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What we do

˜Working with you to improve your pain and quality of life'

The Bradford Pain Management Team based in Bradford Teaching Hospitals NHS Foundation Trust, provide an experienced and specialised approach to the treatment of Chronic Pain.

Chronic pain is a pain that persist for more than 3 months after an injury or illness. It is very common and effects 8-60% of the population. Sadly due to its severity it can have an impact on your employment, daily activities, relationships, mood, sleep and your general health.

Our aim is to work with you to reduce your pain and its impact on your life. We will achieve this by utilising a combination of the most up to date treatment options available, with the primary target of improving function (your ability to achieve your normal daily activity).

Can We Help You?

Chronic pain can be caused by a large number of conditions. We specialise in treating chronic pain when the cause cannot be reversed by medication or surgery. With the exception of back pain and a condition called Complex Regional Pain Syndrome, we are not experts in deciding the cause of the pain. It is important to discuss with your GP any potentially reversible causes for your pain. You may require referral to another specialist who can investigate and start the right treatment.

Back Pain

Back pain usually affects the lower back and arises from 3 places.
  1. Facet Joints, the small joints of the back that join the vertebrae, the bony part of the back together
  2. Sacroiliac Joints, the joints that join the back to the pelvis
  3. Discs, the ˜shock absorbers' of the back
Pain most commonly results from wear and tear and occasionally injury. You will usually have aching in the lower back that may spread through the buttocks and into the legs as far as the knee.

Back pain can also be associated with nerve root pain (See Below)

Nerve Pain
Nerve pain results from injury to a nerve. People use words like burning, shooting and electric shock-like to describe the pain. As well as causing pain, injury to the nerve can also affect its function leading to abnormal sensations (numbness, pins and needles and painful sensitivity) and muscle weakness.

Nerve pains are difficult to treat with conventional painkillers and although the nerve may heal it remains sensitive and functions abnormally for a long time.

Nerve Root Pain
Protected by the bony part of your back called the vertebrae is the spinal cord. The spinal cord is a large collection of nerves that allow the brain to receive information and control movements and other bodily functions.
Nerves leave the spinal cord to travel to different parts of the body. As they exit the back they are called nerve roots. Nerve roots can be irritated or compressed by Disc bulges (Disc Prolapse) or by deformity of the bones of the back due to wear and tear or injury. This produces nerve root pain.

Nerve root pain occurs in the part of the body supplied by the effected nerves. For example injured nerves arising from the lower back will cause pain in the legs and feet.

Other Nerve Pains
As well as being injured at the root, nerves can be injured as they travel through the body. Numerous things can cause this injury:
  • Accident
  • Surgery (-e.g. Amputation, Mastectomy, Chest Surgery, Hernia Repair)
  • Cancer and it's treatment
  • Shingles
  • Medical conditions that gradually damage the nerves (-e.g. Diabetes)
  • Complex Regional Pain Syndrome (See Below)

Abdominal And Pelvic Pain
Chronic pain effecting the abdomen or pelvis can arise from a great number of sources. These include any one of the organs of the digestive system, urinary system or reproductive system, as well as the muscles of the abdomen and pelvic floor and the bones and nerves of the back. Diagnosing a potential cause for your pain is complex and will require help from your GP and quite often other specialists (Gastroenterologists, General Surgeons, Gynaecologists, Urologists). It is important that prior to seeking our help, all possible causes have been fully investigated and any potential treatment started.

In some cases a cause may be found where medicines or surgery do not greatly improve the pain or where such treatment is not possible. Also on occasion, no clear cause may be found. It is in these situations that our assistance will be most helpful. Painful conditions we most commonly see include:
  • Chronic Dyspepsia
  • Irritable Bowel Syndrome
  • Chronic Pancreatitis
  • Endometriosis
  • Interstitial Cystitis
  • Chronic Kidney Pain
  • Chronic Pain Following Infection Or Surgery

