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To the average arthritic patient, pain relief is usually his or her first priority in treatment. Thus, analgesics still have a part to play in the treatment of most arthritic conditions, even though the non-steroidal anti-inflammatory drugs (NSAIDs) have the major therapeutic role in most cases. In the treatment of acute gout, the NSAIDs are the most important, and simple analgesics are relatively unimportant, but in the treatment of rheumatoid and osteoarthritis and other arthropathies, analgesics taken as and if required to cover the more painful periods of a day do have a role, usually in conjunction with NSAIDs and other agents. In general, the simple analgesics are better tolerated than the NSAIDs and less likely to produce gastrointestinal irritation. Although many clinicians consider that simple analgesics have little part to play in the treatment of rheumatoid arthritis and other inflammatory arthropathies, the patient often takes them without the physician's knowledge, in addition to the prescribed treatment. Some recently introduced analgesics bridge the gap between the simple analgesics and the more potent potentially addictive drugs such as pethidine and morphine, which are only indicated in extremely painful crises or after traumatic episodes and surgical operations.

The literature on fibrositis (fibromyalgia), which originated in the early years of the last century in the UK and proliferated there in the first half of this century, has since diminished there in the last 30 years or so, but has increased in Canada and the US. Criteria suggested for diagnosis have created a syndrome with no diagnostic tests, serological or radiological signs, and no truly objective physical signs, but with predictable tender spots on pressure. The syndrome is largely, but not completely, confined to females, mostly of middle age; the symptoms include widespread aching of more than 3 months' duration, disturbed sleep, morning fatigue and stiffness, a failure to respond satisfactorily to any one form of therapy and a tendency to persist over long periods, but without permanent tissue changes. Features of psychological disturbance are present in many patients but not in all or even the majority. Definition of the condition as a disorder of pain modulation - a pain amplification syndrome - would seem to fit the facts best. Most would agree that an abnormal response to stress is an important factor in the appearance of the syndrome, as other stress related disorders, such as the irritable bowel syndrome and tension headaches, may coexist. Response to therapy, whether physical or pharmacological, is on the whole unsatisfactory. This type of patient has been well recognised in hospital clinic and general practice for many years.(ABSTRACT TRUNCATED AT 250 WORDS)

In the differential diagnosis of arthritis and arthralgia, one must consider the possibility of adverse drug reactions being responsible. The distinction between primary cause and secondary aggravation of a pre-existing condition is often difficult and sometimes impossible to make; for instance, oral contraceptives may seem on occasion to precipitate pre-existing rheumatoid arthritis and systemic lupus erythematosus and also to cause temporary symptoms resembling these disorders in previously normal subjects. In addition, serum sickness type reactions, myopathies, electrolyte and fluid disturbances, pseudosclerodermas, bone lesions and local reactions to intra-articular injections have been described. One should therefore be aware of the possibility of drug-induced syndromes resembling rheumatoid arthritis, systemic lupus erythematosus, periarthritis of the shoulders, progressive systemic sclerosis, and other rheumatic and arthritic disorders. Though rarely severe or incapacitating, they may cause considerable diagnostic confusion.

Using arthritis in referring to inflammatory and arthrosis in referring to degenerative conditions of the joints 179 conditions are noted in which 1 or the other or both or allied conditions occur. There are a large number of bacteria which can infect articular structures and arthropathies due to viruses are more common than had been believed. There are numerous postinfective arthropathies traumatic arthropathies and arthropathies due to dietetic causes. Certain drugs have also been known to cause arthropathies. Rheumatic symptoms and serological abnormalities induced by oral contraceptive drugs have been reported. The oral contraceptives appear to be capable of causing the hydrallazine (or reversible systemic lupus) syndrome.

Pain threshold was measured in 106 patients with rheumatoid arthritis, 50 with ankylosing spondylitis, and 50 normal controls using Keele's algometer. In rheumatoid arthritis patients with a low pain threshold had more severe pain for a greater part of the day and required more tablets for pain relief. In ankylosing spondylitis the pain threshold was higher and was not related to pain or analgesic requirements. There was no evidence that pain threshold affected the course or outcome of rheumatoid arthritis in any way.

Giant cell (temporal) arteritis was first described by Horton and colleagues in 1932, and polymyalgia rheumatica in 1957 by Barber who suggested this title for an entity resembling, but distinct from, rheumatoid arthritis of unknown aetiology in the elderly. Arteritic features were sufficiently common in polymyalgia rheumatica to suggest an arteriopathy as a cause, further evidence of this being the change from the clinical picture picture of polymyalgia rheumatica to giant cell arteritis and vice versa in many patients such that the alternative title polymyalgia arteritica was suggested. The clinical picture of polymyalgia rheumatica is that of an elderly patient, more often female than male, usually over 60 years of age, with painful stiffness in the girdle joints and muscles of the shoulders and hips, but seldom with findings in peripheral or intermediate joints. The painful stiffness in the shoulders, hips and thighs is worse in the early morning. An erythrocyte sedimentation rate over 50mm in 1 hour is usual, and there is a rapid and dramatic response to small doses of corticosteroids (around 10mg prednisolone daily). Arteritic and axial arthritic features have been noted by different authors in different ratios, the disorder gradually abating naturally over periods varying from several months to 7 to 10 years. Deaths, when they occur in this elderly group of patients, have usually been unrelated to the disease or its treatment, but osteoporotic vertebral crush fractures are not uncommon. Partial or complete blindness may occur in patients with either giant cell arteritis or polymyalgia rheumatica, often appearing rapidly after cessation of corticosteroid therapy or rapid reduction of dosage.(ABSTRACT TRUNCATED AT 250 WORDS)

Adams,Cliffe, Lessel, andNicholson (1963) reported* thebiological properties ofa newsubstance, 4-isobutylphenyl acetic acid(Ibufenac). As assessed bytheultra-violet erythema test inguineapigs (AdamsandCobb,1958), itproved tohavetwo tofourtimes theanti-inflammatory effect ofaspirin, andits analgesic activity asmeasured byamodificationofthemethodofRandall andSelitto (1957) wasofthesameorder.Their worksuggested that thissubstance mightbea useful substitute for acetylsalicylic acid.Inhumansubjects, after doses of640mg.bymouth,detectable amountswere present inthebloodwithin 30to60minutes, rising toamaximumof2to4mg./100 ml.in2to4hours, andsmall butdetectable amountswerestill present 8hoursafter ingestion ofthedose(Adams, 1963). Chalmers (1963) reported thatIbufenac indoses of 30gr.daily appeared tobeaseffective asaspirin in doses of60gr.daily inthecontrol ofsymptoms in patients withrheumatoid arthritis, side-effects being fewer withIbufenac thanwithacetylsalicylic acid. Tudhope (1964), using the51chromium technique previously employed byScott, Porter, Lewis, and Dixon(1961) andWood,Harvey-Smith, andDixon (1962) withsalicylates, foundIbufenac considerably lessproductive ofgastro-intestina l haemorrhage