kelly starrett (mwod guy!) on ibuprofen

[spezzy]

Interesting read.

http://sanfranciscocrossfit.blogspot.com/2009/06/get-off-ibuprofen-peoples.html

"Ok. Ibuprofen has no place in the life of the athlete obsessed with chasing performance.

Taking an anti-inflammatory drug of any kind makes tendons and ligaments weaker, and stops muscles from getting stronger.

Is this clear enough? Yes, we used to call it Vitamin I. Yes, we used to say that RICE should have a second "I" in it (Rest, Ice, Ibuprofen, Compression, Elevation).

We used to also do "21's" on back and bi's day too. It's not ok.

Here's the low down. Ibuprofen is an NSAID (Non-Steroidal-Anti-Inflammatory-Drug) which is believed to work through the inhibition of cyclooxygenase (COX), thus inhibiting prostaglandin synthesis. Prostaglandins, are like hormones in that they act as chemical messengers, but do not move to other sites, but work right within the cells where they are synthesized. Prostaglandins are vital mediators of the inflammatory cascade. The swelling and subsequent prostaglandin production signals all of the important cells circulating in your body to come and fix/reinforce the challenged tissues. That's right, all that soreness you feel after Fran is the resultant swelling from all the micro-damage you've done to your muscles. It's this very inflammatory response that is responsible for making you a BETTER ATHLETE. The Worst thing you can do is to go through a horrible workout like Fran and then not reap the resultant gains from the training stimulus.

No good coach should allow their athletes to take ibuprofen at anytime. Even if they are hung over..

Why?

NSAIDs have been shown to delay and hamper the healing in all the soft tissues, including muscles, ligaments, tendons, and cartilage. Anti-inflammatories can delay healing and delay it significantly, even in muscles with their tremendous blood supply. In one study on muscle strains, Piroxicam (an NSAID) essentially wiped out the entire inflammatory proliferative phase of healing (days 0-4). At day two there were essentially no macrophages (cells that clean up the area) in the area and by day four after the muscle strain, there was very little muscle regeneration compared to the normal healing process. (Greene, J. Cost-conscious prescribing of nonsteroidal anti-inflammatory drugs for adults with arthritis. Archives of Internal Medicine. 1992; 152:1995-2002.)

Long term NSAID use is hard on your tissues and directly responsible from some pretty gnarly chronic body issues.

So how do we treat acute inflammatory/inflammation pain?

You know the answer.

Ice. (Maybe a little Tylenol if you really, really need it, it's not an NSAID after all)

But remember, Acetaminophen causes three times as many cases of liver failure as all other drugs combined and is the most common cause of acute liver failure in the United States. Even recommended doses especially combined with even small amounts of alcohol (Yes you Crossfitters) have caused irreversible liver failure. Don't be so cavalier about treating your muscle soreness with drugs. Taking pain meds of any kind is serious.

Can you see the difference between treating pain and treating inflammation? Control swelling and Pain with Ice as seen below, it won't short circuit the way your body actually heals itself and becomes stronger. (Hell, the Ice bath might make you a little stronger too.)

Bask in your soreness! Brag about it at work as your friends help you get up off the toliet. And above all, practice all the recovery tricks you know! These include: Proper nutrition, fluid intake, ice bath, fish oil, active recovery, stretching, massage, etc.

Hell, you can even sneak in another quick workout the next day before the 48 hour soreness beat down really kicks in! Quick, let's do Fight Gone Bad before you get too sore from yesterday's double fran!

Seriously. Knock it off. Get off the Vitamin I."

[Cipriana]

I was wondering about the very subject just this morning as I woke up so stiff and sore I had to do a barrel roll to get out of bed. Unfortunately, I staggered to the bathroom and gulped down some ibuprofin before reading this. I'm seriously so sore and stiff I can barely walk. I'm concerned my stiffness/soreness is going to interfere with my workout tonight. I've been pounding water and am seriously considering taking an ice bath.

[wanna_B_nerd]

SONUVA... took some this morning after a jog, it will be my last!

[bigm141414]

Hmm interesting article. Time to dive into the source material...

*...goes for a swim in journal pools...*

[jdanger]

Yeah.. stay off the I whenever possible. Taking NSAIDs to alleviate exercise induced soreness is like trying to build a house while simultaneously setting it on fire every night.. just doesn't make sense and in the long term is probably a net loss.

[Oogiem]

What about good old regular aspirin? That's my go to drug if I really need one.

Has the advantage of also inhibiting blood clots so is a heart attack and stroke preventative. Was recommended by my doctor for the arthritis if I have to have one to sleep.

[jdanger]

Aspirin is still an NSAID but under that context it is fine. What Starrett was targeting was the habitual use of NSAIDs as an exercise recovery method. If your workouts leave you constantly sore for months on end the answer is figure out how to workout smarter not start mega-dosing NSAIDs.

