Research progress of Kinesiophbia in patients with temporomandibular disorders

Qi Zhang,Wen-Jing Ran,Xue Feng,Li-Rong Nie,Ying-Shu Jin,Juan Zhang

1Graduate College, Tianjin University of Traditional Chinese Medicine, 301617, China; 2Infections department, Tianjin Medical University Stomatological Hospital, 300070, China; 3Department of Prosthodontics, Tianjin Medical University Stomatological Hospital,300070,China.

Abstract

Keywords:Temporomandibular disorders,Kinesiophbia,Review

Introduction

Temporomandibular disorders(TMD)is a general term for diseases of the temporomandibular joint and corresponding soft tissues characterized by muscle pain, mandibular dysfunction accompanied by dysfunction, and abnormal joint sounds.Issued data shows that approximately 5% to 18% of people suffer from TMD, and about 50% experienced chronic pain.TMD seriously affects function and physiological functions, due to the long course and high recurrence rate [1].Pain inhibition dysfunction and pain facilitation pathways are enhanced, the maxillofacial pain sensation of TMD patients does not disappear for a long time compared with the general population [4].Patients who have experienced pain for a long time will suffer from painful catastrophe.They will have fear and resistance to activities or sports that may induce or aggravate pain.It may lead to dysfunction,disability, negative emotions, and affect the quality of life of patients [5].Studies have shown that Kinesiophbia is a predictor of maxillofacial pain and TMD[6].There are few studies on TMD in China,this study summarizes the research status of Kinesiophbia,the adverse effects of TMD patients, risk factors and intervention methods, and provides information support for targeted interventions for clinical staff.

Kinesiophbia

The concept of Kinesiophbia

The kinesiophobia is fear of physical movement and activity resulting from a feeling of vulnerability to painful injury or reinjury[6].In 1995,Vlaeyen[7]first included the Kinesiophbia in the fear avoidance model,indicating that the pain response of individuals can be positive or negative: the former is that the patient could recognize the reality of pain and regardless of pain，and dare to face the adverse consequences caused by pain and stick to physical activity or exercise until the previous level of exercise; while the latter patients will treat pain as a disaster，highly alert to pain signals in the surrounding environment, and stop physical activity in order to avoid aggravating pain.At the same time, thereby the resistance of fear will form a vicious circle, which ultimately leads to disability, negative emotions,and affect the quality of life of patients.

Adverse effects of Kinesiophbia on patients with TMD

The Kinesiophbia is an important feature in patients with musculoskeletal disorders.A large number of studies [8] have shown that Kinesiophbia is essential predictor for patients with acute or chronic low back pain [9], fibromyalgia [10] and osteoarthritis [11].TMD has many similarities with the above diseases.It is a disorder of musculoskeletal structure.Pain is one of the main symptoms, but TMD is limited to the maxillofacial region.Due to the longer period of disease, patients who have experienced chronic pain for a long time will catastrophize their pain perception and exaggerate their pain experience, which will cause resistance to mandibular joint movement, hinder the full movement of the joint, and cause symptoms such as muscle contracture and joint adhesion, which will lead to poor treatment results.

Joint noise is a relatively early symptom of TMD patients.The causes of it are joint disc displacement and excessive movement.the temporomandibular joint noose and stagnation can be caused in severe cases[12].However, a prospective study pointed out that patients complained that joint noose symptoms accounted for only 15%, and most patients with TMD experienced only short-term functional limitations[13].

In these patients with milder TMD, avoiding jaw movement will lead to abnormal movement patterns,which will lead to an increase in joint function problems in the long term, forming a cycle with the fear avoidance model, that is, a vicious cycle of cognition and avoidance behavior, eventually leading to negative emotions, the limitation of jaw movement and severe condition.

In the study of the impact of Kinesiophbia on oral health-related quality of life in patients with TMD.our research group found that TMD has a serious impact on patients' quality of life.Regression analysis shows that Kinesiophbia is closely related to patients' oral health related quality of life[14].

