Pain management rheumatoid 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 management of the pain from rheumatoid arthritis involves many modalities including:

Physical therapy and Occupational therapy
Assistive devices
Analgesic or anti-inflammatory medication Disease modifying medication
Biologic therapy

Exercise should be interspersed with rest.

Temporary rest for a specific joint can be provided by a splint, brace, or cane. Doctors or physical therapists can recommend the appropriate kind.

Maintaining an ideal weight may help with aches and pains, since additional weight can put strain on joints. Also, fat cells produce leptins, which are proteins that aggravate inflammation.

Physical therapy is very important for helping patients maintain range of motion and to help reduce swelling and pain. Ultrasound, electrical stimulation, and iontopheresis have all been used with some success. 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 (Lineker et al. 2001).

Moist heat applied to aching joints often eases pain. The best options include a hot shower or bath, hot water bottles, electric heating pads, or heat lamps. Be careful. Burns are not uncommon.

Cold can be applied to help reduce inflammation. Wrap an ice bag in a towel, rather than applying ice directly to the skin.

Capsaicin or counterirritant ointments that increase the blood flow in the skin can have soothing effects similar to applying heat.

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

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

Medications that slow rheumatoid arthritis are called disease modifying antirheumatic drugs (DMARDs). They are effective against rheumatoid arthritis, but also may cause many serious side effects because they weaken the body's defenses.

Non-steroidal anti-inflammatory drugs (NSAIDs) are effective in relieving pain in rheumatoid arthritis (Towheed and Hochberg 1997).

When lifestyle and self-help measures, topical ointments, and acetaminophen are not able to control pain, NSAIDs are typically used next. For people who suffer from rheumatoid arthritis pain and do need NSAIDs, it is important to understand the side effects involved and the ways in which the risk of these side effects can be reduced.

NSAID side effects include:

Ulcers and bleeding in the stomach and upper small intestine (duodenum).

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. A review of several studies (Johnson et al 1994) concluded that the typical increase is 5 mmHg.

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 can become troublesome.

NSAIDs can cause impairment of blood flow in the kidneys, especially in older people (Brooks and Day 1993).

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. In another twist, NSAIDS block the anti-platelet-effect of prophylactic 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. 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 (Singh 1998).

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

The use of anti-ilcer therapies along with NSAIDS reduce potential GI side-effects.

Corticosteroids are used often for acute pain and inflammation because they provide quick relief.

Corticosteroids are available in different forms. Oral steroids often are combined with DMARDs and have sometimes been used for people who experience severe side effects from NSAIDs. Injections of steroids can relieve acute flare-ups of particular joints, but only three to four injections per year max. Intravenous steroids may be applied to "prime the pump."

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 are used in combination with NSAIDs or corticosteroids.

Early, aggressive treatment with DMARDs is effective in slowing the progress of rheumatoid arthritis, and also prevents damage to the heart and other tissue.

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.

Biologics, while effective, must be monitored for safety.

Surgery may be considered when damage to joints impedes daily activity.

The most common kinds of surgery used to repair deformity or disability in rheumatoid 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.

Non-medicine approaches are also important. These include: relaxation, breathing exercises, self-talk, stress reduction, and hypnosis.

The role of diet remains controversial. People should pay attention to foods that may aggravate their arthritis.

Some foods also may help arthritis sufferers. Fish oils have long been part of arthritis treatment. 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.

Other complementary therapies useful for pain control are:

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 techniques to manage pain include diet, exercise, biofeedback, massage, chiropractic care, acupuncture, and self-regulation techniques such as self-hypnosis, relaxation training, yoga, and reiki (a natural healing process using the hands to tap a universal life energy).

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