Susan Oliver Associates - Independent Rheumatology Nursing Specialists

Managing Pain
Arthritis is a word used to describe pain in your joints. The pain can be felt in a number of ways. If you have inflammation in or around the joint this is likely to cause swelling, redness, and heat but sometimes just a damaged or worn joint may also cause pain. These problems may also make you reluctant to move you joint or give you difficulty on movement. Pain caused by damage or inflammation can cause a strain and discomfort to the muscles surrounding the joint. Sometimes you can experience pain as a result of sports injuries and it might be difficult to understand what is causing your pain.	There are many reasons for pain in joints and the most common one that most of us are aware of is the damage and discomfort that is experienced with osteoarthritis. Although osteoarthritis is very common it is important that you know what type of arthritis you have as this will help you understand the best way of managing your pain and the difficulties you experience as a result of the joint discomfort. For instance, if you have joint problems that have been diagnosed as Rheumatoid Arthritis you may need different treatment than for Osteoarthritis or Ankylosing Spondylitis. Once your doctor has seen you and given you a name (diagnosis) for the type of arthritis you have then you can plan to get further information to help you manage your conditions.	One of the hardest things to learn to manage is how to control pain. The health professionals should try and offer you some advice on how to manage your pain and in some cases offer you treatment for pain. However, if you have an opportunity to take part in educational or specialist self management programmes it is likely that these will help you to reinforce your own pain management strategies and improve your knowledge of how to manage your disease. How you feel, how tired you are, how fearful you are and how other things in your life are working all have the potential to make you feel more weighted down by your pain. So, learning to understand how to manage your pain is important.
Pain control back to top
Pain can be disabling and lead to chronic fatigue and a sense of hopelessness. Pain control needs to be tailored to the individuals’ lifestyles, the level of pain experienced and in some cases, how well controlled the disease is. We are all unique individuals and we all have different ways of thinking about health, illness and sensations like pain. How you think about health and illness may also have an effect on how you cope with pain. Most people have experienced some sort of pain before developing arthritis. It may be that your previous experience of pain will affect how you feel you can cope with the pain you may experience with arthritis. Sometime it can help to discuss how you see your illness and how you feel able to cope with the problems you experience. If you are seeing a consultant about your arthritis it should be possible for him to refer you to a specialist nurse or practitioner who can see you and provide specific advice on pain control and education about your disease and any tablets or treatments you might be prescribed. See the section on Why See a Nurse?	In some parts of the United Kingdom there are expert patient programmes that have been introduced to help people learn about coping with a chronic illness. Although these programmes do not focus on the specific issues related to arthritis they can be helpful. If you have rheumatoid arthritis The National Rheumatoid Arthritis Society (NRAS) have very useful information for you www.nras.org.uk If you are seeing a rheumatologist you should have access to a multidisciplinary team. The multidisciplinary team consists of doctors, nurses or practitioners, physiotherapists, occupational therapists and podiatrists. See the section on Why See a Nurse? The team usually has educational programmes specifically tailored to the needs of patients with arthritis (in hospitals this programme is usually for diseases such as Rheumatoid Arthritis). If you have Rheumatoid Arthritis please refer to: http://www.nhs.uk/conditions/ Rheumatoid-arthritis/Pages/ Introduction.aspx	If you have a condition that is referred to as an inflammatory form of arthritis – such as Rheumatoid, Psoriatic Arthritis, Ankylosing Spondylitis you might find this link also helpful. www.versusarthritis.org If you have Osteoarthritis http://www.nhs.uk/ conditions/osteoarthritis/ Pages/Introduction.aspx If you have had an old injury and do not have any underlying diagnosed condition but still experience pain this little video on you tube might help you understand a little more about how pain works. https://www.youtube.com/ watch?v=C_3phB93rvI
In the meantime here are some important facts that may help you in managing your pain:
Medications for pain back to top
All pain relief medication should be taken at regular time intervals when you are trying to get effective pain control. Many people make the mistake of only taking their tablets to relieve pain when the pain is very bad and then wonder why the tablets have not worked. The brain is sensitive to pain messages from the body and if you only take medication occasionally the brain will not be able to 'turn off' the 'help I have pain' messages sent from the painful areas (such as a knee or hip) to the brain. Regular pain relief helps to break the cycle of pain messages going from the painful joints to the brain. If pain relief is used regularly this breaks the cycle. Remember that pain relief does not only mean medicines but also means finding techniques that help you to feel comfortable, for example relaxation, a hot bath or shower. For an easy to follow detailed explanation on the pain and the pain cycle see the leaflet on the arthritis research UK website. www.versusarthritis.org	Achieving good pain control is about using a group of pain control methods as an overall long-term plan. So if you are unable to control your pain it may be right for you to consider taking regular pain control medications with pacing strategies, rest and the use of an aid or device such as a walking aid if you have knee or hip problems. When you have good pain control and you feel the problem has settled - then you should gradually reduce the pain medications. You should think of it as: 1. Step up - when the pain is beginning to be difficult to control - review your pain control strategies and increase medication (according to the medication instructions you were given by your doctor, nurse or pharmacist) And 2. Step down - when the pain is well-controlled review how to gradually reduce your pain control medications and additional strategies (e.g. reduce resting time) and gradually continue to reduce them as long as the pain remains controlled.	Note: When discussing medications it is important that the advice outlined below is only a guide. Medications you take should be used according to the advice provided by the manufacturer and your doctor, nurse or pharmacist who prescribed the medications. Always check with them before making any changes to your medications. You should not exceed the prescribed dose and check that you are safe to take the medications (information is provided in the packaging of your medication).

