Herzlich willkommen! -‐Osteopathie-‐ NSAID´s in der Physiotherapie Seegen oder Fluch? Stefan Grundler Heimerer Akademie FOMT Fortbildungen für Orthopädische Medizin und Manuelle Therapie Kurzer Blick in die Physiologie -‐Osteopathie-‐ Medilearn.de Kurzer Blick in die Physiologie -‐Osteopathie-‐ Bischoff, HP: Praxis der konservaDven Orthopädie Kurzer Blick in die Physiologie -‐Osteopathie-‐ Forth, W: Allgemeine und spezielle Pharmakologie the role of GL, the cardiovascular systems, the kidneys and the liver. GL ncountered side effects (i.e., dyspepsia, nausea, ulcers and bleeding) appear 55 articles Kurzer Blick iwhen n die Physiologie primarily NSAIDs are taken frequently. However, a much re reviews, Ziltener 2009 -‐Osteopathie-‐ dn’t attempt hodological al orally; this es, NSAIDs oodstream, SAIDs can r injection. st common ing cycloprostaglanarachidonic Eisatzmöglichkeit der NSAID´s -‐Osteopathie-‐ • Verschiedene Zielsetzungen • Anästhesie • Chirurgie • Orthopädie Einsatz der NSAID´s Cooney 2016, Sawan 2014, McCartney 2014, Mochikuzi 2016 • Anästhesie: • Bedarf an Opiaten senken. • AlternaDven in Studien: • Tramadol + Paracetamol • Pregabalin • GabapenDn • Aktuelle Leitlinie: KriDsches Überdenken des Einsatz von NSAID´s bei orthopädischen PaDenten. -‐Osteopathie-‐ Einsatz der NSAID´s Yeung 2016, Beckmann 2014, Balboni 2006, Davies 2015, Kann 2Radiation 015 Oncology 1290 I. J. ● Biology ● Physics -‐Osteopathie-‐ Volu • Chirurgie: • Verhinderung heterotope OssifikaDon z.B. bei Hüd-‐TEP. • Klinische Relevanz bleibt unklar. Fig. child Glas gene indu 2332 Join • Aktuelle Empfehlung: Abwägung zwischen NSAID und lokaler Bestrahlung. tion appe (Fig exte deep opm roid neou cond resu alph cycl • NSAID´s mindern Knochenheilung! Fig. 1. Heterotopic ossification (arrows) following total hip arthroplasty. Clin H Einsatz der NSAID´s Carter 2015, Ärzteblag 2013, Maiman 1982 -‐Osteopathie-‐ • Orthopädie: – RheumaDscher Formenkreis – Universalmedikament für Schmerzlinderung und Entzündungshemmung? Medikament Definded Daily Dose gesamt 2013 DDD pro Tag 2013 Ibuprofen 422,4 Mio 1,16 Mio Diclofenac 419,5 Mio 1,15 Mio metamizol) were rarely used (5.4% of all substances), although was prescribed to 40% of the players from one country during they might be as efficient as NSAIDs in treating postexercise the tournament. pain. Acetylsalicylic acid accounted for 2.8% of all painkilling The high use of medication and NSAIDs in particular is not agents (NSAIDs, analgesics and myorelaxants) in adolescent limited to international football. Similar use of medication has 015, ofKüster 013 and 1.2% of male been reported during the Sydney Olympics players as Tscholl well as in22.3% female 2adults in 2000,2 in -‐Osteopathie-‐ adult football players. As its anti-inflammatory and painkilling top-level track and field athletes,5 triathletes15 and also in collefunctions are weak and it carries an increased risk for traumatic giate athletes.16 17 An unpublished review18 of articles published 3–7 10Turnier 17 19 Anzahl pieler Medikamenten Abusus ährend haemorrhage, acetylsalicylic acid is not suitable for Suse in sports between 2003 and w 2010 found that power/sprint dismedicine. ciplines show a similar ‘substance profile’ as ball sports. WM 2 014 anaesthetics or 736 80 % Although endurance athletes rarely used NSAIDs (6.8%±0.2 Injections with local corticosteroids were 44 % zusätzlich vor dem Sdisciplines), piel mostly intra-articular, followed by intramuscular applications.