This booklet is written primarily for people who have chronic (long-term) pain. Many people with chronic diseases such as arthritis live with pain for years. Diseases of the nerves (trigeminal neuralgia, for example), shingles and nerve damage from injury or surgery can also be the cause of chronic pain. Some people learn to cope with the help of drugs, physical treatments and other techniques. Others find the pain more difficult to deal with. Understandably, it may become a dominating and negative force in their lives.
The good news is that increasingly there are new approaches available to help manage pain. These can be helpful even if the person is already coping well. One of the keys to handling pain and its management is understanding. It is important to understand what treatments are available, what they entail and why they are helpful. Also, understanding more about pain itself, its causes and its different characteristics can help people to cope better, even though it does not cure the pain.
What is pain?
Pain is a protective mechanism and acts as a warning. If your hand touches a hot surface it triggers a volley of impulses from heat-sensitive nerve fibres. The result is a rapid, reflex response. Your muscles react and pull your hand away. Although everyone understands what we mean by the word ‘pain’, it is difficult to define. Pain isn’t just physical, it has emotional effects too – making us feel upset or distressed. Pain may, of course, be the result of some kind of injury. In some situations the physical injury is obvious – for example, a cut, a broken bone or a burn. In other situations the ‘injury’ is internal and is caused by chemicals the body itself produces, usually as the result of a process called inflammation. Our bodies have specialised nerve endings which detect temperature and chemical changes or mechanical stresses. These activate nerve endings which send ‘pain’ signals to the spinal cord and then to the brain.
Pain can also be caused when these nerve endings or nerves are permanently damaged and begin to send signals to the spinal cord by themselves. This causes the nerves to react without a cause, or in response to something that would not normally hurt, such as gentle stroking of the skin. This can happen after shingles, after severe nerve injury, after some surgical operations and in some people with diabetes. This type of pain often requires different treatments from that caused by stimulation of normal nerve endings.
In some instances it is difficult to explain the exact cause of chronic pain and this can lead to confusion. This presents a challenge to both the patient and the doctor. It does not mean the pain is imaginary or ‘psychological’ (although psychological factors will influence everyone’s tolerance of pain). Individuals with this type of pain will get most help from a specialist pain clinic, where there is a broader understanding of pain and its effects.
Pain and the brain
The spinal cord has special ‘gate’ mechanisms. These interfere with pain messages coming from the nerves and may block or deflect them so that the pain information which eventually reaches the brain is slightly different. These ‘gates’ either reduce the incoming pain message to the brain or increase it.
Some treatments for pain are aimed at closing the ‘gates’ to reduce the sensation of pain. For instance, transcutaneous electrical nerve stimulation (TENS) is a technique which was developed to close these pain ‘gates’ and helps to control some types of pain. Other treatments, including some drugs, work on the nerve endings themselves to reduce the sensation of pain.
The impact of the pain message once it gets through the spinal ‘gate’ is further changed by even more complex systems in the brain. The pain message can be altered in a number of ways. For example, by:
- how much you concentrate on the pain;
- enjoyable activities which can take your mind off the pain;
- feelings and thoughts and any anxiety or depression, all of which can affect the pain (even when the anxiety or depression was present beforehand);
- drugs which have a direct effect on the brain and can therefore reduce the impact of pain.
All this information can be used to help find new ways to manage pain. These include psychological techniques which help to improve mood, concentrating on other aspects of life, or changing behaviour. For example, some people with chronic pain stop exercising. This makes them unfit, and may make them feel useless. In turn this leads to too much time being spent in resting, when there is little else to think of but the pain and its bad effects on life. By sensible exercise and aiming to get back to work and to leisure activities it is easier to cope with the pain and life can return towards normal.
Most people have had first-hand experience of pain which is easily understandable, manageable and doesn’t last very long. In touching a hot surface, the damage and the cause of pain is obvious. In a child’s case, he or she may find it difficult to understand the pain at first, but after a few times it becomes easier to live with because experience tells us the pain will not last.
The same may be said about all forms of injury, including the pain which follows an operation. Learning to cope with such short-lived pain is an important part of growing up. The experiences of pain we have as children, and the way we are taught to cope with it, may strongly influence how we cope with pain in adult life.
