Muscle andjoint happens below theskinto causetheseproblems. are useditishelpful to know alittleaboutwhat and jointconditions, butto understandhow andwhy they Topical painreliefproductsareusedfor awiderangeof muscle • • • in somecasesrestricting movementinorder toprotect a joint. while Tendons move awayagain. body, andcontractingtheopposingtricepmuscleallowslowerarmto bicep muscleintheupperarmallowslowertomovetowards the pull inonedirection, soalwaysexistin pairs. Forexample,contractingthe Bones moveasaresult of a shockabsorber. also containsynovialfluid that allowthewidestrangeofmovement,suchaskneesandwrists– connective tissuethatcoverstheendsofbones.Somejoints–those movement. Thisisfacilitatedbytheinclusionof fundamental functionoftheskeleton,itwouldnotallowforany because whilethiswouldprovide thestructural supportthatisa most sitesinthebody, thetwobonesare notdirectly joined point inthebodyatwhichtwo that isaffecting oneormore oftheirjoints. in pharmaciesare aftersomethingtohelp withaproblem Most customerswhopurchase topical pain relief products Know thetreatmentoptions available,includingselfcaremeasures. Recognise thesymptomsthat mightwarrantreferral Understand howandwhypainfuljointmuscleconditions occur ligaments OBJECTIVES – tough bands of connective tissue – attach musclestobones, attach toughbandsofconnectivetissue– – , whichare similarinstructure, holdbonestogether, After studying thismodule, assistants will: This module canalsoform partofyourTeam Tuesday training. teamsas partoftheirongoinglearning. Seal assuitablefor usebypharmacy conditions, treatment optionsandcommunication skills . Thismodulehas beenendorsedwiththeNPA’s Training teamwhowishtoincrease theirknowledgeofcommon This moduleissuitable forallmembersofthepharmacy muscles , whichprovides extralubricationandactsas bones contracting. Skeletalmusclescanonly LEARN THE ASSISTANT connect. However, at A joint cartilage, asmooth PROFESSIONAL is the ADVISE & pain

MODULE 9: JANUARY 2016 DID YOU KNOW? Warming up properly before exercise means joints are better ? lubricated and the likelihood of pain or injury is reduced.

Understanding Preventing sports injuries the problem As is often the case, prevention is better than a cure, in that it takes little effort to Customers who ask for a topical painkiller will often be doing so as a result implement some relatively straightforward of physical activity having gone wrong. This may be because of an accident, measures and reduces the chance of the exercising without first warming up, falling over, using equipment wrongly, individual experiencing pain as a result having incorrect technique, or pushing the body beyond what it can cope of an injury. with. Any of these can result in an injury, the most common of which are: Warming up properly before exercise can Sprains are the result of an abnormal or excessive force being applied seem like a waste of time, but it serves an 1 to a joint, injuring the ligament. Commonly affected joints are the incredibly important function in making the knees, ankles and wrists. body ready for the demands of exercise. It makes synovial fluid less jelly-like and more liquid in consistency, which in turn means the Strains are stretching or tearing of muscle fibres as a result of being joints are better lubricated. It also increases forced to contract too strongly or being stretched beyond their limits. 2 blood flow to muscles, tendons and The legs and back are frequently affected. ligaments. It should be done before stretching to reduce the likelihood of pain and injury. A dislocation occurs as a result of a joint being moved beyond its 3 normal range of motion (for example, the shoulder) and often results Using the right equipment, such as in ligament damage. choosing running shoes rather than fashion trainers for jogging, and learning the correct Tendonitis is inflammation of the tendon that attaches two bones. technique for the sport being undertaken It is a common injury in the elbow for those who play tennis or golf. by getting advice from a coach or 4 healthcare professional. A ruptured tendon is a serious condition that usually happens Not pushing the body suddenly, causing severe pain because of a tear in the tissue. This 5 beyond what it can do, and commonly affects the Achilles tendon in the ankle. taking rest periods and days to allow the body to recover. Fractures are breaks in bones. Sometimes these may be tiny cracks, as 6 is the case in shin splints, a painful but self-resolving condition that Staying hydrated by can affect runners. But the break may be much more severe and drinking plenty of water serious, causing extreme pain and resulting in the person being unable to use before exercise, and during, the affected area. if needed.

