JOINT PAIN This is a brief guide to management of joint pain.

Dr Wilf Treasure 25/7/13 TREATMENT OF JOINT PAIN While trying the treatments below it might be helpful to monitor your symptoms in the areas of: pain severity; fatigue; depression; sleep; function; ability to work; quality of life. The exercise that helps best for knee pain and probably hip, ankle and foot pain as well is the sort that increases strength, flexibility and aerobic capacity (Uthman et al. 2013). TABLE 1 (NICE CG 59, 2008) FIRST advice information exercise weight loss if overweight heat and cold applied to the skin capsaican applied to the skin corticosteroid injections in the joint opioids such as codeine Non-Steroidal Anti-Inflammatory Drugs by mouth joint surgery PAIN-KILLERS Pain-killers on their own often dont work very well. They work best when combined with other measures such as those listed in the Table 1. Some pain-killers work well for some people, other pain-killers work better for other people. Neither doctor nor patient can know in advance which painkiller will work best for the individual: its a matter of trial and error. So when getting for pain-killers - on prescription or over the counter - its often a good idea to obtain initially just a small quantity to try before continuing on them or trying an alternative. That said, some pain-killers are more likely to work and some more likely to cause side-effects: comparisons are shown in Tables 2 and 3. Some definitions may help. The (pleasant) placebo and (unpleasant) nocebo effects are physiological changes induced by non-pharmacological mechanisms (Clinical Evidence 2012). Successful pain relief is defined as at least 50% pain relief to a level no worse than mild pain including the placebo effect. Where no figure is entered its because research data are lacking. SECOND paracetamol Non-Steroidal AntiInflammatory Drugs such as piroxicam applied to the skin THIRD aids to daily living supports and braces TENS: Transcutaneous Electrical Nerve Stimulation manipulation and stretching especially for hip

These figures apply to the majority of people but not necessarily to special groups. For instance, compared with other people, patients with rheumatoid arthritis get more benefit from Non-Steroidal Anti-Inflammatory Drugs and less cardiovascular harm (Lindhardsen et al. 2013). TABLE 2 (Moore et al. 2013) PAIN-KILLER Of 100 people, number getting successful pain relief in the short term including the placebo effect 74 46 60 Of 100 people, number getting successful pain relief in the longer term including the placebo effect SIDE-EFFECTS

Paracetamol 500mg and ibuprofen 200mg Paracetamol 1000mg Non-Steroidal Anti-Inflammatory Drug applied to skin Non-Steroidal Anti-Inflammatory Drug by mouth Opiate (oxycodone)

Unlikely tummy upset Rare Unlikely skin irritation

55

42 21

Common tummy upset, kidney damage, cardiovascular risk Common drowsiness, constipation, sickness

TABLE 3 (Nesch et al. 1996) (Panchal et al. 2007) Of 100 people given opiates for about 4w for osteoarthrosis of knee or hip: Number having reduced pain (without the placebo effect) Number having improved function (without the placebo effect) Number having side-effects (without the nocebo effect) Number stopping the opiates because of side-effects (without the nocebo effect) Number getting constipation (variable depending on whether nocebo effect included or not)
REFERENCES Clinical Evidence, 2012. Clinical Evidence - A glossary of EBM terms. Available at: http://clinicalevidence.bmj.com/x/set/static/ebm/toolbox/678178.html [Accessed December 29, 2012]. Lindhardsen, J. et al., 2013. Non-steroidal anti-inflammatory drugs and risk of cardiovascular disease in patients with rheumatoid arthritis: a nationwide cohort study. Annals of the Rheumatic Diseases. Available at: http://ard.bmj.com/content/early/2013/06/07/annrheumdis-2012-203137 [Accessed July 25, 2013]. Moore, A. et al., 2013. Expect analgesic failure; pursue analgesic success. BMJ, 346(may03 1), pp.f2690f2690. Nesch, E. et al., 1996. Oral or transdermal opioids for osteoarthritis of the knee or hip. In Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd. Available at: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003115.pub3/abstract [Accessed June 22, 2013]. Panchal, S.J., Muller-Schwefe, P. & Wurzelmann, J.I., 2007. Opioid-induced bowel dysfunction: prevalence, pathophysiology and burden. International Journal of Clinical Practice, 61(7), pp.11811187.

12 10 8 5 7 to 90

Uthman, O.A. et al., 2013. Exercise for lower limb osteoarthritis: systematic review incorporating trial sequential analysis and network meta-analysis. BMJ (Clinical research ed.), 347, p.f5555.