Coping with Pain and Problems

The pain associated with osteoporosis is due to the fractures (broken bones) it causes. Most broken bones are very painful at the time of fracture, although compression fractures in the spine can be painless.

Everyone responds to pain differently so pain relief that works for one person might not be effective for another. Pain is also affected by other factors such as the other pressures you are facing in your life. Experiencing pain can also lead to low mood and tension which can make the pain more difficult to manage. However, there are many ways pain can be relieved and practical help is available so that you can manage pain better. Most people with fractures recover well and return to full and active lives.

Some of the long-term problems associated with fractures mean that other help and support is necessary. When older people break their hips, other services such as physiotherapy and occupational therapy may be needed to help them to regain their independence.

Compression and wedge fractures in the spine can cause loss of height and curvature of the spine and can also cause shortness of breath and the stomach to be squashed and distended. This can make activities of daily living difficult.

Wrist (Colles’) Fractures

These breaks take six to eight weeks to heal and a plaster cast will usually be applied in a hospital Accident and Emergency Department to stabilise the break and aid healing. Unless you are unwell, a hospital stay will not be necessary.

image showing a cast right hand

Occasionally, if the bones are not in a good enough position to heal, an operation may be needed to stabilise the bone. Usually wires are inserted through the skin and around the fracture and a partial cast will be applied in the operating theatre. Your arm will be elevated after surgery to reduce swelling and a full cast applied when the swelling has gone down. An uncommon complication of Colles’ fracture is a condition known as complex regional pain syndrome(CRPS).

Complex regional pain syndrome and osteoporosis factsheet

Spinal Compression Fractures

For some people these fractures occur suddenly with severe and disabling pain but for many the compression of the bone is ‘silent’ and may only be noticeable if height loss or curvature of the spine occurs.

In between each of the bones in the spine (vertebrae) there are many nerves travelling from the spinal cord to all areas of the body. These are the brain’s messengers. The pain experienced following a spinal fracture may stem from irritation of the nerve root and be made worse by muscle spasm, when the muscle contracts over the site of the injury as a protective mechanism, but the spasm itself can also cause pain.

The experience of compression fractures is varied. Some people have acute pain at the time which resolves as healing takes place. Others, up to 70% of people, have ‘silent’ spinal fractures that cause no pain but may eventually lead to height loss and curvature. Unfortunately, some people will suffer from chronic long-term back pain. Many people recover well from painful compression fractures and cope with any long-term pain problems. For others, these fractures unfortunately lead to being less mobile, sleep problems, mood changes and reduced general health.

Following an injury there are generally two distinct phases of pain. An understanding of this is particularly relevant for people who have had a spinal fracture as a result of osteoporosis. This is because pain may continue after bones heal.

Hip Fractures

Broken hips most commonly occur in people who are over 75 years of age who fall directly onto the hip. If you have broken your hip, you may find that, even after your hip has healed, you are less independent than before. This type of break may have a bigger effect on your life. You may well find that you can’t walk as far and that you need more practical support than before. An operation is normally required to fix or replace the part of the upper end of the thigh bone that has broken (see diagram below). Your surgeon will want to repair the break as soon as possible, but occasionally surgery may be delayed if you have an additional problem such as a urine or chest infection, low levels of red blood cells (anaemia) or heart problems.

The quicker you start to get up after surgery, the more successful your recovery is likely to be. Getting moving earlier reduces your risk of problems after your operation such as chest infection and clotting problems. You will hopefully be up and out of bed the next day with the help of a physiotherapist and a walking frame, and gradually become more mobile as the days progress. After the operation you will have regular strong pain relieving injections or a patient controlled analgesia pump, providing a pain relieving drug straight into your vein. This will make sure you are able to control your pain by giving yourself safe amounts of medicine without waiting for a nurse.

If you are already quite frail before breaking your hip, you may need a period of rehabilitation after your operation so that you can go home safely. The length of stay in hospital can be as short as five days or as long as three weeks.

image showing two types of hip operation pins and screws and a partial hip replacement

Care after Hip Fracture

Types of Pain

Acute Pain

This happens immediately when a bone breaks and will usually lessen over several weeks as injured tissue and bone heals.

When a fracture of the spine occurs, the bone may trap or irritate one or more nerves and relay messages of pain to the brain. Pain can be felt at the point of injury and in other areas e.g. down the arms, legs or around the ribs. This is because the message of pain is following the injured nerve’s pathway. Your doctor may prescribe pain relieving drugs which you should take as directed.

