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Pharmacology Handbook for Physiotherapists is an essential quick-reference guide to common medications, designed specifically for student and professional physiotherapists to assist in their everyday practice.Providing practical and accessible evidence-based information, the handbook will equip physiotherapists with the right knowledge to maximise the benefit of pharmacology and physiotherapy treatments. Written by a multidisciplinary team of specialists, the text is designed to be comprehensive and easy-to-read and is set out by body system to allow quick retrieval of useful information related to the particular condition and medications involved.
Key featuresn Written specifically for physiotherapists to assist their understanding of
pharmacology principles in conjunction with physiotherapy treatmentn Each chapter is written by three experts in their respective fields: a
physiotherapist, a physician and a pharmacist n ‘Physiotherapy practice points’ explain the effects that drugs may have on
treatment and provide valuable information on the actions of medications and how these interact with physiotherapy treatment
n 11 chapters cover basic pharmacology principles, legal and ethical issues, the body systems, women’s and men’s health, as well as a final chapter on medication issues in the young and elderly
THE EDITORSJacqueline Reznik BAppSci, MAPA, MCSP, GradDip(Teaching), GradDip(Neurology), PhDInternational Physiotherapy Consultant, Kfar Yona, Israel; Townsville, Queensland, AustraliaOfer Keren MDDirector of Acquired Brain Injury Rehabilitation Department, Sheba Medical Center, Tel Hashomer; Clinical Senior Lecturer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelJoanne Morris BSc (Hons) Physiotherapy, MSc (Hons) Clinical Biomechanics, Grad Dip Extended Scope Physiotherapy, Doctoral CandidateExtended Scope Physiotherapist, Canberra Hospital and Health Services, Canberra, Australian Capital Territory, AustraliaIftah Biran MD Neurologist and Psychiatrist, Psychotherapist and Behavioural Neurologist; Working as a Psychiatrist Consult (Liaison Psychiatry) to the Department of Neurology, Tel Aviv Medical Center , Tel Aviv; Psychoanalytic candidate, Max Eitingon Institute of Psychoanalysis, Jerusalem, Israel
ISBN 978-0-7295-4214-2
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NoticeThis publication has been carefully reviewed and checked to ensure that the content is as accurate and current as possible at time of publication. We would recommend, however, that the reader verify any procedures, treatments, drug dosages or legal content described in this book. Neither the author, the contributors, nor the publisher assume any liability for injury and/or damage to persons or property arising from any error in or omission from this publication.
National Library of Australia Cataloguing-in-Publication entry Reznik, Jacqueline, author.Pharmacology handbook for physiotherapists / Jacqueline Reznik, Ofer Keren, Joanne Morris, Iftah Biran.
9780729542142 (paperback)Pharmacology–Australia–Handbooks, manuals, etc. Physical therapy–Practice. Physical therapy–Handbooks, manuals, etc.
Keren, Ofer, author. Morris, Joanne, author. Biran, Iftah, author.
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Contents
Foreword ix
Preface/How to use this book x
About the editors xi
Contributors xii
Reviewers xv
Acknowledgements xvi
1 Introduction and background concepts 1
Introduction 1Gregory Kyle, Jacqueline Reznik, Joanne Morris, Ofer Keren
Legal and ethical issues 3Joanne Morris
Basic pharmacology and pharmacokinetic concepts 7Gregory Kyle
Administration and monitoring of medications 13Gregory Kyle, Jacqueline Reznik, Ofer Keren
Physiology of the autonomic nervous system 19Pam Megaw
2 Cardiovascular system 27Bernie Bissett, Imogen Mitchell, Karlee Johnston, Gregory Kyle
3 Respiratory system 46Bernie Bissett, Imogen Mitchell, Karlee Johnston, Richard Talbot
4 Women’s and men’s health 72Kathryn Vine, Miriam Lawrence, Roberto Orefice
5 Orthopaedic and musculoskeletal systems 106Joanne Morris, Miriam Lawrence, Bryan Ashman
6 Neurological system 167Jacqueline Reznik, Ofer Keren, Iftah Biran, Ilana Schumacher
7 Pain and analgesia 199Anthony Wright, Heather AE Benson, Robert Will
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viii PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
8 Endocrine system 226Joanne Morris, Chandima Perera, Jacqueline Reznik, Ofer Keren, Iftah Biran
9 Haematological system 251Anthony Hall, Jacqueline Reznik, Ofer Keren, Iftah Biran
10 Mental health 276Iftah Biran, Jacqueline Reznik
11 Medication issues in the young and the elderly 315Ian Heslop, Jacqueline Reznik, Ofer Keren
Index 326
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This book is not designed to be read ‘cover to cover’ but rather as a handbook that allows easy access to information on disease processes, their signs and symptoms and the medications that are being prescribed for your patients to alleviate those signs and symptoms. The text incorporates many tables that are designed to allow the reader to quickly retrieve useful information regarding a patient’s drug regimen including possible side effects and duration of action, which may be particularly relevant to physiotherapists, both undergraduate and postgraduate. The book is divided into 11 chapters based on body systems, with a background chapter that includes basic pharmacology and legal implications at the beginning and a chapter for age-related implications of medications at the end. Chapters 2 through 10 deal with medications prescribed for various conditions by body system: cardiovascular, respiratory, women’s and men’s health, orthopaedic and musculoskeletal, neurological, pain and analgesia, endocrinological, haematological and mental health. This allows the reader to quickly access the information they require by searching via body system for the desired condition or medication.
This handbook is also not intended to compete with the larger and more concise pharmacotherapeutic textbooks or physiotherapeutic textbooks and, for that reason, more detail regarding the medications and physiotherapeutic interventions has not been included. The physiotherapy practice points outlined in each chapter are designed to explain to the reader the effects that the drugs may have on their treatment and provide valuable information on the actions of medications and when and how this interacts with physiotherapy treatment.
The book is not intended to be a ‘do as I say book’. It tries, albeit on a limited scale, to describe the ‘bigger picture’. Each chapter has been coauthored by a pharmacist, doctor and physiotherapist specialising in that particular area and, where possible, medications used to alleviate signs and symptoms have been described rather than those used for specific conditions. In those cases where exclusive drugs are designed for particular conditions, they have been referred to specifically. All drugs have been referred to by their generic (not brand) names.
At the time of going to print all of the information provided in this book is up to date.
Preface/How to use this book
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CHAPTER
5
Orthopaedic and
musculoskeletal systems
Joanne Morris, Miriam Lawrence, Bryan Ashman
O B J E C T I V E S This chapter will discuss the role that medications have in the supplementary management of the most common musculoskeletal conditions treated by physiotherapists. By the end of this chapter (including cross-referencing with other relevant chapters) the reader should have an understanding of:◆ the major classification of musculoskeletal disorders according to
structure, location, signs and symptoms◆ pharmacotherapy options for the major musculoskeletal disorders◆ usual dosages, routes of administration and major contraindications and
precautions of these medications◆ any potential impact of these medications on physiotherapeutic
management.
O V E R V I E W Arthritis
OsteoarthritisSeptic arthritisRheumatoid arthritis and other synovial joint disordersPsoriatic arthritisCrystal arthropathies
Joint conditions
Adhesive capsulitisAvascular necrosisOsteomyelitisTumours
Maxillofacial disorders
Trigeminal neuralgiaTemporomandibular joint disordersBell’s palsy
Soft tissue conditions
Soft tissue injuries – sprains, strains and contusionsAcute tendon painSubacute/chronic tendon pain
Nerve compression syndromes
BursitisConnective tissue disorders
Spinal conditions
Ankylosing spondylitisSpondylosis/spondyloarthropathy
Trauma
Fractures/acute traumaDislocation
Miscellaneous
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107CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Introduction
Musculoskeletal conditions are conditions of the bones, muscles and their attachments (e.g. joints and ligaments) (Australian Institute of Health and Welfare [AIHW] 2015).
According to the Australian Institute of Health and Welfare (AIHW) 28% of Australians, approximately 6.1 million people, have arthritis and other musculoskeletal conditions (AIHW 2015) (see Figure 5.1).
Fourteen percent of Australians (3.0 million) are affected by back conditions, 8% with osteoarthritis (1.8 million), 3% with osteoporosis (728,000) and 2% with rheumatoid arthritis (445,000) according to 2011–12 self-reported figures (AIHW 2015).
Physiotherapists are key members of the primary and secondary care treating teams for patients with musculoskeletal disorders (MSD) and often are the primary treating clinician. Physiotherapy is a clinically- and cost-effective management strategy for patients with a musculoskeletal disorder. The most common complaints of patients with an MSD are pain, swelling and altered function. Therefore, the predominant reason a patient with an MSD takes medication is to manage pain and inflammation.
