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This module has been endorsed with the NPA’s Training Seal as suitable for use by medicines counter assistants as part of their ongoing learning. Complete the questions at the end to include in your self-development portfolio module 216

Welcome to TM’s OTC topical pain relief Treatment Clinic series. This handy, four-page section is specially designed so that author: Jane Feely, PhD you can detach it from the magazine and keep it for future reference. for this module Each month, TM covers a different OTC treatment area OBJECTIVES: After studying this module, assistants will: to help you keep up-to-date • Be familiar with the common causes of musculoskeletal pain with the latest product • Be able to advise on the OTC products available to help relieve common symptoms developments. In this issue, • Know when to recommend cold or heat therapy we focus on topical pain • Know which customers to refer to the pharmacist relief. At the end of the • Be able to offer self care tips to prevent injury. module there are multiple choice questions for you to complete, so your progress Countless charity campaigns and awareness weeks pain according to its origin. Here, we mainly focus can be monitored by your promote the importance of living a healthy, active on musculoskeletal pain, which is pain, soreness or pharmacist. lifestyle. Yet few of us focus on the unexpected discomfort felt in the muscles or (e.g. a twisted You can find out more in muscular aches and pains that can accompany that or pulled ). the Counter Intelligence Plus trip to the gym or that jog around the park. Pain can also be classified by its duration: training guide. According to Pain UK, 10 million people in the l Acute pain is short term (e.g. a ) UK live with pain. For some, this is the result of a l Chronic pain is long term (e.g. arthritis). The last six topics we have serious, chronic condition such as cancer, whereas Pain occurs for a reason and should not be covered are: for others it comes from poor posture or sleeping ignored. It’s also very common and can interfere l Smoking cessation incorrectly, and for many it’s due to a or with normal, everyday activities. According to l Oral care contracted during sport. Whatever the cause, this Arthritis Research UK, musculoskeletal pain affects l Daily fatigue and stress month’s OTC Treatment Clinic focuses on the topical a large proportion of the population. One study l Dry skin and eczema pain relief products available to help ease pain and revealed that 69 per cent of women and 66 per cent l Insomnia the self care tips you can pass on to customers. of men aged 50 to 59 had experienced pain lasting l Coughs a day or longer at some point during the previous You can complete previous Different types of pain four weeks. A separate study revealed that chronic modules online at: Pain is something we’ve all experienced – a bumped pain, which persists continuously or intermittently www.tmmagazine.co.uk , cut finger or a pulled muscle are all common for more than three months, affects at least 10 per causes. Healthcare professionals (HCPs) often classify cent of the population.

