Do you need to treat muscle pain?

‍What is muscle pain and when does it occur?

Muscle pain is the sensation of discomfort and tenderness in muscles. The intensity of the pain sensation peaks between 24 and 48 hours after exercise activity and eventually disappears completely after 5 to 7 days. [1,2] Muscle pain is a subjective and individual sensation and ranges from muscle tenderness to pain that interferes with daily activities. In other words, one day after your workout, you slightly feel that your muscles are locally sensitive to touch or tighten. Or you can't brush your hair anymore because your biceps cramp with every minimal movement, and sitting on the toilet after legday is tantamount to falling to the glasses. Because muscle pain does not occur immediately but is delayed after a workout, it is called Delayed Onset Muscle Soreness (DOMS). DOMS mainly occurs at the transition from muscle to tendon, the primary site for power transfer, and then spread through the muscle. [2]

How muscle pain occurs is not entirely clear. Various theories describe the possible causes, of which no one theory can explain the whole. Researchers have therefore proposed that a combination of these theories is best suited to explain the development of muscle pain. In short, an unknown training stimulus leads to a mechanical and biochemical disruption in the muscle cell (muscle damage). The immune system responds to the resulting damage to muscle fibers and connective tissue, causing inflammatory activity after a few intermediate steps, causing edema, stimulating sensory nerves and causing DOMS. [2—4] Mainly eccentrically oriented contractions lead to muscle pain, although concentric contractions can also cause muscle pain to a lesser extent [2.5].

How do we measure muscle pain?

Pain is a subjective phenomenon and with the same objective damage to the body, individuals can experience varying degrees of pain. Without damage, you can experience pain, and with damage, you cannot experience pain. Mood, environment, and experience are some of the variety of variables that influence the sensation of pain. [6] This means that pain is a complex construct to measure and may be subject to placebo effects [7]. Muscle pain is usually measured using a visual-analog scale (VAS). Muscle damage is often measured by the presence of indicators in the blood. Creatine kinase (CK), C-reactive protein (CRP), and interleukin-6 (IL-6) levels are increased due to muscle damage and are associated with the presence of DOMS. [3]

What is an unknown training incentive?

A new training stimulus means an exercise you've never done before, an exercise you haven't done for a while, suddenly increasing the training volume and training to failure. Even a change in the position of the barbell can lead to muscle pain. A high bar back squat is not the exact same movement as a low bar back squat, although they are both squat patterns. Eccentric contractions (downward phase biceps curl) lead to more muscle pain than concentric contractions (ascending phase biceps curl). This is in line with muscle damage, which follows the same pattern. Exercises that provide a large amount of tension, when the muscle (s) are stretched, lead to muscle pain more quickly and are more sensitive to changes in volume. An example is performing a dumbbell chest fly with a full range of motion (ROM). Shoulder muscles do not easily end up in such a stretch position due to strength training. Therefore, few people complain about severe muscle pain in their shoulders.

The protective effect of training

After a repeated training stimulus, muscle pain will decrease. Your body is, as it were, armed against muscle pain. This is called the repeated bout effect (RBE) and occurs after just a single training session. [8] You will experience less muscle pain if you perform an exercise more often. Exercise is no longer unknown to your body. Muscle pain may continue to occur to a lesser extent, especially when using high intensities [8]. The protective effect is temporary and disappears when you don't exercise for a few weeks [8,9]. This is why you experience muscle pain after your vacation, while doing the same exercises you did before the vacation.

What are the consequences of muscle pain?

Researchers argue that muscle pain, in association with damage to muscle and connective tissue, leads to changes in kinematics, a limitation in ROM, a loss of strength and changes in the control and activation of muscle fibers [2,4]. The greatest amount of loss of strength occurs in the first hours after training, while muscle pain only sets in later. It is likely that the immediate loss of strength is due to damage to proteins that help control muscle fibers [10]. However, the swelling that occurs as a result of damage, and is related to muscle pain, appears to slow recovery from loss of strength [11]. DOMS reduces the capacity to absorb shocks, which is a risk factor for athletes who perform plyometric activities. As a result of muscle pain, compensatory behavior can occur in another part of the muscle or other muscles. As a result, other tissue structures face an unknown load. An athlete himself may have an incorrect perception of these changes. An overestimation of strength and decreased proprioception have been observed in studies involving athletes. [2] In summary, muscle pain may be a risk factor for developing an injury.

What techniques are there to treat muscle pain?

