Weekly MSK Science Roundup: April 28- May 2, 2025

Get Them Early, Get Them Fresh

Author

Alex Bendersky
April 27, 2025

Monday: Interventional Procedures Show Limited Benefit for Chronic Spine Pain

Comprehensive Summary The systematic review and network meta-analysis investigated the effectiveness of commonly performed interventional procedures for chronic non-cancer spine pain, specifically axial and radicular types. Key findings revealed:

  • Little to No Pain Relief: Moderate certainty evidence showed that procedures such as epidural injections of local anesthetics (with or without steroids), joint-targeted steroid injections, and radiofrequency of the dorsal root ganglion provided little to no pain relief compared to sham procedures for both axial and radicular spine pain.

  • Physical Function Outcomes: Physical functioning improvements were similarly minimal, with moderate certainty evidence supporting limited effects of certain procedures such as epidural steroid injections and joint-targeted injections.

  • Low or Very Low Certainty Evidence: For many interventions, evidence remained uncertain or of poor quality, preventing robust conclusions regarding their effectiveness or harm.

  • Adverse Events: Limited data on adverse events showed low certainty evidence for increased risks with certain procedures like joint radiofrequency ablation and joint-targeted injections.

  • Call for Improved Research: The study highlights the need for future trials to focus on broader outcomes, including mental health, return to work, and social functioning, while improving evidence quality. This research contributes to ongoing debates on the utility of invasive procedures for chronic spine pain, suggesting a need for caution in their use given the lack of convincing evidence for significant benefits.

APA Citation Wang, X., Martin, G., Sadeghirad, B., Chang, Y., Florez, I. D., Couban, R. J., ... & Busse, J. W. (2025). Common interventional procedures for chronic non-cancer spine pain: A systematic review and network meta-analysis of randomized trials. BMJ, 388, e079971. https://doi.org/10.1136/bmj-2024-079971

Tuesday: Behavioral Therapy and Physical Approaches Most Effective for TMD Pain

Comprehensive Summary This systematic review and network meta-analysis explored the effectiveness of treatments for chronic pain associated with temporomandibular disorders (TMD). Below are the main findings:

  • Most Effective Interventions (Moderate Certainty Evidence):

    • Cognitive Behavioral Therapy (CBT) with Biofeedback/Relaxation Therapy: Demonstrated the highest probability of achieving meaningful pain relief (36%).

    • Therapist-Assisted Jaw Mobilization: Similarly effective for pain reduction (36%).

    • Manual Trigger Point Therapy: Also a top-tier intervention for pain relief (32%).

  • Secondary Interventions (Moderate Certainty Evidence): Five interventions were less effective but still outperformed placebo/sham procedures, with effect rates ranging from 23%-30%. These include:

    • Standard CBT.

    • Supervised Postural Exercise.

    • Supervised Jaw Exercise and Stretching (with or without Trigger Point Therapy).

    • Usual Care, which includes self-directed practices like home exercises, education, and reassurance.

  • Physical Function Improvement: Four interventions likely improved physical functioning compared to placebo:

    • Supervised Jaw Exercise and Stretching (43%).

    • Manipulation (43%).

    • Acupuncture (42%).

    • Jaw Exercise and Mobilization (36%).

  • Adverse Events: Evidence regarding adverse events was sparse and of low or very low certainty, underscoring the need for further research in this area.

  • Conclusion: Treatments promoting coping mechanisms and encouraging movement and activity, such as CBT and supervised exercises, proved most effective for chronic TMD pain. However, the certainty of evidence for many other interventions remains limited, emphasizing the need for high-quality studies.

APA Citation Yao, L., Sadeghirad, B., Li, M., Li, J., Wang, Q., Crandon, H. N., ... & Busse, J. W. (2023). Management of chronic pain secondary to temporomandibular disorders: A systematic review and network meta-analysis of randomized trials. BMJ, 383, e076226. https://doi.org/10.1136/bmj-2023-076226

Wednesday: Modest Benefits of Analgesics for Acute Low Back Pain

Comprehensive Summary This systematic review and network meta-analysis evaluated the comparative effectiveness and safety of analgesic medicines for managing acute non-specific low back pain. Below are the key findings:

  • Pain Reduction: Some analgesic medicines may modestly reduce pain intensity compared to placebo, but the evidence is of low or very low confidence. For example, tolperisone, aceclofenac with tizanidine, and pregabalin showed the largest potential pain reductions. However, these findings were limited by risks of bias and imprecision in effect estimates.

  • Adverse Events: Moderate to very low confidence evidence suggests that certain medicines, including tramadol, combinations like paracetamol with tramadol, and baclofen, are associated with a higher risk of adverse events compared to placebo. The most commonly reported adverse events involved the gastrointestinal and nervous systems (e.g., nausea, dizziness).

  • Comparative Effectiveness: The majority of trials provide indirect evidence for the comparative effectiveness of medicines, and results suggest minimal differences in pain reduction or safety profiles among various medicines.

  • General Recommendation: Given the limited and uncertain evidence, the study advises a cautious approach to prescribing analgesics for acute low back pain and prioritizes first-line non-pharmacological treatments such as reassurance, activity encouragement, and self-management.

  • Future Research: High-quality head-to-head trials are urgently needed to improve the evidence base. These studies should address current gaps, such as inconsistent reporting of adverse events and high risks of bias in trials.

