Chapter 7. Musculoskeletal Injuries and Disorders

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Handbook of Nonprescription Drugs > Chapter 7. Musculoskeletal Injuries and Disorders
Musculoskeletal Injuries and Disorders: Introduction
Pain is one of the most common symptoms to prompt a visit to a health care provider. Because pain is a common symptom of
disease or injury, patients often seek medical attention, although many seek to relieve the pain by self-treating with
nonprescription analgesics. Much of the pain for which people attempt self-treatment arises from the musculoskeletal system.
Musculoskeletal pain may be felt in the affected tissue itself or referred from another anatomic source (e.g., hip pain referred
from its primary source in the low back).1
Musculoskeletal pain arises from the muscles, bones, joints, and connective tissue. The development of musculoskeletal pain
can be acute, such as sport injuries (e.g., tendonitis, sprains, and strains), or it can stem from the exacerbation of a condition
(e.g., osteoarthritis). Acute pain is typically defined as pain lasting less than 4 weeks. Pain lasting at least 3 months is
considered chronic pain and may arise from degenerative joint disease, osteoarthritis, or chronic tendonitis (e.g., carpal tunnel).2
Use of nonprescription systemic and topical analgesics remains high, with more than $3,893 million and $516 million spent,
respectively, per year in the United States on such remedies.3 Ideally, a patient experiencing pain will ask a provider to assist in
selecting a nonprescription product. Providers need to communicate effectively to understand the types of pain for which
patients are seeking treatment to better understand the nature of their pain complaints. Providers must also be ready to offer
reasonable recommendations for either treatment or further evaluation.
Musculoskeletal complaints result in a significant amount of lost work days, work limitations, loss of employment, and increased
utilization of the health care system. These complaints are believed to be the greatest contributors to the economic burden of
chronic pain, costing state and federal agencies $100 billion annually. The total annual cost of persistent pain for adults in the
United States, both noninstitutionalized and nonmilitary personnel, is estimated to be between $560 and $635 billion dollars.4,5
More than 100 million adults in the United States battle chronic pain.5
Pathophysiology of Musculoskeletal Injuries and Disorders
The musculoskeletal system includes the muscles, tendons, ligaments, cartilage, and bones. Muscles are attached to bones by
tendons, and ligaments connect bone to bone. Tendons and ligaments normally have limited ability to stretch and twist. Because
of their tensile strength, tendons and ligaments rarely rupture unless subjected to intense forces, but they may become
damaged when hyperextended or overused. Synovial bursae are fluid-filled sacs located between joint spaces to provide
lubrication and cushioning. Cartilage functions as protective pads between bones in joints and in the vertebral column.6
Skeletal, or striated, muscle is composed of cells (myocytes) in which two constituents (actin and myosin) are primarily
responsible for contraction. Muscle contraction also involves several electrolytes within the muscle tissue, including calcium and
potassium. Pain receptors are located in skeletal muscle and the overlying fascia, and those receptors can be stimulated as a
result of overuse or injury to the muscle or surrounding structures.1,6
Somatic pain occurs when pain impulses are transmitted from peripheral nociceptors to the central nervous system (CNS) by
nerve fibers. Common sites of origin are muscles, fascia, and bones. Somatic pain is most commonly myofascial (e.g., muscle
strain) or musculoskeletal (e.g., arthritis).1 (See Chapter 5 for discussion of transduction, transmission, perception, and
modulation of pain.)
Mechanoreceptors and chemoreceptors mediate muscle pain. These nerve endings are heterogeneous: only a single chemical
can stimulate some endings, whereas a variety of chemical, mechanical, and thermal triggers can stimulate others.1,6
Erythema (redness), edema, and hyperalgesia (an exaggerated pain response to minor amounts of noxious stimuli5) at the
affected site characterize the inflammatory response, which develops through participation of multiple mediators, including
histamine, bradykinin, serotonin, leukotrienes, and prostaglandin E.1 Muscle injuries can be categorized as delayed-onset
muscle soreness (e.g., overexertion), myalgia, strains, tendonitis, bursitis, and sprains. Low back pain and osteoarthritis are
common conditions associated with musculoskeletal complaints. Overexertion or repeated unaccustomed eccentric muscle
contraction is associated with delayed-onset (8 hours or more) muscle soreness, which can last for days, usually peaking at
24-48 hours. This pain reflects muscle damage that was presumably initiated by force generated in the muscle fibers; the pain is
thought to be induced by inflammation, acidosis, muscle spasms, and/or microlesions. Prolonged tonic contraction produced by
exercise, tension, or poor posture and by body mechanics can also produce muscle pain. Overexertion is common in individuals
who do not exercise regularly but then begin an exercise regimen at a level of high intensity.
Myalgia, or muscle pain, can result from systemic infections (e.g., influenza, coxsackievirus, measles, and other illnesses),
chronic disorders (e.g., fibromyalgia and polymyalgia rheumatica), and medications (e.g., some cholesterol-lowering agents
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such as HMG-CoA reductase inhibitors). Abuse of alcohol may precipitate acute alcoholic myopathy. Bone and muscle pain
related to a vitamin D deficiency (osteomalacia) may also occur.1
Strains are a result of an injury to a muscle or a tendon. A strain can be caused by an acute injury, or with prolonged overuse, a
strain can become a chronic condition. The movements that cause a strain involve twisting or pulling. Tendons can become
strained when their stretch capacity is exceeded (e.g., hyperextension injury of an arm or leg). The strain injury is caused by
eccentric contraction of the muscle while the muscle is lengthening. A tear of the muscle or tendon can also occur.7
Tendonitis is the inflammation of a tendon, which results from acute injury or from chronic repetitive movements of a body part.
An example of an overuse injury is carpal tunnel syndrome, a condition characterized by tingling or numbness of the first digits
of the hand caused by repetitive use of the hands and wrists. Tendon sheaths become inflamed and constrict the median nerve
as it passes through a narrow channel between the wrist bones.6 Tendonitis can also commonly occur in the Achilles tendon,
which connects the calf muscle to the heel.
Common terms that describe sports-related tendonitis from overuse include tennis or golfers elbow, swimmers shoulder, and
jumpers knee. In sports-related overuse injuries, contributing factors for tendonitis can include increased age, poor technique,
improper conditioning, exercise of prolonged intensity or duration, and poorly designed equipment for specific activities (e.g.,
poor cushioning of athletic shoes).
Finally, certain medications (e.g., fluoroquinolone antimicrobials) are associated with the development of tendonitis or tendon
rupture and carry a boxed warning.8
Bursitis is a common cause of localized pain, tenderness, and swelling, which is worsened by any movement of the structure
adjacent to the bursa, in the joint. Bursitis generally results from an acute injury to the joint or over-repetitive joint action. When
pain is accompanied by the presence of a puncture site (possibly from intra-articular injection), an adjacent source of infection,
or severe inflammation, an infectious cause should be suspected and ruled out before recommending self-treatment.
Sprains are the most common problem with ligaments. Sprains are graded by their characteristics, with grade I sprains resulting
from excessive stretching, grade II sprains resulting from a partial tear, and grade III sprains involving a complete tear of the
tissue. Grade II and III sprains typically result in moderate-severe pain, loss of function of the affected limb, and an inability to
bear weight. Tears and ruptures are more common in ligaments than in tendons. Sprains commonly occur during physical
activity. Approximately 628,000 sprains occur annually in the United States.7
Low back pain is the fifth most likely reason for a physician visit; the lifetime prevalence of developing low back pain approaches
80%.6,9 The National Institute of Arthritis and Musculoskeletal and Skin Disease reports that 25% of people report at least 1 day
of back pain in a 3-month period.10
Main risk factors for the development of low back pain include sedentary lifestyle (particularly one disrupted by bursts of
activity), poor posture, improper shoes, excessive body weight, poor mattress and sleeping posture, and improper technique
when lifting heavy objects. Most patients recover within a few days to a few weeks, even without treatment; if pain persists for
more than 3 months, it is classified as chronic low back pain.2,11 Other causes of low back pain include congenital anomalies,
osteoarthritis, vertebral fractures and compressions, spinal tuberculosis, and referred pain from diseased kidneys, pancreas,
liver, or prostate.1
Osteoarthritis is characterized by a gradual softening and destruction of the cartilage between bones. Cartilage and bone are
destroyed in the joint spaces and regenerated, causing a rearrangement of the synovial architecture. Often referred to as
degenerative joint disease, osteoarthritis is caused by genetic, metabolic, and environmental factors. Heavy physical activity,
repetitive movement, and lifting of heavy weights may aggravate this condition, whereas light-moderate activity does not and is
generally helpful.12,13 Approximately 27 million people in the United States have a diagnosis of osteoarthritis; by 2030, that
number is expected to increase to 67 million.14
Clinical Presentation of Musculoskeletal Injuries and Disorders
Table 7-1 lists many of the presenting signs and symptoms of musculoskeletal disorders and also differentiates other factors.
Pain is a common symptom among all these disorders.
In addition to the pain induced by a sprain, patients have variable degrees of joint function. If a sprain patient has limited joint
function, the injury is most likely a grade II or grade III sprain that requires proper workup to rule out a fracture or tear. If a joint is
visibly deformed, it requires emergency assistance.
Patients with carpal tunnel syndrome often experience a diminished ability to feel heat or cold; a sense that their hands are
swollen, even when they are not; a weakness in the hands; and a tendency to drop things. Symptoms persist during sleep and
even when the hand is not being used, a characteristic that can be used to distinguish this disorder from others.
The pain of osteoarthritis does not correlate directly with the degree of joint damage. Pain is often referred, and proximal
muscles can be involved if a person with osteoarthritis guards the affected joint by changing his or her gait to reduce discomfort.
The pain caused by chronic osteoarthritis often limits the patients activities of daily living (ADLs) (e.g., inability to grip containers
or walk more than a short distance).
Low back pain can also be neuropathic in nature, involving the sciatic nerve, causing sharp referred pain into one or both of the
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patients legs. Low back pain can often limit a patients ability to bend, move, sit, or walk.
Complications of untreated pain-inducing injuries include further tissue damage and (in advanced arthritis) bone and cartilage
remodeling. Pain is associated with significant limitations, including a reduction in ADLs, disability, loss of work time, and
physical impairments (e.g., insomnia). Be sure to look for warning signs and symptoms that preclude self-treatment of such
disorders. (See exclusions for self-treatment in Figure 7-1.)
Treatment of Musculoskeletal Injuries and Disorders
Acute pain is the bodys alarm system; it signals injury by trauma, disease, muscle spasms, or inflammation. Chronic pain,
conversely, may or may not be indicative of injury and requires a primary care providers assessment before treatment is
initiated.
TABLE 7-1 Comparison of Musculoskeletal Disorders
Myalgia Tendonitis Bursitis Sprain Strain Osteoarthritis
Location
Muscles of the Tendon Inflammation of Stretching or tearing Hyperextension of a Weight-bearing joints,

