Managing arthritis pain

How can arthritis pain affect you?

Pain can make it difficult to get on with your everyday activities whether at home, at work or in your leisure time. It’s a natural instinct to try and protect whichever part of the body is painful and this can affect your everyday choices. You may try to avoid jobs that tend to increase your pain or you may turn down opportunities to do things you’d normally enjoy.

Pain isn’t just a physical sensation – it has emotional effects too. If you’ve had pain for months or years, it’s not surprising that it can begin to affect your mood and self-confidence. Living with long-term pain is very different from coping with a short spell of pain, especially if the cause of the pain is unclear and standard treatments aren’t helping.

Other problems linked to long-term pain may include:

• sleep problems
• reduced physical activity
• difficulty with everyday activities
• reduced involvement in family and social activities
• difficulty concentrating or remembering things
• symptoms such as fatigue or weight gain
• side-effects from medications
• missing work, difficulties at work, or having to retire early
• changes in your relationships or sex life.

If your healthcare team haven’t been able to identify the cause of your pain then you may also feel frustrated and let down. You may feel that other people don’t understand how much pain you’re in and you may even begin to ask yourself whether the pain is ‘real’.

What is pain?

Pain is usually a protective mechanism that alerts your brain when your body is being harmed in some way. The nerves in that area send signals through the spinal cord to the brain. The brain locates the injury and triggers a healing process.

Pain signals may be triggered by:

• physical injury or damage to your body – for example, a sprained ankle or damage that occurs as part of a longer-term condition such as osteoarthritis
• chemicals produced within the body itself that can irritate the nerve endings – this may be linked to an infection, an overuse injury or a flare-up of a long-term illness such as rheumatoid arthritis
• damage to nerves that causes them to fire off pain signals to the brain without any physical cause, which sometimes happens in complex regional pain syndrome.

When we have an injury or tissue damage caused by an illness, the nerves in the affected part of the body become more sensitive than normal, so pain signals are triggered more easily and warn us if there’s any further threat to the painful area. Normally, as the injury heals, the nerves become less sensitive again and the pain signals lessen and then stop.

When pain interferes with our daily activities, pain-killing drugs may help by blocking or reducing pain signals to the brain even though they don’t affect the injury or damage directly.

Pain isn’t just a physical sensation – it can have emotional effects too, especially if the cause of the pain isn’t clear or it’s difficult to find effective pain relief. And our emotions or mood can in turn make the pain seem worse or better.

What is long-term pain?

Doctors define long-term pain, or chronic pain, as pain that’s lasted for more than 12 weeks or that’s lasted for longer than would be expected for the type of injury or level of damage.

Sometimes it’s possible to find a specific cause of long-term pain – for example:

• an underlying condition such as arthritis
• nerve damage or disease.

However, with long-term pain, the sensation of pain isn’t always directly related to the injury or damage that caused the pain in the first place. Sometimes messages between the nerves and the brain can become disturbed so that the nerves remain unusually sensitive and continue to fire off pain signals even after a physical problem has cleared up.

Because our bodies are ‘programmed’ to understand pain as a warning sign, our natural reaction is often to protect the affected area from further harm – perhaps by resting it completely, by using it less than usual or by supporting it.

After a time, lack of use leads to weakening of the muscles. As we become less fit, we tire more easily and become more prone to strains and sprains, resulting in further pain. This can easily become a vicious circle.

Treatment for arthritis pain

Drugs used for arthritis pain relief

Most of the medicines used to treat pain from arthritis, joint or muscle pain fall into one of the following categories:

• painkillers
• non-steroidal anti-inflammatory drugs
• steroids.

However, other types of drugs may also be used in particular situations. All of the drug treatments below are designed to control symptoms – they won’t help to heal the damage or cure the underlying condition.

Finding the right pain medications is about striking a balance between the benefits and the possible side-effects. These will vary from person to person and will also depend on how long they’re used for. Stronger painkillers will also tend to have a greater risk of side-effects.

Depending on your own situation it may be advisable to limit the use of stronger pain medicines to times when the pain is particularly severe and to try some other pain management techniques as well to see what works for you. It’s also a good idea to review your medication from time to time to make sure you’re still happy with the balance.

Painkillers

Types of painkillers (analgesics) include:

• simple analgesics like paracetamol
• more complex analgesics, which are chemically related to morphine (sometimes combined with paracetamol, for example co-codamol, co-dydramol)
• tramadol, oxycodone, slow-release morphine, or patches containing fentanyl or buprenorphine.

Non-steroidal anti-inflammatory drugs (NSAIDs)

Types of NSAIDs include:

• aspirin or ibuprofen tablets, which you can buy over the counter at chemists and supermarkets without a prescription
• diclofenac, naproxen or indometacin tablets, which are available with a doctor's prescription
• gels or creams which can be applied to the painful joint (for example, ibuprofen, diclofenac)
• a newer type of NSAID commonly called 'coxibs' (for example celecoxib), which are designed to control pain and inflammation but with a lower risk of digestive problems than with the older NSAIDs.

Steroids

Steroids can be given as:

• tablets (usually prednisolone), which are often prescribed because nothing else works, as in polymyalgia rheumatica (PMR)
• injections either into the joint itself or into soft tissues around the joint.

Steroid injections aren’t generally used in the treatment of long-term pain because of potential side-effects. However, occasionally a steroid injection may be offered to help deal with a flare-up of a long-term condition such as osteoarthritis.

