• Interventional Pain
    • 1

      Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

      By Scott E. Glaser, MD, DABIPP; Rinoo Shah, MD, MBA
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      Transforaminal Lumbar and Thoracic Interventions and Ischemic Spinal Cord Injury

      • SCOTT E. GLASER, MD, DABIPPPresident, Pain Specialists of Greater Chicago, 7055 High Grove Boulevard, Burr Ridge, IL, 60527
      • RINOO SHAH, MD, MBAProfessor and Director, Pain Management Fellowship, Department of Anesthesiology, LSU Health Science Center, Shreveport, LA

      Transforaminal epidural steroid injections have been shown to be associated with catastrophic neurologic complications secondary to spinal cord infarction. The reflexive, ad hoc response of practitioners to these injuries has been to recommend risk minimization strategies to prevent embolism of the injected particulate steroids and to use nonparticulate steroids. This focus on distal embolism as the sole or primary cause of catastrophic outcomes lacks conclusive supporting evidence and does not suffice to protect the patient from paraplegia as it fails to address the root cause of the complications. A root cause analysis of the procedure provides evidence that the injection technique itself—the “safe triangle”—creates a risk of arterial damage and sequelae leading to ischemia of the spinal cord. The evidence is strong that the only way to mitigate or eliminate the risk of paraplegia is to use a different technique to perform transforaminal injections: the Kambin triangle approach. This change in technique is the only definitive solution that addresses the root cause of these catastrophic sequelae associated with transforaminal epidural steroid injections.

      Key Words: Artery of Adamkiewicz, ischemic spinal cord injury, Kambin triangle, safe triangle, transforaminal epidural injection

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    • 2

      Burst Spinal Cord Stimulation: Introduction to a New Age in Neuromodulation

      By Timothy R. Deer, MD; Jason E. Pope, MD; Eric T. Lee, MD; Corey W. Hunter, MD
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      Burst Spinal Cord Stimulation: Introduction to a New Age in Neuromodulation

      • TIMOTHY R. DEER, MD
      • JASON E. POPE, MD
      • ERIC T. LEE, MD
      • COREY W. HUNTER, MD

      Spinal cord neuromodulation has been a long-established treatment option for those suffering from various types of chronic pain. This minimally invasive procedure provides the potential for long-term pain relief, reducing the burden of other types of therapy, such as medications. As with any medical treatment, some patients do not tolerate or respond well to the therapy. This fact has led to recent developments in the technology to improve the therapeutic efficacy. More specifically, in 2010, Dr. Dirk De Ritter described what is known as burst waveforms, which may result in better outcomes than traditional tonic stimulation, which is most commonly used in clinically. An understanding of the mechanism of neuromodulation and how these waveforms disrupt different targets in the pain pathway therefore represents a significant advancement in the world of interventional pain medicine. This evolution of treatment may improve the lives of those suffering from lifelong pain conditions and chronic pain states.

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    • 3

      Vertebral Compression Fractures and Options for Treatment

      By Magdalena Anitescu, MD, PhD; Annie Layno-Moses, MD
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      Vertebral Compression Fractures and Options for Treatment

      • MAGDALENA ANITESCU, MD, PHD
      • ANNIE LAYNO-MOSES, MD

      Vertebral compression fracture, a condition that affects almost one quarter of women in the United States, often presents as unrelenting pain with even minor movement. The condition has a significant effect on the decrease in quality of life of patients affected. Prompt diagnosis and treatment are key in the management of this condition. Although a conservative regimen with back braces and analgesics is the first initial step, invasive procedures, such as kyphoplasty and vertebroplasty, may be employed earlier in cases with severe debilitating pain, which is often not improved by first-line treatment.

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    • 4

      Neuraxial Anesthesia

      By Atisa Beihaghi Britton, MD; Pedram Aleshi, MD
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      Neuraxial Anesthesia

      • ATISA BEIHAGHI BRITTON, MDDepartment of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, Anesthesia Resident
      • PEDRAM ALESHI, MDAssociate Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA

      Neuraxial anesthesia refers to all forms of central blockade involving the spinal, epidural, and caudal spaces. This is achieved by the administration of local anesthetic solution into the cerebrospinal fluid or into the epidural space, where the spinal nerve roots exist. Neuraxial blockade has a wide range of applications, including surgical anesthesia, postoperative analgesia, chronic pain management, and anesthesia and analgesia for labor and delivery. It is considered to be one of the most effective methods of producing anesthesia and analgesia as it provides completely reversible loss of sensation in the desired area. By minimizing the amount of systemic medications that are needed for pain relief or by avoiding general anesthesia altogether, neuraxial blockade provides many advantages, including decreased respiratory depression and somnolence, increased functional ability, earlier ambulation, and earlier return of bowel function after surgery. However, the performance of neuraxial blockade is not without risk and therefore requires a well-trained anesthesia provider for safe and effective administration, monitoring, and management. A detailed understanding of neuraxial anesthesia allows for safer practice for the practitioner and more informed decision making for the patient. 

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    • 5

      Dorsal Root Ganglion Spinal Cord Stimulation: A Novel Target in an Exciting Time in Neuromodulation

      By Timothy R. Deer, MD; Corey W. Hunter, MD; Jason E. Pope, MD; Eric T. Lee, MD
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      Dorsal Root Ganglion Spinal Cord Stimulation: A Novel Target in an Exciting Time in Neuromodulation

      • TIMOTHY R. DEER, MD
      • COREY W. HUNTER, MD
      • JASON E. POPE, MD
      • ERIC T. LEE, MD

      The dorsal root ganglion (DRG) is a cluster of neurons located in the dorsal nerve root and is responsible for relaying sensory signals from the peripheral nervous system to the brain. Previously, the DRG was thought to be a purely supportive structure with no active role in chronic neuropathic pain; more recent evidence, however, suggests that the DRG is directly responsible for the development and even maintaining it. The concept of DRG stimulation is quite similar to traditional stimulation, with one very important difference: rather than placing leads over the posterior aspect of the cord to affect the dorsal columns, the leads are placed over the DRG(s), thus stimulating the cell bodies directly and modulating the pain at the source.

      Key words: causalgia, complex regional pain syndrome, dorsal root ganglion, neuromodulation, reflex sympathetic dystrophy, spinal cord stimulation

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    • 6

      Vertebral Augmentation

      By Siddarth Thakur, MD; Daniel Rothstein, MD, MBA; Kent H Nouri, MD
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      Vertebral Augmentation

      • SIDDARTH THAKUR, MD
      • DANIEL ROTHSTEIN, MD, MBA
      • KENT H NOURI, MD

      Vertebral compression fractures are a prevalent and growing public health problem associated with significant morbidity and economic cost. Most commonly, they occur in osteoporotic patients but are also seen in patients with metastatic cancer and secondary to trauma. Appropriate and timely treatment is imperative. When conservative treatments are inadequate, minimally invasive techniques, such as vertebroplasty and kyphoplasty, can provide substantial pain relief, improve function, and enhance quality of life. For appropriate patient selection, a comprehensive evaluation is essential to confirm the presence of concordant pain. Both vertebroplasty and kyphoplasty are performed percutaneously under radiographic guidance, and cement is injected into the collapsed vertebral body to provide strength and stability. Awareness of early and late procedure-related complications is necessary for perioperative planning. Overall, vertebral augmentation is a safe and efficacious procedure for patients suffering from pain related to vertebral compression fractures.

      This review contains 10 figures, 5 tables, and 74 references.

      Key words: adjacent level fractures, axial low back pain, cement injection, cement leakage, kyphoplasty, osteoporosis, parapedicular, polymethylmethacrylate, spinal metastasis, transpedicular, vertebral augmentation, vertebral compression fracture, vertebroplasty

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    • 7

      Peripheral Nerve Blocks for the Lower Extremity

      By Candace Shavit, MD; Monica W. Harbell, MD
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      Peripheral Nerve Blocks for the Lower Extremity

      • CANDACE SHAVIT, MD
      • MONICA W. HARBELL, MD

      Lower extremity peripheral nerve blocks (PNBs) are often used for surgical anesthesia and postoperative pain management. The use of PNB provides improved analgesia, reduced opioid consumption, and improved patient satisfaction and can facilitate earlier rehabilitation and discharge. As the number of lower extremity total joint arthroplasties is projected to increase significantly, the role of peripheral nerve blocks can be expected to grow in similar fashion. With the growing number of procedures and the increasing focus on patient experience and expeditious hospital discharge, PNBs are increasingly recognized as a powerful tool to improve patient care and facilitate recovery after lower extremity surgery. We provide a basic review of regional anesthesia for lower extremity surgical procedures. The widespread availability of ultrasonography has improved the performance and efficacy of PNBs; thus, we focus on ultrasonography-guided procedures. In this review, we discuss pertinent lower extremity anatomy and sonoanatomy, indications, patient outcome measures, techniques, and complications of the most commonly used blocks.