Facial and Mouth Pain
Facial and mouth pains often arise from irritation or compression of nerves. These nerves arise from the brain and supply and travel through a number of structures in the head before they finally supply the skin of the face or the lining of the mouth and tongue. As a result to discover the source of your pain will require the help of your GP and quite often other specialists in this area including Neurologists, Ear Nose and Throat Surgeons, Maxillofacial Surgeons and Neurosurgeons. It is important that prior to seeking our help, all possible causes have been fully investigated and any potential treatment started. Painful conditions we most commonly see include:
  • Trigeminal Neuralgia
  • Post Shingles Pain
  • Burning Mouth Syndrome
  • Chronic Dental Pain

Headache
From person to person the location, timing and type of pain described as a headache can vary. There can also in some cases be a variety of other symptoms including blood shot eyes, eye watering, visual and hearing disturbance, vomiting, slurring of speech and muscle weakness. This variety occurs because there are a large number of different causes of headache. We cannot help with all headaches and you will need your GP and in some cases a Neurologist to decide which type of headache you have. They may then start treatment that reduces the number and the severity of your headaches.

Generally speaking we are most effective at relieving headaches derived from the neck. The same nerves that supply the scalp over the back of the head also supply the bones of the neck. Thus wear and tear or injury of the neck can produce pain over the back of the head in a condition called Cervicogenic Headache.

We can also help with a headache caused by irritation of a specific nerve supplying the scalp over the back of the head. This occurs in a condition called Occipital Neuralgia.

Complex Regional Pain Syndrome (CRPS)
CRPS is diagnosed by identifying a characteristic group of symptoms affecting a particular part of the body, usually a limb. It often follows injury although this can be minor, and in some individual no trigger can be identified. The symptoms occur in two stages. At first there may be sustained pain, swelling, redness and increased temperature, as an exaggerated and prolonged response to injury. Then there is progression to decreased temperature, painful sensitivity, hair loss and increased nail growth followed by muscle wasting and thinning of bone. Scientists are only beginning to understand the mechanisms that produce these symptoms and are yet to discover why they only develop in a small group of people. We follow the current guidelines on how to manage this pain in the first and second stage.

Cancer Related Pain
People suffering from cancer may have numerous sources of pain. Pain may arise from the cancer itself or from the effect of the cancer on nerves and bones. It may also occur as a side effect of cancer treatment with surgery, radiotherapy or chemotherapy.
We work closely with specialists in cancer treatment (Oncologists) as well as Palliative care to relieve cancer related pain.

Joint Pain
Joint pains may affect one joint or a number of joints. They are most commonly caused by injury or wear and tear (Osteoarthritis) but can also be associated with more complex medical conditions (e.g. Rheumatoid Arthritis). Your joint pains should be assessed and investigated by your GP. You may then require further assessment and treatment by specialist GPs from your local Musculoskeletal Service, by medical doctors that specialises in joint pains (Rheumatologists) or by an Orthopaedic Surgeon. With their combined experience and skills this group of doctors are well placed to identify the cause of your joint pain. They can also offer various treatments that relieve joint pains including injections and surgery and in some cases may commence treatment that can reverse, stop or slow the progression of a condition that has triggered the pain.

We cannot treat the cause of the pain. We will only offer physiotherapy and medication to reduce the pain where this has not been tried already and, in appropriate people, perform procedures that temporarily numb the nerves supplying the joint.

Fibromyalgia
Fibromyalgia is a condition with widespread pain affecting joints and muscles and is associated with fatigue. It can be diagnosed when other causes for these symptoms have been investigated. This in-depth investigation can be carried out by your GP or a medical doctor specialising in joint pains (Rheumatologist). The most effective treatment for this condition is the Pain Management Programme (See Below) along with medication that improves your sleep pattern and mood. Both of these treatments can be offered by your GP.

