Arthritis Pain
New arthritis information and pain caused by arthritis and
arthritis treatment
What Is Arthritis?
The word arthritis literally means joint inflammation but
is typically the word 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.
What Is Pain?
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.
For more information on pain visit medicare
education website.
Most forms of arthritispain are associated with pain that
can be divided into two general categories: acute and chronic
pain. 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.
How Many Americans Have Arthritis Pain?
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.
What Causes Arthritis Pain? Why Is It So Variable?
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.
How Do Doctors Measure Arthritis Pain?
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.
What Will Happen When You First Visit a Doctor for
Your Arthritis Pain?
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.
Who Can Treat Arthritis Pain?
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.
How Is Arthritis Pain Treated?
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 arthritis 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, one
of the 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 pain and suffering.
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 too give
you the most benefits.
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.
What Alternative Therapies May Relieve Arthritis
Pain?
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.
How Can You Cope With Arthritis Pain?
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.
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.
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.
What Research Is Being Conducted on Arthritis Pain?
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
arthritic patient satisfaction.
The list of arthritis 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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