The information in this section was compiled by the Health Experiences Research Group.

Definition of chronic pain

The International Association for the Study of Pain (IASP) defines chronic pain as 'pain which has persisted beyond normal tissue healing time'. Although there is no formally accepted time for this, any pain lasting for more three months is generally considered to be chronic pain. Most people's experience of chronic pain though will have lasted longer than three months.

Those living with chronic pain have their own ways of describing their condition. Their descriptions are usually graphic and intensely personal - people describe their pain as feeling like 'stabbing knives', 'crawling insects', 'hot coals' and so on. 

Chronic pain can reduce people's quality of life, as well as that of their families. People with chronic pain can experience difficulties with work and simple tasks, poor nutrition and weight loss, sleep disturbance, social isolation, marital problems, unemployment and financial problems, anxiety, fear and depression.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Causes of chronic pain

It may be difficult to establish the causes of chronic pain. Some people's pain may be caused by problems with the way in which the nervous system functions, others may experience pain because of previous damage or injury to the body.

Chronic pain may be caused by a combination of factors. Often there may be no physical cause that can be identified. From the patient's perspective, it is usually the chronic pain itself that is a problem, rather than the cause.

Even when two people have the same apparent cause of chronic pain they can experience pain differently. So though it is important to establish whether there is any element of chronic pain that can be put right, it may be less important to identify an overall cause than to manage and treat the pain itself. Chronic pain may actually be the most important diagnosis to make.

The IASP (International Association for the Study of Pain) lists the following diagnoses/health conditions in which chronic pain is likely to be a significant problem. However, many people with chronic pain do not fit with any of these diagnoses/health conditions, while others may have several of them.

- Osteoarthritis

- Rheumatoid arthritis

- Low back, shoulder and neck pain

- Headache, including migraine

- Cancer pain

- Myofascial pain syndromes

- Post-thoracotomy pain

- Chronic regional pain syndromes

- Stump and phantom limb pain

- Neuropathic pain

- Herpes zoster (shingles) and post-herpetic neuralgia

- Trigeminal neuralgia

- Diabetic neuropathy

- Temporomandibular Joint Disorder (TMJ)

- Postmastectomy pain

- Angina pectoris

- Chronic visceral pain syndromes

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Clinical investigation and tests

There isn't a single test that says that chronic pain is or isn't there.

Clinical investigations or tests are used to investigate whether there is a physical and treatable cause for the pain. 

However, chronic pain by definition is pain that persists past normal healing time and even if a test shows abnormalities it may be the remnants from a previous injury or illness and not the cause of the pain. 

Chronic pain is more often due to changes in the nervous system and brain which lead to sensitisation of the pain system (see the 'Talking about..' section: What is chronic pain?). 

MRI

Magnetic Resonance Imaging (MRI) provides doctors with detailed images of any part of the body. They are used to look at the brain, spinal cord and to investigate injuries to bones and joints.

The MRI procedure is non-invasive and painless, it uses a strong magnetic field to make hydrogen atoms inside the body 'bounce'. When the atoms get back into alignment they emit radio waves which can be analysed by computer and produce a series of 'slice' images visible on a screen.  

MRIs can be done through clothing and through dense tissue such as bone. Sequential images, using injected contrast material, can show blood flow through organs - such as during an MR angiogram. 

You will be asked to lie still on a couch, which will move through the scanner tube. Some people find this claustrophobic and the procedure can be noisy (if you feel this will be a problem you should let the MRI team know so they can give you reassurance and help).  

The scanner takes a series of pictures as you move through - each image will take a couple of minutes to produce, although the time taken depends which part of the body is being scanned. You will be able to go home afterwards. There is no evidence of side-effects from MRI though it should be avoided if you are pregnant. 

CT 

CT (computerised tomography) scans, are generally used to examine the head or the abdomen. CT's are created from a series of X-rays taken at different angles, which put together form detailed images of the inside of various parts of the body. 

If you are sent for a CT scan you will be asked to lie down on a couch and remain still as the couch moves through the scanner. The process is painless and non-invasive. Some people do find it slightly claustrophobic. You should not have a CT scan if you are pregnant.

Ultrasound scans

Ultrasound scans are used to examine areas of soft tissue or internal organs (such as the bladder) and can show whether there is evidence of damage, injury or malformation. Ultrasound scans are non-invasive and completely painless.

An ultrasound involves lying down and being physically examined by a doctor (or radiographer) who will pass a small scanner over the area of your pain. Ultrasound scans have no known side-effects and are safe for pregnant women.  