1.Pain Relief

Analgesia is a word used to describe medications to relieve pain. There are a number of types of medication that you need to know about

These include:
Simple' pain relief tablets (analgesics) - many of these can be bought over the counter at the chemist. They are called ' simple' because they are made up of only one type of drug (e.g. paracetamol or aspirin). A tried and tested effective 'simple' pain relief tablet is paracetamol (called Acetaminophen in America). Paracetamol can be very effective particularly if taken regularly and at the right dose.

Creams and packs that you can use to apply to the painful joints, sprains and strains. Some of these are anti-inflammatory creams (e.g. ibuprofen). It is important to know that when creams that are applied to the skin if applied to frequently or liberally they can be absorbed by the body and have effects throughout the body. This is especially important if you are worried about taking a non-steroidal anti-inflammatory tablet by mouth but decide to use a cream instead. Some of the anti-inflammatory creams can be bought over the counter at the chemist. They have been shown to be effective for pain relief in the short term (up to two weeks) particularly for smaller joints.

There are also creams that work by producing a sensation or 'counter irritant effect' (or burning effect). The fine nerve endings recognise the mild irritant and this effect reduces other pain message that the brain receives from the painful joints. One of these creams is a capsaicin cream. These creams can sometimes take several weeks before the pain relief is felt and when first used can cause an initial burning sensation.

Compound Pain relief tablets (analgesics) These tablets are sometimes called ‘compounds’ because the medication is made up of a mixture of two types of pain relief. Some drugs are mixed with paracetamol or aspirin and a stronger form of pain control called an opiod. There are a number of different mixtures and these tend to have slightly more side effects than the simple analgesics. For many of the compound or pure opiod tablets the one of the most common side effect is constipation, drowsiness and difficulty with tasks, so risks of falls might be an issue if you are older and less agile. It is worth being aware of these issues and taken account of them with your doctor or nurse, family and friends, and if you are taking regular compound pain relief make ensure you take regular bulking forming laxatives such as Ispaghula Husks (e.g. Fybogel) to avoid constipation.These can be purchased from your pharmacist. Always check with your doctor that this is safe for you to take. Other side effects can include nausea, vomiting and drowsiness.
Some examples of compound analgesics include these drugs:

Paracetamol 500mg with 8mg Codeine Phosphate (500mg/8mg = Co-Codamol 8/500)
Paracetamol 500mg with 30mg Codeine Phosphate (500mg/30mg = Co-Codamol 30/500)
Opiod drugs are sometimes given on their own without paracetamol or aspirin.