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(where the spine curves to the side) can cause back pain. Arthritis and osteoporosis can also reflective exercise affect the lower back • Pre-existing conditions: pain from other conditions may be felt in the lower back. These later saying that although her back pain has include kidney infections or stones, Sue, 55, comes to the pharmacy for a improved, she has developed a pain down her endometriosis, ovarian cysts, uterine fibroids and product to ease her back pain. She has left leg and a tingling sensation in her . She cancer of the spine. Pregnancy is another been gardening recently and giving the adds that although the pain is agonising, it common cause. house a thorough clean. She also has an tends to come and go. For the majority of people, back pain is not office job that she drives to every day. serious and usually resolves within six weeks. She’s reluctant to take painkillers as she Considering Sue’s earlier symptoms, she could However, BackCare estimates that in up to seven doesn’t like the idea of relying on tablets. be suffering from sciatica, which occurs when a per cent of cases, acute back pain becomes spinal disc presses on the sciatic nerve. Cases of chronic. Sufferers should be referred to the What would you recommend? sciatica often resolve on their own, although pharmacist if they have: This sounds like a case of extra and this can take several weeks. Refer Sue to the • Severe pain that does not improve unaccustomed manual activity putting a pharmacist, who may refer her to a GP. • Pain following an injury or fall strain on Sue’s back. Check Sue’s posture • Numbness or tingling and ask if she’s been doing any heavy What if: • Pain alongside fever, weakness, difficulty digging in the garden. When crouching Between referrals, the pharmacist recommends urinating or unexplained weight loss down, Sue should maintain a straight back that Sue purchases an analgesic. However, you • Swelling or redness on the back. to avoid bending. know that she has asthma. At work, Sue should check that her l and pain chair is suitable. At home, an upright chair Paracetamol is a suitable painkiller for Sue. She According to NHS Choices, shoulder disorders may be the best option while relaxing in can take this as well as applying heat therapy. affect around three in 10 adults at any one time. the evenings. Sue should ensure her car Encourage Sue to be cautious of her posture Among older people, frozen shoulder is seat is comfortable and should work to and to continue doing gentle exercise when common and restricts the normal movement maintain a correct posture at all times. the pain subsides. of the . The rotator cuff (a group of muscles It’s important to achieve the right and that surround the ) balance between rest and gentle activity. What if: can also be affected. Walking and swimming may be suitable While in the pharmacy, Sue asks if she should Shoulder instability (where the shoulder has exercise options, although breast stroke be taking vitamin supplements. an usually large range of movement) or injury can exacerbate back pain in some cases. to the joint at the top of the shoulder can also Considering her age, Sue is likely to be post- occur. This is more common in younger people What if: menopausal and may benefit from taking and those who play sports or activities involving Lifestyle changes have been ineffective and calcium and vitamin D supplements. Following repeated shoulder movements. Sue requests additional topical pain relief. the menopause, women can suffer from A painful, stiff neck can be caused by reduced bone density and a heightened risk of sleeping in an awkward position, using a A heat pad or hot water bottle may be osteoporosis. Nutrients including calcium, computer keyboard for long periods of time or effective at easing lower back pain, vitamin D, magnesium, copper, zinc, vitamin C simply sitting in a draft. Anxiety and stress can particularly while at home in the evenings. and vitamin K are all essential for maintaining also cause tension in the neck muscles. While at work, recommend that Sue tries healthy bones throughout life. Most cases of neck and shoulder pain are a topical analgesic gel or a spray Recommend that Sue takes a calcium and minor and resolve with time. However, anyone formulation for hard to reach areas, such vitamin D supplement, as well as a multi- suffering severe or persistent pain, or whose as her lower back. vitamin and mineral supplement. Check the symptoms came on suddenly or relate to an quantity of calcium and vitamin D in the accident or fall, should be referred to the What if: multivitamin supplement to ensure that Sue pharmacist. Sue returns to the pharmacy two weeks doesn’t take too much. l Osteoarthritis Osteoarthritis (OA) is the most common type Common causes of pain increase the risk of suffering back pain, as can of arthritis in the UK. According to Arthritis l Back pain having a desk job with a poorly designed Research UK, 8.75 million people in the UK have Back pain, particularly affecting the lower back, workstation. sought treatment for OA. This includes a third of is one of the most common causes of pain in the While the exact cause of lower back pain people over 45, as well as 49 per cent of women UK. According to BackCare, the charity for back may not always be obvious, common causes and 42 per cent of men aged 75 and over. and neck pain, an estimated four out of five include: OA occurs when there is wear and tear adults experience back pain at some stage. • Muscle or strain: this may occur after damage in and around the joints. It most The peak age to experience back pain is 35 an accident or fall, or following repeated heavy commonly affects the and , but can to 55 and while anyone can suffer, certain lifting or sudden, awkward movements also occur in the spine and small joints of the factors increase an individual’s susceptibility. • Problems with the spinal discs: these act like hands and feet. Changes within joints lead to These include being overweight, having poor cushions between the vertebrae and cause pain pain, inflammation, stiffness and swelling. posture, smoking or a family history of back if they bulge, rupture or slip There is no cure for OA, although symptoms problems. Heavy manual labour can also • Conditions affecting the vertebrae: scoliosis can be eased with effective pain relief. In severe

