Dr. Bernhard Kügelgen is an outstanding specialist in pain medicine and the head physician of the Koblenz therapy center as well as the medical director of the Koblenz Medical Care Center (MVZ). With extensive expertise in the fields of neurology, psychiatry and physical and rehabilitative medicine, he offers a wide range of treatment options for patients with chronic pain disorders. His particular focus is on holistic treatment approaches that are individually tailored to the needs of his patients.
At the Koblenz Therapy Center and the Koblenz MVZ, which are managed by Dr. Kügelgen and physiotherapist Cecilija Kügelgen, the focus is on comprehensive care for pain patients. Both facilities work closely together to ensure seamless care, which includes both outpatient and day-care treatment forms. This integrative approach enables patients to receive optimal care in one place and from one source. Dr. Kügelgen and his multi-professional team, consisting of a total of fifty employees, attach great importance to promoting patients' self-competence and developing individualized treatment approaches. The therapy center offers multimodal concepts that ensure interdisciplinary treatment and a particularly high degree of individualization.
His extensive specialist knowledge and many years of experience make Dr. Kügelgen a recognized expert in the treatment of pain disorders such as chronic back pain and headaches, migraines, tension headaches, post-traumatic pain, neuropathic pain, fibromyalgia and somatoform pain disorders. He also treats complex regional pain syndromes (CRPS) and neurological disorders such as stroke sequelae, multiple sclerosis and other inflammatory diseases of the central nervous system.
Before working in Koblenz, Dr. Kügelgen gained valuable experience in management positions at several specialist clinics throughout Germany. As the author of numerous publications and educational films, he has made a significant contribution to the further development of pain medicine and is also a founding member of Neuroorthopädie Deutschland and the Bundesarbeitsgemeinschaft chronischer Kreuzschmerz (BAcK). Dr. Kügelgen is not only a highly qualified pain physician, but also a dedicated doctor who is intensively committed to the well-being of his patients. His outstanding work and extensive knowledge make him an important personality in the medical community and a trustworthy contact for patients with chronic pain disorders.
The editorial team of the Leading Medicine Guide had an exciting conversation with Dr. Kügelgen and focused on spinal diseases in old age, also to explain the usefulness of spinal surgery.
Spinal disorders in old age are a common and complex health problem that can significantly affect the quality of life of many older people. With increasing age, age-related changes occur in the spine, which can lead to pain, restricted movement and other health problems. These changes affect the intervertebral discs as well as the vertebral bodies and the surrounding soft tissue. In addition to diseases such as osteoporosis, which weakens the bone structure, other diseases such as spinal canal stenosis or spondylolisthesis can also occur. The treatment of these conditions requires an interdisciplinary approach, which can include conservative measures such as physiotherapy and pain therapy as well as surgical procedures. The aim is to maintain or improve the mobility and quality of life of those affected while minimizing the risks and side effects of treatment.
Age-related changes in the spine: Not every change is a disease - structure and function must be considered separately.
Dr. Kügelgen would like to make one thing clear at the beginning of our conversation: “Basically, there are two things to consider when it comes to changes in the spine. Firstly, we are talking about age-related changes that are clearly recognizable, for example in the purely visual difference between a 20-year-old and a 60-year-old. This cannot be considered a disease. Then there are the wear and tear diseases of the spine. Although these are also age-related changes, they can trigger diseases. In summary, it can be said that not every age-related change is a disease. The second thing is that you have to differentiate between the structure and function of the spine, comparable to a defective car or computer. If you switch off the car or the computer, the function is gone, but the device is not broken. In medicine, it is often assumed that if you see in imaging, for example MRI, that the structure of the spine has changed, then this also has to do with the function. This is not correct. Because if you send a patient with a spine that no longer functions well to rehabilitation for a few weeks and the patient learns to move again, the structure of the spine after rehabilitation will be the same as before, but the function has been restored and the patient can, in case of doubt, participate in life again actively and without pain. The opposite can be observed in young people: The spine is free of signs of ageing, yet they still have back pain after hours of cell phone use. In this case, the structure is intact, but the functionality has suffered. This separation between function and structure is an important aid in solving many back problems. Impaired function leads to restrictions in quality of life, including loss of participation - and of course to pain. So-called conservative therapies or aids do not change the structure, but by improving function they can lead to better mobility and less pain - without structural changes."
Age is not the main factor: Why lack of exercise and misconceptions about spinal surgery do more harm than good.
