Managing the Pain of Arthritis and Chronic Joint Symptoms (CJS)

INTRODUCTION

People with arthritis live with chronic pain. It changes their lives. Some people experience drastic limitations in performing daily life activities. Their joints lock up and they are no longer able to perform the simplest tasks—writing, opening a jar, cutting food, holding a book, climbing a flight of stairs—without pain. Sometimes the pain is so extreme it forces them to quit their jobs and give up the things that make their lives enjoyable. People with arthritis mourn the loss of a “normal” life, and depression is a common side effect. They tire of trying to explain their disease to people who don’t understand.

Arthritis and Chronic Joint Symptoms (CJS) affect nearly 1 in 3 adult Americans, according to the United States Center for Disease Control (CDC).⁴¹ The word “arthritis” literally means joint inflammation. Arthritis is a disease of the joints characterized by pain, swelling, redness, heat and, sometimes, structural changes. Some forms of arthritis, such as rheumatoid arthritis and lupus, can affect multiple organs and cause widespread symptoms. The common thread among the 100 plus conditions falling under the umbrella of arthritis is that they all affect the musculoskeletal system and they all require pain management.

Arthritis is one of the most prevalent chronic health problems and the nation’s leading cause of disability among Americans over the age of 15.⁴² It is second only to heart disease as a cause of work disability.⁴³

Arthritis comprises over 100 different diseases and disorders that can affect every system of the body. It includes all of the following and more:

• Carpal tunnel syndrome
• Lyme disease
• Lupus
• Osteoporosis
• Reflex sympathetic dystrophy
• Scleroderma

In the general population, osteoarthritis, rheumatoid arthritis and fibromyalgia are three of the most common types of arthritis.

According to the National Institute on Aging (NIA) arthritis affects half of all people 65 years of age and over.⁴⁴ That translates to 18 million elderly arthritis sufferers. According to most estimates, based on the projected growth of the over-65 population, that number will increase to about 41 million by 2030 (see figure 3).⁴⁵ All of these people will need informed pain management to deal successfully with their disease.

Figure 3: Projections of US Population Age 65 and Older with Arthritis or CJS Through 2030

In the elderly—those people age 65 and over—osteoarthritis, rheumatoid arthritis and gout are the three most common types of arthritis.

Arthritis is not just an old person’s disease. In its various forms it can start as early as infancy. Three hundred thousand children suffer from juvenile arthritis.⁴⁶ Almost eight and one-half million young adults between the ages of 18-44 have arthritis and millions of others are at risk for developing it. ⁴⁷ It affects people of all racial and ethnic groups, and is more common in women than men.

Figure 4 is a chart published by the Center for Disease Control (CDC) that shows the prevalence of Arthritis or Chronic Joint Symptoms (CJS) among U.S. Adults by Age Group for the year ending 2001, the last full year for which statistics are available.

The effects of arthritis on a person’s life can be devastating. It threatens one’s physical, emotional, psychological, social and economic well being. Physically, one must deal with the sensation of pain, which in some cases can be agonizing.

Feelings of despondency and hopelessness about ever being out of pain again can lead to depression. Inability to perform routine daily activities and a new dependency on others crushes self-esteem. Increasingly immobile, arthritis sufferers often descend into social isolation. Jobs and income may be lost when occupational tasks can no longer be performed.

While there are some issues that are shared by everyone with arthritis, its impact on an active, growing young person raises special concerns. Arthritis affects school, social life, family relationships, dating, sports, and almost every other aspect of a child’s life. Children, teens and young adults must learn new coping skills for living with the pain and other everyday challenges of arthritis.

The economic impact of arthritis is equally devastating. Estimates are that the cost to the US economy from arthritis is nearly $125 billion annually according to a 2003 study that was funded by the Arthritis Foundation and the National Institute of Arthritis and Musculoskeletal and Skin Diseases.48 The exact figures were:⁴⁸

• $42.6 billion in direct costs (payments),
• $82.2 billion in indirect costs (lost productivity).

BARRIERS TO EFFECTIVE TREATMENT

The barriers to effective arthritis pain management include those common to all chronic pain conditions: knowledge deficiencies, fears of legal sanction and patient addiction when prescribing opioids, inadequate pain assessment, poor clinician-patient communication, gender, age and racial/ethnic biases, patient unwillingness to comply with the treatment program, patient under reporting of pain, etc.

