agents are preferred in this patient pop-

ulation.3 Opiate analgesics can be safely

used in treating patients with severe
arthritic pain resistant to nonopioid med-
ications.
In this article, we review treatment
Treatment of Patients
modalities for arthritic pain.
With Arthritis-Related Pain Arthritic pain can arise from inflam-
mation of one or more joints. The causes
Nicholas A. DeAngelo, DO of arthritis are listed in Figure 1. Arthritic
Vitaly Gordin, MD
pain occurs from afferent stimulation of
nociceptors within or around the joint.
Mechanical receptors are distributed in
the interstitial and perivascular tissue
located below the synovial membrane
within the joint capsule.4

Clinical Evaluation
Evaluation of arthritic pain includes a
Many causes of arthritic pain are encountered in clinical practice. Osteoarthritis comprehensive history, physical exami-
is the most common form of arthritis in the United States, afflicting tens of millions nation, laboratory testing, and diagnostic
of people. The authors review current literature on the treatment of patients with x-ray films. Patients have pain as the pre-
osteoarthritis. They discuss nonpharmacologic therapy such as physical therapy, dominant symptom for seeking medical
weight reduction, and osteopathic manipulative treatment. Pharmacologic attention.5 Patients can have pain at one
treatment of patients with osteoarthritis includes acetaminophen, nonsteroidal or multiple joints. It is a nociceptive pain
anti-inflammatory drugs, tramadol hydrochloride, and opiate analgesics in that is characterized by an intermittent
patients who failed all other treatment modalities. Patients who failed medical pain that is worse with mechanical move-
management should be referred for consideration for surgery. ment of the joint. The pain is usually
described as a dull ache or throbbing
pain associated with stiffness and
restricted ROM. Patients may express

P hysicians encounter many causes of

arthritic pain in clinical practice.
Osteoarthritis is the most common form
of arthritis in the United States, afflicting
tens of millions of people and predom-
inantly seen in the elderly.1 Although
no cure exists for osteoarthritis, treat-
ment can decrease pain, improve range
of motion (ROM) in the affected joints,
and lead to increased activities of daily
Dr DeAngelo is a pain management fellow and
Dr Gordin is director of the Pain Medicine Division,
Department of Anesthesiology, Milton S. Hershey
Medical Center, Hershey, Pa.
Dr DeAngelo has no conflicts of interests to dis-
close. Dr Gordin is on the speakers bureau for
Pfizer Inc.
Correspondence to Vitaly Gordin, MD, Director
of the Pain Medicine Division, Milton S. Hershey
Medical Center, 500 Univesity Dr, Hershey, PA
17033-0850.
E-mail: vgordin@psu.edu
This continuing medical education
publication supported by an unrestricted
educational grant from Merck & Co
living (ADL). All treatment for arthritis
should begin with a comprehensive
evaluation of the patient that should
include pain assessment and evaluation
of function. Management of patients
should start with nonpharmacologic
modalities, followed by pharmacologic
therapy. If these first two modalities are
ineffective, the patient should be referred
for a surgical evaluation.
Adequate pain control is essential
as it allows nonpharmacologic modalities
to be effective. The American Pain Society
(APS) has recommended the use of acet-
aminophen for mild to moderate arthritic
pain.2 Nonsteroidal anti-inflammatory
drugs (NSAIDs) are the preferred drugs
for moderate to severe pain. Both the
APS and American Geriatrics Society
Panel on Persistent Pain in Older Per-
sons,3 recommended caution when using
traditional NSAIDs in treating patients
who require long-term daily analgesic
therapy. The cyclooxygense-2 (COX-2)
selective (or nonacetylated salicylates)
signs and symptoms of depression or
anxiety secondary to the chronic debili-
tating state of arthritis.
Physical examination may reveal
reproducible tenderness along the joint
line and surrounding tissues. Decreased
ROM can occur as the result of pain or
pathologic changes. Signs of inflamma-
tion of the synovium, called synovitis,
characterized by warmth, swelling, effu-
sions, and stress pain, may be present.
Instability or deformity of the joint is a
late sign that suggests anatomic and
physiologic changes of the joint periar-
ticular structures. A patient who has a
long-term history of arthritis may have
additional muscle wasting and weak-
ness. Last, functional analysis should be
done by having the patient ambulate and
imitate ADL.
Clinical examination documentation
should include physical function, ROM
of the affected joint(s), gait assesment,
assistive devices needed (eg, cane,
walker, or wheelchair), abilities to accom-

