"Critical Analysis of Chronic Pain Management in Rheumatoid Arthritis PatientTable of ContentsIntroduction: ........................................................................................................................................... 2Patient Information: ............................................................................................................................... 2Background: ............................................................................................................................................ 2Critical Analysis: ...................................................................................................................................... 4Tests and diagnosis: ................................................................................................................................ 5Psycotherapeutic approaches for the management of chronic pain: .................................................... 7Occupational therapy for the management of chronic pain: ................................................................. 9Effectiveness of Physiotherapy in the management of chronic pain: .................................................... 9Alternate treatment methods for chronic pain management: ............................................................. 10The role of Patient education in the management of chronic pain:..................................................... 11Conclusion: ............................................................................................................................................ 12Reference: ............................................................................................................................................. 12 Introduction:Pain that lasts for 3 to 6 months or more is identified as chronic pain. Rheumatoid Arthritis isa chronic inflammatory disease which is characterized by pain, swelling, and stiffness in thejoints. It decreases the mobility and flexibility of affected joints. Chronic erosion of jointtissues over an extended period of time is identified as another cause of chronic pain. Theprimary goal to provide pain relief in patients with rheumatoid arthritis is by controlling theinflammation. In the present essay, we will discuss a case study in which the patient isexperiencing chronic pain due to rheumatoid arthritis. We will critically analyze the casemanagement, treatment, and care provided to the patient right from the first consultation tillthe complete pain relief.Case Study: Patient with chronic pain due to rheumatoid arthritisPatient Information: Ms. X is a 45-year old woman who is married and lives with her husband and 25-years oldson in a single-storey unit. The patient is a full-time employee at a grocery store. The patientcomplains of constant swelling, stiffness that lasted for more than 1 hour in the morning, andpain with occasional numbness and tingling sensation in her hands, wrist, and elbow. Further,the patient informed that due to extreme pain in the shoulder, she could not lift her arms at allin the morning. She expressed difficulty in combing her hair and lifting the objects. Thepatient reported that she began feeling very tired and short tempered these days and is unableto do her daily activities of living. The patient has a pain score of 8/10 on a visual the analog scale. She informed the nurse thatthe pain in the morning is unbearable and gave a rating of 9 to 10 on a visual analog scale.The patient noticed that the symptoms of swelling and pain worsened when she consumeddairy products. Background: Around ten months ago the patient began noticing stiffness in the both the hands in themorning which lasted for a longer time. As the time progressed, the patient startedexperiencing foot and ankle pain and complained of having difficulty in standing for moreextended periods at work and home. Four month ago patient began experiencing pain in herright and left shoulders. A few days back the patient could not lift her arms at all withextreme shoulder pain and consulted the primary care physician.The primary care physician prescribed preliminary blood tests. The patient’s blood testreports revealed the presence of CCP antibodies, elevated ESR, C- reactive protein, andpositive rheumatoid factor. The patient’s primary care physician informed her test results andreferred her to the rheumatologist.Past medical history: The patient was a former smoker. She had stopped smoking eightyears ago.The patient has hypertension. Medication History: The patient is taking OTC medications for pain relief, i.e., 75 mgdiclofenac and 200 mcg of misoprostol twice daily since six months for pain relief. However,the patient informs that she has minimal relief after taking the diclofenac and misoprostol. The patient is prescribed metoprolol 25 mg mane for hypertension. Family History: The patient’s father had type 2 diabetes and experienced two myocardialinfractions (deceased at age 81). The patient’s mother has undergone hip replacement surgeryfor the treatment of severe osteoporosis (deceased at age 74). Assessment: The patient is 5.6 inches tall and weighed 170 lbs. Her body mass index was27.4. The patient has marked swelling, warmth, and tenderness in the metacarpal phalangealjoints with limited digital flexion bilaterally. Capillary refill rate was normal with nosymptoms of ulceration or digital cyanosis. The