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.
|
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 |
