Fatigue in Adults with Chronic Arthralgia/Myalgia in the Temporomandibular Region: Associations with Poor Sleep Quality, Depression, Pain Intensity, and Future Pain Interference

Aims: To examine associations between fatigue and poor sleep quality, depression symptoms, and pain intensity in an adult population with chronic arthralgia/myalgia in the temporomandibular region and to test whether fatigue predicted future pain-related interference above and beyond these other constructs. Methods: The sample included 40 participants with chronic arthralgia and/or myalgia in the temporomandibular region and 21 healthy controls. Participants self-reported fatigue (PROMIS fatigue score), sleep quality (PSQI), depression symptoms (PROMIS depression score), and average pain intensity and completed four weekly surveys of pain-related interference with daily activities. Results: The chronic arthralgia/myalgia group reported greater fatigue than healthy controls (t = 4.85, P < .001). Fatigue was significantly correlated with poor sleep quality (r = .46), higher depression symptoms (r = .41), and higher pain intensity (r = .46) in the chronic arthralgia/myalgia group, and these three variables together explained 39% of variance in fatigue. Greater fatigue-above and beyond sleep quality, depression symptoms, and average pain intensity-was associated with a higher average level of pain-related interference (β = 0.56, t score = 3.30, P = .002) over the following month. Depression symptoms, poor sleep quality, and pain intensity did not significantly predict pain interference above and beyond fatigue (all P > .05). Conclusion: The results suggest that fatigue is a clinically relevant symptom distinct from depression, poor sleep quality, or pain intensity and may be related to worse pain outcomes over the following month in adults with chronic temporomandibular arthralgia/myalgia. Clinicians should assess, monitor, and treat fatigue to the best of their abilities when working with this population.

depression; fatigue; orofacial pain; PROMIS, sleep

1. Boggero IA, Rojas-Ramirez MV, Carlson CR. All fatigue is not created equal: The association of fatigue and its sub-types on pain interference in orofacial pain. Clin J Pain 2017;33:231–237.

2. de Leeuw R, Studts JL, Carlson CR. Fatigue and fatigue-related symptoms in an orofacial pain population. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;99:168–174.

3. Matcham F, Ali S, Hotopf M, Chalder T. Psychological correlates of fatigue in rheumatoid arthritis: A systematic review. Clin Psychol Rev 2015;39:16–29.

4. Sturgeon JA, Darnall BD, Kao MC, Mackey SC. Physical and psychological correlates of fatigue and physical function: A Collaborative Health Outcomes Information Registry (CHOIR) study. J Pain 2015;16:291–298.e1.

5. Aaron LA, Burke MM, Buchwald D. Overlapping conditions among patients with chronic fatigue syndrome, fibro-myalgia, and temporomandibular disorder. Arch Intern Med 2000;160:221–227.

6. Boggero IA, Kniffin TC, de Leeuw R, Carlson CR. Fatigue mediates the relationship between pain interference and distress in patients with persistent orofacial pain. J Oral Facial Pain Headache 2014;28:38–45.

7. Boggero IA, Rojas-Ramirez MV, de Leeuw R, Carlson CR. Satisfaction with life in orofacial pain disorders: associations and theoretical implications. J Oral Facial Pain Headache 2016;30:99–106.

8. Hewlett S, Cockshott Z, Byron M, et al. Patients’ perceptions of fatigue in rheumatoid arthritis: Overwhelming, uncontrollable, ignored. Arthritis Rheum 2005;53:697–702.

9. Kirwan JR, Minnock P, Adebajo A, et al. Patient perspective: Fatigue as a recommended patient centered outcome measure in rheumatoid arthritis. J Rheumatol 2007;34:1174–1177.

10. Repping-Wuts H, Uitterhoeve R, van Riel P, van Achterberg T. Fatigue as experienced by patients with rheumatoid arthritis (RA): A qualitative study. Int J Nurs Stud 2008;45:995–1002.

11. Riley JL 3rd, Benson MB, Gremillion HA, et al. Sleep disturbance in orofacial pain patients: Pain-related or emotional distress? Cranio 2001;19:106–113.

12. Edwards RR, Grace E, Peterson S, Klick B, Haythornthwaite JA, Smith MT. Sleep continuity and architecture: Associations with pain-inhibitory processes in patients with temporoman-dibular joint disorder. Eur J Pain 2009;13:1043–1047.

13. Lei J, Liu MQ, Yap AU, Fu KY. Sleep disturbance and psychologic distress: Prevalence and risk indicators for temporoman-dibular disorders in a Chinese population. J Oral Facial Pain Headache 2015;29:24–30.

14. Schmitter M, Kares-Vrincianu A, Kares H, Bermejo JL, Schindler HJ. Sleep-associated aspects of myofascial pain in the orofacial area among temporomandibular disorder patients and controls. Sleep Med 2015;16:1056–1061.

15. Sommer I, Lavigne G, Ettlin DA. Review of self-reported in-struments that measure sleep dysfunction in patients suffering from temporomandibular disorders and/or orofacial pain. Sleep Med 2015;16:27–38.

16. Dubrovsky B, Janal MN, Lavigne GJ, et al. Depressive symptoms account for differences between self-reported versus polysomnographic assessment of sleep quality in women with myofascial TMD. J Oral Rehabil 2017;44:925–933.

