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Pain and arthritis information bookletNeck and back painMost people experience short spellsof neck pain or back pain that improvewithout specific treatment.If the pain keeps returning, there arepreventative approaches that can helpdeal with the problem. These include: exercises to strengthen the muscles special care with posture or yourworking position extra care during activities that involvebending, twisting or stretching being careful when liftingheavy objects.Neck pain after a whiplash injury canbe difficult to control in some people,but most improve with simple measuresafter a few weeks or months.For some people back pain spreadingdown one or both legs (sciatica) is causedby pressure on nerve roots in the spine.This pain may be relieved by x-ray guidedspinal injections, such as epidurals ornerve root blocks. These are specialistprocedures which are usually carriedout in a day-case operating theatre.A small number of people have backor neck pain that fails to improve andbecomes chronic. It’s often difficult tounderstand why this has happened.This pain is disabling and the challengeis not to let it dominate your life. A painmanagement programme – includingeducation, exercise and coping strategies– may help.Spinal surgery can be highly successfulbut isn’t usually needed and should onlybe undertaken after careful considerationof the alternatives. Most people with backand neck pain won’t benefit from surgery.See Arthritis Research UK bookletsBack pain; Neck pain.Chronic pain syndromesChronic headaches, facial pains andchronic upper limb pain syndrome– previously called repetitive straininjury (RSI) – are examples of chronicpain syndromes. It’s often difficult toidentify exactly what causes the pain,but it’s affected by factors such as theway the sufferer walks, stands and usestheir muscles.As there’s no cure or simple explanationfor many of these chronic pain syndromes,people in chronic pain may see a largenumber of specialists and sometimesreceive different, or even contradictory,explanations and a wide variety ofsuggested treatments. Because theproblem seems to worsen without anycure being available, the person in painmay feel let down by modern medicine.Because it’s so difficult to explain whatcauses chronic pain, people often findit hard to help family, friends, workcolleagues and healthcare professionalsto understand how they’re feeling.Those people, in turn, may then findit difficult to deal with the problem.Page 10 of 28

It’s important tobalance rest andexercise sensibly– a physiotherapistcan advise onappropriateexercises.

Pain and arthritis information bookletHowever, there are pain managementclinics, specialising in the care of chronicpain. Your GP should be able to refer youfor advice and help.In many cases chronic pain leads tochanges in the way people behave –which may then make the pain worse.For example, a person with chronicpain in the right leg may start to standor walk leaning heavily to the left side,which may eventually lead to pain inthe left leg too. When people havechronic pain that prevents them fromdoing things that they need or wantto do, this may often affect their moodand feelings, leading to frustration,anxiety and depression. Just likechanges in the way people walk orstand, these changes in mood canmake the pain feel worse too.In complex regional pain syndrome(reflex sympathetic dystrophy) pain isconfined to a particular region of thebody (for example one arm or one leg)and often has a burning quality. It mayfollow a minor injury, an operationor a stroke or there may be no clearunderlying cause. It’s thought that thecommunication pathways between theaffected limb and the brain becomedisrupted, so the pain is more intense or,if it follows an injury, persists for longerthan expected.Treatment for complex regional painsyndrome may include standardpainkillers or stronger morphine-likepainkillers. However, some people willneed neuromodulatory drugs (forexample gabapentin, pregabalin) whichreduce the pain signals from the nerves tothe brain, or a sympathetic block – aninjection that suppresses the sympatheticnervous system. Rehabilitation is animportant aspect of the treatment andmay include specialist physiotherapy,occupational therapy and psychology.Most people with complex regional painsyndrome will benefit from touching ormoving the affected limb, in spite of pain.See Arthritis Research UK bookletComplex regional pain syndrome (CRPS).What can I do aboutmy pain?There are now more approachesavailable than ever before to helpmanage pain. Drugs, physical treatmentsand coping strategies can all play a part.One of the keys to handling pain is tounderstand what’s happening.DrugsBefore 1900, aspirin and simplederivatives of opium (similar to morphine)were the only pain-relieving drugsavailable, but now there are many more.Although it’s important to consider thebalance of benefit and the risk ofpossible side-effects of drug treatments,in general the risks are far outweighedby the benefits.Page 12 of 28

