INTRODUCTION:

Pain is the highest contributor and complex, multidimensional experience in the world healthcare system.¹ Orthopedic pain may differ in many ways, most common characteristics of pain are deep, aching, or burning. Pain is a critical and multichallenger experience involving numerous factors like physiological, sensory, emotional and environmental.

Pain has no definitive method to measure and only the individual who is experiencing pain can precisely indicate its intensity. “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.”²

International Association for the Study of Pain (IASP) defines pain as “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”.

The term “pain as the fifth vital sign” was initially promoted by the American Pain Society to elevate awareness of pain treatment among healthcare professionals.³

TYPES OF PAIN:

1. Types of Pain Based on Mechanism:

i) Nociceptic pain: Pain produces from the activation of nociceptor in the affected area with the signal transmission through nerves(peripheral) and spinal cord to the brain which activate the reflexes(spinal) followed by voluntary action, perception, cognitive response.

ii) Neuropathic pain: It is a chronic pain causing injury to nervous system.

iii) Psychogenic Pain: It is due to the psychogenic factors which lead to an exaggerated or characteristics of the pain.

iv) Mixed Category Pain: It is a combination of nociceptive and neuropathic pain factors which involves injury to the nervous system with the release of inflammatory mediators leading to neurogenic inflammation.

2. Types of Pain Based on Severity:

i) Acute Pain: It is experienced immediately after injury or surgery upto days.

ii) Chronic Pain: Pain which lasts for months or year after the injury.⁴

3. Types of Musculoskeletal Pain:

Orthopedic pain can be acute or chronic affecting bones, joints, ligaments, muscles and tendons. It can be local or general pain specifying one area or entire body.

i) Bone pain: It is one of the most common types of pain associated with fractures.

ii) Joint pain: It is seen majorly in patients with joint stiffness and inflammation.

iii) Muscle pain: It is a sudden pain due to muscle injuries, spasms and cramps.

iv) Tendon and ligament pain: Caused by sprains, strains and overuse injuries.

v) Fibromyalgia: Characterized by pain in tendons, muscles and joints throughout the body.

vi) Nerve compression pain: Pain that exert pressure on nerves.

vii) Back pain: It has no specific cause, may be of injury or illness.

Causes of Orthopedic Pain:

There are many causes of orthopedic pain which include fractures, joint dislocation, trauma, poor posture, sprains, strain.⁵

Symptoms:

Symptoms vary from person to person depend on whether an injury causes the pain and may overlap.

i) General symptoms:

The symptoms include aching and stiffness, burning sensations and pain worsening with movement.

ii) Fracture symptoms:

If the pain is due to fracture, the symptoms include severe bruising, inflammation and deformity.

iii) Ligaments, muscles, tendons symptoms:

The symptoms like Cramp, localized tenderness is due to injury to ligaments, tendons or muscles.⁶

Diagnosis:

The diagnostic methods are X-rays, CT scan, MRI scan provide images of the bones, more detailed look at the bones and to see soft tissues such as muscles, cartilage, ligaments, and tendons respectively.

Pain Pathway:

Orthopedic pain after postoperative procedures is complex as it is classified into nociceptive and neuropathic pain based on how it is transmitted.⁷Pain pathway follows:

I) Nociceptive pain:

a) Activation and Transduction: The injury/fracture activates the nociceptive receptor present in the terminal nerve fiber, which transmit the stimuli to signal.

b) Transmission: i) Pain signals are transmitted via afferent neurons to the dorsal horn of the spinal cord.

ii) The dorsal horn ascends the signals to cerebral cortex by ascending spinothalamic pathways and thalamocortical. Therefore, the pain experience is dictated by the thalamus and send the signals to cortex.

c) Modulation:

The pain experienced by cortical modulation in cortex followed the pathway with modulation in the medulla, descending pathways and dorsal horn of the spinal cord.

