ACP Recommends Non-Pharmacologic Treatments for Pain Relief From Acute Non–Low Back, Musculoskeletal Injuries Interview with:
Timothy Wilt, MD, MPH
Chair ACP Clinical Guidelines Committee
Professor of Medicine
Minneapolis VA Center for Care Delivery and Outcomes Research.  What is the background for this study?  What are the main findings?

Response: Acute non-low back musculoskeletal pain is common, disabling and costly. Most are treated in outpatient settings. Numerous pharmacologic and nonpharmacologic treatment options exist but there is uncertainty of their benefits, harms and costs. Additionally, opioid prescriptions are common for acute musculoskeletal injuries but have harms and can lead to chronic opioid use including dependence and overdose. ACP and AAFP developed these evidence based guidelines to assist clinicians in providing the highest quality care to their patients by considering information on benefits, harms and costs alongside patient values and preferences. Our main recommendations are as follows:

1)      ACP and AAFP recommend that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient’s treatment satisfaction.

2)      ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain.

3)      ACP and AAFP suggest that clinicians treat patients with acute pain from non–low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain.

4)      ACP and AAFP suggest against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol. What topical NSAIDS are available for pain relief?  Are they over-the-counter or do they require a prescription?  Are there systemic side effects or absorption of the NSAID gels?

Response: Diclofenac gel is available as an over the counter preparation and can be provided with a prescription. The lack of systemic side effects or absorption of the NSAID gel is an important safety advantage of these preparations What should readers take away from your report?

Response: Clinicians have several effective and safe treatment options. Topical NSAID drugs should be first line therapy as they are the safest and among the most effective including immediate and longer term pain relief, improvement in physical function and satisfaction with treatment. It puts relief where the pain is while avoiding harms of systemic absorption. Oral NSAIDS are also effective and generally well tolerated for most adults over the short term. Additional therapies include acupressure and transcutaneous electrical nerve stimulation. Clinicians should avoid prescribing and patients should not request opioids, including tramadol, as they offer little to no additional benefit and have greater short and longer term harms. What recommendations do you have for future research as a result of this work?

Response: Direct head-to-head comparisons to show comparative benefits and harms of one intervention versus another were lacking and needed. Research is needed to understand predictors of long-term opioid use among patients prescribed opioids for acute non-low back pain musculoskeletal pain in order to avoid long-term harms including dependence and overdose. Research is also needed to develop effective communication strategies to aide in implementation of these recommendations. Is there anything else you would like to add?

Response: Implementation of these recommendations from ACP-AAFP will improve the quality of care provided to patients and the health outcomes they obtain including reducing pain, improving physical function and treatment satisfaction while also containing costs. Because this is such a common, disabling and costly  health condition successful implementation will have a large positive individual and societal effect.

Any disclosures?

The ACP-CGC has a rigorous disclosure and conflict of interest policy. All disclosures are listed in the manuscript and the accompanying link.


Nonpharmacologic and Pharmacologic Management of Acute Pain From Non–Low Back, Musculoskeletal Injuries in Adults: A Clinical Guideline From the American College of Physicians and American Academy of Family Physicians
Amir Qaseem, Robert M. McLean, David O’Gurek, Pelin Batur, Kenneth Lin, and Devan L. Kansagara

Annals of Internal Medicine 0 0:0

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Last Updated on August 18, 2020 by