In this chapter the classification of musculoskeletal disorders proposed by the National Institute for Health and Care Excellence (NICE) will be followed (NICE 2015):1 arthritis2 congenital conditions (not included)3 joint conditions4 maxillofacial conditions5 soft tissue conditions6 spinal conditions7 trauma8 vasculitis.Overview of general factors affecting choice of medication
This chapter follows the Australian approved indications as specified in the Therapeutic Goods Administration approved product information. Emphasis
Figure 5.1 Percentage of Australians with musculoskeletal conditions. Adapted with permission from: Australian Institute of Health and Welfare (AIHW), 2015. Arthritis, Osteoporosis and Other Musculoskeletal Conditions. <http://www.aihw.gov.au/arthritis-and-musculoskeletal-conditions/>.
Back problems
Osteoarthritis
Osteoporosis
Rheumatoid arthritis
14%
8%
3%
2%
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108 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
will be placed on those signs and symptoms and conditions most frequently treated by physiotherapists and where the physiotherapist’s input is vital in monitoring the effects of the prescribed medications. The focus of this chapter will be on the major medications prescribed for specific musculoskeletal disorders and their relevance for the physiotherapist (Table 5.1). As indicated, many of the medications prescribed for musculoskeletal disorders are discussed in detail in other chapters of this handbook.
Each category and the specific subgroup of medications will be reviewed in terms of mechanism of action, route of administration, effects and adverse effects. A range of medication options are available for the treatment and/or management of musculoskeletal disorders and physiotherapists are often involved in discussions regarding treatment options. In addition to the impact of the physiotherapy intervention on the patient, the treating physiotherapist can also monitor the impact of the medications intervention using appropriate outcome measures.
P H Y S I O T H E R A P Y P R A C T I C E P O I N T S : M U S C U L O S K E L E TA L D I S O R D E R S
The main complaints of patients with an MSD are pain, swelling, stiffness and altered functional capacity. An integral component of a physiotherapist’s assessment is to gain an understanding of the severity and irritability of the patient’s symptoms and, through thorough assessment, the underlying disease processes. Understanding the underlying disease processes assists the clinical reasoning of the treating team in relation to the provision and monitoring of medications.
The pathophysiology of pain is addressed in Chapter 7. Figure 5.2 provides a basic understanding of the pathophysiology of inflammation at the organ and tissue level, thus providing valuable information regarding the mechanism of action of medications used to treat inflammation.
TABLE 5.1 Medications used in musculoskeletal disorders
General category Specific group
Relevance for
physiotherapist Where addressed
Medications used for musculoskeletal disorders – symptom orientated
Pain +++ See Chapter 7 for additional information
Inflammation +++ This chapter
Muscle spasm +++ This chapter
Medications used for musculoskeletal disorders – disease orientated
Antibiotics + This chapter
Anti-inflammatories +++ This chapter
Autoimmune ++ This chapter
Osteopenia/porosis ++ Chapter 8
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109CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Figure 5.3 highlights the mechanism of action of medications commonly used in the management of inflammation (COX-1 and COX-2 inhibitors). For further information regarding basic pharmacology and pharmacokinetic concepts please see Chapter 1.
Table 5.2 describes the structure, location and signs and symptoms of musculoskeletal disorders in terms of the sites of action for associated medication; disease-specific information and detailed medication management are described in Table 5.3.
Figure 5.2 Acute inflammation. Reproduced with permission from: Kumar, V., Abbas, A.K., Aster, J.C., 2013. Robbins Basic Pathology, ninth ed. Elsevier Sanders, Philadelphia, pp. 29–73.
Extracellular matrix Occasional residentlymphocyte or macrophage
VenuleArteriole
NORMAL
INFLAMED Increased blood flow
Expansion of capillary bedArteriole dilation Venule dilation
1
Neutrophil emigration3 Leakage of plasma2proteins oedema
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110 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Figure 5.3 Action of non-steroidal anti-inflammatory drugs (NSAIDs). Adapted with permission from: Stovitz, S.D., Johnson, R.J., 2003. NSAIDs and musculoskeletal treatment: what is the clinical evidence? The Physician and Sports Medicine 31. <http://www.chiro.org/LINKS/FULL/NSAIDs_and_Musculoskeletal_Treatment.html>.
Tissue injury
Phospholipids
Arachidonic acid
Inflammatory prostaglandins• Recruit inflammatory cells• Sensitise skin pain receptors• Regulate hypothalamic temperature control
Cytoprotective prostaglandins• Protect gastric mucosa• Aid platelet aggregation
Leukotrienes• Bronchoconstriction
Inducers• Cytokines• Growth factors
Inhibitors• COX-2 inhibitors• NSAIDS (non–COX-2)• Aspirin
COX-2(Inducible)
COX-1(Constitutional)
Inhibitors• NSAIDS (non–COX-2)• Aspirin
TABLE 5.2 Structure, location, signs and symptoms of medication
action in musculoskeletal disorders
Structure Location Signs and symptoms a
Tissue level Local tissue trauma Pain, swelling and muscle spasm
Central nervous system Dorsal horn Pain, muscle spasm
aSee Table 5.3 for descriptions of the various signs and symptoms.
Depending on the structure(s) affected and the nature of the patient’s condition (e.g. autoimmune) the clinical signs and symptoms will vary. Listed in Table 5.3 are the clinical characteristics, anatomical locations (where applicable) and signs and symptoms for which physiotherapy treatment may be applicable.
Table 5.4 outlines the disease mechanisms of some of the common MDSs treated by physiotherapists – providing further clarity regarding the mechanism of action of the medications used in the treatment of common conditions. This will be explored in greater detail under disease-specific medication regimens later in the chapter.
Conditions will be subdivided according the NICE classification of musculoskeletal disorders and common medication management will be highlighted.
Text continued on p. 115
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111CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Mu
scu
loskele
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a g
loba
l los
s of
rang
e of
mov
emen
t; ho
wev
er th
ere
is o
ften
a m
ore
mar
ked
loss
of e
xter
nal r
otat
ion
rang
e (W
alm
sley
, Osm
othe
rly a
nd R
ivet
t 201
4)R
isk
fact
ors
incl
ude:
type
1 o
r 2 d
iabe
tes
mel
litus
, thy
roid
dis
ease
, myo
card
ial i
nfar
ctio
n an
d pr
olon
ged
perio
ds o
f im
mob
ility
(Kel
ley
et a
l. 20
13)
Shou
lder
Rhe
umat
oid
arth
ritis
and
ot
her s
ynov
ial j
oint
di
sord
ers
Rhe
umat
oid
arth
ritis
is a
sys
tem
ic, i
nflam
mat
ory,
aut
oim
mun
e di
sord
er th
at re
sults
in jo
int
dest
ruct
ion
and
pers
iste
nt in
flam
mat
ion
of s
ynov
ial t
issu
e (s
ynov
itis)
Res
ults
in m
uscu
losk
elet
al p
ain
and
swel
ling,
as
a re
sult
of th
e de
stru
ctiv
e er
osio
n of
bon
e an
d a
loss
in jo
int i
nteg
rity
Rep
orte
dly
affe
cts
2% o
f Aus
tralia
ns (A
IHW
201
5)
Vario
us
T
AB
LE
5.3
D
efi
nit
ion
s a
nd
cli
nic
al
fea
ture
s o
f m
ajo
r si
gn
s a
nd
sy
mp
tom
s se
en
in
mu
scu
losk
ele
tal
dis
ord
ers
Cont
inue
d
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Sample
proofs
@ Else
vier A
ustrali
a
112 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Mu
scu
loskele
tal
dis
ord
ers
cla
ssifi
cati
on
Sig
ns/s
ym
pto
ms
/sp
ec
ific
dia
gn
osis
Cli
nic
al
ch
ara
cte
ris
tic
sA
na
tom
ic lo
ca
tio
n
Psor
iatic
arth
ritis
Psor
iasi
s is
cha
ract
eris
ed b
y er
ythe
mat
ous,
sca
ly p
atch
es o
f ski
n an
d na
ilsPa
tient
s w
ith p
soria
tic a
rthrit
is (P
sA) m
ay h
ave
spon
dylit
is, o
ligoa
rthrit
is a o
r pol
yarth
ritis
, pr
esen
ting
as p
ain,
stif
fnes
s an
d in
flam
mat
ion,
but
it m
ay a
lso
affe
ct li
gam
ents
, ten
dons
an
d fa
scia
l tis
sue
Vario
us
Cry
stal
arth
ropa
thie
sG
out i
s of
ten
char
acte
rised
by
rapi
d on
set o
f sev
ere
pain
, sw
ellin
g, w
arm
th, e
ryth
ema
and
decr
ease
d ra
nge
of m
ovem
ent i
n th
e af
fect
ed jo
int (
Khan
na e
t al.
