Pain therapy

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The term pain therapy summarizes all therapeutic measures that lead to a reduction in pain . Since the treatment of chronic pain in particular requires an interdisciplinary approach, the term pain management is also often used. This is understood as an umbrella term for all planning, monitoring and controlling measures that are necessary for the design of effective pain therapy. This term, as well as in pain medicine , encompasses aspects such as interventions that cause pain, pain therapy measures, affected persons, documentation and the organization of pain therapy.

The approach of multimodal pain therapy is based on a combined pain treatment, which includes an interdisciplinary treatment of patients with chronic pain conditions (e.g. spinal disorders ), including tumor pain, including psychiatric , psychosomatic or psychological disciplines, according to a medical treatment plan with treatment management.

history

Pain is one of the oldest symptoms that people have sought treatment for. Medical applications of heat or cold in ancient times were based in part on the concept of humoral pathology and were intended to help relieve pain by influencing a disturbed mixture of juices. The sap of the willow bark was already used in ancient Greece against fever and pain of all kinds. The active ingredient was later identified as salicylic acid . The speed of the first surgeons and numerous helpers were decisive. Laughing gas , discovered in 1772, was first used for dental interventions. Morphine became one of the most important analgesics. It is the main alkaloid of opium and was first isolated in 1804 by Friedrich Wilhelm Adam Sertürner . The opium obtained from the opium poppy and the plant itself were used long before. The manufacture of pharmaceutical products from opium poppies was first written about around 4000 BC. Mentioned in cuneiform script.

The realization that chronic pain can acquire its own disease value and require special forms of treatment and facilities led to the establishment of the first pain clinic in the USA as early as the 1940s. John J. Bonica, who died in 1994, is considered to be the founder of modern interdisciplinary pain therapy . Pain therapy institutions have only existed in Germany since the 1970s. The first pain clinic was set up at the University of Mainz under Rudolf Frey and Hans Ulrich Gerbershagen. The first two pain practices with statutory health insurance were founded in January 1982 in Frankfurt am Main (Drs. Flöter) and Hamburg (Drs. Jungck) by doctors who had previously set up pain clinics as chief physicians in their departments .

In June 1996, the German Medical Association in Germany adopted the additional title “ Special Pain Therapy” , which doctors can acquire .

Acute and chronic pain

→ Main article: Pain

Acute pain is useful as a warning and as an indication of the diagnosis of the underlying disease and thus has an important biological function. In addition to generally effective analgesics, the causal treatment of the cause is particularly crucial. This usually means that the pain subsides and disappears after a certain time, for which there are empirical values.

Chronic pain outlasts this expected period of time during which healing usually takes place. In the affected patients it can be stated that there are several causal and persistent factors for this persistence of the pain, which can be found or at least suggested in the somatic , psychological and social areas. In addition to eliminating the cause, treatment must also include alleviating or eliminating the consequences. Comprehensive, interdisciplinary pain management is crucial. Treatment with typical analgesics alone is not sufficient for chronic pain.

Drug influencing the pain pathway

The sensation of pain can be influenced with medication as follows:

  1. Elimination of the noxa :
    1. Steroidal anti-inflammatory drugs ( glucocorticoids ) and non-steroidal anti-inflammatory drugs inhibit inflammation.
    2. Spasmolytics and metamizole relieve painful cramps in the smooth muscles.
    3. Nitrates and molsidomine expand the arterial vessels, improve e.g. B. the cardiac blood flow and can cancel the ischemia pain.
  2. Influencing the pain receptors
    1. Local anesthetics numb the pain receptors (infiltration anesthesia).
    2. Non-opioid analgesics decrease the sensitivity of the pain receptors.
  3. Local anesthetics interrupt the transmission of pain impulses in peripheral nerves (conduction anesthesia) and central nerve tracts (spinal cord anesthesia).
  4. Opiate analgesics inhibit the transmission of pain impulses in the spinal cord and brain ( thalamus ) by supporting the descending inhibitory pathways. They work via opioid receptors (µ, kappa, delta, tau). Fibers branch off from the ascending pain pathway and lead directly to an increase in alertness / alertness and stimulation of the cardiovascular and respiratory systems. Another direct connection is to the limbic system and the corresponding emotions.
  5. Ketamine causes u. a. dissociative analgesia via the NMDA receptor.
  6. Psychotropic drugs (sedatives such as antidepressants, benzodiazepines and neuroleptics) influence the processing of pain in the brain.

