During the course of the day, one may encounter patients who are either reluctant to take oral medications for osteoarthritis pain or cannot take the medications due to potential dilemmas with other medications they are taking. Accordingly, our expert panelists share their experiences with topical NSAIDs, heat therapy products and TENS therapy. Without further delay, here is what they had to say.

Q: What has been your experience in using topical agents to help treat osteoarthritis (OA)? When do you use these modalities in your armamentarium for OA?
A: Karen Duclon, MSN, ARNP-BC, has found topical therapeutic agents useful and effective in treating OA and overuse injuries of the knee. She notes that many of these agents warm the joints, decrease inflammation and assist with mobility. Antonio Giannelli, MsA, PA-C, often recommends topicals for OA, noting that frequent application is the key. He says patients often use topicals to help relieve OA pain in the shoulders, knees, elbows, ankles and feet. Giannelli tells patients to avoid using these products on their hands as they might inadvertently rub their eyes.

Adrienne Berarducci, PhD, ARNP, BC, CCD, says she uses topical modalities such as capsaicin, trolamine or methylsalicylate “rather infrequently” lately due to the emergence of more effective, non-pharmacologic therapies for treating OA.

The topical NSAIDs capsaicin and trolamine are effective for some patients, according to Duclon, who says these treatments provide an alternative for patients who cannot tolerate oral NSAID medications or steroids.
Anecdotally, Dr. Berarducci says she has had very limited success with trolamine salicylate creams. Dr. Berarducci has found in her experience that mild OA responds “fairly well” to capsaicin and methylsalicylate creams and gels. She also points out that they appear to relieve regional muscle discomfort in some individuals with mild OA. However, she cautions that they do require frequent application (seven to 10 times a day) and can be irritating to sensitive skin.

The sensitivity issue is why Giannelli avoids using capsaicin products.

“Most patients use it too much and do not like the burning sensation it gives later in the tub or shower,” explains Giannelli.

Duclon adds that the off-label use of Lidoderm, which is FDA-approved for post-herpetic neuralgia, has been helpful in treating OA pain some patients.

“Patients with flares of increased joint pain have claimed (that Lidoderm) relieved their joint pain enough so they could rest at night or run errands,” points out Duclon.

Q: Are there any topical agents you are selective about using in certain joints?
A: As Giannelli pointed out earlier, Duclon prefers not to use topicals with warming agents such as capsaicin on the hands in order to avoid the risk of patients inadvertently rubbing it in their eyes. In her experience, Duclon says these agents work best on the larger joints in the knees, shoulders and elbows. She adds that her patients often use Lidoderm on the knees and elbows as well as the low back.

As far as selectivity goes when using topicals on certain joints, Dr. Berarducci says it usually depends upon the patient preference. She notes that some patients report using a methylsalicylate gel prior to applying moist heat packs and that this increased pain relief better than using moist heat alone. Dr. Berarducci says the best results for this combination were reported by those who had back pain and/or neck pain.

Most brands of topicals work to some degree in relieving OA pain, according to Giannelli. He reiterates that the key is patient tolerance to frequent application. Giannelli cautions patients to try using a topical on a small area first in order to ensure there is no adverse skin reaction. He also says it is important to increase the patient’s awareness about the active ingredients of a given topical, noting that topicals vary when it comes to percentages of active ingredients.

Q: What success have you had with heat therapy products for OA? At what point do you consider using these products? In your experience, are there any drawbacks to these modalities?
A: Dr. Berarducci says she has had considerable success using heat therapy products and other heat-based modalities to treat OA, especially when it comes to treating OA in the knee, back pain and neck pain.

“These are great products for both short- and long-term relief of musculoskeletal pain,” emphasizes Dr. Berarducci. “I consider using them for almost all patients with OA-related pain – especially for OA in the knee – either as a monotherapy or in conjunction with other pharmacologic and/or non-pharmacologic therapies.”
Duclon adds that thermal heat wraps are helpful for knee and elbow pain while thermal bandages can be soothing for those who have low back pain and stiffness.

She says the only drawback to heat therapy products is the potential for burns in patients with neuropathy, diabetes and other conditions that may cause a loss of sensation to the affected joint or area. Dr. Beraducci concurs on the importance of educating patients about the proper use of heat therapy modalities. Due to the potential burn risk, Dr. Berarducci says she never recommends the use of electric heating pads. Duclon also urges clinicians to caution patients about not using direct heat or heat therapy products over a topical agent such as capsaicin or Lidoderm.

For most individuals with OA, Dr. Berarducci emphasizes that correct usage of continuous heat wraps is “generally more cost-effective” than medications, physical therapy, etc.

In regard to the use of eight-hour continuous heat wraps, Dr. Berarducci says cost may be a drawback for some individuals as the modality is not covered by insurance. However, for most individuals, Dr. Berarducci emphasizes that correct usage of this modality is “generally more cost-effective” than medications, physical therapy, etc.

Dr. Berarducci says moist heat packs/pads are another good alternative if patients apply them several times daily at intervals of 20 minutes on and 20 minutes off.

All the panelists recommend the use of paraffin dips. Dr. Berarducci says this is a good option for patients who have OA in their hands or fingers. Duclon says patient with mild to moderate OA often find that placing their hands in paraffin or warm water helps “decrease stiffness and increase mobility.” Giannelli notes that several of his patients own their own paraffin baths and feel this works well as an adjunct for their pain relief.

“The more crippling the arthritis, the more I recommend (this modality) to patients,” adds Giannelli. He does note that this modality is impractical for those with mild arthritis.

Warm water exercise and pool therapies are also beneficial for those who suffer from OA, according to Dr. Berarducci. She says these represent good opportunities to facilitate both exercise and pain relief. For those who are able to participate, Dr. Berarducci adds that it is covered by some insurers.

Q: What has been your experience in using a TENS unit to help treat OA?
A: Dr. Berarducci has often used TENS therapy, usually adjunctively, to help treat patients with moderate to severe chronic neck and low back pain. The theory behind the TENS unit is that the electrical pulsations alter the perception of pain and stimulate the body’s ability to produce endorphins and encephalins, according to Dr. Berarducci. She notes she has seen mixed responses to this treatment but adds that the improvement of symptoms is better among patients with considerable regional pain and stiffness.
Duclon does not use a TENS unit to treat her patients with OA but notes that studies have documented the effectiveness of TENS in decreasing OA pain in the knee for several hours.

Dr. Adrienne Berarducci is an Assistant Professor and Research Associate in Adult Primary Care at the University of South Florida Colleges of Nursing and Medicine. Her research focus area is osteoporosis and bone metabolism. She maintains a practice in internal medicine.

Ms. Karen Duclon is the Secretary of the West Coast Council of Advanced Nursing Practice. She is a nurse practitioner with rheumatology experience and is currently
in family practice in Clearwater, Fla.

Mr. Antonio Giannelli is a physician assistant with Associated IM Specialists, Rheumatology in Battle Creek, Mich. He is a Clinical Instructor within the Department of Internal Medicine at Michigan State University. He is also a board member of the Society of Physician Assistants in Rheumatology.