Figure no 1: Pain Pathway – Transduction, Transmission and Modulation

II) Neuropathic pain:

Neuropathic pain is the injury to the nervous system mediated by A delta and C fibers.⁸In response to injury, A cell fiber releases neurotransmitters like bradykinin, histamine, serotonin, prostaglandin, acetylcholine, potassium and hydrogen ion based on intensity of stimulus⁹. Neurogenic inflammation is due to the activation of action potential in neuron, releases neuropeptides like Substance P. Secondary hyperalgesia i.e. hypersensitivity of area around injury, involving N-methyl-D-aspartate NMDA receptors and central sensitization.¹⁰

Assessment Scales for Pain:

Pain assessment is a crucial aspect as it helps in diagnosis, treatment, and management strategies for effective patient care and safety. Scales plays an important role to assess the intensity of pain which help healthcare professional to evaluate and manage pain effectively.¹¹Proper pain assessment and adequate pain management is necessary for smooth transition from postoperative period.¹²

I) Unidimensional Pain Scales:

1. Visual Analog Scale (VAS):

It is one of the simplest and widely used pain assessment scale. It is a simple line with endpoints “no pain” and “severe pain”. Patients point a mark on the line scale that represents pain intensity.¹³

2. Numeric Rating Scale (NRS):

It is a horizontal line represented with numbers from 0–10, where patient indicate their level of pain. It is most commonly used due to its simplicity and communication with the patients.¹⁴

3. Verbal Descriptor Scale (VDS):

It gives the descriptive terms (no pain, mild, moderate, severe pain) to describe the pain intensity. Patients select the term that best describes their pain.¹⁵

II) Multidimensional Pain Scales:

1. McGill Pain Questionnaire (MPQ):

The McGill Pain Questionnaire (MPQ) is a questionnaire to be filled by patient to describe pain. The scale helps people to describe sensations like burning or throbbing and emotional impact of pain.¹⁶

2. Brief Pain Inventory (BPI) scale:

Short questionnaire scale which measures both pain intensity and its impact on daily activity. It measures pain intensity, site, pain interference and pain relief for specific time period.¹⁷

3. Pain Disability Index (PDI):

It assesses the degree to which pain interferes with various aspects of a patient's life, including family responsibilities, social activity, occupation, self-care and daily life activity.¹⁸

Technique to Assess and Measure Postoperative Pain:

Summed Pain Intensity Difference (SPID): The sum of the differences between baseline and current pain intensity scores weighted by the time interval between scores. One of the effective methods to measure the pain and efficacy of treatment is the “pain intensity difference (PID)”.

Total Pain Relief (TOTPAR): TOTPAR is total pain relief scores over time interval between scores.¹⁹

Pharmacological Management of Pain:

The pharmacological agent uses to treat pain is analgesia targeting different pain pathway and mechanism. The management of neuropathic pain majorly focuses on treating symptoms.²⁰ Patients experience severe pain and should be given sufficient analgesia to provide relief.²¹ Effective pain control can be achieved with Multimodal analgesia (use of more than one pharmacological class of analgesic medication). Opioid showed severe side effects like respiratory depression, sedation, urinary retention. To avoid addiction of opioid use, the implementation of different classes of medication i.e. Multimodal analgesia has shown an effective outcome with patient satisfaction and increased recovery rate. Effective use of analgesic in postoperative period is a significant constituent of medical audit which helps in monitoring, evaluating and building required modifications in the prescribing practices to attain a rational and cost-effective medical care.²²

1. Non-Opioid Analgesic agents:

a. Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

NSAIDs are used for mild to moderate pain associated with inflammation. NSAIDs inhibit cyclooxygenase (COX) enzymes, further reducing the synthesis of prostaglandin.²³

b. Acetaminophen:

It is used for mild to moderate pain and also used as antipyretic and as an adjuvant to opioids in moderate to severe pain condition.

2. Opioid Analgesics:

Opioids analgesics are used to treat moderate to severe pain. They act pre and post-synaptically on mu, kappa and delta receptor by blocking calcium channel at presynapse inhibiting the release of substance P and glutamate. Postsynaptically it opens up the potassium channel which hyperpolarize the cell membrane increasing the action potential and generate transmission of nociceptive.²⁴

a. Short-Acting Opioids:

Morphine and Oxycodone are used for acute pain management due to their rapid onset of action.

b. Long-Acting Opioids:

Methadone and Extended-release formulations are used for chronic pain management to provide pain relief.

3. Adjuvant Agents:

Adjuvant agents/medication enhances the effect of analgesic and treat the concurrent symptoms.

a. Antidepressants:

serotonin-norepinephrine reuptake inhibitors (SNRIs) and Tricyclic antidepressants (TCAs) are effective in treating neuropathic pain due to their modulatory effects on descending pain pathways.