Recurrent and chronic pain
A common type of recurrent or chronic pain is rheumatic pain. For people with arthritis, the intensity and duration of the pain depend upon the type of arthritis. Gout, for example, causes severe pain during the attack, but once the diagnosis has been made, a strategy to control the disease can be developed. (See separate arc booklet ‘Gout‘).
In osteoarthritis, the cartilage which covers the surface of the bones in the joints becomes roughened and thin. As a result the underlying bone becomes damaged causing pain, stiffness and deformity. When osteoarthritis affects the hands, the pain will often settle after a few weeks or months, although some deformity and stiffness may remain. When osteoarthritis affects other joints such as the hips, knees or spine, the pain may last a long time and, in some cases, it may severely limit normal activities. (See separate arc booklets ‘Osteoarthritis’ and ‘Osteoarthritis of the Knee‘).
Pain-relieving and anti-inflammatory drugs help many people. Physiotherapy, losing weight and exercise may also be very helpful. For some the only effective relief of pain may be achieved by surgery. Replacing, removing or stiffening the joint are effective operations for some people but the risk of surgery has to be weighed against the severity of the problem and the likely long-term benefit surgery will produce. A satisfactory solution can often be found, although some degree of pain is a frequent problem in the life of many people with osteoarthritis.
Rheumatoid arthritis (RA)
For people with rheumatoid arthritis (and other types of chronic inflammatory arthritis) the pain may be more persistent and difficult to control.
This is not true for everyone. Many people are greatly helped by drugs, periods of rest and physiotherapy. For some, the arthritis goes away after a few months or years, or just grumbles on – but causes few long-term problems. (See separate arc booklet ‘Rheumatoid Arthritis’).
For about one in ten people with rheumatoid arthritis, chronic pain is never adequately relieved. This pain is caused either by uncontrolled inflammation in and around the joints, or by the damage and instability which comes as a result of the inflammation. Drugs which control the pain and the inflammation may be very helpful. It is also important to rest and exercise sensibly. Surgery may sometimes be needed for specific painful joints. The difficult problems in rheumatoid arthritis are the unpredictable, painful flare-ups and the risk of the long-term effects of the arthritis which can lead to disability. Help can be provided by the specialist rheumatology team of doctors, nurses, physiotherapists, and other therapists, including psychologists, who work in most hospitals.
Neck and back pain
Most people experience short incidents of neck or back pain which disappear. If the pain recurs, there are preventative approaches which help deal with the problem. Here are some examples:
- exercises to strengthen the muscles;
- special care choosing the way you sit or the position you work in;
- being careful while doing leisure activities such as gardening or sport;
- taking care when you lift heavy objects.
Occasionally spinal surgery is necessary and can be highly successful, but some people have pain even after spinal surgery, so it should never be undertaken without careful thought and planning. (See arc booklets ‘Back Pain‘ and ‘Pain in the Neck’).
A number of people have back or neck pain which fails to improve and they develop chronic pain. This is often difficult to explain. For such people the pain is disabling and the challenge is to avoid it dominating their whole lives. At the outset it is not easy to predict who will end up in these circumstances. However, it has been discovered that some people who have suffered accidental injury find that conscious or subconscious anger (often related to inadequate compensation) can make the pain more difficult to control.
Chronic pain syndromes
Chronic headaches, facial pains, chronic upper limb pain syndrome – previously called repetitive strain injury (RSI) or ‘teno’ – are other examples of chronic pain syndromes. The pain leads to changes in the way people behave and may affect their mood and feelings. In all of these situations, the cause of pain is difficult to describe exactly. The person in pain often feels let down by modern medicine and poorly understood by family, friends and professional advisers. They, in their turn, may then find it difficult to deal with the problem. The person in question may see a large number of specialists and, sometimes, receives conflicting and contradictory explanations and a wide variety of suggested treatments. He or she ends up confused, frustrated, angry and depressed. However, there are ‘pain management’ clinics specialising in the care of chronic pain which are set up to enable people in these circumstances to cope better.
