Tuesday, February 9, 2016

Recovery Cocktail With Vitamins C+E, Ibuprofen, Cold Water Immersion and Whey Works - Long-Term Effects? Unknown!

What's the right strategy to boost workout recovery? A recent study suggests that it could be a mix of NSAID, antioxidants, cold water and whey.
Vitamin C + E, ibuprofen, cold water immersion and whey? Two of these agents have been shown to impair the adaptational response to exercise and thus potentially compromise long-term gains (vitamin C+E and cold water immersion). The other two are either purported (ibuprofen) or proven (whey) ergogenics - ergogenics of which a recent study by scientists from the Hashemite University in Jordan and the University of Alabama in the USA shows that their combination with the formerly named agents is "helpful in protecting performance" in a test during which the competitive athletes (current or former Division I college athletes / club athletes) performed two bouts of high-intensity anaerobic cycling separated by 30 minutes of rest.
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The participants had been randomly assigned in counterbalanced order to start the first week as a treatment or as a control (nontreatment).
  • In the treatment trial, participants were provided with 2 oral doses of 1,000 mg of vitamin C (ascorbic acid with citrus bioflavonoids; General Nutrition Corp., Pittsburgh, PA, USA) and 400 IU of vitamin E soft gel capsules (d-a-tocopherol; General Nutrition Corp.). The first dose was taken with dinner the night before the exercise protocol, and the second dose was taken on the morning of the exercise test. The morning doses were consumed at least 1 hour before the blood sample was taken. Ibuprofen doses (400 mg; 2 ADVIL liquigels, 200 mg capsules; Wyeth Consumer Healthcare, Madison, NJ, USA) were given to participants 30 minutes before each exercise session. The protein supplement, 23 g of whey protein (10.6 g essential amino acids [EAA], 7.3 g of conditionally EAA, and 5.6 g of non EAA ON Sunrise, FL, USA), was mixed with 200 ml of skimmed milk to form a protein shake. The protein shake was given to participants within 3 minutes of finishing each exercise session in the treatment trial. Three to 5 minutes after the end of each exercise session, participants submerged their lower body in cold (10–12.58 C) water for 10 minutes.
  • In the control trial, the subjects performed the same testing protocol consisting of 2 exercise sessions with 6.5–7 hours between AM and PM sessions to replicate morning and afternoon workouts or heats. 
The exercise tests were 2-bout sessions that began with a 15-minute warm-up (stretching and cycling). Each bout consisted of three 30-second Wingate power tests with 3 minutes of active recovery (60 RPM with no resistance) in between. After the 27th minute, a second warm-up for 3 minutes preceded the second Wingate bout for a total of six 30-second Wingate tests per session (Figure 1).
Figure 1: Representation for the Wingate test daily order (Al-Nawaiseh. 2016).
"All Wingate tests were performed using 7.5% of body weight as a resistance. The resistance was applied to the ergometer (E224 Monark) after a 10-second countdown. Participants used the countdown time to accelerate peddling speed. [...] Participants rated their RPE and muscle soreness sensation (pain) before and after each Wingate test. Muscle soreness was assessed using a 10-cm visual analog scale with anchor points “no pain at all” at the left end and “unbearable pain” at the right end. Rated perceived exertion was determined using a 6–20 point scale" (Al-Nawaiseh. 2016).
When they had volunteered for the study, all participants had been asked to quit any kind of exercise and all kinds of supplements 48 and 72 hours before exercise protocols, respectively.
Intense training sessions will always increase ALT, AST & CK - in some cases to extreme values that are 10-100x above "normal". Unfortunately doctors will never learn that in med-school and may misinterpret these changes as indicators of organ failure | learn more!.
Which markers of recovery are actually useful? A recent study from the Federal University of Uberlandia (UFU) in Brazil says (Bessa. 2016): "The best way to use biomarkers to monitor athletes is to perform a screening test like the test we have performed in this experiment, using the type and intensity of exercise commonly practiced by the athletes" (Bessa. 2016). Which test? Well, the study investigated CK, LDH, cardiac troponin T (cTnT), g-glutamyltransferase (gGT), and C-reactive protein (CRP), interleukin-6 (IL-6), MCP-1, and tumor necrosis factor (TNF)-alpha, the neutrophil to lymphocyte ratio, GPX, SOD, CAT, TAS and TBARS immediately before and 3, 6, 12, 24, 48, and 72 hours after exercise. The parameters the scientists consider most useful, however, were: (1) CK (not LDH) plus a differential analysis based on cTnT (cardiac CK), gGT (liver), hematocrit, and platelet levels that is used to make sure the increase in CK is coming solely from muscle damage and (2) the leukocyte to neutrophil ratio as a marker of the progress of the supercompensation process after workouts.
Accordingly, we can expect that the improved mean wattage in the supplement trial is the result of the wicked mix of antioxidants, pain killers, cold water immersion and whey the subjects had to stomach / endure.
Figure 1: The treatment (orange) ameliorated the decrease in mean and minimum power during the PM Wingate trial that was performed after the ingestion of antioxidants, ibuprofen, and whey and cold water immersion (Al-Nawaiseh. 2016).
What is quite surprising about these improvements is that they occured in the absence of reduced perceived pain scores / fatigue during the PM sessions. In conjunction with the lack of significant effects on muscle CK in the blood (not shown in Figure 2), this observation warrants the authors conclusion that the observed effects on the subjects' performance were "apparently not due to reduced muscle soreness or damage" (Al-Nawaiseh. 2016). That's in contarst to previous studies like
  • Pizza et al. (1999), who reported that similar ibuprofen doses lowered CK activity relative to a placebo 3 days after eccentric arm exercise, or
  • Tokmakidis et al. (2003), who found that ibuprofen doses (400 mg every 8 hours for 48 hours) did lower the non-athletic subjects' CK levels and reduced their muscle soreness, without, however, helping to restore muscle function compared with placebo.
Whether these difference are the mere result of differences in the way the exercise / tests were timed (vs. Pizza et al.) or differences in the training level of the subjects, as well as the exercise and testing protocols (vs. Tokmakidis et al.) will have to be tested in future studies.
Bottom line: As the scientists points out in the conclusion to their study, their results "suggest that although the combined use of ibuprofen, cryotherapy, vitamins C and E, and protein drink did not significantly help in protecting from muscle damage and soreness, the combination did help in restoring important muscle function and boosted short-term recovery from high-intensity anaerobic performance" (Al-Nawaiseh. 2016).

