Chapter 7 - Musculoskeletal (Cut off for Exam 1)

Question 1

Musculoskeletal Injuries

Answer 1

• Arises muscles, joints, bones, and connective tissues
• Can be acute from things like sport injuries (tendonitis, sprains, strains) or exacerbated conditions (osteoarthritis)
• Chronic: pain lasting 3+ months
• Acute: pain lasting < 4 weeks
• 100 million+ adults battle chronic pain in US

Question 2

Tendons

Answer 2

Connect bones to muscles, usually stretch and twist, rarely rupture, damaged with hyper extended or overused

Question 3

Ligaments

Answer 3

• Connect bones to bones,
• Usually stretch and twist, rarely rupture, damaged with hyper extended or overused
• More commonly tear or rupture than tendons

Question 4

Synovial Bursae

Answer 4

• Fluid-filled sac between joint spaces

- Lubrication and cushioning

Question 5

Catilage

Answer 5

-Protective pads between bones in joints and spine

Question 6

Skeletal/Striated Muscle

Answer 6

• Responsible for contractions

- Houses pain receptors which are stimulated from overuse or injury

Question 7

Somatic Pain

Answer 7

• Pain impulse from peripheral nocireceptors to CNS by nerve fibers
• Commonly myofascial (muscle strain) or musculoskeletal (arthritis)
• Mediated by mechanoreceptor and chemoreceptor

Question 8

Inflammatory Response

Answer 8

• Edema
• Erythema
• Hyperalgesia

Question 9

Muscle Injury Categories

Answer 9

1. Delayed-onset muscle soreness, overexertion (can last days, peaks in 24-48 hours)
2. Myalgia (systemic infections, chronic disease, medications)
3. Strains (injury to muscle or tendon from strange contraction while lengthening)
4. Tendonitis (inflammation of tendon from acute injury or chronic/repetitive movements)
5. Bursitis (inflammation of bursa from joint injury or infection
6. Sprains (common problem with ligaments, three classes

Question 10

Grade I Sprain

Answer 10

Excessive Stretching

Question 11

Grade II Sprain

Answer 11

Partial Tear

Question 12

Grade III Sprain

Answer 12

Complete Tear

Question 13

Low Back Pain

Answer 13

• 5th most likely reason for physician visit
• Many risk factors
• Can have serious causes
• Chronic if 3 months or more

Question 14

Osteoarthritis

Answer 14

• Gradual softening and destruction of cartilage between bones
• Caused by genetic, metabolic, and environmental factors

Question 15

Musculoskeletal Clinical Presentation

Answer 15

• Pain = common symptom of all categories
• If limited function of joint, likely a grade II/III sprain
• Carpal tunnel - lowered ability to feel hot/cold, false feeling of swelling, weak hands, tendency to drop things
• Osteoarthritis - limits ADLs, pain often referred in proximal muscles due to changed gait or activity
• Low back pain - nerve pain, sharp pain down one or both legs, limits ability to bend, move, sit, or walk

Question 16

Musculoskeletal Treatment Based on Severity

Answer 16

• Acute - alarm system to injury from trauma, disease, muscle spasm, or inflammation
• Chronic - requires PCP assessment before treatment

Question 17

Musculoskeletal Treatment Goals

Answer 17

1. Decreased intensity of pain
2. Decreased duration of pain
3. Restoring function to affected area
4. Preventing re-injury and disability
5. Preventing acute pain from becoming chronic pain

Question 18

Musculoskeletal General Treatment

Answer 18

• Similar symptoms so similar self-treatment
• Nonpharmacologic: RICE (rest, ice, compression, elevation)
• Pharmacologic: Non-Rx oral analgesics and/or topical analgesics for first 1-3 days
• Same for acute low back pain
• Chronic back pain requires medical assessment
• Osteoarthritis - lifestyle changes and use of analgesic (can be a non-Rx), self-treat after diagnosis

Question 19

Musculoskeletal Nonpharmacologic

Answer 19

• Warm up and stretch before physical activity, proper hydration, proper footwear to prevent sport injury
• Muscle cramps - stretching, massaging, and immediate rest
• Electrolyte depletion - oral supplementation and fluids
• RICE: promotes healing and reduces swelling and inflammation from muscle/joint injuries
• Don’t apply ice/heat directly to skin and for more than 15-20 minutes at a time, max of 3-4 times per day
• Heat therapy for noninflammatory injury including acute low back pain but NOT osteoarthritis
• Remove adhesions immediately if you experience burning, itching, discomfort, etc.
• TENS - approved for pain by alteration of pain transmission and increased endorphin production (Don’t use if preggo, pacemaker, or a child)
• Proper posture, ergonomic structure use, better-fitting shoes, acupunture, chiropractics, heat therapy, lifestyle changes, and traction massage are also commonly used

Question 20

Musculoskeletal Pharmacologic Options

Answer 20

1. Systemic Analgesics
2. Topical analgesics
3. Counterirritants

Question 21

Musculoskeletal Systemic Analgesics

Answer 21

• NSAIDs and APAP are common non-Rx
• Limit to 10 days of use
• Seek medical attention if pain lasts longer than this
• APAP - preferred 1st line for osteoarthritis
• Recommend topical NSAIDs rather than systemic for chronic use due to severe and prevalent SE (use PPI for chronic use)

Question 22

Musculoskeletal Topical Products

Answer 22

• Local analgesic, anesthetic, antipruritic, and/or counterirritant effects
• Approved for minor to moderate aches and pains of muscles and joints
• Adjuncts to nonpharmacologic/pharmacologic therapies

