4.1 Introduction

Symptomatic orthopedic pain therapy concentrates on nociception in bones, muscles, tendons, and joints after the pain stimulus has already acted on the body. This means that the nociceptive process has already started. Nociceptors have been irritated, and the pain signals have been transmitted to the brain via the afferent fibers and the spinal cord. Pain has already been perceived in the brain, and the motor and autonomic reactions in the periphery have been initiated. Symptomatic pain therapy acts on the different areas responsible for the transmission and perception of pain, and the reaction to it, with the emphasis varying according to the individual type of treatment (Fig. 4‑1).

In symptomatic pain therapy, unlike causal pain therapy, the physician and patient expect an immediate response. Thus, fast-working analgesics, local injections, physical agents, and directly acting forms of electrotherapy constitute the main focus of treatment.

Symptomatic treatment in the spinal region:

• Therapeutic local injection treatment (TLIT).

• Medication.

• Thermotherapy.

• Physical therapy.

• Electrotherapy.

• Acupuncture.

4.2 Thermotherapy

In many cases, patients apply soothing warmth before consulting a doctor. Heat acts as a local analgesic, removing inflammatory mediators, relaxing muscles, and calming the autonomic nervous system. The cortex and the psyche perceive heat as being pleasant (Fig. 4‑2).

4.3 Massage

The hands are used to massage skin, subcutaneous fatty tissue, muscles, and ligaments. A variety of techniques are applied during a massage:

• Stroking and fractioning.

• Kneading and wringing.

• Cross-frictions.

Special forms of massage include reflex zone massage and connective tissue massage. The connective tissue massage technique involves a specific way of stroking with a fingertip (usually the third or fourth finger), with the hand, arm, and shoulder held in a relaxed position. The direction of the strokes is segmentally orientated.

It is important that the patient is placed in a comfortable and relaxed position during all types of massage. This particularly applies to the affected body part. Massage acts positively on local nociception by removing inflammatory mediators. In addition, the vicious cycle of pain–muscle-cramping–pain is disrupted at the muscular level (Fig. 4‑3).

Contraindications to massage arise, as a rule, from acute pain, inflammation, skin changes, and nerve root compression syndromes.

4.4 Electrotherapy

In electrotherapy, electrical energy is used for the purpose of healing. Different types of currents vary in their physical and biological actions:

• High-frequency currents in the form of short waves, decimeter waves, and microwave therapy act by warming the depths of the tissue being treated. The oscillations are too fast to excite cells directly. The high-frequency currents that are applied therapeutically start at 20,000 Hz, increase to the diathermic ranges of about 3 × 10⁶ Hz, and go up to the short-wave therapeutic range at about 5×10⁷ Hz.

• Low-frequency currents (15–250 Hz) are used in galvanization, where direct current is applied. In this frequency range, an increase in polarization or depolarization is found in the cells, with all transitional stages. A pain-relieving effect has been attributed to the constantly flowing direct current (e.g., in the form of a hydroelectric bath). Bernard’s diadynamic currents are low-frequency currents with alternating frequency and amplitude, which also act to relieve pain. The electric currents are usually applied bipolarly, i.e., using two electrodes.

• Midfrequency currents are sinusoidal alternating currents with frequencies between 1 and 1,000 Hz. The principle of midfrequency or interferential current treatment involves the production of biologically effective frequency ranges within the organism itself. In interferential treatment, two biologically nonirritant midfrequency currents (e.g., 4,000 Hz) are applied to the body using two electrodes. The frequency of the currents differs by up to 100 Hz. Their superposition results in the development of an amplitude- and frequency-modulated current with lower effective frequency, i.e., a frequency that is biologically effective within the body. The advantages of interferential treatment are twofold: the midfrequency stimulating current effectively overcomes the pain-sensitive skin and outer tissue layers, while the low-frequency currents (between 0 and 100 Hz) are first generated in the deeper tissue layers and function there as a form of pain therapy. In this way, electrical currents that cannot be applied directly from external sources at this frequency and intensity are developed at the desired location within the body. The direct action of the low-frequency current in the deeper tissue affects the autonomic nervous system and improves blood flow.

