Pain arthritis

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.

Click here: Second Opinion Arthritis Treatment Kit

Pain is the primary symptom of arthritis.

Information from the Arthritis Foundation

The first step is knowing which type of arthritis or condition a person has, because that will help determine the treatment.

Just as there are different types of arthritis, there are also different types of pain.

Each person needs a pain management plan. What works for one person may not work for someone else.

Pain is the body's alarm system that says something is wrong. When the body is injured, nerves in the affected area release chemical signals. Other nerves send these signals to the brain, where they are recognized as pain.

Arthritis pain is caused by several factors, such as:

• Inflammation, the process that causes the redness and swelling in the joints;
• Damage to joint tissues, which results from the disease process or from stress, injury or pressure on the joints;
• Fatigue that results from the disease process, which can make pain seem worse and harder to handle;
• Depression or stress. A person can get caught in a cycle of pain, limited/lost abilities, stress and depression that makes managing pain and arthritis seem more difficult.

People react differently to pain for several reasons. Physical factors include the sensitivity of the nervous system and the severity of the arthritis. Emotional and social factors include fears and anxieties about pain, previous experiences with pain, energy level, attitude about the condition and the way people around the patient react to pain.

Many people with arthritis have found that by learning and practicing pain management skills, they can reduce their pain.

Pain is aggravated by:

• Increased disease activity
• Stress
• Overdoing physical activity
• Focusing on pain
• Fatigue
• Anxiety
• Depression

Pain is alleviated by:

• Positive attitude and pleasant thoughts
• Appropriate exercise
• Relaxation
• Medications
• Massage
• Distraction
• Topical pain relievers
• Humor
• Heat and cold treatments

Pain signals travel through a system of nerves in the brain and spinal cord. The body can create chemicals that help block pain signals. These chemicals, called endorphins, are morphine-like painkilling substances that decrease the pain sensation.

Different factors cause the body to produce endorphins.

The body produces endorphins in response to external factors, such as medicine. Codeine is one example of a powerful pain-blocking medication. Other external pain control methods, such as heat and cold treatments, can stimulate the body to either release endorphins. Exercise also produces endorphins.

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.

The International Association for the Study of Pain defines pain 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 the skin, chemical signals travel from neurons in the skin through nerves in the spinal cord to the 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.

Pain, swelling, redness, and heat are the cardinal signs of inflammation. Inflammation is the body’s response to injury. Inflammation is an important defense mechanism which helps the body to heal.

In arthritis, however, inflammation, leads to damage. With some forms of arthritis like osteoarthritis, inflammation is localized to the joint. With other, more serious types of autoimmune arthritis, like rheumatoid arthritis and systemic lupus erythematosus, inflammation causes damage in many organ systems.

Doctors use a variety of approaches to treat arthritis pain. These are used in different combinations and at different times during the course of the disease and are chosen according to the patient's individual situation. No matter what treatment the doctor and patient choose, however, the goals are the same: to relieve pain, reduce inflammation, slow down or stop joint damage, and improve the person's sense of well-being and ability to function.

Certain activities can help improve a person's ability to function independently and maintain a positive outlook.

Rest and exercise: People with arthritis need a good balance between rest and exercise, with more rest when the disease is active and more exercise when it is not. Rest helps to reduce active joint inflammation and pain and to fight fatigue. The length of time for rest will vary from person to person, but in general, shorter rest breaks every now and then are more helpful than long times spent in bed.

Exercise is important for maintaining healthy and strong muscles, preserving joint mobility, and maintaining flexibility. Exercise can also help people sleep well, reduce pain, maintain a positive attitude, and lose weight. Exercise programs should take into account the person's physical abilities, limitations, and changing needs.

Joint care: This is particularly important for inflammatory forms of arthritis like rheumatoid arthritis. Some people find using a splint for a short time around a painful joint reduces pain and swelling by supporting the joint and letting it rest. Splints are used mostly on wrists and hands, but also on ankles and feet. A doctor or a physical or occupational therapist can help a person choose a splint and make sure it fits properly. Other ways to reduce stress on joints include self-help devices (for example, zipper pullers, long-handled shoe horns); devices to help with getting on and off chairs, toilet seats, and beds; and changes in the ways that a person carries out daily activities.