B. Antiepileptic:

Used for neuropathic pain be relieved by ant as it stabilizes the neuronal membranes and inhibit excitatory neurotransmission^.25

C. Muscle relaxants:

Used to relieve pain associated with muscle spasms.²⁶

4. Topical analgesics:

A. Lidocaine:

It is used topically to relieve localized pain by blocking nerve signals in the body.

B. Salicylates:

It provides pain relief through their anti-inflammatory properties.

5. Multimodal analgesics:

Combination of different classes of analgesics provide synergistic effects, pain relief with minimum opioid side effects. It is the most common method used in clinical settings for treating post-operative pain.²⁷

6. New and Emerging Analgesics:

a. Cannabinoids:

It is an emerging as potential analgesics significantly used for neuropathic and cancer pain.²⁸

b. Gene Therapy:

Gene therapy holds promise for treating chronic pain by targeting specific pain pathways at the genetic level.²⁹

c. Novel Targets and Molecules:

Research is ongoing to discover new targets and molecules for pain management, offering hope for more effective and safer analgesics in the future.³⁰

Table 1: Pain management in orthopaedic postoperative - drug, dose, interval and maximum dose^31,32,33

Drug	Dose	Interval	Maximum dose	Adverse Drug reaction
1.Non-opioid analgesic agents:
i) NSAIDS
Aspirin	325 – 650mg	4 to 6 hours	4000 mg/day	Gastrointestinal ulcer, Haemorrhage, Tinnitus, Bronchospasm, increased risk of bleeding, Allergic reactions.
Diclofenac	50mg	8hours	150mg/day	Gastrointestinal ulcer, Elevated liver enzymes, cardiovascular events, rash.
Ibuprofen	400mg	4 to 6 hours	3200mg/day	Gastrointestinal bleeding, kidney impairment, Rash, Increased blood pressure.
Naproxen	250-500mg	12 hours	1250mg/day	Gastrointestinal bleeding, cardiovascular events, kidney impairment, Rash.
Indomethacin	25-50mg	8 to 12 hours	150mg/day	Gastrointestinal bleeding, Renal impairment, Rash, Headache, dizziness.
Meloxicam	7.5-15mg	Once daily	15mg/day	Gastrointestinal bleeding, cardiovascular events, kidney impairment, Rash.
Celecoxib	200mg	Once daily	400mg/day	Gastrointestinal bleeding, cardiovascular events, kidney impairment, Rash.
ii) Acetaminophen	650-1000mg	4 to 6hours	4gm/day	Liver toxicity, rash, renal impairment, nausea or abdominal pain.
2.Opioid Analgesic:
Oxycodone	20mg (oral)	3-4 hours		Constipation, drowsiness, nausea, respiratory depression.
Hydrocodone	30mg (oral)	3-4 hours		Hypotension, Peripheral oedema, Syncope, Chest pain
Morphine	30mg (oral)	3-4 hours		Myosis, Pneumonia, Hypotension, Infrequency, Emesis
Codeine	130mg (oral)	3-4 hours		Pruritis, Meiosis, Convulsions, Sedation, CNS depression
Tramadol	100mg (oral)	Once daily		Bradyarrhythmia, Syncope, Torsade’s de pointes, Chest pain
Fentanyl	25µg/h (Transdermal)			Diaphoresis, Anaemia, Asthenia, Anxiety, Urinary retention
Methadone	10mg (oral)	6-8 hours		Cardiac dysrhythmia, Oedema, Hypotension, Extrasystole
Meperidine	300mg (oral)	2-3 hours		Palpitations, Orthostatic hypotension, Shock, Cardiac arrest
3.Adjuvant Agents:
i) Antidepressant
Amitriptyline	0.1-0.5mg/kg	QHS	20-25mg/day	Sedation, weight gain, dizziness, anticholinergic effects.
Duloxetine	30mg	BD	120mg/day	Diaphoresis, Hypersomnia, Hypertensive crisis, Glaucoma
ii)Antiepileptic
Gabapentin	2-6 mg/kg	TID	100-300mg/day	Ataxia, Nystagmus, Stevens-Johnson syndrome, Anaphylaxis, Respiratory depression, Angioedema
Pregabalin	0.3-1.5 mg/kg	BD	300mg/day	Xerostomia, Diplopia, Jaundice, Nasopharyngitis, Tremor
iii)Muscle Relaxant
Baclofen	5mg	TID	80mg/day	Pneumonia, Coma, Somnolence, Urinary complications
Methocarbamol	750mg	QID	3000mg/day	Light Headedness, Seizure, Dizziness, Thrombophlebitis
iv)Topical Analgesic
Lidocaine	1patches	12hrs	4patches	Erythema, Hoarse voice, Methemoglobinemia, Anaphylaxis
v) Multimodal Analgesic
vi) Emerging Analgesic

