Arthritis Pain
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The word arthritis literally means joint inflammation, but
it is often used to refer to a group of more than 100 rheumatic diseases
that can cause pain, stiffness, and swelling in the joints. These
diseases may affect not only the joints but also other parts of the
body, including important supporting structures such as muscles, bones,
tendons, and ligaments, as well as some internal organs. This booklet
focuses on pain caused by two of the most common forms of
arthritis--osteoarthritis and rheumatoid arthritis.
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Pain is the body's warning system, alerting you that
something is wrong. The International Association for the Study of Pain
defines it as an unpleasant experience associated with actual or
potential tissue damage to a person's body. Specialized nervous system
cells (neurons) that transmit pain signals are found throughout the skin
and other body tissues. These cells respond to things such as injury or
tissue damage. For example, when a harmful agent such as a sharp knife
comes in contact with your skin, chemical signals travel from neurons in
the skin through nerves in the spinal cord to your brain, where they are
interpreted as pain.
Most forms of arthritis are associated with pain that can
be divided into two general categories: acute and chronic. Acute pain is
temporary. It can last a few seconds or longer but wanes as healing
occurs. Some examples of things that cause acute pain include burns,
cuts, and fractures. Chronic pain, such as that seen in people with
osteoarthritis and rheumatoid arthritis, ranges from mild to severe and
can last weeks, months, and years to a lifetime.
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Chronic pain is a major health problem in the United
States and is one of the most weakening effects of arthritis. More than
40 million Americans are affected by some form of arthritis, and many
have chronic pain that limits daily activity. Osteoarthritis is by far
the most common form of arthritis, affecting over 20 million Americans,
while rheumatoid arthritis, which affects about 2.1 million Americans,
is the most disabling form of the disease.
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The pain of arthritis may come from different sources.
These may include inflammation of the synovial membrane (tissue that
lines the joints), the tendons, or the ligaments; muscle strain; and
fatigue. A combination of these factors contributes to the intensity of
the pain.
The pain of arthritis varies greatly from person to
person, for reasons that doctors do not yet understand completely.
Factors that contribute to the pain include swelling within the joint,
the amount of heat or redness present, or damage that has occurred
within the joint. In addition, activities affect pain differently so
that some patients note pain in their joints after first getting out of
bed in the morning, whereas others develop pain after prolonged use of
the joint. Each individual has a different threshold and tolerance for
pain, often affected by both physical and emotional factors. These can
include depression, anxiety, and even hypersensitivity at the affected
sites due to inflammation and tissue injury. This increased sensitivity
appears to affect the amount of pain perceived by the individual. Social
support networks can make an important contribution to pain
management.
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Pain is a private, unique experience that cannot be seen.
The most common way to measure pain is for the doctor to ask you, the
patient, about your difficulties. For example, the doctor may ask you to
describe the level of pain you feel on a scale of 1 to 10. You may use
words like aching, burning, stinging, or throbbing. These words will
give the doctor a clearer picture of the pain you are experiencing.
Since doctors rely on your description of pain to help
guide treatment, you may want to keep a pain diary to record your pain
sensations. You can begin a week or two before your visit to the doctor.
On a daily basis, you can describe the situations that cause or alter
the intensity of your pain, the sensations and severity of your pain,
and your reactions to the pain. For example: "On Monday night, sharp
pains in my knees produced by housework interfered with my sleep; on
Tuesday morning, because of the pain, I had a hard time getting out bed.
However, I coped with the pain by taking my medication and applying ice
to my knees." The diary will give the doctor some insight into your pain
and may play a critical role in the management of your disease.
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The doctor will usually do the following:
- Take your medical history and ask questions such as, How long have you
been experiencing pain? How intense is the pain? How often does it occur?
What causes it to get worse? What causes it to get better?
- Review the medications you are using
- Conduct a physical examination to determine causes of pain and how this
pain is affecting your ability to function
- Take blood and/or urine samples and request necessary laboratory work
- Ask you to get x rays taken or undergo other imaging procedures such as
a CAT scan (computerized axial tomography) or MRI (magnetic resonance imaging)
to see how much joint damage has been done.
Once the doctor has done these things and reviewed the
results of any tests or procedures, he or she will discuss the findings
with you and design a comprehensive management approach for the pain
caused by your osteoarthritis or rheumatoid arthritis.
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A number of different specialists may be involved in the
care of a patient with arthritis--often a team approach is used. The
team may include doctors who treat people with arthritis
(rheumatologists), surgeons (orthopaedists), and physical and
occupational therapists. Their goal is to treat all aspects of arthritis
pain and help you learn to manage your pain. The physician, other health
care professionals, and you, the patient, all play an active role in the
management of arthritis pain.
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There is no single treatment that applies to everyone with
arthritis, but rather the doctor will develop a management plan designed
to minimize your specific pain and improve the function of your joints.
A number of treatments can provide short-term pain relief.
