Musculoskeletal disease updates

The SSA would periodically conduct continuing disability reviews CDR to determine whether beneficiaries are still disabled. As a medical chart review company working closely with disability attorneys, we understand that disability applicants would benefit from obtaining the assistance of an experienced disability lawyer. This is most important from the point of view of obtaining detailed narrative statements from the treating physicians that explain the circumstances for which claimants need to use their assistive device.

They can assist disabled individuals to file the initial disability application. In case the claim is denied, disability attorneys also help with filing an appeal and ultimately securing the due disability benefits for their clients.

Save my name, email, and website in this browser for the next time I comment. All Rights Reserved. Website Design by MedResponsive. Quick Contact. May 7, Rajeev Rajagopal 0 Comments. Repetitive stress injuries, such as tendonitis and carpal tunnel syndrome. Musculoskeletal rehab programs can be done on an inpatient or outpatient basis. Many skilled professionals are part of the rehab team, including the following:. A musculoskeletal rehab program is designed to meet the needs of the individual person, depending on the specific problem or disease.

This alarmingly low percentage is reflected in the quality of care for the management of MSK pain. As with many medical issues, strong patient education of musculoskeletal disorders and pain syndromes are important in improving care [ 29 ]. Some pain conditions like chronic widespread pain, whiplash, and fibromyalgia are challenging conditions related to soft tissue pain that are sometimes considered musculoskeletal pain; however, some believe that it may be more helpful in terms of treatment options to consider them as separate conditions [ 30 ].

Delineating between interconnected rheumatologic, musculoskeletal, and psychiatric disorders is a challenging endeavor, and while these conditions definitely affect musculature, it is not clear if adding them to musculoskeletal pain is helpful in terms of discussing disease mechanisms and treatments. These conditions can be classified as nociplastic pain, a new pain classification from the IASP. Somatic nociceptive pain also encompasses syndromes like fibromyalgia and complex regional pain syndrome [ 17 ], and practitioners unfamiliar with the new classification may unknowingly place these syndromes under musculoskeletal pain.

The most common presenting symptom of musculoskeletal disorders is pain. Musculoskeletal pain tends to be intense and localized. For pain in the joints, certain postures or movements may worsen or relieve the pain. Some people with moderate musculoskeletal pain describe the pain as similar to the feeling of an overworked or strained muscle.

Regional pain of a single joint is a common presentation [ 31 ]. Body aches, malaise, and stiffness are all common in musculoskeletal pain patients. Exercise can improve range of motion, mobility, and reduce pain, but patients who exercise must be careful not to overuse or injure muscles and joints [ 30 ].

Fatigue and sleep disorders are common in people with musculoskeletal pain and may be interrelated. Musculoskeletal pain can interfere with sleep or cause a person to wake in the night.

Some patients with musculoskeletal pain may indicate that they cannot find a comfortable position for sleep at all and may try to sleep in recliners or sitting up. This reduces the quality and quantity of restorative sleep which, along with the chronic pain, can cause the patient to experience profound fatigue that can limit function [ 31 ].

Neuropathic pain can have an abrupt onset and often occurs without warning. It must be noted that the experience of musculoskeletal symptoms varies widely among patients [ 31 ]. Furthermore, the severity of symptoms or pain intensity may not necessarily correlate with the severity of the musculoskeletal injury. Musculoskeletal pain represents a diagnostic and therapeutic problem. There is growing evidence that muscle hyperalgesia, referred pain, and widespread hyperalgesia play an important role in chronic musculoskeletal pain.

In addition to the sensory consequences of musculoskeletal pain, the motor control systems are also affected, and the related biomechanics [ 32 ]. According to the pathophysiological categories, pain can be classified into nociceptive, neuropathic, nociplastic, idiopathic, or mixed type [ 32 ].

Due to the significant overlap, ICD allows for sub-diagnoses to full under the realm of multiple parent codes, meaning that a musculoskeletal chronic pain diagnosis may fall under the chronic pain parent code as well as under one of the pathophysiological categories stated above [ 33 ].

An understanding of pain classifications is important when discussing musculoskeletal syndrome pain due to its variable presentation.

