Pillar 2: Control the Pain
In-Clinic Physical Therapy Interventions for Short Term Pain Relief
While the greatest value in attending physiotherapy is in the customization of exercise and eduction you should receive, there are also some pain relief treatments that can be offered which may be of benefit. Here we cover some of the common treatments offered in the physiotherapy clinic. These treatments should be used to settle a flare-up, or as a short term boost to help you get back on track.
Note that some of the treatments in this section are rated as limited to moderate” clinical value (2-3 stars). This means the treatment tends to work for some, but not for others. A characteristic of a limited / moderate rating is that the clinical decision as to whether to use these treatments becomes more important. A physiotherapist experienced in osteoarthritis can assess and help you decide which treatments are likely to be of benefit to you.
Treatments that have been rated as having no significant evidence and are not covered in the treatment guidelines are not included here as there is little evidence for their use. You may, however, which to discuss these treatments for your physiotherapist (taping, dry needling, etc).
The treatments / strategies that may be provided by a physiotherapist are detailed here under the following categories:
Exercise and Education
Machines and Modalities
Hands-On Therapies
Exercise and Education
Supervised Movement and Mobilization Exercises ★★★★
It is important to again note that exercise itself can reduce the pain in an arthritis joint. However, it can also flare it up. It can often be difficult to know where to begin to exercise a painful joint. Will movement make it worse? How far can I go? Should I feel pain with exercise? What type of exercise should I do? What equipment should I use?
These are just a few of the many questions that come up when starting to exercise with knee osteoarthritis. While the long term management of knee osteoarthritis will certainly involve independent exercise and decisions, supervision in those early days when you need pain relief can go a long way towards making sure you don’t do too little or too much.
Light Cardiovascular Exercise ★★★★
Cardiovascular exercise itself improves oxygen delivery and lowers pain levels. Using a stationary bicycle at light resistance is very often an ideal method to get a flared up knee moving and a physiotherapist can assist in determining the appropriate resistance levels in clinci.
Education ★★★★
Education is a key part of any treatment program and, in fact, is what this course is all about. After assessment, your physiotherapist may be able to provide you strategis for immediate pain relief that you may not have already thought of yourself.
To start, an individualized plan of exercises is developed. These exercises are designed to improve flexibility, strength, coordination and balance to achieve optimal physical function. Physical therapists:
Teach you proper posture and body mechanics for common daily activities to relieve pain and improve function.
Show you how to properly use assistive devices such as walkers and canes.
Recommend different treatment options, such as braces and splints to support joints, shoe inserts to relieve stress on the lower extremities, and hot and cold therapy to ease joint pain and stiffness.
Suggest modifications to your environment, such as ergonomic chairs or a cushioned mat in your kitchen, to relieve pain and improve function.
Direct you to community resources that can help in your Knee OA management
Machines and Modalities
Thermal Agents (Heat and Ice) ★★★☆
Ultrasound ★★☆☆
Ultrasound therapy involves applying sound waves to the affected region. This heats up the tissues in the area, increasing circulation, which may have some effect on inflammation. There is research to suggest that ultrasound may provide benefits in the treatment and management of arthritis pain. Ultrasound is a generally safe treatment that is ideal for use due to its cost-effectiveness, portability and ease of use.
It is worthy to note the current literature on ultrasound therapy for arthritis pain lacks consistency and a few deficiencies have been documented. As a result, people should proceed seek guidance from a health professional before using ultrasound on your arthritic joints.
Heat and / or ice can be used at home for the most part, but they may also be used in the clinic. Physiotherapy clinics often have equipment not available in a typical home setting (moist heat pack hydrocollators, motorized icing units, etc) and can trial what kind of thermal agent tends to work best for you. In our experience, the majority of clients Knee OA tend to prefer moist heat over ice.
Transcutaneous Electrical Nerve Stimulation (TENS) ★★☆☆
TENS units are small, portable, non-invasive devices that could provide pain relief. They can be used in-clinic and, if found to be beneficial, can be purchased at a relatively low cost for home use. A physiotherapist can teach you how to use a TENS machine. TENS machines should not be used on those who have pacemakers.
Acupuncture ★★☆☆
Interferential Current Therapy (IFC) ★★☆☆
Interestingly, Interferential Current Therapy (IFC) is not mentioned in isolation in any guidelines that we have seen. It seems to be considered under the same category as Transcutaneous Electrical Nerve Stimulation, which is a less powerful application of electrical current and likely to have a lesser effect. In our clinical experience, in combination with heat therapy, we have seen it provide significant relief to some patients, allowing pain to settle and exercise to begin. A systematic review in 2012 did find significant benefit from using IFC with Knee OA, but concluded that further large scale RCTs were needed to establish standardized treatment.
While it does not help everybody, a trial of IFC is often considered to assist in controlling pain levels to allow for more movement and exercise of the joint.
Acupuncture involves the insertion of very thin needles through the skin at specific points on the body. This technique has its roots in Traditional Chinese Medicine. Traditional Chinese Medicine focuses on the connection and balance between different body systems rather than just the specific areas of pain.
There have been many studies that address the use of acupuncture in arthritis pain management. Acupuncture has been shown to yield anti-inflammatory effects and regulation of immune system function. However, these trials have limitations with sample size, effect size, and control variables. The greatest number of positive trials with the largest effect sizes have been carried out on knee osteoarthritis. Acupuncture’s efficacy therefore remains unclear and it is given a limited recommendation in more sources for Knee OA. It may work well for some people, but not for others, however, the risk of harm is low.
Not all physical therapy clinics have clinician’s trained in acupuncture, although FusionPhysio does. Contact info@fusionphysiochilliwack.com for more information.
Hands-On Therapies
Manual Therapy ★★☆☆
Manual therapy (MT) involves techniques that manipulate and apply pressure to affected joints, muscles, and connective tissue. One example of manual therapy is mobilization: repeated passive motions at low speed. Another method is manipulation: fast movements with small force, small amplitude, and high speed over a joint.
Some research suggests that manual therapy could be a safe and effective complementary therapy option for improving pain and stiffness. However, there is limited high quality evidence available, with existing evidence being prone to bias and poor experimental design. As a result, people with arthritis should proceed with caution. Consult your primary caregiver or rheumatologist to determine your best course of action.
Massage Therapy ★★☆☆
Massage therapy encompasses a variety of different techniques and practices, but always involves manipulating the soft tissues of the body. Massage therapy can be used to treat arthritis pain, targeting affected muscles and tissue to decrease swelling and pain, improve joint mobility, and provide tension and stress relief.
Some people report that massage has yielded positive outcomes in pain management and relaxation. However, evidence of massage therapy’s efficacy in managing arthritis symptoms is insufficient. Many studies do not have sufficient numbers of test subjects and show a high risk of bias. Because of this, massage therapy does not have a high level of recommendation as an arthritis pain management approach.