Similar Pain Scores in Rheumatoid Arthritis and Osteoarthritis Over 45 Years Despite Dramatically Fewer Swollen Joints in Rheumatoid Arthritis: Are Scores Based as Much on Pain Sensitization and Patient Distress as on Inflammation and/or Structural Damage?

This narrative review presents five observations concerning 0 to 10 pain Visual Analog Scale (VAS)/Visual Numeric Scale (VNS) scores in routine care patients with primary diagnoses of rheumatoid arthritis (RA) or osteoarthritis (OA) over more than four decades: (1) Although median RA swollen joint counts declined from 12 of 28 in 1985 to 0 of 28 in two databases in 2021/2022, reflecting excellent control of inflammation, median pain VNS was 5 of 10 in both databases, similar to a 1979 report. (2) Mean or median pain VAS/VNS score was also 4 to 6 in OA in 1979 and appears unchanged in 2022, similar to RA. (3) RAPID3 (Routine Assessment of Patient Index Data 3), a composite of physical function, pain, and patient global assessment, also appears unchanged in RA and OA from 1985 to 2022. (4) Similar 4 to 6 of 10 VAS/VNS pain scores were seen in other rheumatic diseases. (5) Pain scores were significantly higher in patients with RA or OA who screened positive versus negative for anxiety, depression, and/or fibromyalgia on Multidimensional Health Assessment Questionnaire indices, which agree 80% with reference questionnaires. These findings suggest that a traditional view of pain in RA and OA as primarily nociceptive, based on inflammatory activity or structural damage, may be oversimplified. Patients with RA or OA also appear affected by neuropathic pain, based on central/peripheral nervous system pathology, and nociplastic pain, based on pain sensitization. These findings have been possible only with recent excellent control of inflammation in RA and with feasible screening indices for anxiety, depression, and fibromyalgia in all rheumatic diseases.