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Mechanisms, impact and management of pain in rheumatoid arthritis

Key Points

  • Pain in rheumatoid arthritis (RA) results from interplay between joint pathology and processing of pain signals by peripheral nerves, spinal and supraspinal pain pathways

  • Despite good control of inflammation, pain often remains problematic in RA

  • Animal models and modern imaging techniques have illuminated the complex mechanisms that underlie RA pain

  • Fatigue, stiffness and psychological distress are integral components of the RA pain experience

  • Multimodal management of RA pain includes pharmacological, psychological and exercise-based interventions

Abstract

People with rheumatoid arthritis (RA) identify pain as their most important symptom, one that often persists despite optimal control of inflammatory disease. RA pain arises from multiple mechanisms, involving inflammation, peripheral and central pain processing and, with disease progression, structural change within the joint. Consequently, RA pain has a wide range of characteristics—constant or intermittent, localized or widespread—and is often associated with psychological distress and fatigue. Dominant pain mechanisms in an individual are identified by critical evaluation of clinical symptoms and signs, and by laboratory and imaging tests. Understanding these mechanisms is essential for effective management, although evidence from preclinical models should be interpreted with caution. A range of pharmacological analgesic and immunomodulatory agents, psychological interventions and surgery may help manage RA pain. Pain contributes importantly to the clinical assessment of inflammatory disease activity, and noninflammatory components of RA pain should be considered when gauging eligibility for or response to biologic agents. Further randomized controlled trials are required to determine the optimal usage of analgesics in RA, and novel agents with greater efficacy and lower propensity for adverse events are urgently needed. Meanwhile, targeted use of existing treatments could reduce pain in people with RA.

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Figure 1: Pain mechanisms through the natural history of RA.

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Both authors researched the data for the article, provided substantial contributions to discussions of content, wrote the article and undertook review and/or editing of the manuscript before submission.

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D.A.W. is the holder of an Inflammation Competitive Research Programme (I-CRP) grant from Pfizer UK, and has previously acted as a consultant for Pfizer. D.F.M. is supported by the I-CRP grant.

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Walsh, D., McWilliams, D. Mechanisms, impact and management of pain in rheumatoid arthritis. Nat Rev Rheumatol 10, 581–592 (2014). https://doi.org/10.1038/nrrheum.2014.64

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