Musculoskeletal Pain Management

What is the first step when evaluating a patient with musculoskeletal pain?

Assess the pain and determine whether the patient is a candidate for self-care or needs referral.

What does RICE stand for?

Rest, Ice, Compression, Elevation.

For most acute musculoskeletal injuries, what should initial treatment include?

RICE therapy plus or minus an oral or topical analgesic.

How long is acute pain generally defined as lasting?

Less than 4 weeks.

How long must pain last to be considered chronic?

At least 3 months.

What pain scale score is considered mild pain?

1-3 out of 10.

What pain scale score is considered moderate pain?

4-6 out of 10.

What pain scale score is considered severe pain?

7-10 out of 10.

Name two major treatment goals for musculoskeletal pain.

Reduce pain and restore function.

Besides reducing pain, what is another major goal of treatment?

Prevent acute pain from becoming chronic pain.

What is the preferred nondrug treatment during the first 1-3 days after an acute injury?

RICE therapy.

How long should ice be applied at one time?

15-20 minutes.

How often should ice generally be applied?

3-4 times daily.

Why should ice not be left on for prolonged periods?

Excessive icing can reduce blood flow and slow clearance of inflammatory mediators.

During RICE therapy, where should the injured limb be positioned?

At or above heart level.

How long should rest typically continue after an acute injury?

Until pain decreases, usually 1-2 days.

What sign suggests a compression wrap is too tight?

Cold toes, swollen fingers, numbness, or impaired circulation.

What should be used first for acute muscle cramps?

Stretching and massage.

What nondrug measure is often useful for stiffness rather than inflammation?

Heat.

How long should heat generally be applied?

15-20 minutes, 3-4 times daily.

Should heat be applied to inflamed areas?

No. Heat can worsen inflammation.

What common OTC oral medications are used for musculoskeletal pain?

NSAIDs and acetaminophen.

Give two examples of OTC NSAIDs.

Ibuprofen and naproxen.

Self-treatment with oral analgesics should generally be limited to how many days?

10 days.

If pain persists beyond 10 days, what should occur?

Referral to a healthcare provider.

Which oral drug class is generally preferred when inflammation is present?

NSAIDs.

When might acetaminophen be preferred?

When NSAIDs are not appropriate or inflammation is not a major issue.

Which OTC oral option has better evidence for acute low back pain?

NSAIDs.

Is acetaminophen considered first-line for acute low back pain?

No.

What is a reasonable recommendation if acetaminophen fails to control acute low back pain?

Switch to an NSAID if appropriate.

A patient rates back pain as 4/10 for 3 days after lifting a child. Candidate for self-care?

Yes. Mild-to-moderate acute pain without exclusions can be self-treated.

A patient reports back pain for 2 months. Should self-treatment be recommended?

No. Chronic pain requires medical evaluation.

A patient has pain 8/10 after a sports injury. Self-care or referral?

Referral. Severe pain is an exclusion to self-care.

A patient has been taking ibuprofen for 10 days and symptoms remain unchanged. What should you recommend?

Medical evaluation.

A patient with an ankle injury cannot bear weight. Self-care or referral?

Referral. Possible severe sprain, tear, or fracture.

A patient's injured joint appears visibly deformed. What is the recommendation?

Emergency medical evaluation.

A runner reports severe calf pain, swelling, and difficulty walking despite using a topical analgesic for 7 days. Recommendation?

Refer to a healthcare provider.

A patient has low back pain for 3 days and mild stiffness. Best nondrug recommendation?

Heat.

A patient has a fresh ankle sprain with swelling. Heat or ice?

Ice.

A patient asks how to prevent future low back pain. What should you recommend?

Strengthen abdominal and low back muscles and use proper lifting technique.

What is a strain?

Injury to a muscle or tendon.

What is a sprain?

Stretching or tearing of a ligament.

Which structure is injured in a sprain?

Ligament.

Which structure is injured in a strain?

Muscle or tendon.

What condition commonly presents with joint stiffness lasting less than 20-30 minutes?

Osteoarthritis.

What condition commonly causes dull joint pain relieved by rest?

Osteoarthritis.

Which disorder commonly presents with constant pain that worsens with movement and pressure over a joint?

Bursitis.

Which condition often causes pain after use with loss of range of motion?

Tendonitis.

What symptoms are common in carpal tunnel syndrome?

Numbness, tingling, weakness, and dropping objects.

Symptoms persisting at night even when the hand is not being used suggest what condition?

Carpal tunnel syndrome.

What topical NSAID is available OTC?

Diclofenac 1% gel (Voltaren).

What is OTC diclofenac approved for?

Arthritis pain in joints such as knees, hands, wrists, ankles, feet, and elbows.

Should OTC diclofenac be recommended for sports injuries, strains, or sprains?

No.

How long may topical diclofenac take to begin working?

Up to 7 days.

If no improvement occurs after 7 days of topical diclofenac, what should be done?

Contact a healthcare provider.

How long should OTC diclofenac generally not exceed without provider consultation?

21 days.