Other drugs used to treat long-term pain

Alongside painkillers, there are other drugs that can be used to help manage pain, some of which were originally used for other problems. The ones most often used are:

• antidepressant drugs such as amitriptyline – which is prescribed at a lower dose when it’s used for pain relief than it is when used for depression. These can help with pain by helping the brain to control sensations coming from other parts of the body. They can also help if pain is affecting your sleep.
• anticonvulsants or anti-epilepsy drugs (for example, gabapentin, pregabalin). These can be particularly helpful for pain caused by nerve damage.

Nerve blocks and other injection techniques

Injections to block pain are becoming more widely available. They usually combine a local anaesthetic with a steroid and act directly on a nerve. They're not suitable for all types of pain, but they're sometimes helpful for:

• osteoarthritis of the small joints between the bones of the spine
• compression of nerves in the lower spine.

Special scans such as magnetic resonance imaging (MRI) or computerised tomography (CT) are often needed so the specialist can decide the exact site for the injection.

Physical treatments

Manual therapies

Physiotherapists, osteopaths and chiropractors may use a variety of different manual techniques, including:

• manipulation and stretching
• technologies such as ultrasound, laser or interferential treatment
• exercise programmes to strengthen muscles and improve general fitness.

It's important to go to a qualified practitioner, preferably with the guidance of your doctor.

In some conditions, for example back pain, the Alexander technique may also help. The Alexander technique teaches awareness of posture and relaxation to reduce muscle tension.

Transcutaneous electrical nerve stimulation (TENS)

TENS is a technique that uses small pulses of electricity to produce a tingling sensation. It aims to disrupt pain signals by reducing the sensitivity of the nerve endings in the spinal cord. Some people find it very effective, especially when the pain is due to nerve damage.

It's best to get advice from a physiotherapist on where to position the pads, the frequency and strength of the pulses and the length of treatment.

Acupuncture

Acupuncture is used by doctors and other practitioners, often with very good effect. Very fine needles are inserted into specific points in the body. It's thought to work by diverting or changing painful sensations sent to the brain and by stimulating the body's own pain-relieving hormones (endorphins and encephalins).

Hydrotherapy

Many people with long-term pain find exercise in warm water is a comforting and effective way of moving the joints fully and stretching and strengthening the muscles. The warmth of the water soothes pain and because the water supports your weight it reduces the stresses on your joints.

A lack of hospital therapy pools means that access may be limited. However, many facilities offer out-of-hours access on a paid basis – contact your local hospital for details.

Local swimming pools tend to be cooler than aquatic therapy pools, but exercise classes such as aqua-aerobics provide a safe and fun way of exercising. Alternatively, local hotels with spa or aquatic therapy facilities may provide swimming or aqua classes.

Splints

An occupational therapist (OT) may also suggest wearing a splint. The term ‘splint’ covers a variety of devices, which are mostly for the hands but can be for other parts of the body such as the neck or foot. They can be ready-made from soft, flexible material such as neoprene, or tailor-made by the OT from a type of plastic to specifically fit your joints.

Splints may be suggested for various reasons, such as to rest the joint and reduce pain or to correctly position the joints to prevent deformity and improve function. The OT will recommend when you should wear the splint and how long for. Overuse of splints can lead to muscle loss due to lack of use. You should also take it off regularly to allow your skin to breathe.

Psychological therapies

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapies (CBT) is a term used for a wide range of psychological approaches designed either:

• to manage the symptoms of health problems, or
• to change behaviour to improve your ability to function on a day-to-day basis.

All forms of CBT are based on the idea that our thoughts, beliefs, feelings, behaviour and the situations we’re in are all inter-connected. Our thoughts and beliefs can influence our behaviour; our behaviour can influence our feelings; and the situation we’re in can affect our behaviour. CBT includes assessing and understanding these connections and then finding ways to modify them to tackle the problem.

CBT isn’t right for everybody but it is a well-established approach that’s effective for improving people’s mood, health and ability to get on with their daily lives. It isn’t simply about talking or seeking advice, but about learning new skills that should help you to handle challenges in your life more effectively. For example, if fear of pain is causing you to avoid physical activity, then these methods can help in facing those fears.

Psychologists in particular often teach coping skills. These can include:

• relaxation techniques
• goal-setting and pacing
• ways of working on thoughts and beliefs and especially discouraging moods.

Mindfulness

Mindfulness (or mindfulness meditation) is another approach that’s becoming popular to treat health problems. It aims to help focus your attention on present-moment experiences rather than on the thoughts you may hold about those experiences. It can help us to think through our choices rather than acting on impulse when we’re feeling distressed. It’s difficult to understand mindfulness fully just from a description though – it’s better to try it to see if it works for you. There are many psychologists and other professionals who provide training in mindfulness.

If you’d like to do a very simple mindfulness-type exercise, try the following:

1. Whatever you’re doing, stop for a few minutes.
2. Look around and notice five things you can see.
3. Listen carefully and notice five things you can hear.
4. Focus on sensations on the surface of your body and notice five things you can feel.

You might find you feel more focused and your mind seems less busy after doing this exercise. (This exercise is based on one described by a doctor and therapist called Russ Harris. Russ and other professionals, including Tobias Lundgren, JoAnne Dahl and Steve Hayes, have written a number or books and workbooks you might find useful.)