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cases, however, surgery may be help to relieve pain and reduce the required to replace or fuse the redness and swelling caused by affected joint. inflammation. While it is not possible to avoid Compared to oral NSAIDs, OA altogether, looking after joints topical products carry reduced risks can help to minimise a person’s risk. of potential side effects such as stomach irritation, and there is l and strains growing evidence of their Sprains and strains are common, effectiveness at treating chronic minor injuries that affect the conditions, including OA. In fact, muscles and around the NICE guidelines state that oral joints. They often occur if a person paracetamol and/or topical NSAIDs falls or lands awkwardly, and they should be considered before oral are common during sports, NSAIDs for OA. However, topical especially if the person over products may not be suitable for reaches, suddenly changes their children, pregnant or breastfeeding direction or speed, or collides with women, or people with aspirin- Stretching before and after exercise can help to reduce the risk of injuries something – or someone! sensitive asthma. If in doubt, check Sprains occur when one or with the pharmacist. more of the ligaments supporting a joint gets experienced athletes, may suffer. DOMS rarely Ibuprofen is the most common OTC topical stretched, twisted or torn. Sprains commonly requires medical attention unless the pain is NSAID and is available in gel (e.g. Nurofen 5% affect the knees, , wrists and thumbs, severe or there is pronounced swelling. Gel) and spray formats (e.g. Ibuleve Speed Relief with symptoms including pain, swelling, Spray). bruising and tenderness. The person may not be Treating an injury The NSAID diclofenac is available in topical able to use, or put weight on, the affected joint. Many experts advise applying PRICEM: products including Voltarol Emulgel P and Strains occur when fibres in the muscle • Protection – using slings, braces, supports and Voltarol Pain-eze Emulgel. stretch or tear, most commonly in the hamstring athletic tape to support the affected area and Movelat Relief Cream is a mild to moderate muscles or lower back. Symptoms include pain, ensure the injury doesn’t worsen anti-inflammatory and analgesic topical swelling, bruising, muscle spasms and difficulty • Rest – injuries require time to heal, so preparation that contains mucopolysaccharide using the affected muscle. customers should take it easy and not aggravate polysulphate and salicylic acid. To help reduce the risk of sprains and strains, things by continuing to use the affected area it’s important to warm up before exercise, and • Ice – ice packs and cold therapy help to reduce to stretch (cool down) afterwards. Wearing the swelling and inflammation, and can numb pain correct footwear and equipment for the activity • Compression – compression bandages self care tips is also important, as is resting when the body stabilise the affected joint and combat swelling feels fatigued. • Elevation – lifting the injured area higher than While most sprains and strains heal in time, the level of the heart reduces blood flow, which refer to the pharmacist anyone who: minimises swelling and inflammation l Exercise regularly and include weight- • Is in severe pain, or is unable to move or put • Medication – OTC products help to manage training activities weight on the affected joint the pain associated with many minor l Maintain a healthy weight and ensure • Reports numbness, discolouration or coldness musculoskeletal conditions. a balanced diet with a sufficient intake in the injured area of calcium and vitamin D • Has an injury where the affected area looks Topical pain relief l Be aware of your posture, especially crooked or has any unusual lumps, other than While oral analgesics may be the preferred when standing, lifting heavy objects or swelling treatment option for some patients, others may sitting at a desk • Has unsuccessfully tried several treatments. prefer to apply a topical product. l Consider the quality of your mattress – Some customers may find that rubbing a old or sagging mattresses do not provide l Pain after exercise cream or gel onto a sore muscle is effective at sufficient back support Customers may try a new piece of equipment relieving pain. Alternatively, spray formulations l If you sleep on your side, place a pillow at the gym or push themselves a little harder on can be useful for hard to reach areas. Whatever between your knees for support. If you their daily run only to find themselves suffering formulation they choose, advise customers to sleep on your back, place a pillow the following day. Delayed onset muscle read the manufacturer’s instructions carefully underneath your knees soreness (DOMS) after physical activity is very and apply the product as directed. Topical l Gradually introduce new exercises and common, particularly when beginning a new products should not be applied to broken or physical activities. Ensure you warm up exercise programme or changing the nature, infected skin, or near the eyes, mouth or before and stretch (cool down) afterwards intensity or duration of the activity. mucous membranes.They should also not be l Avoid being sedentary for long periods DOMS may be caused by microscopic applied alongside heat pads or underneath tight of time damage to the muscle fibres and many experts bandages. Remind customers to wash their l Listen to your body. Know when to slow believe that this is the body adapting, which in hands thoroughly after application. down and rest time leads to greater strength and stamina. l Wear appropriate footwear – avoid high DOMS typically occurs a day or two after l Topical NSAIDs heels and totally flat shoes. exercise and lasts three to five days. It can range Topical non-steroidal anti-inflammatory drugs from mild to severe and anyone, including (NSAIDs) such as ibuprofen and diclofenac can