Pain and arthritis information bookletThere are painmanagement clinics,specialising in the careof people with chronicpain. Your GP shouldbe able to refer you foradvice and help.Because it’s so difficultto explain what causeschronic pain, people oftenfind it hard to help family,friends, work colleaguesand healthcare professionalsto understand howthey’re feeling.Page 13 of 28

Pain and arthritis information bookletDrugs may be available under severaldifferent names. Each drug has anapproved (or generic) name butmanufacturers often give their ownbrand or trade name to the drug aswell. For example, Nurofen and Panadolare brand names for ibuprofen andparacetamol respectively, which are theapproved names. The approved nameshould always be on the pharmacist’slabel even if a brand name appears onthe packaging, but check with yourdoctor, nurse or pharmacist if you’re inany doubt. We’ll use the approved namesin the sections that follow. Tramadol, oxycodone, slow-releasePainkilling (analgesic) drugsAnalgesics are drugs that act specificallyagainst pain and are helpful for mosttypes of pain: Paracetamol is an example of asimple analgesic.Non-steroidal anti-inflammatorydrugs (NSAIDs and coxibs)NSAIDs combine pain-relieving effectswith an additional action that reducesinflammation. As inflammation is themain cause of pain in many conditions –including most forms of arthritis – thesedrugs can be doubly effective againstchronically painful conditions. More complex analgesics are relatedchemically to morphine but are muchless likely than morphine to causeproblems such as addiction. However,other side-effects such as constipationand drowsiness still occur. Codeineis an example. They’re often usedmore effectively in combination withparacetamol as compound tablets,for example: c o-codamol (paracetamoland codeine) co-dydramol (paracetamoland dihydrocodeine).morphine or patches containingfentanyl or buprenorphine are strongerdrugs which may be used for severepain but are used with more caution.All of these drugs can be seen as partof the morphine family, as can codeineand dihydrocodeine. Opioid analgesicscan cause constipation and may causedrowsiness, especially if taken withalcohol.See Arthritis Research UKdrug leaflet Painkillers.They can be used in combination withthe simple or compound analgesicsmentioned above, and can behelpful even when there isn’t a greatdeal of inflammation – for examplein osteoarthritis: Aspirin and ibuprofen are probablythe best-known NSAID tablets andare widely available over the counterwithout a prescription. Diclofenac, naproxen and indometacinare other commonly used NSAIDtablets. These are available witha doctor’s prescription.Page 15 of 28

Pain and arthritis information bookletAnyone whohas had severeindigestion orpeptic ulcers inthe past shouldusually avoidusing NSAIDs. Some NSAIDs (for example ibuprofen,diclofenac) are also available as gelswhich are applied to the skin aroundpainful joints. These may sometimesproduce local skin irritation. A newer type of NSAID commonlycalled coxibs (COX-2-specific NSAIDs),such as celecoxib or etoricoxib,are designed to control pain andinflammation but are less likely tocause indigestion and stomach ulcerssometimes associated withthe older NSAIDs.Like all drugs, NSAIDs can sometimes haveside-effects, but your doctor will takeprecautions to reduce the risk of these– for example, by prescribing the lowesteffective dose for the shortest possibleperiod of time.NSAIDs can cause digestive problems(stomach upsets, indigestion, or damageto the lining of the stomach) so in mostcases they’ll be prescribed along with adrug called a proton pump inhibitor (PPI),which will help to protect the stomach.NSAIDs also carry a slightly increased riskof heart attack or stroke. Although theincreased risk is small, your doctor willbe cautious about prescribing NSAIDs ifthere are other factors that may increaseyour overall risk – for example, if you’vepreviously had angina or a heart attackor if you smoke, or have circulationproblems, high blood pressure, highcholesterol or diabetes.See Arthritis Research UKdrug leaflet Non-steroidal antiinflammatory drugs.Corticosteroid drugsCorticosteroid drugs (steroids) may begiven either as tablets or by injection.They’re not painkillers, but by reducinginflammation they also reduce the pain.Prednisolone is the most commonlyprescribed steroid tablet forinflammatory arthritis. In certainconditions steroid tablets are prescribedbecause nothing else works, such as inpolymyalgia rheumatica.See Arthritis Research UK bookletPolymyalgia rheumatica (PMR).Steroids can also be given by injection– either into the joint itself or into softtissues near the joint. Steroid injectionsare usually very effective in relieving painand the benefit can last from a few weeksto several months. Sometimes the painmay flare up for a day or so just after theinjection before settling down.Page 16 of 28

