I am specialised in anaesthesia and I have other specialisations in pain therapy, acupuncture and palliative medicine. I work with 5 colleagues in a specialised medical surgery. (In Germany the national health system has two branches: hospitals and medical clinics/surgeries). Our clinic for pain therapy and palliative medicine, is the biggest medical surgery for the therapy of chronic pain in Germany.

1. Acute pain: a warning signal

Acute pain is of vital importance: its task is to warn us when internal or exterior influences are present or are about to begin, which may risk damaging our body. When one manages to find the origin of acute pain, one can succeed to treat it adequately, and thus the intensity of pain is diminished. It is relatively easy to relieve or even make this kind of pain disappear by means of suitable countermeasures, which often indicated in a unequivocal way by the source of the pain.
Everybody knows what enduring acute pain is, everybody has experienced what this means. It is talked about and one can understand it: this phenomenon is socially known and accepted.

2. Chronic pain: a particular and different kind of pain

Chronic pain is a different kind of phenomenon, an illness in its own right. Physical, psychological and social factors can collaborate to make pain become chronic.
At this point the so-called “memory of pain” is created – the brain and its nerves learn to react in a very sensitive and intense manner, even by means of very weak signals. The suppression of pain by means of the opiates of the body itself, is no more able to calm the continual alarm of the nervous system.

3. Painmedicine: the therapy of acute pain

Chronic pain concerns man as a whole.
To understand the complexity of chronic pain, one needs to make an exact definition of what it entails, that is, we need to widen the concept of pain.
Pain does not only involve a bio-mechanical aspect. It is rather a phenomenon determined by biological, psychological, and social factors – therefore we are obliged to change the paradigms that define pain.
Chronic pain therefore not hold its vital task anymore and consequently an important system of alarm (as I mentioned before regarding acute pain).
However, it heavily damages the quality of life of the patient.

4. Preparing the therapy

At the beginning of a possible therapy, that is at the beginning of doctor-patient contact, it is indispensable to make a very detailed analysis of the patient’s condition of health, and of his/her condition of life.
In such a context, importance is not only attributed to the possible functional illness and the perception of the pain itself (bio-mechanical aspect, see above). It is indispensable to dwell upon other particulars too (psychological and social) that can enlighten the quality of life in the most comprehensive way.
In this initial phase, as well as during the therapy itself, the patient must be considered as the doctor’s partner.
Chronic pain considerably reduces the physical activity and the social contacts of the patient. Often the fact that one could not sleep sufficiently, increases the seriousness of the problem.

5. Therapy in course

In the course of chronic-pain illness psychological symptoms increase, as for example, bad mood, lack of energy (physical fragility), growing irritability, etc.
This often leads to a wrong interpretation, because these symptoms are often (erroneously) understood as psychological causes of chronic pain. Moreover social contacts are also involved – worsened by the chronic pain illness.
It is a known fact that worries, fears, sadness and insomnia can increase the sensibility towards pain, that is “psychic” pain (that is, illness of the soul) can worsen chronic pain and can even be its origin.

6. Interdisciplinary therapy

To block the time mechanisms which cause chronic pain, precocious and competent/specialised therapy is indispensable: pain therapy is therefore necessarily interdisciplinary.
It is only effective if it links together very different aspects and modalities, which as a whole succeed in have an influence on all the biological, psychic and social factors which may be at the root of the illness.
The following elements are indispensable: somatic therapy by means of injection, blockage of the nerves, medications, acupuncture...; mental therapy training to go beyond the pain, and progressive relaxation therapy of the muscles; physiotherapy, training (perfecting) of the muscle system, correction of carriage; the so-called “patient education”: the doctor’s competence (chronic pain therapist) is not limited only to medical assistance in the strict sense of the word (bio-mechanical, see above). He is equally responsible for providing the correct information of the patient, he has to explain to him/her and calls him for meetings which should lead to a wholesome education of the patient regarding his/her trouble.
To be able to follow all these factors well, which can eventually contribute to the manifestation of chronic pain, our patients are asked to write a certain kind of “diary of pain” regularly, where the patient is asked to write about the pain in relation to all the above-mentioned factors, and how they positively or negatively, effect his/her quality of life.
Evaluating this “profile of pain”, one manages to adjust the therapy to the patient’s actual needs.
In this continual evaluation process one often discovers problems which had been hidden, and therefore could now be directly integrated in the therapy already in course.
Chronic pain therapy is in itself interdisciplinary – only by uniting many medical fields is one in a position to assume the sick person in all its complexity, giving the right importance to the biological, psychological and social processes which determine the illness, and its course.

