Chronic Pain in Spondyloarthritis
2018 SPARTAN Annual Meeting, “Unmet Needs” Breakout Session
Philip Mease, MD, Swedish-Providence Health System, University of Washington School of Medicine, Seattle, WA, pmease(at)philipmease.com
- To describe our current understanding of the neurobiology and experience of pain in spondyloarthritis (SpA).
- To characterize the variable contribution of central sensitization on illness experience and assessment in SpA.
- To discuss the impact of chronic pain on management of SpA, including treat-to-target strategies.
- To identify gaps in knowledge, unmet needs, and research priorities regarding chronic pain in SpA.
- To brainstorm about feasible research projects that can be collaboratively pursued by SPARTAN investigators to address research priorities.
Pain is arguably considered the most important symptom domain of SpA by patients and clinicians, along with impairment of physical function and fatigue. A core focus of treatment, whether with immunomodulatory drugs to reduce inflammation, analgesics, or non-pharmacologic therapies, is reduction or resolution of pain experience. Recent research on the neurobiology of pain illuminates the complexity and variability of this experience from patient to patient, influenced by genetic, neurobiologic, and psychosocial factors. In particular, we have learned that a significant proportion of patients may experience augmented central sensitization, amplifying pain and other symptoms, such as fatigue, in a manner unresponsive to peripherally-targeted immunomodulatory and analgesic treatments. Yet our methods of pain assessment, e.g. simple VAS/NRS pain scales, or short questionnaires, are not sensitive or discriminant enough to tease out the variable sources of pain in patients, leaving clinicians adrift in their ability to determine the true effects of targeted therapies on pain and other symptoms. Numerous studies have shown that patients with increased central sensitization rate worse subjective outcome measures and as a consequence, are less likely to achieve the target of low disease activity or remission. Not only does this yield worse functional outcomes, but also may lead to inappropriate medication changes and intensification, but even unwarranted surgery. Sophisticated assessments such as neuroimaging and quantitative sensory testing help us understand the variable sources of pain experience but are not practical for everyday clinical use. Multidimensional questionnaires may lack adequate sensitivity and specificity to discern the spectrum of central sensitization in an individual patient. Many clinicians are not aware of our current understanding about the neurobiology of pain and its variability in patients – a major educational gap.
Breakout workshop methods:
The workshop will be divided into two sections. The first section (30 minutes) will include brief educational lectures on state-of-the-art understanding about the neurobiology of pain, pain assessment, and ramifications of central sensitization on treatment in SpA. The second section of the workshop will be to have all attendees participate in a brainstorming session on potential research projects which can be feasibly conducted in a collaborative fashion amongst SPARTAN investigators to address unmet needs and research gaps. This could include but is not limited to the following potential projects: 1) Identification of methods to improve education about pain in SpA; 2) Creation of educational materials to be inserted into SPARTAN educational series, e.g. powerpoint slides for CME programs or stand-alone educational programs on pain in rheumatic disease; 3) Field testing extant questionnaires, classification criteria, and simple sensory testing procedures aimed at identifying fibromyalgia and/or amplified central sensitization in SpA subjects; 4) Comparing SpA patient groups with and without quantifiable “fibromyalgianess” (aka amplified central sensitization) vis a vis various SpA disease activity measures; 5) Longitudinal assessment of treatment outcomes in SpA patients with and without amplified central sensitization; 6) Measuring resource utilization by SpA patients with and without amplified central sensitization; 7) Analyzing relationship of patient characteristics and comorbidities (e.g. gender, obesity) on amplified central sensitization;
The workshop will conclude with establishment of an action plan to address unmet needs and research gaps re. pain in SpA, including formation of a steering committee within SPARTAN to move the plans forward.