<h2>Practice points</h2><ul><li>Acute care consists of education support and the early identification of those patients with either signs or symptoms of ‘red flags’ (serious conditions) or ‘yellow flags’ (psychological and occupational factors) that may influence recovery and lead to chronicity1</li><li>Non-pharmacological treatments for minor musculoskeletal injuries is insufficient2</li><li>Complementary medicines can be used to support healing and recovery. For example, fish oil (&gt;2.7g total omega-3) can reduce inflammation,3 vitamin C can assist in collagen synthesis4 and magnesium may reduce muscle spasm and cramp2</li><li>A proprietary comfrey cream has been shown to have anti-inflammatory, analgesic and tissue regeneration qualities and has been researched successfully in back pain, ankle sprain and soft tissue injury5,6,7,8</li><li>Vitamin D shows promise for those with muscle pain and weakness where deficiency is present2</li><li>Herbal medicines have been evaluated for acute lower back pain.9 White willow bark can be considered for its anti-inflammatory and analgesic properties2</li><li>Ice is the accepted go-to acute treatment to reduce swelling although there is little evidence for efficacy2</li><li>Massage is shown to be effective for lower back pain, however efficacy of both acupuncture and manipulation for acute musculoskeletal injury are yet to be established2</li></ul><h2>Description</h2><ul><li>Minor musculoskeletal injuries include acute soft tissue injury (sprains, strains and bruising), painful muscles and acute back pain</li><li>Acute pain is defined as pain of less than 3 months arising as a result of injury, repetitive movement or can be insidious in nature.2 Recurrent episodes may occur and some people may develop chronic pain1</li><li>Up to 35% of the population can be affected by back pain in a given month9</li><li>The majority (95%) of lower back pain is non- specific; serious conditions are rare causes of acute low back pain1</li><li>Psychosocial and occupational factors may be key influencers on the development of chronic pain. For instance, the risk factors associated with the failure to return to work after low back injury include low expectations of recovery and fear-avoidance behaviours2</li></ul><h2>Management principles </h2><ul><li>Assess for signs and symptoms of serious conditions (‘red flags’), or psychosocial and occupational factors (‘yellow flags’) that may influence recovery1</li><li>Recommend to visit GP for physical examination to assess for serious conditions</li><li>Offer information, assurance and advice to resume normal activity whilst respecting pain levels unless features of serious conditions are identified1</li><li>Manage mild to moderate acute pain with analgesics (e.g. paracetamol or if insufficient non-steroidal anti-inflammatory (NSAID) medication unless contraindicated1</li><li>Use complementary medicines to reduce inflammation and muscle spasm, and promote soft tissue healing and recovery</li></ul>

