Managing your pain

Pain is usually a protective mechanism that alerts your brain when your body is being harmed in some way. The nerves in that area send signals through the spinal cord to the brain. The brain locates the injury and triggers a healing process.

Pain signals may be triggered by:

• physical injury or damage to your body – for example, a sprained ankle or damage that occurs as part of a longer-term condition such as osteoarthritis
• chemicals produced within the body itself that can irritate the nerve endings – this may be linked to an infection, an overuse injury or a flare-up of a long-term illness such as rheumatoid arthritis
• damage to nerves that causes them to fire off pain signals to the brain without any physical cause, which sometimes happens in complex regional pain syndrome.

When we have an injury or tissue damage caused by an illness, the nerves in the affected part of the body become more sensitive than normal, so pain signals are triggered more easily and warn us if there’s any further threat to the painful area. Normally, as the injury heals, the nerves become less sensitive again and the pain signals lessen and then stop.

When pain interferes with our daily activities, pain-killing drugs may help by blocking or reducing pain signals to the brain even though they don’t affect the injury or damage directly.

Pain isn’t just a physical sensation – it can have emotional effects too, especially if the cause of the pain isn’t clear or it’s difficult to find effective pain relief. And our emotions or mood can in turn make the pain seem worse or better.

Doctors define long-term (or ‘chronic’) pain as pain that’s lasted for more than 12 weeks or that’s lasted for longer than would be expected for the type of injury or level of damage.

Sometimes it’s possible to find a specific cause of long-term pain – for example:

• an underlying condition such as arthritis
• nerve damage or disease.

However, with long-term pain, the sensation of pain isn’t always directly related to the injury or damage that caused the pain in the first place. Sometimes messages between the nerves and the brain can become disturbed so that the nerves remain unusually sensitive and continue to fire off pain signals even after a physical problem has cleared up.

Because our bodies are ‘programmed’ to understand pain as a warning sign, our natural reaction is often to protect the affected area from further harm – perhaps by resting it completely, by using it less than usual or by supporting it.

After a time, lack of use leads to weakening of the muscles. As we become less fit, we tire more easily and become more prone to strains and sprains, resulting in further pain. This can easily become a vicious circle.

Pain can make it difficult to get on with your everyday activities whether at home, at work or in your leisure time. It’s a natural instinct to try and protect whichever part of the body is painful and this can affect your everyday choices. You may try to avoid jobs that tend to increase your pain or you may turn down opportunities to do things you’d normally enjoy.

Pain isn’t just a physical sensation – it has emotional effects too. If you’ve had pain for months or years, it’s not surprising that it can begin to affect your mood and self-confidence. Living with long-term pain is very different from coping with a short spell of pain, especially if the cause of the pain is unclear and standard treatments aren’t helping.

Other problems linked to long-term pain may include:

• sleep problems
• reduced physical activity
• difficulty with everyday activities
• reduced involvement in family and social activities
• difficulty concentrating or remembering things
• symptoms such as fatigue or weight gain
• side-effects from medications
• missing work, difficulties at work, or having to retire early
• changes in your relationships or sex life.

If your healthcare team haven’t been able to identify the cause of your pain then you may also feel frustrated and let down. You may feel that other people don’t understand how much pain you’re in and you may even begin to ask yourself whether the pain is ‘real’.

Most of the medicines used to treat pain from arthritis, joint or muscle pain fall into one of the following categories:

• painkillers
• non-steroidal anti-inflammatory drugs
• steroids.

However, other types of drugs may also be used in particular situations. All of the drug treatments below are designed to control symptoms – they won’t help to heal the damage or cure the underlying condition.

Finding the right pain medications is about striking a balance between the benefits and the possible side-effects. These will vary from person to person and will also depend on how long they’re used for. Stronger painkillers will also tend to have a greater risk of side-effects.

Depending on your own situation it may be advisable to limit the use of stronger pain medicines to times when the pain is particularly severe and to try some other pain management techniques as well to see what works for you. It’s also a good idea to review your medication from time to time to make sure you’re still happy with the balance.