Short-Term Relief
- Medications--Because people with osteoarthritis have very little
inflammation, pain relievers such as acetaminophen (Tylenol*) may be effective.
Patients with rheumatoid arthritis generally have pain caused by inflammation
and often benefit from aspirin or other nonsteroidal anti-inflammatory drugs
(NSAIDs) such as ibuprofen (Motrin or Advil).
- Heat and cold--The decision to use either heat or cold for arthritis
pain depends on the type of arthritis and should be discussed with your
doctor or physical therapist. Moist heat, such as a warm bath or shower,
or dry heat, such as a heating pad, placed on the painful area of the joint
for about 15 minutes may relieve the pain. An ice pack (or a bag of frozen
vegetables) wrapped in a towel and placed on the sore area for about 15
minutes may help to reduce swelling and stop the pain. If you have poor
circulation, do not use cold packs.
- Joint protection--Using a splint or a brace to allow joints to
rest and protect them from injury can be helpful. Your physician or physical
therapist can make recommendations.
- Transcutaneous electrical nerve stimulation (TENS)--A small TENS
device that directs mild electric pulses to nerve endings that lie beneath
the skin in the painful area may relieve some arthritis pain. TENS seems
to work by blocking pain messages to the brain and by modifying pain perception.
- Massage--In this pain-relief approach, a massage therapist will
lightly stroke and/or knead the painful muscle. This may increase blood
flow and bring warmth to a stressed area. However, arthritis-stressed joints
are very sensitive, so the therapist must be familiar with the problems
of the disease.
Osteoarthritis and rheumatoid arthritis are chronic
diseases that may last a lifetime. Learning how to manage your pain over
the long term is an important factor in controlling the disease and
maintaining a good quality of life. Following are some sources of
long-term pain relief.
* Brand names included in this booklet are provided as
examples only and their inclusion does not mean that these products are
endorsed by the National Institutes of Health or any other Government
agency. Also, if a particular brand name is not mentioned, this does not
mean or imply that the product is unsatisfactory.
Long-Term Relief
- Medications
Biological response modifiers--These new drugs used for the
treatment of rheumatoid arthritis reduce inflammation in the joints by
blocking the reaction of a substance called tumor necrosis factor, an
immune system protein involved in immune system response. These drugs
include Enbrel and Remicade.
Nonsteroidal anti-inflammatory drugs (NSAIDs)--These are a
class of drugs including aspirin and ibuprofen that are used to reduce
pain and inflammation and may be used for both short-term and
long-term relief in people with osteoarthritis and rheumatoid
arthritis. NSAIDs also include Celebrex and Vioxx, so-called COX-2
inhibitors that block an enzyme known to cause an inflammatory
response.
Disease-modifying antirheumatic drugs (DMARDs)--These are
drugs used to treat people with rheumatoid arthritis who have not
responded to NSAIDs. Some of these include the new drug Arava and
methotrexate, hydroxychloroquine, penicillamine, and gold injections.
These drugs are thought to influence and correct abnormalities of the
immune system responsible for a disease like rheumatoid arthritis.
Treatment with these medications requires careful monitoring by the
physician to avoid side effects.
Corticosteroids--These are hormones that are very effective
in treating arthritis but cause many side effects. Corticosteroids can
be taken by mouth or given by injection. Prednisone is the
corticosteroid most often given by mouth to reduce the inflammation of
rheumatoid arthritis. In both rheumatoid arthritis and osteoarthritis,
the doctor also may inject a corticosteroid into the affected joint to
stop pain. Because frequent injections may cause damage to the
cartilage, they should be done only once or twice a year.
Other products--Hyaluronic acid products like Hyalgan and
Synvisc mimic a naturally occurring body substance that lubricates the
knee joint and permits flexible joint movement without pain. A
blood-filtering device called the Prosorba Column is used in some
health care facilities for filtering out harmful antibodies in people
with severe rheumatoid arthritis.
- Weight reduction--Excess pounds put extra stress on
weight-bearing joints such as the knees or hips. Studies have shown
that overweight women who lost an average of 11 pounds substantially
reduced the development of osteoarthritis in their knees. In addition,
if osteoarthritis has already affected one knee, weight reduction will
reduce the chance of it occurring in the other knee.
- Exercise--Swimming, walking, low-impact aerobic exercise,
and range-of-motion exercises may reduce joint pain and stiffness. In
addition, stretching exercises are helpful. A physical therapist can
help plan an exercise program that will give you the most
benefit.*
* The National Institute of Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse has a separate booklet on arthritis
and exercise.
- Surgery--In select patients with arthritis, surgery may be
necessary. The surgeon may perform an operation to remove the synovium
(synovectomy), realign the joint (osteotomy), or in advanced cases
replace the damaged joint with an artificial one (arthroplasty). Total
joint replacement has provided not only dramatic relief from pain but
also improvement in motion for many people with
arthritis.