Pain Management Options

Pharmacotherapy

Medicines are the classic treatment method for pain. Different classes of substances with different degrees of effectiveness and potential for side effects are used. Typical analgesics are opioids and non-opioid analgesics, as well as adjuvant drugs that influence the cause of pain (for example, inflammation caused by cortisone , vascular spasms with spasmolytics , nitrates ). The choice of the appropriate medication should be individually tailored to the patient.

For example, in a large proportion of patients with advanced cancer, in addition to chronic pain, pain attacks occur which - if the pain treatment is otherwise adequate - are experienced by the patient as breakthrough pain and can significantly impair quality of life. For example, the fast-acting opioid fentanyl , which can be absorbed through the oral or nasal mucosa, can be considered as a treatment .

Substance classes

The following substance classes are available for pain therapy:

WHO level scheme

The WHO recommends a procedure in three stages for drug pain therapy, which was originally developed for pain therapy and palliative treatment of tumor diseases (tumor pain therapy or cancer pain therapy for cancer pain). Starting with the level 1 therapy scheme, the scheme can be increased up to level 3 if the effectiveness is insufficient.

Level 1 : Non-opioid analgesic, possibly in
combination with adjuvants
Level 2 : Weak opioid, possibly in combination
with non-opioid analgesics and / or adjuvants
Level 3 : Strong opioid, possibly in combination
with non-opioid analgesics and / or adjuvants

If medication measures fail, invasive (e.g. surgical) measures can also be used, which are often added as level 4 in more recent publications:

Level 4 : Invasive techniques: epidural injection, spinal injection ,
peripheral local anesthesia , spinal cord stimulation ,
ganglion blockade

Level 1 drugs include nonsteroidal anti-inflammatory drugs (NSAID), metamizole and paracetamol , level 2 tramadol and tilidine , level 3 morphine , hydromorphone , oxycodone , fentanyl , buprenorphine , tapentadol and methadone .

A combination of strong and weak opioids is not indicated. Weak opioids have an antagonistic or partially antagonistic effect and thus neutralize the effect of strong opioids. Also due to the antagonistic or partially antagonistic effect, weak opioids show a ceiling effect , ie the effect is limited when the dose is increased.

The pain-relieving effect of opioids (tested substances: tramadol, codeine, morphine, oxycodone, fentanyl) is based on the guideline Long-term use of opioids for non-tumor-related pain (LONTS), based u. a. based on a meta-analysis of 60 randomized, placebo-controlled studies, in chronic non-tumor-related pain well below the clinically relevant effect with a dose in the lower to medium dose range (e.g. oxycodone maximum 60 mg per day, morphine maximum 120 mg per day ) according to the visual analog scale . Long-term use of the opioid analgesics investigated for up to 3 months showed weak but statistically significant pain relief. Even taking into account other literature, there was no difference in the potency between opiates and analgesics of level 2 (opioids) and level 1 (NSAID) in the clinical pictures examined in the studies osteoarthrosis, neuralgia after herpes zoster, diabetic polyneuropathy, non-specific low back pain and fibromyalgia . An attempt to use opioid-containing analgesics should therefore only be carried out if additional measures are taken and the possible side effects of the level 1 analgesics are taken into account because of the limited analgesic effect in non-tumor-related pain.

Adjuvant drug pain therapy

Antidepressants (e.g. amitriptyline ), neuroleptics or anticonvulsants (e.g. carbamazepine , gabapentin ) can be used for adjuvant drug therapy .

Anesthetic procedure

Anesthesia procedures are used for acute pain therapy within a limited time frame.

Local anesthetics

(e.g. lidocaine , mepivacaine , bupivacaine or ropivacaine ) inhibit the generation or transmission of an electrical impulse. Depending on the isolation of the nerves, as the concentration of the local anesthetic increases, first the vegetative, then the sensitive and finally the motor nerves are blocked.

Local anesthetics are used for

  • Surface anesthesia (for wounds and mucous membranes)
  • Infiltration anesthesia (as an intracutaneous, subcutaneous, or intramuscular injection)
  • Conduction anesthesia (encapsulation of peripheral nerves, nerve plexuses, nerve ganglia)
  • Anesthesia close to the spinal cord ( spinal anesthesia = injection into the liquor, epidural anesthesia = PDA = injection outside the dura); the local anesthetic can be combined with an opioid for the PDA, or the opioid is given alone.