      This review contains 35 figures, 11 tables, 5 videos, and 103 references

      Key words: adductor canal block, analgesia, ankle block, clinical applications of peripheral nerve blocks, complications of peripheral nerve blocks, continuous peripheral nerve catheter, early ambulation, fascia iliaca compartment block, femoral nerve block, lower extremity nerve blocks, lower extremity regional anesthesia, lumbar plexus block, obturator nerve block, peripheral nerve block, peripheral nerve catheter, popliteal block, psoas compartment block, regional anesthesia, regional anesthesia techniques, saphenous nerve block, sciatic nerve block, ultrasonography guided

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  • Headache and Neurological Disorders
    • 1

      Head and Neck Blocks for Headache and Facial Pain

      By Yury Khelemsky, MD; Adham Zayed, MD
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      Head and Neck Blocks for Headache and Facial Pain

      • YURY KHELEMSKY, MD
      • ADHAM ZAYED, MD

      Since medications and interventions may not yield adequate efficacy for many patients with headache and facial pain, the management of these complex conditions often requires a multidisciplinary and multimodal effort. As part of a multifaceted approach, different procedures may have utility in alleviating pain for a variety of pathologies. This article reviews practical considerations for performing occipital nerve blocks, trigeminal nerve blocks, cervical medial branch blocks, cervical epidural steroid injections, sphenopalatine ganglion blocks, and trigger-point injections. Although there is growing evidence for the utility of these varied procedures, further research is warranted to clearly define which patient groups may derive the greatest benefit from these interventions, as well as optimal approaches to enhance their effectiveness. 

      Most recent advances covered (3-5):

      1. Greater occipital blocks performed with lesser occipital blocks are a useful therapy to complement conservative management to reduce length, frequency, and duration of migraine headache.

      2. Cervical medial branch blocks may be helpful for not only for neck pain, but for headache, however, more research is needed in this area.

      3. Although dry needling is effective for myofascial pain, injection of local anesthesia may provide longer lasting relief. 

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    • 2

      Postherpetic Neuralgia: A Patient’s and a Physician’s Perspective

      By James H. Diaz, MD, MHA, MPH, DrPH, FACA, DABA, FACPM
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      Postherpetic Neuralgia: A Patient’s and a Physician’s Perspective

      • JAMES H. DIAZ, MD, MHA, MPH, DRPH, FACA, DABA, FACPM

      Herpes zoster can plague anyone who has had varicella or has received the varicella or chickenpox vaccine. The incidence of herpes zoster increases with age and rises exponentially after 60 years of age. Postherpetic neuralgia (PHN) may occur after herpes zoster at any age but typically occurs after 50 years of age, with over 40% of persons over 60 years of age suffering from PHN after a shingles attack. Up to 1 million new cases of herpes zoster and 200,000 new cases of PHN may now be anticipated in the United States every year, with the incidence rate increasing as the population grows and ages with prolonged life expectancies. Although new antiviral medications will improve and shorten the course of herpes zoster, they do not guarantee the prevention of PHN. Given the high prevalence of PHN in an aging population and the availability of primary prevention by vaccination, the objectives of this review are to describe the epidemiology, pathophysiology, and clinical manifestations of zoster and PHN and to recommend a combination of strategies for the clinical management and prevention of PHN.

      Key words: evidence-based pain medicine, herpes zoster, neuropathic pain, postherpetic neuralgia

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    • 3

      Tension-type Headache: Epidemiology, Diagnosis, and Pathophysiology

      By Paul Rizzoli, MD, FAAN, FAHS
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      Tension-type Headache: Epidemiology, Diagnosis, and Pathophysiology

      • PAUL RIZZOLI, MD, FAAN, FAHSAssistant Professor of Neurology, Harvard Medical School, Clinical and Fellowship Director John R. Graham Headache Center, Brigham and Women’s Faulkner Hospital, Boston, MA

      Tension-type headache (TTH) is a significant but underappreciated condition that is much more frequent than migraine, 42% versus 11%, and produces significant socioeconomic burden. Why then do research advances in this condition seem to lag?

      One reason is that precise epidemiologic data are lacking, with lifetime prevalence estimates varying from about 13 to 78%. Also, classification is confounded by whether or not to include the occasional but universal headache as TTH. Furthermore, TTH pathophysiology is debated, with some feeling that the pathophysiology of TTH is similar to and on a spectrum with migraine, and some feeling that it is entirely separate and related to peripheral and muscular mechanisms. More recently, central pain mechanisms have also been implicated in the pathophysiology. In addition, a large body of information connects stress and TTH.

      Although TTH varies widely in frequency and severity among and within patients, TTH pain, compared with pain in other headache types, could be characterized generally as more mild in severity and more generalized in location. This review discusses the current epidemiologic data and diagnostic challenges in TTH and the current pathophysiologic mechanisms.

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    • 4

      Neuropathic Pain

      By Nantthasorn Zinboonyahgoon, MD; Sherif Al-Hawarey, MD; Grace Chen, MD
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      Neuropathic Pain

      • NANTTHASORN ZINBOONYAHGOON, MD
      • SHERIF AL-HAWAREY, MD
      • GRACE CHEN, MD

      Neuropathic pain is a common but complex condition. The pathophysiology and mechanisms are not fully understood. The evaluation should incorporate a detailed history and physical examination with the selective investigations. There is still no standard classification of neuropathic pain; however, it may be classified as central or peripheral or by location and etiology. The common etiologies of neuropathic pain include diabetes mellitus, chemotherapy, alcohol, inflammation, and HIV. Since neuropathic pain is a chronic condition and unlikely to be cured or to disappear, the goal of treatment includes pain control as well as improved physical functions, attenuated psychological distress, and improved quality of life. The team approach by integrating pharmacologic treatment, physical therapy, pain psychology, and complementary medicine would improve the patient’s quality of life and outcome.

      Key words: classification, diagnosis, etiology, neuropathic pain, treatment

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    • 5

      Pediatric Headache Disorders

      By Raquel Langdon, MD; Marc T DiSabella, DO
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      Pediatric Headache Disorders

      • RAQUEL LANGDON, MDInstructor of child neurology at The George Washington School of Medicine and Health Sciences and co-director of Pediatric Headache and Concussion at the Center for Neurosciences and Behavioral Health, Children’s National Medical Center, Washington, DC
      • MARC T DISABELLA, DOAssistant professor of child neurology at The George Washington School of Medicine and Health Sciences, and director of pediatric headache at the Center for Neurosciences and Behavioral Health, Children’s National Medical Center, Washington, DC

      Headache is the most common neurologic disorder in the population, and most children will experience headaches recurrently throughout childhood and adolescence. Current estimates suggest that one in four children and adolescents experience migraine, one of the most severe forms of headache. It is imperative to differentiate primary headache disorders, including migraine and tension-type headache, from secondary headaches, including posttraumatic and medication overuse headache, to successfully diagnose and manage symptoms. Headache results in significant disability in children, including significant social stigma, school absenteeism, and avoidance of normal activities (eg, athletic and social activities). Headache can be successfully managed by providing patients and their families with a variety of techniques, including healthy lifestyle habits, cognitive-behavioral therapy, selected medications in the appropriate setting, and possibly complementary therapies, which may include acupuncture, physical therapy, and nutraceuticals.

      Key words: headache, migraine, concussion, lifestyle modification

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    • 6

      Migraine: Psychiatric Comorbidities

      By Todd A Smitherman, PhD; Anna Katherine Black, MA; A Brooke Walters Pellegrino, PhD
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      Migraine: Psychiatric Comorbidities

      • TODD A SMITHERMAN, PHDAssociate Professor of Psychology, Department of Psychology, University of Mississippi, Oxford, MS
      • ANNA KATHERINE BLACK, MAGraduate Student, Clinical Psychology, Department of Psychology, University of Mississippi, Oxford, MS
      • A BROOKE WALTERS PELLEGRINO, PHDDirector of Behavioral Medicine, Hartford Healthcare Headache Center, West Hartford, CT

      Psychiatric disorders often co-occur with migraine, and these comorbid conditions compound disability and are risk factors for medication overuse and migraine progression. For these reasons, attention to psychiatric comorbidities in clinical practice is of paramount importance. Assessment of depression, anxiety, and sleep disorders is recommended, focusing on the core cognitive and emotional symptoms of the comorbidities and using measures validated among medical patients. Pharmacologic treatment of migraine and comorbid psychiatric conditions is challenging owing to a lack of agents with proven efficacy for both conditions, side effect profiles that may exacerbate one condition, and potential drug interactions. Existing data suggest that migraineurs with psychiatric symptomatology can obtain positive outcomes with appropriate preventive medications, behavioral interventions for headache or the comorbid condition, or a combination thereof.

