Author Archives: Dr M Kittel

Painkiller use in Chronic Pain

Note, this article is written for the UK and things may differ in other countries

What is chronic pain

Chronic pain is pain that is not helpful for the sufferer. Acute pain is usually helpful as it tells the body something is wrong. For example, you put your hand on a hot surface, the pain quickly tells you to remove it. Afterwards you may have pain because you have a burn and you will do the right thing i.e. put cold water over it. Not so in chronic pain. Chronic pain often represents a pain stamp in the brain when the acute pain has long gone.

“but my pain is real, I know I have back pain, it is always there”

In some cases this is the case i.e. if you have a disk prolapse and therefore severe back pain. But this is not typical chronic pain. In typical chronic pain you have been investigated and little or no cause has been found and you still suffer the pain.

If chronic pain is not caused by a pain stamp in the brain it is often caused by the following

  • Physical inactivity (who doesn’t get back pain when they sit in a chair for 12 hours?)
  • Obesity (if you put 80 tons of the axles of a 40 ton lorry the axles wear out quicker)
  • Lack of exercise (classic example: Patients with dementia in a nursing home sitting in a chair all day. Studies have shown taking them out of the chair a few times a day is better than giving regular painkillers)
  • Other poor lifestyle choices (i.e. diet, smoking, alcohol etc – a classic example are osteoporotic fractures of the spine and elsewhere, terribly painful and often caused by smoking, alcohol and lack of core strength)
  • Aging (with all of the above – yes, sorry, but our joints degenerate and pain becomes more common in older age – I always say weaker joints need stronger muscles)

The classic example “Phantom Pain”.

There is no better example than a sufferer of so called phantom pain. This is for example a patient, who has had their leg amputated and still has severe ankle pain. This ankle pain may even get worse in cold weather etc, just there is no ankle. This usually represents a “pain stamp” in the brain

“So if I have pain, I’ll take painkillers – Right?”

Correct, in acute pain painkillers are a great relief and there is usually no problem with taking painkillers for a short time (unless you are allergic etc). However, again a good example on what not to do is my own son: He had shoulder pain when playing too much table tennis in training and we gave him painkillers instead of telling him to rest or sending him for physio. He continued heavy training sessions. This causes a lot more serious shoulder problems. So if your child has injured themselves on the trampolin, don’t give them more Nurofen just to go back onto the trampolin.

However, in chronic pain painkillers are better avoided. Why – 3 reasons:

  1. Tachyphylaxis.
    Tachyphylaxis means you are getting used to them and need more and more. Simple example. Today you take a Paracetamol for a stomache ache. You never take painkillers, it works perfectly. Over the next month you take it a lot more. Everytime you take more your brain feels cheated. They work less and less. You contact your doctor for more painkillers
  2. Hyperalgesia
    Hyperalgesia is another concept, which affects particularly Opioid Painkillers, for example Morphine, Tramadol, Pain patches of all sorts including Buprenorphine, Codein, Dyhydrocodein and more. This means the brain feels even more cheated and instead of reducing the pain the pain gets worse and worse and you need more and more painkillers yet have more and more pain.
  3. Side effects and long term effects. See example of a list below
Type of Painkillers Main issues
Paracetamol (US: Acetaminophen) Most commonly used painkiller, very toxic in overdose, can cause liver damage.
Ibuprofen and other anti-inflammatories Increases blood pressure, damages kidneys, reduces kidney function, can cause stomache ulcers and serious stomache bleeds.
Codein, (Co-Codamol (UK) Severe constipation, tachyphylaxis, hyperalgesia, nausea and sickness, addiction
Dihydrocodein, Co-dydramol (UK) Severe constipation, tachyphylaxis, hyperalgesia, nausea and sickness, addiction, driving offense*
Pain patches – usually opioid containing with few exceptions Constipation, tachyphylaxis, hyperalgesiia, driving offense*
Morphine Constipation, tachyphylaxis, hyperalgesiia, driving offense*
Gabapentin Tiredness, mood changes, tachyphylaxis,
Pregabalin Addiction, weight gain, memory problems, headaches, sleepiness, driving offense*
Amitriptyline Constipation, Dry mouth, heart problems, falls in the elderly, must not drink alcohol

*In the UK driving when on controlled drugs (most prescription painkillers) is not completely prohibited, but if you cause an accident while taking them you could be criminally prosecuted, particularly if others are involved.

So, in the table above you can see there is simply no painkiller that is good for you long term. They all have side effects to various degrees. When addressing chronic pain, alternative concepts should be applied.


