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.
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 and Vioxx,
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