body locations the bursae within of a ligament within muscle or tendon knees, hips, low back,
around joint joints; common a joint hands
areas locations include
knee, shoulder,
big toe
Signs
Possible Warmth, Warmth, edema, Swelling, bruising Swelling, bruising Noninflammatory

swelling (rare) swelling, erythema, and joints, narrowing of
erythema possible crepitus joint space,
restructuring of bone
and cartilage (resulting
in joint deformities),
possible joint swelling
Symptoms
Dull, constant Mild-severe Constant pain that Initial severe pain Initial severe pain Dull joint pain relieved
ache (sharp pain pain generally worsens with followed by pain, with continued pain by rest; joint stiffness
relatively rare); occurring after movement or particularly with joint upon movement <20-30 minutes;
weakness and use; loss of application of use; tenderness; and at rest; muscle localized symptoms to
fatigue of range of external pressure reduction in joint weakness; loss of joint; crepitus
muscles also motion over the joint stability and function some function
common
Onset
Varies Often gradual, Acute with injury; Acute with injury Acute with injury Insidious development
depending on but can recurs with over years
cause (i.e., develop precipitant use of
trauma = acute, suddenly joint
but drug-induced
= insidious)
Modifying Factors
Elimination of Elimination of Joint rest; RICE; stretching; RICE; stretching; Continuous exercise
cause; use of cause; use of immobilization; use of protective use of protective (light-moderate
stretching, rest, stretching, rest, topical analgesics; wraps (e.g., ankle wraps; topical activity); weight loss,
heat, topical ice, heat, systemic tape, knee brace, counterirritants; analgesic medication;
analgesics, topical analgesics cane); topical systemic analgesics topical pain relievers
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Myalgia Tendonitis Bursitis Sprain Strain Osteoarthritis
Location
systemic analgesics, counterirritants;

