b'CODING Update ComplianceLEGAL NUTRITION UpdateANJC News ANJC Leadership ANJC News! LEGAL EASE NUTRITION Member Scholarships REHAB UpdateChoosing aTopical AnalgesicBy Dr. Donald C. DeFabioCHIRO Assist Relevant Tip: Topical agents target the underlying soft tissue Multimodal chiropractic pain management includes topical substances and there is a growing amount of evidence whichand peripheral nerves at the application site by penetrating LEGAL Q&A underscores their efficacy and use. Topical analgesics (TA) arethe skin via passive diffusion.Topical agents can accumulate well suited for the treatment of localized pain with or withoutto therapeutic concentrations within the local tissue while Executive Directors Update peripheral components and are preferred because of safetymaintaining a low plasma concentration.Penetration and in avoiding kidney, renal and gastric irritation, having a lowerabsorption are highly dependent on the formulation.2020 ANJC AWARDS Menthol, another common TA, is also classified as a coun-risk of drug-drug interactions, providing better compliance and having improved tolerability.In fact, because of theirterirritant like capsaicin.Menthol elicits a cold sensation via overall safety, the American Geriatric Society recommendsTRP-melastatin 8 (TRPM8) channel activation.In addition, the use of topical agents for localized neuropathic andmenthol induces NO dependent local vasodilation when Legislative Update non-neuropathic pain as a front-line measure.applied topically.Therapeutically, menthol levels peak in the TAs can be delivered as in many forms (liquids, creams,skin after 30 minutes, its vasoactive effects last 15-45 minutes, INSURANCE Update INSURANCE Update powders, emulsions, patches, aerosols, etc.) and are oftenand the cooling sensation of menthol begins rapidly and combined with adjuvants to increase both viscosity and TECHNIQUE Updatepersists for an hour post application.absorption to penetrate the outermost layer of the skin (stratum corneum).The stratum corneum is dense, relatively impermeable and hydrophobic, while the pain sensing keratinocytes in the underlying layers of the epidermis are lipophilic.Permeating the stratum corneum is essential because the mechanism of action of TA involves interactions MedicareQ&AMedicare Update with nociceptive neural networks and various inflammatory OUR HEALTHreceptors in the deeper layers of the skin.To facilitate penetration, ultrasound, electricity, light therapy and heat have all been used. Relevant Tip:Transdermal is the percutaneous absorption of an agent to reach therapeutic levels comparable with systemic administration.The effect is primarily systemic - the trans-dermal delivery of medication serves as a reservoir within the local tissues, gradually releasing the active substance into systemic circulation.It is a poor choice for the sudden exacerbation of chronic pain or for acute pain treatment.Living keratinocytes are found in the stratum spinosum of the epidermis and have both analgesic and algesic properties. Relevant Tip:Menthol is found in peppermint, which be safety The analgesic properties involve a wide array of processestaken internally.Once systemic, the effects of menthol on the including nitric oxide (NO), B-endorphins, transient receptorendothelial system are vasoconstriction as opposed to the potential (TRP) channels and cannabinoid-2 (CBD2) receptors.vasodilation effects of local application. These are found in an extensive neural network of the skin and involve unmyelinated nerve fibers.Impacting theseNSAIDs (i.e., diclofenac, ibuprofen, ketoprofen, piroxicam, mechanisms is the goal of TAs. indomethacin, etc.) are also available as TAs both with and Capsaicin is one of the most researched TAs and recognizedwithout prescription.Applied locally they attain therapeutic for its analgesic effect.Useful for peripheral neuropathylevels with little risk for systemic toxicity.Relatively little (diabetic and post herpetic), chronic neck pain and postis known about the mechanism of action of this class of traumatic pain it acts on the TRP-vinilloid-1 (TRPV1) andcompounds aside from their ability to inhibit cyclooxygenase- unmyelinated C-fibers.The unmyelinated C-fibers depolarizedependent prostanoid formation (Hawkey 1999).and create a burning/warming sensation whereas TRPV1Relevant Tip:Local enhanced transdermal serums (LETS) depolarization produces a prolonged desensitization ofare another class of topical agents. These penetrate through the local pain nociceptors.Capsaicin, however,is locallythe epidermis to reach the underlying receptors and release pungent which affects compliance.The FDA has approved athe active ingredient over time.They also create a reservoir high dose capsaicin patch containing 8% capsaicin. effect as a transdermal medication but there is no systemic 12 I Fall 2021 www.anjc.info'