New York Physical Therapy Ebook Continuing Education

Pharmacology Despite considerable research, no drug prevents or repairs cartilage damage. Nevertheless, pharmacological intervention can help reduce pain associated with OA. Pain-relieving and anti-inflammatory medications can be important components of the management paradigm. Medications are delivered orally, injected directly into the joint, or applied topically (Hochberg et al., 2012). Generally, pharmacological intervention follows a progression of drugs. The first line for discomfort is acetaminophen, in doses from 1 to 5 g per day (Hochberg et al., 2012; Quismorio et al., 2011). This medication is as effective as nonsteroidal anti-inflammatory drugs (NSAIDs). If acetaminophen is not sufficiently effective, NSAIDs are tried, though 15% of individuals taking them have an increased risk of side effects such as gastrointestinal bleeding and peptic ulcer disease. Common NSAIDs in the treatment of OA are ibuprofen and naproxen. The NSAID family blocks prostaglandins that trigger inflammation, but there is concern that their use accelerates joint destruction; individuals might develop allergies following long-term use (Quismorio et al., 2011). While taking these medications to reduce joint damage, clients should be advised to use joint protection strategies (e.g., avoid straining hand joints through actions such as forcing a jar open or carrying a heavy shopping bag; Hochberg et al., 2012). COX-2 inhibitors are a form of NSAID that targets COX‑2, an enzyme responsible for inflammation and pain. COX-2 inhibitors appear to have fewer side effects than other NSAIDs. They also block prostaglandin production and protect the stomach better. However, many COX-2 inhibitors were removed from the U.S. market in 2005 when research showed an increased risk of serious cardiovascular events associated with their use (Howes, 2007). The only COX-2 inhibitor that remains on the market in the U.S. is celecoxib, which is sold under the manufacturer’s name of Celebrex and is now approved in some generic versions (U.S. Food and Drug Administration [FDA], 2014). Locally applied topical creams of either capsaicin or methyl salicylate might be helpful, though their use requires several daily applications for pain relief (Hochberg et al., 2012). Opioid combination drugs are used for relief of severe pain but are not 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 competency 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 covered 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 numbness, 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 extensibility, leading to mobility of hand joints that are stiff due to osteoarthritis. Paraffin dips can be completed as needed throughout the day, with ample time for tissue cooling between treatments. 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,

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). Corticosteroids 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 regarding 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 currently 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 furthermore, 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 secretes a lubricating fluid) as a potential player in the inflammatory process in OA pathophysiology, its exact contribution to the disease has not been determined. In the future, advances in molecular 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 counteract the progression of OA (Monemdjou et al., 2010). a burning sensation 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 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 available 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 offering more waveforms and longer battery life. Due to normal effects in which a person’s sensory system becomes accommodated 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 sensory receptors with the electrical

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