Musculoskeletal Problems PDF

College of Pharmacy Fourth Year. Clinical Pharmacy Musculoskeletal Problems Pharmacists are frequently asked for advice about muscular injuries, sprains and strains. Simple practical advice combined with topical or systemic OTC treatment can be valuable...

College of Pharmacy Fourth Year. Clinical Pharmacy Musculoskeletal Problems Pharmacists are frequently asked for advice about muscular injuries, sprains and strains. Simple practical advice combined with topical or systemic OTC treatment can be valuable (1). Significance of questions and answers A-Age In elderly patients, a fall is more likely to result in a fracture; elderly women are particularly at risk because of osteoporosis, so referral to the Dr. is required (X-rays may be the best course of action in such cases) (1). B-Symptoms and history Injuries commonly occur as a result of a fall or other trauma and during physical activity such as lifting heavy loads or taking part in sport. Exact details of how the injury occurred should be established by the pharmacist (1). 1-Sprains and strains Note: Tendons and ligaments are made of fibrous connective tissue. Tendons connect muscle to bone; ligaments connect bone to bone Sprains: a sudden or violent twist or wrench of a joint causing the stretching or twisting of ligaments (2) and sometimes with tearing (1). Strains: injury to a muscle, often caused by overuse, resulting in swelling and pain (2). Early mobilization, strengthening exercises and coordination exercises are all important after both sprains and strains. The return to full activity must occur gradually (1). 2-Muscle pain: Stiff and painful muscles may occur simply as a result of strenuous, such as gardening, or exercise, and the resulting discomfort can be reduced by treatment with OTC medicines (1). 3-Bruising: Bruising (Plate 40) as a result of injury is common and some products that minimize bruising are available OTC. The presence of bruising without apparent injury should alert the pharmacist to the possibility of a more serious condition. Spontaneous bruising may be symptoms of an underlying blood disorder, e.g. thrombocytopaenia or leukaemia, or may result from an adverse drug reaction or other cause (1). 1 4-Head injury: Pain occurring as a result of head injury should always be viewed with suspicion and such patients, particularly children, are best referred for further investigation (1). 5-Bursitis (inflammation of a bursa) The function of a bursa is to reduce friction during movement (1). Clinically, joint swelling is the predominant feature together with associated pain and tenderness (3). 6-Frozen shoulder Frozen shoulder is a common condition where the shoulder is stiff and painful. It is more prevalent in older patients. The shoulder pain sometimes radiates to the arm and is often worse at night (1). NSAIDs could be offered but if symptoms fail to respond with treatment after 5 days, then referral for alternative treatment and physiotherapy should be considered (3). 7-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. It is often difficult to distinguish between the different causes and it is therefore necessary to refer to the doctor (1). (further reading 1) 8-Back pain The main cause is a strain of the muscles or other soft structures (e.g. ligaments and tendons) connected to the vertebrae.Lower back pain that is not too severe or debilitating and comes on after gardening, awkward lifting or bending may be due to muscular strain and appropriate advice may be given by the pharmacist (1). Bed rest is not recommended for simple low back pain. The emphasis is on maintaining activity, supported by pain relief (1). Pain that is more severe, causing difficulty with mobility or radiating from the back down one or both legs may indicate Sciatica and required referral (1). Back pain that is felt in the middle to upper part of the back is less common, and if it has been present for several days, it is best referred to the doctor (1). Kidney pain can be felt in the back, to either side of the middle part of the back just below the ribcage (loin area). If the 2 back pain in the loin area is associated with any abnormality of passing urine (discoloration of urine, pain on passing urine or frequency), then a kidney problem is more likely , referral is advised (1). 