Why management of orthopedic pain is difficult?

Management of orthopedic surgical patients is challenging due to the complexity for specialized care that include conditions like fractures, joint disorders, spine and sports injuries. The management need a keen diagnostic and therapeutic approaches, balancing between physical and psychological factors.

Diagnostic Challenges:

1. Complexity of Orthopedic Disorders:

Musculoskeletal disorders define a wide range of conditions that affect bones, joints, muscles, and ligaments each with its own etiology and pathology, patient history, makes accurate diagnosis difficult.³⁴

2. Limitations of Diagnostic Imaging:

Diagnostic imaging is critical in orthopedic practice, it fails to give information on ligament and tendon tears.³⁵

Therapeutic Challenges:

3. Individualized Treatment Plans:

Orthopedic treatments need to be individualized as each patient conditions changes in site, nature of pain and the patient’s health status. Implementation of personalized treatment plan requires an understanding of the patient's medical history, lifestyle and treatment goals.³⁶

4. Surgical Risks and Complications:

Orthopedic surgeries have high risk and complications like Infections, blood clots, and prosthetic failures.³⁷

Patients experience severe pain in the acute postoperative period after surgery.³⁸

5. Pain Management:

Effective pain management in orthopedic patients is complex in Chronic pain conditions because of risk of long-term use of opioid along with physiotherapy and later changing to multimodal analgesic.³⁹

Rehabilitation and Recovery:

6. Rehabilitation:

Orthopedic conditions require long term rehabilitation depending on the severity of the condition and the type of treatment received. to regain function and mobility. Patient Adherence towards rehabilitation is critical for successful outcomes due to pain, lack of motivation, or socioeconomic barriers.⁴⁰

Psychological and Social Factors:

7. Psychological Impact of Orthopedic Conditions:

Depression, anxiety, and fear of movement are common psychological factors faced in patients with postoperative orthopedic chronic pain and disability.⁴¹

8. Socioeconomic factors:

Socioeconomic factors involving the management and outcomes of orthopedic patients as it requires rehabilitation for long period of time with proper supplement therapy.

Technological Challenges:

9. Technology:

Evolving advanced technology like robotic surgery and advanced prosthetics made a high promise to patients and healthcare systems.⁴²

10. Coordination with healthcare providers:

Effective pain outcome or treatment or satisfaction requires a good coordination between all healthcare providers.⁴³

CONCLUSION:

Orthopedic surgery is one of the most complicated surgery because of the type of surgery or the healing process. Pain after surgery is a common type of acute pain that usually lasts for a few days or weeks. Routine pain assessment is a cornerstone for providing safe, effective, and individualized pain management. Pain should be considered during preoperative, intraoperative, postoperative and at the time of discharge. Effective pain management requires constant reassessment with individualized treatment regimen. Major efforts should be taken by the healthcare professional and patients during the postoperative pain period as it involves the healing period associated with several risk factors like hospital discharge, severity of surgery, physiotherapy mobilization. Implementation of multimodal pain management along with physiotherapy, exercise and patients counselling are effective for reducing postoperative pain.

REFERENCES:

1. Hiren Tilala, Suneesh P.M., Jeenath Justin Doss. K.A Study to Assess the Effectiveness of Cryotherapy on level of pain among patient with Arthralgia in selected Orthopedic Hospital at Rajkot. Int. J. of Advances in Nur. Management. 2020; 8(1): 69-71.

2. V. Indra. Effective Pain Management to Improve Patient satisfaction – A Review. Int. J. Nur. Edu. and Research. 2019; 7(4): 613-615.

