Pain

Pain affecting not only the joints but the body as a whole is one of the most common and debilitating symptoms of RA. Acute and chronic pain can affect your ability to engage in social activities, including family events, hobbies, interactions with friends, and work.¹

Dealing with pain can be exhausting and contribute to fatigue, a common complaint among people with RA. Pain also contributes significantly to the stress of having a chronic disease like RA and may be an important factor in development of depression, a condition common in individuals with RA.²

For a person with RA, chronic pain can be part of a vicious cycle of symptoms. Pain reinforces and exacerbates other symptoms, such as fatigue and sleep difficulties, which, in turn, reinforce and exacerbate pain. This vicious cycle makes effective management and relief of any single symptom that much more difficult to accomplish.

There are effective treatments for pain

The good news for patients with RA is that there are many effective strategies for dealing with pain related to the disease, both joint pain and pain affecting the body in general. These include, but are not limited to, pain medications (both prescription and over-the-counter); mind-body techniques, including biofeedback, meditation, and yoga; other non-drug interventions, including water therapy, massage, and application of heat and cold; and non-invasive therapies, such as transcutaneous electrical nerve stimulation (TENS).

Causes and types of pain in RA

There are several factors that contribute to pain in RA. These include³:

• Increased disease activity during flares or exacerbations
• Inflammation and damage affecting joints
• Extra-articular conditions associated with RA (eg,. conditions affecting the heart, lungs, eyes)
• Infections
• Muscular tension or injury due to joint instability
• Fatigue and anemia
• Drug related causes of pain (eg. side effects, reduction in steroid therapy)
• Psychosocial factors (eg. fear, anxiety, depression, changes in social circumstances)

When talking about pain associated with RA, it is useful to understand the difference between acute pain and chronic pain. Acute pain and chronic pain are often defined in terms of the duration of pain. Acute pain is the pain that you feel when you’ve been injured, such as when you’ve touched a hot stove, pricked yourself with a pin, or strained a muscle. Acute pain is temporary, which means that once the cause of pain has been addressed, the pain should resolve. Chronic pain is very different. It is pain that is not associated with a specific injury or pain-causing event. It is pain that persists for a long period of time, with nerves sending repeated pain signals, without a clearly defined cause that can be addressed.³

Patients with RA may experience both acute and chronic pain. In RA, acute pain may result from increased disease activity during a flare, inflammation and associated swelling in joints, and damage to joints and related structures resulting in bones grinding against one another and misalignment of joints. Acute injuries resulting from joint instability may also cause acute pain. Chronic pain may result from extra-articular manifestations of RA, including inflammation affecting various organ systems, such as the heart, lungs, and eyes, systemic infections, fatigue or anemia, or emotional problems, such as stress, anxiety, and depression. All of these can contribute and lead to a worsening of chronic pain in individuals with RA.³

The first step in pain management is a thorough assessment

If you are experiencing pain, your doctor will perform a thorough assessment to determine the cause or causes and then put together an individualized plan designed to address the cause(s) and provide relief. He or she will ask you about how you perceive your pain, for example, what the intensity and quality of the pain is. Your doctor will also ask about both the emotional and cognitive components of your pain, for example, what role anxiety, stress, or depression may play, and what your thoughts are about your pain, for example, whether it is associated with fears or hopelessness.³

Your doctor will also make an objective assessment of your pain, including³:

• Onset, duration, and sites involved
• Intensity and nature of your pain (for example, whether it is dull or stabbing)
• Whether it improves with rest or worsens with activity
• To what extent swelling contributes to your pain
• Whether heat or redness in joints is associated with your pain
• Whether your pain is present or absent during the night

In the process of evaluation, your doctor may use a questionnaire or structured interview designed specifically to evaluate pain associated with arthritis. Your doctor may also ask you to start keeping a pain diary to capture important information about what you are experiencing during your daily life.³

What are the treatment options for RA-related pain?

There are a variety of management approaches for dealing with chronic and acute pain associated with RA.