Rest, massage and simple pain-killing (analgesic) agents are often enough for the commonest causes of pain. For pain which is more severe the treatment used will vary. Some methods aim to treat the cause of the pain. Other methods aim to reduce the pain directly. For some people with severe pain, stronger drugs and special techniques are needed. Having the correct balance of treatments ensures the greatest benefits with the lowest possible risks. This is usually the role of a doctor – a GP or sometimes a specialist – although other professionals can often help. It is important to seek professional advice about very severe pain, even when it is short-lived. The same is true for less severe pain which lingers on.
The use of drugs has been the most important advance in the control of pain in the 20th century. Before 1900 aspirin and simple derivatives of opium (similar to morphine) were the only analgesic drugs available, but now there are many more. Although the price of a growing use of drugs has been an increase in side-effects, in general these risks are far outweighed by the benefits. Nevertheless, the balance of benefit and risk should always be considered.
Analgesic (pain-killing) drugs
Drugs which specifically act against pain are called analgesics. They include simple analgesics such as paracetamol. More complex analgesic drugs are related chemically to morphine, but with a much lower risk of addiction. These include codeine, dextropropoxyphene and dihydrocodeine. These are often used more effectively in combination with paracetamol, and are made as compound tablets; e.g. paracetamol and codeine (cocodamol), paracetamol and dextropropoxyphene (coproxamol) and paracetamol and dihydrocodeine (codydramol). These compounds often cause constipation and may produce drowsiness, especially if taken with alcohol. They may, however, be very helpful for most types of pain.
Non-steroidal anti-inflammatory drugs (NSAIDs)
These combine pain-relieving effects with an additional action which reduces inflammation. As inflammation is the main cause of pain in many conditions – including most forms of arthritis – these drugs may be doubly effective. Their development has been a major breakthrough in the care of people with arthritis, spinal pain and other chronically painful conditions. They are also used for painful menstruation, headaches and kidney pain. They can be used in combination with the simple or compound analgesics as mentioned above.
Ibuprofen is an NSAID which is available over the counter without prescription, reflecting its good safety record, although it can sometimes cause indigestion even when it is taken with food. Other commonly available NSAIDs include diclofenac, naproxen and indomethacin. These are the official names (also known as the generic or approved names) of the drugs. They may be prescribed also under a manufacturer’s name, which can be confusing. The official name should always be on the pharmacist’s label, but check with the pharmacist or your doctor if you are in doubt. Different manufacturers may make the same drug under different names and in differently coloured or shaped tablets or capsules. If in doubt, ask.
Indigestion and inflammation of the stomach are relatively common side-effects from NSAIDs. A peptic ulcer is a rarer but more serious side-effect. Anyone who has had severe indigestion or peptic ulcers in the past should take care using NSAIDs. They should only be taken at the same time as aspirin with your doctor’s agreement, because aspirin also can cause indigestion. Confusingly they make some people constipated while others develop diarrhoea. Other side-effects of NSAIDs include skin rashes, headaches, muzziness and dizziness. It is also important that people with kidney problems or who take high doses of diuretic (‘water’) tablets be especially careful. Elderly people are often prone to develop more side-effects from most drugs and they must therefore use NSAIDs with caution.
Corticosteroid drugs (steroids) have had a lot of publicity about their possible side-effects. Too little attention has been paid to the fact that they are very effective drugs and may sometimes save lives. It is important that they are used appropriately and in correct dosages. They are not themselves painkillers but, by reducing inflammation, they reduce pain. They are often given by injection into painful joints or tendons. This is usually very effective in reducing pain. In certain conditions steroid tablets are prescribed, such as in polymyalgia rheumatica (see separate arc booklet ‘Polymyalgia Rheumatica’). In other conditions they are used rarely and only with great care.
Other pain control methods
A variety of different techniques can be helpful in reducing pain. Simple measures include the warmth from a hot-water bottle or heating pad, cold from an ice pack or a cold-water compress, massage (with or without the use of creams which create a sense of warmth) and rest. These techniques are often helpful after an injury and for acute flare-ups of more chronic arthritis or back pain. They do not cure the problem, but are soothing and safe when used carefully.