“Of course you see things in older patients that younger people don't have, just as there are few 15-year-olds with gray hair. In the case of the spine, the crucially incorrect term is 'degenerative changes'. Degeneration means wear and tear. However, the spine does not wear out, it ages. And with age there are certain functional changes. However, such changes also occur in young people. Take young gymnasts, for example: They are extremely hypermobile, but this is not a disease. Similarly, there are many young people with extreme mobility - but that alone is not a disease. There are also many young people with a completely healthy spine, but who have back pain because they often spend hours looking down at their cell phones. In this respect, we can say that it is not age that more or less inevitably makes the spine ill. We can therefore say: It is not age that necessarily makes the spine ill. The National Care Guideline (AWMF S3) lists tumors, recent fractures and chronic inflammatory processes as the causes of chronic back pain. Otherwise, the focus is on soft tissue problems - in particular a lack of stamina and coordination, i.e. a lack of harmonious movement. This is precisely why regular exercise is so important. However, imaging procedures are one of the most common causes of misdiagnosis in chronic back pain. Many patients also have the misconception that spinal surgery works like a visit to the dentist - that something is removed or replaced and everything works perfectly afterwards. But this is not how spinal surgery works. Of course you operate on a patient immediately if it's an unstable vertebral fracture, no question about it. But with other possible causes, you don't have to think about an operation straight away,” explains Dr. Kügelgen and then asks the crucial question:
“Why should older people have spinal surgery? The leading symptom here is pain. You then have to ask yourself: what is done to counteract this? As a rule, spinal fusion is performed. This is based on a pathological mechanism that is by no means proven, namely a pain-triggering pathological movement disorder, a so-called 'pincer mechanism'. This hypothesis has not been proven. If this assumption were correct, such operations would have to be much more successful and conservative therapies much less effective. However, the spine is a highly complex structure. Stiffening leads to a reduction in function in the operated section, but not necessarily to freedom from symptoms. At the same time, the neighboring areas of the spine are overloaded, as they now have to compensate for more movement. This is why many patients have more complaints after the operation than before. However, the main reason for such operations is pain. But the pain is caused by a lack of exercise. Older people often move less than younger people. When pain sets in, medication is prescribed. This leads to a vicious circle: more pain → more medication → less exercise → even more pain. As a general rule, painkillers should not be taken for longer than three months! In addition, narcotic measures do not help with tumor-related pain (see S3-AWMF guideline LONTS. However, consistent conservative therapy in line with the guidelines - if necessary in the form of rehabilitation - can achieve significant success.
A special case is the so-called narrow lumbar spinal canal. This is a common justification for surgery, although it has never been clearly established when this diagnosis is actually justified. It is easy to understand that a certain millimeter value for the clear width of the spinal canal is not acceptable if I evaluate a giant of 2 m height the same as a petite woman of 1.60 m height. In addition, the clinical symptoms must clearly match the morphological changes described. In this case, conservative therapy must always fail before surgery is considered. The clinical picture of a functionally narrow lumbar spinal canal was actually described by the Swiss neurosurgeon Benini in 1982 - albeit in a different context. Particularly after prolonged periods of rest, such as those that occurred more frequently during the coronavirus pandemic, affected patients complain of increasing radicular pain, which eventually radiates. The pain travels from the lumbar spine (lumbar) to the distal, and in some cases, neurological deficits may also begin distally. Many patients report that their pain quickly disappears when they bend forward, sit down or put one leg up. The cause of the disease is an insufficiency of the lumbar back muscles, which normally maintain the lumbar lordosis. When these muscles become tired, the lordosis increases slightly - especially in patients with weak ligaments. This causes the foramina intervertebralia, i.e. the intervertebral foramina formed by two adjacent vertebrae, to narrow. As a result, the nerve roots are compressed. As soon as the lordosis is reduced by the above-mentioned measures, the pain disappears immediately. The therapy is always conservative: the affected muscles must be specifically trained - with a focus on endurance and coordination. As soon as the symptoms described occur, the patient should immediately adopt a relieving posture. This usually leads to freedom from symptoms within a few seconds and restores performance,” explains Dr. Kügelgen.
The most important thing is: move, move, move!
“Exercise helps! Older people are also recommended to exercise for 150 minutes a week (if you spread this over 6 days, that would be 6 times 25 minutes). Those who do this will find that the pain subsides. Unfortunately, too few people put this into practice and sit in a spiral of medication and perhaps do a little physiotherapy once a week. Unfortunately, systematic conservative therapy often does not take place today. The above-mentioned guideline describes briefly and clearly what is important:
Overview of the core statements of the national care guideline “Non-specific low back pain”
- Restrained diagnostics
- Pay attention to psyche and social environment
- Exercise instead of bed rest
- Painkillers: as much as necessary, as little as possible
- Chronic pain: combined treatment
Coordination and stamina are important here. Actually, all older people who exercise regularly should be rewarded as if they were undergoing behavioral therapy. A survey once revealed that many normal office workers only move an average of 300 meters a day. That's frightening and it's not surprising that these people get back pain,” warns Dr. Kügelgen.