Nociceptive pain is the most common type of pain following tissue injury and the primarily category of pain implicated in musculoskeletal pain. Nociceptive pain is also known as physiological or inflammatory pain, and has a protective function [ 34 , 35 ]. Patients describe nociceptive pain as sharp, throbbing, or aching and it is usually well localized. Nociceptive pain is a normal sensory experience resulting from the excitation of peripheral pain receptors, which activates the appropriate spinal cord pathways and their sensory nuclei [ 29 , 36 ].

Types of nociceptive pain include somatic pain, bony pain, and visceral pain. Somatic pain originates from superficial tissues such as the skin, subcutaneous tissues, and muscles due to soft tissue inflammation or trauma. It may be intermittent to constant pain, characterized by sharp, knife-like, and it is with localized pain the patient is able to point to exactly where the pain is [ 32 , 35 , 36 ].

Bone pain originates from the body skeleton due to bone fractures and trauma. It is localized, sharp pain, and noted to be deep, depending on the site of origin. It is associated with tenderness of the overlying soft tissue covering [ 32 , 36 ]. Visceral pain originates from deep visceral organs, e. Visceral pain is characterized by dull aching pain, colicky, or cramping in nature.

Other major types of pain include neuropathic pain caused by a primary lesion or dysfunction of the somatosensory nervous system, also known as pathological pain, but it does not have a protective function. Patients describe neuropathic pain as burning, shooting, electric-like, numbness, pins or needles [ 37 , 38 ].

Mixed pain occurs when a component of continued nociceptive pain coexists with a component of neuropathic pain in the same patient. Patients with persistent back and leg pain following lumbar spine surgery failed back surgery syndrome or FBSS represent a common example. The mechanical low back pain represents the nociceptive component, while the radicular lower-limb pain represents a neurological component [ 36 , 37 ].

Idiopathic pain is when pain is disproportionate with the type or degree of tissue injury or there is no definite cause to explain the pain. Psychological factors may be involved with this type of pain [ 36 , 37 ]. Nociceptive pain may overlap with the neuropathic pain due to the limited methods of assessments or evaluation.

Many forms of musculoskeletal pain are relatively straightforward to diagnose. Clinicians rely on patient symptoms and reports, patient history, physical examination, and, in some cases, radiology. The most frequently reported symptoms of musculoskeletal pain are pain, usually localized to a specific area, fatigue, and sleep disruptions often caused by pain.

In many cases, the patient can identify the injury that caused the pain. The evaluation should include information's regarding previous or current therapy including the use of controlled medication, drug abuse and its effects. The physical examination should include a general examination, as well as neurological and musculoskeletal examinations such as sensory, motor, autonomic changes, and deformity [ 40 , 41 ]. This will help in the identification of patients with severe or persistent pain and the more vulnerable groups such as the elderly and disabled [ 40 , 41 ].

A strong history, identifying pain type, severity, functional impact, and context should be conducted in all patients with pain. This will help the identification of patients with persistent pain and help in the selection of treatment options that are most likely to be effective [ 29 , 36 ]. Since MSK pain can be intractable, improving pain-related disability appears to be a more meaningful goal than pain control for some patients, so the use of disability-related metrics of quality-of-life assessments may be particularly relevant [ 42 ].

Any pain assessment tool should include the type of pain, severity, functional impact, and context. This helps guide the provider and patient to treatment options that are most likely to be effective [ 40 ]. However, there is a strong recommendation by many international guidelines for using more comprehensive pain scores like the McGill pain questionnaire [ 43 , 44 ].

Generally, pain assessment tools can be classified into uni-dimensional or multi-dimensional scores [ 36 ]. Uni-dimensional scores measure the pain intensity only, and are usually used for assessment of acute pain, e.

Multi-dimensional scores measure the pain scores as well as the associated symptoms such as sleep disturbance, mood, appetite, behavior, and other related activities.