High-frequency, low-frequency, and interferential therapy act similarly on nociceptors, afferent fibers, muscles, and the autonomic nervous system (Fig. 4‑4, Fig. 4‑5).

4.5 Acupuncture

The word acupuncture comes from the Latin acus, “needle,” and pungere, “to prick.” Both traditional and classical Chinese medicine use a technique known as zhën jiŭ (= insertion and burning, referring to acupuncture together with moxibustion). Fine needles are inserted into specific points on the body. The Chinese term for these acupuncture points is shu xue, where shu means transporting or conducting, and xue means cavity or hole, because in the area of an acupuncture point there is generally a hole in the fascia through which a nerve, vein, or artery exits.

According to Heine (1987), approximately 80% of the traditional acupuncture points have an anatomical counterpart. Morphologically they can be described as perforations of the superficial body fascia tissue by a bundle of blood vessels and nerves.

The analgesic effect of acupuncture is probably due to the release of endorphins, which ease pain. According to Pomeranz (1981), the peripheral pain stimulus activates the analgesic action. This gives rise to a mechanism that acts in three stages. The pain caused by the needle prick acts as a noxious stimulus (1 in Fig. 4‑6), stimulating the nociceptor (2). The pain signals are then further transmitted to the posterior horn of the spinal cord (4) via the afferent fibers (3). It is here that the pain signals are transferred to a second neuron, which in turn transmits the pain signals up to the thalamus and finally to the cortex (5), the place where pain is localized. The body’s own opioid peptides (endorphins) inhibit the transmission of nociceptive information, acting on the synapses of the nociceptive system in the spinal cord (4) and the brain (5). Endogenous opioids are released as inhibitory transmitters from the neurons. These neurons can be thought of as part of the antinociceptive system that is activated by acupuncture (Stux et al 1993).

The classic body acupuncture can be used to treat all forms of chronic pain, acting as an adjuvant form of treatment within orthopedic pain therapy. The treatment should preferably be performed in a stress-relieving position, i.e., with the spine relaxed (Fig. 4‑7).

We have assessed pain patients during a comparative study on the effectiveness of acupuncture within the scope of pain therapy. In this study, acupuncture points were not individually chosen, but were rather based on standardized points for needle insertion (Grifka and Schleuß 1995). The study established that acupuncture using the traditional acupuncture points is significantly more effective than placebo acupuncture, where points were randomly chosen. The reported values for the total amount of pain and the highest level of pain were significantly lower for patients treated with traditional acupuncture over 14 treatment sessions than for patients treated with placebo acupuncture (Grifka and Schleuß 1995). However, the attitude of individual patients to the effectiveness of acupuncture plays an important role (Grabow 1992).

At least 10 acupuncture treatment sessions of at least 15 minutes each are required for effective treatment.

A meta-analysis demonstrated that 75 out of 88 studies showed a positive result when acupuncture was used in pain therapy (Molsberger and Böwing 1997).

4.6 Therapeutic Local Injection Treatment (TLIT)

The patient’s medical history and the results of manual medicine examinations provide important clues to the choice of site for the local therapeutic injection (see Chapter 2, “Medical History,” “Clinical Examination”, and “Neurological–Orthopedic Examination”). Further guidance can be obtained from diagnostic local anesthesia or local pain provocation using saline solutions or contrast agents (see Chapter 2, “Trial Measures for the Diagnosis of Pain”).

Local anesthetics, steroids, or a combination of the two are used for the therapeutic local injection, depending on the aim of the treatment. Pure saline solution is also sometimes used: the hypertonic solution has an osmotic effect on the edemic tissue and dilutes the accumulated inflammatory mediators.

Therapeutic local anesthesia (TLA) is a fundamental part of the TLIT. A few milliliters of dilute (0.5–1.5%) local anesthetic solution are all that is needed to switch off sensitized nociceptors and nerve fibers that have developed into nociceptors. This results in the following effects:

• Pain reduction.

• Decreased nerve excitability.

• Increased local blood flow.

