Musculoskeletal Disorders (1) Flashcards
P
Q
R
S
T
Palliation/provocation
Quality
Region/radiation
Severity
Timing of onset
Strain
Tearing of muscle or tendon
Sprain
Stretching or tearing of ligaments
Musculoskeletal conditions leading to Chronic Pains
Myalgia
Tendonitis
Bursitis
Musculoskeletal pain caused by injury
Strain
Sprain
Overexertion
What drugs can commonly cause myalgia?
statins?
What medications can commonly cause tendonitis?
aromatase inhibitors, fluoroquinolones, glucocorticoids, and statins.
What type of MSK injury can be caused by improper immunization technique?
rotator cuff tear or tendonitis.
Musculoskeletal Goals of therapy
Decreasing severity and duration of pain
Restore function of affected area
Prevent reinjury and disability
Prevent acute pain from becoming chronic persistent pain
Musculoskeletal exclusions for self-care
severe pain
duration of pain +10 days
week of OTC therapy continued pain
signs of systemic illness or condition
Visually deformed joint, limb weakness/numbness, or suspected fracture
pregnant
less than 2 years old
R Therapy
I
C
E
Rest
Ice
Compression
Elevation
Ice Therapy
Decrease swelling
constricts blood vessels
may have numbing effect to help with pain
Heat Therapy
Improves circulation
Relaxes muscles
Help with stiffness, spasms, cramping
Used for noninflammatory pain
Musculoskeletal Non-Drug Therapies
TENS
Acupressure
Spinal manipulation
TENS
Transcutaneous Electrical Nerve Stimulation
Musculoskeletal OTC Topical Therapies
Topical NSAIDs
Counterirritants
Topical Anesthetic
Other Topical Agents
Topical NSAIDs for Musculoskeletal
Diclofenac (Voltaren)
Counterirritants
Rubefacients
Cooling Agents
Vasodilators
Irritants w/o Rubefaction
Topical Anesthetic
Lidocaine
Other Topical Agents
Trolamine Salicylate (Aspercreme)
Systemic Analgesics
Non-NSAID Analgesic
NSAIDs
Skeletal Muscle Relaxants
Opioids
Clinical Considerations for Acetaminophen Use
non-inflammatory, non-severe pain
Liver toxicity
Duplication in therapy
Adult OTC Acetaminophen Dosing
325mg
Take 2 tablets every 4 to 6 hours as needed
10 tablets (3,250 mg)
Adult OTC Acetaminophen Dosing
500mg
Take 2 tablets q6h prn
6 tablets (3,000 mg)
Adult OTC Acetaminophen Dosing
650mg
Take 2 tablets every 8 hours
6 tablets (3,900 mg)
Clinical Considerations with NSAID Use
GI bleed:
History of GI bleeding or ulceration
Concurrently on glucocorticoid, SSRI, or anticoagulant therapy
Drink 3 or more alcoholic drinks per day
Age 60 or older
Clinical Considerations with NSAID Use
Cardiovascular risk:
Active CV disease or ischemic heart disease
Past cardiovascular event <6 months ago
Uncontrolled hypertension
Chronic heart failure
Clinical Considerations with NSAID Use
Renal insufficiency :
Renal insufficiency – avoid in patients:
CrCl <30mL/min
NSAIDs and Pregnancy
Not recommended in pregnant women 20 weeks gestation or later
rare but serious kidney dysfunction in fetus
Reduction in the production of amniotic fluid (oligohydramnios)
NSAIDs taken 30 weeks gestation or later…
Lead to premature closure of fetal ductus arteriosus (fetal artery connecting aorta and pulmonary artery)
Generally avoid NSAID use in 2nd and 3rd trimester of pregnancy unless benefits outweigh potential risks
Strategies to Provide Gastrointestinal Protection
PPI therapy - discontinue when nsaid discontinued
Misoprostol - avoid in women who are/may be pregnant
Select a COX-2 selective NSAID - consider added CV risk
Adult NSAID Dosing OTC
Aspirin
81mg tablets
325mg tablets
Avoid in high doses (>325mg)
Do not use for MSK pain
No max dose
Adult NSAID Dosing OTC
Ibuprofen
200mg tablet or capsule
Take 1-2 tablets q4-6 hours as needed
Adult NSAID Dosing OTC
Naproxen
220 mg tablet
Take 2 tablets once, then take 1 tablet every 8 to 12 hours as needed
660mg/day
Tendon
Muscle to bone
Ligament
Bone to bone
Musculoskeletal Acute status
Less than 4 weeks
Musculoskeletal subacute status
4 weeks to 3 months
Musculoskeletal Chronic status
Greater than 3 months
Musculoskeletal Mild pain
1-3
Musculoskeletal Moderate pain
4-6
Musculoskeletal Severe pain
7-10
Overexertion
Sudden high-intensity exercise after long period of inactivity
Muscle damage caused by force generated in muscle fibers (improper exercise, tension, poor posture)
First Degree Sprain (Grade I):
Minimal ligament damage
1 week
self-care
Second Degree Sprain (Grade II):
Moderate tearing of ligament w/ marked swelling and bruising
2-6 weeks to heal
May require medical referral.
