NSAID and Musculoskeletal Pain: Most Recent Guidelines

The following is the latest set of guidelines from the American Heart Association (AHA) regarding the use of non-steroidal anti-inflammatory drugs (NSAID) in the treatment musculoskeletal pain:

A Stepwise Approach to NSAID Use

Given their cardiovascular risks, COX-2 inhibitors should be a last resort for managing musculoskeletal pain.

Sponsoring Organization
American Heart Association

Background

Evidence that selective COX-2 inhibitors, a type of nonsteroidal anti-inflammatory drug (NSAID), increase the risk for serious cardiovascular events has led to a cascade of drug warnings, safety advisories, and even withdrawals from the market. The lingering issue for practitioners has been to pinpoint the appropriate clinical roles for specific NSAIDs and other pain relievers. Now, the AHA has issued a scientific statement on NSAID use for patients with, or at high risk for, heart disease. The statement places management of musculoskeletal pain in a broader context, synthesizes recent evidence on pharmacologic treatment options, and proposes a stepwise approach to treatment.

Key Contextual Points

1. The risks and benefits of any pain-management approach must be understood in light of current evidence, applied appropriately to the individual patient with musculoskeletal pain.

2. Musculoskeletal symptoms should be considered those from tendonitis/bursitis, degenerative joint problems (e.g., osteoarthritis), or inflammatory joint problems (e.g., rheumatoid arthritis).

3. Initial treatment should focus on nonpharmacologic approaches such as physical therapy, heat or cold therapy, and orthotics.

Stepwise Approach to Drug Therapy, If Needed

Pre-NSAID

Step 1 (short-term use): Use acetaminophen, aspirin, tramadol, or a narcotic analgesic at the lowest safe and efficacious dose. Bear in mind the potential for abuse of narcotics by some patients. Also, for low-dose aspirin users with histories of or risk for gastrointestinal bleeding, a concomitant proton-pump inhibitor may reduce that risk.

Step 2: Use a nonacetylated salicylate such as salsalate, sodium salicylate, or choline magnesium trisalicylate.

NSAID

Step 3: Use a non–COX-2 selective NSAID such as naproxen, ibuprofen, or indomethacin. Naproxen is the widely preferred choice from a cardiovascular standpoint.

Step 4: Use an NSAID with some COX-2 activity such as diclofenac. Diclofenac carries a black box warning against use for perioperative pain in coronary artery bypass graft (CABG) surgery.

Step 5 (the last resort): Use a COX-2–selective NSAID. The only one currently on the market is celecoxib (Celebrex), which carries a broad black box warning about risks for very serious cardiovascular events.

Comment: The authors are clear in saying that COX-2 inhibitor use has been associated with increased risks for MI, stroke, hypertension, and heart failure. They warn that "even a relative lack of COX-2 selectivity does not completely eliminate the risk of cardiovascular events . . . all drugs in the NSAID spectrum should only be prescribed after thorough consideration of the risk/benefit balance." Patients with recent CABG, unstable angina, MI, or ischemic stroke need to be especially cautious. COX-inhibitor use can lead to impaired renal perfusion, sodium retention, and increased blood pressure, thereby increasing the risk for adverse cardiovascular events.

New evidence on the cardiovascular effects of drug therapy for musculoskeletal pain will continue to emerge (e.g., from the forthcoming PRECISION trial comparing celecoxib, ibuprofen, and naproxen). Clinicians should stay abreast of these developments. For now, the AHA’s stepwise approach is a practical one to follow.

— Joel M. Gore, MD

Published in Journal Watch Cardiology March 28, 2007

Citation:
Antman EM et al. Use of nonsteroidal antiinflammatory drugs: An update for clinicians. A scientific statement from the American Heart Association. Circulation 2007 Mar 27; 115:1634-42.

[Original Circulation article (free pdf)] [Medline® abstract]

Copyright © 2007. Massachusetts Medical Society. All rights reserved.

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Neck Pain

The following is an informative article from the British Medical Journal on cervical spondylosis which can cause neck and arm pain. For full text, click on the link below.

Cervical Spondylosis and Neck Pain

BMJ 2007;334:527-531 (10 March), doi:10.1136/bmj.39127.608299.80
[Free full-text BMJ article (pdf)] [BMJ abstract]

Clinical Review

Allan I Binder, consultant rheumatologist
Lister Hospital, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire SG1 4AB.
Correspondence to: allan.binder@nhs.net

Most patients who present with neck pain have "non-specific (simple) neck pain," where symptoms have a postural or mechanical basis. Aetiological factors are poorly understoodw1 and are usually multifactorial, including poor posture, anxiety, depression, neck strain, and sporting or occupational activities.w2 Neck pain after whiplash injury also fits into this category, provided no bony injury or neurological deficit is present.w3 When mechanical factors are prominent, the condition is often referred to as "cervical spondylosis," although the term is often applied to all non-specific neck pain. Mechanical and degenerative factors are more likely to be present in chronic neck pain.