Improving recovery after training is one way to positively influence performance [12]. In addition, muscle pain apparently has a number of potentially negative consequences. It is therefore only logical that methods have been devised to treat muscle pain. The idea is that the negative consequences can be prevented or mitigated and improve performance. However, it is already clear in advance that this is a difficult task. When there is uncertainty about the origin of DOMS, can we come up with suitable treatments for it? By the way, this does explain the diversity found in review articles about treatments for DOMS [2,3].

To find out whether a treatment method is effective, we need to examine the mechanism of action and review relevant studies. Outcome measures are often a reduction in pain visible on a VAS and reductions in blood concentrations of CK, CRP or IL-6. In general, treatments aim to reduce muscle damage and inflammatory activity. The mechanism behind this is a limitation of the available space for swelling and edema. This allows the transport of metabolites, neutrophils and damaged proteins from the muscle into the blood better. [3] In this article, we focus mainly on treating muscle pain, with the awareness that this cannot be completely decoupled from muscle damage.

Before diving deeper into a number of possible treatments, let's summarize what we've found so far.

• The experience of muscle pain is subjective, but it is measurable
• The consequences are an increased risk of injuries, mainly due to the compensatory behavior of other muscles and impaired neural control.
• The RBE protects your body against future muscle damage and pain.
• Treatments for muscle pain focus on accelerating the removal of waste products in the muscle, reducing edema and swelling, and reducing pain sensation.

Massage

What is the mechanism of action?

Massage as a treatment for muscle pain would be effective because massage increases skin and muscle temperature, stimulates blood and lymph flow and leads to increased parasympathetic activity [2]. Improved blood flow ensures a faster removal of biochemical markers (including CK) of muscle damage. An increase in oxygen-rich blood to the affected area leads to a decreased production of prostaglandins, causing less pain and reducing the ROM. In addition, the supply of oxygen-rich blood would stimulate the restoration of ATP renewal in the mitochondria and the active transport of calcium. The accumulation of calcium in the muscle cell is probably the biggest cause of loss of strength in muscle damage. A reduction in calcium accumulation could probably limit loss of strength. Finally, massage has a psychophysiological effect because you relax, improve your mood and thus reduce fatigue [13].

What research results are there?

A somewhat older review shows varying results of massage on blood flow. The variety of massage techniques, duration and timing in research are likely to lead to this conclusion [2]. However, two recent reviews with meta analyses conclude a clear positive effect of massage on muscle pain [3,13]. A review of randomized intervention studies by Guo and colleagues shows a strong effect of massage on muscle pain rating. Especially between 48 and 72 hours after training, massage seems to be most effective. They also observed an effect of massage on maximum isometric strength, which was greatest 72 hours after training. Creatine kinase levels were lower between 48 and 72 hours after training in people who had received a massage. However, the reviewers rightly conclude that the quality of the included studies is poor. [13] Dupuy and colleagues investigated the effect of various recovery therapies on muscle pain and relevant blood parameters in their meta-analysis review. A massage immediately after training had the greatest effect on muscle pain and lasted up to 96 hours after training. In addition, they observed an effect of massage on IL-6 and CK levels at 72 and 96 hours after training. [3]

What is the verdict?

Massage seems to have a good and long-lasting effect as a therapy for muscle pain. If you want to experience less muscle pain, massage is probably the best therapy. However, this will have to take place shortly after the training session. When you perform multiple training sessions per week, this quickly becomes a waste of time. Or your mother-in-law just happens to be good at massaging.

Compression clothing

What is the mechanism of action?

Due to the compression on the limbs, there is less room for swelling and edema. The supply and supply of blood and waste products can take place better, so that, in theory, less muscle pain should occur. [3,14]

What research results are there?

There are varying research results, which will mainly have to do with the prior intensity of training protocols. A review saw a clear effect of wearing compression clothing on the muscle pain experienced. This effect was most visible between 72 and 96 hours after training. This review found no effect of compression garments on indicators of muscle damage. [3] An intervention study shows no effect of wearing compression socks on the muscle pain experienced after eccentric calf training [14].

What is the verdict?

Compression garments can be a way to experience less muscle pain, although the results are very variable. The effect of compression clothing is smaller than massage, but is, on the other hand, a cheaper therapy.

Cryotherapy

What is the mechanism of action?

