Chronic pain syndrome

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Classification according to ICD-10
F45.41 Chronic pain disorder with somatic and psychological factors
R52.1 Chronic uncontrollable pain
R52.2 Other chronic pain
ICD-10 online (WHO version 2019)

The term chronic pain syndrome or chronic pain disease describes a pain that loses its actual function as a warning and guideline and receives an independent disease value . The problem with this definition of the term, however, is the unproven loss of the warning and indication function in the event of long-term pain in the case of improper strain on the musculoskeletal system, which with a prevalence of 33% make up the largest proportion of all pain syndromes.

In everyday language, the term chronic pain is abbreviated .

Taking into account the time dimension, it can be assumed that a chronic pain syndrome develops if pain persists for more than six months (nowadays more than three to six months). Alternatively, chronic pain is sometimes defined without a specific time frame as pain that continues to heal over the expected length of time .

Chronic pain usually leads to a lowering of the pain threshold and inevitably to psychopathological changes and a burden on the personal social environment .

In Germany, the qualified treatment of a chronic pain disorder was offset for the first time in 1996 after negotiations between the National Association of Statutory Health Insurance Physicians and the umbrella organizations of the substitute insurance funds . The number of those affected is estimated at 8 to 10 million in Germany.

ICD key

The problem is that pain disorders are often ascribed either to physical causes (ICD Chapters M and R) or to psychological causes. The classification according to this distinction was difficult and not always clearly possible. Acute pain caused by a herniated disc can be physical, while the chronic pain is caused by psychosocial factors. In 2009, the German edition of ICD-10 introduced the diagnosis F45.41 Chronic Pain Disorder with Somatic and Psychological Factors , with which scientific knowledge about the various causes of chronic pain can be mapped not only on a physical but also on a psychological level. Under F45.41 it says: “Mental factors are assigned an important role in the severity, exacerbation or maintenance of the pain, but not the causal role in its onset.” Under F45.40, however, it says: “It occurs in connection with emotional conflicts or psychosocial stresses, which play the main role in the onset, severity, exacerbation or maintenance of the pain. ”Coding F45.40 assigns the main role to psychological factors at the beginning, but not 45.41. In practice, however, this distinction is often difficult to make.

See also: Somatoform Pain Disorder

to form

Separately highlighted pain syndromes

Pain as a key symptom of a mental illness

Appraisal

The German Society for Neurology (DGN) and the German Society for Neuroscientific Assessment have developed an S2k guideline for the medical assessment of people with chronic pain, which medical experts serve as a basis.

In the cooperation between experts from different specialist disciplines, quality assurance measures for the preparation of expert opinions and the basis for uniform assessments of people suffering from pain in civil, general administrative and social law should be enabled.

In the expert situation, there are 3 categories of pain to be distinguished:

  • Pain as an accompanying symptom of a physical disorder with the subgroups
    • "Usual pain" as an accompanying symptom of a physically perceptible illness or nerve damage.
    • "Exceptional pain" z. B.
      • for stump and phantom pain or
      • as part of a “complex regional pain syndrome” (CRPS).
  • Physically partly explainable pain with psychological comorbidity as numerically the largest group to be assessed.
  • Pain as an expression of a primary mental illness, especially in the context of depressive disorders.

treatment

In the case of chronic pain, especially chronic back pain, in addition to the very efficient and directly cause-related physiotherapy , the resource- and time-consuming multimodal pain therapy is now a treatment method that is increasingly recognized by private and statutory health insurance companies. Among other things, the components of medical therapy, comprehensive information and training for the patient, physical activation, psychotherapy, behavioral and occupational therapy are combined with one another. In addition to medical pain specialists, psychological pain therapists, specially trained physiotherapists, nursing staff, social workers, art or music therapists work together in an interdisciplinary manner in order to alleviate chronic pain and improve the quality of life of chronic pain patients.

Behavior therapy

Vlaeyen and Linton developed the fear-avoidance model specifically for musculoskeletal pain, according to which acute pain is interpreted in a catastrophic way, which is why fear of pain occurs. Fear results in escape and avoidance behavior, such as resting or refraining from physical activity, because the misconception that resting relieves pain is assumed. Gentle behavior leads to pain relief in the short term, but in the long term to impairments in all areas of life, which can contribute secondarily to depressive development (loss of reinforcement). According to the model of learned helplessness, experiencing that no improvement occurs can also contribute to depressive development.

The short-term pain relief through gentle behavior leads to a negative reinforcement of the dysfunctional behavior (Fordyce's operant pain model). When taking medication depending on the severity of the pain (pain contingent), negative reinforcement can also occur, which is why taking it at regular intervals (time contingent) is recommended. It should be noted that the contingent pain consumption is only useful for acute, but not for chronic pain.

