• Joint swelling
• Perceptions about RA may be more important than the actual disease status in how a person experiences pain in RA (29).

Pharmacological

• Disease-modifying anti-rheumatic drugs (DMARDs) reduce inflammation, reduce symptoms, delay or prevent structural damage and improve functional performance of the patients (33).
• Anti-tumor necrosis factor medications may slow progression of RA.

Non-pharmacological

• Social support from friends, family, and professionals (31,33).
• Education on benefits / side effects of medications, joint protection strategies, use of orthoses, coping methods, self-relaxation techniques, and exercise benefits (31,35,47).
• Exercise (includes range of motion exercise, physical therapy, aerobic conditioning, and strength training) (41).
• An exercise prescription is much more likely to occur when a doctor initiates the exercise discussion (41).
• Joint protection strategies like rest and splinting, using compressive gloves, assistive devices and adaptive equipment may lead to long-term reduction in pain (35,47).
• Low-level laser therapy (LLLT) may reduce pain in hand joints. Further study needed to determine optimal dosage, wavelength, and type of LLLT (24).
• Transcutaneous electrical nerve stimulation (TENS) may reduce pain. Further study needed (24,47).

• Joint fusion (arthrodesis), especially for foot joints (62).
• Joint replacement (arthroplasty) (24,62)
• Synovectomy.
  
  Other promising alternative treatment approaches that need further study to verify effectiveness and efficacy in treating pain in RA:
• Borage supplements (20).
• Phytodolor , a proprietary German medicine, has shown favorable results in pain relief in 10 randomized controlled trials (20,95).
• Topical application of Thunder god vine extract (20).
• Muscle relaxation training (20).

General Guidelines

• Check with physician about specific movements to avoid.
• Avoid exercises that include risk of injury or high-impact load, or result in increased joint pain or fatigue (24,49).
• Compliance is a critical factor in maintaining benefits. Educate clients on exercise benefits, specific recommendations and precautions necessary (31,33,41).
• Compliance may improve when there is mutual decision-making, if an association between exercise and benefit is made, and if specific instructions are provided on how to perform the exercises (33,41).
• Physical performance and disease activity may fluctuate even on a daily basis and most of the signs during or after exercise are not harmful (i.e., joint pain during or 1 or 2 hours after the exercise, delayed muscle soreness). Long-term compliance improves if clients are aware of their bodies' responses to exercise and if they learn to modify various training programs according to their fitness and changes in disease activity (31,33,41).
• People with arthritis that exercised in their youth perceive greater benefits from exercise (36).
• Adequately understanding and addressing a person's beliefs and concerns about exercise will increase exercise compliance (24).
• Likewise, the trainer needs to regularly revisit and adjust the exercise regimen to address changes in disease activity, pain status, function, and motivation (24).
• Adapt exercises as needed to accommodate painful sites.
• Heat can be used before exercise to relieve muscle spasms and improve elasticity (47).
• Home-based, individual, or group-based programs appear equally effective, but long-term compliance to home-based exercise may require close supervision (24,49).
• Supplementing a home-based program with an exercise class or other leisure activities such as swimming, walking, or cycling can increase compliance by offering variety (24).

• Aerobic conditioning and strength training can increase aerobic capacity with no detrimental effect on pain (49).
• Aerobic intensity of 60-70% of heart rate maximum, 3 times per week, 30- to 60-minute sessions (24).

• The majority of studies report no change in disease activity (measured by erythrocyte sedimentation rate, joint count, and pain) with strength training, although a few showed decreases (31).
• Progressively strengthen muscles across all major muscle groups of the upper and lower extremities and trunk, not just the affected sites (31,49).
• Intensity and frequency for strength training is 50% to 80% maximum voluntary contraction, 2 to 3 times per week. Start at the lowest range and build gradually to avoid pain and fatigue (47,24).
• When a joint is acutely inflamed, isometric exercises 40% maximal voluntary contraction may provide adequate muscle tone without increasing disease activity (47).
• When joints are not inflamed, isotonic or isokinetic exercises may be used (47).
• Joint swelling and pain can lead to immobilization and decreased activity. Whenever possible, begin strength training before immobilization occurs to minimize the large loss of strength that occurs in immobilized muscles (31).

• Stretching of tight muscles and maintenance of existing range of motion (ROM) should be a primary focus for people with RA (49).
• Tai chi is beneficial for lower-extremity ROM but doesn't provide much aerobic or weight-bearing benefit (36).
• Every joint should be moved in the ROM at least once per day in order to prevent painful contractures.