Guide to Pain Management in Low-Resource Settings

What are specifi c recommendations 
for osteoarthritis of the knee?
Osteoarthritis of the knee is the most frequent type of 
OA, seen in 15.3% of cases. Th
  e pain starts with walk-
ing, in the beginning or later, depending of the severity 
of cartilage damage. With rest, pain disappears gradu-
ally. Gelling pain is seen at the start of walking, disap-
pearing quickly. Pain may be located in the knee joint 
itself, or projected to the calf or thigh, or even to the 

Rheumatic Pain
223
hip. Physical examination reveals cold skin with normal 
coloration. Scraping the patella against the femoral knee 
epiphysis will produce a sensation of shaving an irregu-
lar surface. Th
  e maneuver is usually painful. Th
 e range 
of motion is normal at the beginning, deteriorating 
gradually. Full extension and full fl exion become impos-
sible, and gradually the limitation increases. Abnormal 
movement (lateral motion in full extension) is a sign of 
advanced cartilage destruction. X-rays, especially if tak-
en in a standing position, will demonstrate joint space 
narrowing, which is more pronounced in the internal 
compartment.
Episodically, an infl ammatory attack of OA 
will occur, and the knee will become swollen. Th
 e pain 
worsens and becomes continuous, while maintaining 
its mechanical character. Physical examination reveals 
synovial eff usion with limitation of joint movement. It 
will disappear with rest, in a few days to a few weeks, 
and symptoms will settle to what they were previously. 
Laboratory tests are not necessary when the history is 
evocative. Th
  ey remain normal, as during the normal 
course of the disease. X-rays do not change during the 
infl ammatory attack.
Treatment is indicated mainly for infl ammatory 
attacks, when walking must be limited to allow the joint 
to rest. Exercise to strengthen quadriceps is essential, 
especially when walking is limited. When possible, bicy-
cling is a very good choice, by preventing long displace-
ments that are harmful to the knee joint, while exercis-
ing the quadriceps.
What about osteoarthritis                
in other locations?
Osteoarthritis of the hip is much like knee OA, except 
that the pain is localized to the groin and buttock. It 
can project to the thigh or even the knee joint. Distal 
interphalangeal joint (DIP) OA is named as Heberden’s 
node. It is characterized by two nodes on the dorsal 
aspect of the joint. After a long progression, slight to 
moderate deformity may appear. Th
  e pain is sporadic 
and is mainly seen when the nodes appear, and there-
after during progressive attacks. No treatment is ef-
fective. NSAIDs are eff ective only for the duration of 
attacks. Proximal interphalangeal joint (PIP) OA is 
named Bouchard’s node. It is characterized by a single 
node on the dorsal aspect of the joint. It has the same 
characteristic as Heberden’s node. EULAR guidelines 
for diagnosis are of interest [7].
Pain in OA of the toes is mechanical. Deformi-
ty is seen after long progression. Moderate activity and 
a short of course NSAIDs with joint rest are the best 
strategy. Surgery, when possible, can be a good alternate 
choice. Primary OA of the elbow is very rare. Among 
the secondary forms, using a jackhammer produces a 
special type of OA. Patients have night pain, very simi-
lar to infl ammatory pain, improving or disappearing as 
work resumes. In the ankle, shoulder, wrist, and meta-
carpophalangeal joints, OA is usually secondary.
What is the signifi cance                    
of “soft-tissue rheumatism”?
Soft-tissue rheumatism is the third most frequent cause 
of rheumatic pain. It is seen in 4.7% of the young and 
adult population [1]. Pain is due to periarticular compo-
nents (tendons, tendon sheaths, bursae, and ligaments). 
In the majority of cases, pain is mechanical and related 
to the patient’s activity. Th
  e pain has a high tendency to 
recur. Treatment outcome is unpredictable, from excel-
lent with minimal intervention to resistant with the best 
known strategy. Th
  e best approach seems to be good 
patient education with minimal intervention: NSAIDs 
(high dose) or steroids (15 to 20 mg prednisolone) for 
few weeks, and if necessary local steroid injection (re-
peated once weekly as needed, usually not exceeding 
three consecutive injections).
Soft-tissue rheumatisms are numerous in types 
and location. Th
  e most frequent and important are lo-
cated at the shoulder (tendonitis, acute and subacute 
periarthritis, frozen shoulder, rotator cuff  rupture), the 
elbow (golfer’s and tennis elbow), and the forearm (De 
Quervain’s tenosynovitis), among others.