Stress reduction: People with arthritis face emotional challenges as well as physical ones. The emotions they feel because of the disease-fear, anger, and frustration-combined with any pain and physical limitations can increase their stress level. Although there is no evidence that stress plays a role in causing rheumatoid arthritis, it can make living with the disease difficult at times. Stress also may affect the amount of pain a person feels. There are a number of successful techniques for coping with stress. Regular rest periods can help, as can relaxation, distraction, or visualization exercises. Exercise programs, participation in support groups, and good communication with the health care team are other ways to reduce stress.

Topical treatment

Cold can be an ice pack or a purchased product you place in your freezer and reuse. Generally, cold should be used the first 48 to 72 hours following an acute injury. This means you should use cold rather than heat the first 2 to 3 days after an injury, such as joint sprain or muscle strain. The use of heat in this first days can cause increased swelling in the area and result in more pain.

After an injury is 2 to 3 days old, the body starts trying to heal the injury in a different way. It is then called a sub-acute injury. If the injury persists over a week, the body’s healing process then turns to yet another means of healing. This is called the chronic stage. The chronic stage persists as long as the injury is present. In the sub-acute and chronic stages of healing, both cold and heat can be of benefit. Cold may continue to be of more benefit when swelling remains in the area. Many times cold used during these stages can be more beneficial in reducing swelling over heat. Cold can also be very useful when muscle spasms are present. Some people are sensitive to heat and do not tolerate heat very well. If this is the case, then ice may work better.

These tips for the proper use of cold apply no matter what type of cold you are using. First, cold should only be applied for 15 to 20 minutes at a time. What you don’t want to do is keep reapplying new cold packs one behind the other so the total time of the cold treatment exceeds 15 to 20 minutes. More is not better in this situation. If you do this, then you will over freeze the area decreasing the circulation to the area too much and could very well end up with a nasty case of frostbite. You can also wind up over cooling the nerves in the area end up with damage to the nerves. However, you can reapply cold several times a day. Once your cold pack has been off for approximately an hour and a half to two hours, it is safe to put on another cold pack. The effects of cold last longer than heat since it takes longer for the body to warm up than to cool off. In the acute stage of an injury, frequent application of cold in this manner can be very effective. Keeping the swelling to a minimum can speed up the body’s ability to heal itself. If you apply cold correctly, the area you applied the cold pack to will become red. This is the normal response. If there are blotchy white spots in the red area after you remove a cold pack, this means that the area has been cooled excessively and is a warning sign. You should decrease the amount of time the cold pack is left on the next time.

Cold should be used cautiously over areas that have previously been frostbitten, if you have high blood pressure (hypertension), in certain heart (cardiac) conditions, or over areas where there is nerve damage (neuropraxia). If you have one of these conditions, then you should consult your physician prior to the use of cold.

You can easily make your own reusable ice pack. The easiest way it to just place some ice in a Ziploc bag. Once the ice has melted, it’s time for the ice pack to come off. Then just place the Ziploc bag back in the freezer and it will be ready for the next time you need it.

You can also place a mixture of water and rubbing alcohol in a Ziploc bag. You should use about one part rubbing alcohol to four parts water. The rubbing alcohol will not freeze, so it will form a slush-like mixture. This allows the ice pack to fit better around the area and can be more comfortable. Once you have finished using the ice pack, place it back in the freezer so it will be ready for the next use. You may want to double bag these to avoid leaks.

Heat should never be used during the first 48 to 72 hours after an injury. This can increase the circulation to the area too much increasing the swelling and microscopic bleeding causing the injury to worsen and the pain to increase. Heat can be very effective during the subacute and chronic stages on an injury. Heat can effectively decrease pain, promote healing by increasing circulation, help tight muscles or muscle spasms to relax, and prepare stiff joints for movement. Heat is probably one of the most frequently used methods for home pain management. Everyone has probably used some form of heat at some point in time to help sore, stiff muscles or joints. The effects of heat do not last as long as cold, but can give temporary relief for up to an hour or more. Some common types of heat used in the home include: hot showers or baths, heating pads, microwavable heat packs, and warm compresses. All of these types can be effective, but it is important to remember that all are considered forms of heat when following the guidelines for using heat appropriately.

While heat is probably one of the most widely used home treatments, it is also probably one of the most incorrectly used treatments. Heat is like cold; you don’t want to over heat the tissue are you can get some very bad results. Heat should only be applied for 20 to 30 minutes at a time. Let your muscles cool down for an hour to an hour and a half, and then reapply the heat. The other big problem with prolonged use of heat is the risk of burns. Even if you have your heating pad set on low, prolonged use can cause burning. The heat continues to accumulate is the tissues becoming hotter than the body can handle, and you end up with a burn.