2014
)Pa
in is
the
over
ridin
g sy
mpt
om
Knee
, big
toe,
var
ious
Maxil
lofa
cia
l co
nd
itio
ns
Pain
Con
ditio
ns s
uch
as tr
igem
inal
neu
ralg
ia, t
empo
rom
andi
bula
r joi
nt (T
MJ)
dis
orde
rs
(incl
udin
g os
teoa
rthrit
is) a
nd B
ell’s
pal
sy a
re c
omm
only
trea
ted
by p
hysi
othe
rapy
and
are
as
soci
ated
with
pai
n an
d/or
alte
red
sens
atio
n an
d/or
mus
cle
wea
knes
s
TMJ,
ocu
lar p
ain,
ting
ling
in th
e ch
eek/
mou
th
Infla
mm
atio
nAc
ute
inju
ry a
nd fl
are
of a
rthrit
is m
ay b
e as
soci
ated
with
sw
ellin
g to
the
affe
cted
are
aAf
fect
ed a
rea
Stiff
ness
Loss
of m
ovem
ent i
n th
e af
fect
ed jo
ints
, whi
ch m
ay b
e as
soci
ated
with
chr
onic
syn
oviti
sAf
fect
ed a
rea
Infe
ctio
nD
enta
l and
/or i
nfec
tion
is a
diff
eren
tial d
iagn
osis
for p
atie
nts
with
max
illofa
cial
con
ditio
nsAf
fect
ed a
rea
Beni
gn p
arox
ysm
al
posi
tiona
l ver
tigo
Sudd
en o
nset
of s
ever
e po
sitio
nal d
izzi
ness
that
can
be
asso
ciat
ed w
ith n
ause
a an
d vo
miti
ng
So
ft t
issu
e c
on
dit
ion
s
– i
nclu
din
g c
on
necti
ve
tissu
e d
iso
rders
Pain
Spra
ins,
stra
ins
and
cont
usio
ns a
re a
ssoc
iate
d w
ith p
ain
to th
e af
fect
ed a
rea
Affe
cted
are
a
Infla
mm
atio
nSp
rain
s, s
train
s an
d co
ntus
ions
are
ass
ocia
ted
with
sw
ellin
g an
d er
ythe
ma
to th
e af
fect
ed
area
, whi
ch in
som
e ca
ses
may
resu
lt in
ner
ve c
ompr
essi
on a
nd th
eref
ore
be a
ssoc
iate
d w
ith p
arae
sthe
sia,
ting
ling
etc
Affe
cted
are
aN
erve
com
pres
sion
sy
ndro
mes
suc
h as
car
pal
tunn
el s
yndr
ome
T
AB
LE
5.3
D
efi
nit
ion
s a
nd
cli
nic
al
fea
ture
s o
f m
ajo
r si
gn
s a
nd
sy
mp
tom
s se
en
in
mu
scu
losk
ele
tal
dis
ord
ers
—co
nt’
d
Maxil
lofa
cia
l co
nd
itio
ns
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Sample
proofs
@ Else
vier A
ustrali
a
113CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMSM
uscu
loskele
tal
dis
ord
ers
cla
ssifi
cati
on
Sig
ns/s
ym
pto
ms
/sp
ec
ific
dia
gn
osis
Cli
nic
al
ch
ara
cte
ris
tic
sA
na
tom
ic lo
ca
tio
n
Stiff
ness
The
affe
cted
are
a qu
ickl
y be
com
es s
tiff s
econ
dary
to p
ain,
sw
ellin
g an
d al
tere
d fu
nctio
nAf
fect
ed a
rea
Infe
ctio
nPa
in, s
wel
ling
and
eryt
hem
a co
uple
d w
ith fe
ver
Com
mon
aro
und
the
olec
rano
n bu
rsae
Syst
emic
lupu
s er
ythe
mat
osus
A ch
roni
c, in
flam
mat
ory,
mul
tifac
toria
l aut
oim
mun
e co
nnec
tive
tissu
e di
sord
erC
omm
on fe
atur
es o
f the
dis
ease
incl
ude
a bu
tterfl
y ra
sh a
roun
d th
e ey
es, p
olya
rthrit
is,
haem
atol
ogic
al m
anife
stat
ions
, nep
hriti
s an
d ph
otos
ensi
tivity
(Tar
r et a
l. 20
15; Y
eun
& C
unni
ngha
m 2
014)
Cha
ract
eris
ed b
y un
pred
icta
ble
perio
ds o
f exa
cerb
atio
n (fl
ares
) and
rem
issi
on (Y
eun
& C
unni
ngha
m 2
014)
Vario
us
Scle
rode
rma
A ch
roni
c au
toim
mun
e co
nnec
tive
tissu
e di
sord
er, o
f whi
ch th
ere
are
two
maj
or ty
pes:
lo
calis
ed s
cler
oder
ma
and
syst
emic
scl
eros
isBo
th a
re c
hara
cter
ised
by
exce
ss c
olla
gen
in th
e co
nnec
tive
tissu
esLo
calis
ed s
cler
oder
ma
affe
cts
only
the
skin
and
occ
asio
nally
the
tissu
es b
enea
th th
e sk
in,
resu
lting
in s
tiffn
ess
loca
llySy
stem
ic s
cler
osis
als
o af
fect
s th
e sk
in a
nd u
nder
lyin
g tis
sues
, but
add
ition
ally
the
gast
roin
test
inal
trac
t, lu
ngs,
hea
rt an
d ki
dney
s ca
n be
affe
cted
(Arif
et a
l. 20
15) t
hrou
gh
wid
espr
ead
vasc
ular
lesi
ons
and
fibro
sis
of th
e sk
in a
nd in
tern
al o
rgan
s
Sp
inal
co
nd
itio
ns
Pain
The
sym
ptom
s of
mus
culo
skel
etal
spi
nal c
ondi
tions
are
hig
hly
varia
ble
and
have
a
rela
tivel
y lo
w c
orre
latio
n w
ith ra
diog
raph
ic a
nd a
nato
mic
al fi
ndin
gs (G
ibso
n &
Wad
dell
2005
)Pr
esen
ting
com
plai
nts
may
incl
ude
spin
e pa
in, l
eg a
nd/o
r arm
sym
ptom
s (p
ain,
pa
raes
thes
ia),
func
tiona
l im
pairm
ent a
nd h
eada
ches
Cer
vica
l, th
orac
ic o
r lu
mbo
sacr
al s
pine
Stiff
ness
Patie
nts
frequ
ently
repo
rt st
iffne
ss a
nd re
duce
d ra
nge
of m
otio
nC
ervi
cal,
thor
acic
or
lum
bosa
cral
spi
ne
Mus
cle
spas
mAc
ute
or a
cute
-on-
chro
nic
flare
s ar
e of
ten
asso
ciat
ed w
ith m
uscl
e sp
asm
Cer
vica
l, th
orac
ic o
r lu
mbo
sacr
al s
pine
Cont
inue
d
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Sample
proofs
@ Else
vier A
ustrali
a
114 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Mu
scu
loskele
tal
dis
ord
ers
cla
ssifi
cati
on
Sig
ns/s
ym
pto
ms
/sp
ec
ific
dia
gn
osis
Cli
nic
al
ch
ara
cte
ris
tic
sA
na
tom
ic lo
ca
tio
n
Infe
ctio
nPa
tient
s w
ith s
eptic
arth
ritis
and
/or d
isci
tis a
re p
yrex
ial,
repo
rt ac
ute
seve
re p
ain
Cer
vica
l, th
orac
ic o
r lu
mbo
sacr
al s
pine
Anky
losi
ng s
pond
yliti
sPa
tient
s pr
esen
t with
pai
n, s
tiffn
ess
and
redu
ced
mob
ility
in th
e lu
mba
r spi
ne a
nd
sacr
oilia
c jo
ints
Com
mon
ly a
ssoc
iate
d w
ith p
erip
hera
l arth
ritis
, ent
hesi
tis a
nd a
cute
ant
erio
r uve
itis
(Dag
finru
d, K
vien
& H
agen
200
8)
Lum
bosa
cral
spi
ne is
mos
t co
mm
only
affe
cted
Tra
um
a –
fra
ctu
res a
nd
dis
locati
on
Pain
Dep
endi
ng o
n th
e se
verit
y of
the
inju
ry th
is is
ofte
n as
soci
ated
with
mod
erat
e to
sev
ere
pain
of t
he a
ffect
ed a
rea
In th
e ca
se o
f bot
h fra
ctur
e an
d di
sloc
atio
n th
e po
ssib
ility
of n
euro
vasc
ular
com
prom
ise
is
high
, res
ultin
g in
par
aest
hesi
a, ti
nglin
g et
c
Vario
us
Infla
mm
atio
nD
epen
ding
on
the
seve
rity
of th
e in
jury
this
is o
ften
asso
ciat
ed w
ith m
oder
ate
to s
ever
e sw
ellin
g of
the
affe
cted
are
aVa
rious
Mus
cle
spas
mAc
ute
fract
ures
and
dis
loca
tions
are
ofte
n as
soci
ated
with
mus
cle
spas
mVa
rious
Infe
ctio
n (p
roph
ylac
tic
med
icat
ion)
Ope
n fra
ctur
es a
nd d
islo
catio
ns re
quire
pro
phyl
actic
trea
tmen
t for
infe
ctio
nVa
rious
Vascu
liti
sPa
in a
nd in
flam
mat
ion
The
sym
ptom
s of
vas
culit
is a
re h
ighl
y va
riabl
e an
d de
pend
ent o
n th
e af
fect
ed a
rea,
ho
wev
er th
ey m
ay in
clud
e:•
feve
r•
loss
of a
ppet
ite•
wei
ght l
oss
• fa
tigue
• ge
nera
l ach
es a
nd p
ains
Vario
us
a Olig
oarth
ritis
is a
rthrit
is a
ffect
ing
one
to fo
ur jo
ints
dur
ing
the
first
6 m
onth
s of
dis
ease
.
