400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS

Delayed Onset Muscle Soreness (DOMS) in Athletes

Mechanisms, Prevention and Amelioration A Critical Review

Intro Elite, novice or amateur, a uniting factor amongst athletes is the experience of Delayed Onset Muscle Soreness (DOMS). Often described as pain of stiffness in the muscles affected, there is also muscle swelling, reduction in strength (indicating soft tissue damage) and reduced range of motion (1-3). This state of muscular hyperalgesia is brought on primarily by eccentric exercises(4). The resulting symptoms present in the 24hrs after exercise, tends to peak a week(5). While the DOMS persists an 48hrs and dissipate within

hle es perform nce will suffer(5). Due to this unfortunate

resulting effect of eccentric exercise there is a great volume of information attempting to explain and determine ways of mitigating the after effects of such training. Over the last century many theories have been presented as the possible physiological mechanism behind DOMS. We will examine those that the current literature deems plausible explanations of this condition, and will also cover some that have been disproved. In regard to the prevention and amelioration of DOMS, there are a vast array of treatments and interventions that are used in the belief that they will decrease recovery time, or ameliorate the pain of DOMS and thus allow peak performance sooner. The scope of this review is not so great as to be able to cover all suggested interventions. We will attempt to discuss those of the techniques which have received sufficient attention from researchers as to warrant an educated decision on their efficacy. The resulting conclusions will be of use to sport trainers, exercise professionals and health professionals in the context of design of training or rehabilitation to maximise performance while minimising symptoms of DOMS. It will also garner a further understanding of the condition for those involved in or interested in the aforementioned fields.

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400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS Proposed Mechanisms The exact mechanism behind DOMS has yet to be conclusively proven. There are still several popular theories. While all agree on the key points of symptom and effect the root cause still requires more research. The Great Lactate Myth - There is a common misconception within the general public that lactic acid is the bane of all athletes and the cause of DOMS. It is in fact an unrelated metabolite of exercise and only has its undeserved bad reputation from keeping bad company with Hydrogen ions (H+). H+ is known to irritate nerve endings within the musculature and produce acute symptoms of muscle fatigue. This has been found to be unrelated to the mechanism of DOMS (6, 7). Forced Separation of Actin-Myosin Bonds causing Mechanical Damage - Due to the nature of an eccentric contraction the myofibrils are mechanically separated (as opposed to the concentric contraction ATP regulated release) this is believed to result in damage to the sarcomeres(8). The damage to the tissue causes an inflammatory response in the muscle resulting in the swelling and increased sensitivity to pain. The physical damage to the muscle fibre explains the reduction in contractile ability. The symptoms of DOMS closely resemble those of soft tissue damage (7) as would be expected if this is indeed the mechanism. It has long been noted Creatine Kinase (CK) levels are raised in athletes with DOMS(9), which could be explained by such a breakdown of muscle fibrils. The increase presence of neutrophils also supports this theory s hey re he bodys natural response to the damage. Unfortunately the breakdown of the neutrophils drawn to the site of muscle injury results in the release of free radicals that can cause more injury to damaged myocytes, thus exacerbating the injury(6). This theory seems to currently have the most evidence and support from the professional community. Connective Tissue Damage As pain had been found to be most intensely localised to musculotendinous attachments(4) it has been theorised that DOMS is due to damage to the tendons 2 Alec Nethery 16107508

400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS connecting muscle to bone rather than the muscle structure itself. In this theory the pain is a result of swelling and its properties. This theory is supported by further study that found markers for connective tissue breakdown increased following eccentric exercise(10). However attempts to corroborate these findings have been inconsistent and there is now more consistent evidence supporting other mechanisms. Chemical Stimulation It has also been put forward that the DOMS reaction is in fact a reaction to CK (rather than CK being a by product of DOMS), or to some as yet unidentified metabolite (7). If the CK is irritating the afferent nerve endings within the muscle, without dissipating then this could initiate the reaction resulting DOMS symptoms(6).