Some customers may also seek advice on topical pain relief because they Stretching muscles to improve flexibility, suffer from osteoarthritis. This condition is the result of damage to the before and after exercise. cartilage in a joint, most commonly the knee, which results in swelling, pain and stiffness.

When to refer There are certain red flag symptoms that should ring warning bells. Get your pharmacist involved if a customer reports any of the following: • A joint or limb that looks deformed • Anyone who is taking any type • A joint that is too painful to move or cannot bear of medication weight • A suspected fracture, dislocation, • Severe swelling or bleeding rupture or other serious • Persistent joint pain, tenderness or swelling injury. • Prolonged or severe morning stiffness • Tingling or numbness • Sudden or severe pain DID YOU KNOW? If using a topical NSAID and an oral analgesic, paracetamol should ? be recommended over ibuprofen to avoid cumulative side effects.

Treatment options

Minor sports injuries often respond well to self care measures, usually referred to as PRICE for ease of remembering: Topical OTC products • Protect the area from further injury, perhaps by immobilising it Non-steroidal anti-inflammatory drugs (NSAIDs) • Rest by cutting out exercise and minimising daily activities 1 such as ibuprofen (e.g. Ibuleve, Nurofen 5% Gel), that involve the affected area as much as possible (for felbinac (e.g. Traxam Pain Relief Gel) and diclofenac example, not walking with an injured knee). Supportive (e.g. Voltarol Pain-eze Emulgel) reduce swelling and measures such as crutches or a sling may be helpful inflammation as well as pain. They act both locally • Ice the area for 15-20 minutes every two to three hours, at the site of the problem and systemically (i.e. they avoiding ice burns by wrapping ice packs in cloth so the skin are absorbed into the body). This means that side isn’t touched directly effects similar to those experienced by people • Compress the area with bandages to limit swelling taking oral NSAIDs can occur. • Elevate the injured area above the level of the heart if possible to reduce blood flow and minimise swelling. Rubefacients, sometimes known as counter- Following these steps for a couple of days is usually enough 2 irritants, cause blood to rush to the surface of the to resolve many injuries. skin, which makes it feel warm. This distracts the brain from the pain, but means these ingredients can cause discomfort if applied after a hot bath Additional treatments or shower, during warm weather or to skin that is already irritated or broken. Rubefacient ingredients Compression can limit movement and swelling to prevent include salicylic acid esters, nicotinates, menthol, further damage. Tubular bandages are usually used for this camphor and capsicum oleoresin. OTC product purpose, but the customer’s measurements should be examples include Movelat Relief Gel, Deep Heat checked to ensure the item fits correctly. Heat Rub and Radian B Muscle Rub. Immobilisation is sometimes recommended in order to Heat treatments increase circulation to the prevent further damage and to ease pain. For example, affected area, which helps move away the using a sling for a sprained wrist, splinting a broken finger 3 chemicals that contribute towards the pain. They to the next one, and putting a cast on a broken leg. should not be used immediately after an injury as they can increase the risk of bleeding, nor should Oral analgesics can be used to relieve pain. Ibuprofen is they be applied to broken skin. OTC examples popular because of its anti-inflammatory effect, which is include Voltarol Heat Patch, Thermacare. particularly useful if there is swelling, but there is a risk of cumulative side effects if used with a topical NSAID, so Cold treatments cause numbing and narrowing paracetamol may be a better option. NSAIDs have of blood vessels, which makes it more difficult for also been found to reduce the healing process, for 4 inflammatory chemicals to reach the affected area. example in bone injuries. OTC examples include Deep Freeze Cold Spray, Ibuleve Rapid Cooling Patch. Physiotherapy is a good way of strengthening the surrounding muscles and Bruise reducers do just what they say on the pack. improving the range of motion of an injured Examples include heparinoids (e.g. Hirudoid) and joint, and can speed up the return of normal 5 the herbal remedy arnica. functioning. Techniques including massage, manipulation and exercises are likely to be involved.