S2 JAOA Supplement 8 Vol 104 No 11 November 2004 DeAngelo and Gordin Treatment of Patients With Arthritis-Related Pain

Downloaded From: http://jaoa.org/ on 03/15/2017

 plish ADL, and social and psychosocial
factors that have an impact on the
patients perception of pain.
Treatment Modalities
Nonpharmacologic Treatment
The goals of treatment are (1) control of
pain and (2) improvement of function
and quality of life with minimal toxic
effects from therapy.6 Modes of therapy
include nonpharmacologic, pharmaco-
logic, and surgical. The nonpharmaco-
logic modes of therapy include patient
education, self-management programs,
weight loss, aerobic exercise programs,
physical therapy, occupational therapy,
and the use of assistive devices for ADL
(Figure 2). It has been reported that indi-
viduals who participate in self-manage-
ment programs notice decrease in joint
pain and frequency of arthritis-related
physician visits, increases in physical
activity, and overall improvement in
quality of life.7
Patients with arthritic pain tend to be
deconditioned; therefore, physicians
should emphasize exercise through
patient education and referral for phys-
ical therapy. An exercise program under
the supervision of a physical therapist
combines warm-up using heat, ROM
exercises, followed by muscle-strength-
ening techniques. In addition, patients
also require aerobic conditioning. Swim-
ming is the best therapy for patients with
arthritic pain. It has been reported that
8 weeks of simple aerobic training
increases physical ability and improves
functional status.8
The psychological rewards of exer-
cise such as appearance and self-image
are additionally beneficial as depression
and mood alterations tend to develop in
patients with chronic pain. Similarly,
occupational therapists can assess
patients and recommend proper assis-
tive devices and use of splints to improve
joint function.6 Studies using occupa-
tional therapy and NSAIDs improved
disability in 49% of treated patients.9
Although no formal control studies of
occupational therapeutic interventions
have been done, clinical practice has
demonstrated their effectiveness.
Osteopathic manipulative treatment
(OMT) consisting of thrust, muscle
energy, counterstrain, articulation, and
DeAngelo and Gordin Treatment of Patients With Arthritis-Related Pain
Downloaded From: http://jaoa.org/ on 03/15/2017
Checklist Checklist
 Osteoarthritis  Education
 Rheumatoid arthritis  Occupational assessment
 Ankylosing spondylitis aides
 Reiters syndrome appliances
 Psoriatic arthritis joint protection
 Gout  Physical therapy
 Pseudogout aquatherapy
 Infectious arthritis aerobic exercises
heat
Figure 1. Causes of arthritic pain. strengthening
ultrasound stimulation
transcutaneous electrical
nerve stimulation (TENS)
myofascial release can improve arthritic
 Weight loss
pain, promote healing, and increase
 Acetaminophen
mobility. Although not many studies (increase up to 4 g/d)
have beenn done using OMT alone,
 Nonsteroidal anti-
studies have been done that demonstrate inflammatory drugs
OMT combined with standard medical  Cyclooxygenase-2
care was more efficacious than standard selective inhibitors
care alone in treating patients with (celecoxib and valdecoxib)
chronic pain syndromes.10  Topical creams
nonsteroidal
Pharmacologic Treatment anti-inflammatory cream

Natural CompoundsGlucosamine capsaicin cream
chondroitin is an amino sugar produced  Glucosamine chondroitin
from shellfish. It is a key component of  Tramadol hydrochloride
cartilage. It works to stimulate the syn-  Opioid therapy
thesis of glycosaminoglycan, proteo-  Interarticular injections
glycan, and hyaluronic acid.8 Although corticosteroids
the precise mechanism of action is hyaluronic acid replacement
unknown, glucosamine has been shown  Radiofrequency neuroablation
by clinical experience to help decrease for facet joint arthropathy only
arthritic symptoms. Glucosamine short-  Surgical intervention
term clinical trials have demonstrated
effective symptomatic relief in patients Figure 2. Modes of therapy for arthritis-
with arthritic knee pain due to related pain.
osteoarthritis.8