Multi-dimensional scores are used for the assessment of chronic pain, e. Neuropathic pain diagnostic scales include a set of pain symptoms, clinical examination, or labs. Douleur Neuropathique EN 4 questions DN4 has ten items: seven symptomatic and three from clinical examination. For patients with chronic MSK pain, clinicians and patients should initially select non-pharmacologic treatment, including home exercises and multidisciplinary rehabilitation protocols. In patients with chronic MSK pain who have had an inadequate response to non-pharmacologic therapy, pharmacologic treatment with NSAIDs should be considered as first-line therapy with or without adjuvant therapy [ 46 ].

This includes appropriate advice about nonpharmacological treatment strategies, such as physical activity, rest, exercise, and so on. Comprehensive patient assessments including detailed history taking with the assessment of physical and psychosocial factors. Physical examination including full neurological assessment, but radiological imaging is discouraged unless indicated. Multimodal and multidisciplinary interventions should be part of a treatment strategy for patients with chronic MSK pain.

If other modalities are ineffective, consider the prescription of opioids by comprehensive assessments and screening for opioid abuse, the effectiveness of long-term opioid therapy, monitoring for adherence and side effects, and discontinue opioids because of lack of response, adverse effects, and abuse [ 24 ].

A multimodal approach to pain management consists of using treatments from one or more clinical disciplines incorporated into an overall treatment plan [ 47 , 48 ]. There is strong evidence that the concurrent use of multiple medications that work by different mechanisms of action and at different sites are associated with better analgesia with fewer side effects. This is the premise of multimodal analgesia [ 43 , 44 ].

A multidisciplinary approach address different aspects of chronic pain conditions including biopsychosocial effects of the medical condition on the patient [ 47 , 48 ]. Multidisciplinary pain services offer a variety of coherent treatment approaches that recognize that pain is a multifaceted problem requiring a multifaceted approach and continuity of care [ 49 ].

The core group for the multidisciplinary treatment service may include a pain medicine physician, a physiatrist, a neurologist, a physical and or occupational therapist, and a psychiatrist or clinical psychologist, according to local needs, resources, and available expertise [ 50 ].

In addition, to complete clinical evaluation, psychological evaluation, functional capabilities, disability scores, behavioral responses to pain, and all previous medical records are needed to avoid repeating appropriately performed studies and unsuccessful treatment approaches [ 51 ].

Pharmacological treatment is the mainstay for the management of pain. Since then, the ladder has guided clinicians all over the world in treating pain [ 52 ]. The basic principles of achieving analgesia according to the WHO ladder focus on the main key principles that ensure the analgesic should be taken by the simplest route of administration e.

Effective especially for osteoarthritic pain. Patch used for acute sprains and strains. An updated WHO ladder, e. The integrative medicine therapies can be adopted in each step for reducing or even stopping the use of analgesics for all types of pain. If the non-opioids and weak opioids fail, minimally invasive interventions in step 3 can be recommended before upgrading to strong opioids.

The revised four-step analgesic ladder aligned with integrative medicine principles and minimally invasive interventions is recommended for control of chronic non-cancer pain, including musculoskeletal pain, in order to integrate multimodality therapies for patients who are suffering from pain and can be a key factor in mitigating the opioid epidemic [ 53 ].

List of pharmacological treatments [ 6 , 36 , 37 , 43 , 44 ]. Paracetamol is thought to act both centrally and peripherally. It reduces prostaglandin synthesis from arachidonic acid via inhibition of the cyclooxygenase isoenzymes COX-1 and COX Generally, paracetamol has been used for pain relief across a wide range of indications because of its relative effectiveness in many pain conditions, high tolerability, and minimal adverse effects [ 41 , 54 ].

A meta-analysis has suggested that the use of acetaminophen as monotherapy may be ineffective [ 55 ]. For those with intolerance of or contraindications to the use of NSAIDs, acetaminophen may be appropriate for short-term use.

Regular monitoring for hepatotoxicity is required for patients who receive acetaminophen on a regular basis and beyond the maximum dosage of 3 g daily [ 56 ]. Acetaminophen is available in a fixed-dose combination product with codeine with 30—60 mg and acetaminophen — mg, marketed under the tradename Tylenol A large number of trials have established their short-term efficacy.

