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Ibuprofen risk


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  • #1935248
    spelt with a t
    BPL Member

    @spelt

    Locale: Rangeley, ME

    A cortisone injection did greatly improve my carpal tunnel. It is now just a weak hand and not throbbing stabs up and down my arm. Although it's my understanding that the cortisone actually decreases inflammation OF the carpal tunnel and doesn't affect the tendons and nerves running through it. That may be completely not how it works. But at least I won't need surgery for a couple more years (hopefully more).

    #1935273
    Jennifer Mitol
    Spectator

    @jenmitol

    Locale: In my dreams....

    Cortisone certainly has a role to play in terms of fighting inflammation; it is a very powerful drug with good uses. The issue is directly injecting cortisone into tendons themselves to fight "tendinitis." I actually went to a talk last year titled "can we please stop injecting tendons?"

    There is a ton of documented evidence that injecting cortisone into a tendon will rapidly accelerate the tissue degeneration and tissue breakdown. The problem arises in the timeline: the injections generally feel great! The patient thinks they are better, the physician feels like he or she helped the patient, and everyone is happy. Then 6 months later the pain returns, probably worse than before, and the patient is none the wiser. There are several good studies of tennis elbow (lateral epicondylalgia)…one in particular had people get cortisone injections, another group got PT (exercise and manual therapy, NOT crap interventions like ultrasound or electrical stimulation), and a third group did nothing. The cortisone group improved immediately, the other two groups slowly improved. By 6 months the cortisone group was worse than before, and the PT group was only slightly better than the watch and wait group (both of which were quite a bit better). The point being that you are better off in the long run sitting around watching Oprah than getting your tennis elbow injected. The rate of recurrence or even tendon rupture in folks who have tendon cortisone injections is frighteningly high. But it doesn't happen right away…right away you feel like the injection was a miracle!

    Anyway, another reason why randomized controlled trials with good follow ups are so important. That's where this type of information comes out…..

    #1935309
    Anonymous
    Inactive

    "What does the PT world think of prolotherapy??"

    While we've got your attention, what do you think of platelet rich plasma therapy?

    #1935346
    Jennifer Mitol
    Spectator

    @jenmitol

    Locale: In my dreams....

    Honestly, my opinion is probably quite similar to the prolotherapy, with the only caveat that at least theoretically there is a bit more oomph behind this one than simply injecting hypertonic saline into a degenerated tendon.

    The proposed mechanism here is that you take the body's platelets and inject them into the degenerated tendon, then use the healing properties of the proteins in the blood to spur healing.

    There are no good randomized controlled trials, only small cohort studies of patients who self-select (meaning they'd already decided to have the therapy…which means they approach the treatment with a bias).

    My personal thought, as both a biomechanist and a pain scientist (my post doctoral work has been in the neurophysiology of pain), is that it isn't going to pan out with further scrutiny…and neither will prolotherapy. My reasoning is that histologically we see the tendon actually becoming disorganized as it degrades: instead of nice, neat parallel fibers that should pull in relatively uniform ways, we have a disorganized glob of tangled collagen that cannot pull effectively, and without triggering an overwhelming pain response. Think of tarp lines and how awful of a pitch you'd get if your guy lines were all tangled up and you tried to pitch anyway.

    Simply inducing an inflammatory response, or in the case of platelet- rich plasma therapy actually trying to induce a "healing" response directly, is not going to reorganize those collagen fibers. There is a well-known maxim called Wolff's Law that the body responds to stress by strengthening and reoranizing along the lines of stress. A medical intervention for a mechanical problem doesn't strike me as imminently successful. Surgically you can cut out the degenerated part; mechanically you can induce a noxious eccentric loading to force a reorganization of the collagen (actually rather successful for many people, good RCTs for the knee, Achilles, and lateral epicondylalgia); and from a neurophysiological perspective we are finding some amazing changes in the central nervous system that may affect muscle behavior…which might be why the tendinopathies are happening in the first place. But that's a whole different and way more complicated conversation. But one I love to talk about, by the way. I am a nerd in more ways than my gear closet!

    My long, beleaguered point here is that tendinopathies are terribly complicated, we have no really reliable ways to treat it, don't ever allow a clinician to inject cortisone into any TENDON of your body (it can be injected elsewhere…at least for now), caveat emptor in medicine (oh how much ripping off goes on in the doctors – and PT – office!!!!), and there are tons of great research projects going on that will give us more tools in the near future.

