HEALTH / The will to defeat pain without end: Brenda Houghton visits a pioneering pain relief centre in Liverpool that gives hope to those in constant agony

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'WHEN I first came I was just a zombie. I was taking pain killers, but they didn't do a thing. I was wearing a surgical jacket to support my spine and my hand was strapped up.' John Ball smiles at the memory. His destination was the Pain Clinic at Walton Hospital in Liverpool, the oldest pain relief clinic in the world, and the largest in Europe. Nowadays he cycles seven miles a day to the clinic to work as a volunteer on its pain management course, encouraging new patients.

We all fear the raw, violent assault of pain: mercifully, the mind draws a veil over suffering and later it is hard to describe the agony.

But some people have to live without the relief of that amnesia; their pain is constant and unending. Walton's Pain Clinic treats more than 3,500 people a year, all suffering from chronic pain.

There are two sorts of pain, explains Dr Eric Ghadiali, consultant clinical neuropsychologist at the clinic. 'Acute pain is sudden. It's when you bang your toe, break your leg, have an operation. It's there for a good reason, it's telling you, 'Don't move'. Your muscles tense up and that acts like a splint, then the body heals and the pain gradually goes away. That's mostly what happens.

'But sometimes the pain just carries on; it's not telling you anything you need to know. It's unnecessary, and it's incessant.'

This chronic pain is estimated to afflict some four million people in Britain. This pain, that other doctors have been unable to treat, is what the clinic sets out to relieve.

'All sorts of conditions can produce chronic pain,' says Dr Chris Wells, director of the Pain Clinic. 'Any condition which is painful might go on to become chronic in some people.' The clinic can offer a variety of treatments - drugs, nerve blocks, stimulation techniques - but when nothing works, the patient must accept that the pain is there for life.

For these desperate people, the Walton Hospital offers an intensive four-week pain management course, a 9.30am to 5pm commitment. They study relaxation, stress management and target-setting; have lectures from medical specialists, both on the physical nature of pain - how it travels up the nerve pathways of the body - and the psychological aspects; have daily group therapy and periods of art therapy, swimming classes, sessions on exercise bikes and t'ai chi.

'It's explained to them before they come on the programme that the approach is psychological,' says Dr Ghadiali. 'With pain,' he explains, 'there's a physical bit and a psychological bit, and the psychological bit acts almost like a volume control: it can make the pain worse and it can turn it down.

'If you get very worried - about the pain, about what's causing it, the treatments involved, about losing your job and being in pain for the rest of your life - you get very tense and this will make it worse. It turns the volume on that pain up. If you're more relaxed, if you understand what's causing the pain and that you can do certain things without damaging yourself, the volume goes down.'

You don't have to be a psychologist to recognise that there's a psychological element in pain, he says. 'If you understand the reason for it - in childbirth, or when you're running a marathon, it helps. You still hurt but you don't mind. If the pain's there for no good reason, it feels worse.'

Dr Ghadiali says that recognising there is a psychological side does not mean the pain is not real. 'You can't have imaginary pain. You've either got pain or you haven't. You can pretend you've got pain, but that's malingering. If it hurts, it's real and needs to be dealt with.'

Two patients join the course each week so the group of eight includes absolute beginners, improvers and those about to graduate. 'I feel better after two days,' says Lily Smith, one of the beginners, 'because these people here know about pain. If you haven't had it, you can't understand it because pain's invisible. You can't show it.'

The pain management course is held in an old sewing room at the back of the hospital, which looks more like a scruffy sixth-form common room than an innovative medical wing. Both the surroundings and the apparently casual air can be disconcerting for patients used to the starched formality of most hospitals. But the course is very carefully designed to untangle the strings that are holding people back from normal life.

One of these is movement. When someone has chronic pain, they gradually attempt less and less because they're afraid of the consequences. They become overweight and unfit, their muscles wither, ligaments get shorter and then when they try to move it hurts and they think they were wrong to try. So one strand of the course is teaching them that they won't damage their bodies by moving.

'We give them permission to exercise,' explains Dr Wells. 'Doctors say, 'Oh, you've got back pain, rest, don't do anything'. These people have to understand that they can spend the rest of their lives lying on a bed at home, or they can spend their lives going out and about. They can become fit.'

Joyce Williams, in her fourth and final week, is now completing simple exercises she never thought she would be able to do. 'It's given me such pleasure. I've got osteoarthritis of the knees and lower back, injured my neck in a car accident, broke my wrist and then fractured my leg falling down an escalator in town. You get into a terrible state. You won't go out, won't socialise, feel terrible. I couldn't sleep at night and the tablets made me sick.