Third Degree Sprain (Grade III):
Complete tearing of ligament popping sound
Medical referral/surgery
6-12 weeks
Myalgia Description
Dull, diffuse, constant muscle ache; may also include weakness and muscle fatigue
Tendonitis
Inflammation of tendon around joint
Loss of range and motion
Bursitis
Inflammation of bursae within joints (knee, shoulder)
Clinical Considerations for Diclofenac (Voltaren)
Off-label for general MSK pain
Apply up to 4 grams to affected area up to 4 times daily
Do not apply over broken or compromised skin
Do not use concurrently with oral NSAIDs
Topical Counterirritants MOA
MOA: Create a paradoxical pain-relieving effect by producing a less severe pain to counter a more intense one
Stimulates nerves at site of pain superficially, distracting from the deep underlying pain in muscles and joints
May cause mild irritation, but can rarely cause serious burning of the skin
arachidonic acid (AA) release and metabolism
AA in the membrane lipids
V phospholipase A2 + inflammatory stimuli
Free AA
V Enzymatically via the cyclooxygenase (COX1/2)
Unstable intermediate prostaglandin H2
V Different tissue-specific isomerases
Different biologically active prostanoids
INHIBITION OF PROSTANOID SYNTHESIS
NSAIDs block prostaglandin and thromboxane formation by reversibly inhibiting COX activity. (not selective for COX-1 or COX-2)
NSAIDs Properties
Combined anti-inflammatory, antipyretic, and analgesic properties
Inhibit the COX-mediated generation of prostanoids
Decrease levels of PGE2 in brain surrounding the hypothalamus
Hydrophobic molecules - Carboxylic acid group.
Categorized by class on one or more or key moieties in structure
COX-1
expressed constitutively in most cells. (“housekeeping” functions)
COX-2
readily inducible, its expression levels being dependent on the stimulus
Immediate early-response product markedly up-regulated by shear stress, growth factors, tumor promoters, and cytokines. (sites of inflammation and cancer)
Kidney COX-2
Constitutively expressed in tissues
Regulates renal function and blood flow.
NSAIDS adverse effects
- Central nervous system: Headaches, tinnitus, dizziness
- Cardiovascular: Fluid retention, HTN, edema, MI and congestive heart failure (CHF).
- Gastrointestinal: Abdominal pain, dyspepsia, NV and rarely, ulcers or bleeding.
- Hematologic: Thrombocytopenia, neutropenia, aplastic anemia.
- Hepatic: Abnormal liver function results and rare liver failure.
- Pulmonary: Asthma.
- Skin: Rashes, all types, pruritus.
- Renal: Renal insufficiency, renal failure, hyperkalemia, and proteinuria
COX-2 selective inhibitors
coxibs
COX-2 inhibitors no impact on platelet aggregation,
Aspirin
irreversibly inhibits platelet COX (COX-1) so that aspirin’s antiplatelet effect lasts 8–10 days (the life of the platelet).
Aspirin is now rarely used as an anti-inflammatory medication
Clinical uses is related to its antiplatelet effects.
ACETAMINOPHEN MOA
Reduces central prostaglandin synthesis
Produces analgesia and antipyresis, little anti-inflammatory efficacy.
Weak COX-1 and COX-2 inhibitor in peripheral tissues, no significant anti-inflammatory effects
Skeletal Muscle Relaxants (SMR) types of agents
Antispasticity agents
Antispasmodic agents
Antispasticity agents:
Work at spinal cord and directly on skeletal muscles to improve hypertonicity and involuntary spasms
Antispasmodic agents:
act at the brain stem to decrease muscle spasms through alterations of CNS conduction
Listed in Beers criteria due to increased risk of falls – avoid in elderly patients
Clinical Considerations for SMR Therapy
Only used short term pharm therapy (2-3 weeks)
Long term use cause rebound symptoms and/or withdrawal symptoms
Agents cause dizziness/drowsiness
Assess tolerability before driving vehicle
Avoid alcohol while taking
Can use SMR therapy in combination w/ NSAIDs for added pain relief
Baclofen
Lioresal
Boxed Warning: Avoid abrupt discontinuation due to risk of withdrawal symptoms
Requires renal dose adjustment for CrCl<80, avoid use in CrCl<30
Tizanidine
Zanaflex
Capsule and tablet formulations are not interchangeable
Carisoprodol
Soma
Schedule IV controlled substance
Cyclobenzaprine
Flexeril
Causes anticholinergic side effects (dry mouth, urinary retention, dizziness)
Contraindicated in hyperthyroidism, arrhythmias, heart block
Metaxalone
Skelaxin
No pearls
Methocarbamol
Robaxin
no pearls
Approach to Treating Acute Musculoskeletal Pain
(Non Lower Back)
Topical NSAID therapy with or without topical menthol
Oral NSAID therapy or acetaminophen
Acupressure or transcutaneous electrical nerve stimulation (TENS) therapy
Approach to Treating Low Back Pain
Acute or Subacute Lower Back Pain
Nonpharmacological treatment is recommended for all patients (superficial heat)
Pharmacologic treatment if needed, NSAID or skeletal muscle relaxant therapy recommended
Approach to treating Chronic Lower Back Pain
Nonpharmacological treatment for all
Inadequate response, consider:
NSAIDs
Tramadol
Duloxetine
Last line:
Opioids
Prevention of Musculoskeletal Injury
Before Physical Activity
Warm up and stretching exercises before vigorous exercise
Wrap injured muscles/joints w/ protective bandage or tape
Appropriate, well-fitting footwear
Sufficient fluids
Do not push your physical limits
Prevention of Musculoskeletal Injury
Lifestyle Modifications
Avoid sedentary lifestyle – Activity at least 5 day/wk
Use ergonomic controls to adjust posture, stresses, and motions
Use assistive devices to alleviate pressure on joints if needed (cane, walker)
