The Management of Musculoskeletal Pain: Filling evidence gaps for highly used or high-risk treatments

Musculoskeletal (MSK) conditions are the leading cause of disability world-wide. There are important gaps in the evidence about how to best manage these conditions. This thesis explores the benefits and harms of interventions for MSK pain, including highly used low risk and low-cost interventions (advice and education), high risk interventions (opioids) and high risk / high-cost interventions (spinal cord stimulators). Chapter 2 systematically reviews the evidence for advice/education for spinal pain. The study found that the effects on symptoms were only small, and other treatments are likely required alongside advice/education at the first line. Chapters 3 and 4 present the world’s largest randomised placebo-controlled trial of an opioid for acute spinal pain and found that there was no benefit at the primary timepoint of six-weeks. Longer term harms were poorer mental health and risk of misuse. Chapters 5 and 6 systematically review the evidence for opioids versus placebo for acute MSK pain (Chapter 5), or against placebo and non-opioids for musculoskeletal pain in the emergency department (ED) (Chapter 6), including the most up-to-date evidence such as the trial presented in Chapters 3 and 4. Chapters 5 and 6 found that opioids provide a small to-moderate benefit above placebo, no benefits compared to some other analgesics, but increased the risk of adverse events. Chapter 7 describes the adverse events relating to implantable spinal cord stimulators reported to Australia’s Therapeutic Goods Administration. The study found that the majority of these events were serious and required at least one surgery to correct. It also found that the devices are being removed at a rate of 4 for every 10 implanted. Collectively, this thesis has filled important evidence gaps and has the potential to change guidelines for the management of MSK pain worldwide