Musculoskeletal Conditions

MSK Interventions: Evidence base

Summary of relevant NICE guidance and standards

Resource Key details
NG226 (2022)- Osteoarthritis in over 16s. Diagnosis and management Arthritis should be diagnosed clinically (i.e. does not usually need imaging to confirm the diagnosis) and management should be guided by symptoms and physical function. The core treatments are regular and consistent therapeutic exercise and weight management (if appropriate) with information and support. Manual therapy should only be considered in certain conditions. Acupuncture, dry needling and electrotherapy should not be offered. Pharmacological management should be used if needed alongside non-drug treatments, and at the lowest effective dose for the shortest possible time. Examples include topical non-steroidal anti-inflammatory drugs (NSAIDs) for knee and other joint osteoarthritis. Paracetamol and weak opioids should not be routinely offered unless certain criteria are met, and glucosamine and strong opioids should not be offered. Patients should only be referred for joint replacement if their joint symptoms substantially affect their quality of life and non-surgical management has been ineffective.
NG100 (2020) – Rheumatoid arthritis in adults: management Adults with rheumatoid arthritis should be supported by a multidisciplinary team. Patients with symptoms suggestive of rheumatoid arthritis should be referred for specialist opinion and specific diagnostic tests should be carried out (blood tests for rheumatoid factor and anti CCP antibodies, and x-rays of the hands and feed). Active rheumatoid arthritis should be treated with the aim of achieving a target of remission or low disease activity – this may include multiple drugs (known as cDMARDS, biological DMARDs and other drugs). Corticosteroids and NSAIDs can also be used to manage symptoms in flare-ups. Patients should also have access to specialist physiotherapy, podiatry and occupational therapy. Some patients may also need referral for specialist surgery (where criteria are met)
NG59 (2020) – Low back pain and sciatica in over 16s: assessment and management Think about alternative diagnoses when reviewing people with low back pain. Exclude specific causes e.g. cancer, infection, trauma, inflammatory disease. Consider using risk stratification at first point of contact for each new episode for low back pain. Offer less intensive support for people likely to improve quickly and have a good outcome (e.g. reassurance and guidance on self-management) and more intensive support for those with a risk of a poor outcome e.g. exercise programmes with or without manual therapy, using a psychological approach). Imaging should not be routinely offered in a non-specialist setting – it should only be considered if it is likely to change management. Non-invasive treatments include self-management, exercise programmes, manual therapies as part of a treatment package (manipulation, massage etc.), return to work programmes. Psychological therapy should be considered as part of a treatment package. Orthotics and acupuncture should not be offered. Traction and electrotherapies should not be used. Gabapentanoids, opioids, oral corticosteroids and benzodiazepines should not be offered for managing sciatica. Risk should be taken into account when prescribing NSAIDS. Weak opioids can be considered for low back pain if NSAIDs cannot be used or are ineffective but should not be used for chronic pain. Gabapentanoids, antiepileptics and antidepressants should not be prescribed for low back pain.Invasive treatments include radiofrequency denervation and epidurals where indicated. Spinal injections should not be offered. Spinal decompression should be considered but spinal fusion should only be used if part of a research trial. Disc replacement should not be routinely offered
NG157 (2020) – Joint replacement (primary): hip, knee, shoulder Shared decision making should be supported, including offering alternatives to joint replacement, discussing the risks and benefits and a choice of analgesia and anaesthesia. Preoperative rehabilitation and outpatient rehabilitation should be used The guidance contains detailed information on specific procedures and surgical approaches
CG124 (2023) – Hip fracture management Surgery should be performed on the day of or day after admission. Correctable comorbidities should be identified and treated so that surgery is not delayed. Appropriate pain relief should be given e.g. paracetamol, opioids and nerve blocks. NSAIDs should not be used. The type of hip replacement used should depend on the type of fracture and the aim is to allow people to fully weight bear in the immediate post-operative period. Multidisciplinary management should be used in the rehabilitation period including early supported discharge where appropriate.

Summary of recent studies in the Cochrane Library relating to interventions for common MSK conditions