Nerve conduction velocity test

This test measures the speed at which signals travel along a particular nerve. A small electrical impulse will be applied to a nerve and depending on how quickly the impulse travels, it is possible to assess whether there is anything wrong with the nerve itself. This test may reveal muscle dysfunction.

Laparoscopy

A laparoscopy is an operation to look inside the abdomen. It is often used when people complain of pelvic pain. The operation is usually a day procedure carried out under general or local anaesthetic.

The surgeon makes a small cut about 1-2 cm long under the belly button. A harmless gas is passed into the abdomen to separate the organs making things easier to see. A thin camera with a light - a laparoscope - is inserted through the cut. The surgeon can see pictures of the inside of the pelvis through the scope or on a television screen. 

Laparoscopy is generally safe. There may be some pain the next day around the cut and also in the shoulders. This is because the diaphragm, a large muscle in the abdomen shares the same nerve supply as the shoulders and the diaphragm can be irritated during the operation. 

There is a small risk of damage to structures inside the abdomen, infection and complications due to anaesthesia.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Definition of pain

Everyone feels pain differently and nobody can know what somebody else's pain is like. This makes it difficult both to define and describe pain.

The International Association for the Study of Pain (IASP), describe pain as 'an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage', this defintition is widely used and accepted.

Even when there is no obvious outward sign of injury, damage or abnormality to your body, the experience of pain is real to you. Sometimes the memory of a particular pain is so strong that it never quite disappears, and it can flare-up under certain circumstances.  

Last reviewed November 2012.

Last updated November 2012.

The information in this section was compiled by the Health Experiences Research Group.

General advice about taking pain medicines

Chronic pain can be difficult to treat and you may have to try a number of different medications before one or more are found that help. 

Because types of pain differ we know that ordinary painkillers are not always effective and it may be helpful to try drugs that are also used to treat other conditions. 

For example, a medication that is also used to treat epilepsy or depression can be the best painkillers for certain types of pain. That does not mean that these pains have anything to do with epilepsy or depression. 

Try to make sure that you don't just take more and more of the same medication. If a tablet fails to work after a reasonable time (your doctor should advise you of how long) then there is little point staying on it.

If stopping a medication, this should be done at a different time from starting a new medication so that you can be sure what is a side effect and what might be a withdrawal reaction. Only stay on a medication if your quality of life, in general, is improved by the medication.

Always tell any new doctor you see, for whatever problem, about all medication you are currently taking. Remember that even painkillers you buy in a supermarket or pharmacy may still contain strong drugs which may interact or interfere with medicines you already take for pain.

Always be careful of side effects from your medication, particularly if you have just started taking it. Sometimes, for example, the medicines used to treat pain can cause sleepiness or interfere with your ability to concentrate. 

Special caution is needed when you are driving, operating machinery, or making important decisions.

If you are considering becoming pregnant, discuss this with your doctor in case any medication you are taking may interfere with your pregnancy.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Non steroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are commonly used for chronic pain due to arthritic conditions. NSAIDs work by controlling cyclo-oxygenase (COX) an enzyme which promotes the production of chemicals that cause inflammation and pain in the body.  

There are two forms of the COX enzyme - COX-1 and COX-2. Older NSAIDs (e.g. ibuprofen, diclofenac, ketoprofen, indometacin, naproxen, piroxicam) inhibit both enzyme types, whereas some modern NSAIDs (e.g. celecoxib,and etoricoxib) have high specificity for the COX-2 enzyme. 

COX-2 specific NSAIDs produce similar pain relief and anti-inflammatory effects but have fewer side effects. Most NSAIDs are taken by mouth, but some are available as topical creams.

All NSAIDs can irritate the stomach and small intestine. People who have had a peptic ulcer, have bled from the stomach or had a perforation should avoid NSAIDs or they may need to take other medicines at the same time to help protect their stomachs.  

If you develop abdominal pain or pass any blood you should stop taking the drug immediately and contact your doctor. NSAIDs can also affect the kidneys, may make asthma worse and occasionally cause an allergic reaction. 

NSAIDs can interact with other drugs such as anticoagulants (e.g. warfarin). If you are on other drugs you should consult your GP.

The Arthritis Research Council (ARC) website has more information on Non steroidal anti-inflammatory drugs'. There are also information leaflets about other drugs used in the treatment of arthritis pain. 



