What are the recommended treatment options for arthritis pain management?

Arthritis Pain Management

For arthritis pain management, physical activity and exercise interventions combined with psychological interventions (particularly cognitive-behavioral therapy) demonstrate the most uniformly positive effects on pain reduction across both inflammatory arthritis and osteoarthritis, and should form the foundation of your treatment approach alongside patient education. 1

Initial Assessment Requirements

Before initiating treatment, systematically evaluate the following specific elements 1:

• Patient's functional goals: Identify specific activities the patient cannot currently perform (e.g., climbing stairs, opening jars, walking distances) rather than focusing solely on pain intensity scores 2
• Pain characteristics: Assess severity, type (inflammatory vs. mechanical), spread (localized vs. generalized), and quality (sharp, aching, burning) 1
• Current inflammation and joint damage: Determine if these are adequately treated, as this guides whether disease-modifying therapy needs optimization 1
• Psychological factors: Screen for catastrophizing, fear of movement, pain self-efficacy, and psychiatric comorbidity 1
• Sleep quality: Evaluate whether patient feels refreshed on waking and assess sleep hygiene habits 1
• Obesity presence: Document BMI as weight management shows uniform positive effects on pain 1

Stepped-Care Treatment Algorithm

Step 1: Education and Self-Management (All Patients)

Provide patient education immediately as it shows uniform positive effects on pain in osteoarthritis of the hip/knee and knee specifically 1. Education should include 1:

• Encouragement to stay physically active despite pain
• Sleep hygiene guidelines
• Information about the disease process and pain mechanisms
• Self-management strategies through online or face-to-face programs 2

Step 2: Core Non-Pharmacological Interventions

Physical Activity and Exercise (Highest Priority)

Physical activity and exercise show the most extensive evidence base with uniformly positive effects 1. Implement the following based on arthritis type 1:

• For osteoarthritis (general, hip/knee, knee, foot/ankle): General exercise programs, aerobic exercise, and strength/resistance training all show positive effects with moderate quality evidence 1
• For rheumatoid arthritis: General exercise shows positive effects with low quality evidence 1
• For spondyloarthritis: General exercise shows positive effects 1

Specific exercise prescription 1:

• Strength and resistance training is particularly well-studied for knee OA
• Aerobic exercise demonstrates positive effects for general OA and knee OA specifically
• Quality of evidence ranges from low to moderate (GRADE ⊕⊕ to ⊕⊕⊕)

Psychological Interventions

Cognitive-behavioral therapy (CBT) shows uniform positive effects on pain for both rheumatoid arthritis and osteoarthritis 1. Additional effective psychological interventions include 1:

• Psychosocial and coping interventions for OA (general)
• Biofeedback for RA
• Relaxation interventions for OA (general, hip/knee)

Weight Management

For overweight/obese patients, weight management shows uniform positive effects on pain in RA, spondyloarthritis, and OA of the hip/knee 1.

Orthotics

Consider orthotics for specific joint involvement 1:

• Orthopedic shoes for RA and OA of the knee
• Splints for OA of the hand
• Knee orthoses (especially sleeves, elastic bandages) for OA of the knee
• Effects are small but consistent

Step 3: Pharmacological Management

Pharmacological treatment is a core ingredient of pain management but was not the primary focus of the EULAR guidelines 1. Based on available evidence:

First-Line Pharmacological Options

• Acetaminophen: Safest first-line option for musculoskeletal pain, up to 3 grams daily 2
• Topical NSAIDs: Recommended for specific joints 1
• Topical capsaicin: Shows benefit in knee OA 3

NSAIDs (Use with Caution)

NSAIDs reduce pain and improve function but carry significant risks 4, 3. Key safety considerations 4:

• Can cause ulcers and bleeding in stomach/intestines without warning
• Increase risk of serious cardiovascular thrombotic events, myocardial infarction, and stroke
• Risk increases with longer use, smoking, alcohol consumption, older age, and poor health
• Avoid in patients with cirrhosis, kidney disease, or cardiovascular disease 2
• Use at lowest effective dose for shortest duration necessary

Disease-Modifying Antirheumatic Drugs (DMARDs)

For inflammatory arthritis (RA, spondyloarthritis), DMARDs are the fundamental basis of treatment since inflammation is the main pain mechanism 5. Methotrexate shows effects on articular swelling and tenderness as early as 3-6 weeks, though it does not induce remission or prevent bone erosions 6.

Intra-Articular Corticosteroid Injections

Intra-articular corticosteroid injections are effective for specific joints in both OA and inflammatory arthritis 1, 3.

Opioids (Limited Role)

• Tramadol has poor risk-benefit trade-off and is not routinely recommended 3
• Weak opioids may play a role when other treatments fail 5
• Strong opioids require careful patient selection and monitoring due to adverse effects 3

Step 4: Multidisciplinary Treatment

Consider multidisciplinary intervention only if monotherapy fails 1. Evidence for multidisciplinary treatment is limited, with meta-analyses showing no added effect on pain beyond monodisciplinary therapies 1.

Disease-Specific Considerations

Rheumatoid Arthritis

• Optimize DMARD therapy first as inflammation is the primary pain driver 5
• Many patients continue experiencing pain despite optimal disease control, requiring additional analgesic strategies 5
• CBT, biofeedback, and general exercise show positive effects 1

Osteoarthritis

• Education shows uniform positive effects specifically for hip/knee and knee OA 1
• Exercise therapy (general, aerobic, strength training) has the strongest evidence base 1
• Weight management is particularly important for hip/knee OA 1
• Arthroscopic surgery has no benefit and should not be performed 3
• Total joint arthroplasty should be considered when conservative management fails 3

Psoriatic Arthritis

Evidence for pain management in psoriatic arthritis is notably absent 1. In the absence of specific data, use pain treatment options proven effective in RA to guide management 1.

Common Pitfalls to Avoid

• Do not rely solely on multidisciplinary treatment: Evidence does not support added benefit over focused monodisciplinary interventions 1
• Do not delay exercise therapy: Physical activity shows the most consistent benefits and should be initiated early 1
• Do not ignore psychological factors: Pain in arthritis is multifactorial, and psychological interventions show uniform positive effects 1
• Do not use NSAIDs long-term without considering risks: Serious cardiovascular and gastrointestinal complications can occur 4
• Do not focus only on pain scores: Assess functional goals and quality of life as primary outcomes 1, 2

Monitoring and Reassessment

Focus ongoing assessments on 2:

• Achievement of functional goals (specific activities patient can now perform)
• Pain severity reduction
• Quality of life improvement
• Treatment-related adverse events