Prevention and Amelioration of DOMS Repeated Bout Effect (and subsequent Cross Training effect) - Most research is aimed at speeding the recovery of the muscle of alleviating the pain experienced during DOMS. Research into Repeated Bout Effect (RBE) has however lead to discovery of an interesting effect. RBE studies have consistently shown that a muscle eccentrically exercised will be partially protected from the effects of DOMS should it be similarly exercised again in the following few weeks (1, 11) (up to 6 weeks). This effect has been observed across numerous studies and can be effectively included in a training plan to help reduce DOMS. It has been previously postulated that the initial bout of exercise results in the breakdown through mechanical stress of intrinsically weak muscle fibrils(1). With these fibres disposed of the secondary bout of exercise causes less damage and therefore less DOMS symptoms. This explanation is called in to question by a study that found evidence of repeated bout effect, not only as has been previously shown, within the original muscle group, but also in the corresponding contra-lateral muscle as well(11). This attenuation of recorded symptoms (loss of strength, pain, range of motion) 3 Alec Nethery 16107508

400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS in both limbs was backed up by surface electromyography demonstrating a reduction in medial frequency (20-30%) and points to a neural adaption rather than the elimination of weak myofibrils. It is worth noting that although the conclusion of neural adaption seems logical the authors have ruled out peripheral adaptations not through independent testing for this mechanism (i.e. MRI, biopsy) but through the results of studies focusing on a similar observed cross transfer phenomenon found in eccentric strength training. That being said, this study is more valid than many others in this field as its results can stand alone without relying on the subjective measures of pain or muscle soreness. There is little research available for cross transfer of RBE benefits and considering that some of what is available is inconsistent with these results more study is definitely necessary in this field. Stretching - Given the public acceptance and norm of stretching before, after or in the days following exercise it is surprising to note how little evidence there is behind this mainstream habit. In fact the evidence reviewed for this paper suggests that stretching does not provide any consistent or significant alleviation of muscle soreness due to DOMS. Several studies(4, 12) have found that, although people believe that stretching will reduce stiffness and soreness, when used as an intervention it is only marginally effective at best. In a recent large study(4) (n=2377) only 1 in every 13 participants experienced less bo hersome soreness following exercise if hey s re ched. Even then the relief was found to be, on average, .3 less on a 100 pt scale. This study lacked objectivity in fact it relied purely on self reporting by participants and had low validity in reference to DOMS symptoms in that it only examined muscular soreness and injury occurrence. However it is relevant to the athlete population as they recruited only active healthy adults as opposed to previous studies that did not impose such restrictions. Overall the results were in line with what previous studies had shown that there is little to no attenuation of DOMS symptoms to be gained through stretching. Compression Garments - Another increasingly popular treatment for DOMS is the use of compression garments. This technique is backed by numerous studies advocating their use in the recovery from DOMS. Graduated compression clothing can encourage venous return, prevent 4 Alec Nethery 16107508

400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS oedema and has been shown to reduce strength loss and muscular pain due to eccentric exercise(5). The mechanism of this occurrence is reported on in a Phosphorous magnetic resonance spectroscopy (31-PRMS) study of compression garments use in recovery from eccentric exercise, which examined the level of various metabolites(5). The study found that the compression effect was increasing the membrane turnover rate and therefore speeding recovery. This explanation however was based on the fact that a particular metabolite, phosphodiester (PDE), was alone elevated. It was concluded from previous studies of inflammatory, mitochondrial and metabolic myopathies which resulted in both increased membrane turnover and increased PDE that the presence of one indicated the other. This conclusion however cannot definitively be stated without further evidence. Despite this the testing confirmed the results of similar studies. An earlier study (2) showed that wearing a compression g rmen would promo e f s er recovery of force produc ion, prevent swelling and loss of elbow extension at rest in the exercised arm, and allowed subjects to re urn o d ily c ivi ies sooner. The last being a result of lower reported levels of muscle soreness. Another study of interest on this subject examined professional athletes in rugby(9) exclusively and showed very positive results for this intervention. Though their selection of high level athletes is laudable their protocols were not specific. The muscle stimulus was a regular competition game, this was not standardised in any way beyond the athlete being required to play a minimum 20mins of the match (of a possible 80). Also method of testing for recovery, Creatine Kinase (CK) level, was limited and open to confounding variables. CK is released not only due eccentric exercise but in soft tissue damage such as occurs in a regular tackle. Though the authors recognised this, they would not have been able to standardise the amount of hits a player took and would therefore not be able to determine how much CK build up was from in game injuries and how much from mechanical stress within the muscle. This calls for more specific testing of professional athletes in this field. The application times for the studies varied greatly with the more reliable results of the first two studies discussed being a result of constant wearing of the skins for 4-5 days and the less reliable