Cold therapies come from the RICE line of thought; Rest, Ice, Compression and Elevation. The idea is that exposure to cold causes a drop in the temperature of the skin and subcutaneous tissue. In cryotherapy, the body is briefly exposed to very cold air (-30 to -140 degrees). Receptors in the skin then activate nerve fibers that narrow local arterioles and venules. This means less swelling, lower inflammatory activity, lower vascular permeability, and less oedema. [2,12]

What research results are there?

Studies show varying results, mainly due to the heterogeneity in the applied methodology. The temperature, duration, timing and frequency of treatments may influence the effectiveness. In their review study, Costello and colleagues conclude that there is not enough evidence to recommend cryotherapy for the treatment of DOMS [15]. A recent review only found an effect of cryotherapy on muscle pain immediately after training and up to 6 hours after training. No effect was seen at later times. [3]

The influence of cold therapies on muscle growth has been considered in other studies and appears to be negative [16—18]. Due to the drop in temperature and reduced blood flow to the muscles, the signal for muscle growth is attenuated.

What is the verdict?

Due to the different results of research, it is unclear whether cryotherapy has a positive effect on muscle pain. Other therapies that use cold seem to dampen the signal for muscle growth. Whether this counts for cryotherapy has not been immediately investigated, but it is nevertheless plausible. So you may have less muscle pain, but also less muscle growth. No one probably wants to make that trade-off. In short, the therapy may be effective, but the therapy has an undesirable consequence such as muscle growth the goal is.

(Cold) Immersion

What is the mechanism of action?

Taking a bath would lead to reduced inflammatory activity, less muscle damage and therefore less muscle pain. The pressure of the water stimulates the transport of fluid from the muscle to the blood. As a result, metabolites are removed more quickly. Cold immersion has an anesthetic effect and veins constrict (vasoconstriction) due to the low temperature. This can reduce edema because less fluid enters the muscle in the interstices. Less oedema will lead to a reduced inflammatory response and therefore a lower pain sensation. [3,16]

What research results are there?

A recent review only saw an effect of immersion on inflammatory activity at temperatures below 15 degrees. Although this effect depended on the duration, water temperature, and type of training prior to therapy. This review observed a small effect of immersion on muscle pain and CK values, but no effect on CRP and IL-6 values. Previous studies observed a greater effect on DOMS, which may be explained by the diversity in the therapy used. [3] Cold immersion may reduce the signal for muscle growth. The protein balance is negatively affected by a lower protein structure [16—18]. A recent and well-designed study concludes that cold immersion leads to reduced growth of type 2 muscle fibers, although it did not inhibit an increase in strength. This can be explained by the fact that strength has a major neurological component, which is apparently not affected by cold immersion [17]. Another study investigated the mechanism by which muscle growth can be inhibited by applying two weeks of cold immersion and measuring protein synthesis. The researchers concluded that the cold has a direct negative effect on the build-up of protein elements in the muscle [18].

What is the verdict?

A wide variety of how immersion is applied probably explains the discrepancies in the results. There does seem to be a small effect of cold immersion on muscle pain, so this therapy cannot be ruled out as a potential option. The danger, however, lies in the long term, with cold immersion dampening the signal for muscle growth. As a result, this therapy is not recommended when building muscle mass is the goal.

Contrast water therapy

What is the mechanism of action?

Contrast water therapy alternates between bathing in hot and cold water. This stimulates both the widening (vasodilation) and narrowing (vasoconstriction) of veins and thus limits edema, inflammatory activity and may reduce the sensation of pain. [3]

What research results are there?

A review observed a small effect on muscle pain and a decrease in CK levels in the blood [3].

What is the verdict?

A small effect may be enough reason to give this form of therapy a chance. The application is fairly simple and can probably be done in the shower. However, exposure to cold is not without its drawbacks. The signal for muscle growth could be attenuated. As we explained in cryotherapy and cold immersion, this is probably not worth the trade-off.

Stretching

What is the mechanism of action?

Extensive and prolonged stretching reduces the tension in a muscle-tendon unit at a given length. The muscle-tendon unit is viscoelastic and will slowly lengthen under constant tension, which is called creep. When the muscle-tendon unit is stretched and held to a new length, the tension will decrease. This is called stretch relaxation. Because of these properties, stretching would in theory lead to less muscle damage during eccentric contractions, provided the stretch is applied for more than 6 seconds. [2]

What research results are there?

In the past, research has shown mixed results when stretching was used to prevent or treat muscle pain. A recent review saw no effect of stretching on muscle pain and blood parameters for muscle damage. By the way, stretching itself can also cause muscle damage or muscle pain. An increase in CK values after a heavy stretching session [2] and the increase in muscle pain after training due to stretching [3] confirms this.

