Bone pain: Information for clinicians

You should suspect that pain is of bony origin if there are known bone metastases or a cancer which commonly spreads to bone e.g. breast, lung, renal, prostate.

Bone pain can be extremely debilitating because it affects function in so many ways. The treatment priorities are first getting pain relieved to allow sleep, then when sitting up and finally when moving about.

Red flags

The two things to bear in mind are:

  1. Cord compression from worsening vertebral metastases. Symptoms are worsening pain or heavy legs. 
  2. Risk of pathological fracture in a long bone. Symptoms are sudden worse pain on weight bearing.

Consider urgent scanning for rapidly changing pain.

Clinical features

Bone pain is usually well localised, might be worse on weight bearing (depending on site) and may be tender to touch. Often throbs at night.

An initial approach to treatment
  • Apply hot or cold packs
  • Paracetamol and NSAIDs - alongside a PPI.
  • A COX-2 inhibitor such as Celecoxib may be a good option
  • Titration of a strong opioid - e.g. titrate oral Morphine solution from 2.5mgs 4 hourly
  • A prn dose of analgesia before planned activity may help e.g. before a walk
  • Consider a trial of Lidocaine 5% plaster if the bone pain is very superficial e.g. a rib metastasis
  • Urgent control for severe bone pain - Dexamethasone 6mg a day for 5 days and then review (a good response to steroids may be an indication to refer for radiotherapy)
Specialist care
  • Radiotherapy is always considered for persistent metastatic bone pain. Often a single fraction is used. May cause a pain flare initially - cover with steroids.
  • Bisphosphonates intravenously (eg Zometa) to reduce skeletal events due to bone metastases, but can also help pain. There may be a role for oral bisphosphonates. 
  • Denosumab is a subcutaneous option that oncologists may recommend instead of bisphosphonates, but is much more costly
  • Prophylactic surgery can be dramatically helpful to prevent a pathological fracture and help pain

Recommended Resources

The BMJ Clinical Review - Cancer induced bone pain

Published 29th January 2015

ESMO Cancer pain Guidelines

Published 24th July 2018

Share

Related Services

24 hour Advice Line Michael Sobell Hospice
Close

24 hour Advice Line Michael Sobell Hospice

T. 0203 824 1268

Offers support and advice on palliative care issues to GPs, Care Homes, District Nurses and hospital doctors.

It is also an Advice Line for patients and families who live in Hillingdon and need advice on any aspect of palliative care. 

The Advice Line is answered by hospice nurses in the Inpatient Unit and queries are escalated to the on-call palliative medical team if needed.

Brent North Community Palliative Care Team - based at St Luke's
Close

Brent North Community Palliative Care Team - based at St Luke's

T. 020 8382 8013

North Brent Community Specialist Palliative Care Nurse team provides advice and visiting to palliative care patients in North Brent. The team is based at St Lukes Hospice.

Areas: Queensbury, Fryent, Welsh Harp, Barnhill, Kenton, Northwick Park, Preston, Sudbury, Wembley Central, Alperton, Tokyngton

The team can be contacted for referrals Monday to Sunday 8.30am to 4.30pm. 

After 4.30pm the Out of Hours Telephone Advice line 020 8382 8000 operates and calls will be taken by a nurse on St Lukes inpatient unit

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Community Palliative Care Team - based at Meadow House Hospice
Close

Community Palliative Care Team - based at Meadow House Hospice

T. 020 8967 5179

W. http://meadowhouse.lnwh.nhs.uk/our-services/community-team/

The Community Specialist Palliative Care Nurse Team provides advice and visiting to palliative care patients in Ealing and Hounslow. The team are based at Meadow House Hospice.

The team will visit patients with progressive life limiting illness in their own homes. They provide specialist advice around pain and symptom control and support for patients, their families, and carers during the last stages of illness. They also support patients wishing to die at home through coordination with GPs and hospital teams.

The team is comprised of medical consultants, specialist nurses, physiotherapists, occupational therapists, social workers, a bereavement support officer and a patient and carer advocacy worker

The team can be contacted for referrals Monday to Friday 9.00am to 5.00pm.

Between Monday to Friday 5.00pm and 8.30am, the Out of Hours Telephone Advice line 020 8102 5000 takes calls. Weekends and Bank Holidays 5.00pm to 9.00am.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Community Palliative Care Team - based at St. John's Hospice
Close

Community Palliative Care Team - based at St. John's Hospice

T. 020 7806 4040

St. John's Hospice provides advice and visiting palliative care patients for some parts of Central London.

Referrals can be made Monday to Sunday 9.00am to 5.00pm.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Community Palliative Care Team (South) - Royal Trinity
Close

Community Palliative Care Team (South) - Royal Trinity

T. 020 7787 1062

Royal Trinity Hospice (South) provides advice and visiting palliative care patients of Hammersmith and Fulham, Central London and West London.

They can be contacted 8am -8pm  7 days a week.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Harlington Hospice
Close

Harlington Hospice provides a wide range of palliative care services to the residents of Hillingdon and surrounding areas.

The Hospice hosts a Wellbeing Service (shared with Michael Sobell Hospice), complementary therapies, counselling, lymphoedema service and the CABS team supporting children and adolescents.

The Hospice also hosts Harlington Hospice@Home team, mainly providing night sits, plus inpatient beds based at Michael Sobell Hospice (MSH) in Northwood.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Harrow Community Palliative Care
Close

Harrow Community Palliative Care

T. 020 8102 6163

Harrow Community Specialist Palliative Care Team (LNWHT) provides advice and visiting to palliative care patients in Harrow.

They can be contacted Monday to Friday 8.30am to 4.30pm.

They are based at Honeypot Lane Health Centre, 839 Honeypot Lane, HA7 1AT.

Out of Hours the Pall24 Helpline can be used 3000 200 224

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Hillingdon Community Palliative Care Team
Close

Hillingdon Palliative Care Team (hosted by NHS CNWL) provides specialist advice and visiting to palliative care patients living in Hillingdon. Each GP practice has their own named Clinical Nurse Specialist ( CNS ). A Triage CNS manages calls and referrals each day and they have the option to escalate to consultants if needed.

They can be contacted Monday to Friday 8.00am to 4.30pm excluding bank holidays.

Out of hours phone Michael Sobell Hospice 24 hour Advice Line on 020 3824 1268

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)
Pembridge Community Palliative Care Team (North)
Close

Pembridge Community Palliative Care Team (North)

T. 0208 102 5383 / 0208 102 5000 (out of hours)

Pembridge Community Palliative Nurse Team (North) provides advice and visiting palliative care patients of Hammersmith and Fulham, Central London and West London.

They can be contacted Monday to Friday 8.30am to 5.00pm.

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4 (DOCX)

Related Articles

4th July 2024

Neuropathic pain: Information for clinicians

11th September 2023

Spinal cord compression: Information for patients and carers

Feedback