2023-06-12 08:16:44
Chronic pain persists for more than three months and is the main reason for medical consultation, representing approximately 40% of consultations with general practitioners. In rheumatoid arthritis (RA), the pain is caused by tissue damage induced by inflammation in the joints. Anushka Soni from the University of Oxford explained that although chronic pain in RA either closely related to inflammationshe can persist when inflammation is controlled. If aggressive drug therapy reduces disease activity, it often has little effect on pain and disability.
This can be explained by the fact that circulating neutrophils and the inflammatory cytokines sensitize peripheral neurons to pain independent of inflammation. In addition, joint inflammation in RA patients is linked to increased functional connectivity between regions of the brain that process pain. However, there are individual differences in how the brain processes painwhich could eventually contribute to the development of personalized assessments and treatments.
Pain is traditionally classified as nociceptive when caused by inflammation or tissue damage, and as neuropathic when it is caused by a lesion or disease of the somatosensory system. But recent findings have led researchers to classify a third type of pain, called nociplinary pain, or pain that persists in the absence of inflammation and tissue damage.
The benefits of physical exercise
Les recommandations du National Institute for Health and Care Excellence (NICE) from the UK include exercise among chronic pain management options in RA, but a recent study found a high level of fear avoidance of physical activity in patients.
“Fear-related avoidance behavior is associated with the development of widespread chronic pain“said A. Soni.”If identified at an early stage, it is a problem that could be treated alongside our usual approach to managing rheumatoid arthritis.”
NICE also recommends acceptance and commitment therapy, which has been shown to beneficial for fibromyalgia patientsas well as acupuncture and antidepressants, including duloxetine seems to be the most effective. However, he recommends that patients try non-pharmacological approaches first.
In another session, Andreas Iacovou, Executive Secretary of the Cyprus League Against Rheumatism, described how physical activity can benefit RA patients through its effects on the immune system.
A. Iacovou explained that an inactive and sedentary lifestyle is associated with an increase in the number of M1 macrophages that release inflammatory cytokines that activate pain-sensing neurons and induce pain. On the other hand, physical activity increases the number of M2 macrophageswhich produce anti-inflammatory cytokines that inhibit pain signaling.
The HUNT 3 study provides solid evidence of the benefits of physical activity. It shows that increasing the frequency, duration and intensity of exercise is associated with significant reduction in chronic pain in people of all ages, and especially in older women.
“As healthcare professionals, we must put patients at the center of our concerns“, said A Iacovou. “We need to recognize their physical activity needs and physicians need to know what specific exercise programs are best suited to their needs. »
Physiotherapy, behavioral therapy and virtual reality
During the same session, Thomas Davergne, a physiotherapist in Paris, spoke about the benefits of physiotherapy for patients with RA.
He spoke about the role of the physiotherapist in pain patient education and its care. A systematic review published in 2022 shows that psychological interventions are most effective when carried out alongside physiotherapy, and that pain education programs accompanied by behavioral therapy produce the most lasting effects.
He also presented evidence for a number of experimental therapeutic approaches. One of them is transcutaneous electrical nerve stimulation (TENS). A meta-analysis of 381 studies on TENSpublished in 2020, concluded that “there is moderate certainty evidence that pain intensity is lower during or immediately after TENS compared to placebo and no serious adverse effects“.
A proof-of-concept study published in 2022 showed that motor imagery improves the quality of reaching tasks in healthy people, suggesting that it is a possible treatment option for patients with RA, especially if applied with virtual reality, which has been shown to be effective for relieve chronic pain in patients with fibromyalgia, complex regional pain syndrome and phantom limb pain in amputees.
Another study published at the start of the year, involving 22 randomized controlled trials involving 2,641 patients, also shows that the use mobile phone applications has positive effects on patients with fibromyalgia and osteoarthritis, among other conditions associated with chronic pain.
T. Davergne concluded his presentation by emphasizing the importance of the patient-centred approach. According to the International Association for the Study of Pain, a person’s report of their pain experience should be respected. “This is not always the case in the medical field, but it should be the first therapeutic principle of medical professionals. »
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