Today, the European Pain Federation EFIC® launched its “European Year Against Pain (EYAP)” campaign in Brussels. In doing so, EFIC is putting a health problem on centre stage, from which more than half the total population over age 50 suffers. “Joint pain is among the most frequent health complaints of all and a leading reason for disability,” EFIC President Dr Chris Wells noted. “Joint pain will become an even more urgent problem in future given the prevalence of a sedentary lifestyle, ever more widespread obesity, and the increase in life expectancy. Like chronic pain in general, joint pain causes not only individual suffering but also has an enormous social cost in the form of health care expenses, sick days off work, loss of productivity or occupational disability.” Figures from the US show the economic dimension involved: Between 1996 and 2011, expenses for the treatment of joint complaints increased more than in any other category, namely by 192 per cent. Throughout the EU, musculoskeletal problems constitute the most important diagnosis category in terms of health care spending and the indirect costs of decreased productivity.
Despite major efforts, currently available therapies are not yielding the desired effects and in some cases fall short of the patients’ expectations. The EFIC President: “Care must be improved substantially. Joint pain sufferers must receive adequate, reliable treatment more quickly, treatment that not only fights pain but also enables the joints to retain their functionality. We want to show what is needed to achieve this objective and raise awareness about how worthwhile it can be to invest in the treatment of joint pain.”
The intent of the European Year Against Joint Pain is to inform the public about the diverse symptoms of joint pain and the possible treatments. That way, pain sufferers could also “seek appropriate help on time,” as EFIC President Dr Wells emphasised. The website www.efic.org makes available collected facts and patient information on the various forms of joint pain. There is a variety of initiatives, PR efforts, and conferences in the 37 countries in which EFIC is represented with national chapters. In September, EFIC will stage a topical seminar on this subject in Dubrovnik, Croatia.
Joint pain can take many forms: at least 150 known types
Until now, some 150 different forms of joint pain have been identified, with very diverse causes. For instance, they can be traced to bone fractures or to previous joint surgeries. The most frequent causes of chronic joint problems, however, are wear-related osteoarthritis, crystal deposits (gout) and inflammatory processes. Prof Bart Morlion, President elect of EFIC and coordinator for the European Year Against Pain: “Today we do not yet sufficiently understand the various causes and mechanisms relating to the broad range of forms that joint pain can take. Until now, researchers have concentrated primarily on the most frequent forms. A number of important new findings have been made recently but still have to find their way into actual practice. They pertain to common mechanisms of incurrence or manifestations of whole different forms of joint pain. Policymakers are called on to create the necessary basic framework for tailor-made programmes geared to different patient groups.” Whereas changes in bones should be treated with corresponding active ingredients, for example, highly obese individuals could be offered weight-reduction programmes. It is still paramount that researchers find answers to the many unanswered questions regarding diagnosis and treatment. Prof Morlion: “We are counting on the European Year Against Joint Pain to provide fresh impetus to these efforts.”
Osteoarthritis and gout as widespread ailments
Gout is the most frequent of the painful inflammatory joint diseases. It is characterised by episodes of acute pain that can also develop into a chronic inflammatory condition. Between one and four per cent of the population suffers from gout. The most frequent inflammatory joint disease with an autoimmune cause is rheumatoid arthritis. Less than one per cent of the global population suffers from this disease, which customarily affects multiple joints.
Osteoarthritis is the most frequent form of painful joint problems. This complex disease is characterised by excess wear to the joints, where mechanical pain can be coupled with inflammatory and/or neuropathic pain. Osteoarthritis accounts for a substantial 20 per cent of all chronic pain worldwide. Ten to fifteen per cent of the global population is affected by this disease and its prevalence clearly rises with age. Among all 60 to 70-year-olds, osteoarthritis is diagnosed in 40 per cent of women and 25 per cent of men. It is the most frequent disease of the musculoskeletal system in older people and is the cause of disability in this group more often than any other condition. Symptoms such as joint pain or stiffness do not occur in all patients for which the disease can be proven on an x-ray. This is the case in ten to fifteen per cent of the population, however. Knee, hand and hip joints are the joints most frequently involved.
