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“Everything Hurts”

Christine Stamatos DNP, ANP-C

Director, Fibromyalgia Wellness Center

Division of RheumatologySelf-

Management

Medications&

Treatments

Managing Pain in the Arthritis Patient

Searching for the CAUSE

Conflict of Interest Disclosure• Authors Conflicts of Interest:

• C. Stamatos, No Conflict of Interest

Objectives:

1. Distinguish between inflammatory versus non inflammatory MSK pain

2. Describe at least 10 different conditions

3. Summarize categories of drug treatment for MSK pain

4. Critique current recommendations for NSAIDs

5. Discuss critical issues r/t steroid therapy

Searching for the CAUSE

Self-Management

Medications&

Treatments

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Introduction: Over 171 different types of Arthritis

• Simple Tasks.org• http://www.youtube.com/watch?v=6BAYcmgDxkQ

&feature=youtu.be

Few examples of “Other”Fibromyalgia

Polymyalgia Rheumatica

Systemic Lupus

Sjogren’s Syndrome

Psoriatic Arthritis

Scleroderma

Spondyloarthropathies

Gout/ Pseudogout

Vasculitis: Wegener’s…

Myositis

Paraneoplastic Syndrome

Sarcoidosis

Lyme Arthritis

Diabetic Cheiroarthropathy

Adult Still’s Disease

Neuropathic Arthropathy “charcot” joint

Relapsing Polychondritis

Prevalence:

• OSTEOARTHRITIS 35%

• Rheumatoid Arthritis 17%

• Other 10%

• Unknown 26%Ong et al. (2013) Annals of Epidemiology; 102(3): 80-80Aletaha et al. (2010). A & R; 62(9): 2569-2581.

Types of Arthritis

The Arthritis Epidemic

• 46 million US adults: 1 in 5 now

• 67 million projected for 2030= 20%

• 60-70% over 60 have arthritis

• 61% women…

• Not just older: “Prime of Life”

• 2/3 Dx with arthritis < than 65

McKnight et al. (2010). A C & R; 62(1): 45-53, Ong et al. (2013) Annals of Epidemiology; 102(3): 80-80;Aletaha et al. (2010). A & R; 62(9): 2569-2581.

Projected Prevalence of Doctor-Diagnosed Arthritis Among U.S. Adults Ages 18+ Years, 2005-2030 (1)

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✔ Prevalence not dramatic difference

✔ Impact significantly different!

✔ Lower socioeconomic status associated with more severe PAIN

The Arthritis Epidemic

Prevalence of Arthritis by Race/Ethnicity

Non-Hispanic White 23.8%

Non-Hispanic Black 19.4%

Hispanic 11.1%

American Indian/Alaska Native 25.2%

Asian/Pacific Islander 8.4%

Multiracial/Other 20.7%

Source: National Health Interview Survey 2002, 2003, 2006

Severe Pain Among Adults withArthritis by Race/Ethnicity

Non-Hispanic White 23.1%

Non-Hispanic Black 38.3%

Hispanic 36.4%

American Indian/Alaska Native 28.7%

Asian/Pacific Islander 18.5%

Multiracial/Other 36.6%

Source: National Health Interview Survey 2002, 2003, 2006Bolen et al. (2010). United States, National Health Interview Survey, 2002, 2003, 2006. Prev Chronic Dis; 7(3): 1-15.

Most common cause…

• CHRONIC PAIN

• PHYSICAL DISABILITY✔1 in 20 between 18-64

Data Source: U.S. Census Bureau, 2004 Survey of Income and Program Participation,Wave 5, June-September 2005. as reported in: Hootman JM, Brault MW, Helmick CG,Theis KA, Armour BS. Prevalence and Most Common Causes of Disability Among Adults— United States, 2005. MMWR 2009;58(16):421-426.

Arthritis-Attributable Activity Limitation Among Adults with Arthritis (NHIS 2007-2009)

The Arthritis Epidemic

The Financial Costs

Increase in costs more than 53% in the past decade

Direct costs $267 (office visits, Rx, PT…)

Indirect costs +$110 (lost wages, productivity)

16 days missed $377 billion

Over 3% Gross Domestic Product… and rising 7% in 2030Costs more than caring for DM, Heart Disease and Cancer combined!

Ong et al. (2013) Annals of Epidemiology; 102(3): 80-80; Aletaha et al. (2010). A & R; 62(9): 2569-2581.

