What are the treatment options for musculoskeletal (Musculoskeletal) pain relief?

From the Guidelines

For musculoskeletal pain relief, clinicians should treat patients with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy. This approach is based on a strong recommendation with moderate-certainty evidence from the American College of Physicians and American Academy of Family Physicians guideline published in 2020 1. The guideline suggests that topical NSAIDs can reduce or relieve symptoms, including pain, improve physical function, and improve the patient's treatment satisfaction.

When considering oral medications, oral NSAIDs are suggested to reduce or relieve symptoms, including pain, and to improve physical function, or oral acetaminophen to reduce pain. However, this is a conditional recommendation with moderate-certainty evidence 1. The dosage and frequency of these medications should be individualized, but common regimens include ibuprofen (400-600mg every 6-8 hours, not exceeding 3200mg daily) or naproxen (220-500mg every 8-12 hours, maximum 1500mg daily), and acetaminophen (500-1000mg every 4-6 hours, not exceeding 4000mg daily).

Some key points to consider when managing musculoskeletal pain include:

• The use of opioids, including tramadol, is suggested against due to the potential risks and low-certainty evidence supporting their effectiveness 1.
• Specific acupressure and transcutaneous electrical nerve stimulation may be considered as adjunctive therapies to reduce pain and improve physical function, although the evidence is conditional and of low certainty 1.
• Non-pharmacologic interventions such as rest, ice for acute injuries, and heat for chronic pain can complement medication and should be individualized based on patient preferences and values.

It is essential to monitor patients for adverse events and adjust treatment plans accordingly. If pain persists beyond 7-10 days, worsens, or is accompanied by other symptoms, consultation with a healthcare provider is necessary to rule out more serious conditions requiring different treatment.

From the FDA Drug Label

NSAID medicines are used to treat pain and redness, swelling, and heat (inflammation) from medical conditions such as: different types of arthritis menstrual cramps and other types of short-term pain Cyclobenzaprine hydrochloride tablets are indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions

Musculoskeletal pain relievers include:

• NSAIDs (e.g. naproxen) for pain and inflammation from conditions like arthritis and menstrual cramps
• Muscle relaxants (e.g. cyclobenzaprine) for relief of muscle spasm associated with acute, painful musculoskeletal conditions 2, 3

From the Research

Musculoskeletal Pain Relievers

• Acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) are generally first-line medications for most musculoskeletal pain 4, 5
• Topical NSAIDs are recommended for non-low back, musculoskeletal injuries and can provide pain relief without associated systemic adverse events 4, 6
• Topical formulations of NSAIDs can be effective for pain with fewer side effects 5, 7
• Gel formulations of diclofenac, ibuprofen, and ketoprofen, and some diclofenac patches, provided the best effects for acute conditions such as sprains, strains and overuse injuries 6

Treatment Options

• Acetaminophen is well tolerated, but lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder 4
• Nonselective NSAIDs are effective but should be used with caution in patients with a history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease 4
• Selective cyclooxygenase-2 NSAIDs are a more expensive treatment alternative and are used to avoid the gastrointestinal adverse effects of nonselective NSAIDs 4
• Combination therapy using a small amount of opioid together with a nonopioid pain reliever has been shown effective and reduces opioid consumption 8

Safety and Efficacy

• Local skin reactions to topical NSAIDs were generally mild and transient, and did not differ from placebo 6
• There were very few systemic adverse events and withdrawals due to adverse events were low 6
• Topical NSAIDs provided good levels of pain relief in acute conditions, probably similar to that provided by oral NSAIDs 6
• The use of opioids even for acute pain of short duration has been questioned, and nonopioid therapy may be preferred 8