Thomas Buchheit, MD
Thomas Buchheit, MD, director of the Regenerative Pain Therapies Program at Duke University, Raleigh, North Carolina. Duke.edu
Mounting evidence suggests that our basic assumptions about treating acute pain and preventing chronic pain may be wrong. While it is disconcerting when new research turns a previously held idea on its head, in this case, it’s good news. Learning more about what we are doing wrong—and what we should be doing instead—can help us promote healing and prevent injuries from turning into chronic pain. Bottom Line Personal asked regenerative pain specialist Thomas Buchheit, MD, to set us straight…
For decades, the prevailing approach to treating pain from sprains, strains or muscle injuries has been to aggressively suppress all forms of inflammation.
It is easy to see how we got here. We know that chronic inflammation and inflammatory changes are destructive. Even a casual reader of medical reporting knows that inflammation is implicated in a host of diseases and conditions. Examples: The cumulative effect of decades of gut inflammation is associated with a variety of conditions…and conditions such as rheumatoid arthritis are the result of the chronic inflammatory processes damaging joints. By extension, we have powerful medications, such as steroids, cytokine inhibitors and other disease-modifying agents that improve the lives of patients suffering from these chronic inflammatory conditions.
So it is only natural that we reach for nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen when we sprain an ankle playing with our grandkids or strain our back working in the garden. We believe that reducing the inflammation will make the pain go away.
What we’ve gotten wrong: The medical community has extrapolated our understanding of the danger of chronic inflammation into a general “inflammation bad” assumption. We have assumed that because chronic inflammatory change is damaging, all inflammatory change—including that associated with acute injury—is harmful. But, in fact, when it comes to acute pain, inflammation actually might be good for us.
How inflammation might help: When we are injured, our bodies go into healing mode. Our immune system produces a sequence of biological responses—the healing cascade. Inflammation is not only an early part of that, but it stimulates components of the sequence that follow.
The idea that inflammation plays this role in healing is not new. Several established therapies consist of a controlled introduction of inflammation to stimulate the healing cascade. In a procedure called microfracture surgery, a surgeon pokes holes in bones of the knee so that the resulting inflammation will spur growth of healthy cartilage to replace damaged cartilage. For the same reason, micro-injuries sometimes are introduced to damaged tendons to promote healing. And platelet-rich blood plasma, teeming with inflammation-causing white blood cells, often is injected at an injury site. All these therapies embrace inflammation as a kick-starter of the healing cascade.
Despite our understanding of its role in healing, the bias against inflammation persists. But recently, we’ve seen the most compelling evidence to date to bolster the argument that blanket suppression of the immune response using steroids or NSAIDs for an acute injury is not only counterproductive but also potentially harmful. In early 2022, researchers at Montreal’s McGill University investigated the healing response in mice and humans. When they gave anti-inflammatories to mice with acute sciatic back pain, the mice were more likely to still be in pain 115 days later…while untreated mice started feeling better in just a few days. And when the researchers looked at data on more than 2,000 humans with acute back pain, they found that those who took NSAIDs were far likelier to still have a back-pain complaint up to a decade later.
Conclusion: While suppressing the immune response is analgesic—it reduces your pain—it may convert your pain from acute to chronic because you’ve disrupted the healing cascade.
Change your mindset. Rather than overrelying on anti-inflammatories when you’re in acute pain, shift your thinking to promoting healing. The medical specialty “regenerative pain medicine” promotes restoration of healthy tissue. Practitioners suggest several ways patients can jump-start healing while forgoing anti-inflammatories. Physicians from multiple specialties offer regenerative medicine options. Look for one who uses more than just injections to treat the problem. Search for board certification in a related specialty, such as orthopedic surgery, pain management/anesthesiology or physical medicine and rehabilitation…training and experience…as well as hands-on formal residency training and extensive experience (not just a weekend course) for any procedures they perform.
Exercise. Your tough-as-nails grandparents were right—working through minor aches and pains may be the best way to resolve these issues. Obviously, if there is a fracture, a ligament tear or other serious injury, this may not be possible. If in doubt, make sure a physician and physical therapist guide your exercise routine. Using an injured body part can get it working again and pain-free.
Physical therapy. For a tendon or muscle partial tear or other serious injury that could become chronic, find a good physical therapist. Ask your physician for recommendations. Also find a therapist who analyzes your body mechanics and tailors the treatment to your needs. He/she will know just which movements are most beneficial and will motivate you to perform them.
Stretching and motion strengthening. Tendons heal when they’re put under strain. Eccentric exercises—where the tendon is under strain for various amounts of time, depending on the injury—are especially effective for rotator cuff issues and other tendinopathies. The most reliable remedies for acute back pain are stretching and strengthening, which prevent muscle atrophy, shore up the structure of the spine and spur healing.
Acupuncture. This ancient Eastern practice promotes tissue restoration and reduces pain without suppressing the immune response.
Local anesthesia for surgical procedures. Applying a local anesthesia in addition to, and sometimes instead of, general anesthesia for surgery reduces acute pain without disrupting the inflammatory response.
Just as we once erred in the oversimplification “inflammation bad,” we should avoid a whole-hog embrace of “inflammation good.” There is a sweet spot when it comes to the amount of inflammation that’s beneficial for an acute injury. Anti-inflammatory medications could help you get through the first few days after an accident to reduce your pain so that you can begin using the injured body part—stretching, exercising, doing physical therapy, etc. Just don’t keep using anti-inflammatories beyond that initial acute phase or what’s needed to start functioning. The optimal duration of anti-inflammatories will likely be days, not weeks or months.
We often think that pain is our bodies’ warning system—Don’t stand on this leg because the ankle is sprained and you’ll make it worse. That may be true in a general way, but it’s not an absolute. If we heeded our bodies’ pain signals completely, we would never use our injured parts. So just as there’s a sweet spot for inflammation and room for anti-inflammatories in the healing process, there’s a balance between exacerbating an injury and resting it too much. Most of us can tell if we are pushing too hard and causing damage. If you struggle with that, a physical therapist can help.