Last reviewed November 2012.

Last updated November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Opioids

Opioids are commonly used painkillers (analgesics) which vary in strength ranging from codeine to morphine. They can be taken by mouth, by injection or by applying a patch to the skin. Opioids are generally classified as being 'weak' or 'strong'. Weak opioid is a misleading term because these drugs can be very effective for a variety of pains.

For further information about opioids go to www.painsociety.org - under General public publications, Opioid Medicines for Persistent Pain - Information for patients.

Weak opioids

Codeine and dihydrocodeine are weak opiods. Many medicines containing codeine or dihydrocodeine also contain paracetamol and care should be taken to avoid taking too much paracetamol. The maximum daily dose of paracetamol for an adult is 4 grams (1 gram (1000mg.) 4 times per day). 

Co-codamol, Paracodol, Tylex, Kapake and Solpadol all contain codeine and paracetamol. Remedeine and co-dydramol contain dihydrocodeine and paracetamol. All these medicines can cause nausea and constipation. Simple laxatives, such as senna and lactulose, usually help the constipation. 

Tramadol can act as a weak or strong opioid depending on the dose used.

Strong opioids

Morphine is the most commonly used strong opioid and has been the mainstay for treating pain after operations and pain caused by cancer for many years. Other drugs in this group include oxycodone, hydromorphone, fentanyl, buprenorphine, methadone and pethidine.  

For patients with chronic pain, slow release preparations are used so that their effect lasts over several hours. These are usually taken by mouth. There are also patches that are applied to the skin available for some of the drugs.

Side effects of strong opioids include, nausea, constipation, drowsiness, confusion and itch. Most of these decrease with time. Simple laxatives, such as senna usually help constipation. (If constipation becomes a real problem stronger laxatives will be needed.)  

Suddenly stopping this type of medication may cause a withdrawal reaction and people who want to stop strong opioids should consult their GP.

Last reviewed November 2012.

Last updated November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Tricyclic antidepressants

Tricyclic antidepressants (e.g. amitriptyline) were originally made as antidepressants but can also reduce certain types of pain. They are often co-prescribed with antiepileptics (see other 'Information' section: Antiepileptics).

Common side effects include sedation, dryness of the mouth (inhibits saliva production), constipation and difficulty passing urine. When given at night, the sedation can be useful for sleep. They can take a number of weeks before they are fully effective. If side effects are troublesome, or if pain relief is insufficient, a different tricyclic can be tried. 

It should be noted that tricyclic antidepressants have a licence for use in depression, but not in pain - so the information leaflet provided with them will talk about depression and not refer to pain. 

The Pain Society has a leaflet that explains what it means to take a drug out of license: 'The use of medicines beyond licence - Information for patients' (www.painsociety.org - under General public; publications).

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Antiepileptics

Several drugs that were developed for the treatment of epilepsy have been found to help certain pain conditions. The most commonly used medicine from this group include gabapentin, pregabalin, sodium valproate and carbamazepine. 

They are commonly used to treat nerve pain (neuropathic pain) and are often co-prescribed with tricyclic antidepressants such as amitriptyline (see other 'Information' section: Tricyclic antidepressants).  

Common side effects of these drugs are sedation and dizziness. Some people have also described weight gain, headaches, fluid retention, upper stomach pain and nausea. 

Last reviewed November 2012.

Last updated November 2010.

The information in this section was compiled by the Health Experiences Research Group.

Lidocaine

Lidocaine is a local anaesthetic. In the pain clinic it is used to treat nerve pain (neuropathic pain).  

Lidocaine cannot be taken by mouth, so has to be given as an injection. This is usually slowly injected into a vein by a pump and patients may have to stay in hospital overnight while the injection is given. Lidocaine can also be used as a patch applied to the skin for conditions like post herpetic neuralgia after shingles.

Last reviewed November 2012.

Last updated Novemeber 2010.

The information in this section was compiled by the Health Experiences Research Group.

Capsaicin

Capsaicin is the active ingredient in chilli peppers and is applied in a topical cream or a patch. It is used for pain in post-herpetic neuralgia after shingles, and also in osteoarthritis. Capsaicin over stimulates the pain receptors in the skin and desensitises them reducing pain.

Capsaicin cream

It is really simple to use, you apply it to the area where you are feeling the pain. A small amount should be gently rubbed into the painful area. At the beginning you should apply it 4 times a day. Applying it less often will tend to make it more uncomfortable on each application. The cream should not be applied to inflamed or broken skin. Always wash your hands after applying the cream because you will find it very unpleasant if you rub your eyes, nose or mouth without doing so.

