Beliefs and concerns about pain were associated with craniofacial pain experienced within 24 hours: cross-sectional study

BACKGROUND AND OBJECTIVES : Although craniofacial pain has been associated with negative psychological aspects, how the patient’s perception of their own illness could influence craniofacial pain is not elucidated yet. Therefore, this study aims to identify the main factors and beliefs about the illness that could influence pain intensity and pain duration in people who experienced craniofacial pain in the last 24 hours. METHODS : This cross-sectional study comprised undergraduate students, aged between 18 and 40 years old, who experienced self-reported craniofacial pain in the last 24 hours. Participants answered questions regarding body functions, activities and participation, and personal factors based on the International Classification of Functioning (ICF); In addition, questions from the Brief Illness Perceptual Questionnaire (Brief IPQ) were applied. The analysis was carried out with a single and multiple regression model. RESULTS : The sample comprised 87 volunteers. Pain intensity and duration experienced in the last 24 hours were associate by concerns about the presence of an illness and the need for treatment. Pain intensity was specifically associated with the


INTRODUCTION
Craniofacial pain conditions, including those related to temporomandibular disorders, toothaches, headaches, and trigeminal neuropathic pain [1][2][3] are the most common persistent pain conditions related to oral and craniofacial structures 3 .They affect approximately 25% of the worldwide population at least once in life, being more prevalent in an adult female population 4 .These painful craniofacial conditions exhibit multifactorial etiologies that are still unknown or poorly understood [1][2][3]5 . Hoever, it is well-known that such conditions display an important correlation with other symptoms associated with head and neck structures (i.e.headaches, neck pain, neck disability, among others) 5 .This intimate relationship with other anatomical areas, such as facial skin, meninges, oral mucosa, teeth, bone, temporomandibular joint, muscles, ligaments, and fascia, among others, could also impact body functions 2 .In this sense, the craniofacial region is extensively represented in the somatosensory area of the central nervous system, which facilitates the centralization of pain perception 2 .Thus, changes in the somatosensory cortex of patients with craniofacial pain conditions may be interpreted as a consequence of pain, leading to several associated somatic symptoms 2,5 , such as impairments in appearance, communication and expressing emotions, besides jaw limitations, changes in eating and drinking habits, besides alterations in psychological, sensory, and speech functions 2,[6][7][8][9] .Besides, the majority of individuals who present symptoms of craniofacial pain also experience psychosocial symptoms (i.e., anxiety, depression, among others), which could influence pain-related beliefs (i.e.catastrophizing, fear-avoidance beliefs, among others) 2,6-9 and negatively impact their activities and participation in life activities 2,[6][7][8][9][10] .The presence of psychosocial problems Is related to the chronification of craniofacial pain 2,5 , and the degree of chronic pain is influenced by the beliefs, making the management of these conditions a challenge 2,5,10 .Along with somatic symptoms, craniofacial pain conditions are frequently related to impaired perception of quality of life, stress, depression, and anxiety complaints, which are considered perpetuating factors for craniofacial chronic pain states [6][7][8][9][10][11][12][13][14] , especially in the orofacial area 13 .Another relevant aspect is that such psychosocial impacts of craniofacial pain seem to predominate among women aged between 18 to 44 years old and may represent a risk factor for the maximization of painful behavior 14 .Considering the high prevalence of painful craniofacial conditions and its negative repercussions, there is a need for early identifying factors that could influence on craniofacial pain behavior and characteristics.Such elucidation could help practitioners to better understand craniofacial pain, as well as to improve therapeutic approaches, based on a comprehensive biopsychosocial approach model 2,6 , as recommended by the International Classification of Functioning, Disability, and Health (ICF) 15 .Considering these recommendations, pain and its impact on different aspects of life have been deeply investigated 4,7,8,14,16 , using measurement tools such as the 36-item Short Form Survey 7,8 , and the Oral Health Impact Profile 14,16 .The studies usually in-vestigate how pain has impacted an individual's functioning and other aspects during the past 24 hours or the past week, which is considered an important patient-reported outcome [17][18][19] .Moreover, other studies highlighted that patients' perception of their own illness relevantly affects psychological functions, pain perception, and physical functioning 20,21 .However, literature still lacks evidence on how patients' perception of their own illness could influence craniofacial pain in the last 24 hours.Thus, to provide new perspectives on the factors that influence craniofacial pain conditions, of the present study was to identify the main factors and beliefs about the illness that could be associated with pain intensity and pain duration in people who experienced craniofacial pain in the last 24 hours.