Question 23

Counterirritants

Answer 23

• Produce less severe pain to counter a more intense pain
• Pain relief from nerve stimulation
• Produces mild, local inflammatory reaction which decreases perceived pain of actual injury
• Safe to use in adults and kids 2+ y.o.
• Temporary relief for minor to moderate aches and sprains
• Seek medical attention if burning or blistering occurs

Question 24

Trolamine Salicylate

Answer 24

• Topical analgesic
• Decreases synovial fluid salicylate concentrations lower than aspirin
• Recommended for adults and kids 2+ y.o. is 10-15% 3-4 times per day
• No efficacy studies for topical
• Same CI as salicylates, can be used for hand osteoarthritis

Question 25

Topical NSAIDs

Answer 25

- Topical analgesic - Not currently available non-Rx in US - If injury close to skin surface, same benefits as oral NSAID without SE - Approved for chronic osteoarthritis use

Question 26

Musculoskeletal Combination Products

Answer 26

- Don't combine drugs from the same category usually - Only do so unless the combination is safer and more effective - Often add to counterirritants together as long as they're in different groups - Counterirritants + Skin protectants don't go together (counterproductive)

Question 27

Musculoskeletal Special Populations

Answer 27

- No variability in different ages and races - Avoid in kids < 2 y.o. - Use caution in those too young to communicate SE they are experiencing effectively - Most medications opt for a minimal age of 12 or 18 y.o. - Common in preggo, but may have risks due to lack of categorization (see PCP first) - Topical camphor - preggo compatible (low risk) - Topical salicylates should be avoided in the 3rd trimester due to systemic absorption risk

Question 28

Musculoskeletal Patient Factors

Answer 28

- Consider patient's medical history and conditions - Topicals as adjunct or substitutions of oral medications - Category I counterirritant should be recommended at lowest effective concentration

Question 29

Musculoskeletal Patient Preferences

Answer 29

- Dosage form, ease of use, cost, and odor can effect selection - Ointment increases absorption but are greasy and usually disliked by patients - Rub in topical products (besides patches and solutions)

Question 30

Musculoskeletal Complementary Therapies

Answer 30

- Glucosamine and chondroitin - most common supplement for osteoarthritis - Showed no significant reduction of pain and increase in function of joints - Not recommended for hip/knee osteoarthritis

Question 31

Assessment of MS Injuries

Answer 31

- Note medications, past medications, and preferences - Try to qualify and quantify pain (SCHOLAR-MAC) - Numerical pain scales help (Mild: 1-3, Moderate: 4-6, Severe: 7-10, may need medical intervention) - Intervene if patient chronically uses non-Rx analgesics - Offer education about risks of inadequate treatment and medication overuse

Question 32

MS Counseling

Answer 32

- Tell them dosage, admin. instructions, interactions, self-monitoring techniques - In acute pain, administer non-Rx analgesics early and taper off as pain severity allows - Tell PCP about new or worsening pains

Question 33

MS Evaluation

Answer 33

- Primary indicator is the patient's perception of pain relief - If pain continues or worsens after 7 days, refer them for further evaluation - Lack of return often means successful treatment - Those who return with continued swelling, pain, or inflammation - refer for medical evaluation - Continued pain could indicate a chronic, potentially debilitating, condition

Question 34

MS Exclusions

Answer 34

- Severe pain - Pain that lasts > 10 days - Pain that continues > 7 days after treatment with a topical analgesic - Increased intensity or change in character of pain - Pelvic or abdominal pain - N/V, fever, or other signs of systemic infections or disorders - Deformed joint, abnormal movement, limb weakness, numbness, suspected fracture - Pregnancy - <2 y.o. - Back pain AND loss of bowel/bladder control

Question 35

Methyl Salicylate

Answer 35

-Rubefacient -Causes vasodilation of cutaneous vasculature which promotes reactive hyperemia, inhibits central/peripheral prostaglandin synthesis -Hot effect -Localized and systemic reactions (salicylate toxicity) -Heat increases absorption -Do not use in children -Use caution in patients on anticoagulants EX: Salonpas, Bengay, Icy Hot

Question 36

Camphor

Answer 36

- Group B - Cooling sensation - Depresses cutaneous receptors and at high concentrations stimulates nerve endings in the skin, induces relief of pain by marking deeper visceral pain - CNS toxicity if ingested which can lead to N/V, seizures, dizziness, headache, delirium, coma, and death

Question 37

Menthol

Answer 37

- Group B - Cooling sensation - <1%: depresses cutaneous receptor response (anesthetic) - >1.25%: stimulates cutaneous receptor response (counterirritant) - Triggers TRPM8 receptor that causes cold sensation that travels along pathway similar to somatic pain sensations from affected muscle or joint - Feel coolness followed by warmth - ADR: irritation, rash, burning, swelling - Ex: Aspercreme, Bengay, Icy Hot, Mineral Ice

Question 38

Methyl Nicotinate

Answer 38

- MOA: vasodilation and elevation of skin temperature | - ADE: Decreased BP, decreased HR, syncope

Question 39

Capsicum Preparation

Answer 39

- Group D for acute and chronic pain - Major ingredient of hot chili peppers - MOA: Stimulates TRPV1 and depletes of substance P which causes irritation - Decreases pain but not inflammation - In 2 weeks pain starts to be relieved, but can take 4-6 weeks to fully take effect - Must continually use 3-4 times a day