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Pain management toolbox

Pain management toolbox

Since there are different types of pain and a range of contributing factors, there is no one-size-fits-all approach. 

A single strategy, for example, taking medications, may not be as effective as using a number of strategies at the same time. You and your doctor may need to try a combination of medications, exercise, pacing of activities, relaxation and other treatments, including psychological treatments.

Think about using the below eight strategies to manage your pain. 

Important Note

It is unlikely that changing just one strategy will fix chronic pain. Consult your doctor to find the best approach for you.

pain management toolbox diagram

The eight strategies

It is important to learn to work with the different members of your healthcare team to get the best results. When it comes to communicating with your team about pain, it is helpful to understand the type of information your healthcare professional needs to know. This information helps them to identify your pain to formulate your management plan.

A comprehensive interdisciplinary pain evaluation involves assessing the following factors:

  1. Location and type of pain
  2. Circumstances associated with pain onset
  3. Rating of the intensity of your pain
  4. Impact of pain on your daily activities, mood, rest and sleep
  5. Any important medical history and presence of warning signs
  6. Effectiveness of treatment (medications and other strategies) on your pain
  7. Adverse effects from medications, e.g., nausea, constipation and poor concentration
  8. Factors influencing your adherence to treatment
  9. Goal planning to determine what you would like to do if your pain was better controlled.

Sometimes you need to educate your healthcare team about spinal-related health issues so it is important to know where to direct them. See further resources section on page.

Did you know?

It is normal for pain to fluctuate in intensity during the day or from one day to the next. However, when pain suddenly intensifies or the location or characteristics change, it needs to be checked out.

Team of medical professionals
“I am going to start keeping a pain diary to record what is going on.”

Person with spinal cord injury

What does research tell you?

The assessment and treatment of pain in people with a spinal cord injury relies on a holistic, unified team approach to best utilise the full range of medical and non-medical strategies.

Members of your pain management team can include:

Members of your pain management team can include some or all of the following specialists, each with a different role in helping you manage your pain.

doctorYour GP is often the first point of contact.

doctorYour GP is often the first point of contact.

physiotherapist putting tape on female backGives advice regarding exercise, fitness, postural re-education and ways to relieve pain, and also provides training in community mobility skills.


occupational therapistHelps adapt your home and work environment and teaches you strategies to make daily functioning easier.

clinical psychologist holding clipboardTeaches you different strategies and techniques to think about and cope with pain, e.g., relaxation, mindfulness.

medical-team-of-doctorsThey specialise in the diagnosis, treatment and/or management of pain, e.g., spinal rehabilitation specialist, pain specialist, neurologist, neurosurgeon or orthopaedic surgeon.

middle-aged-smiling-business-woman with arms crossedProvides practical advice, support and help with different aspects of your life affected by your pain, such as work, relationships, family life, income and housing.

psychologist holding clipboardPlans, coordinates and implements recreation and leisure-based activity programs to support and enhance your psychological, social, emotional and physical wellbeing.

medical-woman-doctor-hold-with-clipboardHelps with troubleshooting bowel and bladder issues causing pain.

woman-in-a-medical-white-coat-on-a-white-backgroundInclude practitioners of complementary and alternative medicine. Techniques include acupuncture, chiropractic, massage therapy, naturopathic medicine and reiki. However, most techniques lack evidence in terms of effectiveness. It’s important to be aware of the risks of natural, alternative or holistic treatments.

Please advise your clinician if you try a complementary therapy.


It is normal for pain to fluctuate in intensity during the day or from one day to the next. However, when pain suddenly intensifies or the location or characteristics change, it needs to be checked out.

Keep a pain diary to track any changes in your pain intensity.

Medications for musculoskeletal pain

Simple analgesics

Panadol works to reduce pain and fever by reducing the release of chemicals that are linked to pain and inflammation.

Non-steroidal anti-inflammatory drugs

Aspirin, ibuprofen and Naproxen reduce pain by modifying the inflammatory response and blocking the activity of a certain chemical in your body.

Muscle relaxant (anti-spasticity) medications

Diazepam (Valium), Baclofen (Lioresal) and Tizanidine (Zanaflex) can be effective for spasm-related pain

Medications for neuropathic pain

Anticonvulsant medications

Pregabalin (Lyrica) and Gabapentin (Neurontin) work by reducing the excitability and the abnormal firing in damaged nerves after spinal cord injury.


Duloxetine (Cymbalta), Venlafaxine (Effexor) and low-dose tricyclic drug Amitriptyline (Tryptanol, Endep), work by increasing the amount of chemicals responsible for closing the pain gate and ultimately reduce the volume of pain messages being sent to
your brain.

Narcotics (Opiates) 

Opiate medications, such as morphine and codeine, may be used to treat moderate to severe pain arising from musculoskeletal or neuropathic conditions. They bind to opioid receptors in the central nervous system which changes the way the brain perceives pain.

In people with a spinal cord injury, opioid medications become less effective over time and often result in unpleasant and severe side effects.

