Page 626 - WSAVA2018
P. 626

 25-28 September, 2018 | Singapore
the last 5 years.
Immune system Already covered at each step in pain processing, the immune system is implicitly linked
to even the most acute pain signaling. Systemic reductions in inflammation with steroids, NSAIDs, and many supplements can reduce tissue damage, to both the nervous system and the other collateral systems (musculoskeletal, myofascial). Acupuncture provides immune modulation both systemically and regionally. Cooling and gentle massage have regional effects on immune function.
Muscle and connective tissue Muscle and connective tissue sequella are inevitable with any sort of amplified pain processing, both through guarding of the painful region as well as bystander activation from neuronal and glial amplification. Systemic muscle relaxants such as methocarbamol may aide in reducing muscle tension. Specific regional techniques to reduce muscle tension are generally superior and include: acupuncture, low- level laser therapy, ultrasounds therapy, transcutaneous electrical stimulation, massage and physical therapy. Fascia is recently recognized as having proprioceptive and sensory capacity, and also plays a major role in both the generation of pain, and the treatment of pain and proprioceptive deficits by physical medicine modalities.
Caution is advised when adding these modalities to your practice as there is significantly less regulation of these affiliated professions. Verify an appropriate evidence- based training or go through validated training programs yourself.
Bone and joint Clearly, the most physiologically function a body region, the less pain and accommodation will need to occur. Definitive surgical correction should always be pursued when available. Additionally,
many methods are available to augment bone and
joint function. Inflammation is a key component to the demise of cartilage, and anti-inflammatory products
are irreplaceable in this setting. Other products that
may have an impact in reducing joint inflammation are glycosamino-glycan products such as adequan. While the presence of articular cartilage may improve the effect of GAGs, there is also evidence that decreased inflammatory mediators (such as IL-1) follow treatment and may help joint comfort even when little normal cartilage remains. Intra-articular administration of Hyaluronic acid takes this approach to a more direct level. Intra-articular steroids have some potential harm for damaging cartilage (depo-medrol), although other studies (especially in horses) have shown a cartilage sparing effect of triamcinolone when combined with HA. These injections may have an important role to provide comfort in end-stage joints and facilitate physical therapy. Biologicals such as PRP or stem cells may also improve joint comfort, although more research is needed in these areas. Using local anesthetics in joints has recently come
under fire, as changes in cartilage healing has been found with infusions of bupivacaine directly into joints.
Nutritional supplements directed at cartilage and
joint function include fatty acids, soy and avocado insaponifiables, glucosmine, chondroitin, MSM, elk-velvet antler, green-lipped mussle, milk-based products such as duralactin, myristol, herbals such as dandelion, boswelli, turmeric: etc. Many of these products have merit, some more validated than others. Omega-three fatty acids (50 mg/kg EPA+ DHA) have the highest level of evidence, and are therefore commonly recommended. There are many supplements available, and while they may be helpful, they may also serve to direct money and energy away from validated therapies. Those of animal origin have other concerns, such as disease transmission
and ethical harvesting. Whenever possible, it is recommended to favor products from companies that are pursuing scientific validation for their products. Consider avoiding glucosamine/chondroitin containing products
in spinal cord until further evidence is found that it won’t inhibit central nerve healing.

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