METHODS
This is a cross-sectional study that followed STROBE recommendations 22 and it was developed in the Laboratório de Aprendizagem e Controle Motor (Learning and Motor Control Laboratory -LACOM) of the Physiotherapy Department at Federal University of Pernambuco (UFPE), between July 2019 and June 2021.It was approved by the Ethics Committee for Research with Human Beings of the UFPE Health Sciences Center (approval number: 190415058), and all volunteers involved signed the Free and Informed Consent Term (FICT).The invitation to participate in the research was disseminated through advertisements on social media.A convenience sample was obtained including volunteers that met the following criteria: students enrolled in undergraduate courses at UFPE Health Sciences Center, Recife Campus, aged between 18 and 40 years, regardless of gender, who presented with self-reported complaints of pain in the craniofacial region in the previous 24 hours.Exclusion criteria were the presence of infectious or degenerative disease of the central nervous system, cerebral aneurysm, intracranial hypertension, myopathies, myelopathies, fibromyalgia, symptomatic cervical disc herniation, rheumatoid arthritis, history of brain or spinal tumors, previous history of facial or cervical trauma, presence of surgical procedure in the cervical spine and/or craniofacial segment, or presence of cognitive impairment.After screening for eligibility, the volunteers were contacted in order to check whether they presented with craniofacial pain in the last 24 hours and, if so, the evaluation questionnaire was applied.Eligible volunteers who did not experience pain in the craniofacial region in the last 24 hours at the time of the interview were instructed to contact the researchers when they experienced pain in the last 24 hours, so that they would be able to answer the assessment questionnaire.The assessment questionnaire was designed by the research team and contained ICF-related questions regarding body functions, activities and participation, besides personal factors.The question "How much do you think you are responsible for your health?" was also asked, with answer options ranging from zero to 10.In addition, the seven objective questions of the Brief Illness Perception Questionnaire (Brief IPQ) were included.This is a valid instrument that was adapted for the Brazilian population, which displays answers ranging from zero to 10, aiming at analyzing patient's perception of their own illness 23 .The higher the total score, the greater the perception of the illness as a threat.All variables included in the assessment questionnaire are described in tables 1, 2, 3 and 4.

Statistical analysis
Analyzes were carried out through SPSS software, version 20.0, and STATA software v.14.The Shapiro-Wilk normality test evidenced that all variables were normally distributed.Data were presented as mean and standard deviation with a 95% confidence interval (CI 95%) or number and percentage (%).
To determine the factors that significantly was associated with pain intensity and duration among eligible volunteers, a two-step analysis was performed: In the first step, a simple linear regression was conducted to analyze the relationship between dependent variables (pain intensity and pain duration) with each of the independent variables (information about body functions, activities and participation, personal factors, the seven objective questions of the Brief IPQ, and the question "how much do you think you are responsible for your health?") as displayed in tables 1 to 4. The significant variables in the univariate analysis with p≤0.20 were added to the multivariate model in a hierarchical way, based on the R 2 value, and then analyzed through a multiple linear regression test 24 .In the initial multivariate analysis, all variables with significant R 2 (p≤0.20)were included.However, the choice of the best multivariate model that explained the variation in pain intensity and duration was determined according to the variables that were significant at p<0.05.

RESULTS
Ninety-two volunteers were screened for eligibility, of which 5 were excluded due to: previous craniofacial surgeries (n=2), non-enrollment in undergraduate courses at the UFPE Health Sciences Center (n=1) and, finally, some individuals did not experience pain in the last 24 hours throughout the study period (n=2).In the end, 87 volunteers were included in the study, where most of them were women (n = 72, 82.75% of overall sample), and mean age was 23.22 (4.20) years old.The general characteristics of the sample are described in table 1.
The time point at which the subjects presented pain symptoms was not collected in this study, as this data did not seem important to the analysis in the beginning of the study.However, as this is an important pain measurement, additional information about this limitation was presented in the discussion session.Variables that were significantly associated with pain intensity in the univariate analysis were gender (R 2 =0.011, β=-0.375,p=0.161), as well as the following Brief IPQ questions: "How much control do you feel you have over your illness?" (R 2 =0.013, β=-0.052,p=0.147); "How much do you think your treatment can help your illness?" (R 2 =0.024, β=-0.060,p=0.080) and "How concerned are you about your illness?" (R 2 =0.035, β=0.062, p=0.045), as displayed in tables 2 and 3.