Topic Date of review Findings
Exercise therapy for treatment of acute nonspecific low back pain 2023 (23 studies) Exercise therapy may be no better than placebo treatment for pain relief in the short term (the exercise group had 1% less pain than the placebo group). Exercise therapy may be no better than placebo for improving functional status in the short term. Exercise therapy may also be no better than no treatment for pain relief and function, but this should be interpreted with caution. The authors had very little confidence in the evidence as studies were poorly designed and included few people.
Physical activity and education about physical activity for chronic musculoskeletal pain in children and adolescents 2023 (4 studies) The authors were unable to confidently state whether interventions based on physical activity and education are more effective than usual care for children and adolescents with chronic musculoskeletal pain. There was low certainty evidence that it may lead to improvements in children and adolescents with juvenile idiopathic arthritis
Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews 2023 (seven reviews, 103 studies) NSAIDs and muscle relaxants may reduce acute pain in the short term, but muscle relaxants may be associated with unwanted effects. Paracetamol had no effect on pain and no reviews looked at opioids. Opioids may reduce pain in the short term for chronic pain but may be associated with unwanted effects. NSAIDs may reduce chronic pain in the intermediate term. No review looked at paracetamol for chronic low back pain. The authors had reduced confidence in the quality of the evidence overall, but moderate confidence for some drugs on some types of pain.
Yoga for chronic nonspecific low back pain 2022 (21 studies) Doing yoga for 3 months is probably better than not doing exercise, although improvements are small. There is probably little difference between yoga and other back-related exercise for back-related function at 3 months. The authors found the quality of evidence to be low to moderate.
Systemic corticosteroids for radicular and nonradicular lower back pain 2022 (13 studies) Corticosteroids appear to slightly reduce pain in the short term and allow resumption of normal activities in radicular lower back pain. They may also slightly improve people’s abilities to perform normal activities at long term. They probably do not reduce the likelihood of undergoing surgery to remove a slipped/bulging disc and had no impact on quality of life. For other types of low back pain, the effects of systemic corticosteroids were unclear or suggested no benefits.
Arthroscopic surgery for degenerative knee disease 2022 (16 studies) Arthroscopic surgery provides little or no clinically important benefit in pain or function and probably does not provide clinically important benefits in knee-specific quality of life compared with a placebo procedure.
Exercise therapy for chronic low back pain 2021 (249 studies) Exercise probably reduces pain compared to no treatment in people with long-lasting back pain
Multidisciplinary rehabilitation for older people with hip fractures 2021 (28 studies) Multidisciplinary rehabilitation after surgery compared to usual care in hospital probably results in fewer cases of ‘poor outcome’ at 6-12 months and may reduce the risk of death and poorer mobility. The evidence is not clear on quality of life or differences with usual care at home.
Acupuncture for chronic nonspecific low back pain 2020 (33 studies) Compared with placebo, acupuncture may not be more effective at reducing pain immediately after treatment. It may not improve quality of life. However, acupuncture was better than no treatment for pain relief and functional improvement immediately after treatment
Non-steroidal antiinflammatory drugs for acute low back pain 2020 (32 studies) Update on previous review (that found a small but significant effect in favour of NSAIDs for short term relief of back pain). NSAIDs seemed slightly more effective than placebo for short-term pain reduction. Also, slightly more effective than placebo for reducing disability in acute low back pain
Paracetamol versus placebo for knee and hip osteoarthritis 2019 (10 studies) Paracetamol provides minimal improvements in pain and function for people with hip or knee osteoarthritis. Current clinical guidelines consistently recommend paracetamol as the first line analgesic medication for hip or knee osteoarthritis. The authors argue that their results call for reconsideration of these recommendations
Surgical interventions for symptomatic mild to moderate knee osteoarthritis 2019 (5 studies) There was low quality evidence that there may be little difference between arthroscopic partial meniscectomy and a home exercise programme for the treatment of mild to moderate osteoarthritis. Similarly, surgery may not be better than other interventions to treat this condition
Multidisciplinary biopsychosocial rehabilitation for subacute low back pain 2017 (9 studies) Multidisciplinary treatment may be better than usual care. Individuals receiving multidisciplinary treatments had less pain, less disability and increased likelihood of return to work. However, they may be no better than other treatments.
Celecoxib for rheumatoid arthritis 2017 (8 studies) Celecoxib may improve RA symptoms and alleviate pain more than placebo, but probably provides little or no difference in physical function improvement
Aquatic exercise for the treatment of knee and hip osteoarthritis 2016 (13 studies) This is an update of a previous Cochrane Review. There is moderate quality evidence that aquatic exercise may have small, short term and clinically relevant effects on patient reported pain, disability and quality of life.
Non-steroidal antiinflammatory drugs for sciatica 2016 (10 studies) NSAIDs are no more effective in reducing pain in sciatica than placebo or other drugs. NSAIDs are more effective in overall improvement compared to placebo or other drugs, but this finding should be interpreted with caution as the quality of trials is low.
Professional interventions for GPs on the management of musculoskeletal conditions 2016 (30 studies) There is good quality evidence that a GP alerting system with or without patient directed education on osteoporosis and reminders improves guideline consistent GP behaviour, resulting in better diagnosis and treatment rates.
Massage for low back pain 2015 (25 studies) Authors have very little confidence that massage is an effective treatment for low back pain. There were short term improvements in pain outcomes
Pilates for low back pain 2015 (126 studies) There is some evidence of the effectiveness of Pilates for low back pain but no conclusive evidence that it is superior to other forms of exercise. Pilates is probably more effective than minimal intervention in the short term and intermediate term for pain and disability outcomes. It is more effective than minimal intervention for improvement of function, but it is probably not more effective than other exercises for pain and disability.
Cognitive-behavioural treatment for subacute and chronic neck pain 2015 (10 studies) CBT was found to be statistically better than no treatment in chronic neck pain at improving pain, disability and quality of life, but these effects could not be considered clinically meaningful.For subacute neck pain, there was low quality evidence that CBT statistically significantly better than other types of interventions at improving pain, but this effect was not clinically relevant.
High intensity versus low intensity physical activity or exercise in people with hip or knee osteoarthritis 2015 (6 studies) The review compared low- and high-intensity exercise programmes with each other, not with no exercise or other interventions. There was low quality evidence of a small improvement in pain and function with of high-intensity compared to low-intensity programmes. However, this is unlikely to be of clinical importance. Authors are uncertain as to whether higher intensity programmes may have more harmful effects than those of lower intensity. There is a need for more studies