How Do NSAIDs, Ice, and Laser Compare?
Mark Callanen, PT, DPT, OCS
Inflammation is a frequently discussed topic in clinical settings. Local inflammation is a crucial part of the healing process and is essential for proper regeneration after soft tissue injuries. Patients often seek pain relief and the best way to manage their injuries. The extent to which a clinician understands the inflammatory process and how various anti-inflammatory modalities affect healing can fundamentally influence the duration and course of regeneration of damaged muscle tissue.
Acute Inflammation
A growing body of evidence indicates that suppressing acute inflammation impairs muscle growth and regeneration in both animals and humans. Nevertheless, non-steroidal anti-inflammatory drugs (NSAIDs) are often recommended as a solution for acute inflammation because they can alleviate pain and inflammation by acting on the cyclooxygenase-2 (COX-2) enzyme. However, it appears that NSAIDs can have a negative impact on tissue repair during swelling – they reduce the proliferation, differentiation, and fusion of satellite cells in muscles, which can lead to impaired skeletal muscle repair and growth, and increased fibrosis.
It is therefore not surprising that recent studies show many therapists have incomplete knowledge about the effects of NSAIDs or are unaware of current findings. This is a serious problem in the treatment of musculoskeletal injuries, as physiotherapists play a significant role in this area.
Clinicians should understand that COX-2 enzymes are involved in both pro-inflammatory and anti-inflammatory processes at various stages of inflammation. While blocking COX-2 can reduce the pro-inflammatory response, it can also hinder the resolution of inflammation, negatively impacting healing. Inhibition of inflammation can also disrupt the recruitment of macrophages to the injury site, resulting in slower clearance of damaged fibers, increased fat deposition, smaller muscle fiber size, and delayed regeneration.
Chronic Inflammation
For patients with chronic inflammation, it is important to note that NSAIDs have proven ineffective in treating diffuse, systemic inflammation. A better alternative is steroids (SAIDs), such as prednisone, which can more effectively restore the balance of the inflammatory process, especially in cases of repeated microtrauma, such as overuse of the same muscles. Controlling chronic inflammation is important because it can accelerate muscle degradation and reduce the synthesis of contractile proteins.
However, the positive effect of steroids is time-limited – long-term use leads to protein breakdown and muscle atrophy, and reduces the proliferation and differentiation of myoblasts.
Treating Inflammation
Analgesics and other modalities are more suitable for acute muscle injuries than NSAIDs. For chronic conditions, NSAIDs help with pain but do not reduce inflammation. Steroids are used for chronic local inflammation, but long-term use has a negative impact on muscles, thus caution is necessary.
Ice
People have used it for decades to alleviate inflammation, so it should be a good option – or not? In 1978, orthopedic surgeon Gabe Mirkin, M.D., introduced the well-known acronym "R.I.C.E." (rest, ice, compression, elevation) as a guide for managing inflammation. Its simplicity and widespread acceptance made it the gold standard in the medical community for nearly 40 years. However, this appears to be changing. Dr. Mirkin himself was recently quoted where he now openly rejects at least half of the R.I.C.E. concept.
Research shows that both icing and prolonged rest actually delay recovery. Ice plays a greater role as an analgesic than as a means of reducing inflammation. A 2013 study published in the Journal of Applied Physiology showed that cryotherapy had zero or only a mild effect on pro-inflammatory markers in exercise-damaged muscles.
Laser
So, if R.I.C.E. is no longer the answer, and NSAIDs are detrimental to the tissue healing process in acute injuries and ineffective in chronic inflammation, what is a better strategy? Promoting active recovery is becoming a more common alternative. Gary Reinl, an experienced athletic trainer and author of the book *Iced! The Illusionary Treatment Option*, believes the answer lies in a new acronym, A.R.I.T.A. (Active Recovery Is the Answer).
In line with this concept, laser therapy is finding increasing application in modern training and rehabilitation centers. Laser triggers photobiomodulation (PBM) – a mechanism in which photons induce photophysical and photochemical processes in tissues, leading to physiological changes and therapeutic effects. This process accelerates the inflammatory response and, consequently, tissue healing.
Unlike NSAIDs, which block the inflammatory cascade at the COX-2 level, and ice, which slows inflammation by restricting blood flow, laser acts at a metabolic level directly in the damaged tissue – specifically on mitochondria – thus accelerating the healing process.
Two recent studies compared ice, ice combined with laser, and standalone laser therapy. The conclusion was that laser led to significantly higher results in repeated tests and lower oxidative stress. It was also found that using laser as the sole treatment (without combining it with ice) led to the best post-exercise recovery, resulting in a complete return to baseline within 24 hours.
Changing long-established practices is never easy, but research suggests that the ideal approach to managing pain and inflammation will require a departure from traditional methods. Avoiding ice and NSAIDs in the early stages of the inflammatory process and introducing pro-metabolic modalities, such as laser therapy, could become the new standard of evidence-based practice.