DISCUSSION
Beliefs related to the treatment and concerns about illness are the factors that most influence both the intensity and duration of pain felt in the previous 24 hours.Concerns about pain were included in the two models that explain pain intensity and pain duration in the last 24 hours, therefore, such a variable seems to be the best one to explain pain behavior.The International Association for the Study of Pain (IASP) defines pain as a subjective experience, which is influenced by biological, psychological, and social factors.Thus, pain and nociception are different phenomena, and the painful sensation cannot be explained only by sensory pathways activity, as individual experiences related to pain should also be considered.Based on this, a person's report about a painful experience should be accepted and respected 25 .Although pain generally plays an adaptive role, it may also trigger adverse effects on function, social and psychological well-being.Besides, verbal description is just one among several behaviors to express pain, and the inability to communicate does not invalidate the possibility of a human being or an animal feeling pain 25 .
In the present study, the pain characteristics felt in the last 24 hours were associated with concern about the illness and beliefs related to its treatment, thus demonstrating the influence of psychosocial aspects on pain perception.This finding corroborates other studies in which anxiety and depression were associated with orofacial pain in women, evidencing that the perception of the disease may affect multidimensional aspects of life, including emotional factors and quality of life [26][27][28][29][30] .Furthermore, the present results support the findings of other authors 27 , who carried out a survey involving patients with chronic pain, evidencing that pain and perception of the illness were the main predictors for the presence of anxiety and depression in such a population.In addition, pessimistic beliefs about  treatment success, the severity of the symptoms, the emotional impact, comprehensibility and concerns about the disease, the intensity and inability of pain, as well as variables regarding oral, cognitive, and social interactions may also lead to depression and anxiety symptoms.However, an important contribution brought by the present research is the specific identification of thinking factors related to treatment and the concern regarding the illness as directly associated with pain intensity.Based on this, clinicians should provide more assertive approaches in pain treatment, aiming to address such factors, as psychosocial conditions are very broad and the lack of specification regarding such factors may generate non-specific treatment goals 27 .Similar findings were also found in patients with temporomandibular disorders, who demonstrated that their perception of quality of life was influenced by physical and mental health aspects 28 .Moreover, beliefs about pain play an important role in the experience of and response to pain, and it includes beliefs about one's ability to control pain and catastrophizing 29 .Thus, it is important to recognize that unhelpful pain-related beliefs are relevant predictors of treatment outcomes in craniofacial pain conditions and they can impact patients' lives 30,31 .
In this way, beliefs about the pain consequences should be included in the assessment of craniofacial conditions to provide information for appropriate clinical management.Patients' evaluation of their own illness beliefs may provide basic information about these important predictors, and changes in dysfunctional pain-related beliefs can be powerful targets for the treatment of chronic pain 30,31 .A systematic review found that treatment adherence of chronic pain patients is influenced by pain-related beliefs 10 .To overcome misbeliefs in patients with craniofacial conditions, pain education should be encouraged as an effective choice, and may contribute to breaking the cycle of misinformation and the spread of pain-related beliefs 9 .Previous reports in the literature indicate that changes in the patient's perception of the illness with a focus on treatment goals, as well as developing control beliefs may improve mental health, quality of life, and illness management 32 .
The main limitation of this study is its sample size.However, as it is an exploratory study, the sample size was not calculated, therefore, it is not possible to affirm that the present results are powerful enough to be extrapolated to the overall population with craniofacial pain.Another relevant point is that the present study only performed questions related to the presence of craniofacial pain in the last 24 hours.The time that pain affects each volunteer and the frequency of pain were not investigated, which may be an important missing piece of information about the sample characteristic, and it could possible be an important influencing factor in the pain models.Despite these limitations, the pain biopsychosocial approach is a significant strength of the present study and represents an important patient-reported outcome.This study highlights that psychological, especially pain-related beliefs, should be investigated in craniofacial painful conditions, even before starting clinical treatment.The increased understanding regarding physiological and multidimensional aspects related to pain may con-tribute to improvements in the currently available craniofacial pain literature.

CONCLUSION
The present study identified that the pain intensity and pain duration experienced in the last 24 hours are associated with beliefs related to the treatment and concerns about the disease.Thus, health professionals should be aware of the importance of identifying the presence of multidimensional aspects related to pain, thus conducting clinical treatments that should also include a psychosocial approach in people with craniofacial pain.The relevance of approaches that incorporate health education should also be considered, guiding the patient toward the self-management of their dysfunction and effective strategies for controlling and living with pain.

Table 1 .
General characteristics of the sample.

Table 2 .
Univariate and multivariate analysis of the main factors that influenced pain intensity in people who experienced craniofacial pain in the last 24 hours. Continue...

Table 2 .
Univariate and multivariate analysis of the main factors that influenced pain intensity in people who experienced craniofacial pain in the last 24 hours -continued Coef. = β coefficient; CI = Confidence interval; Brief IPQ = Brief Illness Perception Questionnaire

Table 3 .
Univariate and multivariate analysis of the main factors that were associated with pain duration in people who experienced craniofacial pain in the last 24 hours.

Table 4 .
Univariate analysis of the association between individual factors on pain intensity and duration in people who experienced craniofacial pain in the last 24 hours.

Table 3 .
Univariate and multivariate analysis of the main factors that were associated with pain duration in people who experienced craniofacial pain in the last 24 hours -continued