Cryoanalgesia (icing)

In so-called cold anesthesia , pain receptors in the nerves under the skin are blocked by the influence of cold. The procedure is often used for sports injuries, such as bruises. In the extended cryoanalgesia, nerve pain receptors z. B. switched off / destroyed in joint capsules of the lumbar intervertebral joints by means of a cold probe using liquid nitrogen, which can lead to lasting pain relief in the affected joints.

anesthesia

The general anesthesia (anesthesia) for pain control is used relatively short only to bridge and very painful states (operations, dressing changes, trauma, etc.).

Physiotherapeutic / physical measures

The cutivisceral reflexes run from the sensitive nerves of the skin to the vegetative nerves of the internal organs (e.g. warm compresses on the skin of the abdomen lead to relaxation of the intestine). The sensitive nerves of these skin areas (= Head's zones) also enter the spinal cord at the same level as the sensitive nerves of the associated internal organs, so that when the internal organ is in pain, hypersensitivity or pain in the associated Head's zone can occur (e.g. Left arm pain with angina pectoris or heart attack ).

In addition to sensitive stimuli from the skin, sensitive stimuli from connective tissue (BGW), periosteum and skeletal muscles also move via reflex arcs to both the internal organs and the skeletal muscles and also from one organ to another (see Fig. Reflex arcs of the spinal cord) . Correspondingly, a distinction is made between the Head's zones (skin) and BGW zones (connective tissue of the subcutis), periosteum zones and muscle zones.

One can say that the internal organs project themselves onto the body surface through the nerve structures (so-called Head's zones ). In addition, there are projections that cannot be explained by this: The surface of every part of the body seems to reflect the entire inside of the body (e.g. reflex zones of the foot and hand). The functioning of the acupuncture points is also unclear.

Massage therapy

With certain massage techniques (e.g. reflex zone massage of the trunk, the foot, manual segment therapy, acupressure, etc.) one can influence the assigned internal organ via the reflex arcs. This leads to improved blood flow and muscle relaxation and, as a result, pain relief in these organs. In addition, the increased blood flow removes the substances that irritate the pain receptors in the event of tissue damage. Essential oils (e.g. from rosemary, thyme and Scots pine) also promote blood circulation, relax muscles and therefore relieve pain. They are therefore also used for rubbing in. Pain relief can also be achieved with manual lymphatic drainage, for example after trauma and surgery, including RA ( rheumatoid arthritis ) and CRPS I ( Sudeck's disease , sympathetic reflex dystrophy).

Thermotherapy

Likewise, the application of heat and cold can affect the internal organs. A distinction is made between the supply of heat ( heat therapy ) and heat withdrawal ( cryotherapy ). For trauma and acute inflammation, cold is used, for chronic inflammation and inflammation of the mucous membranes and for muscle tension, heat is used.

Heat causes:

  • fatigue
  • Lowering of the muscle tone (= relaxation) of smooth muscles and skeletal muscles
  • Increase in blood flow through vasodilation
  • Analgesia (pain relief) because of muscle relaxation and increased blood flow

Possible applications are direct Wärmeaplikation ( mud , peat , Körnerkissen , Wärmekissen), irritation of specific skin receptors with a capsaicin -containing carrier material (plasters, ointments, Munari packs ) or infrared radiation ( heat lamps , infrared lamps , infrared heat cabins ).

Cold causes:

  • Increased alertness, general hypothermia makes you sleepy
  • Increase in muscle tone
  • Decrease in blood flow due to vascular constriction and thus hemostasis, followed by reactive hyperemia (increase in blood flow after cold stimulus)
  • Analgesia through cold anesthesia
  • Anti-inflammatory (because it is cooling and decongestant), lowering fever

Local application of ice (approx. –20 ° C) from 5 min. To max. 20 min. (E.g. on the joints); Whole-body cold therapy in dry air (approx. –110 ° C) for a duration of 2 minutes with protection of the acra (e.g. for rheumatism) or as an ice dip (approx. 10 ° C).

Electrotherapy

In addition to direct muscle stimulation, an electric current via the aforementioned reflex arcs improves blood flow, relaxes muscles and, as a result, relieves pain in the internal organs. In addition, the irritation of the sensitive nerve structures causes, on the one hand, the pain receptors to become less sensitive and, on the other hand, an increase in the release of endorphins in the body. This treatment relieves or eliminates painful conditions and the like. a. in: cervical spine syndrome , thoracic spine syndrome , lumbar spine syndrome , arthrosis , sports injuries, circulatory disorders, neuralgia, myalgia, scar and phantom pain, fracture pain, pain in the pelvic floor area.