The high prevalence of comorbidities found in patients with arthritis (especially the elderly) also complicates care. Children with arthritis are particularly at risk for misdiagnosis and under treatment given the all too common assumption that their symptoms are caused by “growing pains.” Additionally, the very nature of arthritis pain sets up a vicious cycle that opposes treatment. People with arthritis find it painful to move. Their avoidance of activity, while understandable, ultimately leads to weakened muscles and deconditioning. As muscles weaken, moving becomes more painful, and patients are less able to move without severe pain.

A visit to any of the arthritis chat rooms on the Internet reveals a common theme: many people continue to experience pain despite medical treatments. The sheer volume of personal testimonies exchanged about what works and what doesn’t begs an important question: Why is this information not being disseminated by their health care providers? It is imperative that clinicians become informed of the many effective treatments available for arthritis and take the initiative to provide their patients with this education.

Included as Appendix K is the National Guideline Clearinghouse™ (NGC™)⁴⁹ summary of the major points of the American Pain Society’s “Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis.”⁵⁰ The Guideline can be obtained from the “Publications” section of the American Pain Society’s Website. URL information is provided in Appendix P.

Four of the most common types of arthritis, which we will explore in further detail, are:

1. Osteoarthritis
2. Rheumatoid arthritis
3. Fibromyalgia
4. Gout

Osteoarthritis - Osteoarthritis is a degenerative disease affecting synovial joints, particularly hands and large weight bearing joints (knees, hips, feet, ankles and the back). It is characterized by the breakdown of a joint’s cartilage, which causes bones to rub against each other. The result is pain and loss of movement. Osteoarthritis has little or no inflammatory components until the advanced stage.

Osteoarthritis (OA) affects approximately 21 million Americans.⁵¹ It is the most common type of arthritis and a leading cause of disability in the US.⁵² As people age, there is a normal deterioration of cartilage. This is commonly seen in people age 55 and older, and is considered normal wear and tear. The incidence of osteoarthritis in men and women changes with age. It occurs more often in men under the age of 45; after that, the scale tips, with women claiming the highest percentage of osteoarthritis cases.⁵³ Since the gradual deterioration of cartilage is a natural part of aging, most people beyond a certain age will contract the disease. Most persons over the age of 75 are affected with osteoarthritis in at least one joint.⁵⁴

Osteoarthritis can occur in younger patients either through a genetic mechanism or, more commonly, because of previous joint trauma, such as a sports-related injury. This could explain why males suffer from osteoarthritis more than women before 45 years of age.

What causes osteoarthritis is not known. Factors that appear to increase the risk of developing osteoarthritis include:

• Heredity
• Obesity
• Injury to a joint
• Repeated overuse of certain joints
• Muscle weakness
• Aging

Blood tests are not used as a diagnostic tool for osteoarthritis. Usually the white blood cell, hematocrit, and erythrocyte sedimentation rate are within normal limits in the patient with osteoarthritis. Physicians make a diagnosis based on a physical exam and history of symptoms including the pain that almost always accompanies osteoarthritis. X-rays can be used to confirm a diagnosis.

MANAGING THE PAIN OF OSTEOARTHRITIS

Osteoarthritis is a degenerative, chronic, lifelong illness that will ultimately affect most elderly people. Estimates are that as many as 80% of those over age 75 have evidence of the disease in at least one joint. When one considers that from 1990 until 2000 the population of Americans age 75-84 years grew by over 20%⁵⁵ and the most moderate projections expect that high rate of growth to continue, this is a problem that will confront the clinician with increasing frequency.

There are a number of medications available to treat the pain of osteoarthritis, but as the age of the patient progresses, devising a pain medication treatment plan can prove difficult due to metabolic changes and comorbidities. When people age, changes occur in the metabolism that affect the efficacy and safety of many medications. Very few research studies include the elderly, so there aren’t always clear guidelines for optimal dosage. In addition, the majority of elderly patients have multiple comorbidities and often take multiple medications. Therefore, in addition to medication, it is strongly recommended that any treatment plan for osteoarthritis include exercise. The American Geriatrics Society (AGS) published “Exercise Prescription for Older Adults With Osteoarthritis Pain: Consensus Practice Recommendations”⁵⁶ as a guide for incorporating exercise into the treatment plan. Appendix L is the NGC™ summary of the major points of the publication. The complete guideline can be obtained from the AGS Website, www.americangeriatrics.org.

