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Comprehensive pain therapy

1 pain and pain genesis

1.1 What is pain?
1.2 How does pain originate?
1.3 Forwarding and pain treatment
2 As occurred the pain diagnosis with back pains?
2.1 Definition specific back pain
2.2 Pain anamnesis and additional discomforts
2.3 Physical examination
3 diagnostics
3.1 Lab examinations
3.2 Image-giving procedures
3.2.1 Computer tomography (CT.) with back pains
3.2.2 Myelographie with back pains
3.2.3 Magnet-resonance stratigraphy:
3.2.4 Scintigraphy with back pains
4 therapy measures
4.1 Base therapy
4.2 Enlarged measures
4.3 Treatment of back pains
4.3.1 Non-medicinal pain therapy
4.3.2 Medicinal pain therapy with back pains

1. Pain and pain genesis

1.1 What is pain?

Pain is an answer of the body to a stimulus, this stimulus can cause an impairment in the body.
The pain feeling depends on different factors, as for example psychic …, to forming the basis diseases, genetic disposition, environmental factors., Even educational level and the childbirth injustice play here a role. Thus we know that south countries are more sensitive to pain than European. Stress situations can affect the pain perception, in certain stress situations it can even be that pains are not perceived.
Pain is a subjective feeling of the singles and can be classified by means of pain protocols and scales.

1.2 How does pain originate?

The nervous system owns so-called Nozizeptoren, these are free Nervenendigungen which are responsible for the absorption and processing of pain.

Nozizeptoren can react to different stimuli:

mechanical stimuli (strong pressure, dissection or loss of a part of the body)
thermal stimuli (cold, heat)
chemical stimuli (cauterisations)



Sleeping receptors can be activated by allergization (inflammation medium gates, like potassium ions, Arachidonsäure, oxygen radicals, prostaglandins, histamine, Bradykinin, Leukotine, Phospholipasse and other).

The Nozizeptoren own Nervenendigungen of the classes C and A-delta:

A delta fibers lead the pain information because of her Myelinschicht very fast (mechanical stimuli, like pressure, thermal stimuli, how cold.

C phases lead the pain information slowly (mechanical, thermal, chemical stimuli)

The Nozizeptorenerregung can be strengthened by repeated pain stimuli, because:

it comes to degradation of the stimulus threshold.
it comes to an increased pain sensibility,
Extended and reinforced pain answer
it can come to the spontaneous activity (pain).
The pain stimulus thereby becomes stronger and becomes discernible.


 1.3 Forwarding and pain treatment

If a stimulus in the body appears, the forwarding and pain treatment occurs as follows:
The pain irritation is processed in the spinal cord. From here the stimulus is further escorted to the brain cortex or an escape reflex is brought on (e.g., Move while touching one were called of object) or it a radiation occurs in other body areas, (e.g., heart pains shine in the left arm).
In the brain cortex pain is perceived and worked on in the Limbischen system and is analysed.
That is every stimulus must not be processed in central nervous system.


With the viscera, like stomach, cholecyst, another Reflexvorschaltung takes place: About the so-called Viszerokutanreflex pain can be perceived in other body areas. Thus pain can emit with heart trouble in the neck area and the left arm, with bile pains pain can be felt in the right arm and in the back.




The central allergization and forwarding of pain occurs about the C fibers and A beta fibers.

By constant peripheral stimulus and without adequate and quick treatment of pain form in the central nervous system so-called memory pain cells which lead to the Chronifizierung of pain and thereby complicate the treatment of pain.


 2. How does the pain diagnosis occur with back pains?

Belongs to the diagnostics:

1. Pain anamnesis
2. Pain analysis
3. Additional discomforts
4. Physical examination

2.1 Definition specific back pain

Symptom complex with mostly acute regional-restricted, in a certain skin area emitting pain, with differently stamped dysfunction and possibly other symptoms which can be a part of another illness (e.g., renal colic).