The team

Consultants

  • Dr Kyriacos Kyriakides BSc MBChB FRCA FFPMRCA
    Lead in Chronic Pain, Bradford Teaching Hospitals NHS Foundation Trust
    Specialist Interest: Spinal Pain, Pelvic Pain, Neuropathic Pain, Neuromodulation
  • Dr Vijay Bandikatla MBBS DA MBA FRCA FFPMRCA
    Specialist Interest: Headache, Cancer Pain, Neuromodulation, Facial Pain
  • Dr Bret Claxton MBChB FRCA MmedSci FFPMRCA
    Specialist Interest: Spinal pain, Knee pain
  • Dr Sanjeeva Gupta MD FRCA FIPP FFPMRCA
    Specialist Interest: Spinal Pain, Neuropathic Pain
  • Dr Rishi Khanna MBChB FRCA FFPMRCA
    Specialist Interest: Spinal Pain, Cancer Pain, Neuromodulation
  • Dr Anthony Swanepoel MBChB FRCA
    Specialist Interest: Spinal Pain, Headache, Facial Pain, Neuromodulation
  • Dr James Taylor BSc MBChB (Hon) MRCS (Eng) FRCA FFPMRCA
    Specialist Interest: Cancer Pain, Spinal Pain


Specialist Pain Nurses

  • Senior Sister Margaret Hargreaves, Lead Pain Nurse Specialist

Pain Management Centre Staff

  • Mr D Chaloner, Enhanced Practitioner in Pain Management, Pain Centre Manager

Physiotherapists

  • Carole Smith, Physiotherapy Co-ordinator Rehabilitation

Clinical Psychology

  • Dr Mark Pitkethly, Consultant Clinical Psychologist:

Service Managers

  • Mrs Liz Parkin, Clinical Services Manager Critical Care, Pain and Sleep
  • Dr Ray Smith, Consultant Anaesthetist & Clinical Lead Day Surgery, ISTC, WWP, Pain, Pre-assessment, York Suite Bradford Teaching Hospitals NHS Foundation Trust

Feedback, complaints and compliments

The sole focus of the service is you, the patient. Unfortunately the nature of chronic pain means that we can never remove it altogether and in some cases we may not achieve any changes in your pain level. What we hope to do is help you to manage your pain and in doing so improve your quality of life. Your feedback is vital so that we can continue to improve and achieve the best results for you and future patients.

We would be grateful if you could take the time to complete a feedback form when this is offered to you.

Complaints

We strive to get things right every time and will always aim to provide a high quality and safe service. However sometimes a problem may arise or something may go wrong and when it does it is your right to tell us or complain.

Please tell us as soon as you have any concerns so that where possible we can resolve the situation. We will not be offended and your valuable feedback will not affect your care.

It is understandable that you may not want to speak to us directly. If this is the case you can either contact PALS (Patient Advice and Liaison Service) or the Chief Executive of Bradford Teaching Hospitals NHS Foundation Trust.

PALS can be contacted on 01274 364021 at Bradford Royal Infirmary or 01274 365853 at St Luke's Hospital. The text phone number for deaf people is 01274 382580 at Bradford Royal Infirmary. You can also email pals@bradfordhospitals.nhs.uk

The Chief Executive
Bradford Teaching Hospitals NHS Foundation Trust
Chestnut House
Bradford Royal Infirmary
Duckworth Lane
Bradford BD9 6RJ

Or

Telephone: 01274 364810¨Free Phone: 0500 777717¨SMS Text: 07970 971819

Contact us

  • Pain Nurse Specialists Mon “ Fri 0830 to 1730 01274 382664
There is an answer machine to leave a message out of office hours. Please leave a message with your name, a brief description of the problem and a contact number and we will ring you back.

  • Secretaries to Drs Claxton, Khanna, Kyriakides and Taylor Mon “ Fri 0830 to 1730 01274 364065
  • Secretaries to Drs Bandikatla, Gupta and Swanepoel Mon “ Fri 0830 to 1730 01274 364090
  • Pain Management Centre 01274 36 5350 (Open Tues 0745-1830, Wed 1230-1830, Fri 0745-1830)

Translators and interpreters

Unfortunately the doctors can only ask questions and examine you using English. If English is not your first language and you require translation we have a range of translators available. Please inform us of any requirement you have using the number on your appointment letter. Ideally you should do this as soon as possible and no later than one week prior to your appointment. If we are not informed and a translator is not made available your appointment may be abandoned if the doctor cannot safely make an assessment. We welcome relatives as translators but require them to translate precisely what we are saying and it is important that you and your relative are comfortable discussing all aspects of your medical history.