7. Professional exchange

The professional exchange of experiences with other fields increases the quality of work. Often (and not only) the patients, but also the doctors, look at the symptoms of the illness only according to certain aspects: being an orthopaedic problem, a neuronal problem, a psychological problem…
However when the therapists work in close collaboration, they can integrate all these aspects and thus the patient is not fragmented into different symptoms, but as a unique person/personality, in its uniqueness and complexity.
The therapists update each other about a given situation, they communicate among them and they decide together on how to carry on the therapy. They speak to the patient in unison. In this way they make the patient feel that he is treated seriously, according to his/her personality, in his uniqueness and complexity.
We feel it is our task to discover this kind of complete vision in the world of health, the only vision which is really suitable for the sick person and therefore to his pain.

8. Our medical centre

There is still a lot of ignorance among patients and doctors regarding this type of therapy, also because within society the phenomenon of chronic pain is not so much recognised and it is often not accepted (see above: but acute pain, yes!) as a “serious” phenomenon.
In our centre, we doctors and therapists realise that it is our task to influence the public opinion by means of publications in the press, on TV and in various manifestations; to offer interdisciplinary courses for doctors and therapists on the phenomenon of chronic pain; to participate in specialisation courses and interdisciplinary congresses; to launch innovative concepts.
We form part of an association for the therapy of chronic pain which is the biggest in Europe (German Pain Association). One of my colleagues occupies an important function in the directive council. We feel the need to guarantee our patients a complete and integrative assistance, by means of the innovative concept that I have just described. Our goal is to guarantee a precocious, competent and integrative therapy that can help avoid that certain symptoms become chronic.
We have at our disposal various concepts with a common criterion: we are creating a network between doctors and therapists so as to utilize the interdisciplinary advantages to the full. These projects are now increasing in other parts of Germany too.
In this way, the modern medicine of chronic pain is able to alleviate the sick persons’ suffering and at the same time it reduces the price of health considerably. (in the national health system).
I will give you two examples of work that have already been accomplished.

1) Palliative network.
Regarding palliative medicine we have succeeded in creating a so-called “palliative” network, which links all the institutions that already work for terminally-ill patients. 20 ‘partners’ have been linked together: made up of family doctors, specialisation doctors, institutions that assist the sick at home, medical information services, various consulting surgeries and some so-called hospices – places where terminally-ill patients spend the last phase of their life, assisted by relatives and health personnel, pharmacies, physiotherapists, palliative services and organisations of various churches that work in this field.
We feel the need to possibly guarantee the dying person a painless, auto-determined and dignified life till the end, in the place where they desire (the majority in their own home).
In this regard it is indispensable to have a professional person always on duty in order to avoid superfluous and undesired hospitalisation. In this way the dying are offered, a competent and interdisciplinary assistance at home, on a 24-hour basis.
The first evaluations have shown that in this way 70% of terminally-ill patients could die at home as they had desired (before it was only 30%) This network of collaboration has helped to considerably increase the quality the quality of medical assistance without causing further cost.

2) Therapy for patients with chronic back pain.
A new interdisciplinary concept of therapy with chronic back pain. Normally 90% of patients with back pain are healed after about a month – with or without therapy. The remaining 10% are the so-called “high risk group”. We have targeted this group of patients with a particular project of assistance.
A 2001 statistic of the German Ministry for Health showed an exaggerated use of diagnostic measures, invasive tests and surgical operations, for this group of patients (according to the above-mentioned bio-mechanical concept of back pain).
Another study showed that only 35% of patients with back pain return to work (after assistance of more than three months) in the first two years of therapy.
The costs of the German government for pre-pension (with consequent back pain that becomes chronic) amounts to 19 billion Euros a year.
We neither have an effective therapy nor a well-coordinated concept for these high risk patients and we lack specialised projects for the complex problem that lies are the root of chronic back pain.
According our programme (a novelty), it is necessary to identify the probable “patient at risk” as soon as possible: the national health service participates in this process by collaborating with the insurance companies according to the length of the sickness.
The intensive programme against back pain is followed by a group of specialised therapists for a minimum of four weeks (and up to two months): it comprises pain therapy, physiotherapy and psychotherapy: training to strengthen circulation and the heart, training of muscles, exercises for the back, training of “normal” everyday movements (walking, weight carrying…); besides: therapeutic interviews, muscle relaxation exercises and mental training to alleviate pain, acupuncture, bio-feedback…
Plenty of documentation with questionnaires and diaries of the patient is necessary to help the therapists find accord on the main procedures and to favour the closest collaboration among all.
The average intensity of pain measured on a scale of 0 to 100 was 63,5 at the beginning of the therapy, after 4 weeks it measured 25,3 and after 8 weeks it was reduced to 18,6.
After 18 months of this programme 92% of patients were considered healed. 57% could return to work after 4 weeks, and 35% after 8 weeks.
It is a win-win situation. Everybody has gained: the patients, the health insurance assistance, the social system, as well as the doctors and therapists who work in this way.

by GABRIELE MUELLER