Corticosteroid injections may be recommended SIGNPOSTING for severe or persistent inflammation. They can be highly For more information, you can: effective, but some people gain only temporary or minimal relief and they can cause side effects. • Use your Counter Intelligence Plus training guide • Visit NHS Choices: www.nhs.uk/Conditions/Sports-injuries Surgery is sometimes, though rarely, required for very bad • Look at information provided by the Chartered Society of injuries, such as torn ligaments or broken bones. Physiotherapists: www.csp.org.uk/your-health/sports-advice. TEST YOURSELFONLINE GOOD PRACTICE KNOWLEDGE IS IMPORTANT WHEN ADVISING CUSTOMERS

Questions ? Scenario

1) What holds bones together? Chris, a man in his 40s, asks whether it is worth seeing a) Ligaments the doctor about his knee, which he thinks he has b) Tendons c) Muscles strained while running. d) Cartilage

2) Which statement is FALSE? a) Synovial fluid acts as a shock What would you recommend? absorber for the joints b) Most bones are directly joined For each part of this scenario, think about the decision you would make and, to each other importantly, why you would choose that option. In addition, for each decision that c) Skeletal muscles exist in you make, think about how you would talk to the customer and provide the opposing pairs necessary advice, and discuss this with your team and pharmacist. d) Synovial fluid lubricates joints

3) Which of the following would NOT 1 2 3 require referral? Agree that a visit to Suggest self care options a) A suspected ruptured Achilles tendon Both options the GP is the best and an OTC product to b) A suspected dislocated shoulder 1 and 2. c) A suspected sprained ankle course of action. relieve any pain. d) A suspected fracture of the lower arm

4) Which of the following is a component of PRICE? a) Putting a heat pack on an injured What if? area Chris says that the foot on the affected leg b) Moving the joint as much as possible is tingling and feeling a bit numb. to prevent it stiffening up c) Compressing the area to minimise swelling d) Applying direct pressure to an affected joint 1 2 3

5) Which of the following is NOT Tell him to put a heat Recommend an OTC Advise him to seek usually recommended as a way of pack on the foot to product containing a medical advice. preventing sports injuries? improve the circulation. local anaesthetic to get a) Warm up before exercising rid of the sensation. b) Cool down by stretching muscles to promote flexibility c) Ask someone who is experienced in the activity to demonstrate the correct technique What if? d) Pushing the body as hard as possible Chris returns a couple of months in order to build muscle strength later saying he has shin splints and asking what to do. 6) Which treatment option would be most sensible for someone who has injured their knee while running but has no red flag symptoms? a) See a specialist sports physio b) Apply a covered ice pack to the 1 2 3 affected area Suggest resting his legs Tell him to go to c) A steroid injection by not running for a the GP as he has Recommend an d) Go for another run to test the joint couple of weeks to allow fractured his lower OTC product. them to heal. leg bone.

Go to www.tmmagazine.co.uk to submit your answers to these questions. When you pass, you’ll be able to download a certificate to showcase your learning. You can also add this to your online, personalised learning log. www.tmmagazine.co.uk

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In a randomised double-blind study, Voltarol® Medicated Plaster provided up to 2x more eff ective relief of pain compared with a non-medicated placebo patch, when applied twice daily for 3 days.1 RELIEVES MUSCLE PAIN & TARGETS INFLAMMATION Diclofenac sodium

For customers suff ering from muscle pain fl are-ups including neck, shoulder, leg or arm pain, and who are looking for an effi cacious plaster or who may choose pain relief based on format.

Reference: 1 GSK Data on fi le, 2011. Product Information: Voltarol 140 mg Medicated Plaster (diclofenac sodium). Indications: Local symptomatic, short-term treatment of pain in acute strains, sprains or bruises of the extremities following blunt trauma. Legal category: P. Licence holder: Novartis Consumer Health, Watchmoor Park, Camberley, Surrey GU15 3YL. Date: 24 August 2015. Information about this product, including adverse reactions, precautions, contraindications, and method of use are available at: https://www.medicines.org.uk/emc/medicine/30684

CHGBI/CHVOLT/0009/15