Drug treatments for acute pain. Acute pain due to joint inflammation or damage often responds well to medications. The most common medications used to treat pain associated with RA are analgesics, including non-steroidal anti-inflammatory drugs (NSAIDs) (aspirin, acetaminophen [Tylenol], ibuprofen [Motrin or Advil], and naproxen [Aleve]) and the synthetic analgesic tramadol (Ultram). Additionally, topical pain relievers like the ointment capsaicin, derived from chili peppers, may be useful in controlling pain.^3,4

In cases where acute pain is more difficult to resolve, combination analgesics (an NSAID plus a narcotic analgesic) or a narcotic analgesic (codeine, oxycodone) may be used. However, use of narcotic pain medications in RA is generally discouraged because of the risk for dependence and addiction, especially considering the long-term nature of RA.^3,4

Other RA medications that control RA-related inflammation, including disease-modifying anti-rheumatic drugs (DMARDs) and newer biologic agents, and glucocorticoids (corticosteroids), are also useful in addressing pain and should play a role in a patient’s overall management strategy for RA.^3,4

Drug treatments for chronic pain. Although drug treatment may play a role in management of chronic pain associated with RA, because of the ongoing nature of chronic pain, a more holistic approach, involving many different types of interventions, is usually recommended.

Non-drug treatments and interventions for RA-related pain

Your overall strategy for managing RA-related pain, both acute and chronic, should include a number of different non-drug treatment approaches. Your management team, including your doctor, nurses, physical and occupation therapists, and psychologist/social worker will play a role in guiding your choice of different treatment modalities.

These modalities or techniques may include mind-body techniques, such as biofeedback, meditation, and yoga; water therapy, massage, and application of heat and cold; and non-invasive interventions, such as transcutaneous electrical nerve stimulation (TENS).

Many of these approaches are based on the idea that the body itself can produce substances that block nerve cells from sending pain messages. These substances are called endorphins and enkephalins. For example, research has shown that massage, meditation, and deep breathing can help the body increase the production of endorphins and get rid of other natural substances, like lactic acid, that increase sensitivity to pain.

Non-invasive mind-body interventions that may be useful in controlling pain (and certainly won’t cause any harm) include:

• Psychotherapy
• Self-hypnosis
• Deep breathing
• Progressive relaxation
• Guided imagery
• Biofeedback

Use of heat and cold and water-based therapies may also be useful in relieving pain related to RA.

Heat therapy. Heat therapy is based on the idea that warmth makes blood vessels dilate, increases blood flow to an area of the body, and encourages muscles to relax. You can use hot packs, a heating pad or electric blanket, an infrared heat lamp, or hot paraffin for heat therapy. Additionally, ultrasound is also used to concentrate heat in tissues. Your physical therapist or doctor may be equipped to provide you with ultrasound or other forms of heat therapy. If you use heat, remember to limit applications to no more than 30 minutes at a time in any one area and to allow that area to return to normal temperature before reapplying heat.

Cold therapy. Cold therapy may also be useful in blocking nerve pain signaling as well as reducing inflammation. Application of cold to a painful area may be done using a cold pack or bag of frozen peas. If you use cold, make sure that you limit treatment to no more than 20 minutes in one area and do not continue after an area has become numb. If you have Raynaud’s syndrome or problems with circulation, do not use cold therapy.

Water therapy. In addition to heat and cold, water therapy, including baths, showers, whirlpools, and pool exercising, can be useful in treating pain.

Exercise. Exercise should be an important part of your overall RA pain management strategy. Talk to your doctor and/or physical or occupational therapist to get ideas about what kind of exercise program is best for you.

Splints and supports. Splints and supports made out of metal or molded plastic are often effective in immobilizing a joint that is injured or inflamed. Work with your doctor and/or physical or occupational therapist to select the splint or support that will best serve your purposes.

Transcutaneous electrical nerve stimulation (TENS). TENS provides a very mild electrical current designed to override nerve pain impulses and provide pain relief. This technique may be useful in addressing both acute and chronic pain. Discuss the use of TENS with your doctor or physical or occupational therapist.