Nocturnal arthritis pain
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.
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Arthritis patients may have difficulty falling asleep because of painful joints.
And they may be awakened by pain. A 1996 National Sleep Foundation (NSF) Gallup Poll found that 30 percent of all nighttime pain sufferers experience arthritis pain at night. The number rises to 60 percent for those over age 50. Nighttime pain sufferers in this age group who experience difficulty sleeping lost an average of 2.2 hours of sleep, 10.7 nights a month. [Ann Rheum Dis 1998;57:434-436 ( July )]
Day and night pain measurement in rheumatoid arthritis
B Rojkovich,a T Gibsonb
a National Institute of Rheumatology, Budapest, Hungary, b Rheumatology Unit, Guy's Hospital, London
Correspondence to: Dr B Rojkovich, National Institute of Rheumatology, Budapest 114, POB 54, Hungary.
Accepted for publication 12 May 1998
OBJECTIVE An attempt was made to see if rheumatoid arthritis (RA) patients can use visual analogue scales (VAS) to distinguish and grade the severity of pain at night, during rest, and on joint movement and to determine if discriminate measurement of these three pain components enhances the value of VAS estimation.
METHODS Two hundred and fifty two consecutive RA patients were evaluated by a single observer using 10 cm VAS for pain at night, at rest during the day, and on movement. Values were correlated against age, disease duration, joint tenderness, swollen joint count, erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and Larsen x ray scores.
RESULTS Night pain was recorded by 71 (28%) and this component of pain was lower than VAS scores for daytime rest and movement. However, those with nocturnal pain had significantly more joint tenderness (p<0.0001), swollen joints (p<0.0001), and higher ESR and CRP. Age, disease duration, and radiographic scores were similar in those with and without night pain. Correlations of joint tenderness were apparent for all three pain scores but only nocturnal pain correlated with swollen joints (p<0.001) and CRP (p<0.005). Age, disease duration, and radiographic severity correlated with daytime rest or movement scores but not nocturnal pain.
CONCLUSION Patients were able to distinguish and estimate the severity of pain at rest, on movement, and at night. The occurrence of night pain characterized those with more active disease and night pain VAS measurement correlated best with measures of joint inflammation whereas daytime pain scores, both at rest and on movement, seemed influenced by the degree of permanent joint damage. Thus, discrete measurement of rest, movement, and nocturnal pain may provide useful information about RA disease status.
J Rheumatol. 1992 Nov;19(11):1756-8.
Nocturnal pain correlates with effusions in diseased hips.
Foldes K, Balint P, Gaal M, Buchanan WW, Balint GP.
National Institute of Rheumatology and Physiotherapy, Budapest, Hungary.
Thirty-five of 50 patients with different hip joint disease had sonographic evidence of joint effusion. Arthrocentesis confirmed effusions in 30 of these 35 patients. Thirty-two of the 35 patients had nocturnal pain. Both nocturnal pain and sonographic evidence of effusion decreased after aspiration (15 patients) and aspiration and injection of corticosteroids (15 patients). In a further group of 61 patients who subsequently had Charnley arthroplasties, 35 had positive sonograms before operation. Of these, 25 had effusions confirmed at operation, the remaining 10 having synovitis and capsule thickening. Again a correlation was found with nocturnal pain. The sensitivity of sonography in detecting hip joint effusion was 92% with a specificity of 70%. Nocturnal pain had a lower sensitivity, 85%, but higher specificity, 94%.
PMID: 1491397 [PubMed - indexed for MEDLINE]
Not just another pain in the back
Walter P. Maksymowych, FRCPC, FACP, FRCP(UK)
OBJECTIVE To review recent developments in diagnosis and treatment of ankylosing spondylitis (AS).
QUALITY OF EVIDENCE Level I evidence from three randomized placebo-controlled trials shows that AS is highly responsive to anti–tumour necrosis factor-a (anti-TNFa) therapies when the standard approach of nonsteroidal anti-inflammatory drugs (NSAIDs) and physical modalities fails.
MAIN MESSAGE Ankylosing spondylitis is associated with disability comparable to that of rheumatoid arthritis. Diagnosis should first focus on eliciting a history of nocturnal back pain, diurnal variation in symptoms with prolonged morning stiffness, and a good response to NSAID therapy. Physical examination is often unrevealing. Pelvic x-ray results are often normal in early disease. Magnetic resonance imaging is the most sensitive imaging technique for detecting early inflammatory lesions and should be considered when history supports the diagnosis but results of plain radiography are normal. When patients have failed at least two courses of NSAID therapy, anti-TNFa therapies are of proven benefit.
CONCLUSION New magnetic resonance imaging techniques and highly effective therapies make AS more readily detectable and manageable.
Other spondyloarthropathies such as psoriatic arthritis and Reiter’s disease may also cause stiffness and pain in the back at night.
Carpal tunnel syndrome is an entrapment neuropathy at the hand-wrist level. Simply put, it is a pressure problem on the Median nerve which is one of the main sensory nerves in the hand. A carpal tunnel syndrome often times is characterized by nocturnal awakening with numbness, tingling, parasthesias (electric shock type pain) in the hand and fingers and can radiate up the forearm sometimes to the shoulder and neck level. In addition, patients often complain of numbness and tingling during repetitive activities with their fingers and wrist. Activities such as driving a motor vehicle, brushing one's teeth, talking on the telephone, knitting, and reading a book are examples of activities that may cause symptoms. One may experience pain or weakness and also complain of dropping items.
Osteoarthritis is often associated with nighttime pain.
Pain with fever or weight loss suggests the presence of a tumor or infection. Pain that is greatest at night or with lying down may be due to malignancies affecting the spine. Any time a patient has trouble finding a comfortable position to sleep in and is awakened by their pain at night, infection and tumor need to be considered.
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