NSG 4235: PICO Question - RA Pain Management with DMARDS & Exercise

This assignment presents a PICO (Population, Intervention, Comparison, Outcome) question focused on rheumatoid arthritis pain management in adults aged 30-60 with the condition for less than 5 years. It investigates the effectiveness of medication (DMARDS) combined with exercise versus medication alone in achieving pain relief. The assignment outlines the research problem, highlighting the limitations of long-term DMARD use and the potential benefits of non-pharmacological interventions like exercise. The research hypothesis proposes that combining medication with physical exercise will lead to more effective pain recovery compared to medication alone, improving joint flexibility, cardiac function, and overall quality of life. The PICO framework is used to develop a research question and hypothesis related to managing pain associated with rheumatoid arthritis using both pharmacological and non-pharmacological interventions.

Running head: PICO QUESTION
PICO Question
Name of the Student
Name of the University
Author Note

1
PICO QUESTION
Patient/Problem
Adult population with rheumatoid arthritis for <= 5 years and age bar in between 30 to 60
years.
Intervention
Medication (DMARDS) and exercise
Exercise: Planning for the physical exercise for 6 months of individualized aerobic exercise
training along with resistance high intensity exercise training for three times per week. This
will be followed by Upper Extremity Exercise Training.
Physical exercise training will be given by a trained physiotherapist and physical training
expert under active supervision of the nursing professional. Medication management will be
controlled by the nurse as per the dosage and administration route recommended by doctor.
Comparison
Medication (DMARDS: Disease Modifying Anti-rheumatoid Drugs) only
Outcome
More satisfactory pain relief: The pain-relief will be accessed on basis of the pain
assessment by pain-score. The recovery from pain will be executed through improvement in
the extremity disability, improvement in the handgrip strength and increase in the self-
efficacy. The pain relief is also attained by improvement in the cardio-vascular functions like
promoting cardio-respiratory fitness along in increase in the flexibility of the wrists and other
joint parts

2
PICO QUESTION
Write out your research problem
Rheumatoid arthritis is an auto-immune disease that causes chronic inflammation in
joints. Unlike wear-and-tear damage of the osteo-arthritis, rheumatoid arthritis affects the
inner lining of the joints resulting in painful swelling that eventually leads to the development
of bone deformity and erosion of bones. The main symptoms of the rheumatoid arthritis (RA)
is swelling and pain in joints that hamper the quality of life of the adults along with
restriction in conducting daily living activities (Okada et al., 2014). The study conducted by
Van Dartel et al. (2013) further highlighted that pain among the patients with RA is
associated with fatigue. Increase level of fatigue associated with pain cause the daily life
experience debilitating, restricting day-to-day functioning. Increase in pain, increases the
severity if fatigue resulting in mood swings, behavior and beliefs. In relation to the
intervention, Van Dartel et al. (2013) highlighted that decrease in pain leads to decrease in
the severity of fatigue and thereby helping to execute daily living activities. Lee et al. (2013)
are of the opinion that pain among the patients with RA hampers the quality of sleep at night.
The peripheral inflammation occurring in pain is modulated by the central nervous system.
Conditioned modulation of pain by the central nervous system hampers the quality of life of
the adults with RA. Andersson, Svensson and Bergman (2013) further stated that chronic
wide-spread pain among the patients with rheumatoid arthritis cause swollen joint, poor
cardiac activity. This restricted movement create barrier towards successful accomplishments
of daily living activities and thereby hampering the overall quality of life.
In order to manage pain, the use of the Disease Modifying Anti-rheumatoid Drugs
(DMARD) is recommended by the healthcare professionals. One of the well known DMARD
include Tubastatin. Tubastatin is a selective histone deacetylase 6 inhibitor, which is found to
display anti-inflammatory and anti-rheumatic effects. Tubastatin mainly executes it function
by inhibiting cytokines TNF-alpha and IL-6 under the action of the THP-1 marcophages