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Many people seek other ways of treating their disease,
such as special diets or supplements. Although these methods may not be
harmful in and of themselves, no research to date shows that they help.
Some people have tried acupuncture, in which thin needles are inserted
at specific points in the body. Others have tried glucosamine and
chondroitin sulfate, two natural substances found in and around
cartilage cells, for osteoarthritis of the knee.
Some alternative or complementary approaches may help you
to cope with or reduce some of the stress of living with a chronic
illness. It is important to inform your doctor if you are using
alternative therapies. If the doctor feels the approach has value and
will not harm you, it can be incorporated into your treatment plan.
However, it is important not to neglect your regular health care or
treatment of serious symptoms.
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The long-term goal of pain management is to help you cope
with a chronic, often disabling disease. You may be caught in a cycle of
pain, depression, and stress. To break out of this cycle, you need to be
an active participant with the doctor and other health care
professionals in managing your pain. This may include physical therapy,
cognitive-behavioral therapy, occupational therapy, biofeedback,
relaxation techniques (for example, deep breathing and meditation), and
family counseling therapy.
The Multipurpose Arthritis and Musculoskeletal Diseases
Center at Stanford University, supported by the National Institute of
Arthritis and Musculoskeletal and Skin Diseases (NIAMS), has developed
an Arthritis Self-Help Course that teaches people with arthritis how to
take a more active part in their arthritis care. The Arthritis Self-Help
Course is taught by the Arthritis Foundation and consists of a 12- to
15-hour program that includes lectures on osteoarthritis and rheumatoid
arthritis, exercise, pain management, nutrition, medication,
doctor-patient relationships, and nontraditional treatment.
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Things You Can Do To Manage Arthritis
Pain
- Eat a healthy diet.
- Get 8 to 10 hours of sleep at night.
- Keep a daily diary of pain and mood changes to share with
your physician.
- Choose a caring physician.
- Join a support group.
- Stay informed about new research on managing arthritis pain.
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You may want to contact some of the organizations listed at the end for additional
information on the Arthritis Self-Help Course and on coping with pain, as
well as for information on support groups in your area.
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The NIAMS, part of the National Institutes of Health, is
sponsoring research that will increase understanding of the specific
ways to diagnose, treat, and possibly prevent arthritis pain. As part of
its commitment to pain research, the Institute joined with many other
NIH institutes and offices in 1998 in a special announcement to
encourage more studies on pain.
At the Specialized Center of Research in Osteoarthritis at
Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois,
researchers are studying the human knee and analyzing how injury in one
joint may affect other joints. In addition, they are analyzing the
effect of pain and analgesics on gait (walking) and comparing pain and
gait before and after surgical treatment for knee osteoarthritis.
At the University of Maryland Pain Center in Baltimore,
NIAMS researchers are evaluating the use of acupuncture on patients with
osteoarthritis of the knee. Preliminary findings suggest that
traditional Chinese acupuncture is both safe and effective as an
additional therapy for osteoarthritis, and it significantly reduces pain
and improves physical function.
At Duke University in Durham, North Carolina, NIAMS
researchers have developed cognitive-behavioral therapy (CBT) involving
both patients and their spouses. The goal of CBT for arthritis pain is
to help patients cope more effectively with the long-term demands of a
chronic and potentially disabling disease. Researchers are studying
whether aerobic fitness, coping abilities, and spousal responses to pain
behaviors diminish the patient's pain and disability.
NIAMS-supported research on arthritis pain also includes
projects in the Institute's Multipurpose Arthritis and Musculoskeletal
Diseases Centers. At the University of California at San Francisco,
researchers are studying stress factors, including pain, that are
associated with rheumatoid arthritis. Findings from this study will be
used to develop patient education programs that will improve a person's
ability to deal with rheumatoid arthritis and enhance quality of life.
At the Indiana University School of Medicine in Indianapolis, health
care professionals are looking at the causes of pain and joint
disability in patients with osteoarthritis. The goal of the project is
to improve doctor-patient communication about pain management and
increase patient satisfaction.
The list of pain studies continues. A NIAMS-funded project
at Stanford University in California is evaluating the effects of a
patient education program that uses a book and videotape to control
chronic pain. At Indiana University in Indianapolis, Institute-supported
scientists are determining whether strength training can diminish the
risk of severe pain from knee osteoarthritis. And a multicenter study
funded by the National Center for Complementary and Alternative Medicine
and NIAMS, and coordinated by the University of Utah School of Medicine,
is investigating the effects of the dietary supplements glucosamine and
chondroitin sulfate for knee osteoarthritis.
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National Institute
of Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
American
Academy of Orthopaedic Surgeons
American
College of Rheumatology
Arthritis
Foundation
American Chronic Pain Association
American Pain Society
National
Chronic Pain Outreach Association, Inc.
http://www.niams.nih.gov/index.htm.
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