Musculoskeletal Problems PDF

MUSCULOSKELETAL PROBLEMS Musculoskeletal disorders are a group of conditions that can affect the joints, muscles, and bones. The most common musculoskeletal disorders in our practice include back pain, arthritis, osteoporosis, and tendonitis.  Significance of questions and answers ❑...

MUSCULOSKELETAL PROBLEMS Musculoskeletal disorders are a group of conditions that can affect the joints, muscles, and bones. The most common musculoskeletal disorders in our practice include back pain, arthritis, osteoporosis, and tendonitis.  Significance of questions and answers ❑Age – child, adult or older people ❑Symptoms ❑Pain, swelling, site and duration ❑History ❑Injury ❑Medical conditions ❑Medication ❑Age Age influences the pharmacist’s choice of treatment other reasons make consideration of the patient’s age important. ▪ In older people, a fall is more likely to result in a fracture ▪ older women are particularly at risk because of osteoporosis. ❑Symptoms and history Injuries commonly occur as a result of a fall other trauma during physical activity, such as ▪ lifting heavy loads or ▪ taking part in sport. ❑ Symptoms and history Sprains and strains ▪ A sprain injury involves the overstretching of ligaments and/or the joint capsule, sometimes with tearing. ✓ The most common sprain involves the lateral ankle ligament. ✓ Referral is the best course of action, consider whether a complete tearing of ligaments has occurred, ✓ a partial tear, the joint is often swollen and the patient experiences severe pain on movement.  ❑ Symptoms and history ▪ A sprain ✓ A complete tear of a knee ligament may involve the tearing of the capsule itself. If this occurs, any blood or fluid can leak out into the surrounding tissues, so the knee may not appear swollen. ❑ Symptoms and history Sprains and strains ▪ Strains are injuries where the muscle fibres are damaged by overstretching and tearing. ✓ Sometimes, the fibres within the muscle sheath are torn. ✓ sometimes, the muscle sheath itself ruptures and bleeding occurs. ✓ Strains are most common in muscles that work over two joints, for example, the hamstring.  ❑ Symptoms and history Early mobilisation, strengthening exercises and coordination exercises are all important after both sprains and strains. The return to full activity must occur gradually. PRACTICAL POINTS First-aid treatment of sprains and strains ▪ The priority in treating sprains and soft-tissue injuries is to apply compression, cooling and elevation immediately, and this combination should be maintained foat least 48 h. ▪ The main aim of this treatment is to prevent swelling. ▪ If swelling is not minimised, the resulting pain and pressure will limit movement and can lead to muscle wasting in the long term or cause prolonged pain and delay recovery.  First-aid treatment of sprains and strains ▪ Ice packs by themselves will reduce metabolic needs of the tissues, reduce blood flow and result in less tissue damage and swelling, but will not prevent haemorrhage. ▪ If possible, after applying a simple elastic bandage or elasticated tubular bandage, which should be snug but not tight, to help control swelling and support the injury. First-aid treatment of sprains and strains ▪ The application of heat can be effective in reducing pain, but only after a few days have elapsed. Heat should never be applied immediately after an injury has occurred, because heat application at the acute stage will dilate blood vessels and and increase blood flow into the affected area ❑Muscle pain ▪ Stiff and painful muscles may occur simply as a result of strenuous and unaccustomed work, such as gardening, decorating or exercise, and the resulting discomfort ▪ can be reduced by treatment with OTC medicines. ❑ Bruising ▪ Bruising as a result of injury is common and some products that minimise bruising are available OTC. ▪ The presence of bruising without apparent injury, or a description by the patient of a history of bruising more easily than usual, should alert you to the possibility of a more serious condition. ❑ Bruising ▪ Spontaneous bruising may be symptomatic of an underlying blood disorder, for example, thrombocytopaenia (lack of platelets) or leukaemia, or may result from an adverse drug reaction or other cause. ❑ Bursitis ▪ which is the inflammation of a bursa. ▪ The function of a bursa is to reduce friction during movement. ▪ Examples of bursitis are ❖ prepatellar bursitis (housemaid’s knee) and ❖ olecranon bursitis (student’s elbow). ▪ Sometimes, these become infected, so if they become inflamed and hot, referral may