Non-steroidal anti-inflammatory drugs (NSAIDs) in musculoskeletal pain.
Non-steroidal anti-inflammatory drugs (NSAIDs), which include aspirin, ibuprofen, naproxen or diclofenac, are widely used to reduce inflammation and musculoskeletal pain. The aim of this review is to describe the effects of NSAIDs in the context of acute and chronic musculoskeletal conditions.
Inflammation is a response to tissue injury. It involves a staged sequence of immune and inflammatory processes induced by chemical mediators, especially prostaglandins. NSAIDs work by blocking the action of an enzyme called cyclooxygenase (COX), which normally catalyses the production of prostaglandins, therefore reducing inflammation and pain. However, because inflammation and the COX pathway facilitate healing the prescription of NSAIDs in tissue injuries is being questioned.
- Ligament injury: NSAIDs for acute ankle sprains seem to promote an earlier return to normal activity, but in a longer term this was associated with a greater incidence of instability and decreased ROM. In laboratory studies, NSAIDs were shown to reduce the mechanical strength of ligaments and delay healing for up to 12 weeks post-injury. NSAIDs therefore seem to increase the risk of tendon re-injury in short term. It is suggested that inflammation and pain may play a protective role, by limiting activity early post-injury, and allowing normal healing
- Tendinopathy: The role of inflammation in the continuum of tendon pathology is debated, and so is the role of NSAIDs. In acute reactive tendinopathies, short-term NSAIDs might help reduce tendon swelling without affecting tendon repair. In chronic/disrepair tendinopathies, tendon healing is based on stimulating cellular activity and repair; NSAIDs are not recommended, as they inhibit tenocytes activation and the chemical signalling of tendon tissue healing. Also, their effect on pain relief was modest. Furthermore, NSAIDs demonstrate negative effects on tendon-to-bone healing.
- Muscle: NSAIDs are not recommended for muscle strains, as they might predispose to early re-injury through pain masking. However, evidence is contradictory for extreme cases, where excessive inflammation itself could lead to further muscle tissue damage. Yet, NSAIDs should be stopped as soon as possible to allow for normal tissue healing and muscle regeneration. NSAIDs also impede normal muscle hypertrophy after exercise (by impairing satellite cells response).
In conclusion, inflammation is not "inherently a bad thing"; also, NSAIDs may compromise recovery, are not risk-free (side-effects, drug interactions), and are not more efficient than Paracetamol for pain relief. Physiotherapists cannot prescribe medication (scope of practice, medico-legal liability), but can be aware of patient intake and redirect those seeking advice/prescription towards their GP or pharmacist > From O’Leary et al., Physiotherapy Ireland 32 (2011) 34-39. All rights reserved to the Author(s).