We learn why doctors are increasingly recommending lifestyle and mind-based approaches for chronic pain.
Chronic pain – pain that persists or recurs for longer than three months – affects more than two in five (43%) adults in the UK, a figure that rises to around three in five (62%) people aged 75-plus.
Until recently, anti-inflammatories and other pain-killing drugs, antidepressants, cortisone injections and surgery were the cornerstones of treatment.
But with a slew of studies suggesting they have little value for chronic pain, doctors are looking for new solutions. One review found paracetamol – a staggering 6,300 tonnes of which are sold annually in the UK – is no better than a placebo for chronic back pain and arthritis.
And the largest-ever investigation into antidepressants prescribed for chronic pain last year found insufficient evidence of effectiveness – or even potential for harm.
Steroid (cortisone) injections, used to relieve inflammation, have also come under scrutiny with a 2019 US study pointing to a lack of conclusive evidence for their efficacy while warning of a danger of faster progression of osteoarthritis and bone loss. Surgery and other invasive procedures have also been deemed no better than a placebo for low back and knee pain.
Pain consultant Dr Deepak Ravindran, and honorary professor at Teesside University’s School of Health, says:
“Prevailing medical thinking has it that if you can find the source of pain and cut it away, numb it or block it with drugs or injections, you can fix it.”
But while there is a place for these things in the treatment of some kinds of pain, they can be useless for so-called primary chronic pain, where there is no definite physical source such as tissue damage, arthritis or disc degeneration, he says.
“This type of pain – known as nociplastic pain or central sensitisation – is a result of nerve cells in tissues inside the brain and spinal cord over-reacting to pain stimuli.”
Pain is a protective system that has evolved to keep us safe, explains Dr Ravindran.
“From childhood, our brains build up a memory bank that influences our experience and perception of pain. An arthritic knee or hip that becomes increasingly painful – even though tests reveal no change in the degree of joint damage – is entirely a result of a sequence of ‘decisions’ made by your sensitised nervous system in response to pain signals.”
Factors like lack of sleep, stress, the food you eat, too little physical activity, too much sitting down and emotional injury can interfere with pain signals and change the memory archive, he says.
Advances in imaging, such as functional MRI scans, that open a window on to our brains in action, have contributed to this more nuanced understanding of pain.
Dr Ravindran cites a US study that found a four-week course of brain retraining techniques led to two-thirds of chronic back pain sufferers being almost or completely pain-free for up to a year. Brain scans found changes in pain-generating regions of the brain.
Such studies help explain how tests can fail to pick up anything wrong in chronic pain sufferers, and why drugs, injections and surgery so often don’t work.
These days, Dr Lucy Ward, consultant in pain management at the Royal Free London NHS Foundation Trust, is more likely to advise her patients to fix their sleep, get more active, and engage in meaningful activities, such as going on holiday, hobbies and socialising, than to suggest medical intervention.
Exercise really does work, though doctors are often hesitant to promote it to someone living with pain. Even light exercise and gentle stretching can help – one pilot in Gloucestershire involving 100 patients found tailored group programmes with an exercise instructor not only improved function and quality of life, but also reduced pain.
Diet is another factor that’s often overlooked, says Dr Ward.
“The right diet can reduce inflammation, a key cause of pain, as well as improving the number of good bacteria in the gut. It’s about helping people understand why pain persists and helping them lead the life they want alongside their pain.”
The National Institute for Health and Care Excellence (NICE), the health watchdog, changed its guidelines on chronic pain treatment in 2021, advising physical and psychological therapies. However, Dr Ravindran cautions:
“Patients can get upset if their drug regimens are suddenly shaken up in favour of, say, breathing techniques, which they think are a poor substitute.
“It is important to understand the rationale and to have rapport and trust with your doctor.”
Dr Margaret Dunham, chair of the Older Person’s Special Interest Group at the British Pain Society (BPS), agrees.
“People need to have their pain acknowledged and their concerns listened to,” she says.
However, accessing one of the 300 specialist NHS pain clinics offering treatments and pain-management programmes is often a postcode lottery and waiting lists are long. A new national survey from the BPS’s Patient Voice Committee about experiences of living with persistent pain found that while seven out of ten of those surveyed had been referred to a pain clinic, three out of ten had waited more than five years for that referral.
Chronic pain sufferer Tim Atkinson, vice-chair of the Patient Voice Committee, says it’s vital to recognise your power to help yourself. Not all doctors are up to speed with the new thinking about pain, he says.
“I spent 20-odd years on the medical treadmill waiting for someone to fix me. Things only improved when I realised I had to take control.”
A seemingly trivial accident left Elizabeth Reilly, 74, from Oxfordshire, with chronic pain for 14 years – until she discovered something that really worked.
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