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In clinical practice, rheumatoid arthritis (RA) can be difficult to manage. This is partially due to the complexity of pain, fatigue, and emotional distress that may not correlate with inflammatory disease activity. While it is true that socioeconomic, personal and comorbid conditions can play a role, it is important to identify patients who may suffer from pain-related syndromes early on.

In their study , Lindqvist and colleagues sought to evaluate rheumatoid patients based on clusters of symptoms (pain, fatigue, sleep quality, mood disturbances, and health related quality of life (HRQoL)) and identify potential associations. This was an observational study based in Sweden; both causality and generalizability to other countries could not be established.

Researchers recruited 1,011 patients, all whom were three years post-RA diagnosis. They were then clustered into three groups: good health status (cluster 1), intermediate health status (cluster 2), and high levels of pain, fatigue and impaired HRQoL (cluster 3).

Those in cluster 3 had a positive association to female gender and a higher tender joint but lower swollen joint count compared to cluster 1. Cluster 3 also had higher body mass index and health assessment questionnaire and global assessment scores at time of diagnosis. These patients may have had symptoms of fibromyalgia. There was no association between cluster type and anti-citrullinated protein status. Interestingly those who did well at year 3 had less baseline pain at diagnosis but a higher swollen joint count, possibly predicting that an "inflammatory phenotype" had a better pain, fatigue, and psychosocial outcome.

Pain, fatigue, and stress are difficult conditions to manage for physicians and patients. Although we are traditionally taught that uncontrolled inflammation causes pain, the management of pain is in fact complex and may not resolve with traditional antirheumatic medications. The treatment of pain and associated fatigue and emotional distress can become a daunting task.

Although further studies are needed to identify the best approach to these patients, it may be beneficial to identify patients in "cluster 3" early and implement a patient-centered approach to their pain. This includes cognitive behavioral therapy, pain management, sleep evaluation, and physical therapy. Patients also may benefit from good social support and consistency with their primary care and doctor visits.

Sneha Patel, MD, practices rheumatology in Ft Worth , Texas.

Read the study here and a Q&A of the highlights here.