Ep 34. GUIDELINES - Managing pain in IA with Ian Scott, Nick Shenker, Yeliz Prior and co-authors

In this episode of Rheumatology Roundtable, Ernest Choy is joined by members of the BSR Guideline Working Group to discuss the new BSR guideline on pain management in inflammatory arthritis. 

The panel explores why dedicated guidance is needed, key recommendations for assessing and managing pain, and the importance of distinguishing active disease from persistent pain. 

The discussion highlights evidence-based approaches including DMARD optimisation, exercise, education, self-management, sleep support, weight management and multidisciplinary care, while challenging the long-term use of opioids and gabapentinoids. 

Patient representative Rebecca Beesley shares the potential impact of the guideline on patient empowerment and shared decision-making. 

The episode also provides practical implementation tips and key take-home messages for clinicians aiming to improve pain care for people living with inflammatory arthritis.

Find the video version of this episode on the BSR YouTube channel. 

Read the full guideline and download the handy infographic and audit tool here. 

Thanks for listening to Talking Rheumatology! Join the conversation on X using #TalkingRheum or tweet us @RheumatologyUK.

BSR is the UK's leading specialist medical society for rheumatology and MSK health professionals. To discover how we can support you in delivering the best care for your patients, visit our website. 

Transcript

00:00:01 

You're listening to the Talking Rheumatology Podcast, brought to you by the British Society for Rheumatology.

00:00:14 Ernest Choy

Hello and welcome to this episode of Rheumatology Roundtable.

I'm Ernest Choy, Editor-in-Chief of Rheumatology Oxford.

Today, we're going to be discussing the BSR guidelines on pain management in patients with inflammatory arthritis.

Joining me today are members of the working group, and I'm going to ask them to introduce themselves to you.

So first of all, Nick?

00:00:41 Nick Shenker

Hi, I'm Nick Shenker.

I'm a consultant rheumatologist at Cambridge University Hospitals and an affiliated assistant professor at the University of Cambridge, and I was the senior author and co-chair of the Guideline Working Group.

00:00:54 Ernest Choy

Rebecca.

00:00:55 Rebecca Beesley

Hi, I'm Rebecca Beasley, and as part of the working group, I've been an expert by experience as a patient, as someone with juvenile idiopathic arthritis for most of my life.

00:01:05 Ernest Choy

Ian.

00:01:06 Ian Scott

Hi, everyone.

My name's Ian.

I'm a consultant rheumatologist working in Stoke and a reading rheumatology at Keele, and I was the guideline working group co-chair alongside Nick.

00:01:16 Ernest Choy

Yeliz.

00:01:17 Yeliz Prior

Hi, everybody.

I'm Yeliz Prior.

I'm a consultant occupational therapist at Northern Care Alliance and a professor of clinical rehabilitation at the University of Salford, and I was a member of the working group.

00:01:29 Ernest Choy

Dee.

00:01:30 Dee Pratt

Hi there, my name is Dee Pratt.

00:01:32 Dee Pratt

I'm a consultant MSK physiotherapist and I work for Surrey Downs Health and Care and I was part of the guideline working group team.

00:01:39 Ernest Choy

Okay, welcome everybody.

00:01:41 Ernest Choy

We will start with Nick.

Can you start by explaining why there is a need for a dedicated guideline to support pain management for inflammatory arthritis at this point?

00:01:53 Nicholas Shenker

Thanks Ernest.

We all know that our patients who have inflammatory arthritis are in pain.

If we ask them, more than a third will say that they've got pain, many of whom will say it's not an acceptable level.

We know that then they can't be validated and that doesn't allow them to accept that they can have chronic pain.

So we thought that there would be a need for the guidelines because the evidence has moved on.

There's not been a UK guideline in pain management for inflammatory arthritis ever.

This is the first one.

There are only a few other pain management guidelines for patients who have musculoskeletal disease.

And so not only is the evidence coming up, but the evidence we know showed that strong opioids, gabapentinoids, are not helpful for our patients, but their number of prescriptions are also going up.

And we think that there's a great need there for this guideline.

We think it's a very good timing for it.

00:02:58 Ernest Choy

Thank you.

I'll come to Ian.

What does the new guideline tell us the main principles clinicians should keep in mind when treating pain in people with inflammatory arthritis?

00:03:10 Ian Scott

Thanks, Ernest.

If I try and reduce the various recommendations to free take-home messages for busy clinicians, I think those follows.

The first is to assess disease activity, and if someone's arthritis is active with lots of synovitis, then to manage this with DMARDs.

This is because we looked at a lot of evidence, and by far the best evidence was that DMARDs are effective in improving pain in people with active inflammatory arthritis, and that's synthetic DMARDs, targeted synthetic and biologic DMARDs.

The second, and I'm delighted to welcome Yeliz and Dee to the podcast because they highlight the importance of non-drug care, is to really think about this to manage someone's pain.