Referral pathways

Referrals for Pain Management must come either directly from your GP or following assessment by your local specialist Musculoskeletal Service. If you feel you may find our service helpful please discuss this with your GP.

First appointment

Outpatient appointments take place at St Luke's Hospital and Eccleshill Community Hospital.

Your first appointment with the doctor will last 30 minutes, which is considerably longer than a conventional doctors appointment. This is to allow time for you to give a complete description of your pain and its impact on your life, and for the doctor to make a thorough assessment. Please arrive at least 10 minutes before your appointment to avoid losing any of this valuable time.

In order for the doctor to gather all of the important information and allow him/her to help manage your pain they will need to ask a number of questions. Please see Questions You Will Be Asked.

It is likely that you will undergo an external examination during the appointment. This will generally involve assessing movement of your joints and/or back as well as testing your muscle strength and skin sensation.

Questions You Will Be Asked

Below is a list of the common questions you will be asked. Pain can often be a difficult thing to describe and when it has been present for some time it may not be easy to recall all the treatments you have tried. It is also important for the doctor to know about any other medical problems and medications. Please take time to consider your answers prior to your appointment and bring a list of your current medications with you.
  • Where precisely is your pain?
  • Does your pain spread from one place to another?
  • When did it start?
  • What do you think triggered it?
  • What words would you use to describe your pain? (For example Aching, Burning, Crushing, Sharp, Stabbing, Tearing, Tightening¦)
  • Are there any activities that make your pain worse?
  • Does anything improve the pain?
  • Which medications do you take for the pain, what are the doses and how much do you think each of them help?
  • Have you tried other pain relieving medications but stopped them because they didn't help or caused side effects?
  • Have you had physiotherapy, acupuncture or attended a chiropractor?
  • Have you had any pain relieving injections or surgery for the pain?
  • Is the pain effecting your sleep and how much sleep do you get?
  • Is the pain affecting your mood?
  • Is the pain affecting you lifestyle and work?
  • Do you have any other medical problems?
  • Have you had any surgery?
  • Other than pain relieving medications what other medications do you take and what are the doses?
  • Are you allergic to any medication?

Cancellations

If you are unable to attend please contact us as soon as possible to rearrange your appointment for a more convenient time. Giving us sufficient notice may allow us to see another patient, who like yourself is waiting for an appointment. The number to ring can be found on your appointment letter. Unfortunately if you do not attend your appointment and have not contacted us in advance to notify us of a problem you will not be given another one. Your GP will then have to refer you for a second time and you will join the back of the queue.

Medications

As with all treatment you are offered the aim of using regular pain relieving medication (Analgesics) is to improve quality of life and day-to-day function (your ability to achieve you normal daily activity). These medications are not able to reverse the cause of your pain or remove it altogether.

Medications are considered effective and at their correct dose when pain levels are halved. Often we will use a combination of medications so as to reduce the dose of anyone medication required to achieve this goal. Medications started or increased that have a negative effect on your function and are a long-term risk to your health will be reduced or stopped.

In general we will only prescribe medications that we intended to be taken regularly, that is every day and sometimes more than once a day. For a medication to keep pain at a reduced level for 24 hours it must be taken regularly to maintain an effective level in the body. Some medications are less effective and some will have absolutely no effect if only taken when pain begins or becomes intolerable.

When prescribing medications for pain we use the World Health Organisations (WHO) analgesic ladder and guidance from the National Institute of Clinical Excellence (NICE). Both these organisations have been guided by scientific evidence and expert opinion. We will move from one step to the next if your pain is not adequately controlled.