Qutenza patches, are now available through the NHS, they contain a high dose of capsaicin which over stimulates the pain receptors in the skin and desensitises them. The patch needs to be applied in the outpatients’ department of a hospital as specialist training is required. The patch is applied to the painful area and left for 30 to 60 minutes and removed. It can take 1-14 days for the full pain relief to take effect. It can provide relief for some for up to three months. Some may not get any benefit from the treatment. The treatment can be repeated every 90 days. (For more information see Qutenza fact sheet).

Last reviewed November 2012.

Last updated November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Pain Management Programmes

A Pain Management Programme (PMP) is a psychologically-based rehabilitative treatment for people whose chronic pain has not been helped or alleviated by other treatments. 

PMPs are delivered in a group setting by an interdisciplinary team of experienced health care professionals who work closely with patients. 

The purpose of PMPs is to reduce the disability and distress caused by chronic pain by teaching physical, psychological and practical techniques to improve quality of life. 

PMPs differ from other treatments provided in pain clinics because pain relief is not their primary goal, although improvements in pain following participation in PMPs have been demonstrated. 

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Goal setting

Used alongside pacing, goal setting can be useful in helping people with chronic pain continue to work and socialise without doing too much. Goal setting means setting a realistic target and working towards it using pacing (see other 'Information' section: Pacing). 

Goals can be physical, for example working towards a number of repetitions of an exercise or increasing the length of time you can sit or stand for. They can be functional, for example digging the garden, cleaning, or walking to the shop or they can be social, for example going to a family party. 

(For people's experiences of using pacing and goal setting see the 'Talking about...' section of this site: Pain management: pacing and goal setting)

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Physical therapies

Heat and Cold

Heat and cold are generally used as self-help measures and some people use them during flare-ups (see the 'Talking about...' section of this site: Coping with flare-up).  

Applying either heat or cold to a painful part of the body can be soothing. This kind of therapy is unlikely to cure chronic pain, though it may offer short-term relief. Heat and cold treatments should be used with care as there can be a danger of burning the skin particularly if you have a lack of sensation. 

Heat treatment can relieve pain by stimulating nerves that can mask painful sensations, decreasing muscle tension and improving blood flow in the area. There are different kinds of heat treatments available including heat packs and hot water bottles which can be put onto any painful areas of the body. Some people prefer to take warm baths/showers.  

Cold treatments consist of the application of cold packs, crushed ice or frozen peas to painful areas of the body, as well as ice-cube massage and cold sprays. Cold may reduce pain by stimulating nerves that mask painful sensations. (In acute pain immediately following injury cold can limit swelling and reduce the release of pain producing chemicals.)  

Sometimes physiotherapists recommend that people try 'contrast baths' of hot and cold. Other heat treatments provided by physiotherapists include heat lamps, ultrasound and short-wave diathermy machines which are thought to work below the skin and reach deeper into the body. 

Ultrasound

Ultrasound machines generate sound waves at high frequency which stimulate cells to accelerate the body's healing process after an injury. Research indicates that ultrasound may not be an effective treatment for chronic pain. 

Low level light therapy/Laser therapy

Low level light therapy/laser therapy machines generate light at selected frequencies. The light, as a form of electromagnetic energy can stimulate cells that are important in the healing process following injury. The light comes out of a pen-like probe that is held over the skin. The doses used in Low level light therapy/laser therapy are too low to damage the skin. 

Massage

Massage is used by many health professionals and therapists and can reduce pain by stimulating nerves to mask signals of pain, reducing muscle spasm and helping with relaxation. 

There is evidence that massage can be effective in helping people to manage chronic pain as part of an overall programme of exercise and education.

If you are hypersensitive then massage can be painful. Sometimes massage is combined with the use of scented oils in aromatherapy.

Joint manipulation and mobilisation 

Physiotherapists, chiropractors and osteopaths use their hands to physically manipulate joints to try to decrease pain and stiffness. The manipulation consists of high velocity thrusts of the joints. Each of these professionals will manipulate the spine for back pain. Physiotherapists also use manipulation to treat other joints.  

There is some evidence, though it is still unclear, that manipulation may be of benefit in early back pain but there is not enough evidence to say if it is effective for chronic pain. 