A common problem with opioid medications is the development of addiction and tolerance. Over time you no longer get the same pain-relieving effects – no matter how high the dose. Long-term, high-dose use can have the reverse effect.

Common side effects of opioids include:

  • Constipation
  • Drowsiness
  • Blurred vision
  • Dry mouth
  • Headache
  • Nausea
  • Brain fog
  • Memory loss.

Other serious side effects are breathing difficulty, worsening of snoring, lowered immunity, depression, overdose and death.

Now I’m not on any pain medication, I’m much happier because I have a clearer head and my memory has improved.

Person with spinal cord injury

What does research tell you?

A number of medications have proven effective in treating chronic pain disorders, and their use separately or in combination may help to control your pain.

Pain management strategies used by people with a spinal cord injury included:


Other medications

medicine bottle icon

more than

anti convulsant medication icon
opioids icon


anti depressants icon



Other medications

medicine bottle icon

more than

anti convulsant medication icon
opioids icon


anti depressants icon


2015 Rural Spinal Cord Injury Project survey of 681 people living with spinal cord injury in rural NSW

It is essential to have a healthy body and mind for ultimate pain control. Exercise can help reduce both neuropathic and musculoskeletal types of pain by releasing natural opioid-like chemicals called endorphins. By using the body’s own pain-relieving chemicals, you can help reduce your pain and improve how you feel.

Exercise strengthens your muscles to help support your bones and joints. This, in turn, improves your posture and ability to perform everyday activities with less effort. After a spinal cord injury, regular exercise helps to maintain muscle conditioning, balance, strength and function.

A physiotherapist can develop an individualised exercise plan for you, including:

  • Modifying your activities
  • Stretching
  • Range-of-motion exercises
  • Strengthening exercises for strong core and postural muscles.

A transcutaneous electrical nerve stimulator (TENS) has been shown to be effective for treating musculoskeletal pain as it blocks the pain signals from the areas of nerve damage.

illustration of a tens machine

Did you know?

Exercising for as little as 3-10 minutes at moderate to high intensity produces significant amounts of endorphins.

What does research tell you?

Engaging people with chronic pain in physical activity improves their pain, physical function as well as quality of life.

Reduced activity leads to weakening of muscles, stiff joints and decreased fitness which results in pain flaring up more quickly. An unhelpful activity pattern involves cycles of over- and under-doing activities. Over-doing results in more pain so you have to cut back your activity level. The result is like being on a rollercoaster:

pacing activity levels chart

Activity pacing or pacing relates to planning for an activity. It is helpful to break down an activity into smaller chunks. The next step is to build up activities over time.

man in wheelchair bounding a basketball on a basketball court

Planning to pace

  1. Think about the things you enjoy doing but have had to cut back or stop due to pain. Brainstorm ways to gradually introduce them back into your daily routine.
  2. Start small and build up gradually towards your goals. Increasing your activity by 10-20% per week will give you long-term results.
  3. Set a very specific routine and stick to it – this will help you achieve your goals.

The way we think and feel has a direct impact on our pain experience. The brain perceives information about pain location, type and intensity. At the same time, pain messages also travel to parts of the brain that deal with thoughts and emotions.

Your thoughts and emotions either increase or decrease your pain perception, acting like a volume control dial in your brain. If you feel unwell, anxious and stressed, messages from the brain cause the pain gates to open wide. As a result, more pain messages get through and your pain experience gets worse.

In some situations, your pain becomes less of an issue, especially when you focus on something else, e.g., your favourite hobby, watching a movie, listening to music or exercising. These activities help stimulate the body’s natural feel-good chemicals and distract your mind. As a result, overactive nerve impulses are reduced and the pain gates close.

Unhelpful thoughts

Unhelpful thoughts make your pain worse and reduce your ability to cope with the pain. They can make you feel worried, for example., ‘There must be something terribly wrong to cause this pain.’ Negative thoughts can also undermine your confidence, for example, ‘I cannot cope with this.’ Both are common in people experiencing chronic pain.

The good news is that thoughts can be changed which help reduce your pain and increase your coping ability. Two different ways to deal with unhelpful thoughts:

  • Challenge unhelpful thoughts, such as “I cannot manage my pain” or “My pain will only get worse in the future”.
  • Adopt an accepting approach to thoughts and do not engage with them.
Planning and goal setting
Planning and goal setting are important to help you achieve what is important, despite the pain. Work out what really matters to you then set achievable goals, break down your goals into smaller, bite-size pieces that are achievable in a daily or weekly timeframe.
Desensitisation involves learning to focus on the pain but then letting it blend into the background and not focussing your attention on it.
Relaxation and meditation
Relaxation and meditation can assist in reducing muscle tension and stress that exacerbate pain by activating pain-reducing brain chemicals.

What does research tell you?

Pain catastrophising (which refers to believing that something is far worse than it actually is) can magnify pain symptoms and increase depression, sense of helplessness, anxiety and loss of function.

Chronic pain impacts your sleep. A lack of sleep affects your brain’s ability to deal effectively with pain and has a negative effect on your mood, energy levels and ability to concentrate.

