rently being researched by the National Institutes of Health, and so far, little evidence supports their use (Macfarlane et al., 2012). Some individuals have used copper bracelets, massive vitamin supplementations, and magnets in an attempt to reduce pain and progression of OA (Macfarlane et al., 2012). Despite their use, these techniques have not been proven effective, and further- more, massive vitamin supplementation can be dangerous. Although recent advances in OA research identify the synovium (i.e., the layer of smooth tissue that lines the joint space and se- cretes a lubricating fluid) as a potential player in the inflamma- tory process in OA pathophysiology, its exact contribution to the disease has not been determined. In the future, advances in mo- lecular biology, diagnostic tools, and imaging systems will likely improve current understanding of the role of the synovium in OA pathophysiology. This knowledge is expected to enhance drug delivery, bioengineering, and gene therapy techniques to alter pathological processes initiated in the synovium and thus coun- teract the progression of OA (Monemdjou et al., 2010). moisturizes the skin to prevent cracking and itching. Moist heat can also be used to reduce stiffness, but it is not as effective as paraffin at reaching small hand joints; liquid paraffin wax encircles the fingers and thumb completely, whereas moist heat leaves air spaces between the semirigid and flat hot packs resting on the top and bottom of the uneven and three-dimensional surfaces of the hand (Bellew et al., 2016). Transcutaneous electrical stimulation (TENS) can also be utilized to reduce musculoskeletal pain. While commercial units are avail- able for purchase over the counter from a variety of places (e.g., drugstores or online retailers), medical-grade units issued to a client under a physician’s order tend to be better in terms of of- fering more waveforms and longer battery life. Due to normal effects in which a person’s sensory system becomes accommo- dated to a specific stimulation, a unit with multiple waveforms is more effective at preventing this accommodation, especially in chronic conditions like OA where the stimulation may be used for months or years. TENS can be applied using high-rate or low-rate stimulation (Bellew et al., 2016). High-rate TENS utilizes the Gate theory to essentially “close the gate” to pain by flooding the sen- sory receptors with the electrical stimulation from the unit instead (Bellew et al., 2016). Low-rate TENS utilizes the endorphin and enkephalin theory, which suggests the body’s own pain media- tors, like serotonin, are activated by the stimulation and therefore reduce pain (Bellew et al., 2016). While high-rate TENS immedi- ately reduces pain, the relief will end once the unit is removed. Conversely, low-rate TENS takes at least 45 minutes to begin al- leviating pain but will continue with pain relief for several hours after discontinuation of the treatment. Due to this, most medical- grade units offer waveforms with combined high and low rates to capitalize on both theories of pain reduction. Clients can be taught how and when to use their TENS unit by therapists and can then use it independently at home. When electrodes are placed around the painful area, TENS has been shown to reduce pain as- sociated with OA (Wu et al., 2021). reader is advised that the values mentioned in the protocols are guidelines. Postsurgical protocols vary considerably across clinical settings. It is important that therapists work closely with surgeons; the number of weeks might vary depending on the individual sur- geon’s protocol, the experience of the therapist working with a surgeon, the client’s joint condition at the time of surgery, and other factors.
plications for pain relief (Hochberg et al., 2012). Opioid combina- tion drugs are used for relief of severe pain but are not commonly used in the treatment of hand and wrist OA. In 2012, the American College of Rheumatology stated that in general, use of opioids for hand OA is not recommended (Hochberg et al., 2012). Corti- costeroids are sometimes administered as intra-articular injections during acute flare-ups (Hochberg et al., 2012). Their effects vary greatly, and they are expensive. Some controversy exists regard- ing whether injected steroids slow the rate of cartilage loss or speed its breakdown. Injections might need to be repeated every four to six months, but repeatedly injecting the same joint might lead to the softening and destruction of surrounding soft tissues. Therefore, it is recommended that no more than three injections a year be introduced to the same area (Cole & Schumacher, 2005). The supplements glucosamine and chondroitin sulfate seem to have helped some people, but their effectiveness has not been proven in tests, and they are expensive. Glucosamine must be used with some caution in diabetic clients because it can raise blood sugar. Glucosamine, chondroitin, and acupuncture are cur- Physical agent modalities Physical agent modalities (PAMs), including the therapeutic use of heat and cold, can aid in symptom management of OA. Prior to use, it is imperative that to avoid doing harm, therapists review specific precautions and contraindications and ensure competen- cy before using PAMs on their clients. Therapeutic cold relieves pain caused by overuse and subsequent active inflammation. Slow icing, which takes approximately 15–20 minutes to administer, is completed with the placement of an ice bag or other cold source over a painful area that has been cov- ered with a layer of toweling. Ice applied for 20 minutes without a layer of protection could result in damage to the skin. Quick ice, or ice massage, is administered by use of an ice cup, which involves quickly stroking an ice cube over the painful area for no more than 5 minutes. Initial discomfort quickly gives way to numb- ness, and the area will become red and cold to the touch (Bellew et al., 2016). Another form of PAMs is paraffin baths. This form of therapeutic heat can be soothing and provide warmth to enhance tissue ex- tensibility, leading to mobility of hand joints that are stiff due to osteoarthritis. Paraffin dips can be completed as needed through- out the day, with ample time for tissue cooling between treat- ments. Use of a commercially available paraffin unit is suggested. Because higher temperatures can cause burns, these units ensure that the temperature does not exceed 130 degrees Fahrenheit (Bellew et al., 2016). Clients dip their hands into the liquid wax while keeping their fingers still, then quickly remove their hands. They should keep their hands out of the wax for at least 3 seconds and then quickly dip them again, repeating this process 8 to 10 times. If hands are moved during the dipping, a burning sensa- tion occurs. Keeping the hands out of the wax longer than they were in provides adequate cooling to allow a coat of wax to build, as opposed to melting off each time the hands are placed in the paraffin unit. Once the dipping is complete, the hands should be wrapped in plastic and placed in a towel wrap or commercially available mitt to hold the heat for approximately 15 minutes. In addition to the warming qualities of the wax, the oil component Surgery Surgery is an alternative only if conservative measures have failed and there are major mechanical symptoms (Hochberg, 2012). Sur- gical options include total joint replacement (arthroplasty), joint fusion (arthrodesis), cartilage transplantation, or arthroscopy to clean the joint by removing pieces of cartilage or bone that have broken off. These procedures are typically performed by ortho- pedists or plastic surgeons who have been specially trained in surgery of the hand and wrist. Hand surgeons work closely with OTs and PTs who specialize in hand rehabilitation (Taylor et al., 2011). The following section discusses postsurgical protocols. The
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