Sprains, strains and bruises: Oral non-steroidal anti-inflammatory drugs compared with other oral pain killers

Sprains, strains, and bruises are common injuries, and people with these injuries often require pain relief, given as a tablet or capsule that is swallowed (oral). Many types of oral painkillers are available to treat such injuries. The authors wanted to know whether there were any differences in people’s pain, swelling, function, or unwanted side effects when sprains, strains, and bruises were treated with oral non-steroidal anti-inflammatory drugs (NSAIDs, e.g. ibuprofen) compared with paracetamol, opioids (e.g. codeine), complementary or alternative medicines, or combinations of these.

What did the authors do?
They searched medical databases up to January 2020 for studies that compared NSAIDs with other painkillers in people with sprains, strains, and bruises. Study participants could be any age. They assessed the included studies to judge the reliability (certainty) of the evidence. They categorised the evidence as being of high, moderate, low, or very low certainty. High certainty means they are confident in the evidence, moderate certainty means they are fairly confident, low or very low certainty means that they are unsure or very unsure of the reliability of the evidence.

Results of searches and description of studies
The review includes 20 studies, with 3305 participants. Seven studies included people with ankle sprain only. Three studies included children only. Most of the participants of the other studies were young adults, and there were slightly more men than women. Few participants were aged over 65 years. Eleven studies compared NSAIDs with paracetamol, six studies compared NSAIDs with opioids, and four studies compared NSAIDs with paracetamol combined with an opioid. Studies reported outcomes at times varying from one hour after taking the medication, up to 10 to 14 days.

Main results
There is no difference between NSAIDs and paracetamol in pain after one to two hours, or after two to three days (high-certainty evidence), and there may be no difference after a week or more (low-certainty evidence). There is low-certainty evidence that NSAIDs may make little difference to swelling after a week or more. The authors are uncertain whether NSAIDs make a difference to return to function after a week or more (very low-certainty evidence). There is low-certainly evidence that NSAIDs may slightly increase unwanted side effects related to the gut.

There is probably no difference between NSAIDs and opioids in pain at one hour (moderate-certainly evidence), and there may be no difference four or seven days after taking medication (low-certainty evidence). They are uncertain whether NSAIDs make a difference to swelling after 10 days (very low-certainty evidence). There is low-certainty evidence that NSAIDs may increase return to function in 7 to 10 days. There is moderate-certainty evidence that NSAIDs probably result in fewer unwanted side effects, such as nausea and dizziness, compared with opioids.

The evidence suggests that there is little or no difference between NSAIDs and paracetamol combined with opioids in pain, swelling, return to function, or unwanted side effects. However, the evidence was very low certainty, so the authors are uncertain of these results.

No studies reported the risk of re-injury after treatment. The authors found no studies comparing NSAIDs with complementary or alternative medicines.

Conclusions
The body of evidence to date has found no difference between NSAIDs and other pain killers for pain relief for strains, sprains, and bruises in younger people. However, the authors need more, and better evidence on return to function and unwanted side effects in all age groups, particularly in older people.

Peter Jones Associate Professor of Emergency Medicine at the University of Auckland, Faculty of Medical and Health Sciences and Director of Emergency Medicine Research Adult Emergency Department, Auckland City Hospital summarized:

“Sprains, strains and bruises are common injuries. Often people are unsure which medication to take, anti-inflammatory drugs, paracetamol or an opioid such as codeine or to treat with a complimentary therapy or alternative medicine. We found evidence that there was no difference between the common pain medications in the amount of pain relief achieved. However, we need more, and better evidence on unwanted effects on the gut in all age groups but particularly in older people.”

This is an update of a Cochrane review published in 2015.