9-Repetitive strain disorder This condition is also termed chronic upper limb pain syndrome, often results after prolonged period of steady hand movement involving repeated grasping, turning, and twisting. The predominant feature is pain in all or one part of one or both arms. The person's job usually involves repetitive tasks, such as keyboard operations (3). There may be crepitus (a creaking, grating sound) when the wrist is moved. Sometimes the symptoms disappear on stopping the job, but they may return when the work is restarted (1). C-Medication Prescribed medication Sufferers, for example, of rheumatoid arthritis or chronic back pain are likely to be taking painkillers or NSAIDs prescribed by their doctor. Although the recommendation of a topical analgesic would produce no problems in terms of drug interactions, if the patient is in considerable and regular pain despite prescribed medication, or the pain has become worse, referral back to the doctor would be appropriate (1). Side-effects. In elderly patients, it should be remembered that falls may occur as a result of postural hypotension, dizziness or confusion as adverse effects from drug therapy. Any elderly patient reporting falls should be carefully questioned about current medication, and the pharmacist should contact the doctor if an adverse reaction is suspected (1). When to refer -Suspected fracture (1). Self-medication: The pharmacist should also -Possible adverse drug reaction: falls enquire about any preparations used in self- or bruising (1). treatment of the condition and their degree of -Head injury (1). (1) effectiveness. -Medication failure (1). -Arthritis (1). Treatment timescale -Severe back pain (1). Musculoskeletal conditions should respond to -Back pain (and/or pins and treatment within a few days. A maximum of 5 needles/numbness) radiating to leg days’ treatment should be recommended, after (1). (1) which patients should see their doctor. -Back pain in the middle/upper back (especially in the older patient) (1). Management -Problems with bladder function (2). A wide range of preparations containing -Patients unable to bear weight on an systemic and topical analgesics is available. injured ankle/foot (3). The oral analgesic of choice would usually be a NSAID, such as ibuprofen, provided there were no contraindications. Taking the analgesic regularly is important to obtain 3 full effect and the patient needs to know this. Topical formulations include creams, ointments, lotions, sticks and sprays (1). 1-Paracetamol Paracetamol has analgesic and antipyretic effects but little or no anti-inflammatory action. It is less irritating to the stomach than is aspirin and can therefore be recommended for those patients who are unable to take aspirin for this reason (1). According to BNF : the patient should not take more than 2 tablet at any one time and not take more than 8 in 24 hours (note: each tablet contain 500 mg) (4). Paracetamol is the drug of choice in pregnancy and breastfeeding (3). Liver toxicity At high doses, paracetamol can cause liver toxicity and damage may not be apparent until a few days later. All overdoses of paracetamol should be taken seriously and the patient should be referred (1). 2-Aspirin Dosage: adults and children over 16 years of age, 300–900 mg every 4–6 hours when required; maximum daily dose 3600 mg (5). Unlike paracetamol, aspirin is associated with problems in its use (3). A-It should not be given (as an analgesic or antipyretic ) to children under 16 years because of its suspected link with Reye’s syndrome (1). B-Indigestion Gastric irritation (indigestion, heartburn, nausea and vomiting) is sometimes experienced by patients after taking aspirin, and for this reason the drug is best taken with or after food. When taken as soluble tablets, aspirin is less likely to cause gastric irritation and it is also available as an enteric-coated version which is designed so that the aspirin is released lower down the GI tract to try and prevent adverse effects. However, evidence indicates that enteric coating does not reduce the risk of aspirin- induced gastric bleeding (1). The pharmacist should also remember that enteric-coated preparations will not be released quickly and so they are inappropriate where rapid pain relief is required. The local use of aspirin, e.g. dissolving a soluble tablet near an aching tooth, is best avoided, since ulceration of the gums may result (1). C-Bleeding Aspirin can cause GI bleeding and should not be recommended for any patient who either currently has or has a history of peptic ulcer. Aspirin affects the platelets and 4 clotting function, so bleeding time is increased, and it has been suggested that it should not be recommended for pain after tooth extraction for this reason. The effects of anticoagulant drugs are potentiated by aspirin, so it should never be recommended for patients taking these drugs (1). D-Pregnancy Aspirin (as an analgesic) is best avoided in pregnancy (1). E-Hypersensitivity Hypersensitivity to aspirin occurs in some people; it has been estimated that 4% of asthmatic patients have this problem and aspirin should be avoided in any patient with a history of asthma. When such patients take aspirin, they may experience skin reactions (rashes and urticaria) or sometimes shortness of breath, bronchospasm and even asthma attacks (1). 