Information ⬇
Editors
Musculoskeletal Pain
Essentials
- Musculoskeletal pains are mostly short-term and resolve spontaneously.
- Non-pharmacological therapies constitute the first-line treament and they are combined, if needed, with pharmacotherapy.
- In drug treatment, paracetamol and topical and oral nonsteroidal anti-inflammatory drugs are preferred.
Principles
- Musculoskeletal pain is a common cause for a visit to a general practitioner, while the majority of cases of ordinary pain can also be treated without the doctor's help, i.e. by rest, OTC drugs or exercise.
- Avoidance of physical activity is seldom necessary, but in trauma and in many strain-induced pain conditions (e.g. various types of tendinitis), avoiding exertion may be of help for a start.
- Non-pharmacological interventions (e.g. exercise and therapeutic exercise) form the basis of treatment.
- In the initial treatment for musculoskeletal injury (especially for exercise-related injury), a functional principle is PEACE (Protect-Elevate-Avoid anti-inflammatory modalities-Compress-Educate), and in the follow-up treatment, LOVE (Load-Optimism-Vascularisation-Exercise).
- The preferred drug treatments include paracetamol, topical anti-inflammatory agents and courses of oral conventional nonsteroidal anti-inflammatory drugs.
- In other than high-risk patients the cost-effectiveness of COX-2-selective anti-inflammatory drugs is poor.
- In prolonged musculoskeletal pain, the factors causing and maintaining the pain, including the loading factors and ergonomics at work, should be assessed.
- In chronic musculoskeletal pain, a thorough assessment by occupational health care with possible interventions and multidisciplinary rehabilitation may be advantageous.
Physiotherapy
- Instead of passive treatment methods, physiotherapeutic expertise should be utilized for the evaluation of functional capacity, for activating the patient and for guidance of therapeutic exercise.
Drugs
- Paracetamol can be used as primary medication in less severe acute musculoskeletal pain. Paracetamol for Osteoarthritis
- Nonsteroidal anti-inflammatory drugs (NSAIDs)
- Topically administered NSAIDs are more effective than placebo in local acute musculoskeletal pain Topical Nsaids for Acute Pain in Adults. They have been found to have a short-term effect also in chronic musculoskeletal pain Topical Nsaids for Chronic Musculoskeletal Pain in Adults.
- Oral NSAIDs
- When considering medication, the primary question is whether a drug totally different from NSAIDs should be prescribed (e.g. paracetamol, topical therapies). Long-term use of NSAIDs is not recommended Safe Use of Non-Steroidal Anti-Inflammatory Drugs (Nsaids).
- In inflammatory rheumatic disease, in pain caused by injury, or in acute back pain, paracetamol or an NSAID is in most cases the most sensible therapy.
- NSAIDs are effective in acute cases of musculoskeletal pain.
- They are not equally beneficial in long-term musculoskeletal pain, such as osteoarthritis, where the adverse effects may be emphasised. NSAIDs may, however, be used in the treatment of arthosis, if paracetamol does not provide sufficient effect.
- NSAIDs are not recommended in the long-term treatment of chronic low back or neck pain.
- Avoid oral NSAIDs in patients with a risk of gastrointestinal tract bleeding or with anticoagulant therapy.
- In patients at risk, NSAIDs may be combined with misoprostol or a proton pump inhibitor Safe Use of Non-Steroidal Anti-Inflammatory Drugs (Nsaids).
- The use of COX-2-selective drugs may be justifiable in cases where the use of non-selective NSAIDs is associated with an increased risk of gastrointestinal haemorrhage. The coxibs are not general analgesics to be used, for example, for acute low back pain or sports injuries.
- Avoid all NSAIDs in patients with an arterial disease or its risk factors.
- Muscle relaxants may help in the treatment of low back pain, but the adverse effects (e.g. vertigo and somnolence) restrict their use Muscle Relaxants for Non-Specific Low Back Pain.
- Less potent opioids (e.g. codeine and tramadol) can be tried in prolonged low back pain and osteoarthritis, if NSAIDs or paracetamol do not provide sufficient pain relief. Side effects limit the use of opioids, which should be as short-term as possible. The risk of adverse interactions with, for example, antidepressants must be taken into account.
- Potent opioids are only used with special indications.
- For tricyclic antidepressants there is evidence of efficacy in fibromyalgia (e.g. amitriptyline, initially 10 to 25 mg daily, with a maintenance dose of 25 to 150 mg daily, is also used in other chronic pain conditions).Duloxetine (30-60 mg/day), milnacipran (50-100 mg/day), pregabalin (25-300 mg/day) and gabapentin (300-1 200 mg/day) may also be tried for fibromyalgia Fibromyalgia.
- Subacromial glucocorticoid injection can be helpful in the treatment of rotator cuff tendinitis. Glucocorticoid injections can also be used in other conditions of soft tissue pain Local Glucocorticoid Injections in Soft Tissues and Joints.
References
- Mäntyselkä P, Kumpusalo E, Ahonen R, Kumpusalo A, Kauhanen J, Viinamäki H, Halonen P, Takala J. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain 2001 Jan;89(2-3):175-80. [PubMed]
- Turunen JH, Mäntyselkä PT, Kumpusalo EA, Ahonen RS. How do people ease their pain? A population-based study. J Pain 2004 Nov;5(9):498-504. [PubMed]
- Karjalainen K, Malmivaara A, Mutanen P, Roine R, Hurri H, Pohjolainen T. Mini-intervention for subacute low back pain: two-year follow-up and modifiers of effectiveness. Spine (Phila Pa 1976) 2004 May 15;29(10):1069-76. [PubMed]
- Hayden JA, van Tulder MW, Malmivaara AV, Koes BW. Meta-analysis: exercise therapy for nonspecific low back pain. Ann Intern Med 2005 May 3;142(9):765-75. [PubMed]
- Mattila R, Malmivaara A, Kastarinen M, Kivelä SL, Nissinen A. Effects of lifestyle intervention on neck, shoulder, elbow and wrist symptoms. Scand J Work Environ Health 2004 Jun;30(3):191-8. [PubMed]
- Bjordal JM, Ljunggren AE, Klovning A, Slørdal L. Non-steroidal anti-inflammatory drugs, including cyclo-oxygenase-2 inhibitors, in osteoarthritic knee pain: meta-analysis of randomised placebo controlled trials. BMJ 2004 Dec 4;329(7478):1317. [PubMed]
Evidence Summaries ⬆