[Hrunter]

Like jdanger said, its still an NSAID.

While it can help with pain and anti-coagulation, it will still have the aforementioned effects.

If you're taking it for your Arthritis, ye still have to weigh the benefit versus the side effects and contraindications.

Just putting it out there, use of Aspirin for prophylaxis of ischemic or acute stroke is effective (reduces mortality rate by 10%) but if used solely for this, maybe consult a doctor to look for risk factors of hemorrhagic stroke. While the benefits still typically outweigh the risks, this is one of the reasons (in some places) Aspirin is contraindicated for first aid treatment of strokes.

[Hermione Gainser]

Well, damn.

[Oogiem]

If you're taking it for your Arthritis, ye still have to weigh the benefit versus the side effects and contraindications.

I try to keep it down to once a month or so. Usually after way too much heavy work and I'm just flat aching everywhere but esp. my hips and back. When I can't sleep because I'm in pain an aspirin is a whole lot better than my attitude without enough sleep. ;-)

[catspaw]

My sciatic nerve sometimes acts up for weeks at a time, and my doctor's only advice is to pop nsaids like they were candy. Which of course I don't want to do, but she's not very helpful about alternatives. I'm actually hoping taking a bunch of fish oil over time might be a good alternative.

[Hrunter]

@ Oogiem That's rough. The best I can relate is car accident soft tissue damage and that's no where near as persistent as arthritis >.<

Its good that you can manage the frequency of severe flare ups! I can imagine with it being joints as opposed to muscles heat treatment may not be as effective. Do you have other things that work for it?

@catspaw My mom has sciatica, I've not heard of fish oil for it yet! Do you know what specifically causes it to act up? If your doctor advised NSAIDs, I can only imagine it involving the nerve being compressed through some sort of swelling

Just to put it out there, other NSAIDs by name:

Diclofenac

Cambia (Powder solution), Cataflam, (tablets), Diclofenac (tablets), Felctor (transdermal patch), Pennsaid (solution), Solaraze (Gel), Voltaren (Gel), Voltaren-XR (Tablets), Zipsor (Capsules)

Aloxiprin

(still looking up trade names)

Diflunisal

Dolobid (Tablets)

Magnesium Salicylate

Doan's, Doan's PM, Doan's Extra Strength, Novasal, Mobidin, Arthriten, KneeRelief, Durabac Forte, Combiflex ES, Cafgesic Forte, Pamprin Cramp Menstural Relief, Diurex, Trilisate, Choline Magnesium Trisalicylate, Tricosal, "CMT", Myogesic, Magsal, Mobigesic, Tetra-Mag, Keygesic-10,

Methyl Salicyclate

Medrox, Banalg, Thera-Gesic, Ben Gay, Dendracin, Dendracin Neurodendraxcin, Menthoderm, Rub A-535

Salsalate

Disalcid, Salsitab, Salflex, Argesic-SA, Amigesic, Marthritic, Mono-Gesic, Anaflex

Willow Bark (Salicin)

Metabolises into Salicylic acid

BC Powder (all varieties, contains Aspirin)

Okay. The list is just really long -.- Here's a bunch of them, not sorted by ingredient.

Celebrex

Lodine, Lodine XL

Nalfon

Ansaid

Advil, Motrin, Motrin IB, Nuprin

Indocin, Indocin SR

Actron,Orudis, Orudis KT, Oruvail

Arthritab, Bayer Select, Magan, Mobogesic

Meclomen

Ponstel

Mobic

Relafen

Naproxen, Naprosyn, Naprelan, Aleve, Anaprox

Clinoril

Tolectin

Bextra

Chemically speaking, if it ends in -fen, -fenac, -fenic, -oxib, and sometimes -ac, you'll want to search the ingredients online to see if they're NSAID.

[Oogiem]

Do you have other things that work for it?

Single malt scotch, but that has it's own issues...

Seriously though, alcohol does actually help.

[andygates]

I want to see studies showing that ibuprofen does actually affect performance in athletes who use it that way. Coach chappie is making a hypothesis and trotting it out as a proof: very common among fitness writers. Especially with the "omg don't EVER" grade of emphasis.

The hypothesis isn't a bad one. But until you show me a bunch of athletes split into a number of test groups (ibuprofen at will, paracetamol at will, ice at will) it remains a hypothesis.

(IMO: There's no need for pills for garden-variety DOMS; if you hurt that hard you're doing something silly, usually just plain overreaching: keep on overreaching that hard for a season and ouchies await. I use Vitamin I long-term to stop the Auld Injurie from acting up, and naughtily short-term when my ITBs are firing like sparklers -- that's bad because I know the solution is rollery goodness, ow ow ow, but pills are quick and they work anywhere, anytime)

[Hrunter]

I'll dig around for you and see what I can find.