Mu
scu
los
kele
tal
dis
ord
ers
cla
ss
ificati
on
Vascu
liti
s T
AB
LE
5.3
D
efi
nit
ion
s a
nd
cli
nic
al
fea
ture
s o
f m
ajo
r si
gn
s a
nd
sy
mp
tom
s se
en
in
mu
scu
losk
ele
tal
dis
ord
ers
—co
nt’
d
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Sample
proofs
@ Else
vier A
ustrali
a
115CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
TABLE 5.4 Disease mechanisms in musculoskeletal disorders and
examples of disease states for each category
Mechanism(s) Disorder(s)
Vascular HaematomaAvascular necrosisDeep vein thrombosis
Inflammatory/autoimmune Rheumatoid arthritisSystemic lupus erythematosusPsoriatic arthritisAnkylosing spondylitis
Infections OsteomyelitisSeptic arthritisInfective bursitis
Degenerative/genetic Osteoarthritis
Neoplastic Sarcoma (Ewing’s, chondrosarcoma and osteosarcoma)Soft tissue sarcoma
Trauma Fracture, soft tissue sprain, strain and contusion
Metabolic/nutritious/toxic Osteopenia
Arthritis
Osteoarthritis
Osteoarthritis (OA) is one of the primary causes of illness in the world, affecting 8% of the Australian population (AIHW 2015); hip and knee arthritis alone is a leading cause of global disability (Cross et al. 2014; Reid et al. 2014; Woolf & Pfleger 2003).
Pharmacological management
Oral treatment
Regular paracetamol is currently the recommended first-line treatment (see Table 5.11 later), and is combined with NSAIDs (see Table 5.12 later) if symptoms are not controlled with paracetamol alone. An anti-inflammatory dose of fish oil may also have benefit in osteoarthritis (Therapeutic Guidelines Limited 2010a).
However, a recent meta-analysis has indicated that the evidence for single therapy paracetamol is lacking, and has questioned its role as single therapy in the treatment of OA (da Costa et al. 2015).Topical treatment
Topical NSAIDs and capsaicin treatments (see Table 5.14 later) have been shown to improve short-term (up to 10 days) pain when compared to placebo rubs (Therapeutic Guidelines Limited 2010a).Intraarticular treatment
A single intraarticular corticosteroid injection can provide symptomatic relief for up to 4 weeks and up to 12 weeks in hip and trapeziometacarpal joint
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Sample
proofs
@ Else
vier A
ustrali
a
116 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
osteoarthritis (see Table 5.15 later). The effect of repeated doses appears to be less successful, and a general guide is that an individual joint should not be injected more than 4 times per year (Therapeutic Guidelines Limited 2010a).
These injections should only be given by, or under the supervision of, experienced clinicians. Local anaesthetic may be used before, or mixed with, the corticosteroid.
Only corticosteroids specifically formulated for the purpose should be used for intraarticular injection or injection into soft tissue.
Table 5.5 gives examples of appropriate doses. The dose must be adjusted to the specific requirements of the patient according to the size of the joint or soft tissue lesion, the severity of the condition, the response obtained and the patient’s tolerance of the corticosteroid. The total volume of the injection administered will vary depending on the amount of local anaesthetic (see Table 5.15).Other treatment
Patient uptake of the use of glucosamine sulfate and chondroitin sulfate for symptomatic benefit in osteoarthritis has been widespread despite limited
TABLE 5.5 Examples of doses of local corticosteroid injections
Corticosteroid
Dose
Comments
Small joint
(e.g. hand)
Medium
sized joint
(e.g. wrist)
Large joint
(e.g. knee)
Soft tissue
(e.g. bursa)
Betamethasone sodium phosphate + betamethasone acetate 5.7 mg/mL
0.5–1 mL 1 mL 1–2 mL 1–2 mL Usually used for injection into smaller joints
Methylprednisolone acetate 40 mg/mL
n/a 1 mL 1–2 mL 1–2 mL Methyprednisolone is crystalline and is formulated as a suspensionIt is not suitable for injection into small joints or superficial soft tissue sites, where it may cause fat atrophy and can be an irritantIt could be used in a large bursa such as a trochanteric bursa
Triamcinolone acetonide 10 mg/mL
0.5–1 mL 1 mL 1–2 mL 1–2 mL Triamcinolone acetonide is the least soluble injection and provides the longest duration of action (up to 21 weeks)
Triamcinolone acetonide 40 mg/mL
n/a n/a 0.5 mL n/a
Adapted from: Therapeutic Guidelines Limited, 2010. Joint aspiration and injection, Table 12.6. In: eTG complete [Internet]. Therapeutic Guidelines Limited, Melbourne.
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117CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
evidence (see Table 5.14 later). For patients with osteoarthritis of the knee who want to try alternative therapies a 3–6 month trial of glucosamine sulfate either with or without chondroitin sulfate may be indicated, although not strongly supported by evidence (Therapeutic Guidelines Limited 2010a; Towheed et al. 2005).
For patients who have uncontrolled pain and where surgery is pending or not possible, oral opioids may be tried (see Table 5.13 later). The risk of adverse effects is high and the benefit is minimal, so this approach must be made with caution (Therapeutic Guidelines Limited 2010a).
For further information see Chapter 7.
P H Y S I O T H E R A P Y P R A C T I C E P O I N T S : O S T E O A R T H R I T I S
It is common practice for corticosteroid injections to be used in conjunction with physiotherapy as a means of improving functional status, strength and range of movement while the patient is experiencing lower pain levels (Hawkins & Ghazi 2012; Jowett et al. 2013; Roddy et al. 2014). Physiotherapists are therefore directly involved in the care of patients post-injection. Patients are commonly advised to undertake gentle range of movement exercises of the injected joint 0–48 hours after the injection as this will assist with the circulation of the corticosteroid around the joint. There is variability in the post-injection advice, depending on site/structure injected, however generally patients should be advised to avoid any heavy activity for 5–7 days post-injection (Brukner & Khan 2012). This is particularly important as it is possible that patients will feel significantly better post-injection and therefore are likely to increase their activity levels. Outcomes from corticosteroid injections are mixed: they are used to provide short-term relief (1–6 weeks), but no long-term benefit is evident in the majority of cases (Jüni et al. 2015).
It is widely accepted that exercise is an essential component of OA management, in which physiotherapists play a significant role (French et al. 2013). Depending on the pain medication of the patient, the physiotherapist can provide guidance regarding the best time to undertake exercise in accordance with the efficacy of the pain medication – for specific information regarding the duration of action of pain medications see Tables 5.11, 5.12, 5.13 and 5.14.
Septic arthritis
Definition
Septic arthritis is an infection of a joint that may be bacterial, fungal, mycobacterial or viral in origin (Carpenter et al. 2011).
Clinical significance
Permanent disability and increased mortality are associated with a delayed diagnosis of septic arthritis. In the presence of infection the cartilage of the joint can be destroyed in a matter of days if antibiotic management is not commenced (Carpenter et al. 2011).
