Industrial Medicine and Acute Musculoskeletal Rehabilitation. 2. Medications for the Treatment of Acute Musculoskeletal Pain

Carolinas Medical Center University, Charlotte, North Carolina, United States
Archives of Physical Medicine and Rehabilitation (Impact Factor: 2.57). 04/2007; 88(3 Suppl 1):S10-3. DOI: 10.1016/j.apmr.2006.12.009
Source: PubMed


This self-directed learning module highlights medications used in the treatment of acute musculoskeletal pain in the context of industrial rehabilitation. It is part of the study guide on industrial rehabilitation medicine and acute musculoskeletal rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article compares various skeletal muscle relaxants, addresses issues related to nonsteroidal anti-inflammatory medications, provides an algorithm for acute pain management in an injured worker, and discusses topical medications for the treatment of pain. OVERALL ARTICLE OBJECTIVE: To summarize medication options in the treatment of acute musculoskeletal pain in the setting of injured workers.

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    • "It was first synthesized in 1961, and, in 1977, the 10 mg dose was approved as an adjunct to rest and physical therapy for the relief of muscle spasm associated with acute painful musculoskeletal conditions, influencing both gamma (γ) and alpha (α) motor systems [1–4]. However, the sedation produced at this dose limited its use until 2003, when the efficacy of cyclobenzaprine hydrochloride 5 mg was established in two well-designed clinical studies [2, 5]. "
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    ABSTRACT: The purpose of this study was to investigate cyclobenzaprine pharmacokinetics and to evaluate bioequivalence between two different tablet formulations containing the drug. An open, randomized, crossover, single-dose, two-period, and two-sequence design was employed. Tablets were administered to 23 healthy subjects after an overnight fasting and blood samples were collected up to 240 hours after drug administration. Plasma cyclobenzaprine was quantified by means of an LC-MS/MS method. Pharmacokinetic parameters related to absorption, distribution, and elimination were calculated. Cyclobenzaprine plasma profiles for the reference and test products were similar, as well as absorption pharmacokinetic parameters AUC (reference: 199.4 ng ∗ h/mL; test: 201.6 ng ∗ h/mL), Cmax (reference: 7.0 ng/mL; test: 7.2 ng/mL), and T max (reference: 4.5 h; test: 4.6 h). Bioequivalence was evaluated by means of 90% confidence intervals for the ratio of AUC (93%-111%) and C max (93%-112%) values for test and reference products, which were within the 80%-125% interval proposed by FDA. Cyclobenzaprine pharmacokinetics can be described by a multicompartment open model with an average rapid elimination half-life (t (1/2)β ) of 3.1 hours and an average terminal elimination half-life (t (1/2)γ ) of 31.9 hours.
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    ABSTRACT: This article provides a review for current practice. Strict guidelines are not available on some topics, and they may never be drafted because pain is such a unique individual experience. It is recommended to coordinate care with other medical specialties when patients present with organ dysfunctions or are at the extremes of age. More data are required in the field of pain management, particularly with regard to renal and hepatic dysfunction. In turn, these data serve as a foundation for physicians making practice decisions based on current evidence. Until this is achieved, clinicians must rely on anecdotal evidence and the experiences of others to treat a complex issue: pain.
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    ABSTRACT: Topical formulations of non-steroidal anti-inflammatory drugs (NSAIDs), in particular diclofenac (DI), have become popular for treating various acute and chronic painful inflammatory conditions. To perform a literature review of (1) the use of topical NSAIDs; (2) the pharmaceutical, pharmacokinetic and pharmacodynamic properties of a medicated plaster (patch) containing diclofenac epolamine (DI-EP, Flector Tissugel, Flector patch) compared with other formulations of topical NSAIDs; and (3) evaluation of the clinical findings from studies with this novel DI-EP patch. (1) Pharmacokinetic studies involved determination of DI from DI-EP and separately epolamine (EP) and the epoxide metabolite (N-oxide-EP) in laboratory animals and humans; the latter being the major metabolite in humans. About 2% of DI is absorbed by the skin in humans and is excreted in the urine. Maximum plasma concentrations of 17.4 ng/mL DI are reached at 5.4 hours (approximate steady state conditions); the plasma elimination half-time (t(1/2)) being 26.4 hours. Low systemic levels of DI and EP are produced from DI-EP. Pronounced accumulation of DI occurs in the muscle layers and in synovial fluids of arthritic patients; (2) No significant toxicity occurs from EP nor N-oxide-EP, while that of oral DI-EP was similar to that from DI; and (3) In acute musculoskeletal conditions (sprains, tendonitis and sports injuries) and osteoarthritis DI-EP patches control pain and signs of joint or physical injury compared with placebo controls by 3-5 days with almost complete pain relief at 14 days. DI-EP was shown to have equivalent therapeutic effect to another DI diethylammonium gel formulation (Voltaren Emulgel). There were no reports of serious adverse events in the gastro-intestinal (GI) tract, kidneys or liver from DI-EP. Mild GI symptoms and skin reactions occur in 2 and 10% of patients, respectively. The patch delivery of DI in DI-EP affords controlled delivery of the active drug in contrast to that from application of gels or ointments of NSAIDs.
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