One example is transcutaneous electrical nerve stimulation (TENS). The adhesive electrode is attached to the pain area itself, the Head's zones or other reflex zones. Then alternating current in the form of low-frequency pulses between 1 and 100 Hz is given for 3 × 30 minutes / day. The current strength is set individually so that the current is not painful. Another therapy method is "Small Fiber Matrix Stimulation". In contrast to TENS, the pain fibers in the top layers of the skin are specifically activated by means of an electric current. By stimulating the pain-relieving and pain-relieving nervous system, the procedure should lead to a regression of the pathological neuronal changes in the spinal cord that have arisen in the course of chronification.

Acupuncture / acupressure

The acupuncture is a branch of Traditional Chinese Medicine (TCM). It is based on the body's vital energies, which circulate on defined longitudinal paths, the meridians , and have a controlling influence on all body functions. A disturbed flow of energy should be balanced again by stimulating the acupuncture and acupressure points on the meridians. The irritation can take place through vibration (acupoint massage = APM), pressure ( acupressure ) or needle pricks.

There is no scientifically recognized evidence for the existence of the assumed energies, meridians and acupuncture points. Whether acupuncture is suitable for treating pain is controversial. The largest study to date ( gerac studies ) could not prove any specific effectiveness of acupuncture for chronic deep back pain, chronic knee pain for knee osteoarthritis and chronic headaches; acupuncture treatment based on its traditional principles is as effective as a sham treatment where needles are stuck somewhere.

Multimodal pain therapy

→ Main article: Multimodal pain therapy

Multimodal pain therapy is an interdisciplinary treatment lasting several weeks for patients with chronic pain conditions. In contrast to purely somatically oriented treatment approaches, multimodal pain therapy (MMS) is a biopsychosocial form of therapy in which medical, physiotherapeutic and psychological treatments are sensibly combined with one another. In the implementation, various specialist disciplines (doctors, physiotherapists, psychologists and nursing staff) work together under medical treatment management according to a standardized treatment plan. The course of treatment must be checked and documented by means of a regular interdisciplinary team meeting. Multimodal pain therapy is increasingly recognized today by private and statutory health insurance companies.

psychotherapy

People who define themselves through performance feel that an illness has hurt their self-esteem. You put yourself under pressure and stress, which also weakens the immune system. The disease "pain" represents a special level of suffering. The psyche is connected to the hypothalamus through the limbic system (urges, drive, feelings, primary memory, day and night rhythm, etc.), which provides survival programs with the help of the pituitary (hormonal center) , the vegetative, the sensible and the motor nervous system. Therefore, stress and mental disorders can generally lead to hormonal disorders and vegetative dysfunction.

Pain is associated with fear and often with aggression. In particular, the fear of the pain recurring (fear of pain) leads to the avoidance of (supposedly) pain-inducing movements and ultimately leads to a pronounced avoidance behavior of movement at all ("I have to take care of myself"). This in turn causes a dysfunctional weakening of the muscles. In addition, the fear leads to increased muscular tension. Often, chronic pain (especially the experience of being at the mercy of pain) leads to depression, which in turn can maintain or intensify the pain. This can lead to the vicious circle of pain.

The treatment of chronic pain (lasting at least six months) or acute pain that occurs more frequently includes pain management therapy , a procedure that is counted as behavioral therapy . A major goal is to improve the expectation of self-efficacy , i.e. H. the assessment of those affected to be able to deal successfully with the pain. For this purpose, those affected learn which of their behaviors and thoughts are unfavorable and possibly even aggravating pain in dealing with the pain, and alternative, favorable behaviors and thoughts are developed or conveyed.

Methods of psychological pain management:

  • Relaxation: Pain tends to occur in stressful and stressful situations; conversely, it turns out that in the state of relaxation the perceived pain intensity decreases. Therefore, different relaxation methods can be used very sensibly, e.g. B.
  • Improvement of the perception of body processes, e.g. B. through biofeedback : Using measuring devices, body functions can be reported back directly. In this way, the connection between psychological experience and physical symptoms can be “made visible” and the person concerned learns to control his or her body functions himself. The relaxation reaction can be demonstrated and practiced using biofeedback of skin conductivity . The feedback of the muscle tension by means of EMG (e.g. feedback of the forehead muscle activity in case of tension headache), or the vessel size by plethysmography is also frequently used . For migraines z. B. performed vasoconstriction training of the temporal artery , or reported the skin temperature of the hand back. Recent studies also show that neurofeedback of the brain waves above the anterior cingulate cortex can lead to a reduction in the experience of pain.
  • Cognitive therapy : Recognizing thoughts that promote pain (e.g. catastrophizing ), developing more helpful thoughts (see below)
  • Directing attention : This is about directing the focus of attention away from the pain to other (internal or external) content, e.g. B. on non-painful parts of the body, a thought, an idea, or externally on a picture, a conversation, etc.
    • Helpful thoughts such as B. “Today the pain is less severe than it was before”, “Everything is fleeting, including the pain”, “In the past xy helped me” etc.
    • Positive imagination : imagination exercises , e.g. For example: a place of strength, a place of inner peace, fantasy journeys
  • Establishing pleasant activities such as B. “read a book”, “walk”, “bathe” or “go to the cinema”; supported by physical training and physiotherapeutic measures
  • operant methods to reduce avoidance behavior, e.g. B.
    • Time contingent medication intake: Medication should not be taken when needed, but regularly at a fixed point in time, as otherwise the pain behavior (avoidance behavior) is maintained by negative reinforcement (see operant conditioning ) and the risk of developing dependency is high.
    • Have the limits for stress (walking, climbing stairs, etc.) determined, gradually increasing the activities (instead of unnecessary rest)
  • Mindfulness-based methods , acceptance of pain:
    • Refraining from struggling with pain
    • realistic dealing with the pain
    • Interest in positive everyday activities
  • Self-care : e.g. B. Avoid long work without breaks (“have to persevere”), set limits (say “no”), express wishes, do something good for yourself (pleasant activities, see above)

Neurosurgery

Neurosurgical measures are seen as the last resort ; Examples:

Societies

Several societies and associations strive to research and treat pain:

See also

literature

  • Thomas Flöter, Manfred Zimmermann (Ed.): The multimorbid pain patient. Thieme, Stuttgart 2003, ISBN 3-13-133071-6 .
  • German network for quality development in nursing (DNQP, ed.), Doris Schiemann (author): Expert standard pain management in nursing, development - consent - implementation. Verlag Fachhochschule Osnabrück , Osnabrück 2005, ISBN 3-00-012743-7 .
  • Susanne Holst , Ulrike Preußiger-Meiser: Successful pain therapy. Finally live pain-free again. New treatments and effective drugs for acute and chronic pain. Südwest, Munich 2004, ISBN 3-517-06727-X .
  • Uwe Junker, Thomas Nolte (Hrsg.): Basics of special pain therapy. Curriculum Special Pain Therapy of the German Society for Pain Therapy e. V. according to the course book of the German Medical Association . Urban & Vogel, Munich 2005, ISBN 3-89935-218-1 .
  • Stefan Jacobs, Ines Bosse-Düker: Behavioral hypnosis for chronic pain. A short program for the treatment of chronic pain. (= Therapeutic practice). Hogrefe Verlag, Göttingen 2005, ISBN 3-8017-1732-1 .
  • Franz-Josef Kuhlen: History on the subject of pain and pain therapy. In: Pharmacy in our time . 31 (1), pp. 13-22 (2002), ISSN  0048-3664 .
  • Ministry of Labor, Health, Family and Social Order Baden-Württemberg, Stuttgart and State Medical Association BW (Ed. 1994 ff.): Pain therapy for tumor patients. A guide. Common recommendation of the tumor centers, Kassenärztl. Vereinig., State Medical Association. Health policy 13th 3rd unchanged edition.
  • Holger Thiel, Norbert Roewer: Anesthesiological pharmacotherapy. General and special pharmacology in anesthesia, intensive care medicine, emergency medicine and pain therapy. Thieme, Stuttgart a. a. 2004, ISBN 3-13-138261-9 .
  • Julia Thomass, Bertram Disselhoff, Thomas Flöter: In a good mood with TENS! A. M. I. Acupuncture Medicine Information, Giessen 2004, ISBN 3-927971-18-9 .
  • Torsten Wieden, Hans-Bernd Sittig (Hrsg.): Guide to pain therapy. Elsevier, Urban and Fischer, Munich a. a. 2005, ISBN 3-437-23170-7 .
  • Michael Zenz, Michael Strumpf, Anne Willweber-Strumpf: Paperback of pain therapy. Bochum guidelines for diagnosis and therapy. 2nd Edition. Wissenschaftliche Verlagsgesellschaft, Stuttgart 2004, ISBN 3-8047-2046-3 .
  • Eberhard Klaschik : Pain therapy and symptom control in palliative medicine. In: Stein Husebø , Eberhard Klaschik (ed.): Palliative medicine. 5th edition, Springer, Heidelberg 2009, ISBN 3-642-01548-4 , pp. 207-313.
  • Birgit Kröner-Herwig, Regine Klinger, Jule Fretlöh, Paul Nilges (eds.): Pain Psychotherapy . Basics - diagnostics - clinical pictures - treatment. 7th, completely updated and revised edition. Springer, Berlin 2011, ISBN 978-3-642-12782-3 .

