How nice it is to have news that you’ve been waiting for, to relieve the pain. Years later, one day somewhere, you come across the cookies your mother made for you when you were a kid. The sun that shines after the rain, entering a warm house from the icy street, lying in bed when exhausted, your favorite team defeating its arch-rivals, waking up with the smell of toast in the morning, leaving the door of a doctor’s office with the joy of dispelling doubts, how beautiful it is. And how nice it is to receive a warm hello from your friends and loved ones. I want to start by saying hello to all of you. I would like to thank the organizing committee, Tümata group, my esteemed chairman Oruç, and all the other participants for inviting me here. Especially after Verres’ wonderful presentation of this beautiful multi-snapshot, I’m going to compare you to some more solid stuff. When we say pain, what we do, I will start from there first, then I will try to reveal what we do in pain.
Look, Abdin Dino compares us with such a caricature while drawing pain. And a relative of mine, Sultan Çakıcı, who died at the age of thirty-five from gynecological cancer, says in his own words: “I am afraid of sleeping at night / dreaming, dreaming / expressing my thoughts, suffering”. “I am afraid of laughing, crying, afraid / living with these fears all the time…” We lost the Sultan at a young age, but his lines still decorate my speech and he says that everything is a pain, birth is pain, sickness is pain, old age is pain, death is pain, because of his love. With these lines, Buddha reveals that separation is pain, even hatred is pain. And he really says that the worst of the pain is living with the pain. After all, Hippocrates said that “pain relief is the art of God, because it is even more terrible than death”. That’s why we algologists may think for a moment that we become divine when we relieve pain. This is not megalomania. Because millions of people around the world still continue to experience both moderate and severe pain, especially for cancer and non-cancer reasons. And today, headaches, backaches, neck pains, toothache-related pains, knee pains are things we all encounter in our daily life.
Turkey’s pain map was drawn up in a study conducted in Turkey. In a study conducted with the participation of four thousand people in seven regions, the distribution of pain types according to regions, gender and age was revealed. Their living standards and social status were examined. The Eastern Anatolia region is still the region that suffers the most. And it has been seen that 69 percent of Turks, that is, 48 million people, still live with pain, and they are mostly faced with headaches. Women feel more pain than men and it has been revealed that 10 percent of Turkey’s population still cannot have sexual intercourse due to pain. And it has been revealed that 85 percent of those experiencing pain resort to medication and the most commonly used pain reliever is aspirin. It was revealed that those who were exposed to pain changed at least three doctors in diagnosis and treatment, that is, they went from doctor to doctor. Today, again, 50% of these chronic pain sufferers feel tired, 11% can’t walk, 10% can’t have sexual intercourse due to pain, and 36% are ready to spend all their money, so “doctor save me from this, all my money is yours.” never mind!” Studies show that 55% of them still think about death, that is, they mention suicide.
In a study we conducted at Gazi University, we conducted a one-day pain questionnaire. In our current study on hospitalized patients, 511 patients were included in the study in 38 departments. It has been revealed that pain scores are high even at rest, ie 71%, and they still experience insomnia due to pain, and they have pain even in their beds in hospital conditions. Therefore, pain is an indicator of the deterioration of the bio-psycho-social balance and harmony of the organism in general. I want to draw your attention here, bio-psycho-social. We cannot rule out biological, psychological and social factors. But pain is always personal, it varies greatly from person to person; Gender, language, religion, race, socio-cultural environment seriously affect the pain threshold. But the important thing is that pain should be considered as real by physicians. Even if we cannot find an objective finding, I would like to emphasize that we should not immediately classify your pain as psychological. I am saying that pain, which is perhaps one of the most common symptoms faced by human beings today, should not be treated as a mere finding but as a disease today.
We will definitely consider pain as a complaint that needs to be taken seriously, but we have to see chronic pain as a disease as well. Because studies have revealed that 700 million work days are lost and 60 billion dollars of damage occurs every year, especially due to chronic pain. And today, the European Pain Federation has issued a declaration against pain in Europe, saying that pain relief is a right to health. Today, I have seen the reflections of this situation in Europe in Turkey. Turkey pain association started its studies. We have joint works with the European pain association and the current president of the European pain association is a Turk. And when I say this, I say it very proudly. Serdar is our teacher.
