Rethinking Pain: Care Strategies for Patients with Rheumatic Diseases

Announcer:
You’re listening to Living Rheum on ReachMD. On this episode, we’ll discuss the complexity of pain management in psoriatic arthritis and axial spondyloarthritis with Dr. Philip Mease. He’s a Clinical Professor at the University of Washington School of Medicine and the Director of Rheumatology Research at Swedish Medical Center in Seattle. Let’s hear from Dr. Mease now.

Dr. Mease:
Historically, we have had this idea of pain arising from hitting your finger with a hammer or passing your finger through a flame as being some type of noxious stimulus that’s occurring in the periphery, getting transmitted through the spinal cord to the brain, and being interpreted as pain. We now know that the idea of pain being caused by inflammation or mechanical irritation is too simplistic. So the International Association for the Study of Pain has come up with nomenclature. The classic kind of pain caused by inflammation in a joint or inflammation of the spine is what we call nociceptive pain.

But there are two other kinds of pain which are very important. One of them is called nociplastic pain. This is where there’s nothing that we can see in the periphery that is causing pain, but nonetheless, there is an experience of pain in the central nervous system. And when we have a chronic autoimmune condition like psoriatic arthritis, axial spondyloarthritis, rheumatoid arthritis, or osteoarthritis, there is a certain percentage of individuals who will have ramped-up nociplastic pain going on, which will amplify the experience of pain. A problem that can arise is that if we find that a patient has a lot of pain going on and we feel that they are not being successfully treated with one of their advanced immunomodulatory medicines is that we may think, “Oh, we need to change medicines,” when it may be mainly nociplastic pain that the patient is experiencing, and we need to think about other approaches to treatment.

I should add too that there’s a third kind of pain called neuropathic pain. This is where there’s an actual injury or disease of the nerve itself. An example is diabetic peripheral neuropathy, or when you have spinal stenosis and you get a impingement on one of the nerves coming out of the spine, or carpal tunnel syndrome, where you have impingement on a nerve in the wrist. This is the third kind of pain that can contribute.

When a patient comes in and says, “Doc, I’m painful,” and we identify them as having psoriatic arthritis or rheumatoid arthritis, the first thing to do is to address the inflammatory process that’s causing injury to the joints and generating nociceptive pain. We’ll select any one of a number of immunomodulatory medicines ranging from methotrexate to biologics to manage that part of the patient’s illness.

But then we want to identify if there is another form of pain, like nociplastic pain. If a patient comes back in and their inflammatory markers in the blood are normal, their examination shows resolution of swelling of joints, and an MRI scan of the spine shows no light-up, then we think, “Oh, we may have vanquished or helped improve inflammation here,” but the patient still is painful. And then if they also say, “Well, I’m very fatigued, my sleep is very poor,” then we start to get a clue that nociplastic pain may be present. Unfortunately, we don’t have a diagnostic blood test or even sophisticated fMRI imaging that we can do, so we have to have a clinical instinct that it’s going on and address it with treatments that are appropriate for nociplastic pain. All of these are things that can, in a multidisciplinary and multimodal fashion, address this form of pain.

Announcer:
That was Dr. Philip Mease talking about pain management in psoriatic arthritis and axial spondyloarthritis. To access this and other episodes in our series, visit ReachMD.com slash Living Rheum, where you can Be Part of the Knowledge. Thanks for listening!