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Clinical Pharmacy > Muscles, Ligaments and Tendons > Flashcards

Muscles, Ligaments and Tendons Flashcards

1
Q

What is contained within robaxacet?

A

acetaminophen and methocarbamol

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2
Q

What is contained in robaxisal?

A

ASA and methocarbamol

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3
Q

What is contained within robax platinum?

A

ibuprofen and methocarbamol

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4
Q

What products is chlorzoxazone in?

A
  • parafon forte, tylenol aches and strains and acetazone
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5
Q

What products is orphenadrine in?

A
  • solo or in combination - norflex (mainly over the counter)
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6
Q

What is methocarbamol?

A

central acting skeletal muscle relaxant , but does not work directly on the contractile mechanism of the striated muscle, motor endplate or nerve fiber

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7
Q

What is the MOA of methocarbamol?

A

unknown, but it is thought to cause skeletal muscle relaxation due to general CNS depression

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8
Q

What is methocarbamol used to treat?

A
  • used to treat acute, painful, musculoskeletal muscle spasms
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9
Q

What is the onset of action of methocarbamol?

A

12-24 hours

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10
Q

What is the MOA of orphenadrine?

A
  • works by mechanisms related to analgesic and anti-cholinergic properties Exact mechanism of action have not been determined
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11
Q

What is orphenadrine used to treat?

A
  • used to treat painful muscle spasm due to acute musculoskeletal conditions
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12
Q

What is the onset of orphenadrine?

A

24 hours

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13
Q

What is the mechanism of chlorzoxazone?

A
  • muscle relaxant due to its central acting properties
  • does not act directly on the muscles, but it works on the spinal cord and brain level to decrease skeletal muscle spasm, provide pain relief and increase mobility of the muscle
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14
Q

What is the main SE of chlorzoxazone?

A

hepatotoxicity

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15
Q

What is the onset of cholzoxazone?

A

within 12-24 hours

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16
Q

What are the main SE of methocarbamol?

A
  • drowsiness, dizziness, light headedness, headaches, urine discolouration (black, blue, green or brown)
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17
Q

What are the main SE of orphenadrine?

A

CNS SE, constipation, dry mouth and blurred vision

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18
Q

What are the main SE of chlorzoxazone?

A

CNS SE, urine discoloration (orange-red), impaired hepatic function

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19
Q

What are the main contraindications of skeletal muscle relaxants?

A
  • pregnancy, anticholinergic activity, narrow angle glaucoma, prostate hypertrophy, arrhythmias
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20
Q

What are the drug interactions associated with skeletal muscle relaxants?

A
  • other Ach agents, CNS depressants, MAO inhibitors, increase CNS AE, alcohol
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21
Q

What are the effects that topical analgesics exert?

A
  • analgesic effects (raise pain threshold at terminal nerve ending)
  • anesthetic (block pain receptors to numb the area)
  • antipruritic (relieve itching)
  • counterirritant effects (stimulate cutaneous sensory receptors)
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22
Q

What is an counterirritant?

A

a substance that is rubbed into the skin over a painful joint, tendon, ligament or muscle to relieve pain
- other agents are often needed as an adjuvant (oral analgesics, support bandages, rest, ice compression)

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23
Q

When are counterirritants of particular use?

A
  • for patients that cannot tolerate AE associated with other oral analgesics
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24
Q

What is the MOA of counterirritants?

A
  • paradoxical pain- relieving effect achieved by producing a less severe pain to counter a more intense one
  • produces mild, local inflammatory reaction. Does this by producing redness (methyl salicylate, turpentine oil, strong ammonia solution), by producing a rolling effect (camphor and menthol), by vasodilation (methyl nicotinate)
  • there can also be a placebo effect associated with a counterirritant (pleasant warmess, coolness or smell associated)
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25
Q

What causes the feeling of warmth in a topical agent?

A
  • methyl salicylate, capsaicin, trolamine salicylate
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26
Q

What causes the feeling of cold from an analgesic?

A
  • menthol or camphor
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27
Q

What is a “ no odour” product contain?