For All Chronic Pain (WHO analgesic Ladder)

  1. Paracetamol
  2. Paracetamol + Anti-inflammatory (-e.g. Ibuprofen)
  3. Paracetamol + Anti-inflammatory + Weak Opioid (-e.g. Codeine Phosphate, Co-codamol, Dihydrocodeine)
  4. Paracetamol + Anti-inflammatory + Strong Opioid (-e.g. Tramadol, Morphine, Oxycodone, Fentanyl or Buprenorphine Patches)

For Nerve Pain (NICE Guidance)

  1. Paracetamol + Capsaicin cream
  2. Gabapentin/Pregabalin or Amitriptyline/Nortriptyline
  3. Combination of Medications in step 2
  4. Duloxetine
  5. Tramadol and Lignocaine patches

Please note that the use of medications such as Diazepam, Temazepam and Lorazepam has no place in the treatment of chronic pain and will not be prescribed or recommended by our service.

Paracetamol And Other Anti-Inflammatories

Paracetamol is an anti-inflammatory medication with minimal risk of side effects when taken at recommended doses. It can be an effective pain relieving medication for numerous causes of pain and can improve the effectiveness of other medications.

Other anti-inflammatories such as Ibuprofen and Diclofenac may also provide excellent pain relief. However they have a number of side effects, which means that they cannot be used by all patients and should only be used for a short period of time in the majority.

Side effects

  • Irritation of the stomach. They should only be taken with a regular antacid medication and after eating. They should not be taken if you have a history of stomach ulcers or gastritis
  • Thinning of the blood. They should be used cautiously in people already taking medication to thin the blood because of an increased risk of bleeding
  • Kidney Failure. They should not be taken if you already have kidney failure and may cause kidney failure in healthy people if taken for a long time
  • Worsening of asthma. They can cause a severe asthma attack in some asthmatics
  • Worsening of Cardiovascular Disease. There is evidence to suggest that long-term use can increase the risk of a heart attack or stroke

These side effects may still occur if anti-inflammatory gels are used as the medication is absorbed into the blood.

Opioids

Opioids are Morphine or Morphine-Like medications and are classified as weak or strong.

Weak Opioids

  • Codeine
  • Dihydrocodeine
  • Co-Codamol - Codeine And Paracetamol

Strong Opioids

  • Morphine Sulphate Tablets (MST) or Oromorph
  • Oxycodone (Oxycontin or Oxynorm)
  • Fentanyl Patches
  • Buprenorphine Patches (Butrans or Transtec patches)

Opioids at appropriate doses may offer very effective pain relief (50% reduction in pain). They do however have a number of harmful side effects especially the strong opioids when taken long-term.

Short-term Side Effects

  • Dizziness
  • Nausea
  • Vomiting
  • Drowsiness
  • Confusion

Long-term Side Effects

  • Constipation
  • Itching
  • Weight Gain
  • Lack Of Sex Drive
  • Reduced Fertility
  • Irregular Periods
  • Erectile Dysfunction In Men (The Inability To Keep An Erection);
  • Reduced Ability To Fight Infection
  • Increased Levels Of Pain
  • Dependency

Our aim is to minimise the dose required by combining opioid with other medications and therapies. Ideally we would like all our patients to spend as little time as possible taking opioids or if there is no alternative we would like the dose to be as low as possible.

Various opioids are available. This can be useful because individuals may find different opioids more effective for their pain than others. They may also be able to tolerate one opioid more than another with respect to side effects. Your doctor may trial various opioids to discover the most effective and best tolerated (Opioid Rotation) and will increase doses gradually to reach the optimal relief with minimal exposure.

Having various opioids available also allows your doctor to pick one that will interact least with your current medication and will be safest when your other medical conditions are taken into account.

The problem with the variety of strong opioids is that there is confusion outside of Pain Management over the potency of these medications and so there is a tendency to increase your overall exposure rapidly. We will make an assessment of your exposure during your appointment and screen you for side effects. We may advise a trial reduction in dose to assess whether what you are taking is making a significant contribution to your pain relief or having a negative impact on your function.

Gabapentin/Pregabalin

Gabapentin and Pregabalin are drugs initially prescribed for the treatment of epilepsy but are now known to be effective in the treatment of nerve pain. We will trial Gabapentin before Pregabalin. To minimise common side effects, which most people experience as these drugs are started and when the dose is increased, we start at a low dose and increase it slowly.

