In addition to supplements and protein shakes, your proactive athlete patient may also be popping ‘vitamin I’, or ibuprofen, as part of their regimen. Inflammation can slow down training and affect their overall performance, so many athletes wind up taking ibuprofen prophylactially to guard against it. But should athletes really be using this NSAID as a training aid?
Guest contributor: Rory Gibbons, BSc, Kin, ND Cand 2017
Since ibuprofen is so widely used among athletes, it might be interesting to examine if their reliance on it actually helps or hinders their performance.
Even with a prevalence of around 90% in certain sports, this certainly does not mean ibuprofen is the key to success. Research shows that while non-steroidal anti-inflammatory drugs (NSAIDs) are very good at their job as pain-relievers and anti-inflammatories, they can have detrimental effects on skeletal muscle tissue and tissue in the gastrointestinal tract.
Ibuprofen mechanism of actions
Ibuprofen is an NSAID, which carries analgesic (pain-reducing) and antipyretic (heat-reducing) properties. The exact mechanism of action of ibuprofen is unknown, however ibuprofen is postulated to be a non-selective inhibitor of the multi-form enzyme cyclooxygenase (COX). This enzyme is a key player in the synthesis of prostaglandins (inflammation modulators) via a specific metabolic pathway (see diagram). It acts to inhibit cyclooxygenase-1 and cyclooxygenase-2 enzymes, which in turn dampen protective prostaglandin synthesis and inflammatory prostaglandin synthesis, respectively. The antipyretic effect of ibuprofen is believed to occur at the level of the hypothalamus, which is the centre in the brain that controls our body’s temperature. NSAID drugs will bind to receptors in the hypothalamus, resulting in a dissipation of heat via changes in blood flow to heat outlets like our skin.
Since ibuprofen does not have the ability to block one COX enzyme without blocking the other, taking this drug can have a negative impact on areas that are not necessarily targeted for pain-relief, such as the intricate lining of our gastrointestinal tract. As a result, it is considered “nonselective”, when compared to other anti-inflammatory medications.
Ibuprofen is thought to be a non-selective inhibitor of cyclooxygenase. Although it does suppress pain caused by inflammation, the absence of gastric mucosal protection can cause gastrointestinal issues from prolonged use.
The effects on skeletal muscle
Delayed onset muscle soreness (DOMS) is a phenomenon that will occur 24-72 hours following progressive exercise (exercise that occurs at a higher and/or longer duration than the athlete’s usual exercise regime) and is frequently the reason why athletes take ibuprofen before exercising. However, taking ibuprofen prophylactically to eliminate pain is only providing a disservice to the body’s healing process.
Research has shown that levels of pain and ratings of perceived exertion do not differ if the athlete takes ibuprofen prophylactically or not at all, given the same exercise. This particular study also showed that there were higher levels of inflammatory markers present in the athletes taking ibuprofen, indicating an additive effect of injury (the type of injury was not specified).
Pain and inflammation are the body’s response to damage from trauma (accidental trauma or athletic training) or disease (ex. Crohn’s, ulcerative colitis, cancer, etc). Taking ibuprofen will dampen pain and inflammation and potentially lead the athlete to injuring already damaged tissue more. Once that pathway is down, pain will no longer let us know when to stop.
Taking ibuprofen prophylactically may block the production of collagen, the foundation of connective tissue strength.
Much like we sense pain, we respond to increased stress and adapt to it. Inflammatory enzymes (specifically cyclooxygenase-2) and prostaglandins are integral in the responsiveness and adaptation of connective tissue to mechanical stimuli, and if they are not present then injured tissue may be predisposed to further injury. Prophylactic ibuprofen use may also inhibit skeletal muscle from adapting to prolonged endurance activity, by blocking the production of new blood vessels and collagen in the active tissues. Furthermore, ibuprofen’s inhibitory effects may slow the synthesis of collagen, the foundation of connective tissue strength. Continually taking ibuprofen preventatively may reduce the rate of collagen production and subsequent tissue repair following exercise and/or injury.
The effects on the gut
Ibuprofen has a damaging effect on muscle, but it does not just stop there. It is common knowledge that “ibuprofen wrecks the gut”. Studies of endurance athletes have shown that 50-80% report upper and lower GI manifestations, most commonly heartburn and diarrhoea.
But why? Our body is smart when it comes to blood flow, giving needy muscles nutrients by increasing blood flow in their direction. During periods of exercise, blood will be shunted towards the tissue that is most in need, such as the skeletal muscles putting in the time and effort. However, this happens to the detriment of tissues the body deems “less important” at the time, such as gastrointestinal tissue. If this state of blood flow continues for a prolonged time, the tissue can become ischemic and damaged. Keep in mind this is what happens when the body is functioning without any additional substances, such as ibuprofen.
