Pain and rheumatology: an overview of the problem

One of the most common reasons to visit a doctor is musculoskeletal pain. And one of the first symptoms of a rheumatological disorder is pain – so it’s great to find this succinct overview of pain in rheumatological disorders. I think one of the saddest findings I’ve read recently (I blogged about it a while ago) is that people who see a rheumatologist may have their disease process managed – but their pain problem may remain untouched. There is a misconception that pain is simply ‘a response to inflammation’ or ‘joint derangement’ – but it’s never really that simple!

This paper by Montecucco, Cavagna, & Caporali identifies five groups of pain disorder in rhematological diseases: acute pain, like gout, related to local tissue damage with nociceptive activation; chronic pain, which may be triggered by tissue damage or disease, but is often perpetuated by other factors such as central nervous system involvement – the three remaining groups of pain disorder are all subsumed under this chronic pain heading; inflammatory pain, such as rheumatoid and some osteoarthritis, involves increases in pain especially over night, with reduction after activity, and often with morning stiffness; mechanical pain, which is often a feature of osteoarthritis where the joint mechanics are altered – this pain is often worse during the day and relieved somewhat with rest, and although there may be some stiffness in the morning it usually lasts about 10 minutes or so; and the final type of pain is neuropathic pain, not often thought to be a feature of rheumatological problems, but involves disease or trauma to the somatosensory system – it could be peripheral, or it could be in the CNS and it may also be in response to heightened sensitisation secondary to the initial disease.

The authors briefly discuss fibromylagia – I posted about this recently also, discussing a paper that suggests perhaps FM doesn’t belong with rheumatologists at all, because it’s becoming apparent that it is a disorder of the central nervous system involved increased sensitivity to nociceptive input, probably associated with reduced functioning of the descending inhibitory pathways. Their suggestion is that it is ‘not clearly classifiable as inflammatory or mechanical’, but they’re not prepared to include it in the neuropathic group because the pain experience is slightly different.
Neuropathic pain is thought to be more commonly perceived as burning, tingling, hyperalgesia especially to hot or cold, and often involving allodynia.

The paper goes on to review the epidemiology of rheumatic pain. I don’t think there would be many who would argue that chronic pain associated with these problems is common and this paper indicates there is research to suggest it is an increasing burden even in developing countries such as Vietnam, Peru and China. Despite this increasing prevalence, the underlying disorders vary from country to country.

The burden of pain is also discussed – rheumatic diseases are probably the most prevalent cause of functional limitation that does not reduce life expectancy. While pain doesn’t kill, people live a long time with poor function, lowered quality of life, and use a wide range of support services including health care in this time.

I was struck by the estimates of the economic cost of pain in these disorders – 1 – 2.5% of GNP in USA, UK, France and Australia. OA is thought to cost the USA more than $60 billion per year.

The final quite brief section in this paper draws attention to the different ways in which people express their pain – I couldn’t agree more. Psychosocial factors are integral to the pain experience, so it makes sense to include psychosocial management along with disease management. Would that this happened where I work – sadly, though, the rheumatology clinics don’t routinely have pain management using any approach let alone a cognitive behavioural one! And this despite many studies showing the effectiveness multi and interdisciplinary pain management using a cognitive behavioural approach on the lives of people with these painful conditions.

This paper is a very brief summary of pain in rhematological disorders, but as an overview it does what it oughta. I like the many references, and they’re all quite recent, so if you’re wanting to get your head around pain in these problems, it is a worthwhile paper to get hold of.

Montecucco, C., Cavagna, L., & Caporali, R. (2009). Pain and rheumatology: An overview of the problem European Journal of Pain Supplements DOI: 10.1016/j.eujps.2009.07.006