But when we look at the facts, we still have places on the walls whose phone numbers are given to treat herniated disc. Therefore, we all know that those who fall into the sea hug a snake when we really deal with our people. For this reason, I would like to emphasize here that pain treatment is a necessary thing, that chronic pain is a disease on its own, and that many branches of medicine in general are related to this disease, and that it should be handled in a multifaceted manner, not by a single branch, but by a team when necessary. That the treatment is a team effort, that surgical departments, psychiatry, physical therapy, neurology and algology are important in this team, that patient education and psychotherapy are undeniable, that pain can be relieved with drug therapy, physical therapy methods, nerve blocks, intra-articular injections, radio frequency methods or surgical methods. I want to point out that it can be treated. And therefore, today, algology disciplines have been established in medicine, and there are algology disciplines in 22 universities in our country, there are algology disciplines in our training hospitals, and the pain specialists dealing with this have now accepted the ministry, we as pain specialists and our teachers who work to raise the younger generations after us is important. In this way, I want to say that pain is no longer destiny.
When we take a look at the pains that we treat with algorithmic approaches, cancer pains in particular, neck pain, shoulder-arm pain, low back pain, neuropathic pain, pain of unknown cause, headache, facial pain, back pain, vascular system-related and Post-traumatic pain, in general, all kinds of pain can be treated by algology disciplines. For this, it is important to evaluate the patient in detail, you have to listen and examine the patient for at least half an hour. Then the treatment is oral, analgesic treatments, painkillers, interventional methods, these are Trigger Point Injection, nerve blocks, somatic or sympathetic nerve blocks, depending on the location of the pain. When we consider the patients who have had discectomy methods by entering the disc when necessary, or steroid injections into the epidural region, or who have had three or four low back surgeries, which we call Epidural Lysis, and who are currently visiting doctors and doctors because of adhesions and my leg aches, we have to emphasize the epidural lysis methods applied to them. Facet joint injections, especially in patients with low back pain, I would like to point out that not every patient with low back pain has a herniated disc, and their facets should be thoroughly examined. Of course, hip joint pain and radio frequency, thermal radiation applications are another of these applications. The important thing will be handled with the awareness of the team, thus relieving the pain in a much shorter time will prevent us from losing both time and money.
When it comes to being in the right place at the right time, that is, the right diagnosis and treatment, of course, this is an advertisement, we call Gazi University Medical Algology Department, but currently, algology disciplines have been established in 22 universities and these treatments are possible. We started this business in such a small room in 1984, but today we provide this service with a modern three-bed system and team, with at least three doctors, nurses, one staff member, one cleaning service staff. And these services can be provided in operating room conditions, under x-ray, under scope, and under sterile conditions. I have just mentioned that, with the election of Serdar Aydın teacher for the European term presidency, international meetings are held in our country, as in the world, on pain. The last time we held it was in 2008, and in 2009, these meetings will be held in the coming periods.
When pain is mentioned, it is necessary to distinguish neuropathic and nociceptive pain well. While nociceptive pain occurs with the deterioration of the tissue, which are pains that manifest themselves as burning, tingling, heat sensitivity, electric shock, it is now concluded that more diabetes patients, post-shingles, post-herpes patients, such as carpel tunnel, even lumbar hernia are a neuropathic pain. studies are presented. Here are the days when we feel really bad when we encounter chronic pain such as burning, stinging, electric shock pain. But the important thing is the necessity of good treatment of acute pain. If acute pain is not treated well in time, it can become chronic. For him, it should never be forgotten that problems that seem small can grow over time.
I would like to say that the incidence of pain such as diabetic neuropathy strokes, strokes, Postherpetic neuralgia, cancer pains, Carpal tunnel syndrome is high in the society when it becomes neuropathic pain. Therefore, if it is treated in the acute period, then it does not become chronic, and if this relationship between pain, sleep and anxiety, that is, this vicious cycle is interrupted in time, the patient will not become chronically painful.
Pain treatment is one of the most important tasks in health care. And today, pain control methods include drugs, physical medicine methods, which we call non-invasive methods, psychological methods, invasive methods, interventional methods, surgical methods when necessary, and then complementary methods, as discussed today, among the treatment methods aside, without denying or discarding them. We are in the situation.