Why are topical NSAIDs often preferred before oral NSAIDs?

Lower systemic exposure and fewer systemic adverse effects.

What is a common adverse effect of topical diclofenac?

Mild skin irritation.

What topical anesthetic is available OTC?

Lidocaine 4%.

What type of pain is lidocaine most useful for?

Neuropathic pain.

Should topical analgesics be applied to broken skin?

No.

Should heating pads be used over topical counterirritants?

No.

Should tight bandages be applied over counterirritants?

No.

What should a patient do if blistering develops after a topical analgesic?

Discontinue use and seek medical attention.

Is a sensation of warmth or coolness normal with counterirritants?

Yes.

When should a patient seek medical attention while using topical products?

Burning pain, blistering, severe redness, or worsening symptoms.

What must patients do after applying capsaicin?

Wash hands thoroughly.

Why should patients avoid touching their eyes after applying capsaicin?

It can cause significant burning.

What counseling point is important with topical capsaicin?

Initial burning usually decreases with repeated use.

How often is capsaicin usually applied?

3-4 times daily.

Pain lasting more than 10 days should trigger what?

Referral to a healthcare provider.

Severe pain (>6/10) is considered what?

An exclusion for self-care.

Inability to bear weight after injury suggests what?

Medical evaluation is needed.

Visible joint deformity requires what?

Immediate medical attention.

Persistent symptoms after 7 days of a topical analgesic require what?

Referral.

A patient has worsening pain despite self-treatment. What is the recommendation?

Refer for further evaluation.

A patient presents with chronic low back pain. Self-care or referral?

Referral for medical evaluation.

A patient reports shoulder pain beginning after a vaccination with reduced range of motion. What condition should be suspected?

SIRVA (Shoulder Injury Related to Vaccine Administration).

Should suspected SIRVA be self-treated?

No, medical evaluation is required.

For musculoskeletal self-care, who is the ideal candidate?

A patient with mild-to-moderate pain, short symptom duration, and no exclusions for self-treatment.

A 24-year-old twists her ankle playing basketball yesterday. It is swollen and painful to walk on, but she can still bear weight. What is the best initial recommendation?

RICE therapy (Rest, Ice, Compression, Elevation) for the first 1-3 days. Consider an oral NSAID if needed for pain.

A patient sprained his ankle 30 minutes ago and asks if he should use a heating pad. What should you recommend?

No. Use ice initially because heat may worsen swelling and inflammation.

A 35-year-old presents with low back pain for 3 days after moving furniture. Pain score is 4/10. Acetaminophen has not helped much. Appropriate recommendation?

Trial of an NSAID (ibuprofen or naproxen) plus heat therapy if stiffness is present.

A patient reports low back pain that started 4 months ago. Can the pharmacist recommend self-treatment?

No. Chronic pain should be medically evaluated before self-treatment.

A 29-year-old has shoulder pain for 2 days after painting the ceiling all weekend. Pain worsens with arm movement. Most likely condition?

Tendonitis from repetitive overuse.

A patient reports sharp calf pain that worsens when walking and has not improved after 7 days of self-treatment. What should you recommend?

Referral to a healthcare provider.

A patient presents with knee pain rated 8/10 after falling from a ladder. Self-care or referral?

Referral. Severe pain is an exclusion for self-care.

A patient has an injured ankle with obvious deformity. What is the recommendation?

Immediate medical evaluation.

A patient asks for an OTC product for newly diagnosed knee osteoarthritis. Which topical treatment is a reasonable option?

Topical diclofenac (Voltaren Arthritis Pain Gel).

A patient applies Voltaren gel for knee arthritis and asks when it should start helping. What do you tell them?

Improvement may take up to 7 days.

A patient has used Voltaren gel for 8 days with no improvement. What should the pharmacist recommend?

Contact a healthcare provider.

A patient asks how long oral ibuprofen should be used for self-treatment of a muscle injury.

No longer than 10 days without medical evaluation.

A patient has elbow pain from tennis and asks about prevention. What counseling is appropriate?

Proper technique, conditioning, stretching, and appropriate equipment.

A patient complains of wrist tingling, numbness in the thumb and index finger, and symptoms that wake them at night. Most likely condition?

Carpal tunnel syndrome.

A patient says, "My hand feels swollen but it looks normal, and I keep dropping things." What condition should be suspected?

Carpal tunnel syndrome.

A patient asks what symptom suggests their compression wrap is too tight.

Cold toes, swollen fingers, numbness, or impaired circulation.

A patient has ankle swelling after an injury and wants to know where the leg should be positioned.

Elevated at or above heart level.

A patient asks if more ice is always better after an injury. What should you tell them?

No. Ice should only be applied for 15-20 minutes at a time.

A patient with acute back pain asks if acetaminophen or ibuprofen has better evidence. What is the best answer?

NSAIDs generally have better evidence for acute low back pain.

A patient using warfarin wants to use a methyl salicylate-containing cream daily. What concern exists?

Possible increased anticoagulation/bleeding risk due to salicylate absorption.