Treatments Compared for Managing Musculoskeletal Pain in Primary Care

A comprehensive review published online in PLOS One provides a “critical assessment” of the evidence available for various interventions used in the treatment of pain in primary care. 

A team of researchers sought to summarize the evidence on currently available treatments for the five most common musculoskeletal pain types presented in primary care: back, neck, shoulder, knee, and multi-site pain. They analyzed data on patient populations, interventions, and treatment outcomes for pain and function. The quality of the systematic reviews and strength of evidence were also graded. The type of treatments reviewed included self-management advice, exercise therapy, aids/devices, pharmacologic treatments (eg, oral/topical analgesics, local injections), and various referral options (eg, cognitive-behavioral therapy, pain-coping skills). 

A total of 71 Cochrane systematic reviews met the inclusion criteria as well as 75 non-Cochrane reviews that evaluated a gap not covered. 

Self-management advice and education demonstrated small effects on pain and function outcomes. It was strongly recommended as a first-line treatment option for musculoskeletal pain although the overall strength of evidence was graded as limited.

Exercise therapy demonstrated significant positive effects on pain, function, quality of life, and work-related outcomes for both short- and long-term periods across all musculoskeletal pain types. The strength of evidence was graded as strong.

Manual therapy may provide some benefit in pain and function but was not found to be superior to other non-pharmacologic treatments—such as exercise—for patients with acute or chronic musculoskeletal pain. It is unclear whether efficacy varies across patient subgroups or by the experience of the individual performing manual therapy. The overall strength of evidence was graded as limited. 

Analgesics such as NSAIDs, COX-2 selective inhibitors, and opioids were shown to reduce musculoskeletal pain in the short-term. However, the potential for adverse events such as gastrointestinal bleeding and opioid-induced hyperalgesia require closer attention. The overall strength of evidence was graded as moderate.  

Pharmacologic injections (ie, corticosteroids, hyaluronate) were shown to provide relief for shoulder and knee pain in the short-term (up to 3 months) but efficacy for back and neck pain is still uncertain. With regard to guided vs. unguided procedures, frequency, dose, and the active ingredient, the “current evidence is equivocal on the optimal procedure”. The overall strength of evidence was graded as strong.

The routine use of aids and devices (eg, orthotics, tapes, braces, cervical collars, other support devices) was found not to be effective for improving pain, function, and/or work outcomes in patients with neck, shoulder, back, and knee pain. The overall strength of evidence was graded as limited. 

The efficacy of other treatments including acupuncture, ultrasound, TENS, laser, ice/hot packs were not backed by strong evidence. Improvements in pain and function were not clinically significant when used alone or in combination with other treatments. The overall strength of evidence was graded as limited.

Psychosocial interventions demonstrated beneficial effects especially in patients with poor prognosis pre-treatment. Outcomes of this intervention may be affected by other factors such as the individual providing the treatment, the settings where treatment was administered, and the components of treatment. Current evidence showed medium effect sizes for neck, back, and multi-site pain. The overall strength of evidence was graded as moderate. 

Surgical interventions showed short-term efficacy for pain and function particularly for neck, shoulder, knee, and back pain. The efficacy of surgery as a first-line treatment option has not been established in current literature. Other evidence showed surgery was not superior to conservative treatment options in the long-term. The overall strength of evidence was graded as limited apart from specific indications for surgery (eg, end-stage degenerative knee joint disease, refractory and persistent pain and functional limitation).

In general, the best available evidence pointed to self-management advice, exercise therapy and psychosocial interventions as effective strategies for managing musculoskeletal pain in primary care. Corticosteroid injections may offer short-term relief of knee or shoulder pain, while other pharmacologic interventions such as NSAIDs and opioids may benefit in the short-term but carry the risk of adverse effects. Study authors added that more research is needed to evaluate the appropriate dose and application for the “most promising agents”. 

For more information visit journals.plos.org.