Changes

===Ice, Inflammation and Healing===

If NSAIDs are bad for healing, should we treat with ice? So far I have found no definitive studies, but ice has a difference mechanism of action from NSAIDs. By cooling the tissues, ice temporarily reduces inflammation, thereby flushing the wound. It does not directly impact any of the body's enzymes or other processes. If applied for a longer period of time, ice will produce a periodic increase in blood supply that creates a further flushing effect. I have found that ice can produce dramatic improvements in healing speed. See [[Cryotherapy - Ice for Healing]] for more details.

=NSAIDs and Acute kidney failure=

Kidney failure while running is extremely rare, and seems to require multiple factors to come together. Looking at the [http://en.wikipedia.org/wiki/Comrades_Marathon Comrades Marathon], a 90 Km/56 Mile ultramarathon in South Africa, there have only been 19 cases of kidney failure between 1969 and 1986, it even though thousands of people participate each year<ref name="rhabdo1"/>. The following are considered factors in acute kidney failure related to running.

* '''Sickness'''. A viral or bacterial infection is often a factor in exercise related kidney failure.

Looking at the analysis<ref name="coxibs"/> of nine cases of continued kidney failure in Comrades Marathon, seven had taken NSAIDs, four may have had a viral or bacterial infection. The combination of dehydration, rhabdomyolysis, infection and NSAIDs are a perfect storm for the kidneys.

=NSAIDs and Hyponatremia=

The kidneys are responsible for removing excess fluid from the blood as well as excreting or withholding sodium. If kidney function is compromised, then this can result in [[Hyponatremia]], which can be fatal. Some studies<ref name="hypo"/><ref name="hypo2"/><ref name="siadh"/> have shown a correlation between NSAID use in races and [[Hyponatremia]], but others<ref name="nohypo"/><ref name="Dumke-2007"/> have not. Using NSAIDs when hydration is a concern increases the risk of problems occuring.

=NSAIDs and Sickness=

Because a bacterial or viral infection puts more stress on the body, including the kidneys, taking NSAIDs and continuing to run increases your risk of complications. If the sickness is too bad to run without NSAIDs, you probably shouldn't run.

=NSAIDs for Pain Reduction=

The primary purpose of NSAIDs is generally for reducing pain, and they are remarkably effective at achieving this. If you need a painkiller, acetaminophen is probably a better choice than ibuprofen, though be careful as it's easy to overdose on Acetaminophen (see below). Acetaminophen has limited anti-inflammatory properties, so it shouldn't impair healing as much as ibuprofen, but it is still good as a painkiller. Combining acetaminophen or other NSAIDs with [[Caffeine]] further improves their painkilling effectiveness. After a major race I can sometimes have so much leg pain that I can't [[Zeo Sleep Monitor|sleep]] and a little acetaminophen can make all the difference. While the acetaminophen may impair healing somewhat I believe the trade-off in improved [[Zeo Sleep Monitor|sleep]] is worthwhile. After all, the lack of [[Zeo Sleep Monitor|sleep]] itself will impair healing, so it's a reasonable compromise.

=NSAIDs and DOMS=

Delayed Onset Muscle Soreness (DOMS) generally occurs between 24 and 72 hours after unusual or severe exercise, such as racing a marathon or downhill running. The use of NSAIDs to prevent or treat DOMS has been widely researched, with somewhat mixed results. Even scholarly reviews of the research have differing conclusions<ref name="Cheung-2003"/> <ref name="Smith-1992"/> <ref name="Baldwin Lanier-2003"/><ref name="Howatson-2008"/>. My conclusions based on the available research are:

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=NSAIDs and Intestinal Damage=

As little as one hour of intense cycling can result in indications of small intestinal damage<ref name="van Wijck-2011"/>. This is believed to be due to the redirection of blood away from the digestive system and towards the active muscles. These markers are significantly higher if 400mg ibuprofen (the standard single adult dose) is taken before the exercise<ref name="VAN Wijck-2012"/>. The marker used is Plasma Intestinal Fatty Acid Binding Protein which is an early marker of intestinal necrosis<ref name="Vermeulen Windsant-2012"/>.

[[File:Ibuprofen and GI damage.jpg|none|thumb|500px|The level of a marker of intestinal damage during and after 60 minutes of cycling at 70% [[VO2max|V̇O₂max]].]]

=NSAIDs and Racing=

Taking NSAIDs in ultramarathon events can improve performance by reducing pain and acute inflammation, but doing so represents a significant risk. There is some evidence<ref name="wser1"/> <ref name="wser2"/> that many runners taking NSAIDs have the same level of pain and greater damage markers compared with non-users. This may be because the runners push themselves to a similar level of pain, with the NSAIDs allowing them to do more damage.