Effects of poor sleep

effects of poor sleep diagram

Did you know?

  • During sleep many active processes occur that are essential for maintaining good health.
  • Alcohol interrupts your sleep cycles and causes disrupted sleep and early awakening. Drinks like coffee and soft drinks cause problems with getting to sleep and staying asleep.

Sleep after a spinal cord injury

Sleep patterns often change after a spinal cord injury affecting the amount and quality of sleep. You might be awake longer, wake up more frequently and have reduced rapid eye movement (REM) sleep. REM sleep is the deep restful sleep when important body processes occur including body rest and repair – it is also when you dream.

Certain factors disrupt sleep patterns,
such as spasms, changing position in bed
and overnight bladder care.

People with higher injury levels are likely to have more problems producing a natural chemical known as melatonin. A lack in melatonin makes it difficult to get to sleep and/or stay asleep.

More than 60% of people with quadriplegia have obstructive sleep apnoea (OSA). Common signs and symptoms include:

  • Daytime sleepiness
  • Loud snoring
  • Episodes of stopping breathing during sleep
  • Sudden waking with gasping or choking
  • Awakening with a dry mouth or sore throat
  • Morning headache
  • Poor memory
  • Problem with concentration.

A respiratory and sleep physician treats OSA with the support of your GP.

Treatment options for sleep apnoea

  • Healthy lifestyle changes
  • Breathing devices
  • Mouthpieces
  • Therapy for mouth and facial muscles
  • Implants
  • Surgical procedures.

What does research tell you?

Sleep and pain are interrelated but research has shown that poor sleep is more strongly linked with chronic pain than the other way around.

Tips for having a good night’s sleep

Good quality sleep is the result of good sleep habits, also known as sleep hygiene. Consider the following strategies to help you get a good night’s sleep:

  • Make your bedroom a sanctuary for sleeping
    Don’t set up your bedroom like an office or entertainment room. Instead, make sure you have good ventilation, fresh air, a constant comfortable temperature and you create a quiet space without TV or video games.
  • Have a set routine that symbolises sleep for you
    Relax before going to bed, listen to relaxing music or do mindfulness exercises.
  • Aim for gentle exercise
    Exercise every other day for good quality sleep. Avoid exercising just before bedtime.
  • Avoid caffeine
    Caffeine after 3pm can increase your alertness and make it more difficult to get to sleep.
  • Avoid alcohol
    Alcohol initially makes you feel drowsy but then increases the likelihood of waking up in the early hours of the morning.
  • Try relaxation strategies
    Do deep breathing exercises, progressive muscle relaxation or mindfulness meditation for 15 minutes before going to bed to help you relax.
  • Distract your mind from the pain
    Pain can be particularly severe overnight. Listen to music, the radio or an audiobook to keep your mind off the pain.
  • Practice desensitisation
    Learn to focus on the pain but teach yourself to let it blend into the background. As you change your focus, you will feel less distress. Desensitisation can be a particularly helpful strategy for coping with neuropathic pain.

Things to consider in understanding and managing fatigue

The energy bank

You have a certain amount of energy in your energy bank so think carefully about how to spend your energy currency by planning your everyday activities.


Understand what triggers fatigue as increased awareness will give you more control. Triggers of fatigue include overdoing an activity, eating an unhealthy diet and poor sleep patterns.

Reduce strain

Minimise physical stress and strain on
your body.

It’s a question of balance

Do not let your pain or fatigue levels dictate what you do. Balance periods of activity with rest. Stick to a level of activity you can easily cope with then gradually increase your activity level.


Be confident when communicating with others about your pain and fatigue and the impact on your everyday life.

Relaxation and meditation

Activate pain control pathways from the brain to reduce pain.

Planning tips

Take time to plan and order your activities. Perform more challenging tasks earlier in
the day when you feel fresh and have
more energy.

The right fuel

Eat a nutritious balanced diet to improve your energy levels.

Did you know?

Strategies for managing chronic pain, such as developing a pacing plan and activity plan, are also effective for managing fatigue.

Good nutrition is important so your body functions well. After a spinal cord injury your body’s nutrition needs change and good nutrition becomes even more critical.

Benefits of having a good and healthy diet with good nutrition

  • Stay healthy
  • Keep your skin in good condition
  • Improve bladder and bowel function
  • Maintain a healthy weight
  • Reduce your pain.

Did you know?

Weight loss and good nutrition can reduce pain.

Maintaining a healthy weight is especially important after a spinal cord injury. It is also a crucial part of your pain management program. Gaining weight makes you feel lethargic and aggravates painful conditions such as arthritis, low back pain, shoulder, wrist and elbow pain, and carpal tunnel syndrome (nerve compression at wrist).

Being overweight causes problems with mobility and transfers, leads to muscle and joint strain, and changes the suitability and fit of your equipment. At its worst, being overweight impacts your ability to be independent when carrying out daily tasks.

woman on bike and man in a wheelchair in the park