So in addition to reducing someone's disease activity, we found a lot of evidence, albeit of low quality, that many non-drug interventions help, such as exercise and physical activity, orthotics, education, weight management and improving sleep quality.

And the third and final message, as Nick mentioned, is to rethink our approach to using analgesics.

So we found no evidence to support the use of long-term opioids, nor gabapentinoids in people with inflammatory arthritis.

Yet we know many people in every year prescribe these.

I think it's around one in four people with inflammatory arthritis in the UK each year receive a long-term opioid prescription.

And these drugs aren't without risks.

But what we've done in the guideline is summarise all the evidence.

We've got a lot of non-drug interventions that we've shown help.

We know that they're safe and really it's to think about getting an increased use of those things to help people's pain.

00:04:45 Ernest Choy

Fantastic.

I want to come back quickly to Nick.

So Ian mentioned that we need to assess disease activity as his first point, but what about assessment of pain?

What are the most important messages from the guideline?

00:04:59 Nicholas Shenker

We have to ask people how much pain that they are in.

Pain's very individual.

You'll get a range of different responses.

But the evidence is quite clear that people know whether they're living with an acceptable level pain or not.

Very often that number will be 3 out of 10.

It's an individual thing.

So you have to assess pain in two ways.

First is to ask 0 to 10, what number is your pain?

The second is to follow that up with, is that an acceptable level or not?

If it's not acceptable pain, you have to be able to assess that more holistically.

You ask about sleep, mood, function, and fatigue.

And you ask about those four things because there's treatments for each of those.

And that's all part of this guideline.

If someone's pain is acceptable, they don't necessarily need an assessment of their joints.

But if their pain is not acceptable, they'll need a face-to-face assessment.

00:06:05 Ernest Choy

Okay, well, Ian mentioned that Yeliz and Dee are very important in the working group because they are looking at the non-pharmacological care.

So I want to turn to Yeliz next.

The guideline places a strong emphasis on non-pharmacological interventions.

So what should MDT members take away from this guidance?

00:06:29 Yeliz Prior

Absolutely. I think the key message for MDT members is that pain in inflammatory arthritis is not just a biomedical issue and it cannot be managed effectively through medication alone.

The guideline is very clear that high quality pain care must include non-pharmacological approaches as a core component and not as an optional extra.

From an occupational therapy perspective, this means focusing on what really matters to people's everyday lives.

That includes supporting work participation, helping people to stay in or return to employment, and addressing challenges with daily activities.

So practical challenges or strategies such as pacing, joint protection, and ergonomics are essential.

These are not minor adjuncts.

They directly influence pain, function, and long-term outcomes.

So education and supportive self-management are also central.

A patient needs to understand the nature of their pain, including the role of central sensitization and interaction with mood, sleep, and activity.

So when people understand their condition, they are better able to make informed decisions and engage with strategies that reduce pain and hopefully improve their quality of life.

So the guidelines strongly reinforces that education should be routinely offered, not just assumed.

Fatigue and sleep are two areas that are often under-recognized but have significant impact on pain.

So fatigue management interventions, while the evidence on direct pain reduction is mixed, are still important because fatigue amplifies pain experience and limits engagement in daily activities.

Similarly, supporting healthy sleep is critical.

So poor sleep and pain are closely linked and addressing sleep can have meaningful effects on oral symptom burden.

Finally, none of these works in, of course, isolation.

So the guidelines emphasizes coordinated MDT working across primary and secondary care.

So that includes rheumatologists, nurses, physios, occupational therapists, psychologists, everybody working together alongside patients themselves.

So pain management requires a shared, holistic approach with a clear communication and consistent messaging.

00:08:57 Ernest Choy

That's great.

Dee, do you have anything more to expand on upon Yeliz’s comments?

00:09:05 Dee Pratt

Yes, there's a couple of other things I'd like to pull out because as Yeliz said, it's very much an MDT approach that's been recommended and I'd obviously advocate that as well.

But from a physiotherapist perspective, it's also been advocated in the recommendations that those with inflammatory arthritis should have access to a physiotherapist who has a rheumatology speciality, so they can provide the right support mainly around the exercise.

So from an exercise and physical activity perspective, it's about making surewe support these people to be safe when they're exercising and are physically active, to make sure they have the optimal benefits from doing that.

And also actually what platforms there are to become active and to maintain activity.

So whether it's a group based exercise or individualised programme, and it's all about promoting movement in general.

There's no specific exercises that are recommended.

It's all based on that individual consultation with that person who's going through that lived experience of inflammatory arthritis.

And I think even with those clinical consultations, what clinicians need to be aware of is ensuring that they're creating that supportive environment to have those real open and honest conversations, because some of the areas are very sensitive areas to be discussing.

So, and that includes, you know, making sure that clinicians are empathetic and putting themselves in the shoes of those people going through that experience of having inflammatory arthritis, but also that there's as much understanding as possible that's been embedded to those conversations, particularly around when we're discussing patient-centred goals during pain assessments as well.

So I think just a few other things to pull out there from the recommendations and even discussions around weight management.

