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Multiple joint pain or polyarthralgia is defined as aches in the joints, joint pains, arthralgia of multiple joints, and multiple joint pain. Polyarthritis is the word usually used to describe pain affecting five or more joints, while a patient with 2 to 4 joints involved would be said to have the oligoarticular disease.

Polyarthralgia is more common in women and even more so with increasing age.

Types of Multiple Joint Pain

Multiple Joint pain (arthralgia) can be categorized as :

Inflammatory or non-inflammatory – Swelling of the joint, along with redness of the overlying skin and warmth of the area, are signs of an inflamed joint (arthritis). The absence of swelling, redness, and warmth of the affected joint, despite the pain, is an indication of non-inflammatory joint pain.
Mono-, oligo-, polyarticular – Monoarticular refers to one joint, whereas oligoarticular refers to two to four joints and polyarticular is more than four joints (five or more). This approach is often adopted for arthritis.
Generalized or localized – Generalized joint pain refers to diffuse pain, often with a regular change in the location of the joint pain (flitting), and may affect multiple joints simultaneously. Localized joint pain refers to pain within a specific joint or joint.

Etiology

Peripheral oligoarticular arthritis and polyarticular arthritis are more commonly associated with a systemic infection (eg, viral) or systemic inflammatory disorder (eg, RA) than is monoarticular arthritis. A specific cause can usually be determined (see Table: Some Causes of Pain in ≥ 5 Joints* and Some Causes of Pain in ≤ 4 Joints); however, sometimes the arthritis is transient and resolves before a diagnosis can be clearly established. Axial involvement suggests a seronegative spondyloarthropathy (also called spondyloarthritis—see Overview of Seronegative Spondyloarthropathies) but can also occur in RA (affecting the cervical spine but not the lumbar spine).

Infection (usually viral)
A flare-up of a systemic inflammatory disorder
Gout or pseudogout
RA
Seronegative spondyloarthropathy (usually ankylosing spondylitis, reactive arthritis, psoriatic arthritis, or enteropathic arthritis)
Osteoarthritis
Juvenile idiopathic arthritis
Chronic polyarticular arthralgia in children is most often due to the following:
Chronic polyarthralgia in adults is caused most often by RA and osteoarthritis.
Noninflammatory polyarticular pain in adults is most often due to the following:
Chronic polyarticular arthritis in adults is most often due to the following:
Acute polyarticular arthritis is most often due to the following:

Symptom of multiple joints pain

The following are the most common symptoms of multiple joint pain or polyarthritis arthritis. However, each individual may experience symptoms differently. Symptoms may include:

Inflamed, painful joints
Stiff joints
Enlarged and/or deformed joints (such as fingers bent toward the little finger and/or swollen wrists)
Frozen joints (joints that freeze in one position)
Cysts behind the knees may rupture, causing lower leg swelling and pain
Hard nodules (bumps) under the skin near affected joints
Low-grade fever
Inflamed blood vessels (vasculitis) may occur occasionally, leading to nerve damage and leg sores
Inflamed membranes around the lungs (pleurisy), the sac around the heart (pericarditis), or inflammation and scarring of the lungs themselves, may lead to chest pain, difficulty breathing, and abnormal heart function
Swollen lymph nodes
Sjögren’s syndrome (dry eyes and mouth)
Eye inflammation

If a person has four or more of the following symptoms, he/she may be diagnosed with multiple joint pain:

Morning stiffness that lasts longer than one hour for at least six weeks
Three or more joints that are inflamed for at least six weeks
Presence of arthritis in the hand, wrist, or finger joints for at least six weeks
Blood tests that reveal rheumatoid factor
X-rays that show characteristic changes in the joints

Diagnosis

Selected Extra-Articular Manifestations Associated with Conditions That Result in Polyarticular Joint Pain*

Skin and mucous membranes
Rash

Erythema infectiosum

Reticulated (lacy) rash
Human parvovirus B19 infection
Facial exanthema (slapped cheek)
Human parvovirus B19 infection
Malar rash
SLE, human parvovirus B19 infection, Lyme disease, rosacea, seborrhea, dermatomyositis
Plaques (scalp, navel, gluteal cleft)
Psoriasis
Heliotrope
Dermatomyositis
Erythema chronicum migrans
Lyme disease
Erythema marginatum rheumaticum
Rheumatic fever
Erythema nodosum
Sarcoidosis, Crohn’s disease
Pyoderma gangrenosum
IBD, RA, SLE, ankylosing spondylitis, sarcoidosis, Wegener’s granulomatosis
Palpable purpura
Hypersensitivity vasculitis, Schönlein- Henoch purpura, PAN
Livedo reticularis
Antiphospholipid-antibody syndrome, vasculitis, cholesterol emboli

Lesions

Keratoderma blennorrhagicum
Reactive arthritis, psoriatic arthritis
Discoid skin lesions
Discoid lupus erythematosus, SLE, sarcoidosis
Gottron’s papules or plaques
Dermatomyositis
Vesicopustule on an erythematous base
Gonococcal arthritis

Eyes

Iritis or uveitis
Spondyloarthropathies, sarcoidosis, Wegener’s granulomatosis
Conjunctivitis
Spondyloarthropathies, SLE, Wegener’s granulomatosis
Cytoid bodies (retinal exudates)
SLE
Scleritis
RA, relapsing polychondritis
Ischemic optic neuritis
Giant cell arteritis, Wegener’s granulomatosis

