Pain and its impact on the treatment of rheumatic disease

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Pain and its impact on the treatment of rheumatic disease

New insights into pain mechanisms; Practical advice on pain management

Long treated as a side effect, pain is now widely recognized as an

integral part of patient care. While the last decade has brought

extraordinary advances in the unravelling of pain mechanisms at the

molecular level, evaluating and alleviating pain remains an ongoing

challenge for physicians, particularly rheumatologists. The December

2005 issue of Arthritis & Rheumatism offers a timely examination of

pain as it pertains to rheumatology practice.

" Rheumatologists are increasingly required to address pain as a

specific symptom, " notes leading author -Ann Fitzcharles, M.D.,

of Montreal General Hospital, McGill University. " Pain management is

no longer simply a quick fix with a single pill, but rather an

approach to the patient as a whole biopsychosocial being. "

What is rheumatic pain? How is it affected by inflammation? How is it

linked to a patient’s psychological state? Drawing on the latest

research into this complex factor, Dr. Fitzcharles and her

collaborators demystify both the process and the experience of pain

for patients with rheumatoid arthritis (RA) and related diseases.

Pain mechanisms are not hard wired, but constantly in a state of

change. But neurotransmitters and inflammatory molecules make

rheumatic pain feel chronic. Rheumatic pain, as the authors explain,

is transmitted by not only the central nervous system, but also

receptors in the joint tissue and cartilage. Because rheumatic pain

travels through small, slow-conducting fibers, it is perceived as a

pervasive aching rather than as acute, localized stabs. Inflammation

also plays a role in activating pain pathways that usually lie

dormant – comprising as many as one-third of the total number of

pain-transmitting nerves. What’s more, molecular evidence suggests

that stress and depression may increase a rheumatic patient’s

production of pain-provoking inflammatory agents.

How can a rheumatologist accurately assess a patient’s pain? As Dr.

Fitzcharles acknowledges, clinical evaluation of pain is difficult

and subjective. In addition to using time-honored tools – namely,

the visual analogue scale of pain severity and patient

questionnaires – in real-life practice, the rheumatologist must take

cues from the patient during the interview and examination, heeding

spontaneous movement, musculoskeletal structure, and verbal

complaints, as well as consider the patient’s psychosocial history

and coping strategies.

Beyond the prescription of a pill, what works to relieve rheumatic

pain? " There is no gold standard regarding the ideal management of

chronic pain in rheumatic diseases, " observes Dr. Fitzcharles. " Ideal

pain management should encompass a wide range of both pharmacological

and nonpharmacological interventions. " The authors culminate with a

comprehensive review of complementary treatment approaches, including:

Exercise. According to studies, regular physical activity not only

maintains muscle tone and helps to improve function, but also induces

the production of endogenous opioids – endorphins and other natural

painkillers.

Herbal and dietary supplements. For example, decreased pain has been

recorded among RA patients receiving supplementation with an omega-3

enriched diet for 12 months. This dietary change reduced the need for

antirheumatic medication.

Topical applications. Used for centuries as home remedies, healing

ointments have shown clinical promise for the care of rheumatic

conditions. In one recent study, topical diclofenac performed as well

as ingested diclofenac in relieving knee joint pain.

Opioid analgesics. The cornerstone of pain management in cancer,

opioids are increasingly prescribed for patients with musculoskeletal

pain. However, only limited data support the long-term use of opioids

in patients with rheumatic pain. It is not clear, as yet, if opioids

provide sufficient benefit to counterbalance the possible harmful

effects.

" Rheumatologists will need to become familiar and comfortable with

the use of newly developed strategies for pain management to ensure

optimal treatment, " Dr. Fitzcharles concludes. " Improved function and

rehabilitation, and not simply palliation, should be the main goal of

pain management in rheumatologic practice. "

www.interscience.wiley.com/journal/arthritis