be indicated. ❑Fibromyalgia ▪ Fibromyalgia refers to chronic widespread pain affecting the muscles but not the joints. ▪ Tender spots can be discovered in the muscles and the condition can be associated with a sleep disturbance. ▪ This condition may be precipitated by psychological distress and physical trauma. Fibromyalgia ▪ Prescribed medication (e.g. tricyclics, non-steroidal anti- inflammatory drugs [NSAIDs] and gabapentin) is of limited benefit in these situations, ▪ often‘talking therapies’, such as cognitive behavioural therapy, have more to offer. ❑Frozen shoulder ▪ Frozen shoulder is a common condition where the shoulder is stiff and painful. ▪ It is more prevalent in older patients. ▪ Patients can sometimes relate the problem to injury, exertion or exposure to cold, but frozen shoulder may occur without apparent cause. ▪ It is more common in those with diabetes. ❑Painful joints ▪ Pain arising in joints (arthralgia) may be due to arthritis, for which there are many causes. ▪ The pain may be associated with swelling, overlying inflammation, stiffness, limitation of movement and deformity of the joint.  cause of arthritis ❖osteoarthritis (OA), ▪ which is not only due to degeneration of a joint, sometimes from wear and tear, ▪ but also associated with genetic ▪ predisposition. ▪ This often affects the knees and hips, especially in the older population. cause of arthritis ❖ Rheumatoid arthritis (RA), ▪ which is a more generalised illness caused by the body turning its defences on itself and where there is inflammation and swelling of the synovium of joints, particularly of the hands and feet.  cause of arthritis ❖gout ▪ A problem sometimes seen in the pharmacy is patients with episodes of acute gout. ▪ It is sometimes associated with the use of diuretics, such as bendroflumethiazide or indapamide. ▪ The most usual presentation is sudden severe pain in the metatarsal–phalangeal joint (‘base’) of the big toe. ▪ The condition is caused by deposition of uric acid crystals in the joint. ▪ In patients who have had previous episodes, the diagnosis is clearer, and ibuprofen (if tolerated) is a highly effective treatmentPatients with repeated episodes ▪ should be on a preventative treatment, such as allopurinol. cause of arthritis Infection, usually with signs of overlying inflammation and swelling. A joint infection is rare, but serious and occasionally fatal ❑Low back pain ▪ Non-serious acute back problems need to be treated early by encouraging activity. ▪ Acute back pain is generally regarded as lasting less than 6 weeks, subacute for 6–12 weeks and chronic longer than 12 weeks. ▪ The main cause Low back pain ✓ strain of the muscles or other soft structures ✓ it is the cushion between the bones (intervertebral disc) that is strained and that bulges out (herniates) and presses on the nearby nerves (as in sciatica). ❑ Low back pain ▪ Lower back pain that is not too severe and has come on spontaneously or after gardening, or bending may be due to muscular strain (lumbago), and appropriate advice can be given in the pharmacy. ▪ bed rest is not recommended for simple low back pain and is to be avoided. ▪ If the back pain in the loin area is associated with any abnormality of passing urine (discolouration of urine, pain on passing urine or frequency), then a kidney problem is more likely. ❑Repetitive strain disorder ▪ Repetitive strain disorder covers several arm conditions, mainly affecting the forearm. ▪ Tenosynovitis is the term that has been used to refer to conditions around the wrist. ▪ There may be crepitus (a creaking, grating sensation or sound) when the wrist is moved. ▪ Sometimes, the symptoms disappear on stopping the job, but they may return when the work is restarted. ❑ Whiplash injuries ▪ Neck pain following a car accident can last for a long period – up to 2 years in some cases ▪ Good posture is important and keeping both the back and the head straight has been shown to reduce pain and help recovery. ▪ The use of physiotherapy and paracetamol or NSAIDs, such as ibuprofen, may help.  