Arthritis Pain Management

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What is Arthritis?

Most of us either know someone who has arthritis, or have experienced it ourselves. Impacting nearly 25% of American adults, arthritis is one of the top reasons cited for work disability. It’s also extremely expensive. According to the CDC, arthritis costs around $304 billion a year due to lost wages and healthcare costs (1).  

So what exactly is arthritis? The term arthritis covers many different conditions (over 100 of them), which fall into two categories: osteoarthritis (OA) and inflammatory arthritis (IA). OA is the most common type of arthritis, and occurs when the cartilage between bones wears down, causing bones to become less protected (2). IA, in contrast, occurs when joint inflammation is caused by the immune system, rather than mechanical wearing down of cartilage. Common types of IA include:

• Rheumatoid arthritis - A disease that occurs when the immune system attacks its own tissues, including membranes that are found in the joints.
• Ankylosing spondylitis - Arthritis of the spine that can cause spinal bones to fuse.
• Gout - A condition where extra uric acid (a bodily waste product) turns into hard crystals that accumulate in the joints causing pain (usually in the joint of the big toe).
• Psoriatic arthritis - A disease that causes inflammation of both the joints and skin.

People with arthritis typically experience pain, stiffness, and swelling in their hips, knees, hands, and/or spine, although other parts of the body can also be affected.

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What Causes Arthritis Pain?

First of all, it is important to understand that osteoarthritis is universal. From our early 20’s and until we die, cartilage wear-down occurs in the joints of every human being. However, these structural changes are not predictors of pain. Osteoarthritis is best thought of as “wrinkles on the inside”: normal, non-dangerous changes in the joints that occur over a person’s lifespan, which are not inherently painful. In fact, some people have advanced osteoarthritis, but little-to-no pain; others have mild osteoarthritis, but extreme joint pain.

The same is true for inflammatory arthritis: some people with IA experience little-to-no pain, while others experience extreme pain. Furthermore, though people with IA may experience bouts of increased inflammation, their pain may continue long after the inflammation has subsided.[1]

If structural changes (like cartilage wear-down and inflammation) are not strongly correlated with pain levels, then what causes arthritic pain?

The answer is that all pain that humans experience is biopsychosocial. This means that the pain we experience is related to our biological reality (for example, the wear-down of cartilage in our joints), our psychological reality (for example, our thoughts, mood, fears, and past experiences of pain we’ve had in our lives), and our sociological reality (for example, our socioeconomic status and access to medical care).[2] In other words: our pain is impacted by many factors that are not purely biological.

In light of the biopsychosocial nature of pain, it is helpful to assess whether your arthritis pain is primary, secondary, or a combination of the two. Primary arthritis pain is caused by the nervous system amplifying pain signals and/or interpreting neutral sensations as painful, and can be successfully treated by addressing psychosocial pain drivers. Numerous studies have found evidence that Primary Pain plays a role in both OA and IA[3][4]. Secondary arthritis pain, in contrast, is caused by structural issues (such as inflammation or tissue damage). Since the brain moderates all pain, the sensation of Primary and Secondary pain is similar -- but the drivers are very different. Assessing whether you have primary pain, secondary pain, or a combination of the two is crucial for identifying the most effective treatment for your arthritis pain.

How can you assess the nature of your arthritis pain? Here are some guidelines:

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Primary arthritis pain:

‍Mild and moderate arthritis pain is almost always primary. What factors are indicative of primary arthritis pain?

• You have been diagnosed with osteoarthritis (rather than inflammatory arthritis)
• Pain has persisted for more than six months
• Pain came on during a time of stress
• Pain came on without an injury
• Symptoms are inconsistent (for example: pain sometimes lessens/disappears and sometimes intensifies)
• Symptoms are triggered by things that are not body-related (such as food, weather, stress, or thoughts)
• Symptoms spread or move
• You have a large number of symptoms at the same time
• Symptoms are symmetrical (for example: they affect both wrists or both knees), or symptoms affect an entire arm/leg or whole side of the body
• Pain comes on with a delay AFTER movement and exercise
• Doctors can’t explain symptoms
• You have experienced past or current traumatic experiences

If your arthritis pain is consistent with some or all of these characteristics, it is likely that your pain is Primary, and should be treated as such.

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Secondary arthritis pain:

Severe arthritis pain is more likely to be secondary (though in some cases it is Primary). What factors are indicative of secondary arthritis pain?

