What is the approach to managing a patient with polyarthralgia (multiple joint pains) in an outpatient department (OPD)?

Approach to Polyarthralgia in Outpatient Department

The management of polyarthralgia in an outpatient setting should follow a structured stepped-care approach that begins with comprehensive assessment, personalized management planning, and progresses through increasingly specialized interventions as needed. 1

Initial Assessment

History and Examination

• Determine the nature and extent of pain-related disability
• Assess whether pain is inflammatory or mechanical in nature
• Evaluate joint distribution pattern (small vs. large joints, symmetric vs. asymmetric)
• Document duration, timing, and pattern of joint pain
• Check for associated symptoms (morning stiffness, swelling, redness, warmth)
• Assess for extra-articular manifestations (rash, fever, weight loss, fatigue)
• Evaluate pain-related factors:
  • Beliefs and emotions about pain
  • Social influences related to pain
  • Sleep problems
  • Obesity

Laboratory Investigations

• Complete blood count
• Inflammatory markers (ESR, CRP)
• Autoantibody testing (RF, ACPA, ANA) as indicated
• Thyroid function tests (hypothyroidism can present with polyarthralgia) 2
• Metabolic panel including liver and kidney function

Imaging

• Plain radiographs of affected joints
• Consider ultrasound for patients with inflammatory polyarthralgia (can predict progression to rheumatoid arthritis even in ACPA-negative patients) 3

Personalized Management Plan

Step 1: Education and Self-Management

• Provide educational materials about joint protection and pain management 1
• Offer psychoeducation about pain mechanisms and coping strategies
• Recommend online or face-to-face self-management interventions

Step 2: Non-Pharmacological Interventions

Physical Activity and Exercise

• Recommend appropriate physical activity based on joint involvement 1, 4
• Consider referral to physiotherapy for individually tailored exercise program
• Recommend low-impact aerobic exercise, strengthening exercises, and aquatic exercise 4
• Start with lower intensity and gradually increase over time

Weight Management

• For overweight/obese patients, discuss weight management options 1
• Target initial weight loss of ≥5% of body weight 4
• Consider referral to dietitian or weight management program

Sleep Interventions

• Provide education about sleep hygiene practices 1
• For persistent sleep disturbances, consider referral to sleep specialist

Orthotics and Assistive Devices

• Recommend appropriate orthotics (splints, braces) if indicated 1
• Consider referral to occupational therapist for assistive devices and ergonomic adaptations

Step 3: Pharmacological Management

Topical Treatments (for knee OA)

• Topical NSAIDs as first-line pharmacotherapy 1, 4
• Topical capsaicin (0.025% to 0.075%) for knee pain 1

Oral Medications

• Acetaminophen/Paracetamol (up to 3,000-4,000 mg/day) 1, 4
• Oral NSAIDs at lowest effective dose for shortest duration possible 1, 4
  • Evaluate GI, renal, and cardiovascular risk before prescribing
• For neuropathic pain component, consider:
  • Duloxetine (shown effective for OA pain) 5
  • Pregabalin (for fibromyalgia component if present) 6
• For inflammatory arthritis, consider disease-modifying agents like methotrexate if indicated 7

Joint-Specific Treatments

• Intra-articular corticosteroid injections for monoarticular or oligoarticular involvement 1

Step 4: Multidisciplinary Treatment

• If multiple treatment options are indicated or monotherapy fails 1
• Consider referral to pain management specialist
• Cognitive-behavioral therapy for psychological factors affecting pain
• Comprehensive rehabilitation program

Special Considerations

Inflammatory Arthritis

• Early referral to rheumatologist if inflammatory arthritis is suspected 4
• Look for morning stiffness >30 minutes, symmetric joint involvement, positive autoantibodies
• Early intervention is crucial for better outcomes 8

Immune-Related Arthritis

• Consider immune checkpoint inhibitor-related arthritis in patients on cancer immunotherapy 1
• May present as oligoarthritis of large joints or symmetric polyarthritis
• May require corticosteroids or disease-modifying antirheumatic drugs

Endocrine Disorders

• Consider thyroid dysfunction in patients with polyarthralgia and systemic symptoms 2
• Isolated ACTH deficiency can present with polyarthralgia and elevated inflammatory markers 9

Post-Vaccination Syndrome

• Be aware of polyarthralgia following certain vaccinations 10
• May require NSAIDs with or without short-term corticosteroids

Common Pitfalls to Avoid

• Delaying referral to rheumatologist when inflammatory arthritis is suspected
• Overreliance on medications without implementing exercise and weight management
• Using oral NSAIDs as first-line therapy instead of topical treatments
• Neglecting psychological aspects of chronic pain
• Failing to provide adequate education on self-management strategies

By following this structured approach, clinicians can effectively manage polyarthralgia in the outpatient setting, improving pain control and functional outcomes while minimizing disability and chronic ill-health.