Painkillers

Types of painkillers (analgesics) include:

• simple analgesics like paracetamol
• more complex analgesics, which are chemically related to morphine (sometimes combined with paracetamol, for example co-codamol, co-dydramol)
• tramadol, oxycodone, slow-release morphine, or patches containing fentanyl or buprenorphine.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Types of NSAIDs include:

• aspirin or ibuprofen tablets, which you can buy over the counter at chemists and supermarkets without a prescription
• diclofenac, naproxen or indometacin tablets, which are available with a doctor's prescription
• gels or creams which can be applied to the painful joint (for example, ibuprofen, diclofenac)
• a newer type of NSAID commonly called 'coxibs' (for example celecoxib), which are designed to control pain and inflammation but with a lower risk of digestive problems than with the older NSAIDs.

Steroids

Steroids can be given as:

• tablets (usually prednisolone), which are often prescribed because nothing else works, as in polymyalgia rheumatica (PMR)
• injections either into the joint itself or into soft tissues around the joint.

Steroid injections aren’t generally used in the treatment of long-term pain because of potential side-effects. However, occasionally a steroid injection may be offered to help deal with a flare-up of a long-term condition such as osteoarthritis.

Other drugs used to treat long-term pain

Alongside painkillers, there are other drugs that can be used to help manage pain, some of which were originally used for other problems. The ones most often used are:

• antidepressant drugs such as amitriptyline – which is prescribed at a lower dose when it’s used for pain relief than it is when used for depression. These can help with pain by helping the brain to control sensations coming from other parts of the body. They can also help if pain is affecting your sleep.
• anticonvulsants or anti-epilepsy drugs (for example, gabapentin, pregabalin). These can be particularly helpful for pain caused by nerve damage.

Nerve blocks and other injection techniques

Injections to block pain are becoming more widely available. They usually combine a local anaesthetic with a steroid and act directly on a nerve. They're not suitable for all types of pain, but they're sometimes helpful for:

• osteoarthritis of the small joints between the bones of the spine
• compression of nerves in the lower spine.

Special scans such as magnetic resonance imaging (MRI) or computerised tomography (CT) are often needed so the specialist can decide the exact site for the injection.

Manual therapies

Physiotherapists, osteopaths and chiropractors may use a variety of different manual techniques, including:

• manipulation and stretching
• technologies such as ultrasound, laser or interferential treatment
• exercise programmes to strengthen muscles and improve general fitness.

It's important to go to a qualified practitioner, preferably with the guidance of your doctor.

In some conditions, for example back pain, the Alexander technique may also help. The Alexander technique teaches awareness of posture and relaxation to reduce muscle tension.

Transcutaneous electrical nerve stimulation (TENS)

TENS is a technique that uses small pulses of electricity to produce a tingling sensation. It aims to disrupt pain signals by reducing the sensitivity of the nerve endings in the spinal cord. Some people find it very effective, especially when the pain is due to nerve damage.

It's best to get advice from a physiotherapist on where to position the pads, the frequency and strength of the pulses and the length of treatment.

Acupuncture

Acupuncture is used by doctors and other practitioners, often with very good effect. Very fine needles are inserted into specific points in the body. It's thought to work by diverting or changing painful sensations sent to the brain and by stimulating the body's own pain-relieving hormones (endorphins and encephalins).

Hydrotherapy

Many people with long-term pain find exercise in warm water is a comforting and effective way of moving the joints fully and stretching and strengthening the muscles. The warmth of the water soothes pain and because the water supports your weight it reduces the stresses on your joints.

A lack of hospital therapy pools means that access may be limited. However, many facilities offer out-of-hours access on a paid basis – contact your local hospital for details.

Local swimming pools tend to be cooler than aquatic therapy pools, but exercise classes such as aqua-aerobics provide a safe and fun way of exercising. Alternatively, local hotels with spa or aquatic therapy facilities may provide swimming or aqua classes.

