• Amir Qaseem, Robert M McLean, David O'Gurek, Pelin Batur, Kenneth Lin, Devan L Kansagara, Clinical Guidelines Committee of the American College of Physicians, Commission on Health of the Public and Science of the American Academy of Family Physicians, Thomas G Cooney, Mary Ann Forciea, Carolyn J Crandall, Nick Fitterman, Lauri A Hicks, Carrie Horwitch, Michael Maroto, Reem A Mustafa, Janice Tufte, Sandeep Vijan, and John W Williams.
• American College of Physicians, Philadelphia, Pennsylvania (A.Q.).
• Ann. Intern. Med. 2020 Nov 3; 173 (9): 739748739-748.

DescriptionThe American College of Physicians (ACP) and American Academy of Family Physicians (AAFP) developed this guideline to provide clinical recommendations on nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting. The guidance is based on current best available evidence about benefits and harms, taken in the context of costs and patient values and preferences. This guideline does not address noninvasive treatment of low back pain, which is covered by a separate ACP guideline that has also been endorsed by AAFP.MethodsThis guideline is based on a systematic evidence review on the comparative efficacy and safety of nonpharmacologic and pharmacologic management of acute pain from non-low back, musculoskeletal injuries in adults in the outpatient setting and a systematic review on the predictors of prolonged opioid use. We evaluated the following clinical outcomes using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system: pain (at ≤2 hours and at 1 to 7 days), physical function, symptom relief, treatment satisfaction, and adverse events.Target Audience And Patient PopulationThe target audience is all clinicians, and the target patient population is adults with acute pain from non-low back, musculoskeletal injuries.Recommendation 1ACP and AAFP recommend that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with topical nonsteroidal anti-inflammatory drugs (NSAIDs) with or without menthol gel as first-line therapy to reduce or relieve symptoms, including pain; improve physical function; and improve the patient's treatment satisfaction (Grade: strong recommendation; moderate-certainty evidence).Recommendation 2 AACP and AAFP suggest that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with oral NSAIDs to reduce or relieve symptoms, including pain, and to improve physical function, or with oral acetaminophen to reduce pain (Grade: conditional recommendation; moderate-certainty evidence).Recommendation 2 BACP and AAFP suggest that clinicians treat patients with acute pain from non-low back, musculoskeletal injuries with specific acupressure to reduce pain and improve physical function, or with transcutaneous electrical nerve stimulation to reduce pain (Grade: conditional recommendation; low-certainty evidence).Recommendation 3ACP and AAFP suggest against clinicians treating patients with acute pain from non-low back, musculoskeletal injuries with opioids, including tramadol (Grade: conditional recommendation; low-certainty evidence).

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