Nociceptors and afferent fibers are reversibly switched off after local anesthetics have infiltrated the tissue. This abolishes the excitability of pain transmission, sensitive end organs, and the ability of sensitive sections of nerve fibers to transmit signals, and does so in a reversible manner at a local level. The effectiveness of local anesthesia decreases as nerve fiber diameter increases. For this reason, sensitive nerves are initially blocked and motor nerve fibers are blocked when high doses are injected. TLA is directed toward the sensitive nerve fibers. Local anesthetics reduce the permeability of the membrane to cations, especially sodium ions. This results in diminished membrane permeability with reduced levels of excitability.

Neurophysiologically based TLA measures break the link between muscle tension and the excitation of nociceptors (Zimmermann 1993). A nociceptor or nerve block results in a reduction in pain and nerve excitability and an increase in local blood flow for a period of 3 to 8 hours, depending on how long the applied local anesthetic works effectively. Experience shows that the pain-relieving effect is maintained longer than would be expected from the local anesthetic’s duration of action. This is especially the case with repeated administration. The state of reduced excitability continues, so that it is possible to obtain a permanent effect with a series of 8 to 12 infiltrations on consecutive days.

Infiltrating a local anesthetic multiple times into the area of nociception and the outgoing afferent fibers results in a desensitization of overactive neural elements. The frequency and intensity of the transmitted excitatory impulses that are required for pain perception and motor or autonomic reactions decline.

If chronification has already set in, the use of repeated TLA disrupts the vicious circle of adaptive posture–nerve irritation–increased muscle tension and pain at the neural level. The desensitization of nociceptors and afferent fibers, with an increase in irritation thresholds, leads to the same mechanical stimuli causing less pain. In this phase, causal pain therapy has to be implemented by relieving positioning, exercises, etc. In chronic spinal pain syndromes, the repeated use of TLA in the area of nociception and afferent fibers results in a reduction in pain perception and pain processing (Zieglgänsberger 1986).

Rydevik’s (1990) and Olmarker and Rydevik’s (1993) groups studied the reactive inflammatory changes in nerves and nerve roots (e.g., due to prolapsed intervertebral disk tissue). They demonstrated that a defined chronic compression evokes an inflammatory and edematous change in the nerve root. This change can be largely prevented by the use of lidocaine injections (Yabuki et al 1996).

Most local anesthetics also act as vasodilators, so blood flow increases markedly in the infiltrated area. However, this also means that injected medication is more rapidly removed by the circulatory system. In most cases, however, there is no indication for the addition of vasoconstrictors to the local injection treatment used for spinal symptoms. Notable specific side effects of the administration of local anesthetics are cardiovascular complications when the blood levels are too high, and allergic reactions. These complications are rare, however.

A maximum of 10 mL of 0.5 to 1% local anesthetic is used at each injection treatment session in order to avoid elevated blood levels. Intravascular application is avoided by constant aspiration.

4.7 Orthokine Therapy

4.7.1 Causal Therapy with Interleukin-1 Receptor Antagonist Protein (IL-1Ra)/Orthokine/EOT Technique

As early as the 1920s, in connection with research into tuberculosis, there were already speculations that special proteins act as messengers in “cell communication” (Zinsser and Tamiya 1926). Since then, a succession of new proteins has been characterized and increasingly complex networks of messengers have been discovered, initially with inconsistent nomenclature. In 1991, all mediators were for the first time grouped together under the term cytokines, and a systematic naming system was introduced (Klein 1991).

Interleukin 1 (IL-1) was first described in 1940, under the name “endogenous pyrogen.” It was subsequently found that this protein can be detected in all cells of the body, and that IL-1 receptors exist (Dower et al 1984).When the biological actions of IL-1 were studied, it was found to significantly participate in the genesis and maintenance of acute and chronic inflammation as well as in the destruction of tissue. The nerve root, along with the articular cartilage, is an important target tissue in this context. In nerve root compression syndrome, pain mediators, IL-1 in particular, are released at the nerve root coursing there and cause a local inflammatory process.

Interleukin-1 receptor antagonist protein (IL-1Ra) is the only naturally occurring antagonist so far discovered within the cytokine family (Liao et al 1984). More precise studies and experiments were able to demonstrate that a disproportionate ratio between agonist and antagonist seemed to govern certain disorders (Lennard 1995).

