IntroductionPain remains the most important problem for people with rheumatoid arthritis (RA). Active inflammatory disease contributes to pain, but pain due to non-inflammatory mechanisms can confound the assessment of disease activity. We hypothesize that augmented pain processing, fibromyalgic features, poorer mental health, and patient-reported 28-joint disease activity score (DAS28) components are associated in RA.MethodsIn total, 50 people with stable, long-standing RA recruited from a rheumatology outpatient clinic were assessed for pain-pressure thresholds (PPTs) at three separate sites (knee, tibia, and sternum), DAS28, fibromyalgia, and mental health status. Multivariable analysis was performed to assess the association between PPT and DAS28 components, DAS28-P (the proportion of DAS28 derived from the patient-reported components of visual analogue score and tender joint count), or fibromyalgia status.ResultsMore-sensitive PPTs at sites over or distant from joints were each associated with greater reported pain, higher patient-reported DAS28 components, and poorer mental health. A high proportion of participants (48%) satisfied classification criteria for fibromyalgia, and fibromyalgia classification or characteristics were each associated with more sensitive PPTs, higher patient-reported DAS28 components, and poorer mental health.ConclusionsWidespread sensitivity to pressure-induced pain, a high prevalence of fibromyalgic features, higher patient-reported DAS28 components, and poorer mental health are all linked in established RA. The increased sensitivity at nonjoint sites (sternum and anterior tibia), as well as over joints, indicates that central mechanisms may contribute to pain sensitivity in RA. The contribution of patient-reported components to high DAS28 should inform decisions on disease-modifying or pain-management approaches in the treatment of RA when inflammation may be well controlled.
Background: DAS28 is interpreted as the inflammatory disease activity of RA. Non-inflammatory pain mechanisms can confound assessment. We aimed to examine the use of DAS28 components or DAS28-derived measures that have been published as indices of non-inflammatory pain mechanisms, to inform interpretation of disease activity.
Background Pain remains the most important problem for people with RA. Pain due to non-inflammatory mechanisms can confound the assessment of disease activity. People with established RA may fulfil fibromyalgia classification criteria, which may be associated with a more painful experience. Objectives We hypothesise that abnormal central pain processing in RA is associated with patient-reported DAS28 components and fibromyalgic features. Methods Fifty people with stable, longstanding RA recruited from a rheumatology outpatient clinic were recruited. All were using pharmacologic treatments for RA. They were assessed for pain pressure thresholds (PPT) at 3 separate sites (knee, tibia and sternum), 28 joint disease activity score (DAS28) and fibromyalgia classification criteria (Widespread Pain Index and Symptom Severity Scale). Pain (McGill, ICOAP and Likert scale), fatigue (Fatigue Severity Scale), depression (Beck Depression Index II) and anxiety (State-Trait Anxiety Index) were assessed. Multivariable analysis was performed to assess the association between PPT and DAS28 components, DAS28-P (the proportion of DAS28 derived from the patient-reported components of visual analogue score and tender joint count), questionnaires or fibromyalgia status. Results Median (IQR) age was 60 (54 – 69) and 76% were female, while 21% smoked. Analgesia was taken by 69% (paracetamol 63%, NSAID 16%, opiate 37%). More sensitive PPTs at the medial knee, tibia and sternum were each associated with higher patient-reported DAS28 components (r<-0.45 for all comparisons), higher DAS28-P (r<-0.40), greater reported pain (r<-0.30) and poorer mental health scores (r<-0.12). Multiple regression analysis showed that these associations were not explained by age or gender. A high proportion of participants (48%) satisfied classification criteria for fibromyalgia, which was also associated with more sensitive PPTs at all sites measured, higher patient-reported DAS28 components, higher DAS28-P, greater reported pain and poorer mental health scores. Multiple regression confirmed that fibromyalgia was associated with higher VAS (aOR, 95% CI 3.7, 1.4 – 9.5, p=0.008), independent of other DAS28 components, age and gender. Concurrent RA and fibromyalgia was not associated with any particular biologic or DMARD; nor smoking, age or gender. Neither PPTs nor fibromyalgia were consistently associated with higher inflammatory DAS28 components (higher swollen joint counts or higher acute phase response). Conclusions People with established RA commonly satisfy fibromyalgia classification criteria, and these people report poorer mental health and display increased pain sensitivity to pressure at non-articular sites. Fibromyalgic symptoms, sensitivity to pain and poorer mental health are all associated with increased DAS28 scores. However, high disease activity scores in some people with RA may reflect augmented pain processing rather than active inflammatory disease. Pain in RA should be managed alongside inflammatory disease activity, as non-inflamma...
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