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. Online ahead of print.


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).