-‐ 8 Davon vs 27.3%±0.4 in power/sprint their declared use of corticosteroids (15.0%±0.3 vs 4.6%±0.1) They were performed in almost 8% of all players participating -‐ Davon 4 Spieler CorDson intratendinös und and β-2-agonists (6.8±0.2 vsvor 2.3%±0.1) increased significantly ( p<0.05). In in adult male tournaments, and in about 3% of female adults intraarDkulär jedem Spiel popular events such as the Bonn Marathon 2009,20 Berlin and male adolescent football players (see table 2). The amount U 17 2005 320 56 % of administration seems to depend highly on the national team Marathon 201021 and El Andalus Ultramarathon,22 47–61% of physician. Whereas 23 of 32 team physicians did not perform athletes used NSAIDs or other painkilling agents. The particiBonn M arathon 2 010 3913 49 % E innahme dem Lauf any injections for musculoskeletal symptoms during the 2014 pants usingvor NSAIDs had an almost five times higher incidence 8 -‐ Davon % Frauen, meist D iclofenac > 100mg, World Cup, four players from one national team received of 61 adverse events (gastrointestinal cramps and bleeds, NSAID´s im Sport Ibuprofen > 800mg Figure 1 Prescribed medication during the FIFA World Cup. N=9124 for the 2002, 2006, 2010 and 2014 FIFA World Cups; N=2236 for the 2003 NSAID´s im Sport Tscholl 2015, Küster 2013 • HypothePscher Benefit: • Während sportlicher Belastung: • Weniger Krämpfe • Weniger Schmerzen • Höhere Leistung • Post-‐ sportliche Belastung: • Schnellere RegeneraDon leichter Verletzungen • Weniger Muskelkater -‐Osteopathie-‐ S3; figure 4). Joint and muscle pain after the race were significantly more frequent in the analgesics cohort than in controls (1301 vs 955 respondents, p<0.001, online supplementary table S3; figure 5). NSAID´s im Sport Tscholl 2015, Küster 2013, Brune 2009 a regression analysis which resulted in a comparable adjusted analgesic-related risk of 3.0 (95% CI 2.1 to 4.1; p<0.001, figure 6). To investigate whether the incidence of AEs was dosedependent, a risk estimation of the size of the dose was conducted. The high dose resulted in a significantly higher risk of AEs compared with the lower dose or con-‐Osteopathie-‐ trols. Even the low-dose group presented a higher risk of • HypothePscher Benefit: • Während sportlicher Belastung: • Weniger Schmerzen à NEIN Downloaded from bmjopen.bmj.com on August 26, 2013 - Published by group.bmj.com Consumption of analgesics before sports increases CV, GI and renal problems • Weniger Krämpfe à NEIN Figure 3 Incidence adverse events (OR 9.04; 95% CIof5.31 to 15.39 vs (AEs, 3.20; derived 95% CIfrom 2.32 to online supplementary table S3). Rounded percentages are 4.42 (figure 2)). given in online supplementary table S3. differences and There were similar numbers ofThe half-marathon between the groups were highly significant; p<0.001. marathon runners in all the analgesics cohort compared Figure 5 Percentage of runners experiencing muscle and/or joint pain after the race. Rounded percentages are given in online supplementary table S3. The differences are highly significant (***p<0.001). with controls. 4 A 4–10 times higher incidence of each type Küster of M, AERenner was B, Oppel P, et al. BMJ Open 2013;3:e002090. doi:10.1136/bmjopen-2012-002090 observed in the analgesics cohort compared with controls (overall incidence 16% vs 4%, online supplementary table S3; figure 3), with a calculated risk difference of 13%. The difference in the incidence of AEs between the two cohorts was most prominent with respect to GI cramps and CV events (after the race). In the analgesics cohort, GI cramps were the most frequent AE (reported by 14% of the cohort), followed by CV AEs after the race (9%). In the controls, CV AEs after the race were the most frequently reported AE (3%, online supplementary table S3). Notably, haematuria was reported only in the Figure 4 Reasons for premature termination of the race. Rounded percentages are given in online supplementary table analgesics cohort. The differences in the incidence of • Höhere Leistung à keine verlässlichen Daten, vermutlich kein Medikamenteneffekt NSAID´s im Sport Kjaer 2013, Trappe 2002, Mackey 2013, Ziltener 2010 • HypothePscher Benefit: E554 -‐Osteopathie-‐ ANALGESICS AND MUSCLE PROTEIN SYNTHES • Post sportliche Belastung: • Weniger Muskelkater à JEIN • Schnellere RegeneraDon leichter Verletzungen à NEIN Fig. 2. FSR (%/h) of mixed skeletal muscle protein before and after the eccentric exercise bout. ACET, acetaminophen group (n ' 4); IBU, ibuprofen group (n ' 7); PLA, placebo group (n ' 6). *P " 0.05 from preexercise. 