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Clinical - Winter > 12 - Pain 2 > Flashcards

12 - Pain 2 Flashcards

1
Q

What are skeletal muscle relaxants?

A

Group of agents that act predominantly w/in CNS to relieve pain associated w/ skeletal muscle spasms

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2
Q

Which OTC products are skeletal muscle relaxants?

A
  • Methacarbamol (most common; most often in combination w/ analgesic)
  • Chlorzoxazone (less common)
  • Orphenadrine
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3
Q

What is the MOA, indication, and onset of methocarbamol? Is it used as a first line agent?

A
  • MOA = unknown, thought to cause skeletal muscle relaxation due to general CNS depression
  • Indication = tx of acute, painful, musculoskeletal muscle spasms
  • Onset = 12-24 h
  • Not first line b/c of SE
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4
Q

What is the MOA, indication, and onset of orphenadrine? Is it used as a first line agent?

A
  • MOA = mechanisms similar to analgesic and anti-cholinergic properties; exact MOA unknown
  • Indication = tx of painful muscle spasms due to acute musculoskeletal conditions
  • Onset = more than 24 h
  • Not first line b/c of SE
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5
Q

What is the MOA and indication for chlorzoxazone?

A
  • MOA = muscle relaxant due to central acting properties; works at spinal cord and brain level to decrease skeletal muscle spasms
  • Indication = acute relief of pain and discomfort due to musculoskeletal conditions
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6
Q

What are SE of methocarbamol?

A
  • Drowsiness, dizziness
  • Light-headedness, headache
  • Urine discolouration (black, blue, green, or brown)
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7
Q

What are CIs of methocarbamol?

A
  • Pregnancy

- Caution in px w/ seizure disorder, hepatic or renal impairment

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8
Q

What are SE of orphenadrine?

A
  • CNS (drowsiness, dizziness, headache)

- Anticholinergic effects (constipation, dry mouth, blurred vision)

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9
Q

What are SE of chlorzoxazone?

A
  • CNS (drowsiness, dizziness, headache)
  • Urine discolouration (orange to purple/red)
  • Impaired hepatic function
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10
Q

What are CI of orphenadrine?

A
  • Pregnancy
  • Caution in px w/ seizure disorder, hepatic or renal impairment
  • Anticholinergic (glaucoma, prostate hypertrophy, arrhythmias)
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11
Q

What are drug-drug interactions for all of the skeletal muscle relaxants?

A
  • Other ACh agents
  • CNS depressants
  • MAO inhibitors
  • Alcohol
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12
Q

What are the most commonly used topical analgesics?

A

Those w/ counterirritant effects

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13
Q

What is the MOA of counterirritants?

A
  • Paradoxical pain (produce a less severe pain to counter a more intense one)
  • Produce mild, local inflammatory reaction
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14
Q

Which ingredients are considered “heat” therapy?

A
  • Methyl salicylate
  • Capsaicin
  • Trolamine salicylate
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15
Q

Which ingredients are considered “cold or ice” therapy?

A

Menthol or camphor

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16
Q

Which ingredient is used in no odour products?

A

Trolamine salicylate

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17
Q

What are some precautions w/ methyl salicylates and trolamine salicylate?

A
  • Avoid use when taking anticoagulants
  • Avoid use if allergic to salicylates
  • Caution w/ salicylate sensitive asthmatics
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18
Q

What is the length of treatment for counterirritants?

A

Maximum 7 days, except capsaicin (usually 14 days, but may need a max. of 4-6 weeks)

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19
Q

What effect does capsaicin produce once applied?

A

Produces a transient feeling of warmth, but diminishes w/ repeated applications

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20
Q

What is the MOA of capsaicin?

A

Reduces substance P in sensory neurons (responsible for transmission of pain impulses)

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21
Q

When is capsaicin used? When is it not used?

A
  • Used in osteoarthritis pain, postherpetic neuralgia, and lower back pain
  • Not used on wounds or damaged skin
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22
Q

What are some instructions specific for capsaicin?

A
  • Must apply at least 3x/day to provide pain relief and for burning sensation to diminish
  • Burning sensation will diminish w/ regular use
  • Apply for 3-4 weeks for optimal response
  • Discontinue if condition worsens or doesn’t improve after 28 days
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23
Q

What are topical NSAID analgesics used for?

A

Relief of muscle, joint, and back pain

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24
Q

What is the recommended length for topical NSAID analgesics?

A

Short term (7 days)

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25
Q

What is a benefit to topical NSAIDs?

A

For some conditions (ex: osteoarthritis), provide similar pain relief properties as oral NSAIDs w/o the GI adverse effects

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26
Q

What is the dosing for diclofenac diethylamine gel (Voltaren Emulgel)?

