Wednesday, September 24, 2008

Sports injuries and NSAID

NSAIDs are some of the most widely consumed medications in the world. Painful conditions i.e. mostly acute conditions of athletes are treated with non steroidal anti-inflammatory drugs (NSAID). While NSAIDs have become synonymous with the management of acute musculoskeletal injuries, their efficacy has yet to be proven. The major goal of clinicians when treating acute musculoskeletal injuries is to return athletes to their pre-injury level of function, ideally in the shortest time possible and without compromising tissue-level healing.
1. According to Fournier PE et al (2008), there is a lack of high-quality evidence to use NSAIDS.
2. According to
Fournier PE et al (2008), the adverse effects of NSAIDS medications include potential negative consequences on long-term healing process. According to Mehallo CJ et al NSAIDs are not recommended in the treatment of completed fractures, stress fractures at higher risk of nonunion, or in the setting of chronic muscle injury.
According to
Almekinders LC, Stretch-induced muscle injuries or strains, muscle contusions and delayed-onset muscle soreness (DOMS) are common muscle problems in athletes. Anti-inflammatory treatment is often used for the pain and disability associated with these injuries. The most recent studies on nonsteroidal anti-inflammatory drugs (NSAIDs) in strains and contusions suggest that the use of NSAIDs can result in a modest inhibition of the initial inflammatory response and its symptoms. However, this may be associated with some small negative effects later in the healing phase.
Baldwin examined the use of NSAIDs for attenuating exercise-induced muscle injuries (EIMI), with an emphasis on their safety and usefulness for improving muscle function and reducing soreness. However it is concluded that, there is a lack of agreement concerning NSAID effectiveness for this purpose. According to Fournier PE et al, Mehallo CJ et al and variour others, in all tentative cases, if used, length of NSAID treatment should always be kept as short as possible & must be for analgesic purposes only.
Effect of specific drugs:
1. Nonsteroidal anti-inflammatory drugs Vs analgesic drugs in the treatment of an acute muscle injury.
In a animal study
Rahusen FT, hypothesized that, the effects of nonsteroidal anti-inflammatory drugs are no different than the effects of an analgesic (acetaminophen) without anti-inflammatory action in an experimental, acute muscle contusion model. He concluded that, rofecoxib as a nonsteroidal anti-inflammatory drug and acetaminophen as a non-nonsteroidal anti-inflammatory drug analgesic have similar effects. The lack of differences in wet weights and histology suggests that the anti-inflammatory effects of rofecoxib are not an important feature of its action. He further suggested that, the routine use of nonsteroidal anti-inflammatory drugs in muscle injuries may need to be critically evaluated because low-cost and low-risk analgesics may be just as effective.
2. Cyclo-oxygenase-2 inhibitors: beneficial or detrimental for athletes with acute musculoskeletal injuries?
The following is a review of a paper by
Warden SJ reveal following important points:
The latest class of NSAIDs - selective cyclo-oxygenase-2 inhibitors or the COXIBs were developed to reduce the adverse gastrointestinal (GI) effects of traditional NSAIDs. There is currently no randomised, controlled trial evidence of the tissue-level effects of COXIBs on acute musculoskeletal injuries.
While they have beneficial anti-inflammatory and analgesic properties, and appear to facilitate earlier return to function following acute injury, the effect of COXIBs on tissue-level healing is currently unknown. In experimental animal models of acute injury, COXIBs have been shown to be detrimental to tissue-level repair. Specifically, they have been shown to impair mechanical strength return following acute injury to bone, ligament and tendon. Clinically, this may have implications for ongoing morbidity and future injury susceptibility. Extrapolation of animal studies to clinical setting may however find significant limitations.
More importantly recently studies showed link between one COXIB (rofecoxib) and an increased risk for adverse cardiovascular events. In comparison, traditional NSAIDs do carry the potential for greater adverse GI effects and their clinical effects on tissue-level healing remain relatively unknown but they do not appear to be associated with adverse cardiovascular effects, and they are effective pain relievers and cheaper alternatives.
Review of Topical NSAIDS applications for sports injuries & acute pain
One previous systematic review reported that topical NSAIDs were effective in relieving pain in acute conditions like sprains and strains, with differences between individual drugs for efficacy.
1. The empirical evidence supporting the use of topical NSAIDs in acute soft tissue injuries is weak. According to
Heyneman CA., patient ratings of improvement consistently favor NSAID treatment over placebo. Although it is very difficult to differentiate the placebo effect from the natural course of improvement in these patients, the overall impression given by these studies is that of superior efficacy of topical NSAIDs over placebo. The study by Akermark and Forsskahl suggests that indomethacin applied topically is as effective as therapeutic doses of oral indomethacin. Further studies need to be conducted to generalize this conclusion to other NSAIDs. Studies comparing the relative efficacy of topical NSAIDs with counterirritants available over-the-counter (e.g., menthol, camphor, methylsalicylate) also would be useful.
2. But according to a meta-analysis by,
Mason L, topical NSAIDs were effective and safe in treating acute painful conditions for one week. Similarly Moore RA reported, Topical non-steroidal anti-inflammatory drugs are effective both in relieving pain in acute and chronic conditions.
Russell AL compared Piroxicam 0.5% topical gel to placebo in the treatment of acute soft tissue injuries. He found that piroxicam 0.5% gel, administered as 5 mg q.i.d. is an effective treatment of musculoskeletal injuries (sprains and tendinitis), is significantly more effective than placebo, and is well tolerated.

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