Dietary supplementation for reduction of muscle soreness during physical therapy: Case report
Author(s): Dennis R. Sparkman
Vol. 2, No. 3 (2008-07 - 2008-09)
Dennis R. Sparkman
Southwest Immunology, Inc. Ennis, TX 75119 USA
Abstract
Objective: The current literature offers ample evidence to
support the use of amino acid therapy to prevent muscle
soreness following overuse and to help maintain and restore
muscle tissue following prolonged periods of inactivity. The
purpose of this case report is to demonstrate that a
carbohydrate-amino acid supplement can safely be used
during physical therapy to prevent muscle soreness.
Methods: A 74-year old female underwent elective hip
replacement surgery followed by a week of rehabilitative
physical therapy. The patient elected to use a carbohydrateamino
acid supplement as a means to prevent muscle
soreness following physical therapy and consented to
observation.
Results: During the course of physical therapy the patient
reported no muscle soreness on the days following therapy
while using the carbohydrate-amino acid supplement. The
one occasion where the supplement was not used following
physical therapy, noticeable discomfort due to muscle
soreness was reported.
Conclusions: This case report supports the use of
carbohydrate-amino acid supplementation to prevent
muscle soreness while restoring lean muscle and strength
following physical therapy, even though definite conclusions
cannot be drawn from a single case report design. Current
literature in conjunction with this case report supports the
need for properly designed studies to further investigate
the therapeutic benefits of a carbohydrate-amino acid
supplement as an adjunct to physical therapy and
rehabilitation.
Key Words: Dietary Supplements, Physical Therapy
Modalities, Inflammation, Muscles, and Amino Acids.
Introduction
Following any unaccustomed or prolonged use of the
muscles that leads to overuse will inevitably result in muscle
soreness. This muscle soreness is referred to as delayed
onset muscle soreness or DOMS.1,2 Because DOMS is not
a direct manifestation of the resulting disruption of the
contractile component of the muscle tissue and muscle
membranes, the soreness is not felt immediately. DOMS
is a symptom of the damage that occurs when soluble
muscle proteins leak into the extra cellular space resulting
in local inflammation and the muscle swelling that ensues.
Peak levels of DOMS have been shown to coincide with
peak levels of edema.3,4 For this reason, the soreness
begins to develop gradually following exercise and can last
for several days. Although this muscle soreness is most
often associated with athletic training, it can affect anyone,
especially persons undergoing physical therapy. Because
DOMS can have a negative impact on muscle function and
reduce one’s ability to perform physical activities, it can
curtail further physical activities for days. For the patient
requiring physical therapy following surgery or an injury,
the muscles can be weakened and/or atrophied from
physical inactivity. Such a scenario makes the patient an
ideal candidate for experiencing DOMS during physical
therapy, even though physical therapists strive to manage
therapy intensity to maintain a balance between strength
gains and muscle soreness. For this reason, finding an
effective intervention to prevent or reduce DOMS while
helping to rebuild atrophied muscles would facilitate a
patient’s physical therapy and recovery.
The role of oral supplementation of amino acids in the
prevention of DOMS is a field of interest for nutritional
science that has a direct and practical application in the
field of sports medicine. Oral supplementation with 77 mg/
kg branched chain amino acids (BCAA) before exercise
has been reported to suppress endogenous muscle protein
breakdown.5 This finding was corroborated in another study
whereby giving 100 mg/kg of BCAA before, during and after
exercise showed a protein sparing effect on muscle
proteins.6 Supplementation with 12-g/day BCAA for 2 weeks
plus 20 g before and after exercise reduced serum creatine
phosphokinase (CPK) for several days following exercise.7
A recent study that investigated administering 5 g BCAA
before exercise noted a reduction on DOMS for several
days following exercise.8 Previous studies have shown that
administering 40 g EAA after exercise results in a change
from net protein degradation to net protein synthesis.9
Carbohydrate-amino acid mixtures have also recently been
shown to help reduce muscle soreness. When a liquid
carbohydrate beverage was consumed 10-minutes before
and immediately after exercise, it resulted in a more
favorable anabolic response, although it did not alter the
catabolic response.10 When a solution of 8% carbohydrate
+ 2% protein was consumed immediately following exercise,
there was a perceived reduction in soreness among
athletes.11 Administration of a 6% carbohydrate solution
containing 6 g EAA during weight resistance exercise
suppressed cortisol release, stimulated insulin release and
reduced myofibrillar protein degradation12,13 and increased
the anabolic response.14
Mixtures of amino acids have also been reported to reduce
DOMS. Mixes of amino acids have been shown to reduce
serum CPK activity following exercise.15,16 When an amino
acid mixture containing 60% essential amino acids was
given at a total daily dose of 7.2 g twice daily on the day of
exercise and for 4 days following exercise, there was a
statistically significant reduction in both serum CPK levels
and DOMS in the days following exercise.17
A recent study has described the use of beta-hydroxy-betamethylbutyrte
(HMB) in the prevention of DOMS. In this
study administration of 3g HMB/0.3g KIC for 14 days prior
to a single bout of eccentric resistance training determined
that CPK and DOMS were significantly reduced after 14
days supplementation with HMB/KIC compared to
controls.18 One previous study looked at the effects of short
term HMB supplementation on eccentric resistance training
found that six days supplementation with 40 mg/kg HMB
did not reduce DOMS after a single bout of exercise.19
This case report examines the role for using a carbohydrateamino
acid supplement containing HMB in the prevention
of muscle soreness during post-operative physical therapy.
