Pain management for 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

The primary aims of arthritis treatment are:

• Pain management
• Restoration of normal activity
• Slowing down progression of disease

For most patients, control of pain is the most important issue.

There must be a critical balance between activity and rest. Frequent short breaks may be necessary to reduce arthritis symptoms such as inflammation, pain, and fatigue.

Exercise, a key component of arthritis treatment, should be interspersed with rest periods.

Temporary rest for a specific joint can be provided by a splint, brace, or cane. Doctors or physical therapists can recommend the appropriate use of these supports for arthritis symptoms.

Maintaining ideal weight may help with aches and pains for two reasons. Additional weight puts strain on joints. Also, adipocytes-fat calls- manufacture leptins, proteins that promote inflammation.

Physical therapy is another important component of care. One Canadian study involving 117 people found that education, exercise, and other forms of physiotherapy led to lasting improvements in morning stiffness and other rheumatoid arthritis symptoms.

Heat applied to an aching joint can ease the pain and muscle soreness associated with arthritis. Use heat sources that gently warm muscles, such as a hot shower or bath, hot water bottles, electric heating pads, or heat lamps. To prevent burns, check the skin periodically and be careful not to fall asleep while applying heat.

Cold can be applied to help reduce inflammation or relax muscle spasms. Wrap an ice bag in a towel, rather than applying ice directly to the skin. Neither heat nor cold should be applied if a patient has circulatory problems.

Capsaicin or counterirritant ointments that increase the blood flow in the skin can provide temporary relief.

It is extremely important to handle capsaicin ointments carefully and to wash your hands thoroughly-especially your fingertips-after each application to avoid spreading the cream onto sensitive areas. If capsaicin comes into contact with wounds, the mouth, the nose, or other mucosal surfaces-especially the eyes-it can cause very severe pain. Also, recent reports have shown that topical arthritis agents can cause severe burns so be cautious.

Drug treatments for rheumatoid arthritis can be divided into two categories, those that treat the symptoms of pain and inflammation and the more aggressive drugs that slow the progression of rheumatoid arthritis.

Medications that treat acute rheumatoid arthritis symptoms include corticosteroids (also known as steroids), and non-steroidal anti-inflammatory drugs (NSAIDs).

Medications that slow rheumatoid arthritis are called disease modifying anti-rheumatic drugs (DMARDs). This category includes a wide range of drugs that affect the body's immune system. They are effective against rheumatoid arthritis, but also cause many serious side effects because they weaken the body's immune system.

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving pain in rheumatoid arthritis. The best-known NSAID is aspirin. As with aspirin, the side effects of NSAIDs are potentially severe including stomach and small bowel ulcers, liver and kidney dysfunction, and elevated risk for cardiovascular events such as heart attack and stroke. Many experts suggest that acetaminophen be taken first.

Long-term treatment with NSAIDs can raise blood pressure. This may be troublesome for people with already elevated blood pressure or other risk factors for coronary heart disease.

Long-term use of NSAIDs can lead to retention of salt and water in the body. In people who are at risk of congestive heart failure, this is dangerous.

NSAIDs can cause impairment of blood flow in the kidneys, especially in older people. This problem will go away once the drug is no longer taken.

Because NSAIDs interfere with the clotting function of blood platelets, their use can prolong bleeding time and make it more difficult to stop bleeding. This may be a problem for people who take blood thinners. They also block the anti-platelet effect of aspirin.

Short-term use of an NSAID-for one to two weeks-is generally safe. The risk of side effects increases with age, dose, and duration of use. Depending on interpretation of the numbers, the risk can appear high or low. Some estimates put the number of hospitalizations due to gastrointestinal side effects of NSAIDs at more than 100,000 per year and deaths due to NSAID gastrointestinal side effects at more than 16,000 per year. These figures are high because many people are taking NSAIDs.

The Food and Drug Administration has predicted that 2% to 4% of patients who take NSAIDs on a daily basis for 1 year will have a symptomatic GI perforation, an ulcer, or bleeding. In rheumatoid arthritis patients with no risk factors for NSAID-related ulcers, the risk of developing ulcer complications was 4 out of every 1,000 patients (0.4%) per year.

Generally, the most serious side effects-namely bleeding and ulcers in the stomach and small intestine-are most common in people who:

take high doses of NSAIDs
are 65 years or older
have a history of stomach or intestinal ulcers
are using anticoagulants such as Coumadin
are using corticosteroids
smoke tobacco
drink alcohol

In a large study of people whose average age was 68 years, about 14 out of 1,000 people (1.4%) developed ulcers or bleeding in the stomach and upper small intestine over the course of 6 months. The longer they took NSAIDs, the more likely they were to develop complications.