      Keywords: anxiety, comorbidity, depression, insomnia, migraine, pharmacotherapy, relaxation, stress management

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    • 7

      Difficult to Treat (refractory) Chronic Migraine: Outpatient Approaches

      By Lawrence Robbins, MD, (retired)
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      Difficult to Treat (refractory) Chronic Migraine: Outpatient Approaches

      • LAWRENCE ROBBINS, MD, (RETIRED) Assistant Professor of Neurology, Dept. of Neurology, University of Illinois; (retired) Assistant Professor of Neurology, Dept. of Neurology, Rush Medical College, Chicago, Il

      This comprehensive review addresses the many challenges in treating refractory migraine. Issues relating to pathophysiology are covered. A unique “refractory scale for migraine patients” is introduced. The definition and role of medication overuse headache are presented with a much different perspective than is usually found. Issues outside of medication that are covered include active coping, acceptance, resilience, and catastrophizing. A number of outpatient treatments are thoroughly discussed. These include the role of onabotulinum toxin, the application of polypharmacy, when to employ sphenopalatine ganglion  blocks, the role of occipital and trigger-point injections, the implementation of long-acting opioids, the advantages of stimulants, and the possible use of monoamine oxidase inhibitors. Miscellaneous approaches include muscle relaxants, nasal or intravenous ketamine, transcranial magnetic stimulation, memantine, and ergonovine. Finally, many cutting-edge “refractory clinical pearls” are listed. 

      This review contains 8 highly rendered figures, 4 tables, and 25 references.

      Key Words: Headache, migraine, chronic, refractory, medication overuse, alternative, treatments

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    • 8

      Nerve Blocks and Neurostimulation in the Treatment of Migraine

      By Matthew S Robbins, MD
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      Nerve Blocks and Neurostimulation in the Treatment of Migraine

      • MATTHEW S ROBBINS, MDAssociate Professor of Clinical Neurology, Albert Einstein College of Medicine, Chief of Neurology, Jack D. Weiler Hospital, Montefiore Medical Center, Director of Inpatient Services, Montefiore Headache Center, Associate Program Director, Neurology Residency, Bronx, NY

      Peripheral nerve and sphenopalatine ganglion blocks are a safe, effective treatment option for headache disorders, although, despite a wealth of anecdotal experience, the evidence is conflicting for efficacy in chronic migraine prophylaxis. Neurostimulation has emerged as an effective treatment modality for migraine with both noninvasive and minimally invasive options available. Such options include transcutaneous supraorbital nerve stimulation for prophylaxis and single-pulse transcranial magnetic stimulation for the acute treatment of migraine with aura. Although occipital nerve stimulation may be effective for some patients with intractable chronic migraine, the evidence is mixed and procedure-related complications are common. Emerging treatment modalities for acute and preventive treatment of migraine include noninvasive vagus nerve stimulation and implanted sphenopalatine ganglion stimulation.

      This review contains 5 highly rendered figures, 2 tables, and 106 references.

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    • 9

      Tension-type Headache: Acute and Preventive Therapies

      By Melissa Rayhill, MD
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      Tension-type Headache: Acute and Preventive Therapies

      • MELISSA RAYHILL, MDAssistant Professor, Department of Neurology, University at Buffalo School of Medicine, the State University of New York at Buffalo

      Tension-type headache (TTH) is an incredibly common condition. The clinician should be careful to distinguish TTH from migraine and from causes of secondary headache. The importance of regular sleep, nutrition, hydration, and appropriate management of life stressors cannot be overemphasized. The mainstays of abortive pharmacologic therapy for TTH are the nonsteroidal antiinflammatory drugs. Most of these drugs are thought to have roughly equivalent efficacies based on many older clinical trials and more recent meta-analyses. The side effects of this drug class can be severe and include renal toxicity and gastrointestinal bleeding; these drugs may also increase cardiovascular risk. Tricyclic antidepressants are thought to be the most effective preventive therapy for TTH, particularly amitriptyline. Other antidepressant medications as well as muscle relaxants may also be beneficial in some patients. A number of other nonpharmacologic and procedural therapies exist, although the evidence supporting the use of these treatments is variable. However, in many patients, these other modalities can be helpful therapeutic adjuncts. In this review, we also discuss the evidence base for physical therapy, acupuncture, trigger-point injections, massage therapy, and psychological therapy. 

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    • 10

      Migraine: Behavioral Treatment

      By Elizabeth K Seng, PhD
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      Migraine: Behavioral Treatment

      • ELIZABETH K SENG, PHDAssistant Professor, Ferkauf Graduate School of Psychology, Yeshiva University, New York, NY

      Behavior change is an essential component of any migraine management plan. Behavioral migraine treatments are interventions designed to change a patient’s behavior with the result of a reduction in migraine symptoms and migraine-related disability. Behavioral treatments commonly target medication adherence, behavioral and psychosocial factors known to precipitate migraine (including stress, sleep, and skipping meals), maladaptive cognitive patterns, and comorbid psychiatric symptoms (most commonly depression and anxiety). Guidelines and evidence from randomized clinical trials indicate that biofeedback, relaxation treatments, and cognitive-behavioral therapy are effective preventive migraine treatments. Patient education and self-monitoring are foundational components to any behavioral intervention for migraine. Portable personal technology is increasingly becoming an essential part of migraine patient care and provides another avenue for supporting adherence to medication and behavioral migraine management.  

      Key words: anxiety; behavior; biofeedback; cognitive-behavioral therapy; depression; migraine; psychology; relaxation; sleep; stress

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    • 11

      Migraine Epidemiology, Impact, and Pathogenesis

      By Amy A Gelfand, MD; Dawn C Buse, PhD
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      Migraine Epidemiology, Impact, and Pathogenesis

      • AMY A GELFAND, MDDirector, Pediatric Headache, Division of Child Neurology, Department of Neurology, UCSF Benioff Children’s Hospital, San Francisco, CA
      • DAWN C BUSE, PHDAssociate Professor, Department of Neurology, Albert Einstein College of Medicine of Yeshiva University, Assistant Professor, Clinical Health Psychology Doctoral Program, Ferkauf Graduate School of Psychology of Yeshiva University, Director of Behavioral Medicine, Montefiore Headache Center Bronx, NY

      Migraine is a common and often disabling neurologic disorder. No longer thought of as neurovascular in etiology, migraine is now known to be a complex disorder of the brain with strong genetic underpinnings. The impact of migraine may extend beyond the affected individual to also impact partners and children. Although many patients search to identify “triggers” of migraine, teasing out such relationships can be remarkably complex. The premonitory phase of a migraine attacks can include symptoms such as food cravings, photophobia, and increased yawning—symptoms that could, for example, lead a person to mistakenly conclude that the migraine attacks are “triggered” by eating chocolate, bright lights, or being tired. We review current evidence on the epidemiology, impact, and pathophysiology of migraine. 

      Key words: epidemiology, impact, migraine, pathophysiology

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  • Special Topics
    • 1

      Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

      By Jo Ann LeQuang, BA; Joseph V. Pergolizzi Jr, MD; Robert B. Raffa, PhD, Professor Emeritus; Robert Taylor, PhD
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      Opioid Therapy for Chronic Noncancer Pain: Safe, Effective, Appropriate?

