Much ado about soft tissue injury

THE Bard partook of the weed, but did he venture near the anti-inflammatories.

In the tragedy of soft tissue injury, it has become almost cultural to reach for the box of non steroidal anti-inflammatories, because, as we all know, they are pain relief right? Is not all inflammation bad? Those ads on TV show ibuprofen putting out the fire of back injury don't they?
If you see the acronym NSAID on a packet of medication, it is classifying a drug as one that interferes with a natural rescue process of your body, but its effect is not delivered by a steroid. The agent is therefore free of the side effects that come as part of the deal with potent steroids, namely weight gain, moon face, acne or even interruption of wound healing.
The list is longer, so you'd be thinking, "sweet, I can take NSAIDs with a clear conscience." However, NSAIDs come with their own "down side / side effects". The question is, when are they beneficial, and are we just following the advice of TV personalities who care more about their brand than your health?
Before we examine this wonder class of drugs' pedigree, let's ask the question that if the body has its own healing and repair systems, should we even be interfering? Since injury is a tragedy to the injured person, it makes sense to utilise the Bard in depicting the gravitas of injury and our weapons to withstand its consequences.
Act One: the injury. The injuries they procure, must be their schoolmasters - King Lear.
Odds on you will have noticed that you are injured. Enter Calor, Dolor, Tumor and Rubor. They are of the family Inflammazione and are here as harbingers of doom. Calor puts the heat on you. Dolor is the pain merchant. Tumor is known for his expansive sense of presence - swelling. Rubor is dressing you in redness for your injured part.
Inside there's a lot going on that the four harbingers are indicating. It's the inflammatory cascade where damage is bleeding, and the body is mobilising its forces to repair the breach. Thank goodness! Unfortunately Dolor and Tumor are excelling at their work and you start to want to inhibit their effectiveness. The natural means of preventing a runaway inflammatory process is good old Rest Ice Compress and Elevate, but you want more bang for your buck. You are starting to think how good it is not to be in Shakespearean times, and reach not for a strip of willow bark to chew (aspirin) but for the box of NSAIDs.
NSAIDs are used for their anti tumor and anti dolor abilities (swelling and heat). You will probably feel better, but as Robert Granter writes in Clinical Sports Medicine, their use is generally well accepted in situations of excessive inflammation like bursitis (not a regular injury). However in treating acute and overuse conditions (more regular injuries) their use is widely debated.
Act Two: the inflammation. ... And from his holiness use all your power to stop their marches 'fore we are inflamed - King John.
Before we leap on inflammation and label it the scourge of our day, consider this: in the context of tissue injury it is protective; it is a response of the immune system, purely acting in our best interests; it has a purpose - to clear out dead cells and clean up damaged tissues, and to start the rebuild. Too little and the bacterial onslaught may get a foothold. Arachidonic acid is liberated from the cell walls in the injury event and in essence this is like the project manager calling in all the tradesmen for the repairs. Simplistic of course but NSAIDS inhibit the enzymes and chemicals that are there to conduct the inflammatory process. Act Three: the tissues. ... hold, hold my heart! And you my sinews, grow not instant old, but bear me stiffly up ... Hamlet
Many of our injuries have not shown benefit from NSAIDs in the literature (research that is, not Shakespeare). Ligaments show an adverse effect of continued pain and instability beyond six months. A better ploy might be the strategy of Northern Irish physios who found immediate early movement and advice sped up the return to normality.
Tendon injuries do show debatable evidence, but more so in chronic injury (more than three months' duration). They are also touted as feasible for pain relief early in injury, but paracetamol has mild anti inflammatory effects and pain relief, without the side effects.
Muscle injuries have shown possible adverse effects such as interference in the rebuild: protein production is inhibited and this affects the quality of tissue repair. Some people take NSAIDs before a sports event, which seem to allow more damage to the muscles as the presence of creatine kinase indicates muscle damage.
Bone injuries have shown delayed bony consolidation, and it is recommended that in the first two weeks of a fracture that they are avoided.
Delayed healing, reduced strength of healing tissue, increased fibrosis (weakness of repair tissue) - these are all the trade offs that you don't get to decide on when you place two little white pills on your tongue.
Bursitis and Impingement Syndromes show clear benefit from using NSAIDs, so at last, when you get yourself a pinchy trochanter, these drugs can help.
Act Four: the relief. ... I would not have thee linger in thy pain ... Othello.
Overwhelmingly so, I have noticed my patients tend to believe that to take a NSAID is to treat their pain. This is the fault of marketing as it has failed to match the drug to the purpose. Because on the whole, most people will not suffer with NSAIDS, the advertising seems to have gotten away with favouring "targeted pain relief" over "anti-inflammation". If you take a NSAID after the inflammatory phase of injury, it is potentially a useless substance in your body and an investment in the side effect game of chance. There are better drugs to offer analgesia (pain relief), and by coincidence they are known as analgesics.
Act Five: Resolution. ... Sir I will use my utmost skill in his recovery ... Pericles.
In the art and science of physical therapies, peripheral issues bring themselves to bear across the season of injury recovery, being external agents, chemicals, salves or balms. I often asked myself why we were advocating a way to interfere with nature's processes, when comfort was of greater importance than repair. Yes it is true that we need to mitigate the effects of the injury and provide pain relief, but there are better ways. Anti inflammatory comfort is provided well with timely massage, ultrasound, ice, positioning advice and movement with guidance. A lot of people are more sceptical of medicating. To this way of thinking, should our minds be dedicating ...
Greg Bell is a physiotherapist practising at Bell Physiotherapy. www.bellphysio.co.nz