The Garmisch therapeutic approach to chronic pain amplification syndrome
Therapy
The wide range of problems with their bio-psycho-social effects mean that a multidisciplinary programme of treatment centred around the patient and the family will always be required. Medical and medicinal therapy is placed on an equal footing with psychological treatment, nursing care, physiotherapy, occupational therapy and social-pedagogic care.
In our Specialist Clinic we have developed a unique approach to therapy that has brought good results over the past few years.
Therapy objectives
The understandable wish of patients and parents to make sure the pain is reduced as quickly as possible cannot always be granted immediately. Pain has taken on its own role in the child’s life and the life of the family. We focus our treatment on helping children rediscover a sense of achievement and on strengthening their self-confidence and their autonomy. Wherever possible, psychic conflicts are addressed and combined solutions are sought.
Drug therapy
This is of minimum value in the treatment of chronic pain amplification syndrome. Drugs to block pain and inflammation work only for a limited time, if they work at all. We never cease to be shocked by the quantity of drugs that children take every day in spite of the fact that they cannot feel any improvement. We will usually discontinue any regular pain medication, following discussion with the child, and provide medication solely on request or as bridging therapy. Experience has shown that this acute medication will be requested only occasionally. Patients prefer local measures such as cold or warm compresses applied to painful areas.
To address the central cause of the pain, drugs with coanalgesic effects are used, which affect the metabolism of the CNS. These include tricyclic antidepressants and serotonin reuptake inhibitors. These drugs can also be effective in children and young people experiencing pain episodes. They are of limited effectiveness, however, and they take effect only after a certain time. The indication should be given after careful consideration and with discretion.
Since the introduction of our therapy programme we have been able to reduce drastically the amount of medication taken by our young patients.
Medical information
One of the main priorities in medical therapy, alongside ruling out the important differential diagnoses mentioned above, is providing patients and families with comprehensive information about the illness and the possible therapies available. Patients feel that they and their problems are being taken seriously; that they are not alone; that therapy is possible; that chronic pain has lost its function as a warning signal; and that pain has lost its destructive (i.e. joint-damaging) power. Our patients are motivated to increase their range of action and mobility in spite of the pain, to stand up against the pain, and to rediscover a sense of enjoyment in their daily activities. Experience has shown that an increase in physical activity is followed, after a certain time, by a reduction in pain.
Psychological care
The psychological care of pain patients at Station 6 is structured around three fundamental principles: The children and young people take part in discussions; a group therapy programme is offered; and, last but not least, discussions with the parents especially of younger patients play an important role in the treatment.
One-to-one interviews
The content and structure of one-to-one interviews are largely determined by the wishes and desires of the patients. These interviews can focus on the development of social or communicative skills or on improving patients’ body awareness and body scheme. Alternatively, the interview can concentrate on dealing with illness as a reality that will determine the patient’s lifestyle.
Our experience shows, and research confirms, that when patients wrestle to find words to describe their condition, this can contribute towards relieving the burden of their painful lives. It is of secondary importance here whether the interviews address the perception of bodily processes, whether experiences encountered are described in words, or whether other thoughts are carefully sorted and formulated. Although concentrating on one’s own experience in this way (which is something most patients are unaccustomed to doing) does not directly make the pain disappear, it does place the patient's experience on a different basis, since it enables the experience to be perceived on as many different levels as possible. This approach can be summed up in a few words: the more pleasant moments there are in a patient’s life, the less time there is left over for the pain, which will therefore automatically be reduced.
Group treatment
This objective is also followed in psychological group treatment, although here, in addition to perception and development of internal processes, patients’ encounters with each other and with the carers play a crucial role. As well as teaching relaxation techniques and visualisation and body awareness exercises, group therapy is designed to help children and young people achieve a positive image of their body, which has a considerable effect in its own right on psychovegetative systems disturbed by pain and lack of sleep.
Discussions with parents
The illness of a child always affects parents very deeply and has tangible effects on their daily lives. A pain disorder in a child therefore cannot be treated without taking into consideration its effects on the other members of the family and offering them help and support as far as possible. We do this by providing an opportunity for discussion, either as a one-to-one interview with a team member or as a larger-scale talk with the whole team or sections of the pain management team.
Communication within the family plays an important role with relation to the onset and persistence of chronic pain that cannot be explained merely by a somatic correlative. Small changes in speaking habits can thus often produce noticeable relief for all the parties involved. This search for relief is not carried out by evaluating what is the correct and what is the incorrect way to act; instead, the team works together with the patients and parents to look for new ways that are perceived by all family members as helpful and sensible in concrete situations.
If the patients or their parents prefer to receive psychotherapeutic care in their home town, we will support them in their search for a psychotherapist in private practice.
Nursing care
Chronic pain patients typically have a long experience of suffering, including numerous visits to the doctor and numerous stays in hospital. The chronic nature of the pain, the feelings of helplessness encountered by patients and their families and the lack of any clear diagnosis frequently lead to a sense of uncertainty visible on the faces of patients and parents when they visit our pain station for the first time. This uncertainty is often based on experiences of being accused of inventing symptoms when no objective evidence of severe pain can be found.