    I'm guessing several of you have some tendon issues…if you PM me I can send along some descriptions of the eccentric loading protocols for you to try (if you haven't already…) for your particular body part. I'm happy to help…and it costs you nothing but your continued advice on how to lighten my pack ;)

    #1935864
    Bill Segraves
    BPL Member

    @sbill9000-2

    Lots of great stuff in this thread. One thing about cartilage regeneration – while there's no evidence that the hyaline cartilage that's at many joint surfaces can regenerate, there is evidence that small meniscal tears do seem to heal with appreciable frequency. That leaves open the possibility that drugs could potentially interfere with that healing process.

    #1935955
    Mike W
    BPL Member

    @skopeo

    Locale: British Columbia

    >> exercise and manual therapy, NOT crap interventions like ultrasound or electrical stimulation <<

    Oh, I really smiled at that one :)!

    I've long been a believer that if you injure yourself there is no magic to recovery… just hard work. I think the modern age magic in PT (electronic gadgets) have been an easy sell because we are very much a lazy society that doesn't want to exert ourselves to get better (backpackers excluded of course :).

    That said, I may take (Ibuprofen, Aleve, Acetaminophen etc.) if I think it will help relieve the pain of my injury while I work out with strengthening and stretching exercises. I like to get back to activity as fast as possible after an injury. If these drugs allow me work out harder and more efficiently while recovering, then I use them but I never take anything for my usual aches and pains (my normal aches and pains remind me I'm alive… and have had some fun times in the past).

    I will however mention that much to my surprise, I have recently tried Intramuscular Stimulation (IMS) and have had unbelievable results treating what I call "Fly Fisherman's elbow" (serious fly fisherman will no what I'm talking about, but for others it is a nasty combination of tennis elbow and golfers elbow…repetitive stress injuries). After suffering terribly for 20 years my PT suggested I try IMS. I refused the treatment (don't believe in magic, just hard work), so I continued stretching and strengthening with minor success.

    My PT finally convinced me to try IMS and in only a few treatments, I had lost about 80% of the pain! This pain reprieve allowed me to work hard at the gym (strengthening and stretching) and I'm still doing well considering I've just finished another rather intense season of fly fishing. I'll probably go back in the spring for a "tune-up" (IMS) before the next fishing season begins but I'm still in pretty good shape considering how much I abused my arm in the past six months (and no drugs needed for pain and inflammation). I now believe in MAGIC!

    #1941330
    Lynn Tramper
    Member

    @retropump

    Locale: The Antipodes of La Coruna

    "First of all, no NSAID will "interfere" with cartilage healing or worsen osteoarthritis, because cartilage doesn't heal…it has no blood supply and once it is damaged that damage is permanent. We don't even have good ways to surgically repair it yet."

    Maybe my wording was poorly chosen. Ibuprofen causes thinning of joint cartilage, even in people who have no initial cartilage problems but are taking it for other problems. Adding this drug on a chronic basis to joints that are already compromised is even worse. And rather than using the words 'cartilage healing', it is more correct to say cartilage maintenance and turnover. Cartilage CAN heal, though when it does happen, it is a very slow process, but cartilage is normally actively maintained, and Ibuprofen interferes with this maintenance. The COX-2 inhibitors don't seem to have this side effect, so are probably better if you absolutely need an anti-inflammatory for muscle/tendon/joint/bone pain. Agreed, they can all have nasty gastrointestinal side effects, but I assumed everyone knew that by now…? The NSAIDS are also pretty hard on your kidneys. Also agreed that acetominophen is a poor choice, as it is hard on your liver and has no anti-inflammatory properties. It is a pain killer and lowers fever, not a lot more. However, as pointed out all drugs (in fact anything you put in your body, even food) can have side effects. Caveat Emptor…

    #1945877
    zorobabel frankenstein
    BPL Member

    @zorobabel

    Locale: SoCal

    I started carrying Ibuprofen last year to deal with altitude headaches I sometimes get. I try to stay away from all medication and deal with pain, but for this scenario I though taking Ibuprofen is safer than AMS. I only took one pill so far – in the evening at camp, it helped with the headache, and I got a great nights sleep as a side effect (no more back pain).
    I'm trying to change my breathing habbit (more breathing) and it's working. I realized on some of the trips with headaches, I was actually breathing less – it felt like I was expending less energy (just strolling with a lighter pack while waiting for my wife to catch up).
    What would be a safer alternative for fighting the brain swell? – beside acclimatization of course.
    I ask this more out of curiosity than need, as the Ibuprofen container will most likely expire with 90% of it's content intact.

    #1945886
    Bob Gross
    BPL Member

    @b-g-2-2

    Locale: Silicon Valley

    First of all, you might consider ordinary aspirin rather than the other drugs.

    Secondly, I've seen lots and lots of people at altitude with symptoms. In my opinion, 80% of the problem comes from dehydration. So, you might consider attacking that as a root cause.