Manipulation is generally safe but it can be harmful if the joints in the spine are inflamed or infected, or if you have a slipped disc. If you have osteoporosis or fractured vertebrae, the bones can be further damaged by manipulation. Also, if you have circulatory problems some forms of manipulation can be harmful.

Physiotherapists also use more gentle manual procedures known as mobilisations which move the joints but with much less force than manipulations. There is no evidence that these are effective for chronic pain.

Traction

Traction stretches the spine gently either using a machine of weights and pulleys or by the therapist applying a manual force. Scientific research suggests that traction is unlikely to be of benefit to someone with chronic pain. 

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Complementary therapy

Complementary therapies have become very popular and are used by a lot of people with chronic pain.

The main complementary therapies are acupuncture, herbal medicine, homeopathy, osteopathy and chiropractic. These five have received most attention from scientific researchers. There are many others that are not included here - see the 'Talking about...' section of this site: 'Complementary approaches' for individual perspectives.  

Like treatments used in conventional medicine it is unrealistic to expect complementary treatments to cure chronic pain. The important thing may be to find out what is available to you, and to ask about complementary approaches with members of your healthcare team or other people with chronic pain.  

Before starting any kind of complementary therapy you should check if the person you plan to consult is a registered practitioner. Members of your healthcare team may be able to recommend particular practitioners to you, as will members of your support group if you have joined one. To date there is a lack of scientific evidence to back up claims that complementary therapies are effective. 

If you use complementary therapies you are advised to discuss this with your doctor and other members of your healthcare team so that they have a full picture of your treatments.

Herbal medicine

Herbal medicine uses substances derived from plants (and sometimes animals) to treat a wide range of illnesses and health problems including pain. 

The natural products are manufactured into pills, tablets, powders, ointments and medicines. It is important that you use reliable brands of herbal remedies as poorly manufactured herbs can be contaminated with other products. 

Herbs have been used in medicine for many years and many conventional medicines, aspirin for instance, have been developed from plant products. Some herbal medicines are thought to act by triggering the body's natural processes to help deal with illness. 

Herbal medicine is generally considered to be safe but like conventional medicines, some herbs are dangerous or highly unpleasant particularly at very high doses. Herbal medicines may also produce unpleasant side effects when used with conventional medicines. If you are using herbs it is important, therefore, that you discuss this with your GP and with an expert herbalist. 

For more details about herbal medicine and registered herbalists contact

- The National Institute of Medical Herbalists www.nimh.org.uk

Acupuncture

Acupuncture involves the insertion of fine solid needles into the body for the purposes of disease prevention, therapy and health promotion. 

In Traditional Chinese Medicine (TCM) acupuncture is used as part of a system of therapies that also include herbal medicine and advice about exercise and diet. In Chinese philosophy acupuncture is said to improve the flow of vital energy known as 'Qi' through channels in the body known as 'meridians'. The idea of 'Qi' and 'meridians' is not accepted in western medicine and there has never been any scientific evidence that they actually exist. 

Acupuncture may reduce the activity in nerves that carry sensations of pain and may also trigger the release of endorphins (the body's natural pain killers) in the brain. 

Modern acupuncture needles are made of stainless steel. They are sterilised to reduce the risk of infection, and, in the UK, all needles used in treatments should be single-use and disposable. They are very thin and you are likely to feel nothing or just a mild sensation as they are inserted. Sometimes the needles are moved to create a sensation, and sometimes they are stimulated with a small electric current.

Acupuncture may be effective in reducing pain at least for short periods of time, and so may help people to manage their pain. However, the scientific evidence for this is not clear. 

Acupuncture is thought to be safe with few risks or side effects. There have been rare cases of needles inserted in the chest puncturing the lung. Also, there is a risk of infection under some circumstances.  

The best way to reduce these risks is to ensure that your acupuncturist is a regulated health professional. There are many websites devoted to acupuncture and acupuncturists including: 

- The Acupuncture Association of Chartered Physiotherapists (www.aacp.uk.com)

- The British Acupuncture Council (www.acupuncture.org.uk). 

Chiropractic and osteopathy

Chiropractors believe that health problems, including pain, can be due to the vertebrae - the bones of the spine - being out of line with each other. Osteopaths also believe that problems with the position of vertebrae in the spine cause problems in the body resulting in illness and pain. 

Chiropractors and osteopaths use their hands to physically manipulate the spine to try to improve health and encourage healing by correcting the alignment of the vertebrae. (Manipulation is also carried out by physiotherapists.)

