The Clinical journal of pain
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Muscle hyperalgesia and referred pain plays an important role in chronic musculoskeletal pain. New knowledge on the involved basic mechanisms and better methods to assess muscle pain in the clinic are needed to revise and optimize the treatment regimes. Increased muscle sensitivity is manifested as (1) pain evoked by a normally non-nociceptive stimulus (allodynia), (2) increased pain intensity evoked by nociceptive stimuli (hyperalgesia), or (3) increased referred pain areas with associated somatosensory changes. ⋯ Some manifestations of sensitisation, such as expanded referred muscle pain areas in chronic musculoskeletal pain patients, can be explained from animal experiments showing extrasegmental spread of sensitisation. An important part of the pain manifestations (eg, tenderness and referred pain) related to chronic musculoskeletal disorders may be due to peripheral and central sensitization, which play a role in the transition from acute to chronic pain. In recent years, it has become evident that muscle pain can interfere with motor control strategies and different patters of interaction are seen during rest, static contractions, and dynamic conditions.
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Optimal treatment for patients with chronic pain remains elusive. A growing international consensus advocates evidence-based practice with assessment of clinical outcomes to improve the process and outcome of care. Clinical decision making about treatment options for an individual patient should include the patient's clinical presentation, available evidence, and patient preferences. ⋯ Outcome measurement has come a long way and core domains to be measured have been established. Establishing normative data is a next main goal. Important methodologic and practical challenges remain to formulate evidence that can be applied to the individual patient with chronic pain.
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Pain remains a highly prevalent problem for patients with cancer and typically falls into one of 3 types: visceral, somatic, and neuropathic. A mechanistic, pathophysiologic approach to pain management involves a good assessment of the type of pain, followed by tailoring of the treatment based on the diagnosis. ⋯ Especially for difficult-to-manage pain patients, additions to the opioid analgesic armamentarium can potentially better individualize pain management, and provide another option to be used for opioid rotation. Among the most recent Food and Drug Administration-approved opioid analgesics for acute pain and persistent pain are oral immediate-release and extended-release formulations of oxymorphone, whereas for breakthrough pain, the ultrarapid-acting opioid, fentanyl effervescent buccal tablets, has newly been developed and indicated within the United States.