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Publication Date: February 2001
Questions and Answers about Arthritis
Pain
What Is Arthritis?
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. 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.
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.
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 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.
- 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 that will give you the most benefit.*
* The National Institute of Arthritis and Musculoskeletal and Skin
Diseases Information Clearinghouse has a separate booklet on arthritis and exercise.
- 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.
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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 patient satisfaction.
The list of 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.
Where Can You Find More Information on Arthritis
Pain?
National Institute of Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
Phone: 301-495-4484 or 877-22-NIAMS (226-4267) (free of charge)
TTY: 301-565-2966
Fax: 301-718-6366
http://www.niams.nih.gov/
The clearinghouse provides information about various forms
of arthritis and rheumatic disease and bone, muscle, and skin diseases.
It distributes patient and professional education materials and refers
people to other sources of information. Additional information and updates
can also be found on the NIAMS Web site.
American Academy of Orthopaedic Surgeons
P.O. Box 2058
Des Plaines, IL 60017
Phone: 800-824-BONE (2663) (free of charge)
www.aaos.org
The academy provides education and practice management services for orthopaedic surgeons and allied health professionals. It also serves as an advocate for improved patient care and informs the public about the science of orthopaedics. The orthopaedist's scope of practice includes disorders of the body's bones, joints, ligaments, muscles, and tendons. For a single copy of an AAOS brochure, send a self-addressed stamped envelope to the address above or visit the AAOS Web site.
American College of Rheumatology
1800 Century Place, Suite 250
Atlanta, GA 30345
Phone: 404-633-3777
Fax: 404-633-1870
www.rheumatology.org
This association provides referrals to doctors and health
professionals who work on arthritis, rheumatic diseases, and related
conditions. It also provides educational materials and guidelines.
American Physical Therapy Association
1111 North Fairfax Street
Alexandria, VA 22314-1488
Phone: 703-684-2782 or 800-999-2782, ext. 3395 (free of charge)
www.apta.org
This association is a national professional organization
representing physical therapists, allied personnel, and students. Its
objectives are to improve research, public understanding, and education
in the physical therapies.
Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
Phone: 404-872-7100 or 800-283-7800 (free of charge)
or call your local chapter (listed in the telephone directory)
www.arthritis.org
This is the major voluntary organization devoted to arthritis.
The foundation publishes a free brochure, Coping With Pain, and
a monthly magazine for members that provides up-to-date information
on all forms of arthritis. The foundation also can provide addresses
and phone numbers for local chapters and physician and clinic referrals.
American Chronic Pain Association
P.O. Box 850
Rocklin, CA 95677
Phone: 916-632-0922
www.theacpa.org
This association provides information on positive ways
to deal with chronic pain and can provide guidelines on selecting a
pain management center.
American Pain Society
4700 West Lake Avenue
Glenview, IL 60025-1485
Phone: 847-375-4715
www.ampainsoc.org
This society provides general information to the public
and maintains a directory of resources, including referrals to pain
centers.
National Chronic Pain Outreach Association, Inc.
7979 Old Georgetown Road, Suite 100
Bethesda, MD 20814-2429
Phone: 301-652-4948
Fax: 301-907-0745
neurosurgery.mgh.harvard.edu/ncpainoa.htm
This association operates an information clearinghouse
offering publications and cassette tapes for people with pain. It also
publishes a newsletter that includes information on pain management
techniques, coping strategies, book reviews, and support groups.
Acknowledgments
The NIAMS gratefully acknowledges the assistance of Susana
Serrate-Sztein, M.D., and Barbara Mittleman, M.D., of the NIAMS; John
H. Klippel, M.D., Medical Director, Arthritis Foundation; Brian M. Berman,
M.D., Director of the Complementary Medicine Program, University of
Maryland, School of Medicine; and Laurence A. Bradley, Ph.D., Professor
of Medicine/Rheumatology, University of Alabama at Birmingham in the
preparation and review of this booklet.
The mission of the National Institute of Arthritis
and Musculoskeletal and Skin Diseases (NIAMS), a part of the National
Institutes of Health (NIH), is to support research into the causes,
treatment, and prevention of arthritis and musculoskeletal and skin
diseases, the training of basic and clinical scientists to carry
out this research, and the dissemination of information on research
progress in these diseases. The National Institute of Arthritis
and Musculoskeletal and Skin Diseases Information Clearinghouse
is a public service sponsored by the NIAMS that provides health
information and information sources. Additional information can
be found on the NIAMS Web site at http://www.niams.nih.gov/.
NIH Publication No. 01-4856