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.
Síntesis amplia/ Revisión panorámica de revisiones sistemáticas
ABSTRACT: Overall the evidence base was large; we identified 43 systematic reviews covering hundreds of studies and thousands of participants. Evidence clustered around particular outcomes, interventions and populations. Outcomes The vast majority of evidence is on quality of life and prevention outcomes Evidence on satisfaction with services and safeguarding is severely limited Interventions Physical activity interventions are those most widely evaluated in systematic reviews, followed by occupational therapy interventions No evidence is available on some key social care interventions, e.g. direct payments Populations The majority of evidence concerns people with long-term conditions (e.g. dementia, cancer, stroke) There is much less evidence on older people or people with mental health problems Evidence on learning or physical disabilities is extremely limited. Interventions with evidence of positive effect Evidence of positive impact was found for seven of the 14 social care interventions examined in the included reviews: physical activity, occupational therapy, supported employment, lay/peer support, hip protectors, assistive devices and personal assistance. Evidence on the scale of positive impacts was available for five of these interventions. Larger positive impacts resulted from integrated employment and mental health support and from hip protectors. Both larger and smaller impacts were found across eight physical activity reviews and two occupational therapy reviews. Smaller impacts resulted from a lay-led self-management intervention. Interventions with evidence of harm Two reviews contained evidence that interventions shown to be effective for some populations could potentially cause harm to vulnerable social care recipients. Tai chi, though effective for older people in general, was found to increase the rate of falls among frail older people. Exercise was found to have positive impacts on people exercising for rehabilitation after a period of ill health, but a negative impact on the psychological QoL of people exercising to manage their condition. Interventions not shown to be effective There were seven interventions for which no conclusive positive evidence was found. All available evidence on the following interventions was inconclusive: structured communication, safeguarding training, home hazard assessment. All available evidence on case management and social support interventions showed no evidence of difference between intervention and control groups. Of two reviews on alternative therapies, one found no evidence of difference between groups and another found inconclusive evidence. Inconclusive evidence was also found for some interventions shown to be positive in other reviews: physical activity, occupational therapy, personal assistance, assistive devices, lay/peer support, supported employment. No evidence of difference was found in some reviews for interventions which were found in other reviews to have positive effects: physical activity, assistive devices, lay/peer support, supported employment. On balance, the overall evidence suggests that physical activity interventions and occupational therapy are effective. What are the implications? Implications for policy and practice The greatest portion of evidence included in this review of reviews is about physical activity – evidence suggests that these types of interventions can be effective for people with long-term conditions and non-frail older people and may address both quality of life and delay or reduce the need for social care support. Moreover, although physical activity interventions may typically be regarded as not within the remit of social care, they may be relatively cheap and easy to implement, and therefore worth considering. More complex and perhaps more recognisably social care interventions such as occupational therapy are also supported by the review-level literature. The large and medium effects resulting from integrated mental health and employment services also underscore the value of complex social care interventions. Moreover, the integrated nature of this particular intervention suggests that the current drive in the UK to integrate health and social services (Department of Health 2011) may prove to be successful. Wider evaluation of integrated services is certainly warranted. A last key message for policymakers and practitioners is the need to recognise the influence of contextual factors on the success of social care interventions, in particular the need for safety measures when implementing social care interventions with particularly vulnerable groups. Implications for research The great breadth and extent of evidence contained within this review of reviews is clear. However, assessing the available review-level evidence across the whole of social care also makes clear that there are significant gaps in the evidence examining impact on ASCOF outcomes. There is severely limited evidence on satisfaction with services and safeguarding outcomes in existing systematic reviews There is little use of quality of life measures designed to evaluate the impact of social care interventions included in reviews There is limited review-level evidence on many social care interventions, and none for some key intervention types There is scant evidence on key populations groups – people with physical and learning disabilities There is no review-level evidence on cost-effectiveness. How did we get these results? The research involved identifying and analysing evidence from systematic reviews to answer the following research questions: Which social care interventions can effectively improve outcomes for services users in the four outcome domains set out in the ASCOF: quality of life, prevention, satisfaction and safeguarding? How much impact do effective social care interventions have on ASCOF outcomes?
ANTECEDENTES: musculoesqueléticos condiciones (MSC) son muy prevalentes en la sociedad de hoy en día, con los altos costos de salud resultantes y los efectos negativos importantes sobre la salud y la calidad de vida del paciente. El objetivo principal de esta revisión fue sintetizar la evidencia de revisiones sistemáticas sobre los efectos de la terapia de ejercicio (ET) en el dolor y la función física en pacientes con CMM. Además, la evidencia de los efectos de ET en la patogénesis de la enfermedad, y si los componentes particulares de los programas de ejercicios están asociados con el tamaño de los efectos del tratamiento, también fue explorado.
MÉTODOS: Se incluyeron cuatro condiciones comunes: fibromialgia (FM), dolor de espalda baja (LBP), dolor de cuello (NP), y dolor de hombro (SP), y cuatro enfermedades musculoesqueléticas específicas: la osteoartritis (OA), la artritis reumatoide (AR), La espondilitis anquilosante (AS) y osteoporosis (OP). En primer lugar, se incluyeron revisiones Cochrane con la actualización más reciente fue enero de 2007 o después y, a continuación, se realizaron búsquedas de revisiones no Cochrane publicados después de esta fecha. El dolor y el funcionamiento físico fueron seleccionados como los resultados primarios.
RESULTADOS: Se identificaron 9 críticas, que comprende un total de 224 ensayos y 24.059 pacientes. Además, se incluyó una revisión abordar el efecto del ejercicio sobre la patogénesis. En general, encontramos evidencia sólida de apoyo ET en la gestión de las MSC, pero había diferencias sustanciales en el nivel de evidencia de la investigación entre los grupos diagnósticos incluidos. Las diferencias de medias estandarizadas para la OA de rodilla, dolor lumbar, FM, y SP variaron entre 0,30 y 0,65 y fueron significativamente a favor del ejercicio para el dolor y la función. Para NP, cadera OA, AR, y AS, las estimaciones del efecto fueron generalmente más pequeños y no siempre significativo. Había poca o ninguna evidencia de que la ET puede influir en la patogénesis de enfermedades. La única excepción fue para la osteoporosis, donde no había evidencia de que ET aumenta la densidad mineral ósea en mujeres posmenopáusicas, pero no se encontraron efectos significativos para los resultados clínicamente relevantes (fracturas). Para el dolor lumbar y la rodilla OA, no había evidencia que sugiere que el efecto del tratamiento aumenta con el número de sesiones de ejercicio.
CONCLUSIONES: Existe evidencia empírica de que ET tiene efectos clínicos beneficiosos para la mayoría de las MSC. Excepto para la osteoporosis, parece que hay una brecha en la comprensión de las formas en que ET influye mecanismos de la enfermedad.
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.
