Your questions on pain relief

Q) I have been diagnosed with arthritis in the spine. This is as a result of muscle spasms in my upper back (which I have had on and off for the last 11 years), sometimes left side and sometimes right. It is now occurring more frequently, and has occurred six times in the last eight months, which last for four to five days, and the pain is quite excruciating. Codeine, diazepam and paracetamol do not ease the situation at all. I have about 30 seconds to do anything before I need to place my hand on my back to help relieve some of the pain. I have had two osteotemies and two total knee replacements and also have arthritis in my hands, so I am quite used to pain, but this is something else and is quite wearing me down. I am wondering if you could throw any light on the situation for me on how to manage the pain?

Sandra, Wiltshire - 2012

A) I wonder if the severe pain and muscle spasms are due to ‘something getting caught’ or becoming misplaced in the spine. Sometimes, malalignment can cause such severe episodes, and gentle manipulation (by physiotherapists, chiropractors or osteopaths) can solve the problem relatively quickly. Sometimes little bits of tissue called plica can get caught up between the small facet joints of the neck. The facet joints allow your head to turn and they depend on the smooth movement of the two surfaces of the joint. If something gets in between the surfaces, then movement stops and pain starts, usually quite dramatically. Again, physical treatments such as gentle manipulation can be of help.

This answer was provided by Dr Philip Helliwell in 2012, and was correct at the time of publication.

Q) I’m 23 and have just been diagnosed with degenerative arthritis of my spine resulting from Scheuermann’s disease. I was wondering how common this is? I am not old or overweight and have no sports injury, so I don't seem to fit into any of the common causes of arthritis. I just wondered if there are likely to be many others like me out there!

Sarah via email - 2013

A) Scheuermann’s disease is a benign condition of the spine occurring in adolescents. It consists of inflammation of the outer parts of the spinal bones (vertebrae). It is self-limiting but can cause pain and stiffness when it is active, and can result in the affected person becoming prematurely ‘round shouldered’ due to forward bending of the spine. It is uncommon in its most severe form but I suspect milder, less bothersome cases occur more frequently. In your case, if you had suffered pain and stiffness of the spine in your teens I suspect it would have been picked up at the time. From time to time we see traces of it when taking spinal x-rays for other reasons, and it seems to have passed un-noticed in these people. Whatever the cause of back pain it is advisable to keep the back muscles strong and the spine flexible to prevent future deterioration.

This answer was provided by Dr Philip Helliwell in 2013, and was correct at the time of publication.

Q) I’ve recently been prescribed painkillers for osteoarthritis, but I don’t really like taking medication and worry about taking too many or becoming dependent on them. How do I know when I'm taking too many painkillers?

Name withheld, via email - 2016

A) Simply put, you shouldn't be taking more than the instructions on the packet for over-the-counter preparations or on the label for prescribed medications.

In my experience, many people aren't using painkillers in the most effective way to manage their pain, using them too little rather than too much. The reasons for this are often related to myths that exist around painkillers.

Painkillers don't normally mask more serious problems

People worry painkillers will mask more serious problems. If you find yourself needing painkillers regularly for more than a week without a good explanation or diagnosis for your pain, then it’s worth speaking to your GP, practice nurse or pharmacist to get a proper assessment of your problem.

But normally painkillers won’t mask more serious damage.

Use painkillers at the right time and at the right dose

People worry that they'll become addicted to painkillers. This won’t happen in the short term and with most painkiller medications taken as prescribed or instructed.

There are some stronger painkillers that need careful monitoring when used for longer periods of time as the body becomes used to having them in the system. But these drugs are only available on prescription and should be monitored by a doctor to check for side-effects, make sure they're still necessary and assess if there are other problems developing with ongoing use.

Many of the common side-effects of stronger painkillers, such as constipation or nausea, can be managed with input from your doctor or pharmacist. 

I completely understand why people worry that they'll come to rely on painkillers. But when used properly, at the right time and the right dose, they can help people to get back to normal activities, sleep well and do the things they enjoy more quickly. Unfortunately, people tend to suffer with pain and wait for it to become really bad before taking a dose of painkillers, rather than using the clock to gauge when to take the next dose.

Use painkillers regularly at the lowest dose needed

I advise people with joint and back pain to use painkillers regularly, at the lowest dose needed to control their pain and allow them to get back to normal activities. Sometimes this means planning ahead – if you have osteoarthritis in your knees and know you have a busy day on your feet ahead of you, it’s well worth taking painkillers in advance to keep you comfortable during the day. The same is true with back pain.