3-NSAIDs Note: ibuprofen is OTC in UK (naproxen OTC in UK only for primary dysmenorrhea) while in USA ibuprofen and naproxen are OTC (1, 4, 6). Ibuprofen has analgesic, anti-inflammatory and antipyretic activity and causes less irritation and damage to the stomach than does aspirin. (Further reading 2) Indigestion NSAIDs can be irritating to the stomach, causing indigestion, nausea and diarrhoea, but less than aspirin. Gastric bleeding can also occur. For these reasons, it is best to advise patients to take NSAIDs with or after food, and they are best avoided in anyone with a peptic ulcer or a history of peptic ulcer. Elderly patients seem to be particularly prone to these effects (1). Hypersensitivity Cross sensitivity between aspirin and NSAIDs occurs, so it would be wise for the pharmacist not to recommend them for anyone with a previous sensitivity reaction to aspirin. Since asthmatic patients are more likely to have such a reaction, the use of NSAIDs in asthmatic patients should be with caution (1). Contraindications Sodium and water retention may be caused by NSAIDs and they are therefore best avoided in patients with congestive heart failure or renal impairment and during pregnancy, particularly during the third trimester. Breastfeeding mothers may safely take ibuprofen since it is excreted in only tiny amounts in breast milk (1). Caution NSAIDs is best avoided in aspirin-sensitive patients and should be used with caution in asthmatics. Adverse effects are more likely to occur in the elderly and paracetamol may be a better choice in these cases (1). 5 4-Codeine and Dihydrocodeine Codeine is a narcotic analgesic. It is commonly found in combination products with aspirin, paracetamol or both. Constipation is a possible side-effect and is more likely in elderly patients and others prone to constipation. Codeine can also cause drowsiness and respiratory depression, although this may be unlikely at OTC doses. Dihydrocodeine is related to codeine and has similar analgesic efficacy. Side effects include constipation and drowsiness. Like codeine, the drug may cause respiratory depression at high doses (1). 5-Caffeine Caffeine is included in some combination analgesic products to produce wakefulness and increased mental activity. A cup of tea or coffee would have the same action. Products containing caffeine are best avoided near bedtime because of their stimulant effect. It has been claimed that caffeine increases the effectiveness of analgesics but the evidence for such claims is not definitive (1). Topical analgesics There is a high placebo response to topical analgesic products. This is probably because the act of massaging the formulation into the affected area will increase blood flow and stimulate the nerves, leading to a reduction in the sensation of pain (1). Counterirritants and rubefacients Counterirritants and rubefacients cause vasodilatation, inducing a feeling of warmth over the area of application (1). (Further reading 3) A-Methyl salicylate Methyl salicylate is one of the most widely used and effective counterirritants (1). B-Menthol When applied to the skin in a topical analgesic formulation, menthol gives a feeling of coolness, followed by a sensation of warmth (1). C-Capsaicin/capsicum Capsicum preparations produce a feeling of warmth when applied to the skin. A small amount of Capsaicin needs to be rubbed well into the affected area. Patients should always wash their hands after use; otherwise they may transfer the substance to the eyes, causing burning and stinging (1). Topical anti-inflammatory agents Topical gels, creams and ointments containing NSAIDs are widely used. Ibuprofen, diclofenac , ketoprofen and piroxicam are available in a range of cream and gel formulations. Topical NSAIDs should not be used by patients who experience adverse reactions to aspirin, such as asthma, rhinitis or urticaria (1). 