Clinical recommendation for musculoskeletal conditions (3.5) Flashcards
For acute low back pain;
A) Who is the patient
B) What are the symptoms
C) How long have the symptoms been present
D) Actions taken
E) Medications
F) Allerges
G) Trigger point for referral
A)
- Common in individual between 40-69 yo
- Caution in elderly due to risk of stress fracture
Often due to
- Repetitive stress on lower back including frequent bending, lifting heavy object
- Long period of sitting down e.g. truck driver
- Acute injury from excessive twisting e.g. golf and gymnastic
B)
- Location – localised or diffuse
- Nature of pain – acute low back pain often described as aching or “stiff”
- Onset –quick onset of pain and reduction in mobility, often following exertion
- Restriction in movement – worse following activity and relieved at rest
C)
- When did the pain first appear? Is it precipitated by strenuous, unaccustomed work, or recent exertion?
- Has symptoms been present > 48 hours?
D)
- Any interventions in reducing pain?
E)
- Are they currently taking any analgesic?
- Are they on any cold and flu medications containing analgesic?
F)
- Codeine
G)
- Worsening pain over several days
- Pain that radiates to the leg(s)
- Severe shooting pains into the leg(s) with loss of function/weakness in your leg(s) - sciatica
- Urinary or bowel incontinence
- Need for analgesic for > 7 days
- Persistent pain after 4 weeks
What are some topical NSAIDs and topical Rubefacients used in acute low back pain treatment?
Use RICER first
Topical NSAIDs
- Good analgesic esp in individual who cannot tolerate oral NSAID due to GI adverse effect
- No sensation of heat
- Include ibuprofen (Nurofen® gel), ketoprofen (Orudis® gel), diclofenac (Voltaren® gel), benzydamine (Difflam® gel) and piroxicam (Feldene® gel)
- Massage gently into affected area two to four times daily; does not need to be “rubbed in”
- Common adverse effects: Itch, rash, skin irritation
Topical rubefacient
- known as counter irritant
- Cause vasodilatation , producing warmth and distract patient from pain
- Contains salicylates, menthol e.g. Metsal® , Dencorub® cream
- Apply to the affected area two to three times daily
- Salicylates: caution in patients with aspirin allergy
- Common adverse effect: Rash, skin irritation
Other tx include
- Herbal remedies (devil’s claw, white willow bark, cayenne)
- Acupuncture
- Massage
- Copper containing gel
- Arnica gel, cream or spray
What are some systemic analgesics used in acute lower back pain?
Paracetamol
- 1st line analgesic
- Generally well tolerated – adverse effects are rare unless overdose
- Safe in pregnancy and breastfeeding
Aspirin
- Not 1st line
- Commonly associated with GI bleed especially in elderly
- Avoid in patients with asthma, past history of GI bleed, children under age of 16
- Avoid concurrent administration with warfarin
- Avoid in pregnancy and breastfeeding
NSAIDs
- Ibrupofen, diclofenac, naporxen sodium
- Similar efficacy, choice dependent on patient
- Avoid in elderly (increased risk of GI bleed and compromised renal function), patient with asthma and past history of GI bleed
- Avoid in pregnancy
- Safe in breastfeeding
- Many drug interactions including anticoagulant
- Common adverse effect: heartburn, GI ulceration, diarrhoea, hypertension
- Take NSAID with or soon after food to reduce risk of GI adverse effects
What about compound analgesic with codeine for acute lower back pain treatment
- Include paracetamol and coideine, aspirin and codeine
- These product contain 8-15mg of codeine – these dose are too low to provide significant reduction in pain but enough to cause adverse effects (sedation and constipation)
What is some self care for acute low back pain?
- Good posture
- Exercise at a moderate level for at least 30 minutes on all or most days of the week
- Proper lifting technique
- Wear low-heeled shoes with arch supports and cushioned heels
- Take regular breaks to stand, stretch and walk
- Have bed mattress on a firm base and use a low pillow for sleeping
For strain and sprain;
A) Who is the patient
B) What are the symptoms
C) How long have the symptoms been present
D) Actions taken
E) Medications
F) Allerges
G) Trigger for referral
A)
- Common in individual between 25-34 yo
- Often due to overexertion or sport related injury
- Caution in elderly and children due to risk of stress fracture
B)
- Location and nature of pain
> Strain pain worsen when patient exert the “pulled” muscle; no limitation on mobility
> Sprain characterised by sudden onset of pain, swelling, warmth and limited range of movement following injury
C)
- Patient normally seek advice immediately, esp when injury involved weight bearing joints such as ankle and knee sprain
D)
- Any interventions in reducing pain?
E)
- Are they currently taking any analgesic?
- Are they on any cold and flu medications containing analgesic?
F)
Codeine
G)
- Suspected fracture; more common in young children below 12 y.o. and elderly
- Bone abnormalities (joints look deformed)
- Accompanying head injury
- Severe pain at rest
- Pain & wt bearing not better within 5-7 days.
- Associated injury to skin (may require tetanus prophylaxis)
- Suspected arthiritis or other diseases
How to treat strain and sprain?
- Immediate Care: Start with R.I.C.E.R; no H.A.R.M for the first 48 hours
H- heat
A-alcohol
R-running
M-massage
- Analgesic (1st line paracetamol)
- Dose and counselling similar to use of analgesic in treating low back pain
Self-care for strain and sprain
- Gradually increase movement after pain and swelling subside
> Sprain and strain related injury can take 1 up to 6 weeks to recover depending on severity of injury
To prevent future injury
- Wear suitable footwear and protective clothing when playing sport
- Warm up before sport
- Run on even surface
- Allow adequate recovery time in between training session
