NSAIDs for Soft Tissue Lesions
by Warren Hammer, MS, DC, DABCO
November 4, 2002, Volume 20, Issue 23
It seems to have become standard procedure for nonsteroidal anti-inflammatory drugs (NSAIDs) to be used for acute injuries. Their main action is to inhibit prostaglandins, pro-inflammatory mediators responsible for the production of painful stimuli. There is no question that they often reduce pain and swelling, and therefore help a patient perform motion earlier during recovery, but what is the effect on the soft tissue? Elder, et al.,1 asked the question and performed experiments on the medial ligaments (right knee) of 50 rats through surgical transection. Half of the ligaments were given Celecoxib, a COX-2 inhibitor similar to Celebrex, for the first six days of recovery, while the other half were not. (The injured animals were sacrificed 14 days after the operation.) The ligaments given the anti-inflammatory had a 32-percent lower load to failure than the untreated injured (control) ligaments.
Elder, et al., state that to their knowledge, there were no previous reported studies regarding the effect of COX-2 inhibitors on any soft tissue disorders. This article tells us that these drugs, which have been widely advertised, were never tested for their effects on soft tissue. I suppose that patients with osteoarthritis or rheumatoid arthritis have been relieved of pain, but they are in a precarious situation if they experience an injury to their soft tissue.
Whatever happened to the acceptance of nature and its innate healing ability? There's an old adage: "Hurry to give a new drug while it's still working." I always thought that inflammation was the body's first line of defense against acute injury. Why inhibit a normal bodily reaction? It makes no sense to immediately give an anti-inflammatory drug to a recent injury. An inflammatory response is beneficial by removing cellular debris from sites of injury to allow quicker healing.2 This type of intervention is similar to the old theory of prescribing aspirin as soon as a slight fever arises.
The COX-2 inhibitors were developed to minimize the gastrointestinal symptoms caused by the earlier NSAIDs, such as Advil and Motrin. NSAID use has been linked to disorders ranging from dyspepsia to gastric ulceration with bleeding. Contraindications to use are patients over 60 years of age, arthritis, a history of gastrointestinal disease, anticoagulant or corticosteroid.1 The study determined, "Complications related to NSAID use among arthritis patients are responsible for 16,500 deaths per year in the United States.3
NSAIDs may delay muscle healing in minor stretch injuries.4 In a trial that treated acute hamstring injuries with NSAIDs versus a placebo group with the same physiotherapy regimen, reduction of pain and swelling, and return to normal strength, were no better with or without NSAIDs. It noted, "Surprisingly, in the group with severe strains, reduction of pain was better in the placebo group." As a result, this study did not advocate the use of NSAIDs in acute hamstring strains.4
Recently, Mariano Rivera, the great Yankees relief pitcher, was diagnosed with a shoulder strain. The strain was confirmed by MRI, and he received an injection of cortisone. Several weeks later, he was pitching again, and re-aggravated the shoulder. He was sent back to rehabilitation, with the hope that he would be available to pitch in the postseason. It seems logical that any inflammatory ability of his body to create healing was immediately repressed, and his "strain" was not given a chance to completely heal.
Some Like It Hot
The two most popular nonprescription medications in the U.S. - ibuprofen (i.e., Advil) and acetaminophen (i.e., Tylenol) - have been promoted as "first-line" management of acute low back pain. These analgesics may cause potential kidney, stomach, and liver problems, however. Self-administered topical heat wraps may offer a drug-free alternative treatment for acute back pain.
In a recent study in the journal Spine, the authors compared eight hours/day of low-level topical heat therapy with maximal recommended dosages of ibuprofen and acetaminophen. Pain, muscle stiffness, disability, and back flexibility were compared in almost 400 people with back pain, ages 18-55, over two days of therapy and two days of follow-up.
Heat-wrap therapy was more effective than either drug. Heat wraps were significantly more effective than ibuprofen and acetaminophen in terms of self-reported pain relief. In the heat-wrap group, back flexibility was greater, and disability and muscle stiffness were lessened to a greater degree.
Based on these findings, continuous low-level heat-wrap therapy may be better than painkillers for acute back pain. Simply wrap a Velcro belt with a heating element around your torso.
There is still, however, a place for anti-inflammatory medication: