Rheumatologists need to increase their awareness of new pain management techniques and strategies, which not only focus on improved function and rehabilitation but also on the underlying mechanisms at the molecular level, according to a detailed review in the December issue of Arthritis & Rheumatism.¹

"There have been huge advances in pain research at the molecular level, but we are still lagging behind in translating these advances into practice," Mary-Ann Fitzcharles, MB, ChB, a rheumatologist and pain specialist in the department of rheumatology at McGill University in Montreal, Quebec, Canada, tells CIAOMed. "As clinicians, we are only just beginning to be aware of this and address our patients' pain," she says.

Dr. Fitzcharles and colleagues point out that rheumatologists are increasingly required to address pain as a specific symptom, and therefore need to become more familiar and comfortable with newly developed strategies for pain management to ensure optimal treatment. Going forward, "rheumatologists and pain specialists are going to be much more tightly linked than we are today, and really use each other's strengths to manage our patients even better," Dr. Fitzcharles says. Better management means not only palliative care, but also improved function and rehabilitation.

Pharmacologic and nonpharmacologic interventions needed

"Pain management is no longer simply a quick fix with a single pill, but rather an approach to the patient as a whole biopsychosocial being," the investigators write. According to studies cited in the review, regular physical activity not only maintains muscle tone and helps to improve function, but also induces the production of endogenous opioids.

A reduction in pain was also observed among rheumatoid arthritis patients who received an omega-3-enriched diet for 12 months, and topical applications have shown clinical promise for the care of rheumatic conditions. In one recent study, topical diclofenac was as effective as oral diclofenac in relieving knee joint pain.

"Physicians [are increasingly going to be] looking at other modalities to treat pain," Dr. Fitzcharles tells CIAOMed. "For inflammatory pain, we will be using medication, but it is quite amazing to see the impact that nonpharmacological treatments can have."

Link between neurotransmission, inflammation, and rheumatic pain

Dr. Fitzcharles and colleagues note that while pain mechanisms are constantly in a state of change, neurotransmitters and inflammatory molecules make rheumatic pain feel chronic.

Rheumatic pain is transmitted by the central nervous system and receptors in the joint tissue and cartilage. Because rheumatic pain travels through small, slow-conducting fibers, it is perceived as a pervasive aching rather than as acute, localized stabs. Inflammation also plays a role in activating pain pathways that usually lie dormant, the investigators write. And molecular evidence suggests that stress and depression may increase production of inflammatory agents in rheumatic patients.

Clinical judgment key in evaluation of pain

Evaluating pain in the rheumatic patient is key, Dr. Fitzcharles says. In addition to using the visual analogue scale of pain severity and patient questionnaires, the rheumatologist must take cues from the patient during the interview and examination, heeding spontaneous movement, musculoskeletal structure, and verbal complaints, as well as consider the patient's psychosocial  history and coping strategies, she points out.
"All of these patient-related factors, combined with the personal clinical experience as well as the biases of the treating physician, will be used to formulate an assessment of pain," the study authors conclude.

Reference

1. Fitzcharles MA, Almahrezi A, Shir Y. Pain: understanding the challenges for the rheumatologist. Arthritis Rheum. 2005;52:3685-3692.