Splints

An occupational therapist (OT) may also suggest wearing a splint. The term ‘splint’ covers a variety of devices, which are mostly for the hands but can be for other parts of the body such as the neck or foot. They can be ready-made from soft, flexible material such as neoprene, or tailor-made by the OT from a type of plastic to specifically fit your joints.

Splints may be suggested for various reasons, such as to rest the joint and reduce pain or to correctly position the joints to prevent deformity and improve function. The OT will recommend when you should wear the splint and how long for. Overuse of splints can lead to muscle loss due to lack of use. You should also take it off regularly to allow your skin to breathe.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapies (CBT) is a term used for a wide range of psychological approaches designed either:

• to manage the symptoms of health problems, or
• to change behaviour to improve your ability to function on a day-to-day basis.

All forms of CBT are based on the idea that our thoughts, beliefs, feelings, behaviour and the situations we’re in are all inter-connected. Our thoughts and beliefs can influence our behaviour; our behaviour can influence our feelings; and the situation we’re in can affect our behaviour. CBT includes assessing and understanding these connections and then finding ways to modify them to tackle the problem.

CBT isn’t right for everybody but it is a well-established approach that’s effective for improving people’s mood, health and ability to get on with their daily lives. It isn’t simply about talking or seeking advice, but about learning new skills that should help you to handle challenges in your life more effectively. For example, if fear of pain is causing you to avoid physical activity, then these methods can help in facing those fears.

Psychologists in particular often teach coping skills. These can include:

• relaxation techniques
• goal-setting and pacing
• ways of working on thoughts and beliefs and especially discouraging moods.

Mindfulness

Mindfulness (or mindfulness meditation) is another approach that’s becoming popular to treat health problems. It aims to help focus your attention on present-moment experiences rather than on the thoughts you may hold about those experiences. It can help us to think through our choices rather than acting on impulse when we’re feeling distressed. It’s difficult to understand mindfulness fully just from a description though – it’s better to try it to see if it works for you. There are many psychologists and other professionals who provide training in mindfulness.

If you’d like to do a very simple mindfulness-type exercise, try the following:

1. Whatever you’re doing, stop for a few minutes.
2. Look around and notice five things you can see.
3. Listen carefully and notice five things you can hear.
4. Focus on sensations on the surface of your body and notice five things you can feel.

You might find you feel more focused and your mind seems less busy after doing this exercise. (This exercise is based on one described by a physician and therapist called Russ Harris. Russ and other professionals, including Tobias Lundgren, JoAnne Dahl and Steve Hayes, have written a number or books and workbooks you might find useful.)

Long-term pain can greatly affect your ability to carry out daily activities. You may find certain movements are particularly painful so you avoid them altogether. But it’s important to remain as active as possible as lack of use can lead to loss of strength and coordination. And trying some of the ideas below may help to minimise the pain relief medicines you need to take.

Exercise

Long-term pain affects the way you move your body. You may stop using specific joints as you normally would, or you might reduce your level of activity overall. This results in a steady loss of joint mobility, muscle strength, co-ordination and balance – and it probably won’t stop the pain. And by trying to protect the painful area you may put strain on other parts of the body, resulting in secondary pain.

Increasing your physical activity and maintaining a good posture can help you cope more effectively with pain by:

• improving your ability to carry out daily tasks
• making you feel better in yourself
• giving you more energy
• improving your sleep
• helping to control your weight – which is especially important if you have leg pain.

How can I increase my physical activity?

Simple things like aiming to walk a little more each day will lead to gradual but important improvements in your physical fitness. But more structured forms of physical activity will increase the benefit.

Community activity or exercise groups are an excellent way of increasing physical activity and have the added benefit of meeting other people. Leisure or community centres, libraries and GP surgeries often hold details of local activities.

Walking is particularly good for your health. The ‘Walking for Health’ scheme has over 600 local groups, so there’s likely to be one close to you. Walks are designed for all abilities. Stand tall with your stomach pulled in when you’re walking as good posture minimises the strains on your body.

Other community activities that offer significant health benefits and may help with pain are t’ai chi and qigong. Both consist of gentle low-impact movements that you can do either standing or sitting, so they’re suitable for anyone.