analgesics systemic systemic analgesics
analgesics
Key: RICE = rest, ice, compression, elevation (Table 7-2).
Treatment Goals
Treatment of the patient with musculoskeletal complaints encompasses many different goals, including (1) decreasing the
subjective intensity (severity) of pain; (2) decreasing the duration of pain, when possible; (3) restoring function of the affected
area; (4) preventing re-injury and disability (i.e., improve ADLs); and (5) preventing acute pain from becoming chronic
persistent pain.
General Treatment Approach
Patients with musculoskeletal injuries present with common symptoms (especially pain and swelling of the affected area) and
have similar self-treatment approaches. Nonpharmacologic therapy consisting of rest, ice, compression, and elevation (RICE)
along with nonprescription oral analgesics and/or topical analgesics during the first 1-3 days following injury is helpful.7 Before
treatment can be recommended, however, the patient should be carefully screened to ensure appropriateness of self-treatment.
The algorithm in Figure 7-1 presents a stepwise approach to self-management of pain for patients who are not excluded for
self-care.
Patients with acute low back pain are candidates for self-treatment. Management of acute back pain includes rest for 1-2 days
and nonprescription oral or topical analgesics. Chronic low back pain requires medical evaluation before initiating therapy.15
Pain associated with osteoarthritis is approved for self-treatment after an initial medical diagnosis. The general treatment
approach includes appropriate lifestyle changes (including physical activity and weight loss) and use of an analgesic, which may
be a nonprescription medication.13
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Self-care of musculoskeletal injuries and disorders. Key: ADR = Adverse drug reaction; FDA = Food and Drug Administration; OTC =
over-the-counter; RICE = rest, ice, compression, elevation. (Source: Adapted from Self-care of self-limited pain. In: Albrant DH, ed. The
American Pharmaceutical Association Drug Treatment Protocols. 2nd ed. Washington, DC: American Pharmaceutical Association;
2001:424-5.)
Nonpharmacologic Therapy
Injury from playing sports or exercising can be prevented by warming up and stretching muscles before physical activity,
ensuring proper hydration, and wearing appropriate footwear. Stretching must be done cautiouslywithout bouncingto avoid
muscle strain. For muscle cramps, stretching and massaging the affected area followed by immediate rest will loosen the
muscle. For electrolyte depletion, oral supplementation of wasted electrolytes is appropriate, including fluids containing
potassium, sodium, and magnesium (e.g., sports drinks or enhanced waters).
RICE therapy promotes healing and helps reduce swelling and inflammation associated with muscle and joint injuries
(Table 7-2). 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. Ice therapy can also be
recommended for patients with osteoarthritis experiencing pain and/or swelling.13,16 Both ice and heat, at temperatures outside
the skins threshold for tolerance, can be damaging and can result in blistering or burning; therefore, neither therapy should be
applied directly to the skin.
TABLE 7-2 Guidelines for RICE Therapy
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Rest the injured area and continue until pain is reduced (generally 1-2 days). Slings, splints, or crutches can be used, if
necessary.
As soon as possible, apply ice to the injured area in 15- to 20-minute increments, at least 3-4 times a day. Continue the
ice-pack therapy until swelling subsides (usually 1-3 days, depending on the severity of injury).
Apply compression to the injured area with an elastic support or an elasticized bandage as follows:
- Choose the appropriate size bandage for the injured body part. If preferred, purchase a product specifically designed for the
injured body part.
- If ice is also being applied to the injured area, soak the bandage in water to aid the transfer of cold.
- Wrap the injured area by overlapping the previous layer of bandage by about one-third to one-half its width.
- Wrap the point most distal from the injury (e.g., if the ankle is injured, begin wrapping just above the toes).
- Decrease the tightness of the bandage as you continue to wrap. If the bandage feels tight or uncomfortable, or if circulation
is impaired, remove the compression bandage and rewrap it. Cold toes or swollen fingers indicate that the bandage is too
tight.
- After using the bandage, wash it in lukewarm, soapy water; do not scrub it. Rinse the bandage thoroughly and allow to air
dry on a flat surface.
- Roll up the bandage to prevent wrinkles, and store it in a cool, dry place. Do not iron the bandage to remove wrinkles.
Elevate the injured area at or above the level of the heart 2-3 hours a day to decrease swelling and relieve pain.
Key: RICE = Rest, ice, compression, elevation.
Heat therapy is an alternative for patients who develop pain of a noninflammatory nature. It has been studied in the treatment of
acute low back pain with favorable effects.9,15 In addition, osteoarthritis guidelines recommend heat as adjunct
nonpharmacological treatment for pain and stiffness.13,16 Although its mechanism of action is not fully understood, heat may
alleviate pain by increasing blood flow, reducing muscle spasm, and improving stiffness. Heat should be applied for 15-20
minutes, 3-4 times a day. Heat should not be applied to inflamed areas because it can intensify vasodilation and exacerbate
vascular leakage.17 Furthermore, heat should not be used with topical analgesics or over broken skin.
Heat should be applied to the affected area in the form of a warm wet compress, heating pad, or hot-water bottle. Ease of use
favors newer, heat-generating adhesive and wrap products (e.g., ThermaCare, Precise, and various generic brands), which can
be worn on the affected area up to 8 hours (some products can be used for 12 hours). The products come in various shapes,
including back, hip, neck, knee, wrist and hand, shoulder, elbow, and lower abdomen. For nonadhesive products, the darker
side of the heat cells should be placed toward the skin.
The adhesive products should be applied on dry skin that is free of lotion. There are product exceptions to this that have unique
directions (e.g., ThermaCare menstrual product, BodiHeat), such as placing the adhesive side on the undergarment or clothing.
Heating devices should not be used on areas of skin with decreased sensation, a practice that can lead to a skin burn.
Specifically, ThermaCare heat-generating products should not be placed on the back of the knee or inside the bend of the
arm.18
Although not generally associated with many side effects, at least two brands of heat-generating patches have been recalled for
causing burns along with skin irritation.19,20 Patients should be advised to remove the patch immediately if they have any pain
or discomfort, itching, or burning. Heat wraps should be worn over a towel or layer of clothing in patients older than 55 years;
heat wraps should not be used during sleep.
Limited scientific information is available regarding contrast therapy (alternating heat and ice) to aid in sports injury recovery.
Anecdotally, some individuals report relief, but insufficient scientific evidence exists to recommend this therapy.21,22
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Transcutaneous electrical nerve stimulation (TENS) therapy is used widely by various practitioners (e.g., physical therapists,
physicians, and chiropractors) in the treatment of pain. FDA has approved TENS therapy for nonprescription use as a class II
medical device for the relief of pain associated with sore, aching muscles; joint pain; or chronic intractable pain.23-25 Pain relief
is thought to come from two mechanisms: alteration of pain transmission and an increase in the production of natural
endorphins. A TENS device is typically used for an interval of 15-30 minutes up to 3 times daily. The electrode pads can be
placed on various areas of the body for pain relief (e.g., back, legs, ankles, arms, and shoulders), but placement is product
dependent. Because of safety concerns patients should avoid placing the electrodes on the throat, chest, or head or over the
carotid arteries. The electrodes also should not be placed on open wounds, rashes, inflamed skin, cancerous lesions, or areas
of skin with altered sensation, or over topical analgesics. Patients with internal or attached medical devices (e.g., pacemakers,
defibrillators, electrocardiograms, and respirators); pregnant patients; and the pediatric population should not use
nonprescription TENS devices.24,25 The directions for proper and safe use of these devices are product specific, so the health
care provider should review the directions with the patient.
Proper posture and the use of ergonomic controls (e.g., a chair with back support or an ergonomic keyboard) improve function
and reduce pain. Heel lifts and better-fitting shoes are recommended for patients with Achilles tendonitis or low back pain.
Approaches to chronic low back pain also include therapeutic interventions such as heat therapy, massage with traction, and,
most important, mobilization with exercise or physical therapy. Chiropractic manipulation and acupuncture are also commonly
used for the treatment of back pain.15
Pharmacologic Therapy
Systemic Analgesics
NSAIDs and acetaminophen are commonly used nonprescription analgesics; they are often employed in the initial treatment of
musculoskeletal injuries. Systemic analgesic therapy should be limited to 10 days of self-care use,26 and patients should seek
appropriate medical care if the condition continues beyond this period or worsens during the course of treatment. (See
Chapter 5 for dosages, safety, and properties of nonprescription systemic analgesics.)
For the treatment of osteoarthritis of the hip and knee, acetaminophen (rather than NSAIDs) has been recommended historically
by some organizations as first-line therapy, despite data suggesting that NSAIDs provide slightly improved pain relief.12,27 This
initial treatment recommendation is made on the basis of drug safety rather than efficacy. Chronic use of NSAIDs leads to more
severe and prevalent side effects (e.g., nephropathy, gastrointestinal ulcerations and bleeding, and the potential for cardiac
events). Recent recommendations published by the American College of Rheumatology (ACR), however, include both
acetaminophen and NSAIDs among their initial therapy options. They recommend that if NSAIDs are used chronically for the
management of osteoarthritis, a proton-pump inhibitor should be considered for gastrointestinal protection. See Chapter 13 for
further information on risks of long-term use of proton-pump inhibitors. The ACR guidelines do express a strong
recommendation to consider using topical NSAIDS rather than systemic NSAIDs in patients 75 years of age and older.13
Topical Products
Topical analgesics may have local analgesic, anesthetic, antipruritic, and/or counterirritant effects. Nonprescription topical
analgesics are approved specifically for the topical treatment of minor-moderate aches and pains of muscles and joints (e.g.,
simple backache, arthritis pain, strains, bruises, and sprains).28 They are recommended as adjuncts to pharmacologic and
nonpharmacologic therapy of musculoskeletal injuries and disorders.
Counterirritants
Topical counterirritants are applied to the skin to relieve pain.28,29 Counterirritation is the paradoxical pain-relieving effect
achieved by producing a less severe pain to counter a more intense one. The pain relief results more from nerve stimulation
than depression.28,29 When applied to the skin at pain sites, counterirritants produce a mild, local inflammatory reaction, which
provides relief to the site underlying the skin surface being treated. These induced sensations distract from the deep-seated
pain in muscles, joints, and tendons. Pain is only as intense as it is perceived to be, and the perception of other sensations
caused by the counterirritant or its application (e.g., massage, warmth, or redness) causes the sufferer to disregard the
sensation of pain.29 On the basis of their topical effects, counterirritants are classified into four types (Table 7-3). Table 7-4 lists
examples of commercially available products.
All regulations and labeling for topical counterirritants are based on the detailed previous proposed rulemaking documents
published in the Federal Register in 1979 and 1983.28,30 FDA has recognized the ingredients in Table 7-3 as safe and effective
(Category I) counterirritants for use in adults and in children ages 2 years and older.30 Note that many topical nonprescription
analgesic products have age limits older than 2 years.
Labels for most counterirritants indicate that the product is to be used for the temporary relief of minor-moderate aches and
sprains of muscles and joints. In addition, the labeling recommended by most of FDAs review panels includes claims for
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simple backache, arthritis pain, strains, bruises, and sprains.30 In September 2012, FDA issued a Drug Safety Communication
about serious burns associated with nonprescription topical counterirritants. Forty-three case reports of chemical burns were
identified in FDAs Adverse Event Reporting System (AERS) database and medical literature. Most of the second- and third-
degree burn cases were associated with topical counterirritant products with higher concentrations of menthol as the single
ingredient or with a combination product containing greater than 3% menthol and 10% methyl salicylate. In many of the case
reports, the reactions occurred with only one application, and the resulting injury occurred within 24 hours.31,32 FDA
recommendations for users of nonprescription topical analgesic products are presented in Table 7-5. In the consumer version of
the communication, FDA states that, although a feeling of warmth or coolness is normal with topical counterirritant use, patients
should seek medical attention if burning pain or blistering occurs.32
Table 7-3 provides dosing information for the various counterirritants.
The following sections describe the commonly used counterirritants currently available in the United States.
Methyl Salicylate. Methyl salicylate occurs naturally as wintergreen oil or sweet birch oil; gaultheria oil, teaberry oil, and
mountain tea are other names for the compound. Methyl salicylate is usually combined with other ingredients (e.g., menthol
and/or camphor).
TABLE 7-3 Classification and Dosage Guidelinesa for Nonprescription Counterirritant External Analgesics
Concentration
Group Ingredients Mechanism of Action Frequency and Duration of Use
(%)
A Allyl 0.5-5.0 Rubefacients (increase blood For all counterirritants: Apply no more than
isothiocyanate 1.0-2.5 flow) 3-4 times/day for up to 7 days
Ammonia water 10-60
Methyl salicylate 6-50
Turpentine oil
B Camphor 3-11 Produce cooling sensation As above in group A

Menthol 1.25-16.0
C Histamine 0.025-0.1 Cause vasodilation As above in group A

dihydrochloride
Methyl nicotinate 0.25-1.0
D Capsicum 0.025-0.25 Incite irritation without For acute pain: As above in group A;
Capsicum 0.025-0.25 rubefaction; are as potent as For chronic pain: Apply 3-4 times/day for
oleoresin group A ingredients duration of pain (often long-term use with
medical supervision)
Capsaicin 0.025-0.25
a Dosages approved for adults and for children 2 years and older.
Source: Reference 28.