Pharmacological management
Diagnostic specimens should always be taken before starting antibiotic therapy. Pus should be drained and the joint irrigated to reduce the pathogen load, protect the articular surface and improve the diffusion of the antibiotic into the joint.
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118 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Empirical therapy is the same as what would be used in long bone osteomyelitis (see ‘Osteomyelitis’ below). Directed therapy should then be guided by microbiology results of cultures and susceptibility testing from the aspirate.
Once directed therapy starts, antibiotic therapy must continue for the following duration (Therapeutic Guidelines Limited 2010c):◆ neonate – 3 weeks (all IV therapy)◆ child – 3 weeks (minimum of 3 days of IV therapy)◆ adult – 4 weeks (minimum of 2 weeks of IV therapy).
Rheumatoid arthritis and other synovial joint disorders
Rheumatoid arthritis
Definition
Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory, progressive, autoimmune disease, with joint synovitis as its predominant clinical manifestation (Breedland et al. 2011; Iversen, Chhabriya & Shadick 2011).
Clinical significance
RA affects around 400,000 Australians and is the second most common type of arthritis, after osteoarthritis. The disease is more common among females and in older age groups (AIHW 2009). Further tests including blood tests and imaging are required to confirm a diagnosis of RA.
Pharmacological management
Rheumatoid arthritis treatment can be described in four groups as listed in Table 5.6 below.
Recommendations for treatment of early RA are described in Figure 5.4. For further pain management information see Chapter 7.
Figures 5.4 and 5.5 detail recommendations for the progression of medications in the management of early RA (under 6 months), first-line treatments and when medications should be increased or changed according to the patient’s prognosis and the disease activity. Specifically, Figure 5.5 highlights the ‘2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis’ (Singh et al. 2012).
Psoriatic arthritis
Definition and clinical significance
Psoriatic arthritis (PsA) is a chronic, systemic inflammatory disease, classified as a seronegative spondyloarthropathy (Cinar et al. 2015). Sufferers of psoriasis include 1–3% of the population of the world, and 42% go on to develop psoriatic arthritis. It is therefore estimated that PsA has a prevalence of 0.1–1.0% in the general population (Mease & Armstrong 2014).
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119CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
TABLE 5.6 Medication management of rheumatoid arthritis (RA)
Class of treatment
Examples of
medications used Place in therapy, extra information
Disease-modifying antirheumatic drugs (DMARDs)
Methotrexate (MTX)Hydroxychloroquine (HCQ)SulfasalazineLeflunomide (LEF)Cyclosporin
Reduce or resolve synovial inflammation and therefore prevent joint damageCan be used alone or in combination and all have dose limiting side effectsChoice depends on arthritis severity, patient’s age, childrearing status and coexisting conditions
Corticosteroids Prednisolone/prednisone (prednis(ol)one)HydrocortisoneBetamethoasoneOrtisoneDexamethasoneMethylprednisoloneTriamcinolone
Used while waiting for a response from a DMARD or to achieve remission quickly, either as pulse oral, intravenous or intramuscular therapy or as intraarticular therapyLong-term significant adverse effects (e.g. cardiovascular and osteoporosis) that limit long-term use
Biological disease-modifying antirheumatic drugs (DMARDs)
AbataceptAdalimumabCertolizumabEtanerceptGolimumabInfliximabTocilizumabAnakinra
Are considered if remission is not achieved with the appropriate use of DMARDsShould only be used under the supervision of experienced specialists, and the Australian Rheumatology Association has specific recommendations for when and how they are to be used (Australian Rheumatology Association 2011)Before commencing treatment patients must be screened for tuberculosis and hepatitis B and C as the immunosuppression caused by DMARDs can cause these diseases to re-emerge
Symptom management NSAIDs NSAIDs improve symptoms of RA, but do not reduce joint damage and have significant adverse effectsUsed before DMARD therapy is started or intermittently during flare-ups
Fish oil Has been shown to reduce symptoms and the need for NSAIDs and may also give cardiovascular protection
Analgesia (paracetamol and opiates)
Should be used to facilitate activity rather than to relieve painParacetamol should be used to reduce the NSAID loadOpiates should only be added if paracetamol and NSAIDS do not adequately control pain or ability to function or exercise and should only be used for a fixed short period of time such as 3 weeksSee Chapter 7 for more detail
NSAIDs, non-steroidal anti-inflammatory drugs.Adapted from: Therapeutic Guidelines Limited, 2010. Rheumatoid arthritis: pharmacological management. In: eTG complete [Internet]. Therapeutic Guidelines Limited, Melbourne. See Table 5.19 later for further information.
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120 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Figure 5.4 American College of Rheumatology recommendations in the treatment of early rheumatoid arthritis (disease duration less than 6 months). Adapted with permission from: Singh, J.A., Furst, D.E., Bharat, A., et al., 2012. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis (RA). Arthritis Care and Research 64 (5), 625–639.
DMARDmonotherapy
CombinationDMARDtherapy
(double andtriple therapy)
DMARDmonotherapy
OrHCQ and MTX
Anti-TNF with orwithout MTX
OrCombination
DMARD therapy(double and triple
therapy)
Targetlow
diseaseactivity orremission
Low High
Moderate
WithWithout WithWithoutFeatures of poorprognosis
Disease activityEarly RA
Features of poorprognosis
Pharmacological management
NSAIDs and intraarticular corticosteroid injections are usually first line, with DMARDs used in resistant cases (see Tables 5.12 and 5.15). In polyarticular cases DMARDs are always used (see Tables 5.18 and 5.19 later). Fish oil is also used as an NSAID-sparing agent, as recommended in the Australian Therapeutic Guidelines (Therapeutic Guidelines Limited 2010e).
Methotrexate is the DMARD of choice in psoriatic arthritis as it benefits both the arthritis and the skin. It is given either orally, subcutaneously or intramuscularly, but always with folic acid supplementation (see Table 5.18 later for further information). There is also evidence to support the use of sulfasalazine, leflunomide and cyclosporin for this indication.
In cases where DMARDs are poorly tolerated or not effective, good evidence supports the use of the tumour necrosis factor (TNF) inhibitors adalimumab, etanercept, golimumab and infliximab – see Table 5.19 (Therapeutic Guidelines Limited 2010f).
For further pain management information see Chapter 7.
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121CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Figure 5.5 Recommendations for the use of disease-modifying anti-rheumatic medications and biologic agents in the treatment of RA. DMARD, disease-modifying anti rheumatic drugs; HCQ, hydroxychloroquine; LEF, leflunomide; MTX, methotrexate; TNF, tumour necrosis factor. Adapted with permission from: Singh, J.A., Furst, D.E., Bharat, A., et al., 2012. 2012 update of the 2008 American College of Rheumatology recommendations for the use of disease-modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis (RA). Arthritis Care and Research 64 (5), 625–639.
Switch to anti-TNF biologics or non-TNF biologics
Reassess orif any adverse
event
Reassess orif non-seriousadverse event
Add or switch toabatacept orrituximab
MTX monotherapy or combination DMARD therapy(including double or triple therapy)
DMARD monotherapy
Reassess
Add MTX, HCQ orLEF
(as appropriate)
Add orswitch toanotherDMARD
Switch to another type or category of anti-TNF or non-TNF biologics
Switch to a non-TNFbiologic
Add or switch to anti-TNF biologics
If seriousadverse event
Reassess
Low disease activitywith poor prognosis or
moderate/highdisease activity
Low disease activitywithout
poor prognosis
Reassess
Reassess
Reassess
Crystal arthropathies
Gout
Definition
Gout is an inflammatory disorder characterised by the deposition of monosodium urate (MSU) crystals in articular and peri-articular structures (Punzi et al. 2012). It is often associated with co-morbidities such as cardiovascular disease, chronic kidney disease, obesity and type 2 diabetes (Robinson & Horsburgh 2014).
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122 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Further tests to confirm diagnosis include blood tests to ascertain the presence of raised urate and analysis of joint aspirate.Pharmacological management
Management involves providing rapid pain relief for acute attacks, preventing further attacks and preventing the complications of gout such as the formation of gouty tophi and destructive arthritis.
Acute gout treatment focuses on treating the inflammation only, with the following agents used:◆ NSAIDs with indomethacin being the agent of choice (see Table 5.12 later)◆ colchicine – use is limited by adverse effects (see Table 5.17 later)◆ corticosteoids, oral or intraarticular (if more than one joint is involved or
NSAIDs are contraindicated) – see Table 5.15.Any changes to allourinol or probenecid therapy must be avoided during an
attack, as sudden changes in uric acid concentrations can precipitate further acute attacks.