The blog author cites only one source. And its from 1992. I'm gonna dig around for something... more recent.

Search:

ibuprofen vs acetaminophen healing muscles

Result:

[1] http://fellrnr.com/wiki/NSAIDs_and_Running

Links contained:

[2] http://fellrnr.com/wiki/Cryotherapy_-_Ice_for_Healing

Cited Reference:

[1] http://jcem.endojournals.org/content/86/10/5067.long

[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC522152/?tool=pubmed

[3]http://www.ncbi.nlm.nih.gov/pubmed/18212134

Thoughts so far:

Result [1] Interesting how they're debating paracetamol as similar to an NSAID. If this is the MoA, then its reasonable. I can understand them still trying to make the differentiation because its 'non-salicylate', for the purposes of salicylate sensitivity and allergic reaction. The research in Reference [1] does work to prove it, but in hypothesis two about the results, they state that they did not measure the supporting informations during this test.

Reference [1] states: "We previously reported that ibuprofen and acetaminophen inhibit the normal increase in skeletal muscle protein synthesis after high intensity eccentric resistance exercise." I'll try to find that.

Reference [1] summarizes: "In summary, these findings suggest that PGF2α is increased in human skeletal muscle after eccentric resistance exercise. The common analgesics IBU and ACET, when consumed at maximal over the counter doses, blunt this response. This attenuated PG response may profoundly influence the anabolic response of muscle to this form of exercise. More information is needed about the isoform(s) of cyclooxygenase in human skeletal muscle and the metabolic consequences of PG blockade in skeletal muscle."

Further elaboration:

Reference [1] also mentions: "These results suggest that ibuprofen and acetaminophen have a comparable effect on suppressing the normal increase in PGF2α in human skeletal muscle after eccentric resistance exercise, which may profoundly influence the anabolic response of muscle to this form of exercise. "  ( "...exercise-induced change in PGF2α in the placebo group (77%) was significantly different (P < 0.05) from those in the ibuprofen (−1%) and acetaminophen (−14%) groups.")It should be mentioned that the persons in this test were given the daily maximum dosage.  (1200mg Ibuprofen or 4000mg paracetamol.)Reference [1] discusses: "The main findings of this study were 1) PGF2α increases after eccentric resistance exercise; and 2) both IBU and ACET attenuate this increase.It was somewhat surprising that in addition to IBU, ACET had a profound attenuating effect on PGF2α levels after the exercise bout compared with those in the placebo group. In fact, compared with placebo, ACET also blunted the PGE2 response to exercise, whereas IBU did not have a significant effect. ... However, these findings are consistent with our previous findings that both IBU and ACET block the increase in muscle protein synthesis after the same high intensity eccentric exercise bout (21).""There are two likely explanations for our findings regarding the similarity of effect of these drugs on PG regulation in skeletal muscle. First, the dose of the drugs must be considered. The dose of the IBU and ACET used in the current study was based on FDA limitations on the maximal over the counter doses. These dose limitations are derived considering safety and efficacy and are probably unrelated to any previously examined effects on skeletal muscle. ACET is considered to be a pure analgesic and is not considered to elicit antiinflammatory activity (11, 19, 26). IBU is also considered to be a pure analgesic when taken at the dose used in the current study (i.e. 1200 mg/d) and reportedly only has antinflammatory activity at doses above this level (11, 19, 26). It appears that maximal over the counter doses of these drugs inhibit cyclooxygenase activity in skeletal muscle in an equivalent manner. "

[2] cites there is insufficient evidence to suggest ice 'improves clinical outcome". I assume, by clinical outcome the author is referring to treatment outcome.

Ice -is- known to numb the injured area as its primary effect. This is, in my training, the primary reason it is used in emergency treatment. It is intended to provide the secondary effect of reducing swelling (by vasoconstriction.)

The question is, however, do they affect preformance. Since the Action of Ice on the body is different than those of Ibuprofen and Paracetamol, it is reasonable to suggest that affects on the actual recovery (and subsequent preformance) would be difficult to measure on the same scale.

(I should apologize for not continuing to search for further evidence in either direction. Its late -.-)

In terms of overall impact including analgesic effect however, Ice does provide the benefit of pain relief without the negative incidence of PG inhibition. In this aspect as the blog author suggests, it would be superior to full (OTC) dose Ibuprofen and paracetamol.

Another consideration to take is the actual course of treatment.

Ibuprofen OTC

1200 mg over 24 H

The dosage here is often 200mg x 2 @ 8H intervals.

Paracetamol OTC

4000 mg over 24H

The dosage (Extra Strength) here is 500 mg x 2 @ 6H intervals.

Ice

15 on, 15 off

As needed over 24 H

While the first two allow for a person to remain mobile, Ice (unless you're bundling the heck out of the area) requires a person to remain stationary. However, Ice is more maintenance.