3
PICO QUESTION
(Vishwakarma et al., 2013). Okada et al. (2014) are of the opinion that inflammation
associated with rheumatoid arthritis can cause damage to other parts of the body. Though,
improved treatment options are there but prolong use of the pain management medication
results in unwanted side-effects. According to Watanabe et al. (2013) there are several risk
factors behind the implementation of the DMARD for pain management in RA. Prolong use
of the DMARD results in the generation of small intestinal damage along with increasing the
vulnerability of developing complications related to stomach and digestion.
Thus the main problem statement, prolong use of the DMARD for the effective
management of pain among the adults with RA is not a plausible options as it might increase
the chances of developing additional side-effects. Manning et al. (2014) argued that non-
pharmacological interventions for the effective management of pain can be employed for
managing pain among the patients with RA with no possible side-effects. However, unlike
medicines, the non-pharmacological interventions like physical exercise are unable to extract
quick results or pain relief.
Write out your research hypothesis
The implementation of the medication management (pharmacological intervention)
along with practice of the physical exercise (non-pharmacological intervention) will help to
bring effective recovery from pain in comparison to the individuals who will receive only
medication management of pain. The research hypothesis is mainly driven by the systematic
review conducted by Giné-Garriga et al. (2014). The systematic review conducted by Giné-
Garriga et al. (2014) over the randomized control trials highlighted that exercise has certain
benefits over the frail adults suffering from joint pain. Regular practice of the mild-to-
moderate physical exercise helps to improve the gait function of the adults suffering from
joint pain. The improvement of the gait function helps to reduce the pain and thereby

4
PICO QUESTION
improving the quality of life of the older adults along with decrease in the chances of
accidental falls. Ambrose and Golightly (2015) are of the opinion that physical exercise is an
effective non-pharmacological intervention for the effective management of the chronic pain.
Physical exercise helps to improve general health, reducing disease risk and severity of pain.
Thus the main research hypothesis is effective implementation of the pharmacological and
non-pharmacological interventions among the adults suffering from RA for 5 years of more
will be helpful in reducing the severity of pain. The decrease in the level of pain will be
associated with improvement in flexibility of the joints, cardiac functions, physical fitness
and gait functions and thereby helping to improve the quality of life of the adults. Moreover,
the use of physical exercise along with the medication management of pain will extract better
results in comparison to the individuals who will be given only medication management. The
use of non-pharmacological interventions along with the medication management will help to
reduce the dosage requirement of DMARDS for pain management of RA and thereby helping
to reduce the side-effects of long-term use of DMARDS.
The hypothesis also include effective use of the multi-disciplinary team like nursing
professionals, physiotherapists, physical training experts and doctors for improving the
quality of care of the adults suffering from RA.

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PICO QUESTION
References
Ambrose, K. R., & Golightly, Y. M. (2015). Physical exercise as non-pharmacological
treatment of chronic pain: why and when. Best practice & research Clinical
rheumatology, 29(1), 120-130.
Andersson, M. L., Svensson, B., & Bergman, S. (2013). Chronic widespread pain in patients
with rheumatoid arthritis and the relation between pain and disease activity measures
over the first 5 years. The Journal of rheumatology, 40(12), 1977-1985.
Giné-Garriga, M., Roqué-Fíguls, M., Coll-Planas, L., Sitja-Rabert, M., & Salvà, A. (2014).
Physical exercise interventions for improving performance-based measures of
physical function in community-dwelling, frail older adults: a systematic review and
meta-analysis. Archives of physical medicine and rehabilitation, 95(4), 753-769.
Lee, Y. C., Lu, B., Edwards, R. R., Wasan, A. D., Nassikas, N. J., Clauw, D. J., ... & Karlson,
E. W. (2013). The role of sleep problems in central pain processing in rheumatoid
arthritis. Arthritis & Rheumatism, 65(1), 59-68.
Manning, V. L., Hurley, M. V., Scott, D. L., Coker, B., Choy, E., & Bearne, L. M. (2014).
Education, self‐management, and upper extremity exercise training in people with
rheumatoid arthritis: A randomized controlled trial. Arthritis care & research, 66(2),
217-227.
Okada, Y., Wu, D., Trynka, G., Raj, T., Terao, C., Ikari, K., ... & Graham, R. R. (2014).
Genetics of rheumatoid arthritis contributes to biology and drug
discovery. Nature, 506(7488), 376.

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PICO QUESTION
Van Dartel, S. A. A., Repping‐Wuts, J. W. J., Van Hoogmoed, D., Bleijenberg, G., Van Riel,
P. L. C. M., & Fransen, J. (2013). Association between fatigue and pain in rheumatoid
arthritis: does pain precede fatigue or does fatigue precede pain?. Arthritis care &
research, 65(6), 862-869.
Vishwakarma, S., Iyer, L. R., Muley, M., Singh, P. K., Shastry, A., Saxena, A., ... &
Rathinasamy, S. (2013). Tubastatin, a selective histone deacetylase 6 inhibitor shows
anti-inflammatory and anti-rheumatic effects. International
immunopharmacology, 16(1), 72-78.
Watanabe, T., Tanigawa, T., Nadatani, Y., Nagami, Y., Sugimori, S., Okazaki, H., ... &
Koike, T. (2013). Risk factors for severe nonsteroidal anti-inflammatory drug-induced
small intestinal damage. Digestive and Liver Disease, 45(5), 390-395.