"g)Vitamin D: Low vitamin D levels indicate increased inflammation and with increasedincidence of numerous diseases (Egerer, et al., 2009).h)Stool test: To check whether the patient has GI inflammation, microbiota, and pancreaticexocrine function. GI imbalances are reported to be associated with the pathogenesis ofrheumatoid arthritis(Egerer, et al., 2009).Treatment: The primary goal of pain relief is inflammation control. Chronic erosion of jointtissue over the time causes chronic pain in the patients with rheumatoid arthritis. There aremany treatment options available for providing pain relief to the patients. Pharmacological agents:Non-steroidal anti-inflammatory drugs and analgesic are commonlyprescribed for providing pain relief to the patients with rheumatoid arthritis. a)Analgesics: Paracetamol (acetaminophen) is used with or without opioids for symptomcontrol in the patients with rheumatoid arthritis. It can also be prescribed in combination withNSAIDs. However, it is does not reduce morning stiffness. Acetaminophen is an over-the – counter medication which is effective for alleviating acute muscular pain, bone pain andsome types of chronic pain syndromes. Long term use of acetaminophen can cause liverfailure. The dose of acetaminophen should not be more than 4000 mg in a day (Kumar andBanik, 2013). b)Nonsteroidal Anti-inflammatory Drugs (NSAIDs): They act as local anti-inflammatorymediators in rheumatoid arthritis. They are found to be more effective than analgesics forrelieving pain arthritis patients due to their anti-inflammatory and analgesic properties. Theyinteract with endogenous receptors for opioids, serotonin, glutamate and GABA. Celecoxibwas the first medication from the group of cyclooxygenase -2 which was approved by theFDA in 1998 for the treatment of rheumatoid arthritis and osteoarthritis (Chen, et al., 2008).NSAIDs reduce morning stiffness, pain, and swelling in the joints. However, they do notinfluence the acute phase radiologic progression.Celecoxib, diclofenac sodium andibuprofen are the NSAIDs used for the treatment of rheumatoid arthritis and pain relief.Long-term use of cyclooxygenase II (COX II) inhibitors increases the risk of cardiovasculardiseases and has negative effects on clotting of the blood. High doses of NSAIDs increase therisk of ulcers and kidney failure (Kumar and Banik, 2013). c)Opioid medications: Opioids such as codeine, hydrocodone and oxycodone are used incombination with NSAIDs and acetaminophen for the management of acute pain. Long acting opioids are recommended for the pain which is present throughout the day.Constipation, drowsiness and nausea are the most frequent side effects of opioids (Kumar andBanik, 2013).d)Antidepressants: The role of antidepressants in the pain relief is clearly unknown. But, arandomised, double-blind clinical study conducted in 48 female patients with rheumatoidarthritis proved that a dose of dothipein 150 mg daily provided pain relief and decreased theduration of early morning stiffness in the patients (Kumar and Banik, 2013).e)Glucocorticoids: They are the strong anti-inflammatory medications that block theimmune responses and relive inflammation, pain and joint stiffness.Prednisone andbetamethasone injection are the two commonly used glucocorticoids for the treatment ofrheumatoid arthritis (Kumar and Banik, 2013).f)Disease-modifying antirheumatic drugs (DMARDs): DMARDs are prescribed for thepatients who are unresponsive to NSAIDs. They are slow acting medictions. Tumor necrosisfactor, interlukin 1 inhibitors, T cell co-stimulation inhibitors and B cell depleters are the fourcategories of biological DMARDs. They improve the quality of life to a greater extent in thepeople with rheumatoid arthritis. They are often prescribed in combination with NSAIDs orglucocorticoids for the treatment of rheumatoid arthritis. Methotrexate and tofaitinb are someof the examples of DMARDs. Methotrexate is most commonly used DMARD due to its lowtoxicity and strong inflammatory properties. The dose usually ranges from 7.5 to 15 mg perweek either orally or by injection. Psycotherapeutic approaches for the management of chronic pain:The original nociceptive source of the pain cannot explain the intensity of the painexperienced by patients with chronic pain. Depression and anxiety are most commonlyexperienced by the patients with chronic pain. Pharmacological strategies should address boththe pain complain and psychological distress experienced by the patients with chronic pain.Psychotherapeutic techniques can be used in conjugation with medications to address thepsychological distress and pain complains. The approaches to psychotherapy vary dependingon the type of the pain experienced by the patient. Patients with chronic pain may have poorto fair response to narcotics. They often have psychological symptoms such as depression oranxiety. Therefore, supportive and cognitive behavioural therapy will be beneficial for thepatients (Dixon, et al., 2007).Cognitive-behavioural therapy: Many researches and studies have proved the effectiveness ofcognitive behavioural therapy in the management of chronic or continuous pain. Patientssuffering from chronic pain may have negative, inappropriate and catastrophic thoughtswhich worsen the intensity of pain. The cognitive-behavioural therapist teaches skills thathelp the patients to focus and restructure the negative thoughts into the realistic appraisal. Ithelps the patients to deal with their pain more easily. During chronic pain the patientdevelops negative thoughts which cause more physical and psychological distress. It isimportant to make the patient recognize these negative thoughts and then rationally disputethem. The therapist will assign homework to the patients which they have to completebetween the cognitive behavioural therapy sessions. A typical homework given to the patientswith chronic pain is to complete a pain journal. The patients are advised to identify thespecific thoughts, action and behaviours that worsen or alleviate the pain and write them in adairy. It helps the patients to gain control over the pain and reduces the feeling ofhelplessness. Progressive relaxation technique, stretch-based relaxation, guided imagery andmusic therapy are some of the methods that reduce muscle tension and stress. They make thepatient feel increase sense of pain control (Hurkmans e al., 2011). Progressive muscle relaxation is recommended to the patients who are able to tense and relaxtheir muscles without exacerbating the pain. A stretch-based relaxation program isrecommended to the patients who are unable to move any of their body parts due to pain.Deep breathing is a relaxation technique in which the patients are taught to slow and deepbreathing that allows the expansion of their abdomen. It helps to control anxiety in the patient(Forestier et al., 2009). Mindfulness is another method which helps the patients to focuses on the development ofawareness. It helps the patients to identify the present moment of bodily sensations andmental activities that help the body to relax and calm the mind (Eccleston, et al., 2009). Biofeedback is a psychophysiological technique for the management of chronic pain. In thismethod the patient learns to interpret the physiological data regarding certain physiologicalfunctions and provides a feedback. For example, the patient may use biofeedback identify theareas of tension in his or her body and simultaneously learns to relax those body parts inorderto reduce muscular tension. Instruments that help to monitor brain electrical activity, bloodpressure, blood flow, muscle tone, electrodermal activity, heart rate, and skin temperaturehelps the patients to obtain feedback about the tension areas.Hypnosis is a like a biofeedback method which helps to treat a variety of pain disorders. It isperformed by using relaxation and imagery techniques. Post-suggestion phase is an importantpart of hypnosis where the patient uses the new behaviour after the completion of hypnosis. Occupational therapy for the management of chronic pain:Chronic pain is associated with sensory, perceptual, psychological and enviormental factors.Occupational therapy is based on the occupational behaviour frame of references. Thetherapist not only assesses the patient’s daily activity levels but also evaluates the coping andpsychosocial areas, physical environment, social networking, and ergonomic, work orfunctional capacity to design the treatment. In addition, the patient’s current vocational andnon-vocational skills and interests are reviewed and personal concept of health and wellnessand perception of pain is assessed. Then activities and interventions are designed to remediatethe physical or mental skills that allow the patient to engage in her occupation. Theinterventions for pain management include patient education and training to preventinflammation and pain, joint protection, work simplification, proper body mechanics andtherapeutic exercise (Radomski and Latham, 2008).Effectiveness of Physiotherapy in the management of chronic pain:Physiotherapy or physical therapy involves physical treatment of the joints and muscles. Themain goal of physical therapy in arthritis is to improve the mobility and restore the utilizationof the affected joints. It increases the strength to support the joints and maintains the fitnessand improves the ability to perform daily activities of living. During physical therapy thetherapist focuses on the body’s ability to engage in movements such as getting out of thechairs, climbing stairs, playing a sport or doing recreational activities. Before starting thephysical therapy, the therapist assesses the patient to identify the needs of the patient. Thephysical assessment includes functional assessment as stated earlier where the therapist checkthe patient’s transfer status, analysis of gait, and ability to perform activities of daily living.The therapist checks the range of joint motions, muscle strength test, postural assessment andrespiratory function. After the assessment, the therapist develops an individualized plan of exercise to improveflexibility, strength, coordination and balance to achieve optimal physical functions. Thetherapist teaches proper body posture and mechanics which helps to alleviate pain and improves function while performing daily activities. Hot and cold therapies are used to easethe joint pain and stiffness (Hurkmans e al., 2011). a)Heat and cold therapy: Heat causes muscle relaxation, while cold reduces the sensationof pain. Applying hot packs or ice packs at the site of inflammation provides pain relief. Thepatients can be suggested to take a relaxing hot bath for pain relief or exercising in a warmpool. Heat therapy has analgesic effect which provides relief from muscle spasms andrestores the elasticity of periarticular structures. Hot-pack, infrared radiation, paraffin,fluidotherapy, or hydrotherapy are some of the methods of thermotherapy. The patient shouldbe recommended to use any of the thermotherapy method for 10-20 minutes once or twicedaily. Cold therapy is preferred in active joints as intra-articular heat can worsen the patient’scondition. Cold therapy can be applied using a cold-pack, ice, nitrogen spray, andcryotherapy (Hurkmans e al., 2011). b)Balneotherapy: It is an ancient method of treating ailment in the patients with rheumaticdiseases. The primary goal of balneotherapy is to increase the range of motion, strengthenmuscles, relieve painful muscle spasms, and improve the patient's well-being. Using hotwater with minerals has significantly improved the effectiveness of balneotherapy.Balnetherapy provides pain relief by increasing the pain threshold at the nerve ending andsimultaneously decreasing the perception of pain. It reduces muscle spasm by affecting thegamma muscle fibres, peripheral vasodilatation, and decreases the synthesis of inflammatorymediators. Moreover, balneotherapy activates the parasympathetic nervous system andincrease the release of acetylcholine from the central nervous system. It also increases therelease of endorphins and reduces the pain (Verhagen, et al., 2015). Alternate treatment methods for chronic pain management:a)Acupressure: It provides pain relief by interrupting the transmission of pain stimuli.During acupressure the production of body’s natural painkillers is stimulated by applyingfinger pressure at acupressure points on the body. It works on the gate control theory(Dubouloz, et al., 2008). b)Distraction: It is cognitive therapy which can be utilized for a short duration not morethan 2 hours at a time. Prolonged utilization of distraction technique may cause fatigue andexhaustion resulting in severe pain (Dubouloz, et al., 2008).. "