Current rheumatology reports
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Glucocorticoids (GC) are a standard treatment for pediatric rheumatic disease. Recent literature highlights skeletal vulnerability in children with rheumatic illness, including vertebral and peripheral fractures and reductions in bone mineral density in longitudinal follow-up. Annual vertebral fracture incidence of 4-6 % in those recently diagnosed and prevalence of 7-28 % in those several years post diagnosis have been reported. ⋯ Bone mass accrual is typically suboptimum across time, although the use of potent steroid-sparing anti-inflammatory agents may counteract the effects of GC and active disease. Vitamin D insufficiency warrants ongoing monitoring. Additional targeted studies are justified to increase understanding of bone health risks in this population.
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The recent increase in the number of patients taking opioids chronically for pain has not yielded the expected benefits in reduction of symptoms and improved function. Chronic pain patients typically respond well initially to opioid medications, but regular use is associated with adverse psychological and physical effects. ⋯ In the common rheumatological conditions of fibromyalgia and osteoarthritis, opioid treatment is of limited benefit because of lack of efficacy and prominent side effects. Chronic opioid therapy may be more usefully regarded as a form of comfort care, reserved for those patients who have exhausted other treatments and prospects of recovery.
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Pain is the most common reason patients with inflammatory arthritis see a rheumatologist. Patients consistently rate pain as one of their highest priorities, and pain is the single most important determinant of patient global assessment of disease activity. Although pain is commonly interpreted as a marker of inflammation, the correlation between pain intensity and measures of peripheral inflammation is imperfect. ⋯ Although several studies have examined the effects of reducing inflammation for patients with inflammatory arthritis, very few clinical trials have examined the safety and efficacy of treatment directed specifically towards pain pathways. Most studies have been small, have focused on rheumatoid arthritis or mixed populations (e.g., rheumatoid arthritis plus osteoarthritis), and have been at high risk of bias. Larger, longitudinal studies are needed to examine the mechanisms of pain in inflammatory arthritis and to determine the safety and efficacy of analgesic medications in this specific patient population.
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Despite advances made in its understanding and treatment, chronic pain remains an unsolved and all too common problem. One of the main obstacles to successful management of pain is the high variability of many patients regarding both response to treatment and susceptibility to adverse effects, which curtails the utility of therapeutic intervention. Understanding the causes of this variability is an important challenge which may lead to a new era in rational pain management. ⋯ Rational personalized pain management must take into consideration both ever-increasing knowledge of pharmacogenetics and pharmacokinetics and a broad, clinically based attitude incorporating co-morbidities, both physical and psychiatric, and concomitant medications. Novel models for testing in-vivo pain processing, for example assessment of conditioned pain modulation (CPM), are also promising approaches to use of rational data for empirical treatment of pain. Last, listening to the patient and understanding the context in which pain has affected his or her life is an important part of maintaining the personal nature of therapeutic interaction with patients suffering from pain.
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Review
The role of the central nervous system in osteoarthritis pain and implications for rehabilitation.
It has been known for some time that central nervous system (CNS) pain amplification is present in some individuals with osteoarthritis; the implications of this involvement, however, are just starting to be realized. In the past year, several research reviews have focused on evidence supporting shared mechanisms across chronic pain conditions for how pain is generated and maintained in the CNS, irrespective of the underlying structural pathology. This review article focuses on current literature describing CNS amplification in osteoarthritis by discussing peripheral sensitization, central sensitization, and central augmentation, and the clinical manifestation of central augmentation referred to as centralized pain, and offers considerations for rehabilitation treatment and future directions for research.