Chronic Pain

This lasts beyond the expected healing time, sometimes defined as longer than three months, and remains even though the bone and surrounding tissue has healed. It is possible the pain is now due to a change in posture and the extra strain that this puts on muscles and ligaments and pressure on nerves.

The experience of pain can become a vicious circle as the strain creates muscle tension which increases the duration and intensity of pain. This creates a fear of future pain which leads to more muscle tension, followed by a hunched position as you try to reduce the pain. Long-term pain can be a difficult and depressing situation to cope with and may also affect relationships with those closest to you.

Managing persistent pain after fractures factsheet

Pain Relief

There is no easy solution that will stop all pain but a good working partnership between you, your family and your GP is a helpful starting point on the road to a happier, less painful life. Here is a range of options to try out to find the right one for you:

Drug Treatments to Relieve Pain

There are many different types of drug treatment. Some are available over the counter, while others are only available on prescription. A thorough assessment of your pain may be necessary before your doctor can decide which pain relieving drug may be the most appropriate for you. Be sure to tell the doctor how severe your pain is, where it is, how often you feel it, what makes it better or worse and how long it lasts. Your doctor will also need to know if you are taking any other medicines, including pain relievers. You may find it helpful to track the course of your pain and the effectiveness of treatment by imagining on a scale of 0 – 10 the severity of pain (0 equal to no pain, 10 equal to the most severe pain ever experienced). Recording scores in a diary between visits to the doctor with comments may help to remind you of any worsening or improvement to your symptoms.

Pain relieving medications can be given in a variety of ways but are mainly given as tablets to swallow. Other ways to take pain relievers include tablets dissolved under the tongue, suppositories, gels rubbed onto the skin, patches and various injections.

Pain relieving drugs after fractures factsheet

Mild Pain

Pain relievers such as paracetamol or the non-steroidal, anti-inflammatory drug (NSAID) ibuprofen, are sometimes given for mild pain.

NSAIDs are available over the counter in a number of different form but can cause inflammation to the lining of the stomach. Ibuprofen should only be used for the short term (a few days) unless your doctor advises otherwise. These types of drugs can also sometimes make asthma symptoms worse and cause problems such as fluid retention and effects on the kidney or heart. Check with your GP first. NSAIDs have both pain relieving and anti-inflammatory effects and may be helpful in the initial stages following a broken bone. There is a belief amongst some doctors that NSAIDs should be avoided in the initial days postfracture as they may dampen the inflammatory process and delay bone healing although opinion differs on this. Again, this group of drugs should only be taken as prescribed and not on an empty stomach as ulceration of the stomach lining may occur.

Paracetamol is a commonly used pain reliever. One to two tablets should be taken every four to six hours to a maximum of eight in 24 hours. Paracetamol has a pain relieving effect but no anti-inflammatory properties. It does not cause as much gastric irritation as NSAIDs.

Paracetamol should not be used by anyone with known liver problems, due to its toxic effect on the liver in high doses. Your local pharmacist or your doctor will be able to advise you further.

Remember to take your pain relievers regularly, as prescribed. This helps to keep on top of the pain and prevents it escalating out of control. Taking only one tablet instead of two and only when the pain is unbearable is not going to control the pain. It may also mean that you end up feeling worn out and irritable with yourself and those around you.

Moderate (Stronger) Pain

The group of drugs commonly used to help control moderate pain includes co-dydramol, co-codamol and co-codaprin. These drugs contain either paracetamol or aspirin plus codeine or dihydrocodeine. The codeine products available over the counter contain lower doses of codeine than products prescribed by your doctor. If a stronger pain relieving effect is required, then codeine, dihydrocodeine and tramadol may be used sometimes in conjunction with paracetamol or NSAIDs. Your doctor will help you find the most effective medicine.

NSAIDs, such as ibuprofen, can be used alongside paracetamol. However always check your medications to make sure you are not taking two products that both contain paracetamol, or both contain NSAIDs, as there will be a maximum number of each you can take daily.

Codeine is very useful to help with pain but it can cause constipation or nausea (see box below).

Severe Pain

For a minority of people, particularly following a newly broken bone or following an operation to repair a broken hip, strong drugs such as morphine may be necessary for a short while. The side effects associated with these drugs include drowsiness and confusion which can increase the risk of a fall and further fractures occurring, especially for frail, older people. Morphine and other similar drugs may cause nausea in the first week or two, therefore an anti-sickness drug may be useful initially until the nausea settles. Your doctor will have to balance the effects of any treatment of pain against your medical history and safety.