A
  • do not have wintergreen oil or camphor

- instead have trolamine salicylate

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28
Q

What are the pieces of precautionary advice that we should be giving about external analgesics?

A
  • external use only
  • do not apply to wounds
  • do not bandage
  • avoid contact with the eyes
  • not to be used in children less then 2
  • not to be used more than tid or qid
  • do not apply heat or other thermotherapy device concurrently with counterirritants
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29
Q

When should the use of methyl salicylate or trolamine salicylate be avoided?

A
  • should be avoided when taking anticoagulants
  • when allergic to salicylate
  • caution should be exercised for salicylate sensitive asthmatics
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30
Q

What are the clinical considerations of using an external analgesic?

A
  • lack scientific evidence
  • few studies suggest a high placebo component here (due to subjective nature of pain)
  • massaging aspect may be an important component of efficacy
  • desired effect local vs systemic
  • no rationale exists for combining the use of more than one counterirritant product
  • 7 days of use is reasonable length of time for most products, except capsaicin
  • topical analgesic does not alter the underlying process
  • may be helpful with symptomatic relief or distraction
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31
Q

What is the MOA of using capsaicin?

A
  • when applied produces a transient feeling of warmth, but diminishes with repeated applications (tachyphylaxis)
  • due to depletion of substance P (a chemical that allows the transmission of pain impulses) in sensory neurons
  • reduces pain but not inflammation
  • pain is usually relieved within 14 days, but occasionally delayed by 4-6 weeks
  • may be beneficial in OA pain, postherapeutic neuralgia and lower back pain
  • do not use on wounds or damaged skin
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32
Q

Anytime a pain signal happens, there is a release of the product known as ____

A

substance P - takes a long time to deplete the substance P

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33
Q

Capsaicin needs to be applied ______

A

3x a day (needs to do this to provide optimal pain relief and may cause initial burning sensation to persist)

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34
Q

Continued application for _____ is necessary for the optional response of capsaicin

A

3-4 weeks

35
Q

Capsaicin treatment should be discontinued in what cases?

A
  • if the condition worsens or does not improve after 28 days, and consult a physician
36
Q

How long can topical NSAIDs be used for?

A
  • can be used only for 7 days
37
Q

Trials have found what when comparing topical and oral NSAIDs?

A
  • in OA for example

- found that topical NSAIDs have similar pain relied properties compared to oral NSAIDs yet have less GI SE

38
Q

How is voltaren (diclofenac) used?

A
  • should be applied over the affected area 3-4 times daily (1.16%) and rubbed gently into the skin
  • the amount depends on the size of the painful area
  • after application, wash hands
  • for voltaren 2.32%, dosing is every 12 hours
39
Q

What is acute back pain?

A
  • pain lasting under 4 weeks
40
Q

What is sub-acute back pain?

A
  • 4-12 weeks
41
Q

What is chronic back pain?

A
  • over 12 weeks
42
Q

Describe acute low back pain?

A
  • often mechanical in nature

- resulting from a sprain or a strain of muscles or ligaments that support the lumbar spine

43
Q

What is the aetiology or acute low back pain?

A

repetitive or awkward use of lumbar muscles

  • improper technique in lifting heavy weight or bending
  • strenuous and unaccustomed work (gardening, decorating, painting or exercising)
  • improper posture
  • excessive muscle tension from psychological stress
  • improper shoes
44
Q

What are some of the other causes of low back pain?

A
  • inflammatory ot traumatic injuries to joints and ligaments
  • disc injury
  • neurological involvement
  • arthritis
  • malignancy and infection
45
Q

What ages are low back pain most prevalent in?

A

45-64 years of age

46
Q

Low back pain is benign in more than _____ of people

A

90%

47
Q

What are the symptoms of low back pain?

A
  • most acute lower back pain is mechanical in nature - pulled muscle, strain and ligaments
  • symptoms may range from muscle ache to spasm
  • involved low back, buttock, posterior thigh
48
Q

What are the main risk factors associated with experiencing lower back pain?

