Advanced Musculoskeletal Physiotherapy Self-directed Learning Modules:
Physiotherapy Arthroplasty Review Clinic
2014
Module 5: Pharmacology
Prepared by Alfred Health on behalf of the Victorian Department of Health 2014
1
Module 5: Pharmacology
Contents
Module 5: Pharmacology 2
5.1: Background 3
5.2: Basic Pharmacology 5
5.3: Medication History Taking 7
5.4 Pain and analgesia 9
5.5 Other Pharmacological Agents 11
Module 5 Pharmacology 2
5.1: Background
LEARNING OBJECTIVES:1. To be familiar with the Drugs, Poisons and Controlled Substances Act
2. To become familiar with the National Prescribing Services website and Competency Standard
3. To understand your local organisation’s policies and procedures regarding medications
4. To be familiar with the schedule of poisons (Poisons standard 2010)
5. To be familiar with the national strategy for quality use of medicines
6. To understand common abbreviations and definitions used in pharmacology
KNOWLEDGE:
· Identify what is the scope of practice for an advanced musculoskeletal physiotherapist in relation to medications for your local organisation.
· What are the 9 different schedules used to classify poisons and what are the principles of scheduling poisons?1
· What schedules apply to the following medications:1
o Morphine
o Ibuprofen (single dose 200mg)
o Ibuprofen (pack >25 dosage units)
o Diclofenac
o Indocid
o Codeine
o Oxycodone
o Gabapentin
o Tramadol
o Aspirin
o Paracetamol (single dose 500mg)
o Paracetamol (pack >25 dosage units)
o Diazepam
· What are the responsibilities of a health professional in regards to the quality use of medicines?4, 5, 7
· What do the following mean?
o q.i.d.
o Stat.
o b.i.d.
o o.m.
o p.r.n.
RECOMMENDED RESOURCES
1. Australian Government ComLaw (2010) Poisons Standard 2010
http://www.comlaw.gov.au/Details/F2010L02386
2. Australian Government Department of Health and Ageing (2004) National Strategy for Quality Use of Medicines http://www.health.gov.au/internet/main/publishing.nsf/content/nmp-pdf-natstrateng-cnt.htm
3. Department of Health Victoria (2013) Drugs & Poison Controls in Victoria Information for registered health practitioners. http://www.health.vic.gov.au/dpcs/reqhealth.htm
4. Kumar, S and Grimer, K (2005) Nonsteroidal antiinflammatory drugs (NSAIDs)and physiotherapy management of musculoskeletal conditions: a professional minefield? Therapeutics and Clinical Risk Management. 1(1): 69–76. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661609/#__ffn_sectitle
5. Lum, E, Mitchell, C & Coombes, I (2013) The competent prescriber: 12 core competencies for safe prescribing. Australian Prescriber. 36, 1, 13-16.
http://www.australianprescriber.com/magazine/36/1/13/6
6. National Prescribing Service Australian Government Department of Health and Ageing (2013) NPS Medicinewise http://www.nps.org.au/
7. National Prescribing Service Australian Government Department of Health and Ageing (2013) Prescribing Competencies Framework http://www.nps.org.au/health-professionals/professional-development/prescribing-competencies-framework
Module 5.1 Pharmacology: Background 3
5.2: Basic Pharmacology
LEARNING OBJECTIVES:1. To understand the basic pharmacokinetics and pharmacodynamics of drug classes commonly used to treat musculoskeletal conditions
2. To become familiar with the internet resources available to provide detailed information about medications either by generic or trade name
3. To become familiar with medications prescribed for common co-morbidities that may interact with medications used to treat musculoskeletal conditions
KNOWLEDGE:
· What are the definitions of the following drug classes? (Monash physiotherapy resource)
o Opiod Analgesic
o Non-opiod Analgesic
o Antibiotics
o Anticoagulant
o Antiplatelet agent
o Benzodiazepines
o Corticosteroids
o NSAIDs
· Use online resources to describe for each of the following medications:1-5
o Mechanism of action
o Indications
o Precautions/Contra-indications
o Adverse effect
o Drug interactions
o Dosage
o Patient education
o Common brand names
§ Paracetamol
§ Salicylates (Aspirin)
§ NSAIDS (Ibuprofen, Naproxyn, Diclofenac, Indomethacin, Celecoxib)
· Selective
· Non-selective
§ Opioids
· Oxycodone
· Tramadol
· Codeine
§ Diazepam
§ Neuropathic pain medications (Amitriptyline, gabapentin, pregabalin)
§ Antibiotics
· What are common trade and brand names of medications prescribed for the following conditions:1, 4
o Hypertension
o Atrial Fibrillation
o Diabetes
o Rheumatoid Arthritis
o Cholesterol
o Asthma
o Depression
o COPD
o Epilepsy
· What is the “triple whammy” effect?6
RECOMMENDED RESOURCES
1. Australian Medicines Handbook (No date) https://shop.amh.net.au/
2. Helme, R (2006) Drug treatment of neuropathic pain. Aust Prescriber. 29,72-75 http://www.australianprescriber.com/magazine/29/3/72/5#.UWzAgcqKSYs