In addition, there is a hypervigilance towards possibly painful stimuli, which, according to the gate control theory, tends to lead to an increased perception of pain. The gate control theory states that pain impulses from the periphery are modulated by the brain through descending pain-relieving impulses. The use of relaxation methods has proven itself on the one hand to reduce the general level of tension and to divert attention.

Pain can also be maintained by stabilizing conflict-ridden relationships, avoiding conflicts or receiving affection. If this is the case, it makes sense to integrate self-confidence and communication training into the therapy.

In summary, the following behavioral therapeutic strategies come into question:

  • Cognitive restructuring of dysfunctional beliefs such as: "Resting reduces pain", or "Physical activity increases pain."
  • Building up physical activity while observing appropriate performance limits
  • Time contingent taking medication for chronic pain
  • Relaxation training
  • Recognition and modification of pain-causing stressors (for example in migraines)
  • Possibly social skills training

literature

Individual evidence

  1. ↑ What are the causes of musculoskeletal pain?
  2. ↑ DC Turk, A. Okifuji: Pain terms and taxonomies. In: D. Loeser, SH Butler, JJ Chapman et al: Bonica's management of pain . 3. Edition. Lippincott Williams & Wilkins, 2001, ISBN 0-683-30462-3 , pp. 18-25.
  3. ↑ a b Erich Rauch, Florian Rauch: Pain Therapy: Acute Pain - Chronic Pain - Palliative Medicine . Georg Thieme Verlag, 2010, ISBN 978-3-13-155052-1 , p. 58 ( limited preview in Google Book search).
  4. ↑ W. Rief, R.-D. Treede, U. Schweiger, P. Henningsen, H. Rüddel, P. Nilges: New pain diagnosis in the German ICD-10 version . In: The neurologist . tape 80 , 2009, p. 340-342 , doi : 10.1007 / s00115-008-2604-1 .
  5. ↑ a b Bernd Graubner: ICD-10-GM 2014: international statistical classifications of diseases and related health problems . Deutscher Ärzteverlag, 2013, ISBN 978-3-7691-3537-4 , p. 198–199 ( limited preview in Google book search or at icd-code.de ).
  6. ↑ Michael Dobe, Boris Zernikow: Therapy of pain disorders in children and adolescents: A manual for psychotherapists, doctors and nursing staff . Springer-Verlag, 2012, ISBN 978-3-642-32671-4 , p. 35 ( limited preview in Google Book search).
  7. ↑ a b c AWMF - 2012 - S2k guideline for medical assessment of people with chronic pain
  8. ^ LR Van Dillen, SA Sahrmann, BJ Norton, CA Caldwell, MK McDonnell, NJ Bloom: Movement system impairment-based categories for low back pain: stage 1 validation. In: J Orthop Sports Phys Ther. 2003 Mar, 33 (3), pp. 126-142, PMID 12683688 .
  9. ^ Classification Of Low Back Pain Using Movement System Impairments .
  10. ^ LR Van Dillen, SA Sahrmann, JM Wagner: Classification, intervention, and outcomes for a person with lumbar rotation with flexion syndrome. In: Phys Ther. 2005 Apr, 85 (4), pp. 336-351, PMID 15794704 .
  11. ↑ M. Harris-Hayes, SA Sahrmann, BJ Norton, GB Salsich: Diagnosis and management of a patient with knee pain using the movement system impairment classification system. In: J Orthop Sports Phys Ther. 2008 Apr, 38 (4), pp. 203-213, PMID 18434664 , doi: 10.2519 / jospt.2008.2584 . Epub 2007 Nov 21.
  12. ^ LR Van Dillen, KS Maluf, SA Sahrmann: Further examination of modifying patient-preferred movement and alignment strategies in patients with low back pain during symptomatic tests. In: Man Ther. 2009 Feb, 14 (1), pp. 52-60, PMID 18032090 , Epub 2007 Nov 26.
  13. ↑ Health insurance recommends multimodal pain therapy for back pain . In: Deutsches Ärzteblatt
  14. ↑ Inpatient multimodal pain therapy ( memento of the original from November 19, 2015 in the Internet Archive ) Info: The archive link was automatically inserted and not yet checked. Please check the original and archive link according to the instructions and then remove this notice. Professional Association Accident Clinic Frankfurt.  @1@ 2Template: Webachiv / IABot / www.bgu-frankfurt.de
  15. ↑ a b c d e f g h i j k Christiane Hermann, Herta Flor: Chronic pain . In: Martin Hautinger (ed.): Cognitive behavior therapy . Beltz, Weinheim 2011, ISBN 978-3-621-27771-6 , pp. 223-229 .