Examples include:

Codeine Phosphate 30-60mg every four hours (according to doctor’s prescription but usually to a maximum of 240mg per day).

Tramadol - 50-100mg 4 hourly (according to doctor’s prescription).
Compound and opiod pain relief tablets have to be prescribed by your doctor. There are a number of different drugs and your doctor will discuss the choices with you and the maximum dose you should take. The doctor will also discuss what other treatments you are taking to ensure that the medication you receive does not interact with any other medicines.
For a patient information leaflet on pain relief see https://www.britishpainsociety.org/
people-with-pain/

Non-Steroidal Anti-Inflammatory Drugs (often called NSAIDs) There are lots of different types of these drugs and they are effective in reducing pain but they do come with some side effects that you need to be aware of (see Note below) Your doctor has to prescribe the majority of the NSAIDS although one or two can be purchased at lower dosages over the counter (for example, ibuprofen). In some cases you may also be prescribed another tablet to be taken whilst you are taking an NSAID. The tablet is one to provide additional protection for your stomach – for example they are called Proton Pump Inhibitors (e.g. Omeprazole). The Arthritis Research Campaign (arc) produce an information leaflet on NSAIDs and this can be accessed at www.arthritisresearchuk.org/
arthritis-information/
drugs/nsaids.aspx

A group of NSAIDS called COX IIs provide some benefits for people who are at an increased risk of having a stomach ulcer. You can read more about these type of medications at: www.nice.org.uk/
advice/ktt13/chapter/
options-for-local-implementation

REMEMBER: The general advice is that you should discuss your pain with you doctor or nurse and that together with them you must consider your personal and individual risks related to take any medication. If you are prescribed an NSAID or COX II the recommendation is that you should have the lowest dose that will help your pain for the shortest length of time. Please discuss this information in more detail with your doctor or nurse as they will want to make sure you are safe on medication but importantly get the right level of pain relief.

2. Hot and cold packs.
There is a very small amount of evidence supporting the use of hot or cold packs but they can help you cope with having something easy to use at home, when you need some pain relief. These pains can be used useful to reduce pain. Cold packs can be purchased over the counter and are usually stored in the freezer. Some people find them a little uncomfortable when first applied to the painful joint but do gain some relief for a little while after applying. They can be used frequently during the day and provided you do not damage the skin by putting the frozen pack directly in contact with your skin (it is best to have a fine cloth around the pack) they are very safe and without side effects.

Hot packs may be useful especially for stiff or aching joints and muscles. Again you must be careful that you do not damage your skin. Skin that is painful may not be able to properly recognise when the heat is burning or damaging the skin. Make sure that you don’t let the pack get too hot and test the temperature before applying to a painful joint. As with cold packs it would be advisable to wrap a fine piece of cloth around the pack. These packs are made from a range of products and can be heated in the microwave - but do make sure that you use the packs as advised by the manufacturers.

3. Transcutaneous Electrical Stimulation (TENS).
TENS machines have two small electrode pads that need to be attached to the skin. The TENS machine works by providing mild electrical impulses that stimulate the touch sensors in the skin reducing the pain messages to the brain. A small battery powers the electrical impulses, the level and type of impulses can be adjusted. TENS machines can be purchased from chemists. Although TENS machines may be useful to some people it might be worth taking specialist advice from the hospital physiotherapist/practitioner who may be able to advise you as to whether you might benefit from using a TENS machine. Research evidence to date has not proved conclusive evidence of its value for chronic pain.