Among the suggestions offered are:

• Flexibility (Range-of-Motion) Exercises
• Strength Training
• Aerobic Training

The guideline is careful to point out the following contraindications:

• Absolute contraindications include:
  • uncontrolled arrhythmias
  • third degree heart block
  • recent electrocardiographic changes
  • unstable angina
  • acute myocardial infarction
  • acute congestive heart failure
• Relative contraindications include:
  • cardiomyopathy
  • valvular heart disease
  • poorly controlled blood pressure
  • uncontrolled metabolic disease

The guideline also includes the qualifying statement: “Exercise programs should be individualized to address the specific needs of the patient.”

Rheumatoid Arthritis - Rheumatoid arthritis (RA) affects the entire body, not just the joints. It can lead to deformity of the joints and ultimate disability. RA is characterized by inflammation in the lining of joints and/or internal organs. Over prolonged periods of time, RA can cause damage to bone, cartilage, tendons and/or ligaments of joints, leading to pain and loss of movement. Damage to the lungs, heart, nerves and eyes can also occur, making it difficult for a person to lead an active, normal life.

The cause of RA is unknown. It is known, however, that RA is an autoimmune disease. The immune system attacks healthy joint tissue causing inflammation and subsequent joint damage. RA affects approximately 2 million Americans. Women are three times more likely to have RA than men.⁵⁷ The first signs of RA tend to present in individuals from 25 to 50 years of age, but appear more frequently in older people. RA also affects children and young adults. Juvenile Rheumatoid Arthritis (JRA) is the most common form of arthritis in young people. Risk factors for rheumatoid arthritis include:⁵⁸

• Being female
• Genetic predisposition
• Aging (incidence of new cases increases up to age 70, then declines)
• Smoking cigarettes over a long period of time

There are several symptoms that help differentiate RA from osteoarthritis:⁵⁹

1. RA tends to affect joints in a symmetrical fashion (e.g., both knees instead of one).
2. The stiffness seen in active RA is typically worst first thing in the morning, and can last from one to two hours to the entire day. Patients with osteoarthritis generally do not experience prolonged morning stiffness.
3. With RA, inflammation generally occurs in the knuckles and at the joints closest to the hands, nearer the base of the fingers.

In addition to pain, inflammation of joints, swelling, soreness, stiffness, difficulty moving, and pain, other symptoms of RA include:

• Loss of appetite
• Fever
• Loss of energy
• Anemia

Pain and swelling usually occurring in the same joints on both sides of the body (commonly experienced in the hands or feet) and lumps under the skin (rheumatoid nodules) in areas subject to pressure (e.g., elbows) are other features of RA. The degree of joint inflammation and frequency of pain “flares” varies from person to person. Some people may be affected only mildly, experiencing only occasional flares of worsening joint inflammation. For others, the disease is continuously active and progressively worsens over time. Slightly less than one-half of affected individuals have complete remission, and approximately one in ten individuals is severely disabled.⁶⁰

Final diagnosis of RA is based on the overall symptoms, the patient’s medical history, physical exam, x-rays, and lab tests that include a test for rheumatoid factor, an antibody found in the blood of about 80% of adults with RA.

MANAGING THE PAIN OF RHEUMATOID ARTHRITIS

Currently there is no cure for RA. There are drugs that are used to slow the progression of the disease, such as disease-modifying anti-rheumatic drugs (DMARDs); and biologic therapies (or simply biologics). There are several treatment guidelines available that will provide valuable up-to-date information, such as those published by the American College of Rheumatology⁶¹ which were recently updated and can be accessed through the Website, www.rheumatology.org/research.