TABLE 7-4 Selected External Analgesic Products
Trade Name Primary Ingredients
Menthol-Containing Products
Aspercreme Heat Pain Relieving Gel Menthol 10%
Bengay Ultra Strength Pain Relieving Patch Menthol 5%
Icy Hot No Mess Applicator Menthol 16%
Mineral Ice Menthol 2%
Camphor-Containing Products
JointFlex Pain Relieving Cream Camphor 3.1%
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Trade Name Primary Ingredients
Menthol-Containing Products
Capsaicin-Containing Products
Capzasin Arthritis Pain Relief No-Mess Applicator Capsaicin 0.15%
Capzasin-HP Arthritis Pain Relief Cream Capsaicin 0.1%
Zostrix Hot and Cold Therapy Capsaicin 0.025%
Zostrix-HP Arthritis Pain Relief Cream Capsaicin 0.075%
Histamine Dihydrochloride-Containing Products
Australian Dream Pain Relieving Arthritis Cream Histamine dihydrochloride 0.025%
Trolamine Salicylate-Containing Products
Aspercreme Cream/Lotion Trolamine salicylate 10%
Sportscreme Deep Penetrating Pain Relieving Rub Cream Trolamine salicylate 10%
Combination Products
ActivOn Topical Analgesic Ultra Strength Arthritis Histamine dihydrochloride 0.025%; menthol 4.127%
Arthritis Hot Cream Methyl salicylate 15%; menthol 10%
Bengay Ultra Strength Pain Relieving Cream Methyl salicylate 30%; menthol 10%; camphor 4%
Flexall Ultra Plus Relieving Gel Menthol 16%; methyl salicylate 10%; camphor 3.1%
Icy Hot Cream Extra Strength/Precise Pain Relieving Cream Methyl salicylate 30%; menthol 10%
Mentholatum Ointment Camphor 9%; natural menthol 1.3%
Mentholatum Deep Heating Extra-Strength Pain Relieving Rub Methyl salicylate 30%; menthol 8%
Cream
Salonpas Pain Relief Patch Methyl salicylate 10%; menthol 3%
Sloans Liniment Turpentine oil 47%; capsaicin 0.025% (from capsicum

oleoresin)
Tiger Balm Arthritis Rub Cream Camphor 11%; menthol 11%
TABLE 7-5 FDA Recommendations for Application of Nonprescription Topical Analgesic Products
If pain, swelling, or blistering of the skin occurs after application of a topical analgesic, patients should immediately
discontinue use of the product and seek medical attention.
Do not bandage the area tightly where the product has been applied.
Do not use any heat where the product has been applied.
Do not apply to wounded, damaged, broken, or irritated skin.
Do not allow these medications to come in contact with the eyes, or inside the nose, mouth, or genitals.
Source: References 31 and 32.
As a rubefacient, methyl salicylate causes vasodilation of cutaneous vasculature, thereby producing reactive hyperemia. This
increase in blood pooling and/or flow is hypothesized to be accompanied by an increase in localized skin temperature, which in
turn may exert a counterirritant effect. Because of its rubefacient action, methyl salicylate is responsible for the hot action in
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many topical counterirritant products.29

