Musculo-Skeletal Pain

From time to time we all suffer with what doctors call musculoskeletal problems: that is aches, pains and twinges in our muscles and joints. These have literally dozens of causes, and while some problems are minor and short-lived others are more serious and, unfortunately, lifelong. Many of them result from the knocks, bumps and strains that our bodies suffer in the course of our normal activities or exercise, while others are due to mild rheumatic conditions, and we can take care of these ourselves with advice and medication when necessary from a pharmacy. This article is intended to; help you to decide what you can look after for yourself; how to do it; what may need medical investigation and treatment, and some of the most common causes and symptoms of musculoskeletal pain and treatment.

Rheumatism and Arthritis
Rheumatism is a general description for any pain, soreness or stiffness in the muscles, joints or sinews that hold our bones together, which is long-term and not the result of a knock, injury or strain. Arthritis means literally "inflammation of the joints" and covers a wide range of medical conditions, all of which are long-term but with different causes and degrees of seriousness. Many over-the-counter medicines these days can be recommended for rheumatic and mild arthritic pain, so how do you know what you can use safely and effectively, and how do you know when you ought to be seeking your doctor's, rather than your pharmacist's advice? A look at the main rheumatic conditions will give you an idea.

Osteoarthritis (OA) Osteoarthritis is due to the wearing out of the cartilage between the bones that stops them rubbing together and damaging each other. This causes the bones to become hardened and deformed and bony projections form, particularly on the finger joints, knees, hips and spine, causing pain, often severe, and joint stiffness that restricts movement. OA is very common and an almost natural result of getting older. Cartilage wear starts in our teens and we nearly all have some joint damage, but usually without symptoms, by our forties. Overuse or misuse of joints through work or sport, and injury, obesity or poor posture can all speed up the process. By the age of 60 about 20 per cent of people have developed symptoms painful enough to need treatment. Mild symptoms can be treated with over-the-counter pain relieving medicines (see below), but more serious pain will need prescription drugs. Various types of exercise and physiotherapy can help relieve stiffness and immobility, but sometimes joint replacement surgery is the only answer to OA.

Rheumatoid arthritis (RA) This condition is due to inflammation of the lining of the joints, and can lead to damage and deformity of the joints, tendons and ligaments which hold our skeletons together and keep them flexible. RA is an auto-immune disease, where the body is attacked by its own cells that normally defend it against attack by outside agents such as bacteria. The main symptoms are inflammation and swelling and pain in the hands, wrists and knees, and stiffness on getting up in the morning. Symptoms can affect the whole body, and include tiredness, depression, fever, poor circulation and dry eyes. The condition can fluctuate through phases of improving and getting worse. Except in the very mildest cases treatment is with prescription drugs to reduce inflammation, ease pain and to try to stop the condition worsening.

Muscular rheumatism (fibromyalgia, fibrositis) This is a condition of aching and pain involving muscles, tendons and ligaments, but not joints. The cause is unknown, but seems to be connected with poor sleeping, and may start following an injury, accident or viral infection. There may be a connection with ME (myalgic encephalomyelitis, also known as chronic fatigue syndrome). Pain and soreness can occur anywhere in the body, with shoulders, neck, elbows, chest, knees and lower back most commonly affected. There may also be general feelings of tiredness and depression. Unlike OA and RA, this condition can go away completely.

Treatment is with non-prescription pain relieving medication to start with, going on to stronger prescription drugs if necessary. Antidepressants are sometimes prescribed. Relaxation techniques and regular exercise are often helpful in relieving the condition.

Sprains, strains and injuries
Pain and inflammation in the muscles, joints and tendons are often the result of over-exertion or injury from physical activity, be it sport, gardening, decorating or a hundred and one other things. Most can be self-treated, although medical advice should be sought if there is severe pain that does not ease off after a short time, or if the area affected cannot move. The following are the most common conditions.

Sprains
A sprain occurs when a ligament or the capsule of tissue surrounding and holding a joint together gets overstretched, and surrounding muscle tissue may also be torn. There may be some blood leakage from the torn tissues, giving the affected area a bluish look, and fluid oozes from damaged cells causing swelling . Ankles, knees and wrists are often damaged in this way. Treatment is with RICE (see Panel 1), and pain-relieving, anti-inflammatory medication.

