better diagnose and manage their patients. The Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) have been the most widely employed diagnostic protocol for TMD research since its publication in 1992.3 This classification system was based on the biopsychosocial model of pain4 that included an Axis I physical assessment, using reliable and well-operationalized diagnostic criteria, and an Axis II assessment of psychosocial status and pain-related disability. The intent was to simultaneously provide a physical diagnosis and identify other relevant characteristics of the patient that could influence the expression and thus management of their TMD. Indeed, the longer the pain persists, the greater the potential for emergence and amplification of cognitive, psychosocial, and behavioral risk factors, with resultant enhanced pain sensitivity, greater likelihood of additional pain persistence, and reduced probability of success from standard treatments.5

The RDC/TMD (1992) was intended to be only a first step toward improved TMD classification, and the authors stated the need for future investigation of the accuracy of the Axis I diagnostic algorithms in terms of reliability and criterion validity—the latter involving the use of credible reference standard diagnoses. Also recommended was further assessment of the clinical utility of the Axis II instruments. The original RDC/TMD Axis I physical diagnoses have content validity based on the critical review by experts of the published diagnostic approach in use at that time and were tested using population-based epidemiologic data.6 Subsequently, a multicenter study showed that, for the most common TMD, the original RDC/TMD diagnoses exhibited sufficient reliability for clinical use.7 While the validity of the individual RDC/TMD diagnoses has been extensively investigated, assessment of the criterion validity for the complete spectrum of RDC/TMD diagnoses had been absent until recently.8

For the original RDC/TMD Axis II instruments, good evidence for their reliability and validity for measuring psychosocial status and pain-related disability already existed when the classification system was published.9–13 Subsequently, a variety of studies have demonstrated the significance and utility of the original RDC/TMD biobehavioral measures in such areas as predicting outcomes of clinical trials, escalation from acute to chronic pain, and experimental laboratory settings.14–20

Other studies have shown that the original RDC/TMD biobehavioral measures are incomplete in terms of prediction of disease course.21–23 The overall utility of the biobehavioral measures in routine clinical settings has, however, yet to be demonstrated, in part because most studies have to date focused on Axis I diagnoses rather than Axis II biobehavioral factors.24

The aims of this article are to present the evidence-based new Axis I and Axis II DC/TMD to be used in both clinical and research settings, as well as present the processes related to their development.

Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain Special Interest Group†

Aims: The original Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I diagnostic algorithms have been demonstrated to be reliable. However, the Validation Project determined that the RDC/TMD Axis I validity was below the target sensitivity of ≥ 0.70 and specificity of ≥ 0.95. Consequently, these empirical results supported the development of revised RDC/TMD Axis I diagnostic algorithms that were subsequently demonstrated to be valid for the most common pain-related TMD and for one temporomandibular joint (TMJ) intra-articular disorder. The original RDC/TMD Axis II instruments were shown to be both reliable and valid. Working from these findings and revisions, two international consensus workshops were convened, from which recommendations were obtained for the finalization of new Axis I diagnostic algorithms and new Axis II instruments. Methods: Through a series of workshops and symposia, a panel of clinical and basic science pain experts modified the revised RDC/TMD Axis I algorithms by using comprehensive searches of published TMD diagnostic literature followed by review and consensus via a formal structured process. The panel’s recommendations for further revision of the Axis I diagnostic algorithms were assessed for validity by using the Validation Project’s data set, and for reliability by using newly collected data from the ongoing TMJ Impact Project—the follow-up study to the Validation Project. New Axis II instruments were identified through a comprehensive search of the literature providing valid instruments that, relative to the RDC/TMD, are shorter in length, are available in the public domain, and currently are being used in medical settings. Results: The newly recommended Diagnostic Criteria for TMD (DC/TMD) Axis I protocol includes both a valid screener for detecting any pain-related TMD as well as valid diagnostic criteria for differentiating the most common pain-related TMD (sensitivity ≥ 0.86, specificity ≥ 0.98) and for one intra-articular disorder (sensitivity of 0.80 and specificity of 0.97). Diagnostic criteria for other common intra-articular disorders lack adequate validity for clinical diagnoses but can be used for screening purposes. Inter-examiner reliability for the clinical assessment associated with the validated DC/TMD criteria for pain-related TMD is excellent (kappa ≥ 0.85). Finally, a comprehensive classification system that includes both the common and less common TMD is also presented. The Axis II protocol retains selected original RDC/TMD screening instruments augmented with new instruments to assess jaw function as well as behavioral and additional psychosocial factors. The Axis II protocol is divided into screening and comprehensive selfreport instrument sets. The screening instruments' 41 questions assess pain intensity, pain-related disability, psychological distress, jaw functional limitations, and parafunctional behaviors, and a pain drawing is used to assess locations of pain. The comprehensive instruments, composed of 81 questions, assess in further detail jaw functional limitations and psychological distress as well as additional constructs of anxiety and presence of comorbid pain conditions. Conclusion: The recommended evidence-based new DC/TMD protocol is appropriate for use in both clinical and research settings. More comprehensive instruments augment short and simple screening instruments for Axis I and Axis II. These validated instruments allow for identification of patients with a range of simple to complex TMD presentations. J Oral Facial Pain Headache 2014;28:6–27. doi: 10.11607/jop.1151

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Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) for Clinical and Research Applications: Recommendations of the International RDC/TMD Consortium Network* and Orofacial Pain

Articles describing motor function in five chronic musculoskeletal pain conditions (temporomandibular disorders, muscle tension headache, fibromyalgia, chronic lower back pain, and postexercise mus...