Other physical methods are used by practitioners, such as physiotherapists, osteopaths and chiropractors. They use a variety of different manual methods, including massage, manipulation and stretching, to relieve pain and to help return the muscles and joints to normal. They may also use electrical techniques, such as ultrasound, laser or interferential treatment. Exercise programmes, initially supervised by a physiotherapist, may help to control pain from arthritis and rheumatism. They produce muscular relaxation and may also improve general fitness.
It is important to go to a qualified practitioner, preferably with the advice and guidance of your doctor. If there is no improvement after a few weeks of treatment, further investigations should be considered.
Transcutaneous electrical nerve stimulation (TENS)
This is a technique which uses small pulses of electricity which produce a tingling sensation. It aims to reduce the sensitivity of the nerve endings in the spinal cord in order to close the pain ‘gates’. It does not help everybody, but some people find it is a very effective means of pain control. TENS has few side-effects although some people become allergic to the jelly used to apply the pads. A physiotherapist will usually advise on the correct position of the pads, how to select the frequency and strength of the pulses, and how long the treatment should last.
Acupuncture has become popular in this country recently and is used by doctors and other practitioners for many purposes. It is sometimes used to relieve pain, often with good effect. It is thought to work by stimulating the body’s own pain-relieving hormones.
The role of the psychologist is important and one which is often misunderstood. They are specialists who work often as part of the team in pain management clinics, and help in teaching people how to think differently about their pain and other problems and to modify their behaviour accordingly. Sometimes involving groups of people with similar pain problems, these techniques are increasingly used to help people develop better ways of dealing with their symptoms.
Although some people are suspicious of this approach at first, it has proved to be very successful. Pain is never a purely physical phenomenon. It may make one person feel more isolated, another more irritable, more depressed or more dependent on others. When the pain is chronic or its cause difficult to determine, the psychological and social effects need to be specifically addressed.
These are helpful with many conditions. They work in part by relaxing the tense and painful muscles and also by relieving the anxiety which makes pain more difficult to bear. Relaxation tapes, yoga, special methods like the Alexander technique (relaxation and posture) and sometimes hypnosis can be helpful. They are often used by pain management clinics. It is worth asking your doctor’s views about these approaches.
Unfortunately, for some people pain is long-lasting, does not respond fully to drugs or physical treatments and cannot be cured by surgery. Time sometimes helps people to adjust, but the pain may continue and come to dominate life. In this case altering lifestyle may be important. Learning to rest sensibly, avoiding certain activities, asking for help, using gadgets and home adaptations are all important ways of adjusting and learning to cope. A doctor, social worker, physiotherapist, or occupational therapist can help with these changes. New hobbies, new outlooks and the love and support of family and friends make the pain bearable and – for many – make life enjoyable again.
There remains an even smaller minority who – despite everything – are overcome by intolerable pain. They are usually referred to a specialist pain management clinic. Often the pain means they have to rest for long periods, can only walk or move awkwardly because of their pain. They find themselves in a vicious circle of pain, anxiety and depression. They become unfit, weak and increasingly isolated or dependent on others.
People in this situation need to learn new ways to cope with their pain and keep on living a worthwhile and fulfilling life. It is difficult, but not impossible, to pluck up the courage to do exercises despite the pain, to find other things to concentrate on and to refocus thoughts away from the pain. This can be achieved with help from family and friends as well as from specialists.
Pain can be treated and usually settles by itself. For those people for whom pain becomes a more permanent part of life, there are many techniques available which, alone or in combination, are effective.
Cartilage – strong material on bone ends that acts as a shock absorber. Its slippery surface allows smooth movement between bones.
Neuralgia – a severe pain, often felt along the route of a nerve.
Peptic ulcer – a hole in the lining of the digestive tract. Peptic ulcers in the stomach can be caused by non-steroidal anti-inflammatory drugs (NSAIDs).
Spinal cord – a cord which runs down the centre of the spine and contains the nerves which connect the brain to all the other parts of the body. The nerve fibres are surrounded by several protective layers and pass through the vertebrae (the bones of the back). The spinal cord and the brain together form the central nervous system.
Tendon – a strong fibrous material that anchors muscles to bone.
Trigeminal neuralgia – a condition which produces pain in the trigeminal nerve in the face.