Ears, nose, and throat

Oral ulcers
SLE, Behçet’s syndrome, reactive arthritis, Wegener’s granulomatosis
Parotid enlargement
Sjögren’s syndrome, sarcoidosis
Macroglossia
Amyloidosis
Scalp tenderness
Giant cell arteritis
Bloody or severe sinusitis
Wegener’s granulomatosis
Inflammation of the ear, sparing the lobe [corrected]
Relapsing polychondritis

Nails

Onycholysis
Psoriatic arthritis, hyperthyroidism
Pitting
Psoriatic arthritis
Clubbing
IBD, Whipple’s disease, hyperthyroidism

Nodules

RA, gout, Whipple’s disease, rheumatic fever, amyloidosis, sarcoidosis
Tophi
Gout
Jaundice
Hepatitis, hemochromatosis
Hyperpigmentation
Whipple’s disease, hemochromatosis
Telangiectasia
Scleroderma
Thickened skin
Scleroderma, amyloidosis, eosinophilic fasciitis
Hair thinning
Hypothyroidism, SLE

Musculoskeletal system

Tender points
Fibromyalgia
Heberden’s nodes (DIP joints), Bouchard’s nodes (PIP joints)
Osteoarthritis
Boutonnière and swan-neck deformities
RA, SLE, Ehlers-Danlos syndrome
Dactylitis (“sausage digits”)
Spondyloarthropathies
Bursitis and enthesitis
Spondyloarthropathies

Constitutional conditions

Fever
Bacterial or viral infection, Still’s a disease, subacute bacterial endocarditis, neoplasm
Bradycardia
Hypothyroidism

Cardiovascular system

Mitral regurgitation and stenosis
Rheumatic fever
Aortic regurgitation
Ankylosing spondylitis, rheumatic fever, relapsing polychondritis, reactive arthritis, Marfan syndrome, Takayasu’s arteritis
Cardiomyopathies
Viral infection, amyloidosis, sarcoidosis, SLE, polymyositis
New murmur, fever
Bacterial endocarditis, rheumatic fever
Diminished peripheral pulses
Giant cell arteritis, Takayasu’s arteritis

Gastrointestinal system

Splenomegaly
Felty’s syndrome, tumor-associated arthritis
Hepatomegaly
Whipple’s disease, hemochromatosis, amyloidosis, Wilson’s disease
Positive fecal occult blood test
IBD

Genitourinary system

Prostatitis
Reactive arthritis, ankylosing spondylitis
Urethritis or cervicitis
Reactive arthritis, gonococcal arthritis
Scrotal or vulvar ulcers
Behçet’s syndrome
Hypogonadism
Hemochromatosis
Balanitis circinata
Reactive arthritis

Neurologic systemEntrapment neuropathies

RA, hypothyroidism, hyperparathyroidism
Facial palsy
Lyme disease
Peripheral neuropathy
SLE, amyloidosis
Chorea
Antiphospholipid-antibody syndrome, SLE, rheumatic fever
Mononeuritis multiplex
RA, SLE, Lyme disease, vasculitis (e.g., PAN)
Seizures

Findings of Laboratory and Imaging Tests and Associated Conditions That Result in Polyarticular Joint Pain

LABORATORY OR IMAGING TEST CONDITION

Complete blood count

Anemia
Many inflammatory arthritides, especially SLE, RA, IBD, and human parvovirus B19 infection
Thrombocytopenia
SLE, human parvovirus B19 infection
Thrombocytosis
Acute-phase reaction, vasculitis, infection
Leukopenia
SLE, RA, Felty’s syndrome, Sjögren’s syndrome, human parvovirus B19 infection
Leukocytosis
RA, vasculitis, reactive arthritis, infection
Eosinophilia
SLE, RA, IBD, sarcoidosis, dermatomyositis, scleroderma, Churg-Strauss syndrome, PAN, eosinophilic fasciitis, cholesterol emboli

Chest radiograph

Infiltrates or nodules
RA, sarcoidosis, Wegener’s granulomatosis, Churg-Strauss syndrome
Serositis
SLE, RA
Upper lobe fibrosis
Ankylosing spondylitis
Diffuse fibrosis\
RA, scleroderma, polymyositis
Rheumatoid factor
Healthy persons; RA, SLE, Sjögren’s syndrome, sarcoidosis, reactive arthritis, PMR, polymyositis, psoriatic arthritis, endocarditis, chronic infections, cancer, chronic liver disease, many nonrheumatic causes

Joint aspiration

Culture
Infection
Crystals
Gout, pseudogout
White blood cell count
Inflammation: > 2,000 per mm3 (2 × 109 per L)
Probable infection: > 50,000 per mm3 (50 × 109 per L)
Inflammatory markers: elevated erythrocyte sedimentation rate or C-reactive protein (CRP)
Infection, most inflammatory arthritides, advanced age, PMR, giant cell arteritis, cancer, anemia, pregnancy; menses
Antinuclear antibody
Healthy persons; SLE, RA, scleroderma, Sjögren’s syndrome, vasculitis, polymyositis, medications, many nonrheumatic causes
Hepatic transaminase: elevated aspartate transaminase or alanine transaminase
SLE, PAN, sarcoidosis, hemochromatosis, Sjögren’s syndrome, infectious hepatitis, polymyositis