In cervical spondylosis, degenerative changes start in the intervertebral discs with osteophyte formation and involvement of adjacent soft tissue structures. Many people over 30 show similar abnormalities on plain radiographs of the cervical spine, however, so the boundary between normal ageing and disease is difficult to define.w4 Even severe degenerative changes are often asymptomatic, but can lead to neck pain, stiffness, or neurological complications.

I will concentrate on the diagnosis of cervical spondylosis and the evidence available for the different treatments. I will also mention some practical measures that are thought to be important but have not yet been studied. Specific conditions like fibromyalgia, disc prolapse, and whiplash will not be considered, although some patients with these conditions may have been included in therapeutic studies.

Summary points

--The diagnosis of cervical spondylosis is usually based on clinical symptoms.
--Patients need detailed neurological assessment of upper and lower limbs as cervical degeneration is often asymptomatic, but can lead to pain, myelopathy, or radiculopathy.
--"Red flag" symptoms identify the small number of patients who need magnetic resonance imaging, blood tests, and other investigations.
--The best treatments are exercise, manipulation, and mobilisation, or combinations thereof.
--Radiculopathy has a good prognosis and may respond to conservative measures.
--Results of neck surgery for myelopathy or intractable pain are often disappointing.

Box 1 Presenting features of cervical spondylosis

Symptoms

--Cervical pain aggravated by movement.
--Referred pain (occiput, between the shoulder blades, upper limbs).
--Retro-orbital or temporal pain (from C1 to C2).
--Cervical stiffness—reversible or irreversible.
--Vague numbness, tingling, or weakness in upper limbs.
--Dizziness or vertigo.
--Poor balance.
--Rarely, syncope, triggers migraine, "pseudo-angina"w15.

Signs

--Poorly localised tenderness.
--Limited range of movement (forward flexion, backward extension, lateral flexion, and rotation to both sides).
--Minor neurological changes like inverted supinator jerks (unless complicated by myelopathy or radiculopathy).

Box 3 "Red flag" features and the conditions they may suggest

Malignancy, infection, or inflammation

--Fever, night sweats.
--Unexpected weight loss.
--History of inflammatory arthritis, malignancy, infection, tuberculosis, HIV infection, drug dependency, or immunosuppression.
--Excruciating pain.
--Intractable night pain.
--Cervical lymphadenopathy.
--Exquisite tenderness over a vertebral body.

Myelopathy

--Gait disturbance or clumsy hands, or both.
--Objective neurological deficit—upper motor neurone signs in the legs and lower motor neurone signs in the arms.
--Sudden onset in a young patient suggests disc prolapse.

Other

--History of severe osteoporosis.
--History of neck surgery.
--Drop attacks, especially when moving the neck, suggest vascular disease.
--Intractable or increasing pain.

[References available in the free full-text pdf version]

© 2007 BMJ Publishing Group Ltd.

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Acute & Chronic Pain

Question:

What are the main differences between acute and chronic pain?

Answer:

Acute pain, even though is not a pleasant sensation, serves a useful function. Without the sensation of pain we could easily injure or burn ourselves without knowing it. Another example: if we do not feel the pain caused by a disease condition, such as acute appendicitis, we would not know that we suffer from a serious medical condition and neglect to seek medical help; so in this case pain acts as a warning signal telling us that something is wrong with our body. Acute pain is usually associated with other signs of increased sympathetic nervous system activity, such as increase in blood pressure, rise in heart rate, sweating, pallor, anxiety, fear and restlessness.

On the other hand, chronic pain is the sensation of pain that continues after the complete healing of the initial cause of pain and might last for months, weeks or years. It no longer serves a useful function, and becomes a disease on its own. It is not associated with rise in blood pressure or heart rate, but is rather accompanied with significant changes in personality and behavior. It leads to depression, anxiety and anger. In some cases it can be accompanied with manifestations of hypochondriasis and hysteria as well as certain personality disorders. it leads to employment difficulties, job loss, socio-economic consequences, drug dependence and abuse, as well as family difficulties and divorce. In severe and intractable cases, it can even lead to suicide.

One of the examples of chronic pain conditions is shingles (herpes zoster), an extremely painful condition caused by the reactivation of a dormant varicella-zoster virus which infects young people--mostly children--causing the disease known as chickenpox. After the resolution of this disease, the virus becomes dormant (goes to sleep) and remains in the body hidden in the brain and the spinal cord in certain nerve tissue relay structures called ganglia.

Later on in life the virus can reactivate as a result of a variety of factors, such as decreased immunity, cancer, HIV infection, trauma to the nervous system, toxic exposure, severe illness and many other conditions. When the virus reactivates (wakes up) it spreads along the individual nerves connected to these ganglia. causing severe nerve pain and rash. The older the person the more likelihood of continuation of pain after the complete healing of the rash, which is the result of permanent nerve damage.

This is a perfect example of differences between acute and chronic pain and it illustrates how an acute condition could turn into a chronic disease.