Yoga has been shown to be helpful for low back pain, reducing pain and helping people to perform everyday activities more comfortably.

Whatever type of physical activity you prefer, check that your instructor is properly qualified. Take some time to speak to them about your specific needs before starting an activity.

Increasing your general level of activity is the best long-term strategy to manage and cope with persistent pain. But there may be times when you need help from a physiotherapist – for example, if you have difficulty with particular activities, if you’re prone to falling, or develop new problems.

Your physiotherapist will assess your difficulties before showing you specific exercises to move your joints, strengthen your muscles and improve your coordination and balance. Follow the instructions you’re given carefully to get the most benefit from the exercises.

Joint protection

It’s important to understand how your condition affects your joints and causes pain so that you can think about how best to move without unnecessary strain.

An occupational therapist (OT) will be able to offer further advice on joint protection techniques. Joint protection doesn’t mean you should stop using your painful joints but it may involve finding different ways of doing particular tasks or using gadgets to help you.

Your OT will be able to advise you on the gadgets available and may also make suggestions on how to reorganise your home or work environment to reduce unnecessary strain.

Pacing

If you have long-term pain then you may also experience extreme tiredness (fatigue). A key aspect in managing pain and fatigue is finding the right balance between activity and rest, otherwise known as pacing.

Too much rest is likely to increase stiffness and over time can result in the muscles weakening, so that getting active again becomes harder than ever. On the other hand, pressing on to get everything done when you’re having a good day is likely to lead to more pain and fatigue the next day.

Try taking short breaks of 3–5 minutes every 30–45 minutes to sit and rest your joints. Or you might find that even shorter breaks of 30 seconds every 5–10 minutes might suit your lifestyle better.

Try also to switch between jobs that you find tiring and those you find easier or more enjoyable. Finding time for the things you enjoy in between the things you need to do will be good for your mental wellbeing.

Your occupational therapist, physiotherapist or psychologist can offer further advice on pacing your activities. You may find it helpful to make a note of your daily activities and highlight times when pain or fatigue caused difficulties. This will help you to spot any patterns and may suggest possible solutions.

Relaxation

Many people find that learning relaxation techniques can help in managing pain and reducing stress. There are a number of options available.

Some approaches take you off on a scenic journey describing restful locations (this is known as guided imagery), while others focus on tensing and relaxing various parts of your body (progressive muscle relaxation). It’s worth trying a few different approaches to decide what works best for you.

Self-directed forms of relaxation include:

• meditation, which involves concentrating on breathing or a sound (called a mantra) that you repeat to yourself
• breathing techniques which, once mastered, can be performed anywhere to relieve anxiety.

You may need to attend a class to learn some of the techniques, but regular practice will increase the effectiveness of relaxation.

It’s best to apply relaxation techniques in a way that supports the activities you want to do. Often brief spells of relaxation that you can incorporate into your activities work best. Longer relaxation exercises that act as a form of escape from reality are perhaps less useful, though you may want to try them occasionally.

Getting a good night's sleep

Pain may make it difficult to get to sleep or it may wake you from your sleep. If you often lose sleep this can make the pain seem worse, which in turn can disturb your sleep even more.

Establishing a regular bedtime routine may help to break this cycle. You might want to try a warm bath, calming music or relaxation techniques before going to bed. A supportive pillow, and avoiding caffeine or watching TV close to bedtime may also help. Your occupational therapist can help you to identify other things that might help to improve your sleep.

Sleep medications are usually only partly effective for most people and they’re not ideal for long-term sleep problems. However, there are very effective psychological methods for improving sleep.

If modifying your night-time routine isn’t enough on its own, then cognitive behavioural therapies (CBT) may help you to establish a regular pattern of sleep. Ask your GP to refer you if you’d like to try CBT for your sleep problems.

Coping better at work

It can be challenging to remain in work if you have long-term pain. Learning practical things that you can do to help manage the pain, such as joint protection, pacing, exercise and relaxation, will help. If your company has an occupational health advisor, you may want to discuss this with them.