    Then, think about what you are doing with the pills. Are you merely trying to block the headache pain, or are you trying to alleviate the root cause of the pain? That's why I mentioned aspirin.

    You mentioned your breathing. For the average person, when they reach a high elevation, the first two things that adjust are the respiration rate and the heart rate. In some people, perhaps you, the body does not react to the thin air very quickly or very fully, so the respiration and heart do not adjust much. This is what may be creating the problem for you.

    If you can't work this out by ordinary means, then you ought to see a physician who knows something about altitude sickness, and they can prescribe Diamox (acetazolamide). Yes, I know that you don't like pills. Diamox works pretty good, assuming that you are not allergic to sulfa drugs. You take it for a day or two before you get to the mountain, and it sort of forces your body to start the adaptation more fully and quicker than it would on its own.

    I know a guy who consistently got sick above 11,000 feet, and he had huge headaches and all that. Then he started taking Diamox starting one day before he started up into the mountains, and he has had no symptoms since then.

    –B.G.–

    #1945915
    Anonymous
    Inactive

    "What would be a safer alternative for fighting the brain swell? – beside acclimatization of course."

    Diamox

    #1945917
    Lynn Tramper
    Member

    @retropump

    Locale: The Antipodes of La Coruna

    Bob's recommendation is worth a try. But I think that the few times you will likely need to use an NSAID, if it works for you then fine. Occasional use is not going to do you any harm. It is not yet clear that aspirin (also an NSAID) is any less detrimental to cartilage than the likes of Ibuprofen. The jury is still out on aspirin, but it is a very good anti-inflammatory as long as your stomach tolerates it.

    #1945921
    Bob Gross
    BPL Member

    @b-g-2-2

    Locale: Silicon Valley

    I wouldn't put it as the Diamox fights swelling in the brain. Diamox is carbonic anhydrase inhibitor. Say that fast three times. What that means is that it makes some subtle changes in your blood chemistry, and it causes the body to start the altitude adaptation earlier, or more fully. So, it isn't really doing much that your body couldn't do on its own… assuming that your body had a normal response to altitude. But, some percentage of people have this "blunted response," so they take Diamox to speed things up.

    1. Assuming that you are not allergic to sulfa drugs, it can't hurt much to take Diamox. Although the standard dosage is standard for moderate elevation travel, some people I know take a half dose and find that it works for them. I also know a guy who takes several times more than the standard dose, and he claims that it works even better for him. The problem is that the bigger the dosage, the more likely that you will have more side effects.
    2. What are the side effects? For most people, you get a bit of tingling in the fingers and toes, and that can be mistaken for frostbite if you aren't paying attention. Also, it ruins the taste of carbonated beverages, since the carbonation comes from carbonic acid, and this is a carbonic anhydrase inhibitor. So, you have to hold off that beer celebration for a couple of days after your trip so that the drug washes out of your bloodstream first.

    –B.G.–

    #1945925
    Anonymous
    Inactive

    "I wouldn't put it as the Diamox fights swelling in the brain."

    It is a diuretic, and has everything to do with preventing swelling in the brain, which is caused by a build up of fluid.

    http://www.medicinenet.com/acetazolamide-oral/article.htm

    #1945935
    Bob Gross
    BPL Member

    @b-g-2-2

    Locale: Silicon Valley

    This always seems like a contradiction to some users. They hear one person claim that dehydration causes 80% of the high altitude symptoms. Then they hear another claim that a diuretic flushes excess fluid out of your system. Those seem contradictory on the surface.

    Somebody might claim that they will intentionally dehydrate themselves in order to minimize the chance of any edema anywhere. Well, it just is not that simple and I can almost guarantee that'll get poor results.

    Diamox changes your body's "set point" for where the water balance should be. Then, you can continue to drink lots (as you should for a dry environment), but your body has a different balance on when to discard the excess fluid.

    –B.G.–

    #1946347
    Jennifer Mitol
    Spectator

    @jenmitol

    Locale: In my dreams....

    The reason your brain swells (cerebral edema), or your lungs fill with fluid (pulmonary edema), and you get dehydrated at altitude is that the water in your system is maintained by pressure gradients: as the air pressure at altitude decreases, the pressure inside your blood and organs is now out of balance with the environment and the fluid begins to seep into other spaces…your brain, your lungs, your face, your hands…any tissues that are lower on the pressure gradient (which is basically everything outside your blood vessels).

    The reason you are dehydrated is that the fluid is seeping into spaces that cannot use it, thus you do not have enough available water to maintain blood volume.