In addition to the mechanisms described previously, topically applied methyl salicylate products inhibit both central and
peripheral prostaglandin synthesis. Studies on the rate and extent of percutaneous absorption of various commercially available
methyl salicylate preparations show direct tissue penetration rather than redistribution by the systemic blood supply, indicating a
localized effect of the topical product.29
Localized reactions (e.g., skin irritation or rash) and systemic reactions (e.g., salicylate toxicity) may occur with the use of methyl
salicylate. Strong irritation may cause local reactions such as erythema, blistering, neurotoxicity, or thermal hyperalgesia. In
addition, heat exposure and exercise after applying methyl salicylate have been shown to cause a threefold increase in systemic
absorption of salicylate, which can lead to increases in adverse systemic reactions.33Table 7-5 reviews appropriate precautions
to take when using topical analgesics. Because percutaneous absorption of salicylate can occur, methyl salicylate should be
avoided in children and used with caution in individuals who are sensitive to aspirin. Concomitant use of salicylate-containing
topical analgesics and maintenance warfarin therapy has been implicated in prolonging prothrombin time.29 Chapter 5 describes
other potential drug interactions related to systemically absorbed salicylates.
The report of the American Association of Poison Control Centers documents 10,000 encounters of methyl salicylate exposure
in children ages 6 years and younger.34 In children of that age, just a teaspoon of wintergreen oil can cause death.34 Although
an FDA survey found that oral ingestion of methyl salicylate in ointment form caused no deaths and that few cases manifested
severe symptoms,28 regulations require the use of child-resistant containers for liquid preparations containing concentrations
greater than 5%.
Camphor. Although camphor occurs naturally and is obtained from the camphor tree, approximately three-fourths of the
camphor used is prepared synthetically.
In concentrations of 0.1%-3.0%, camphor depresses cutaneous receptors and is used as a topical analgesic, anesthetic, and
antipruritic. In concentrations exceeding 3%, particularly when combined with other counterirritant ingredients, camphor
stimulates the nerve endings in the skin and induces relief of pain and discomfort by masking moderate-severe deeper visceral
pain, with a milder pain arising from the skin at the level of innervation. When applied vigorously, it produces a rubefacient
reaction.
Concentrations higher than those recommended are not more effective and can cause more serious adverse reactions if
accidentally ingested.30 The risk of toxicity relates to both the concentration of camphor in the ingested product and the extent of
absorption of camphor into the body. CNS toxicity, expressed primarily as tonic-clonic seizures, is the major toxicity and begins
to occur as early as 10 minutes following ingestion. High doses of camphor can cause nausea, vomiting, colic, headache,
dizziness, delirium, convulsion, coma, and death.
Case reports of camphor toxicities in children continue.35,36 In 2009, the American Academy of Pediatrics Committee on Drugs
reaffirmed their statement on camphor, noting that although nonprescription camphor-containing preparations cannot exceed
concentrations of 11%, camphor toxicity continues. The academy advised parents to be aware of this potential danger and
recommended use of modalities that do not contain camphor.37
Menthol. Menthol is either prepared synthetically or extracted from peppermint oil (which contains a 30%-50% concentration of
menthol). Menthol may be used safely in small quantities as a flavoring agent and has found wide acceptance in candy, chewing
gum, cigarettes, cough drops, toothpaste, nasal sprays, and liqueurs. It is also used as a permeability enhancer to increase
absorption of other topically administered medications.38
At concentrations less than 1%, menthol depresses cutaneous receptor response (i.e., acts as an anesthetic); at concentrations
greater than 1.25%, menthol stimulates cutaneous receptor response (i.e., acts as a counterirritant).
Recent studies have led to the identification of heat- and cold-sensitive receptors within sensory neurons called transient
receptor potential (TRP) cation channels. Topically applied menthol activates the TRPM8 menthol receptor, triggering the
sensation of cold.38 The resultant cold sensation travels along pathways similar to the somatic pain sensations from the affected
muscle or joint, which distracts from the sensation of pain. The initial feeling of coolness is soon followed by a sensation of
warmth.
Menthol is contraindicated in patients with hypersensitivity or sensitization to the agent (e.g., urticaria, erythema, and other
cutaneous lesions).38 Treatment should be discontinued if the patient develops irritation, rash, burning, stinging, swelling, or
infection.
Methyl Nicotinate. Although nicotinic acid is inactive topically, methyl nicotinate readily penetrates the cutaneous barrier.
Vasodilation and elevation of skin temperature result from very low concentrations, with higher penetration rates seen with
hydrophilic mediums (i.e., gels). One study showed that indomethacin, ibuprofen, and aspirin significantly depress the skins
vascular response to methyl nicotinate. Because these three drugs suppress prostaglandin biosynthesis, the vasodilator
response to methyl nicotinate is mediated, at least in part, by prostaglandin biosynthesis.39
Generalized vascular dilation can occur when methyl nicotinate passes through the skin into the circulatory system. Therefore,
persons who apply methyl nicotinate over large areas may experience a drop in blood pressure, a decrease in pulse rate, and
syncope caused by generalized vascular dilation.27
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Capsicum Preparations. Capsicum preparations (capsaicin, capsicum, and capsicum oleoresin) are derived from the fruit of
various species of plants of the nightshade family. Capsicum contains about 1.5% of an irritating oleoresin, the major component
of which is capsaicin (0.02%). Capsaicin is the major pungent ingredient of hot (chili) peppers.
When applied to normal skin, capsaicin elicits a transient feeling of warmth through stimulation of the TRPV1 receptor. The
mechanism of action is thought to be directly related to capsaicins effects on the depletion of substance P. This substance is
found in slow-conducting, unmyelinated type C neurons that innervate the dermis and epidermis. It is released in the skin in
response to endogenous (e.g., stress) and exogenous (e.g., trauma or injury) factors. It appears that pruritic stimuli along with
pain impulses are conveyed to central processing centers by type C fibers in the skin, for which capsaicin has selective activity.
Local application of capsaicin to the peripheral axon appears to deplete substance P from sensory neurons. The depletion
occurs both peripherally and centrally, presumably as the result of impulse initiation. When substance P is released, burning
pain occurs but abates with repeated applications. The diminishing sensation experienced with repeated applications can lead
to adherence-related failures; health care providers should inform their patients about such effects and the importance of
continuing therapy.40
Capsaicin has additional indications in comparison to other counterirritants. Capsaicin is used to reduce the painbut not the
inflammationof rheumatoid arthritis and osteoarthritis; it is also used in a wide variety of other pain disorders (e.g.,
postherpetic neuralgia, psoriasis, and diabetic neuropathy).
The optimal dose of capsaicin varies among patients. The efficacy of capsaicin decreases (and local discomfort increases)
when capsaicin is applied less often than directed because the drugs duration of action is 4-6 hours. Pain relief is usually noted
within 14 days after therapy has begun, but relief will occasionally be delayed by as much as 4-6 weeks.
Once topical nonprescription capsaicin has begun to relieve pain, its use must continue regularly 3 or 4 times a day. If capsaicin
treatment is stopped and the pain returns, treatment can be resumed. Capsaicin may produce a sensation of burning or stinging
pain. However, as a result of tachyphylaxis, this local effect diminishes in intensity with repeated applications, typically within a
few days but as long as 1-2 weeks.40-42 To reduce the likelihood of capsaicin reaching topically sensitive areas (e.g., mucous
membranes), patients should be instructed to use a glove for application and to wash their hands following use.40 If the hands
are the site of application, the patient should wait 30 minutes after application and then wash his or her hands. During use,
capsaicin should not come in contact with the eyes or other sensitive areas of the body, as it will cause a burning sensation.40
Capsaicin is available in a roll-on applicator or patch formulation, which may be preferred by some patients because of their
ease of application. Patients using such formulations should still be instructed to wash their hands after handling the product.
Use in patients with hypersensitivity to capsaicin is contraindicated. The agent should be discontinued temporarily if skin breaks
down (i.e., skin is weeping and red; small ulcers are present), and the agent should not be applied to wounds or damaged skin.
In addition to skin reactions, capsaicin has also been associated with a cough, runny nose, or sneezing if particles are inhaled.40
Overdose with use of capsaicin has not been reported, but more serious and intense side effects are reported with higher
concentrations.43
Capsaicin is also available in a prescription patch formulation (Qutenza 8%) approved for the treatment of postherpetic
neuralgia.43
Additional Counterirritants
Allyl isothiocyanate, ammonia water, turpentine oil, and histamine dihydrochloride are also classified as Category I
counterirritants by FDA, but few counterirritant preparations contain those ingredients. Most products that contain them also
contain other topical analgesics, making any beneficial action or side effects of the products indistinguishable from other
ingredients. In addition, very little evidence supports the efficacy of such compounds. Allyl isothiocyanate, ammonia water, and
turpentine oil are rubefacients, so they should be expected to have effects similar to those of methyl salicylate. However,
histamine dihydrochloride causes vasodilation, similar to the action of methyl nicotinate.
Pharmacotherapeutic Efficacy and Recommendations for Counterirritants
Literature regarding the efficacy of counterirritants is conflicting; given their age, in some instances, current studies are lacking.
However, Cochrane reviews evaluating the use of counterirritants in specific conditions and current guidelines for osteoarthritis
provide some guidance on their use.
A 2009 Cochrane review reports that topical rubefacients (those specifically containing salicylates) are not supported by enough
evidence to be recommended for use in acute or chronic pain. The authors noted that studies in assessing acute pain were
limited; however, the studies included showed a 50% pain reduction in 1 in 3 patients treated after 1 week and a 50% pain
reduction for 1 in 6 patients treated after 2 weeks. For chronic pain, however, the study concluded that topical rubefacients
compare poorly with topical NSAIDs.44
After the Cochrane review, one study evaluated the use of a nonprescription combination methyl salicylate and menthol patch
for the treatment of mild-moderate muscle strain; the results showed that pain relief was approximately 40% better in those
using the 8-hour patch versus placebo.45 These patches (Salonpas Pain Relief Patch and Salonpas Arthritis Pain Patch) are the
only nonprescription analgesic patches to undergo FDA approval of a New Drug Application, which was granted in 2009.
Conflicting recommendations exist with capsaicin. An updated Cochrane Review in 2012 focused on reevaluating low
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concentration (<1%) capsaicin products for the treatment of chronic neuropathic pain. This review was conducted because the
authors believed the 2009 conclusion might have been biased and ultimately may have overestimated capsaicins efficacy. They
utilized a stricter approach to the evaluation of evidence for inclusion in the updated review. The 2012 review states that there is
insufficient evidence to make a conclusion about low-dose capsaicin in treating neuropathic pain but that it unlikely has any
meaningful effect.42
The National Institute for Health and Clinical Excellence guidelines for osteoarthritis do not support the use of rubefacients, with
the exception of capsaicin.16,46 The 2012 ACR guidelines for the management of osteoarthritis conditionally recommend topical
capsaicin as an initial option for the hand. The guidelines also conditionally recommend that capsaicin should not be used in the
management of osteoarthritis of the knee. They do not make any recommendations regarding nonprescription topical analgesics
in the management of osteoarthritis of the hip.13
Other Topical Analgesics
Trolamine Salicylate
Trolamine salicylate is a category III ingredient (insufficient data are available to establish safety and efficacy). Despite this
designation, several nonprescription products contain trolamine salicylate as the primary ingredient (Table 7-4).
Trolamine salicylate, or triethanolamine salicylate, is not a counterirritant analgesic. It has been suggested that trolamine
salicylate is absorbed through the skin and results in synovial fluid salicylate concentrations below those of oral aspirin. The
recommended topical dosage of trolamine salicylate for adults and for children 2 years and older is a 10%-15% concentration
applied to the affected area not more than 3 or 4 times a day. There are no recent studies published regarding the efficacy of
topical trolamine salicylate.
Trolamine salicylate is still available over the counter and may be most useful to those patients who do not favor the localized
irritation or the scent of Category I counterirritants. ACR guidelines conditionally recommend trolamine salicylate as an option for
osteoarthritis of the hand.13
Trolamine salicylate has the same drug interactions and contraindications as other salicylates (see Chapter 5). During use, the
agent should not contact the eyes or mucous membranes.
Topical NSAIDs
Traditional topical NSAIDs are not currently available for nonprescription use in the United States, but they are available for
prescription use (e.g., diclofenac). Their application on acute soft tissue strains and sprains, where the target tissue is situated
closer to the skin surface, is reported to provide the benefits of oral NSAIDs with minimal systemic side effects. A 2010
Cochrane review recognizes the effectiveness of topical NSAIDs to treat acute musculoskeletal pain,47 and a 2012 Cochrane
review supports their use in the management of chronic pain from osteoarthritis.48 Several guidelines recommend topical
NSAIDs to be considered early in treatment for osteoarthritis.13,16,27
Combination Products
General guidelines for nonprescription drug combination products state that Category I active ingredients from the same
therapeutic category should not ordinarily be combined, unless the combination is deemed safer or more effective and has
enhanced patient acceptance or quality of formulation.30 Four separate chemical and/or pharmacologic groups of
counterirritants provide four qualitatively different types of irritation. Many marketed preparations aim for at least two such
effects when greater potency is desired, provided that each active ingredient is from a different group.
Combining counterirritants with skin protectants is irrational; the protectants oppose and may nullify counterirritant effects.
Preparation labels must list the active ingredients, including their concentrations, and must identify them by their officially
recognized, established names. In addition, manufacturers voluntarily list ingredients on the label. Many manufacturers of
combination products list only some of the active ingredients under the active heading, and they list many of the other
pharmacologically viable products in the inactive ingredients section (e.g., BenGay Vanishing Scent Gel lists camphor and
Aspercreme Heat Pain Relieving Gel lists capsaicin under inactive ingredients). Although the concentrations of inactive
ingredients are not listed, they are generally below therapeutically determined amounts and are added for reasons other than
pain-relieving effects. The manner of use and the frequency of applications should also be indicated.28
Product Selection Guidelines
Special Populations
No significant variability in response has been noted among patients of different ages or racial backgrounds.
Variability related to the minimum age of patients does exist in product labeling. According to the tentative final monograph
published in the Federal Register in 1983, use of external analgesics, as labeled within the confines of the statement, is to be
avoided in children younger than 2 years.30 However, most available products elect to label the minimum age as older than 12
years, and some products (particularly capsaicin products) list 18 years and older. Providers should follow labeling instructions
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for the products used. These products should be used cautiously, or avoided, in populations who cannot effectively
communicate side effects they are experiencing after application of a topical analgesic. Of particular concern is use of such
products in young children.
Musculoskeletal complaints are common in pregnancy, but complications may occur; therefore, patients should be evaluated by
their primary care provider.49 Limited information is available regarding use of nonprescription topical analgesics in pregnancy.
Capsaicin, in the prescription patch formulation, is pregnancy category B. One source lists the nonprescription formulation as
category C, but limited data are available to determine a pregnancy classification.50 Camphor, menthol, methyl salicylate,
trolamine salicylate, and methyl nicotinate are not categorized. Topical camphor is suggested to be compatible during pregnancy
based on a determination of limited data that it is low risk.51 Definitive recommendations are not available because of the
limitedor in some cases, complete lack ofdata that are available on topical use in pregnancy. Consideration should be given
to the systemic absorption of topical salicylates, particularly in the third trimester. Information regarding salicylates in pregnancy
can be found in Chapter 5.
Patient Factors
The choice of treatment for acute pain syndromes and chronic conditions such as osteoarthritis is patient dependent. In addition
to nonpharmacologic treatment, oral drug therapy is often employed. One should consider a patients history (taking note of
exclusions for self-treatment), other medications the patient is taking, and any known allergies to medications. Topical
analgesics are used as an adjunct or substitute to oral drug therapy. If a counterirritant is selected, one with Category I
ingredients should be recommended. Product concentrations are variable; in general, the lowest effective dose should be
recommended for the shortest duration needed.
Patient Preferences
Factors that impact product selection include dosage form, ease of use, cost, and even odor of the preparation. Dosage forms
available include solutions, liniments, gels, lotions, ointments, creams, and patches. Oleaginous preparations (ointments and
oil-based liniments) have increased absorption compared with solutions, gels, lotions, and creams, but they are greasy and
generally less acceptable to patients. The use of patches is becoming more popular because of their simple application and long
duration of action. With the exception of patches and solutions, topical products should be rubbed into the skin.
Complementary Therapies
The most common dietary supplement used for osteoarthritis contains glucosamine and chondroitin. Published data regarding
these supplements are conflicting because of population size, trial duration, preparations used, and outcomes measured (i.e.,
quality of life, pain indices, and radiologic changes). The National Institutes of Health and National Center for Complementary
and Alternative Medicine has provided the largest study, the Glucosamine/Chondroitin Arthritis Intervention Trial (GAIT).52 Initial
results from this 6-month study showed no benefit in mild pain but showed a statistically significant reduction with moderate-
severe pain. However, only 22% of patients enrolled in the study were categorized as having moderate-severe pain; therefore,
the GAIT trial concluded that further studies are needed because of the small population size. A 2-year follow-up using patients
from the GAIT trial showed no clinical difference in reduction of pain and function and joint space width compared with
placebo.53,54 The new ACR guidelines conditionally recommend that patients with osteoarthritis of the hip and knee should not
use glucosamine or chondroitin sulfate.13 These products and other complementary therapies are discussed in greater detail in
Chapter 51.
Assessment of Musculoskeletal Injuries and Disorders: A Case-Based Approach
Routinely, the health care provider should inventory all patient medications, including pain medications, and should note the
patients satisfaction with or preference for past treatments. In addition, the health care provider should ask about aspects of the
patients medical history that relate directly to the origin or treatment of pain.
Before an attempt is made to treat a pain complaint, the health care provider should qualify and quantify the pain. Inquiry about
the cause, duration, location, and severity of pain, as well as factors that relieve and exacerbate the pain, will help assess the
pain. Chapter 2 outlines effective strategies for obtaining information from patients about specific complaints. Using a pain scale
helps to quantify the intensity of a patients pain. With the numerical pain scale, the health care provider asks the patient to rank
the present pain on a scale of 0-10, with 0 being no pain and 10 being the worst pain the patient can imagine. Typically, mild
pain is defined as 1-3, moderate pain 4-6, and severe pain 7-10 on the numerical pain scale.1 Initially, pain scores establish a
baseline for pain before treatment. In addition, a high pain score can be used to screen for patients who would be better served
by seeking an appropriate medical evaluation. Pain scores also serve as a measuring device for therapeutic outcomes. Other
scales are available for pain rating in children (Wong-Baker FACES Pain Scale), adolescents, people who do not speak English,
and other special populations.
A chronic painful condition presents a different set of challenges. An observant health care provider should intervene with a
patient who regularly purchases nonprescription analgesics. If additional interviewing indicates an inadequately treated pain
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problem, additional workup by an appropriate provider should be made. Education should be offered regarding the risks of
inadequate treatment as well as the overuse of medications.
Cases 7-1 and 7-2 are examples of the assessment of patients with musculoskeletal injuries and disorders.
Case 7-1
Relevant Evaluation Criteria Scenario/Model Outcome
Information Gathering
1. Gather essential information about the

