PharmacyTimes.com [Internet]. Fudin J. Should Topical NSAIDs Have Strict Heart Risk Warnings?; 2018 March 10 [cited 18 Jun 12]. Although this article’s title implies concerns about topical NSAID safety, it ends up answering that concern with very reassuring data, and it turns into a piece suggesting that the FDA needs to make it clearer that only oral NSAIDs are of concern, while topical is an extremely safe alternative! “ … all topical vehicles of diclofenac delivery result in only a small fraction of the diclofenac that actually reaches the systemic circulation compared with the oral route.” BACK TO TEXT
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about me • more about PainScience.com
Meditation has been proven to reduce chronic pain in several scientific studies. Research from Duke University found that people suffering from chronic back pain saw significant reductions in pain and psychological distress after practicing a form of meditation that focuses on releasing anger. In another study, meditators experienced a 40% reduction in pain intensity.
How it works: A misaligned spine can cause muscle tension (read: pain). Both physical therapy and chiropractic treatment improve spinal alignment. Physical therapists strategically stretch and strengthen the muscles that help hold the spine in place. Chiropractors manipulate the spine to relieve areas of tension on the muscles. Consult your primary-care doctor for a referral.
Over the past two decades, evidence has emerged to demonstrate that topical versions of NSAIDs are well absorbed through the skin and reach therapeutic levels in synovial fluid, muscle, and fascia. … For chronic conditions like osteoarthritis, the data are of fair quality and are persuasive. On balance, there’s good evidence to show that topical NSAIDs are clinically- and cost-effective for short term (< 4 weeks) use, especially when pain is localized.

In summer 2018 I had my first personal experience with dramatic relief from Voltaren Gel (topical diclofenac). It’s not the first time I have found it useful, but it was the first time it was amazing. I’d been having some unexplained knee pain intermittently for several weeks when it kicked up a notch or two and became constant and even started waking me up at night. When I finally remembered to try Voltaren Gel — I’m not sure what took me so long — things were bad enough that it was going to be obvious if it worked. And it was! After many days of constant discomfort ranging from 3-6 on a 10-scale, it just ended: half an hour after applying the stuff, I simply didn’t have that problem anymore. Hallelujah! It’s been weeks since then with no relapse. Although the pain was not terrible, this is actually one of the clearest examples of pain relief from any treatment that I’ve ever enjoyed.
Meditation and mindfulness. Mindfulness meditation, which focuses on awareness of the present moment, can reduce the way we perceive pain. In one study, only four days of training led to a 40% reduction in pain rating and a 57% reduction in pain-unpleasantness.[14] This kind of meditation can help you to control back pain, fibromyalgia, and migraines. Read more about meditation and mindfulness for pain control here.
Research shows that certain forms of magnesium can be effective for pain relief and muscle relaxation, as well as nerve pain. Many people in our society are magnesium deficient, so it may be a good idea to supplement. Magnesium glycinate is known to be a highly bioavailable form. Magnesium citrate can be used by those who tend toward constipation, as it has an additional effect of loosening the bowels.

The NF-kB molecule is a transcription factor that controls the transcription of DNA for the perpetuation of the inflammatory immune response. It acts as a switch to turn inflammation on and off in the body. NF-kB has the ability to detect noxious stimuli, such as infectious agents, free radicals, and other cellular injuries, and then directs DNA to produce inflammatory cytokines. The NF-kB proteins are localized in the cytoplasm of the cell and are associated with a family of inhibitory proteins known as inhibitor of kB (IkB).[43,119] The TNF-α, and especially IL-1b, can also directly stimulate enzymes known as matrix metalloproteinases, which break down extracellular collagen matrix, a hallmark of inflammatory joint disease.[32,76,77] The IkB proteins are normally bound to NF-kB and block their nuclear localization signal. A variety of provoking stimuli can degrade the IkB and result in the nuclear translocation of NF-kB to be free to activate DNA synthesis of inflammatory cytokines [Figure 2].
In contrast, the guidelines of the American Pain Society and American College of Rheumatology have in the past recommended topical methyl salicylate and topical capsaicin, but not topical NSAIDs. This reflects the fact that the American guidelines were written several years before the first topical NSAID was approved for use in the United States. Neither salicylates nor capsaicin have shown significant efficacy in the treatment of OA.
If you are using a topical anti-inflammatory there is a risk that your skin can become sensitive to light (photosensitivity). If you are using a preparation that contains ketoprofen you should cover the area of skin where ketoprofen has been applied (to protect it from sunlight). Also, you should not use a sunbed, or expose your skin to sunlight during treatment, and for two weeks after stopping.
Funny how things like this slip through the cracks. I communicate with patients and professionals locally and abroad more or less all day every day, study and research musculoskeletal pain problems obsessively, and am more or less constantly immersed in answering the question, “What can you do for body parts that hurt?” And yet I didn’t hear about this stuff for a good year after it had already hit the shelves.