The important thing is to know that pain is indeed undertreated. We have to act knowing this fact, otherwise we know that it is not necessary to kill the patient to relieve the pain. I can give a high dose of morphine to relieve a patient’s pain, but there is no need to kill the patient. The right place, the right dose, the right place to use morphine. Today, analgesics are used by the world health organization within the framework of usage principles. In other words, it provides symptomatic control of pain, analgesic effects are increased and side effects are minimized. When using them, increasing the quality of daily life, providing painlessness at rest, movement and sleep, this is the main thing, especially for cancer patients. To provide painlessness both at rest, in motion and during sleep.
For this, we primarily use analgesics, namely painkillers, orally, we prefer. When it gets better, we give it at intervals and before the pain starts. Currently, I have a patient who takes painkillers six times a day, I have a patient who takes painkillers three times a day, and I have one patient who takes painkillers. The important thing is to give the medicine at regular intervals according to the patient’s pain before the pain starts; otherwise, the way of application is wrong. That’s why we have to give before the pain starts. While it is certain that a patient with pain will have pain after the operation, it is not the right method to give painkillers when it is known that he says he has pain. We anesthesiologists already do this for post-operative pain.
Patient-controlled methods of analgesia, we put a device in the patient’s hand, press a button, relieve his own pain. We have now started to apply this to chronic pain.
Therefore, step treatment is the step treatment put forward by the World Health Organization, pain, increasing pain, starting with simple analgesics first, then continuing with morphine-like drugs, which we call weak opioids, and then the strongest opioids, namely morphine group drugs, at the top. , give to the patient at the top of the ladder.
And today, especially cancer pain, up to 95% of pain can be treated and controlled in pain centers. I’m really saying for cancer pain, when it is not treated adequately, 69% of patients commit suicide, studies have shown this. Therefore, when it is not treated, we have to treat it, knowing that it has a significant impact on his daily life activities, emotional life, motivation, interaction and communication with family and relatives, that is, his quality of life. At the top, we treated with ablative methods, that is, with drugs, we applied other methods, and at the top, we used other methods of destroying the nerves, now completely desensitizing the nerves. I’ll come to that a little later with slides. And especially in cancer patients, the patient’s pain is controlled with special devices that we call morphine pumps, thin probes placed in the spine and pumps, where the patient can take the desired dose of morphine by himself. And morphine, as you really know, comes across as an opoid, morphine-like, and natural synthetic drug that is also derived from hashish, which we use as the gold standard today. But when it comes across as weak or strong effective drugs, for example, you stick a tape on the body as you can see below. This patch stays on the patient’s body for three days and can control the patient’s pain by secreting a certain amount of the drug into the blood. The patient can control the pain by removing this tape by himself, by removing it and changing this tape every three days. But when sticking this tape, it is not like sticking dozens of tapes all over the body, as you can see. To show that this app is not the right app.
There are some rumors about morphine. Morphine is addictive, tolerance develops, respiratory depression, constant analgesic conditioning, what we can call superstition. If you use morphine in the right place and in the right dose, it’s okay. But is there addiction? Yes, there is addiction. For patients who never use drugs, look, it has been revealed that addiction is rarely seen at a rate of one in ten thousand. Physicians are still afraid of prescribing morphine, that is, doctors are already afraid and hesitant to prescribe morphine right now. Of course, patients are also afraid, patients are also afraid of it. But in the end, fear is of no use, the important thing is that if the doctor and the patient communicate well and understand each other’s language and the common language, it is possible to solve the problem in this way.
We said invasive methods, that is, neuroablative methods, neuro-modulative methods, methods performed under operating room conditions, and we will look at them. I said radio frequency applications, neuroablation methods.
Of course, think about it this way, please, a patient with low back pain, all kinds of doctors are treating low back pain today. As you can see here, GPs, GPs, neurologists, rheumatologists, physical therapists, neurosurgeons, orthopedists, acupuncturists, physiotherapists, massage therapists, everyone treats. But when a patient with low back pain enters the hospital, when he takes a step, if a physical therapist catches him, he applies physical therapy, if the surgeon catches him, he performs surgery, if I catch him, I stick a needle. Then, we have to reveal that such a method is not correct and that we all have to speak the common language. So this job has a sequence, a sequence, a ladder system, we have to implement that system. That’s why, if it gets better with non-invasive methods, physical therapy methods, drugs, massage, it is very nice. If it does not improve, I will apply my methods again, if my methods do not benefit, the surgeon will operate if there are surgical indications. Therefore, it can be said that no one should undergo surgery for a herniated disc without urinary incontinence, without stool incontinence, without severe paralysis and without falling.