76 ! 19% (P " 0.05) in PLA (0.058 ! 0.012%/h), and was unchanged (P # 0.05) in IBU (35 ! 21%; 0.021 ! 0.014%/h) and ACET (22 ! 23%; 0.010 ! 0.019%/h) (Fig. 2). Whole body phenylalanine turnover (Ra phenylalanine) was unchanged (P # 0.05) in response to exercise (PLA: 0.67 ! 0.05 vs. 0.63 ! 0.05 $mol ! kg%1 ! min%1) or either drug (IBU: 0.67 ! 0.04 vs. 0.63 ! 0.03; ACET: 0.66 ! 0.05 vs. 0.62 ! 0.03 $mol ! kg%1 ! min%1). The CK response to the exercise was large and highly variable among the three groups. CK was significantly elevated in all three groups after the exercise, but the overall response was not different among the groups (Table 2). Because some of the nine sites did not elicit a soreness response, the average level of perceived muscle soreness underrepresented the primary findings blunted the protei mally seen after th surprisingly, aceta on protein metabol From our data, blunting protein m clooxygenase inhib Goldberg (30) nea intact in humans. T of protein synthesis three different cyc domethacin, and m we hypothesized th oxygenase and hav metabolism. Howe the amount of inhi studies that showe 25, 30, 34) compar after consumption of ibuprofen. None that the 1.2 g/day ibuprofen is potent sis response to res What is less clea ited the increase in bout. The most log phen also inhibits however, to our kn amined the influe muscle metabolism data and the resu aminophen hypoth central nervous sy -‐Osteopathie-‐ „Ein Indianer kennt keinen Schmerz....“ „Kannst Du nicht mehr gehn, nimmst Du Voltaren....“ NSAID´s im Sport Alcorocho 2015, Jones 2015, Fernandez-‐Jean 2015 • -‐Osteopathie-‐ any unnecessary pressure. Eighty-three percent of experts begin mobilization of the affected area based on level of pain. Echography of the affected area after K 48onsens to 72 hours is2 recommended Spanischer 015 – by 80% of experts, as well as the administration of inflammation bioregulators (Table 1). muskuläre Beschwerden: Table 1. Therapeutic Indications in the Inflammatory Phase Unanimity Strongly Recommend Cryotherapy Compressive bandage Elevation Non-use of NSAIDs Sport Rest No weightbearing of affected limb No complete Drain haematoma with symptoms immobilization Analgesia Inflammation bioregulators Ecography after 48/72 hours Mobilize affected area as tolerated Recommended NSAID´s im Sport Mehallo 2006, Shang 2013 • Fazit und Ausblick • 48 h post Verletzung keine oralen NSAID • Analgesie mit Paracetamol, evtl. Opiate • Topische analgePsche Anwendung mit Sprays • KurzfrisPger Benefit für Subgruppen nicht auszuschließen • LangfrisPge generelle Nachteile relaPv sicher -‐Osteopathie-‐ Konzept der FOMT -‐Osteopathie-‐ • IntegraDon der besten Ergebnisse • „eigene Leitlinien“-‐ Erarbeitung • NSAID´s für welche PaDentengruppe, zu welchem Zeitpunkt in welcher Dosierung • Benefit und Risiken • AlternaDven: Homöopathie, Akupunktur,... parietal visceral craniosacral Pharma, Innere Medizin Heil-‐ prakDker -‐prüfung Spaß am Lernen Aku-‐ punktur Evidenz-‐ basiertes Arbeiten Vielen Dank für die Aufmerksamkeit! -‐Osteopathie-‐ Fragen, Literaturliste und Rehanewsleger unter: www.heimerer-‐akademie.de www.fomt.info [email protected] hgp://www.facebook.com/ fomt.info
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