<h2>Primary recommendations</h2><h2> FISH OILS (OMEGA-3)</h2>Mechanism of action<ul><li>Anti-inflammatory - omega-3 partially replaces arachidonic acid in inflammatory cell membranes and competes with it for cyclooxygenase and lipoxygenase, leading to reduced production of proinflammatory metabolites3</li></ul>Research<ul><li>To date there are no trials on the use of omega-3 supplements during acute inflammation2</li><li>A controlled study amongst non-surgical neck and low back pain patients (n = 250) attending a neurosurgical practice taking 1200 mg/day of omega-3 supplements followed up after 1 month. Results: 78% of the participants remained compliant and 22% doubled the dosage themselves. Improvement of overall pain and joint pain was reported by 60% whilst 59% discontinued their NSAIDs10</li></ul>Dosage1-4 g fish oil daily (depending on dietary intake of fish).2Adverse effectsWell tolerated especially when taken with meals. Very mild and rare side effects such as gastric upset, blood thinning effects in very large doses &gt;10 g daily.2Key interactions<ul><li>Antihypertensive drugs: may have additive hypotensive effect depending on fish oil dose. BP should be monitored when patient is on high dose fish oil11</li><li>Anticoagulant and antiplatelet agents: high doses of fish oil (&gt;3 g/day omega-3 fatty acids) may increase the risk of bleeding with these drugs. There is conflicting data multiple clinical trials have found no increase in risk of bleeding with antiplatelet or anticoagulant drugs, however there are some studies that suggest an interaction, particularly at higher doses. Use with caution under supervision of a healthcare professional (HCP) and monitor11</li><li>Chemotherapeutic agents: may decrease drug effect. Avoid concomitant use11</li></ul><h2> VITAMIN C</h2>The healing of musculoskeletal tissues, such as bone, tendons and ligaments is dependent on the capacity of collagen synthesis and cross-linking. Vitamin C may enhance collagen synthesis and soft tissue healing.4Mechanism of action<ul><li>Increases collagen synthesis - preclinical studies demonstrate that vitamin C increases type-1 collagen synthesis4</li><li>Reduces oxidative stress parameters - after musculoskeletal injury inflammatory cells overproduce reactive oxygen species resulting in oxidative stress4</li></ul>Research<ul><li>To date clinical evidence does not replicate the results seen in animal models4</li></ul>Dosage1000 mg/day.12Adverse effectsWell tolerated. High doses can cause nausea, heartburn, abdominal cramps and diarrhoea.Key interactionsAluminium-containing antacids: increases drug side effects. Vitamin C chelates aluminium and increases aluminium absorption. To avoid interaction separate dose of medication by at least 2 hours11<ul><li>Antihypertensive drugs: may have an opposing effect to drug a clinical trial 6 week in duration with a treatment of both vitamin C 500 mg and grape seed extract 1000 mg increased blood pressure in hypertensive patients. Interaction possible. Avoid combination of vitamin C and grape seed extract with hypertensive patients11</li><li>Desferrioxamine - opposing drug effect. Vitamin C may cause transient deterioration of cardiac function with desferrioxamine, avoid concomitant use11</li><li>Estrogen – may increase blood levels of drug. Possible interaction. Use with caution under supervision of HCP11</li><li>Paracetamol – high doses of vitamin C (&gt;3g) may decrease the elimination rate of paracetamol. Possible interaction. Use with caution under supervision of HCP11</li><li>Protease inhibitors - decrease drug effect. Use with caution under supervision of HCP11</li></ul><h2> COMFREY PAIN RELIEF CREAM*</h2>Mechanism of action<ul><li>Analgesic - relieves pain and swelling associated with painful joint and muscle problems, contusions, sprains, or other blunt injuries5,7,13</li><li>Anti-inflammatory - relieves pain and swelling improving movement and mobility5,13,14</li><li>Tissue regeneration - stimulates granulation (new connective tissue) and supports callus formation13</li></ul>Research<ul><li>Ankle sprains - an investigator-blind, randomised, controlled, parallel-group, multicentre trial (n =164) compared comfrey cream* to diclofenac gel and it was shown to be non-inferior for acute unilateral ankle sprains.5 Also, it was more effective in relieving pain than placebo6</li><li>Lower back pain - a randomised, double-blind, placebo- controlled, multicentre trial (n=120) evaluated the efficacy of comfrey cream* for acute upper and lower back pain with no identifiable cause. 4 g of the comfrey cream* applied three times daily for 5 days was superior to placebo with a reduction of pain intensity of 95.2% in the active group compared to 37.8% in the placebo group7</li><li>Acute soft tissue injuries - a prospective, open, multicentre surveillance study investigated comfrey cream* for bruising, sprains, strains, painful muscles and joints (n= 163) over 2 weeks. There was a significant regression and night-time pain at rest, pain during palpitation, pain during motion, painful muscle tension, swelling and impaired motility. 93.3% of patients using the comfrey cream* had a good or excellent therapeutic effect8</li></ul>DosageApply 2-6 cm of the cream to the affected area 3-4 times daily.Adverse effectsCaution if allergic to peanut oil contained in the comfrey cream*. In rare cases hypersensitivities may occur.Key interactionsNone known*A proprietary formulation (Kytta-Salbe) containing 100 g of cream containing 35 g 99% pyrrolizidine alkaloid reduced comfrey (Symphytum officinale) fluid extract (1:2, ethanol 60% V/V).<h2> Special consideration </h2><h2> VITAMIN D</h2>A link appears to exist between vitamin D deficiency and muscle pain and weakness.2 One study in a community health clinic found 93% of patients with non-specific musculoskeletal pain were found to be vitamin D deficient and 100% in those who were under 30 years of age. A review on vitamin D deficiency concluded that it should be considered as a differential diagnosis in the evaluation of musculoskeletal complaints.2