Because there is no cure, pain management is extremely important in RA. As with osteoarthritis, the pain is managed primarily through two avenues:

1. Medication
2. Lifestyle modification

Medication – pain medications include nonsteroidal anti-inflammatory drugs (NSAIDs) like aspirin, ibuprofen and naproxen. Several newer drugs are also available, although as of this writing the popular prescription drug Rofecoxib has been removed from the market. Pain medications won’t slow the progress of the disease, but they will help RA patients live a more normal life. NSAIDs generally are used throughout the course of the disease and over time have been known to cause stomach problems, such as bleeding and ulcers, in some individuals.

Lifestyle modification - a healthy lifestyle is critical in living with RA. The basic elements of a healthy lifestyle are:

• EXERCISE - Exercise provides many benefits. It maintains muscles, flexibility, and mobility in joints. It helps prevent weight gain—or promotes weight loss—which is very important because extra weight adds stress to joints. Exercise can also help people sleep and maintain a positive out-look.
• STRESS REDUCTION - Stress reduction can help some people cope with pain and fatigue. There are many stress reduction techniques, such as biofeedback, breathing exercises and visualization exercises that have proven beneficial. Recently meditation has been gaining popularity as a stress reduction tool. The Arthritis Foundation has prepared “12 Ways to Zap Stress Now”⁶² that can prove very helpful to patients. A copy is included as Appendix M.
• A HEALTHY DIET - A healthy diet is key to feeling as well as possible and maintaining as normal a lifestyle as possible. That can be tough with RA because certain foods might interfere with the efficacy of medications. It can also be tough because there can be disabilities present that make it difficult to prepare food. The Arthritis Foundation’s “Guidelines for a Healthy Diet”⁶³ (see figure 5) recommend a simple, common sense approach to nutrition.

Patients can also be referred to a nutritionist who specializes in arthritis, or an arthritis counselor, for personalized advice.

Figure 5: Guidlines for a Healthy Diet

Fibromyalgia - Fibromyalgia (FM) is a chronic pain syndrome involving profound pain. It includes widespread aches, stiffness, soft tissue tenderness, general fatigue and sleep disturbances. Any body part can be affected. The most common sites are the hands, neck, back, shoulders and pelvic girdle. Additional symptoms may include irritable bowel and bladder, headaches and migraines, restless leg syndrome, impaired memory and concentration, skin sensitivities and rashes, dry eyes and mouth, anxiety, depression, ringing in the ears, dizziness, vision problems, Raynaud’s Syndrome, neurological symptoms and impaired coordination.

People with FM report that the severity of the pain and stiffness is often worse in the morning. The range and intensities of FM symptoms varies with each individual. Most people with FM experience pain intensities that wax or wane over time. Unlike osteoarthritis and rheumatoid arthritis, FM causes no damage to tissues.⁶⁴

FM affects approximately 2% of the US population. It affects women, men, the elderly and children of all ages and races, but is seven times more common in women than men, and occurs most frequently in women of childbearing age.⁶⁵

The core cause or causes are not known, but it is commonly believed to be a “…disorder of central processing with neuroendocrine/neurotransmitter dysregulation.”⁶⁶ Most researchers agree that the FM patient experiences higher levels of sensitivity to pain due to abnormal sensory processing in the central nervous system.⁶⁷ Studies now point to the possibility of abnormally high levels of substance P (a chemical that tells the body how much pain it feels) in the spinal cord, as well as lower than normal levels of chemicals that help control pain, mood, sleep and the immune system.⁶⁸

Other factors thought to trigger fibromyalgia include:

• Stress
• Anxiety
• Depression
• An accident or operation
• Over-exertion
• Weather changes
• Hormonal fluctuations

Because FM shares many of the same symptoms as chronic fatigue syndrome and other disorders, it is often misdiagnosed. According to the National Foundation for Fibromyalgia, as many as 12 million Americans suffer from FM but have not been diagnosed because of its elusive nature. Children with FM are often told they have growing pains. The National Fibromyalgia Association estimates that it takes an average of five years for an FM sufferer to be accurately diagnosed.

There are no laboratory tests for fibromyalgia. It is diagnosed using medical history, self-reported symptoms—including pain—and physical exam. Diagnostic criteria include:

• Generalized musculoskeletal pain in at least three anatomical sites for at least three months
• Reproducible tenderness in at least six specific points throughout the body
• Presence of other common FM symptoms
• Exclusion of other disorders that can cause similar problems (e.g., hypothyroidism and hyperparathyroidism)

MANAGING THE PAIN OF FIBROMYALGIA

Managing the pain of fibromyalgia can be more complicated than managing the pain of other forms of arthritis because FM often is accompanied by comorbidities.