Medication ❑The pharmacist should asked about prescribed medication and self-medication that may be tried. When to refer ▪ Suspected fracture ▪ Possible adverse drug reaction: falls or bruising ▪ Head injury ▪ Whiplash injuries ▪ Medication failure ▪ Suspected arthritis or gout ▪ Severe or prolonged back pain ▪ Back pain (and/or pins and needles/numbness) radiating to leg ▪ Back pain in the middle/upper back (especially in the older patient)  Treatment timescale Musculoskeletal conditions should respond to treatment within a few days. A treatment of maximum 5 days should be recommended, after which patients should see their doctor MANAGEMENT most minor conditions associated with pain, discomfort and/fever can be treated at home with ✓ OTC painkillers ✓ and lifestyle changes, such as getting more rest and drinking enough fluids. ✓ A wide range of OTC preparations containing systemic and topical analgesics are available for self- care. ✓ Topical formulations include creams, ointments, lotions, sticks and sprays. MANAGEMENT Paracetamol ✓ Paracetamol has analgesic and antipyretic effects, but little or no anti-inflammatory action. ✓ the drug can be effective in reducing both pain and fever. ✓ The dose for an adult is 0.5–1 g every 4–6 h. The maximum dose is 4 g (eight 500 mg tablets) per day. It is important that this is not exceeded. ✓ Paracetamol can be given to children aged 2–3 months. ✓ A wide range of paediatric formulations, including sugar-free syrupand suppositories. ✓ Paracetamol is generally considered safe in pregnancy and while breastfeeding. ✓ However, in pregnancy, the lowest effective dose should still be used and the duration of use kept to a minimum.  Overdose risk – liver toxicity ✓ At only slightly higher doses than 4 g a day, paracetamol can cause liver toxicity and damage may not be apparent until a few days later. ✓ Paracetamol is a component of many multi-ingredient medicines sold over the counter with names that may not indicate paracetamol as an ingredient. MANAGEMENT Ibuprofen ✓ Ibuprofen has analgesic, anti-inflammatory and antipyretic effects. ✓ The usual dose is 200–400 mg three times a day with food. ✓ The maximum dose allowable to recommend for OTC use is 1200 mg in 24 h. ✓ On prescription, the maximum dose is higher at 600 mg four times a day – 2400 mg in 24 h. ✓ Ibuprofen tablets or capsules should not be given to children under 12 years of age. ✓ Ibuprofen suspension 100 mg in 5 ml is available OTC for children. ✓ Ibuprofen suspension 200 mg in 5 ml is available OTC intended for children aged 7 years and over. Ibuprofen ✓ Ibuprofen tablets or capsules should not be given to children under 12 years of age. ✓ Ibuprofen suspension 100 mg in 5 ml is available OTC for children. ✓ Ibuprofen suspension 200 mg in 5 ml is available OTC intended for children aged 7 years and over. Ibuprofen safe in pregnancy and Breastfeeding ? ✓Ibuprofen should be avoided in pregnancy, particularly during the third trimester. ✓ Breastfeeding mothers may safely take ibuprofen, since it is excreted in only small amounts in breast milk.  Adverse effects of Ibuprofen ▪ Indigestion and gastrointestinal (GI) ulceration ▪ Bleeding ▪ Renal impairment ▪ Hypersensitivity Contraindicationsof Ibuprofen ✓ Sodium and water retention may be caused by ibuprofen and other NSAIDs, and they are therefore best avoided in ▪ patients with congestive heart failure or ▪ renal impairment.  Interactions of Ibuprofen ❑ Ibuprofen and other NSAIDs can aggravate renal dysfunction when people are also ❖ taking angiotensin-converting enzyme (ACE) inhibitors ❖ or angiotensin-receptor blockers (ARBs), and greater care is needed in such patients. ❖ If a diuretic is also being taken, the combination of all three can be particularly hazardous for the kidneys – the so-called triple whammy. Interactions of Ibuprofen ❑ Ibuprofen (and other NSAIDs) interacts with lithium. ▪ NSAIDs inhibit prostaglandin synthesis in the kidneys and reduce lithium clearance. ▪ Serum levels of lithium are thus raised. ▪ Lithium toxicity manifests o GI symptoms, o polyuria, o muscle weakness, o lethargy and o tremor.  Interactions of Ibuprofen ❑Care should be taken, and ibuprofen is best avoided, if the patient is taking ▪ antiplatelet drugs, such as clopidogrel or low-dose aspirin (i.e. 75 mg daily). ▪ It should not be used at all if the patient is on warfarin. Interactions of Ibuprofen ▪ care is needed if the patient is on a selective serotonin reuptake inhibitor (such as citalopram or fluoxetine) ▪ serotonin–noradrenaline reuptake inhibitor (such as venlafaxine or duloxetine), as there is an increased risk of gastrointestinal bleeding if ibuprofen is used.  