4. Pacing and rest
Pacing is a term used to modify the stress or workload levels on your joints as well as learning to rest yourself mentally and physically. It means finding ways in your life to balance times of work with times to rest. Painful joints may need some recovery time - for example, changing tasks from standing or walking to sitting or lying down to read a book. This takes the weight off the joint (or joints) and allows some of the muscles that have been doing most of the work to relax. Pacing also means recognising especially bad or difficult days and finding ways of being flexible about how much you should do that day.

Resting can sound difficult, especially if you are being asked to rest when you are experiencing pain, or have plenty of tasks that you want to do today and don’t like resting anyway! But…learning relaxation techniques can relieve the tension and ultimately constant pain messages to the brain. Fatigue will affect how you perceive pain and how you cope with it. Learning ways to relax completely can be a real trial for some people others, are gifted at it! You need to find the best way to help you relax. Some people find certain types of music help others like absolute quiet. It is useful to try resting on a bed for a short time each day when the pain is bad, lying in a dark room, without any additional noises or distractions that remind you of things to be done. A short sleep may even be worthwhile. Set an alarm to ensure that you only sleep for a certain period of time so that over time you don’t lose your normal night sleep patterns.

5. Managing Fatigue
Fatigue is a very common symptom for those who are suffering with pain or difficult mobility problems. Fatigue can also be an added problem with some types of inflammatory joint diseases such as Rheumatoid Arthritis, Psoriatic Arthritis, and Ankylosing Spondylitis.

www.arthritisresearchuk.org/
arthritis-information/
arthritis-and-daily-life/
fatigue.aspx

Fatigue is often not mentioned or fails to be recognised and sometimes you may feel that you are the only one who is exhausted and failing to cope - interestingly when I see new patients who come along having recently been diagnosed and 'I say are you feeling exhausted ?' they look relieved and surprised to have their fatigue recognised. Many say they felt they must be 'weak' or a 'being pathetic' because they were feeling so fatigued. It comes, in a way as a relief to many to realise that it can be part of a disease like RA. www.nras.org.uk/
invisible-disease-rheumatoid-arthritis
-and-chronic-fatigue-report

Fatigue can be an indicator that the disease has become more active, particularly with diseases such as Rheumatoid Arthritis, and may be accompanied by increasing length of Early Morning Joint Stiffness. In addition fatigue can be as a result of anaemia.

Managing fatigue will be part of an overall strategy as highlighted in the same way as coping with pain. It will require a combined approach using rest, passive exercise and better pain control.

6. Swimming and Hot baths
Water takes away gravity, resting your joints from their weight bearing work. It means that joints can move more freely and the muscles can have a greater degree of movement without taking any specific strain. Sometimes hydrotherapy treatments are offered to help your mobility and teach you how to improve the range of movements in your joints. These exercises can sometimes be continued in warm local swimming pools where local support may also be provided. You can find out about the availability of such facilities by contacting your local leisure centre or health club.

Hot baths help relaxation and gives a sense of well-being and pain relief. People who experience early morning joint stiffness often find taking their pain medication then getting into a hot shower or bath will help their pain control and reduce some of their stiffness.

7. Exercise
The balance of rest, relaxation and exercise can improve pain control and maintain mobility. For most types of arthritis exercise is essential and beneficial. This is because joints and muscles need to move regularly and muscles need to maintain their muscle strength and bulk. Some of the pain experienced in arthritis is related to the stiffness that can be experienced following periods of inactivity or early morning stiffness (EMS).

The different types of exercises will vary according to the type of problems you have and the difficulties you are experiencing. If you are seeing a rheumatologist they will refer you to a physiotherapist to advise you on an exercise regime. However it is important to know whether you are doing 'active exercise' or 'passive exercise'.
Active exercise
Active exercise is what most people do to keep fit and reduce weight. It involves things like going for a walk or gardening. They often require the body and the joints to bear weight and work against a force - such as lifting or digging in a garden spade.