Often these drugs may be given initially for two to three days following a spinal fracture before moving to a codeine/paracetamol combination if appropriate. However, if pain is severe and long-standing, it may sometimes be necessary to continue with strong pain relievers. Some people worry that they will become addicted to these types of drug. In reality, it is not usually a problem coming off long-term opiates, if it is done gradually with the supervision of your doctor.

Sometimes, admission to hospital after spinal fracture for assessment and pain management can help to break the cycle of acute pain

General Advice to Avoid Constipation

Bowl of cereal & Fruit• Include plenty of fibre in your diet through eating lots of fresh fruit and vegetables.
 Linseed may be a useful, natural alternative to laxatives and may be sprinkled onto your cereal or mixed into food. Porridge is another good source of fibre.

• Do not ignore the feeling of needing to go to the toilet, as this can make constipation worse.

• Establish a regular routine for using the toilet.

• Remain as mobile as possible, e.g. go for walks because not moving about can reduce the way the bowels work.

• Consider the use of a regular laxative treatment such as senna. Seek advice from a pharmacist or your doctor for the most suitable preparation for you.

Other drug treatments for pain

Sometimes, low doses of anti-depressants such as amitriptyline may be prescribed. Your doctor is not suggesting you are depressed but is using this type of drug because it can help to control associated nerve pain. The drowsiness these drugs cause can, however, aid sleep at night. The dose for pain is a fifth to a quarter of that for depression. Diazepam (a muscle relaxant) may also be considered because it is useful in relieving any persistent muscle spasms you may have experienced during the acute period of pain.

Anti-epileptic drugs such as gabapentin are sometimes used as they can have a pain relieving effect.

Calcitonin is a hormone that occurs naturally in the body which, by acting on the skeleton regulates the amount of calcium in the blood. Given for the first week or two following a painful fracture it may help to reduce pain. Calcitonin is given by injection following advice from a specialist doctor.

It is important to take any medicines prescribed for you correctly and report any adverse side effects to your doctor. If you feel your pain is not being effectively controlled, do tell your doctor.

Drug Free Treatments for Pain

It may sometimes be helpful to use other therapies or treatments. You may find some of the following useful to reduce your pain.

Transcutaneous Electrical Nerve Stimulation (TENS) Machines

image of a TENS machine

A TENs machine works on the same principle as rubbing an area after it has been hurt. The body relays this touch message to the brain which in turn lessens or blocks the feeling of pain by stopping the pain message from reaching the brain. TENs also encourages the body to produce endorphins, a group of chemicals that occur naturally in the brain and have pain relieving properties similar to opiate drugs such as morphine.

TENs machines are quite small and portable. Some can be clipped to the waistband of a skirt or trousers so mobility is not restricted. The machine itself has wires with small adhesive pads attached to them which are placed on either side of the spine, just above the area of pain, or following a painful nerve pathway e.g. around the ribs. When in use, a tingling sensation is felt but this should not be painful or unpleasant. The depth and frequency of the tingling pulse can be easily adjusted to suit your individual needs.

You can often borrow a TENs machine on a trial basis for around 28 days from a physiotherapist or doctor’s surgery. They are also sold in most high street pharmacist shops.

Hydrotherapy

This is exercise therapy in water. Exercises in water seem to be particularly helpful in relieving pain. Warm water and the support it provides to the body encourages relaxation of tight muscles and joints which, in turn, reduces pain and increases mobility.

If you are very disabled, have not enjoyed swimming in the past or cannot swim, you will need a specialised physiotherapist to help with this. Hydrotherapy is not widely available. Pools are often located within physiotherapy departments and a doctor’s referral is required. Some local swimming baths run specific classes for people who wish to do some active exercises in water, but do let the instructor know about any existing medical conditions.

Relaxation

Selection of CDs

• Living with Chronic Pain by Neil Berry To find out more details, contact PO Box 84, Blackburn, BB2 7GH or visit www.paincd.org.uk

• Relax and Release your Pain

• A Good Night’s Sleep both by Jan Sadler Pain Support, 1 Penoweth, Mylor Bridge, Falmouth, TR11 5NQ www.painsupport.co.uk

• Arthritis Care Relaxation CD (See Useful Contacts page 64)

• Complete Relaxation by Glenn Harrold (Diviniti Publishing Ltd) Commercially available

• Breathe Away Pain and Discomfort

• A Walk in the Country both by Marcia Murray www.wellbeing-relaxation.co.uk Telephone Number: 01484 662635

• Kindly Awareness: Managing Pain, Illness and Stress with Guided Mindfulness Meditation by Vidyamala Burch (Breathworks Commercially available & www.breathworks-mindfulness.org.uk Telephone number: 0161 834 1110

• Mindfulness Meditation for Pain Relief by Jon Kabat-Zinn (Sounds True Inc. US) Commercially available

It is easy to fall into a vicious circle of pain, tight muscles, stiffness and more pain. You may find it useful to learn how to relax particularly if you are in lot of pain. There is a range of materials available in the form of music, spoken word and peaceful sounds which can aid relaxation. Commercially prepared relaxation CDs and digital downloads are available from the high street, internet stores, libraries and some charities and organisations such as the Pain Relief Foundation and Arthritis Care.