The risk factors for developing the side effects related to NSAIDs were being over the age of 75, having a history of ulcers of the stomach or upper small intestine, having a history of bleeding from the stomach or small intestine, and having a history of heart disease. Of people with none of these risk factors, fewer than 1% can expect to develop bleeding or ulcers from taking NSAIDs for one year. For people with any single risk factor, about 2% per year can expect to develop this complication. People with a combination of any three of the risk factors have an 8% to 10% per year chance of developing bleeding and ulcers. For people with all four risk factors, the risk is 18% per year.

When NSAIDs are needed, they must be used carefully. The use of NSAIDs has been associated with about 20% to 30% of all hospital admissions and deaths due to stomach ulcers in patients aged 65 and older.

Some research suggests that the long-term use of some NSAIDs, especially indomethacin, may lead to more severe changes in joints affected by arthritis than would be expected in untreated joints. These studies suggest that NSAIDs may inhibit processes involved in cartilage repair and may accelerate cartilage destruction.

Most patients who take long-term NSAIDS usually take a stomach protecting medicine as well. In addition, patients need to be cognizant of the far more serious risk of cardiovascular events associated with NSAID use.

Corticosteroids are used often for acute pain and inflammation because they provide quick relief. They also are used to slow joint damage during early stages of rheumatoid arthritis.

Corticosteroids are available in different forms. Oral steroids often are combined with DMARDs. Injections of steroids can relieve acute flare-ups of particular joints, but only three to four injections per year are considered safe. Injections also are used for rheumatoid arthritis in children in place of oral medications. Finally, intravenous steroids may be applied as an alternative to DMARDs.

Long-term use of corticosteroids can cause severe side effects and make withdrawal difficult. Side effects may include high blood pressure, infections, cataracts, glaucoma, diabetes, psychosis, and osteoporosis. Additional side effects that may cause concern include weight gain and fluid retention, irregular menstruation, acne, excess hair, bruising easily, irritability, and insomnia.

Steroid withdrawal is risky and steroids should only be discontinued under a doctor's supervision.

Medications that slow the progression of rheumatoid arthritis are called disease modifying antirheumatic drugs (DMARDs). These drugs are used to prevent damage to joints and limit development of rheumatoid arthritis. DMARDs have a delayed effect and may be used in combination with drugs that address immediate pain and inflammation such as NSAIDs or corticosteroids.

Early, aggressive treatment with DMARDs has sometimes been effective in slowing the progress of rheumatoid arthritis, and also might prevent damage to the heart and other tissue. Over time (usually two years), the effectiveness of these drugs decreases while the risk of serious side effects increases.

DMARDs are a broad category that includes a wide range of different drugs that also have been used for other conditions. Different kinds of DMARDs include tumor necrosis factor (TNF) blockers, other biologic response modifiers, and immunosuppressants.

Examples of the most commonly used DMARDs include methotrexate (Rheumatrex, Trexall), hydroxychloroquine (Plaquenil), leflunomide (Arava), sulfasalazine (Azulfidine, Azulfidine EN-Tabs) and minocycline (Dynacin, Minocin).

Biologic response modifiers are DMARDs that have been engineered to modify the body's inflammatory response. They work by targeting specific proteins that contribute to inflammation during rheumatoid arthritis.

Other types of arthritis where biologic therapy is used are psoriatic arthritis, ankylosing spondylitis, and lupus. Unfortunately, there are no effective biologics for osteoarthritis.

Surgery may be considered when damage to joints has become intolerable.

The most common kinds of surgery used to repair deformity or disability in arthritis are joint replacement, tendon reconstruction, and synovectomy. Other surgical procedures that may be considered include arthroscopic removal of damaged tissue, arthrodesis, osteotomy, and tenosynovectomy.

Transcutaneous electrical nerve stimulation (TENS) or high frequency electrical stimulation may be pain relieving. These are often referred to as electroanalgesia.

There are many different techniques for relaxation. One of the most popular is progressive relaxation, in which a person relaxes areas of tension in the body.

Breathing exercises and other forms of stress reduction can be useful.

The role of diet in managing arthritis remains controversial. However, there some people who acknowledge that certain foods aggravate their arthritis.

Foods also may help arthritis sufferers. Fish oils have long been part of arthritis treatment. More than 100 years ago, British doctors gave their patients cod liver oil to alleviate rheumatism. Today, researchers have validated that certain fish oils help relieve rheumatoid arthritis pain. Seafoods rich in Omega-3 fatty acids, the type of oil shown to be beneficial, include salmon, tuna, sardine, herring, anchovies and mackerel. Omega-3-enriched eggs, pasta and other products also are coming on the market.