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400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS rugby study only having 12hrs application. Until further testing is done for this shorter time frame we would recommend application of at least 48 hrs (2, 5, 13) to observe benefits.

Other Therapies Massage is commonly used to alleviate DOMS but as with stretching there is little evidence supporting its effectiveness(14). While it has been shown to reduce pain there is not consistent evidence indicating any correlating improvement in muscular function. Cryotherapy and Thermotherapy have both received significant attention due to their perceived pain relief effects (14-16). There is however much contrasting evidence as to their usefulness. Some sources having found evidence of improved muscular function and others not only not finding improved muscular function but not even finding pain relief(17, 18). The conclusion drawn from these studies is that a standardised method for delivery should be determined for further testing. More research into the most effective duration and type of warm ups (13% decrease in discomfort for 10 mins(19)) would be beneficial.

Future Treatment? A 2010 study (7) determined that the substance Bradykinin (whose increase is known to correlate with early stages of DOMS) could be blocked with a receptor antagonist. If injected with said antagonist there was no evidence of muscular hyperalgesia post exercise. Bradykinin up regulates nerve growth factor (NGF) within muscle, if not blocked. The resulting sensitivity could then be reversed at peak levels of hyperalgesia (48hrs) with an injection of NGF antibodies. While this is an exciting direction for the research to be heading (it could necessitate the rejection of the current theories on the mechanisms behind DOMS) it is still in early stages of development. So early that the test subjects of this study were rats. With so little information currently available this cannot be taken as hard evidence on the subject but does serve to demonstrate the vast regions of this subject yet to be explored.

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400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS Conclusion In regard to mechanism we can only conclude that though there is significant data implying mechanical damage to the myofibrils due to high tension forced release, it is not yet definitively the mechanism. Other theories still persist and find support and will continue to do so until the mechanism can be observed or tested directly to determine cause. Until the mechanism can be fully understood it will remain difficult to prescribe fully effective treatments. Currently the most effective method to reduce the severity of DOMS in athletes is use of the RBE within a training schedule. Warming up has also been suggested as effective though not to a great degree. Cool downs and Stretching were shown to have no effect on DOMS. Areas such as massage, Cryotherapy and thermotherapy warrant further attention as to whether they can be utilised to promote muscular function recovery, rather than just pain relief.