Urinalysis

Hematuria
SLE, Wegener’s granulomatosis, PAN
Proteinuria
SLE; Wegener’s granulomatosis, amyloidosis
Elevated alkaline phosphatase
Bone metastases, Paget’s disease, osteomalacia, PMR, ankylosing spondylitis, hyperparathyroidism
Electrocardiogram: atrioventricular block
Lyme disease, neonatal lupus, ankylosing spondylitis
Double-stranded DNA
SLE, especially lupus nephritis
Anti–SS-A (anti-Ro) and anti–SS-B (anti-La) antibodies
Sjögren’s syndrome, SLE; healthy persons
HLA-B27
Healthy persons; spondyloarthropathies, reactive arthritis
Elevated uric acid
Gout, psoriatic arthritis, Paget’s disease; healthy persons
False-positive VDRL
SLE, anticardiolipin antibody syndrome
Cytoplasmic antineutrophil cytoplasmic autoantibody (c-ANCA)
Wegener’s granulomatosis
Elevated creatinine
SLE, Wegener’s granulomatosis, vasculitis
Elevated creatine kinase (CPK)
Polymyositis, dermatomyositis, hypothyroidism
Elevated calcium
Hyperparathyroidism, cancer, sarcoidosis

Treatment

Non-pharmacologic therapies

Non-pharmacologic therapies include treatments other than medications and are the foundation of treatment for all people with rheumatoid arthritis.

Rest

When joints are inflamed, the risk of injury of the joint itself and the adjacent soft tissue structures (such as tendons and ligaments) is high. This is why inflamed joints should be rested. However, physical fitness should be maintained as much as possible. At the same time, maintaining a good range of motion in your joints and good fitness overall are important in coping with the systemic features of the disease.

Exercise

Pain and stiffness often prompt people with rheumatoid arthritis to become inactive. However, inactivity can lead to a loss of joint motion, contractions, and a loss of muscle strength. These, in turn, decrease joint stability and further increase fatigue.

Regular exercise especially in a controlled fashion with the help of physical therapists and occupational therapists can help prevent and reverse these effects. Types of exercises that have been shown to be beneficial include range-of-motion exercises to preserve and restore joint motion, exercises to increase strength, and exercises to increase endurance (walking, swimming, and cycling).

Physical and occupational therapy

Physical and occupational therapy can relieve pain, reduce inflammation, and help preserve joint structure and function for patients with rheumatoid arthritis.

Specific types of therapy are used to address specific effects of rheumatoid arthritis:

The application of heat or cold can relieve pain or stiffness.
Use of ultrasound to help reduce inflammation of the sheaths surrounding tendons (tenosynovitis)
Passive and active exercises to improve and maintain range of motion of the joints
Rest and splinting to reduce joint pain and improve joint function
Finger-splinting and other assistive devices to prevent deformities and improve hand function.
Relaxation techniques to relieve secondary muscle spasm

Occupational therapists also focus on helping people with rheumatoid arthritis to be able to continue to actively participate in work and recreational activity with special attention to maintaining good function of the hands and arms.

Nutrition and dietary therapy

Weight loss may be recommended for overweight and obese people to reduce stress on inflamed joints.

People with rheumatoid arthritis have a higher risk of developing coronary artery disease. High blood cholesterol is one risk factor for coronary disease that can respond to changes in diet. A nutritionist can recommend specific foods to eat or avoid in order to achieve a desirable cholesterol level.

Changes in diet have been investigated as treatments for rheumatoid arthritis, but there is no diet that is proven to cure rheumatoid arthritis. No herbal or nutritional supplements, such as cartilage or collagen, can cure rheumatoid arthritis. These treatments can be dangerous and are not usually recommended.

Smoking and alcohol

Smoking is a risk factor for rheumatoid arthritis and it has been shown that quitting smoking can improve the condition. People who smoke need to quit completely. Assistance in quitting should be obtained if needed. Moderate alcohol consumption is not harmful to rheumatoid arthritis, although it may increase the risk of liver damage from some drugs such as methotrexate. People should discuss the safety of alcohol use with a doctor because recommendations depend on the medications a person is taking and on their other medical conditions.

Measures to reduce bone loss

Inflammatory conditions such as rheumatoid arthritis can cause bone loss, which can lead to osteoporosis. The use of prednisone further increases the risk of bone loss, especially in postmenopausal women. It is important to do a risk assessment and address risk factors that can be changed in order to help prevent bone loss.

Patients may do the following to help minimize the bone loss associated with steroid therapy:

Use the lowest possible dose of glucocorticoids for the shortest possible time, when possible, to minimize bone loss.
Consume an adequate amount of calcium and vitamin D, either in the diet or by taking supplements.
Use medications that can reduce bone loss, including that which is caused by glucocorticoids.
Control the disease itself with appropriate medications prescribed by your doctor.

Medical management of acute polyarthritis

Hospitalize the patient in the presence of any of the following :

Significant, concomitant internal organ involvement
Signs of bacteremia, including vesiculopustular skin lesions, Roth spots, shaking chills, or splinter hemorrhages
Systemic vasculitis
Severe pain
Severe constitutional symptoms
Purulent (group III) synovial fluid in 1 or more joints
Immunosuppression

Medications

There are many medications available to decrease joint pain, swelling, and inflammation and hopefully, prevent or minimize the progression of the disease. The type of drugs that your doctor recommends will depend on how severe your arthritis is and how well you respond to the medications.