Figure 6: Comorbid Conditions Associated with Fibromyalgia⁶⁹

There are a number of medications that are used to treat fibromyalgia. Among them are the traditional medications used to reduce pain, like the NSAIDs; however, there are other medications developed for other illnesses that have also proven to have some benefit for patients with FM. These include some of the antidepressants. As with all other forms of arthritis, careful exercise is very beneficial.

On their Website, www.arthritis.org, the Arthritis Foundation offers some other approaches to treatment that have had some degree of success in treating patients with FM.⁷⁰

Gout - According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), gout is one of the most painful rheumatic diseases.⁷¹ It is also one of the most common and represents 5% of all arthritis sufferers, afflicting more than 1 million Americans, primarily men over 40. Gout does affect women, too, and a women’s chance of developing gout increases after menopause.⁷²

A metabolic disorder in which uric acid builds up in the blood and crystals form in joints and other places, gout is a type of arthritis called “crystal arthritis,” because very small crystals form in the joint space. The body reacts to these crystals by trying to remove them and the result is a painful inflammation.

Gout is classified as either primary (the most common type) or secondary, depending on the cause of the high levels of uric acid in the blood (hyperuricemia). Many people develop hyperuricemia, but not all people with the condition develop gout. Why is not known, but it is known that between 70% and 95% of hyperuricemia cases are the result of under-excretion of uric acid, rather than uric acid over-production.

More than 99% of primary gout cases are idiopathic and the cause of the hyperuricemia cannot be determined. The remaining 1% of primary gout cases are traceable to either of two rare inherited enzyme defects that affect purine synthesis in the cells.

Gout is characterized by sudden, severe attacks, usually in the big toe. (See figure 7.) Feet, ankles and knees are commonly affected, but gout can also be experienced in the elbow, hand and other joints. Unlike most other types of arthritis, which develop slowly, an attack of gout happens suddenly, often overnight, and is intensely painful.

Figure 7: Signs and Symptoms of Gout

Gout has been known for centuries, and was once called the “Rich Man’s Disease,” because it so often afflicted those men wealthy enough to afford good food like red meat and shell fish, and wine and other alcoholic beverages—and could afford to eat a lot of it!

We know that certain foods do indeed affect gout, as does obesity. According to information on the University of Maryland School of Medicine Website⁷³ some of the risk factors for gout include:

• Age - usually the first occurrence is between 40-50 years of age
• Gender - it is far more common in men than in women
• Heredity - 10%-20% of patients with gout report a family history of gout
• Obesity - research shows a clear link between body weight and uric acid levels
• Alcohol use - this is especially prevalent in younger males
• Hypertension and diuretics - estimates are that anywhere from 25%-50% of gout sufferers have hypertension, and the use of diuretics is highly associated with gout

Figure 8: Points to Remember

MANAGING THE PAIN OF GOUT

For literally hundreds of years the standard treatment for gout was colchicine⁷⁴ which prevents or relieves attacks by reducing inflammation. Colchicine, which will not relieve most other kinds of pain, is still used and is most effective if started within 48 hours of the onset of an attack. When taken by mouth it can cause side effects like diarrhea, nausea, and abdominal cramps. NSAIDs have also become a popular treatment of choice. High doses of aspirin and aspirin-containing products should be avoided during acute attacks, but low dose aspirin can be continued.

Diet and Gout
As with any form of arthritis, a healthy diet is advised. In addition to following the “Guidelines for a Healthy Diet” (see figure 5.) NIAMS also suggests that people with gout may need to completely avoid these foods which are high in purines that are known to raise uric acid levels:

• Kidney
• Broths, gravies
• Sardines, anchovies
• Liver
• Sweetbreads

Gout can be very successfully controlled through diet, lifestyle modification and medication. Unlike other forms of arthritis, a patient can have one gout attack and never have another one—or not have another one for years. There are several things a patient can do to help prevent future attacks such as maintain a healthy weight, stay away from alcohol, avoid foods that are high in purines and drink a lot water which facilitates flushing uric acid from the body.

