Ways of Treating Pain
Physical Methods
Include physiotherapy, osteopathy and chiropractic
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Medication
* Specific pain killing drugs (analgesics) which can be given by mouth, by
suppository or through the skin by way of patches
* Anti-inflammatory drugs, including NSAIDs & Cox-2 inhibitors
* Antidepressants and drugs used in epilepsy-these are used not in pain
clinics for treating depression or epilepsy but because they can have a
direct effect on certain forms of pain ('nerve pain')
* Muscle relaxant drugs
* Drugs which act on a special part of the nervous system, sometimes
involved in chronic pain, called the Sympathetic nervous system
* Steroids-usually used in special injections around nerves or into joints
* Other drugs which are usually used by other doctors in different illnesses
but which have also been found to be useful in chronic pain;
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Nerve Blocks
In some cases, simple nerve blocks with a long acting local anaesthetic plus
an injectable steroid may result in relief of pain which lasts much longer
than the normal duration of the local anaesthetic e.g. Shoulder pain, some
forms of neuralgia which affect the back of the head, chest wall pain, groin
pain etc. In patients with sciatica, use is made of epidural injections,
which provide diagnostic information together with pain relief by using a
small needle to deliver local anaesthetic and anti-inflammatory steroid
medications onto the surface of the spinal column. Epidural injections can
also be carried out in the neck and in the upper back for pain in these
areas. In patients with pain, which involves a certain part of the nervous
system known as the Sympathetic Nervous system, certain blocks, known as
Sympathetic Blocks may be helpful e.g. chronic abdominal pain, chronic
pelvic pain and chronic angina together with some forms of pain in the arm
and leg. Trigger Zone Injections with local anaesthetic are used in patients
suffering from conditions involving muscle spasm; in these cases, benefit
can be obtained by repeating the injections using Botulinum Toxin (Botox or Dysport). In most cases, nerve blocks are carried out as Day Case
procedures.
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Joint Injections
Joint injections, using injectable steroid plus local anaesthetic, can be
very helpful in spinal pain where they can decrease the pain and
inflammation that may be present in the small joints of the spine called
facet joints. They can be done in the neck as well as in the upper & lower
back. The procedures are done under x-ray guidance so as to increase their
accuracy. They are usually done under local anaesthesia plus light
intravenous sedation. Other joints, which are often injected so as to give
relief from chronic pain, are the hip & shoulder joints.
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Radiofrequency
Radiofrequency (RF) facet denervation is a therapeutic procedure designed to
decrease or eliminate pain symptoms from the spinal facet joints. The
procedure is normally carried out on a Day Case basis.
The procedure involves placing a special needle, through which is passed a
small electrode, near the facet joints under x-ray guidance. An electric
current is then used to destroy the tiny sensory nerves that supply the
joints.
When successful, pain relief following a RF procedure can last considerably
longer than any relief following local anaesthetic and steroid blocks. This
procedure can be used on any area of the spine-neck, upper back & lower
back. Before patients can be scheduled for a RF facet denervation, they must
undergo diagnostic facet injections so as to verify the exact source of
their symptoms. Patients are given light intravenous sedation plus a local
anaesthetic during the procedure, however they will not be 'knocked out'.
Some co-operation is needed from the patient in order to increase the
accuracy of the technique and to add to its safety. Pain relief benefits
from the RF denervation should be apparent within 2-4 weeks although
sometimes it may take longer; there is, however, no guarantee of success!
The procedure, when done by experts, is very safe.
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Pulsed
Radiofrequency
Pulsed Radiofrequency is a technique designed to give long-term relief of
pain. It is used when one can identify a particular nerve or ganglion as the
cause of the pain. A special needle, through
which is passed a small electrode, next to the nerve or ganglion concerned
and a high frequency current (Radiofrequency Current) is delivered in short
bursts through the needle; this simply 'stuns' the nerve without causing any
clinically obvious signs of damaging. The procedure is usually done under
X-ray control in order to increase accuracy and safety. In some cases, e.g.
shoulder pain or pain at the back of the head, Xray is not necessary. This
technique has also been found helpful in some cases of low back pain, where
pain is coming from the intervertebral discs. In order to maximise safety
and accuracy, the nerve is first located by gentle stimulation and the
patients feel a tingling sensation in the area where the pain is located. A
tiny dose of local anaesthetic is then administered. The stunning procedures
are often done under Intravenous sedation as day cases.
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Stimulation
Therapy
TENS - Trans Cutaneous Electrical Stimulation, involves wearing special pads
which are attached via cables to a small machine which delivers a tiny
electric current through the skin over the area of the pain.
ACUPUNCTURE - is another form of stimulation therapy.
Both these techniques may be of help in some patients with chronic pain
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More
invasive procedures
THE RACZ CATHETER (EPIDUROLYSIS); this is used to release some of the scar
tissue from around trapped nerves in the Epidural space of the spine;
special drugs such as cortisone can reach the affected areas in an effort to
reduce pain and to improve mobility. Dr. Gabor Racz pioneered this
procedure.
Scarring is most commonly caused from bleeding into the Epidural space
following back surgery and subsequent healing. Sometimes scarring can also
occur when a disk ruptures and its contents leak. A catheter (small tube) is
inserted in the Epidural space and is gently advanced into the area of
scarring. This is done in the operating theatre under sterile conditions and
using Xray control. Drugs will then be injected through this catheter. The
injection consists of a mixture of local anaesthetic and a steroid as well
as other medications used to soften the scar tissue. The patient receives
deep intravenous sedation and analgesia, which makes the procedure easy to
tolerate.
SPINAL CORD STIMULATION; this involves the stimulation of spinal nerves
using tiny electrical currents. In carefully selected patients, the
technique can block chronic pain. A special electrode, which is powered by
an implanted battery or receiver, is implanted via the skin into the
epidural space onto the surface of the spinal cord.
DRUG DELIVERY SYSTEMS; this involves implanting a pump into the patient's
body so as to deliver pain-relieving drugs directly to the spinal cord.
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Physical Medicine
In some cases, referral to a Consultant Rheumatologist may be necessary e.g.
where pain is coming from many joints; such cases need expert investigation,
as the pain may be associated with a more generalised condition.
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Psychological
help &
Pain Management programme
A Pain Management Programme is a psychologically-based rehabilitative
programme for people with chronic pain, which remains unresolved by
currently available methods of therapy. Such programmes have two aims, viz.;
to reduce the disability and distress caused by chronic pain by teaching
sufferers physical, psychological and practical techniques to improve their
quality of life. They differ from standard pain clinic therapy in that pain
relief is not the primary goal. The content of such programmes include,
Physical reconditioning, posture and body mechanics training, applied
relaxation techniques, information & education about pain & its management,
medication review & advice, psychological assessment & intervention
(cognitive therapy), together with a graded return to the activities of
daily living.
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Surgery
In some cases, referral to a Consultant Surgeon may be necessary in order to
relieve chronic pain; surgery, however comes at the very end of the line and
everything possible is done at the Pain Clinic in order to avoid surgery.
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