These medications include:

Analgesics – Prescription-strength drugs that relieve pain but not inflammation.
Non-steroidal anti-inflammatory drugs (NSAIDs – such as aspirin, ibuprofen or naproxen, COX-2 inhibitors (celecoxib))Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include aspirin, ibuprofen (Motrin, Advil), and naproxen (Naprosyn, Aleve).
Antidepressants- Drugs that block pain messages from your brain and boost the effects of endorphins (your body’s natural painkillers).
Antibiotic therapy – is indicated for septic polyarthritis or bacteremia with joint involvement (eg, disseminated gonococci). Systemic antibiotics are used after appropriate cultures are taken. Prolonged treatment of Chlamydia -induced reactive arthritis with antibiotics may be of benefit; this is not true for other forms of reactive arthritis.
Corticosteroids – Corticosteroids to heal the nerve inflammation and clotted blood in the joints. It is an effective alternative to NSAIDs and colchicine for patients in whom these drugs may be contraindicated or hazardous (eg, patients with advanced age, renal insufficiency, congestive heart failure, inability to take oral medications). Regimens include the following:
Intramuscular – (IM) injection of a long-acting crystalline preparation (eg, triamcinolone acetonide 60-80 mg), with an option to repeat once after 24-48 hours
Muscle Relaxants- These medications provide relief from spinal muscle spasms, spasticity & increase muscle tone by increasing blood flood to the cell.
Neuropathic Agents- Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, and tingling.
Opioids – Also known as narcotics, these medications are intense pain relievers that should only be used under a doctor’s careful supervision.
Topical Medications- These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation through the skin.
Calcium & vitamin D3 – to improve bones health and heal fractures.
Omega-3 fatty acids – There are lots of natural anti-inflammatories, but the best studied by far are omega-3 fatty acids. These heart-healthy, brain-boosting fats are especially prevalent in seafood, especially fatty fish such as salmon, sardines, and tuna. Studies have found that adding omega-3s to the diet can reduce joint pain and morning stiffness in people with RA, says Chaim Putterman, M.D., chief of rheumatology at Montefiore Medical Center and Albert Einstein College of Medicine in New York City. Not a fan of fish? Fish oil capsules can give you the same benefits. But beware: High concentrations of omega-3s can thin the blood, so consult your doctor for the right dose
Gamma-linolenic acid (GLA)- is another fatty acid with anti-inflammatory properties, says Robert Zurier, M.D., who has studied the effects of GLA in rheumatoid arthritis patients at the University of Massachusetts Medical School. GLA is found mostly in botanical oils—evening primrose, black currant seed, and especially borage oil, its richest source. The patients in Dr. Zurier’s studies took three 1,000-milliliter capsules of borage oil every day for six months and reported less joint pain and stiffness than patients who took placebo capsules, and they also reduced their dose of nonsteroidal anti-inflammatory drugs.

Dietary supplement -to remove the general weakness & improve the health.

Disease-modifying anti-rheumatic drugs – (DMARDs) such as hydroxychloroquine, methotrexate, sulfasalazine, and leflunomide improvement in symptoms may require four to six weeks of treatment with methotrexate. Improvement may require one to two months of treatment with sulfasalazine and two to three months of treatment with hydroxychloroquine.
Biologic agents – (such as infliximab, etanercept, adalimumab, certolizumab and golimumab, tocilizumab, rituximab, abatacept, anakinra, tofacitinib) Biologics tend to work rapidly, within two weeks for some medications and within four to six weeks for others. Biologics may be used alone or in combination with other DMARDs. Usually, they are reserved for patients who do not adequately respond to DMARDs, or if adverse prognostic factors are present.

When choosing DMARDs, the following principles should be considered:

.Combinations of DMARDs may be more effective than single drugs. For example, hydroxychloroquine, sulfasalazine, and methotrexate together are more effective than methotrexate alone or the other two together.