In summary I prefer people to use painkillers in a way that allows them to live with less pain and keep doing the things they enjoy, rather than not using medications that can help, suffering with pain and doing less.

This answer was provided by Dr Tom Margham in 2016, and was correct at the time of publication.

Q) I'm 55 and suffer from arthritis in my knees and fingers. Unfortunately I'm not allowed to take anti-inflammatory tablets as I’m taking aspirin. I've tried all manner of natural remedies but nothing works. I'm a piano teacher and as you can imagine it's no fun having pain and stiffness in my joints in my hands. Is there anything that you could advise for my situation?

Diana, Kent - 2010

A) There's no absolute reason not to use low-dose aspirin and anti-inflammatory tablets together, but doctors don’t like the combination because of the risks to the stomach. Some doctors might argue that the anti-inflammatory drug naproxen could be used as a substitute for aspirin. On the whole there has been a trend for GPs to avoid non-steroidal anti-inflammatory drugs (NSAIDs) altogether as they may cause stomach ulcers and raise the chance of a heart attack. As with any drug the pros and cons have to be balanced.

What alternative treatments could you take? Paracetamol at a decent dose (up to eight tablets daily) may also control your symptoms well. The evidence for glucosamine isn't strong and the same applies to fish oil, but you could try these for a trial period. It's also important to keep the muscles around the joints strong so don’t neglect those exercises, particularly for the knees.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.

Q) My husband has arthritis in both shoulders and has a lot of pain, especially at night when he can't get comfortable and pain keeps him awake. He takes normal painkillers and every three months or so has cortisone injections from the doctor. But despite this the condition is getting worse and the pain is increasing.

We were wondering if going to the gym and getting advice from them would help, or sauna and steam?  He's tried glucosamine but says it doesn't help. I've asked him to try massage, but as yet I haven't persuaded him. What would you recommend?

Marged, via email - 2015

A) Anyone who’s experienced shoulder pain will empathise with your husband. There’s an awful lot of activities of everyday living that rely on our shoulders working well. You’re on the right track with your thoughts on going to the gym though.

The shoulder is an amazing joint – combining strength with the largest range of movement of any joint in the body. The price we pay for this range of movement however is that the joint is very prone to problems relating to muscle weakness or imbalance, which happens very quickly in a painful joint. Poor muscle control leads to a sloppy joint that is unstable and painful.

Physiotherapy followed by continued work to strengthen the muscles of the shoulder and keep the flexibility and range of movement is the order of the day here. This can be combined with treatments like injections every now and then as needed to control the pain, so that the exercises are possible.

If things continue to worsen despite treatments like physiotherapy and injections then shoulder surgery may be an option. An orthopaedic surgeon can advise if arthroscopy (keyhole surgery) will help or whether a shoulder joint replacement is required. But technology and expertise in shoulder replacements is many years behind that of knee and hip replacements. So they're used more as a last resort to help manage pain and don’t have anything like the function of the original joint.

So in summary – press on with exercises, physiotherapy, painkillers and injections as necessary, with surgery as an option if these things don’t help.

This answer was provided by Dr Tom Margham in 2015, and was correct at the time of publication.

Q) I have osteoarthritis in both knees, not very severely, and can still walk short distances. However, in bed at night, I tend to wake up about 4 or 5 am with considerable pain in my left knee, sufficient to make it difficult to go back to sleep. Can you explain why it should be more painful when I'm in bed? Is there anything I can do about it, apart from taking painkillers?

Susan, Hertfordshire - 2010

A) This is a common problem. There may be a number of reasons why this occurs. Night pain is often an indicator of severity and is used to assess the need for further treatment, such as an operation. From what you say, this may not apply in your case. It may be worth getting a medical ‘update’ on your condition, however. Sometimes pain is more noticeable when there's little else going on but, in that case, people usually find it difficult to get off to sleep. If you're woken up by the pain it suggests that the arthritis has reached a more advanced stage. It may help to take a drug with a long duration of action, say 12 hours, at bedtime. Some anti-inflammatory pills are formulated in this way, as are some painkillers – they're usually labelled ‘modified (or slow) release’.

This answer was provided by Dr Philip Helliwell in 2010, and was correct at the time of publication.