Osteoarthritis is more than just a joint disease
For a long time, osteoarthritic pain was neglected and the mechanisms behind it and possible therapies for it were incorrectly assessed. Prof Morlion: “In the meantime, we know that osteoarthritis is more than a joint disease. There is a complex interplay between it on the one hand and obesity, metabolic syndrome and cardiovascular diseases on the other.” Hormone-like messengers such as adipokines, myokines and cytokines were found to be the common denominator of these diseases. They are secreted into the blood by joint tissue, muscles and fat and promote inflammatory processes and cartilage degeneration. Prof Morlion: “The challenge continues to be to treat osteoarthritis in a joint-preserving manner. Recently a decisive step was taken when the various manifestations of osteoarthritis were described. The Osteoarthritis Research Society International (OARSI) also published guidelines for non-surgical treatment. What is new about these guidelines is that they contain varying recommendations depending on the clinical subcategory, for instance, whether comorbidities exist in the case of knee osteoarthritis.” The key treatments suitable for all patients comprise gymnastics and water gymnastics, weight control, strength workouts, and trainings.
Using drugs on a mechanism basis
The goal for joint pain of the most varied kinds has to be to prevent this pain from becoming chronic. On that all experts agree. The risk of this happening is high, however. With osteoarthritis, for instance, many patients do not seek out medical help until a considerable period of time has elapsed. 66 per cent try to improve the situation with non-prescription food additives and drugs while 41 per cent of the patients experience joint pain at least one year prior to the diagnosis.
The range of available therapies is as broad as the causes and manifestations of joint pain are varied. Application of heat and cold, electrotherapies, exercise strategies, strength workouts or weight loss are among the important non-drug treatment approaches. In terms of drug therapy for joint pain, a new approach is becoming increasingly established – namely a selection of substances geared to the mechanisms of the given manifestation of pain. Conventionally, the therapy for joint pain had been geared to the pain severity as modelled on the WHO pain ladder – with non-opioid analgesics and non-steroidal anti-inflammatory drugs (NSAIDs) used for mild severity, “weak” opioids for moderate pain and “strong” opioids for severe pain.
Prof Morlion: “A new approach has now become increasingly established, namely to select the therapy by the mechanism underlying the given pain and by the target of the given drug.” For joint pain, this means that nociceptive inflammatory pain should be treated as a rule by reducing inflammation with steroids or NSAIDs, non-inflammatory nociceptive pain by opioid and non-opioid analgesics, and neuropathic pain by antidepressants or anticonvulsants, or various types of rheumatic disorders with monoclonal antibodies. Prof Morlion: “That is progress because it means the therapies more closely match the patient’s needs than with the conventional escalation strategies from weaker to stronger drugs.”
For many joint pain sufferers, exhaustive use is not made of the available drug options for pain therapy. One reason is a concern about undesirable effects – especially in elderly patients. Prof Morlion elaborated: “There have been a number of improvements lately, however. New opioids for example have attained sustainable success when used on slight gastrointestinal or cognitive impairments and the risk of dependency is small.” The local administration of pain killers has also been shown to reduce side-effects. Recently published methods involving antibodies that block nerve growth factors show the potential of biological therapies for osteoarthritis, too. They are aimed at peripheral pain mechanisms and hardly penetrate the central nervous system. Thus, side-effects such as sleepiness or nausea are problems of the past. Prof. Morlion urged the following: “Pain should in any case be treated at an early stage, because we can now also determine the cause of it more quickly.”
European Year Against Pain
“Each year we turn attention on a special form of pain or a special health care problem with our regular EYAP information offensive staged in coordination with the International Association for the Study of Pain (IASP)”, said EFIC President Dr Chris Wells Our intent is to point out the health problem of pain in all its facets and consequences, to support pain patients and to sensitize the broader public. In addition, we consider it essential to make policymakers aware of the challenges that chronic pain poses for the health care system and to set a priority in this area.”