Tim Hardiman, Musculoskeletal Physiotherapist, November 2018.
Physiotherapists are often asked about the potential benefits of the various creams that are purported to help people with pain or movement problems. Because of the expanding knowledge of adverse side effects of many medicines, people wonder about the benefits of the creams we see advertised and whether they may be safer than tablets.
Anti-inflammatory medicines and creams are an interesting example. Non-steroidal anti-inflammatories (NSAIDS) have a long list of serious side effects including stomach ulcers and bleeding as well as heart attack and stroke risks.
All NSAIDS work to interrupt the production of inflammatory hormones called prostaglandins. Since their introduction in the late 1800’s these drugs are among the most commonly used worldwide.
Unfortunately, a direct consequence of the action of these drugs on prostaglandins results in weakening of the lining of the gut, and consequently ulcers. Routine consumption of NSAIDS has been shown to cause around 3 events per 1000 patients per year of heart attack or stroke (x4 above usual levels). 20-40 per 1000 per year may experience a stomach bleed. When treating short-term conditions for people without cardiovascular disease, the risks of these events associated with taking NSAIDS are probably very low.
New research suggests that substantial pain relief can occur with the use of topical anti-inflammatory creams. The suggestion is that because the active ingredients are able to penetrate to the affected tissue (superficial joints or tissues such as the ankle, knee, wrist and elbow, rather than deeper joints such as the shoulder, hip, spine) there is less exposure of the active ingredient to the whole person (including their gut).
Studies comparing the benefit of these creams to placebo (the same cream, without the active medicine in it) suggest that about 10% more people will report a significant reduction in their pain than those using the placebo cream. Of note in a study of one of these creams was that there is moderate quality evidence suggesting that 6 in 10 people using an anti-inflammatory cream reported improvements in arthritis symptoms after 6-12 weeks use. The group using the placebo cream had 5 in 10 reporting similar results!
Another way of expressing this is that for every 6 people using the cream, one person has a benefit greater than placebo, and that the placebo response is strong when it comes to these creams.
There is little to no evidence suggesting that anti-inflammatory creams work for certain types of pain such as low back pain, headache or neuropathic pain. Creams likely present a safer risk profile for people needing pain relief for superficial structures than oral NSAIDS.
It is much more difficult to assess the myriad of alternative creams and gels, since they do not need to pass the rigours of validated trials that pharmaceutical products do. They are often marketed aggressively despite weak or non-existent evidence and quality controls during the manufacturing process are lax compared to medicines.
You can walk into many chemist shops and see posters about the miraculous magnesium oil sprays that penetrate the skin, bypassing the gut and targeting your sore muscles directly (assuming you are low in magnesium obviously). Most products quote the same weak evidence from quite a few years ago that blood serum magnesium levels slightly increased after bathing in magnesium chloride, said to mimic the therapeutic benefits bathing in the Dead Sea. What they don’t tell you is that urine levels didn’t change, a raft of other blood markers also rose, levels only rose in ‘non-athletes’, the sample size was tiny and over a two-week period levels returned to normal. Also, a comprehensive literature review in 2017 found that there is no evidence to suggest magnesium oil can be absorbed topically & concluded that any benefit from using magnesium oil is likely due to a placebo effect.
Pain relief for musculoskeletal conditions can occur with appropriate exercise too. Which is why physiotherapists will often prescribe safe and specifically targeted exercise to speed recovery, prevent recurrence and improve functional outcomes for people with pain or movement problems. So whilst there is room for topical NSAID’s for specific and superficial pain in the short term, developing good behaviours, awareness and routine with respect to exercise and movement is likely the best way forward.
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