We know that weight management is more of an issue generally in the population, but ultimately what the guidelines do bring out is that those living with obesity who are overweight and do have inflammatory arthritis, a healthy diet is generally recommended.

There's no specifics around it, but the general benefits of that are recommended too.

And also it's acknowledged that within rheumatology services, there's not ultimately direct access to psychological therapy.

So from a psychology perspective, there's more work that needs to be done and more collaboration across the patient pathway between primary, secondary care, community services and the voluntary care sector to enable joined up care.

So those people with inflammatory arthritis who need that psychological support can access it when they need it.

So that's what I would add.

00:11:46 Ernest Choy

Thank you, Dee.

I'll come back to Ian.

Are there particular tools or sections of the guidelines you would encourage clinicians to use to help with implementation?

00:11:57 Ian Scott

Thanks, Ernest.

It's hard, isn't it?

You're a busy clinician, you've got time limited and you've got a big guideline to go through.

So there's two things that we've put in the guideline to hopefully help with that.

The first is a graphical abstract, which was put together primarily by one of our evidence synthesis team members, Tilly Smith at Keele.

And that summarizes all the recommendations in a way that's very easy to view and understand at a single glance.

And hopefully everyone will be familiar with that as the guidelines launched.

The second is we put together tables listing each of the recommendations in detail.

So you don't have to go through all the text to try and pick out the relevant bits.

You can just see in a nutshell a table for the assessment, the drug treatment and the non-drug treatment.

And I think I'm hopeful that will be really helpful to clinicians to assimilate that information quickly.

And the third is we developed an audit tool, like all the guidelines, that can be used to assess patient care against the guideline recommendations.

And audits, as we know, is an important tool for improving care and implementing guidelines.

And if anyone's interested in using that and taking part of an audit, I think it'll be a lot more powerful if we do it as a community.

Contact myself, contact Nick, contact anyone in the guideline working group, and we can think about how to take that forward.

Thank you.

00:13:17 Ernest Choy

Fantastic.

OK, so Rebecca, what difference will this make for patients?

00:13:23 Rebecca Beesley

Absolutely. I see this guideline as a huge step forward in empowering patients.

And I love the way it's been written with those graphical abstracts and points to make it easier to understand for both medical teams and for patients themselves.

So I think it will really help patients understand what their options are because I know there have been times in my life where I feel like my pain hasn't been taken seriously and I haven't been listened to as well as perhaps I should have been.

And having this would almost feel like a tool in my hands to be able to go to my medical team and say, okay, what are my options?

What are the medication options?

What are the non-drug options available to me?

And use it as a prompt and a discussion tool with my medical team to kind of try and get better care and treatment for my pain.

So I think empowerment is a really important one for patients.

I'm also particularly pleased that this guideline isn't specific to a particular age group or particular condition, but it covers all of inflammatory arthritis as a whole.

And that's very much like a move towards, you know, treating these conditions throughout their life course, which is so important.

I myself have had juvenile arthritis since the age of 10.

My diagnosis hasn't changed once I became an adult.

I'm an adult with JAA and having a guideline like this will hopefully help my medical team to be able to know the best options for my care and helping with my pain management, you know, throughout all those stages.

So for children, young people with inflammatory arthritis now, hopefully they will get better care as their treatment progresses throughout their lives by having this guideline that covers the whole life course, which is really, really positive step forward.

I also think it just helps hugely towards that shared decision making, which I touched upon.

You know, this is not just about going to a doctor and saying, you know, what can you do, what medicine can you prescribe, but actually making those decisions together as a kind of true, true partnership, which is that ideal that all patients kind of strive for and, you know, good, good medical teams would want to see as well that shared decision making.

So you are helping that patient to kind of get the most fulfilled life they can with the options available.

So yeah, definitely really, really positive guideline. I've been delighted to be part of the working group for it.

00:15:42 Ernest Choy

I'll give the final word to Nick.

What key message would you like listeners to remember after hearing this discussion?

00:15:51 Nicholas Shenker

Yeah, thanks to Rebecca and absolutely, we were hugely helped by your input and the other patient experts who joined the guideline.

Take home messages is I think this guideline might open up different conversations with patients during the consultation, asking about whether pain's at an acceptable level, slightly awkward if you've not done that before, and it does lead to areas that I've been surprised about.

The big question that I've found helpful is asking people if they understand what the cause of their pain is.

I think health beliefs is a big area that we touched on as part of the guideline.

That's one way to get into it.

It's a hugely complex area that needs expert assessment to really get to grips with it.

But a simple question as to ask what is the cause of the pain that you're experiencing can be very enlightening.

And I'd encourage us all to be doing that.

00:16:53 Ernest Choy

Okay, thank you everybody for your contribution.

I hope the listeners have enjoyed this podcast.

And if you're interested in any of the documents related to this podcast, they are available on the BSR website.

And I look forward to welcome you to the next Rheumatology Roundtable.

00:17:19 

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