Gabapentin

Breakfast

Lunch

Tea

100mg

For 3 days

200mg

For 3 days

300mg

For 3 days

100mg

300mg

For 3 days

200mg

300mg

For 3 days

300mg

300mg

For 3 days

300mg

100mg

300mg

For 3 days

300mg

200mg

300mg

For 3 days

300mg

300mg

300mg

Continue with this dose

Pregabalin

Breakfast

Tea

50mg

50mg

For 7 days

100mg

100mg

For 7 days

150mg

150mg

For 7 days

300mg

300mg

Continue with this dose

It may take between four and six weeks before there is any reduction in pain. You should stop increasing the dose when your pain is improved by about 50%. If side effects become intolerable at a particular dose return to a lower dose and remain on that dose until your next appointment.

Side Effects

Common side effects

  • Drowsiness
  • Dizziness

Less common side effects

  • Weakness
  • Unsteadiness
  • Swelling in the legs
  • Weight gain
  • Nausea and Vomiting
  • Change in mood (Depression, Anxiety, Aggression, Suicidal Thoughts)
  • Joint and Muscle Pains

If you feel you want to stop taking these drugs please do so gradually by reversing the dose changes. A sudden reduction in dose may cause increased pain and symptoms of anxiety and depression.


Amitriptyline/ Nortriptyline

Amitriptyline and Nortriptyline are drugs initially prescribed for the treatment of depression but are now known to be effective in the treatment of nerve pain. We will trial Amitriptyline first but for some people Nortriptyline causes less sedation. To minimise common side effects, which most people experience as these drugs are started and when the dose is increased, we start at a low dose and increase it slowly.

If you have problems with glaucoma, an irregular heart beat or difficulty with passing water, you should tell the doctor before starting these medications, as all of these problems can be made worse.

Amitriptyline/ Nortriptyline

Week 1

10mg at night

Week 2

20mg at night

Week 3

30mg at night

Week 4

40mg at night

Week 5

50mg at night and continue with this dose

It may take between four and six weeks before there is any reduction in pain. You should stop increasing the dose when your pain is improved by about 50%. If side effects become intolerable at a particular dose return to a lower dose and remain on that dose until your next appointment.

Common side effects

  • Sleepiness
  • Dizziness

Less common side effects

  • Dry Mouth
  • Constipation
  • Difficulty with passing water
  • Palpitations
  • Blurring of vision
  • Disorientation, Anxiety, Agitation

Duloxetine

Duloxetine is a drug that is prescribed to treat depression but it is also known to be effective in the treatment of nerve pain. You will be started at a dose of 60mg once per day and this may be increased to 120mg. It will take four to six weeks to experience any reduction in pain.

Common side effects

  • Dry Mouth
  • Headache
  • Drowsiness
  • Dizziness
  • Nausea

Less common side effects

  • Constipation
  • Difficulty with passing water
  • Palpitations, Flushing and Sweating
  • Blurring of vision
  • Change in mood (Depression, Anxiety, Aggression, Suicidal Thoughts)
  • Joint and Muscle Pains
  • Loss of Appetite and Weight Loss
  • Increased Blood Pressure


Capsaicin Cream

Capsaicin is the fiery chemical found in chilli. A cream containing Capsaicin can be applied to the skin in the region of your pain. This will cause a burning sensation that stimulates and then deactivates nerves, producing pain relief. It is important to avoid unintentional spread of the cream to sensitive areas such as the eyes. Side effects of the cream are minimal but it should not be applied to broken skin and you should stopping applying it if a rash develops. It may also rarely worsen your breathing if you are asthmatic.


Lignocaine Patches

Lignocaine patches are used to reduce nerve pain. A maximum of 3 patches can be applied to a painful area of skin. You should not apply a lignocaine patch to broken or inflamed skin. A patch or patches can be applied at the most for 12 hours in a 24 period and should be kept away from the eyes and mouth. The side effects are minimal but you should tell the doctor if you are taking any medicines for an irregular heartbeat as these may interact with the lignocaine in the patch causing your heart beat to slow or become more irregular.

It is important to dispose of the patches carefully after use. Children and pets may come to serious harm if they accidently eat the patch.