COVID-19 COVID-19 Evidence Alerts from McMaster PLUS is a new service that alerts users to current best evidence for clinical care of people with threatened, suspected or confirmed COVID-19 infection.
Visit the site Sign up for alerts
Busse JW, Sadeghirad B, Oparin Y, et al. Management of Acute Pain From Non-Low Back Musculoskeletal Injuries: A Systematic Review and Network Meta-analysis of Randomized Trials. Ann Intern Med. 2020 Aug 18. doi: 10.7326/M19-3601. (Systematic review)

BACKGROUND: Patients and clinicians can choose from several treatment options to address acute pain from non-low back musculoskeletal injuries.

PURPOSE: To assess the comparative effectiveness of outpatient treatments for acute pain from non-low back musculoskeletal injuries by performing a network meta-analysis of randomized clinical trials (RCTs).

DATA SOURCES: MEDLINE, EMBASE, CINAHL, PEDro (Physiotherapy Evidence Database), and Cochrane Central Register of Controlled Trials to 2 January 2020.

STUDY SELECTION: Pairs of reviewers independently identified interventional RCTs that enrolled patients presenting with pain of up to 4 weeks' duration from non-low back musculoskeletal injuries.

DATA EXTRACTION: Pairs of reviewers independently extracted data. Certainty of evidence was evaluated by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.

DATA SYNTHESIS: The 207 eligible studies included 32 959 participants and evaluated 45 therapies. Ninety-nine trials (48%) enrolled populations with diverse musculoskeletal injuries, 59 (29%) included patients with sprains, 13 (6%) with whiplash, and 11 (5%) with muscle strains; the remaining trials included various injuries ranging from nonsurgical fractures to contusions. Topical nonsteroidal anti-inflammatory agents (NSAIDs) proved to have the greatest net benefit, followed by oral NSAIDs and acetaminophen with or without diclofenac. Effects of these agents on pain were modest (around 1 cm on a 10-cm visual analogue scale, approximating the minimal important difference). Regarding opioids, compared with placebo, acetaminophen plus an opioid improved intermediate pain (1 to 7 days) but not immediate pain (=2 hours), tramadol was ineffective, and opioids increased the risk for gastrointestinal and neurologic harms (all moderate-certainty evidence).

LIMITATIONS: Only English-language studies were included. The number of head-to-head comparisons was limited.

CONCLUSION: Topical NSAIDs, followed by oral NSAIDs and acetaminophen with or without diclofenac, showed the most convincing and attractive benefit-harm ratio for patients with acute pain from non-low back musculoskeletal injuries. No opioid achieved benefit greater than that of NSAIDs, and opioids caused the most harms.

PRIMARY FUNDING SOURCE: National Safety Council. (PROSPERO: CRD42018094412).

Related DynaMed Topics

Discipline Area Score
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Surgery - Orthopaedics 6 / 7
Physical Medicine and Rehabilitation 6 / 7
Internal Medicine 6 / 7
Neurology 5 / 7
Special Interest - Pain -- Physician 5 / 7
Comments from MORE raters

General Internal Medicine-Primary Care(US) rater

This is a broad project, but I would like more depth before accepting the results. Focusing on topical NSAIDs: 1) there is no indication of bias assessment or subgrouping trials by using trial registration to check for selective reporting or publication biases. The Cochrane RoB2 tool recommends checking the original trial registration for analysis intentions. In the prior ACP review of back pain, these biases were not assessed. A key study was included that found benefit from tramadol, but should not have been included because of selective reporting (PMID 29204616); 2) no assessment of the role of vehicles for topical treatments; and, 3) no citations to identify which studies contributed to which analyses, which prevents close examination of the results. Among the RCTs cited for topical NSAIDs, the one that addressed these issues found no benefit (PMID 28345425). This RCT may be the best available, but I am not certain because I do not know which trials contributed to which analyses.

Internal Medicine rater

I don't think this is going to change practice at our medical center. The treatments highlighted in green as "among the most effective" are already the mainstays of therapy. And the density of the paper makes it pretty much unreadable by primary care clinicians.

Neurology rater

Acute pain from non–low back musculoskeletal injuries are a very common problem in daily clinical practice. This is very important review. The use of systematic and comprehensive ways in finding and appraising the evidence is the main strength of this review. This review showed that topical and oral NSAID are beneficial. The use of tramadol and opioid are not beneficial. Some limitations have been addressed for this review. Further trials and review are warranted.

Physical Medicine and Rehabilitation rater

The inclusions are too heterogenous.
Comments from EvidenceAlerts subscribers

Dr. Gabriel Symonds (8/25/2020 6:39 AM)

The title is confusing. What are non-low-back musculoskeletal injuries? We are told later that they vary from sprains to fractures. With such diverse diagnoses, how can one usefully compare treatments of which there are as many as forty-five? The conclusion is badly written. Since diclofenac is a NSAID, it is confusing to say ‘…followed by oral NSAIDs and acetaminophen with or without diclofenac’ It would be more helpful to clinicians if this investigation had compared different analgesic regimens in the same conditions, for example, whiplash, contusions, or muscle strains. And surely a fractured femur is going to need a different order of analgesia than a fractured rib!