6 Because of the higher likelihood of aspirin sensitivity in patients with asthma, caution should be exercised when considering recommending a topical NSAID (1). Heparinoid and hyaluronidase Heparinoid and hyaluronidase are enzymes that may help to disperse oedematous fluid in swollen areas. A reduction in swelling and bruising may therefore be achieved. Products containing heparinoid or hyaluronidase are used in the treatment of bruises, strains and sprains (1). Glucosamine and chondroitin There is some evidence that glucosamine sulphate (which stimulates cartilage production) and chondroitin (which inhibits cartilage destruction) improve the symptoms of OA in the knee and that glucosamine may have a beneficial structural effect on joints (1). Practical points First-aid treatment of sprains and strains The injured limb should be rested to facilitate recovery. The acronym RICE is a useful aidememoire for the treatment of sprains and strains. R – Rest I – Ice/cooling C – Compression E – Elevation (1). The priority in treating sprains and soft-tissue injuries is to apply compression, cooling and elevation immediately, and this combination should be maintained for at least 48 h. The aim of the treatment is to prevent swelling. If swelling is not minimized, the resulting pain and pressure will limit movement, lead to muscle wasting, cause pain and delay recovery (1). (Further reading 4) Heat The application of heat can be effective in reducing pain. However, heat should never be applied immediately after an injury has occurred, because heat application at the acute stage will dilate blood vessels and increase blood flow into the affected area – the opposite effect to what is needed. After the acute phase is over (1 or 2 days after the injury), heat can be useful (1). Heat should be applied to the affected area in the form of a warm wet compress, heating pad, or hot water bottle (6). Prevention of recurrent back pain Good posture, lifting correctly, a good mattress and losing excess weight can help (1). Irritant effect of topical analgesics Preparations containing topical analgesics should always be kept well away from the eyes, mouth and mucous membranes and should not be applied to broken skin. Intense pain and irritant effects can occur following such contact. Sensitization to counterirritants can occur; if blistering or intense irritation of the skin results after application, the patient should discontinue use of the product (1). 7 References: 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 2-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 3-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4 th edition. 2017. 4-BNF-74 5-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010. 0 6-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 1-A common cause of arthritis is osteoarthritis (OA), which is due to wear and tear of the joint. This often affects the knees and hips, especially in the older population (1). Another form of arthritis is rheumatoid arthritis (RA), which is a more generalized illness caused by the body turning its defenses on itself (autoimmune disease). Other forms of arthritis can be caused by gout or infection. A joint infection is rare but serious and occasionally fatal (1). 2-The maximum daily dose allowable for OTC use of ibuprofen is 1200 mg and ibuprofen tablets or capsules should not be given to children under 12 years. Ibuprofen suspension 100 mg in 5 mL is available OTC (1). The OTC dose of naproxen in USA is 220 mg every 8-12 hours (maximum 660 mg) [ in case of patients over age 65 years: 220 mg every 12 hours (maximum 440 mg)] (6). 3-Counterirritants produce mild skin irritation, and the term rubefacient refers to the reddening and warming of the skin. The theory behind the use of topical analgesics 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. Simply rubbing or massaging the affected area produces sensations of warmth and pressure and can reduce pain (1). The mode of action of topical analgesics is therefore twofold: one effect relying on absorption of the agent through the skin, while the other on the benefit of the massage (1). 