Osteoarthritis and the inflammatory arthritides, namely rheumatoid arthritis, psoriatic arthritis, and spondyloarthritis, are the most frequently encountered rheumatic diseases in the population. Pain is the most common manifestation among patients with arthritis.
Osteoarthritis is the most common form of arthritis. Joints in the hands, knees, hips, and spine are most commonly affected. On the other hand, rheumatoid arthritis affects small and medium-sized joints and is characterized by symmetric and erosive arthritis.
Psoriatic arthritis presents as mild monoarthritis or severe polyarthritis. It can involve the axial skeleton while spondyloarthritis, in most cases, affects the spine. Some forms can affect the peripheral joints in the hands, feet, arms and leg.
Major clinical improvements over the last few years have been developed to improve the outcome of osteoarthritis ad inflammatory arthritis. Pain management in these diseases has been studied to provide the best possible care for the individual.
Multiple individual factors influence pain. These factors include illness beliefs, mood, obesity, sleep disturbance, and the pattern of rest and activity throughout the day. Patient education, orthotics, psychological and behavioral intervention, weight management, pharmacological, and joint-specific treatment were found to be effective in pain management. The choice for a specific intervention is not only determined by the effects and severity of pain. It must be tailored individually to promote well-being and participation.
Patient education was found to be an integral part in the pain management of inflammatory arthritis in the study of Zangi, H., et al in 2015. The primary goal of education is to enable patients to manage their illness, adjust to their condition, and maintain quality of life. Recommendations for patient education have been provided.
Those with inflammatory arthritis should have access to and be offered patient education throughout the course of the disease. Patient education should include individual or group sessions, which can be provided thru face-to-face or online interactions and supplemented by phone calls or multimedia materials. Healthcare professionals should be competent and have the knowledge and skills necessary to provide effective patient education.
The systematic review conducted by Da Silva, J., et al in 2018 discussed the association of chronic widespread pain and excess mortality. The excess mortality is explained by psychological and lifestyle factors such as decrease in physical activity, increase in body mass index, unhealthy diets, and smoking. Depression and anxiety had a positive correlation with the severity of pain and disability of patients. Social support predicted longevity in an elderly population. This study supports the view that lifestyle modification and targeting depression and other psychological aspects of chronic widespread pain decreased mortality.
In a systematic review by McAlindon, T.E., et al in 2014, it was shown that appropriate treatment for osteoarthritis of the knee consisted of biomechanical intrerventions (knee braces, knee sleeves, and foot orthosis), intra-articular corticosteroids, exercise (land-based and water-based), self-management, education, strength training, and weight management. In knee-only osteoarthritis, a cane (walking stick) was found to be beneficial.
Balneotherpy, defined as the use of baths containing thermal mineral waters was considered appropriate only for multiple joint osteoarthritis. Paracetamol was found to be effective in oasteoarthritis without co-morbidities since this drug can cause gastrointestinal adverse effects and multi-organ failure. Topical non-steroidal anti-inflammatory drugs have been found to be effective in knee-only osteoarthritis. Oral non-steroidal anti-inflammatory drugs (COX-2 inhibitors) were found to be effective in individuals without co-morbidities and multiple-joint osteoarthritis with moderate co-morbidity risk.
Pain is the predominant symptom in inflammatory arthritis and osteoarthritis. This can impair the functional capacity and daily life of an individual. Pain management support can reduce pain, decrease disease burden, and improve well-being. Healthcare professionals should therefore have adequate knowledge, training, and skills to ensure effective pain management. This study discussed the positive effects of multiple pain treatment modalities and provided recommendations for effective pain management in those with inflammatory arthritis and osteoarthritis.
The objectives of the systematic literature review were to evaluate the existing scientific evidence of the health professional’s approach in pain management and provide recommendations forpain management in people with inflammatory arthritis and osteoarthritis.
Geenen et. Al in 2018 conducted a review of 186 systematic reviews and meta-analysis of randomized controlled trials. The task force that comprised the 18 members consisted of patient representatives, nurses, physiotherapists, psychologists, rheumatologists, a general practitioner, an occupational therapist, a clinical epidemiologist, and a research fellow.
The literature search included systematic review in one of the selected diseases namely, rheumatoid arthritis, spondyloarthritis, psoriatic arthritis, and osteoarthritis, with pain as the outcome measure. General pharmacological and joint specific medical and surgical treatment studies were excluded in the review.