The list over the following page gives details of a small selection of relaxation and meditation CDs that have been recommended by charity members, health professionals and other organisations involved in pain relief. It must be recognised that the charity does not endorse these products, and some may not meet individual needs or preferences in terms of style and content.

Try these simple steps:

• Make sure you will not be disturbed. Put on some gentle music and burn aromatherapy oils or candle containing lavender, which is known for its relaxing properties.

• Make sure you will be warm and comfortable enough. Lie down on the bed in a comfortable position or recline in a comfortable armchair, perhaps covering yourself with a rug. Use plenty of cushions for support and put one between your thighs.

• Close your eyes and let your whole body feel so heavy that it is sinking into the bed/chair. Let your mind float away. Remain like this for 20 minutes or however long suits you then gently stretch out your body as you might when waking in the morning and ease yourself into an upright sitting position.

• Stay sitting for a minute before getting up. After you have practised your relaxation, always get up slowly so that you do not feel dizzy. Remember to blow out the candles!

If you find it hard to relax,this approach may work for you:

1. First learn to feel when your muscles are working and when they are relaxed. Do this first by tensing them, holding for a second and then letting go completely.

2. Work through your body bit by bit, tensing and then relaxing each big group of muscles.

3. Start with your feet. Tense your toes and legs, hold for a second and then let go completely.

4. Let your knees roll gently out, hold and let go.

5. Tighten your buttocks, then relax.

6. Don’t forget your arms.

7. Screw up your face muscles in a frown, make an O with your mouth and then change your mouth shape as if saying E, then stop, relax and feel the difference.

8. Finally, do a whole body stretch from head to toe. Repeat steps 1 to 8 three times

Self Management Courses

As health information is now easier to obtain, the relationship between patients and doctors is changing. Informed patients are more interested in options and explanations and often want to take more control of their own health. This positive attitude is particularly relevant in the management of long-term conditions such as fractures associated with osteoporosis.

Self-management courses aim to give people the skills and knowledge to help manage pain, symptoms and emotional problems and also to communicate effectively, set goals and make decisions about their health. Ask your doctor if there is a self-management course in your area, or contact The Expert Patients Programme (EPPCIC) .

Expert Patients Programme Community Interest Company

The EPPCIC provides courses for people living with any long-term health conditions. This is a not-for-profit group working through the NHS and other organisations. For more information see http://selfmanagementuk.org/ or call 0800 988 5560

Physiotherapy and Exercise

Following a broken bone, particularly in the spine or hip, your doctor may refer you to a physiotherapist. The physiotherapist will assess you prior to starting any treatment in order to meet your needs and monitor progress.

The aims of physiotherapy include:

• Reducing the risk of a fall

• Improving balance and co-ordination

• Improving muscle strength, flexibility, breathing and posture

• Improving mobility

• Increasing confidence and well being

• Reducing/controlling pain

• Helping with changing shape after spinal Fractures.

Physiotherapists can use a combination of pain relieving techniques including TENs machines, hydrotherapy and relaxation, as described above. They may also use the effect of heat. This can work to reduce muscle spasm by improving blood supply to the painful area. This simple treatment can be easily used at home with either a heat pad/wheat bag or a covered hot water bottle.

Spinal fractures due to osteoporosis can sometimes cause severe back pain. It may seem unbelievable when you are in pain but exercising regularly can actually help to reduce pain. Spinal fractures may cause pain with the slightest movement, so gentle controlled moves can help. You may want to rest in bed or a comfortable chair but try not to do this for long periods unless told to do so by your doctor.

Remaining immobile for too long can create its own set of problems, such as blood clots, pressure sores, poor circulation, chest infections and you may lose bone density. Most therapists agree that in the early stages after breaking a bone, while the injury is healing, rest with gentle movement is best. However, it is just as important to regain mobility and prevent deterioration of the muscles which hold the spine in place. Even if you suffer from severe curvature of the spine, it is possible that suitable exercise may bring relief and improvement. You may need advice from a physiotherapist.