As it acts by binding to the IL-1 receptor, the competitive binding of receptors seems to play a decisive role in pathology. An excess of IL-1Ra has to be present to repress IL-1 enough to antagonize its biological actions (Arend et al 1990; Seckinger et al 1990). This is the starting point for Orthokine therapy using anti-inflammatory substances in the form of autologous IL-1Ra, which have an anti-inflammatory effect, are antiedemic, and are pain relieving.

Human IL-1Ra has also been successfully cloned. Recombinant IL-1Ra has been successfully applied experimentally and in the treatment of rheumatism, where it has been used as a systemic treatment by means of subcutaneous injection (Carter et al 1990; Arend et al 1991b; Smith and Arnett 1991; Campion et al 1996; Bresnihan et al 1998).

Recombinant IL-1Ra has, however, several disadvantages in comparison to the autologous substance. The glycosylation of the protein varies between individuals, and it appears that higher surplus concentrations of the recombinant version are needed to repress the IL-1 at the receptor. In addition, a reaction occurring at the point of needle insertion has frequently been observed (Antin et al 1994; Bresnihan et al 1998). Finally, as the human DNA is combined with additives, the possibility of potential allergic reactions should be considered.

It is possible to manufacture autologous IL-1Ra using the EOT technique. To this end, a special technique is used to prepare the patient’s own blood and apply it in the form of an autologous conditioned serum with a spinal injection (Fig. 4‑10, Fig. 4‑11, Fig. 4‑12, Fig. 4‑13, Fig. 4‑14, Fig. 4‑15, Fig. 4‑16, Fig. 4‑17, Fig. 4‑18).

It is known that natural IL-1 and IL-1Ra occur to a greater extent in the monocytes of the human blood. It was also proven that certain surface structures stimulate the production and distribution of IL-1Ra. When preparing the patient’s blood, the property of the glass beads contained in the Orthokine syringe or EOT syringe with their special surface structure is used to stimulate the monocytes to produce larger quantities of IL-1Ra.Thus, after an incubation period of 6 to 9 hours at 37°C (Fig. 4‑12), a concentrate of autologous conditioned serum enriched with IL-1Ra develops that is centrifuged and then extracted sterilely and frozen (Fig. 4‑13, Fig. 4‑14, Fig. 4‑15, Fig. 4‑16). With the injection of the autologous concentrate from IL-1Ra, the inflammatory process at the nerve root (Fig. 4‑18) can therefore counteract the cause of the pain. It can be assumed that the less the initial damage is, the longer the effect will last.

In medical terms, Orthokine therapy can be repeated as often as necessary if it works well and the effect is long-lasting. The injection intervals are based on the individual outpatient or inpatient treatment plan, depending on the disease presentation and the severity of the symptoms.

4.8 Adverse Effects of Orthokine/Cortisone

Compared to the cortisone and analgesic preparations commonly used during injections near the spine, Orthokine has nearly no side effects. Especially patients with back pain with recurrent symptom peaks undergo repeated injections and can benefit from an alternative therapy that is nearly free of adverse effects. This is particularly interesting for patients in whom cortisone can be used to only a limited extent, such as patients with diabetes or cardiovascular diseases, e.g., labile arterial hypertension. Orthokine does not increase blood glucose or blood pressure and does not cause any gastrointestinal discomfort.

Fig. 4‑19a–f shows the original documentation of a male patient with insulin-requiring diabetes and blood glucose regulation with an insulin pump who underwent, inter alia, treatment with spinal injections for a spinal syndrome. The patient was given both a cortisone injection (triamcinolone 10 mg) and an Orthokine injection. As can be seen from the documentation log of the insulin pump and the patient’s remarks, one low-dosage cortisone dose (triamcinolone 10 mg) as a periarticular facet infiltration already led to pronounced blood glucose fluctuations (Fig. 4‑19a–d) that clearly complicated insulin adjustment and, in turn, created a very high risk of hypoglycemia.

In contrast, the blood glucose trend of the insulin pump log in the Orthokine injection period (Fig. 4‑19f) was similar to that of the injection-free period (Fig. 4‑19e).

Systemic adverse effects on the Orthokine itself in the form of allergic reactions are not known. The patient is advised to avoid activities involving physical exertion on the day of the injection, such as participating in sports or using a sauna.