Other methods, non-medical and non-pharmaceutical should be used and painkillers should be weaned as soon as possible. CBT (cognitive behavioural therapy) for example is a great way to train the brain to ignore pain


Feeling safe in a restaurant / pub during COVID-19

Its not difficult to be COVID safe, but it takes thought, training and some investment

Last night (7/7/2020) I went to a local restaurant with my wife, who is a nurse. The food was excellent, the service impeccable, the staff wore face masks or visors. But the whole experience did not feel very COVID safe. And their website says nothing about what changes they have implemented. There is a lot of advice out in the open how to run a COVID safe service for staff and clients, for example here However, while I am no expert in how to run a good kitchen, we certainly run a COVID safe surgery and below some ideas on what I will look for for my next restaurant / pub visit:

  1. The restaurant / pub states on their website what COVID safe changes they have made (if this is not the case, it may indicate management hasnt’ thought this through or doesn’t care. Restaurant / pub owners had 3 months to think this through and inform themselves).
  2. Staggered bookings are made so clients dont have to wait in a crowded space
  3. Handgel station at the entrance and both sides of toilets. Paper towels. Signs, like on cruise ships, to use paper towels to open toilet doors. Paper towel bins on both sides.
  4. Check regularly soap and handgel isn’t empty, nothing worse than 40 people pressing the lid of an empty dispenser.
  5. Social distancing signs on  floors.
  6. Printed single use menus on normal paper inspire more confidence than laminated menus that dont get wiped when the heat is on and distributed to different tables…
  7. Single use condiments (sachets) rather than salt and pepper in glass containers
  8. Staff wear face masks / visors
  9. Staff have the opportunity to gel their hands frequently with dispensers on the walls
  10. Tables get wiped after every visit with soapy water or use single use paper table cloth
  11. Paper sheets under plates and where cutlery lies.
  12. Staff wear some form of ID saying they have been COVID trained and are COVID aware.

All the above would inspire confidence. In terms of the restaurant we went to yesterday I will keep monitoring their website and see what management and the owners do and once they have implemented a COVID safe way of working we will definitely return.

In the meanwhile I would suggest that as many of us as possible ask COVID questions to pubs and restaurants when we are booking, so they understand the general public wants to be protected and it is good for business to be COVID aware, COVID equipped and COVID trained.

Dr M Kittel, July 2020


Viral Gastroenteritis Diet

Self-care for adults:

BRAT diet

For vomiting, follow these instructions in order:

  1. Do not eat or drink anything for several hours after vomiting.
  2. Sip small amounts of water or suck ice chips every 15 minutes for 3-4 hours.
  3. Next, sip clear liquids every 15 minutes for 3-4 hours. Examples include water, sports drinks, flat soda, clear broth, gelatin, flavored ice, popsicles or apple juice. Do not drink citrus juices or milk. Increase fluids as tolerated.
  4. When you can tolerate clear liquids or diluted apple juice for several hours without vomiting and if you’re hungry, try eating small amounts of bland foods. Try foods such as bananas, rice, applesauce, dry toast, soda crackers (these foods are called BRAT diet). For 24-48 hours after the last episode of vomiting, avoid foods that can irritate or may be difficult to digest such alcohol, caffeine, fats/oils, spicy food, milk or cheese.
  5. When you can tolerate bland food, you can resume your normal diet.
  6. Kefir can help to re-populate the gut with good bowel bacteria, but use the sugar free versions.

Retake medications if vomiting occurs within 30 minutes of taking usual medication. If you vomited after taking oral contraceptive pills, use a back-up contraception method for the rest of the month.

If diarrhea is the only symptom, try Imodium, a non-prescription (over-the-counter) medication available at any pharmacy according to package directions. Follow a bland diet (see 4 above). After the passage of a soft, formed stool, you can resume a normal diet. Call for medical advice if you have no improvement within 48 hours after starting Imodium.


Warts and Verrucas

Topical treatment for warts and verrucas

Topical treatment includes wart paints containing salicylic acid or similar compounds, which work by removing the dead surface skin cells. I recommend Salactol Paint.
The paint is applied once daily. Treatment with wart paint usually makes the wart smaller and less uncomfortable; 70% of warts resolve within twelve weeks of daily applications.
• Soften the wart by soaking in a bath or bowl of hot soapy water.
• Rub the wart surface with a piece of pumice stone or emery board.
• Apply wart paint or gel accurately, allowing it to dry.
• Cover with plaster or duct tape.
If the wart paint makes the skin sore, stop treatment until the discomfort has settled, then recommence as above. Take care to keep the chemical off normal skin.

How about other methods?

Other methods have scientifically not proven more successful and are often not available on the NHS


  • Not trying for long enough
  • Not being persistent with the treatment


Dr Kittel’s Mental Health Resources – Bracknell

Adult Mental Health

Image result for mental health

Find below a list of Mental Health Resources that you may find useful for your own Mental Health journey. You may also wish to register on this website (see registration section on the right hand side) for occasional non-promotional local NHS information emails by Dr Kittel and Forest Health PPG.

