Page 236 Guide to Pain Management in Low-Resource Settings

224 Ferydoun Davatchi

ness may last until noon or even well ffof fracture. With increasing lifespan, osteoporosis will pain. Morning sti
become more frequent, in any region of the world. Th e into the afternoon in severe cases.
ed it, Examination reveals swelling of the joint, due fiWorld Health Organization (WHO) has classi
usion and synovial hypertrophy. ESR is ffsince 1991, as “public enemy number one,” along with to synovial e
cardiac infarction, stroke, and cancer. raised, CRP is positive, and in more than 75% of cases,
Unfortunately, osteoporosis has no clinical rheumatoid factor (RF) is positive in the serum. Recent-
manifestation until fracture occurs. Th e only way to ly, anti-CCP (cyclic citrullinated peptide) has gained
c for RA, although not fimake a diagnosis before a fracture occurs is by bone much attention as being speci
densitometry. It is a very expensive procedure, not in all patients. X-rays will, after 6 months to 1 year’s du-
available for general use in developing countries. X- ration of arthritis, show joint demineralization, followed
cult and late. More than 30% of the by joint surface erosion, and later joint destruction. Th e ffiray diagnosis is di
bone mass has to disappear for it to be diagnosed by disease is chronic, lasting decades, but it can go in re-
nitive). Treatment is based fia plain x-ray of the spine. Th e gold standard of treat- mission (temporary or de
ment is bisphosphonates, mainly alendronate. Unfor- on a combination of two or more disease-modifying
uoride is antirheumatic drugs (DMARDs) such as methotrexate, fltunately it is an expensive drug. Natrium
cheap and can be made up by most pharmacies. It may chloroquine, sulfasalazine, and low-dose prednisolone
increase bone mass, although results are controversial; [2]. In refractory cases, biological agents will be of help.
20 to 40 mg daily, used for 1 year and then stopped for In countries where biological agents are not available or
ord them, a combination of several ff6 months before it is used again, may increase bone patients cannot a
mass without decreasing bone strength. Calcium sup- immunosuppressants can be considered.
plements or dairy products along with enough vitamin
D (800 units daily of vitamin D ) have to be added to
3 Pearls of wisdom
the diet as well.
Remember:

Is rheumatic arthritis a very • Th e decision tree (Fig. 1) is self-explanatory. As
an example: If the pain is mechanical and the
frequent disease?
nd out if the fispine is involved, it is important to
ecting pain started insidiously or if it had an acute onset. ffRheumatic arthritis is not very frequent (a
around 1% of the population). Other autoimmune dis- In case of insidious onset, ordinary low back pain
eases causing arthritis include spondyloarthropathies, or cervical pain is by far the most likely cause.
connective tissue diseases (such as systemic lupus ery- • Th e decision tree cannot give you a diagnosis, but
thematosus, dermatopolymyositis, or progressive sys- it may be of help as to where to search for the di-
temic sclerosis), and vasculitides (such as periarteritis agnosis.
rst step is to distinguish between mechani- finodosa or Wegener’s granulomatosis). • Th e
ammatory pain, which should not be flTh e incidence of rheumatic arthritis is even cal and in
culty is when the patient fficult. Th e di ffiects too di fflower in certain regions of the world; in Asia it a
only 0.33% of the population [1]. It mainly involves complains of continuous pain. If you question the
nd a mechani- fiperipheral joints, but it can involve other organs too patient carefully, you can usually
ammatory character in the continuous fl(lungs, heart, kidneys), although not frequently. Joint cal or in
involvement will lead to progressive destruction, caus- pain.
ing disability in a few years if the patient is not treated. • Clinical examination will help to elucidate the di-
nger joints (metacarpophalangeal and prox- agnosis. If necessary, laboratory tests and X-rays fiWrist and
ected, but will be of help. ffimal interphalangeal), are most commonly a
other joints are also involved (elbow, knee, ankle and • Th e remainder of the decision tree is used in a
ammatory similar manner. flfoot, hip, and shoulder). Th e pain is an in