What should one know               
about osteoporosis?
Osteoporosis is a natural course of bone physiology if 
one lives long enough. From birth to young adulthood 
(around 30 years of age), bone mass increases. After 
that, the body gradually starts losing its bone reserves. 
In women the rate of loss is very low until menopause, 
and then it accelerates for 10 to 15 years before slow-
ing down again. In men, the descending curve is uni-
form. Th
  e decrease of bone mass density (BMD) makes 
the bone fragile. Th
  e quality of bone also degrades with 
age, even if bone mass remains stable, increasing the 
fragility of bones. Both phenomena increase the risk 

224
Ferydoun Davatchi
of fracture. With increasing lifespan, osteoporosis will 
become more frequent, in any region of the world. Th
 e 
World Health Organization (WHO) has classifi ed  it, 
since 1991, as “public enemy number one,” along with 
cardiac infarction, stroke, and cancer.
Unfortunately, osteoporosis has no clinical 
manifestation until fracture occurs. Th
  e only way to 
make a diagnosis before a fracture occurs is by bone 
densitometry. It is a very expensive procedure, not 
available for general use in developing countries. X-
ray diagnosis is diffi
  cult and late. More than 30% of the 
bone mass has to disappear for it to be diagnosed by 
a plain x-ray of the spine. Th
  e gold standard of treat-
ment is bisphosphonates, mainly alendronate. Unfor-
tunately it is an expensive drug. Natrium fl uoride  is 
cheap and can be made up by most pharmacies. It may 
increase bone mass, although results are controversial; 
20 to 40 mg daily, used for 1 year and then stopped for 
6 months before it is used again, may increase bone 
mass without decreasing bone strength. Calcium sup-
plements or dairy products along with enough vitamin 
D (800 units daily of vitamin D
3
) have to be added to 
the diet as well.
Is rheumatic arthritis a very 
frequent disease?
Rheumatic arthritis is not very frequent (aff ecting 
around 1% of the population). Other autoimmune dis-
eases causing arthritis include spondyloarthropathies, 
connective tissue diseases (such as systemic lupus ery-
thematosus, dermatopolymyositis, or progressive sys-
temic sclerosis), and vasculitides (such as periarteritis 
nodosa or Wegener’s granulomatosis).
Th
 e incidence of rheumatic arthritis is even 
lower in certain regions of the world; in Asia it aff ects 
only 0.33% of the population [1]. It mainly involves 
peripheral joints, but it can involve other organs too 
(lungs, heart, kidneys), although not frequently. Joint 
involvement will lead to progressive destruction, caus-
ing disability in a few years if the patient is not treated. 
Wrist and fi nger joints (metacarpophalangeal and prox-
imal interphalangeal), are most commonly aff ected, but 
other joints are also involved (elbow, knee, ankle and 
foot, hip, and shoulder). Th
  e pain is an infl ammatory 
pain. Morning stiff ness may last until noon or even well 
into the afternoon in severe cases.
Examination reveals swelling of the joint, due 
to synovial eff usion and synovial hypertrophy. ESR is 
raised, CRP is positive, and in more than 75% of cases, 
rheumatoid factor (RF) is positive in the serum. Recent-
ly, anti-CCP (cyclic citrullinated peptide) has gained 
much attention as being specifi c for RA, although not 
in all patients. X-rays will, after 6 months to 1 year’s du-
ration of arthritis, show joint demineralization, followed 
by joint surface erosion, and later joint destruction. Th
 e 
disease is chronic, lasting decades, but it can go in re-
mission (temporary or defi nitive). Treatment is based 
on a combination of two or more disease-modifying 
antirheumatic drugs (DMARDs) such as methotrexate, 
chloroquine, sulfasalazine, and low-dose prednisolone 
[2]. In refractory cases, biological agents will be of help. 
In countries where biological agents are not available or 
patients cannot aff ord them, a combination of several 
immunosuppressants can be considered.
Pearls of wisdom
Remember:
• Th
  e decision tree (Fig. 1) is self-explanatory. As 
an example: If the pain is mechanical and the 
spine is involved, it is important to fi nd out if the 
pain started insidiously or if it had an acute onset. 
In case of insidious onset, ordinary low back pain 
or cervical pain is by far the most likely cause.