There is some evidence, though it is still unclear, that manipulation may be of benefit in early back pain but there is not enough evidence to say if it is effective for chronic pain. 

Manipulation is generally safe but it can be harmful if the joints in the spine are inflamed or infected. If you have osteoporosis or fractured vertebrae the bones can be further damaged by manipulation. Also, if you have circulatory problems some forms of manipulation can be harmful. A registered chiropractor or osteopath will carry out an examination to test for these. 

To find out more about chiropractic and to find a registered practitioner contact the General Chiropractic Council (www.gcc-uk.org). For information and a list of registered osteopaths contact the General Osteopathic Council (www.osteopathy.org.uk).  

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Cognitive-behavioural therapy (CBT)

Cognitive-behavioural therapy (CBT) is a psychological treatment that uses a practical approach that can help with a variety of problems.

In chronic pain, CBT aims to change thoughts - what people say to themselves - and the way they interpret the world around them and their own experiences. Just like other habits, thinking can get stuck in a rut which leads to distress and to poor decisions. Learning to identifying those unhelpful patterns and to change them can make an emotional difference and a practical one. It fits well with other techniques in pain management like relaxation, pacing and goal setting (see other 'Information' sections: Pacing; Goal Setting). 

Cognitive-behavioural therapy encourages people to take control of chronic pain rather than letting chronic pain control them. 

People with chronic pain often say that they feel the pain controls them: using cognitive and behavioural methods, they say that they feel more in control.

The treatment is generally short-term and is delivered by clinical psychologists working as part of a Pain Management team.

Other healthcare professionals including physiotherapists, nurses, counsellors and psychiatrists may also use principles of CBT in their work. 

For more information about CBT see the pamphlet 'Making sense of CBT available from MIND via their on-line shop (www.mind.org.uk, email: publications@mind.org.uk, Tel. 0844 448 4448).

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Pacing

Pacing can be used to help people manage daily activities whilst keeping pain under control. It involves an individual finding the level or time that they can do an activity or task or hold a posture for before the pain 'kicks in' and working within this 'tolerance level'. This means breaking tasks/activities up and stopping for a rest or changing to a different activity before the pain increases.  

Pacing can help prevent flare-ups of pain due to over activity by making sure you keep active at the same level and don't overdo things on good days. It is also an important part of managing flare-ups should they happen. 

During a flare-up of pain it is sometimes necessary to reduce levels of activity and then gradually pace them up again as pain subsides.  

Pacing can be used to help people work towards goals by gradually increasing the 'tolerance levels' for the activities involved in that goal. (see other 'Information' section: Goal setting).  

(For people's experiences of using pacing and goal setting see the 'Talking about...' section of this site: Pain management: pacing and goal setting). 

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

TENS (Transcutaneous Electrical Nerve Stimulation)

TENS (Transcutaneous Electrical Nerve Stimulation) is a method of pain relief that uses small amounts of electrical current. The TENS machine - about the size of a small mobile phone - generates a small electrical current which is passed into the body through electrodes taped onto the skin.

TENS has been shown to stimulate nerves so that the painful sensations are interrupted on their way to the brain. TENS will not cure chronic pain or take away the pain completely, though it is thought that TENS can reduce pain for some of the time. 

TENS can be worn and switched on for long periods of time, and it is thought that leaving the machine on for hours rather than minutes may be beneficial.

There are few side effects of TENS, though some people have noticed a redness on the skin under the electrodes after use which can be itchy. It is a good idea to let your physiotherapist know that you intend to use TENS as s/he will be able to give you more advice about how best to use the machine. 

TENS machines are widely available in shops and through the internet and are sometimes loaned from pain clinics.  

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Exercise

For people with chronic pain, inactivity can become one of the biggest barriers to living a full life. Without regular use the body's muscles, ligaments, tendons, bones and joints can become weak and stiff, and this can lead to low levels of stamina and energy.  

Healthcare professionals usually encourage people with chronic pain to exercise and to be active in any way they find comfortable. Even though people with chronic pain may find it difficult to run or swim long distances, any kind of physical activity can be helpful, particularly if it is done regularly.  

Walking - even short distances - is good exercise. There are also other exercises that are known to help strengthen or loosen parts of the body. Physiotherapists can advise people about appropriate exercises and also devise and supervise individual exercise plans.  

Physiotherapists can also offer guidance with pacing and goal setting (see other 'Information' sections: Pacing; Goal setting) and can supervise you, which can help to improve motivation. Most people find that they need to allocate time and space for exercise on a regular basis to feel the benefit.  