Urate lowering therapy with allopurinol can be commenced once the attack has settled and appropriate lifestyle factors or medication changes have been made. The aim is to reduce the plasma urate level to <0.3 mmol/L, and monthly blood test are recommended to allow appropriate dose adjustment. During the initiation and dose titration period, concurrent treatment with cholchicine or an NSAID is recommended to prevent an acute exacerbation. Oral prednis(ol)one can be used in patients in whom NSAID or colchicine is contraindicated (Therapeutic Guidelines Limited 2010g).
Some patients do develop an asymptomatic hyperuricaemia due to genetic factors, medication or concurrent medical problems. These patients should not be treated with urate lowering therapy unless they develop gout symptoms (Therapeutic Guidelines Limited 2010g).
For further pain management information see Chapter 7.
Joint conditions
Adhesive capsulitis
Definition
A disorder that affects the capsule of the glenohumeral joint, it is generally accepted that adhesive capsulitis is divided into three stages: 1) the painful stage, 2) the adhesive phase and 3) the resolution stage (Walmsley, Osmotherly & Rivett 2014).
Pharmacological management
Analgesia
Simple oral analgesic such as paracetamol and NSAIDs should be used first line (see Tables 5.11 and 5.12). Limited evidence suggests that topical NSAIDs are not effective in adhesive capsulitis. If pain persists despite simple analgesia, and it is interfering with the activities of daily living, immediate release opioids (codeine, tramadol or oxycodone) can be considered for short-term use, with an active
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fect
sC
OX-
2 in
hibi
tion
caus
es
anti-
infla
mm
ator
y an
d an
alge
sic
actio
nA
redu
ctio
n in
re
nal f
unct
ion
occu
rs w
ith b
oth
CO
X-1
and
CO
X-2
inhi
bitio
nM
ost N
SAID
s ar
e no
n-se
lect
ive
(inhi
bitin
g bo
th
CO
X-1
and
CO
X-2)
Pain
due
to
infla
mm
atio
n,
tissu
e in
jury
and
in
flam
mat
ory
arth
ropa
thie
s
Nau
sea,
dys
peps
ia, G
I ul
cera
tion
or b
leed
ing,
ra
ised
live
r enz
ymes
(e
spec
ially
dic
lofe
nac)
, di
arrh
oea,
hea
dach
e,
dizz
ines
s, s
alt a
nd fl
uid
rete
ntio
n, h
yper
tens
ion
Use
pre
caut
ion
in p
atie
nts
with
th
e fo
llow
ing:
• ca
rdio
or c
ereb
rova
scul
ar
dise
ase
• ac
tive
GIT
dis
ease
• hi
stor
y of
NSA
ID-in
duce
d hy
pers
ensi
tivity
reac
tions
• pr
e-ex
istin
g re
nal d
isea
se, o
r co
ncur
rent
use
of n
ephr
otoc
xic
med
icat
ions
• he
patic
• el
derly
• de
hydr
atio
n•
asth
ma
• co
agul
atio
n di
sord
ers
or
conc
urre
nt a
ntic
oagu
lant
or
antip
late
let m
edic
atio
ns•
preg
nanc
y an
d br
east
feed
ing
Dos
e re
duct
ion
may
be
re
quire
d in
:•
rena
l dis
ease
• he
patic
dis
ease
• el
derly
Very
littl
e di
ffere
nce
in
anti-
infla
mm
ator
y re
spon
se
betw
een
diffe
rent
NSA
IDs,
so
choi
ce o
f age
nt d
epen
ds o
n in
divi
dual
resp
onse
and
tole
ranc
eTh
ere
is n
o ra
tiona
le fo
r usi
ng
mor
e th
an o
ne N
SAID
at a
tim
e (e
xclu
ding
low
-dos
e as
pirin
)
Ce
lec
ox
ib
Adul
t ora
l:20
0–30
0 m
g da
ily in
1–2
dos
esD
o no
t use
>20
0 m
g da
ily lo
ng te
rmH
alf-l
ife: 4
–15
hour
sD
iclo
fen
ac
Adul
t ora
l/rec
tal:
75–1
50 m
g da
ily in
2 o
r 3 d
oses
(max
imum
20
0 m
g da
ily)
Chi
ld >
1 ye
ar o
ral/r
ecta
l:0.
5–1
mg/
kg (m
axim
um 5
0 m
g) 2
or 3
tim
es
daily
Topi
cal:
1% g
el, r
ub in
to th
e af
fect
ed a
rea
3 or
4
times
dai
lyH
alf-l
ife:1
–2 h
ours
Eto
ric
ox
ib
Adul
t ora
l:30
–120
mg
once
dai
lyH
alf-l
ife: 2
2 ho
urs
Ibu
pro
fen
Adul
t ora
l:20
0–40
0 m
g 3
or 4
tim
es a
day
(max
imum
2.
4 g
daily
)C
hild
>3
mon
ths,
ora
l:5–
10 m
g/kg
(max
imum
400
mg)
3 o
r 4
times
a d
ay.
Topi
cal a
dult,
chi
ld >
12 y
ears
:ru
b 4–
10 c
m in
to th
e af
fect
ed a
rea
if ne
eded
, up
to 4
tim
es d
aily
T
AB
LE
5.1
2
De
tail
ed
de
scri
pti
on
of
no
n-s
tero
ida
l a
nti
-in
fla
mm
ato
rie
s (N
SA
IDS
)
%�&��'()*+)(,������-(����"�������*+. 0121).*/���34+64.3��5
����������������� ������������� ����������� ����������������������� ������ ����������������������������������� ���� �� ������������������� ���������� ������������ ��� � �������������� �������������!� �� ��"�#��� ��������������������� ��� ����������������� ��������"��� ������������ � ����������������������� �������� �������� ���$�������������������������������"
Sample
proofs
@ Else
vier A
ustrali
a
141CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Cont
inue
d
Med
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
eC
om
mo
n s
ide
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
CO
X-2
sele
ctiv
e in
hibi
tors
hav
e m
inim
al e
ffect
on
CO
X-1,
but
they
ar
e st
ill as
soci
ated
w
ith G
I sid
e ef
fect
s at
ther
apeu
tic
dose
s
Abou
t 60%
of p
atie
nts
will
resp
ond
to a
ny N
SAID
; tho
se
who
do
not r
espo
nd to
one
may
re
spon
d to
ano
ther
To re
duce
com
plic
atio
ns:
• try
a to
pica
l NSA
ID b
efor
e us
ing
one
oral
ly•
use
the
low
est e
ffect
ive
dose
fo
r the
sho
rtest
per
iod
of ti
me
• us
e pa
race
tam
ol to
ena
ble
low
er d
oses
of N
SAID
Hal
f-life
:2–2
.5 h
ours
Ind
om
eth
ac
in
Adul
t ora
l:25
–50
mg
2–4
times
dai
lyAd
ult r
ecta
l:10
0 m
g on
ce o
r tw
ice
daily
Chi
ld o
ral:
Initi
ally
0.5
–1 m
g/kg
twic
e da
ily (m
axim
um
of 4
mg/
kg)
Hal
f-life
: 4.5
–6 h
ours
Ke
top
rofe
n
Adul
t, or
al:
200
mg
once
dai
lyAd
ult,
rect
al:
100
mg
at b
edtim
eTo
pica
l:Ap
ply
to th
e af
fect
ed a
rea
2–4
times
dai
lyH
alf-l
ife: 1
.5–2
hou
rsK
eto
rala
c
Adul
t, IM
/IV:
10 m
g fo
llow
ed b
y 10
–30
mg
ever
y 4–
6 ho
urs
(max
imum
90
mg
daily
)Ad
ult,
oral
:10
mg
ever
y 4–
6 ho
urs
(max
imum
40
mg
daily
)H
alf-l
ife: 4
–6 h
ours
Me
fen
am
ic a
cid
Adul
t, or
al:
Up
to 5
00 m
g 3
times
dai
lyH
alf-l
ife: 3
–4 h
ours
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����������������� ������������� ����������� ����������������������� ������ ����������������������������������� ���� �� ������������������� ���������� ������������ ��� � �������������� �������������!� �� ��"�#��� ��������������������� ��� ����������������� ��������"��� ������������ � ����������������������� �������� �������� ���$�������������������������������"
Sample
proofs
@ Else
vier A
ustrali
a
142 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Med
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
eC
om
mo
n s
ide
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
Me
lox
ica
m
Adul
t, or
al:
7.5–
15 m
g on
ce d
aily
Hal
f-life
: 20
hour
sN
ap
rox
en
Adul
t, or
al:
Con
vent
iona
l pro
duct
, 250
–500
mg
twic
e da
ilyC
ontro
lled
rele
ase
prod
uct,
750–
1000
mg
once
dai
ly (u
p to
a m
axim
um o
f 125
0 m
g da
ily)
Chi
ld >
2 ye
ars,
ora
l:5–
7.5
mg/
kg (m
axim
um 5
00 m
g) tw
ice
daily
Hal
f-life
: 12–
15 h
ours
Pa
rec
ox
ib
Adul
t, IM
/IV:
40 m
g si
ngle
dos
eH
alf-l
ife: 6
.5–7
hou
rs (a
ctiv
e m
etab
olite
)P
iro
xic
am
Adul
t, or
al:
10–2
0 m
g on
ce d
aily
, usu
ally
for n
o m
ore
than
14
days
Topi
cal:
Appl
y to
the
affe
cted
are
a 3
or 4
tim
es
daily
.H
alf-l
ife: 3
0–50
hou
rsS
ulin
da
c
Adul
t, or
al:
200–
400
mg
daily
in 1
or 2
dos
esH
alf-l
ife:1
6 ho
urs
(act
ive
met
abol
ite)
Adap
ted
from
: Aus
tralia
n M
edic
ines
Han
dboo
k Pt
y Lt
d, 2
015.
