Following any acute fractures or musculoskeletal surgeries ( such as bone-joint-tendon-muscle repair or replacement), the related muscles go into involuntary spasms to protect the underlying bone from displacement. But, the spasm worsens the pain. I now routinely prescribe a combination of high-dose Tylenol (Acetaminophen) and muscle-relaxant Robaxin (Methocarbamol) on a fixed or scheduled basis for such patients. I find the same combo useful for acute exacerbations of chronic neck & back pain and all sprains.
This is an old pair (both approved in the 1950s!) and old is still gold! Tylenol calms the ouch while Robaxin tackles the twitch. I prescribe them as SCHEDULED (i.e. at fixed times irrespective of pain level) for the first 3-4 days then switch to PRN (as needed basis), in addition to PRN low-dose Oxycodone. The benefits I see:
–💡 Much low pain spikes (as in they don’t fall behind on pain control with scheduled doses)
–💡 Much lower need for Narcotics and NSAIDs***
–💡 Better participation rates in physical therapy (or physiotherapy), early discharges
–💡 Cheap & None to minimal side-effects
–💡 Less need for Narcotics means less delirium risk
The effectiveness of scheduled versus ‘as needed’ acetaminophen is shown in studies like this, this & this. As for adding Methocarbamol, we need more studies but my experience over the years of using this safe drug is very positive. A 2013 study that looked at scheduling Intravenous Acetaminophen with Methocarbamol pre-op for hip & knee surgeries saw significant reductions in opioid use, better mobility & earlier discharges. A 2017 retrospective analysis showed reduced hospital length of stays for rib-fracture patients who received Methocarbamol, while a small 2021 study of pain control in rib fractures in young adults showed significantly less need for narcotics in those who received methocarbamol.
The doses I prescribe and recommend:
Acetaminophen 1000 mg three times a day with food scheduled 4 days then PRN (as needed)
Methocarbamol 500 to 750 mg three times a day with food, scheduled 4 days, then PRN
If there are concerns about liver disease, I cut Acetaminophen to 1000 mg twice a day Check with your pharmacist for dosing Methocarbamol in renal failure and in those with known delirium risks – but 500mg 3 times a day is a pretty low dose on the safety range and effective with room to go up – read more here.
(***NSAIDs such as Ibuprofen or Naproxen have a good role to play in non-surgical acute pain scenarios but surgeons often frown at their routine use post-op due to bleeding risk and controversial data on delayed healing of fractures and joints – though I feel a short duration shouldn’t hurt. Instead, consider Topical NSAIDs such as Diclofenac are found to be comparable to oral NSAIDs in effectiveness)
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