Assessment tools of Kinesiophbia on patients with TMD

The scale for Kinesiophbia

The scale was compiled by Miller to evaluate pain beliefs in patients with chronic pain in 1991 [15].The scale consists of 17 items using the Likert 4 scale,from 1(very disagree)to 4(very agree),four entries(4,8, 12, 16) are scored in reverse, and the total score is the sum of the scores of the entries,ranging from 17 to 68 points.When the score is ＞37, it indicates that the patient has a kinesiophbia, higher scores mean higher levels of kinesiophbia.At present, the scale has been translated and applied in Italy, Turkey, Denmark and other countries because of its rigorous design and good reliability [16].In 2005, Wowen [17] revised the simplified version of TSK, TSK-11, which showed good psychometric properties.Koho [18] conducted a questionnaire survey on 1034 patients with chronic pain to verified the reliability and validity.The scale's Cronbach's α coefficient was 0.78 and the retest reliability was 0.83, indicating that the scale has good internal consistency and validity.Acar emphasized that the TSK scale is well-structured and standardized,proved to have good reliability and vadility after cultural adaptation in many countries, which can be used for assessment of patients with chronic pain.The Chinese version of TSK was introduced into China by Hu Wen [19] in 2012.The Cronbach's α coefficient is 0.788, and the test-retest reliability is 0.860, indicating the scale has good reliability.

TampascaleforKinesiphobiafor temporomandibular disorders

TSK-TMD was developed in 2010 by the Visscher[20]based on TSK (18 items) revised by Vlaeyen in 1995.During the revision process, he replaced "body" and"physical activity" with "mandibular joint" and"mandibular joint movement", and replaced "pain"with "symptoms".All items are considered to be suitable for TMD patients after expert consultation,which forms the original TSK-TMD (18 entries).This research shows good psychometric attributes by using pain catastrophic scale and pain analog scale.Finally,after exploratory factor analysis and confirmatory factor analysis, the final English version of TSK-TMD is obtained,which contains 12 items and 2 dimensions,which are fear avoidance and somatic focus.Fear avoidance is a reflection of the belief that joint activity may cause(re)injury or increase pain.somatic focus is a reflection of beliefs about potential and serious medical problems.The scale uses a Likert 4-point scale,ranging from 1(strongly disagree)to 4(strongly agree),ranging from 12 to 48 points.The higher the score,the higher the patient's level of Kinesiphobia.The Cronbach's α of the scale is 0.83, and the test-retest reliability is 0.73.Due to its good reliability and validity,the scale has been translated into Chinese[21],Korean [22], Japanese [23] and Portuguese [24] for widely use.Chinese version of TSK-TMD was introduced by in 2015, the results show that the Cronbach's α of the Chinese version of TSK-TMD is 0.919, and the structural validity can explain 71.9% of the variability, indicating that the Chinese version of TSK-TMD has good reliability and validity.

Factors affecting TMD patients with Kinesiphobia

Gender

Gender is generally considered to be a factor to kinesiphobia in patients with TMD.The proportion of female is relatively large among people with TMD.Due to hormonal and psychological effects, they are more sensitive to pain, which causes fear of the jaw movements.The issued shows that the proportion female patients are six times than the males in patients with chronic pain [25].This may be related to the lower tolerance and sensitivity of pain.A study by Park et al.[26] showed that female patients had severe pain intensity, higher scores of stress and depression, and higher scores of kinesiphobia.

Pain intensity

Pain is an unpleasant subjective feeling and experience of an individual, and the persistence of pain can cause fear behavior in patients [27].Related studies have shown that patients with longer periods of pain have a higher fear of movements and a higher incidence of disabilities.Pain intensity is also why patients with oral and maxillofacial pain seek treatment [28].Woby[17]pointed that pain intensity can predict the patient's level of Kinesiophbia in the study of the reliability and validity of TSK-11.Park [26] divided TMD patient pain into current pain intensity and the most severe pain intensity.Correlation analysis showed that both were closely related to Kinesiophbia.Regression analysis showed that the most severe pain intensity of patients can predict the level of Kinesiophbia.

Psychological factors

A retrospective study [29] pointed out that compared with the healthy group, TMD patients showed greater psychological disorders, with about 85.7% of TMD patients having psychological problems such as anxiety,depression and psychological stress.Studies have shown that the higher the anxiety level, the greater the risk of chronic pain in TMD patients,and the increased anxiety and fear of pain will lead to disability, which will interfere with daily activities [30].Depression increases patients' pain perception and predicts the occurrence of chronic syndrome [31].Relevant studies have pointed out that the incidence of depression in patients with chronic pain is 30.54% [32].In addition,the fear avoidance belief is also an important factor affecting the anxiety disorder.In related studies on low back pain, the belief that avoiding activity can generalize pain, which is a major factor in patient disability and can explain 23% of daily life loss and 26% of the loss of work capacity [33].Avoidance occurs in the expectation of pain rather than on pain,so avoidance is easy to continue, the patient's correction of the expectation of pain and the false belief in physical activity is less, the long-term avoidance has a more serious impact on physiological function, and the pain problem is further worsened[34].

Self-efficacy

Self-efficacy refers to an individual's speculation and judgment on his/her ability to perform a certain behavior [35].Studies have shown that self-efficacy is a mediator of pain-related fear and avoidance behaviors and an effective predictor of painful disability [36].When self-efficacy was high, increased pain-related fear did not lead to increased pain or functional disability.When self-efficacy is low,pain-related fear will increase and patients' pain and functional disability will worsen, suggesting that self-efficacy is an important factor influencing pain-related fear and avoidance behavior[37].

TMD function problem

Although in other studies of musculoskeletal disorders,pain has been identified to predict adverse outcomes in patients, this may be related to the patient's disease characteristics.Vlaeyen [7] pointed out that compared with the pain level, the patient's functional problems(not related to pain) are more related to the degree of motor fear, and can predict the occurrence of adverse outcomes.Visscher [20] pointed that compared with pain,the functional problems of TMD patients,namely,joint noise, and joint lock accurately predict the occurrence of patients with Kinesiophbia.The possible reason is that patients often feel embarrassed and annoyed by joint sounds, so avoiding the frequency of joint activity is higher, thus entering the cognitive avoidance behavior cycle of Kinesiophbia,the patient's jaw is more restricted, severe joint noose, anxiety and depression are more common.

Interventions to improve TMD patients with Kinesiophbia

Relieve pain in patients with TMD

Laat[38]pointed that the treatment of chronic pain has the goal of reducing pain and improving the healthy quality of life of patients.Actively reducing or improving pain is an important strategy to improve the fear of TMD patients.Liu [39] applied pain diary to personalized, targeted pain guidance and education to effectively improve TMD patients with fear and reduce fear avoidance beliefs.In addition, Acupuncture therapy can promote blood circulation to promote blood circulation and relieve pain, relieve urgency,improve the absorption of inflammatory reactive substances and activate endogenous morphine-like substances to relieve pain [40].Ding [41]observed the effect of acupuncture combined with massage on TMD.Compared with the control group, the pain of the treatment group was reduced, the opening was restricted and the joint mobility was improved, and the chewing, swallowing and speech of the temporomandibular joint were promoted.Physiological function recovery.Aromatherapy,acupressure, etc.also play an active role in pain relief methods.In clinical work,medical staff can choose the appropriate method to help patients relieve pain.Nursing staff can help patients correctly understand the pain and help patients adapt to the pain, encourage them to face the pain, take the initiative to adapt to the life changes brought by the pain, and try to reduce patients because of pain to avoid joint activity.

Exercise therapy

Exercise therapy is widely used in oral and maxillofacial pain, including TMD pain, because of its low trauma and economic effectiveness [42].The goal of exercise therapy is to reduce symptoms of muscle and joint pain and improve motor function by moving the whole body and parts of the body.Patients can achieve the purpose of treatment by self-exercise of mandibular joint.Exercise therapy including stretching,enhancing muscle movements and endurance sports,and through dynamic jaw movement respectively,resistance training, coordinate training and position of functional exercise, aimed at improving masticatory muscle, fascia, tendons and ligaments, and oral cavity facial muscles around the flexibility and ductility,relieve tension, improve muscle activity not harmonious, alleviate muscle pain [43, 44].The clinician should select and apply exercise therapy according to the actual situation of the patient When implementing health education, informing the patient about the purpose and function of joint exercise,overcome the fear caused by lack of knowledge, and record the week card by means of the Internet platform or joint exercise, monitoring patient compliance,inducing patients' fear of moving, promoting mandibular functional recovery.

