What are the alternative pain management options for rheumatoid arthritis?

Alternative Pain Management for Rheumatoid Arthritis

Nonpharmacologic interventions should be implemented as essential adjuncts to pharmaceutical treatment in rheumatoid arthritis, with occupational therapy, dynamic exercise programs, and cognitive behavioral therapy providing the strongest evidence for pain reduction and functional improvement. 1

Core Nonpharmacologic Interventions

Patient Education and Self-Management

• Patient education about disease pathophysiology, self-management skills, and joint protection principles leads to improved health and physical function. 1
• Education should be delivered in a patient-centered manner by a multidisciplinary care team including rheumatologists, nurses, physical and occupational therapists, psychologists, and primary care physicians. 1

Occupational Therapy (Highest Priority)

• Occupational therapy is particularly beneficial for instruction about joint protection and prescription of assistive devices, orthotics, and splints, which can substantially improve function and reduce pain. 1
• Joint protection techniques reduce stress on affected joints and should be taught systematically. 1
• Assistive devices should be provided to help with mobility and activities of daily living. 2

Exercise Programs

• Dynamic exercise programs incorporating both aerobic exercise and progressive resistance training improve fitness and strength, have salutary benefits on lean body mass, and are safe. 1
• Regular, low-to-moderate intensity exercise improves mobility and strength in patients with degenerative arthritis. 2
• Dynamic exercises have shown indisputable, often symptom-relieving effects in established rheumatoid arthritis. 1

Rest and Activity Modification

• Adequate rest reduces fatigue associated with active rheumatoid arthritis. 1
• Resting joints during periods of poorly controlled inflammation lessens disease symptoms. 1

Adjunctive Physical Modalities

Thermal Modalities

• Heat and cold applications can be recommended for pain relief in patients with degenerative arthritis. 2
• These provide short-term relief of pain rather than affecting disease activity. 1

Hydrotherapy

• Hydrotherapy has shown symptom-relieving effects in established rheumatoid arthritis. 1

Splinting and Orthotics

• Splints may provide symptomatic relief, particularly for specific joint involvement. 2
• Use of splints or orthoses has been investigated with some positive effects reported in randomized controlled trials. 1

Psychological Interventions

Cognitive Behavioral Therapy

• Cognitive behavioral therapy benefits patients with fatigue by enhancing self-management and reducing their sense of helplessness. 1
• This addresses the psychological burden of chronic pain and disability. 1

Topical Analgesics (Bridging to Pharmacologic)

Topical NSAIDs

• Topical NSAIDs are preferred over oral NSAIDs in patients ≥75 years to minimize cardiovascular risks. 2
• Begin with topical analgesics rather than oral medications in older patients with comorbidities. 2

Topical Capsaicin

• Topical capsaicin can be considered as an alternative for pain relief in patients with degenerative arthritis. 2
• This provides localized pain relief without systemic effects. 3

Interventional Approaches

Intra-articular Glucocorticoid Injections

• Patients with inflammatory activity predominantly in single isolated joints should receive local intra-articular glucocorticoid injection. 1
• Joint infiltrations play an important role in pain management for rheumatoid arthritis. 3

Important Caveats and Limitations

Evidence Limitations

• The efficacy of nonpharmacologic interventions in early arthritis has not been formally tested, and there is no indication that they improve long-term outcomes such as radiographic progression. 1
• Nonpharmacologic interventions should only be applied as an adjunct to pharmaceutical treatment, not as monotherapy. 1
• When positive, randomized controlled trials showed short-term relief of pain only, rather than an effect on disease activity. 1

Interventions with Insufficient Evidence

• Acupuncture, laser therapy, compression gloves, transcutaneous electrical nerve stimulation (TENS), ultrasound, thermotherapy, and homeopathy have controversial effects. 1
• There is limited evidence that a vegetarian diet may have a modest effect on symptoms. 1

Clinical Pitfalls

• Do not rely on nonpharmacologic interventions alone when active inflammation is present—DMARDs remain the fundamental basis of treatment since the main mechanism of pain in rheumatoid arthritis is inflammation. 3
• Recognize that patients with fibromyalgia can have high disease activity scores due to high tender joint counts and patient global assessment in the absence of swollen joints or elevated acute phase reactants. 1
• When joint tenderness, fatigue, and subjective disease activity are disproportionate to provider assessments, investigate noninflammatory causes of pain such as regional musculoskeletal pain syndromes or osteoarthritis rather than escalating immunosuppressive therapy. 1

Multidisciplinary Team Approach

All nonpharmacologic approaches to patient management are best undertaken in a patient-centered manner by a multidisciplinary care team that includes a rheumatologist, nurses, physical and occupational therapists, psychologists, and a skilled primary care physician. 1