Pain Management for Chronic Pain: Outpatient and Inpatient Pain Management at Clinics

Targeted pain relief is always advisable when pain persists for longer than 6 months. On average, however, it takes 8 years for patients with pain to seek professional pain treatment at a specialized pain center.

Pain is a natural protective mechanism of the body that normally results from

• an injury,
• inflammation, or
• overuse

. A distinction is made between acute and chronic pain.

Acute Pain

Acute pain occurs when tissue damage causes a certain threshold to be exceeded. Triggers can include

• mechanical,
• chemical,
• thermal, or
• electrical stimuli

. Specific nerve receptors (nociceptors) transmit the stimulus to the spinal cord. The speed of transmission depends on the thickness of the nerve pathways involved. Thus, two types of pain transmission from the source of pain to the spinal cord can be distinguished:

• thin C-tracks: 1.5 meters per second
• faster A-tracks: 15 meters per second

The latter trigger a reflex response, such as pulling a body part away from the source of danger.

The spinal cord transmits the pain impulse to the brain. The brain then assesses in a flash where and how intensely the pain is being experienced and, if necessary, initiates physical countermeasures. For example, by releasing endorphins, it can initially suppress the sensation of pain.

This can be observed, for instance, in accidents. As a result, the body remains functional and can react calmly in the face of ongoing danger. In this case, the pain only becomes noticeable once the body has calmed down.

Chronic Pain

Chronic pain is defined as pain that persists for more than six months. The sensation of pain is then no longer related to the original injury or inflammation. For this reason, chronic pain can be considered a distinct clinical condition.

Exactly how chronic pain develops has not yet been definitively proven scientifically. However, it is believed to involve neuroanatomical changes. The brain develops what is known as a “pain memory,” so that even a very slight stimulus can trigger a renewed pain response.

This is where modern pain management approaches such as relearning and behavioral therapy come into play.

Pain management encompasses the treatment of all forms of chronic pain in children and adults. These primarily include:

• Cancer pain
• Back pain
• Head and facial pain
• Joint, muscle, and soft tissue pain
• Nerve pain (neuralgia)
• Complex Regional Pain Syndrome (CRPS)
• Phantom pain
• Pain associated with circulatory disorders (e.g., angina pectoris, coronary heart disease (CHD), or peripheral arterial occlusive disease (PAOD))

The following forms of therapy are distinguished in pain management:

Pharmacological pain management

Pain medications are by far the most commonly prescribed drugs in Germany. A distinction is made between strong, weak, and moderately strong pain medications.

Pharmacological pain management follows the stepwise approach developed by the WHO (World Health Organization). Pain control is initially started with Step 1 medications and can be escalated to Step 3 if necessary.

• Step 1: Non-opioid analgesics (nonsteroidal anti-inflammatory drugs, metamizole, acetaminophen)
• Step 2: Weak opioid, possibly in combination with Step 1 medications
• Step 3: Strong opioid, possibly in combination with Step 1 medications

In addition to pain relievers, so-called adjuvants such as 

• antidepressants,
• antipsychotics, and
• anticonvulsants

be used. These are intended to support pain relief and positively influence the patient’s psychological state or, for example, relieve muscle tension.

If medication fails to relieve pain, surgical interventions (Stage 4) may be used.

Neuromodulation and Neurostimulation in Pain Management

Neuromodulation can be an important step toward pain relief when

• the three stages of pharmacological pain management are ineffective, or
• the side effects caused by high drug dosages are too severe.

In this procedure, pain-relieving medications are administered directly to the site causing the pain via a permanently implanted pain pump. The active ingredients are released directly into the spinal canal; therefore, this therapy is also called intrathecal neuromodulation (intrathecal = within the cerebrospinal fluid space, i.e., in the fluid surrounding the spinal cord).

Neurostimulation is a treatment for severe pain that uses electrical impulses. Electrodes send these weak impulses to the site of the pain, thereby masking the sensation of pain.

During the trial phase, these electrodes are placed on the skin; if the therapy is successful, an electrode system is implanted directly.

Physical Therapy for Pain Management

For many types of recurring pain, exercise has a positive effect on pain perception. Endurance sports such as

• hiking,
• walking,
• swimming, or
• cycling

are recommended for relieving back and joint pain.

However, light strength training under the guidance of a physical therapist and learning alternative movement patterns—such as those taught in back training classes—can also help relieve pain.