What is the verdict?

Stretching muscles does not appear to be a way to reduce muscle pain. If you're unfamiliar with stretching, it could actually cause muscle pain.

Vibration

What is the mechanism of action?

In vibration therapy, the body is partially or completely exposed to a repetitive force. Muscles then tighten and relax at a rapid pace. In daily life, you are exposed to various forms of vibration, such as in a train or bus. Vibrating platforms are used to train the body with both static and dynamic movements. Vibration therapy before training improves muscle spindle activity and muscle pre-activation. This results in a lower threshold for motor neurons to control muscle fibers. As a result, a larger pool of muscle fibers is used during training and less muscle damage occurs. Vibration therapy after training could reduce the pain sensation by directly affecting the sensitivity of nerve endings or by removing waste products into muscle more quickly. [19]

What research results are there?

A review observed an effect of vibration therapy on muscle pain 24, 48, and 72 hours after training. The researchers also saw an effect on CK levels 24 and 48 hours after training. The effect on both outcomes peaked 48 hours after training. The studies included in this review are of poor quality and varied in their approach [20].

What is the verdict?

Vibration therapy is a potential option for reducing muscle pain. However, more qualitative experimental studies are desirable [20]. It is unclear what the effect is on performance and muscle growth, including possible negative effects. In addition, it is unclear which application and timing of vibration achieves the best effect [19]. At the moment, there is simply not enough information to give advice.

Active recovery

What is the mechanism of action?

It seems special to mention exercise as a treatment for muscle pain due to movement. But there is definitely a good theory behind it. Exercise is very effective in relieving muscle pain in the short term [2]. Just think of the enormous muscle pain you experience in your legs when you've been sitting still for a while on the day after your leg workout. As soon as you start walking, the muscle pain subsides slightly. Increased blood flow, elimination of waste and/or increased endorphin release may explain this effect [3].

What research results are there?

A review confirms the short-term effect of exercise. Up to six hours after training, active recovery was effective for relieving muscle pain, but this was no longer the case in all hours afterwards. However, research shows no decrease in CK, IL-6 and CRP levels as a result of active recovery [3].

What is the verdict?

Active recovery is a way to reduce the feeling of muscle pain for a short time. It probably won't be able to do more than that for you. If you experience a lot of muscle pain, exercise is a quick but short-term solution.

Anti-inflammatory drugs

What is the mechanism of action?

Based on the belief that increased inflammatory activity and edema contribute to the development of muscle pain, anti-inflammatory drugs have been suggested as treatment. A common example is ibuprofen. Anti-inflammatory drugs inhibit the enzyme cyclooxygenase (COX), which converts arachidonic acid to prostaglandins [4]. Prostaglandins sensitize nerve endings, which can cause pain. The intake of anti-inflammatory drugs leads to a reduction in the inflammatory response and edema and therefore to a reduction in pain [2].

What research results are there?

The effectiveness of anti-inflammatory drugs shows mixed results in research. A distinction can be made between taking anti-inflammatories before training, after training, or both. In particular, taking anti-inflammatory drugs proactively seems to be the most effective. [2]. Although anti-inflammatory drugs appear to work for what they were designed to do, chronic use can have a negative effect on muscle growth. COX may play an important role in muscle growth, so limiting COX activity may be counterproductive. [4]

What is the verdict?

Although anti-inflammatory drugs have no negative effect on muscle growth in the short term, this is unclear for the long term. Taking an anti-inflammatory drug to treat muscle pain is probably not problematic for a few times and may alleviate the pain sensation. Possible side effects of anti-inflammatory drugs include gastrointestinal problems. The potential disadvantages outweigh the advantages.

Antioxidants

What is the mechanism of action?

Every form of training leads to oxidative stress due to the high processing of oxygen, resulting in the production of free radicals. Oxidant intake could reduce oxidative stress by reducing the concentration of free radicals. [21]

What research results are there?