Develop a TMD patient self-management plan

Due to the limited development of oral health in China,the public has a low awareness rate of TMD,and TMD patients have a high level of disease uncertainty, so they cannot properly deal with the symptoms of TMD,resulting in jaw movement avoidance and fear, etc.Therefore, it is crucial to formulate a self-management plan for TMD patients with Kinesiophbia.Self-management refers to monitoring and managing symptoms and symptoms of disease through patients'own behaviors, teaching patients the knowledge and skills needed for self-management through relevant health education courses, so that patients can solve various physical and emotional problems brought to daily life by diseases with effective support [45].Giovanna [46] constructed a self-management scheme for TMD patients based on the literature on the effectiveness and applicability of self-management therapy for TMD patients' symptoms and the knowledge level of patients' diseases.Specifically, it includes patient health education, mandibular joint movement, massage, heat and humidity therapy, diet Suggestions and behavior change strategies, among which, mandibular joint functional exercise plays an important role in improving mandibular joint function.Clinical medical personnel should draw lessons from previous studies to develop a self-management plan suitable for TMD patients in China, attach importance to mandibular joint exercise, improve patients'self-management ability and treatment compliance,and improve patients'oral health.

Psychological behavior intervention

Cognitive behavior intervention refers to the psychotherapy method of correcting bad cognition by changing patients' thinking beliefs and behaviors to eliminate bad emotions and negative behaviors [47].Cai [48] pointed out in their intervention study on Kinesiophbia in patients with total knee arthroplasty that cognitive behavioral intervention can effectively reduce the level of Kinesiophbia, improve the self-efficacy level of patients, ensure the amount of rehabilitation training and promote the rehabilitation of joint function.At present, there are few domestic and foreign studies on the intervention of motion phobia in TMD patients, but some studies have pointed out [49]that cognitive behavioral intervention is an important method to treat and improve the quality of life of TMD patients, with significant effect in alleviating anxiety,depression and improving the quality of life of patients.Peters [50] pointed out that psychological intervention plays an important role in the treatment of TMD,especially cognitive behavioral therapy,which plays an important role in participating in biofeedback,reducing pain intensity, activity interference and depression degree.Glaros [51] conducted cognitive and behavioral intervention on TMD patients.Within one year of follow-up, compared with the control group, the degree of limitation of oral function was significantly reduced and the pain was also improved.Turner [52] conducted cognitive and behavioral intervention on patients with chronic pain, including problem coping skills and resolution strategies.The results showed that the pain intensity,limitation degree of mandibular joint were significantly improved, the degree of emotional distress was significantly reduced,and the level of oral health-related quality of life was improved [53].In clinical work, nursing staff should learn from previous psychological behavior intervention methods to intervene in patients with TMD and pay attention to the impact of behavioral changes on patients.

Multidisciplinary joint intervention

Multidisciplinary joint intervention refers to the guidance and intervention of patients by rehabilitation therapists, physiotherapists, psychological counselors,doctors and nurses, including progressive body muscle training, pain care, cognitive management of Kinesiophbia, Control strategies for negative emotions such as anxiety and depression can reduce patients'fear avoidance beliefs and fearful behaviors through multidisciplinary joint intervention [54].A systematic review of patients with chronic low back pain indicated that after multidisciplinary rehabilitation training for patients, the pain intensity of the patients was significantly reduced and the level of Kinesiophbia was reduced[55].

Summary

Due to the limitations of research tools and language,the public's awareness of TMD is low.At present, the research on the fear of TMD is not taken seriously in China.Follow-up researchers should promptly assess the level of Kinesiophbia and influencing factors in patients with TMD, and pay attention to the cognitive behavior changes.Develop TMD patients'self-management programs, apply cognitive behavioral interventions and other strategies to patients, correct patients' wrong thinking and thinking, and teach patients to master the main points of temporomandibular joint function training.If necessary,through medical, nursing, rehabilitation, physical therapy, psychology and other multi-disciplinary cooperation to alleviate the pain of patients, reduce the level of kinesiophbia, improve self-efficacy and social support, thereby improving the quality of life of patients.