Aus
tralia
n M
edic
ines
Han
dboo
k (o
nlin
e). A
ustra
lian
Med
icin
es H
andb
ook
Pty
Ltd,
Ade
laid
e. <
http
://am
honl
ine.
amh.
net.a
u/>.
T
AB
LE
5.1
2
De
tail
ed
de
scri
pti
on
of
no
n-s
tero
ida
l a
nti
-in
fla
mm
ato
rie
s (N
SA
IDS
)—co
nt’
d
%�&��'()*+)(,������-(����"�������*+) 0121).*/���34+64.3��5
����������������� ������������� ����������� ����������������������� ������ ����������������������������������� ���� �� ������������������� ���������� ������������ ��� � �������������� �������������!� �� ��"�#��� ��������������������� ��� ����������������� ��������"��� ������������ � ����������������������� �������� �������� ���$�������������������������������"
Sample
proofs
@ Else
vier A
ustrali
a
143CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMS
Med
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
e
Co
mm
on
sid
e
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
CL
AS
S:
Op
ioid
s
Op
ioid
s u
sed
in
MS
K
co
nd
itio
ns:
Cod
eine
Dex
tropr
opox
yphe
neFe
ntan
ylM
orph
ine
Oxy
codo
neTr
amad
ol
Activ
ate
opio
id
rece
ptor
s in
the
cent
ral a
nd
perip
hera
l ne
rvou
s sy
stem
s to
pr
oduc
e an
alge
sia,
re
spira
tory
de
pres
sion
, se
datio
n an
d co
nstip
atio
n
Acut
e or
chr
onic
pa
inN
ause
a an
d vo
miti
ng,
dysp
epsi
a,
drow
sine
ss,
dizz
ines
s,
head
ache
, or
thos
tatic
hy
pote
nsio
n,
itch,
dry
mou
th,
mio
sis,
urin
ary
rete
ntio
n,
cons
tipat
ion
Use
with
cau
tion
in th
e fo
llow
ing
patie
nt g
roup
s:•
unco
rrect
ed e
ndoc
rine
abno
rmal
ities
, hy
poth
yroi
dism
, adr
enoc
ortic
al
insu
ffici
ency
, acu
te a
lcoh
olis
m,
mya
sthe
nia
grav
is, C
NS
depr
essi
on•
epile
psy
or a
reco
gnis
ed ri
sk fo
r se
izur
e•
rais
ed in
tracr
ania
l pre
ssur
e•
hypo
tens
ion,
sho
ck•
phae
ochr
omoc
ytom
a•
gast
roin
test
inal
ileu
s•
resp
irato
ry d
epre
ssio
n•
rena
l im
pairm
ent
• he
patic
impa
irmen
t•
elde
rly•
preg
nanc
y an
d br
east
feed
ing
Avai
labl
e in
man
y di
ffere
nt d
ose
form
s (im
med
iate
rele
ase,
slo
w re
leas
e,
mix
ture
s, ta
blet
s, s
ache
ts, c
apsu
les)
; ta
ke c
are
to a
lway
s se
lect
the
corre
ct
dose
form
Alw
ays
use
a re
gula
r lax
ativ
e fo
r pe
ople
requ
iring
regu
lar o
pioi
ds to
pr
even
t con
stip
atio
nPh
ysic
al d
epen
denc
e is
com
mon
Rec
omm
ende
d do
ses
are
for t
hose
th
at a
re o
pioi
d na
ive
Patie
nts
with
a h
isto
ry o
f opi
oid
use
may
requ
ire h
ighe
r dos
es
Co
de
ine
Adul
t, or
al:
30–6
0 m
g ev
ery
4 ho
urs
if ne
eded
(max
imum
24
0 m
g in
24
hour
s)C
hild
>1
year
, ora
l:0.
5–1
mg/
kg e
very
4–6
hou
rs if
nee
ded
(max
imum
24
0 m
g in
24
hour
s)D
urat
ion
of a
ctio
n: 3
–4 h
ours
Prac
tice
poin
ts:
• av
aila
ble
in fi
xed
dose
com
bina
tions
with
asp
irin,
ib
upro
fen
and
para
ceta
mol
• co
dein
e (a
pro
drug
) is
met
abol
ised
to m
orph
ine;
pe
ople
with
nor
mal
cod
eine
met
abol
ism
m
etab
olis
e 30
mg
of c
odei
ne to
app
roxi
mat
ely
4.5
mg
of m
orph
ine
• m
etab
olis
ed b
y C
YP2D
6 w
hich
has
gen
etic
va
riatio
n, re
sulti
ng in
som
e pa
tient
s be
ing
ultra
-rapi
d m
etab
olis
ers
incr
easi
ng th
eir r
isk
of
toxi
city
and
som
e be
ing
slow
met
abol
iser
s w
ho
do n
ot m
etab
olis
e su
ffici
ent c
odei
ne to
hav
e a
bene
ficia
l effe
ct
T
AB
LE
5.1
3
De
tail
ed
de
scri
pti
on
of
op
ioid
s
Cont
inue
d
%�&��'()*+)(,������-(����"�������*+3 0121).*/���34+64.3��5
����������������� ������������� ����������� ����������������������� ������ ����������������������������������� ���� �� ������������������� ���������� ������������ ��� � �������������� �������������!� �� ��"�#��� ��������������������� ��� ����������������� ��������"��� ������������ � ����������������������� �������� �������� ���$�������������������������������"
Sample
proofs
@ Else
vier A
ustrali
a
144 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Med
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
e
Co
mm
on
sid
e
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
De
xtr
op
rop
ox
yp
he
ne
pra
cti
ce
po
ints
Do
not u
se b
ecau
se:
• ev
iden
ce fo
r use
is la
ckin
g; n
o be
nefit
ove
r reg
ular
par
acet
amol
w
hen
used
in c
ombi
natio
n w
ith
regu
lar p
arac
etam
ol•
regu
lar u
se m
ay le
ad to
ac
cum
ulat
ion
of a
nd th
e ca
rdio
toxi
c no
rdex
tropr
opox
yphe
ne•
very
toxi
c in
acu
te o
verd
osag
e•
regu
lar m
onito
ring
of re
nal f
unct
ion
and
ECG
s m
ust b
e pe
rform
ed
De
xtr
op
rop
ox
yp
he
ne
:Ad
ult,
oral
:10
0 m
g ev
ery
4 ho
urs
whe
n ne
cess
ary
(max
imum
60
0 m
g da
ily)
All p
rodu
cts
have
bee
n w
ithdr
awn
from
the
mar
ket
in s
ever
al c
ount
ries
due
to s
afet
y co
ncer
ns; i
t is
still
avai
labl
e in
Aus
tralia
, but
rest
rictio
ns fo
r pre
scrib
ing
exis
t (ht
tp://
ww
w.tg
a.go
v.au
.atla
ntis
2.an
u.ed
u.au
:204
8/al
ert/
dext
ropr
opox
yphe
ne-p
ain-
kille
rs-c
onta
inin
g-de
xtro
prop
oxyp
hene
-di-g
esic
-and
-dol
oxen
e-10
-oc
tobe
r-201
3)
Fe
nta
ny
l p
rac
tic
e p
oin
ts
Also
ava
ilabl
e in
pat
ch a
nd lo
zeng
e fo
rm, w
hich
are
use
d in
chr
onic
pai
n
Fe
nta
ny
l – a
cu
te p
ain
:Fo
r use
in c
hron
ic p
ain
(see
Cha
pter
7)
Adul
t, su
bcut
aneo
us:
Ag
e (
ye
ars
)In
itia
l d
os
e (
in m
cg
)
ev
ery
4 h
ou
rs a
s r
eq
uir
ed
<39
100–
200
40–5
975
–150
60–6
940
–100
70–8
540
–75
>85
year
s30
–50
Intra
nasa
l, ch
ild 1
–12
year
s:1.