patients symptoms and medical history,
including:
a. description of symptom(s) (e.g., nature, Patient presents with a complaint that his back is really hurting him and that he is
onset, duration, severity, associated having difficulty moving around without pain. He reports that his pain right now is
symptoms) a 4 out of 10.
b. description of any factors that seem to Yesterday he was working outside in the yard all day for the first time this spring.
precipitate, exacerbate, and/or relieve the
patients symptom(s)
c. description of the patients efforts to He has tried a heat patch, which he wore for 8 hours; he has not experienced any
relieve the symptom(s) significant relief.
d. patients identity Alexander Smith
e. age, sex, height, and weight 70 years old, male, 5 ft 11 in., 205 lb
f. patients occupation Retired
g. patients dietary habits He eats a diet high in carbohydrates and red meat. He does not eat a balanced
diet, avoiding vegetables, poultry, and fish.
h. patients sleep habits He finds that it is getting more difficult to sleep through the whole night; on
average, he sleeps about 7 hours a night.
i. concurrent medical conditions, He has a history of osteoarthritis, diabetes, coronary artery disease, uncontrolled
prescription and nonprescription hypertension, dyslipidemia, and anemia. He occasionally has problems with his
medications, and dietary supplements back. His current medications include acetaminophen arthritis formulation, 1300
mg every 8 hours, 2-3 doses a day; metformin 1000 mg twice a day; metoprolol
succinate 25 mg once daily; enalapril 10 mg once daily; aspirin 81 mg once daily;
pravastatin 40 mg once daily; and B12 injections monthly.
j. allergies Penicillin
k. history of other adverse reactions to None

medications
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l. other patient preferences He prefers patch formulations for convenience.
Assessment and Triage
2. Differentiate patients signs/symptoms Patient is experiencing acute back pain as a result of his burst of activity
and correctly identify the patients primary yesterday with his yard work.
problem(s).
3. Identify exclusions for self-treatment Patient does not have any exclusions for self-care. If his pain were more severe
(Figure 7-1). (>6 on pain scale), a referral would be recommended.
4. Formulate a comprehensive list of Options include:

therapeutic alternatives for the primary (1) Refer patient to PCP for further assessment and treatment.
problem to determine if triage to a (2) Continue nondrug measures (heat).
medical provider is required, and share (3) Continue APAP alone.
this information with the patient or (4) Recommend an NSAID.
caregiver. (5) Recommend adjunct topical analgesic, single or combination product (methyl
salicylate, trolamine salicylate, camphor, menthol, or capsaicin).
(6) Take no action.
Plan
5. Select an optimal therapeutic Recommend nondrug measures, including 1-2 days of rest. Recommended
alternative to address the patients therapy would include a topical counterirritant in a patch formulation because the
problem, taking into account patient patient prefers that. Continue APAP, which is a regular scheduled medication for
preferences. his osteoarthritis that is a systemic analgesic. Patient has uncontrolled
hypertension, so avoid systemic NSAIDs.
6. Describe the recommended therapeutic A topical analgesic medication to treat the pain is appropriate, and we can select
approach to the patient or caregiver. a patch formulation.
7. Explain to the patient or caregiver the An oral nonsteroidal anti-inflammatory should not be used because you regularly
rationale for selecting the recommended have elevated blood pressure readings. A topical analgesic will help treat your
therapeutic approach from the considered muscle pain.
therapeutic alternatives.
Patient Education
8. When recommending self-care with

nonprescription medications and/or
nondrug therapy, convey accurate
information to the patient or caregiver:
a. appropriate dose and frequency of Apply Salonpas original patch (methyl salicylate 6.3%, menthol 5.7%, and
administration camphor 1.2%) 3-4 times a day.
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b. maximum number of days the therapy This medication can be used for up to 7 days.
should be employed
c. product administration procedures Apply the patch to your back on clean, dry skin where the pain is occurring. A
new patch can be applied 3-4 times per day. Do not wear a patch for more than 8
hours. Wash hands before and after you apply the patch. It is not recommended
to use heat when you are using this medication.
d. expected time to onset of relief You should experience some improvement shortly after application.
e. degree of relief that can be reasonably This medication will help reduce the pain but not eliminate it.
expected
f. most common side effects It is normal to feel warmth in the area where the medication is applied. Some
minor skin irritation may occur.
g. side effects that warrant medical Immediately remove the product and contact your primary care provider if you
intervention should they occur experience any symptoms that would indicate a severe reaction (e.g., excessive
redness, blistering, rash, burning, or stinging).
h. patient options in the event that If this topical medication does not adequately relieve pain, please contact me to
condition worsens or persists recommend a different topical medication.
i. product storage requirements Keep out of childrens reach.
j. specific nondrug measures Rest for a day or two so as not to further aggravate your condition. Do not use
heat over this medicated patch.
Solicit follow-up questions from the Does the Tylenol that I take for my arthritis help my back?
patient or caregiver.
Answer the patients or caregivers Yes, Tylenol is a medication that can help with pain from any cause, but it does
questions. not reduce inflammation.
Evaluation of Patient Outcome
9. Assess patient outcome. Monitor for a reduction in the patients reported pain level using a pain scale. In
addition, monitor for improved mobility.
Key: APAP = Acetaminophen; NA = not applicable; NKA = no known allergies; NSAID = nonsteroidal anti-inflammatory drug;
PCP = primary care provider.
Case 7-2
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1. Gather essential information about the patients

symptoms and medical history, including:
a. description of symptom(s) (e.g., nature, onset, Patient presents with a complaint that she hurt her ankle during her
duration, severity, associated symptoms) basketball game last night. She reports that her pain is an 8 out of 10.
She is struggling to walk in the pharmacy and is favoring her right
ankle. Upon examination, you observe that her ankle is very swollen
and discolored.
b. description of any factors that seem to During the game last night, she collided with another player, and her
precipitate, exacerbate, and/or relieve the patients ankle rolled when she fell.
symptom(s)
c. description of the patients efforts to relieve the She has been icing while awake for 15 minutes on and then 15 minutes
symptom(s) off. She also slept with her ankle elevated.
d. patients identity Madison Jones
e. age, sex, height, and weight 17 years old, female, 5 ft 5 in., 140 lb
f. patients occupation High school student
g. patients dietary habits She does not eat a regular diet outside of dinner with her family.
h. patients sleep habits Sleeping habits are erratic because of her schedule and social
activities. She sleeps 8 hours on school nights but likes to sleep in on
the weekends.
i. concurrent medical conditions, prescription and She is currently experiencing acne. Her current medications include a
nonprescription medications, and dietary multivitamin daily and adapalene gel applied at bedtime.
supplements
j. allergies NKA
k. history of other adverse reactions to medications. None
l. other (describe) _______ NA
Assessment and Triage
2. Differentiate patients signs/symptoms and Patient appears to have at least sprained her ankle but may have a
correctly identify the patients primary problem(s) more serious injury such as a fracture or torn tendons around
(Table 7-1). her ankle.
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3. Identify exclusions for self-treatment (Figure 7-1). Patient is experiencing pain that is severe (8 out of 10 on pain scale)
and is having significant difficulty putting weight on it.
4. Formulate a comprehensive list of therapeutic Options include:

alternatives for the primary problem to determine if (1) Refer patient to PCP for further assessment and treatment.
triage to a medical provider is required, and share (2) Recommend nondrug measures (ice initially).
this information with the patient or caregiver. (3) Recommend systemic analgesic.
(4) Recommend topical analgesic, single or combination product
(methyl salicylate, trolamine salicylate, camphor, menthol, or
capsaicin).
(5) Take no action.
Plan
5. Select an optimal therapeutic alternative to Refer patient to PCP for further evaluation because of the severity of
address the patients problem, taking into account pain. Recommend to continue nondrug measures including rest,
patient preferences. elevation, compression, and ice (Table 7-2).
6. Describe the recommended therapeutic approach Self-treatment is not appropriate for your condition. You should contact
to the patient or caregiver. your primary care provider.
7. Explain to the patient or caregiver the rationale The severity of your pain requires further evaluation by your primary
for selecting the recommended therapeutic care provider.
approach from the considered therapeutic
alternatives.
Patient Education
8. When recommending self-care with Criterion does not apply in this case.
nonprescription medications and/or nondrug
therapy, convey accurate information to the patient
or caregiver:
Solicit follow-up questions from the patient or Do you think they will want me to get an x-ray?
caregiver.
Answer the patients or caregivers questions. Your primary care provider may recommend an x-ray to rule out
the possibility that you fractured a bone. Your primary care provider will
be able to make that determination once he or she examines
your ankle.
Evaluation of Patient Outcome
9. Assess patient outcome. Follow up with patient to determine the outcome of her visit with her
primary care provider.
Key: NA = Not applicable; NKA = no known allergies; PCP = primary care provider.
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Patient Counseling for Musculoskeletal Injuries and Disorders
Consultation with the patient should include explanation of the expected benefit of any recommended medication, the
appropriate dose and drug administration schedule, application directions, potential adverse reactions, potential drug-drug or
drug-disease interactions, and self-monitoring techniques for assessing response to therapy. Printed materials reinforce verbal
information. Many such pamphlets or single-page handouts are available from national professional societies (e.g.,
www.arthritis.org). These materials offer advice on exercise, diet, and sleep habits, as well as the advantages and
disadvantages of pharmacologic therapy.
In acute pain management, early administration of nonprescription analgesics should be employed to prevent escalating pain,
with downward tapering of the analgesic doses as pain severity allows. Patients should be assessed for the appropriateness of
nonprescription oral analgesics (Chapter 5).
Patients should be instructed to notify their primary care provider if the pain worsens in quality or severity, or if new acute pain
develops. Other sudden uncharacteristic pains may be harbingers of new tissue damage.
The box Patient Education for Musculoskeletal Injuries and Disorders lists specific information about topical analgesics, as well
as preventive and nondrug measures to provide patients.
Evaluation of Patient Outcomes for Musculoskeletal Injuries and Disorders
The primary indicator of treatment effectiveness is the patients perception of pain relief. If a patient reports the pain is still
present or has worsened after 7 days of using topical nonprescription analgesics,30 the health care provider should refer the
patient for further evaluation. In many instances, the lack of a return visit indicates a successful treatment regimen (the provider
may call the patient in a few days to determine whether the complaint has resolved). However, a patient who returns with signs
of continued swelling, pain, or inflammation should be referred for medical evaluation. The continued pain may indicate an
ongoing process that could lead to long-term disability or decreased mobility.
Key Points for Musculoskeletal Injuries and Disorders
Self-treatment of patients presenting with pain secondary to an injury or a disorder of the musculoskeletal system should
be limited to those with mild-moderate pain who have no exclusions for self-treatment (Figure 7-1).
Self-treatment of acute musculoskeletal injuries should include nondrug therapy, such as rest, ice, compression, and
elevation (RICE). Heat therapy may also provide benefit after symptoms of inflammation have abated.
Systemic analgesics are valid first-line agents to treat the majority of musculoskeletal injuries and disorders.
Acetaminophen is preferred in noninflammatory diseases, whereas NSAIDs are preferred if inflammation is present. Side
effects and drug interactions should be considered before therapy is chosen (see Chapter 5).
Health care providers should counsel patients on the discussion points listed in Table 7-5 to avoid chemical burns with
topical nonprescription analgesics.
Health care providers should monitor the outcome of self-treatments and advise patients who self-treat their acute
musculoskeletal injury with nonprescription topical analgesics to seek medical attention if their symptoms do not improve
after 7 days. Patients who experience pain for greater than 10 days, regardless of treatment, should also be referred.
Patient Education for Musculoskeletal Injuries and Disorders