Strains
Strains are injuries to muscle tissue only. If the muscle sheath is torn there will be some internal bleeding. Strains can occur anywhere around the body, including the neck and shoulders. If care is not taken during healing permanent scar tissue can form which shortens the muscle, reducing its efficiency and leaving it prone to further injury. Treatment is as for sprains.

Back pain
lumbago and sciatica Most of us will get pain in the lower back at some time. Muscular pain is called lumbago and it is usually caused by over-exertion, lifting heavy objects or twisting awkwardly. The pain is felt across the lower back, and it may radiate to the buttocks, groin and thighs. There may be stiffness, spasm in the muscles and tilting of the back to one side. With rest and self-treatment lumbago will normally ease off within a few days. Back pain may also be due to a cartilage separating bones in the spine (vertebrae) slipping out of place and allowing the vertebrae to rub together and trap a nerve. This condition is known as sciatica and it causes sharp pain that that spreads down the thighs; there may also be a tingling feeling or numbness. Any back pain that does not improve in a week with rest and self-treatment requires medical attention.

Repetitive strain injuries (RSI's) When muscles and joints are overworked by repeated use, strain or inflammation may occur that can become a long-term problem if proper attention is not paid to them. Sports-related conditions such as 'tennis elbow' is a well-known example and, in these days of increasing computer use, RSI's involving the hands, wrists, arms, neck and shoulders are becoming increasingly common. These can be avoided by not working for too long at a stretch and taking regular breaks, and by ensuring that the equipment used, including chairs, is set up for comfortable use. If left to develop for too long, RSI's can lead to permanent disablement.

Self-medication for musculoskeletal conditions
Pain relievers
There are two ways of treating musculoskeletal pain: with medicine that is taken internally (systemic), and by applying pain-relieving preparations directly to the affected area (topical).

Systemic treatment
The three main pain relievers that can be bought without prescription are

• Ibuprofen
• Aspirin
• Paracetamol

Ibuprofen and aspirin, known as anti-inflammatories are, in theory at least, the best treatment as they act by reducing inflammation at the site of the pain or injury, helping healing as they reduce pain. Paracetamol is thought to work within the brain on the area that controls the perception of pain. However, perception of pain and the effectiveness of pain relievers varies greatly between individuals, and some people find that paracetamol is more effective for them than anti-inflammatories. Some medicines also contain codeine or dihydrocodeine, for a stronger pain-relieving effect. Some natural food supplement substances have been found effective for osteoarthritis (see Panel 2).

Although they are generally very safe, the anti-inflammatories, especially aspirin, have some possible drawbacks that mean that some people should be careful about taking them.

Cautions with anti-inflammatories

• They can cause indigestion and other stomach upsets, and in severe cases bleeding in the stomach. This can be largely avoided by taking them with or after food. Also, soluble (dissolved in water before taking) or dispersible (dissolved in the mouth) forms of these medicines are less likely to cause problems. People who have ulcers or stomach problems should not take medicines containing anti-inflammatories.
• They can bring on attacks in people with asthma. While this only happens in a small proportion of asthmatics, sufferers should only take anti-inflammatories if they know that they do not cause them problems. The chance of a problem is much lower with ibuprofen than with aspirin.
• People with heart, kidney or liver problems, particularly if they are elderly, should not take anti-inflammatories without consulting their doctor first.
• Pregnant women should not take anti-inflammatories.
• Children under 16 should not take aspirin, but ibuprofen is quite safe.
• Aspirin and ibuprofen can cause problems if taken together with some other medicines, so you should always tell the pharmacist about any other medicines you are taking.
  

Caution with paracetamol

• Paracetamol is a very safe medicine, but if too much is taken it can cause liver damage. Adults should never take more than the maximum recommended dose of two tablets four times a day and children proportionately less (ask the pharmacist about the correct dose). Make sure that other medicines you may be taking do not contain paracetamol.

Topical treatment
There are two types of topical treament:

• Anti-inflammatories. Creams and gels containing ibuprofen or one of several other anti-inflammatories. The medication is massaged directly onto the affected area.
• " 'Warm-up' medications. These are creams, lotions, sprays and rubs that contain substances that open up the small blood vessels on the surface of the skin, making the skin feel warm and producing a comforting feeling that masks pain. They are usually rubbed in vigorously (except sprays).
  

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