    Now, you take a diuretic in order to flush all that extra fluid from your body…because once it seeps into the interstitial spaces it does no good, or just can harm you if it seeps into your lungs or brain. But, even though you are taking a diuretic you still need to continue to drink lots of water in order to maintain as much fluid in the blood as possible. Sort of like pouring water into a leaking bucket…but you've got to just keep pouring….

    Interestingly, since ibuprofen was mentioned again, a great study just came out last year that showed regular prophylactic doses of ibuprofen taken just prior to ascending, then continuously while at altitude, had the same effect on reducing altitude sickness as the group that took Diamox. The regimen studied is 600mg every 6 hours starting one day prior to ascending, then continuously while at altitude.

    Interesting, eh?

    #1946373
    zorobabel frankenstein
    BPL Member

    @zorobabel

    Locale: SoCal

    Thanks Bob, Tom, Lynn and Jennifer. It's all clear as mud now :). Really, I think I get it, thanks!

    Fortunately I don't consistently get a headache at altitude; I also never had to change a trip because of altitude sickness.
    Bob, you're probably right, dehydration surely is a factor in headaches for me, altitude or not, especially if I'm not wearing a hat while exposed to the sun. Sleeping 2-4 hours and driving another 5 hours mostly in the dark before a trip surely doesn't help…

    The reason I was considering Ibuprofen was not for blocking the headache, but for its anti-inflammatory properties. I was reading that persons affected by HACE are not usually aware of the symptoms, and was thinking it's safer to prevent HACE than sustain injury, if I suspect myself of HACE. Unfortunately taking Diamox has to start a few days before the trip it seems… not the quick fix I was looking for.
    I had no idea aspirin had anti-inflammatory properties (like I said, I'm not a pill fan), thanks for opening my eyes!
    Jennifer, about the leaking bucket… would one make things worse if drinking a lot of water without a diuretic?

    #1946417
    HkNewman
    BPL Member

    @hknewman

    Locale: The West is (still) the Best

    Never have taken it unless prescribed but with the muscle/cartilage problems written about, I'll go with the pain and try to remember to stretch it out properly.

    #1946504
    Bob Gross
    BPL Member

    @b-g-2-2

    Locale: Silicon Valley

    People who are completely healthy and go to high elevation without any symptoms can drink a lot of water without a problem, and it just keeps the kidneys working. People who are taking high doses of Tylenol and things like that need to drink a lot of water to avoid a kidney problem. They rest of us just drink as much as we need, and experience has taught us about how much that is. If I don't urinate at least twice per day, then I am probably dehydrated.

    I understand that you report headaches, but it might be from the simpler forms of altitude illness. Full-blown HACE is kind of uncommon except at very high elevation (like 18,000 feet and above). The only person that I saw with HACE symptoms had been to nearly 23,000 feet. However, just last summer one friend got sick around 10,000 feet, and it was thought to be some combination of HAPE and HACE, or at least the symptoms were a combination.

    Yes, if you do take Diamox, you need to start it a day or two before you start going high. Exactly what elevation that is will vary from person to person. A bunch of us were going up very high (nearly 23,000 feet), so we started a half-dose of Diamox the day before we started from a 9000 foot trailhead. Then we went to a full dose when we went above 14,000 feet.

    Last year when I was descending from a 14,000 foot peak, I saw a large military group starting up from 12,000 feet. Apparently some were taking Diamox, some were taking some new secret drug, and probably some were taking a placebo. I would love to see the results from that test. The military people were headed to Afghanistan.

    –B.G.–

    #1946840
    Jennifer Mitol
    Spectator

    @jenmitol

    Locale: In my dreams....

    Ideally you take it before you are symptomatic, but you honestly don't have to. You can start Diamox after onset of symptoms…the only time I ever took it was during a trek to the Everest base camp. I started getting loopy at about 12,000 and started then…my friend started at 16,000'. We were both fine…the symptoms went away.

    Yes, if you are healthy just keep drinking…your kidneys will do the diuresis for you. But if you see how puffy your face gets at altitude, or your hands…it's a great visual to see what is happening to your tissues when the ambient pressure goes down.

    The point of taking a diuretic such as Diamox is to quickly rid your brain and lungs of excess fluid that can lead to HACE and HAPE. Otherwise your body should be able to keep up with everything…when it can't, THAT'S altitude sickness.

    #1946847
    Anonymous
    Inactive

    "The point of taking a diuretic such as Diamox is to quickly rid your brain and lungs of excess fluid that can lead to HACE and HAPE. Otherwise your body should be able to keep up with everything…when it can't, THAT'S altitude sickness."

    This post and your original post on Diamox provide the best explanation yet of what causes AMS/HACE/HAPE.

    Thanks for posting, Jennifer.

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