Vinod Chandran MD, PhDVarious forms of exercise and proper nutrition can help patients with conditions like psoriatic arthritis better cope with chronic pain and improve their quality of life, says a Clinical Assistant Professor at the Cumming School of Medicine at the University of Calgary in Calgary, Alberta, Canada.
"Chronic pain forces patients to think about the basics in their life like eating better, exercising more, and focusing on good sleep hygiene," says John Pereira MD, CCFP, a physician at the Calgary Chronic Pain Centre and President-Elect of the Pain Society of Alberta, speaking here at the annual meeting of the Canadian Dermatology Association about chronic pain management. "Patients will continue to have pain, but their quality of life can improve substantially."
Gradually taking up exercise is a way to lower levels of inflammation long-term, says Dr. Pereira. Some forms of activity, like supervised yoga, also enhance mental well-being and may ward off co-morbidities like depression, adds Dr. Pereira.
"The postures, deep breathing and mindfulness play a role in pain management," says Dr. Pereira, in an interview with Dermatology Times.
Unfortunately, very little education about pain management has been part of the curriculum in most medical schools, notes Dr. Pereira. A 2011 study that included 117 US and Canadian medical schools found that US medical schools devote a median of nine teaching hours on pain and its management, compared to a median of 19.5 hours in Canada. As a percentage in the US, it represents 0.3% of the total curriculum hours.1 J Pain.2011 Dec;12(12):1199-208
Earlier this year, Nora Volkow, MD, Director of the National Institute on Drug Abuse in Bethesda, MD, told a senate hearing in the US that students studying veterinary medicine get "much more training on how to address pain" than medical students.
1Mezei L, Murinson BB, Johns Hopkins Pain Curriculum Development Team. Pain education in North American medical schools. J Pain. 2011;12(12):1199-208.
Next: Diagnosing pain
With the expansion in recent years of prescription opioids for patients who have chronic non-cancer pain, and with the associated risk of addiction, it is imperative to find other strategies to manage chronic non-cancer pain. While Dr. Pereira says opioids can have a role in pain management, it is critical to evaluate if patients are at high risk of addiction to opioids.
"The key is assessing patients carefully and making sure that alternative treatments have been considered," says Dr. Pereira. "We have useful screening tools to help identify which patients are more likely to develop aberrant drug behaviors.
"You can reach a point of diminishing returns with these medications," says Dr. Pereira. "Many patients are interested in natural approaches to pain management."
Natural approaches to control inflammation include carefully graded exercise and dietary modifications such as eating more fish high in omega-3 fats, according to Dr. Pereira.
Vinod Chandran, MD, PhD, Assistant Professor of Medicine, Division of Rheumatology, University of Toronto, Staff Physician, Division of Rheumatology, University Health Network, suggests that dermatologists routinely enquire if their patients with psoriasis have sensations of pain, particularly joint pain.
"Patients (with psoriasis) may see a dermatologist and not mention that they are also having pain," says Dr. Chandran, a member of the Group for Research and Assessment of Psoriasis and Psoriatic Arthritis. "Dermatologists should ask if patients have joint pain or swelling and back pain. If they say that they do, they should be sent to a rheumatologist."
If patients continue to go undiagnosed with arthritis, by the time they undergo x-rays, their arthritis may be quite advanced, stresses Dr. Chandran. "There needs to be early diagnosis of psoriatic arthritis," says Dr. Chandran.
Ideally, clinics should feature both dermatologists and rheumatologists to optimize management of psoriasis and psoriatic arthritis, says Dr. Chandran. Failing an actual clinic, these specialists should be in virtual contact, which would expedite referral of patients from a dermatologist to a rheumatologist or the reverse, puts forth Dr. Chandran.
"If there is inflammatory pain, there needs to be management of the inflammation," says Dr. Chandran. "Even when patients are taking a biologic (therapy) to treat their psoriatic arthritis, it is important they maintain activity like stretching and yoga to maintain their mobility."
Patient with psoriasis and psoriatic arthritis have a high prevalence of metabolic co-morbidities, including obesity. These co-morbidities will improve if patients with psoriatic arthritis exercise regularly. If patients have depression, activity will likely improve their mood, says Dr. Chandran. "Depression is very common in these patients," he notes, adding many patients with psoriatic arthritis are in the prime of their life. "If you are more physically active, you are in a better mental state."
Next: Managing pain
One of the challenges with psoriatic arthritis management is differentiating between inflammatory pain and mechanical pain, according to Dr. Chandran.
"Many of our patients (with psoriatic arthritis) are overweight and obese, and they have mechanical joint and back pain associated with that," says Dr. Chandran.
Weight loss and strengthening core muscles through activity are ways to reduce pain (both inflammatory and mechanical) associated with arthritis, points out Dr. Chandran. If back pain becomes a major challenge, medications like non-steroidal, anti-inflammatory drugs can be prescribed. In the setting of chronic musculoskeletal pain, Dr. Chandran notes the use of opioids is discouraged. Inflammatory pain also diminishes with weight loss and increased activity, says Dr. Chandran.
Patients with psoriatic arthritis can also experience cutaneous pain when their psoriasis is severe, notes Dr. Chandran. As a patient population, psoriatic arthritics appear to tolerate chronic pain better than patients with rheumatoid arthritis, says Dr. Chandran.
It was shown that patients with psoriatic arthritis have less tenderness when compared to patients with rheumatoid arthritis.2
2Buskila D, Langevitz P, Gladman DD, Urowitz S, Smythe HA. Patients with rheumatoid arthritis are more tender than those with psoriatic arthritis. J Rheumatol. 1992;19(7):1115-9.
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