Primary

<h2>Secondary recommendations</h2><h2> MAGNESIUM</h2>Mechanism of action<ul><li>A role in both nerve conduction and muscle activity3</li></ul>Research<ul><li>Anecdotally used to alleviate muscular pain and spasm, however there is minimal current evidence to support or reject magnesium in otherwise well patients with musculoskeletal pain and injury2</li></ul>Dosage300-600 mg/day.2Adverse effectsToo much magnesium can cause diarrhoea and gastric upset. In this case divided doses recommended.Key interactions<ul><li>Amphotericin-B: may decrease blood levels of nutrient. Assess nutrient status and supplement if indicated11</li><li>Antiarrhythmic drugs: Mg may have additive antiarrhythmic effect. Use with caution under supervision of a HCP and monitor11</li><li>Anticoagulant and antiplatelet agents: Mg may reduce the efficacy of warfarin. Avoid concomitant use11</li><li>Antihypertensive drugs (calcium channel blockers): Mg may have additive hypotensive effect. Use with caution under supervision of a HCP and monitor11</li><li>Biphosphonates: Bisphosphonates may form complexes with multivalent cations such as Mg. Avoid concomitant use11</li><li>Digoxin, chlorpromazine, penicillamine, tetracycline, nitrofurantoin and quinolone antibiotics: May decrease drug effect, separate medication and Mg by at least 2 hours11</li><li>Gabapentin: may decrease drug effect. Avoid concomitant use11</li><li>Loop and thiazide diuretics: may decrease blood levels of nutrient. Assess nutrient status and supplement if indicated11</li><li>Proton pump inhibitors: PPIs may cause hypomagnesaemia if taken long-term (usually &gt;1 year). Assess nutrient status and supplement if indicated11</li><li>Proguanil: may decrease drug effect. Avoid concomitant use11</li><li>Rocuronium: may have additive inhibitory effects on acetylcholine release. Use with caution under supervision of a HCP and monitor11</li></ul><h2> HERBAL MEDICINES FOR INFLAMMATION AND PAIN</h2><ul><li>Devil’s claw (Harpagophytum procumbens), turmeric (Curcuma longa), boswellia (Boswellia serrata) and ginger (Zingiber officinale) have been used traditionally in inflammatory disorders therefore they could have application in the treatment of minor musculoskeletal injuries</li><li>A systematic review on plant food supplements with anti-inflammatory properties found despite long-term traditional use turmeric and devil’s claw warranted further investigation. Boswellia was seen as the most promising for the treatment of pain and inflammatory conditions16</li><li>Cayenne (Capsicum frutescens) cream topically probably produces more favourable results than placebo in chronic lower back pain (three trials, n = 755, moderate quality evidence)9</li><li>Lavender oil applied topically by acupressure for lower back pain may reduce subjective pain intensity and improve lateral spine flexion and walking time compared to untreated participant’s (n=61, very low quality trail)9</li></ul><h2> WHITE WILLOW BARK (SALIX ALBA)</h2>Mechanism of action<ul><li>Anti-inflammatory - in-vitro and animal studies have shown down regulation of inflammatory mediators tumour necrosis factor-and nuclear factor-kappa B15</li><li>Analgesic15</li></ul>Research<ul><li>A Cochrane review included two trials of white willow bark with participants suffering from acute exacerbations of chronic lower back pain lasting longer than 6 months. The review of the trials found a standardised dose of 120 mg and 240 mg of salicin (white willow bark’s active) reduced pain more than placebo and comparable to the NSAID, rofecoxib9</li></ul>DosageWhite willow bark equivalent to 240 mg salicin/daily.9Adverse effectsMay relate to allergic reactions in salicylate-sensitive individuals.9Key interactions<ul><li>Warfarin, aspirin and antiplatelet drugs - additive effect. Found to have mild-anti-platelet effect, increased self-reported bleeding with warfarin. Use with caution under supervision of a HCP11</li></ul>

