Management of Chronic Pain

• Pain management programmes (see article above)

• Physiotherapy, using exercises which aim to improve muscle strength/flexibility and therefore function
• Hot/cold therapy
• Graded motor imagery
• Mirror therapy

• Chronic pain is associated with:
• Depression (30-40%)
• Anxiety (25%)
• Suicidal ideation (32%) or attempts (5-14%)


• Psychological approaches include acceptance and commitment therapy (ACT) or cognitive behavioural therapy (CBT)
• Management aims to address:
• Impact of pain on QoL and mood
• Patient's function and social interactions
• Pain avoidance behaviours

• Activates Aδ fibres, leading to:
• Endogenous neurotransmitter and hormone release
• Up-regulation of analgesia-associated genes
• Effective for migraines, tension headaches and osteoarthritis

• NICE suggests considering amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline

• One should not initiate:
• Antiepileptics including gabapentinoids
• Antipsychotics
• Benzodiazepines
• Ketamine
• Simple analgesia e.g. paracetamol, NSAIDs
• Opioids

• TENS acts upon peripheral nerves via electrodes placed on the skin
• A battery-operated unit delivers stimulation of alterable intensity (0 - 50mA) and frequency (0 - 200Hz)
• Works by closing the pain gate, through stimulation of:
• Aβ fibres using high frequency (50 - 100Hz)/low amplitude TENS, leading to stimulation of pain-inhibitory GABA receptors
• Aδ fibres using low frequency (1 - 5Hz)/high amplitude TENS, leading to stimulation of the PAG and therefore descending inhibitory pathways
• No longer recommended by NICE due to a lack of evidence

• Lidocaine infusions in chronic neuropathic pain, although not recommended by NICE
• IV regional blocks for CRPS e.g. local anaesthetic, ketamine, steroids or guanethidine

• Local anaesthetic or steroids are injected into highly irritable, localised bands of muscle
• The pain relief allows exercise to take place, minimising recurrence
• Not recommended by NICE

• Reduce inflammation in the intra-articular space
• Examples include cervical or lumbar facet joint injections under fluoroscopic guidance

• May use local anaesthetic ± corticosteroids as a diagnostic or therapeutic procedure
• E.g. stellate ganglion block for upper limb CRPS
• E.g. suprascapular nerve for shoulder pain
• May use alcohol or phenol to cause neurolysis e.g. cancer pain, with effects lasting up to six months

• Indicated in a variety of neuropathic pain syndromes (see article above)
• Needle placed next to the nerve under fluoroscopic guidance and high-voltage electrical pulses are applied to burn the nerve and prevent the conduction of pain
• The current is applied in a pulsatile fashion with a maximum temperature of 42°C to avoid coagulation of nervous tissue

• Commonly used to treat pain arising from the spine, with evidence of short-term relief but limited long-term benefit
• Three common approaches:
• Caudal: for leg pain arising from lumbar levels
• Transforaminal: for lumbar radiculopathy
• Interlaminar


• Spinal cord stimulators are another option

• May be used for cancer pain or spasticity, although no longer recommended for chronic, non-malignant pain
• Direct delivery of drugs to dorsal horn reduces dose required (and therefore side effects) and increases efficacy