Pain as a result of musculoskeletal problems of the back, neck, shoulder, knee and multi-site pain is an increasing cause of diminished quality of life, and increased demands on healthcare. Prognosis is often poor with many people reporting persistent symptoms 6 to 12 months after consulting their primary care practitioner. Furthermore, the likelihood of persistent or recurrent clinical symptoms may accentuate the physical, psychological, and socio-economic impacts of musculoskeletal pain.
Musculoskeletal pain is managed by a plethora of treatment options, most delivered in primary care by first contact clinicians such as general practitioners, physiotherapists, chiropractors and osteopaths. These include non-pharmacological treatments (e.g. self-management advice and education, exercise therapy, manual therapy and psychosocial interventions), complementary therapies (e.g. acupuncture), and pharmacological interventions (e.g. analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections). For those with refractory symptoms, surgical interventions (e.g. arthroscopic debridement, total knee replacements, and laminectomies) may be considered. However, for the overarching aim of reducing pain and improving function, recommendations are equivocal in respect to the effectiveness of various treatment options that are used across a range of common musculoskeletal pain presentations. For example, evidence for the effectiveness of corticosteroid injections for relief of shoulder or knee pain is inconsistent. Similarly, the efficacy and safety of simple analgesics and NSAIDs for reducing symptoms associated with osteoarthritis and back pain is uncertain. In order to provide optimal care to patients with musculoskeletal pain and ensure the efficient use of healthcare resources, a comprehensive overview of the available evidence for the most effective treatment options for musculoskeletal pain presentations is essential.
Different types of manual therapy, or mobilization, can be used to treat people with spinal alignment problems. For some acute musculoskeletal pain, these techniques have been shown to speed recovery. Medications such as nonsteroidal anti-inflammatories (NSAIDs) may be used to treat inflammation or pain. In patients with musculoskeletal disorders such as fibromyalgia, medications to increase the body’s level of serotonin and norepinephrine (neurotransmitters that modulate sleep, pain, and immune system function) may be prescribed in low doses. Some of the medicines used to aid sleep include zolpidem (Ambien), eszopiclone (Lunesta), and ramelteon (Rozerem).
Other treatments may include:
• Injections with anesthetic or anti-inflammatory medications in or around the painful sites
• Exercise that includes muscle strengthening and stretching
• Physical or occupational therapy
• Relaxation/biofeedback techniques
• Osteopathic manipulation (a whole system of evaluation and treatment designed to achieve and maintain health by restoring normal function to the body)
• Therapeutic massage
The source of pain usually cannot be established using conventional means. For this reason, most musculoskeletal pain conditions are labeled anatomically as regional pain syndromes, such as back pain and neck pain. For shoulder pain, there are many traditional diagnostic labels, such as supraspinatus tendinitis, frozen shoulder, subacromial bursitis, among other, but contemporary research has shown that traditional diagnostic tests for these conditions lack reliability, validity, or both.4-6 Therefore, even shoulder pain becomes a regional musculoskeletal condition. Knee pain may result from injuries to the menisci or other intra-articular structures, but in the absence of trauma the cause of knee pain is elusive.
The effectiveness of the drugs used in musculoskeletal pain conditions is disappointing. Many are ineffective. Others are successful in reducing the level of pain, but the effect is modest or lasts briefly. The effect of drugs on disability and quality of life is nil or minimal. It seems that prescribing drugs satisfies a humanitarian urge by offering some degree of pain relief. This may be a valuable achievement in the context of daily pain, but if complete resolution of pain and disability is the aim of treatment, we must admit that there is no pharmacologic therapy by which these goals can be reached. Recent developments offer new perspectives regarding the pharmacologic treatment of musculoskeletal pain that may provide a better means of satisfactory pain management.