Can more natural alternatives to NSAIDs really make the pain go away?
Most of us have had the experience of being in pain at some time or other in our lives. Often, it is connected with illness, when it can be acute but transient. Sometimes, it is 'purposeful pain', such as the pain of childbirth. But, for a surprisingly large number of people, pain of either known or unknown origin is a regular feature in their lives - something known as 'chronic pain'.
If you have had an ache or pain lasting for more than three months, then you are one of the millions of people with chronic pain. The latest figures show that chronic pain affects over 20 per cent of people - mostly adults - worldwide (JAMA, 1998; 280: 147-51).
As well as being relentlessly uncomfortable, chronic pain clouds the way you think and feel about yourself and life in general. Pain is rarely a symptom on its own (Lancet, 1999; 353: 2233-7), but is often associated with fatigue, sleeplessness, withdrawal from activity, compromised immune function, and mood changes such as hopelessness, fear, depression, irritability and anxiety - each of which can heighten the perception of pain.
Chronic pain can affect your relationships with others and your work. In one 1997 US study, chronic pain was responsible for 12 per cent of the workforce missing work that year; 42 per cent said chronic pain affected their family relationships, and 48 per cent had experienced depression (Med Clin North Am, 1999; 83: 787-808).
The usual treatment
It would be reasonable to think that medical science had come up with effective ways to treat such a widespread problem. Certainly, relief of acute pain (as seen with cancer) and postsurgical pain are on medicine 's current agenda. Physicians now refer to this type of pain as the 'fifth vital sign', and monitor it as closely as heart rate, blood pressure, respiration and body temperature.
Nevertheless, our approach to pain is still rather crude. Pain-relieving drugs (analgesics) are the most common approach. Mild discomfort can be relieved with paracetamol (acetaminophen) and aspirin, and over-the-counter and prescription NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen. Stronger drugs may be used to manage more difficult pain.
It is not surprising that most of us, when faced with a headache, backache or sports injury, will simply reach for a bottle of our preferred analgesic. It is often effective and, sometimes, even appropriate. But NSAID use, particularly over the longer term, has many disadvantages.
One American review revealed that around 107,000 individuals are hospitalised annually for NSAID-related gastrointestinal (GI) complications, and at least 16,500 NSAID-related deaths occur each year among arthritis patients alone (Am J Med, 1998, 105: 31S-8S). The vast majority (81 per cent) of these patients had no GI problems before they began taking NSAIDs (Arch Intern Med, 1996, 156: 1530-6).
Earlier, the US Food and Drug Administration had put the death rate higher, estimating that NSAID use accounted for up to 20,000 deaths per year - comparable to the number of cases of Hodgkin 's disease or of AIDS in the US each year (J Rheumatol, 1991, 18 [Suppl 28]: 6-10).
Similar scenarios are seen in the UK and Germany (Akt Rheumotol, 1999; 24: 127-34).
Other evidence suggests that recent use of NSAIDs by elderly patients can double the odds of being admitted to hospital with an episode of congestive heart failure (CHF) (Arch Intern Med, 2000; 160: 777-84). A further study found that, when NSAIDs are used alongside diuretics, the risk of CHF is doubled yet again (Arch Intern Med, 1998; 158: 1108-12).
Chronic pain is difficult to treat because it has so many different causes. It usually will not resolve on its own or respond to routine pain-relief methods. This may be why there is a greater chance of improvement in people who undergo a combination of treatments at the same time (Med Clin North Am, 1999; 83: 555-83).
Alternative medicine has a lot to offer in this regard. Manipulative therapies such as osteopathy and chiropractic have proven track records for relieving all types of pain. Massage may also help, though relief is generally temporary. There is an impressive amount of data to show that acupuncture can relieve several types of chronic pain, including backache and headache. Diet (with special attention to potential allergens) may be a useful way of dealing with chronic headaches and inflammatory conditions, and physical activity can strengthen joints and muscles, which helps to repair and prevent damage.
For this road test, we looked for products that addressed the most common types of chronic pain: backache, headache, muscle strain and sports-type injuries. And as we in the West take far too many pills for pain, we specifically looked for approaches that did not involve swallowing anything and yet were easy to incorporate into the lifestyle.
In general, these products fall into two categories: those that deal with the electromagnetic (EM) forces of the body; and those that provide local pain relief through light analgesic effects.