A very complete and recent review looked at the effect of antioxidants on muscle pain. A total of 50 studies were reviewed and reviewed. Muscle pain was measured from 6 to 96 hours after exercise. Antioxidants have an effect on muscle pain, but this effect is so small that it is not relevant in practice. This was the case at every measured time. The overall evidence is of low to medium quality, which makes the results less reliable. [21] Turmeric is worth mentioning separately. A well-designed experimental study shows a clear effect of turmeric supplementation on muscle pain, provided it is taken 7 days after training [22]. High doses of antioxidants can cause side effects such as gastrointestinal problems, but this is very rare [21]. In addition, there is a possibility that high doses of antioxidants interfere with signaling for muscle growth. While this is primarily theoretical, the slight positive effect of antioxidants on muscle pain will not be worth the potential trade-off. [23]

What is the verdict?

Taking antioxidants to treat muscle pain provides an effect that is so small that it is not relevant in practice. Turmeric supplementation offers more perspective, but it is not clear what the long-term consequences of a high intake are.

RBE as a therapy for muscle pain

The repeated bout effect is the best therapy for muscle pain, with the advantage that the body realizes this itself. If you give the same training impulses, they will eventually no longer lead to the same muscle pain as in the beginning. You experience the most muscle pain when introducing new exercises or by rapidly increasing training volume. However, some exercises always seem to generate muscle pain, which is related to a high peak load during a stretch phase. Like a Romanian deadlift, for example. The RBE is temporary and will need to be maintained to benefit from it. Not exercising for four to 12 weeks may lose the effect [8]. So you can positively influence muscle pain by letting the RBE work for you. This means that you do not change exercises unnecessarily often and do not aggressively open the volume button. Complex exercises should be included in your program for at least 10 weeks. You can alternate simple isolation exercises more often, but at least 5 weeks is preferred. In addition, you can use an introduction week when you start a new schedule so that you are not overloaded with tons of muscle pain [24].

The limitations of research

Overview studies show a high degree of heterogeneity in the results. This means that many different treatment protocols are used in research. This is logical, because there are many ways to apply treatments. This includes frequency, timing, duration and the implementation of the treatment [3.7]. In addition, the effect of a therapy will be more visible when the training prior to therapy is intensive. If you trick someone with all kinds of eccentrically oriented training protocols, a therapy will take effect more quickly. In research, this is a good way to statistically see an effect. The question is whether this is a representation of reality. In reality, not every workout does you inflict so much muscle damage on yourself. In addition, the RBE will do its job when you perform exercises multiple times.

In addition, it is important to understand that the studies discussed look at an effect of therapies on muscle pain and indicators of muscle damage. These studies are not looking at an effect of these therapies on performance or muscle growth. It is therefore not possible to draw conclusions about possible performance improvements from these studies. The effect on performance and muscle growth is another research question that requires a different approach. A 2020 review observed no effect of massage on strength, jump strength, sprint performance or endurance, while massage does have an effect on muscle pain [3.7]. An effective therapy for muscle pain therefore does not necessarily translate to performance improvements. In fact, it can even lead to reduced performance. We see that reflected in research by. Cold water therapies are effective for treating muscle pain but attenuate the signal for muscle growth [16—18]. And that's exactly what you don't want. On the other hand, it cannot be ruled out that the treatments discussed may have an effect on muscle pain and perhaps on sports performance in some way. At the moment, however, there seems to be little evidence for the latter. It is also not ruled out that there are a range of other potentially effective treatments. More research is needed to fill the gaps in our knowledge.

Conclusion

Muscle pain is a common consequence of unknown training stimuli. Muscle pain can lead to a loss of strength, ROM and changes in the control of muscle fibers. Some therapies for treating muscle pain are effective, although the majority are not. Some treatments only help with muscle pain, and others reduce the underlying inflammatory activity. It is precisely treatments that influence inflammatory activity that appear to have a negative effect on muscle growth by suppressing protein synthesis. The big question is whether you should even use muscle pain treatments in your current training protocol. In particular, you experience muscle pain when there are unknown training stimuli. This is the case when you; have not trained for a while, introduce new exercises or suddenly start training a lot more. You manage these variables by following a somewhat logical and structured training program so that the RBE can enter. In that case, you will not cause excessive amounts of muscle pain. Moreover, it is not necessary to make big steps in training volume or intensity to make progress. If your training program is a series of unknown training stimuli, treating muscle pain is pointless. Logically structuring your training schedule is the solution and it's best to invest your energy there. Nevertheless, there will be situations where you experience muscle pain, that's simply part of the game. If you want to reduce pain, massage is probably your best option. Active recovery can relieve your muscle pain in the short term. Therapies that expose you to cold are better avoided because of the negative effect on muscle growth. Improving sports performance through therapies that relieve muscle pain is not plausible given current evidence.

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