APA Citation Wewege, M. A., Bagg, M. K., Jones, M. D., Ferraro, M. C., Cashin, A. G., Rizzo, R. N. R., Leake, H. B., Hagstrom, A. D., Sharma, S., McLachlan, A. J., Maher, C. G., Day, R., Wand, B. M., O'Connell, N. E., Nikolakopolou, A., Schabrun, S., Gustin, S. M., & McAuley, J. H. (2023). Comparative effectiveness and safety of analgesic medicines for adults with acute non-specific low back pain: Systematic review and network meta-analysis. BMJ, 380, e072962. https://doi.org/10.1136/bmj-2022-072962

Thursday: Muscle Relaxants Offer Limited Benefits for Low Back Pain

Comprehensive Summary This systematic review and meta-analysis assessed the efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain (LBP). Key findings include:

  • Limited Pain Relief:

    • Non-benzodiazepine antispasmodics may provide a modest reduction in pain intensity (mean difference of -7.7 on a 0–100 scale) at two weeks or less for acute LBP.

    • This reduction, supported by very low certainty evidence, falls short of being clinically significant.

  • No Effect on Disability:

    • Muscle relaxants showed no meaningful reduction in disability across time points (short-term or longer durations), with evidence ranging from low to very low certainty.

  • Adverse Events:

    • Non-benzodiazepine antispasmodics may increase the risk of adverse events (e.g., drowsiness, dizziness, nausea), with a relative risk of 1.6 compared to placebo (low certainty evidence).

    • Serious adverse events were not significantly increased (very low certainty evidence).

  • Acceptability and Tolerability:

    • Muscle relaxants demonstrated little to no impact on acceptability, as discontinuation rates due to adverse events remained low across trials (very low certainty evidence).

  • Heterogeneity in Outcomes:

    • Results varied considerably among trials due to differing methodologies, biases, and definitions of non-specific LBP, highlighting the need for cautious interpretation of findings.

  • Clinical Implications:

    • Muscle relaxants might offer minor pain relief for acute LBP but are unlikely to provide meaningful clinical benefits.

    • Clinicians should engage patients in shared decision-making and consider safer, non-pharmacological options as first-line treatments.

  • Call for High-Quality Research:

    • Larger, placebo-controlled trials with robust methodologies are urgently needed to better understand the efficacy and long-term safety of muscle relaxants in managing non-specific LBP.

APA Citation Cashin, A. G., Folly, T., Bagg, M. K., Wewege, M. A., Jones, M. D., Ferraro, M. C., Leake, H. B., Rizzo, R. R. N., Schabrun, S. M., Gustin, S. M., Day, R., Williams, C. M., & McAuley, J. H. (2021). Efficacy, acceptability, and safety of muscle relaxants for adults with non-specific low back pain: Systematic review and meta-analysis. BMJ, 374, n1446. https://doi.org/10.1136/bmj.n1446

Friday: Evidence Gap Identified in Common Orthopedic Procedures

Comprehensive Review This umbrella review investigated the effectiveness of 10 common elective orthopedic procedures by analyzing meta-analyses and randomized controlled trials (RCTs). The findings indicate:

  • Limited High-Quality Evidence: For many procedures, evidence supporting their effectiveness compared to non-operative care was insufficient or of low quality. Only carpal tunnel decompression and total knee replacement demonstrated consistent superiority over non-operative care.

  • Procedures Without RCT Comparison: Key interventions such as total hip replacement and meniscal repair lacked RCTs comparing them to non-operative care, raising questions about their clinical effectiveness.

  • No Significant Benefit: Procedures like anterior cruciate ligament (ACL) reconstruction, partial meniscectomy, rotator cuff repair, subacromial decompression, lumbar spine decompression, and spinal fusion showed similar outcomes to non-operative alternatives.

  • Inconsistent National Guidelines: Many national clinical guidelines continue to recommend these procedures despite insufficient evidence, relying heavily on observational studies or expert opinions rather than rigorous RCTs.

  • Urgent Need for Research: The study emphasizes conducting definitive, high-quality RCTs to better evaluate the clinical effectiveness of these procedures and guide evidence-based clinical decision-making.

  • Ethical Implications: Without strong evidence, differentiating between genuine surgical benefits and placebo effects or natural recovery remains challenging, highlighting the need for cautious surgical decision-making.

  • Impact on Healthcare Systems: Optimized decision-making, based on robust evidence, could reduce costs, improve resource allocation, and strengthen patient trust in orthopedic interventions. The findings emphasize a critical gap between the widespread use of orthopedic surgeries and the availability of high-quality evidence validating their effectiveness. This calls for an urgent commitment to prioritizing research and aligning clinical practices with evidence-based guidelines.

APA Citation Blom, A. W., Donovan, R. L., Beswick, A. D., Whitehouse, M. R., & Kunutsor, S. K. (2021). Common elective orthopaedic procedures and their clinical effectiveness: Umbrella review of level 1 evidence. BMJ, 374, n1511. https://doi.org/10.1136/bmj.n1511

Weekly Theme: Evidence-Based Pain Management

This week's studies collectively highlight a significant trend in pain management research: many common interventions for pain—both pharmacological and procedural—show limited effectiveness when subjected to rigorous scientific scrutiny. From spine injections to muscle relaxants and orthopedic surgeries, the evidence suggests we may need to reconsider our approach to treating pain conditions. Notably, non-pharmacological interventions like cognitive behavioral therapy and supervised exercise programs showed promising results for certain conditions, indicating a potential shift toward more holistic, less invasive treatment paradigms. Stay tuned for the PDF and comprehensive article review on LinkedIn.