5.  Treatment options for chronic pain

The choice of a pain therapy will depend on your specific type of pain, how severe it is, and how well any other therapies have worked. If your current treatment is not controlling your pain or is causing uncomfortable side effects, you and your doctor may well consider other options, including:

Medication

Medication is often the first therapy that doctors use to manage chronic pain. Each patient will have a unique response to any medication, so your doctor will usually need to try a variety of drugs and dosages to find the most effective combination. Your treatment will depend on the type and severity of your pain, along with how well your pain responds to that treatment.

Pain relieving drugs can be delivered orally, rectally, transdermally or as an injection (intravenous, subcutaneous, intramuscular). These are all termed called 'systemic delivery' because the medication is distributed though your circulatory system.

The first step is usually to try a common oral pain reliever such as aspirin, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs). Some of these medications are available without a prescription.

If these medications do not control your pain, your doctor may try opioids. Opioids will either replace or combine with what you're already taking. Weak opioids such as codeine are usually given orally as pills. Stronger opioids such as morphine or fentanyl can also be given orally, but are sometimes administered through skin patches (fentanyl only), suppositories, or via an external infusion system.

Your doctor may combine other types of drugs with your pain relievers. These might include anti-inflammatory steroids, anticonvulsants, or antidepressants. These drugs may be effective treatments for specific types of pain, or for pain with specific causes. Your doctor may prescribe steroids to help relieve an inflammation, for example.

Some drugs will have a more profound effect if they are injected close to the site of your pain or close to the course of the nerves that conduct the pain sensation. These drugs are referred to as nerve blocks.

Therapeutic nerve blocks involve the injection of a local anaesthetic and/or steroids at the site of the pain. This injection is directed to the nerve that serves the area where you are feeling pain. You may benefit from a single nerve block, but if you have a more complex pain condition you may require more. Nerve blocks typically only achieve temporary pain relief. So if your pain is not managed within four to six months, your doctor will often consider other pain treatments.

Sometimes your doctor will need to leave a plastic tube (catheter) in the area to allow easy follow-up administration of the medicine. If prolonged pain management is required, the catheter may be connected to a small pump and the entire device implanted under your skin. This therapy is known as intrathecal drug delivery (IDD).

The spinal cord is like a highway for pain signals traveling to the brain. Because intrathecal drug delivery delivers medicine directly to where your pain signals travel, IDD can control your pain with a fraction of the medicine that would be required for systemic delivery. With lower doses, the side effects associated with any oral medications can be greatly reduced.

IDD allows your pain medication to be delivered directly into the intrathecal space (where fluid flows around the spinal cord) though a small, soft catheter. A reservoir of the pain medication is usually contained in a special pump, which is surgically implanted under your skin, usually just above or below the belt line.

A catheter connects to the pump and runs under your skin to the precise delivery site. As the pump releases medication at a set rate, the dosage flows through the catheter and into the intrathecal space.

People with certain kinds of chronic pain may be candidates for IDD therapy. The following criteria are used to determine whether IDD is appropriate for a chronic pain sufferer:

  • More conservative therapies have failed to adequately help the pain.
  • An observable pathology exists that is associated with the pain.
  • Further traditional surgical intervention is not indicated.
  • No serious untreated drug habituation for the pain condition exists.
  • Psychological evaluation and clearance for implantation have been received.
  • No medical issues exist that could present complications with surgery.

In general, IDD is indicated for:

  • Chronic, intractable pain of malignant or non-malignant origin
  • Nociceptive or mixed pain
  • Stable or changing pain patterns

IDD may also be suitable if you have a non-malignant pain that is unresponsive to other treatments, if you have undergone an unsuccessful neurostimulation trial, or if you are experiencing intolerable side effects from oral opioid medication.

When considering IDD as an option, it is important to remember that all surgery carries risks including infection and other complications.

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Physiotherapy

Physiotherapy, or physical therapy, is the physical treatment of joints and muscles. Activity and pain control go hand in hand, with combined implications for your ongoing mobility and quality of life. So the controlled movement and exercise of painful body parts often helps to restore function to stiff joints and muscles.

A physiotherapist may be able to help you through:

  • Assessment of movement, strength, endurance, and other physical abilities.
  • Assessment of the impact of an injury or disability on your physical functioning.
  • Assessment of physical preparation for work and sports.
  • Program planning and education to restore movement and reduce pain.
  • Individualized treatment of an injury or disability based on scientific knowledge, a thorough assessment of the condition, environmental factors, and lifestyle.

Your physiotherapy may be passive or active. Passive therapies include massage and hot or cold pads, and are typically only effective for treating pain two to four weeks after an injury. Active physiotherapy includes exercises such as exercise and posture/gait correction, and is often continued for up to 12 weeks. Active treatments help relieve chronic pain by building or reconditioning your muscles so that they can move more normally.

