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The MOST effective treatments for musculoskeletal pain: The (latest) research is IN!

A very interesting article came out just recently: “Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence.”1 (Check it out if you like. It’s free.) It attempts to give an overview of the effectiveness of all the various current treatments for neck, back, shoulder, knee, and multi-site pain. The conclusions may be surprising to you (if you don’t spend all your free time reading research, that is.) Several things that you may have read about or that have been recommended to you by friends/family/even doctors are not all they’re cracked up to be.

I have summarized what the researchers concluded and I’ve provided my own two cents for what it’s worth. Remember, the conclusions here are based on the best evidence that we have for the moment.

 

Self-management advice and education: Effectiveness of this intervention was hard to assess because it was not tested in isolation, but instead added as part of other interventions. The size of the effects were small or not clinically significant. However, experts continue to strongly recommend advice and education as the first line of defense.

My take: I personally believe advice and education are all that is necessary to recover from most conditions if one follows it faithfully and has patience and persistence. However, left to their own devices, many people start to lose motivation and those who don’t see immediate effects will often begin to question the effectiveness of the advice they receive and stray, and fail. That’s why it can be helpful to have a coach/guide, i.e. a PT.

 

Exercise therapy: Moderate to high quality reviews demonstrated medium to large effect for exercise therapy to improve pain, function, and quality of life for shoulder, knee, back, and multi-site pain in the short- and long-term. For neck pain, the size of effect wasn’t provided, but exercise was generally found to improve function. The optimal type and mode of delivery cannot be determined from the evidence, but functional exercise appears to be more beneficial.

My take: Across a wide range of conditions, exercise was found to have large beneficial effects. Interestingly, exactly what type of exercise and how much was done didn’t seem to make much difference. Basically, do some exercise. Ideally, the exercise would resemble or be a component of some activity that is meaningful to you. Get moving. I have talked in a previous post about the need to create some adaptation and that stressing the system (i.e. exercise) is the only way to do that.

 

Manual therapy: Moderate to high quality reviews shows small effect sizes or no clinical effectiveness of manual therapy compared to sham or other treatments. It may offer some beneficial effect in the short term, but may not be superior to other treatments. “Compared with other treatments, manual therapy appears to confer little or no clinically important effect on pain intensity, functional status, global improvement or return to work among patients with acute, subacute or chronic back pain with or without sciatica.”

My take: Manual therapy probably does offer some immediate, transient decreases in pain (just like rubbing your head after bumping it does), but these effects don’t appear to have a meaningful benefit in the long-term. Therefore, manual therapy may be useful to allow immediate exercise to be more comfortable but its addition to a treatment program has no clear benefit. This is particularly true for back pain.

 

Analgesics: Moderate to high quality reviews show Cox-2 inhibitors (like Celebrex), opioids, and NSAIDs (like Aleve or Advil) reduce pain in the short term and have moderate effect sizes. Of course they can have side effects ranging from GI distress to cardiovascular events.

Injections: High quality reviews demonstrate that corticosteroid injections are effective in the short-term for moderate to severe shoulder and knee pain. Viscosupplementation (hyaluronic acid injections like Synvisc, Euflexxa, Orthovisc, etc.) may be helpful in the short-term but the evidence quality was not great. Evidence suggests injections—with or without corticosteroids—for neck and back pain are not effective.

My take: Oral or topical medications seem to be effective in the short-term for relieving pain and improving function across the board. Injected medications are effective in the short-term for knee and shoulder pain, but effects on neck and back pain are unclear. Viscosupplementation remains a mixed bag. If you decide to opt for medication it is probably a good idea to use the period of decreased pain to exercise since the effects of medication are short-lived and the effects of exercise appear to be more long-term.

 

Orthotics, tapes, braces, neck collars and other supports: Moderate quality reviews show small or clinically insignificant effects for most of these treatments on pain, function, or return-to-work. Lumbar supports and neck collars, in particular, are ineffective. Patellar taping has some short-term benefit in patients with patellofemoral pain.

My take: These items/treatments typically cost money (some cost quite a lot of money) for little to no benefit. Though not mentioned in this paper, their continued popularity and use may be because they offer some placebo effect. If the result of using one of these items is that you feel more comfortable and confident when you do exercise, then I generally don’t recommend against them for short-term use. But I cannot recommend that you rely solely on these as treatment options. The cost-benefit ratio is poor.

 

Modalities such as heat/ice, ultrasound, laser, electrical stimulation, and acupuncture: Moderate to high quality reviews concluded little effectiveness for heat/ice, electrotherapy, laser, and ultrasound. Acupuncture may have moderate short-term effects for knee and back pain and even shorter-term effects for neck and shoulder pain, but the strength of the evidence is limited.

My take: These modalities are time-wasters that supplant more effective treatments (exercise, anyone?) for little to no benefit besides placebo. They waste the patient’s time and money. Acupuncture may offer some short-lived pain relief but it is not an effective long-term solution by itself, and its high cost along with its risk of side effects (yes, it’s not without risks!) means its cost-benefit ratio is questionable.

 

Psychosocial interventions: Moderate to high quality reviews demonstrate that psychosocial interventions have medium-sized beneficial effects maintained at long-term for neck, back, and multi-site pain. Research on its effects for shoulder and knee pain is lacking, so conclusions cannot be made. These interventions were usually included alongside usual care and seem to be most effective for patients with a poor prognosis prior to treatment.

My take: We continue to recognize that pain is very complicated and is affected by mental and emotional stress, depression/anxiety, exaggerated fear avoidance behaviors, and more. Aiming interventions at these psychological aspects of pain while continuing to provide more “traditional” physical therapy is clearly logical, necessary, and, most importantly, effective. Psychosocial interventions are particularly important when dealing with persistent pain conditions.

 

Surgery: High quality reviews suggest surgery for neck, shoulder, knee, and back pain does provide benefits for pain and function in the short-term. Available evidence also suggests that there are no long-term benefits for surgery compared to conservative treatment. One caveat is the clear benefit of joint replacement for painful end-stage arthritis.

My take: Surgery seems to be helpful in the short-term but the advantage over conservative treatment diminishes in the long-term, so you may get quicker relief with surgery but your results in 1-2+ years may be the same as if you didn’t get surgery. For you, getting out of pain quicker may well be worth the cost and inherent risks of surgery, but keep that in mind. The devil is in the details and each patient’s individual situation affects the decision for surgery. Younger, more active people who suffered a traumatic injury are more likely candidates for surgery than older, less active people with painful conditions that developed over a long time.

 

So that is the 30,000-foot view of our current understanding of effective treatments for musculoskeletal pain. Again, some of it may be surprising but I don’t make this stuff up. I’m quoting research, and when we look at things scientifically we start to see that a lot of what we think works is actually just piggybacking on placebo and the natural course of healing. Truly effective treatments will improve outcomes over and above placebo and the healing effects of time.

In conclusion:

In: self-management advice and education, exercise, pain medication and corticosteroids (for most things), and psychosocial interventions.

Out (use sparingly or not at all): orthotics, taping, braces, modalities.

Possibly useful, with caveats: manual therapy, surgery.

 

At Gotham Physical Therapy, we focus on advice, education, and exercise and add in manual therapy when we think it will help our patients move and exercise better. If you’re interested in learning more about getting your therapy with us then click the link below.

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  1. Babatunde OO, Jordan JL, Van der Windt DA, et al. Effective treatment options for musculoskeletal pain in primary care: A systematic overview of current evidence. PLoS One. 2017;12:e0178621.