BACKGROUND & AIMS: Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
METHODS: A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
RESULTS: Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
CONCLUSION: This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
OBJECTIVES: To conduct an overview on psychological interventions, orthoses, patient education, ergonomics, and 1⁰/2⁰ neck pain prevention for adults with acute-chronic neck pain.
SEARCH STRATEGY: Computerized databases and grey literature were searched (2006-2012).
SELECTION CRITERIA: Systematic reviews of randomized controlled trials (RCTs) on pain, function/disability, global perceived effect, quality-of-life and patient satisfaction were retrieved.
DATA COLLECTION & ANALYSIS: Two independent authors selected articles, assessed risk of bias using AMSTAR tool and extracted data. The GRADE tool was used to evaluate the body of evidence and an external panel to provide critical review.
MAIN RESULTS: We retrieved 30 reviews (5-9 AMSTAR score) reporting on 75 RCTs with the following moderate GRADE evidence. For acute whiplash associated disorder (WAD), an education video in emergency rooms (1RCT, 405participants] favoured pain reduction at long-term follow-up thus helping 1 in 23 people [Standard Mean Difference: -0.44(95%CI: -0.66 to -0.23)). Use of a soft collar (2RCTs, 1278participants) was not beneficial in the long-term. For chronic neck pain, a mind-body intervention (2RCTs, 1 meta-analysis, 191participants) improved short-term pain/function in 1 of 4 or 6 participants. In workers, 2-minutes of daily scapula-thoracic endurance training (1RCT, 127participants) over 10 weeks was beneficial in 1 of 4 participants. A number of psychosocial interventions, workplace interventions, collar use and self-management educational strategies were not beneficial.
REVIEWERS' CONCLUSIONS: Moderate evidence exists for quantifying beneficial and non-beneficial effects of a limited number of interventions for acute WAD and chronic neck pain. Larger trials with more rigorous controls need to target promising interventions.
BACKGROUND: This article is the first in a series presenting the strongest published evidence for physical and rehabilitation medicine (PRM) to date coming from the Cochrane Collaboration. The intent of the series is to stimulate ideas for reviews and research in neglected areas of PRM.
AIM: To systematically review the rehabilitation contents of the Cochrane Collaboration on disabilities due to spinal disorders or pain syndromes in adults.
METHODS: The Cochrane Database of Systematic Reviews was searched at the end of June 2013 for articles relevant for PRM about disabilities resulting from spinal disorders or pain syndromes in adults. Retrieved papers were classified according to the PRM approach: active therapies, which require active participation by patients to achieve treatment goals, and passive treatments, which rely on the application of external forces. The quality of the reviews was checked against the AMSTAR checklist.
RESULTS: Reviews on spinal disorders or pain syndromes were found in the Cochrane Back Group (CBG) and in the Pain, Palliative and Supportive Care Group (CPPSCG). Thirty-eight (42.8%) of 89 Cochrane reviews in the CBG and 7 (2.4%) of 293 Cochrane reviews in the CPPSCG were included. All were of high quality (range, 8-11 points out of 11 on the AMSTAR checklist). The contents of the reviews are given in detail.
CONCLUSION: This review presents an overview of the current evidence for PRM in the treatment of disabilities due to spinal disorders or pain syndromes in adults. Within PRM there is ample space for research in the Cochrane Collaboration and for producing original studies (randomized controlled trials [RCTs]).
CLINICAL REHABILITATION IMPACT: To apply evidence-based clinical practice, clinicians must be familiar with the current best evidence.
OBJECTIVES: To systematically investigate current scientific evidence about the effectiveness of multidisciplinary team rehabilitation for different health problems.
DATA SOURCES: A comprehensive literature search was conducted in Cochrane, Medline, DARE, Embase, and Cinahl databases, and research from existing systematic reviews was critically appraised and summarized.
STUDY SELECTION: Using the search terms "rehabilitation", "multidisciplinary teams" or "team care", references were identified for existing studies published after 2000 that examined multidisciplinary rehabilitation team care for adults, without restrictions in terms of study population or outcomes. The most recent reviews examining a study population were selected.
DATA EXTRACTION: Two reviewers independently extracted information about study populations, sample sizes, study designs, rehabilitation settings, the team, interventions, and findings.