Secondary

<h2>Diet and lifestyle</h2><ul><li>Advise to stay active: Provides a small beneficial effect on pain, rate of recovery and function compared to bed rest and compared to specific exercise regime in mixed populations with lower back pain.1</li><li>Heat therapy: Heat wraps show promise for lower back pain.2</li><li>Acupuncture: Evidence in non-specific lower back pain.2</li><li>Spinal manipulation: Mixed reviews on benefits for lower back pain with scant evidence for acute neck conditions.2</li><li>Massage: A Cochrane review of massage for sub-acute (4 wks. to 3 mo.) lower back pain showed massage may be of benefit.2</li></ul><h2>SPRAINS AND STRAINS</h2>RICE Therapy For the first couple of days, follow RICE to help bring down swelling and support the injury. <ol><li>Rest – stop any exercise or activities and try to not to put any weight on the injury.</li><li>Ice – apply an ice pack to the injury for up to 20 minutes every 2 to 3 hours.</li><li>Compression – wrap a bandage around the injury to support it.</li><li>Elevate – keep it raised on a pillow as much as possible.17</li></ol>

Diet & lifestyle

<h2>References</h2>1. Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. The National Health and Medical Research Council. Australian Academic Press, 2003
 2. Kotsirilos V. A guide to evidence-based integrative and complementary medicine. 2011. Australia, Churchill Livingstone, Elsevier, 623-643
 3. Braun L et al. Magnesium Herbs &amp; Natural Supplements. An evidence-based guide. Vol 2 Elsevier Australia, 2015, 677-692
 4. DePhillipo N et al. Efficacy of vitamin C supplementation on collagen synthesis and oxidative stress after musculoskeletal injuries. A Systematic Review. The Orthopaedic Journal of Sports Medicine. 2018. 6(10)
 5. Predel H et al. Efficacy of comfrey root extract ointment in comparison to a diclofenac gel in the treatment of ankle distortions: results of an observer-blind, randomised, multicentre study. Phytomedicine 12 (2005) 707-714
 6. Koll R. Efficacy and tolerance of a comfrey root extract (Extr. Rad Symphyti) in the treatment of ankle distortions: results of a multicentre, randomised, placebo-conrolled, double-blind study. Phytomedicine 11 (2004) 470-477
 7. Gianetti B et al. Double-blind, placebo-controlled, randomised, parallel-groups, multi-centre clinical trials for the evaluation of efficacy and safety of an ointment of comfrey extract in comparison to placebo in the treatment of acute upper or low back pain. Br J Sports Med 2010; 44:637-641
 8. Tschaikin M. Efficacy and tolerability of topical use Symphytum officinale extract. Sonderduck aus Naturheilpraxis. 2004; 4:2-4
 9. Oltean H et al. Herbal medicine for low-back pain (Review) Cochrane Library, Cochrane Database of Systematic Reviews, 2014, Issue 12
 10. Maroon J et al. Omega-3 fatty acids as an anti-inflammatory: an alternative to nonsteroidal anti-inflammatory drugs for discogenic pain. Surg Neurol. 2006 Apr;65(4):326-31
 11. Blackmores Institute. Complementary Medicines Interaction Guide. 10th edition, 2019
 12. Phelps K et al. General Practice The Integrative Approach. Australia, Churchill Livingstone, Elsevier, 637-647
 13. Koll R. Therapeutic properties of tolerance of topical comfrey preparations. Fortschritte der Medizin 120, 2002, 1-9
 14. Grube B et al. Efficacy of a comfrey root (Symphti office. Radix) extract ointment in the treatment of patients with painful osteoarthritis of the knee: results of a double-blind, randomised, bicenter, placebo-controlled trial. Phytomedicine, 2007; 14:2-10
 15. Shara M et al. Efficacy and safety of willow bark (Salix alba) extracts. Phytother Res. 2015 Aug; 29 (8):1112-6
 16. Lorenzeo D. Plant food supplements with anti-inflammatory properties: a systematic review. Crit Rev Food Sci Nutr 2013;53(5):507-16
 17. NHS. Sprains and strains. https://www.nhs.uk/conditions/sprains-and-strains/ Accessed July 2019

Musculoskeletal injuries

Recommended for you

Acne

Stress and mild anxiety

Respiratory tract infections

Cognitive health