Oral NSAIDs are the initial oral medication of choice in the treatment of OA, regardless of anatomic location, and are recommended over all other available oral medications [ 55 , 56 ]. These have analgesic and anti-inflammatory properties and may be used as the sole method of treatment for mild-to-moderate pain.

Clinical considerations for the safety of long-term use of NSAIDs include appropriate patient selection, regular monitoring for the development of potential adverse gastrointestinal, cardiovascular, and renal side effects, and potential drug interactions.

Doses should be as low as possible, and NSAID treatment should be continued for as short a time as possible [ 56 ]. Prolonged use of NSAID treatment is also associated with other adverse effects including inhibition of platelet function and increased bleeding time, as well as bronchospasm following the administration of aspirin and other NSAIDs in some patients with asthma [ 36 , 57 ]. COX-2 selective inhibitors refer to a class of analgesic and anti-inflammatory drugs. COX-2 is found in inflammatory cells, tissue damage, synovia of joints, endothelium, and the CNS [ 37 , 43 ].

However, COX-2 had fewer gastrointestinal side effects than traditional NSAIDs , but long-term use of COX-2 inhibitors may be associated with increased risk of cardiovascular side effects and this should be taken into account especially in cardiac and susceptible patients [ 40 ].

Topical NSAIDs, like topical diclofenac, are effective for reducing musculoskeletal pain and should be considered in the treatment of patients with chronic pain conditions, particularly in patients who cannot tolerate oral NSAIDs [ 58 ]. In the United States, the FDA approved topical diclofenac in for osteoarthritic pain, responsive in the joints of the hand, knees, and feet in particular. Suitable for pain that is severe enough to require daily, around-the-clock, long-term opioids.

Weak opioid. It is inactive prodrug; converted in the liver to morphine by the enzyme CYP2D6. Opioids produce their effect by acting as agonists at opioid receptors, which are found in the brain, spinal cord, and sites outside the CNS. Opioids are available in different forms and can be used by different routes of administrations, e.

The main indication for opioids is to provide analgesia and pain relief for both cancer and non-cancer pain. At the same time, most opioids have a similar spectrum of adverse effects, e. It is important to know that opioids are not the first-line therapy for chronic pain; the risks, benefits, and availability of non-opioid treatments should be addressed first with patients [ 61 ].

Opioids should be considered for short- to the medium-term treatment of carefully selected patients with chronic non-malignant pain, for whom other therapies have been insufficient and the benefits may outweigh the risks of serious harms such as addiction, overdose or even death.

Patients prescribed opioids should be advised of the likelihood of common side effects such as nausea and constipation [ 40 ]. The dramatic rise in the prescription of opioids, resulting from the increase in the prevalence of chronic pain, and the increase in dosage and frequency of prescriptions lead to overdose and death.

The risks associated with opioid use may have created a growing need for clinical guidance on decision-making for opioid prescriptions [ 6 ]. The influence of polysubstance abuse and the use of illicit opioids like synthetic fentanyl may also contribute heavily to overdose deaths as discussed above.

Another systematic review found a wide range of estimates of the rates of misuse of opioids used to treat patients with chronic pain, depending upon, among other things, study setting and case definition. These medications were originally developed to treat seizures, but they are used to treat some forms of pain including neuropathic pain.

Gabapentin and pregabalin are effective for the treatment of patients with neuropathic pain, and FDA approved in the United States for neuropathic pain conditions like spinal cord injury, shingles, and diabetic neuropathy. These medications have a more tolerable side-effect profile compared to other anti-convulsants. There is recent concern of respiratory depression when this medication is used in conjunction with CNS depressants, including opioids, and in patients with baseline respiratory impairment.

Flexible dosing may improve tolerability. Perioperative gabapentinoids are a useful component of perioperative multimodal analgesia and have been shown to reduce opioid requirements. Pregabalin is recommended also for the treatment of patients with fibromyalgia [ 65 , 66 ]. It seems to have a specific effect, however potential adverse events should be discussed [ 40 ]. Tricyclic antidepressants TCA e. The pharmacological actions of TCAs can be linked to their effect as a calcium channel antagonist, sodium channel antagonist, and their NMDA receptor antagonist effect.