Aspirin ▪ Aspirin is an anti-inflammatory, analgesic drug indicated for headache, transient musculoskeletal pain, dysmenorrhoea and pyrexia. ▪ It is given in an OTC dose of 300–900 mg every 3–4 h as required, to a maximum of 12 tablets (3.6 g) daily. ▪ It is also commonly prescribed at low dose (75 mg daily) as an antiplatelet. Its OTC use has diminished for several reasons: ▪ In inflammatory conditions, most prescribers prefer anti- inflammatory treatment with another NSAID, as these tend to be better tolerated and more convenient for most patients. ▪ It causes more gastric irritation than paracetamol or ibuprofen. ▪ As a strong antiplatelet agent, it affects blood clotting which may lead to bleeding. ▪ It should not be used for gout or where there is history of gout, as it will aggravate the condition. ▪ It should not be given to children under 16 years of age because it may cause Reye’s syndrome. ▪ Aspirin interacts significantly with a large number of drugs, such as NSAIDs, including ibuprofen, antiplatelet drugs, such as clopidogrel, selective serotonin reuptake inhibitors, such as citalopram or fluoxetine, and serotonin– noradrenaline reuptake inhibitors, such as venlafaxine or duloxetine. With these there is an increased risk of gastrointestinal bleeding. Aspirin in Pregnancy and breastfeeding Aspirin should be ▪ avoided in pregnancy. It should not be used at all in the last trimester. ▪ It should not be taken while breastfeeding.  MANAGEMENT ❑ Codeine and dihydrocodeine ▪ Codeine is a narcotic analgesic and is a prodrug which is metabolised by the body to morphine to become effective. ▪ Dihydrocodeine is related to codeine and has similar analgesic efficacy, but does not require metabolism to be effective. MANAGEMENT Codeine and dihydrocodeine cannot be supplied OTC as single ingredients. They can only be supplied OTC as combination products with other analgesics as The indication is for acute moderate pain which is not considered to be relieved by other analgesics, such as paracetamol or ibuprofen alone.  MANAGEMENT Caffeine ▪ It has been claimed that caffeine increases the effectiveness of analgesics. ▪ Caffeine is included in some combination analgesic products to enhance wakefulness and increased mental activity. ▪ It is probable that doses of at least 100 mg are needed to produce such an effect. ▪ OTC analgesics contain 30–50 mg per tablet. ▪ A cup of tea or coffee is likely to have a similar effect. Topical preparations for painful conditions ❑ Topical non-steroidal anti-inflammatory drug products Topical gels, creams and ointments containing NSAIDs are widely used. One suggestion of the pharmacology is that rubbing is largely responsible for the benefit. Topical NSAIDs, such as ibuprofen, diclofenac, felbinac, and benzydamine, are available OTC topical NSAIDs should not be used by patients who experience adverse reactions to aspirin, such as asthma, rhinitis or urticaria. Rarely, GI side effects have occurred, mainly dyspepsia, nausea and diarrhoea.  Topical preparations for painful conditions ❑ Counterirritants and rubefacients ▪ Counterirritants produce mild skin irritation, ▪ rubefacient refers to the reddening and warming of th e skin. ▪ The theory behind their use is that they bombard the nervous system with sensations other than pain (warmth and irritation), and this is thought to distract attention from the pain felt ▪ There are many proprietary formulations available, often incorporating a mixture of ingredients with different properties. Counterirritants and rubefacients ❑Methyl salicylate ▪ Methyl salicylate is one of the most widely used counterirritants. ▪ The agent is generally used in concentrations between 10% and 60% in topical analgesic formulations. ❑Menthol ▪ Menthol has a cooling effect when applied to the skin and acts as a mild counterirritant. ▪ Used in topical formulations in concentrations of up to 1%, menthol has antipruritic actions, ▪ but at higher concentrations, it has a counterirritant effect. Counterirritants and rubefacients ❑Capsaicin/capsicum ▪ Capsicum preparations produce a feeling of warmth or ‘burning’ when applied to the skin. ▪ They do not cause reddening because they do not act on capillary or other blood vessels. ▪ Patients should always wash their hands after use; otherwise, they may inadvertently transfer the substance to the eyes or lips, causing burning and stinging. ❑Glucosamine and chondroitin ▪ There is some limited evidence that the ‘nutriceuticals’, glucosamine sulphate and chondroitin, improve the symptoms of OA in the knee. ▪ Adverse effects are uncommon, but include abdominal discomfort and tenderness, heartburn, diarrhoea and nausea. ▪ Some are produced from natural sources (the shells of crabs and other crustaceans), while others are synthesised from glutamic acid and glucose. Dosing In clinical studies of osteoarthritis, the typical glucosamine dosage has been 1.5 g/day as a single dose or in divided doses of up to 3 times per day (treatment duration of up to 3 years).