'Now I'm a totally different person. Last week I went out with my husband and I haven't been able to do that for years. Even getting ready to go out, I got this lovely feeling inside. I do the exercises - I didn't know your muscles waste. I practise the breathing: you can feel the tension lifting. You deal with the pain much better, you say, 'You're not getting the better of me this time.' '

As patients learn to move, they also learn to relax, releasing the frustration and tension that boosts their pain. 'If I'm on my bike and feel a bit iffy,' says John Ball, 'I just get off, lean against the wall and let myself relax for five or 10 minutes, then I'm as right as rain.'

Some of the activities take the patients by surprise. 'The art therapist told us to lie down on a piece of paper and draw round ourselves and we felt a bit funny about it,' says Sara Bloom, in her third week. 'He said, 'Write or draw what's outside you and what affects you, and what's inside you.' It was my first week and you could tell it was really negative: I did a zig- zaggy bit where my pain was, and all my words were really negative. And then we did some this week and it was completely different. My outlook was positive. So although we all thought, 'Oh that's going to be a load of rubbish', it was good therapy really and teaches you to express yourself.'

'We all talk about how we're feeling,' explains Chris Banks, in her second week. 'We discuss afterwards whatever it is we've done and we have a laugh - it's really good.'

Laughter, says Dr Ghadiali, is always a good sign. 'If you're laughing it means you're relaxed, you're feeling comfortable with yourself. Even though you're in pain you can enjoy life a little, which is the message of the programme.'

Patients, he says, have become preoccupied with themselves and with the dark side of things; as they change they start looking at other people and take themselves less seriously. 'We encourage them to give each other hints about where they're going wrong or doing well and that sparks off humour.' But what helps most is realising they are not alone. Meeting others in the same boat is a huge bonus: all the participants say the course would not work half so well if it wasn't done as a group.

On the course, patients are taught to put their pain to the back of their minds. For instance, they have to take their tablets regularly rather than waiting until the pain hits. 'If you only take pain killers when the pain gets bad,' explains John Ball, 'you're giving your subconscious permission to present the pain to you saying, 'Here it is.' '

According to Dr Wells, drugs are not the best treatment for people with chronic pain. 'Any drug powerful enough to affect the central nervous system is powerful enough to be addictive.' He has seen patients holding on to their pain as a way of staying on the drug they have become addicted to.

The group also learn to avoid stress, to stay away from upsetting situations, to relax or go for a walk when they feel under pressure. 'Dr Wells did us a diagram of how pain travels, the gates it goes through so you can switch off,' says Pat Coan. 'I might be waiting for a bus and it isn't coming and I mustn't get bothered. So I just relax. It's working quite well.'

Some people find relaxation difficult. Sara Bloom, who started at the same time as Pat, is still having trouble. But she is determined to master it. 'Tension is part of my problem. I can actually get in my car now and drive for an hour and a half. I could only drive for 15 minutes before and I'd get out doubled up. Now I get out straight.'

The changes in four weeks are remarkable, and patients can expect the improvements to continue if they keep working at it. But Walton can only meet a fraction of the demand. Some wait years for a place; they come from as far as Scotland and the Channel Islands, and even from abroad.

Somehow, chronic pain has been overlooked. St Thomas's Hospital, London, has copied the pain management course, and so have hospitals in Manchester and Nottingham, but many cities do not have even a proper pain clinic, much less a course like this.

In America, where Dr Wells studied pain management, some companies, Boeing for instance, will pay for an employee to go on a pain management course because it is worth the expense to get them back to work. An insurance company will pay to have someone with whiplash injuries rehabilitated within six months, because it's cheaper than paying out thousands of dollars in accident litigation.

Here, Walton has now opened a multi-disciplinary Pain Research Institute alongside the Pain Clinic, where postgraduates from all over the world can both teach and research pain relief, but this is entirely funded by charity. Taking away the pain, it seems, is not yet a national priority.

Physical improvement is not the only gain. Most patients are extremely depressed when they arrive, unable to focus on anyone outside. Now they speak with amazement about how they have changed.

'I helped my son with his homework last night,' says Chris Banks, beaming with pleasure. 'It was usually, 'Oh ask your dad'. I couldn't concentrate. But last night I could sit for a full hour talking it through, actually helping him. It was great.'-

(Photograph omitted)