Pain and arthritis information bookletSee Arthritis Research UKdrug leaflets Local steroid injections;Steroid tablets.Side-effects usually develop only whensteroid tablets are used for more thana few months, and are more likely to occurwith larger doses. The most commonside-effects are increased appetiteand weight gain, muscle weakness,and anxiety or sleeplessness. They mayalso cause thin, slow-to-heal skin or thin,fragile bones (osteoporosis). However, therisk of developing osteoporosis can bereduced by medication.See Arthritis Research UKdrug leaflet Drugs for osteoporosis.Drugs for nerve pain and chronicpain syndromes Tricyclic antidepressants (mostcommonly amitriptyline or dosulepin)are prescribed to be taken at night forpeople who have chronic widespreadpain, especially fibromyalgia wheredisturbed or unrefreshing sleep isthought to contribute to the ongoingpain. These drugs act partly by improvingsleep and partly by helping the brainto control sensations coming from theupper body and limbs. At the low dosesused for chronic pain they aren’t trulyanti-depressant. Side-effects includedrowsiness in the morning and a drymouth, although these aren’t usually aproblem if the dose is increased slowly. abapentin, carbamazepine andGpregabalin are members of a groupof neuromodulatory drugs (drugs thatact on the nervous system) often usedto treat epilepsy. However, they can alsobe useful in controlling some types ofpain, particularly where the pain is dueto nerve damage.Nerve blocks and other injectiontechniques for painIncreasingly, pain specialists are usinginjections to block pain by a directaction on a nerve or on the spinalnerve root when other treatments fail.These injections usually combine alocal anaesthetic with a corticosteroid.They’re not suitable for all types ofpain, but they’re sometimes helpful forosteoarthritis of the small facet jointsbetween the bones of the spine or forcompression of nerves in the lower spine.Increasingly, painspecialists areusing injectionsto block pain bya direct action ona nerve or on thespinal nerve root.Page 17 of 28

Pain and arthritis information bookletLearning to restsensibly, avoidingcertain activities,asking for help, andusing gadgets andhome adaptationsare all importantways of adjustingand learningto cope.The exact site for the injection can usuallyonly be decided after special scans,such as magnetic resonance imaging(MRI) or computerised tomography (CT).The specialist can then place theneedle accurately by following an x-rayimage, which is displayed on a screen.These treatments are for symptomcontrol and aren’t cures.arthritis or back pain. They don’t cure theproblem, but they are safe and soothing.Physiotherapists, osteopaths andchiropractors may use a variety ofdifferent manual techniques, includingmassage, manipulation and stretching,to relieve pain and to help return themuscles and joints to normal. They mayalso use technologies such as ultrasound,laser or interferential treatment.Exercise programmes, initially supervisedby a physiotherapist, may help tocontrol your pain. They help to relaxand strengthen the muscles and mayalso improve general fitness. Pilates orcore stability exercises are increasinglyrecommended for people with backpain. Exercise at a time when you’re notfeeling too stiff and take some painkillersbeforehand if you need to. Take time torelax and rest afterwards.Simple measures that can help to relievejoint or muscle pain include: a heated wheat or rice pad or ahot-water bottleIt’s important to go to a qualifiedpractitioner, preferably with the adviceand guidance of your doctor. If there’sno improvement after a few weeks oftreatment, further investigations maybe needed. It’s better to exercise littleand often rather than a lot occasionally.Find a form of exercise that you enjoy soyou’re more likely to continue with it. a n ice pack or a cold-water compress massage (with or without creamsTranscutaneous electrical nervestimulation (TENS)Other pain relieftreatments and therapiesthat create a sense of warmth, calledrubefacients) adequate r est time.These techniques are often helpful afteran injury and for sudden flare-ups ofThis is a technique that uses small pulsesof electricity to produce a tinglingsensation. It aims to disrupt pain signalsby reducing the sensitivity of the nerveendings in the spinal cord. It doesn’t helpeverybody, but some people find it veryPage 18 of 28

