Evid Based Nurs 9:45 doi:10.1136/ebn.9.2.45
  • Treatment

Paracetamol, non-steroidal anti-inflammatory drugs, and combination treatment did not differ for pain relief after musculoskeletal injury

 Q What is the relative effectiveness of oral paracetamol (acetaminophen), oral non-steroidal anti-inflammatory drugs (NSAIDs), and combination treatment for acute pain relief after musculoskeletal injury?



randomised placebo controlled trial.


unclear concealment.


blinded (patients, healthcare providers, and outcome assessors).

GraphicFollow up period:

5–8 days after initial presentation. Pain was assessed up to 3 days.


emergency department (ED) of a university teaching hospital in Hong Kong.


300 patients ⩾16 years of age (mean age 37 y, 59% men) who presented to the ED with a painful acute limb injury. Exclusion criteria were substance abuse; dementia; indigestion; peptic ulceration or haemorrhage; recent anticoagulation; pregnancy; adverse reactions to study drugs; renal or cardiac failure; hepatic problems; rectal bleeding; chronic NSAID consumption; asthma; chronic obstructive airways disease; chronic pain syndromes; previous analgesia for the same injury; or physical, visual, or cognitive impairment.


oral paracetamol, 1 g, and indomethacin placebo (n = 66); indomethacin, 25 mg, and paracetamol placebo (n = 71); diclofenac, 25 mg, and paracetamol placebo (n = 69); or paracetamol, 1 g, and diclofenac, 25 mg, (combination) (n = 94). After hospital discharge, patients continued with the medication to which they were randomised but received the paracetamol/paracetamol placebo regimen 4 times/day and the NSAID/NSAID placebo regimen 3 times/day.


change in mean pain score at rest and with activity using a 10 cm visual analogue scale (VAS), and adverse effects. The study had >80% power to detect mean differences between groups of >13 mm on the VAS.

GraphicPatient follow up:

98% (intention to treat analysis).


In the first hour, none of the groups had a mean change in VAS score >13 mm. The combination group was first to achieve a difference of >13 mm and had the greatest reduction in pain scores at each follow up, but at no time point did the difference between the 4 groups for change in pain score at rest or with activity reach statistical significance (comparisons for pain at rest in table). More patients in the combination group had adverse events, but none were severe; the combination group did not differ from the other groups except for abdominal pain, which occurred in more patients in the combination group than the indomethacin group (percentage difference –6.5%, 95% CI –13.5 to –0.3).


Oral paracetamol was as effective as oral non-steroidal anti-inflammatory drugs and combination treatment for acute pain relief after musculoskeletal injury.


  1. Patricia Kelly Rosier, APRN-BC, MS
  1. Berkshire Medical Center, Pittsfield, Massachusetts, USA

      EDs frequently treat patients with complaints of pain. This important topic is addressed in the study by Woo et al that compared oral paracetamol, oral NSAIDs, and a combination of both to treat acute musculoskeletal pain. Recent reports of safety issues with NSAIDs have raised concerns about the appropriateness of using these medications. However, it should be noted that paracetamol is not without risk. Overuse of paracetamol is a leading cause of liver failure and hepatotoxicity in the western world,1 although this may be less of a concern when managing acute pain. Clinicians must be aware of the risks associated with the analgesics they prescribe. The results of the study by Woo et al did not show a statistically significant difference in change in pain scores between treatment groups. The small differences noted with combination treatment did not approach the level of reduction believed necessary to make a clinical difference.2 Adverse events were more common in the combination treatment group but were not severe. The limited sample makes it difficult to generalise to other populations or painful conditions.

      Woo et al have added to the limited research evidence on the relative effectiveness of paracetamol and NSAIDs, showing that these medications were safe and effective analgesics in the sample studied. The decision on which to prescribe may be influenced by the risk of adverse effects in individual patients or by patient preference.


      Mean differences between groups in change in pain score at rest from baseline to 3 days*

 Q What is the relative effectiveness of oral paracetamol (acetaminophen), oral non-steroidal anti-inflammatory drugs (NSAIDs), and combination treatment for acute pain relief after musculoskeletal injury?


      • For correspondence: Dr T H Rainer, Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Shatin, Hong Kong. rainer1091{at}

      • Source of funding: no external funding.

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