NIAMS lists four stages of gout:

1. Asymptomatic (without symptoms) hyperuricemia - elevated levels of uric acid in the blood but no other symptoms.
2. Acute gout or acute gouty arthritis - hyperuricemia has caused the deposit of uric acid crystals in joint spaces and leads to a sudden onset of intense pain and swelling in the joints. An acute attack commonly occurs at night and can be triggered by stressful events, alcohol or drugs, or the presence of another illness.
3. Interval or intercritical gout - the period between acute attacks
4. Chronic tophaceous gout - the most disabling stage, it usually develops over a long period, such as 10 years. The disease has caused permanent damage to the affected joints and sometimes to the kidneys.

Of all the forms of arthritis, gout is the one that a patient can learn to live with most easily. With proper treatment, and education, most people with gout will not progress to this most advanced stage.

EDUCATING THE ARTHRITIS PATIENT

Patient education is of paramount importance in developing an effective arthritis treatment strategy. A patient diagnosed with arthritis will have many questions and concerns:

• What type of arthritis is it?
• Did I inherit it?
• Is there a cure? Will it go away? Will it get worse?
• What are the symptoms?
• How is it diagnosed?
• What is causing the pain?
• How do you treat it?
• Are there any side effects to the medication(s)?
• What can I do to help control the pain other than medication?
• Are natural herbs and supplements helpful?
• What can I do to stop the disease from progressing?

Education is knowledge, and with knowledge, many unfounded fears can be dismissed, allowing for more positive actions. Education encourages arthritis patients to participate in defining appropriate therapies for achieving maximum pain relief and functional restoration. Clinicians should present all of the options and their benefits, share what they know about what has worked for other patients, and explore the combination of modalities that are most comfortable for the patient based on their likes, dislikes and beliefs about pain. When a patient is well informed and involved in the process, he or she can take more responsibility for successfully managing the treatment program.

Whenever possible, patients should be given information that they can take home, read, and if appropriate, share with family members, friends and work colleagues. Most of the professional rheumatology organizations offer comprehensive patient education tools that can be printed or ordered from the Internet. Patients should be directed to self-help courses and support groups, as well as sources for information about alternative therapies (acupuncture, chiropractic, biofeedback, meditation, diet, nutrition, etc). There are several organizations in Appendix P that can provide assistance in locating these resources.

Good communication, like education, can avert misunderstandings and potential problems. Patients in pain want to know that health care providers care about their pain, and are doing everything they can to relieve it. Definition and implementation of a systematic methodology for discussing pain and its effect on a person’s life assures patients that pain, and not just the disease, is indeed a priority.

The Arthritis Foundation offers a patient education brochure entitled, “Managing Your Pain.” This brochure is available at no charge on the Arthritis Foundation Website, http://www.arthritis.org/conditions/pain_center/managepain.asp.

SUMMARY

Arthritis, with its many forms, varying symptoms and prevalence of pain, poses a singularly complex treatment challenge for clinicians. With the aging population, it will increasingly burden individuals and the economy. Responsible pain management programs will require clinicians to educate themselves on reliable diagnostic methods, pain assessment tools and recommended treatments. They will need to study and demystify the intricate interplay between the physical treatment of pain and the emotional and cognitive demands of a patient whose life may seem irreparably altered. Utilization of a multidisciplinary/multimodal approach as well as patient education and communication cannot be over emphasized as new and higher standards for pain care are being set.

Occupational therapy, including the use of adaptive devices and instruction in lifestyle modification, has been used successfully with arthritis patients to improve functional performance. There are many assistive devices that can make daily chores at work and/or home easier. Such devices include everything from jar openers, button fasteners, extension devices, grippers, energy absorbing shoes, raised toilet seats, orthotics inserts, etc. There are numerous companies that offer a wide selection of arthritis aids and most of them have online catalogs for easy ordering.

Research in new, more effective treatment and pain management options are always underway. It is critical for the health care professional to remain abreast of these changes. In Appendix P, Resources, you will find URL addresses and contact information for several organizations devoted to arthritis to help you provide the most up-to-date care possible for your patients.

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