<ref name="rhabdoGenes">Recurrent rhabdomyolysis in a collegiat... [Med Sci Sports Exerc. 2006] - PubMed - NCBI http://www.ncbi.nlm.nih.gov/pubmed/16540825</ref>

<ref name="siadh"> http://www.sciencedirect.com/science/article/pii/S0002934307001672</ref>

<ref name="Dumke-2007">{{Cite journal | last1 = Dumke | first1 = CL. | last2 = Nieman | first2 = DC. | last3 = Oley | first3 = K. | last4 = Lind | first4 = RH. | title = Ibuprofen does not affect serum electrolyte concentrations after an ultradistance run. | journal = Br J Sports Med | volume = 41 | issue = 8 | pages = 492-6; discussion 496 | month = Aug | year = 2007 | doi = 10.1136/bjsm.2006.033597 | PMID = 17331976 }}</ref>

<ref name="VAN Wijck-2012"> {{Cite journal | last1 = VAN Wijck | first1 = K. | last2 = Lenaerts | first2 = K. | last3 = VAN Bijnen | first3 = AA. | last4 = Boonen | first4 = B. | last5 = VAN Loon | first5 = LJ. | last6 = Dejong | first6 = CH. | last7 = Buurman | first7 = WA. | title = Aggravation of exercise-induced intestinal injury by Ibuprofen in athletes. | journal = Med Sci Sports Exerc | volume = 44 | issue = 12 | pages = 2257-62 | month = Dec | year = 2012 | doi = 10.1249/MSS.0b013e318265dd3d | PMID = 22776871 }}</ref>

<ref name="HyldahlKeadle2010">{{cite journal|last1=Hyldahl|first1=Robert D.|last2=Keadle|first2=Justin|last3=Rouzier|first3=Pierre A.|last4=Pearl|first4=Dennis|last5=Clarkson|first5=Priscilla M.|title=Effects of Ibuprofen Topical Gel on Muscle Soreness|journal=Medicine & Science in Sports & Exercise|volume=42|issue=3|year=2010|pages=614–621|issn=0195-9131|doi=10.1249/MSS.0b013e3181b95db2}}</ref>

<ref name="Arendt-NielsenWeidner2007">{{cite journal|last1=Arendt-Nielsen|first1=Lars|last2=Weidner|first2=Morten|last3=Bartholin|first3=Dorte|last4=Rosetzsky|first4=Allan|title=A Double-Blind Randomized Placebo Controlled Parallel Group Study Evaluating the Effects of Ibuprofen and Glucosamine Sulfate on Exercise Induced Muscle Soreness|journal=Journal Of Musculoskeletal Pain|volume=15|issue=1|year=2007|pages=21–28|issn=1058-2452|doi=10.1300/J094v15n01_04}}</ref>

<ref name="LoramMitchell2005">{{cite journal|last1=Loram|first1=L.C.|last2=Mitchell|first2=D.|last3=Fuller|first3=A.|title=Rofecoxib and tramadol do not attenuate delayed-onset muscle soreness or ischaemic pain in human volunteers|journal=Canadian Journal of Physiology and Pharmacology|volume=83|issue=12|year=2005|pages=1137–1145|issn=0008-4212|doi=10.1139/y05-113}}</ref>

<ref name="Howatson-2008"> {{Cite journal | last1 = Howatson | first1 = G. | last2 = van Someren | first2 = KA. | title = The prevention and treatment of exercise-induced muscle damage. | journal = Sports Med | volume = 38 | issue = 6 | pages = 483-503 | month = | year = 2008 | doi = | PMID = 18489195 }}</ref>

<ref name="Mishra-1995"> {{Cite journal | last1 = Mishra | first1 = DK. | last2 = Fridén | first2 = J. | last3 = Schmitz | first3 = MC. | last4 = Lieber | first4 = RL. | title = Anti-inflammatory medication after muscle injury. A treatment resulting in short-term improvement but subsequent loss of muscle function. | journal = J Bone Joint Surg Am | volume = 77 | issue = 10 | pages = 1510-9 | month = Oct | year = 1995 | doi = | PMID = 7593059 }}</ref>

<ref name="Sayers-2001"> {{Cite journal | last1 = Sayers | first1 = SP. | last2 = Knight | first2 = CA. | last3 = Clarkson | first3 = PM. | last4 = Van Wegen | first4 = EH. | last5 = Kamen | first5 = G. | title = Effect of ketoprofen on muscle function and sEMG activity after eccentric exercise. | journal = Med Sci Sports Exerc | volume = 33 | issue = 5 | pages = 702-10 | month = May | year = 2001 | doi = | PMID = 11323536 }}</ref>

<ref name="Bourgeois-1999"> {{Cite journal | last1 = Bourgeois | first1 = J. | last2 = MacDougall | first2 = D. | last3 = MacDonald | first3 = J. | last4 = Tarnopolsky | first4 = M. | title = Naproxen does not alter indices of muscle damage in resistance-exercise trained men. | journal = Med Sci Sports Exerc | volume = 31 | issue = 1 | pages = 4-9 | month = Jan | year = 1999 | doi = | PMID = 9927002 }}</ref>

<ref name="journals.ut.ac.ir"> {{Cite web | last = | first = | title = The Effect of Taking Naproxen Drug on the Level of Perceived Pain and Changes of CPK Serum after Eccentric Exercise - Harakat Volume: 37, Issue:| url = http://journals.ut.ac.ir/page/article-frame.html?langId=en&articleId=1003701| publisher = | date = | accessdate = 3 January 2013}}</ref>

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