Review question

What were the effects (benefits and harms) of oral NSAIDs compared with other oral analgesics for treating acute soft tissue injuries?

Type of review

The authors searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (12 September 2014), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2014 Issue 8), MEDLINE (1966 to September 2014), EMBASE (1980 to September 2014), CINAHL (1937 to November 2012), AMED (1985 to November 2012), International Pharmaceutical Abstracts (1970 to November 2012), PEDro (1929 to November 2012), and SPORTDiscus (1985 to November 2012), plus internet search engines, trial registries, and other databases. They also searched reference lists of relevant articles and contacted authors of retrieved studies and pharmaceutical companies to obtain relevant unpublished data.

Relevance for nursing

Acute soft tissue injuries are common and costly. The best drug treatment for such injuries is not certain, although NSAIDs are often recommended. Therefore, nurses need to understand what evidence exists supporting the use of analgesics in treating soft tissue injuries as well as the adverse effects of these medications to provide the best pain management for their patients.

Characteristics of the evidence

The authors included 16 studies, of which nine studies compared NSAIDs with paracetamol (acetaminophen), four studies compared NSAIDs with opioids, and four compared NSAIDs with combination analgesics comprising paracetamol and an opioid. The majority of the evidence was either low quality or very low quality. The authors found no studies comparing NSAID versus complementary and alternative medicine. None of the studies reported reinjury.

Summary of key evidence

The authors included 16 trials, with a total of 2144 participants. Two studies included children only. The other 14 studies included predominantly young adults, of whom over 60% were men. Seven studies recruited people with ankle sprains only. Most studies were at low or unclear risk of bias; however, two were at high risk of selection bias, three were at high risk of bias from lack of blinding, one was at high risk of bias because of incomplete outcome data, and four were at high risk of selective outcome reporting bias. The evidence was usually either low quality or very low quality, reflecting study limitations, indirectness such as from suboptimal dosing of single comparators, imprecision, or one or more of these. Thus, the authors are either uncertain or very uncertain of the results.1

There is, generally, low or very low quality but consistent evidence of a lack of differences in analgesic efficacy between NSAIDs and any of the comparator groups [paracetamol (acetaminophen), opioid, or combination paracetamol plus opioid analgesics] for acute soft tissue injuries. Where studies found statistically significant differences in pain outcomes, the size of the difference was clinically unimportant. Although the evidence was either low or very low quality, there was no evidence of a difference in swelling or return to function between NSAID and paracetamol (acetaminophen), but there was weak evidence of more gastrointestinal adverse effects with NSAID. There was low or very low-quality evidence for a functional benefit and fewer gastrointestinal adverse effects for NSAID compared with opioid containing analgesics. This result is of uncertain applicability because the evidence is heavily influenced by a single large study of a now-unavailable COX-2-selective NSAID, valdecoxib (Bextra; Pfizer, Peapack, New Jersey, USA), which was compared with an opioid analgesic given in a suboptimal dose. There is very low-quality evidence of a lack of difference in return to function and gastrointestinal adverse effects between NSAID and paracetamol (acetaminophen) plus opioid analgesic. The current evidence should not be extrapolated to children or adults older than 65 years, as these groups were not well represented in the studies.1

Best practice recommendations

The authors found no evidence for an important difference between NSAIDs and paracetamol (acetaminophen) for people with strains, sprains, and bruises for pain relief, swelling, or return to function at 7 days or over. However, there was some evidence that people treated with NSAIDs had slightly more side-effects related to the stomach or intestines. Although there was some evidence to suggest a greater return to function at 7 days and fewer side-effects for people with sprains, strains, and bruises using an NSAID compared with an opioid, the authors cannot say if this would apply to drugs that are currently available. This is because most of the evidence came from a study that tested an NSAID that is no longer on the market. The authors found no evidence for an important difference between NSAIDs and a combination of paracetamol (acetaminophen) and opioid for people with sprains, strains, and bruises regarding pain relief, swelling, return to function at 7 days or over, or gut-related side-effects. However, the combination painkiller used in the studies is not now in common use. This means that we cannot be sure that these results would currently apply. The authors found no studies comparing NSAIDs and complementary and alternative medicines. Also, no studies looked at the risk of reinjury after treatment.1

Research recommendations

Further studies of analgesic efficacy between oral analgesics currently used for acute soft tissue injury in young adults should not be the priority; none of the evidence thus far has shown a discernable difference between any of the analgesics for the outcome of pain. However, the review raises other questions. The evidence regarding return to function and adverse effects is incomplete, and this should be the primary focus of future research around pharmacological interventions for acute soft tissue injuries. Further research is also warranted in the very young or very old with these injuries, again with a focus on functional benefit and adverse effects.

Acknowledgements

Phyllis Brown Whitehead is a member of the Cochrane Nursing Care Field.

Conflicts of interest

The authors report no conflicts of interest.

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