• Th
  e decision tree cannot give you a diagnosis, but 
it may be of help as to where to search for the di-
agnosis.
• Th
 e fi rst step is to distinguish between mechani-
cal and infl ammatory pain, which should not be 
too diffi
  cult.  Th
 e diffi
  culty is when the patient 
complains of continuous pain. If you question the 
patient carefully, you can usually fi nd a mechani-
cal or infl ammatory character in the continuous 
pain.
•  Clinical examination will help to elucidate the di-
agnosis. If necessary, laboratory tests and X-rays 
will be of help.
• Th
  e remainder of the decision tree is used in a 
similar manner.

Rheumatic Pain
225
References
[1]  Davatchi F. Rheumatic diseases in the APLAR region. APLAR J Rheu-
matol 2006;9:5–10.
[2]  Davatchi F, Akbarian M, Shahram F, et al. DMARD combination ther-
apy in rheumatoid arthritis: 5-year follow-up results in a daily practice 
setting. APLAR J Rheumatol 2006; 9: 60–63.
[3]  Davatchi F, Jamshidi AR, Banihashemi AT, Gholami J, Forouzanfar MH, 
Akhlaghi M, Barghamdi M, Noorolahzadeh E, Khabazi AR, Salesi M, 
Salari AH, Karimifar M, Essalat-Manesh K, Hajialiloo M, Soroosh M, 
Farzad F, Moussavi HR, Samadi F, Ghaznavi K, Asgharifard H, Zan-
giabadi AH, Shahram F, Nadji A, Akbarian M, Gharibdoost F. WHO-
ILAR COPCORD study (stage 1, urban study) in Iran. J Rheumatol 
2008;35:1384.
[4]  Dayo RA, Diehl AK, Rosenthal M. How many days of bed rest for 
acute low back pain? A randomized clinical trial. N Engl J Med 
1986;315:1064–70.
[5]  Medscape. Back schools for nonspecifi c low back pain. Available at: 
www.medscape.com/viewarticle/485199.
[6]  Medscape. Low-intensity back rehab programs promote quicker return 
to work. Available at: www.medscape.com/viewarticle/531807.
[7]  Medscape. New guidelines to diagnose hand osteoarthritis. Available at: 
www.medscape.com/viewarticle/569860.
[8]  Peul WC, van Houwelingen HC, van den Hout WB, Brand R, Eekhof 
JA, Tans JT, Th
  omeer RT, Koes BW; Leiden-Th
  e Hague Spine Interven-
tion Prognostic Study Group. Surgery versus prolonged conservative 
treatment for sciatica. N Engl J Med 2007; 356: 2245–2256. 
[9]  Wikipedia. World population. Available at: http://en.wikipedia.org/
wiki/World_population.
Fig. 1. Decision tree for rheumatic pain. OA, osteoarthritis; STR, soft-tissue rheumatism.

Diffi
  cult Th
  erapeutic Situations and Techniques

229
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
and training purposes with proper citation of the source. Not for sale or commercial use. No responsibility is assumed by IASP for any injury and/or damage to persons or property 
as a matter of product liability, negligence, or from any use of any methods, products, instruction, or ideas contained in the material herein. Because of the rapid advances in the 
medical sciences, the publisher recommends that there should be independent verifi cation of diagnoses and drug dosages. Th
  e mention of specifi c pharmaceutical products and any 
medical procedure does not imply endorsement or recommendation by the editors, authors, or IASP in favor of other medical products or procedures that are not covered in the text.
Guide to Pain Management in Low-Resource Settings
Chapter 30
Dysmenorrhea, Pelvic Pain, and Endometriosis
Susan Evans
Case report
A 25-year-old married woman presents with pelvic pain 
on most days each month, especially during the time of 
her period.  She suff ers crampy period pain before and 
during her period, sharp stabbing pains that come at 
any time and wake her at night, bladder symptoms (uri-
nary frequency, urgency, and nocturia), headaches, and 
dyspareunia (painful sexual intercourse).
What are the treatment options?
Th
  is woman has chronic pelvic pain, with a combina-
tion of diff erent types of pain, and she probably has en-
dometriosis. For pain control she will need treatment 
for each type of pain:
• Th
  e oral contraceptive pill and a nonsteroidal an-
ti-infl ammatory drug (NSAID) are good fi rst-line 
options for her period pain. If the pain persists, 
and high-level laparoscopic surgery to remove 
endometriosis is not available, then continuous 
progestogen or a levonorgestrel intrauterine de-
vice are options.