      • JO ANN LEQUANG, BADirector of Scientific Communications, NEMA Research, Inc., Bonita Springs, FL
      • JOSEPH V. PERGOLIZZI JR, MDNEMA Research, Inc., Naples, FL
      • ROBERT B. RAFFA, PHD, PROFESSOR EMERITUSDepartment of Pharmaceutical Sciences, Temple University School of Pharmacy, Philadelphia, PA Adjunct Professor, Department of Pharmacology and Toxicology, University of Arizona College of Pharmacy
      • ROBERT TAYLOR, PHDExecutive Director of Operations, NEMA Research, Inc., Bonita Springs, FL

      In determining the appropriate role of opioids, two public health crises must be balanced: the opioid abuse epidemic and the “silent” crisis of unrelieved chronic pain. Opioids can be used safely and effectively in selected patients; however, clinicians must be aware of their abuse liability and individual risk factors for opioid misuse. A number of opioids are approved for use in the United States, and although there are class effects, there can be great variability among patients with regard to opioid response. In addition to the medication, prescribers must also determine the most appropriate dose and route of administration. Considerations must be made for special population, such as the renally impaired, those with hepatic dysfunction, and pediatric and elderly patients. Another factor is abuse-deterrent properties. Of particular interest as an opioid agent is buprenorphine, which is available in various routes of administration and because of its unique pharmacokinetics may be administered to renally compromised and elderly patients without dosing restrictions. Buprenorphine is also associated with a lower abuse liability than other opioids. Patients suffering moderate to severe pain syndromes should not be denied access to effective pain control, which in some cases may appropriately include opioid therapy.

      Key words:Buprenorphine, Chronic Pain, Opioid, Opioid Abuse, Opioid Prescribing, Risk Factors for Opioid Abuse

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    • 2

      Physicians' Role in Curbing the Worst Drug Crisis in America: Prescription Opioid Abuse

      By Gururau Sudarshan, MD, FRCA; Sairam Atluri, MD, FIPP
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      Physicians' Role in Curbing the Worst Drug Crisis in America: Prescription Opioid Abuse

      • GURURAU SUDARSHAN, MD, FRCADirector, Cincinnati Pain Physicians, Cincinnati, OH
      • SAIRAM ATLURI, MD, FIPPDirector, Tristate Pain Management Institute, Cincinnati, OH

      Opioids have an important role in the management of acute, cancer, and chronic pain. However, their indiscriminate use in chronic pain has led, in part, to the epidemic of prescription drug abuse, resulting in a dramatic increase in morbidity and mortality in America. Most of this abuse originates from legitimate prescriptions by physicians. Prescribing opioids to chronic pain patients while restricting them to those who abuse them is very challenging, and physicians seek appropriate and unbiased prescribing guidelines. Our review, based on analysis of the available literature, focuses on striking a balance between overprescribing and underprescribing. The core concept of this strategy relies in using screening tools to identify patients who are at high risk for opioid abuse along with diligent monitoring using prescription monitoring programs and urine drug screens, while also limiting opioid doses. Hopefully, using these principles, physicians can more confidently prescribe opioids to those who would benefit from these powerful drugs and at the same time keep opioids away from those who could potentially be harmed.

      Key Words: abuse, addiction, chronic pain, dose limitation, misuse, monitoring, opioids, overdose, screening

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    • 3

      Pain and Chemical Dependency

      By Sanford M Silverman, MD
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      Pain and Chemical Dependency

      • SANFORD M SILVERMAN, MDCEO and Medical Director, Comprehensive Pain Medicine, Pompano Beach, FL, Affiliate Assistant Professor of Clinical Biomedical Science, Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL

      Pain can mean different things to different people. At the same time, it is a subjective and objective sensation. For the patient experiencing pain, it is an unpleasant sensation that causes undue suffering. Chemical dependency or addiction is characterized by inability to consistently abstain, impairment in behavioral control, and craving; diminished recognition of significant problems with one’s behaviors and interpersonal relationships; and a dysfunctional emotional response. It is a complex chronic disease of brain reward, motivation, memory, and related circuitry. The prevailing view of opioid therapy for chronic pain is a pendulum swinging between opiophobia and opiophilia. The intersection between pain and addiction is also a moving target. Various stakeholders have attempted to find a balance between addressing the crisis of chronic pain in society and not exacerbating the problem of substance abuse. The pain practitioner must recognize the duality that exists between chronic and chemical dependency and must assess risk prior to using controlled substances to manage that pain, and if things go awry, the physician must have an exit strategy. Discharging problem patients merely transfers the problem elsewhere. Offering patients a solution to iatrogenic dependence on controlled substances is a viable and compassionate path for both the patient and the practitioner.

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    • 4

      Serotonin Syndrome

      By Ravi Mirpuri, DO; Danielle Perret Karimi, MD
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      Serotonin Syndrome

      • RAVI MIRPURI, DOChief Resident, Department of Physical Medicine and Rehabilitation University of California, Irvine, Orange, CA
      • DANIELLE PERRET KARIMI, MDAssociate Dean, Graduate Medical Education, Associate Physician, Department of Physical Medicine and Rehabilitation, University of California, Irvine, Orange, CA

      Serotonin syndrome (SS) is a complication that occurs due to drug interactions that result in an increase in serotonin in the central nervous system. This syndrome is classically described as a triad of altered mental status, autonomic hyperactivity, and neuromuscular abnormalities that can be life threatening. As such, prompt detection is crucial so that treatment can be delivered to prevent long-term complications from hyperthermia, malignant hypertension, and/or cardiac arrhythmias. Determining the diagnosis can be difficult as several other conditions have similarities to SS; these include malignant hyperthermia, neuroleptic malignant syndrome, and anticholinergic toxicity. If appropriately managed, SS typically resolves within 24 hours once all serotoninergic medications are discontinued. If inappropriately prescribed, serotoninergic drugs such as antibiotics, analgesics, supplements, or antidepressants may all contribute toward inducing this preventable syndrome, if given in excess. This comprehensive review of SS provides the clinician with a detailed understanding of the pathogenesis, diagnosis, and treatment of this complex disease state

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    • 5

      Pain in the Intensive Care Setting

      By Beverly Chang, MD
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      Pain in the Intensive Care Setting

      • BEVERLY CHANG, MDAssistant Professor, Department of Anesthesiology, Perioperative and Pain Medicine, New York University Langone Medical Center, New York, NY

      Pain occurs frequently in the intensive care setting even among nonprocedural patients. Pain in the critical care setting creates significant downstream burdens in the recovery and psychological health of patients. Moderate to severe pain is reported in a significant number of intensive care unit (ICU) patients without significant differences in pain scores between trauma/surgical patients and medical ICU patients. However comparatively, medical ICU patients were found to experience higher pain intensity. Many of these patients reported a lack of pain relief from their analgesics, and 90% described experiencing the highest levels of distress due to difficulty in communicating their pain. This review covers the physiology of pain, physiologic effects of pain, challenges of pain management in the ICU, preemptive analgesia, multimodal analgesia, and treatment of pain. Figures show classification of chronic pain syndromes, the major neural pathways involved in nociception, pain transmission pathway and treatment interventions, and the analgesic pain ladder. Tables list incidence of chronic postoperative pain, risk factors for developing persistent postoperative pain, basic principles of the World Health Organization pain ladder, side effects of opioids, opioid medications, effects of ketamine, comparison of ester and amide local anesthetics, and characteristics of commonly used local anesthetics.

      This review contains 4 figures, 8 tables, and 60 references.

      Key words: Pain in the ICU; Pain management; Postoperative pain; Preemptive analgesia; Analgesic pain ladder

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    • 6

      Acute Care: Pain Management

      By Claudia Ranniger, MD, PhD
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      Acute Care: Pain Management

      • CLAUDIA RANNIGER, MD, PHDDirector, Simulation Center, George Washington University CLASS Center, George Washington, University Hospital, Washington, DC

      Pain is a chief complaint in more than 50% of emergency department (ED) visits. Injury accounts for approximately one-third of presentations associated with pain; other common diagnoses include neck and back pain, minor infections, abdominal pain, and headache. In the ED, pain is underdiagnosed and undertreated, and existing pain management practices in the ED are inconsistent.  Inadequate pain management is common, and pain remains unchanged or worsens during the ED visit for more than 40% of patients.  Patient satisfaction improves when expectations for pain control are met. This review covers the pathophysiology of pain and the practice of pain management. Figures show the approach to pain management in the ED, an example of a numerical and visual analog scale pain rating scale, field block of the pinna, ultrasound probe and hand position for ultrasound-guided regional anesthesia, regional anesthesia of the face, innervation of the hand and fingers, regional anesthesia of the median, radial and ulnar nerves, innervation of the foot, ultrasound-guided regional anesthesia of the posterior tibialis nerve, regional anesthesia of the sural nerve, and method of regional anesthesia of the dorsal foot. Tables list local anesthetics and anesthetic combinations, common nonnarcotic pain relievers, commonly used parenteral opioids for acute pain, commonly prescribed oral opioid-containing pain medications, principles of pain assessment in the ED, and advantages and disadvantages of in- and out-of-plane approaches to ultrasound-guided nerve block.

