BACKGROUND AND PURPOSE:

• The best drug treatment for acute soft tissue injuries (bruise, sprains, strains, etc.) is not well known
  • NSAIDs are commonly recommended
  • Oral opioids for acute pain management may be leading to dependence
• In an update to a 2015 Cochrane review, Jones et al. (Cochrane Database Syst. Rev. 2020) assessed the benefits or harms of NSAIDs compared with other oral analgesics for treating acute soft tissue injuries

METHODS:

• Systematic review and meta-analysis
• Data sources
  • CENTRAL | MEDLINE | Embase to January 2020
  • Other databases were searched to February 2019
• Inclusion criteria
  • Randomized or quasi-randomized controlled trials
  • Trials included individuals soft tissue injury
  • Compared oral NSAIDs vs
    • Paracetamol (acetaminophen)
    • Opioid
    • Paracetamol plus opioid
    • Complementary and alternative medicine
• Study design
  • Acute soft tissue injury definition: Sprain, strain, or contusion of a joint, ligament, tendon, or muscle occurring within 48 hours of inclusion in the study
  • Two review authors independently assessed studies for eligibility, extracted data, and assessed risk of bias
  • Quality of the evidence was assessed using GRADE criteria
• Primary outcomes
  • Pain
  • Swelling
  • Function
  • Adverse effects
  • Early re-injury

RESULTS:

• 20 studies included | Combined total of 3305 participants
  • 3 studies included children only | Remainder included predominantly young adults
  • Approximately 60% were male | 40% female
  • 7 studies recruited only people with ankle sprains
• Certainty
  • Evidence related to pain relief was generally high certainty
  • There was a combination of certainty with most outcomes
• No studies reported re-injury rates
• No studies compared NSAIDs with oral complementary and alternative medicines

NSAIDs vs Paracetamol  

• 11 studies | 1853 participants
• No differences between the two groups for pain at
  • 2 hours (1178 participants, 6 studies; high-certainty evidence)
  • Days 1 to 3 (1232 participants, 6 studies; high-certainty evidence)
  • ≥7 days (467 participants, 4 studies; low-certainty evidence)
• Little difference between the groups in numbers of participants with minimal swelling at ≥7 days 
  • 77 participants, 1 study; low-certainty evidence
• Little difference between the groups for return to function at ≥7 days
  • 386 participants, 3 studies; very low-certainty evidence
• NSAIDs may slightly increase the risk of GI adverse events compared with paracetamol
  • 1504 participants, 10 studies; low-certainty evidence
• There was little difference in neurological adverse events between the NSAID and paracetamol groups
  • 1679 participants, 9 studies; low-certainty evidence

NSAIDs vs Opioids

• 6 studies | 1212 participants
• There was no difference between the groups in pain at
  • 1 hour (1058 participants, 4 studies; moderate-certainty evidence)
  • Days 4 to 7 (706 participants, 1 study; low-certainty evidence)
• No important difference between the groups in swelling
  • 84 participants, 1 study, very low-certainty evidence
• NSAID group were more likely to return to function in 7 to 10 days
  • 542 participants, 2 studies; low-certainty evidence
• NSAIDs use less likely to result in GI or neurological adverse events compared with opioids
  • 1143 participants, 5 studies; moderate-certainty evidence

NSAIDS vs Paracetamol and Opioid Combination

• 4 studies | 240 participants
• The applicability of findings from these studies is questionable
  • The dextropropoxyphene combination analgesic agents used are no longer in general use (used in 2 of 4 studies)
  • The paracetamol doses were suboptimal
• No difference between the groups in pain at
  • Day 1 (51 participants, 1 study; very low-certainty evidence)
  • Day 3 (149 participants, 2 studies; very low-certainty evidence)
  • Day 7 (138 participants, 2 studies; very low-certainty evidence)
• No difference between groups for the following  
  • Swelling (230 participants, 3 studies; very low-certainty evidence)
  • Return to function at day 7 (89 participants, 1 study; very low-certainty evidence)
  • Risk of GI or neurological adverse events (141 participants, 3 studies; very low-certainty evidence)

CONCLUSION:

• In the context of soft tissue injuries
  • No differences were found between NSAIDs and paracetamol at 1 to 2 hours and 2 to 3 days | There may also be no difference in pain at day 7 and beyond
  • NSAIDs may be slightly associated with more GI upset compared to paracetamol  
  • There is probably no difference between NSAIDs and opioids in pain at 1 hour, and there may be no difference at days 4 or 7
  • NSAIDs probably result in fewer GI and neurological adverse effects compared with opioids
• The authors note that participants tended to be younger and these results really are not generalizable to adults ≥65 years of age

Learn More – Primary Sources:

Oral non-steroidal anti-inflammatory drugs versus other oral analgesic agents for acute soft tissue injury

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