Pain in Rheumatoid Arthritis
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PAIN ASPECTS OF ARTHRITIS (DA WALSH AND S KELLY, SECTION EDITORS)
Pain in Rheumatoid Arthritis David A. Walsh & Daniel F. McWilliams
Published online: 30 October 2012 # Springer Science+Business Media New York 2012
Abstract Rheumatoid arthritis (RA) is an inflammatory disease of synovial joints, and pain is the predominant problem for people with RA. Pain in RA is distressing in its own right and adversely affects disability and psychosocial outcomes. RA pain may be due to joint inflammation and also augmented by central sensitization and structural joint damage. Noninflammatory pain mechanisms may confound the assessment of disease activity in RA, and treatment should aim to both suppress inflammatory disease and relieve pain symptoms. Effective treatment stratification requires a full assessment of pain mechanisms by clinical history and examination, as well as objective assessment of synovitis and joint damage. Biologic therapies and joint replacement surgery have major impacts on RA pain, but may only be available to those with most severe or advanced disease. Holistic approaches to pain management are indicated, including pharmacologic analgesia where randomized controlled trials (RCTs) offer evidence of efficacy. Keywords Rheumatoid . Arthritis . Pain . Central sensitization . Analgesics
Introduction Rheumatoid arthritis (RA) is the commonest inflammatory joint disease and has major impacts on quality of life, productivity, and health care utilization. Patients with RA identify pain as their most troublesome problem [1, 2], and D. A. Walsh (*) : D. F. McWilliams Arthritis Research UK Pain Centre, Academic Rheumatology, University of Nottingham, City Hospital, Nottingham, NG5 1PB, UK e-mail: [email protected] D. F. McWilliams e-mail: [email protected]
pain adversely impacts on disability, psychological distress, and sleep disturbance. Indeed, pain may contribute more to patients’ disability than does the structural joint damage [3–7]. As with other chronic painful conditions, pain in RA is associated with important mood disturbance [8]. Low mood may be a consequence of pain, but may also contribute to its distressing quality and impair facility to cope with pain. Sleep disturbance and fatigue are also major problems for people with RA [9]. Pain disturbs sleep directly in RA and also exacerbates low mood, which itself is associated with poor sleep patterns [10–12]. Pain, therefore, is both a direct problem for people with RA and indirectly contributes to the disease’s psychological and social impact.
Epidemiology of Pain in RA Risk factors for more severe pain in RA have been researched less thoroughly than outcomes such as radiologic damage and inflammatory disease activity. Risk factors for pain may differ from prognostic factors for these more traditional outcomes, particularly in contemporary practice where inflammatory disease activity may be amenable to medical treatment [13•]. High disease activity is certainly associated with RA pain, and radiographic changes may be linked t
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