Inflammation = pain = take ibuprofen = reduced inflammation = reduced pain = yay!
Right?!
Given that you are about to read an article on this, you might have already guessed that things are not this simple. At least in the context of training.
Ibuprofen is just one example of an over the counter non-steroidal anti-inflammatory drug (NSAID). Depending on the report you read, up to 50% of elite and recreational athletes regularly take NSAIDs, most commonly Ibuprofen, to reduce pain and inflammation following training (see Warden 2010 and references therein). The question is whether this has a positive or negative impact on long term performance.
Inflammation and Training Adaptations
Training adaptations are a stress response. When you exercise, the body is put under stress. Training adaptations are simply the body making changes to ensure that if you do the same exercise again your body does not feel such high stress. So: if you repeatedly lift a heavy weight, your body makes changes in your muscle that make it strong … so if you lift that weight again it is no longer ‘heavy’ i.e. it no longer stresses the body so much. Your body is always seeking to remain comfortable!!
So, training adaptations rely on the body feeling stress and communicating it to the machinery that makes the training adaptations, e.g. builds muscle to make it stronger. The inflammatory response is part of the body feeling and responding to this stress. NSAIDs work by stopping the inflammatory response (Wikipedia has a great page on these drugs if you want to know more!). As such, it seems plausible that NSAIDs may prevent or reduce training adaptations.
But what does the research say? Most research to date has looked at the interaction between muscle hypertrophy and strength, and NSAIDs.
Certain studies have shown no effect, however it is typically those using low dose or selective NSAIDs (ibuprofen and other over the counter NSAIDs are typically non-selective) (Krentz et al 2008; Burd et al 2010; Paulsen et al 2010; Mikkelsen et al 2011). However, other studies have shown blunted muscle protein synthesis and related responses in response to resistance training when NSAIDs are taken (Trappe et al 2002; Mackey et al 2007; Mikkelson et al 2009; Markworth et al 2014; D’Lugos et al 2018). In addition, studies in vitro, in animals and some human studies have indicated an impairment of satellite cell recruitment or activation in response to training when NSAIDs are taken. Satellite cells are muscle precursor cells that are important for muscle repair and hypertrophy, being recruited particularly in highly trained individuals. From a functional perspective, more recently Lilja et al (2018) showed leg muscle hypertrophy and strength increases across an 8-week resistance training programme were blunted in individuals taking 3 x 400mg ibuprofen per day (1,200mg per day). It should be noted that this is well within the recommended daily dose to treat inflammation (200-400mg 4-6 x day, i.e. max. 2400mg per day).
Clearly, more research is needed! There are only a limited number of studies available and they are primarily in young healthy recreational athletes. Elite athletes have not been extensively tested. We know elite athletes have different physiology to recreational athletes and therefore the response to NSAIDs may differ. However, overall, I think the balance of evidence currently available indicates that chronic intake of NSAIDs can inhibit muscle hypertrophy and strength adaptations.
NSAIDs, Digestion and Nutrient Availability
The signalling molecules that NSAIDs block to reduce inflammation include molecules that have other functions in the body. Notably, platelet aggregation is reduced, there is increased gastric acid secretion, and reduced bicarbonate and mucus secretion. In addition, the NSAID itself can irritate the lining of the stomach. Together this can lead to gastric ulcers, bleeding along the digestive tract, nausea and diarrhoea. The longer and higher doses that are taken, the increased risk of these symptoms.
There is some evidence that risk of iron and vitamin C deficiency increases with NSAID consumption, which is likely the result of the blood losses and tissue damage. As athletes are already at increased risk of iron insufficiency due to higher red blood cell counts and turnover, requirements in energy metabolism and losses in sweat this impact may be significant. In addition, vomiting and diarrhoea reduces absorption of macronutrients, micronutrients and water. This can lead to reduced energy availability, further micronutrient deficiencies and dehydration. All of which may impact health and performance in training.