17. Boggero IA, Schneider VJ 2nd, Thomas PL, Nahman-Averbuch H, King CD. Associations of self-report and actigraphy sleep measures with experimental pain outcomes in patients with temporomandibular disorder and healthy controls. J Psychosom Res 2019;123:109730.

18. Exposto FG, Arima T, Svensson P. Sleep disorders and chronic orofacial pain. Curr Sleep Medicine Rep 2019;5:104–111.

19. Nicassio PM, Moxham EG, Schuman CE, Gevirtz RN. The contribution of pain, reported sleep quality, and depressive symptoms to fatigue in fibromyalgia. Pain 2002;100:271–279.

20. Bonvanie IJ, Oldehinkel AJ, Rosmalen JGM, Janssens KAM. Sleep problems and pain: A longitudinal cohort study in emerging adults. Pain 2016;157:957–963.

21. Manning K, Kauffman BY, Rogers AH, Garey L, Zvolensky MJ. Fatigue severity and fatigue sensitivity: Relations to anxiety, depression, pain catastrophizing, and pain severity among adults with severe fatigue and chronic low back pain. Behav Med 2020:1–9.

22. Ulus Y, Akyol Y, Tander B, Durmus D, Bilgici A, Kuru O. Sleep quality in fibromyalgia and rheumatoid arthritis: Associations with pain, fatigue, depression, and disease activity. Clin Exp Rheumatol 2011;29(6 suppl 69):s92–s96.

23. Hockey GRJ. A motivational control theory of cognitive fatigue. In: Ackerman PL (ed). Cognitive Fatigue: Multidisciplinary Perspectives on Current Research and Future Applications. Washington, DC: American Psychological Association, 2011:167–187.

24. van der Linden D. The urge to stop: The cognitive and biological nature of acute mental fatigue. In: Ackerman PL (ed). Cognitive Fatigue: Multidisciplinary Perspectives on Current Research and Future Applications. Washington, DC: American Psychological Association, 2011:149–164.

25. Evans DR, Boggero IA, Segerstrom SC. The nature of self-regulatory fatigue and “ego depletion”: Lessons from physical fa-tigue. Pers Soc Psychol Rev 2016;20:291–310.

26. Boggero IA, Rojas Ramirez MV, King CD. Cross-sectional associations of fatigue subtypes with pain interference in younger, middle-aged, and older adults with chronic orofacial pain. Pain Med 2020;21:1961–1970.

27. Dahan H, Shir Y, Velly A, Allison P. Specific and number of comorbidities are associated with increased levels of temporomandibular pain intensity and duration. J Headache Pain 2015;16:528.

28. Younger J, McCue R, Mackey S. Pain outcomes: A brief review of instruments and techniques. Curr Pain Headache Rep 2009;13:39–43.

29. Schiffman E, Ohrbach R, Truelove E, et al. 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. J Oral Facial Pain Headache 2014;28:6–27.

30. Buysse DJ, Reynolds CF 3rd, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh sleep quality index: A new instrument for psychiatric practice and research. Psychiatry Res 1989;28:193–213.

31. Singer J. A simple procedure to compute the sample size needed to compare two independent groups when the population variances are unequal. Stats Med 2001;20:1089–1095.

32. Soper, D.S. (2021). Free statistics calculators: Home. Accessed 23 May 2022. https://www.danielsoper.com/statcalc

33. Aickin M, Gensler H. Adjusting for multiple testing when reporting research results: the Bonferroni vs Holm methods. Am J Public Health 1996;86:726–728.

34. Yoon IA, Sturgeon JA, Feinstein AB, Bhandari RP. The role of fatigue in functional outcomes for youth with chronic pain. Eur J Pain 2019;23:1548–1562.

35. Kravitz HM, Katz RS. Fibrofog and fibromyalgia: A narrative review and implications for clinical practice. Rheumatol Int 2015;35:1115–1125.

36. Egerton T, Chastin SF, Stensvold D, Helbostad JL. Fatigue may contribute to reduced physical activity among older people: An observational study. J Gerontol A Biol Sci Med Sci 2016;71:670–676.

37. Karshikoff B, Sundelin T, Lasselin J. Role of inflammation in human fatigue: Relevance of multidimensional assessments and potential neuronal mechanisms. Front Immunol 2017;8:21.

38. Bidonde J, Busch AJ, Schachter CL, et al. Aerobic exercise training for adults with fibromyalgia. Cochrane Database Syst Rev 2017;6:CD012700.

39. Canori A, Amiri AM, Thapa-Chhetry B, et al. Relationship between pain, fatigue, and physical activity levels during a technology-based physical activity intervention. J Spinal Cord Med 2021;44:549–556.

40. Towery P, Guffey JS, Doerflein C, Stroup K, Saucedo S, Taylor J. Chronic musculoskeletal pain and function improve with a plant-based diet. Complement Ther Med 2018;40:64–69.

41. van den Akker LE, Beckerman H, Collette EH, Eijssen IC, Dekker J, de Groot V. Effectiveness of cognitive behavioral therapy for the treatment of fatigue in patients with multiple sclerosis: A systematic review and meta-analysis. J Psychosom Res 2016;90:33–42.