When should and should you recommend the use of oral ibuprofen, ibuprofen gel and naproxen to your patients.
The treatment of acute injuries to the musculoskeletal system is often made more difficult by the extent of the inflammation and the patient's pain. The examination can be limited by severity and irritability, protective mechanisms such as muscle protection, diffuse swelling, emotional reaction to pain and, in patients with multiple trauma, significant pain can mask additional injuries. Using pain medication can help us overcome these obstacles to examination while improving pain and function.
NSAIDs are one of the most commonly prescribed classes of drugs for pain and inflammation. A staggering 5-10% of all drugs prescribed annually come from this class, not counting over-the-counter purchases. Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) can be beneficial to this experience, and it is not uncommon for our patients to have taken these prior to being examined by a physical therapist. As a scope clinician, it is important to have some awareness of the effects of this anti-inflammatory drug.
Pharmacodynamics and pharmacokinetics of NSAIDs
In short, NSAIDs block prostaglandin synthesis by inhibiting cyclooxygenase enzymes (COX-1 and COX-2). Different types of anti-inflammatory drugs will inhibit one or both types of COX, which will have implications for possible side effects and understanding which drug to choose and why. COX-1 produces prostaglandins and thromboxane A2, which control the mucosal barriers in the GI tract and other physiological effects such as platelet aggregation. While COX-2 produces prostaglandins that are related to inflammation, pain, and fever. In summary, COX-2 inhibition is most likely the desired effect of the anti-inflammatory, antipyretic, and analgesic response of NSAIDs. while COX-1 inhibition plays an important role in undesirable side effects such as GI and kidney toxicity.
Basic concepts of pain pharmacology for physiotherapists
Most NSAIDs inhibit both COX-1 and COX-1, including aspirin, ibuprofen and naproxen. Examples of drugs that are selective COX-2 inhibitors are celecoxib and rofecoxib (this list is not exhaustive). You may be wondering why we don't just use COX-2 inhibitors instead? These drugs tend to be significantly more expensive and there is an ongoing debate about the risk of stroke when COX-2 inhibitors are used selectively versus non-selective Cox inhibitors. It seems to be limited to one question: does the cardiovascular risk outweigh the gastrointensinal benefit of using selective inhibitors?
What is the evidence for the use of NSAIDs in acute MSK injuries?
Because of the mechanism of action of anti-inflammatory drugs and the pathophysiology of acute inflammations, these drugs are generally always effective for the treatment of acute injuries or pathological processes with inflammation. That being said, there must be enough inflammation for the drug to be effective, and it must be present long enough for the drug to be effective. Otherwise, you are exposing someone to side effects for no reason.
Medicines have to reach a stable state in the bloodstream in order to achieve a consistent therapeutic benefit. Because of this, there is some evidence that NSAIDS may provide little benefit under certain conditions compared to simply using acetaminophen to improve pain, indulgence, and function. This is because the soft tissue injuries they are trying to treat are mild in nature and therefore most of the swelling and loss of function will be resolved if the drug consistently reaches therapeutic levels.
Current or oral ibuprofen?
According to a Cochrane study, people who use ketoprofen gel or diclofenac gel seem to be more likely to achieve a 50% reduction in pain intensity in the musculoskeletal system compared to placebo. These results are similar between oral and topical versions of NSAIDs. It is also important to remember that current releases are also systemically absorbed so this does not guarantee a reduction in adverse effects.
For patients who do not want to take medication, an up-to-date alternative is a great advantage. Do not underestimate this effect.
Side effects of the use of NSAIDs
As already explained, the inhibition of COX-1 can lead to a large number of potential side effects of NSAIDS. These include increased cardiovascular risk, increased bleeding, gastrointestinal ulceration, nephrotoxicity, exacerbation of asthma, hepatotoxicity, articular cartilage degeneration, increased risk of tendon rupture and suppression of bone formation and healing. Caution is also advised when patients suffer from respiratory diseases such as asthma. When you know these associated risks for such little benefit, when do you see NSAIDS and are you using them correctly?
Change the scope of your exercise
Physiotherapists should always work as part of their practice, and when it comes to medication there can be a gray area of what you can and cannot do. Learn everything you need to know in this excellent pharmacology course about Physioplus and move out of the gray into the clear.