•  Amitriptyline starting at 10 mg at early evening, 
daily, and increasing slowly as tolerated up to 25 
mg daily could be prescribed for her sharp stab-
bing pains and the bladder symptoms.
•  A careful history should identify dietary triggers 
for her bladder symptoms and the cause of her 
dyspareunia (see below).
•  Regular daily gentle exercise should be encour-
aged to help reduce pain levels.
•  Her headaches should be managed.
• Th
  e decision to refer her to a surgeon will depend 
on whether her period pain becomes unmanage-
able or she has diffi
  culty becoming pregnant. It 
will also depend on the surgical skills available.
How frequent is pelvic pain?
Pelvic pain is underreported, undertreated, and under-
estimated throughout the world. It aff ects approximate-
ly 15% of all women aged 18–50 years. Although it is 
complex to treat, the improvement in quality of life that 
can be achieved is very rewarding. Most women have 
more than one type of pain. Th
  eir symptoms include 
any, or all of:
• Dysmenorrhea
• Dyspareunia
• Neuropathic pain
• Bowel dysfunction
• Bladder dysfunction
• Vulval pain
• Bloating
•  Chronic pelvic pain
Frequently, their pain symptoms have been present 
for years without diagnosis or management. Th
 e pain 
aff ects their education, employment, relationships, self-
esteem, general wellbeing, sleep and sometimes fertility, 
so it is important to realize that patients needs emotional 

230
Susan Evans
as well as physical support. Th
  is chapter will provide an 
overview of pharmacological and non-pharmacological 
interventions for eff ective pelvic pain control.
How can I assess the cause of pain 
in a woman with pelvic pain?
Pelvic pain is assessed with a history, an examination, 
and special investigations.
History
Ask about the date of the last period in case of pregnan-
cy, and make a list of each pain or symptom the patient 
has. For each pain, ask her to describe what it feels like, 
where it is, when it occurs, how many days she has it 
per cycle, and what aggravates or relieves it. Ask about 
bladder symptoms (nocturia, frequency, urine infec-
tions, urgency), ask about bowel function (constipation, 
diarrhea or bloating, pain opening her bowels during 
her period), ask about pain with movement and pain in 
other areas of the body (e.g., migraine or muscle tender 
points), ask whether intercourse is painful, and ask how 
many days a month she feels completely well.
Examination
Assess the patient’s general well-being (depression, pos-
ture, and nutrition), the abdomen (for sites of pain, ten-
derness, peritonism, or masses), the vulva (for tender-
ness, skin lesions, or vulval infection), the pelvic fl oor 
muscles (for tenderness and spasm), the vagina (for 
nodules of endometriosis posterior to the cervix or in 
the rectovaginal septum, or congenital anomalies), and 
the pelvis (for uterine or adnexal masses, pregnancy). 
Vaginal examination is rarely necessary in virgins.
Investigation
Exclude pregnancy, including ectopic pregnancy, screen 
for sexually transmitted diseases if appropriate, and take 
a cervical smear if available (unnecessary for virgins). 
Ultrasound may show an endometrioma, but it is often 
normal, even with severe endometriosis.
How can I plan treatment               
for pelvic pain?
Th
 e treatment recommended depends on the symp-
toms present. Most women will have more than one 
pain symptom. Plan a treatment for each separate pain 
symptom. Remember to treat any coexisting health 
problems to allow patients more energy to cope with 
their pain:
•  Premenstrual syndrome (PMS), depression, anxi-
ety
• Menorrhagia
• Acne
• Constipation
•  Poor nutrition, poor posture, lack of exercise
•  Other pain conditions, including migraine
How can I treat dysmenorrhea                              
on day 1–2 of the menstrual cycle?
Pain at this stage of the cycle is usually uterine pain. 
Management options at the primary care level include 
monophasic oral contraceptive pills, such as 20–35 μg 
ethinyl estradiol with 500–1,000 μg norethisterone or 
150 mg levonorgestrel, as well as pain medication. Th
 e 
pain medication of fi rst choice should be an NSAID tak-
en early on in the episode of pain, such as ibuprofen at 
a dose of 400 mg initially and then 200 mg three times 
daily with food. For moderate or severe pain, opioids 
should be off ered. Nonpharmacological options include 
hot or cold packs over the lower abdomen, Vitex agnus 
castus (chasteberry) 1 g daily (avoid if pregnant; ineff ec-
tive if on oral contraceptive pills), vitamin E (400–500 
IU natural vitamin E from 2 days before period until day 
3) and zinc 20 mg (as chelate) twice a day. Traditional 
Chinese Medicine (acupuncture and herbal therapies) 
are also popular, but they should only be recommended 
if aff ordable and if the patient has a positive attitude.
