august 2020 • Annals of internal Medicine

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

Qaseem et al.

DOI: 10.7326/M19-3602

Content curated by:David Rodrigues

Key message

No tratamento das lesões musculoesqueléticas que não a lombalgia com duração de menos de 4 semanas a nova Guideline do American College of Physicians e American Academy of Family Physicians recomenda que os Anti-inflamatórios não esteróides tópicos (AINEs)devem ser o tratamento de primeira linha. Com uma recomendação forte com evidência moderada a suportar, defendem que os AINEs tópicos não apenas melhoram a dor, mas também melhoram a função física e estão associados a uma alta satisfação com o tratamento. Vale a pena a leitura.

Abstract

Description: The American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP. Methods: This guideline is based on a systematic evidence review on the comparative efficacy and safety of nonpharmacologic and pharmacologic management of acute pain from non–low back, musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. We evaluated the following clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events. Target Audience and Patient Population: The target audience is all clinicians, and the target patient population is adults with acute pain from non–low back, musculoskeletal injuries. Recommendation 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 (Grade: strong recommendation; moderate-certainty evidence). Recommendation 2a: 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 (Grade: conditional recommendation; moderate-certainty evidence). Recommendation 2b: 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 (Grade: conditional recommendation; low-certainty evidence). Recommendation 3: ACP and AAFP suggest against clinicians treating patients with acute pain from non–low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence). Musculoskeletal injuries are common and are most frequently treated in outpatient settings. In 2010, they accounted for more than 65 million health care visits in the United States and 4 of 5 injuries that were treated in a physician's office were musculoskeletal (1). The estimated annual cost of treating musculoskeletal injuries was $176.1 billion in 2010 (1). Acute musculoskeletal pain lasts less than 4 weeks and includes strains and sprains, soft tissue injuries, whiplash, and various other conditions ranging from nonsurgical fractures to contusions (2). Numerous treatment options exist, including nonpharmacologic and pharmacologic interventions (nonopioid and opioid) (3–6). In the United States, approximately one fifth of patients presenting with pain in the outpatient setting receive an opioid prescription (7) and opioid prescriptions for acute musculoskeletal injuries, such as ankle sprains, are common (8, 9). As of 2015, 2 million persons had an opioid use disorder involving prescription opioids (10), although prescribing rates have decreased in recent years.