  1. A list of Mental Health Self Support Messages by Dr M Kittel
  2. A list of counselling and other support organisations in and around Bracknell. For direct access to IAPT during COVID-19 click here
  3. The excellent “Books on Prescription” service by Bracknell Library
    1. A prescription form
    2. A synopsis for every book
  4. PHQ9 and GAD7 are good markers of Depression and Anxiety, respectively. You can self score for depression here: and for anxiety here Please send the results of the completed forms to me / the GP who has pointed you to this website.
  5. NEW: Probiotics appear to be excellent self help in reducing depression. See here for more information

Child Mental Health

Click here for a self help leaflet on Child Anxiety


Back Pain – Tips and tricks


Low back pain and Sciatica are incredibly common conditions in highly developed, civilised societies. According to some reports, more indiginous societies (i.e. tribes in the Amazon etc.) rarely suffer back pain. This is probably due to better core strength in less civilised peoples.


What should I do with acute back pain in a nutshell: 5-point plan:

  1. Initially, take painkillers that you are not allergic to i.e Ibuprofen (beware indigestion) and / or Co-codamol (beware constipation) over the counter and take them regularly for a few days. Always read the drug information sheet in the pack. Don’t take them long term.
  2. Read the NHS write up on back pain, it contains lots of good information.
  3. Buy Robin McKenzie “Treat your own back” (see below)
  4. Ask your doctor  to refer you for physio if your backpain hasnt improved after 2 weeks or see your practice physiotherapist.
  5. Contact your doctor, should you have any “red flag symptoms” described in the NHS leaflet.
  6. If you suffer chronic back pain, improve your core strength with Pilates. There are many free courses, I am using “Trifecta Pilates” for my own back pain successfully. There are many sessions online.

More on Low back pain and Sciatica

These 2 conditions are the most common ones causing patients pain and disability. There is a really good overview on the NHS website . However, there are a few additional resources that I  would like to share.

  1. The Book: Robin McKenzie, “Treat Your Own Back” for a quick fix.
    • This is a 30 year old book based on a 60 year old method that my own doctor recommended to me and truly, with a few stretches, a lot of people are able to improve their back pain quite significantly. Thus, I believe it is the best £10 I ever spent on my own back.
  2. StartBack Tool
    • The StartBack Tool is a good tool to assess the chance of Chronification in Low Back Pain. Click here to download and complete it. The scoring method is explained on the second page. If you score highly, seek help early, as you are much more likely to suffer this condition for a long time.
  3. The Back Pain Booklet
    • Almost 20 years old, this booklet is still very relevant and helpful. Click here to download this file. It is double sided A5 and a bit tricky to print, but the content is very good

Why an MRI scan is commonly a useless investigation

An MRI scan is a tool to get a good 3D photograph of our spine. It is very sensitive to abnormalities like disc bulges, slippage etc. However, many people with disc bulges lead completely normal lives without any symptoms. Equally, people with entirely normal MRI scans suffer severe back pain. Click here for MRI scan results of the spine for normal people without back pain.

Should I see my GP with Low Back Pain?

Most GPs are not well placed to treat Low Back Pain. Apart from painkillers, with a various degree of side effects and health hazards attached to them, they often can do little to help back pain. However, many practices now employ senior physiotherapists (First Contact Physiotherapists), who can be helpful in the assessment and treatment co-ordination of Back Pain.

Of course there are exceptions where Low Back Pain has more serious causes and there is a good summary on the NHS website quoted above. If you think your symptoms may be more serious, you should see a health professional quickly.

What about painkillers?

Taking Painkillers short term is fine, but they suppress the pain, dont cure the problem. They also have lots of bad long term side effects (the affect your kidneys and increase your blood pressure, cause bowel spasticity and more_)

And very quickly, they become less effective. We call this “Tachyphylaxis” and furthermore, in patients taking long term painkillers there is a phenomenon called “Hyperalgesia”. I have seen it many times: Patients on long term painkillers have awful amounts of pain, some patients ended in suicide. And on top of this, a lot of painkillers are controlled drugs (CD4). So, if you are involved in an accident and driving with them you could end up in prison. You may have heard that half of the US is addicted to Morphine based painkillers.

So remember, grabbing painkillers is an easy short term solution, but pain is there for a reason. Back pain usually tells something i.e. that more needs to be done to strengthen your back and that you may sit too much. So, dont allow long term painkillers to rule your life, take action now. Take a fitness and lifestyle changing approach. Think “what can I do to make myself better” rather than medicalising what is essentially a social problem and often caused by too much sitting and too little activity / too little core strength.

