EULAR Releases Recommendations for Pain Management in OA, Inflammatory Arthritis

The European League Against Rheumatism (EULAR) has released recommendations to enable health professionals to provide knowledgeable pain management support for patients with inflammatory arthritis and osteoarthritis (OA). The recommendations have been published in the Annals of the Rheumatic Diseases.

A multidisciplinary task force conducted a systematic review to evaluate evidence regarding the effects of multiple treatment modalities on pain in this patient population. The task force identified 186 studies that met the inclusion criteria. Overall, physical activity, exercise interventions, and for psychological interventions overall has positive effects on pain. In addition, educational interventions, orthotics, weight management, and multidisciplinary treatment had positive effects on pain for particular disease groups.

A summary of the recommendations is as follows:

• Pain management assessments should include patient needs and preferences, patient pain characteristics, and current inflammation and joint damage as sources of pain. The following pain-related factors may need additional attention: the extent of pain-related disability, beliefs and emotions about pain and pain-related disability, social influences related to pain and its consequences, sleep problems, and obesity.
• Patients should receive personalized management plans to help reduce pain and improve pain-related function and participation in daily life. Plans should be guided by shared decision-making, the needs of the patient, the health professional’s assessment, and evidence-based treatment options.
• All patients should receive education. Patients should have access to educational materials, including brochures or links to online resources with encouragement to stay active and sleep hygiene guidelines. Patients should also have access to psychoeducation by the health professional and online or face-to-face self-management interventions.
• Consider a multidisciplinary intervention if more than one treatment options are indicated and if monotherapy failed.

Patients should receive physical activity and exercise recommendation if indicated:

• The clinician and patient should collaboratively determine whether active, supervised physical exercise, or multidisciplinary treatment is indicated.
• Patients should be referred to a physiotherapist for individually graded physical exercise or strength training if the patient is not able to initiate physical activity and exercises without help.
• Consider a multidisciplinary intervention, including cognitive-behavioral therapy (CBT), if psychosocial factors such as fear of movement or catastrophizing cognitions underlie a disabled, sedentary lifestyle.

Patients should receive orthotics if indicated:

• Orthotics, daily living aids, an assistive device, or ergonomic adaptation can be offered if a patient has pain during daily activities and impedes functioning.
• If the patients want assistive support, consider referral to an occupational therapist, who can offer education about appropriate ways to use joints and ergonomic principles, appraise the need for the use of an orthotic or assistive device, give advice about how to acquire assistive support, fit the customized aid to the patient, offer training, and refer the patient to the appropriate specialist.

Patients should receive psychological or social interventions if indicated:

• If psychological factors interfere with effective pain management and functional status, consider providing basic social and psychological management support or referral to a psychologist, social worker, self-management support program, CBT, or multidisciplinary treatment.
• If psychopathology is present, discuss treatment options with the patient and the patient’s primary care physician.

Patient should receive sleep interventions if indicated:

• In patients who report sleep disturbance, inquire about causes and offer basic education about good sleep hygiene practices.
• If sleep remains disturbed, refer to a therapist or specialized sleep clinic.

Patients should receive weight management if indicated:

• In patients with obesity, explain that obesity can contribute to pain and disability.
• Discuss accessible weight management options with the patient or refer the patient for appropriate specialized weight management support.

Patients should receive pharmacological and joint-specific pain treatment if indicated:

• Clinicians should ask about the patient’s existing use of prescribed and over-the-counter analgesics and consider if the frequency is safe.
• Clinicians should ask or refer for further specialist or medical advice if there are concerns or if additional pharmacological treatment may be indicated.

Reference

Geenen R, Overman CL, Christensen R, et al. EULAR recommendations for the health professional’s approach to pain management in inflammatory arthritis and osteoarthritis [published online May 3, 2018].  Ann Rheum Dis. doi: 10.1136/annrheumdis-2017-212662