Information for Patients and Clinicians

• Gabapentin (RCHT1650)
• Pregabalin (RCHT1654)
• Steroid injections (RCHT1714)
• Tricyclics (RCHT1655)

• Botox injections in the pain clinic (RCHT 511)
• Cryotherapy (RCHT 564)
• Facet Denervation (RCHT 07)
• Greater occipital nerve block (RCHT1803)
• Intravenous lidocaine infusion (RCHT1145)
• Peripheral Nerve Stimulation (PNS) RCHT1185
• Pulsed radiofrequency (RCHT 993)
• Spinal injections (RCHT1357)
• Stellate ganglion block (RCHT 490)
• Suprascapular nerve injection (RCHT1776)
• Trigger point injections (RCHT 488)

• Driving and pain medications (RCHT1505)

• Following spinal implant procedures (RCHT 1610)

• patients with back pain
• patients with neck pain
• patients with knee pain
• patients with foot pain
• patients with shoulder pain
• patients with elbow pain

Yoga exercise videos:

• 45-minute beginner's yoga video class

Pilates exercise videos:

• 30-minute chair-based pilates video
• 30-minute pilates video class designed for patients with chronic pain
• 30-minute pilates video class for patients with back pain
• 30-minute pilates video class for patients with arthritis
• 30-minute pilates video class for patients with knee pain

• Click here to view a series of videos about mindfulness movement
• Click here to view a series of videos about Tai Chi
• Click here to view video 1 for patients with shoulder and neck pain
• Click here to view video 2 for patients with shoulder and neck pain

Meditation and sleep

Bedtime meditation

Getting a better night's sleep. Watch this video class that takes you step by step towards a comfortable seated practice of meditation.

Finding Peace in a Frantic World

A selection of six different meditations, taken from the book ‘Mindfulness: Finding Peace in a Frantic World’

Finding Your Ground

Mindfulness in the Time of Coronavirus is another collection of meditations that will help you explore alternative anchors for your attention, your feet, seat or hands. There are three versions of the Finding Your Ground meditation of different lengths. If you can, try to use the ten-minute version twice a day or the twenty or thirty-minute version once a day.

Sleepio

Sleepio is a six-week cognitive behavioural therapy sleep improvement programme, which you can enrol on for £45 and complete at home.

Anxiety and mindfulness

The SAM App

The Self-help App for the Mind (SAM) is free to download and will help you to understand what causes your anxiety, monitor your anxious thoughts and behaviour over time and manage your anxiety through self-help exercises and private reflection.

Be mindful

Be Mindful is an online course for reducing stress, depression and anxiety based upon mindfulness-based cognitive therapy.

Mindfulness Cornwall

Mindfulness Cornwall is a charity which aims to help people learn about and use mindfulness in their everyday lives. They offer an 8-week courses and individual appointments.

Living with chronic pain (listen online - audio CD)

Living with chronic pain is a free to access site which has 10 audio tracks covering a variety of topics including living with chronic pain, how to improve your fitness sleep and diet as well as a step-by-step approach to goal setting, how to use “Relaxation” to get a better night’s sleep.

ESCAPE-pain

ESCAPE-pain is an online structured program for people with knee, hip and back pain. It integrates educational videos with an exercise program. The resource is free and available here

Healthy Cornwall

The Make A Change Physical Activity page contains links to a variety of local walking, running, swimming and other sports activities. There is something for everyone no matter your age or ability.

The Expert Patient Programme

The expert patient programme is open to all patients in Cornwall and run by a team of trained volunteers. As part of the course, you attend six weekly sessions, which last two and a half hours, where you will learn how to manage your condition and meet other people who share similar experiences. The registration form and contact details are at the bottom of the page.

Reconnect2life

Reconnect2life is an interactive webpage where you can click through a series of information pages at home about understanding pain, improving your fitness and how you think about pain and how pain effects your mood. The health and fitness section also includes a step-by-step how to do it guides and videos on Tai Chi and Body conditioning.

Body reprogramming

Body reprogramming is a course for people who have Chronic Primary Pain, such as fibromyalgia. It provides an understanding of the condition and explores ways to help you reduce your symptoms. The course is composed of 6 sessions, each about 2 hours long.
If you would like to take part please contact your GP because they must refer you directly for this.

The Pain Management Plan

The Pain management Plan book, is a self-directed cognitive behavioural therapy learning programme, which can be purchased from Amazon and worked through at home.

painTrainer

painTRAINER is an interactive, free, online program that teaches you effective strategies to manage your pain. The painTRAINER program is made up of 8 sessions, each lasting about 30-45 minutes.

Pathway through pain

Pathway through pain is an online pain management program which you can enrol on for £40 and complete at home.

Your pelvis and pelvic muscles

Your pelvis is made up of several structures including the bones and muscles of your skeleton, your pelvic floor muscles, as well as your reproductive and urinary organs, rectum, and perineum (the skin around your anus and genitals).