Dr M Kittel, March 2020



A Kidney Friendly Lifestyle

Key Messages for good Kidney Health

  • Increase your vegetable intake massively (at least 5-a-day, better 9-a-day!)
  • Reduce salt in your diet (kidneys have to get rid of all salt from the body)
  • Reduce your protein intake significantly (protein clogs up kidneys).
  • Reduce fats and sugar in your diet (general drivers of obesity)
  • Reduce pesticides and environmental contaminants in your diet (again a lot of what both kidneys and liver do is getting rid of those)
  • Eat fresh food, cook yourself (avoid additives and bad fats, know what goes into your dinner!)
  • Avoid food additives, the list is endless.
  • Drink Plenty (unless you have very advanced kidney disease, here you need fluid restriction)
  • Be active, do plenty of exercise (general fitness helps your kidneys, too)
  • Stop smoking (always toxic, vaping is less toxic overall)
  • Alcohol in moderation.
  • Loose weight (obese people have a higher risk of kidney problems)
  • Be very careful with painkillers (i.e. Ibuprofen is a real enemy of good kidney health)
  • Research your kidney friendly diet, CKD etc online, start here


Kidneys and CKD (Chronic Kidney Disease)

Related image

Kidneys are amazing organs. They detoxify our bodies on a daily basis and get rid of most things the liver and bowels cannot get rid off. And many people have healthy kidneys until their old ages. However, an increasing number or people in the UK have Chronic Kidney Disease. (CKD), similar to blood pressure is actually a condition rather than a disease as most people dont really suffer with it. Many people do not have any symptoms or only have minor symptoms until the condition is relatively advanced.

Doctors in the UK tend to warn patients when their eGFR (Glomerular Filtration Rate = the rate at which your kidneys work) drops below 60, which is an arbitrary, yet probably sensible line according to todays knowledge. NICE classifies most people with a

For a more complicated NICE classification of CKD click here

Diagnosis of CKD 3

Usually, patients need 2 readings of an eGFR (the rate at which your kidney works) below 60, 3 months apart, to be diagnosed with CKD stage 3. A single reading is not enough. Stage 3 means that you have now moderate disease (stage 2 is mild and stage 1 is normal and these stages are medically only important for people with pre-existing kidney damage).

Prevention of CKD3

However, I would encourage everybody with CKD 2 to already take measures to avoid their kidney function to drop. Aging drops kidney function anyway, but it is the acceleration of this drop we need to avoid. Simply go to the top of this page for the key messages.

I have got CKD 2 or 3 – What next?

  1. Dont panic – most people with CKD 3 will NEVER end up on dialysis or need a kidney transplant
  2. Get informed – the internet is your oyster. There is so much written about a kidney friendly lifestyle.
  3. Prepare – Change your diet, get fitter, try to be positive and happy if you can, drink plenty of water, implement the key changes listed above.
  4. Be critical – Protein clogs kidneys up, yet a lot of recipes even on really good websites contain too much protein and too little vegetables. Also, remember, replacing animal protein such as meat and dairy products with plant proteins such as beans, lentils and tofu is better for your kidneys.  Learn about kidneys. Make up your own mind. And do what you think is right.

Dr Kittel’s Musli-type Cereal for good bowel health

Cereal against Constipation, Abdominal Pain and / or nausea caused by a slow bowel passage

woman with abdominal pain from constipation

Start the day with a mix of fibre and seed containing foods with plenty of fluids can relieve slow bowel transit and constipation in 80-90% of patients and reduces abdominal pains significantly. The addition of natural Kefir (without sugar) additionally improves gut bacteria. It reduces the transit time of your food and relaxes your bowels by adding bulk. Fibrous foods like the ones outlined below consumed regularly are thought to reduce the risk of bowel cancer in the long term. A slow bowel passage can be the cause of a large variety of symptoms of which abdominal pains and nausea are the most common.

Recipe of the Musli type cereal


  • Rye Flakes
  • Oat Flakes
  • Dried Fruit (careful if you are diabetic)
  • Linseed
  • Pumpkin seeds
  • Sunflower seeds

What to do

  • All these ingredients can be obtained at health food stores i.e. Holland & Barretts and mixed according to taste in a big cereal container.
  • Eating a bowl of this cereal every day will after a few days relieve most peoples constipation, reduce bowel transit times for food, reduce bowel spasm through prolonged bowel transit and “relax” your bowels by adding bulk.
  • To improve your gut microbiome I also advise the addition of some Probiotics. You may wish to eat this with Kefir (great source of “good bacteria” / Probiotics (unless you are allergic to dairy etc)
  • Should you still suffer symptoms after starting your dietary changes, please see your doctor again.
  • For very young children that cannot yet have the above cereal I usually recommend to give Porridge with some Linseed and a mashed up banana for breakfast (mash and mix banana into hot porridge to cool down and add linseed). You can also put linseed into yoghurts etc.

Good Luck! – Dr Martin Kittel