Anti-inflammatory DrugsPrimary
pharmacologic management of arthritic life of warfarin sodium.12,13 It can cause
pain includes the use of analgesics and hepatic toxicity and should be used cau-
anti-inflammatory drugs. Acetamino- tiously in patients with known chronic
phen is a drug with purely analgesic alcohol abuse or liver disease.14-16
properties that allows patients to avoid For patients with severe pain,
NSAIDs, thereby resulting in fewer side NSAIDs are statistically superior to acet-
effects and potential cost savings. The aminophen.17 Risk factors with NSAIDs
dose of acetaminophen can be up to are bleeding perforation, edema, hyper-
4000 mg/d, and acetaminophen should tension and/or congestive heart failure.
be combined with nonpharmacologic COX-2 specific inhibitors might offer a
therapeutic modalities.11 Although acet- lower instance of risk factors than non-
aminophen is a safe analgesic, it can be specific NSAIDs.6 One recent exception
associated with clinically important is rofecoxib (Vioxx), which was recently
adverse events such as prolonging half- withdrawn from the market because of
JAOA Supplement 8 Vol 104 No 11 November 2004 S3
 increased risk of cardiovascular compli-
cation. Overall caution still must be exer-
cised in patients with hypertension, con-
gestive heart failure, renal insufficiency,
and gastric ulcer disease. The American
College of Gastroenterology (ACR)
endorsed the use of nonselective NSAIDs
with gastroprotective agents in patients
at high risk, as described in 1995 ACR
recommendations as an alternative to
the use of COX-2 specific inhibitors.18

Topical AnalgesicsTopical anal-
gesics (eg, methylsalicylate or capsaicin
cream) are adjunctive modes of therapy
for patients who cannot take systemic
anti-inflammatory therapy. Quantitative
systemic review of topically applied
NSAIDs have shown these agents to be
effective in patients with osteoarthritis.19
Capsaicin cream is available over the
counter in single-strength (0.025%) or
triple-strength (0.075%) ointment that
can be applied to the symptomatic joint
four times daily.
Tramadol hydrochloride is a cen-
tral-acting oral analgesic that has a
unique dual mechanism of action. It is a
very weak
-agonist that also inhibits
the reuptake of norepinephrine and sero-
tonin. It has been approved for the use of
moderate to severe pain and can be used
as adjunctive therapy for arthritic pain. It
has been shown that tramadol
hydrochloride can allow a significant
reduction in the dose of NSAID without
compromising relief of pain.20 In patients
who are unable to tolerate NSAIDs, tra-
madol has been found to be comparable
to the analgesic effects of ibuprofen in
patients with arthritis. 21 The most
common side effects are dizziness,
nausea, constipation, and somnolence.22
Tramadol is given in 50-mg doses every
4 to 6 hours and should be titrated slowly
to reduce side effects. The total daily dose
should not exceed 400 mg.
Tramadol should be used with cau-
tion in patients taking serotonin selec-
tive reuptake inhibitors because it may
lead to an increase in serotonin and
increase the risk of seizures or serotonin
syndrome. Tramadol is not a controlled
substance; however, it can be addictive in
patients with addictive tendencies.