In this setting, since Ibu and Aceta are even an option and we haven't even started talking about heat treatment, I presume this is a situation of temporary relief of minor-moderate injury. One would have to consider mobility, analgesic effect, maintenance (as these needs will vary by person and incident) versus the effect of PG inhibition.

Also.

*** Warning of Hrunter's neurotic pedantry ***

While this does vary from region to region (please check your local protocols)

The current public treatment protocols are a little different than what is suggested above.

The acronym RICE for critical incidents, in particular muscloskeletal injury requiring medical attention, at this time is:

Rest

Immobilize

Cold

Elevation

To better prevent internal tissue damage and pain with muscloskeletal injury, immobilization is more a priority than reducing the temperature of the affected tissues.

Ice has also been changed to Cold due to an incidence rate of neglect wherein first aiders (or people pretending they know what they're doing) have succeeded in freezing (read: caused frostbite) affected tissues. This causes more damage. There're also just a few too many people coming across the scene of an incident where they just can't confirm whether its a muscular versus bone injury. Humans really have to work on that there x-ray vision.

In non-critical incidents, or in post hospital care under the direction of a doctor, heat may be advised. Where cold is used to numb and secondarily reduce swelling, heat is used to relax and promote blood flow. This helps counter the effects of spasm, which can promote mobility and reduce pain.

In either incidence, temperature changes to injured tissues must be monitored for signs of burns or frostbite. The protocol regarding duration for heating or cooling is "15 on, 15 off." The longest it should be left on is 15 minutes, the minimum it should be off is 15 minutes.

As always, this information is for temporary use - either for minor injuries or treatment prior to medical aid. The directions of doctors and rehabilitative professionals regarding individual cases will always supercede these protocols.

~~~~

I... need to work less.

[Zima]

So the main ingredient in Excedrin is an NSAID, and that's the medicine I use for headaches.

My question is - what else can I take for headaches I get at work about every other day? Going to the gym cures it usually, but sometimes you can't wait for 6pm when you're in the gym...especially when there's still work to do and the headache is preventing that.

[Hrunter]

Hmm. I guess the big question is... what's causing your headaches? There're so many things that can, but... is it maybe something environmental?

If its allergies, some anti-histamines would do the trick. If not... hmmm.

[andygates]

Interesting linksauce there, I'll read up that lot when I'm not scarfing eggs before work

Workplace headache (like workplace backache) can often be posture or stress derived. Slouching in your cube with a tense neck? All wired up trying to strangle the boss of Desktops for playing politics with your team again? Chasing deadlines of death?

[Zima]

Mental anguish from either having not enough to do or being bombarded with requests, while thinking about how this job is far below my mental capacity and level of education, and about my lack of interest in this field, combined with eye strain from excel spreadsheets and overall tension from being in the office environment.

[Hemi]

zima, i've been there and regular massage therapy (every 2 wks), stretching, and drinking lotsa water helped TONS ...later when i changed jobs the chronic pain went away altogether.

[Zima]

Already drink lots of water and stretch...Not a fan of getting touched by a stranger, unless it's a girl I'm dating. So I'll wait until I have a girlfriend again.

But of all of the ideas you mentioned, I like the changing jobs one the most

[Hrunter]

Well, if its an option where you are in your life, go for it! At the least you can look, right?

Do you have a type of hobby of yours that lets you challenge your brain? Giving yourself the opportunity to flex that mental muscle may at least help alleviate -some- of that cognitive dissonance.

[Zima]

I LOVE opportunities to actually think at work, and when I get to be really busy and achieve lots of stuff. I end up feeling energized at the end of the day rather than tired if I work hard and use my brain. My parents both hold math PhDs - it's in my damn blood to solve problems. And I'm a very driven person who feels best when achieving things and making progress towards goals.

Unfortunately many entry level corporate jobs involve doing completely mundane stuff...right now I started a job that's basically lots of quality control in excel...and pulling data and making powerpoints. And too much free time...gah, how I hate free time. I don't know why I needed a college degree for this, and I'm certainly looking. In fact I took Monday off because I've got an interview elsewhere.

As far as hobbies outside of work - just hitting the gym cures all headaches for me. Also minor colds, hangovers back when I partied more, bad moods...it's like a miracle drug. If I could hit the gym in the *middle* of my workday I'd never need headache meds.

[nightlight]

@catspaw i had a sciatic nerve injury in college and had to have surgery. i don't have an answer as to why they prescribe NSAIDs so copiously, all I know is if my back goes out prescription aleve and flexeril are the only things that save me. However, this is all stemming from an acute injury -- as an athlete, I understand what K Starr is getting at. I try not to medicate unless absolutely necessary. I don't do Ibuprofen for exercise related aches and pains. I think as with everything, there's a middle ground.