With around 30% of people thought to use natural remedies for osteoarthritis (Tsui et al., 2012), isn’t it time we looked a little more closely at what’s available? For instance, does it make sense to use bromelain for back pain? Just how effective and safe is this NSAID alternative?
What is Bromelain?
Bromelain is a plant protease, an enzyme usually derived from pineapple or papaya and sometimes used as a meat tenderizer in powdered form. Taken orally, bromelain has been used to treat acute post-operative and post-traumatic conditions where swelling is a problem, particularly in cases of nasal sinus issues, burns treatment, and in allergic rhinitis.
Uses of Bromelain
Some women have used it as a traditional remedy for inducing labor due to a purported stimulating effect on muscle contraction. Others have used bromelain to enhance antibiotic absorption, inhibit blood platelet aggregation (blood clotting), prevent epinephrine-induced pulmonary edema, and for mild ulcerative colitis. Use of bromelain to treat osteoarthritis and low back pain is also popular and it is for this condition that the natural remedy has gained most attention by medical researchers.
Is Bromelain Effective for Pain Relief?
The combination of bromelain with trypsin and rutin in the product Phlogenzym has been found to reduce pain and improve knee function for patients with osteoarthritis (Klein and Kullich, 2000). This combination appears to be comparable to diclofenac but the use of bromelain alone has not been comprehensively studied as yet and there remains no proof of its effectiveness for myalgia. A study using 300mg of bromelain three times a day immediately after intense exercise was found to have little effect on muscle soreness, pain, flexibility or weakness (Stone et al., 2002).
The main reason why many clinicians remain skeptical about bromelain’s use for musculoskeletal pain conditions is that the enzymes are unlikely to reach a significant concentration outside of the gastrointestinal tract and, therefore, are unlikely to be able to exert any significant anti-inflammatory effect. Unfortunately, many studies, including a recent one looking at rotator cuff repair and recovery, fail to use bromelain in isolation, rendering the results pretty much useless in regards to recommending the supplement to help with pain and mobility; this particular study focused on a product (Tenosan) containing arginine L-alpha-ketoglutarate, methylsulfonylmethane, hydrolyzed type I collagen and bromelain.
Bromelain’s Mechanism of Action
Bromelain may act as an anti-inflammatory by altering the migration and activation of leukocytes, although high concentrations of the enzymes would be needed to exert such an effect. Bromelain also has the capacity to affect the growth of malignant cells and to inhibit platelet aggregation, thus making it appear to some as an attractive natural cancer remedy and a good idea for those worried about ischemic stroke or deep vein thrombosis. However, again, such effects are likely only possible at concentrations in the bloodstream higher than realistically achievable. Additionally, plasma contains proteinase inhibitors that may simply inactivate bromelain, rendering it useless as a natural anti-inflammatory or anti-cancer agent.
Bromelain’s Side Effects
Although there is little evidence to support the use of bromelain for low back pain there are some potential interactions and side effects to consider. It may be natural to assume that natural products have no side effects but many do in fact have the potential to cause serious adverse reactions, just like pharmaceuticals. Bromelain may lead to gastrointestinal distress, including diarrhoea, and those with an allergy to pineapple, or even to wheat flour, celery, papain, carrot, fennel, cypress pollen, and grass pollen may have problems with the supplement due to cross-allergenicity. Anyone with an allergy to ragweed, chrysanthemums, marigolds, daisies, and echinacea could also have an adverse response to bromelain.
Talk to Your Physician
In addition, bromelain can make certain drugs more or less effective, especially if it is combined with other natural supplements or foods. The anticoagulant effect of bromelain may increase the risk of bleeding and could be particularly problematic if a patient takes the supplement believing it to be helpful before and after back surgery. This is why it is vital that patients tell their physician about all the medications they are taking, prescribed or otherwise – physicians will usually tell patients to stop taking bromelain at least two weeks prior to surgery in order to reduce the risks of excess blood loss. Those taking a bromelain supplement may also enhance the absorption of certain antibiotics, including amoxicillin and the tetracyclines. Caution is advised over combining these drugs.
In conclusion then, there seems to be little evidence to support the use of bromelain for anything other than osteoarthritic knee pain and even that evidence is of relatively low value. Bromelain may help relieve low back pain from conditions such as spinal stenosis but there is nothing but anecdotal evidence to support such a use and the potential side effects of the natural remedy need taking into account by all patients.
Stone MB, Merrick MA, Ingersoll CD, et al. Preliminary comparison of bromelain and Ibuprofen for delayed onset muscle soreness management. Clin J Sport Med 2002;12:373-8.
Tsui T, Boon H, Boecker A, Kachan N, Krahn M., Understanding the role of scientific evidence in consumer evaluation of natural health products for osteoarthritis an application of the means end chain approach. BMC Complement Altern Med. 2012 Oct 30;12:198. doi: 10.1186/1472-6882-12-198.
Klein G, Kullich W. Short-term treatment of painful osteoarthritis of the knee with oral enzymes. Clin Drug Invest 2000;19:15-23.
Gumina S, Passaretti D, Gurzì MD, Candela V., Arginine L-alpha-ketoglutarate, methylsulfonylmethane, hydrolyzed type I collagen and bromelain in rotator cuff tear repair: a prospective randomized study. Curr Med Res Opin. 2012 Nov;28(11):1767-74. doi: 10.1185/03007995.2012.737772. Epub 2012 Oct 19.