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Observational Study
. 2022 Sep 10;24(1):218.
doi: 10.1186/s13075-022-02903-w.

Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies

Fowzia Ibrahim  1 , Margaret Ma  2   3   4 , David L Scott  2 , Ian C Scott  5   6
Affiliations
Observational Study

Defining the relationship between pain intensity and disease activity in patients with rheumatoid arthritis: a secondary analysis of six studies

Fowzia Ibrahim et al. Arthritis Res Ther. .

Abstract

Background: Pain is the main concern of patients with rheumatoid arthritis (RA) while reducing disease activity dominates specialist management. Disease activity assessments like the disease activity score for 28 joints with the erythrocyte sedimentation rate (DAS28-ESR) omit pain creating an apparent paradox between patients' concerns and specialists' treatment goals. We evaluated the relationship of pain intensity and disease activity in RA with three aims: defining associations between pain intensity and disease activity and its components, evaluating discordance between pain intensity and disease activity, and assessing temporal changes in pain intensity and disease activity.

Methods: We undertook secondary analyses of five trials and one observational study of RA patients followed for 12 months. The patients had early and established active disease or sustained low disease activity or remission. Pain was measured using 100-mm visual analogue scales. Individual patient data was pooled across all studies and by types of patients (early active, established active and established remission). Associations of pain intensity and disease activity were evaluated by correlations (Spearman's), linear regression methods and Bland-Altman plots. Discordance was assessed by Kappa statistics (for patients grouped into high and low pain intensity and disease activity). Temporal changes were assessed 6 monthly in different patient groups.

Results: A total of 1132 patients were studied: 490 had early active RA, 469 had established active RA and 173 were in remission/low disease activity. Our analyses showed, firstly, that pain intensity is associated with disease activity in general, and particularly with patient global assessments, across all patient groups. Patient global assessments were a reasonable proxy for pain intensity. Secondly, there was some discordance between pain intensity and disease activity across all disease activity levels, reflecting similar discrepancies in patient global assessments. Thirdly, there were strong temporal relationships between changes in disease activity and pain intensity. When mean disease activity fell, mean pain intensity scores also fell; when mean disease activity increased, there were comparable increases in pain intensity.

Conclusions: These findings show pain intensity is an integral part of disease activity, though it is not measured directly in DAS28-ESR. Reducing disease activity is crucial for reducing pain intensity in RA.

Keywords: Disease activity assessment; Pain intensity; Remission; Rheumatoid arthritis.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Mean pain intensity scores stratified by disease activity categories at 12 months. Mean scores are represented by the black dots, and 95% confidence intervals by vertical black bars. Each patient’s pain VAS score is plotted as grey points, with “jitter” applied across the horizontal axis to prevent overplotting; early = early active RA trials; established = established active RA trials; remission/LDA = remission/LDA studies; REM = remission; LDA = low disease activity; MDA = moderate disease activity; HDA = high disease activity
Fig. 2
Fig. 2
Scatterplots demonstrating relationship between pain intensity scores and DAS28-ESR and its components at 12 months. All studies = all studies pooled; early = early active RA trials; established = established active RA trials; remission/LDA= remission/LDA studies. Spearman’s rank correlation coefficients with P-values are given for the variables plotted on each scatterplot and linear regression lines plotted
Fig. 3
Fig. 3
Bland-Altman plots of 12-month pain intensity scores and patient global assessments. Pain = pain intensity visual analogue scale scores; dashed lines show upper and lower limits of agreement
Fig. 4
Fig. 4
Mean pain intensity scores at 6 and 12 months in patients by disease activity status at each time-point. Error bars show 95% confidence intervals; percentage change in pain intensity scores from baseline is shown
See this image and copyright information in PMC

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