3. Lippincott Williams and Wilkins (2008) Clinical Pharmacology made incredibly easy. 3rd edition. Springhouse.
4. MIMS Australia (No date) MIMS 100% Pure knowledge www.mims.com.au
5. Therapeutic guidelines limited (2011) Therapeutic guidelines www.tg.org.au
6. Thomas, M (2000) Diuretics, ACE inhibitors and NSAIDs—the triple whammy. Medical Journal Australia. 172: 184-185.
National Prescribing Service
7. Analgesic options for pain relief. (2006) http://www.nps.org.au/publications/health-professional/nps-news/2006/analgesic-options-for-pain-relief
8. Ibuprofen for pain and fever. (2013) http://www.nps.org.au/medicines/muscles-bones-and-joints/anti-inflammatory-medicines-nsaids/ibuprofen
9. Muscles, bones and joints. Musculoskeletal system. (2013) http://www.nps.org.au/medicines/muscles-bones-and-joints
10. Opioid pain relievers. Narcotic analgesics. (2013) http://www.nps.org.au/medicines/pain-relief/opioid-pain-relievers
11. Pain relief. Analgesia. (2013) http://www.nps.org.au/medicines/pain-relief
Module 5.2. Basic Pharmacology 6
5.3: Medication History Taking
LEARNING OBJECTIVES:1. To understand the key principles of history taking in relation to medications most relevant to the management of musculoskeletal conditions
2. To understand what clinical assessment needs to occur with patients requiring medications
KNOWLEDGE:
1. History Taking
· What are the important questions to include in the history taking that are necessary for safe and efficacious use of medicines in patients presenting with musculoskeletal conditions?3,
· What questions in the history taking will determine what type of pain is present?3
· What are the questions to ask when assessing a patient’s analgesic needs?1-4,
· What is the significance of a patient reporting the following history of:
o Gastric ulcers
o Renal failure
o IVDU
o Multiple medications
o Recent surgery
o Heart condition
o Lung/kidney/heart transplant
o Rheumatological conditions eg SLE
o Recent DVT
o Diabetes
o Osteoporosis
o An open wound
· What medications and substances other than prescription medicines need to be included when taking a medication history?3
· What social questions need to be asked in relation to medication use?3
· What risk factors identified in the history may indicate poor compliance with adherence of medications?3
2. What should be included in a clinical assessment of patients requiring medications, and in particular opioid medication?1-4
RECOMMENDED RESOURCES
1. Bryant, B & Knights, K (2011) Pharmacology for Health Professionals. 3rd edition. Mosby Elsevier. Chapter 15, Analgesics, p 277-307.
2. Egol, K , Koval, K & Zuckerman, J (2010) Handbook of Fractures. 4th edition. Lippincott Williams and Wilkins. Chapter 7, Orthopaedic Analgesia, p 63-76
3. Fitzgerald R, (2009) Medication Errors: the importance of an accurate drug history. British Journal of Clinical Pharmacology. 67, (6), 671-675. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2723207/pdf/bcp0067-0671.pdf
4. Neal, M (2009) Medical Pharmacology at a Glance. 6th edition. Wiley-Blackwell. Chapter 29, Opioids and analgesics, p 64-65; Chapter 32, NSAIDs, p 70-71.
Module 5.3 Medication History Taking 8
5.4 Pain and analgesia
LEARNING OBJECTIVES:1. To understand what medications are appropriate for pain ranging from mild to severe
2. To understand pain pathways and mechanisms of pain to aid the discussion with the medical team to prescribe the most appropriate medications
KNOWLEDGE:
· Describe the concept of the WHO analgesic ladder and recent adaptations to it?5
· What is the difference between nociceptive pain mechanisms (somatic and visceral) and neuropathic pain mechanisms?
· What psychological characteristics are associated with high levels of pain?4
· What are risk factors for chronic pain? 4
· How can pain be objectively measured?
· What are some examples of evidence based, effective acute musculoskeletal pain management strategies both pharmacological and non-pharmacological ?