Your pelvic muscles move things by contracting and then relaxing. All muscles work in tandem with other nearby muscles, with them all coordinating various stages of contraction and relaxation to achieve organised movement. Some of this movement is conscious, for example when you choose to cross your legs, and some of it is involuntary, for example when your bladder relaxes and expands so that it can fill with urine.

Your pelvic floor muscles are a specialised set of muscles, positioned at the base of your pelvis, which help keep your pelvic organs in the correct place and control your bladder, bowel, and sexual functions.

Pelvic muscle overactivity

Like all muscles, your pelvic muscles can become hypertonic (overactive), which means the muscle may become painful, weaker, less responsive and move out of time with other nearby structures, leading to a loss of the coordinated movement described above.

You won’t necessarily “feel” pelvic muscle overactivity because some of the muscles, such as those in your pelvic floor, are involuntary so you are not conscious of whether they are contracting, relaxing or hypertonic.

Symptoms of pelvic muscle overactivity

As well as pain, the loss of the coordinated movement may cause changes in your bladder and bowel habit and have an effect on your sex life. Symptoms of overactive pelvic muscles include:

Changes in your bladder habit such as:

• Needing to go to the toilet a lot
• Needing to rush to the toilet and finding it difficult to “hold on”
• Difficulty passing urine
• Only passing small amounts of urine
• Feeling like you cannot empty your bladder

Changes in your bowel habit such as:

• Feeling bloated
• Constipation
• Needing to go to the toilet a lot
• Needing to rush to the toilet and finding it difficult to “hold on”
• Difficulty passing stool and needing to strain

Changes in your sex life such as:

• Loss of libido
• Pain before during and/or after sexual intercourse
• Erectile dysfunction

Understandably, any and all of these symptoms are very stressful and can be very distressing, which may lead to thoughts, feelings and behaviours that themselves can cause pelvic muscle overactivity, and so make things worse.

Further information

Click here to view a booklet entitled: "An introduction to pelvic pain" (PDF only, 2.2MB) produced by the Pelvic Pain Foundation of Australia. This short guide contains lots of information about different types of pelvic pain, advice about how to reduce your symptoms and is aimed girls, women, men and families.

While all of us have been told to “relax” at some point in our lives, many of us don’t know how to do this properly, and especially how to target specific muscle groups like your pelvic floor muscles.

We would like you to spend about a week learning: 1) How to relax properly; 2) How to relax your pelvic floor muscles; 3) Stretch your pelvic skeletal muscles.

Then we would like you combine all of these activities into a single exercise regimen and build this into your daily routine.

We hope you will quickly notice that your symptoms improve with these changes, and that you will learn over time how much, when and what exercises you need to do to control and manage your symptoms.

Step 1: How to relax properly

Start by reading this handout entitled "The Mitchell Method of Physiological Relaxation" (PDF only, 927KB) produced by the Pelvic, Obstetric and Gynaecological Physiotherapy Network. This guide describes how to relax.

Try to practice this for 5-10 minutes, once per day, every day, for one week or until you become comfortable with the process and can develop a pleasant feeling of comfort through your whole body.

Once you have done this, move onto the next step.

Step 2: How to relax your pelvic floor muscles

Click here to reach the Pelvic Physiotherapy website, which aims to help patients with pelvic pain and other disorders.

The webpage describes a series of exercises to help relax your pelvic floor called “Sniff, flop and drop”. Try to familiarise yourself with these exercises and practice them for 5-10 minutes, once per day, every day, for one week or until you become comfortable with them.

Now try to combine the two, by first using the “Mitchell” relaxation routine to relax your whole body, before then working though the “Sniff, flop and drop” exercises from the website.

Once you feel settled with this, move onto the next step.

Step 3: How to stretch your pelvic skeletal muscles

Click here to view a handout entitled: "Easy Stretches to Relax the Pelvis" produced by the Pelvic Pain Foundation of Australia. These exercises are suitable for both men and women.

Try to familiarise yourself with these exercises and practice them for 5-10 minutes, once per day, every day, for one week or until you become comfortable with them.

Now try to combine all three exercises, by first using the “Mitchell” relaxation routine to relax your whole body, then work though the “Sniff, flop and drop” to relax your pelvic floor and then finishing with the easy stretches to relax your pelvis.

Is there anything else that I can do to help?

Specialist pelvic floor physiotherapist

If you find it difficult to understand or perform these self-directed exercises, or would simply prefer to be seen in person, you may benefit from seeing a specialist pelvic floor physiotherapist. Please contact your GP about it. You may need to arrange this privately depending on what services are available in your area.

Pelvic floor injection therapy

If your pelvic floor muscles are so painful that you cannot complete any physiotherapy, you may benefit from seeing a gynaecologist with a specialist interest in this area, who may be able to perform injection to relax some of the overactive muscles in your pelvis. Please contact your GP about it. You may need to arrange this privately depending on what services are available in your area.

