Non-pharmacologic strategies superior to drugs for ‘poorly understood’ rheumatic pain
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SAN DIEGO — Non-pharmacologic approaches to pain management in rheumatology, like exercise and meditation, can be superior to pharmacologic strategies, according to a speaker at the 2023 Congress of Clinical Rheumatology West.
Addressing attendees, Yvonne C. Lee, MD, MMSc, of the Northwestern University Feinberg School of Medicine, argued that the main driver of this pharmacologic inferiority is that the causes of rheumatic pain remain “poorly understood.”
“Not all pain in patients with rheumatic disease is due to active joint inflammation,” she said.
Lee challenged rheumatologists to better understand pain both in broad terms and as it impacts individual patients.
“We need to take a step back and think about pain and what it is,” she said. “Many of us bury our heads in the sand and hope that the patient doesn’t raise the question.”
According to Lee, pain can be categorized as nociceptive, neuropathic and nociplastic. Nociceptive pain arises when there is actual or threatened tissue damage.
“Nociceptive pain is pain working the way it should,” Lee said. “It is alarm system.”
Neuropathic pain, meanwhile, is triggered by a lesion or disease impairing the somatosensory system. Lastly, nociplastic pain arises from altered nociception despite no clear evidence of tissue damage, and often presents what Lee referred to as a “volume control problem.
“For people with this nociplastic pain problem, it affects other sensory systems as well,” she said.
According to Lee, it is critical for rheumatologists to remember that they may be managing patients with all three of these types of pain. Additionally, although laboratory results and tender or swollen joint counts may indicate that therapeutic interventions are effective, patient pain may persist.
“Abnormalities in central nervous system (CNS) pain processing are associated with nociplastic pain, which can lead to worse response to DMARDs,” Lee said.
However, experts turning to peer-reviewed data for evidence of why this occurs may be disappointed, she added.
“Data regarding treatment of this CNS pain processing are sparse,” she said.
In the absence of any clear answers, Lee offered some pearls for achieving pain control without relying on pharmacologic interventions to control pain. One is to improve the control of inflammation.
“Another is to educate the patient about pain and really discuss nonpharmacologic strategies,” Lee said.
Increased physical activity, acupuncture, mindfulness or meditation approaches like yoga and tai chi, along with improving sleep, can have beneficial effects on pain, she said. In addition, the 2017 revised EULAR guidelines on managing fibromyalgia can be useful for patients across the spectrum of rheumatic diseases.
“Within these recommendations, there was basically only one thing that garnered a strong recommendation, and that was exercise,” Lee said. “There was 100% agreement.”
Meanwhile, a lack of sleep can trigger a “vicious cycle” with increases in pain, loneliness and isolation, according to Lee.
“Improving sleep will likely improve pain,” she said. “However, it is contingent upon that sleep improving.”
However, improvements in pain resulting from improved sleep are often small, Lee added.
“Future studies are needed to determine what thresholds need to be met,” she said.
In the end, a multimodal approach — using pharmacologic approaches to manage inflammation and non-pharmacologic approaches for pain — may have the greatest impact on pain overall, according to Lee.
“The other thing is whether multi-component therapies are needed, and they probably will be,” she said.
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Lee YC. Pain Mechanisms in Rheumatic Diseases: Towards a Targeted Approach to Pain Management? Presented at The Congress of Clinical Rheumatology West; Sept. 7-10, 2023 (hybrid meeting).
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