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National Institute of Arthritis and
Musculoskeletal and Skin Diseases
Questions and Answers About
ARTHRITIS PAIN
What Is Arthritis?
The word arthritis literally means joint inflammation, but 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 fact sheet focuses on pain caused by two of the most common forms of
arthritisosteoarthritis
and rheumatoid arthritis.
What Is Pain?
Pain is the bodys 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 persons 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 a lifetime.
How Many Americans Suffer From 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 suffer
from some form of arthritis, and many have chronic pain that limits daily activity.
Osteoarthritis is by far the most common form of arthritis, affecting about
16 million Americans, while rheumatoid arthritis, which affects about 2.1 million
Americans, is the most crippling 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.
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 problems.
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. 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 had
this problem? 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
- 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).
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 an arthritis
patientoften 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 all people 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
- MedicationsBecause 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 coldThe 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 ProtectionUsing 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.
- MassageIn 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 very familiar with the problems of the disease.
- AcupunctureThis procedure should only be done by a licensed acupuncture
therapist. In acupuncture, thin needles are inserted at specific points in
the body. Scientists think that this stimulates the release of natural, pain-relieving
chemicals produced by the brain or the nervous system.
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.
Long-Term Relief
- Medications
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.
Disease-modifying anti-rheumatic drugs (DMARDS )These are drugs used
to treat people with rheumatoid arthritis who have not responded to NSAIDs.
Some of these include 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.
CorticosteroidsThese are hormones that are very effective in treating
arthritis. 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 only be done once or twice a year.
- Weight reductionExcess 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.
- ExerciseSwimming, 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 Arthritis and Musculoskeletal
and Skin Diseases Information Clearinghouse has a separate fact sheet on arthritis
and exercise. See the end of this fact sheet for contact information.)
- SurgeryIn 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. 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. Nonetheless, some alternative or complementary
approaches may help you to cope or reduce some of the stress of living with
a chronic illness. 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.
Another technique is to substitute distraction for pain. Focus your attention
on things that you enjoy. Imagine a peaceful setting and wonderful physical
sensations. Thinking about something that is enjoyable can help you relax and
become less stressed. Find something that will make you laugha cartoon, a funny
movie, or even a new joke. Try to put some joy back into your life. Even a small
change in your mental image may break the pain cycle and provide relief.
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.
You may want to contact some of the organizations listed at the end of this
fact sheet 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.
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.
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What Research Is Being Conducted On
Arthritis Pain?
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.
Recent NIAMS studies show that levels of several neuropeptides
(compounds produced by cells of the nervous system), such as substance P,
are increased in arthritic joints. Substance P is involved in the transmission
of pain signals via the nervous system. At the University of Missouri-Kansas
City, researchers are studying effects of substance P in the spines of animals
with chronic arthritis. Findings from this study may be used to develop specific
drugs for chronic pain such as that associated with arthritis.
NIAMS studies are also looking at other aspects of pain. At
the Specialized Center of Research in Osteoarthritis at Rush-Presbyterian-St
Lukes 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 of 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 patients
pain and disability.
NIAMS-supported research on arthritis pain also includes projects
in the Institutes Multipurpose Arthritis and Musculoskeletal Diseases Centers.
At the University of California in 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 persons ability to deal with rheumatoid arthritis and
enhance their quality of life. At the Indiana University School of Medicine
in Indianapolis, health care professionals are monitoring joint pain in patients
with osteoarthritis and documenting this information. The goal of the project
is to improve doctor-patient communication about pain management and increase
patient satisfaction.
Where Can You Find More Information
on Arthritis Pain?
- Arthritis Foundation
1330 West Peachtree Street
Atlanta, GA 30309
404/872-7100 or call your local chapter, (listed in the telephone directory)
800/283-7800
World Wide Web address: http://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 their local chapters and
physician and clinic referrals.
- American Chronic Pain Association
P.O. Box 850
Rocklin, CA 95677
916/632-0922
The 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
847/375-4715
The Society provides general information to the public and maintains a directory
of resources, including referrals to pain centers.
- National Chronic Pain Outreach Association, Inc.
P.O. Box 274
Millboro, VA 24460
540/997-5004
The Association operates an information clearinghouse offering publications
and cassette tapes for people with pain. They also publish a newsletter that
includes information on pain management techniques, coping strategies, book
reviews, and support groups.
- NAMSIC
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
301/495-4484
Fax: 301/587-4352
TTY: 301/565-2966
World Wide Web address: http://www.nih.gov/niams/
* Brand names included in this fact sheet 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.
Acknowledgments
The NIAMS gratefully acknowledges the assistance of John H. Klippel, M.D.,
Clinical Director, National Institute of Arthritis and Musculoskeletal and Skin
Diseases; 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.
The National Arthritis and Musculoskeletal and Skin Diseases Information Clearinghouse
(NAMSIC) is a public service sponsored by the NIAMS that provides health information
and information sources, including additional information on arthritis. The
NIAMS, a part of the National Institutes of Health (NIH), leads the Federal
medical research effort in arthritis and musculoskeletal and skin diseases.
The NIAMS sponsors research and research training throughout the United States
as well as on the NIH campus in Bethesda, Maryland, and disseminates health
and research information.
BW 1/98
Office of Scientific and Health
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