A Novel Multimodal Treatment for Management of Pain in Rheumatoid Arthritis; A Case Series

Aim To present a novel understanding of Rheumatoid arthritis (RA) as a summation of motor neuropathy and an exaggerated expression of Hilton????????s law which links synovial irritation with muscle spasm leading to development of myofascial trigger points (MTrPs) and taut bands in muscles resulting in the severe pain, stiffness and inflammatory features of RA. Patients and methods- Six women on regular rheumatology care, sought our treatment for refractory pain (NRS 6.4+-0.85), stiffness and functional compromise in various joints as indicated by their disability of arm shoulder and hand (DASH right 58.83+-13.08, left 59.33+-14) and lower extremity functional scale (LEFS 42.33+-6.69) scores. They gave informed consent for pulsed radiofrequency (PRF) of whole innervation of the muscles responsible for knee/shoulder/elbow movement followed by ultrasound guided dry needling (USGDN) of affected muscles. After documenting the effects of PRF at 7 days USGDN was initiated and continued for 8-10 sessions. Medications included paracetamol, chlorzoxazone, pregabalin and continued antirheumatic medications. Results: PRF reduced the rest pain and stiffness (50-70 %) but not movement pains (30-50 %) or RROM, activity levels and disability all of which improved after USGDN along with CRP reduction (n2). Wasted muscles regained their normal contours, DASH (right 61.7 %, left 56.5 %) and LEFS (68 %) scores improved. NRS post treatment (0.66+-0.32) Conclusion: A novel perspective of motor neuropathy working independently and/or through Hilton????????s law helped develop effective treatments to reduce inflammation and hence relieve pain and stiffness in 6 RA patients. PRF and ultrasound guided dry needling (USGDN) target specific nerves and muscles directly involved in producing the inflammation.