Opiate AnalgesicsOpiate analgesics
cannot replace anti-inflammatory
therapy. They should be used as an
S4 JAOA Supplement 8 Vol 104 No 11 November 2004
Downloaded From: http://jaoa.org/ on 03/15/2017
adjunctive therapy when patients pain
may not be responsive to other pharma-
cologic modes of therapy. They are rec-
ommended for severe intractable chronic
pain to improve a patients quality of
life.5 The American Pain Society and the
American Academy of Pain Medicine
have published joint guidelines on the
use of more potent opioids in the man-
agement of chronic nonmalignant pain.23
Opiate analgesic therapy should include
a clear diagnosis, integrate interdisci-
plinary treatment modalities, and include
appropriate ongoing patient moni-
toring.22
Because arthritic pain occurs pri-
marily with mechanical movement,
patients usually describe an intermittent
pain associated with activity. Short-acting
or immediate-release opiates are recom-
mended for this type of pain. For those
patients who have pain at rest and are
not opiate nave, opiate analgesics in con-
trolled-release formulations may be rec-
ommended. Some continuous-release
medications include morphine, oxy-
codone, and transdermal fentanyl. In
addition, methadone is an opiate that
has a half-life of approximately 23 hours
and can provide a longer duration of
action similar to the controlled-release
medications.
In treating patients with chronic
nonmalignant arthritic pain with opiate
analgesics, physicians should do an eval-
uation of patients, provide a written treat-
ment plan stating the objectives and
goals, obtain informed consent and
agreement for treatment including mon-
itoring of urine and serum medication
levels, periodic review, additional con-
sultations if needed, and accurate and
complete medical records. The Federa-
tion of State Medical Boards of the United
States (Web site: www.fsmb.org) has spe-
cific guidelines for the use of controlled
substances for the treatment of pain.
Procedures and Surgical Treatment
Intra-articular steroid injections can pro-
vide relief lasting for months. However,
Neustadt24 states that corticosteroids may
actually increase the progression of
osteoarthritis. Local anesthetics are used
in conjunction with corticosteroids to
offer immediate relief and improve accu-
racy of diagnosis. It has also been noted
DeAngelo and Gordin Treatment of Patients With Arthritis-Related Pain
that local anesthetics can be more effec-
tive than a placebo in treatment of
osteoarthritis.25
Patients with spondyloarthropathy
and associated arthritic pain may also
benefit from corticosteroid injections into
the facet joint in the spine. In addition,
patients who have obtained short-term
relief with facet joint injections may have
longer relief with radiofrequency neu-
roablation of the medial nerves that
innervate the facet joint. This is a low-
risk procedure that can be offered to
patients with isolated and severe low
back pain due to facet joint arthritis.
Hyaluronic acid (sodium hyaluro-
nate, hyaluronan) is a mucopolysaccha-
ride that is found in synovial fluid of
articular joints. It is a viscous compound
that provides lubrication to the joint. As
people age, the body produces less and
less hyaluronic acid. Hyaluronic acid
replacement, referred to as viscosupple-
mentation, is done by injecting hyaluron-
ic acid directly into the painful joint.
Studies are inconclusive; however, some
studies show viscosupplementation
affording pain relief for up to 6 months.5
Patients with severe symptomatic
arthritis and associated arthritic pain that
has failed to respond to medical therapy
or minimally invasive therapy (or both)
and who have limitations in ADL may
require referral to an orthopedic surgeon
for evaluation for joint replacement. Sur-
gical treatment modalities may include
arthroscopic debridement, osteotomies,
and total joint arthroplasties.
Comment
Arthritic pain is one of the most ubiqui-
tous complaints for which patients are
seen in their physicians offices. Treat-
ment modalities should be tailored to an
individual patients needs. Patient edu-
cation, exercise, weight reduction,
NSAIDs, systemic analgesics, and top-
ical analgesic agents have all been found
to be beneficial,26
Patients benefit from a multidisci-
plinary approach that includes educa-
tion and physical therapy. The goals of
the treatment of patients with arthritis
include pain control and improvement of
function while minimizing the side
effects of pharmacologic therapy.
 References
1. Lawrence RC, Helmick CG, Arnett FC, Deyo RA,
Felson DT, Giannini EH, et al. Estimates of the
prevalence of arthritis and selected musculoskeletal
disorders in the United States. Arthritis Rheum.
1998;41;778-799.
2. American Pain Society. Guidelines for the Man-
agement of Pain in Osteoarthritis, Rheumatoid
Arthritis, and Juvenile Chronic Arthritis. Glenview,
Ill: American Pain Society; 2002.