Occupational therapists can help by assessing work tasks in order to modify and reduce the effort required. They may recommend changes to your physical working environment and can provide support by liaising with your employer. Some may carry out workplace assessments with you.

Other self-help tips

Other pain-relief techniques that might help include:

• a heat pad, heated rice pad or a hot-water bottle
• an ice pack or a cold-water compress
• massage (with or without creams that create a sense of warmth)
• rest and good quality sleep – disturbed or unrefreshing sleep can increase pain, so speak to your doctor if you have this problem.

These techniques are often helpful after an injury and for sudden flare-ups of arthritis or back pain.

Because nobody else can experience your pain or fully understand what it’s like to live with it, only you can decide what treatments or therapies are right for you. But that can be difficult if you’re feeling low or anxious or if you don’t know what support is available in your area.

Taking some time to think about what’s worked, what hasn’t and what your priorities are may help in making choices that fit in better with your way of life. A useful first step in forming a pain management plan is to think about how your pain affects your life.

Try completing each of the following phrases. "Since my pain began...":

• I spend more time thinking about
• I spend less time thinking about
• I spend more time doing
• I spend less time doing

Below are some of the methods people use to deal with ongoing pain. Which ones have you tried?

• Taking drugs
• Distracting yourself
• Looking for information
• Modifying your home
• Homeopathy
• Taking time off work
• Resting
• Trying to relax
• Using braces or aids
• Seeking a clear diagnosis
• Massage
• Chiropractic treatment
• Seeing your GP
• Other alternative treatments
• Complaining
• Denying you have pain
• Asking for help with tasks
• Stopping painful activities
• Seeing another doctor
• Exercise
• Looking for the answer
• Pacing activities
• Surgery
• Hydrotherapy
• Acupuncture

These methods listed aren’t necessarily good or bad – some of them may work for some people, but that doesn’t mean they’ll be right for you. There may be other things on your list as well.

When you’ve thought about your own list, ask yourself the following questions about each method:

• Has doing it honestly helped your pain in a lasting way?
• Has it helped you to live the kind of life you want to live, especially in the long-term?

Weigh up the benefit you got from each method against the time and energy you put into it. Use this to decide:

• whether it’s worth trying a particular method more often
• whether to try something different.

When we have problems, we automatically try to work them out. And sometimes we refuse to give up on a problem even though we’re not getting anywhere. At the other extreme, we sometimes feel confused or scared when we have problems and give up or do nothing. As you look at your pain-management methods, see if you notice yourself doing this.

Ask yourself the following:

• Do you feel that the ways you’re trying to manage pain are successful?
• Do they improve your life?
• Do you ever feel like you’re struggling and getting nowhere?
• Does trying to control pain actually stop you from doing what you want to do?

Seeking treatment for pain is useful when it works, but it can hold you back when it doesn’t, and can create a life focused on pain instead of on what you really want to do.

If you think some methods aren’t working, discuss this with your healthcare team. There may be some treatments that you need to continue to control a specific condition or others that shouldn’t be stopped suddenly. But beyond those you do have choices.

If you find yourself stuck in a trap, trying things that aren’t helpful or don’t suit your lifestyle, then try refocusing on your goals. Think about the circumstances that will get you there. Try not to let pain, fatigue or other symptoms distract you.

Try the following exercise to remind yourself that you can determine your own focus:

1. Put your index finger in front of your face and stare at it.
2. What looks clear and what looks blurry?
3. Shift your focus beyond your finger. What looks clear and what looks blurry?

Which view shows you more of what is around you and gives you a more complete picture?

Sometimes we focus on one issue that feels close, like the finger. These issues don’t always affect us in the same way if we look at a wider view.

As you do this exercise, don’t think about it too much or try too hard to figure it out. It’s enough to simply notice what the experience is like of switching focus and seeing what’s in front of you in a different way.

These exercises won’t always help you to find the right answer, but they might help you feel more confident about letting your experience be your guide and using the quality of your life as a measure for the success of pain management methods.