Alec Nethery 16107508

400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS References 1. Starbuck C, Eston R. Exercise-induced muscle damage and the repeated bout effect: evidence for cross transfer. European Journal of Applied Physiology. 2012;112(3):1005-13. 2. Kraemer WJ, Bush JA, Wickham RB, Denegar CR, Gomez AL, Gotshalk LA, et al. Influence of compression therapy on symptoms following soft tissue injury from maximal eccentric exercise. Journal of Orthopaedic & Sports Physical Therapy. 2001;31(6):282-90. 3. Slater H, Arendt-Nielsen L, Wright A, Graven-Nielsen T. Effects of a manual therapy technique in experimental lateral epicondylalgia. Manual therapy. 2006;11(2):107-17. Epub 2005/05/26. 4. Jamtvedt G, Herbert RD, Flottorp S, Odgaard-Jensen J, Havelsrud K, Barratt A, et al. A pragmatic randomised trial of stretching before and after physical activity to prevent injury and soreness. British journal of sports medicine. 2009;44(14):1002-9. 5. Michael I. Trenell KBR, Carolyn M. Sue and Campbell H. Thompson. COMPRESSION GARMENTS AND RECOVERY FROM ECCENTRIC EXERCISE: A 31P-MRS STUDY. JSSM. 2006;5(1):106-14. 6. Macintyre D, Reid W, Lyster D, McKenzie D. Different effects of strenuous eccentric exercise on the accumulation of neutrophils in muscle in women and men (Differents effets d'un exercice excentrique epuisant sur l'accumulation de neutrophiles dans le muscle des femmes et des hommes). European Journal of Applied Physiology. 2000;81(1-2):47-53. 7. Murase S, Terazawa E, Queme F, Ota H, Matsuda T, Hirate K, et al. Bradykinin and nerve growth factor play pivotal roles in muscular mechanical hyperalgesia after exercise (delayed-onset muscle soreness). The Journal of neuroscience : the official journal of the Society for Neuroscience. 2010;30(10):3752-61. Epub 2010/03/12. 8. Loram LC, Mitchell D, Fuller A. Rofecoxib and tramadol do not attenuate delayed-onset muscle soreness or ischaemic pain in human volunteers. Canadian Journal of Physiology & Pharmacology. 2005;83(12):1137-45. 9. Gill ND, Beaven CM, Cook C. Effectiveness of post-match recovery strategies in rugby players. British journal of sports medicine. 2006;40(3):260-3. Epub 2006/03/01. 10. Hotta N, Sato K, Zhihu S, Katayama K, Akima H, Kondo T, et al. Ventilatory and circulatory responses at the onset of exercise after eccentric exercise. European Journal of Applied Physiology. 2006;97(5):598-606. 11. Howatson G, van Someren K. Evidence of a contralateral repeated bout effect after maximal eccentric contractions. European Journal of Applied Physiology. 2007;101(2):207-14. 12. Pope RP, Herbert RD, Kirwan JD, Graham BJ. A randomized trial of preexercise stretching for prevention of lower-limb injury. / Protocole randomise d'etirement avant l'exercice pour la prevention des blessures des membres inferieurs. Medicine & Science in Sports & Exercise. 2000;32(2):271-7. 13. Jakeman J, Byrne C, Eston R. Lower limb compression garment improves recovery from exercise-induced muscle damage in young, active females. European Journal of Applied Physiology. 2010;109(6):1137-44. 14. Farr T, Nottle C, Nosaka K, Sacco P. The effects of therapeutic massage on delayed onset muscle soreness and muscle function following downhill walking. / Effets du massage therapeutique sur la douleur musculaire differee et la fonction musculaire suite a une marche en descente. Journal of Science & Medicine in Sport. 2002;5(4):297-306. 15. Goodall S, Howatson G. The effects of multiple cold water immersions on indices of muscle damage. Journal of Sports Science & Medicine. 2008;7(2):235-41. 16. Vaile JM, Gill ND, Blazevich AJ. THE EFFECT OF CONTRAST WATER THERAPY ON SYMPTOMS OF DELAYED ONSET MUSCLE SORENESS. Journal of Strength & Conditioning Research (Allen Press Publishing Services Inc). 2007;21(3):697-702.

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400888 Assignment 1 Critical Literature Review Mechanism, Prevention and Amelioration of DOMS 17. Minder PM, Noble JG, Alves-Guerreiro J, Hill ID, Lowe AS, Walsh DM, et al. Interferential therapy: lack of effect upon experimentally induced delayed onset of muscle soreness. Clinical Physiology & Functional Imaging. 2002;22(5):339. 18. Craig JA, Barron J, Walsh DM, Baxter GD. Lack of effect of combined low intensity laser therapy/phototherapy (CLILT) on delayed onset muscle soreness in humans. Lasers Surg Med. 1999;24(3):223-30. 19. Law RY, Herbert RD. Warm-up reduces delayed onset muscle soreness but cool-down does not: a randomised controlled trial. Aust J Physiother. 2007;53(2):91-5.

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