Using Ice / Cold Water Immersion After Workouts Will Impair Muscle and Strength Gains, as well as Vascular Adaptations | more
Practically speaking, athletes who compete in events that require repeated anaerobic performance (over 24h) should thus benefit from the combined use of antioxidant vitamins, an NSAID (ibuprofen), 10 minutes of lower body cold water submersion, and 23 g whey protein (10 g EAA).

What you should not forget, however, is the fact that at least 2 of the 4 'ingredients' of this 'recovery cocktail' have been shown to inhibit the long(er)-term adaptation to exercise. The chronic use of cold water immersion and high(er) doses of vitamin C + E in conjunction with exercise can thus not be recommended... and if you care about organ and cartilage health, the same goes for the use of NAIDs | Comment!
  • Al-Nawaiseh, Ali M., Robert C. Pritchett, And Philip A. Bishop. "Enhancing Short-Term Recovery After High Intensity Anaerobic Exercise." The Journal Of Strength & Conditioning Research (2015).
  • Bessa, Artur, et al. "Exercise intensity and recovery: Biomarkers of injury, inflammation and oxidative stress." J. Strength Cond. Res (2016).
  • Pizza, F. X., et al. "Anti-inflammatory doses of ibuprofen: effect on neutrophils and exercise-induced muscle injury." International journal of sports medicine 20.2 (1999): 98-102.
  • Toakmatidis, Savvas P., et al. "The effects of ibuprofen on delayed muscle soreness and muscular performance after eccentric exercise." The Journal of Strength & Conditioning Research 17.1 (2003): 53-59.