More specifically, the analgesic effect is believed to be due to the presynaptic reuptake inhibition of the monoamines such as serotonin and norepinephrine [ 38 , 65 , 66 ].

While some state that tricyclic antidepressants should not be used for the management of pain in patients with chronic low back pain [ 65 , 66 ], recent studies have indicated that low doses of amitriptyline may be an effective treatment for low back pain [ 67 ]. There is also anecdotal evidence that nortriptyline may have a beneficial effect, and further research may be indicated in this area.

Serotonin norepinephrine re-uptake inhibitor SNRI e. Selective serotonin re-uptake inhibitors SSRIs such as fluoxetine 20—80 mg may be considered for the treatment of patients with fibromyalgia, although it has not been successful in treating many forms of neuropathic pain [ 6 , 61 ]. Musculoskeletal agents commonly used for pain treatment include baclofen, tizanidine, and cyclobenzaprine.

Baclofen is a gamma-aminobutyric acid GABA agonist whose method of action is not fully understood, but can inhibit monosynaptic and polysynaptic reflexes at the spinal level. It is used as a skeletal muscle relaxant as well as in the treatment of spasticity. Tizanidine is a central alpha-2 adrenergic receptor agonist with resulting inhibition of spasticity by increasing presynaptic inhibition.

Cyclobenzaprine is a muscle relaxant thought to act primarily via 5-HT2 receptor antagonism on the brainstem, impacting both gamma and alpha motor neurons. Carisoprodol is metabolized to meprobamate, which is both sedating and possibly addictive, so the use of carisoprodol is not recommended, particularly because alternatives are available [ 68 ].

Anti-anxiety medications are often prescribed to treat the anxiety that accompanies acute pain as well as anxiety resulting from fluctuations in chronic pain. Some shorter-acting benzodiazepines carry a risk of abuse and addiction, for example lorazepam. Concurrent use of opioids and respiratory depressants like benzos have been implicated in a higher risk of adverse side effects, especially overdose-related deaths. There is poor and little evidence to support long-term benzodiazepine usage, and treatment should therefore be given for the short term until the patient can be placed on the appropriate long-term treatment, i.

Clonidine and tizanidine have been used in the treatment of chronic pain disorders. Tizanidine has also been used in myofascial pain disorders as well as for painful muscle spasms [ 64 ]. These are worn 12 h on and 12 h off. Few side effects such as skin redness and irritation may be reported [ 73 ]. Evidence supports that capsaicin can be used for the treatment of both chronic neuropathic and musculoskeletal pain. The main adverse reaction with topical capsaicin patches is localized skin irritation.

Due to its poor efficacy, it should be considered in the treatment of patients when first-line pharmacological therapies have been ineffective or not tolerated [ 74 ]. Topical capsaicin is FDA approved for the treatment of peripheral diabetic neuropathy of the feet, and postherpetic neuralgia PHN in the United States [ 75 ].

The use of bone marrow concentrate for the treatment of musculoskeletal disorders has become increasingly popular over the last several years. Typically, bone marrow is obtained by iliac crest aspiration, and contains progenitor cells like mesenchymal stem cells, as well as cytokine and growth factors [ 76 ]. Musculoskeletal Examination Renato C. Author Information Authors Renato C. Broadly, a musculoskeletal system exam could classify as a: Screening MS exam- a quick assessment of overall structure and function.

Local twitch response elicited by the snapping palpation of the taut band. Issues of Concern The mechanical functions of the body are carried out by the coordinated functioning of the musculoskeletal system. Clinical Significance Musculoskeletal disorders constitute a significant cause of disability and morbidity globally. Nursing, Allied Health, and Interprofessional Team Interventions In current day practice, primary health care faces unprecedented challenges necessitating a more comprehensive, multi-disciplinary service delivery model.

Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Wilson CH. The Musculoskeletal Examination. Butterworths; Boston: Ned Tijdschr Geneeskd. Reliability and concurrent validity of knee angle measurement: smart phone app versus universal goniometer used by experienced and novice clinicians.

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