patient’s joints were tender and swollen. Therapid three score was found to be 21.8. Vitals: Blood pressure was 145/90 mm Hg. Heart rate – 75 bpm, no murmurs or rub notes areobserved. Respiration rate- 18 breaths per minute. Lungs were clear to auscultationbilaterally. Laboratory Test and Examination:In addition to an x-ray of feet, hands, and shoulders,the rheumatologist has ordered X-ray test, the complete blood count, thyroid level test,vitamin D levels test, Deoxypyridinoline test, stool test and Bone densitometry. Diagnosis: The rheumatologist informs the patient that she may most likely have rheumatoidarthritis. The nurse and the rheumatologist briefly discussed the common facts aboutrheumatoid arthritis and treatment options with the patient.Medication: Prednisone 5 mg orally, thrice daily and corticosteroid injection were prescribedto the patient. The nurse administered the injection in each of the patient’s shoulders. Celecoxib 100 mg orally twice daily was prescribed for the patient. Common side effects ofthe medications are discussed with the patient, and all her questions were answeredTwo weeks later during the follow-up visit, the laboratory test reports have confirmed that thepatient has rheumatoid arthritis. The patient informed the rheumatologist that her shouldersfelt a little better, but she was still having pain and difficulty while raising her arms. During the follow-up visits the rheumatologist prescribed oral methotrexate 2.5 mg orallydaily for three days in a week, folic acid to the patient and advised her to continue taking 5mg prednisone orally thrice daily and Celecoxib 100 mg orally twice daily. Therheumatologist recommended the patient to consult a physical therapist for further assessmentand treatment of her shoulders. Further, the patient was advised on activity moderation abouther work.The nurse discussed the common side effects and provided written information about themedications to the patient. Further, the nurse gave advises for living with rheumatoidarthritis. The patient was informed to take adequate rest for energy conservation. Also, thepatient was taught relaxation methods. The patient continued to receive treatment for attended regular follow-up visits. During thefollow-up visits, the patient’s laboratories were monitored, and the dosage of the medicationswas adjusted as her symptoms improved. During the third month of treatment, prednisone was discontinued, and the patient wassuggested to continue taking methotrexate. The patient resumed her regular activities ofliving. The rapid three score decreased to 4. Patient informed that joint stiffness in themorning was minimal and had no difficulty in raising her arms. The patient has three swollenand tender joints. The patient reported that she attended the physical therapy sessionsregularly and practiced the exercises regularly. Critical Analysis: Rheumatoid Arthritis is an auto-immune disease which causes inflammation, swelling, andpain in the joints. The lining of the joints gradually thickens and swells and causes damage orloss of cartilage. It also results in loss of fluid and space in the joints making them more stiffand immobile. Early diagnosis helps to stop further damage to the joints. RheumatoidArthritis is a systemic disease and it affects the joints, eyes, cardiovascular system, respiratory system, and other body parts and organs. Women are most commonly affectedthan younger men. People with a parental history of rheumatoid arthritis are more likely to beaffected by arthritis than those individuals who do not have a family history of rheumatoidarthritis. Unhealthy lifestyle and genetic factor are identified as the primary cause ofrheumatoid arthritis (McInnes and Schett., 2011). Proper medication, healthy lifestyle and exercises provide relief from the symptoms ofrheumatoid arthritis in the patient. The early symptoms of rheumatoid arthritis include dulland severe aching pain, inflammation and stiffness in joints. The patients may experiencediscomfort in lifting the hands to hold things, bending over or combing the hair. They mayalso have pain during walking, fatigue, depression, and high fever. Rheumatoid arthritis maylead to osteoporosis making the bones weak and brittle. Some of the complications ofrheumatoid arthritis are carpal tunnel syndrome, cervical myelopathy, and vasculitis. Tests and diagnosis: a)Complete blood count (CBC): It helps to check if the patient has high erythrocytesedimentation rate or CRP. It helps to monitor WBC count and rule out the possibility ofinfection. Monitoring RBC count and haemoglobin level helps to rule out anaemia (Egerer, etal., 2009; Majithia and Geraci 2007) .b)Thyroid levels and lipid levels are monitored to rule out thyroid disorders andhypercholesterima. c)Antinuclear antibodies:They are most commonly elevated in inflammatory arthritis andindicate the level of disease activity. They are useful for tracking treatment efficacy (Egerer,et al., 2009; Majithia and Geraci 2007).d)High-sensitivity C-reactive protein (hs-CRP): It is a standard acute phase reactant proteinused to monitor general inflammation.e)Rheumatoid factor: RF is an autoantibody, most relevant to rheumatoid arthritis (Egerer,et al., 2009; Majithia and Geraci 2007).f)Deoxypyridinoline (DPD): A marker of bone resorption tracked by a urine test to helpmonitor treatment efficacy for osteoporosis (Egerer, et al., 2009; Majithia and Geraci 2007). "