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Three Part Question

In [adults with acute soft tissue injury] are [topical or oral NSAIDs] better at [reducing pain and improving function]

Clinical Scenario

A 30-year-old woman presents with a 7-day history of patellar tendonitis. You think of treating her with oral NSAIDs. However, you have seen some information about NSAIDs in a gel form. This seems an appealing alternative and you wonder if there is any evidence of its efficacy.

Search Strategy

MEDLINE 1966 to October week 3 2007, CINAHL 1982 to October week 3 2007, AMED 1985 to January 2007, SPORTDiscus 1830 to May 2007 and EMBASE 1996 to 2007 week 43 via the OVID interface. Cochrane database February 2007. PEDro database accessed 29 October 2007.
Medline, CINAHL, AMED, the Cochrane database: [{(exp ibuprofen OR exp anti-inflammatory agents, non steroidal) AND (exp gel OR exp administration, topical) AND (exp soft tissue injuries OR exp tendinopathy OR exp tenosynovitis OR exp ligaments OR muscles, skeletal OR athletic injuries)}] LIMIT to human AND English language.
SPORTSDiscus, add (exp nonsteroidal anti-inflammatory agent) (exp ointment) (exp tendinitis) (exp muscle, exp sprain, exp injury)
EMBASE add (exp tendinitis)
In addition the PEDro database was also searched with search terms: [topical NSAIDs]

Search Outcome

A total of 197 unique records were found. Four papers were retrieved, one of which was a critical review, two compared topical versus oral NSAIDs in osteoarthritis, so there was only one relevant paper which was a randomised controlled trial

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Whitefield et al, 2002, UK	'soft tissue injury' Topical 5% ibuprofen (N=50); Oral 400mg tds (N=50) Military recruits (95% male) 8 dropouts – unrelated to treatment	RCT double dummy	Primary outcome: time to 'completely better'	1. Gel = 14+ days (n=24); Oral = 13.5 days (n=30); p=0.23 NSS	Wide variety of injuries treated Massaging placebo gel may have therapeutic benefit. Sample size mentioned but not fully explained. Possibility of type II error.
			2.VAS pain at rest 30min,days 1,2	2. NSS
			3. VAS active movement pain 30min days 1,2	3. NSS
			4. site tenderness 30min days 1,2	4.NSS
			5. interference with movement 30min days 1,2	5.NSS
			6. swelling on days 1,7,14	6.NSS
			7. change in the condition	7.NSS
			8. patient preference	8. 71% gel; 8% oral; 21% neither
			9. patient satisfaction	9.Excellent - 60% gel; 71% oral.Satisfactory – 36% gel; 27% oral. Poor – 4% gel; 2% oral

Comment(s)

The study had high compliance due to its military setting. Although the rationale, in part, for using gel is its improved tolerability and reduced risk of toxicity, this study excluded patients with a high risk of NSAID-related toxicity. The gel contained 5% ibuprofen but some gels now have 10%. There were no study-related adverse events.

Clinical Bottom Line

Topical 5% ibuprofen is as effective as oral ibuprofen in the treatment of soft tissue injuries.

References

1. Whitefield, M. O'Kane, CJA. Anderson ,S. Comparative efficacy of a proprietary topical ibuprofen gel and oral ibuprofen in acute soft tissue injuries: a randomised, double blinded study J. Clin Pharmacy Therapeutics 2002: 27: 409-417