A
  • age
  • occupation
  • posture
  • height and weight
  • pregnancy
  • smoking
49
Q

What are the main red flags with lower back pain?

A
  • pain in the middle to upper part of the back
  • pain is present for several days (more than 5 days)
  • bladder or sexual dysfunction
  • fever/chills; vertebral tenderness
  • age over 50 or under 20
  • constant pain, nighttime pain, no relief with postural change (or increased/unrelieved with rest)
  • loss of movement or range of motion
  • unexplained weight loss
  • chronic liver disease, inflammatory arthritis, gout
  • weakness, numbness or tingling in legs
  • long term steroid use
  • history of malignant disease
  • high risk of fractures
  • no improvement to treatment after 1 month
  • sciatica, herniation, cauda equina syndrome, compression fracture
  • visceral pain (organs)
50
Q

What are the treatment goals for treating back pain?

A
  • symptomatic relief of pain and promotion of rapid recovery
  • improve the patients functional ability
  • decrease long term disability
  • prevent or minimize recurrences of back pain
  • prevent or minimize work absences
  • promote healthy behaviours (exercise/diet)
51
Q

What is the new treatment philosophy of treating back pain?

A
  • greater self reliance
  • return to activity ASAP
  • encouraging patients to think of the things they can still do
  • staying active
  • avoid de-conditioning and debilitation (muscle atrophy)
52
Q

What are the most common non-pharm measures of treating back pain?

A
  • cryotherapy (ice) - first 24-48 hours
  • thermotherapy
  • exercise
  • rest only is it is essential (1-3 days at most)
  • prolonged bed rest- potential to have debilitating effect
  • psychosocial management- improving coping skills- control/avoid anxiety or depression
53
Q

What is the role of skeletal muscle relaxant in acute lower back pain?

A
  • generally not recommended as a 1st line therapy
  • muscle relaxants are more effective than placebo but no more effective than placebo but no more better than NSAIDs in relieving acute LBP
  • may have a role as a sedative and/or analgesic agent
  • short term use is ideal (2-3 days)
  • beneficial effects of muscle relaxants last no longer than 4-7 days (max)
  • use for longer periods may lead to dependence issues
  • SEs inclue: drowsiness, dizziness have been reported in 30% of patients. At effects - - CI’s/avoid alcohol
  • most common agent methocarbamol
54
Q

What should be used for full doses for pain with inflammation?

A

NSAIDs - takes about 2-4 weeks to get full effect

55
Q

What are non-pharms for preventing pain?

A
  • follow a program emphasizing flexibility
  • aerobic conditioning/rehabilitation
  • proper posture
  • proper use of body mechanics
  • weight loss
  • ongoing education to prevent back pain
  • assist with strategies to minimize back pain
56
Q

In how many days should back pain improve in?

A
  • 7-10 days

- continue ordinary activities with in the limits permitted by pain

57
Q

What is the duration of self treatment of lower back pain?

A
  • generally most patients recover in a month’s time
58
Q

When should lower back pain be referred?

A
  • loss of motion or sensory function
  • increasing pain
  • loss of bladder and bowel function
  • failed treatment
  • any other red flags
59
Q

Use ice in the first _____ hours followed by heat

A

24-48 hours

60
Q

What is a contusion?

A
  • damage to the blood vessels in muscles followed by bleeding, bruising and sometimes clotting
61
Q

What is the purpose or tendons?

A
  • joins muscles to bones
  • under normal conditions the tendons have limited ability to stretch and twist
  • damage when extended or overused
62
Q

What is tendonitis?

A
  • due to chronic overuse of tendon (carpal tunnel syndrome)

- acute injuries

63
Q

What is tenosynovitis?

A
  • tendon is irritated and inflamed

- causes pain, swelling and sometimes a crackling sound when moving

64
Q

What is the purpose of a ligament?

A
  • joining bones to other bones to help form joints
65
Q

What is a first degree sprain?

A
  • excessive stretching
66
Q

What is a second degree sprain?