· What analgesics maybe prescribed by the GP or consultant in the following musculoskeletal conditions:
o 1st episode acute low back pain
o Haematoma to the thigh
o Trochanteric bursitis post THA
o Acute episode of chronic low back pain
o Acute episode of osteoarthritis
o Chronic pain post TKA
RECOMMENDED RESOURCES
1. Australian government National health and medical research council (2010) Acute pain management: scientific evidence. 3rd edition.
http://www.nhmrc.gov.au/guidelines/publications/cp104
2. Leung, L (2012) From ladder to platform: a new concept for pain management. Journal of Primary health care. 4, 3, 254-258.
http://www.rnzcgp.org.nz/assets/documents/Publications/JPHC/September-2012/JPHCViewpointLeungSeptember2012.pdf
3. Moseley, GL (2007) Reconceptualising pain according to Modern Pain Science. Physical Therapy Reviews. 12, 3, 169-178
http://www.ingentaconnect.com/content/maney/ptr/2007/00000012/00000003/art00002
4. Turk, D & Okifuji, A (2002) Psychological Factors in Chronic Pain: Evolution and Revolution. Journal of consulting and clinical psychology. 70, 3, 678-690.
http://www2.warwick.ac.uk/fac/med/study/ugr/mbchb/phase1_08/semester2/healthpsychology/integration/chronic_pain.pdf
5. Vargas – Schaffer, G (2010) Is s the WHO analgesic ladder still valid? Twenty-four years of experience. Canadian Family Physician. 56, 6, 514-51.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902929/
Module 5.4 Pain and Analgesia 10
5.5 Other Pharmacological Agents
LEARNING OBJECTIVES:1. To understand the pharmacological management of Gout
2. To understand the pharmacological management of a patient with an infected wound
3. To understand the pharmacological management of joint infection
KNOWLEDGE:
· What is the pharmacological management of a suspected acute episode of gout?
· Describe the use of antibiotics in the management of:
o Surgical wound infection
o Bone and joint infection (with prosthesis insitu)
RECOMMENDED RESOURCES:
Coakley, G, Matthews, C, Field, M, Jones, A, Kinglsey, G, Walker, D, Phillips, M, Bradish, C, McLachlan, A, Mohammed, R, & Weston, V (2006) BSR & BHPR, BOA, RCGP and BSAC Guidelines for management of the hot swollen joints in adults. Rheumatology. 45, p1039-1041. http://www.rheumatology.org.uk/includes/documents/cm_docs/2009/m/management_of_hot_swollen_joints_in_adults.pdf
Fagan, H (2005) Approach to the Patient with Acute Swollen/Painful Joint. Clinics in Family practice. 7, 2, p305-319. http://www.familypractice.theclinics.com/article/PIIS1522572005000127/references
Khanna, D et al (2012) 2012 American College of Rheumatology guidelines for management of gout. Part 1: systematic nonpharmacologic and pharmacologic therapeutic approaches to hyperuricemia. 64, 10, p1431-1446.
http://www.ncbi.nlm.nih.gov/pubmed/23024028
Monu, J &Pope, T (2004) Gout: a Clinical and Radiologic Review. Radiologic Clinics of North America. 42, 1, p169-184. http://www.ncbi.nlm.nih.gov/pubmed/15049530
Weston ,V & Coakley, G (2006) Guideline for the management of the hot swollen joints in adults with a particular focus on septic arthritis. Journal of Antimicrobial Chemotherapy. 58, 3, p492-493.
http://jac.oxfordjournals.org/content/58/3/492.long
Therapeutic guidelines Australia (2010)Antibiotic Version 14 (2010) http://www.tg.org.au
Up to date
Calderwood, S (2012) Beta-lactam antibiotics: Mechanisms of action and resistance and adverse effects
http://www.uptodate.com/contents/beta-lactam-antibiotics-mechanisms-of-action-and-resistance-and-adverse-effects
Calderwood, S (2012) Penicillins
http://www.uptodate.com/contents/penicillins
Berbari et al (2013) Clinical manifestations and diagnosis of prosthetic joint infections
http://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-prosthetic-joint-infections?source=search_result&search=joint+infections&selectedTitle=4%7E150
Berbari et al (2013) Treatment of prosthetic joint infections
http://www.uptodate.com/contents/treatment-of-prosthetic-joint-infections?source=search_result&search=joint+infections&selectedTitle=1%7E150
Berbari et al (2013) Epidemiology and prevention of prosthetic joint infections
http://www.uptodate.com/contents/epidemiology-and-prevention-of-prosthetic-joint-infections?source=search_result&search=joint+infections&selectedTitle=8%7E150
Garlington et al (2012) Evaluation of infection in the older adult
http://www.uptodate.com/contents/evaluation-of-infection-in-the-older-adult?source=search_result&search=joint+infections&selectedTitle=40%7E150
Anderson et al (2013) Antimicrobial prophylaxis for prevention of surgical site infection in adults
http://www.uptodate.com/contents/antimicrobial-prophylaxis-for-prevention-of-surgical-site-infection-in-adults?source=search_result&search=wound+infections&selectedTitle=2%7E150
Anderson et al (2014) Basic principles of wound management
http://www.uptodate.com/contents/basic-principles-of-wound-management?source=search_result&search=wound+infections&selectedTitle=4%7E150
Module 5.5 Other Pharmacological Agents 12