Combining a DMARD – with another drug, such as methotrexate plus a TNF-α antagonist or an IL-1 receptor antagonist or a rapidly tapered corticosteroid, may be more effective than using DMARDs alone.
Methotrexate – is a folate antagonist with immunosuppressive effects at a high doses. It is anti-inflammatory at doses used in RA. It is very effective and has a relatively rapid onset (clinical benefit often within 3 to 4 wk). Methotrexate should be used with caution, if at all, in patients with hepatic dysfunction or renal failure. Alcohol should be avoided. Supplemental folate, 1 mg PO once/day, reduces the likelihood of adverse effects. CBC, AST, ALT, and albumin and creatinine level should be determined about every 8 wk. When used early in the course of RA, efficacy may equal the biologic agents. Rarely, a liver biopsy is needed if liver function test findings are persistently twice the upper limit of normal or more and the patient needs to continue to use methotrexate. Severe relapses of arthritis can occur after the withdrawal of methotrexate. Paradoxically, rheumatoid nodules may enlarge with methotrexate therapy.
Hydroxychloroquine – can also control symptoms of mild RA. Funduscopic examination should be done and visual fields should be assessed before and every 12 mo during treatment. The drug should be stopped if no improvement occurs after 9 mo.
Leflunomide – interferes with an enzyme involved with pyrimidine metabolism. It is about as effective as methotrexate but is less likely to suppress the bone marrow, cause abnormal liver function, or cause pneumonitis. Alopecia and diarrhea are fairly common at the onset of therapy but may resolve with the continuation of therapy.\
Sulfasalazine – Sulfasalazine (Azulfidine, generic) works best when the disease is confined to the joints. Symptom relief occurs within 1 – 3 months. Side effects are common, particularly stomach and intestinal distress, which usually occur early in the course of treatment. (However, serious gastrointestinal side effects, such as stomach ulcers, occur less frequently with sulfasalazine than with NSAIDs.) A coated-tablet form may help reduce side effects. Other side effects include skin rash and headache. Sulfasalazine increases sensitivity to sunlight. Be sure to wear sunscreen (SPF 15 or higher) while taking this drug. People with intestinal or urinary obstructions or who have allergies to sulfa drugs or salicylates should not take sulfasalazine.
Minocycline – Minocycline (Minocin, generic) is a tetracycline antibiotic that is generally reserved for patients with mild RA. It can take 2 – 3 months before symptoms begin to improve and up to a year for full benefit. Side effects include upset stomach, dizziness, and skin rash. Long-term use of minocycline can cause changes in skin color, but this side effect usually disappears once the medication is stopped. Minocycline can cause yeast infections in women. It should not be used by women who are pregnant or planning on becoming pregnant. Minocycline increases sensitivity to sunlight and patients should be sure to wear sunscreen. In rare cases, minocycline can affect the kidneys and liver.
Tofacitinib- Tofacitinib (Xeljanz) is the newest DMARD. Approved in 2012, tofacitinib is the first in a new class of drugs. It works by blocking “Janus kinase” molecules involved in joint inflammation. There is hope that DMARD might be an alternative to biologic DMARDs and a new option for patients with moderate-to-severe RA who have not been helped by methotrexate. Tofacitinib, which is taken as a twice-daily pill, can be used alone or in combination with methotrexate. Tofacitinib may increase the risk for serious infections. Because it is new a drug, long-term side effects are still unknown.
Gold- Gold used to be a time-honored DMARD for rheumatoid arthritis but its use has decreased with the development of newer DMARDs and biologic drugs. Gold is usually administered in an injected form because the oral form, auranofin (Ridaura, generic), is much less effective. There are two injectable forms of gold: Gold sodium thiomalate (Myochrysine, generic) and aurothioglucose (Solganal, generic). It can take 3 – 6 months before injections have an effect on RA symptoms. Gold injections can cause a number of side effects including mouth sores and skin rash and in rare cases more serious problems such as kidney damage.
Azathioprine-Azathioprine (Imuran, generic) suppresses immune system activity. It takes 6 – 8 weeks for early symptom improvement and up to 12 weeks for full benefit. Azathioprine can cause serious problems with the gastrointestinal tract including nausea and vomiting, often accompanied by stomach pain and diarrhea. Azathioprine can also cause problems with liver function and pancreas gland inflammation and can reduce white blood cell count.
Cyclosporine – Like azathioprine, cyclosporine (Sandimmune, Neoral, generic) is an immunosuppressant. It is used for people with RA who have not responded to other drugs. It can take a week before symptoms improve and up to 3 months for full benefit. The most serious and common side effects of cyclosporine are high blood pressure and kidney function problems. While kidney function usually improves once the drug is stopped, mild-to-moderate high blood pressure may continue. Swelling of the gums is also common. Patients should practice good dental hygiene, including regular brushing and flossing.
Immunomodulatory, cytotoxic, and immunosuppressive drugs – Treatment with azathioprine or cyclosporine (an immunomodulatory drug) provides efficacy similar to DMARDs. However, these drugs are more toxic. Thus, they are used only for patients in whom treatment with DMARDs has failed or to decrease the need for corticosteroids. They are used infrequently unless there are extra-articular complications. For maintenance therapy with azathioprine, the lowest effective dose should be used. Low-dose cyclosporine may be effective alone or when combined with methotrexate. It may be less toxic than azathioprine. Cyclophosphamide is no longer recommended due to its toxicity.

Biologic agents

Biologic response modifiers other than TNF-α antagonists can be used to target B cells or T cells. These agents are typically not combined with each other.