We strive to nurture a close degree of contact with our patients when providing nursing care. In this regard, our first priority is to recognise the pain experienced and to take it seriously. This is essential if a relationship of trust is to be established between the patient and the nursing staff and therapists. The degree of pain experienced often restricts patients so much in their daily activities that living a normal life, involving regular school attendance, sporting activities or contact with friends, becomes more and more difficult. Our aim is to provide patient-orientated care in order to support the transition to a normal daily schedule. Meals are taken together in the lounge and the day is structured around mealtimes. This provides patients with the opportunity to get to know each other quickly. This group dynamic can in its own right have positive effects in terms of reducing the level of pain felt, according to the principle of ‘a trouble shared is a trouble halved’, and is encouraged by nursing staff to the greatest extent possible. The paediatric nurse/carer assigned to the patient assists in coordinating the comprehensive therapy programme. If motivation is lacking or if anything is unclear in any of the therapy units, further help will be willingly provided. Chronic pain often does not have any corresponding physical signs. Pain that comes in waves of greatly varying intensity is another issue addressed by nursing staff, who work to reduce the severity of the pain by applying local measures such as applying heat and cold, cupping massages or individual acute medication. Our extensive experience means that we can take an empathetic approach to difficult situations. Intensive exchanges between nursing staff and other therapists in the team is vital in this regard. This contact takes place during regular team meetings, and is optimised by professionally organised team supervision. This enables variations in patients to be reacted to quickly and strengthens the good contact between team and patient.
This way, in spite of all the pain, there is always room for fun and light-hearted, positive moments at the Station.
Training therapy
Experience has shown that pain patients benefit from an active therapy programme. Of primary importance in this programme is the skill of the therapist in motivating the patients to undergo movement therapy in spite of considerable pain.
Our children and adolescents train for at least one hour every day on various items of equipment in the fitness room. Performance is improved over the course of the residential stay. In addition, patients participate in aquatraining, dance therapy and movement games.
The frequency and enthusiasm with which most patients join in in the active therapy units, even though they usually avoid any physical activity at home, never cease to amaze us. Training therapy affords patients the quickest way of measuring their progress and provides an enormous boost to their self-esteem.
To ensure that this progress is maintained, a home training programme is developed together with the patients during their residential stay. Training in the fitness centre, jogging, cycling or swimming with friends should be planned as a regular part of the daily routine at home.
Posture and movement training
An inert posture can affect patients’ mood and personality. Posture training and improving body awareness via methods such as yoga, tai ch’i or Feldenkrais Method enable patients to improve their mood and strengthen their personality.
We optimise work movements and practice individual movement sequences in isolation. These sequences can be the continuous motion of normal walking, or a compound movement in sport, such as the serve in tennis.
Nurturing inner strength
Regaining an inner balance is particularly important for children and young people, since they pursue numerous activities and are constantly under pressure to perform. We take a holistic approach that can involve craniosacral therapy, reflex zone therapy, acupuncture or other therapies.
Creative potential is nurtured as part of ccupational therapy. Paint, clay and other materials are used to create products that children can be proud to take home with them.
Depicting their own body in different colours of paint can stimulate children and young people to reassess their negative attitude towards themselves, improve their perception of their body, or simply be good fun.
Social pedagogic care within the ‘Play and Movement' therapy unit
Once per week, members of Social Services and psychologists work together in a therapy unit focusing on movement during play and new experiences. No-one is asked to perform to the limit of their ability or to do anything dangerous or overly dramatic; rather, the objective of the ‘Play and Movement’ activity is to allow both new and familiar experiences to take place at the same time in an atmosphere of enjoyment and heightened awareness.
Patients and carers together approximate the adventure of daily life and attempt, when the weather permits, to spend as much time as possible enjoying the beautiful natural environment of the Werdenfelser Land. Sometimes, they take walks to scenic locations in the vicinity, practise archery, go on the dry luge run, play minigolf, go boating on the natural lakes located nearby, go bathing or take part in any one of a range of ‘indoor’ activities when the weather conditions are unfavourable.
Ensuring that personal contact takes place in a good atmosphere therefore plays a major role for the therapists, because the relationship between patient and carer is considered a crucial element of the curative psychosocial work carried out at the Paediatric Rheumatism Clinic. Our goal is therefore to achieve an engaging but light-hearted sense of togetherness, and thereby to promote patients' social integration, boost their self-esteem and give them courage to face the future.
Complementary therapy units
Analgesic and muscle-relaxing measures: We have a wide range of procedures on offer, and patients decide for themselves which procedures are of benefit to them. They can choose between cold and warm compresses, fango, electrotherapy, massage, swimming pool therapy and heat chambers with infrared heat. These relaxing forms of therapy are particularly appreciated by children and young people. They are not where the main focus of the treatment lies, however, since they require only passive involvement on behalf of the patients.
Prognosis
The prognosis will be determined by whether the children and parents accept the diagnosis and are prepared to make changes in their lifestyle. We can tell how successful therapy has been by the degree to which patients are integrated socially. Absences of school often fall dramatically after only the first residential course of treatment. Many children start to lead an active life at home once again and rediscover their interest in sport, music or other hobbies. Usually, although not always, this is accompanied by a reduction in the pain.
Stressful situations in everyday life can accentuate difficulties and can mean that additional therapy is required. Since the children and young people are already familiar with the treatment, however, the length of any subsequent residential stays is reduced. Sometimes a telephone call with the doctors or psychologists is enough to motivate patients and give them the strength to overcome their difficulties once more. Some patients manage to reduce the pain to a level where it is manageable on a daily basis for several months, or even in the long term.
Send Email