Multimodal Pain Management Plan

Patient Information Leaflet about Managing Pain

Pain is described as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.
Pain that persists for more than 3 months is called persistent pain or chronic pain.
You may need to use more than one method to manage your pain effectively.

Some General Information

For you to feel pain, the pain message has to be carried from the area where you are feeling pain to your brain. The pain message can be decreased or blocked in many places along the system that is carrying your pain message.

Pain is broadly divided into inflammation type pain due to tissue damage or nerve type pain due to damage or dysfunction of the nerves. Methods used to treat these two types of pain are different. Some patients may have both these types of pain and may need more than one type of medication to treat their pain.

Some Ways of Managing Pain

TENS (Transcutaneous Electrical Nerve Stimulation): This simple devise, if used properly, may help some patients manage their pain better. TENS may not be a cure for your pain but can contribute to managing your pain. If your doctor thinks that TENS may help your pain you will be advised about this.

Physiotherapy: One of the main purpose of referring you to physiotherapy is to learn, from an expert, the appropriate exercises and do them regularly at home. You will also have the opportunity to learn about good posture, lifting and handling techniques, pacing and coping techniques etc. from an expert. You should be able to gradually increase the physiotherapy exercises as guided by the physiotherapist. This is particularly important if the medications or injection treatment decreases your pain and enables you to be more active.

Medications: Medications used to treat the inflammation type and nerve type pain are different. Some patients may have both these types of pain and may need more than one type of medication to treat their pain. Some patients are prescribed co-codamol. This contains paracetamol and codeine which is a weak opioid. Both paracetamol and codeine work by different mechanisms and can help each other and provide better relief than when they are taken alone.
Sometimes paracetamol or co-codamol can be given with an anti-inflammatory medication like naproxen or ibuprofen (Neurofen) if there are no contraindications. They can help each other and provide better pain relief. Anti-inflammatory medications should always be taken after you have had something to eat to reduce the chances of a stomach ulcer. You should not take these medications if you have a stomach ulcer, kidney problem or asthma.
If your doctor thinks that you have nerve type pain you may be started on amitriptyline / nortriptyline and/or gabapentin or pregabalin. You will be given a leaflet explaining the medication given and some of the possible side effects.

Simple Methods
Pacing and Coping
Pain Management Programme
Paracetamol, Anti-inflammatory
Weak opioid – codeine, etc.
Strong opioid – morphine, etc.
Medications for local application:
Capsaicin cream 0.025% and 0.075%
In some selected cases surgery may be indicated.
Injections can be used to diagnose where the pain is coming from and/or to treat pain (facet joint nerve block, Epidural steroid injection) Cauterising the nerves to prolong the pain relief obtained by injections (Radiofrequency Denervation)
If simple things like TENS, physiotherapy, medications, etc. are not able to control your pain fully, injection treatment may be considered and this will be discussed with you. If you agree to have the injections you will be informed about what injections can do and what you should do if the injections help your pain. Most injections are done under x-ray guidance.

If you are on any blood thinning medications other than 75 mg asprin please informs your doctor. Some injections carry a significantly higher risks if you are on blood thinning tablets.
If you have any infection or being treated for an infection please inform your specialist.

Diagnostic injections: These injections helps to find out the source of pain, e.g. facet nerve pain (medial branch block) helps to identify if your pain is coming from the facet joints in the spine. Please note down the intensity of your pain before the injection on movements, bending, extension of the spine and other activities and imaging this pain as 100%. You will be asked to all the movements than caused or increased you pain after the injection to find out if your pain is better, e.g. 50% or 80% better than before the injection. This will help decide if a radiofrequency denervation will prolong the duration of pain relief.

Epidural steroid injections: These injections normally help pain in the lower limb or the upper limb. Steroids are not licenced for epidural injections but are used worldwide to treat pain. We cannot predict the duration of pain relief and the amount of pain relief epidural steroid injections will provide as it varies between patients. However if they help they can be repeated.

Some useful links:
Faculty of Pain Medicine (UK):
British Pain Society (UK):
Spinal Intervention Society, USA:

Disclaimer: Please follow the advice given by the health care professional. This leaflet if only for information only and the provider of this leaflet is not responsible for any adverse effects due to information in this leaflet.