      This review contains 13 highly rendered figures, 6 tables, and 105 references

      Key words: Acute pain, Pain management, Oligoanalgesia, Pain assessment, Inadequate pain management, Acute pain management, Pain management in the emergency department, Pain in the ED, Pain presentation

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    • 7

      Opioid-induced Constipation: A Comprehensive Overview

      By Trisha Patel, MD; Hamilton Chen, MD; John Michels, MD; Justin Hata, MD
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      Opioid-induced Constipation: A Comprehensive Overview

      • TRISHA PATEL, MD
      • HAMILTON CHEN, MD
      • JOHN MICHELS, MD
      • JUSTIN HATA, MD

      In the United States, 4.3 million adults are regularly taking opioid medications. Opioid-induced constipation (OIC) is underdiagnosed considering the prevalence of opioid use among Americans. This review is intended to clarify issues related to OIC. OIC is caused by opioids binding to specific receptors in the gastrointestinal system, resulting in various anatomic effects, including decreased gastric motility, increased sphincter tone, reduced intestinal secretions, and increased water absorption in the bowel. Various treatments include water and fiber consumption, laxatives, enemas, cessation of opioids, and central and peripheral opioid antagonists. OIC is treatable, but timely diagnosis and patient education are paramount for successful resolution.

      Key words: chronic pain; constipation; mu, delta, and kappa receptors; myenteric plexus; opioid; opioid-induced constipation; opioid receptor antagonists; submucosal plexus

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    • 8

      Paraplegia Following Epidural Steroid Injection

      By Devin Peck, MD
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      Paraplegia Following Epidural Steroid Injection

      • DEVIN PECK, MDAssociate Partner, Austin Pain Associates, Austin, TX

      Paraplegia following epidural steroid injection is, fortunately, an exceedingly rare complication. The differential diagnosis includes epidural hematoma, spinal cord injury/infarction, epidural abscess, and conversion disorder. Less likely diagnoses include worsening of underlying pathology, a new compressing lesion, or subarachnoid injection.

      The artery of Adamkiewicz enters the spinal canal via the neural foramen and provides blood supply to the lower two thirds of the spinal cord via the anterior spinal artery. Avoidance of the artery during a transforaminal epidural steroid injection is facilitated by entering the inferior portion of the foramen.

      Acute management of neurologic complications arising from an epidural steroid injection is facilitated by rapid identification of etiology. In the case of epidural hematoma, avoidance of permanent deficit is more likely when patients undergo prompt decompression. The role of intravenous steroids in acute spinal cord injury is controversial. Chronic management includes extensive rehabilitation, including physical and occupational therapy. Treatment of musculoskeletal nociceptive pain, such as due to shoulder overuse, and neuropathic pain is vital to optimize the patient’s participation in rehabilitative therapy.

       

      Keywords: Epidural Steroid Injection; Complications; Spinal Cord Injury; Epidural Hematoma; Epidural Abscess; Artery of Adamkiewicz; Anterior Spinal Artery Syndrome; Particulate Steroid; Fluoroscopic Guidance

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    • 9

      Patient-controlled Analgesia

      By Devin Peck, MD
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      Patient-controlled Analgesia

      • DEVIN PECK, MDAssociate Partner, Austin Pain Associates, Austin, TX

      Patient-controlled analgesia (PCA) is a method for controlling pain in which a patient is able to self-administer pain medications via activation of a mechanical distribution system. The key element of PCA is that the patient is in control of the analgesia. Respiratory depression is preceded by sedation, and a sedated patient is unable or unlikely to push the PCA button. The pump can also be programmed to have a continuous infusion rate, which is administered to the patient regardless of whether the patient activates a dose. Basal rates bypass the safety mechanism of patient control and can place the patient at higher risk for respiratory depression and sedation. Initiation of a PCA is often most appropriate in patients requiring frequent as-needed dosing of medications or when such dosing is anticipated. Patients’ acceptance of the technique is high, related in part to a sense of control over their own pain relief, a reduction in the delay for the receipt of pain medications, not receiving injections, and not having to interrupt or to bother nurses.

       

      Key words: analgesic delivery systems, morphine metabolism, multimodal pain management, opioid pharmacology, opioid side effects, patient-controlled analgesia, patient safety, respiratory depression 

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    • 10

      Patient-controlled Epidural Analgesia/continuous Epidural Catheters

      By Devin Peck, MD
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      Patient-controlled Epidural Analgesia/continuous Epidural Catheters

      • DEVIN PECK, MDAssociate Partner, Austin Pain Associates, Austin, TX

      Although useful for management of many types of pain, the most common indication for epidural catheter placement is for management of labor pain. High lumbar and thoracic epidural catheter placement has gained increasing popularity in recent years for the management of postoperative pain. The technique is most commonly employed for procedures in which a thoracic or an extensive abdominal incision is anticipated.

      Absolute contraindications for epidural catheter placement include patient refusal, uncorrected hypovolemia, increased intracranial pressure, local infection at the planned site of insertion, and patient allergy to amide/ester local anesthetics. Relative contraindications include coagulopathy, an uncooperative patient, severe anatomic abnormalities of the spine, sepsis, and hypertension. The advantages include attenuation of the sympathetic response to surgical stimulation and pain; effects on the cardiovascular, respiratory, and gastrointestinal systems; thromboprotective effects; and possibly limitation of tumor spread. The risks of epidural catheter placement include epidural hematoma, infection, nerve or spinal cord injury, dural puncture, or respiratory or cardiovascular depression from a high block.

      Epidural opioids provide analgesia without causing motor or sympathetic blockade. Epidurally administered local anesthetics may result in decreased postoperative ileus, nausea, vomiting, and sedation, which can be associated with opioids. Local anesthetics and opioids act additively or synergistically and, when used together, can lead to a reduction in the dose of each drug. 

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    • 11

      Patient With a History of Active substance Abuse Requesting Opioids for Chronic Pain

      By Martin J Carney, B.S; Mark R. Jones, M.D; Harold J. Campbell, B.S; Burton R. Beakley, M.D; Alan D. Kaye, MD, PhD
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      Patient With a History of Active substance Abuse Requesting Opioids for Chronic Pain

      • MARTIN J CARNEY, B.S
      • MARK R. JONES, M.D
      • HAROLD J. CAMPBELL, B.S
      • BURTON R. BEAKLEY, M.D
      • ALAN D. KAYE, MD, PHDProfessor, Program Director, and Chairman, Department of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LAV

      Health care providers face a considerable challenge when treating chronic pain patients with prescription opioid medications. Although indications exist for the use of these drugs, their addictive nature and street value render them high-risk targets for abuse, misuse, and diversion. All patients receiving opioids should, therefore, be screened for abuse potential before beginning opioid therapy, be required to sign an opioid agreement, and receive close monitoring throughout the course of their treatment. Patients who present with a history of active substance abuse are at higher risk for iatrogenic dependence and necessitate more frequent monitoring. Herein arise several ethical issues, such as the principle of justice, which mediates equitable treatment for all patients. This review discusses the disease underlying substance abuse and clinical manifestations thereof, as well as relevant pathophysiology, ethical issues, and guidelines for the safe treatment with opioids.

      Key words: addiction, ethics, opioids, safety, substance abuse 

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    • 12

      Vasovagal Response After Pain Procedures

      By Erik Helander, MBBS; Ethan Phan, MPH; Ben Homra, MBBS Candidate; Alan D. Kaye, MD, PhD
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      Vasovagal Response After Pain Procedures

      • ERIK HELANDER, MBBSResident, Department of Anesthesiology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LA
      • ETHAN PHAN, MPHSenior Medical Student Louisiana State University School of Medicine, New Orleans, LA
      • BEN HOMRA, MBBS CANDIDATEUniversity of Queensland SOM-Ochsner Clinical School, New Orleans, LA
      • ALAN D. KAYE, MD, PHDProfessor, Program Director, and Chairman, Department of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LAV

      Vasovagal syncope (VVS) is a specific type of syncope associated with hypotension, bradycardia, and peripheral vasodilation usually lasting 20 seconds and rarely longer than several minutes. It is caused by emotional stress, fear, pain, instrumentation, blood phobia, heat, and orthostatic stress. When a triggering event is present, VVS is usually preceded by autonomic symptoms of pallor, sweating, nausea, and abdominal discomfort. It is a frequently cited immediate adverse event during pain procedures, with rates ranging between 0 and 8.7%. The use of moderate sedation has been shown to reduce the risk of first-time and repeat episodes of vasovagal reactions. However, early detection, simple conservative management, and a willingness to terminate the procedure have resulted in no serious adverse outcomes. 