Rituximab – is an anti-CD 20 antibody that depletes B cells. It can be used in refractory patients. The response is often delayed but may last 6 mo. The course can be repeated after 6 mo. Mild adverse effects are common, and analgesia, corticosteroids, diphenhydramine, or a combination may need to be given concomitantly. Rituximab is usually restricted to patients who have not improved after using a TNF-α inhibitor and methotrexate. Rituximab therapy has been associated with progressive multifocal leukoencephalopathy, mucocutaneous reactions, delayed leukopenia, and hepatitis B reactivation.
Abatacept – a soluble fusion cytotoxic T lymphocyte-associated antigen 4 (CTLA-4) Ig, is indicated for patients with RA with an inadequate response to other DMARDs.
Anakinra – is a recombinant IL-1 receptor antagonist. IL-1 is heavily involved in the pathogenesis of RA. Infection and leukopenia can be problems.
TNF-α antagonists – (eg, adalimumab, etanercept, golimumab, certolizumab pegol, and infliximab) reduce the progression of erosions and reduce the number of new erosions. Although not all patients respond, many have a prompt, dramatic feeling of well-being, sometimes with the first injection. Inflammation is often dramatically reduced. These drugs are often added to methotrexate therapy to increase the effect and possibly prevent the development of drug-neutralizing antibodies.
Tocilizumab – blocks the effect of IL-6 and has clinical efficacy in patients who have responded incompletely to other biologic agents.
Tofacitinib – is a Janus kinase (JAK) inhibitor that is given orally with or without concomitant methotrexate to patients who do not respond to methotrexate alone or other biologic agents. Although there are some differences among agents, the most serious problem is an infection, particularly with reactivated TB. Patients should be screened for TB with PPD or an interferon-gamma release assay. TNF-α antagonists should probably be stopped before major surgery. Etanercept, infliximab, and adalimumab can and probably should be used with methotrexate. High-dose infliximab should not be used in patients with severe heart failure.

However, the risk of side effects from treatment must be weighed against the benefits on an individual basis.

Other strategies to manage multiple joint pain

Other important strategies that can help you manage rheumatoid arthritis include:

Self-management courses – can help people with rheumatoid arthritis and other chronic (ongoing) conditions to build skills and confidence in becoming more actively involved in your healthcare and in managing rheumatoid arthritis day today.
Aids and equipment – supports such as walking aids and specialized cooking utensils reduce joint strain and can help you to manage pain and fatigue. An occupational therapist can give you advice on aids. You can also phone the Independent Living Centre for advice.
Relaxation techniques – muscle relaxation, distraction, guided imagery, and other techniques can help you manage pain and difficult emotions such as anxiety.
If exercise is causing sharp pain, stop immediately.
If lesser aches and pains continue for more than 2 hours afterward, try a lighter exercise program for a while.
Using large joints instead of small ones for ordinary tasks can help relieve pressure, for instance, closing a door with the hip or pushing buttons with the palm of the hand.
Start with the easiest exercises, stretching and tensing of the joints without movement.
Next, attempt mild strength training.
The next step is to try aerobic exercises. These include walking, dancing, or swimming, particularly in heated pools. Avoid heavy impact exercises, such as running, downhill skiing, and jumping.
Tai chi, which uses graceful slow sweeping movements, is an excellent method for combining stretching and range-of-motion exercises with relaxation techniques. It may be of particular value for elderly patients with RA.Exercise –It is important for patients with RA to maintain a balance between rest (which will reduce inflammation) and moderate exercise (which will relieve stiffness and weakness). Studies have suggested that even as little as 3 hours of physical therapy over 6 weeks can help people with RA and that these benefits are sustained. The goal of the exercise is to
Maintain a wide range of motion
Increase strength, endurance, and mobility
Improve general health
Promote well-being
In general, doctors recommend the following approaches

A common-sense approach to exercise is the best guide

Support – a peer support group can provide understanding, advice, support and information from others in a similar situation. Contact MOVE muscle, bone & joint health for more information.
Complementary therapies – such as massage or acupuncture may be helpful. Consult your doctor or rheumatologist before commencing any treatment. Fish oil supplements may also be helpful as they contain a certain type of fat called omega-3. Current research suggests omega-3 fats can help reduce inflammation in rheumatoid arthritis.
Diet – Many patients with RA try dietary approaches, such as fasting, vegan diets, or eliminating specific foods that seem to worsen RA symptoms. There is little scientific evidence to support these approaches but some patients report anecdotally that they are helpful. In recent years, a number of studies have suggested that the omega-3 fatty acids contained in fish oil may have anti-inflammatory properties useful for RA joint pain relief. The best source of fish oil is through increased consumption of fatty fish such as salmon, mackerel, and herring. Fish oil supplements are another option, but they may interact with certain medications. If you are thinking of trying fish oil supplements, talk to your doctor first.
Pain with Stress Management – Patients can learn strategies to cope with the stress and frustration of living with chronic pain. Relaxation and stress management techniques such as guided imagery, breathing exercises, hypnosis, or biofeedback can be helpful. Although there is no definitive evidence to support their efficacy, some patients report relief with modalities such as acupuncture, massage, and mineral baths.
Assistive Devices – There are many different types of assisted devices that can help make life easier in the home. Kitchen gadgets, such as jar openers, can assist with gripping and grabbing. Door-knob extenders and key turners are helpful for patients who have trouble turning their wrists. Bathrooms can be fitted with shower benches, grip bars, and raised toilet seats. An occupational therapist can advise you on choosing the right kinds of assistive devices.
Miscellaneous Supportive Treatments – Various ointments, including Ben Gay and capsaicin (a cream that use the active ingredient in chili peppers), may help soothe painful joints. Orthotic devices are specialized braces and splints that support and help align joints. Many such devices made from a variety of light materials are available and can be very helpful when worn properly.

Herbal Remedies

1. Massage

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This is the first out of the most efficient home remedies for rheumatoid arthritis in the body that I want to reveal in this entire writing.

When being applied properly, massage can help to relieve the pain caused by rheumatoid arthritis as it can relax your stiff muscles. Massage will help to boost your blood circulation, which is essential for alleviating the discomfort due to the symptoms of rheumatoid arthritis.