Pain radiation in other areas:

Certain pains are perceived in the range one or several nerve roots in the spine: Pains in the cervical vertebra column with radiation in the arms, pains between the ribs, pains in the area of the lumbar vertebra column emit in both bones, in the breech and last. One calls this radikulären pain. This puts out from approx. five to eight percent of all back pains.

Sensibility disorders, reflex disorders or motor failures of the musculature can originate. The kind of pains is piercing and moving. All motions are mostly sore.

Slipped disk:

An operation with slipped disk is necessary, if:

Acute hemiplegia functionally important muscle
intensive pains after fruitless conservative therapy from approx. two to three months
Occurrence of vesical disorders and rectum disorders
Occurrence of cross section symptoms

2.2 Pain anamnesis and additional discomforts

To the pain anamnesis belong the duration of the topical pain stage, the circumstances of the pain entry, e.g., spontaneously, after trauma or a known fact.
Pain strength, pain course, preillnesses, informal anamnesis, preoperations are also very important etc.

The following questions are important:

1. How is pain, z. B.stechend, pulling, burning?
2. Where is pain and where does he begin?
3. Where does pain emit, e.g., locally, limits, outside from certain skin areas, in the course of a certain nerve?
4. Since when pain exists?
5. What was the trigger for pain, e.g. (Lift to a load, fall, infection, wrong motion?
6. When he appears, z. B.nach strain, with the lying, in rest, in motion?
7. Do accompanying discomforts exist, e.g., pain radiation in both bones, in the breech, disorders of the vesical evacuation or the bowel?
By which is he strengthened or relieved, e.g., by warmth, cold, strain, rest?


Pain division:

1. mechanical pain:
* becomes increasingly by motion
* makes amends by rest

2. inflammatory pain:
* becomes better by motion
* makes amends by rest

3. psychogener pain:
* always continues

2.3 Physical examination

The position of the body is examined from that point of view whether a skew position of the spine exists in the form of Skoliose (lateral Verbiegung of the spine), kyphosis or hyperhollow back. It is also important to judge the shoulder state, pelvic state and bone length differences.

3. Diagnostics

3.1 Lab examinations

 Here certain lab parametres must be identified. The most important parametres are: Blood count, liver values, tip to acute inflammations, protein, cataphoresis, potassium, calcium, phosphate, urine state, creatinine, thyroid gland hormones.

3.2 Image-giving procedures

They are mostly overestimated. The anamnesis and the clinical findings are more important here, but as a supplement images should be made.

3.2.1 Computer tomography (CT.) with back pains

This is the method of the choice of the representation of knöchernerer changes.
The examination area must be very narrow here (exact clinical information and question).
Documentation of the findings in the soft part window and osseous window.
Satisfactory soft part contrast, if necessary 2-D reconstructions
Primarily axial incision guidance, but 2-D reconstructions is with pathological findings obligat.


  3.2.2 Myelographie with back pains

This is an invasive and risky procedure with injection of a contrast medium.
It is mostly indicated only for the operation planning.
It can be complemented with a CT.

3.2.3 Magnet-resonance stratigraphy:

This procedure achieves an excellent soft part contrast.
Peripheral structures are shown indirectly.
The examination levels can be freely chosen.
There is no ray strain.
Small Verkalkungen are not surely tangible.
With contemporary examination technology this procedure to the CT. is with the spine diagnostics consider
A CT. is necessary if necessary as a specific supplement.

3.2.4 Scintigraphy with back pains

This is up an unspecific searching procedure with suspicion
Fracture differentiation (freshly or old)

4. Therapy measures

We divide the treatment one in:

4.1 Base therapy

4.2 enlarged measures.

4.1 Base therapy

Belong to it:
Allergization for the behaviour and activity change
Conservative measures (e.g., discharge by degree bed storage)
Warmth / cold uses
Motion and activity should be maintained: Who rests which rusts.