Exercises that help with posture and build muscle strength may also help reduce pain and increase your sense of well being. Gentle exercises, such as lying on your front and gently raising the head and shoulders by pushing up with your arms, can help to build up the back muscles which can be beneficial to pain. Care needs to be taken when carrying out this type of exercise and it should be undertaken with guidance from a physiotherapist. For more exercises that may help reduce pain, ask your doctor to refer you to a physiotherapist.

Exercise and osteoporosis Booklet

Complementary Therapies and Pain

Most complementary therapies have not undergone the rigorous testing and clinical trials expected of conventional medicine so you are unlikely to find proof that they work to reduce pain. However, having gathered sufficient information, you may wish to try complementary therapy as part of your pain management plan.

Some of the most commonly used therapies are acupuncture, osteopathy, herbal medicine, the Alexander 

Technique, aromatherapy, chiropractic and reflexology.

Reflexology Chart

 

Complementary and alternative therapies and osteoporosis Factsheet

Pain Management Clinics

Most people will find something to help live with the ups and downs of their pain. For those who do not, a referral to a pain management clinic may be considered.

This type of clinic is usually situated within a hospital. The aim of the clinic, which you will probably attend for several weeks, is to enable you to understand the reasons for your pain. It will also help you to understand the effect it has on your life and the lives of those around you, how to use various methods to manage or reduce your pain and perhaps divert your mind from it. Goal setting is often used as a way to help you to return to your usual activities.

In the course of your time at the clinic you will probably see a consultant, a physiotherapist, a nurse specialising in pain management and an occupational therapist who will see how you are managing at home. Sometimes you may also see a psychologist who can help you to cope with the emotional and psychological effects of chronic pain. Many who attend this type of clinic also enjoy meeting others who are experiencing similar problems and pain. In some cases, good friendships are formed. You may also be able to join a patient support group.

Not all pain clinics work in this way. Some do not offer lifestyle advice and complementary therapies and may solely focus on the control of pain by various types of drug treatments. Be prepared that in some areas there is quite a long waiting list to be seen in these clinics.

Managing your pain means that the prevention, lifestyle changes and safety measures learned need to be continued on a long-term basis to maintain good control of your pain.

Surgery (Operations) to Help with Pain

There are surgical techniques called percutaneous vertebroplasty and balloon kyphoplasty which may help with the pain of spinal fractures. However, these are not widely available in the UK.

Percutaneous vertebroplasty, balloon kyphoplasty and osteoporosis factsheet

Living with Fractures (Broken Bones):

Pain isn’t the only consequence of a fracture, there are lots of other knock-on effects including loss of height and changing body shape due to spinal fractures, loss of independence and fear of falling associated with hip fracture. However, there are other things you can do to feel positive about the future. Our Helplineoffers help and support relating to pain and problems caused by fractures. The following factsheets may be helpful to you.

Daily living after fractures | Managing persistent pain after fractures | Out and about after fractures | Travel insurance and osteoporosis | Pain relieving drugs after fractures | Financial help after fractures | Complementary and alternative therapies and osteoporosis | Percutaneous vertebroplasty, balloon kyphoplasty and osteoporosis

Your Questions: Living With Broken Bones

What kind of effect will osteoporosis have on my sexual relationship?

Relationships, particularly physical relationships, can become strained especially if someone with osteoporosis becomes fearful of pain because of previous fractures – or fearful of further fractures. The most important thing is to talk with your partner about fears and concerns and, if appropriate, to discuss which positions might be most comfortable for sexual intercourse. Often partners will be worried themselves about causing more problems so sharing your feelings will be essential. Experimenting (and keeping a sense of humour!) often helps.

I’m worried that osteoporosis will mean I will lose independence and have to move into a home. Is there anything I can do to stop this happening?

Losing independence and having to move out of your own home is a natural and very common fear for you to have, but there are lots of things you can do to make sure your own home is safe and easy for you to live in:

• Make sure items used regularly are within easy reach to avoid stretching, bending down or having to stand on a chair.

• Wire baskets attached to the underside of shelves provide extra storage space within easy reach.

• Use a long handled dustpan, brush and mop.

• Consider a top loader washing machine to avoid bending down with heavy, wet washing.

• Use a perching stool for working at the sink.

• Various aids for opening jars, cans and bottles are available in department stores and chemists.

• A built-in oven at the correct height, instead of a free-standing one, prevents unnecessary bending.

• Have power points located at waist height to avoid bending.

• Use a lightweight vacuum cleaner.

• A ‘grab’, also known as an extending arm, can be useful to pick things up.

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