Conclusion: FM is related to worse scores on the DAS28, HAQ, and SF-36 in patients with RA. The presence of FM may have major implications in the interpretation of the DAS28 score because it is related to higher scores independently of objective evidence of RA activity.
Report of the ACR Pain Management Task Force.
(Arthritis Care Res. 2009;62: 590–599.)
Introduction
Pain is the most common symptom of patients with rheumatic disorders and can occur in both inflammatory and noninflammatory conditions. As a complex phenomenon with a strong subjective component, pain can be influenced by the nature of the underlying disease, personal predisposition (biologic and psychological), as well as environmental and psychosocial factors that impact the pain experience. In the management of patients with musculoskeletal disease, therefore, the characterization of pain (e.g., its onset, duration periodicity, and impact on functioning) is important in establishing the diagnosis and developing a comprehensive treatment plan to reduce pain and to improve quality of life.
Although rheumatologists diagnose and treat pain, they do not characterize themselves as “pain physicians.” Rather, in their professional identity, many rheumatologists consider themselves more narrowly as subspecialists who treat musculoskeletal disorders that have a component of acute and chronic nonmalignant pain. Furthermore, rheumatologists have traditionally approached pain from the perspective of the proximal causes of pain such as tissue injury and inflammation, and have concentrated therapy on reducing inflammation either locally or systemically. The therapies used have been predominantly pharmacologic and include nonsteroidal antiinflammatory drugs (NSAIDs), disease-modifying agents including biologics, and corticosteroids. Although commonly recommended, nonpharmacologic psychosocial interventions such as cognitive-behavioral therapy or body-based therapies including exercise are generally considered less effective by rheumatologists despite evidence that such approaches can be highly efficacious depending on the setting or disease.
For most conditions treated by rheumatologists, the etiology of pain has been conceptualized primarily in the context of events in peripheral tissue. As a result, rheumatologists have relied heavily on pharmacologic therapies directed at the immune system to control symptoms, especially in inflammatory disease. Correspondingly, for patients with major or irreversible tissue damage, whether arising in inflammatory or noninflammatory disease, surgery has been the mainstay of treatment, with pharmacologic therapy used as a transition until a definitive operation is performed. Given this approach, events in the central nervous systems contributing to the experience of pain have received less attention in treatment, with additional analgesic, psychosocial, or interventional therapies receiving neither extensive investigation nor widespread or appropriate use. This approach may limit the utilization of newer and multidisciplinary approaches to pain management in the care of patients with rheumatic disease as well as the conduct of cutting-edge pain research by rheumatologists.