With all necessary physical activity, it is important not to overdo it.

Physical Pain Therapy

The following also have positive effects on pain perception:

• massages,
• heat, or
• cold therapy, as well as
• electrotherapy (TENS).

For example, massages and heat help relax the muscles. Cold reduces blood flow to the tissues and can thus also have a pain-relieving effect.

Electrical stimulation helps relax muscles and relieve pain © Microgen | AdobeStock

In electrotherapy, the muscles are stimulated by electrical impulses. This improves blood flow and relaxes the muscles. The stimulation threshold of the nerve receptors also becomes less sensitive as a result of the stimulation, and the body releases its own endorphins.

Acupuncture

Acupuncture is a branch of Chinese medicine. In this procedure, thin needles are inserted into specific points (acupuncture points) on the skin.

For certain types of pain, such as

• headaches,
• rheumatism, and
• osteoarthritis

, acupuncture can have a positive effect on pain perception. In some cases, the costs are covered by health insurance.

Psychotherapeutic Pain Management

Pain places a heavy psychological burden on the patient. This intensely unpleasant sensation almost inevitably leads to constant mental preoccupation with the topic of pain. This circumstance gives rise to further psychological problems, such as fear of pain (pain anxiety) and depression.

Approximately 5 to 14% of patients with chronic pain commit suicide at some point in their lives. Furthermore, negative emotions increase inner tension, which in turn intensifies the pain.

To break this cycle of pain, anxiety, and depression, psychological care is strongly recommended as part of pain management.

In particular, behavioral therapy approaches such as

• cognitive therapy,
• attention diversion,
• self-care, and
• relaxation exercises (e.g., progressive muscle relaxation, autogenic training)

are part of psychotherapeutic pain management.

Individualized Treatment Approaches

In pain management, too, the trend is toward individualized treatment for each patient. Healthcare providers take an approach that involves applying various concepts. This allows them to help patients based on their individual clinical presentations.

In multimodal pain management (MMS), 

• doctors,
• physical therapists,
• nurses, and
• psychologists

from various disciplines work hand in hand according to a defined treatment plan. The course of therapy is regularly discussed in interdisciplinary team meetings and adjusted as needed.

Interventional pain management (nano-endotherapy) is the specialty of radiologists. The focus here is on the patient and their specific pain, as well as collaboration with primary care physicians and specialists in other fields, such as

• dentistry,
• psychology,
• physical therapy, and
• osteopathy.

Interventional pain management brings together expertise from a wide variety of medical fields. This results in a treatment approach that utilizes a range of methods, from high-tech endoscopic instruments to naturopathic treatments. 

Endoscopy is a minimally invasive surgical procedure. It allows the physician to examine and assess organs and tissue areas directly inside the body.

At the same time, the physician can already initiate steps toward healing. Using the endoscope or a catheter, they can correct abnormalities with tiny instruments or precisely administer medication directly to the target site.

These instruments are becoming increasingly miniaturized and are often coated with nanomaterials. This allows them to have anti-inflammatory effects, for example. In this way, many chronic pain conditions can be treated without subjecting the body to major surgery or numerous stressful diagnostic procedures.

Interventional pain management thus operates on the principle of “less is more.”

Interventional pain management is used to treat a wide variety of conditions, including, for example,

• back pain and spinal disorders,
• numbness and tingling in the extremities, and
• to investigate unexplained chest pain.

Neurosurgical Pain Management

Neurosurgical pain management represents, so to speak, the last resort for patients with pain. It is used when none of the above-mentioned forms of pain therapy provide relief.

The goal of neurosurgical pain management is the surgical severing of nerve pathways to interrupt the transmission of pain signals to the brain. It is used, for example, in cases of trigeminal neuralgia.

The goal of any pain management approach is to achieve a level of pain with which the patient can live comfortably. While freedom from pain without medication is the ideal, it is not always achievable. What is important is “pain emancipation.”

In addition to pain management with medication, guidance toward greater joy in life is also central to the therapy.

The patient’s active participation is crucial in this process. The cycle of increased focus on pain and social withdrawal can only be broken through a change in the patient’s behavior.

Engaging in more social, cultural, and physical activities—without overexerting oneself—as well as improving one’s ability to relax have a positive effect on all patients with chronic pain. The goal of specialized pain therapy is to help patients enjoy life and look positively toward the future despite living with chronic pain.