Pain and arthritis information bookleteffective, especially when the pain is dueto nerve damage. Some people becomeallergic to the jelly used to apply thepads, but otherwise TENS has few sideeffects. A physiotherapist can advise youon the correct position of the pads, thefrequency and strength of the pulses,and how long the treatment should last.AcupunctureAcupuncture is used by doctors andother practitioners for many purposesincluding pain relief – often with goodeffect. Very fine needles are inserted intospecific points in the body. It’s thoughtto work by diverting or changing thepainful sensations that are sent to thebrain and by stimulating the body’s ownpain-relieving hormones (endorphinsand encephalins).Psychological techniquesPsychologists are specialists whooften work as part of the team in painmanagement clinics. They help peopleto think differently about their painand change their behaviour as a result.Although some people are suspiciousof this approach at first, it has proved tobe very successful in helping people tomanage their symptoms. Pain is never apurely physical phenomenon, and whenthe pain is chronic, or its cause is difficultto determine, the psychological and socialeffects need to be specifically addressed.

Pain and arthritis information bookletRelaxation techniques andsleep patternsRelaxation techniques are helpful inmany conditions. They work by: relaxing the tense and painful muscles relieving the anxiety that makes painmore difficult to bear.Relaxation tapes, yoga and hypnosiscan sometimes be helpful. Specialmethods like the Alexander technique(which teaches awareness of postureand relaxation to reduce muscle tension)may also help. They’re often used by painmanagement clinics. It’s worth askingyour doctor about these techniques.It’s recognised that disturbed orunrefreshing sleep increases thesymptoms of pain – especially musclepain. If you wake still feeling tired or wakefrequently during the night, a doctor orphysiotherapist may be able to adviseyou about improving this.See Arthritis Research UK bookletsFatigue and arthritis; Sleep and arthritis.Self-help and daily livingUnfortunately, for some people pain islong-lasting, doesn’t respond fully todrugs or physical treatments, and can’tbe cured by surgery. In this case it’sworth thinking about lifestyle changes.Learning to rest sensibly, avoidingcertain activities, asking for help,and using gadgets and home adaptationsare all important ways of adjusting andlearning to cope. A doctor, social worker,physiotherapist or occupational therapistcan offer expert help and advice withthese changes.

Pain and arthritis information bookletArthritis Research UKWhat should I do if mypain is severe?Research and newdevelopmentsFor a small minority of people pain canbe severe and disabling. The pain oftenmeans you have to rest more, or can onlywalk or move awkwardly. This can resultin a vicious circle of pain, anxiety anddepression, and becoming physicallyunfit. It can be difficult to pluck up thecourage to do exercises despite the pain,to find other things to concentrate on andto refocus your thoughts away from thepain. People affected in this way shouldbe referred to a pain management clinic.Learning new ways to cope with pain canhelp. It can be helpful in certain situationsto focus more on improving your abilityto function rather than trying to reducepain. This can sometimes be achieved bydeveloping strategies to help with fearof movement. With help from family andfriends, as well as from specialists, you canstill have a fulfilling life.Alongside the University of Nottinghamand local NHS Trusts, Arthritis ResearchUK are proud to support the world’sfirst national centre for research intounderstanding the mechanismsof pain in arthritis.See Arthritis Research UK guideLiving with long-term pain: a gui

See Arthritis Research UK booklets Keep moving; Physiotherapy and arthritis. Also see our range of drug leaflets and surgery booklets. Rheumatoid arthritis Rheumatoid arthritis is a form of inflammatory arthritis in which the affected joints become warm, swollen and painful. The pain may