Pain

Pain is a universal phenomenon. It is an unpleasant sensation felt by more than half of the world's population. Pain is a perception which is real and leads to considerable deterioration of quality of life in patients with arthritis and other rheumatological conditions. It has complex causes and is a leading cause of morbidity. Pain limits ability to perform day-to-day activities, maintain social relationships and lead productive life. 'Pain is a perfect misery, the worst of evils, and when excessive, overturns all patience' (John Milton).
Pain as a sensation starts from sensors in skin and other organs and reaches brain via nerve channels passing through spinal cord. It can be nociceptive (produced by injury), neuropathic (due to irritation of nerve), mixed or psychological. Fast pain is one which occurs after an injury. Localization of this pain is sharp and accurate and is protective in nature. Slow pain is a delayed perception after tissue injury that helps in healing. Descending chemical and electrical impulses from brain modulate pain perception to a significant extent.
Pain may be described in various ways such as sharp, shooting, burning, nagging, dull and aching. Being a subjective sensation, it is very difficult to quantify pain. Severity of pain is generally measured by visual analog or numerical rating scales which ask the patients to rate the severity of their pain on a 1-10 or 1-100 scale. Back pain can be as severe as cancer pain whereas severity of arthritis pain can be almost half that of pain during childbirth. Pain leads to restlessness, anxiety and depression. Physical effects of pain include nausea, vomiting, palpitations, urinary incontinence, rise in blood pressure, etc.
Pain does need treatment but it must be realized that pain is a protective phenomenon. Pain in arthritis limits movements that can be damaging. Chemical substances released during slow pain help in healing.
One must learn to bear and live with at least some of arthritis pain. We have many effective drugs for pain relief, but not all work in patients in identical way. Though invaluable in pain management, they are notorious for causing skin rashes, acidity and other more severe abdominal problems, liver and kidney toxicity as well as effects on heart and blood pressure. They interact with some other drugs such as those used for diabetes and blood pressure. Control of disease causing pain e.g. rheumatoid arthritis alleviates need for pain medication.

Guidelines by European League against Rheumatism (EULAR) on use of pain killers include following:

  1. Avoid long term use
  2. Use as and when required and not continuously
  3. Use lowest effective dose for shortest duration
  4. Use only one painkiller at a time
  5. Avoid in stomach ulcer and kidney disease


Prescription of painkillers must be individualized after assessment of need and risk factors. Paracetamol (maximum dose: 4 grams/day) is a comparatively safe painkiller. Local application of heat or ice pack or an ointment should also be tried in all cases of musculoskeletal pain. Patient education regarding self-help, social support, joint protection and assistive devices, physical therapy and exercise, acupuncture and music therapy are important non-drug measures in pain management.

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