What I Wish I Knew About Treating Chronic Pain in People with Psoriatic Arthritis?

As a rheumatologist, treating patients with psoriatic arthritis (PsA) has been both a rewarding and humbling experience. PsA is a complex and heterogeneous disease that not only affects joints and skin but also challenges us with its systemic nature. Among the most perplexing aspects of care is managing chronic pain; an issue that can persist even in the absence of active inflammation. Over the years, I have learned important lessons that have significantly shaped the way I approach chronic pain in patients with PsA. If I could go back to the beginning of my practice, there are many things I wish I had known earlier.

The Importance of Differentiating Pain Types

One of the most critical lessons has been the importance of distinguishing between inflammatory pain and chronic pain syndromes such as fibromyalgia. Early in my career, it was tempting to focus predominantly on managing inflammation using disease-modifying antirheumatic drugs (DMARDs) and biologic therapies. These treatments are essential for slowing disease progression, reducing joint damage, and improving function. However, I quickly realized that for many patients, inflammation control does not equate to pain relief.

Patients would return to the clinic reporting persistent pain despite normalized inflammatory markers and improved joint counts. At first, this was puzzling. It became clear that many of these individuals were dealing with overlapping chronic pain syndromes; conditions that amplify the body’s pain response and are not necessarily driven by active inflammation. Understanding and acknowledging these distinctions is the first step in truly addressing patient suffering.

Chronic Pain Isn’t Always Inflammation

What I’ve come to understand is that chronic pain in PsA is often multifactorial. Central sensitization, a phenomenon in which the nervous system becomes hypersensitive and amplifies pain signals, can play a significant role. This process makes individuals more sensitive to stimuli that would not normally be painful. Recognizing when pain is being driven by central mechanisms, rather than ongoing inflammation, has transformed my approach to treatment.

Unfortunately, central sensitization and associated conditions like fibromyalgia are often underdiagnosed or misunderstood, both by physicians and patients. This gap in understanding can lead to frustration on both sides, particularly when traditional anti-inflammatory treatments fail to provide relief.

The Power of a Holistic Assessment

Over time, I have evolved my clinical practice to include a more holistic and individualized assessment for every PsA patient. A thorough initial evaluation doesn’t just include a musculoskeletal exam and lab tests; it now incorporates a comprehensive screening for comorbid conditions that can contribute to chronic pain and impact disease outcomes.

Obesity, metabolic syndrome, diabetes, and cardiovascular disease are common in PsA and have direct and indirect effects on pain perception and inflammation. Mental health conditions such as anxiety, depression, and sleep disturbances are especially significant. These issues not only increase the perception of pain but also interfere with patients’ ability to manage their disease effectively.

Addressing these comorbidities early and revisiting them regularly is essential for long-term success. I’ve learned that ignoring these contributing factors can result in a fragmented treatment approach and poorer outcomes overall.

Educating the Patient is Foundational

Another vital piece of the puzzle is patient education. Many patients assume that all joint pain must be due to inflammation. When their pain persists despite effective control of disease activity, they may feel confused, disheartened, or even disbelieved.

Part of my role now includes explaining the different mechanisms of pain. I talk about how chronic pain can develop from the nervous system itself through mechanisms like central sensitization and why this pain often doesn’t respond to traditional anti-inflammatory therapies. I’ve found that when patients understand these concepts, they become more engaged and open to broader management strategies.

Education fosters trust and helps align expectations. Patients begin to see that pain relief may not come in the form of a pill alone, but rather through a multifaceted and collaborative approach.

Lifestyle Modifications Are Key

Over the years, I’ve come to see lifestyle changes not as adjuncts to therapy, but as core components of pain management in PsA. Encouraging patients to adopt anti-inflammatory diets rich in vegetables, whole grains, lean proteins, and healthy fats can have significant effects on both systemic inflammation and overall well-being.

Exercise, particularly low-impact activities such as swimming, tai chi, or yoga, helps maintain joint function, reduces stiffness, and improves mood and sleep. Many patients fear that exercise will worsen their pain, so providing reassurance and tailored guidance is important. Collaborating with physical and occupational therapists has helped many of my patients regain confidence in movement.

Sleep hygiene, stress management, and regular routines are often overlooked but play a critical role in pain control. I’ve seen meaningful improvements in patients who commit to improving sleep patterns and managing daily stress through techniques like mindfulness, meditation, or cognitive behavioral therapy (CBT).

A Multidisciplinary Team Makes All the Difference

In more complex cases, or when chronic pain is particularly refractory, I refer patients to a multidisciplinary care team. This can include pain specialists, physiatrists, physical and occupational therapists, psychologists, and social workers. Each professional brings a different perspective and skill set, working together to address the multifaceted needs of the patient.

Psychological support, in particular, is often transformative. Chronic pain takes a toll on mental health, and mental health conditions in turn worsen the perception of pain. CBT and other forms of counseling help patients develop coping strategies, shift unhelpful thought patterns, and improve their ability to function despite pain.

Pain management specialists can also offer advanced treatment modalities such as nerve blocks, trigger point injections, or neuromodulation techniques when appropriate. Social workers help navigate insurance issues, access to care, and support systems all of which impact a patient’s ability to follow through with treatment plans.

The Role of Empathy and Patience

Perhaps the most important lesson I’ve learned is the power of empathy and patience. Treating chronic pain in PsA is not a linear process. It requires time, trust, and a willingness to adapt treatment strategies as new challenges arise. Every patient’s journey is unique, and what works for one person may not work for another.

As a clinician, I’ve learned that simply listening without immediately trying to “fix” everything can be incredibly healing. Validating a patient’s experience and making them feel heard can be the first step toward meaningful improvement. Sometimes, just knowing that their pain is real and that someone is committed to helping them navigate it makes a world of difference.

Conclusion

Treating chronic pain in patients with psoriatic arthritis goes far beyond controlling inflammation. It requires a deeper understanding of pain mechanisms, a willingness to embrace holistic care, and a commitment to individualized treatment plans. By distinguishing between inflammatory and non-inflammatory pain, addressing comorbidities, prioritizing patient education, and leveraging a multidisciplinary approach, we can dramatically improve the quality of life for those living with PsA.

Ultimately, the journey has taught me to look beyond the lab results and swollen joint counts; to see the whole person behind the diagnosis. That shift in perspective has made me a better doctor, and I believe it leads to better outcomes for my patients.