The Medicolegal Challenges of Managing Joint Pain
Joint pain may be either acute or chronic. Acute joint pain arises from infection, trauma, autoimmune and inflammatory processes. Without prompt diagnosis and appropriate management, there is a high risk of long-term consequences, including disability. Septic arthritis is a particular concern as it is associated with high levels of both morbidity and mortality. However, emerging infectious and reactive causes of arthritis, including viral agents such as Zika and COVID-19, are likely to become more prominent in the future.
Chronic joint pain most commonly arises due to arthritis. Osteoarthritis (OA) is the predominant form of the disease, affecting approximately one-third of people over the age of 65. It occurs in women more often than men. The prevalence of OA is rising, partly due to the increasing prevalence of risk factors, which include obesity, physical inactivity and joint injury. However, it is likely that other factors also contribute. Typically, the hips, knees, hands, feet or spine are affected; frequently more than one joint is involved. However, there is little correlation between reported pain level and changes to the joint visible on imaging. Symptom presentation is heterogeneous and it is likely that there are a number of different pathways that result in similar structural changes and pain outcomes.
The burden of illness associated with joint pain can be significant. After diabetes and dementia, OA is the third most likely condition to be associated with disability. Joint pain causes functional limitations, loss of independence, poor sleep leading to fatigue, and psychiatric symptoms, particularly depression. There is also an economic effect; patients with joint pain report less productivity, both in terms of an increased number of days off work and reduced productivity when at work. Many also take early retirement due to their condition.
Despite this, under-diagnosis and under-treatment of joint pain is common. This is particularly the case in patients with other chronic conditions, in whom the pain may be attributed to other causes. However, joint pain may directly affect the management of these conditions. For example, patients with cardiometabolic conditions may be unable to exercise to control their bodyweight, an important factor in most treatment plans. Not surprisingly, OA of the knees or hips is associated with a higher risk of mortality both from all causes combined and cardiovascular diseases, with much of this association being due to OA-related difficulty in walking. This factor also predicts a higher risk of serious complications in patients with diabetes, as well as a higher rate of incident diabetes in those who do not already have the disease.
Management of joint pain usually focusses on reducing pain and improving function and quality of life. Unfortunately, many of the pharmacological treatments available offer only limited relief and may be unsuitable for use with specific comorbid conditions, or are associated with significant side effects when used long-term. Currently, the most effective and safest non-surgical option for knee and hip OA is physical activity. It has been shown to reduce pain, increase function and reduce the risk of major mobility limitations. It also helps to reduce excess body weight, and thus the strain on the joints, as well as stiffness and weakness. Furthermore, there are positive effects on mood, lipid metabolism, hyperglycaemia and systemic inflammation. The best effects are seen when exercise, involving both strengthening and aerobic activities, is combined with other self-management strategies including maintaining a healthy bodyweight. However, patients may be reluctant to engage with a programme of physical activity if they fear that it may exacerbate their pain.
If non-surgical methods do not successfully control the symptoms of joint pain, surgical replacement of the joint may be recommended. As well as the general risks associated with all surgery, patients may suffer from complications specific to this procedure. These include chronic pain, venous thromboembolism, loosening and instability of the implant and prosthetic joint infection. Some of these may require revision surgery if they become severe. There is also a small risk of death following joint replacement. These risks appear to be moderated by patient age and obesity, so candidates for surgery should be carefully selected in order to reduce the risk of adverse events. It is also important that patients are made aware of the fact that joint replacement does not always offer a cure. Up to 30% of patients with knee or hip OA who undergo joint replacement report little or no improvement in their symptoms, or a more generalised dissatisfaction with the results of surgery. Joint replacement is a painful procedure and effective post-operative pain relief should result in earlier and better functional recovery, thus improving patient satisfaction.
While joint pain is a common condition, there is clearly an unmet need for better treatments, particularly non-surgical ones. Future developments include antibodies to nerve growth factor which act on the peripheral nervous system to provide effective pain relief. Additionally, a more tailored approach to pain management could be achieved by identifying subsets of patients with different pathophysiologies and targeting therapies appropriately. These developments have the potential to substantially improve outcomes and quality of life for patients with joint pain.
Further reading:
Hawker GA. Osteoarthritis is a serious disease. Clin Exp Rheumatol. 2019 Sep-Oct;37 Suppl 120(5):3-6. Epub 2019 Oct 14.
Shah A, Cieremans D, Slover J, Schwarzkopf R, Meftah M. Trends in Complications and Outcomes in Patients Aged 65 Years and Younger Undergoing Total Knee Arthroplasty: Data From the American Joint Replacement Registry. J Am Acad Orthop Surg Glob Res Rev. 2022 Jun 15;6(6):e22.00116.
