Special pain therapy

Pain that stays for weeks and months is no longer the same as pain that began three days ago. It loses its warning function, changes sleep, mood, mobility and everyday life — and often can no longer be traced back to a single structure that could be operated on. That is what special pain therapy is there for: a medical additional qualification of its own for the recognition and treatment of chronic pain. Eyad Al-Kahlout, Specialist in Neurosurgery, holds the additional qualification in Special Pain Therapy; after recognition as a specialist it requires twelve months of further training and an eighty-hour course.

The aim is not freedom from pain at any price, but function: walking, sleeping, working, doing things again. A treatment plan that makes the intensity of the pain the only measure regularly leads astray in chronic pain — and often to ever more medication with ever less movement.

Who is it suitable for?

For people in whom the pain in the spine no longer goes away of its own accord and in whom a procedure is either not indicated or would not be the right thing.

• Persistent back or neck pain — low back pain or neck pain over weeks to months, without a structure being found whose treatment would change it.
• Nerve pain — burning, shooting or electric pain with tingling or numbness, for instance after a herniated disc or in a permanently irritated nerve root. This pain needs different medication from a muscle or joint pain.
• Pain from the joints of the back — facet joint osteoarthritis or SI joint syndrome, when training alone is not enough.
• Symptoms that have remained after an operation — when the procedure has removed the narrowing but the pain has not disappeared. That is more frequent than many expect.
• The time up to a decision — when an operation is on the table but is still being held off, or when the time until a procedure has to be bridged.

This route is not suitable as long as a treatable cause has been overlooked. That is why the examination stands at the beginning — and, where there are warning signs, rapid assessment.

What happens exactly?

1. Pain historyDetailed and structured: since when, where, how does it feel, what makes it worse and what relieves it, how is your sleep, what no longer works in everyday life, which medications were taken in which dose for how long and what did they achieve. Added to that the review of all previous findings. This takes longer than a usual consultation and is the most important part.
2. ClassificationPhysical and neurological examination with the question of which type of pain is present: pain from muscles, ligaments and joints, pain from a damaged nerve structure, or both. Added to that the assessment of what part lack of sleep, worries, fear of movement and the occupational situation play — not as a side issue, but because they help to determine the course.
3. Treatment planA plan with an order and with points in time: what comes first, what only alongside, what is limited in time, by what it is measured whether it helps, and when a fresh decision is made. Every building block has an aim and a date on which it is reviewed whether that aim has been reached.

The building blocks

• Movement and training — the building block with the best evidence and at the same time the most uncomfortable one. Which sport it is matters less than regularity and a progression that does not depend on the pain of the day.
• Physiotherapy — supervised training, strengthening, mobilisation, followed by a programme of your own. Manual therapy, massage and heat can loosen things in the short term and make movement possible, but they do not replace it. We are glad to write you a referral.
• Explanation of the pain — understanding why a pain can remain although no damage is progressing takes the fear out of movement. That is not an empty phrase, but an effective part of the treatment.
• Relaxation and psychological methods — relaxation techniques, pain coping, and where needed psychotherapeutic support. They do not treat “the head instead of the back”, but the processing that runs alongside every chronic pain.
• Medication — limited in time, at the lowest effective dose, with a clear aim and regular review. More on this in the next section.
• Targeted injections — where there is radiating nerve pain, a periradicular therapy can relieve for a few weeks and make training possible in the first place; we provide this treatment at our practice. Injections at the facet joints or at the sacroiliac joint and denervation of the joint nerves come into consideration in selected cases.
• Everyday life and sleep — regular sleep, breaks before the point of exhaustion rather than after it, a step-by-step return to what has been given up. Anyone who waits until the pain is gone usually waits too long.

Medication: what is established and what is not

The well-known analgesic ladder of the World Health Organization — from simple painkillers through weak to strong opioids — was developed for tumour pain. It cannot simply be transferred to chronic pain without a tumour disease, because other rules apply there: it is not the rung that decides, but the type of pain, the aim, and the question of whether a medication has actually achieved something after a set period.

• Anti-inflammatory painkillers — for pain from muscles, ligaments and joints, for a limited time and at the lowest effective dose, so that movement remains possible. The stomach, the kidneys, the heart and circulation and interactions limit their use, especially in later life.
• Co-analgesics for nerve pain — medications that were originally developed against depression or epilepsy and that work at a low dose in neuropathic pain, for instance amitriptyline, duloxetine, gabapentin and pregabalin. They do not work at once, but are introduced slowly at a rising dose; tiredness, dizziness and a dry mouth are common.
• Opioids — a trial of treatment limited in time, nothing more. The German guideline names them as an option in chronic back pain, in osteoarthritis pain and in individual forms of nerve pain, always with a set aim and regular review; in primary headache and in pain as the leading symptom of a mental illness they are regarded as not indicated. If the trial does not bring the agreed gain, they are tapered off — that is part of the plan from the start.
• What often does not help — in acute back and neck pain, opioids were no better than a dummy medication in a placebo-controlled trial; pregabalin did not relieve the leg pain in sciatica any better than placebo, but caused more side effects. Uncomfortable results, which spare you months with an ineffective medication.

