Heat Rubs, Sport Creams Not So Hot for Treating
Arthritis, Injury Muscle Pain
In osteoarthritis, taking oral ibuprofen is more
effective but has potential side effects: drug interactions with
aspirin, and GI complications for some people
By Lisa Esposito, Editor, Health Behavior News
Service
July 13, 2009 - Popular over-the-counter creams,
heat gels and other rub-on or spray-on remedies for sports injuries and
arthritis aches are unproven and a waste of money, said the author of a
new systematic review.
“The point is, you go to any pharmacy in the U.S.
and find tons of these things, but they don’t work,” said Andrew Moore,
a biochemist at the University of Oxford and senior author of the
Cochrane review of 16 studies.
These preparations are thought to work by producing
a counter-irritant effect. The warmth and redness they cause - and with
some, the strong smell - distract users from, or offset, their
musculoskeletal pain.
Known as topical rubefacients (a substance that
causes the skin to become red, especially a cream or ointment used as a
counterirritant), they can include a variety of active ingredients.
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The review focused on preparations containing one
or more salicylates. (Aspirin is a salicylate.)
“Some add local anesthetics, capsaicin, adrenal extracts. By and large
it’s a very mixed bunch,” Moore said.
Familiar brands like Aspercreme contain a
salicylate, as do Ben Gay and Icy Hot balms, which also have menthol
additives. (Ben Gay and Icy Hot patches contain menthol alone.) Some,
but not all reviewed preparations offer “heat action.”
The review appears in the current issue of The
Cochrane Library, a publication of The Cochrane Collaboration, an
international organization that evaluates research in all aspects of
health care. Systematic reviews draw evidence-based conclusions about
medical practice after considering both the content and quality of
existing trials on a topic.
The topical medicine studies looked at participants
ages16 and older.
Seven studies included 697 people with acute
conditions like strains or knee and ankle sprains and lower back
injuries.
Nine studies looked at 579 participants with
chronic conditions like osteoarthritis, bursitis, older sports injuries
and rheumatic back pain.
Most studies compared salicylate preparations with
a placebo (sham) preparation lacking an active ingredient.
In acute pain studies, although 64 percent for
patients in rubefacients group reported that their pain was reduced by
half or more - compared with 34 percent for patients in the placebo
group - this advantage was wiped out when researchers eliminated lower
quality studies from the analysis.
The evidence for chronic conditions held up better,
with pain relief success at two weeks of treatment reaching 45 percent
for rubefacients group and 28 percent for placebo group.
One small study found that these preparations were
no better than oral aspirin.
In another small study of chronic pain, salicylates
outperformed a preparation contained etofenamate, which is in the NSAID
drug class that includes ibuprofen.
Data quality and quantity was a problem for the
reviewers.
“We’re looking at a few hundred patients. It’s
sobering,” Moore said. “The smaller, older studies tend to show an
effect while the larger, better, recent trials show no effect at all.”
So what does help? Moore points to cream that the
review did not cover:
“Topical local anesthetics work. Topical capsaicin
works, particularly for some people with neuropathic pain. Some topical
NSAIDs work extremely well in strains and sprains.
Capsaicin is a hot-pepper derivative. It was not
used as a main ingredient in review studies but was sometimes present as
an additive.
“With NSAID creams, you get good local
concentration in the joints, unlike oral NSAIDs, where you only get a
fraction of the medicine in the joints,” Moore said.
But there’s no sign that people will stop rubbing
salicylates like Tiger Balm into a sore pitching shoulder or an
arthritic knee.
Scott Zashin, M.D., is a clinical associate
professor of medicine at the University of Texas, Southwestern Medical
School and author of a book on arthritis pain. He recalls, “I used to
use Ben Gay all the time when I played soccer. I felt better with it at
that time.” He said the warmth produced at the pain site might cause the
muscles to relax.
He said topical rubefacients lead to “not much harm
and even some safety advantages, for instance to people with problems
taking oral meds.”
In osteoarthritis, taking oral “ibuprofen is more
effective but it has potential side effects: drug interactions with
aspirin, and GI complications for some people.”
The review found few side effects from topical
rubefacients when used correctly: applied in small amounts, only to the
affected area. In the studies, people used the treatments at least once
a day.
The UK and U.S. experts advise consumers to look at
heat rubs and the like with a cold and wary eye.
“You have to look at cost,” Zashin said.
“A very expensive brand might not be more effective
than a generic, but just have better marketing. It’s not a miracle
product.”
The Cochrane review discloses that two co-authors
have consulted for pharmaceutical companies and received lecture fees
from them related to analgesics.
For his part, Moore calls on rubefacient makers to
show more transparency: “If any of these products want to be taken
seriously, they would make their chemical trials public and have them
reviewed so that everyone could look at the evidence.”
Would he recommend salicylate creams to consumers?
“I wouldn’t waste the money. You might as well rub
your skin with a bit of spit.”
Earlier Study Inconclusive
A similar review published in BMJ (British Medical
Journal) in March of 2004, concluded that rubefacients containing
salicylates may be effective in the treatment of acute pain, but trials
of musculoskeletal and arthritic pain suggested moderate to poor
efficacy.
Generally, the authors noted that results were
unreliable due to a lack of “good clinical trials.”
Their data sources were electronic databases and
manufacturers of salicylates.
And, they selected randomized double blind trials
comparing topical rubefacients containing salicylates with placebo or
another active treatment, in adults with acute or chronic pain.
BMJ 2004;328:995 (24 April),
doi:10.1136/bmj.38040.607141.EE (published 19 March 2004)
Information Source:
The Cochrane Collaboration is an international
nonprofit, independent organization that produces and disseminates
systematic reviews of health care interventions and promotes the search
for evidence in the form of clinical trials and other studies of
interventions. Visit http://www.cochrane.org for more information.
Matthews P, et al. Topical rubefacients for acute
and chronic pain in adults. Cochrane Database of Systematic Reviews.
Issue 3, 2009.
