Ep. 35 AUA 3

Episode Summary:

Join Dr. Dan and Justine, a pain coach, on this episode of 'It's Not In Your Head' podcast as they delve into the complexities of managing various aspects of chronic pain, particularly central sensitization, its causes, and various treatment strategies. You'll gain practical advice on how to identify symptoms and consequences, as well as address the neuroinflammation itself and what is driving it. They also get into how to most effectively choose the right care team for the types of pain you have, as well as how to select the most optimal footwear for various situations. Whether you're a patient or provider, this episode offers valuable insights into improving the quality of life for those looking to better manage chronic pain.

Episode Overview:

• The episode features a rapid series of ask-us-anything (Q&A) questions from listeners around treating sensitization, choosing your care team, and selecting footwear for various chronic pain conditions.

Key Topic: Central Sensitization

• Definition: Central sensitization is explained as a spectrum of nervous system disorders, usually involving neuroinflammation and neurological changes that amplify pain and other sensations.

• Inventory Tool: The Central Sensitization Inventory (CSI) is recommended for self-assessment. Scoring is categorized as:

  • Subclinical (<30)

  • Mild (30–39)

  • Moderate (40–49)

  • Severe (50–59)

  • Extreme (>60)

• Eight diagnostic buckets: Dan and Justine outline symptom clusters linked to central sensitization, including widespread pain, sensory sensitivities (light, sound), sleep disturbance, cognitive issues ("brain fog"), emotional/psychiatric symptoms, autonomic dysfunction (like POTS and IBS), motor symptoms (restless legs, cramps, non-epileptic seizures), and fatigue syndromes.

Understanding the Causes

• Ten main drivers of central sensitization: These include persistent (undiagnosed or undertreated) injury, inflammatory disorders (rheumatoid arthritis, spondyloarthritis, psoriatic arthritis), metabolic and endocrine problems (diabetes, hyperthyroidism, celiac disease), pre-existing anxiety/depression, hypermobility, obesity, and deficiencies in omega-3, vitamin D, homocysteine, and B12.

• Clinical approach: Treat the primary neuroinflammatory drivers and refer for co-existing conditions as needed (e.g., rheumatology).

Managing the Consequences

• Lifestyle management: Conservative strategies include optimizing sleep, diet (protein, calories, macros), pacing, movement, energy management, mindfulness, and breathing exercises. These help mitigate pain and improve function, especially in individuals with high sensitization.

• Treating consequences: Directly treating secondary issues (fatigue, mood, sleep disturbance, deconditioning) is crucial due to their feedback effect on sensitization and pain severity.

• Specific management for autonomic/pots symptoms: Incremental increase of fluids (2.5–3L/day), salt supplementation, compression garments, and medications (propranolol, fludrocortisone, midodrine)—medication usually managed by specialists.

Medication and Treatment Highlights

• Medications: Amitriptyline and duloxetine may help reduce pain area; low-dose naltrexone is discussed for microglia stabilization and neuroinflammation.

• Long COVID and fatigue: The episode mentions Italian research into drug combinations (PEA, luteolin) for post-COVID neuroinflammation; similar management principles are applied here.

Clinical Decision-Making: Care Team Selection

• Care spectrum: How to choose clinicians—whether interventional, conservative, or hybrid approaches—should be matched to the type and complexity of pain, presentation, and CSI score.

• Interventional approaches fit focal, intermittent pain, while conservative approaches are disproprionately impactful for widespread, severe sensitization (CSI >60).

• Patient empowerment: Patients are encouraged to take ownership of their care teams ("you are the employer") and to collaborate across specialties for comprehensive management.

Practical Footwear and Orthotics Advice

• CRPS and neuropathic pain: Looser, wider shoes can help with allodynia; flip-flops may help in some cases but are not ideal for long-term use.

• Functional advice: Buy the same shoe model for replacements to avoid biomechanical changes; strength-building, orthotics for short-term support, and heel wedges or cups for certain conditions like Morton's neuroma.

• Load management: Small reductions in body weight can significantly decrease load on the feet—a practical tip for pain management.

• Sensory solutions: Insoles with surface texture can help increase sensory input and improve gait function, especially in neuropathy.