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NSAIDs have anti-inflammatory (reduce inflammation), analgesic (relieve pain) and antipyretic (lower temperature) effects. Although different NSAIDs have different structures, they all work by blocking cyclooxygenase (COX) enzymes. There are two main types of COX enzymes: COX-1 and COX-2. Both types produce prostaglandins; however, the main function of COX-1 enzymes is to produce baseline levels of prostaglandins that activate platelets and protect the lining of the gastrointestinal tract, whereas COX-2 enzymes are responsible for releasing prostaglandins after infection or injury. Prostaglandins have a number of different effects, one of which is to regulate inflammation. Most NSAIDs inhibit both enzymes, although a few are available that mainly inhibit COX-2. The pain-relieving and anti-inflammatory effects of NSAIDs are mainly due to inhibition of COX-2, and their unwanted side effects are largely due to inhibition of COX-1.
Over-the-counter (OTC) pain relievers. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil, Motrin IB, others) or naproxen sodium (Aleve), might relieve acute back pain. Take these medications only as directed by your doctor. Overuse can cause serious side effects. If OTC pain relievers don't relieve your pain, your doctor might suggest prescription NSAIDs.
Rutin is a flavonoid composed of the flavonol quercetin and the disaccharide rutinose. Rutin is found naturally in a variety of plants, and dietary sources include black tea and apple peels. Rutin’s natural anti-inflammatory potential is attributed mainly to its powerful antioxidant activity. Rutin also helps maintain the levels of reduced glutathione, which is a powerful biological antioxidant. The combination of these activities helps to minimize the cellular damage and resulting inflammation caused by the various oxidative processes.
Often patients will experience a different response in treatment with a different medication. This could be why some medications have helped your symptoms while others do not have a significant effect. This is not unusual, and it is difficult to predict which medications will most benefit a given individual. The best way to determine which NSAID is best for you is to try different options. Often a physician will recommend one NSAID, and if adequate relief of symptoms is not obtained within several weeks of treatment, another NSAID can be tried.
According to recommendations of the Arthritis Foundation, when treating conditions related to arthritis it is best to use “fish oil capsules with at least 30 percent EPA/ DHA, the active ingredients. For lupus and psoriasis, 2 grams EPA/DHA three times a day. For Raynaud’s phenomenon, 1 grams four times a day. For rheumatoid arthritis, up to 2.6 grams fish oil (1.6 grams EPA) twice a day.”
"I don't use topical pain relievers often, but when I do I use a product called Biofreeze ($15; performancehealth.com). It's a menthol-based gel that soothes local aches and pains in much the same way that ice therapy works but with less skin irritation, and the ability to be mobile once it's applied. It's also the product physical therapists and massage therapists choose." — Yusuf Jeffers, Tone House coach
People with sensitive skin, infants, children, pregnant women, and seniors might be at a higher use using these products. People with kidney problems or kidney failure in the past shouldn’t try an Ibuprofen cream. If you take aspirin, prescribed blood thinners such as Coumadin (warfarin) or have bleeding of the gastrointestinal tract, consult your healthcare provider before using these topical pain products. Do not use salicylates that cause blood to be thinner.
"Yoga Tune Up Therapy Balls ($15; yogatuneup.com). Hands down. They're like a surgeon's scalpel to your fascia. I use them on myself and with clients both pre-and post- workout to improve soft tissue and enhance mobility. They've really helped change my body for the better. Also, they're super easy to travel with." — Adam Rosante, fitness and nutrition coach and best-selling author of The 30 Second Body (BTW, we've got exclusive HIIT moves from his book here.)
A warming cream from Sombra with a pleasant orange scent. Good for the relief of pain related to inflammation. It doesn't contain any artificial fragrances or dyes. Also suitable for muscle pain and aches. Sombra also sells a cooling gel and different packaging formats for various uses. The gel is also free of animal ingredients so vegans can happily use it when they experience joint or muscle pain. This gel uses a warming sensation to help alleviate pain and inflammation. Users should take care to wash their hands after application to avoid getting it in their eyes or around the eye area.

I’ve just emphasized that Voltaren is mainly appropriate for shallow inflammation, but there is some evidence that Voltaren might be able to “reach deeper.” This is hardly the stuff of medical certainty yet, but researchers Huang et al found that Voltaren treated pain coming from deep inside the spine, right in the centre.6 They concluded that it could be a “convenient and safe clinical intervention” for a few types of back pain. An anti-inflammatory gel will likely fail with many kinds of back pain, but there’s also virtually no down-side to trying. See my low back pain tutorial for extremely detailed information about medications for back pain.


There's a reason there are so many roll-ons on this list. They're super handy and easy to use. This CobraZol gel provides quick relief that lasts up to 10 hours. It's a good choice for both chronic and acute pain. This gel comes in a 2 oz format. Believe it or not, this stuff actually contains cobra venom. Venom apparently is thought to help de-active pain pathways and reduce pain. This roll-on is a great way to manage pain and help users wean off of more serious and potentially dangerous pain medications.

Bark from the white willow tree is one of the oldest herbal remedies for pain and inflammation, dating back to ancient Egyptian, Roman, Greek, and Indian civilizations, as an analgesic and antipyretic agent. Because of the gastric side effects of aspirin, there has been a resurgence in the use of white willow bark for the treatment of inflammatory syndromes. The mechanism of action of white willow bark is similar to that of aspirin which is a nonselective inhibitor of COX-1 and COX-2, used to block inflammatory prostaglandins.[48]

Acupuncture: Acupuncture may provide even more relief than painkillers, according to one 2013 review. In 11 studies of more than 1,100 people, this Chinese medicine staple improved symptoms of lower back pain better than simulated treatments and, yes, in some cases, NSAIDs. The needles appear to change the way your nerves react and may reduce inflammation around joints (which is only one of the therapy's benefits), says DeStefano.
Meditation and mindfulness. Mindfulness meditation, which focuses on awareness of the present moment, can reduce the way we perceive pain. In one study, only four days of training led to a 40% reduction in pain rating and a 57% reduction in pain-unpleasantness.[14] This kind of meditation can help you to control back pain, fibromyalgia, and migraines. Read more about meditation and mindfulness for pain control here.
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