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10 Articles in Volume 15, Issue #10
2015 Has Been a Good Year for Clinical Progress
Addison’s Original 1855 Cases Reveal Stories of Chronic Pain
Can We Prevent Chronic Pain?
Letters to the Editor: Nerve Fiber Testing, Fibromyalgia
Medication Guide for Pain—A Short Primer for Primary Care
Odd Pet Behavior During SCS Trial—Case Report
Opioid-Induced Constipation: New and Emerging Therapies—Update 2015
Palliative Care: Dying With Dignity
PPM Editorial Board: Year in Pain Management 2015
QT Intervals and Antidepressants

PPM Editorial Board: Year in Pain Management 2015

Board members weigh in on the year's best advances in pain management.

Central Sensitization and Central Sensitivity Syndromes

By Robert J. Gatchel, PhD, ABPP

Yunus recently stated that central sensitization (CS), originally described as central sensitivity, is a concept of great importance in clinical medicine.1 In 2013, my colleagues and I suggested that CS can lead to “…a cascade of neuroinflammatory, neuroendocrine, and autonomic dysregulation.”2

This CS construct has received much clinical attention in recent years because many prevalent pain-related syndromes (for example, widespread pain, fibromyalgia, temporomandibular joint and muscle disorder, irritable bowel syndrome, just to name a few) often have overlapping symptoms, but no well-delineated or known organic pathophysiology specific to each of them. This suggests that CS may be a common link underlying these pain syndromes.

Yunus also used the term central sensitivity syndrome (CSS) to denote these pain-related syndromes. Although the syndromes were earlier assumed to be quite separate, they are now conceptualized as different types of CSSs, with CS as the root cause.3 Patients who have any one of this “family” of CSSs also frequently report an elevated sensitivity to pain (ie, hyperalgesia), as well as pain in response to normally non-painful stimuli (ie, allodynia).

These advances led our group to conduct a number of clinical research studies on CS and CSSs. We have developed a psychometrically-sound self-report measure of CSSs—the Central Sensitivity Inventory (CSI).4 The CSI is now being widely used, both nationally and internationally. This testifies to the great clinical interest in these often difficult-to-understand pain syndromes.

Osteopathic Manipulative Medicine

By Leonard B. Goldstein, DDS, PhD

With the publication of “Pain Management and Osteopathic Manipulative Medicine [OMM] in the Army: New Approaches for the Osteopathic Medical Profession,”5 we see that the U.S. Army Surgeon General’s Pain Management Task Force provides a strong endorsement for the practice of OMM, to create OMM Continuing Medical Education (CME) opportunities, and to improve research in OMM’s role in pain management.

This comprehensive restructuring of the Army’s approach to pain management provides a unique opportunity for the civilian osteopathic medical profession to collaborate with Army physicians in OMM training, teaching, and research.

The OMM department at my institution at A.T. Still University School of Osteopathic Medicine in Arizona, working in conjunction with the A.T. Still University Arizona School of Dentistry and Oral Health, will be conducting a “Inter-professional Collaborative Ressearch Project” for the use of OMM in the treatment of temporomandibular disorders and facial pain. The study will use electromyography and ultrasonography imaging to demonstrate physiologic changes.

Multiple published studies have demonstrated the effectiveness of OMM in pain management. These studies (and many others) all concluded that OMM/OMT was effective in relieving chronic low back pain, as well as safe and well accepted by patients.

Link Between the Foot and Cerebellum

By C. Norman Shealy, MD, PhD

For centuries, poor posture was a well know cause of most musculoskeletal pain. With the rise of modern medicine, posture and its ill effects fell from notice. Now, researchers are re-examining the role of foot hyperpronation as a primary pathological mechanical event that results in postural distortions (poor posture).

Brian A. Rothbart, DPM, PhD, reviews his long career and provides a nice re-examination of the research that led to the discovery of the etiology of postural distortions and resulting chronic musculoskeletal pain.6 This research is three-fold:

  • Foot hyperpronation was found to be the primary pathomechanical event that results in postural distortions. 
  • Two inherited, abnormal foot structures were found to be the most common cause of foot hyperpronation; Primus Metatarsus Supinatus (aka Rothbarts Foot) and the PreClinical Clubfoot Deformity. Dr. Rothbart notes that the PreClinical Clubfoot Deformity "is actually the same foot structure that has been found in the fossil records of a hominin (Australopithecus sediba) dating back over four million years."
  • These two foot structures are linked to dysfunction of the cerebellum, which results in global postural distortions.

This research has lead Dr. Rothbart to study mechanical receptors on the bottom of the foot, as well as where to place foot wedges in order to attenuate hyperpronation. "I postulated that poor posture starts in the mechanical receptors stimulated by the two abnormal foot structures and ends with the cerebellum automatically adjusting the posture according to the information it receives from these abnormal foot structures," he noted.

"The more severe the hyperpronation, the greater is the distortion in the patterns of stimulation and hence, the greater is the distortion in the signals to the cerebellum," he added. The result of poor posture is stress on the joints and muscles. Unless the posture is corrected, the pain will become chronic.

This discovery and subsequent development of proper specific orthotic corrections of the feet has relieved pain in a huge majority of patients. I have seen adequate photographs and case reports from Dr. Rothbart and at least one of his trained specialists to consider this a very major breakthrough.6

Easy to Use Naloxone for Opioid Overdose

By Jeffrey Fudin, PharmD, DAAPM, FCCP, FASHP

Finally, a naloxone product that comes with pharmacokinetic data and usability analysis was approved for in-home (or pre-hospital) use by the FDA. Manufactured by Kaléo Pharma, Evzio received a fast-track approval status from the FDA in April 2014. Specifically it is “indicated for the emergency treatment of known or suspected opioid overdose, as manifested by respiratory and/or central nervous system depression”.7  

More recently, brand name Narcan came back to the market as an intranasal product with a similar indication, also fast-tracked with an FDA approval just prior to Thanksgiving 2015.

Indeed these products are a much needed resource to reverse opioid-induced respiratory depression (OIRD) and prevent opioid overdose deaths, most of which occur in the presence of caregivers or loved ones.8 In fact, many local, state, regional, and national professional organizations and municipalities now encourage dual prescribing of naloxone in the face of a recognized opioid epidemic.

With over 16,000 deaths from prescription opioids reported in 2013, and an additional 9,000 from heroin,9 access to naloxone is not just about supplying substance abusers; it’s clearly also about mitigating against unpredicted risks for unsuspecting patients that receive chronic opioid therapy who develop acute onset medical issues, in those that have unanticipated increased opioid blood levels from new drug interactions or food supplements, or other unpredicted risks.


Last updated on: May 16, 2016
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