The Arthritis Research Campaign has an illustrated leaflet 'Keep Moving' which shows simple stretching, strengthening and fitness exercises (also suitable for those without arthritis) and gives specific exercise tips for osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, osteoporosis and back pain.  

'Keep Moving' is available free from ARC, St Mary's Gate, Chesterfield, Derbyshire, S41 7TD.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Pain Clinic

Pain Clinics vary in the treatments offered and not all hospitals have a pain clinic. Sometimes a consultant with an interest in pain will prescribe drugs or give injections to try to control pain. Others may offer acupuncture as well as other complementary therapies.  

Sometimes pain clinics have psychologists, nurses or physiotherapists attached to them who can give advice on things like exercise and living a fuller life with pain. 

Some hospitals have specific Pain Management Programmes that aim to teach a group of patients with similar problems about pain, how best to cope with it and how to live a more active life.  

 
If you would like to attend a Pain Clinic, ask your GP for a referral to the nearest clinic. Or you can contact the Pain Society Secretariat directly to find out what is available in your area (tel: 020 7631 8870) or write to the Pain Society, 21 Portland Place, London W1B 1PY.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Spinal cord stimulation

Spinal cord stimulation uses electrical impulses to block nerves carrying pain signals to the brain. An operation is carried out under local anaesthetic and sedation as the patient has to be awake to assist in positioning of the stimulator. 

Small electrodes are implanted in the spine and a small transmitter, no bigger than a matchbox, that generates electrical impulses is placed under the skin usually in the abdomen. The person with chronic pain can operate the transmitter with a remote control. 

There is scientific evidence that spinal cord stimulation may help to reduce pain for some, but not all people with chronic pain.  

As well as general risks with operations further complications can include:

- The need for further operations to reposition electrodes that move or to replace batteries.

- Infection either in the front where the transmitter is placed or in the epidural space at the back sometimes requiring surgery to remove spinal cord stimulator.

- A risk of meningitis.

- Interference from external machines. Some types of body scanners such as MRI scan or security body scanners in airports can interfere with the stimulator. 

Short wave diathermy, a treatment used by Physiotherapists for soft tissue injury can potentially interfere with the stimulator.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Injection therapy

The evidence for the effectiveness of injections in treating chronic pain is inconclusive. Many injection treatments do provide short-term relief, but long-term benefit is unlikely. All injections carry a risk of complications and side effects so people should discuss the balance of risk to benefit with their doctor.

There are many forms of injections, into various parts of the body. Commonly local anaesthetics are used with or without other drugs such as steroids.  

Lower back pain

Injections for lower back pain can be given into various parts of the back:

- Facet joint injections (there is a facet joint on each side of each vertebra) 

- Epidural injections (into the space next to the spinal cord) 

- Caudal injections (into the membrane over the spinal cord, near the base of the spine)

Facet joint injections are sometimes used when the facet joints are thought to be the source of the pain. The injection includes corticosteroid drugs and an anaesthetic drug. Epidural injections are injections of local anaesthetic, which then act on the nerve roots and spinal cord. It is a kind of nerve block. 

Injections are also used in other areas of the back (such as trigger points, ligaments and painful areas), but this is less common. 

Epidural injections and injections into the root sleeve (space around the nerve root) are also sometimes used to try to provide temporary relief for sciatica (where pain is shooting down into the leg). 

However, there is no strong evidence from reviews about injection therapy. 

Informed health online (www.informedhealthonline.org) has a review of the effectiveness of injections for back pain. 

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Back surgery

Surgery is only used in a few cases (probably less than 1% of all cases of back pain). For example, a large piece of displaced disc can press on the nerves of the spinal cord and cause bladder problems (such as difficulty in passing or controlling urine). In this rare situation you need urgent surgery to remove the disc fragment. 

For severe cases of sciatica, surgery may sometimes be needed to relieve the pressure on the nerve. The disc is not removed, but trimmed back flush with the line of the vertebra. Taking the pressure off a nerve can allow the nerve pain and function to recover, but neither of these is guaranteed and there is a risk of worsening pain.

Spinal Instability - in those with instability due to fractures, tumours, hypermobile ligaments, severe disc degeneration, or spondylolisthesis, stabilising the unstable segment in the spine can improve back pain, but this is not guaranteed and there is a risk of worsening pain.

