What medications can a physiotherapist (physical therapist) recommend for musculoskeletal pain or inflammation?

Medication Recommendations for Physiotherapists

Direct Answer

Physiotherapists should NOT prescribe or formally recommend specific medications, as this falls outside their scope of practice in most jurisdictions; however, they can educate patients about over-the-counter options and refer to physicians or pharmacists for medication management. 1

Current Practice Reality

Despite scope of practice limitations, evidence shows that physiotherapists frequently provide medication guidance:

• 81% of musculoskeletal physiotherapists sometimes or often recommend oral NSAIDs, and 82.1% recommend acetaminophen to patients. 1
• 55.5% make specific dosing recommendations, and 45.2% recommend specific brand names, which technically exceeds their professional scope. 1
• Most physiotherapists (85.5%) provide information on side effects, though knowledge gaps exist—particularly regarding renal, respiratory, and allergic risks of NSAIDs (fewer than 31% could identify these). 1

Evidence-Based Patient Education Framework

When patients ask about pain management, physiotherapists can educate them about first-line options that physicians typically recommend:

First-Line: Topical NSAIDs

• Topical NSAIDs (such as diclofenac gel) are the recommended first-line pharmacological treatment for acute musculoskeletal injuries, providing superior pain relief with minimal systemic side effects. 2, 3, 4
• Topical NSAIDs reduce pain by 1.08 cm on a 10-cm visual analog scale at 1-7 days compared to placebo, with high treatment satisfaction (OR 5.20). 2, 3
• Pain relief begins within 2 hours of application. 5
• Topical formulations are particularly valuable for elderly patients (≥75 years) and those with renal risk factors where oral NSAIDs pose greater risks. 3, 5

Alternative First-Line: Oral Acetaminophen

• Acetaminophen is a safe first-line oral option with moderate-certainty evidence showing pain reduction of 1.07 cm on a 10-cm VAS at 1-7 days. 2, 4
• Acetaminophen is well-tolerated with fewer gastrointestinal side effects than NSAIDs. 4, 6
• Maximum dose is 4000 mg daily (two 650mg caplets every 8 hours, not exceeding 6 caplets in 24 hours). 7
• Lower doses should be used in patients with advanced hepatic disease, malnutrition, or severe alcohol use disorder. 6

Second-Line: Oral NSAIDs

• Oral NSAIDs (ibuprofen, naproxen) provide pain reduction of 0.99 cm on a 10-cm VAS at 1-7 days but carry higher systemic risks than topical formulations. 2, 3
• NSAIDs should be used with extreme caution in patients with history of gastrointestinal bleeding, cardiovascular disease, or chronic renal disease. 8, 6
• The combination of ibuprofen plus acetaminophen shows superior effectiveness in preventing pain persistence (adjusted hazard ratio 0.72) compared to single agents. 9

Critical Safety Information to Communicate

NSAID Precautions:

• Gastrointestinal risks include ulcers and bleeding (RR 5.36 for serious GI events). 2
• Cardiovascular risks exist, particularly with prolonged use. 2
• Renal impairment can occur, especially in elderly patients. 3, 8
• Contraindicated in aspirin-sensitive asthma due to risk of severe bronchospasm. 8
• NSAIDs inhibit platelet aggregation and prolong bleeding time—use caution with anticoagulants. 8

Acetaminophen Precautions:

• Hepatotoxicity risk with doses exceeding 4000 mg daily or in patients with liver disease. 7, 6
• Do not use for more than 10 days without physician direction. 7

Appropriate Physiotherapist Actions

Physiotherapists should:

• Educate patients about evidence-based first-line options (topical NSAIDs, acetaminophen) that physicians typically recommend. 2, 3, 4
• Provide information on potential side effects and risks of common analgesics. 1
• Refer patients to their physician or pharmacist for specific medication recommendations, dosing, and brand selection. 1
• Emphasize non-pharmacological approaches as primary interventions: patient education, regular exercise, individual/group physical therapy, early mobilization, and functional support. 2, 3

What NOT to Recommend

• Opioids should be avoided—they provide similar pain relief to NSAIDs but cause significantly more side effects. 3, 4
• Menthol gel alone is ineffective (no significant functional improvement vs. placebo). 4
• Glucosamine shows no statistically significant pain reduction. 4
• Muscle relaxants (cyclobenzaprine) combined with ibuprofen show no benefit over placebo. 2, 4