Effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence.

Objective

To identify the current best evidence on treatment options for the five most common musculoskeletal pain presentations (back, neck, shoulder, knee, and multi-site pain) in primary care.

Methods

Systematic literature review, included studies (n=146)

Quality assessment performed using AMSTAR

Strength of evidence evaluated using a modified GRADE approach

Outcome

Best available evidence shows that patients with musculoskeletal pain problems in primary care can be managed effectively with non-pharmacological treatments such as exercise therapy, self-management advice, and psychosocial interventions. For the short-term pain relief, corticosteroid injections (for knee and shoulder pain) can be effective treatment options and may be used in addition to non-pharmacological treatments.

Babatunde O, Jordan J, Van der Windt D, Hill J, Foster N, Protheroe J. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLOS ONE 2017;12(6):e0178621.

Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial.

Objective

To compare the effects of a program of specific exercises and load management education, a single corticosteroid injection, and no treatment in individuals with gluteal tendinopathy.

Methods

Interventions: education and exercise program of 14 sessions over eight weeks led by a physiotherapist (EDX; n=69), one corticosteroid injection (CSI; n=66), and a wait and see approach (WS; n=69).

Main outcomes: Pain (NPRS), global improvement in hip condition at eight weeks and at 52 weeks.

Outcome

Education plus exercise led to greater pain relief and global improvement than corticosteroid injection use or no treatment by eight weeks.

After 52 weeks, rates of global improvement remained higher for education plus exercise than for corticosteroid injection use.

The findings of this study support the use of exercise therapy and education as management approach for gluteal tendinopathy.

Mellor R, Bennell K, Grimaldi A, Nicolson P, Kasza J, Hodges P et al. Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial. BMJ 2018;2(361):k1662.

Is arthroscopic surgery beneficial in treating non traumatic, degenerative medial meniscal tears? A five year follow-up

Objective

To investigate if a combination of arthroscopy and exercise therapy compared to exercise therapy alone is a superior treatment method in non-traumatic, degenerative medial meniscus tears in a 2 and 5 year follow-up.

Methods

69 patients with MRI verified degenerative medial meniscus tear and radiographic osteoarthritis grade ≤1 were randomly assigned to either arthroscopic treatment followed by exercise therapy for 2 months or to the same exercise therapy alone. Follow-up at 24 and 60 months.

Main outcomes: KOOS, Lysholm Knee Scoring Scale, Tegner Activity Scale and pain (VAS).

Outcome

Both groups showed highly significant clinical improvements from baseline to the follow-ups at 24 and 60 months on KOOS, Lysholm Knee Scoring Scale and VAS however, no group differences were found at any of the testing occasions.

The findings support the use of exercise therapy as initial treatment of degenerative medial meniscal tears as arthroscopic surgery followed by exercise therapy was not superior to the same exercise therapy alone for this type of patients.

Herrlin S, Wange P, Lapidus G, Hållander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surgery, Sports Traumatology, Arthroscopy 2012;21(2):358-364.

Treatment of patients with rotator cuff tears – comparative evidence on the effectiveness of tendon repair and conservative treatment for mainly supraspinatus tendon tears.

Objective

To evaluate evidence on the effectiveness of tendon repair compared with the conservative treatment of rotator cuff tear (Meta-analysis).

To investigate the difference in mid-term outcome between physiotherapy, acromioplasty and tendon repair to treat non traumatic supraspinatus tendon tears and to compare the effectiveness of supervised physiotherapy and home exercises alone (RCT).

Methods

Meta-analysis: Study population comprised of adults with rotator cuff tears. Three RCTs were included. Intervention: Surgical repair of the tendon tear. Comparison: Placebo, sham or other conservative treatment. Outcomes: Pain, function, quality of life and mobility of the shoulder.

RCT: To examine the difference between physiotherapy, acromioplasty and tendon repair outcomes, patients were randomized into one of three treatment groups: physiotherapy (group 1); acromioplasty and physiotherapy (group 2); and rotator cuff repair, acromioplasty and physiotherapy (group 3). Primary outcome: change in total Constant score (CS) at 5 year-follow-up. Study population comprised of patients with isolated and symptomatic full-thickness supraspinatus (SSP) tears who were referred for surgery.

RCT: To compare the effectiveness of supervised physiotherapy and home exercises alone patients were randomly assigned one of two groups: supervised physiotherapy (SP) (5 SP sessions between 2 and 10 weeks after the operation) and home-exercise (HE) alone (oral and written detailed instructions for 3 months after the operation). Primary outcome: between group difference in CS at 1-year follow-up. Study population comprised of patients with arthroscopically verified and repaired full-thickness SSP tendon tear.

Outcome

Meta-analysis indicated that at one-year follow-up there were no clinically important differences in function (CS), or pain (VAS), between patients with full-thickness (mainly SSP) tendon tear, treated surgically or conservatively.

RCT found no statistically or clinically significant differences between the outcomes of conservative treatment, acromioplasty or RC repair in patients with nontraumatic SSP tendon tear.

Supervised physiotherapy and home exercises seemed equally effective at 1-year follow-up, At 3-month follow-up, patients with supervised physiotherapy experienced less pain.

Ryösä A. Treatment of patients with rotator cuff tears – comparative evidence on the effectiveness of tendon repair and conservative treatment for mainly supraspinatus tendon tears. University of Turku. Doctoral Dissertation; 2022.