Rethinking Ibuprofen

A few months ago, I wrote a paper on the relationship between NSAIDs—that’s non-steroidal anti-inflammatory drugs, like ibuprofen and aspirin—and connective tissue health.*

What I found out really changed the way I think about ibuprofen. Below is a summary of what I found out. If you’d like, here’s a link to the full paper; it’s moderately, though not overly, technical.

A few notes about NSAIDs to start: they are a hugely popular drug—I would be very surprised if anyone reading this paper had never taken an aspirin or ibuprofen—and for good reason. They’re effective at reducing pain and inflammation, and thus improving mobility and, say, being able to sleep. They’re inexpensive and easily attainable without a prescription.

That’s all the upside.

Here’s the downside: it seems NSAIDs interfere with the production of healthy connective tissue. This may not initially seem like a big deal, but when you consider that literally every muscle, every muscle cell, every organ and nerve and bone and artery … that all of that is wrapped in layers of connective tissue, that it is literally a structural part of every system in our body … then the issue may start to seem a little bigger. It did for me.

Even on a gross anatomical level, there have been numerous studies** concluding that NSAID use post-injury, or post-surgery, actually inhibits tendon-to-bone repair. As in, if you tore your rotator cuff, there are quite a few studies suggesting that regularly taking ibuprofen actually makes your shoulder weaker by the time it’s recovered.

This, of course, is the exact opposite of a lot of conventional thinking, of the way I thought about it for most of my life.

The conventional, and pretty logical, idea is that inflammation is often a sort overreactive protection mechanism your body does to guard, say, a sprained ankle. It swells way up, and hurts, so you don’t use it. This swelling up—inflammation—doesn’t allow for very good fluid exchange, which is indeed an important part of healing: getting the toxins out and fresh stuff in. An anti-inflammatory can decrease this swelling and thus increase fluid exchange in the injured tissue.

It turns out, though, that some of the big players in breaking down tissue, notably a class of hormone-like compounds called prostaglandins, are also big players in building up tissue. These prostaglandins actually do a myriad of important activities (some of which have to do with the gut; you may have heard of intestinal problems stemming from too much NSAID use; it’s the only side effect I’d ever heard of before writing this paper).

Thus, when we take NSAIDs that act systemically in inhibiting the production and release of prostaglandins, we’re actually tinkering with a much bigger part of our physiology than the sprained ankle.

Of course, the effects of the sprained ankle becoming less inflamed are rather immediate, and the potentially weakened local ligament structure and diminished prostaglandin production in rest of the body happen over a longer arc of time, and thus tend to be harder for us to track. That’s one of the big benefits of these scientific studies: some people did track what happens, and the results of most of what I read suggest that regular NSAID use does more harm than good in this long-term, and even medium-term, scope of time.

So, what to do with all this information?

Here’s one scenario: you’re out hiking in the woods, and you roll your ankle and have to walk out. By all means, if I were you, I’d take a big dose of ibuprofen to reduce pain, increase mobility and decrease the damage that I’d be doing by walking on an injured joint.

Other scenarios, like being sore after a workout, or sustaining an injury that you can afford to not move around on for awhile, or a host of other conditions that may warrant daily NSAID use (the following with the huge disclaimer of consulting your doctor and your common sense both, all that) … Can you let it rest, and just deal with, dare we say invite, the inflammatory process?

For more immediate relief: local, manual ways of helping move wastes out and fresh fluids in can be really helpful with no particular downsides. These would include massage (especially for post-workout kind of soreness, and later on, but not immediately after, for traumatic injury), and ice or cold/warm hydrotherapy.

It’s ill-advised to take NSAIDs prophylactically, i.e. before a workout you anticipate you might get sore during. There are studies suggesting that with this practice you would be more likely to, for example, rupture a tendon pulley while rock climbing, or pull a hamstring while running.

I’ll emphasize here that most of the studies I read were examining relatively long-term use and its consequences. This is not a doomsday blog post saying that you should never take NSAIDs. If I had to choose between falling asleep and taking 400 mg of ibuprofen, I’d probably choose the latter almost every time.

However, if I had to take that dose to fall asleep, or get through the day without pain, day after day … I’d be on the keen lookout for alternatives.

*this paper was recently published in the 2012 Yearbook for the International Association of Structural Integrators. If you’d like a copy, they’re $55 and you can use this order form.

**I’m not going to footnote any studies here. They’re all in the endnotes of the paper.

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