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Managing Osteoarthritis-associated Pain

Personalised pain management

Read time: 40 mins
Last updated:4th Nov 2022
Published:10th Nov 2020
  • Learn why linear pain scales alone are often insufficient
  • Understand the value of functional assessment tools
  • Help patients set individual goals and develop a comprehensive pain management plan
  • Discover the biopsychosocial approach to better understand pain from a patient's perspective

Linear scales not optimal for osteoarthritis

Linear scales for pain such as visual analogue scales (VAS), are routinely used in clinical trials because of their simplicity and adaptability to a broad range of populations and settings1. As patients are asked to place a mark on a line at a point representing their pain severity, the VAS is often treated as a scale with equality between intervals and subjected to arithmetical operations and statistics (for example, percent change in score). However, some patients find it difficult to judge how to rate their pain on the VAS line, describing it as "not very accurate", "sort of random", "almost guesswork" or having to "work it into numbers first"2.

A study examining the scaling properties and responsiveness of the pain VAS in patients with joint pain awaiting replacement surgery showed that using raw data or change scores will either underestimate or overestimate true change and that VAS is only a valid tool for measuring pain at one point in time3. Further, older patients may find completing the pain VAS difficult because of cognitive impairments or motor skill issues1.

The Numeric Rating Scale (NRS) for pain is another single-item scale used for estimating patients’ pain intensity1. Neither the VAS nor NRS provides a comprehensive evaluation of pain and so there are questionnaires available that evaluate the multiple dimensions of acute and chronic pain1:

  • McGill Pain Questionnaire (MPQ and short-form MPQ) is a generic pain measure (pain intensity and quality) useful mainly for research
  • Chronic Pain Grade Scale (CPGS) is useful for comparing chronic pain severity across groups and in response to treatment
  • Short Form 36 Bodily Pain Scale (SF-36 BPS) evaluates pain in the context of overall health status, making it most suitable for comparing across populations and between subgroups within populations
  • Intermittent and Constant Osteoarthritis Pain (ICOAP) is a measure of osteoarthritis-specific pain, recommended for description and evaluation of pain in both research and clinical practice – it evaluates the impact of pain on mood, sleep and quality of life
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Functional assessment tools for osteoarthritis

Functional assessment tools and patient goal setting for osteoarthritis may lead to a more personalised approach

Functional assessment tools

There are a number of functional assessment tools that can be useful in patients with osteoarthritis (OA), which are demonstrated in Figure 1.

PFI_Osteo_Fig2.1.png

Figure 1. Functional assessment tools useful in patients with osteoarthritis (Adapted5). OA, osteoarthritis; WOMAC, Western Ontario and McMaster Universities Osteoarthritis Index.

There have been reviews and meta-analyses of outcome measures for patients with hip or knee OA and attempts to define an international standard4,6,7. However, this has been challenging, given the varying levels of evidence available for some measures. In general, the WOMAC questionnaire was demonstrated to be superior to all other instruments for evaluating hip and knee function7.

Hip disability Osteoarthritis Outcome Score (HOOS) and the Knee Injury and Osteoarthritis Score (KOOS) and were developed as extensions of the WOMAC, and are non-proprietary comprehensive alternatives. Short forms are also available (HOOS-PS and KOOS-PS) but do not include a measure of pain and so they are often used in combination with VAS or NRS7.

There are also pain and function assessment tools for use specifically in patients receiving joint replacements. These include the Oxford knee and hip scores8 and various knee scores such as that of the American Knee Society Score (AKSS)9.

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Individual goal-setting in osteoarthritis

Individual goal-setting should form the foundation of a personalised pain management strategy for osteoarthritis

The importance of goal-setting

It is very common for patients with chronic pain to feel overwhelmed and isolated because of their condition. They often use ineffective coping patterns, limit their activity and become preoccupied with the single goal of decreasing their pain. Having pain reduction as a solitary goal puts patients at risk for frustration, depression, and decreased adherence to treatment14.

