Key to Pain Paradoxes

Here we would like to pause on the key to pain paradoxes occurring in deforming arthrosis. To this end, it is essential to have a grasp of the entire chain of interactions arising between various factors involved in the formation of pain syndromes. 

Observation of patients suffering from deforming arthrosis has shown that the clinical aspect of their pain develops gradually and lags somewhat behind the structural changes in the joint. It may seem strange, but there is no direct link between the severity of pathological changes in the joint, the intensity of the pain syndrome and the degree of functional disruption in the limb. Physicians have often encountered cases in which patients experience insignificant pain in the presence of pronounced changes in the joint and, to the contrary, cases in which patients complain of unbearable pain in the presence of moderate manifestations of deforming arthrosis. The question arises: is there a logical explanation for such observations? It is not easy to find the answer to this question in the literature.

In encountering such cases, physicians have found themselves in a difficult position due to the lack of understanding of mechanisms responsible for the appearance and formation of pain syndromes in this disorder, as well as of its link to the degenerative changes in the joint cartilage. It is possible only to assume that pain mechanisms not yet fully understood are at work within the framework of the pathogenesis of deforming arthrosis, and that those pain mechanisms function independently of the mechanisms responsible for the degeneration of the joint cartilage.      

Special study of this issue has shown that at a specific development stage of deforming arthrosis the synovial (arthrogenic) and extrasynovial components of pain syndromes form a unified pathological algesic (pain) system, which then implements various mechanisms to activate pain generators distributed both within and without the damaged joint. The key to pain paradoxes in this disorder lies in the discovery of specific functional links between various pain sources. Very often, patients whose X-rays show identical joint damage have differing sets of triggers involved in the formation of pain syndromes. This circumstance explains the differences observed in the clinical manifestations of pain syndromes in patients who would seem to be absolutely identical (in terms of development of the disorder). Therefore, it is perfectly obvious that the approaches to eliminating pain in such patients will also differ.

For the physician, the “key” to the solution of the pain syndrome in osteoarthrosis lies in knowing that all patients have their own (characteristic of them alone) set of pain triggers. And this set of pain triggers has the property of periodically updating itself in connection with the progression of the disease and the accumulation of structural distortions in the affected limb. The stagewise character of the pathological process is reflected in effectuation of various mechanisms of activation of sources of peripheral pain, located both inside and outside the affected joint.

Experience shows that the ineffectiveness of pain-relief therapy in patients is explained by incomplete coverage of all the types of pain they are feeling at the time of treatment, as well as the lack of an individual approach to their prescription. Success cannot be hoped for in pain-relief therapy for deforming arthrosis of the knee and hip joints without exact diagnosis of the character of the pain and the use of appropriate treatment methods.  

Currently, when the patterns consistent in the formation of extrasynovial pain have become clear, and the magnitude of involvement of various tissues in the damaged joint has been recognized, one can only be upset at the continuing ignorance of modern medicine in such a critical and obvious aspect of pain therapy. The formation of pain syndromes in deformative arthrosis of the knee and hip joints involves three pain launch mechanisms simultaneously: the joint mechanism in the form of damage to the synovial membrane, and two extrasynovial mechanisms – muscle imbalance and osteoreflexive disruptions. Their influence on the modality of pain sensations depends upon which pain mechanism plays the leading role in any given instance. The most widely varied manifestations of pain syndromes are possible depending upon their structure.   

The site of the deforming arthrosis, which limits the manifestation of some pain mechanisms and leads to the action of others intrinsic only to that anatomical region, most directly affects the structure of the pain syndrome. It is very important that specialists not be surprised by this sort of pain transformation; they must anticipate such a situation in connection with the stagewise character of osteoarthrosis and, coincidentally, with the succession of chronic pain trigger mechanisms at various stages of development of this disease. It is entirely evident that attacking the extra-articular sources of pain is a vital untapped resource for improving the outcome of treatment of patients with deforming arthrosis. However, the currently accepted diagnostic algorithm in the examination of this category of patients is not designed to identify them. Adjusting the methods of evaluating such patients is a job of the near future.

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