The WHO recommendation that adults should engage in at least 150 minutes of moderate physical activity per week comes from the “Global Recommendations on Physical Activity for Health”, which were published by the WHO in 2010. These guidelines emphasize the importance of regular exercise to promote health and prevent disease.
“People really make a big mistake when they think they are changing the structure of the spine in order to restore function. There is no evidence for this. If you interfere with the spine, which is a highly complex chain of movement, you end up disrupting the harmony of movement. Guidelines specify when surgical intervention is required. The first thing to mention here is an unstable fracture, which can be caused by a fall, for example, and must be operated on immediately. Tumors must also be surgically removed. Metastases are more common than tumors that originate from the bone. Surgical intervention may also be necessary for chronic forms of inflammation,” says Dr. Kügelgen about the three classics of necessary spinal surgery.
There is no reason to operate on older people more often!
“Older people often have more pain because they don't move enough. They then go to the doctor with the pain, have an MRI scan, for example, and are told what is wrong with their spine. Fatefully, they are then often advised to take it easy, which is exactly the wrong approach. There is no wear and tear, it is normal ageing. And older people also need to be motivated to exercise. If this is then implemented, they will notice a clear improvement after just three weeks. Anesthesia is good for acute pain. However, if painkillers are taken for more than three months, their effectiveness diminishes and painkillers actually make the pain worse. What really helps to reduce pain is endurance and coordination. But you can't train muscles with painkillers. The fact is, however, that spinal surgery on older people is generously remunerated and the need for surgery is easy to justify. Good, consistent rehabilitation is highly recommended before any planned surgery. In many cases, it can then be established that an operation will not be necessary at all because the pain will improve considerably as a result of the activity and exercises during rehabilitation. I had a 93-year-old patient who was already in a wheelchair due to severe pain and was recommended to have an operation. However, she did not want to have an operation and underwent 6 weeks of rehabilitation. Today she is pain-free and walks ten kilometers a day. The thing that helps people with severe back pain the most is well-trained, enduring and well-coordinated muscles as compensation,” Dr. Kügelgen explains.
The hospital reform enacted for the federal state of North Rhine-Westphalia will have a lasting effect.
In Germany, there is increasing criticism of the high number of operations in hospitals, as many procedures are classified as unnecessary or superfluous. Studies show that financial incentives in the healthcare system could play a role, as hospitals are paid per procedure through the flat rate per case system. This leads to economic pressure, which may contribute to more operations being performed than are medically necessary. And particularly in the case of procedures such as back or joint surgery, there are indications that conservative treatments could often be an equally effective alternative.
The hospital reform in North Rhine-Westphalia, which was passed in July 2024, aims to streamline the range of services offered by hospitals and focus on key areas. Many hospitals will have to prepare for significant cuts, as numerous applications, for example for the continuation of cancer treatments or orthopaedic procedures such as hip and knee operations, will be rejected. According to State Health Minister Karl-Josef Laumann, this reform is intended to improve the quality of medical care by allowing specialized clinics to take on complex procedures, while smaller hospitals remain focused on less specialized services. In this way, the state government wants to ensure that patients receive the best possible treatment and that hospital structures are made more efficient. At the same time, emergency care is to remain local. However, critics fear that hospitals could suffer financial losses without these lucrative interventions. The reform is due to come into force from 2025, although there is still room for change in the ongoing consultation process.
“Due to the hospital reform, many hospitals are fearing for their existence as applications for operations are being rejected. However, it is unacceptable that people are operated on the supposedly 'degenerative' spine, often resulting in deterioration, more pain, less movement and less participation, just so that these hospitals can survive. This hospital reform is therefore long overdue! And one thing will also become clear: If people are operated on less specifically on the spine, there will not be more sick people. Hospitals that do good and meaningful work should also be well paid. However, it is not acceptable for spinal surgery to be performed in hospitals with single-digit case numbers per year just so that they can manage economically,” Dr. Kügelgen sharply criticizes.
The joy of movement: The path to sustainable health.
“It is important for patients to be helped to make the necessary behavioral changes in order to reintegrate exercise into their everyday lives. You have to take them by the hand and accompany them so that they understand and persevere. Patients need to learn to enjoy exercise, they need to hear praise. I am always delighted to hear from my older patients who are deeply grateful because I have introduced them to exercise, because they feel so much better and experience real moments of happiness. Of course, everyone should find out for themselves what they enjoy most. One person likes group sports, another wants to go into the forest and go for a walk, etc. Ultimately, it's about motivating people to exercise so much that they are really unhappy when they can't do their new exercise ritual. It has to become second nature and an integral part of everyday life. And it usually takes 6 to 24 months to achieve a sustainable change in behavior. If people spent half of the time they spend on their health on their health instead, we would need far fewer doctors. Everyone should spend 150 minutes a week exercising,” Dr. Kügelgen repeatedly advises, and we end our conversation with this urgent advice.