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l Rubefacients and counter-irritants relief, but it’s important to apply the correct OTC products that are designed to cool These ingredients act as irritants and produce a temperature at the right time. People with and relieve sprains and sore muscles include warm feeling in the affected area, which some diabetes, those with active infections or anyone Ralgex Freeze Spray and Deep Freeze Cold Spray people find soothing. Common examples found with poor circulation should not apply cold or and Gel. in OTC products include salicylates and heat packs unless medically advised. nicotinates along with menthol, camphor, l Heat eucalyptus and turpentine oil. There are various l Ice With the exception of muscle spasms associated OTC brands available, including Algesal and Ice is most effective when applied within 48 with lower back strains, heat should not be Deep Heat. Such products are available in cream hours after an injury. Immediate application applied until 48 hours after an injury has and spray formulations. helps to reduce bleeding in the tissues, and occurred. Heat causes blood vessels to dilate, Capsaicin occurs naturally in cayenne pepper prevents and minimises swelling. It can also bringing more blood to the affected area, which and warms the skin when applied to sore relieve pain by numbing the affected area. As stimulates the healing of damaged tissues. Heat muscles and joints. OTC products include Radian the injury begins to heal, ice can be applied to also helps to relax muscle spasms and ease B Muscle Rub and Ralgex Cream, which contain further reduce pain and muscle spasms. stiffness. To avoid burns and scalds: capsicum oleoresin. Various ice products are available that can be • Place a towel between the heat and the skin Such products should not be applied to stored in the freezer until required. Alternatively, • Check the skin regularly broken or inflamed skin and users should avoid ice packs can be made from ice cubes wrapped • Apply products that are warm rather than hot contact with their eyes, lips and other sensitive in a plastic bag or damp tea towel. • Don’t use a heat pad while sleeping – areas. Hands should be washed thoroughly after Ice can cause frostbite if the skin is not prolonged heat can cause burns if unattended application and use should be discontinued if properly protected. So pass on these tips to • Apply heat for a maximum of 30 minutes or persistent skin irritation develops. customers to help them protect their skin: according to the manufacturer’s instructions. • Don’t apply ice directly. Rub a small amount of Heat can be applied in the form of heat l Complementary treatments oil over the area where the ice will be applied. pads, hot water bottles or heat lamps, but a Arnica ointment is a popular OTC treatment, Place a cold, damp flannel over the oil before warm bath or shower can also be effective. particularly for bruises and swelling after applying the ice There are a number of heat patch products contusions. Products include Weleda Arnica • If the skin is broken or there are stitches, available OTC, including Voltarol Thermal Patch, Ointment and Nelson’s Arnicare range. protect the area with a plastic bag, not oil Nurofen Express Heat Patches and Deep Heat Tiger Balm is another complementary • After five minutes, check the colour of the skin. Heat Patches. treatment option, which can be used by adults If the skin is bright pink or red, remove the ice. If and children from two years of age to soothe not, apply it for a further five to 10 minutes More information sore and aching muscles. • Ice should not be applied for longer than 20 to l Arthritis Research UK: 0300 7900 400 30 minutes. Take frequent breaks and reapply www.arthritisresearchuk.org Ice and heat therapy when the surrounding skin looks and feels l BackCare: 0208 9775 474 Ice and heat therapy can provide effective pain normal (around 30 to 60 minutes). www.backcare.org.uk.

assessment questions: topical pain relief

For each question, select one correct answer. Discuss your answers with your pharmacist. 5. When it comes to applying ice therapy, customers should: a) Not apply ice directly to the skin but rub a 1. Which of these statements is FALSE? 3. Which of the following is NOT small amount of oil over the area and place a a) Musculoskeletal pain is pain, soreness or recommended when treating an injury? cold, damp flannel on top. If the skin is broken discomfort felt in the muscles or joints (e.g. a) Protect, support and rest the or there are stitches, replace the oil with a bag n a twisted ankle) n affected area to ensure the injury b) Leave the ice in place for at least 50 to 60 b) Acute pain is long-term (e.g. arthritis) n doesn’t worsen n minutes n c) Pain occurs for a reason and should b) Apply ice packs and cold therapy to c) Avoid taking breaks and allow the ice to sit not be ignored n help reduce swelling and inflammation, on the injured area n d) Back pain, particularly lower back pain, and numb pain n d) Only apply ice 48 hours after the injury has is one of the most common causes of pain c) Keep the injured area below the occurred and once the area has been treated in the UK n level of the heart to reduce swelling with heat therapy n and inflammation n 2. Which of these statements is TRUE? d) Take OTC analgesics to help manage 6. Which of the following is a recognised self a) According to BackCare, one in five adults any pain n care tip to help prevent musculoskeletal pain? experience back pain at some point in their a) Exercise regularly and include weight-training lives n 4. Which of the following treatment activities to strengthen muscles that support b) The peak age to experience back pain options can be applied topically to major joints n is 25 to 45 n relieve pain? b) Quickly and regularly introduce new exercises c) Everyone is equally as likely to suffer a) NSAIDs n to keep muscles strong n from back pain. There are no recognised b) Rubefacients and counter- c) Be sedentary for long periods of time to allow risk factors n irritants n muscles to recover n d) For the majority of people, back pain is not c) Complementary treatments n d) If you experience an injury, continue to push serious and usually resolves within six weeks n d) All of the above n yourself as normal n

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