Passive exercise
This is where the joints and muscles are worked but not against a specific weight or force. It involves moving the muscles and joints through a wide range of movements, this can be done while lying on the bed or sitting in a chair. The Arthritis Research Campaign has produced a leaflet that can be used as a wall chart www.arc.org.uk

If you have any doubts about the safety or your ability to undertake any exercise regime you should discuss this with your own doctor before starting an exercise programme. www.arthritisresearchuk.org/
arthritis-information/
arthritis-and-daily-life/
exercise-and-arthritis.aspx

8. Weight Loss
It is very difficult to lose the weight, particularly when problems with mobility significantly reduce opportunities to undertake vigorous exercise regimes. However, it is worthwhile knowing that weight reduction for individuals with OA will be of benefit. People with arthritis who are overweight have greater damage to the joints and increasing difficulties with mobility and exercising. Losing weight can be a very effective way to reduce your pain. It may be worth seeking advice about a suitable diet that will help you lose weight yet ensure you maintain a healthy balanced diet.

9. The use of aids (walking sticks, joint protection, footwear).

For healthcare professionals, encouraging individuals to use various aids or assistive devices is often the hardest thing to achieve, yet one of the simplest ways of reducing fatigue, improving mobility, reducing pain and protecting joints. This is partly because most of us simply do not wish to consider the use of any form of aid seeing it as recognition of a problem or a 'giving in'. Yet the use of some equipment can be liberating, allowing more energy and time for other activities. Coming to terms with using any form of aid often is most effective when supported by help and advice from a member of the multi-disciplinary team.

Walking Aids
The way we use our body and our joints is taken for granted when everything works well. When a joint fails or is painful it is common for people to continue to walk, go up and down stairs etc but with pain and increasing difficulty. It is often achieved without the use of aids but usually is achieved at the cost of the other joints having to take the extra weight. This means that other joints will take the weight but not in a way that the joint is designed to. This means the weight will be distributed differently and add an extra load to healthier or less painful joints.

An example of this is when you have a painful knee. To continue to walk you protect the painful joint by throwing your weight onto the 'good' knee. This results in the body changing the mechanics of how you position your back before movement, distributing the weight onto the 'good' knee joint. The good knee has to cope with the abnormal load by distributing the force through other joints. This can result in not only a painful knee but in addition a painful ankle or hip too. To minimise the risk of this a walking stick could help by taking some of that additional load and maintaining a better body posture. When the knee settles and pain and function improves you can then store the walking stick away.

Joint Protection
Some types of arthritis or functional problems can be improved with the use of joint protection. It is quite common for people who have some types of arthritis (e.g. Rheumatoid Arthritis) to be assessed by an occupational therapist/ or rheumatology practitioner. The therapist or practitioner will assess the activities you undertake and see where stress on joints can be reduced to protect the joints and keep them in their normal alignment. The process of assessment will often include providing practical advice on how to avoid abnormal stresses or forces on the joints and can include additional pieces of equipment such as kettle tippers reducing the need to lift a full kettle of water. When joints are more effectively protected pain can be reduced.

Footwear
Podiatrists are specialist trained in managing foot problems and other difficulties related to the foot and diseases that affect the feet. For many forms of arthritis early practical advice on footwear can be very effective. Our joints work as shock absorber taking for our bodies. When we are young there is a tissue called cartilage that lines all healthy joints and is nice and spongy and provides an effective cushioning for movement. As we grow older this cartilage become less flexible and in osteoarthritis may become worn away allowing two joints to move against each other without the cushioning effect of cartilage. One way of improving the 'shock absorber' or cushioning effects that used to be achieved by our young healthy joints is to ensure that shoes have good cushioning included in them. The trainer is a good example of cushioning support that a shoe can provide.

However, there are a number of problems that might be experienced with different types of arthritis. A thorough foot assessment often proves very useful. The assessment will look at whether the arch support of your foot is maintained, and that you are bearing you weight down effectively onto your ankle and foot. Sometimes the use of an arch support can be very effective.