5 m
cg/k
g (m
axim
um 1
00 m
cg);
if ne
eded
, a
seco
nd d
ose
of 0
.75–
1.5
mcg
/kg
(max
imum
10
0 m
cg) m
ay b
e gi
ven
afte
r 5–1
0 m
inut
esD
urat
ion
of a
ctio
n: 0
.5–2
hou
rs
T
AB
LE
5.1
3
De
tail
ed
de
scri
pti
on
of
op
ioid
s—co
nt’
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Sample
proofs
@ Else
vier A
ustrali
a
145CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMSM
ed
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
e
Co
mm
on
sid
e
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
Mo
rph
ine
pra
cti
ce
po
ints
Peak
ana
lges
ia fo
llow
ing
a do
se o
f m
orph
ine
occu
rs w
ithin
:•
60 m
inut
es a
fter c
onve
ntio
nal o
ral
liqui
d•
50–9
0 m
inut
es a
fter S
C in
ject
ion
(30–
60 m
inut
es a
fter I
M)
• 20
min
utes
afte
r IV
inje
ctio
nD
o no
t use
con
trolle
d re
leas
e pr
oduc
ts
for a
cute
pai
n m
anag
emen
tAv
oid
use
in re
nal i
mpa
irmen
t due
to
accu
mul
atio
n of
toxi
c m
etab
olite
Mo
rph
ine
– a
cu
te p
ain
:Fo
r use
in c
hron
ic p
ain
(see
Cha
pter
7)
Adul
t, ch
ild >
50 k
g, IV
:In
itial
ly, 0
.5–2
mg;
repe
at e
very
3–5
min
utes
and
tit
rate
as
abov
eAd
ult,
child
>50
kg,
SC
/IM:
Ag
e (
ye
ars
)In
itia
l d
os
e (
in m
g)
ev
ery
2 h
ou
rs a
s r
eq
uir
ed
<39
7.5–
12.5
40–5
95–
10
60–6
92.
5–7.
5
70–8
52.
5–5
>85
year
s2–
3
Adul
t, or
al:
Do
not u
se c
ontro
lled
rele
ase
prod
ucts
for t
reat
men
t of
acu
te p
ain
Con
vent
iona
l ora
l pro
duct
, ini
tially
5–1
5 m
g ev
ery
4 ho
urs
Chi
ld (1
–12
year
s an
d <5
0 kg
):IV
infu
sion
: ini
tially
0.0
2–0.
04 m
g/kg
/hou
rIV
bol
us: i
nitia
lly 0
.05
mg/
kg (o
ver a
t lea
st 5
m
inut
es) e
very
2 h
ours
Subc
utan
eous
: 0.1
–0.2
mg/
kg e
very
4 h
ours
Dur
atio
n of
act
ion:
2–4
hour
s (in
ject
ion,
imm
edia
te re
leas
e ta
blet
and
liq
uid)
12–2
4 ho
urs (
mod
ified
rele
ase
tabl
ets a
nd su
spen
sion)
Cont
inue
d
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Sample
proofs
@ Else
vier A
ustrali
a
146 PHARMACOLOGY HANDBOOK FOR PHYSIOTHERAPISTS
Med
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
e
Co
mm
on
sid
e
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
Ox
yc
od
on
e p
rac
tic
e p
oin
ts
May
be
tried
as
an a
ltern
ativ
e op
ioid
fo
r pat
ient
s in
tole
rant
of m
orph
ine
Do
not u
se c
ontro
lled
rele
ase
tabl
ets
for a
cute
pai
n as
slo
w o
nset
and
offs
et
mak
e ra
pid,
saf
e tit
ratio
n im
poss
ible
Ox
yc
od
on
e –
ac
ute
pa
in:
(For
use
in c
hron
ic p
ain
see
Cha
pter
7)
Adul
t IV:
0.5–
2 m
g; re
peat
eve
ry 3
–5 m
inut
esAd
ult,
subc
utan
eous
:
Ag
e (
ye
ars
)In
itia
l d
os
e (
in
mg
) e
ve
ry 2
ho
urs
<39
7.5–
12.5
40–5
95–
10
60–6
92.
5–7.
5
70–8
52.
5–5
>85
year
s2–
3
Adul
t, or
al:
Do
not u
se c
ontro
lled
rele
ase
tabl
ets
for t
reat
men
t of
acu
te p
ain
Con
vent
iona
l ora
l pro
duct
: ini
tially
5–1
5 m
g ev
ery
4 ho
urs
Acut
e pa
in: c
hild
>1
year
,C
onve
ntio
nal o
ral p
rodu
ct: i
nitia
lly 0
.1–0
.2 m
g/kg
(m
axim
um 5
mg)
eve
ry 4
–6 h
ours
Dur
atio
n of
act
ion:
3–4
hour
s (in
ject
ion,
imm
edia
te re
leas
e ta
blet
s,
caps
ules
and
ora
l liq
uid)
12 h
ours
mod
ified
rele
ase
prod
ucts
T
AB
LE
5.1
3
De
tail
ed
de
scri
pti
on
of
op
ioid
s—co
nt’
d
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Sample
proofs
@ Else
vier A
ustrali
a
147CHAPTER 5 ORTHOPAEDIC AND MUSCULOSKELETAL SYSTEMSM
ed
icati
on
Mech
an
ism
of
acti
on
Ind
ica
tio
ns
fo
r
the
rap
eu
tic
us
e
Co
mm
on
sid
e
eff
ec
tsP
rac
tic
e p
oin
tsC
om
mo
n a
du
lt, c
hild
do
sa
ge
ra
ng
es
Tra
ma
do
l p
rac
tic
e p
oin
ts
Anal
gesi
c ef
fect
sta
rts w
ithin
1 h
our o
f or
al a
dmin
istra
tion
and
peak
s at
2–
4 ho
urs
Do
not u
se c
ontro
lled
rele
ase
prod
ucts
fo
r acu
te p
ain
man
agem
ent
6–10
% o
f Cau
casi
ans
and
1–2%
of
Asia
ns la
ck th
e en
zym
e C
YP2D
6;
thes
e pe
ople
may
obt
ain
redu
ced
anal
gesi
a w
ith tr
amad
olR
educ
e do
se in
rena
l, he
patic
im
pairm
ent a
nd th
e el
derly
Tra
ma
do
l
Adul
t, IV
/IM:
50–1
00 m
g ev
ery
4–6
hour
s, u
p to
a to
tal d
aily
dos
e of
600
mg
Adul
t, or
al (c
onve
ntio
nal p
rodu
ct):
50–1
00 m
g ev
ery
4–6
hour
s w
hen
nece
ssar
y (m
axim
um 4
00 m
g da
ily o
r 300
mg
daily
if
>75
year
s)Ad
ult,
oral
(12-
hour
con
trolle
d re
leas
e pr
oduc
t):50
–200
mg
ever
y 12
hou
rs (m
axim
um 4
00 m
g )
Chi
ld >
1 ye
ar, o
ral (
conv
entio
nal p
rodu
ct:
On
ly u
se
d in
ch
ild
ren
un
de
r s
pe
cia
lis
t
su
pe
rvis
ion
1–2
mg/
kg e
very
4 h
ours
whe
n ne
cess
ary
(max
imum
400
mg)
Dur
atio
n of
act
ion:
3–6
hour
s (im
med
iate
rele
ase
caps
ules
and
in
ject
ions
)12
–24
hour
s m
odifi
ed re
leas
e ta
blet
s
CN
S, c
entra
l ner
vous
sys
tem
; MSK
, mus
culo
skel
etal
.Ad
apte
d fro
m: A
ustra
lian
Med
icin
es H
andb
ook
Pty
Ltd,
201
5. A
ustra
lian
Med
icin
es H
andb
ook
(onl
ine)
. Aus
tralia
n M
edic
ines
Han
dboo
k Pt
y Lt
d, A
dela
ide.
<ht
tp://
amho
nlin
e.am
h.ne
t.au/>.
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Sample
proofs
@ Else
vier A
ustrali
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