Here is facet denervation, a dog model as you can see here, if I stick a needle in the dog’s eye, under a scope, operating room conditions, under x-ray. Or you can see the patient below, who has undergone three brain surgeries, and you can see how the radiocopies have dispersed, he has four or five nails, placing the appropriate catheters on this patient, placing morphine pumps intrathecally and epidurally when necessary, a simple surgical intervention, a one-centimeter incision. It is possible to do this job, by placing the morphine pump, we can do these in operating room conditions under sterile conditions and without seriously anaesthetizing and putting the patient to sleep.
When you place such a pump, it is possible to control the patient’s pain. Sympathetic blocks have a very serious place in cancer pain. In a patient with facial pain in head and neck cancer, stellate ganglion blockade; you have seen here, by inserting a needle in the side of the neck and applying radio frequency, or in a stomach pancreatic bowel cancer, Celiac ganglion blockade is done with a needle by entering it from the side of the stomach, from the back or from the front, or in a coccyx, a rectum, a gynecological cancer. It is possible to control the ganglion or the coccyx by entering it with a needle and seeing it under x-ray. Trigeminal neuralgia in the head area. Serious problem, facial pain, can’t eat, can’t brush his teeth, a patient who is uncomfortable even with the wind, comes with a lightning-like pain on his face, as you can see a radio frequency application, just under his eye, on the side of the chin with a needle, find the nerve and see it under X-ray. remove the nerve. Or facet denervation in a neck pain, Suprascapular nerve Pulse RF application in a patient with shoulder pain can be tried, all are possible.
In a patient with foot pain and in a patient with Morton’s cyst, we can eliminate the pain of that cyst by applying radio frequency again.
Vertebroplasty is to place a cement in cases where the spine collapses and the bone collapses, which neurosurgeons, orthopedists and we can apply today. Or we can control the pain by giving electrical stimulation with a pasha catheter.
Therefore, if we look at the event as the blind look at the elephant, the events in question grow seriously, one says a giraffe, one says a whale, one says a snake, one says a hippopotamus, but the sick, that is, an elephant, should never think about what I am.
Therefore, beyond these, there are complementary medicine techniques, a neural therapy is now applied by neural therapists, for all kinds of pain you see here. I would like to state that the pain of the patient can be controlled by giving local anesthesia from the lower and upper poles on both sides of the tonsil, or by making local anesthesia injections and small needles to certain points on the head, certain points on the hand, certain points on the hip or waist, certain points on the shoulder.
Another thing that is up to date, you see very often on television these days, ozone therapy. Ozone, medical ozone, consists of a mixture of oxygen and ozone. Today, scientifically proven and large numbers of scientific articles have started to appear. As you can see here, we can use ozone in all kinds of non-healing wounds, especially in allergic or asthma patients, in intestinal patients in patients with colitis or spastic colon, or in patients with multiple sclerosis, as well as where we use ozone in chronic pain and all pain treatment. maybe there will be an answer. Ozone can be injected into the intestinal, i.e. ruptured disc, as can be seen here, ozone is injected into the knee joint for knee pain, and in the study on this, 68 of the 97 patients I have done are currently above moderate, that is, with a pain score of above 7 and a success of 70%. It’s a disease I have. As can be seen, after a simple infection was cleared with local anesthesia and only one needle sticking to the knee, the patient felt no pain at the end of a five-session application, and we achieved a recovery of over 70%.
So what did we do with music therapy? It is a news in the newspaper Hürriyet that they relieve pain with music at Gazi University. We recorded a significant decrease in the pain scale of the patients after music therapy. With this study, we showed that the pain scales you see here decrease, and that after music therapy, hormones such as acth and cortisol show a decrease in pain. However, this study has not yet been published in a serious scientific journal, since the number of subjects is low at the moment. This study is still in progress, if we increase the number of subjects of this study, I hope we will publish it.
Yes, I believe that great people know how to listen and I hope you listen to me like this, I think that our lives continue without ever forgetting our debt to millions of martyrs who died for our country, just as Atatürk listened to this villager and citizen, and today, at the point where our country has come. and thank you.
Gazi University, Head of Algology Department. Ankara