DATA SYNTHESIS: A total of 14 reviews were included to summarize the findings of 12 different study populations. Evidence was found to support improved functioning following multidisciplinary rehabilitation team care for 10 of 12 different study population: elderly people, elderly people with hip fracture, homeless people with mental illness, adults with multiple sclerosis, stroke, acquired brain injury, chronic arthropathy, chronic pain, low back pain, and fibromyalgia. Whereas evidence was not found for adults with amyetrophic lateral schlerosis, and neck and shoulder pain.
CONCLUSION: Although these studies included heterogeneous patient groups the overall conclusion was that multidisciplinary rehabilitation team care effectively improves rehabilitation intervention. However, further research in this area is needed.
• The approach taken to evaluate the current published scientific evidence on the efficacy, effectiveness and economic consequences of multidisciplinary pain programs (MPPs) for patients with chronic pain (CP) not related to cancer, was to analyze and synthesize the findings from systematic reviews (SRs) including meta-analyses. Given the cost and consequences of CP, whether MPPs are therapeutically and financially effective are important issues of consideration.
• MPPs in this report are defined as being a comprehensive approach that involves coordinated interventions among a variety of disciplines working together in the same facility in an integrated way with joint goals and with ongoing communication. The patient is considered to be an active participant who assumes significant responsibility within the rehabilitation process with the staff playing a teaching and consulting role.
• The rationale for MPPs as a therapeutic approach is to provide simultaneous assessment and management of somatic, behavioural and psychosocial components of CP. MPPs aim to improve quality of life outcomes, to increase patient independence and to restore physical, psychological, social, and occupational functioning.
• Treatment strategies available at MPPs usually vary from centre to centre in terms of the setting (inpatient versus outpatient), number of hours and days involved, and type, intensity, and nature of treatment modalities offered. Patients seen at MPPs
are often not representative of all those with CP and alternatively, not all CP patients should attend MPPs. As tertiary centres, MPPs are generally selected for patients with complex and long-standing pain problems.
• From the twelve SRs on the effectiveness of MPPs, five met the inclusion criteria. Four of these SRs focused on MPPs as the primary intervention of interest, whereas one SR considered MPPs among several other interventions.
• The results from a recent good quality SR tend to support the effectiveness of intensive MPPs for chronic low back pain patients in terms of their effects on functional improvement and pain reduction. The results from one clinical trial included in one of the SRs support the use of MPPs in patients with chronic pelvic pain in terms of daily activity level and self-rating scales.
• The other SRs found limited evidence and therefore the findings were considered to be inconclusive regarding the effectiveness of MPPs in managing CP in other conditions such as fibromyalgia and widespread musculoskeletal pain, and shoulder
and neck pain.
Musculoskeletal pain, the most common cause of disability globally, is most frequently managed in primary care. People with musculoskeletal pain in different body regions share similar characteristics, prognosis, and may respond to similar treatments. This overview aims to summarise current best evidence on currently available treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee and multi-site pain) in primary care.
METHODS:
A systematic search was conducted. Initial searches identified clinical guidelines, clinical pathways and systematic reviews. Additional searches found recently published trials and those addressing gaps in the evidence base. Data on study populations, interventions, and outcomes of intervention on pain and function were extracted. Quality of systematic reviews was assessed using AMSTAR, and strength of evidence rated using a modified GRADE approach.
RESULTS:
Moderate to strong evidence suggests that exercise therapy and psychosocial interventions are effective for relieving pain and improving function for musculoskeletal pain. NSAIDs and opioids reduce pain in the short-term, but the effect size is modest and the potential for adverse effects need careful consideration. Corticosteroid injections were found to be beneficial for short-term pain relief among patients with knee and shoulder pain. However, current evidence remains equivocal on optimal dose, intensity and frequency, or mode of application for most treatment options.
CONCLUSION:
This review presents a comprehensive summary and critical assessment of current evidence for the treatment of pain presentations in primary care. The evidence synthesis of interventions for common musculoskeletal pain presentations shows moderate-strong evidence for exercise therapy and psychosocial interventions, with short-term benefits only from pharmacological treatments. Future research into optimal dose and application of the most promising treatments is needed.
