Introduction

Musculoskeletal pain is the type of pain that often occurs, There are 20%-30% of people in the world who experience musculoskeletal pain and there are more than 150 diagnoses of muscle, joint, and connective tissue such as tendon and ligament that are associated with pain (WHO, 2021).

Patients with musculoskeletal pain have clinical features such as decreased activity, stiffness, weakness, pain on movement, and decreasing range of motion which is not associated with joint (Arendt-Nielsen, Fernández-de-las-Peñas, & Graven-Nielsen, 2011).

Musculoskeletal pain therapy in general is NSAIDs (non-steroidal anti-inflammatory drugs), anticonvulsants, opioids, opioid analgesics or nonopioids (Schug & Arshad, 2017).

The therapy should work quickly so that NSAIDs with a fast onset of action such as Ketorolac and Ibuprofen are often the choice.

NPS or Numeric Pain Scale is an instrument to assess pain intensity. NPS was chosen because it has been tested for reliability and validity and describes the pain felt by the patient. NPS could also be used for repeated measurements.

The purpose of this study was to compare the effectiveness of pain reduction between intravenous administration of Ibuprofen and Ketorolac.

Materials and Methods

This study used a quasi-experimental method with non-randomized, non-equivalent, active comparison, and open-label study. This study consisted of 60 samples conducted by the purposive sampling method. The samples were divided into two groups, namely the Ibuprofen and Ketorolac therapy groups (n = 30). Therapy is given intravenously at a dose of 800 mg for Ibuprofen and 30 mg for Ketorolac.

This research is registered in the research register of the Ministry of Health's clinic with the title Comparison of Intravenous Ibuprofen and Ketorolac for Acute Musculoskeletal Pain from Various Etiologies. This research has received ethical eligibility from the Health Research Ethics Committee of the Faculty of Medicine, Duta Wacana Christian University (ethical eligibility Number: 1146 / C.16 / FK / 2020)

Results and Discussion

In the study, 60 subjects were divided into two groups (n = 30) with more male subjects than women. The mean age in the Ibuprofen group was 58.50 ± 10.487 and the Ketorolac group 52.9 ± 18.626. The mean initial pain intensity in the Ibuprofen therapy group was 63.33 ± 8.841 and in the Ketorolac group 59.33 ± 12,847 (Table 1).

There was no significant difference between the initial pain intensity of the two groups (p = 0.107) with the mean pain intensity of the Ibuprofen group 63.33 ± 8,841 and the Ketorolac group 59.33 ± 12,847. The pain intensity after giving therapy in the two groups showed a significant difference (p = <0.005) with the mean pain intensity in the Ibuprofen group and the Ketorolac group, respectively, after 8 hours 38.67 ± 10.417 and 42.00 ± 8052, after 16 hours 31.67 ± 11.769 and 38.00 ± 7.144, 24 hours 24.33 ± 13.047 and 34.67 ± 7.303, and after 48 hours 17.33 ± 13.880 and 26.67 ± 7,581 (Table 2). There was a significant difference in reduction of pain intensity between the two groups within hours (Figure 1).

Rescue medication was administered to 40 study subjects, namely the Ibuprofen group 23 (76.7%) subjects and 17 (56.7%) Ketorolac subjects (Table 3).

Adverse events in this study occurred in the Ketorolac therapy group with a total of 11 (36.7%) subjects and no adverse events in the Ibuprofen therapy group (Table 4).

The basic characteristics of this study indicated that men experienced more acute musculoskeletal pain than women, but this difference did not have a significant effect on pain intensity and therapy effectiveness (p = 0.794). The mean age of the patients in the two groups did not have a significant difference, namely 58.50 in the Ibuprofen group and 52.9 in the Ketorolac group (Shanechi, Eke, & Gottlieb, 2018). Comedication in the form of vitamins and steroids was significant in the Ibuprofen group, and this comedication could have a better effect on reducing pain intensity in the Ibuprofen group.

Vitamins including vitamins C, D, and B complex are known to have a role in pain improvement (Carr & McCall, 2017; Gazoni, Malezan, & Santos, 2016; Pierik, 2015). Steroids have functions as an anti-inflammatory agent that can inhibit the synthesis of nerve mediators such as PGE2 (Helde-Frankling & Björkhem-Bergman, 2017).

In this study, five measurements of the Numeric Pain Scale (NPS) were taken, the first measurement taken before giving therapy and the fourth measurement after therapy. The mean of the pain intensity on the Ibuprofen group before giving the therapy was 63.33 ± 8,841 and the Ketorolac group 59.33 ± 12,847, and there was no significant difference in pain intensity in the two groups (p = 0.107). The final measurement after 48 hours, Ibuprofen group showed 17.33 ± 13,880 and the Ketorolac group was 26.67 ± 7,581, and the amount of reduction in pain intensity in the Ibuprofen group was 46.00 ± 16,316, and the Ketorolac group was 32.67 ± 10,148. The mean pain intensity and the mean reduction in pain intensity in the two groups showed a significant difference (p = 0.006, p = 0.001). The results obtained indicate that Ibuprofen has better effectiveness in reducing acute musculoskeletal pain compared to Ketorolac.

There was no significant difference in giving rescue medication to the two groups (p = 0.171). In the Ibuprofen therapy group, 23 subjects needed rescue medication in the form of pain relief due to pain that arose between the times of giving Ibuprofen therapy. Intravenous ibuprofen 800 mg has a maximum concentration time of 30 to 60 minutes and a maximum concentration time of 0-4 hours depending on the subject's metabolism (Samuel, Nguyen, & Choi, 2017).

In the Ketorolac therapy group, there were 17 subjects who received rescue medication, 30 mg intravenous ketorolac could reach a maximum concentration in 1 to 2 hours, and the effects can last for 6 to 8 hours (Kroll, 2012; Lyon, Claus, Jarrett, & Stevermer, 2019).

Adverse events occurred only in the Ketorolac therapy group. Intravenous ketorolac can be given in a dose of 10 mg to 30 mg with a maximum dose of 1 day in adults is 120 mg. The higher the intravenous ketorolac dose, the greater the chance for adverse events to occur. In this study, Ketorolac was administered every 12 hours as much as 30 mg, thus allowing adverse events to occur (Shanechi et al., 2018). Adverse events that can be identified in this study were disorders of the gastrointestinal tract in the form of pain. Subject experiencing Gastrointestinal pain is given therapeutic treatment in the form of proton pump inhibitors or PPIs. The absence of an adverse event in the Ibuprofen therapy group can be influenced by comedication in the form of PPIs or H2 blockers, which can prevent pain from occurring to gastrointestinal bleeding (Nugent, Falkson, & Terrell, 2018)

The limitation faced by the researcher is that this study uses a non-randomized quasi-experimental method in which the subjects are not randomly divided into each group, this causes a bias in the intensity and reduction of pain felt by the subject due to various pain etiologies. In this study was also conducted with non-blinding, namely, there is no disguise in the administration of therapy so that researchers know the drugs given to the research subjects.

Conclusion

Intravenous ibuprofen has better effectiveness in treating non-specific acute musculoskeletal pain than intravenous Ketorolac. Intravenous Ibuprofen has shown superiority in safety that proven in the adverse event, although intravenous ibuprofen group has higher needs of rescue medication.

Funding Support

The authors declare that they have no funding support for this study.

Conflict of Interest

The authors declare that they have no conflict of interest.