Include physiotherapy, osteopathy and chiropractic
- Anti-inflammatory drugs, including NSAIDs and Cox-2 inhibitors.
- Antidepressants and drugs used in epilepsy. In pain clinics these drugs are not used for treating depression or epilepsy but because they can have a direct effect on certain forms of 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.
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 alone. This method is used for shoulder pain, some forms of neuralgia which affect the back of the head, chest wall pain and groin pain. 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. This method is used in 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.
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 and 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 and shoulder joints.
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, and 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 and 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.
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 damage. 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.
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.
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 occurs when a disk ruptures and its contents leak. A catheter (small tube) is inserted into the epidural space and is gently advanced into the area of scarring. This is done in the operating theatre under sterile conditions and using X-ray 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.
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 generalized condition.
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 aim 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 includes physical reconditioning, posture and body mechanics training, applied relaxation techniques, information and education about pain and its management, medication review and advice, psychological assessment and intervention (cognitive therapy) together with a graded return to the activities of daily living.
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.