The pain-adaptation model: a discussion of the relationship between chronic musculoskeletal pain and motor activity.

N Engl J Med 2003;349:1943-53. Copyright © 2003 Massachusetts Medical Society. pium is a bitter, brown, granular powder derived from the seedpod of the poppy ( Papaver somniferum ). People have used opium for the relief of pain and suffering for thousands of years. Before the 19th century, opium was cultivated and used chiefly in the Middle East, whereas in Europe and the United States it was a luxury available mainly to the elite. During the 19th century, several historical events conspired to make opium and other opioids more readily available. The production of opium increased rapidly, and after the morphine alkaloid was identified in 1806 pharmacologic production of opioid drugs began. Use of morphine-containing tinctures such as laudanum became commonplace, especially in the treatment of the “travails” and “boredom” of Victorian women. Morphine-containing cures for colic, diarrhea, dysmenorrhea, and other painful conditions were widely available and could be bought from doctors and pharmacists. With the rise of the “street use” of opium and heroin, legal controls were introduced. In the United States, the first attempts to control the abuse of narcotics came at the end of the 19th century, when a few states instituted limited controls. By the 1940s, opioids were so tightly restricted that they could be used legally only when they were prescribed by physicians according to strict regulatory controls. The legal use of opioids was thus placed entirely in the hands of physicians, who were, and still are, liable to lose their medical licenses and risk criminal prosecution if they prescribe these drugs inappropriately. The immediate effect of such strict regulatory control was that physicians became reluctant to prescribe opioids, and as a result pain was woefully undertreated. 1 Through the efforts of advocates of pain control, toward the end of the 20th century opioid therapy was reestablished as an invaluable and accepted treatment for acute pain, pain due to cancer, and pain caused by a terminal disease. The most difficult issue now facing physicians who treat patients with chronic pain probably is whether and how to prescribe opioid therapy for chronic pain that is not associated with terminal disease, including pain experienced by the increasing number of patients with cancer in remission who need long-term opioid therapy. Many of the issues involved in the treatment of patients with pain due to cancer in remission are the same as those in the treatment of patients with chronic pain that is unrelated to malignant conditions. Our review addresses specific questions about dose and toxicity in the light of recent studies that suggest a need to modify current practices in the use of opioid therapy for chronic pain.

Opioid therapy for chronic pain

Recent years have brought growing recognition of the need for clinical criteria for myalgic encephalomyelitis (ME), which is also called chronic fatigue syndrome (CFS). An Expert Subcommittee of Health Canada established the Terms of Reference, and selected an Ex- pert Medical Consensus Panel representing treating physicians, teaching faculty and researchers. A Consensus Workshop was held on March 30 to April 1, 2001 to culminate the review process and establish consensus for a clinical working case definition, diagnostic protocols and treatment protocols. We present a systematic clinical working case definition that

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Myalgic Encephalomyelitis/ Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols

Evolution of neuropsychiatric ideas in US and UK - 1800-2000 neuropsychiatric evaluation neuropsychology neuroimaging for neuropsychiatry clinical neurophysiology in neuropsychiatry autonomic nervous system functional neuroanatomy of the limbic system and prefrontal cortex neurochemical neuroanatomy psychoneuroendocrinology psychoneuroimmunology - interactions between the brain and the immune system drug treatment in neuropsychiatry neurobiological mechanisms of human anxiety neuropsychiatry of mood disorders hallucinations and delusional thinking neuropyschiatric aspects of the schizophrenias perceptual disturbances in focal neurological diseases memory emotional disorders associated with hemispheric dysfunction frontal lobe lesions pain transmission and modulation neuropathic pain pain and psychopathology neuropsychiatry of suicide the neuropsychiatry of aggression neuropsychiatry of mental retardation and cerebral palsy autism and pervasive developmental disorders transient disorders of memory and consciousness somatization and conversion disorders neurobiology of drug abuse neuropsychiatry of alcohol and drug abuse language and neuropsychiatry neuropsychiatric aspects of sexual dysfunction psychiatric aspects of epilepsy basal ganglia diseases Gilles de la Tourette Syndrome and obsessive compulsive disorder cortical dementia neurobehavioural features of cerebrovascular disease neurobehavioural aspects of cerebral white matter disorders trauma neuromuscular diseases behavioural syndromes in neurotoxicology assessment of the brain in legal cases - neuropsychologic and neuropsychiatric considerations the neuropsychiatry of disability and rehabilitation current diagnostic issues in neuropsychiatry.

Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual

Lower torso pain and muscle guide hip, thigh and knee pain and muscle leg, ankle and foot pain and muscle guide

Myofascial pain and dysfunction : the trigger point manual

Myofascial pain and dysfunction , Myofascial pain and dysfunction , کتابخانه دیجیتال جندی شاپور اهواز

Myofascial pain and dysfunction

(1952). The Myofascial Genesis of Pain. Postgraduate Medicine: Vol. 11, No. 5, pp. 425-434.

Janet Travell

Papers

Travell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual

Myofascial pain and dysfunction : the trigger point manual

Myofascial pain and dysfunction

Myofascial pain and dysfunction

The myofascial genesis of pain.