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    • 13

      Strategies to Optimize the Efficacy of Regional Anesthesia

      By Jeremy Pearl, MD; Pedram Aleshi, MD
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      Strategies to Optimize the Efficacy of Regional Anesthesia

      • JEREMY PEARL, MDClinical Instructor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA
      • PEDRAM ALESHI, MDAssociate Professor, Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA

      The mode of delivery of epidural solutions has progressed from clinician-delivered boluses, to automated continuous epidural infusions and the addition of patient-controlled epidural analgesia (PCEA), and now to programmed intermittent epidural boluses (PIEBs) in addition to PCEA. Currently, there is promising evidence for the use of combination PIEB and PCEA to minimize additional bolus requirements and reduce the amount of local anesthetic consumed, as well as improved patient satisfaction. There are few data regarding this mode of delivery in peripheral nerve catheters. The existing data in the peripheral nerve catheters do not show a clear advantage for the use of the programmed intermittent bolus (PIB) method. More studies are needed in various peripheral nerve/fascia plane blocks to answer this question. Studies looking at the median effective dose in 50% of patients of local anesthetics for labor epidurals (minimum local anesthetic concentration [MLAC]) have allowed the comparison of the relative potency of different local anesthetics. Even though the absolute numbers are not useful, we know that ropivacaine is only 60% as potent as bupivacaine for its analgesic potency and development of motor block, so it provides no advantage over bupivacaine for the labor epidural setting. MLAC studies have also allowed the study of adjuvants and their effect on labor analgesia. Fentanyl, epinephrine, and clonidine have been studied, showing significant local anesthetic–sparing effects. The risks and benefits of each adjuvant should be weighed for each patient, but fentanyl and epinephrine have an excellent benefit-to-risk ratio.

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    • 14

      Sodium Channel Modulation in the Perception and Management of Pain

      By Dennis Paul, Ph.D; Harry J. Gould III, M.D., Ph.D
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      Sodium Channel Modulation in the Perception and Management of Pain

      • DENNIS PAUL, PH.DProfessor of Pharmacology and Experimental Therapeutics, Departments of Neurology, Pharmacology and Experimental Therapeutics, and Anesthesiology, Neuroscience Center of Excellence, Center of Excellence for Oral and Cranio¬facial Biology, Pain Mastery Center of Louisiana, Alcohol and Drug Abuse Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, LA
      • HARRY J. GOULD III, M.D., PH.DProfessor of Neurology and Neuroscience, Departments of Neurology, Internal Medicine, Section of Physical Medicine and Rehabilitation, and Anesthesiology, Neuroscience Center of Excellence, Center of Excellence for Oral and Craniofacial Biology, Pain Mastery Center of Louisiana, Louisiana State University Health Sciences Center, New Orleans, LA

      Sodium channels play a pivotal role in maintaining homeostasis and proper intracellular ion concentrations that are vital to all living cells for function and survival. In excitable tissues such as neurons and heart cells, sodium channels are responsible for establishing and maintaining the transmembrane electrochemical gradient, which is critical for intercellular communication and for the transduction, generation, modulation, and transmission of impulses that underlie normal physiologic function, the perception of stimuli, and the execution of appropriate behavioral responses. Injury and disease often affect changes in the channel density and subtype distribution present in cellular membranes, thereby upsetting the critical electrochemical balance necessary for normal functioning. When such changes affect the systems that process noxious stimulation and are acute and transient, they are beneficial. The pain that is perceived alerts us to current or impending injury and aids in vigilance during wound healing. But when the changes are persistent, the painful signals are no longer protective but, instead, become unrelenting and destructive to the quality of life. Because changes in sodium channel quantity and distribution play such a central role in the perception of pain and the development and maintenance of nociceptive chronicity, significant effort has been expended on discovering ways to affect sodium channel expression and function that might be effective in preventing or managing many painful conditions. The implications of modifying sodium channel expression and function for future therapeutic benefit are the subject of this review.


      Key Words: Acute pain, chronic pain, sodium channels

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    • 15

      Iatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning

      By R. Blake Windsor, MD, FAAP; Jean Solodiuk, RN, PhD
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      Iatrogenic Withdrawal Syndromes in Children: A Review of Sedative and Analgesic Weaning

      • R. BLAKE WINDSOR, MD, FAAPAssistant in Pain Medicine, Department of Anesthesia, Peri-Operative, and Pain Medicine, Adjunct in Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Instructor in Anaesthesia, Harvard Medical School, Boston, MA
      • JEAN SOLODIUK, RN, PHDResearch Associate, Department of Anesthesia, Peri-Operative, and Pain Medicine, Harvard Medical School, Boston, MA

      Iatrogenic withdrawal syndromes develop in children exposed to prolonged sedative and analgesic medications. Signs of withdrawal include central nervous system irritability, gastrointestinal dysfunction, and autonomic dysfunction. The most important steps to the safe management of sedative and analgesic weaning in children are the early identification of the risk of withdrawal, use of a validated withdrawal assessment scale, use of nonpharmacologic interventions, and administration of medication for weaning, if indicated. This article reviews the physiologic mechanisms of opioid tolerance and withdrawal, validated pediatric withdrawal scales, and safe management of iatrogenic withdrawal syndromes. Figures illustrate cellular responses to acute and chronic exposure to opioids. A suggested algorithm for the safe and rapid weaning of sedative and analgesic medications, using the best available evidence, is discussed.

      Key words: analgesic weaning, opioid tolerance, pediatric withdrawal, sedation weaning, weaning algorithm for children

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    • 16

      Pharmacologic and Technological Innovations in Pain Medicine

      By Anita Gupta, DO, PharmD; Hawa Abubakar, MD
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      Pharmacologic and Technological Innovations in Pain Medicine

      • ANITA GUPTA, DO, PHARMD
      • HAWA ABUBAKAR, MD

      The experience of pain is subjective, and treatment modalities should aim at providing the greatest amount of pain relief while minimizing adverse effects. Pharmacologic and technological innovations are making this possible. By taking advantage of new manufacturing processes, the pharmaceutical industry is retooling old and effective drugs. SoluMatrix diclofenac uses nanotechnology to address the need for an effective nonsteroidal antiinflammatory drug at the lowest possible dose to minimize risks associated with cardiac, renal, and gastrointestinal side effects. Intravenous acetaminophen provides an additional alternative in multimodal analgesia in instances when the oral or rectal route of delivery is not desirable. Liposomal bupivacaine uses liposomal encapsulated, resulting in a local anesthetic with a prolonged duration of action that can be used effectively in the management of postoperative pain. With the recognition that opioid therapy still remains a mainstay in pain management, advances in science have allowed for the development of peripherally acting mu opioid receptor antagonists such as naloxegol, which minimize the bothersome side effect of opioid-induced constipation. In terms of interventional pain management, advances in radiofrequency ablation (RFA) technology have resulted in cooled RFA, which allows for the creation of larger spherical lesions, thereby alleviating pain by interfering with neurotransmission. Advances in stem cell research have led to the application of multipotent cells with the aim of treating the underlying disease process and thereby eliminating pain. Finally, pharmacogenetics testing and smart drugs provide an avenue via which issues surrounding how medication is consumed, determination of effectiveness, and ensuring compliance and adherence can be optimized.

      Key words: Pain, Pharmacology, Medications, Technology, Innovation, Smart Pills, Personalized Medicine, Biotechnology, Device, Surgery, Multimodal

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    • 17

      Ketamine Infusions for Complex Regional Pain Syndrome

      By Roy K. Esaki, MD, MS
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      Ketamine Infusions for Complex Regional Pain Syndrome

      • ROY K. ESAKI, MD, MS

      Ketamine is an N-methyl-d-aspartate(NMDA) receptor antagonist that has been increasingly used in the management of treatment-resistant chronic pain conditions, particularly representing neuropathic involvement or central sensitization. Complex regional pain syndrome (CRPS) is a prototypical condition often treated with ketamine infusions. Although the analgesic benefits of ketamine as an opioid-sparing adjunct in the preoperative period have been well studied, the use of ketamine to mitigate chronic pain conditions remains largely anecdotal, composed largely of case reports and uncontrolled small studies. The limited evidence and published reports support the use of ketamine infusions as one aspect of a comprehensive, multimodal approach for CRPS. Although ketamine infusions are relatively safe when titrated appropriately, with minimal respiratory depression, side effects include sympathetic activation, unpleasant psychomimetic effects, lower urinary tract symptoms, and hepatic dysfunction. 