The recent proliferation of products and devices using EM forces is intriguing, and those with some knowledge of acupuncture and electroacupuncture will already have an understanding of the possibilities of using the body 's own healing impulses to bring about pain relief.
Trauma affects the electrical potential of cells in damaged tissues, creating an area of much higher resistance than in healthy tissues (Becker RO, The Body Electric, NY: William Morrow & Co, 1985). Electricity, like water, tends to take the path of least resistance, so impulses simply bypass the injured area. This leads to a reduced blood flow and a much slower healing process (Physician Sportsmed, 1993; 21: 85-93). Applying microcurrents of electricity to injured or inflamed areas may help restore blood flow to the area and accelerate the healing process. In addition, some manufacturers claim that electrical stimulation helps to release pain-relieving endorphins - though evidence for this is less plentiful.
In rating each product, we looked for a clear statement of what the product could and could not do, and whether there were any adverse effects from using the product. We also looked for any research evidence relating to either the product or the theory behind it.
We also assessed how practical the product was to use. This especially applied to the energy treatments. TENS machines, for example, can relieve pain, though only in some people (Cochrane Database Syst Rev, 2001; 3: CD003222). But these are often not portable, and the wires and pads need to be carefully positioned and may restrict movement. Better alternatives are devices that can be slipped into a handbag, suitcase, office medicine cabinet or desk for easy application whenever pain strikes.
As usual, we considered value for money. But, unlike a supplement taken every day, pain-relieving products tend to be used sporadically and, as the perception of pain is subjective, some individuals will require more pain relief than others. Thus, in this area at least, value for money is not easily determined (and some would argue that swift pain relief is priceless).
Pain Ease Patch
Distributor: Lifes2good (0845 602 1632)
This simple device comprises two patches, each with a tiny integrated battery, connected by a fine wire. This is endorsed by rugby player Keith Wood and former Wimbledon champion Virginia Wade OBE, and is recommended for back pain, muscle spasm, sore shoulders, knee and joint pains, and other chronic muscular aches and pains (see www.lifes2good.com). These patches have been tested in several small, unpublished trials in the UK and Germany, and found to ease fibromyalgia and period pains, among other conditions. The patches are discreet and reusable - good for 500 hours of therapy. For best results, the patches should be used continuously for three to five days.
Although extremely sticky, we felt that it provided good value (around 5 p/hr of use) and had reasonable evidence of efficacy.
Distributor: UK Care Products (0114 281 3030)
Each 'click' of the PAIN(R)GONE pen delivers a detectable (1-2 Hz), but controlled, electrical charge which, says the manufacturer, stimulates the production of endorphins and lessens the perception of pain.
Unpublished (in peer-review journals) studies by hospitals in Sheffield, Gwent and elsewhere attest to the pen 's effectiveness in providing temporary relief from tennis elbow, low-back and large-joint pain, and knee-joint disease. The distributor further suggests that it can help arthritis, rheumatism, sciatica, osteoporosis, toothache, migraine, period pain, sports injuries, and muscle aches and pains. However, not everyone may be able to give themselves the 30 or 40 (sometimes uncomfortable) recommended 'jabs' for pain relief.
While initially expensive, it is a robust and clever design, and can deliver as many as 100,000 jabs (35 jabs work out to 2 p), making this cheaper over the long run than any of the other products reviewed.
Distributor: Transpen Marketing Ltd (01254 263 174)
Price: lb11.99 (two-patch pack)
What looks like little more than a large Band-Aid plaster has published evidence to back it up. Acustat is a microporous polymer membrane that stores a strong negative electrostatic charge to provide microcurrent therapy. Once in contact with the skin, it steadily and painlessly discharges a current of 20 microamperes over 48 hours.
It can treat delayed-onset muscle soreness (Med Sci Sports Exerc, 2002; 34: 602-7), and numerous reports and case studies, many from sports therapists, claim that it works (see www.drugfreepainrelief.co.uk). By comparison to others in this road test, this was expensive - one patch costs lb2.75 per day to use and, once discharged, is not reusable. Nevertheless, the labelling was clear and the patch is convenient to use. However, an allergic-type reaction to the adhesive is possible.