Vegetarian diets, in addition to reducing the risk of heart disease and other maladies, also appear to play a positive role in relieving arthritis pain, according to several studies. One report found that 90 percent of the patients studied had better grip strength and less pain and swelling, morning stiffness and tenderness after one month on vegetarian diets.

Good information from the Arthritis Foundation

Used alone or in combination with other forms of treatment, complementary approaches to arthritis pain relief include:

• Acupuncture - Originating in China, this age-old practice involves inserting long, extremely slender needles into specific points along the body to relieve pain and discomfort.
• Biofeedback - This involves a learning process whereby certain visual or auditory (sound-based) feedback allows you to train yourself to initiate responses that help control or normalize your psychological response to pain.
• Chiropractic - According to the International Chiropractic Association, the primary focus of chiropractic is the detection, reduction and correction of spinal misalignments and nervous system dysfunction. Doctors of chiropractic attempt to get to the root cause of a health problem, rather than just treat the symptoms. Chiropractic seeks to maximize the natural strengths of the body and its capacity to heal itself without the use of drugs or surgery.
• Hypnosis - This involves entering an altered state of consciousness whereby suggestions inserted while in that state can lead to changes in behavior or, in the case of pain, altered physical sensations. Self-hypnosis involves inducing an altered state of consciousness — and thus controlling pain sensation — by yourself.
• Visual Imagery - The practice of using one’s imagination to create mental pictures can help relieve pain – why it works isn’t understood. Typically, this involves closing your eyes and imaging something like a healing energy washing over your body, or the “wires” to the pain being severed.

Complementary therapies used to supplement medications, alone or in combination with other forms of therapy. Complementary techniques to manage pain include diet, exercise, biofeedback, massage, chiropractic care, acupuncture, and self-regulation techniques such as self-hypnosis, relaxation training, yoga, reiki (a natural healing process using the hands to tap a universal life energy) and Jin Shin Jyutsu (a process to balance the body’s energies to bring optimal health and well-being).

The quality of research supporting these approaches varies from therapy to therapy. In some cases, the research is of better quality than that supporting the use of some medications and many surgical procedures. In other cases, the research is not as strong. As with any treatment approach, use of complementary therapies should be discussed with your doctor.

Homeopathic Medicine - Homeopathy is an alternative, non-toxic approach used to treat illness and relieve discomfort in a wide range of health conditions. Founded in Germany in the late-1860s, the practice of homeopathy is based on using the “law of similars” to stimulate a healing response — a principle that goes back to the days of Hippocrates. The law of similars states that a substance that will cause disease symptoms in a normal person can, when given in homeopathic dilutions to an ill individual, prompt the same set of symptoms to initiate a healing response. Homeopathic preparations, called remedies, must be prepared in a certain way, and the dilution used will depend on the symptoms being treated. Make sure you consult with your physician before taking traditional and homeopathic remedies at the same time. Mixing medications can result in harmful medical interactions.

A recent study found that hydrotherapy is particularly beneficial for arthritis sufferers. One hundred thirty-nine patients with chronic rheumatoid arthritis were randomly assigned to receive hydrotherapy, seated immersion, land exercise, or progressive relaxation.

Patients attended 30-minute sessions twice weekly for 4 weeks. Physical and psychological measures were completed before and after intervention, and again at a 3-month follow-up.

The results showed that all patients improved physically and emotionally, as assessed by the Arthritis Impact Measurement Scales 2 questionnaire. The patients' belief that their pain was controlled by chance happenings decreased, signifying not just improvement in their condition but also in their belief to be able to manage their symptoms.

However the data revealed conclusively that the hydrotherapy patients showed significantly greater improvement in joint tenderness and in knee range of movement (women only) than the other patients. And at the follow-up measurement, the hydrotherapy patients maintained the improvement in emotional and psychological state.

The report concluded that although all patients experienced some benefit, "hydrotherapy produced the greatest improvements", and the researchers stated that there is clear evidence of the benefits of hydrotherapy for arthritis sufferers to support the continued use of this therapy as an effective adjunct treatment.

Bee venom is a very old treatment for pain and there are many people today who swear by the analgesic benefits of bee venom. Bee venom therapy is usually provided by a beekeeper or by someone who knows how to manage bees. During the treatment, a bee is removed from a jar or hive with tweezers, held over a specific area of the body, which the bee is provoked to sting. The number, sites, and frequency of the stings depend on the patient and the medical condition. A chronic problem like arthritis can involve 2-3 sessions per week, several stings at a time, for 1-3 months.

Research Study: Moving away from the hive and into the laboratory, cell lines from rats, mice and men were used to investigate the action of bee venom at the molecular level. It was found that melittin, the principal peptide in bee venom, actually blocks the expression of inflammatory genes that can cause the painful tissue swelling in rheumatoid arthritis.

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