• You are diagnosed with inflammatory arthritis (such as rheumatoid arthritis, gout, or Lupus)
• Pain has persisted for less than six months
• Symptoms are consistent (pain is present all the time at a relatively uniform intensity, and manifests in a specific part of the body)
• Symptoms do not spread or move

It is important to note that it is common for people with secondary arthritis pain to have primary arthritis pain as well. This means that even if you have secondary arthritis pain, your pain may be partially or primarily driven by primary pain, and primary pain treatment may dramatically reduce your pain levels.

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Ways to Treat Arthritis Pain?

If you are experiencing what you believe to be arthritis pain, it’s a good idea to consult your doctor to rule out serious joint problems such as tumors, loose bodies/fragments, and serious cartilage lesions/tears. Keep in mind, however, that radiological tests like x-rays and MRIs are poor predictors of pain. These tests should be used to rule out serious concerns such as tumors, not to identify the cause of pain. Remember: structural joint changes that appear in x-rays or MRIs are universal, normal, and not inherently painful (just like wrinkles).

Be aware that false positives and misinterpretation of radiology findings are common in the biomedical model. If a medical professional tells you that your pain is caused by a structural issue identified in a radiological test, it is worth seeking a second opinion. More importantly, seeing a clinician who is trained to look at radiology through a biopsychosocial lens can give you a full, scientifically-grounded understanding of your pain. Such a clinician will help you identify whether your symptoms are driven by primary pain, secondary pain, or a combination of the two.

What are the best treatments for Primary and Secondary arthritis pain?

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Primary Pain:

If you have Primary arthritis pain, you will have the best results by adopting a brain-first approach addressing the psychosocial factors driving pain. Treatments such as Pain Reprocessing Therapy (PRT), Emotional Awareness and Expression Therapy (EAET), and Pain Neuroscience Education have been shown to significantly reduce Primary Pain. These techniques utilize education and exposure to help the nervous system process pain as non-dangerous, ultimately reducing pain levels in measurable and lasting ways.

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Secondary Pain:

For arthritic conditions with a strong secondary component (IA conditions such as gout or Lupus, and OA cases presenting severe degenerative change), pain generally responds best to a combination of medical treatment and Primary Pain treatment. Consult with a medical provider to identify the best medications and/or procedures for addressing structural aspects of your arthritis. IA conditions such as gout or Lupus are generally treated with medications, and severe degenerative joint change can be treated with surgery such as joint replacement. It is important to note that surgery should be considered a last-resort treatment for severe cases of arthritis.

While pursuing appropriate treatment for the structural causes of your arthritis pain, is it recommended that you pursue Primary Pain treatment as well. As previously noted, Primary Pain treatments such as PRT can be extremely effective at reducing arthritis pain even if there is a significant Secondary component to your pain. This is because pain is always partially driven by psychosocial factors, including thoughts, past experiences, and emotions.

Regardless of whether your arthritis pain is Primary or Secondary, certain factors are beneficial across-the-board for reducing arthritis pain. These include:

• Movement: movement is crucial for keeping down pain levels. In fact, inactivity can cause deconditioning (bodily changes that result from low activity levels), which can cause pain levels to increase.
• Stress reduction: stress, anxiety, and fear can amplify pain sensations in the body. Identifying sources of stress and fear, and working to minimize them, help drive down pain levels.

Other pain relief techniques: Various other treatments and techniques may be helpful for reducing arthritis pain in the short term, as long-term treatment of the underlying pain mechanism(s) is underway. These include:

• Injections, such as shots of cortisone or hyaluronate
• Physical therapy to increase activity levels, strength, and range of motion. Make sure your PT helps reduce fear and encourages you to incorporate movement into your life.
• Hot and cold therapy, such as placing heating pads or ice packs on painful areas. Over-the-counter topical creams (like capsaicin, which is made from chili peppers) can also provide temporary relief.
• Acupuncture, an ancient Chinese procedure that involves inserting thin needles into specific areas of the body.
• Massage therapy, for stress relief and temporary pain relief.
• Mindfulness activities like meditation, yoga, tai chi, and certain breathing techniques can lower stress and anxiety, which has been found to decrease inflammation and pain. These alternative pain management methods may also help eliminate depression, which frequently accompanies chronic arthritis pain.

Note that while these treatments can provide short-term relief, they should not be depended upon for long-term pain management. The core treatment for arthritis pain should use a biopsychosocial approach to address the root cause(s) of pain.

A pain management app can be helpful for managing and treating arthritis pain. In many cases, these apps will allow you to easily track and monitor your symptoms, as well as the various aspects of your life that impact your arthritis and overall health (like your diet, sleep, exercise, mood, and medication).

Lin’s integrative pain management app provides you with a pain relief coach, a diagnostic team, a personalized care plan, and treatment for Primary and Secondary pain. If you are ready to tackle your arthritis pain, Lin is ready to help you.