Page 234 Guide to Pain Management in Low-Resource Settings

222 Ferydoun Davatchi

How do you diagnose or secondary (related to mechanical eff ort, metabolic
a rheumatological disease? disorders, or genetic malformation, infl ammatory ar-
thritis, infectious arthritis). It is seen in 9.6% of the
Th e characteristics of each joint, the chronology of the population aged 15 or older in Asian-Pacifi c countries
symptoms, the number and location of involved joints, [1]. Th e starting age depends mainly on the joint, with
and the pattern of involvement are usually enough to individual variation, which is probably due to varia-
suspect a diagnosis, or better, to make a diagnosis. In tion in genetics. At the beginning, OA may not be
many cases (soft-tissue rheumatisms, low back pain, or painful, or the pain may be episodic. Laboratory tests
mechanical cervical pain), no laboratory investigation are unnecessary. CBC, ESR, CRP, RF, uric acid, and in-
is necessary. In others, simple laboratory tests as men- fectious diseases tests, mainly Wright for brucellosis
tioned above will be suffi cient. When necessary, plain and PPD (purifi ed protein derivative) for tuberculosis,
X-rays will often give suffi cient information. are normal.
Plain X-ray is not necessary for the diagnosis,
What are the principles of treatment? helping essentially to demonstrate the severity of car-
tilage destruction. Th e radiographic signs appear late
Although treatment has made great advances in the last (months or years after the onset) and are mainly joint
decade (biological agents, sophisticated immune modu- space narrowing and osteophytes.
lators, etc.), in many cases good advice and minimal Th ere is no specifi c treatment to cure or even
medications will control the patient’s pain effi ciently. stop the progress of OA. Pain, on the contrary to
Th e majority of low back pain will respond well to a few what the patient thinks, is acting in his/her favor. Pain
days of rest and anti-infl ammatory drugs. After resting, shows what activity is harmful to the joint and how
patients have to be taught how to strengthen their mus- much activity it can aff ord without interfering with the
culature with adequate exercises and must be advised normal physiology of the cartilage. Pain-killing tech-
about maintaining daily activities. Th e same is true for niques are usually harmful for the joint, unless they
cervical pain, osteoarthritis, and many of the soft-tissue are given concomitantly with rest. In many instances,
rheumatisms. It is a false idea that mechanical pain, like there is no need for complete rest or medication. Ex-
osteoarthritis, needs analgesics or anti-infl ammatory plaining the physiology of pain is the best treatment
drugs for a long time or forever. Continuous use of an- for the prevention of fast degradation of the joint. Joint
algesics will lead to more cartilage damage in the joint, activity is permitted to the degree that pain is not too
while correct use of the joint will help to arrest or slow severe. In severe cases, anti-infl ammatory drugs, ei-
down the cartilage degradation. If nonsteroidal anti- ther NSAIDs or steroids, are preferable as analgesics.
infl ammatory drugs (NSAIDs) are necessary, there is Th ey are given for 2 to 3 weeks (150 mg indomethacin
no need to go for the new generation of COX-2 drugs, or diclofenac, 15 mg prednisolone), along with moder-
which are very expensive. Indomethacin and diclofenac ate joint rest. After this period, medication is stopped,
are cheap, eff ective, and widely available. New therapies, and the patient is advised about adequate joint activity.
mainly biological agents, have changed the outcome Exercise to improve muscle strength is very important,
of crippling rheumatic disease. Unfortunately, they are which by improving joint physiology helps to slow
very expensive and not aff ordable in many places. How- down the disease process.
ever, tried and true medications, available since the
mid-20th century, can still make a vast diff erence, if cor- What are specifi c recommendations
rectly combined and used. Some of them are relatively for osteoarthritis of the knee?
aff ordable (e.g., chloroquine, prednisolone).
Osteoarthritis of the knee is the most frequent type of
What do you need to know OA, seen in 15.3% of cases. Th e pain starts with walk-
about osteoarthritis? ing, in the beginning or later, depending of the severity
of cartilage damage. With rest, pain disappears gradu-
Osteoarthritis (OA) is the mechanical disorder par ally. Gelling pain is seen at the start of walking, disap-
excellence. It is due to degeneration of the cartilage pearing quickly. Pain may be located in the knee joint
and may be primary (related to age or menopause) itself, or projected to the calf or thigh, or even to the