3. AGS Panel on Persistent Pain in Older Persons.
The management of persistent pain in older per-
sons. J Am Geriatr Soc. 2002;50(suppl):S203-S224.
4. Gardner GC, Gilliland BC. Arthritis and peri-
arthritic disorders. In: Loeser JD, Butler SH, Chapman
CR, Turk DC, eds. Bonicas Management of Pain. 3rd
ed. Philadelphia, Pa: Lippincott, Williams & Wilkins;
2001:503-521.
5. Baird Carroll L. First-line treatment for
osteoarthritis. Part 1: Pathophysiology, assessment
and pharmacologic interventions. Orthop Nurs.
2001;20(5):17-24.
6. American College of Rheumatology Sub-com-
mittee on Osteoarthritic Guidelines. Recommen-
dations for the medical management of
osteoarthritis of the hip and knee: 2000 update.
Arthritis Rheum. 2000;43:1905-1915.
7. Superio-Cabuslay E, Ward MM, Lorig KR. Patient
education interventions in osteoarthritis and
rheumatoid arthritis: a meta-analytic comparison
with nonsteroidal anti-inflammatory drug treat-
ment. Arthritis Care Res. 1996;9:292-301.
8. Kovar, PA, Allegrante JP, Mackenzie CR, et al.
Supervised fitness walking in patients with
osteoarthritis of the knee. A randomized, con-
trolled trial. Ann Intern Med. 1992;116:529-534.
9. Moratz V, Muncie HL Jr, Walsh MH. Occupa-
tional therapy in the multidisciplinary assessment
and management of osteoarthritis. Clin Ther
1986;9:24-29.
10. Gamber RG, Shores JH, Russo DP, Jimenez C,
Rubin BR. Osteopathic manipulative treatment in
conjunction with medication relieves pain associ-
ated with fibromyalgia syndrome: Results of a ran-
domized clinical pilot project. J Am Osteopath
Assoc. 2002;102:321-325.
As a charter member of the US Bone and Joint Decade (USBJD), the
American Osteopathic Association (AOA) is enhancing its efforts to
reduce suffering from bone and joint disorders during the USBJD, from
2002 to 2011. Publishing CME publications such as this one is among
the many ways that the AOA is supporting the efforts of USBJD.
DeAngelo and Gordin Treatment of Patients With Arthritis-Related Pain
Downloaded From: http://jaoa.org/ on 03/15/2017
11. Oddis CV. New perspectives on osteoarthritis. 22. American Pain Society. Principles of Analgesic
Am J Med. 1996;100(suppl 2A):10-15. Use in the Treatment of Acute Pain and Cancer
Pain. 5th ed. Glenview, Ill: American Pain Society;
12. Hyiek EM, Heiman H, Skates SJ, Sheehan MA, 2003.
Singer DE. Acetaminophen and other risk factors
for excessive warfarin anticoagulation. JAMA. 23. American Academy of Pain Medicine and
1998;279:657-662. American Pain Society. The Use of Opioids for the
Treatment of Chronic Pain. Glenview, Ill: Amer-
13. Fitzmaurice DA, Murray JA. Potentiation of ican Academy of Pain Medicine and American Pain
anticoagulant effect of warfarin. Postgrad Med J. Society; 1997.
1997;73:439-440.
24. Neustadt, DH. Intraarticular steroid theapy. In:
14. Schiodt FV, Rochling FA, Casey DL, Lee WM, Moskowitz RW, Howell DS, Goldberg VM, Mankin
Acetaminophen toxicity in an urban country hos- HJ, eds. Osteoarthritis: Diagnosis and Medical/Sur-
pital. N Engl J Med. 1997;337:1112-1117. gical Management. Philadelphia, Pa: WB Saunders
Co; 1992:493-510.
15. Whitcomb DC, Block GD. Association of acet-
aminophen hepatotoxicity with fasting and ethanol 25. Creamer P, Hunt M, Dieppe P. Pain mecha-
use. JAMA. 1994;273:1845-1850. nisms in osterarthritis of the knee: Effect of intra-
articular anaesthetic. Br J Rheumatol.
16. Seifert CF, Lucas DS, Vondracek TG, Kastens 1995;34(suppl):45.
DJ, McCarty DL, Bui B. Patterns of acetaminophen
use in alcoholic patients. Pharmacoltherapy. 26. Dieppe P, Chard J, Faulkner A, Lohmander S.
1993;13:391-395. Management of osteoarthritis. Clinical Evidence.
2000;3:529-541.
17. Altman RD, IAP Study Group. Ibuprofen, acet-
aminophen and placebo in osteoarthritis of the
knee: a six-day double-blind study. Abstract.
Arthritis Rheum. 1999;42(suppl 9):S404.
18. Lanza FL, and the Members of the Ad Hoc Editors Note
Production of this supplement to
Committee on Practice Parameters of the American
College of Gastroenterology. A guideline for the the JAOA was under way 6 months
treatment and prevention of NSAID-induced ulcers. before Merck & Co voluntarily
Am J Gastroenterol. 1998:93:2037-2046.
withdrew rofecoxib (Vioxx) from
the market because of increased car-
19. Moore RA, Tramer MR, Carroll D, Wiffen PJ,
McQuay HJ. Quantitative systematic review of top- diovascular events associated with
ically applied non-steroidal anti-inflammatory the medications long-term use.
drugs. BMJ. 1998;316:333-338.
20. Schnitzer TJ, Kamin M, Olson WH. Tramadol
allows reduction of naproxen dose among patients
with naproxen-responsive osteoarthritis pain.
Arthritis Rheum. 1999;42:1370-1377.
21. Dalgin P, and the TPS-OA Study Group. Com-
parison of tramadol and ibuprofen for the chronic
pain of osteoarthritis. Abstract. Arthritis Rheum.
1997;40(suppl 9):S86.
JAOA Supplement 8 Vol 104 No 11 November 2004 S5