Many people who use heat also use some type of analgesic rub or lotion. You should never use these rubs and heat at the same time. These rubs are basically a type of heat. They give warmth to the area and change the circulation to the area. This is a very quick way to get a burn. If you have used a rub, then you should wait an hour or two before you use heat.

Like cold, heat penetrates more deeply if it is moist instead of dry. There are several commercial moist heating pads available on the market today. A hot compress is a form of moist heat. You will have to rewet the towel several times with warm water however since it will cool off fairly rapidly. If you have a regular heating pad, you can make your own moist heat. Place the heating pad in a plastic protective bag (you don’t want to shock yourself!). Moisten a towel with warm water, wringing out the excess water well. Place the moist towel next to your skin and the heating pad wrapped in the plastic bag over the towel. If you use a microwavable form of heat, you can also wrap that in a warm moist towel to get the benefits of moist heat.

You should check the area you are heating frequently to be sure it is not overheating and trying to burn. Once you remove heat, the redness should disappear after 20 minutes or so. If it does not then it means that the area overheated and was trying to burn. It the redness is still there the next day, you gave yourself a first degree burn. Never place heat on an area that is still red from a previous heat application!

Heat should not be used in the acute stage of an injury.

Heat should not be used by persons who have decreased or impaired sensation. Some common instances where impaired sensation may be present include: diabetes with neuropathies, stroke, head injury, and nerve damage.

Heat should not be used where there is compromised circulation. This could include peripheral vascular disease (PVD), arterial insufficiency, cardiac conditions, and diabetes.

Heat should not be used over malignant tumors.

Heat should not be used over open wounds or areas of suspected infection.

Heat should not be used over an area that has moderate or severe swelling (edema).

Heat should not be used over skin conditions.

Heat should not be used with acute inflammation.

Healthful diet: With the exception of several specific types of oils, there is no scientific evidence that any specific food or nutrient helps or harms people with arthritis. However, an overall nutritious diet with enough-but not an excess of-calories, protein, and calcium is important. Some people may need to be careful about drinking alcoholic beverages because of the medications they take for arthritis. Those taking methotrexate for rheumatoid arthritis, may need to avoid alcohol altogether because one of the most serious long-term side effects of methotrexate is liver damage.

Climate: Some people notice that their arthritis gets worse when there is a sudden change in the weather. However, there is no evidence that a specific climate can prevent or reduce the effects of arthritis. Moving to a new place with a different climate usually does not make a long-term difference in a person's arthritis.


Arthritis medicines fall into three broad categories. The first are analgesics. These medicines control pain but do not control inflammation. Examples include acetaminophen, tramadol (Ultram), propoxyphene, and other narcotic pain relievers.

The second group consists of non-steroidal anti-inflammatory drugs (NSAIDS). These drugs control inflammation so that symptoms such as swelling, redness, heat, and pain are relieved. Examples of drugs that are in this category include ibuprofen (Advil), naproxen (Aleve, Naprosyn), nabumetone (Relafen), etodolac (Lodine), celecoxib (Celebrex), and meloxicam (Mobic).

Topical NSAIDS include Pennsaid and Voltaren gel.

The last category of drugs are the anti-rheumatic disease-modifying drugs (DMARDS). These drugs slow down the progression of arthritis and thus reduce pain. Examples of these drugs include hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), methotrexate, azathioprine (Imuran), and the newer biologic drugs such as Enbrel, Remicade, Humira, Cimzia, Simponi, Actemra, Orencia, Rituxan, and Xeljanz.

Lyrica is a successor to gabapentin (Neurontin) which itself has been used to treat chronic pain. The FDA recently approved Lyrica for the management of neuropathic pain – a particularly agonizing and debilitating type of pain caused by nerve damage associated with diabetes and shingles. Lyrica works by restoring the action of overactive nerves to more normal levels. Lyrica is more potent than Neurontin, so it is more effective at lower doses. Side effects seen in clinical trials included dizziness, sleepiness, dry mouth, bloating, blurred vision, weight gain, and difficulty with concentration and attention.

A patch containing an anesthetic- the Lidoderm patch- has been used to treat localized pain. It is relatively safe and easy to use.

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