New guideline for managing acute pain from musculoskeletal injuries

In a 2017 practice guideline based on a systematic review of noninvasive treatments, the American College of Physicians (ACP) recommended superficial heat, massage, acupuncture, and spinal manipulation as initial treatment options for patients with acute low back pain, in addition to a nonsteroidal anti-inflammatory drug (NSAID) or skeletal muscle relaxant if desired. But is a similar approach effective for treating pain resulting from acute musculoskeletal injuries not involving the lower back? To answer this question, the American Academy of Family Physicians (AAFP) joined the ACP in developing another practice guideline on management of acute pain from non-low back, musculoskeletal injuries in adults, a synopsis of which appeared in Practice Guidelines in the December 1 issue of American Family Physician. These are some key practice points from the guideline:

• Topical NSAIDs are the most effective intervention for acute musculoskeletal pain other than low back pain.
• Although oral NSAIDs and acetaminophen are effective for acute pain relief, combining them does not improve effectiveness.
• Although moderately effective for pain relief, opioids increase gastrointestinal and neurologic adverse effects and lead to long-term use in 6% of people treated.
• Acupressure and transcutaneous electrical nerve stimulation techniques are effective nonpharmacologic options for acute pain.

In an accompanying editorial, Dr. David O'Gurek and I, who represented the AAFP on the guideline committee, and Dr. Melanie Bird, AAFP Clinical and Health Policies Manager, discussed some of the guideline's highlights and limitations. A systematic review and network meta-analysis of randomized, controlled trials provided direct and indirect comparisons of various treatment options on outcomes that included pain relief and physical functioning, symptom relief, treatment satisfaction, and adverse events.

Topical NSAIDs improved all efficacy outcomes with minimal adverse effects, while oral NSAIDs and acetaminophen improved fewer outcomes and were more likely to cause adverse events. We suggested against using opioids, including tramadol, for acute musculoskeletal injury pain due to their poor adverse effect profile and the risk of prolonged use, ranging from 6% in low-risk to 27% in high-risk populations. We also noted that "equitable coverage and affordability of first-line treatments" are essential to reduce well-known disparities in pain management; for example, though a topical NSAID is now available over-the-counter, it costs significantly more than oral NSAIDs and acetaminophen and may not be covered by health insurance plans.