Research now indicates that ibuprofen exacerbates exercise-induced intestinal injury significantly, increasing permeability of the stomach, duodenum and the rest of the small intestine. The increased spacing between the gut cells allows potentially threatening pathogens into the bloodstream and elicits stress on the immune system.
The gut damage may even have an inhibitory effect on the absorption of nutrients post-exercise, thus impeding recovery. The hypothesis of pathogens/digestive enzymes permeating the gut lining and the absorptive capacity post-exercise has not yet been fully investigated and warrants further studies.
Four other ways to address pain
So now that we have discussed how ibuprofen eliminates pain/inflammation and can amplify damage to skeletal muscle and our gut lining during exercise, what are some tactics for patients to eliminate pain before, during and after exercise?
- Determine the cause of the pain.
Pain can be a result of a whole host of issues. Poor biomechanics can cause damaging repetitive use of muscles and ongoing damage of passive structures in joints, such as ligaments and meniscus. If we can work with the athlete to move more efficiently (for instance, improve gait patterns by consciously using different muscles), there will be less stress on the joints and musculature.
Stretching out tight tissues and strengthening unbalanced muscles will also help immensely in joint/muscle function, leading to less pain. Often athletes (more specifically newer athletes) will begin their pursuit of competition at a level that is too advanced, at a speed that is too fast. This can be a shock to their body, which may not be able to adapt to the sudden increase in training, causing a higher inflammatory response – and in turn higher levels of pain.
The failure to adapt may also result in injury, and therefore, pain and inflammation. In order to prevent this from happening, the athlete needs to follow a graduated training program that outlines proper overload and appropriate recovery techniques, facilitated by a person who understands human physiology and movement.
Sometimes mental/emotional trauma can cause an exaggeration of pain. This may not be obvious at first, so taking a thorough history and exploring the mental/emotional facets of the patient’s life is necessary. Once those issues are dealt with, pain may be more easily managed or even disappear completely.
Support/control the inflammatory process.
A common misconception in the world of sport is to completely suppress inflammation, by taking antiinflammatory products like ibuprofen and using methods like icing, following exercise and acute injury. There are times to allow the natural inflammatory process to proceed healing and there are times to suppress it. Because of this, every situation needs to be assessed for severity, progression and duration of pain/inflammation. For more information on supporting and controlling the inflammatory process, please refer to Notes on natural anti-inflammatories, p.12.
Don’t neglect cool-down!
We can break down the act of athletic exercise/competition into three phases: warm-up, competition and cooldown. It is common to see a thorough warm-up phase (foam rolling, dynamic stretching, etc.), a 100% effort during the competition phase, and then a brief or absent cool-down phase.
So why is this? It could be due to lack of energy following competition, too many distractions or simply ignorance to the importance of a proper cool-down. A cool-down usually consists of, but is not limited to, much lighter exercise (10-15% of competition), followed by stretching and/or soft tissue work, like massage or foam rolling.
A cool-down does not have to be long! Continuation of light exercise will help to sustain blood flow to active tissues, clearing out leftover toxins, such as lactate and other metabolic by-products. It can also prevent pooling from the sudden stoppage of the muscle-blood pump that is the skeletal muscle. However, we cannot forget the hardest working muscle of them all, the heart. Light exercise following hard exercise helps the heart lower its workload gradually instead of suddenly, as if the athlete stopped moving after a sprint to the finish line. Ten to 15 minutes of light exercise similar to competition is enough time to help the body start to wind down from hard work.
During exercise, tiny micro-tears occur in active musculature and once exercise stops, repair of that tissue begins. A simple regime of post-exercise static stretching of the major active muscles will facilitate repair by realigning muscle fibres and preventing contracture of tendons. Partaking in a regular postexercise stretching routine will also help to maintain long-term elasticity in the muscle tissue that will translate to lower levels of pain during exercise and lower levels of delayed onset muscle soreness.
To get the most out of a post-exercise regime, recommend a professional who can develop a personalized stretching routine for the patient and can physically show them how they should be moving throughout it.
Dangers of dehydration
Roughly 75% of our body is made up of water and even the slightest change in levels can cause problems. Dehydration upsets mineral balance, slows enzymatic activity, causes toxins to accumulate more easily and affects your lungs and breathing, just to name a few. Don’t wait until you’re thirsty before getting up to get a glass of water. By then you’re already dehydrated.
Label the water bottle
Label a clear water bottle with different times, indicating 250ml (about one glass) of water for each one hour interval. When it’s the time marked on your bottle, your water should be at the same level. It’s a great visual reminder to make sure you’re drinking enough water throughout the day.