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.
OBJETIVOS: Actualizar un informe anterior sobre los beneficios comparativos y los daños de los fármacos anti-inflamatorios no esteroides orales (AINE), el paracetamol, over-the-counter suplementos (de condroitina y glucosamina), y agentes tópicos (AINE y rubefacientes, incluyendo capsaicina ) para la osteoartritis.
FUENTES DE DATOS: MEDLINE Ovid (1996-enero de 2011), la base de datos Cochrane (hasta el cuarto trimestre de 2010), y listas de referencias.
Métodos de revisión: Se incluyeron ensayos aleatorios, estudios de cohortes, estudios de casos y controles y revisiones sistemáticas que cumplieron los criterios de inclusión predefinidos. Para cada estudio, los investigadores extrajeron datos sobre la población de estudio, diseño del estudio, análisis de datos, seguimiento y resultados, y evaluaron la calidad con criterios predefinidos. Se evaluó la fuerza total de cada conjunto de pruebas utilizando criterios predefinidos, que incluyó el tipo y número de estudios; riesgo de sesgo; consistencia; y la precisión de las estimaciones. Los metanálisis no se realizaron, aunque se reportaron estimaciones agrupadas de los estudios publicados previamente.
RESULTADOS: Se incluyeron un total de 273 estudios. En general, no se encontraron diferencias claras en la eficacia para el alivio del dolor asociado con diferentes AINE. El celecoxib se asoció con un menor riesgo de complicaciones ulcerosas (RR 0,23; IC del 95%: 0,07 a 0,76) en comparación con los AINE no selectivos. Receten simultáneamente de los inhibidores de la bomba de protones, el misoprostol y antagonistas H2 a reducir el riesgo de úlceras gastroduodenales detectadas endoscópicamente en comparación con placebo en personas AINE prescritas. Celecoxib y, AINE sin aspirina más selectivos parecen estar asociados con un mayor riesgo de graves (CV) daños cardiovasculares. No hay una clara asociación entre el uso prolongado de AINE o dosis más altas y un mayor riesgo de sufrir graves daños CV. No hubo diferencias claras entre la glucosamina o condroitina y los AINE orales para el dolor o la función, aunque la evidencia de una revisión sistemática de ensayos de mayor calidad sugiere que la glucosamina tenía algunas muy pequeñas ventajas sobre el placebo para el dolor. Ensayos de cabeza a cabeza no mostraron diferencias entre los AINE tópicos y orales para la eficacia en pacientes con osteoartritis localizada, menor riesgo de trastornos gastrointestinales (GI) eventos adversos, y un mayor riesgo de eventos adversos dermatológicos, pero GI y cardiovasculares graves daños no fueron evaluados. No hay pruebas de cabeza a cabeza comparación salicilatos tópicos o capsaicina a los AINE orales.
CONCLUSIONES: Cada uno de los analgésicos evaluados en este informe se asoció con un conjunto único de los riesgos y beneficios. La elección de la analgesia óptima para una persona con artrosis requiere una cuidadosa consideración y discusión a fondo de las compensaciones pertinentes.
INTRODUCTION: Osteoarthritis of the knee affects about 10% of adults aged over 60 years, with risk increased in those with obesity, and joint damage or abnormalities. Progression of disease on x rays is commonplace, but x ray changes don't correlate well with clinical symptoms.
METHODS AND OUTCOMES: We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of non-surgical treatments for osteoarthritis of the knee? What are the effects of surgical treatments for osteoarthritis of the knee? We searched: Medline, Embase, The Cochrane Library and other important databases up to October 2006 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS: We found 74 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS: In this systematic review we present information relating to the effectiveness and safety of the following interventions: acupuncture, capsaicin, chondroitin, education to aid self-management, exercise and physiotherapy, glucosamine, insoles, intra-articular corticosteroids, intra-articular hyaluronan, joint bracing, knee replacement, non-steroidal anti-inflammatory drugs (including topical non-steroidal anti-inflammatory drugs), opioid analgesics, osteotomy, simple analgesics, and taping.
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.