Guidelines

Individual evidence

  1. ↑ Andreas-Holger Maehle: pain management. In: Werner E. Gerabek , Bernhard D. Haage, Gundolf Keil , Wolfgang Wegner (eds.): Enzyklopädie Medizingeschichte. De Gruyter, Berlin / New York 2005, ISBN 3-11-015714-4 , pp. 1302 f .; here: p. 1302.
  2. ^ O. Lafont: From the willow to aspirin. In: Rev Hist Pharm (Paris). 2007 Jul, 55 (354), pp. 209-216; PMID 18175528 .
  3. ^ Morphine was first isolated from opium in 1804, Austrian Chamber of Pharmacists, accessed November 17, 2008
  4. ↑ RJ Huxtable, SK Schwarz: The isolation of morphine - first principles in science and ethics. In: Mol Interv. 2001 Oct; 1 (4), pp. 189-191. Full text (HTML) Full text (PDF) PMID 14993340
  5. ↑ Seefelder, Matthias: Opium - Eine Kulturgeschichte p. 21 Landsberg 1996.
  6. ^ Meinolfus Strätling, A. Schneeweiß, Peter Schmucker: Medical University of Lübeck: Clinic for Anesthesiology. In: Jürgen Schüttler (Ed.): 50 Years of the German Society for Anaesthesiology and Intensive Care Medicine: Tradition and Innovation. Springer, Berlin / Heidelberg / New York 2003, ISBN 3-540-00057-7 , pp. 479-486, here: p. 483.
  7. ↑ A. Caraceni et al. Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. In: Palliat Med. 2004 Apr; 18 (3), pp. 177-183. PMID 15198130
  8. ↑ G. Zeppetella, MD Ribeiro: Opioids for the management of breakthrough (episodic) pain in cancer patients. In: Cochrane Database Syst Rev. 2006 Jan 25; (1), S. CD004311. PMID 16437482
  9. ↑ Pain Therapy. In: Eberhard Aulbert, Friedemann Nauck, Lukas Radbruch (eds.): Textbook of palliative medicine. Schattauer, Stuttgart (1997) 3rd, updated edition 2012, ISBN 978-3-7945-2666-6 , pp. 146-264.
  10. ↑ Lukas Radbruch, Frank Elsner, Jan Gärtner: Algesimetry in cancer pain therapy. In: Eberhard Aulbert et al. (Hrsg.): Textbook of Palliative Medicine. 2012, pp. 157-174.
  11. ^ Jürgen Sorge: Epidemiology, Classification and Clinic of Cancer Pain. In: Eberhard Aulbert et al. (Hrsg.): Textbook of Palliative Medicine. 2012, pp. 146–156.
  12. ^ World Health Organization: Cancer pain relief. With a guide to opioid availability (2 ed.). WHO (Geneva). 1996. Google Books Preview
  13. ^ E. Reinecke, Holger Sorgatz: SS guideline LONTS. Long-term use of opioids for non-tumor pain. In: The pain. 2009; 5, pp. 440-446.
  14. ↑ TR Tolle, RD Treede, M. Zenz: long-term use of opioids for non-cancer related pain (LONTS). In: The pain. 2009; 5, pp. 437-439.
  15. ↑ Overview of the basic studies on small fiber matrix stimulation by Jung et al. (2012, Eur J Pain), Rottmann et al. (2010, Eur J Pain) and others under [1] , accessed on March 30, 2016.
  16. ↑ journalMED: Neurologists: Acupuncture only helps against migraines like a placebo , accessed on May 27, 2010.
  17. ↑ In- patient multimodal pain therapy, Accident Clinic of the Accident Insurance Association, Frankfurt
  18. ↑ Health insurance recommends multimodal pain therapy for back pain , Deutsches Ärzteblatt
  19. ↑ B. Kröner-Herwig: Biofeedback. In: H.-D. Basler et al: Psychological pain therapy. 4th edition. Springer, Berlin 1999, p. 627 ff.
  20. ↑ a b c Paul Nilges, Harald C. Traue: Psychological aspects of pain. In: Behavioral Therapy & Behavioral Medicine. 2007, 28 (3), pp. 302-322.