A
  • Apply over affected area 3-4 times daily and rub gently into skin
  • Apply twice daily for extra strength (2.32%)
  • Wash hands before and after application
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27
Q

What are the categories of back pain?

A
  • Acute = less than 4 weeks
  • Sub-acute = 4-12 weeks
  • Chronic = over 12 weeks
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28
Q

What is normally the cause of acute low back pain?

A

Sprain or strain of muscles or ligaments that support the lumbar spine

29
Q

What are less common causes of low back pain? Do any of these require referral?

A
  • Inflammation or traumatic injury to joints and ligaments
  • Disc injury
  • Neurological involvement
  • Arthritis
  • Malignancy and infection
  • All require referral
30
Q

What are sx of low back pain?

A
  • Range from muscle ache to spasm

- Involves low back, buttock, and posterior thigh

31
Q

What are risk factors for low back pain?

A
  • Age (peak = 45-64 y/o)
  • Occupation
  • Posture
  • Height and weight
  • Pregnancy
  • Smoking
  • Stress
32
Q

What are red flags for low back pain?

A
  • Pain in middle to upper back
  • Pain for more than 5 days
  • Bladder or sexual dysfunction
  • Fever/chills; vertebral tenderness
  • Age over 50 or under 20 y/o
  • Constant pain; nighttime pain; no relief w/ postural change
  • Loss of movement or range of motion
  • Unexplained weight loss
  • Chronic liver disease; inflammatory arthritis
  • Weakness/numbness or tingling in legs
  • Long-term steroid use
  • High risk for fractures
  • No improvement to tx after 1 month
  • Visceral pain (organs)
33
Q

What are the recommendations for tx of low back pain?

A
  • Greater self-reliance
  • Return to activity ASAP
  • Stay active
  • Avoid de-conditioning and debilitation
34
Q

What are non-pharms for low back pain?

A
  • Cryotherapy (first 24-48 hours, up to 72 h)
  • Thermotherapy
  • Exercise
  • Rest only if essential (1-3 days max.)
  • Improve coping skills (control/avoid anxiety or depression)
35
Q

What are pharm options for low back pain?

A
  • Internal analgesic (acetaminophen, ibuprofen/naproxen, ASA, codeine combinations)
  • Skeletal muscle relaxants
  • Topical analgesics (methylsalicylate/ capsaicin/ menthol; diclofenac gel)
36
Q

Should skeletal muscle relaxants be recommended for acute low back pain?

A
  • Not 1st line
  • Better than placebo but no better than NSAIDs
  • Can use short term (2-3 days) as a sedative and/or analgesic agent
37
Q

What is the recommended pharm approach for acute low back pain?

A
  • Acetaminophen if no inflammation present
  • NSAIDs based on co-morbidities
  • NSAIDs given at full dose for pain w/ inflammation; use for 2-4 weeks
  • Dose both on regular schedules
38
Q

What are non-pharms for prevention of low back pain?

A
  • Follow a program emphasizing flexibility
  • Aerobic conditioning
  • Proper posture
  • Proper use of body mechanics
  • Weight loss
39
Q

What is the monitoring for low back pain?

A
  • Improvement in 7-10 days

- Continue everyday activities w/in limits permitted by pain

40
Q

When should a px be referred after they have tried tx for low back pain?

A
  • Loss of motion or sensory function
  • Increasing pain
  • Loss of bladder and bowel function
  • Failed tx (trial of at least 2 analgesics for 2-4 weeks each)
  • Any other red flags
41
Q

What is a muscle strain?

A

Muscle fibres pulled apart causing pain, reduced movement, and sometimes swelling (aka pulled muscle)

42
Q

What is a muscle contusion?

A

Damage to blood vessels in muscles followed by bleeding, bruising, and sometimes clotting

43
Q

What is tenosynovitis?

A
  • Tendon is irritated and inflamed

- Causes pain, swelling, and sometimes crackling sound when moving

44
Q

When does damage occur to tendons?

A

When extended or overused

45
Q

What is the difference between tendons and ligaments?

A
  • Tendons join muscles to bone

- Ligaments join bone to bone to form joints

46
Q

What are the categories of ligament sprains?

A
  • 1st degree = excessive stretching
  • 2nd degree = partial tear
  • 3rd degree = complete tear of tissue
47
Q

What are red flags for muscle strains and sprains?

A
  • Severe pain or weakness in any limb
  • Visually deformed joint or abnormal joint movement
  • Joint pain w/ systemic symptoms (fever)
  • Suspected or obvious fracture
  • Increased intensity of pain or any change in character of pain
  • Inability to bear any weight on injured limb
  • Pain lasting longer than 2 weeks
  • Swelling lasting more than 14 days after RICE therapy
48
Q

What is RICE therapy?