3. Dinesh Kumar Suganandam, Jasmin Ruby Anand, Amala Rajan, Georgene Singh, Bijesh Kumar Yadav. Procedural pain on Satisfaction. Asian J. Nursing Education and Research. 2020; 10(2): 171-174.

4. Cousins M.J. Introduction to Acute and Chronic Pain: Neural Blockade in Clinical Anesthesia and Management of Pain. Philadelphia: JB Lippincott, Inc.; 1988.

5. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res. 2017; 10: 2287-98.

6. Syed MA, Azim SR, Baig M. Frequency of orthopedic problems among patients attending an orthopedic outpatient department: a retrospective analysis of 23,495 cases. Ann Saudi Med. 2019; May-Jun; 39(3): 172-7. doi: 10.5144/0256-4947.2019.172. PMID: 31215227; PMCID: PMC6832329.

7. Dafny N. Pain Principles. In: Neuroscience Online: An Electronic Textbook for the Neurosciences. Department of Neurobiology and Anatomy, The University of Texas Medical School at Houston. [Accessed 21 October 2022].

8. Phillips WJ, Currier BL. Analgesic pharmacology: I. Neurophysiology. J Am Acad Orthop Surg. 2004; 12: 213-20. doi: 10.5435/00124635-200407000-00002.

9. Levine JD, Reichling DB. Peripheral mechanisms of inflammatory pain. In: Wall PD, Melzack R, editors. Textbook of Pain. 4th ed. Edinburgh: Churchill Livingstone; 1999. p. 59-84.

10. Graefe SB, Rahimi N, Mohiuddin SS. Biochemistry, Substance P. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jul 30. [Updated 2024 Jan-]. PMID: 32119470

11. Sudireddy R, Venkateswarlu BS. A Study on Pain Assessment and Management in Post-Operative patients. Res J Pharm Technol. 2021; 14(3): 1612-4. doi: 10.5958/0974-360X.2021.00286.

12. Lakshmi Ramamoorthy. Post-operative Pain Management Strategies: Nursing Perspectives. Asian J. Nursing Education and Research. 2021; 11(2): 189-192.

13. Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual Analog Scale for Pain (VAS), Numeric Rating Scale for Pain (NRS), McGill Pain Questionnaire (MPQ), Short Form McGill Pain Questionnaire (SFMPQ), Chronic Pain Grade Scale (CPGS), Short Form36 Bodily Pain Scale (SF36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care Res. 2011; 63(S11)

14. Safikhani S, Gries KS, Trudeau JJ, Reasner D, Rüdell K, Coons SJ, Bush EN, Hanlon J, Abraham L, Vernon M. Response scale selection in adult pain measures: results from a literature review. J Patient Rep Outcomes. 2018; Sep 6; 2: 40. doi: 10.1186/s41687-018-0053-6. PMID: 30238085; PMCID: PMC6127068.

15. Jensen MP, Karoly P, Braver S. The measurement of clinical pain intensity: a comparison of six methods. Pain. 1994; 27(1): 117-26.

16. Melzack R. The McGill Pain Questionnaire: major properties and scoring methods. Pain. 1975; 1(3): 277-99.

17. Cleeland CS, Ryan KM. Pain assessment: global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994; 23(2): 129-38.

18. Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The Pain Disability Index: psychometric properties. Pain. 1990; 40(2): 171-82.

19. Singla N, Hunsinger M, Chang PD, McDermott MP, Chowdhry AK, Desjardins PJ, Turk DC, Dworkin RH. Assay sensitivity of pain intensity versus pain relief in acute pain clinical trials: Acttion systematic review and meta-analysis. J Pain. 2015; 16: 683-91.

20. Khemchand R. Surana, Abhijeet G. Parkhe, Eknath D. Ahire, Anuprita R. Pawar, Survarna Khairnar, Sunil K. Mahajan, Dhananjay M. Patil, Deepak D. Sonawane, Sanjay J. Kshirsagar. Current Therapeutic Targets for Neuropathic Pain. Asian Journal of Pharmaceutical Research. 2022; 12(1): 96-4.

21. DA Helen Sheeba, V Gauthami Yadav. Complex Regional Pain Syndrome and Its Treatment: An Overview. Research J. Pharmacology and Pharmacodynamics. 2012; 4(3): 133-143.