Osteoarthritis was divided into osteoarthritis in general, osteoarthritis of the knee, osteoarthritis of the hip, osteoarthritis of the knee and hip, osteoarthritis of the hand or wrist, and osteoarthritis of the foot or ankle. The effect of the treatment option for pain in the included articles were categorized into ‘positive effect’, ‘no effect’, and ‘unclear effect.’
‘Positive effect’ included articles that stated positive effects of the treatment option on pain. ‘No effect’ included articles that has neither positive nor negative effects. ‘Unclear effects’ included articles that state a combination of both no effects and positive effects.The Grades of Recommendation, Assessment, Development and Evaluation (GRADE) system was used to rate the evidence of the reviews and meta-analysis independently by two assessors. Strength of recommendation was determined and were scored accordingly.
Proper assessment of the patient by the health professional is essential in pain management. Assessment include patient’s needs and preferences regarding pain management, activities and values in daily life, pain characteristics (severity, type and quality), social factors such as work, family and friends, sleep problems, obesity, and previous and ongoing pain treatments and perceived efficacy.
In this study, patient education had a uniform positive effect on pain in osteoarthritis of the knee and osteoarthritis of the hip.No effect on pain was noted for spondyloarthritis and osteoarthritis of the hand or wrist.
Physical activity and exercise likewise showed positive effects and were essential in pain management. General exercise was effective in reducing pain in spondyloarthritis, osteoarthritis in general, osteoarthritis of the hip, osteoarthritis of the knee, and osteoarthritis of the foot or ankle. Aerobic exercise was effective in osteoarthritis in general and osteoarthritis of the knee. Strength and resistance training was effective in osteoarthritis in general, osteoarthritis of the hip and osteoarthritis of the knee. Weight management in obese patients also showed positive effects on pain management.
Orthotics have shown positive effect on pain management. These include orthopedic shoes in rheumatoid arthritis and osteoarthritis of the knee, splints in osteoarthritis of the hand, and elastic bandages in osteoarthritis of the knee.
Psychological or social interventions such as cognitive behavioral therapy, self-management support programs, and referral to psychologist if necessary were also shown to have positive effects in reducing pain. If sleep disturbance is present, interventions like education on sleep hygiene and referral to a therapist or clinic showed small positive effects on overall pain management.
Pharmacological treatment was not included in the review of the study but has been evaluated in different studies to be effective in pain management of inflammatory arthritis and osteoarthritis. These include oral or topical NSAIDS (non-steroidal anti-inflammatory drugs), intraarticular glucocorticoid injections and drugs for neuropathic pain. Miscellaneous therapies such as acupuncture and massage were also excluded in the study but have been shown to have positive effects in osteoarthritis of the knee. Pain in psoriatic arthritis is higher than other forms of arthritis but due to lack of studies involving psoriatic arthritis, pain treatment options in rheumatoid arthritis can be used as a guide to pain management in psoriatic arthritis.
Recommendations in pain management include patient education, physical activity and exercise, orthotics, psychological interventions, education on sleep hygiene, weight management, and pharmacological interventions. In this study, physical activity, exercise, and psychological interventions were most uniformly positive in the disease groups while educational interventions, orthotics, and weight management were shown positive for specific disease groups.
1. Michelsen, B., et al. A Comparison of Disease Burden in Rheumatoid Arthritis, Psoriatic Arthritis and Axial Spondyloarthritis. PloS One. 2018.
2. Zangi, H., et al. EULAR Recommendations for patient education for people with inflammatory arthritis. Annals of the Rheumatic Disease. 2016.
3. Da Silva, J., et al. Chronic Widespread pain and increased mortality: biopsychosocial interconnections. British Medical Journal. 2017.
4. Koffel, E., et al. A Meta-analysis of Group Cognitive Behavioral Therapy for Insomnia. Sleep Medicine Review. 2015.
5. Smith, M., et al. Cognitive-Behavioral Therapy for Insomnia in Knee Osteoarthritis. Arthritis and Rheumatology. 2015.
6. McAlindon, T.E., et al. OARSI Guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage, 2014.
7. Combe, B., et al. 2016 Update of the EULAR recommendations for the management of early arthritis. Annals of the Rheumatic Disease. 2016.