A
  • partial tear
67
Q

What is a third degree sprain?

A
  • complete teat of the tissue
68
Q

What is usually the cause of a sprain?

A
  • usually by joint being wretched or twisted
  • inversion of the ankle (turning inward at an extreme ankle)
  • tearing the anterior cruciate ligament of the knee during rotations or twisting motions
    • this is a common injury in sports such as basketball, etc
69
Q

What are the red flags of a sprain?

A
  • severe pain or weakness in a limb
  • visually deformed joint or abnormal joint movement
  • joint pain with systemic symptoms (fever)
  • suspected or obvious fracture
  • increased intensity of pain or any change in the character of pain
  • inability to bear any weight on the injured limb
  • pain lasting longer than 2 weeks
  • swelling continues over 14 days after PRICE therapy incorporated
70
Q

What are the treatment goals associated with treating muscle, ligament, tendon tears, etc?

A
  • minimize swelling and hasten healing
  • prevent long term disability
  • optimize patients ability to perform daily activities
  • minimize ADR and prevent drug-drug interactions
  • prevent re-injury
71
Q

What does PRICE stand for? What are the other non-pharms used for self treatment?

A
  • protection, rest, ice (for 20 minutes), compression (apply a compression bandage) and elevation (refer to MD or physio for advice and care if necessary)
  • thermotherapy
  • rehabilitation
72
Q

What should NOT be done during the first 24 to 48 hours after an injury?

A
  • no HEAT (increases bleeding)
  • no ALCOHOL (increases swelling)
  • no RUNNING
  • no MASSAGE (increases swelling and bleeding)
73
Q

What is the role of cryotherapy in the acute stage of injuries?

A
  • decreases metabolism and inflammation
  • slows nerve conduction velocity
  • vasoconstriction - leading to decreased deem and hemorrhage
  • excessive icing should be avoided because it can reduce vascular clearance of inflammatory mediators and cause further tissue damage
74
Q

What groups of people do we not want to recommend cryotherapy to?

A
  • cold induced urticaria and in those with raynauds syndrome
75
Q

What is the process of applying cryotherapy?

A
  • apply gel packs (cooled in the fridge, not the freezer)
  • wet towel or cloth placed between the skin and ice can facilitate transfer of cold to the skin and prevent frostbite
  • apply for 20 minutes or until the skin feels numb (whichever is shorter)
  • application of cryotherapy should continue until swelling decreases - 2 to 48 hours
76
Q

What does heat due in the sub-acute stage of injuries?

A
  • produces vasodilation
  • increase tissue perfusion of oxygen and nutrients
  • helps with the removal of CO2, metabolic waste products, and pain mediators
  • relaxes muscles and can decrease muscle spasm
77
Q

Heat can help to clear any ______ from the area

A

inflammatory mediators

78
Q

What are the different topical therapeutic options?

A
  • counterirritant
  • capsaicin
  • topical and NSAID analgesic
79
Q

What is the monitoring parameters associated with a grade 1 ankle injury?

A
  • IMPROVEMENT: swelling and discomfort should begin to subside in 48 hours - should be able to move the ankle
  • DOT: 7-10 days
  • REFERRAL: ankle is extremely painful, swelling and discolouration does not subside or worsen. Impossible to bear any weight on the affected leg
80
Q

After swelling subsides, ____ may be used to promote the healing process

A

heat

81
Q

What is recommended within 48 hours after the initial resting stage?

A

mobilization of the injured part is recommended to prevent scarring

82
Q

What is considered to be the first line therapy in OA?

A
  • acetaminophen (therefore there is no inflammation in this early stage)
83
Q

What are some of the non-charm tx of OA?

A
  • lifestyle changes: weight loss an diet
  • exercise (strength training and improve flexibility)
  • occupational or physiotherapy
  • reduce mechanical stresses/improve footwear
  • TENS
  • stress management
  • heat, cold tx
84
Q

What is the minimum single toxic dose of acetaminophen?

A
  • 7.5 - 10 g over an 8 hour period

Clinical Pharmacy (24 decks)

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