The Arthritis Epidemic

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The Personal Costs:

Burden of Chronic Pain/ Disability• 30-40% chronic pain is not well controlled

o Nearly 20% describe Mod- SEVERE pain

• 60% of adults with pain say it’s lasted > 1 year

• 50% of these adults describe persistent pain

• > 50% also have chronic fatigue/ sleep problems

• 40-44% “Can’t think clearly, feel helpless, can’t remember life without pain”

• 20-30% (and higher) experience depression & those with

chronic pain are 3 x more likely depressed

Breivik et al. (2006). Eur J Pain; 10: 287-233.

The Arthritis Epidemic

Over 30 million cases are related to modifiable causes • Expanding waists

o > 65% Adults 20 yo and older have BMI > 25 kg/m2

o For every 2 pt drop in BMI (10 lbs) symptomatic OA by 50%

(Felson et al., 1992 from the Framinghan Osteoarthritis study)

• Inactivity: childhood obesity leads to adult obesity

• Sports related injury/ Joint protection: “the weekend warrior”

The Arthritis Epidemic

Managing Arthritis Pain

• Medical therapies

o Medications: fast and easy, lots of issues

• Analgesics• Adjuvant tx O• Disease modifying agents

o Interventional procedures/ devices

o Surgical interventions: 90% increase in jt replacements in past 10 ys

• Weight loss & Exercise:

http://www.youtube.com/watch?v=L2kRnU7HWPIo For every 1 lb loss decrease load joint 4 lbs

o Without it, nothing else works as well!

o It works!

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Managing Arthritis Pain

• Self-Management Techniques

o Coping skills training based on CBT principles

o In combination with OTHER strategies is MOST effective

o Examples:

• Frank Keefe PhD, Psychologist Duke University• Coping Skills Training Program for Arthritis

• Kate Lorig R.N. Dr.P.H., Stanford University• Arthritis Self Management Program

But First…“everything hurts”You must figure out what is causing the pain…

Through Case Studies today… hope to provide some reference

“If you remember nothing else, remember the people… Each one of these cases is real…”

Ask a few KEY questions:

Key Questions: When the pain is everywhere…

• Any joint swelling: pattern is importanto One or more jointso Symmetricalo Persistent/ intermittent- migratory

• Stiffness: o 10-15 minso Over 30-60

• Constitutional symptoms: fever/ chills/ wt loss/ fatigue• Cardiac: chest pain, palpitations• Pulmonary: dyspnea, cough, pain on inspiration• Rash, sensitivity to sun• Raynaud’s• Dryness/ ulcerations: mouth/ eyes/nose• Paresthesias (absence of stimuli)/ Dyesthesias (abn response to touch):

location, migratory, associated with weakness• Medical history: PMH, recent exposure illnesses/ stressors• Recent labs: CBC, CMP, ESR/ CRP• Family history• Coping? Any hx of depression/ anxiety

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10 Reasons to wonder… Simple Tasks Campaign

1. Presence of swelling, especially multiple joints/ or recurrent sx

2. Weakness with elevated ESR, CPK

3. New “blue or white” changes fingers/ toes, especially with ulcers

4. New headaches, with or without visual change, elevated ESR

5. New fixed swelling & tightness of skin hands and/or feet

6. New butterfly rash and joint pain (or fevers)

7. Elevated ESR with joint pain, swelling, fevers, rash, or weakness

8. Sudden wrist or foot drop, with fevers and rash

9. Morning stiffness lasting more than 45 mins

10. Back pain that is “worse in the morning”, better with activity

Here’s Your PatientThink about the following…

Case Studies

1. What are the key factors to be taken from this initial intake?

2. Are there any additional things you would like to know?

3. How would you progress from here?

4. Take home message from each CASE.

Measures of Inflammation

Important to determine: completely changes treatment options…

• ESR

• CRP

• Liver Proteins

o Fibrinogen

o Ferritin

• Complement levels

• Change in CBC:

o Anemia

o Thrombocytosis

o WBC… low with virus, high bacteria, high steroids- otherwise…nl

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Rheumatoid Rheumatoid Arthritis

Typically: Adults/ JIA kids• Sudden onset• Am stiffness profound > 60 mins• Highly destructive, often quickly• “I feel like I broke a bone”• Unresponsive to NSAIDs• Can involve:

- eyes- lungs- skin

• Weight loss initially not uncommon• High measures of inflammation• Spine can be involved- cervical

Rheumatoid Arthritis

Early Late

With treatment- shouldn’t progress…

Presentation:

• Pain

• Fatigue- overwhelming

• Arthralgias/ myalgias

• Fever/ chills/ Malaise

• Loss appetite

Labs:

• Elevated APR

• RF/ CCP/ ANA

Seronegative RA: no RF/CCP

2010 ACR/ EULAR Classification

A. Joint involvement:1 large joint 02- 10 large joints 1 1- 3 small joints 2 4- 10 small joints 3 >10 joints (at least 1 small joint)** 5

B. Serology (at least 1 test) Negative RF and negative ACPA 0 Low-positive RF or low-positive ACPA 2 High-positive RF or high-positive ACPA 3

C. Acute-phase reactants Normal CRP and normal ESR 0 Abnormal CRP or abnormal ESR 1

D. Duration of symptoms< 6 weeks 0> 6 weeks 1Aletha et al. (2010). A & R; 69(2): 2569-2581.

Rheumatoid Arthritis

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Polymyalgia Rheumatica: Temporal Arteritis

Initial Presentation:1. Rarely under 50 yo2. Sudden onset, though often described as insidious3. Previously healthy, recent illness/ stress/ trauma4. Symmetrical proximal “girdle”

Shoulders, hipsImaging studies show periarticular inflammation

5. Associated with elevated APR 6. Rapid, profound response to low dose steroids7. Self limiting 1-3 y8. May be associated with TA 10% time

Inflammation of temporal arteriesVisual loss, headaches, jaw claudicationHigh suspicion if ESR > 80…TA also known as Giant Cell Arteritis.40% associated with PMR

Systemic Lupus Can look like SOOO many different things…

Almost always associated with:• Profound, at times disabling FATIGUE• Diffuse arthralgias/ myalgias, not always associated with swelling• ANA greater than 1:320-640; 95%• Insidious onset/ or sudden, intermittent flares • Often associated with Rash…malar, annular, systemic often photosensitive…

Systemic Lupus Erythematosis

The Rashes of SLE

Often associated with:• Sicca symptoms- dry eyes/ dry mouth (+ SSA/B)• Oral ulcerations• Joint inflammation- not erosive, can be as painful• Raynaud’s, vasculitis• CNS/ PNS symptoms- especially new onset• Pericardial/ pleural effusion• Renal dysfunction especially with + dsDNA• Bleeding disorders: plt ct, + LAC, ACL/ B2 glyco

Systemic Lupus Erythematosis

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The Antibodies:Mixed Connective Tissue/ RUPUS

Drug induced

Scleroderma: Limited & Systemic

“sclerosis” hardness + “derma” skinHard Skin

Highest mortality rate of any connective tissue diseaseOverwhelming fatigue, arthralgias, pain- can be severe!!

Scleroderma: Limited

Limited: anti Centromere

• Calcinosis

• Raynaud’s: – preceeded by long hx

• Esophageal: GERD

• Sclerodactyl- distal

• Telangiectasias

• Pulmonary HTN- DLCO

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Scleroderma: Systemic

Systemic: anti Scl70• Severe Raynaud’s

– Sudden onset, recent– Ischemic changes: digital ulcerations– Osteolysis- shortening

• Greater risk internal organ dysfunction– GI: GERD, malabsorption

– Renal- sudden rise BP, frequent monitoring

• Sclerodactyly- diffuse/ severe associated with Pruritus

• Interstitial Fibrosis - DLCO- Lung Volumes– May also have Pulm HTN

Sjogren’s Syndrome“Dryness”- Sicca symptoms- dry eyes, dry mouth

Comorbid FM (or just looks like FM…)

What do we know: anti Ro (SSA)/ La (SSB) with + ANA1. Chronic, slowly progressive, attack of salivary glands…2. One of most common, as common as SLE3. Primary Sjogren’s: more severe, higher risk lymphoproliferative px

- Elevated APR, low complements, hypergammaglobulin, - parotid enlargement, cryoglobulins and vasculitis*

4. Secondary r/t SLE or RA- still VERY irritating

j g ySjogren’s Syndrome

With many extraglandular manifestations:

Often looks like FM

1. Most significant: fatigue & neurologic dysfunction

2. Arthralgias/ Arthritis (60-70%)

3. Pulmonary (20-70%)

4. Vascular: Raynaud’s (35-40%) & Vasculitis (5-10%)

5. Neurologic (2-38%): peripheral & central**

6. Lymphoproliferative disease (5%)- 44 x risk

7. Pregnancy associated with neonatal CHB

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Seronegative Spondyloarthropathies

Psoriatic Arthritis Ankylosing Spondylitis

Inflammatory Bowel Disease Reactive Arthritis

Seronegative Spondyloarthropathies:Ankylosing Spondylitis

• May take 5-15 ys before Dx

• “Inflammatory Back”- young adult**

• HLAB27 90%

• Uveitis- inflammatory eye- visual loss “Painful, Red”, unilateral

• Sacroilitis: most common initial feature- symmetrical

• Asymmetrical destructive joint inflammation- Enthesopathies “tendons”