Many women with severe dysmenorrhea become 
fearful as their period approaches. Th
  ey fear pain that 
they cannot control. By providing them with strong an-
algesics to control severe pain if it occurs, this anticipa-
tion of pain can be reduced and they can regain control 
of the pain. Th
  erefore, “on-demand” doses of analgesics 
should be provided.
How can I treat prolonged dysmenorrhea? 
Could the patient have endometriosis?
Dysmenorrhea (painful cramps) for more than 1–2 
days is often due to endometriosis, even in teenagers. 
A woman with endometriosis also has a more painful 
uterus than other women. She thus has two causes for 
her pain. Management options include on the prima-
ry care level all the treatments used for dysmenorrhea 
above, a levonorgestrel intrauterine device, continuous 
progestogen (norethisterone 5–10 mg daily, dydroges-
terone (a synthetic hormone similar to progesterone) 

Dysmenorrhea, Pelvic Pain, and Endometriosis
231
10 mg daily, or depot medroxyprogesterone acetate to 
achieve amenorrhea). If referral to a well-equipped hos-
pital is an option, surgery, preferably laparoscopy, to di-
agnose and remove endometriosis, if medical treatments 
have failed, would be indicated. Hysterectomy is only in-
dicated if the patient is older and her family is complete. 
Conserve the ovaries where possible in premenopausal 
women. Ovarian endometriomas can usually be treated 
with cystectomy rather than oophorectomy.
How can I treat ovulation pain?
Normal ovulation pain should only last for 1 day, oc-
curs 14 days before a period, and changes sides each 
month. Management options include an NSAID when 
pain occurs, an oral contraceptive pill to prevent ovu-
lation, or continuous norethisterone 5–10 mg daily to 
induce amenorrhea. If more than the primary care lev-
el is available, and pain is severe or always unilateral, a 
laparoscopy with division of adhesions and removal of 
endometriosis is indicated. An ovary should only be 
removed if severely diseased, and the patient’s fertility 
needs have been discussed and carefully considered.
How can I treat a woman with pelvic               
pain and bladder symptoms? 
Many women with pelvic pain describe frequent urina-
tion, nocturia, pain when voiding is delayed, suprapubic 
pain, vaginal pain, dyspareunia, or the feeling of having 
a urinary tract infection. Th
  is feeling is often due to in-
terstitial cystitis of the bladder. Th
  ere may be a history 
of frequent “urinary tract infections” but with negative 
urine culture. First, exclude urine infection, chlamydia, 
and gonococcal or tuberculous urethritis. Th
 en ensure 
suffi
  cient fl uid intake to avoid concentrated urine. Iden-
tify and avoid dietary triggers if present. Common trig-
gers include coff ee, cola drinks, tea (including green 
tea), vitamins B and C, citrus fruit, cranberries, fi zzy 
drinks, chocolate, alcohol, artifi cial sweeteners, spicy 
foods, or tomatoes. Peppermint and camomile teas are 
usually acceptable. If food triggers are present, pain usu-
ally follows within 3 hours of food intake. Provide in-
structions about how to manage symptom fl ares (drink 
500 mL water mixed with 1 teaspoon of bicarbonate 
of soda. Take a paracetamol (acetaminophen) and an 
NSAID if available. Th
  en drink 250 mL water every 20 
minutes for the next few hours). For symptom control, 
try amitriptyline 5–25 mg at night, oxybutynin (start 
with 2.5 mg at night, increase slowly to 5 mg three times 
a day), or hydroxyzine, especially for those with allergies 
(start with 10 mg at night, increase slowly to 10–50 mg 
at night).
Many women with bladder symptoms develop sec-
ondary pelvic fl oor dysfunction with dyspareunia and 
severe muscular pelvic pain. If pain persists, consid-
er cystoscopy with hydrodistension. All medications 
should be avoided in pregnancy, if possible. Also note 
that hydroxyzine is contraindicated in epileptics.