A
  • Rest
  • Ice (20 mins) to reduce pain, inflammation and bruising
  • Compression to help swelling go down (don’t wrap too tight)
  • Elevation - keep injured area above heart to reduce swelling
49
Q

What are non-pharms for muscle strains and sprains?

A
  • RICE therapy
  • Thermotherapy
  • Rehabiliation
50
Q

What are pharm options for muscle strains and sprains?

A
  • Internal analgesics (acetaminophen, ibuprofen/naproxen, ASA)
  • Topical analgeics (counterirritants)
51
Q

What is the no HARM principle of tx for muscle strains and sprains?

A
  • No heat, alcohol, running or massage (increases bleeding, swelling, or can make injury worse)
  • Applies to acute stage of injury for 24-48 hours
52
Q

What is the benefit of cryotherapy in acute injuries?

A
  • Decreases metabolism and inflammation
  • Slows nerve conduction
  • Vasoconstriction => decreased edema and hemorrhage
53
Q

In which group of px should cryotherapy be used w/ caution?

A

Px in which vasoconstriction is already a problem

54
Q

What are the directions for use of cryotherapy?

A
  • Use a gel pack (cooled in fridge not freezer), bag of frozen peas, or cold compress
  • Place wet towel or cloth between skin and ice to prevent frostbite
  • Apply for 20 mins or until skin feels numb, whichever is shorter
  • Repeat q2h until swelling decreases (2-48 h)
55
Q

What is the benefit of heat for sub-acute injuries (after 48 h)?

A
  • Produce vasodilation
  • Increases tissue perfusion of oxygen and nutrients
  • Helps w/ removal of CO2, waste, and pain mediators
  • Relaxes muscle and can decrease muscle spasms
56
Q

In which px groups should heat be used w/ caution or avoided?

A
  • Active bleeding
  • Fresh hematoma/bruise
  • Caution in px w/ sensitive skin (won’t be able to tell if being burned)
  • Rheumatoid arthritis (heat can activate enzymes that damage cartilage)
57
Q

Which topical product is the best option for muscle strains and sprains?

A

Topical NSAIDs b/c have anti-inflammatory properties, so are actually treating the problem w/ few SE

58
Q

What is the monitoring for a grade 1 ankle injury?

A
  • Improvement in swelling and discomfort in 48 hours
  • Should be able to move the ankle
  • 7-10 days of therapy
59
Q

When should a grade 1 ankle injury be referred?

A
  • Ankle is extremely painful
  • Swelling and discolouration doesn’t subside or worsens
  • Impossible to bear weight on affected leg
  • Obvious deformity
60
Q

Is osteoarthritis an inflammatory disorder?

A

Typically non-inflammatory, but later stages can include inflammation issues

61
Q

What is the pathophys of osteoarthritis?

A
  • Initially, cartilage thickens, but eventually cartilage softens and pieces break off
  • Cartilage deteriorates resulting in bone against bone, leading to changes in bone
62
Q

What are risk factors for osteoarthritis?

A
  • Advancing age
  • Female
  • Obesity
  • Occupation
  • Family history/genetics
  • Joint injury or surgery
  • Joint overuse or injury w/ certain sports
  • Quadriceps muscle weakness
63
Q

What are signs and sx of osteoarthritis?

A
  • Pain - initially felt near the joint, aggravated w/ activity or prolonged use
  • Joint stiffness - occurs in mornings or after time of non-use; generally lasts less than 30 mins
  • Occasional joint instability
  • As condition progresses, may have bony swelling
64
Q

What is the treatment plan for OA?

A
  • Requires diagnosis
  • Tx progression should correlate w/ disease progression
  • Tx focused on sx relief
65
Q

What are some non-pharms for OA?

A
  • Lifestyle changes (weight loss of at least 5%)
  • Exercise (strength training and aquatic exercises)
  • Joint protection (splints, taping, braces)
  • Improve footwear
  • Occupational or physiotherapy
  • Reduce “mechanical” stresses or use ambulation aids (canes, walkers)
  • Stress management
  • Heat
  • Massage
66
Q

What is the drug of choice for OA?

A
  • Acetaminophen up to 1 gram QID (lowest effective dose should be used)
  • Trial for 1-2 weeks
67
Q

What is the recommended tx for OA for px w/ incomplete relief w/ acetaminophen?

A
  • Topical agents (diclofenac, capsaicin)
  • Topical NSAIDs preferred over oral in px 75 years and older
  • Max. effect = 2 weeks for topical NSAID, 4 weeks for topical capsaicin
  • Oral NSAIDs are second line; must assess risks from CV, GI, and renal complications before starting
68
Q

What is the minimum single toxic dose of acetaminophen?

A

7.5-10 g over an 8 hour period

Clinical - Winter (24 decks)

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