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Non-Pharmacological Pain Management of Rheumatoid Arthritis

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Peter Pham
Peter Pham
Peter Pham
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Yvonne C. Lee
Yvonne C. Lee
Yvonne C. Lee
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Abstract

Purpose of review Many individuals with rheumatoid arthritis (RA) continue to suffer from pain despite treatment with disease-modifying antirheumatic drugs. In this review, we aim to summarize the evidence for non-pharmacological approaches for managing pain in RA. Recent findings Few studies have examined the effect of non-pharmacological therapies on pain in patients with RA. Of these studies, many were not designed to specifically target pain and examined pain as a secondary outcome. While most studies reported within group improvements in pain, the magnitude of improvement varied, and differences between intervention and control groups often were not statistically significant. Summary We recommend non-pharmacologic approaches for management of RA, based primarily on data for improving pain-related outcomes (e.g., physical function, overall health), as opposed to pain itself. The evidence base for non-pharmacologic interventions for pain remains poor, and there is a critical need for large RCTs designed to specifically target pain.
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Vol.:(0123456789)
Curr Rheumatol Rep (2025) 27:21
https://doi.org/10.1007/s11926-025-01184-x
REVIEW
Non‑Pharmacological Pain Management ofRheumatoid Arthritis
PeterPham1· YvonneC.Lee2
Accepted: 5 February 2025
© The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2025
Abstract
Purpose of review Many individuals with rheumatoid arthritis (RA) continue to suffer from pain despite treatment with dis-
ease-modifying antirheumatic drugs. In this review, we aim to summarize the evidence for non-pharmacological approaches
for managing pain in RA.
Recent findings Few studies have examined the effect of non-pharmacological therapies on pain in patients with RA. Of these
studies, many were not designed to specifically target pain and examined pain as a secondary outcome. While most studies
reported within group improvements in pain, the magnitude of improvement varied, and differences between intervention
and control groups often were not statistically significant.
Summary We recommend non-pharmacologic approaches for management of RA, based primarily on data for improving
pain-related outcomes (e.g., physical function, overall health), as opposed to pain itself. The evidence base for non-pharma-
cologic interventions for pain remains poor, and there is a critical need for large RCTs designed to specifically target pain.
Keywords Rheumatoid Arthritis· Nonpharmacological· Physical Activity and Exercise· Rehabilitation· Alternative
Medicine· Cryotherapy
Introduction
Rheumatoid arthritis (RA) is a chronic autoimmune dis-
ease that is three times more likely to affect women than
men [1]. RA is characterized by joint pain, inflammation,
and stiffness that may take a debilitating toll on the mental
and physical health of the patient. The American College
of Rheumatology (ACR) published guidelines for the use
of disease-modifying anti-rheumatic drugs (DMARDs) to
treat RA [2], and these pharmacological therapies have had
a significant impact in managing RA disease progression.
However, despite treatment with strong DMARDs and effec-
tive control of joint inflammation, a significant proportion
of patients with RA still experience pain that interferes with
their daily activities [3, 4]. As a result, patients with RA may
resort to other pharmacologic treatments for pain, such as
long-term opioids [5, 6]. However, chronic opioid use has
not been demonstrated to improve quality of life in patients
with RA and may be associated with significant adverse
effects [7].
Given the lack of effective pharmacologic pain manage-
ment strategies for patients with RA, it is important to con-
sider non-pharmacologic options, particularly when pain is
not controlled by peripherally targeted DMARD therapy.
The data supporting non-pharmacologic interventions for
pain largely comes from studies of other pain conditions,
such as osteoarthritis, which suggest that non-pharmacologic
interventions are as effective pharmacologic interventions
for pain, with fewer side effects [8–10]. Non-pharmacologic
interventions may also have more broad-ranging effects,
improving pain as well as pain-related symptoms, such as
sleep disturbances, fatigue, and cognition.
The ACR published guidelines for non-pharmacologic
interventions, such as exercise, rehabilitation, and diet, for
the management of RA in 2022 [11]. While pain is men-
tioned as an outcome in these guidelines, the guidelines are
not specific to pain and provide recommendations based on
the totality of evidence for multiple outcomes, including
function, disease activity, fatigue, and mental health. There
has not been a recent comprehensive review of the evidence
* Yvonne C. Lee
yvonne.lee@northwestern.edu
1 Chicago Medical School, Rosalind Franklin University, 3333
N Green Bay Rd, NorthChicago, IL60064, USA
2 Northwestern University Feinberg School ofMedicine, 633
North St. Clair Street, 18-093, ChicagoIllinois60611, USA
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Acupuncture involves the stimulation of acupoints, which are located at specific sites of the human body, by insertion of fine metal needles, followed by manipulation. Acupuncture has been proven to be an effective treatment in pain relief. Available evidence showed that acupuncture alleviates acute pain in conditions such as postoperative pain, acute back pain, labour pain, primary dysmenorrhea, tension-type headaches and migraines. In addition, acupuncture relieves chronic pain, for example, low back pain (LBP), knee osteoarthritis (KOA), headache, shoulder pain, and neck pain. For other diseases like insomnia, drug addiction and stroke, more high-quality randomized control trials (RCTs) are needed to confirm the efficacy of acupuncture, although there are particular difficulties surrounding adequate blinding and control group designs. Recent biomedical technology unveils the mechanisms of acupuncture. Studies have found that adenosine triphosphate (ATP) and transient receptor potential vanilloid (TRPV) channels are involved in the stimulation of acupuncture at the acupoint area. In the central nervous system (CNS), neurotransmissions including opioids, serotonin, norepinephrine, orexin and endocannabinoid are modulated by acupuncture to induce analgesia. Moreover, acupuncture reduces cyclooxygenase-2 (COX-2) and prostaglandin E2 (PGE2) levels on the peripheral level by acting on the hypothalamic-pituitary-adrenal (HPA) axis, mediating peripheral opioid release. Acupuncture helps to treat insomnia by inhibiting sympathetic activity and down-regulating the HPA axis. Additionally, acupuncture reduces the effects of positive and negative reinforcements by modulating dopamine release in the nucleus accumbens. Recently, i-needles have been developed to allow for the analysis of metagenomics, meta-transcriptomics, and host-microbiome relationships following acupuncture, while skin implantable microsensors or needle-shaped microsensors are feasible for monitoring real-time microenvironmental changes in acupoints and even target organs. These studies may further accelerate the understanding of acupuncture's action mechanism.
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The effect of group-based cognitive behavioural therapy for insomnia in patients with rheumatoid arthritis: A randomised controlled trial
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