What pain therapy can achieve — and what it cannot

What is realistic: fewer peaks of pain, quieter sleep, greater resilience, less fear of movement, frequently a lower consumption of medication — and an everyday life that can be planned again. The measured effects of the individual building blocks are mostly moderate; in studies, exercise programmes improve pain on average by a few points on a hundred-point scale. The strength lies in the combination and in the duration, not in the individual appointment.

What it does not achieve: it does not reverse wear, it does not remove a narrowing in the spinal canal, and it does not replace a procedure that is necessary because of an increasing paralysis or because of warning signs. In chronic pain it rarely leads to complete freedom from pain. Anyone who begins with that expectation experiences every intermediate step as a failure — which is why we set the aims together beforehand.

Risks and limits

The risks lie with the medication. Anti-inflammatory agents can put a strain on the stomach, the kidneys and the heart and circulation; co-analgesics make you tired and dizzy at first, which in later life raises the risk of falling; opioids lead to constipation, tiredness and difficulty concentrating, with longer use to habituation and physical dependence, and with continued increases in dose they can even intensify the pain. That is why every long-term medication is reviewed regularly and coordinated with the treatment by the general practitioner.

Another limit is an organisational one: a complete interdisciplinary programme over several weeks takes place in hospitals and day clinics, not in a practice. If such a programme is the next sensible step, we say so and agree the way there with you.

Preparation and course

Before the appointment: bring a complete list of your medication with you, including the remedies without a prescription and the preparations that were unsuccessful in the past. Previous findings, images on a storage medium, reports on earlier injections and how long they worked, and notes on what no longer works in everyday life are helpful. Anyone who wishes to can keep a simple pain diary for two weeks.

Afterwards: a treatment plan is not drawn up once, but adjusted. If a medication does not work after the agreed period, it is stopped instead of increased. If the character of the pain changes, a fresh examination follows. Setbacks after exertion or in difficult phases of life are part of the course. New deficits, increasing weakness or warning signs, by contrast, are always a reason to get in touch at once.

Alternatives and more far-reaching concepts

If treatment in the consulting room is not enough, an interdisciplinary multimodal pain therapy comes into consideration: a set programme over at least a week, in which medical, physically exercising and psychological methods interlock according to a common plan. Such programmes are offered in pain clinics and day clinics. An analysis of randomised trials found that in chronic low back pain they reduce pain and restriction more than usual care and more than purely physical treatments — at moderate to low certainty of the data.

Alongside that, the routes described on the disease pages remain: a targeted injection in root pain, and, where the finding fits and the symptoms match, a decompression. An operation is not, however, a pain therapy: it treats pressure on a nerve or an instability, not a pain that has become chronic.

Frequently asked questions

Does pain therapy mean that I will not be operated on?

No. It means that the decision for or against a procedure depends on the cause and not on the intensity of the pain. If a nerve is constricted and is causing the matching symptoms, an operation remains a subject. If the pain has become chronic, a procedure as a rule does not improve it.

Will I become dependent on painkillers?

With anti-inflammatory agents and co-analgesics this risk does not exist. With opioids, longer intake regularly produces a physical habituation that makes a step-by-step tapering off necessary. That is precisely why they are begun for a limited time, with a fixed aim and a review appointment.

Why should I move if it hurts?

Because in chronic back symptoms, pain on movement does not mean damage. Taking things easy weakens the muscles and fitness, and the sensitivity rises further. The progression follows a plan and not the form of the day — that is the difference between training and overloading.

Do I need a mental illness in order to have psychological support?

No. Pain coping and relaxation techniques are tools for dealing with a lasting pain, regardless of whether a mental illness is present. That lasting pain changes mood and sleep is a consequence, not a cause.

How long does it take until something gets better?

That depends on the type of pain and on how long the symptoms have lasted, and cannot be predicted responsibly. Medications against nerve pain need weeks until the dose is settled; training works over months. What we can promise is an appointment at which it is reviewed together whether the route taken has achieved anything.

If an operation has been recommended to you elsewhere and you are unsure whether the pain comes from there at all, you can obtain a second opinion from us. We look at your images, examine you and tell you frankly whether we share the recommendation — and which route is open without an operation. What you should bring is on the page Your first appointment.