Stabilisation surgery for the relief of back pain alone is not recommended. Informed health online (www.informedhealthonline.org) has a review of the effectiveness of Decompression and fusion surgery.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Joint replacement

Joint replacements are usually carried out when osteoarthritis is identified as a major reason for chronic pain. The most common types of joint replacement are hip and knee replacements though other joints can be replaced. The parts of the bones that make up the joint are removed under general anaesthetic and replaced with artificial parts made of metal and plastic. 

When osteoarthritis is a major source of the pain then the operation has a good chance of removing most and sometimes all of the pain. With rehabilitation from a physiotherapist a high degree of function can be restored.

The Arthritis Research Campaign has several leaflets on joint replacements. These are: 

- Shoulder and elbow replacement : an information booklet.

- A new Hip Joint: an information booklet 

- A new Knee Joint: an information booklet.  

Copies are available from their website www.arc.org.uk or by writing to arc Trading Ltd, James Nicolson Link, Clifton Moor, York YO30 4XX, United Kingdom.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Laparoscopy/ Laprascopic surgery

Laparoscopy is an operation to look inside your abdomen by using a laparoscope. A laparoscope is like a thin telescope with a light source. It is used to light up and magnify the structures inside the abdomen. (See other Information section: Laparoscopy).  

In addition to simply looking inside, a doctor can use fine instruments which are also passed into the abdomen through another small incision in the skin. Laparoscopic surgery is sometimes used in the treatment of pelvic pain due to endometriosis. Laparoscopic surgery is sometimes called 'key-hole surgery' or 'minimal invasive surgery'. 

Patient UK (www.patient.co.uk) has a leaflet on Laparoscopy and laparoscopic surgery. Most GPs in the UK have these same leaflets on their computer to print out for patients and carers. 

Informed health online (www.informedhealthonline.org) has a review of the effectiveness of laparoscopic surgery is for pelvic pain due to endometriosis.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Sex and chronic pain

People with chronic pain may become less interested in having sex because of anxiety about aggravating pain. 

It may help to plan your sex life more by working out which time of day your muscles and joints are least painful and trying to spend some time with your spouse or partner then. 

Some medications used for pain relief, for instance certain tranquillisers and antidepressants, can reduce people's natural interest in sex.  

Pain Concern (www.painconcern.org.uk) have a leaflet about sex and chronic pain.

See also the 'Talking about...' section of this site: Relationships and sex life.

Last reviewed November 2012.

The information in this section was compiled by the Health Experiences Research Group.

Work and chronic pain

Work can be a major concern for people with chronic pain though ideally it should be seen as a realistic goal. Though some people may lack confidence about returning to work or have concerns about resuming certain activities associated with work (particularly if they have caused pain in the past), most barriers can be overcome. 

A combination of pain management and vocational training can often help those with chronic pain get back to work or find out about training opportunities.  

For more advice about finding work contact your local Jobcentre. If you experience any problems about finding work, or are having difficulties managing your work because of chronic pain, your local Jobcentre should be able to put you in touch with the Employment Service (ES).  

The ES has produced a useful booklet 'Sources of Information and Advice' (PGP6) which lists many of the specialist organisations offering advice on employment and disability issues. Also the ES has special advisers who can offer employment help and support to people with disabilities. 
 
If you have experienced any form of discrimination at work because of chronic pain a good place to start getting help is the Citizens Advice Bureau. Your trade union representative may be able to advise and help you.  

If you want to find out more about the Disability Discrimination Act and the changes that are due to be introduced in October 2004, all the information is available through the Disability Rights Commission website (www.drc-gb.org). For people living in Wales and Scotland the website address is the same. 

There is also a Disability Discrimination Act Information Line that offers information about the DDA 24 hours a day. Call 08457 622 633 or 08457 622 644 (textphone).  

For more information about disability issues and access to work, education and training see the government's disability website (www.disability.gov.uk). 

Employment Service's Disability Service

In cases where someone's condition has lead to prolonged sickness and absence from work, specialist help is available through the service above. You can contact this service through your local Job Centre or Employment Services office (listed in your local telephone directory).  

Disability Employment Advisers (DEAs) are specially trained to recognise and help overcome the employment problems associated with disability. DEAs can make assessments of the type of work likely to be most suitable for someone and can help find such work.  

New Deal for Disabled People (NDDP)

At the moment a Personal Adviser service is being developed for those who have a long term illness or disability, particularly if they are already receiving incapacity benefit.  

Last reviewed November 2012.