© Karatara
January 3, 2024
Margit Hiebl
Nothing is as personal as pain. Everyone experiences it differently. On neurological backgrounds, pain psychology, alleviating chronic ailments, and revolutionary methods of pain therapy.
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When toe and chair leg meet, pain is a pretty clear thing. But what if the pain cannot be precisely attributed? And that over the years? Is it just imagined, as many say? However, around 12 million people in Germany are affected by it.
According to the German Pain Society , costs of about 38 billion euros arise annually - 10 billion of which are for treatments, while the rest is caused by sick pay, work absences, and early retirement.
Dr. Claudius Gall, a specialist in neurosurgery, is one of the few specialists in Germany in this field with the additional designation "Special Pain Therapy." In the "Pain Workshop" in Munich, he and his colleagues deal with the backgrounds and new approaches to dealing with chronic pain.
What exactly is pain?
Pain is initially a "perception." This means every pain is real – there is no imagined pain. The body is supplied with pain fibers everywhere except the brain. If these are stimulated – by whatever means – it leads to pain. However, there are two different mechanisms that lead to the sensation of pain: acute and chronic.
What's the difference?Acute means: hand on a hot stove. Tissue destruction releases electrical impulses that travel via the spinal cord to the brain and into consciousness. Chronic pain arises from a malfunction of certain nerves and can develop as a result of an acute pain experience.
A classic example is phantom pain, such as pain in a non-existent knee joint during weather changes.
How can chronic pain be recognized?
This is pain that lasts longer than 6 months in the same region and has at least a moderate intensity. Chronic pain also leads to side effects in all areas: it affects the sleep-wake cycle, mood, and libido.
Thus, chronic pain becomes an independent condition – it has physical elements at the nerve cell level but also interferes with many other social, private, and professional areas. Our task in pain therapy is to find out the relationship between acute and chronic pain, as both must be treated very differently.
Dr. Claudius Gall, specialist in neurosurgery
What differences are there What is in the treatment?In acute pain, causal therapy is crucial: In the case of a fracture, a cast is applied, and as soon as it is closed, the pain stops. If the pain becomes chronic, a so-called multimodal pain therapy is needed – an individual combination of various therapy components.
How do you classify chronic pain?With us, all patients must first fill out the German Pain Questionnaire – a kind of pre-screening. It queries pain intensity, depression, tension levels, and a whole range of factors in the social context. However, the decisive assessment is the personal anamnesis, the personal initial interview, which lasts between 45 and 50 minutes. You have to take your time for this, in order to classify and understand.
To what extent understand?Let me put it this way: In the German language, there is a distinction between pain and suffering. When pain becomes chronic, it becomes suffering and distress. This terminology implies that the whole person starts to suffer from this symptomatology.
Pain always has a fear component – because often you don't know what's causing this pain. You just feel threatened and vulnerable. A proper diagnosis not only helps to find the right therapy but also serves to alleviate the patient's fear.
What does multimodal pain therapy look like?The first pillar is classical painkillers, the analgesics. In the modern approach, this is a combination of various substances that are individually low in dose but together very effective, with fewer side effects. Additionally, there are co-analgesics, which are not painkillers themselves,but enhance the effect of painkillers, such as certain antidepressants.
And what are the other components?
The second pillar is movement therapy approaches. Initially, it is about patients identifying safe movement boundaries within which they can move without increasing pain. If I have chronic pain, it is a relationship crisis between the body and the brain.
Normally, we do not feel the body at all. Pain patients, however, feel it constantly. The first step to resolving this relationship crisis is to say: Okay, get to know each other again.
This is me. The pain, this is me. My soul or my psyche. And we both now have to try to exist in some way. The third pillar is pain psychotherapy. It involves identifying stressors and seeing how to deal with pain differently. Often, pain is also an expression of stress and the associated tension, which in turn amplifies pain.
What other possibilities are there?
If conservative methods are exhausted for back and leg pain, neuromodulation has been an option for several years. The most important procedure is called spinal cord stimulation. A small impulse generator with electrodes is implanted under the skin. These lie on the spinal cord and thus on the pain pathway.
Through electrical interference signals, pain transmission in the pain pathway is reduced – so we achieve a halving of pain in 70 percent of our patients. This is controlled by the patient with a wireless remote control – so they also gain control over their pain.
A lot will be done in the foreseeable future – for example, systems will measure and control the parameters themselves. There is also something new in the field of chronic migraine: On the one hand, triptans, which restore a normal vessel width in the blood vessels in the brain during an acute attack. Or a vaccine that introduces receptor antagonists – substances that dock at certain points in the vessels similar to the body's own and thus stabilize the diameter – but over a longer period.
© Anna Shvets
Are there actually differences in pain perception?Yes, big ones. Because the question is always: How many resources does a person have to deal with pain? If someone has used up a lot of their mental energy due to personal or professional problems and stress, it will hit them harder than someone who is in a stable environment.
And of course, dealing with pain is also culturally influenced. In Northern Europe, the motto “an Indian knows no pain” still applies – it is different in southern countries. There, the pain has to be let out with crying and screaming. That means we always have to take into account the life situation and background of people.
Are men more sensitive to pain than women?I don't think so. But women are more likely to seek medical treatment and are more open to changes in perspective. For men, this often succeeds through the connection to sleep. If you can significantly improve that, it opens a door to the pain lock for them.
I always say, the patient only occupies certain rooms in this pain castle and has put a padlock on certain doors and thrown away the key. They don't want to go in there anymore. But maybe there's a key to the room where the pain came from.
What other "tricks" do you have up your sleeve?I propose a deal: You give me your pain through this or that therapy, in return you get freedom from pain or at least relief. But for some patients, it's easier to keep the pain. For example, if it's an expression of post-traumatic stress disorder after sexual abuse in their youth. Then this patient won't give me the pain – but if I'm really good, in half a year or three-quarters of a year, they're ready to undergo appropriate psychotherapy.
Can chronic pain be completely treated away?Our primary treatment goal is an improvement in quality of life. Of course, I can bomb a patient with painkillers so much that they just lie in the corner. Then they have no more pain, but also no quality of life. In therapy, we try to reduce the pain and not cause too many side effects, which can be more unpleasant than enduring the remaining pain.
It's also about a change in perspective: I want to change the view from a half-empty glass to a half-full one. Patients compare themselves to how they were 20 years ago – as a doctor and therapist, I compare them to their peers. Also important: The complaints must be accepted, then you can teach patients to become effective again step by step. But that takes time.