4.2 Enlarged measures

The aim of enlarged measures is an improved pain processing and one
general conditioning. This can be reached by:
Neuraltherapie or TLA (Therapeutic local anaesthesia)
Balance of the muscles
Physiotherapy and physical therapy

Physiotherapy and effects

 Physiotherapy leads to the muscle recovery

Pain lysis
Mobilisation of tense parts
Muscular balance

Massage treatment (hydromassage)
Relaxation of the musculature

Manual therapy (maneuver only by doctors)
Gelenkdeblockierung, so lysis of the blocking

Manual therapy by physiotherapists
segment ale mobilisation and stabilisation

local pain fight

Lysis of a raised muscle tone

Pain lime-tree posts
Muscle recovery

Electric stimulation
Pain dullness
Muscle recovery

Connective tissue massage
reflector broad Schmerzhemmung

Correction of false statics

Swimming, mechanical training therapy
Muscle recovery

Back school
long-term correction of the position and motion sequences
Stabilisation of the muscles
Discharge of sore structures
4.3 Treatment of back pains

4.3.1 Non-medicinal pain therapy

Belong to it
Physiotherapy, like physiotherapy, therapeutic exercises, thermo therapy, hydropathy, Balneotherapie

Enlarged procedures
e.g., ultrasound treatment
TENS device (trancutane electric nerve stimulation)


e.g., sport, muscle stamina training, back school etc.

4.3.2 Medicinal pain therapy with back pains Drugs after pain type


Nozizeptorpain transferred pain
Neurogener pain

NASR, cox-2-Hemmer, Kortikosteroide


Local anaesthetics



Antidepressants (medicine against depressions)


Tone associates:

(reinforced muscle tone, muscle spanning)

Flupirtin, Tolperison, Lokalanäasthetika (Betäubungsmittel)

Muskelrelaxanzen (medicine to the muscle relaxation)  NASR

To Osteogen drugs (Osseous-partly):

Biphosphonate, z. B. Alendronsäure (medicine to the osseous construction)



Antikonvolsiva (medicine against cramp attacks)
Opioide Drugs after pain duration


less than one week
one week up to three months
longer than three months
NASR: z.B. ASS, Ibuprofen, Diclofenac, Endometacin NASR, Ibuprofen, Diclofenac, Mydocalm, Endometacin,ASS
NASR, z.B. Diclofenac, Ibuprofen, Endomecin, ASS
Flupirtin Flupirtin Flupirtin
Local anaesthetics, e.g. Procain, Meaverin Local anaesthetics, e.g. Procain, Meaverin Local anaesthetics, e.g. Procain, Meaverin
Korticosteroide (cortisone hatliges medicine)
z.B. Prednisolon, Dexamethason
 Opioide( z.B. Morphin) Opioid, wie z.B. Morphin, Tramadol, Tilidin
 Local anaesthetics, e.g., Procain, Meaverin
Korticosteroide (cortisone hatliges medicine)
  Antidepressants, e.g., Amitriptylin, Doxipen, Clomipramin


(relaxing, sleep-supporting, reassuringly)


Muscle-being relaxing medicine, e.g., Tetrazepam and Mydocalm



Analgesics to WHO – degree pattern


Degree 1

Degree 2
Degree 3
• Acetylsalicylsäure, z. B. Aspirin
• Ibuprofen, z. B. Imbun
• Paracetamol, z. B. ben-u-ron
• Metamitazol, z. B. Novalgin
• Diclofenac, z. B. Voltaren
• Etoricoxib, z. B. Arcoxia
• Celecoxib, z. B. Celebrix

• Tilidin und Naloxan, z. B. Valoron N
• Tramadol, z. B. Tramal long
• Dyhodrocodein, z. B DHC

• PalladonHydromorphon, z. B. Junista (Valeron)

• Fentanyl, z. B. Durogesic

• Morphin, M-long. MST, Kapanol, Capros,
• Oxycordon, z. B, Oxygesic
• Buprenophin, z. B. Temgesic, Transtic


To sum up:

Pains should be treated adequately, ever rather the treatment the better, because to be able to counteract thus the Chronifizierung of pain.
Easy therapy measures consider, and produce the diagnosis by the anamnesis, as well as exact physical examining and include the patients with in the treatment.


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