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CASE STUDY

CASE STUDY

T.C. is a 54-year-old postal worker with a long history of bilateral knee pain who self-referred to outpatient physical therapy. The patient’s current medication includes daily ezetimibe (for hyperlipidemia) and over-the-counter acetaminophen and ibuprofen. During the initial patient interview, T.C. tells the therapist that his knee pain has been increasing over the past several months to the extent that he is concerned he will not be able to make it to his goal retirement age of 65 years. As T.C. is talking, the therapist observes bilateral ulnar deviation of T.C.’s metacarpophalangeal joints and Swan-neck deformities of the first two fingers. When the therapist notes her observation, T.C. adds that his hands are also stiff and painful, especially for long periods in the morning, and that he has had progressive difficulty quickly moving envelopes and packages in and out of his carrier bag. Upon closer examination of T.C.’s wrists, the therapist observes radial deviation with swelling that feels “boggy” on palpation. Examination of T.C.’s lower extremities reveals mild valgus deformities, no edema, and no loss of motion around the knee. The only positive findings are decreased strength in bilateral hamstrings, quadriceps, and hip abductors. The physical therapist provides T.C. with a lower extremity strengthening home exercise program. She asks T.C. to follow up with his primary care physician or a rheumatologist for further evaluation. T.C. says that he does not want to take time off to see more healthcare providers and does not see why this is necessary. T.C. feels that these new leg exercises will help him get stronger, and that he may just try to “power through” the pain with his current medication regimen.

REHABILITATION FOCUS

Inflammation is a complex response to cell injury that occurs in vascularized tissues. The chemical and cellular mediators of inflammation attempt to eliminate the cause of cell injury and clear away debris in preparation for tissue healing (regeneration and/or repair). Several inflammatory mediators also cause pain. In autoimmune rheumatic diseases such as rheumatoid arthritis or metabolic arthropathies, the cause of cell injury cannot be eliminated and the result is a chronic condition of pain and tissue damage. Several classes of anti-inflammatory drugs decrease both inflammation and pain. Other drugs such as glucocorticoids and disease-modifying antirheumatic drugs are more directly targeted at reducing inflammation via modifying immune processes. In contrast, analgesic drugs only decrease pain, without affecting the inflammatory process. In gout, a metabolic disease associated with precipitation of uric acid crystals in the joints, drug treatment of acute episodes targets the inflammation, whereas treatment of chronic gout targets both inflammatory processes and the production and elimination of uric acid.

Drug classes discussed in this chapter relieve pain and decrease inflammation, which are almost universal conditions shared by patients seen by physical therapists, regardless of their diagnosis. Some drugs or drug classes are more generally aimed at inhibiting inflammation, while others are targeted ...

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