Can we achieve pain stratification in musculoskeletal conditions? Implications for clinical practice

Abstract

In the last few years there has been an increased appreciation that pain perception in rheumatic and musculoskeletal diseases (RMDs) has several mechanisms which include nociceptive, inflammatory, nociplastic and neuropathic components. Studies in specific patient groups have also demonstrated that the pain experienced by people with specific diagnoses can present with distinctive components over time. For example, the pain observed in rheumatoid arthritis has been widely accepted to be caused by the activation of nociceptors, potentiated by the release of inflammatory mediators, including prostaglandins, leukotrienes and cytokine networks in the joint environment. However, people with RA may also experience nociplastic and neuropathic pain components, particularly when treatments with disease modifying anti-rheumatic drugs (DMARDs) have been implemented and are insufficient to control pain symptoms. In other RMDs, the concept of pain sensitisation or nociplastic pain in driving ongoing pain symptoms e.g. osteoarthritis and fibromyalgia, is becoming increasingly recognised. In this review, we explore the hypothesis that pain has distinct modalities based on clinical, pathophysiological, imaging and genetic factors. The concept of pain stratification in RMD is explored and implications for future management are also discussed.

Keywords: neuropathic pain; nociceptive pain; nociplastic pain; pain sensitisation; rheumatic and musculoskeletal diseases.

Figure 1

Schematic representation of the biopsychosocial model of pain.

Figure 2

A summary of pain mechanisms in rheumatic and musculoskeletal diseases and factors influencing pain.

Figure 3

Approaches to pain stratification and management in the clinic. VAS, visual analogue scale; NRS, numerical rating scale; DAS28, disease activity score 28 for rheumatoid arthritis; BASDAI, bath ankylosing spondylitis disease activity index; LANNS, leeds assessment of neuropathic symptoms and signs, DN4, douleur neuropathique; NPQ, neuropathic pain questionnaire; TNF, tumor necrosis factor alpha.