A small proportion of people may obtain good pain relief with opioids long-term if the dose can be kept low, and especially if their use is intermittent.

The risk of harm increases substantially at doses above an oral morphine equivalent of 120 mg/day.

If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available.

Further information can be found on the Opioids Aware website resource which has been produced for patients and healthcare professionals and aims to support safe prescribing of opioid medicines.

Click here to view Faye’s story, which describes, from her parent’s perspective, the sequence of events that ultimately led to her untimely death from respiratory depression.

Click here to view Sean’s story, which describes the devastating impact strong opioid prescribing had on his life, and how he has engaged with more effective non-drug therapy that has been life-changing.

Step 1: Establish your patient’s total oral morphine equivalent dose

Click here to view the conversion factors listed on the Opioids Aware website.

Calculate the total daily dose for each opioid drug your patient is taking and multiply this by the relevant conversion factor to generate an oral morphine equivalent dose for that drug.

Sum the oral morphine equivalent doses for each drug together to generate their total oral morphine equivalent dose.

Step 2: Establish a dose reduction timetable

For patients on a single formulation of a drug

There are many ways to do this. We recommend tapering the drug dose by ~10% every fortnight starting with the morning dose. However, the amount and the time of day when the taper starts can be varied to accommodate patient preference.

For patients on multiple formulations of a drug

Initially keep the “regular” (modified-release) dose of the drug the same and taper the “when required” (immediate-release) doses of the drug.

Keep the same frequency of the “when required” (immediate-release) doses of the drug (i.e., 4 times per day), but decrease the dose each week (i.e., 15 mg to 10 mg to 5 mg etc) until it is stopped entirely.

Then taper the regular modified-release dose of the drug as described in the section above.

Step 3: Establish a review schedule

This could be arranged as 2-, 4- and 6-month appointments for example.

Consider using clinical withdrawal scale as part of your assessment.

If your patient is progressing with the drug taper

• Do not reverse the taper; slow or pause rate as needed.
• Continue taper to the lowest effective dose or drug is stopped entirely.
• Once lowest effective dose is reached, extend interval between doses.

If your patient is not progressing with the drug taper

• Reinforce the rationale for embarking on the taper

If you have severe pain whilst you are taking a large dose of opioid medication, it means the drugs are not working and should be reduced or stopped.

The risk of harm increases substantially at doses above an oral morphine equivalent dose of 120 mg/day.

Common opioid side effects

Side effects are extremely common with opioid drugs and include nausea, vomiting, constipation, pruritus, dizziness, dry mouth, sweating and sedation.

If you are suffering from any of these symptoms it is likely because of your opioid medicine and reducing or stopping the drug will mean you will suffer less from these unpleasant side effects.

Long-term harms of opioids

Patients who take opioid medicines for a prolonged period are at risk of several long-term harms including:

• Fractures and falls: Opioids increase the risk and incidence of falls. This is particularly important as you become older.
• Endocrine abnormalities: Opioids cause reduced libido, amenorrhoea, erectile dysfunction, infertility, depression, and fatigue.
• Immune system: Opioids reduce your body’s ability to fight infections and detect cancer cells.
• Opioid induced hyperalgesia: Opioids cause a state of abnormal pain sensitivity, which paradoxically may be making your pain worse.
• Dependence and addiction: ~10% of patients who are prescribed long-term opioids may be dependent or addicted to their medication.

Monitoring for long-term opioid harms

Endocrine function should be monitored regularly if a patient reports symptoms consistent with potential dysfunction, such as decreased libido, sexual dysfunction or fatigue.

Recommended tests include:

• Blood pressure
• Electrolytes (especially if tramadol is used)
• Fasting glucose levels
• Thyroid function tests
• Serum testosterone, sex-binding globulin, LH/FSH and oestradiol levels
• Bone density (in an ‘at-risk’ group)

Before starting a patient on an opioid medication

Opioid Risk Tool (ORT): This is a quick 5-point questionnaire which assesses prospective risk for opioid abuse or aberrant drug related behaviour. A score of 0-3 is low risk, 4-7 moderate risk, and 8 or higher is considered high risk for opioid misuse.

Pain medications should not be withheld simply because a patient is considered high risk for opioid misuse, but other non-opioid treatments should be trialled in the first instance where possible.

If the use of an opioid is unavoidable, your patient may benefit from regular assessment using the COMM questionnaire below, and limiting the quantity and duration of their prescriptions. Consider referring your patient to pain clinic for further advice.

For a patient already taking prescribed opioids

Current Opioid Misuse Measure (COMM): This is a 17-point questionnaire which aims to identify opioid misuse during chronic opioid therapy. A score of 9 or higher is suggestive of opioid misuse.

If your assessment is suggestive of opioid misuse, your patient may benefit from a referral to a drug addiction specialist service.