4-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 hemorrhage (1). Ice packs applied at least 3-4 times a day. Ice should not be applied for more than 15-20 minutes because excessive icing causes considerable vasoconstriction and reduces vascular clearance of inflammatory mediators from the damaged area (6). The area should be wrapped around with a cotton-wool pad and held in place with a crepe bandage. Once the injury has been protected and a compression bandage applied, an ice pack should be used. Its function is to produce vasoconstriction, thus preventing further blood flow into the injured area from the torn capillaries and, in turn, minimizing further bruising and swelling (1). The affected limb should be elevated to reduce blood flow into the damaged area by the effect of gravity. This will, in turn, reduce the amount of swelling caused by oedema. 8  Clinical Pharmacy. Fourth Year. Clinical Pharmacy. 2020-21. 1-Weight loss Background 1- Obesity is a growing epidemic, particularly in developed countries. As a consequence, the risk of diseases such as diabetes and cardiovascular disease are also increasing (1). 2-Although a number of measures of obesity have been proposed, the internationally accepted measure is the body mass index (BMI). This is calculated as weight (kg) divided by height squared (m2) (1). 3-A BMI of over 25 is classified as overweight and for obesity the value is 30 (1). 4-Although a number of causes of obesity have been proposed, and genetics may play an important role, for a significant proportion of the population it results from an imbalance between energy intake (food and beverages) and energy expenditure (exercise) (1). 5-In addition, certain medical conditions (e.g., hypothyroidism) and medicines (e.g., corticosteroids, beta-blockers, anticonvulsants) can cause weight gain (1). Table 1: Benefits of 5- to 10-kg weight loss (2). Condition Health benefit 20 25% fall in overall mortality. 1 Mortality 30 40% fall in diabetes-related deaths. 40 50% fall in obesity-related cancer deaths. 2 Blood pressure 10 mm Hg fall in diastolic and systolic pressures. Up to a 50% fall in fasting blood glucose. 3 Diabetes Reduces risk of developing diabetes by over 50% Fall of 10% Total Cholesterol, 15% LDL and 30% 4 Lipids triglycerides. Increase of 8% HDL. Significance of questions and answers A-Age and body mass index Orlistat 60 mg capsules are available OTC for individuals aged 18 and over with a BMI of 28 kg/m2 or greater, to be used in conjunction with a reduced calorie diet that is low in fat and with exercise (2). B-Previous medical history 1-Kidney disease, or renal stones, is a contraindication to orlistat. Patients with hypothyroidism on thyroxine should be referred if they wish to take orlistat as it can reduce control of the condition (2). 2-There is also an interaction with antiepileptic drugs so people on these will need to be referred to their doctor (2). C-Medication 1-The doses of some medicines may need to be adjusted if the patient loses weight. Weight loss is likely to lead to improvements in metabolic control in diabetes, to changes in cholesterol levels and to lower blood pressure in hypertension. Doses of diabetic, cholesterol lowering and antihypertensive medication may therefore need to be changed (2). 2-Other medicines where the patient needs to check with their physician before starting Orlistat are amiodarone, acarbose, ciclosporin and levothyroxine. There is an increased risk of convulsions when orlistat is given with antiepileptics (2). 3-Patients on warfarin or other oral anticoagulants should not be supplied with OTC orlistat. Orlistat may be prescribed by a doctor to those on these drugs with a requirement to monitor anticoagulant effects (2). 4-Patients on the combined oral contraceptive will need to use additional contraception if they develop severe diarrhea while taking orlistat (2). D-Current diet and physical activity 1-Patients need to adjust their diet so as to lose weight. They need to be on a low fat diet. Exploring current fat intake and helping the patient to assess the extent of the change needed is essential (2). 2-Regular physical activity is also a key to weight management, and the pharmacist needs to gauge the current amount of exercise taken (2). Treatment timescale If weight loss has not been achieved after 12 weeks, then the patient should stop taking Orlistat (1). Management 1-Orlistat inhibits pancreatic and gastric lipase, which reduces the absorption of fat from the gut (1). 2-OTC Orlistat is taken at a dose of 60 mg three times daily immediately before, during or up to 1 h after meals. If a meal is missed or does not contain fat, orlistat should not be taken (2). 3-While taking it, the patient s diet should be mildly hypocaloric and with approximately 30% of calories from fat (e.g. in a 1800 kcal/day diet, this equates to