HCPs should help patients recognise that while their pain may or may not improve, their level of functioning and management of their condition will. Chronic pain requires day-to-day management and HCPs are in an ideal position to educate and support self-management approaches for patients. Goal-setting approaches have been shown to increase progress toward mutually agreed goals and encourage adherence to physicians’ recommendations15.

Goal setting encourages patient accountability, development of active coping strategies, and some control over their condition. It also allows HCPs to monitor patient progress, determine the extent of continued treatment, and feedback on goal completion: reinforcing future goal setting14.

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The biopsychosocial approach to managing osteoarthritis pain

Self-reported osteoarthritis (OA) pain and clinical symptoms often correlate poorly: minor physical symptoms can be associated with increased pain intensity or duration. Conversely, marked degenerative changes may be associated with no change in self-reported pain, or no pain at all16. The biopsychosocial model of pain helps explain this phenomenon. The model accounts for the impact of social, psychological, behavioural and physical factors on a patients' experience of pain (Figure 2)17,18.

OA_T2_Fig_2_2022-01.png

Figure 2. The biopsychosocial approach to managing osteoarthritis pain (Adapted19).

The biopsychosocial approach considers all aspects of an individual's life that influence and dynamically interact to affect their experience of pain. For example, a person's expectations and self-efficacy (their belief in their ability to complete tasks and reach goals) can affect their experience of pain and are associated with changes in mood, sleep and coping abilities. The biopsychosocial approach considers the overall needs of an individual, including social and psychological factors that affect their quality of life and ability to carry out activities of daily living, employment-related activities, family commitments and hobbies20.

Osteoarthritis_t2_Fig_3_2021.png

Figure 3. Biopsychosocial factors to consider when assessing a person with osteoarthritis (Adapted20).

Apart from a comprehensive physical and pain assessment – including a functional pain assessment, pain characteristics, previous and ongoing pain treatments, inflammation and joint damage – and discussing treatment options, other factors to consider include20:

  • social factors: family life, daily activities, lifestyle expectations
  • health beliefs: concerns, expectations, current knowledge of OA
  • attitudes to exercise
  • occupational factors: short and long-term effects
  • mood: depression, anxiety, life stresses
  • sleep quality
  • support networks
  • comorbidities, including other musculoskeletal pain
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Advice and goals for Marie

Marie_3.png

 

After assessing the effect of osteoarthritis on Marie’s function, quality of life and expectations, the specialist gave her educational material regarding her condition and informed her of additional resources. The specialist discussed with Marie various pharmacological and nonpharmacological treatment options and lifestyle modifications to help control her osteoarthritis (OA) pain and increase her ability to function. This section includes a short quiz to help reinforce your learning.

Let’s take a look at the nonpharmacological treatment options:

  • Weight loss through a combination of diet and exercise
  • Physical therapy
  • Bracing - a knee unloader brace was prescribed to relieve some of Marie’ s symptoms
  • Occupational therapy - helps patients by providing an individual functional assessment and joint-protective strategies to be used during their activities of daily life to maintain function

Marie’s ‘prescription’

Marie was prescribed an exercise programme, to be implemented gradually, and advised about patellar taping or use of a knee sleeve for additional support.

  • Marie was cautioned to avoid high-impact activities like running and jumping, and encouraged to take up low-impact activities such as swimming and cycling, which have been proven beneficial for the arthritic knee
  • Marie was also counselled to avoid activities that load the patellofemoral joint, such as squatting and ascending and descending stairs because she had significant patello-femoral disease
  • Marie’s programme of physical therapy aimed to increase range of motion (ROM) and flexibility, especially in the hamstrings. Muscle strength training for both quadriceps and hamstrings was suggested, as was proprioceptive retraining. The importance of stretching all major muscle groups that cross the joint to maintain range of motion was stressed. Tight hamstrings in particular can exacerbate knee pain, and Marie showed evidence of this
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References