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    • 18

      Chronic Pelvic Pain: the Neuropathic Pain Basis

      By Stanley J. Antolak Jr, MD
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      Chronic Pelvic Pain: the Neuropathic Pain Basis

      • STANLEY J. ANTOLAK JR, MD

      Chronic pelvic pain (CPP) in both genders has been chiefly the province of surgical subspecialists. Morphologic end-organ processes have been studied for decades without significant advances in understanding the etiology of CPP or developing adequate therapeutic outcomes. The neurogenic basis of CPP has received little attention. Several peripheral nerves may be the source. The largest of these is a pudendal nerve and is the most important because it is a mixed nerve and affects sensory and motor symptoms in both the somatic and autonomic nervous systems. Nerve compression and stretch are the two most important etiologic factors.

      Practitioners can diagnose these painful neuropathies by a careful symptom history and physical examination. The most important diagnostic tool is sensory examination of the pudendal territory using pinprick. Various neurophysiologic tests can confirm pudendal neuropathy. The smaller peripheral nerves affect CPP.

      Because pudendal neuropathy is a tunnel syndrome related to cumulative, repetitive microtrauma, it can be treated accordingly. Treatment options include nerve protection, medications (analeptics, tricyclic amines), perineural infiltrations of local anesthetics with or without corticosteroids, and, in a significant minority, decompression of the pudendal nerves. The smaller nerves often respond to a program of postural correction and perineural anesthetic blockades. All patients require attention to central sensitization. Treatment success depends on the duration of symptoms, etiology, and severity of nerve damage. The last item can only be evaluated at surgery. Complete cures of CPP, treated using each modality, can be measured by validated symptom scores for as long as 13 years.

      To progress in the diagnosis and treatment of CPP, interspecialty studies are needed that distinctly separate neurogenic from nonneurogenic CPP. To date, this has not been done. Thus, diagnostic, etiologic, and treatment conclusions are quite limited. CPP provides a rich foundation for clinical research for neurologists.

      Key Words: abdominal cutaneous neuropathy, chronic pelvic pain, interstitial cystitis, irritable bowel syndrome, middle cluneal neuropathy, neurogenic pelvic pain, pudendal neuropathy, sexual dysfunction, thoracolumbar junction syndrome 

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    • 19

      Opioid-sparing Analgesics in Chronic Pain Management

      By Maricela Schnur , MD, MBA; Michael Fitzsimons, MD; Fangfang Xing, MD
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      Opioid-sparing Analgesics in Chronic Pain Management

      • MARICELA SCHNUR , MD, MBAResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
      • MICHAEL FITZSIMONS, MDAssistant Professor, Harvard Medical School, Director, Division of Cardiac Anesthesia, Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA
      • FANGFANG XING, MDResident Physician, Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA

      Chronic pain impacts the lives of millions of people in significant medical and psychosocial ways. Pharmacologic treatments are steering away from chronic opioid therapy due to serious side effects, an epidemic of prescription opioid abuse, and a lack of clear long-term benefit.  Therefore, nonopioid medications such as nonsteroidal antiinflammatory drugs, acetaminophen, tricyclic antidepressants, lidocaine patch, and anticonvulsants are important opioid-sparing or primary treatment options. Agents such as capsaicin, cannabis, botulinum toxin, and ketamine are less frequently prescribed adjuncts that are under active investigation to determine their roles in chronic pain therapy. Understanding the research can help the clinician determine the risks and benefits of these medications for their patients. In the future, dose and delivery optimization, combination therapy, elucidating the biology of pain, and developing novel agents will improve pharmacologic approaches to treatment.          

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    • 20

      Acute Postoperative Pain

      By Kelly Zach, MD ; Julio A. Gonzalez-Sotomayor, MD
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      Acute Postoperative Pain

      • KELLY ZACH, MD Pain Medicine Fellow, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR
      • JULIO A. GONZALEZ-SOTOMAYOR, MDClinical Associate Professor, Director, Inpatient Adult Pain Service, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University, Portland, OR

      Inadequate management of acute postoperative pain increases morbidity and mortality. Poorly controlled pain results in delayed hospital discharge and may lead to the development of chronic pain. Current evidence supports the implementation of a multimodal analgesic regimen, where different pharmacologic and nonpharmacologic interventions are used. The selection of the different components of this multimodal analgesic approach should consider their potential benefits and limitations, as well as the unique patient characteristics and the surgical procedure. It is the responsibility of the perioperative health care provider to formulate an optimal pain management strategy to ultimately enhance patient satisfaction and improve short- and long-term outcomes.

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    • 21

      Approach to the Patient With an Abnormal Drug Screen

      By Jeffrey Hopcian, MD; John Henry Harrison, MD; Magdalena Anitescu, MD, PhD
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      Approach to the Patient With an Abnormal Drug Screen

      • JEFFREY HOPCIAN, MDAssistant Professor, Department of Anesthesia, Case Western Reserve University
      • JOHN HENRY HARRISON, MDResident physician, University of Chicago Medicine, Department of Anesthesia and Critical Care
      • MAGDALENA ANITESCU, MD, PHD

      Urine drug testing has become widely used in clinical practice as a measure to monitor patient adherence to treatment plans and assess the efficacy of the treatment prescribed. In many circumstances, the clinician is challenged with an abnormal urine drug screen either for a new patient or for a patient presumed to be compliant with the medication regimen; proper interpretation of the test result and a detailed history and physical examination during the visit are necessary to identify the cause of the abnormality and properly care for the patient.

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    • 22

      Unusual Drugs of Abuse in Chronic Pain Patients

      By Elyse Cornett, PhD; Shilpadevi Patil, MD; Harish Siddaiah, MD; Justin Creel; Matthew B. Novitch, BS; Charles Fox, MD; Alan D. Kaye, MD, PhD
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      Unusual Drugs of Abuse in Chronic Pain Patients

      • ELYSE CORNETT, PHDClinical Research Coordinator, Department of Anesthesiology, LSU Health Sciences Center Shreveport, Shreveport, LA
      • SHILPADEVI PATIL, MD
      • HARISH SIDDAIAH, MD
      • JUSTIN CREEL
      • MATTHEW B. NOVITCH, BS
      • CHARLES FOX, MDProfessor and Chairman, Department of Anesthesiology, LSU Health Sciences Center Shreveport, Shreveport, LA
      • ALAN D. KAYE, MD, PHDProfessor, Program Director, and Chairman, Department of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LAV

      Chronic pain occurs in one third of the American population. Management of chronic pain is a growing area in health care; however, there is a dilemma for health care providers to treat the chronic pain of individuals who have known current or suspected drug abuse or addiction. Even if the individual is not addicted to opiates or prescription pain medications, it is possible to become addicted to a new substance. The National Institutes of Health considers drug addiction a neurophysiologic disease, and as of 2014, 24.6 million people in the United States abuse drugs. As more patients are seeking treatment for chronic pain, health care providers are seeing an increase in patients who have a history of drug abuse or addiction, and it is imperative that health care providers are aware of how best to care for these patients. This review discusses chronic pain and the drugs that are typically used to treat chronic pain, as well as drugs that have been reported to be abused in chronic pain patients. There are limited or no data available on the more recent designer drugs, such as bath salts, K2 (spice), and even common drugs of abuse, such as methylenedioxymethamphetamine (MDMA). More research should be conducted on what drugs are abused in chronic pain patients, especially nonopioid drugs such as stimulants. This information would help educate health care providers and create better pain treatment regimens for patients who abuse drugs.