The objectives of self-treatment are to (1) reduce the severity of pain; (2) reduce the duration of pain, when possible; (3) restore
function to the affected area; (4) prevent re-injury and disability; and (5) prevent acute pain from becoming chronic persistent
pain. Certain nondrug measures and nonprescription counterirritants can relieve pain symptoms from a sudden and recent
muscle, tendon, or ligament injury; an overuse injury (e.g., tendonitis, bursitis, or repetitive stress injury); low back pain; or
arthritis. For most patients, carefully following product instructions and the self-care measures listed here will help ensure
optimal therapeutic outcomes.
Preventive Measures
To prevent muscle or joint strains and sprains, do warm-up and stretching exercises before playing sports or exercising,
and wrap injured muscle or joint with protective bandage or tape.
To prevent repetitive strain, exercise the muscles that are vulnerable to the injury, and use ergonomic controls to adjust
posture, stresses, motions, and other damaging physical factors.
To prevent tendonitis and cramps, warm up and stretch muscles before physical activity, drink sufficient fluids, and do
not exercise to the point of exhaustion. To help prevent nocturnal leg cramps, raise the foot of the bed. For Achilles
tendonitis, wearing better-fitting shoes with heel lifts may help reduce the symptoms.
To prevent or reduce the occurrence of low back pain, do exercises to strengthen the muscles of the low back and
abdomen, and use assistive devices (i.e., cane or walker), if needed.
To prevent or reduce the occurrence of osteoarthritis, avoid a sedentary lifestyle; keep joints active; lose weight, if
19 of 22 3/15/2015 1:17 AM
overweight; and use assistive devices, if needed.
Nondrug Measures
For pain related to muscle or joint injuries, begin treatment with RICE therapy (Table 7-2).
For periodic muscle cramps, stretch and massage the affected area immediately; then rest or reduce activity of the
muscle to allow it to loosen.
For stiffness, apply heat to the affected area in the form of a warm wet compress, a heating pad, or a hot-water bottle.
For osteoarthritis, try a combination of nondrug measures, including applying heat or cold to the affected area,
supporting the area with splints, and doing range-of-motion and strength-maintenance exercises.
Nonprescription Medications
For mild-moderate muscle pain, take a nonprescription systemic analgesic for no longer than 10 days23 (see Chapter 5
for a listing of nonprescription analgesics), and/or use a topical counterirritant for no longer than 7 days27 (Table 7-3
provides recommended dosages of counterirritants).
Do not use counterirritants if your skin is abraded, sunburned, or otherwise damaged.
When using counterirritants, especially capsaicin, wash your hands after application and before touching your eyes and
mucous membranes, or before handling contact lenses.
Gently rub a thin layer of counterirritant product into affected muscles or joints until you cannot see the product. Thick
application of the product does not make the product work better.
Do not put a tight bandage or dressing over an area treated with a counterirritant. Do not use heat/warming devices with
counterirritants.
Do not treat a child 2 years of age or younger with counterirritants unless a primary care provider supervises the use.
Follow age limits on product labeling.
If you have asthma, and symptoms of wheezing and shortness of breath worsen while you are using a mentholated
formulation, stop using it.
If you are receiving anticoagulation therapy (especially warfarin), do not use products containing salicylates (including
aspirin, methyl salicylate, and trolamine salicylate).
If a counterirritant causes excessive redness and blistering or hives and vomiting, stop using it.
When to Seek Medical Attention
A feeling of warmth or coolness is normal; however, if burning pain or blistering occurs, seek medical attention.
If you experience nausea, vomiting, colic, and other unusual symptoms while using a product containing camphor, seek
medical care immediately.
If the pain has been present for more than 10 days or has worsened, consult a primary care provider.
If the symptoms persist after more than 7 days of treatment with a topical product, or if the pain is constant and felt in
any position, consult a primary care provider.
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Chapter 7. Musculoskeletal Injuries and Disorders

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Handbook of Nonprescription Drugs > Chapter 7. Musculoskeletal Injuries and Disorders

Musculoskeletal Injuries and Disorders: Introduction

Pathophysiology of Musculoskeletal Injuries and Disorders

Clinical Presentation of Musculoskeletal Injuries and Disorders

Treatment of Musculoskeletal Injuries and Disorders

Myalgia Tendonitis Bursitis Sprain Strain Osteoarthritis

Muscles of the Tendon Inflammation of Stretching or tearing Hyperextension of a Weight-bearing joints,

Possible Warmth, Warmth, edema, Swelling, bruising Swelling, bruising Noninflammatory

Myalgia Tendonitis Bursitis Sprain Strain Osteoarthritis

systemic analgesics, counterirritants;

Key: RICE = rest, ice, compression, elevation (Table 7-2).

General Treatment Approach

Key: RICE = Rest, ice, compression, elevation.

B Camphor 3-11 Produce cooling sensation As above in group A

C Histamine 0.025-0.1 Cause vasodilation As above in group A

Methyl nicotinate 0.25-1.0

Source: Reference 28.

Trade Name Primary Ingredients

Aspercreme Heat Pain Relieving Gel Menthol 10%

Bengay Ultra Strength Pain Relieving Patch Menthol 5%

Icy Hot No Mess Applicator Menthol 16%

Mineral Ice Menthol 2%

JointFlex Pain Relieving Cream Camphor 3.1%

Trade Name Primary Ingredients

Capzasin Arthritis Pain Relief No-Mess Applicator Capsaicin 0.15%

Capzasin-HP Arthritis Pain Relief Cream Capsaicin 0.1%

Zostrix Hot and Cold Therapy Capsaicin 0.025%

Zostrix-HP Arthritis Pain Relief Cream Capsaicin 0.075%

Histamine Dihydrochloride-Containing Products

Australian Dream Pain Relieving Arthritis Cream Histamine dihydrochloride 0.025%

Trolamine Salicylate-Containing Products

Aspercreme Cream/Lotion Trolamine salicylate 10%

Arthritis Hot Cream Methyl salicylate 15%; menthol 10%

Mentholatum Ointment Camphor 9%; natural menthol 1.3%

Salonpas Pain Relief Patch Methyl salicylate 10%; menthol 3%

Sloans Liniment Turpentine oil 47%; capsaicin 0.025% (from capsicum

Tiger Balm Arthritis Rub Cream Camphor 11%; menthol 11%

Do not apply to wounded, damaged, broken, or irritated skin.

Source: References 31 and 32.

many topical counterirritant products.29

Other Topical Analgesics

Product Selection Guidelines

Assessment of Musculoskeletal Injuries and Disorders: A Case-Based Approach

Relevant Evaluation Criteria Scenario/Model Outcome

1. Gather essential information about the

d. patients identity Alexander Smith

f. patients occupation Retired

k. history of other adverse reactions to None

Relevant Evaluation Criteria Scenario/Model Outcome

l. other patient preferences He prefers patch formulations for convenience.

Assessment and Triage

4. Formulate a comprehensive list of Options include:

8. When recommending self-care with

Relevant Evaluation Criteria Scenario/Model Outcome

i. product storage requirements Keep out of childrens reach.

Evaluation of Patient Outcome

Relevant Evaluation Criteria Scenario/Model Outcome

1. Gather essential information about the patients

d. patients identity Madison Jones

f. patients occupation High school student

k. history of other adverse reactions to medications. None

l. other (describe) _______ NA