Physiotherapy can also help improve the range of motion in your joints after pain-related inactivity. Each joint is designed to have a range of motion that is limited by its structure. Range-of-motion exercises are designed to gently move the joint through its normal range, to help prevent or remedy stiffness. These exercises will never include actions that stress or overextend the joint. You should ask your doctor or physiotherapist to show you how to do range-of-motion exercises safely.

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Electrical stimulation / neurostimulation

Electrical stimulation (also known as neurostimulation) can help reduce the pain sensation in specific areas of your body. Some stimulation devices, such as Transcutaneous Electrical Nerve Stimulation (TENS), work well if applied on the skin. This system uses electrodes, which are applied directly next to the painful area of the body. The electrodes are connected to a neurostimulation device, which functions on a battery and is usually carried on your belt.

Other more sophisticated neurostimulation devices can be surgically implanted, so that the electrical stimulation can be applied more directly to the nervous system.

These implantable medical devices use a small system (often referred to as a 'Pain Pacemaker') that is surgically placed under your skin in the abdominal area. The stimulator sends carefully controlled electrical pulses (which are felt as tingling sensations) to the spinal cord. These electrical impulses block the chronic pain signals so that they can't be received by your brain. The pulses are delivered via a special medical wire, surgically implanted along an incision near the spinal column.

Because this kind of neurostimulation works where the pain signals travel, its electrical impulses can be directed to block the specific site of your chronic pain. And neurostimulation does not involve any medication, so there are very few of the side effects that often accompany other types of treatment. In fact, neurostimulation may even reduce your need for pain medication.

Neurostimulation is most effective for neuropathic pain, typically when the pain is of non-malignant origin (i.e. a source other than cancer) and is affecting your trunk or limbs. The following criteria are usually used to determine whether an implant is appropriate:

  • More conservative therapies have failed to adequately relieve the pain.
  • An observable pathology exists that is associated with the pain.
  • Further traditional surgical intervention is not indicated.
  • No serious untreated drug habituation for the pain condition exists.
  • Psychological evaluation and clearance for implantation have been received.
  • No medical issues exist that could present complications with surgery.

Normally, any pain treatment involving surgical procedures will only be employed after simpler, less invasive methods have failed to relieve the pain.

It is important to remember that all surgery carries risks including infection and other complications.

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Psychological support

Because pain can have a profound social and psychological impact on the people it affects, you may be offered support as a supplement to any medical treatment. Talking to a professional counsellor or psychologist can help with the negative effects that pain may have on your mobility, social interactions, and relationships.

Chronic pain can be extremely stressful in the way it affects your relationships, work, or ability to take part in daily activities. You, family members and significant others may all bring a unique mix of feelings, expectations, beliefs, personality traits, experiences, support systems, and skills to the situation.

Psychologists, psychiatrists and counsellors work with pain patients on many levels - from relaxation techniques to coping and self-monitoring skills. Talking about your pain and its impacts can often help you and your loved ones to understand its various effects.

Joining a support group can also help. Hearing how others have dealt with similar issues, or just knowing that others are having the same experience as you, can bring great psychological relief.

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Surgery

Corrective surgery may provide pain relief by correcting an underlying problem, such as a structural back problem or a bulging disk. On the other hand, repeated surgeries may bring little or no pain relief in some cases.

The decision to have surgery depends on your physical condition and the underlying cause of your pain. Modern diagnostic tests, such as MRI and CT scans, can help your doctor determine whether structural problems are causing your pain. Surgery is usually only considered after other treatments have failed, unless the cause of your chronic pain is clearly mechanical - a disc irritating a nerve or scar tissue obstructing the bowel, for example. If such a problem is identified, a surgeon may perform surgery and try to relieve the problem.

Neuroablation is the destruction of nerves that serve as pathways to the brain. It is usually only considered when all other types of treatment have failed. The surgeon may use heat to sever the nerves that are transmitting pain signals and the effects may be permanent or the nerves may grow back over time.

Surgery may bring pain relief or it may cause a different pain. It is important to remember that all surgery carries risks, including infection and other complications.

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Complementary therapies

In addition to the accepted medical treatments, there are many other types of treatments aimed at the relief of chronic pain. In certain cases, people's pain has been relieved by chiropracters, osteopaths and even traditional Chinese healing methods such as acupuncture.

Chiropractic care is a hands-on therapy based on the theory that many medical disorders (especially disorders of the nervous system) may be caused by small dislocations in the spine called vertebral subluxations. Both chiropractic and osteopathic treatments usually involve adjusting the joints and bones in your spine, by using twisting, pulling, or pushing. Some practitioners also use heat, electrical stimulation, or ultrasound to help relax your muscles before beginning a spinal adjustment.

This type of care is often used in conjunction with other therapies, but may not be suitable for everyone.

However, if you'd like to try any of these avenues you shouldn't be shy about discussing it with your pain specialist. They will probably be well-informed on complementary pain therapies, and can offer advice on those most suitable for your type of pain problem.

If your current therapy is not effectively controlling your pain - or is causing uncomfortable side effects - it is important to talk to your doctor, and ask to be referred to a Pain Specialist near you.

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