      Key words: chronic pain, drug abuse, marijuana, methamphetamine, opioids

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    • 23

      Abuse-deterrent Formulations in the Treatment of Chronic Pain

      By Sanford M Silverman, MD
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      Abuse-deterrent Formulations in the Treatment of Chronic Pain

      • SANFORD M SILVERMAN, MDCEO and Medical Director, Comprehensive Pain Medicine, Pompano Beach, FL, Affiliate Assistant Professor of Clinical Biomedical Science, Department of Integrated Medical Sciences, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton, FL

      Prescription drug abuse is the fastest growing problem in the United States. According to the Centers for Disease Control and Prevention (CDC), enough opioid pain relievers were sold in 2010 to provide every adult in the United States with the equivalent of a typical dose of 5 mg of hydrocodone every 4 hours for 1 month. Many solutions have been proposed to address this problem, including treatment guidelines, political solutions (statutory changes), Risk Evaluation and Mitigation Strategy (REMS), and technological innovations. Many opioid products are manipulated (crushed, snorted, injected, etc.) to facilitate abuse. Since extended-release/long-acting (ER/LA) opioids contain a large amount of opioid contained in a single delivery system, they are a favorite target of abusers. In short, the goal of an abuser is to convert an ER/LA opioid into an immediate-release one. Abuse-deterrent formulations (ADFs) are intended to make manipulation more difficult or to make abuse of the manipulated product less attractive or less rewarding. One such technological solution is the development of ADFs for opioid pain medications. The Food and Drug Administration's (FDA) guidelines for industry released in 2015 establish the rationale and methodology for the development of ER/LA opioids that contain abuse-deterrent properties. The goal is to deterabuse, realizing that it is impossible to preventabuse.

      Key words: abuse-deterrent formulations, abuse-deterrent opioids, CDC guidelines, FDA opioid guidelines, opioid abuse, opioid deaths, opioid diversion, opioid overdose, prescription drug abuse, REMS 

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    • 24

      Labor Pain Pathophysiology and Analgesic Options

      By Alan D. Kaye, MD, PhD; Elyse Cornett, PhD; Matthew B. Novitch, BS; Justin Creel; Brendon M Hart, DO; Alexander D Allian, MS; Ben Homra, MBBS Candidate; Eric M Helander, MBBS
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      Labor Pain Pathophysiology and Analgesic Options

      • ALAN D. KAYE, MD, PHDProfessor, Program Director, and Chairman, Department of Anesthesiology, Professor, Department of Pharmacology, Louisiana State University Health Sciences Center New Orleans, New Orleans, LAV
      • ELYSE CORNETT, PHDClinical Research Coordinator, Department of Anesthesiology, LSU Health Sciences Center Shreveport, Shreveport, LA
      • MATTHEW B. NOVITCH, BS
      • JUSTIN CREEL
      • BRENDON M HART, DO
      • ALEXANDER D ALLIAN, MS
      • BEN HOMRA, MBBS CANDIDATEUniversity of Queensland SOM-Ochsner Clinical School, New Orleans, LA
      • ERIC M HELANDER, MBBS

      Regional neuraxial blocks, such as spinal and epidural anesthetics, are used for most women in the United States for labor pain. They are the most effective methods for preserving consciousness and the ability to participate in the second stage of labor. Regional neuraxial blocks may be augmented by combining spinal and epidural techniques, postlabor nonopioids and opioids, distraction therapy, and patient-controlled analgesia. In addition, several alternative analgesic methods have been recently recommended for labor pain without consensus on their respective efficacies, including yoga, exercise during pregnancy, acupuncture, hypnotism, hydrotherapy, and therapeutic massage. This review focuses on current updates and recent trends in labor pain management, the pathophysiology of labor pain, and the basic mechanisms supporting the efficacies of systemic, inhalation, neuraxial, and local analgesia during labor. 

      Key words: epidural, fentanyl, labor pain, local anesthetic, spinal analgesia

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    • 25

      Continuous Peripheral Catheters/regional Anesthesia in Postoperative Pain Management

      By David E. Hirsch, MD, MBA; Daneshvari R. Solanki, FRCA
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      Continuous Peripheral Catheters/regional Anesthesia in Postoperative Pain Management

      • DAVID E. HIRSCH, MD, MBA
      • DANESHVARI R. SOLANKI, FRCA

      As the number of surgical procedures has increased worldwide, so has the need for safe and effective postoperative pain control. Regional anesthesia, in which a provider uses local anesthesia and potentially other medications to provide anesthesia by focusing on blocking sensation at the surgical site, has become an important part of the postoperative pain regimen, thereby improving outcomes and comfort. Regional anesthesia plays a critical and significant role with regard to preemptive analgesia and multimodal anesthetic techniques. With the widespread use of ultrasonography and the introduction of peripheral nerve catheters, regional anesthesia has grown in its ability to provide longer-lasting, safe, and targeted pain control. Extended-relief lipid emulsion bupivacaine is another example of recent developments in drug technology that will further aid regional anesthesia delivery in the future.

      This review contains 5 figures, 4 tables, and 23 references. 

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    • 26

      Pathophysiology of Pain: Why Does Chronic Pain Hurt? the Multiple Hit Theory

      By Jack M Berger, MS, MD, PhD; Vladimir Zelman, MD, PhD
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      Pathophysiology of Pain: Why Does Chronic Pain Hurt? the Multiple Hit Theory

      • JACK M BERGER, MS, MD, PHD
      • VLADIMIR ZELMAN, MD, PHD

      Acute pain hurts and most often is the result of tissue injury. Chronic pain also hurts. Although those who suffer from chronic pain also tend to associate the onset with an injury, illness, or surgical procedure; the root cause is far more complex. Chronic pain most often does not follow dermatomal distributions associated with any injury, disease or surgical procedure. And more often than not, chronic pain sufferers also suffer from various forms of depression and/or anxiety. The process of central sensitization resulting from tissue injury has been elucidated, as has many of the molecular changes within the brain that perpetuate chronic pain. Genetics, epigenetics, environmental stressors, and emotional stressors all play roles to varying degrees in the development of the chronic pain state. This article explores how synaptic memories form in the brain as a result of both physical and emotional traumas (multiple hits) resulting in progression to chronic pain, because of failure of the brain’s descending modulatory mechanisms to prevent or control “the pain.”

      This review contains 15 figures, and 178 references.

      Key words: Epigenetics, memory, central sensitization, chronic pain

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    • 27

      Antiepileptic and Antidepressant Drugs Used in the Treatment of Pain

      By Lucia Daiana Voiculescu, MD
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      Antiepileptic and Antidepressant Drugs Used in the Treatment of Pain

      • LUCIA DAIANA VOICULESCU, MDAssociate Professor, Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU School of Medicine, New York, NY

      Antiepileptics and antidepressants are two categories of drugs frequently used as adjuvant analgesics. They interfere with the pain pathways at different levels through complex and not always well-defined molecular mechanisms. Although only a few have been licensed for use in the treatment of certain types of pain, anticonvulsants and antidepressants are widely prescribed off-label for pain associated with a variety of conditions. Most solid data come from experience with their use for postherpetic neuralgia, pain associated with diabetic neuropathy, and fibromyalgia. Anticonvulsants and antidepressant drugs are frequently used as first-line therapy in the treatment of pain, especially neuropathic type.

      Key words: antidepressant drugs, antiepileptic drugs, carbamazepine, gabapentinoids, neuropathic pain, off-label use, serotonin-norepinephrine reuptake inhibitors, serotonin syndrome, tricyclic antidepressants, use in specific populations

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    • 28

      Physical Medicine and Rehabilitation: Modalities and Exercise

      By Steven Calvino, MD; Jacob LaSalle, MD; David Fealey, MD
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      Physical Medicine and Rehabilitation: Modalities and Exercise

      • STEVEN CALVINO, MDAssistant Professor, Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY
      • JACOB LASALLE, MDFellow Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY
      • DAVID FEALEY, MDResident Department of Anesthesiology, Perioperative Care and Pain Medicine, New York University School of Medicine, New York, NY

      Function is the marker by which those in the medical profession treating patients with pain strive to improve. The profession of physical medicine and rehabilitation has, at its tenet, the goal of improving or even restoring physical function and therefore plays an integral role in the care of patients with pain. Physical modalities such as temperature therapy with both heat and cold; manual therapies, including manipulation, mobilization, massage, traction, and transcutaneous electrical nerve stimulation; and kinesio taping, are important adjunct therapies often employed in comprehensive rehabilitation programs. Although there is in general a lack of rigorous scientific evidence to support the use of these alternative modalities individually, their low-risk profiles, low cost, and ease of application combined with plenty of anecdotal evidence for their efficacy make them indispensable to the pain practitioner. Incorporating these adjunct therapies in conjunction with appropriate exercise protocols along with pharmacologic and interventional tools may place the pain patient at a distinct advantage, improving function and pain perception. In the following review, we introduce these concepts to allow guidance for incorporation into the treatment algorithm of common pain conditions.

       This review contains 16 figures, 2 tables and 79 references

      Key words: cryotherapy, exercise, manipulation, manual, massage, mobilization, temperature, traction, transcutaneous electrical nerve stimulation

       

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