22. Morshed Nasir, Rawshon Ara Parveen, Nazmun Nahar Alam. Pattern of Analgesic Use in Post-Operative Pain Management in a Tertiary Level Teaching Hospital in Bangladesh. Research J. Pharm. and Tech. 2016; 9(5): 493-496.

23. Nageeb AGM Hassan, Alhabib SM, Alghamdi AH, Nasser NA, Alshehri SM. Prevalence of pain and self-medication pattern of Paracetamol and NSAIDs among university students in United Arab Emirates. Res J Pharm Technol. 2021; 14(6): 3393-8. doi: 10.52711/0974-360X.2021.00590.

24. Syeda Zuleqaunnisa Begum, Mohammed Jalal Mohiuddin, Kauser Nazima Hassan, Khair Unnisa Sadaf, Khudsiya Taher, Salman Ali, Mohd Akram. A Comparative Study of NSAIDs + Opioids V/S NSAIDs + TCAs Perioperatively for Pain Management in the Department of Orthopedics. Res J Pharm Technol. 2022; 15(12): 5501-6. doi: 10.52711/0974-360X.2022.00928.

25. Queremel Milani DA, Davis DD. Pain Management Medications. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 ;Jul 3.

26. Van Tulder MW, Furlan AD, Bombardier C, Bouter LM. Non-steroidal anti-inflammatory drugs for low back pain. Cochrane Database Syst Rev. 2003; (2).

27. Baranidharan G, McCarthy A, Lunt M, et al. The role of capsaicin in pain management. Br J Pain. 2020; 14(2): 73-82.

28. Moore RA, Derry S, Aldington D, et al. Combination therapy for the treatment of pain. Pain. 2019;160(S1)

29. Whiting PF, Wolff RF, Deshpande A, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA. 2015; 313(24): 2456-73.

30. Gaur V, Patel M, Kumar P, et al. Gene therapy approaches for pain management. Pain Res Manag. 2021; 2021: 1-12.

31. Finnerup NB, Kuner R, Jensen TS. Advances in pharmacotherapy for neuropathic pain. Nat Rev Neurol. 2017; 13(9): 583-97.

32. Queremel Milani DA, Davis DD. Pain Management Medications. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jul 3.

33. Wickham R. The role of advanced practitioners in oncology. J Adv Pract Oncol. 2017; 8: 475-90. doi: 10.6004/jadpro.2017.8.5.4.

34. Goodman LS, Gilman AG. Goodman and Gilman Manual of Pharmacology and Therapeutics. Section II, Neuropharmacology, Chapter 18, Opioids, Analgesia, and Pain Management.

35. Smith T, Johnson K. Socioeconomic barriers in orthopedic patient management. Orthop Care Rev. 2020; 29(1): 92-104.

36. Jones M, Patel R. Limitations of diagnostic imaging in orthopedic practice. Orthop Imaging J. 2017; 22(3): 312-20.

37. Brown C, Jones M, Smith L. Challenges in individualized treatment plans for orthopedic patients. J Orthop Res. 2019;37(4):567-79.

38. Garach Bhavikkumar D., Parth D. Raiyani. Postoperative pain after spine surgery: Comparative efficacy of diclofenac and etoricoxib in combination with tramadol and paracetamol at lower doses. Research J. Pharmacology and Pharmacodynamics. 2013; 5(1): 62-69.

39. Miller D, Johnson R, Thompson A. Surgical risks and complications in orthopedic procedures. J Surg Orthop. 2020;42(5):678-85.

40. Lee H, Chen P. Multimodal pain management in orthopedic patients. Pain Manag J. 2018; 15(2): 145-58.

41. Smith T, Lee H, Johnson K. Diagnostic challenges in musculoskeletal disorders. Int J Musculoskelet Med. 2018; 34(6): 543-59.

42. Smith T, Johnson K. Socioeconomic barriers in orthopedic patient management. Orthop Care Rev. 2020; 29(1): 92-104.

43. Williams S, MacAuley D. Psychological impact of chronic orthopedic conditions. J Orthop Psychol. 2019; 10(3): 234-42.

Received on 28.08.2024 Revised on 25.12.2024

Accepted on 03.03.2025 Published on 02.08.2025

Available online from August 08, 2025

Research J. Pharmacy and Technology. 2025;18(8):3939-3944.

DOI: 10.52711/0974-360X.2025.00566

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.