Distributor: Heel Inc
Price: lb8.14 (50-g tube)
Traumeel is a homoeopathic anti-inflammatory cream made from 14 plant extracts, including Arnica, Calendula, Chamomilla, Echinacea, Hamamelis, Hypericum, Millefolium and Symphytum. Tested in several small clinical studies in adults and children, it proved to be safe and effective for treating trauma injuries and inflammation. The majority of the trials were published in the Journal of Biomedical Therapy, the official journal of SOHNA - Society of Homotoxicology for North America, and a division of Heel Inc, the product 's manufacturer.
That's not to say it doesn't work. In 1997, Traumeel was the first homoeopathic preparation ever to be listed in the US drugs 'bible' Physicians' Desk Reference for pain relief - but we would have liked to see an independent analysis. While the ointment is petroleum-based, the gel version is not.
Labelling was adequate and no side-effects have been reported with this product. Although pricier than a typical tube of, say, homoeopathic Arnica, Traumeel seems to have a wider variety of applications.
Distributor: Health Perception (UK) Ltd
Price: lb5.95 (100-mL tube)
This non-sticky, non-greasy, alcohol-based gel can be used up to six times daily to soothe aches and pains. In addition to glucosamine, it also contains horse chestnut extract and menthol, as well as several parabens preservatives, which have been associated with oestrogenic effects. Oral glucosamine works (slowly) for some, but not all, pain sufferers, but there is almost no published evidence to suggest that a topical application will work as well or better.
We could find only one randomised, double-blind, placebo-controlled trial of a cream containing glucosamine sulphate, chondroitin sulphate and camphor for osteoarthritis of the knee (J Rheumatol, 2003; 30: 523-8). In 63 patients, the cream had a significant pain-relieving effect within four weeks of starting treatment.
Value for money is hard to assess since the cream is likely to work slowly. But used several times a day on large areas of skin, a 100-mL tube is not likely to go very far.
MSM Joint & Muscle Balm
Distributor: Higher Nature (01435 882 880)
Price: lb8.40 (95-mL jar)
A light cream containing 10 per cent MSM (methylsuphonylmethane, a source of sulphur) as well as extracts of eucalyptus, rosemary, peppermint, frankincense, ginger, black pepper, lemongrass, aloe and capsicum, it uses fewer synthetic preservatives than GlucOsamine (see above). The slightly irritating ingredients cause a temporary reddening of the skin which, Higher Nature says, is normal and proof of its 'deep heat' action. But which is the most active ingredient? Like Tiger Balm (see below), it should not be applied to broken or sensitive skin and may stain clothing.
Again, value for money is difficult to assess as everyone will use it differently. However, if applied sparingly as suggested, it may represent good value for money.
Manufacturer: SSL International (0161 654 3000)
Price: lb4.19 (19-g jar)
A paraffin-based ointment comprising essential oils of menthol, camphor, cajeput, peppermint, clove and cassia (cinnamon), Tiger Balm is reputed to provide temporary relief from muscle aches and pains. It comes in two versions: red and white.
Only one study has looked at its use for pain-relief. In 1996, Tiger Balm, paracetamol and placebo were compared in people suffering from acute tension headaches. The Chinese remedy worked as well as the paracetamol and significantly better than placebo. Its effects, however, were relatively short-lived. Although effective from 5-15 minutes after application, it ceased to work after three hours (Austral Fam Physician, 1996; 25: 216-20).
Of all the topicals tested here, Tiger Balm is the cheapest - one tiny jar will go a long way. However, it is a strong mix of oils, and skin irritation is a possibility for some users (Contact Derm, 1990; 22: 137-40).
Distributor: D Jay Ltd (0121 236 2073)
Price: lb5.91 (four-patch pack)
ACUMED patches are small, microporous, hypoallergenic plasters containing a membrane of zinc and copper in a magnetic field. The patches can be placed directly over the painful area or on specific acupuncture points, as outlined in a booklet that comes with the product.
There is some evidence that small magnets can ease superficial pain, but ACUMED seemed reluctant to pass on any research data and, without knowing, for instance, the strength of the magnet, who knows whether or not it will work.
We checked the polarity of the magnet ourselves with a magnet tester. The side that goes against the skin emits a positive charge, yet most (but not all) texts suggest that negative fields promote healing. It is also not clear whether the patches work like copper bracelets do - by aiding the absorption of the metals through the skin.
Each plaster needs to be left on for five to seven days and cannot be reused. The patches work out to around lb1.25 each.