As such, individuals taking NSAIDs, particularly those taking maximal doses over a prolonged period, should pay careful attention to changes in bodyweight, hydration, energy levels during and after training, and indicators of iron insufficiency. If bodyweight drops consistently, pee is not straw coloured, energy levels are low, and there are signs of anaemia individuals should seek medical advice and consider the following dietary interventions:
Loss of bodyweight and reduced energy in training: increase protein and carbohydrate intake by 10%, assess impact over 1 week and continue to increase if losses persist.
Dark pee: Increase water intake and add salt to all meals, until pee is light coloured.
Signs of anaemia: Increase iron intake from food, for example by increasing red meat intake, and consume iron containing foods alongside vitamin C containing foods to support iron absorption in the gut.
Inflammation and Competition
All of the above is really thinking about NSAIDs in the context of long term adaptation to training. Competition is very distinct to training. The adaptations have already taken place and you now need to do everything you can to maximise performance in one or more events over a short time period. In this setting, reducing pain and inflammation through use of NSAIDs may enhance performance by enabling you to recover rapidly and push harder … particularly across multiday events as tissue damage and fatigue accumulate.
Pathological Inflammation
An inflammatory response to an injury, autoimmune reaction, pathogen or other adverse event may be causing trauma or greater harm to the body (see a medical professional). And / or inflammation related pain may be so great you cannot carry out your daily activities. In these cases, NSAIDs may well be necessary. If this is the case, by being aware of the potential impact on training adaptations and nutrient availability, you can better understand your performance in response to training and the changes you may want to make to your diet across this period.
Conclusion
Whilst more research is needed, the evidence indicates that NSAIDs can inhibit training adaptations in young healthy athletes, at least in response to resistance training. NSAIDs may also impact nutrient availability, which may further impact training and performance. Therefore individuals should weigh up the cost:benefit of taking these drugs in the short and long term. As ever, context is everything!
References and further reading …
Burd et al (2010). Effect of a cyclooxygenase-2 inhibitor on postexercise muscle protein synthesis in humans. Am J Physiol Endocrinol Metab. 298 (2): E354 – E361.
D’Lugo et al (2018). Prior acetaminophen consumption impacts the early adaptive cellular response of human skeletal muscle to resistance exercise. J Apply Physiol. 124 (4): 1012 – 1024.
Krentz et at (2008). The effects of ibuprofen on muscle hypertrophy, strength and soreness during resistance training. Appl Physiol Nutr Metab. 33 (3): 470 – 475.
Lilja, M et al (2018). High doses of anti inflammatory drugs compromise muscle strength and hypertrophic adaptations to resistance training in young adults. Acta Physiol (Oxf). 222 (2).
Mackey et al (2007). The influence of anti-inflammatory medication of exercise-induced myogenic precursor cell responses in humans. J Appl Physiol. 103 (2): 425 – 431.
Markworth et al (2014). Ibuprofen treatment blunts early translational signalling responses in human skeletal muscle following resistance exercise. J Apple Physiol. 117 (1): 20 – 28.
Mikkelson et al (2009). Local NSAID infusion inhibits satellite cell proliferation in human skeletal muscle after eccentric exercise. J Appl Physiol. 107 (5): 1600 – 1611.
Mikkelson et al (2011). Local NSAID infusion does not affect protein synthesis and gene expression in human muscle after eccentric exercise. Scand J Med Sci Sports. 21 (5): 630 – 644.
Paulsen et al (2010). A COX-2 inhibitor reduces muscle soreness, but does not influence recovery and adaptation after eccentric exercise. Scand J Med Sci Sports. 20 (1): e195 – e207.
Trappe et al (2002). Effect of ibuprofen and acetaminophen on post exercise muscle protein synthesis. Am J Physiol Endocrinol Metab. 282 (3): E551 – E556.
Warden, S.J. (2010). Prophylactic use of NSAIDs by athletes: A risk / benefir assessment. The phys and Sports Med. 38 (1): 1 – 7.
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