2. Evening Primrose Oil

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Evening primrose oil is one kind of plant oil that can help to relieve morning stiffness and pain effectively. This plant oil has gamma-linolenic acid properties – an essential fatty acid that can help to relieve the intensity of numerous symptoms caused by rheumatoid arthritis.

Take 540 mg to 2.8 g of evening primrose oil in divided doses every day. Remember to consult an expert to get proper dosage because this oil may interfere with some medications.

3. Epsom Salt

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Epsom salt is also a great and highly effective natural remedy that can help to soothe the pain and swelling due to rheumatoid arthritis. Epsom salt is an abundant source of magnesium, so it can help to regulate the pH levels in your body effectively as well. In turn, it can help to reduce rheumatoid arthritis, stiffness, and pain in the joints. In addition, it can help to mineralize bone well.

Add 2 cups of Epsom salt to a bathtub full of warm water.
Soak in the bathtub within about half an hour.
Apply this method up to 3 times weekly.

In fact, this is also one of the best home remedies for rheumatoid arthritis in the body that people should make use for good!

4. Ginger

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In naturopathy and Ayurvedic as well, ginger has been used for people at all ages to deal with inflammatory conditions, including rheumatoid arthritis. Ginger contains a compound named gingerol – a powerful agent with natural anti-inflammatory properties, helping to relieve swelling and pain due to rheumatoid arthritis effectively.

You can add ginger into daily food dishes or drink two or three cups of ginger tea every day.
Alternatively, you can chew some fresh ginger slices every day.
Use ginger oil to rub onto your affected area. Then expose that area to sunlight for five to ten minutes to generate heat and warmth. Apply this tip on regular basis.

In brief, making use of ginger is one of the most effective home remedies for rheumatoid arthritis pain that people should never look down and should apply for good!

5. Garlic

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Thanks to its powerful anti-inflammatory properties, garlic is also advisable for dealing with rheumatoid arthritis. Garlic can help to inhibit the pro-inflammatory substances (also called “cytokines”) production, helping to relieve swelling and pain efficiently and fast.

You can take garlic capsules. For correct dosage, remember to consult experts.
You can also eat one or two raw garlic cloves every day

6. Apple Cider Vinegar

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Apple cider vinegar is considered very useful in helping people relieve several symptoms caused by rheumatoid arthritis. Being rich in minerals, such as phosphorus, potassium, magnesium, and calcium, apple cider vinegar can help to relieve rheumatoid arthritis pain effectively.

You should use some apple cider vinegar to directly apply to the affected area of your body. Then, use warm castor oil to massage your painful area. Finally, use a cotton cloth to wrap that area and use plastic to cover it. Apply this method every day before bedtime for good results as desired.
Mix one teaspoon of honey with one tablespoon of raw, unfiltered apple cider vinegar and add them to 1/2 cup of warm water. Consume this solution once every day.

7. Turmeric

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Turmeric can help to reduce the risk of joint rheumatoid arthritis by blocking certain cytokines and enzymes causing rheumatoid arthritis.

You can add turmeric powder into your daily meals to benefit from this natural ingredient.
Alternatively, you can take turmeric in form of capsules by 500 – 1,000 mg three times daily. Remember to consult experts initially.
Bring 1 quart of water to a boil. Add 1 tablespoon of turmeric powder and boil it for another 10 minutes. Allow it to cool and drink it once or twice daily.

Note: Do not consume high doses of turmeric because it can act as a blood thinner as well as lead to a stomach upset.

This is actually one of the best home remedies for rheumatoid arthritis pain that I would like to reveal in this entire article and want my readers to make use for good!

8. Fish Oil

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Fish oil contains omega-3 fatty acids – DHA and EPA – that have a powerful anti-inflammatory ability and can help to relieve pain as well. In addition, fish oil can help to prevent the risks of heart disease, which rheumatoid arthritis sufferers are usually at high risk.

Add cold-water fish like salmon and tuna to your daily diet
Take up to 2.6 grams of fish oil (containing 30% DHA/EPA at least) 2 times every day.

Note: Before taking fish oil supplements, remember to consult your doctor because the supplements could interfere with some types of medications you are taking.

9. Hot And Cold Compresses

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Alternating hot and cold compresses is also a great way to reduce the symptoms caused by rheumatoid arthritis. While a cold compress can dull the pain and relieve rheumatoid arthritis and joint swelling, a hot compress can help to relieve pain by relaxing sore joints and muscles.

For the cold compress, use a thin towel to wrap some ice cubes.
For the hot compress, use a towel to wrap a hot water bag.
Put the hot compress right onto the affected area and let it stay within just three minutes.
Remove the hot compress and place the cold compress immediately in its place within just one minute.
Repeat these steps for fifteen to twenty minutes 2 – 3 times every day until your pain is relieved.

10. Parsley

In research conducted by JNR (Journal of Natural Remedies) on rats, it was found that extract made of fresh leaves of parsley had reduced inflammation in their paws. Therefore, using it as a home remedy to relieve you from your arthritis pain can have a positive impact.

11. Carrots

Carrots have an abundance amount of Vitamin C and beta carotene. Beta-carotene and Vitamin C both have antioxidant properties that kill free radicals which are responsible for arthritis inflammation.

12. Rosemary

Rosemary has a polyphenol called rosmarinic acid which is a potent antioxidant and inflammation reliever.