  1. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form‐36 Bodily Pain Scale (SF. Arthritis Care Res (Hoboken). 2011;63(S11):S240–S252.
  2. Jackson D, Horn S, Kersten P, Turner-Stokes L. Development of a pictorial scale of pain intensity for patients with communication impairments: Initial validation in a general population. Clin Med J R Coll Physicians London. 2006;6(6):580–585.
  3. Kersten P, White PJ, Tennant A. Is the pain visual analogue scale linear and responsive to change? An exploration using Rasch analysis. PLoS One. 2014;9(6):99485.
  4. Saleh KJ, Davis A. Measures for pain and function assessments for patients with osteoarthritis. Journal of the American Academy of Orthopaedic Surgeons. 2016;24(11):e148–e162.
  5. verywellhealth.com. How physical function is assessed for osteoarthritis. Available at: https://www.verywellhealth.com/physical-function-osteoarthritis-patients-2552214. Accessed 25 March 2020.
  6. Rolfson O, Wissig S, van Maasakkers L, Stowell C, Ackerman I, Ayers D, et al. Defining an international standard set of outcome measures for patients with hip or knee osteoarthritis: Consensus of the International Consortium for Health Outcomes Measurement Hip and Knee Osteoarthritis Working Group. Arthritis Care Res (Hoboken). 2016;68(11):1631–1639.
  7. Lundgren-Nilsson Å, Dencker A, Palstam A, Person G, Horton MC, Escorpizo R, et al. Patient-reported outcome measures in osteoarthritis: a systematic search and review of their use and psychometric properties. RMD open. 2018;4(2):e000715.
  8. Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, et al. The use of the Oxford hip and knee scores. Journal of Bone and Joint Surgery - Series B. 2007;89(8):1010–1014.
  9. Reddy KIA, Johnston LR, Wang W, Abboud RJ. Does the Oxford Knee Score Complement, Concur, or Contradict the American Knee Society Score? J Arthroplasty. 2011;26(5):714–720.
  10. McAlindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthr Cartil. 2014;22(3):363–388.
  11. Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72(2):220–233.
  12. Bruyere O, Honvo G, Veronese N, Arden NK, Branco J, Curtis EM, et al. An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO). Semin Arthritis Rheum. 2019;49(3):337–350.
  13. Ryan S. Managing lifestyle factors in adults with osteoarthritis. Nurs Stand. 2015;29(46):43–50.
  14. Mirgain SA and Singles J. Goal setting for pain rehabilitation clinical tool. 2016. Available at: https://www.va.gov/WHOLEHEALTHLIBRARY/tools/goal-setting-for-pain-rehabilitation.asp. Accessed 30 December 2021.
  15. Schulman-Green DJ, Naik AD, Bradley EH, McCorkle R, Bogardus ST. Goal setting as a shared decision making strategy among clinicians and their older patients. Patient Education and Counseling. 2006;63(1–2):145–151.
  16. Fukui N, Yamane S, Ishida S, et al. Relationship between radiographic changes and symptoms or physical examination findings in subjects with symptomatic medial knee osteoarthritis: a three-year prospective study. BMC Musculoskeletal Disorders. 2010;11(1):1–10.
  17. Gatchel R. Comorbidity of chronic pain and mental health disorders: The biopsychosocial perspective. American Psychologist. 2004;59(8):795–805.
  18. Turk D, Monarch E. Biopsychosocial perspective on chronic pain. In: Psychological approaches to pain management: A practitioner’s handbook (3rd ed.). New York: The Guilford Press; 2018.
  19. Bartley E, Palit S, Staud R. Predictors of Osteoarthritis Pain: The Importance of Resilience. Current Rheumatology Reports. 2017;19(9):57.
  20. National Institute for Health and Care Excellence (NICE). Holistic approach to osteoarthritis assessment and management. In: Osteoarthritis: care and management. NICE Clinical Guidelines, No. 177. 2020. National Institute for Health and Care Excellence (UK) https://www.ncbi.nlm.nih.gov/books/NBK333054/. Accessed 22 October 2021.

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