• Predominately men

• Ascending typically

• Occiput to wall

• Forward flexion limited

• No chest expansion

• At risk bone loss

• Valvular problems*

• May Co exist with IBD (10-15%)

Seronegative Spondyloarthropathies:Ankylosing Spondylitis

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Seronegative Spondyloarthropathies: Psoriatic Arthritis

Psoriatic Arthritis 15-30% those with Psoriasis

1. Arthropathy may proceed Psoriasis or come years later

2. May coexist with other forms

3. Erosive OA looks similar: symmetry vs. asymmetry in PsA

4. Mild Psoriasis < 5% BSA

5. Nail changes: pitting, thickening/ thinning

6. Dactylitis

7. HLAB27 50%

8. Sacrolitis: usually asymmetrical vs. AS symmetrical

Inflammatory Bowel Disease

1. GI tract #1 Immune organ: disruption here… problematic

2. 6-25%

3. Symptoms may resemble FM- arthralgias without overt swelling

4. Pauciarticular, asymmetrical, and migratory

5. Prefers lower extr but not essential

6. Also associated with dactylitis and enthesitis

7. May be seen with erythema nodosum “inflammation fat”

Reactive Arthropathy: ? STD or recent GI infections?

1. Chlamydia

2. Shigella/ Salmonella, Campylobacter

Seronegative Spondyloarthropathies: Inflammatory Bowel Disease, Reactive Arthritis

Crystalline Arthropathies: Gout & Pseudogout

• Both acute • asymmetrical/ oligoarthropathy• Self limited• Yet destructive, subclinical often

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Crystalline Arthropathy: Gout

• Men more likely than women till menopause, then same• Highly familial• Initially intermittent, infrequent, few joints• As years progress more often, involving more joints• Easy to treat if known & compliant• Diet can help but ... MODERATION most important consideration

- beer (Hops) and VERY high protein content• 1st attack often distal r/t temperature, crystals accumulate• Any rapid change in UA in serum brings attack• Most respond to Allopurinol- consistently• Goal mnt UA low< 5.0• Alcohol competes for UA clearance • Tophi resolve with treatment

Crystalline Arthropathy: Calcium Pyrophosphate Disease CPPD “Pseudogout”

• May be monoarthicular or polyarticular• Can be asymptomatic with No flares, intermittent flares, continuous• Usually older but some genetic dz associated with younger• Overproduction of pyrophosphate in abnormal cartilage- OA• Diagnosis confirmed by X ray and pattern of joints involved• Some metabolic disorders: Hyperparathyroid and Hemachromatosis

- 2nd and 3rd MCP more likely involved…• No dietary recommendations• More common Women > 70 • Wrist, hand, knee, elbow• Tx: NSAIDs & colchicineSome trial with other DMARDs

Infectious Arthropathy:

• Acute, sudden onset r/t recent infectious process or trauma• Important to obtain hx:

- recent exposure: outdoor, STD, GI infection- recent surgery/ severe rash/ skin lesions

• Constitutional symptoms, localized reaction, CBC• Synovial fluid when possible!!! • Very helpful distinguishing: synovial cell ct/ culture• Lyme: large joint, asymmetrical• Viral arthritis: RA like- 6-12 wks (parvo virus)• HCV: frequently arthritis- disproportionate to overt joint swelling “FM like”

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Inflammatory Myopathies

• Polymyositis

• Dermatomyositis

• Usual presentation: insidious, progressive, painless symmetrical

proximal weakness over 3-6 months BUT

• Associated with overwhelming fatigue, can see low grade fever, wt loss,

and pain often from recruitment of smaller muscle groups

• Dysphagia

• Heliotropic rash, capelike rash, &

• Gottrons papules

• High relation to malignancy

o Greatest risk in 1st 3 ys after dx

CPK/ AldolaseEMG/ NCSMuscle Bx

Paraneoplastic Arthropathy

• Up to 50% patients with cancer develop paraneoplastic syndrome• Rheumatic: hypertrophic osteo, polyarthritis, myositis, & vasculitis. • Symptoms my coincide or precede Cancer by as much as 2 years. • Progression of rheumatic symptoms mirrors malignancy and

resolves with tx of underlying malignant lesion• Should be considered when APR elevated and failing to• Polyarthritis: variable, often lower extr, sudden and severe,

asymmetrical or symmetrical, non erosive

Vasculitis: several different forms-complex & uncommon

• All associated with significant APR & constitutional sx- profound with significant arthralgias/ myalgias

• As name implies: vasculitis- affects vasculature and classified by size blood vessels involved.