13. Kale

Kale is a vegetable that is a rich source of antioxidants, Vitamin C, Vitamin K, and beta-carotene that can reverse arthritis inflammation.

14. Coriander

According to medical research conducted by the All India Institute of Medical Sciences, coriander powder has the potential to reduce swelling and inflammation. It can also be digested as green leaves.

15. Olive Oil

Olive oil, especially raw ice-pressed, has many health benefits starting from reducing your blood cholesterol to diabetes and inflammation. It can be used as cooking oil that could not only make your dish tastier but also loads with various health benefits. The anti-inflammatory properties of olive oil relieve arthritis joints pain.

16. Green tea

Green tea is a wonder drink that is loaded with antioxidants that have anti-inflammatory properties. Along with relieving you from severe arthritis pain, green tea has many health benefits from lowering your LDL cholesterol to minimizing the risk of bladder cancer.

17. Pineapple

The stems of pineapples are rich in a protein called bromelain. It acts as a digestive enzyme that relieves arthritis inflammation.

18. Blueberries

Blueberries are rich in various minerals and are considered to be the potential sources of antioxidants. However, always go for organically grown berries because they have higher amounts of polyphenols than the non-organically grown ones. These polyphenols and antioxidants prevent cell damage and reduce inflammation.

Homeopathic treatment for multiple joint pain

The treatment for Rheumatoid Arthritis may vary from case to case – some require short-term whereas others require long-term treatment. The duration of treatment depends on various factors such as the severity, duration, and extent of the illness, nature of treatment taken for the same, and general health of the patient.

Common Homeopathy medicines

African – Useful for chronic arthritis with a feeling of bruising and soreness. The painful parts feel worse from being moved or touched.
Bryonia – Helpful for stiffness and inflammation with tearing or throbbing pain, made worse by motion. The condition may have developed gradually and is worse in cold dry weather. Discomfort is aggravated by being touched or bumped, or from any movement. Relief can be had from pressure and from rest. The person may want to stay completely still and not be interfered with.
Calcarea carbonica- Helpful for deeply aching arthritis involving node formation around the joints. Inflammation and soreness are worse from cold and dampness, and problems may be focused on the knees and hands. Common symptoms are: weakness in the muscles, easy fatigue from exertion, and a feeling of chilliness or sluggishness. The person who benefits from Calcarea is often solid and responsible, but tends to become extremely anxious and overwhelmed when ill or overworked.
Aurum metallicum- This remedy is often prescribed for wandering pains in the muscles and joints that are better from motion and warmth, and worse at night. The person may experience deep pain in the limbs when trying to sleep.
Causticum – Useful when deformities develop in the joints, in a person with tendon problems, muscle weakness, and contractures. The hands and fingers may be most affected.. Stiffness and pain are worse from being cold, and relief may come with warmth. The person often feels best in rainy weather and worse when the days are clear and dry.
Calcarea fluorica – Helpful when arthritic pains improve with heat and motion. Joints become enlarged and hard, and nodes or deformities develop. Arthritis after chronic injury to joints also responds to Calcarea fluorica.
Dulcamara – Indicated if arthritis flares up during cold damp weather. The person gets chilled and wet. They are often stout, with a tendency toward back pain, chronic stiffness in the muscles, and allergies.
Kali bichromicum – This is useful when arthritic pains alternate with asthma or stomach symptoms. Pains may suddenly come and go, or shift around. Discomfort and inflammation are aggravated by heat and worse when the weather is warm.
Kali carbonicum – Arthritis with great stiffness and stitching pains, worse in the early morning hours and worse from cold and dampness, may respond to Kali carbonicum. The joints may be becoming thickened or deformed.
Kalmia latiflora – Useful for intense arthritic pain that flares up suddenly. The problems start in higher joints and extend to lower ones. Pain and inflammation may begin in the elbows, spreading downward to the wrists and hands. Discomfort is worse from motion and often worse at night.
Ledum palustre – Arthritis that starts in lower joints and extends to higher ones are candidates for this remedy. Pain and inflammation often begin in the toes and spread upward to the ankles and knees. The joints may also make cracking sounds. Ledum is strongly indicated when swelling is significant and relieved by cold applications.
Pulsatilla – Applicable when rheumatoid arthritis pain is changeable in quality, or when the flare-ups move from place to place. The symptoms (and the person) feel worse from warmth, and better from fresh air and cold applications. Can benefit people who are emotional and affectionate, sometimes having teary moods.
Rhododendron – Strongly indicated if swelling and soreness flare up before a storm, continuing until the weather clears. Cold and dampness aggravate the symptoms. Discomfort is often worse toward early morning, or after staying still too long.
Rhus Toxicodendron – Useful for rheumatoid arthritis, with pain and stiffness that is worse in the morning and worse on first motion, but better from continued movement. Hot baths or showers, and warm applications improve the stiffness and relieve the pain. The condition is worse in cold, wet weather. The person may feel extremely restless, unable to find a comfortable position, and need to keep moving constantly. The continued motion also helps to relieve anxiety.
Ruta graveolens – Arthritis with a feeling of great stiffness and lameness, worse from cold and damp and worse from exertion, may be helped by Ruta graveolens. Tendons and capsules of the joints can be deeply affected or damaged. Arthritis may have developed after overuse, from repeated wear and tear.

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