Patients with arthritis in our practice are often referred to physical therapists during the course of their management. One question I often hear from patients when I suggest physical therapy is, "But, why can't I do exercises at home?"

So the big misconception here is that physical therapy is just a bunch of glorified exercise instruction. Nothing could be further from the truth. Physical therapy plays an extremely important role in the management of the patient with arthritis.

Before we go into the treatment modalities that physical therapists use, let's start with exercises since they are an integral part of treatment.

Exercises consist of stretching, strengthening, and range of motion. In addition, as patients get older they need different types of training such as with balance and gait. Finally, the physical therapist in conjunction with the occupational therapist may look into activities of daily living and suggest some modifications that may be helpful.

But where physical therapy plays a major role is in using different modalities to relieve pain and speed the healing process.

Diathermy is a treatment method which delivers deep heat. It is useful for chronic pain conditions such as deep muscle injury or arthritis.

Precautions in regard to skin and subcutaneous tissue depth should be attended to. For example, a person who is skinny will require much less diathermy than an obese person. Also patients with damage to sensory nerves probably should not receive diathermy.

Iontophoresis (IP) is a procedure where an electric current pushes ionically charged chemicals (ie., glucocorticoids or steroids) through the skin to reach deeper tissues. IP can be used for calcific tendonitis and inflammatory conditions such as arthritis. Contraindications to use of iontophoresis include allergy to the chemical being applied, open wounds, or neurologic deficits that impair a person's ability to feel.

Iontophoresis also should not be used near metallic implants, wires, or staples.

Ultrasound (US) is a type of treatment in which high-frequency sound waves are used to "heat up" superficial soft tissues and to help with tissue healing. Ultrasound can be used for tendon injuries or for short-term pain relief related to muscle strain or spasm. Contraindications of ultrasound include the use of US directly over recently surgically manipulated nerves such as a recent laminectomy, directly over malignant tumors, and over joint replacements and permanent pacemakers. US should also not be used in areas of thrombophlebitis (blood clots), near the eyes, over the uterus, ovaries, and testicles. US also should not be used in areas of acute inflammation, over the epiphyseal plates of growing children, and over breast implants of any type.

Phonophoresis (P) is the use of ultrasound to transport therapeutic medications to subcutaneous tissues. P can be used for inflammatory conditions such as tendonitis, arthritis, and bursitis. The same cautions and contraindications exist as for US.

Electrical stimulation (ES) is the process of using electrical current to deliver a therapeutic effect by generating an action potential in nerve tissue. This action potential leads to two potential results. The first is a change in sensory input, ie. a reduction in the ability to perceive pain. The second is a muscle contraction. Low grade muscle contractions can often relieve the severe muscle spasms that occur in association with arthritis. ES can be used for chronic pain related to arthritis, bursitis, or tendonitis. It is also useful for muscle spasm as well as neuropathic or radicular pain (pain from pinched nerves in the spine).

It has the same contraindications as US.

Low-level laser therapy- also known as cold laser- acts through the absorption of photon radiation. This leads to changes in cellular oxidative metabolism. Evidence indicates that levels of inflammatory and pain mediators such as prostaglandin E2 can be reduced with this modality. Cold laser can be used for minor musculoskeletal pain, osteoarthritis, chronic neck and low back conditions, and fibromyalgia.

It should be used with caution in patients with malignant tumors or in those being treated with anticoagulants, corticosteroids, or immunosuppressive drugs and should not be used over the thyroid gland or over reproductive organs.

Patients and those providing the cold laser treatment should use safety goggles to limit eye exposure to laser light.

These are only a very small portion of the many therapeutic modalities a physical therapist has in their arsenal. In the care of patients with arthritis, physical therapists are an indispensable member of the team.