• Often associated with severe “multi” organ involvement-o Lungo Heart and great vesselso Kidneyo Skin: purpura- painful, ulcerationso Eye: Inflammatory changes- can result in loss visiono GI- ischemic changeso Acute onset Neuro: central/ or peripheral

• Antibodies to: ANCA (antineutrophil cytoplasmic antibodies) or immune complex mediated (hypersensitivity reaction, cryoglobulinemic)

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Osteoarthritis: Spinal Stenosis

• Most COMMON form of arthritis• Over 200 joints of the body• Can affect any joint: spine/ hands/ knees most common• Least likely: ankles, shoulders, MCPs• Pain is related to mechanical forces• Strongly Age related, increases with age• Stiffness noted, but short- less than < 5-30 mins• Restrictive movement, crepitus, and bony changes.• Thought to be degenerative with no Inflammation- not so…• Beware of other problems as one joint becomes painful…

Osteoarthritis: Degenerative changes

Soft Tissue Rheumatism: No systemic findings

• Regional Pain syndrome: injury or overuse pattern

o Tendinitis, bursitis, CTS

• Fibromyalgia: Widespread Pain

o Bilateral, above and below waist

o Central processing problem

o Associated with # somatic sx

• Fatigue• Cognitive• IBS, HA, Cystitis, RLS

o Mood disorders/ hx of trauma

o Non restorative sleep

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Fibromyalgia

Doing it all!!

Wolfe et al. (2010). A,C & R; 62(5): 600-610.

Depression/ Anxiety and chronic pain

• Incidence of depression as high as 65% with chronic pain

o Arthritis patients up to 30% depression/ anxiety disorder

• Depression often associated with multiple pain complaints

o Not always easy to differentiate

• Anxiety frequent co- morbid condition

• He (2008)

Features of Autoimmunity

• Cell death underlying all specific cells r/t certain dz

• Young peoples not necessarily the elderly

• Women targeted: overall ration 3:1

• Risk factors: significant but not total…external – polygenic ?? Unclear inheritance

• Non contagious

• Neonatal: cross placental possible- SSA heart block, unlikely in first 6 months,

• Trigger suspects: NO ONE KNOWS but…o Infection- viruses & bacteria

o Diet

o Vaccinations

o Accidents, trauma, stress and surgery

• Complex immune response with multiple antibodies present

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Understanding Anti inflammatory Treatment:

Corticosteroids

NSAIDs

NSAIDs… what you need to know

Glucocorticoid Treatment: Anti inflammatory effect and Immunosuppression

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Adverse Effects of Steroids

Figure. 1. Most worrisome AEs. The most worrisome AEs according to 140 patients (left) and 110 rheumatologists (right). All AEs receiving at least 3% of the total score per group are depicted. Scores are corrected for the different numbers of participants per country. Similar scores for AEs by patients and rheumatologists are depicted in white and discordant scores, defined as a difference of at least 3%, are depicted in black. CVD: cardiovascular disease; DM: diabetes mellitus; AEs: adverse eventsFrom van der Goes, M. C.

Sleep: Do’s

• Keep a neat and comfortable bedroom

• Relax before going to bed; read in living room; listen to soothing music

• Keep your room at a temperature that will help you sleep

• Make bedroom conducive to sleep (not too much light), minimize irritating sounds.

• Take pain medication before bedtime if pain wakes you up

• Have a set time and routine for getting to bed

• Wake up at same time as much as possible, even on weekends.

• Reserve the bedroom for sleep and sex.

• Balance activity and rest throughout the day.

• Eat balanced or mini meals.

• Allow for transition period before bedtime.

• Get out of bed if not asleep after 20 minutes; go do something that is not exciting for

30 minutes, then try again

Sleep: Don’ts• Don’t go to bed if not drowsy.

• No heavy meals before bedtime, caution especially if GERD.

• Have radios, TVs, stereos, computers, and cell phones on in the bedroom.

• Eat or drink caffeinated food or beverages after 2-3:00 p.m.

• Drink alcohol to help you go to sleep (poor quality sleep).

• Take unscheduled naps during day, and not after 3:00 p.m.

• Be too active one day and a slug the next. Be consistent if possible

• Exercise 2-3 hours before bedtime.

• Stay out of bed longer than 30 minutes.

• Smoke right before bed

• Try not to use antihistamines/ hypnotics to help with sleep, poor quality.

• Don’t let children or pets interfere with your sleep.

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