Patient and methods
The patient was a 74-year old Caucasian female who had
undergone elective left hip replacement. She was 5 feet 8
inches tall, weighed 175 lbs.
The patient had become progressively immobile over a
period of approximately 2-years due to the degenerative
left hip. At the time of surgery, the patient was barely able
to walk across the room without having to stop to sit and
rest. Because a great deal of her time was sedimentary,
she had become weak and lost muscle strength.
The patient requested to be provided with a sample of a
patent-pending carbohydrate-amino acid dietary
supplement that was designed to prevent or significantly
reduce muscle soreness following muscle overuse. Her
intention was to use the product during her physical therapy
to aid in reducing muscle soreness and to help regain
muscle strength. Her request was granted and in return
permission was obtained from the patient to observe and
interview her during the physical therapy.
The patient used a pre-production sample of a
carbohydrate-amino acid dietary supplement. A single
serving of the supplement contained 44 g of a proprietary
blend which consisted of sucrose, maltodextrin, calcium
beta-hydroxy-beta-methylbutyrate, L-leucine, Lphenylalanine,
L-lysine, L-threonine, L-valine, L-histidine,
L-isoleucine, L-methionine). Among the eight essential
amino acids, 40% was made up of the branched chain
amino acids. The recommended serving of approximately
50 g was mixed with 500 ml of water and consumed
immediately following physical therapy.
Results
Following a successful hip replacement and recovery, the
patient was moved from the hospital on the fifth day to a
local rehabilitation center in the Southwest United States.
On the seventh post-operative day, physical therapy was
started and consisted of hip abductions, hip extensions,
knee raises, knee flexions, ankle pumps, bed supported
knee bends and straight leg raises. As therapy progressed,
rubber bands were added to add resistance to the exercise
routine.
Immediately following each physical therapy session, the
patient consumed one dose of the carbohydrate-amino acid
supplement. Each day prior to physical therapy the patient
was asked to rate the level of muscle soreness in her legs
from the previous day’s therapy using a visual analog scale
(VAS) of 1 to 10 with one being no soreness and ten being
the most severe soreness. Following six of her daily physical
therapy sessions, the patient reported no muscle pain,
as indicated with a VAS soreness value of 1, when the carbohydrate-
amino acid supplement had been used immediately
post-therapy the preceding day. Other hip replacement
patients in her therapy group were interviewed to determine
if they were experiencing muscle soreness in conjunction
with the physical therapy regimen. The other patients
who were not using any type of supplementation reported
that they did experience muscle soreness and discomfort,
especially in their thighs. Although physical therapy
sessions are not typically conducted on the weekends, her
assigned physical therapist was on weekend duty and gave
the patients an unscheduled session of physical therapy.
Following this session, the patient did not have the carbohydrate-
amino acid supplement, which was routinely prepared
and brought in daily by a family member. In this one
instance where the patient did not receive post-therapy
nutritional supplementation, she did report a noticeable
amount of discomfort from muscle soreness the following
day and reported a VAS soreness value of 4. The patient
commented that her thighs were sore and felt some tightness
in her muscles. This VAS soreness value when not
using the supplement was a noticeable increase over previous
values when the supplement was used and the degree
of muscle soreness noted is a reasonable value for
what one would expect for the level of muscle exertion
employed during physical therapy. No further soreness was
noted on subsequent therapy sessions when the supplement
was used.
Discussion
The present case report observes that a post-surgical
patient who used a carbohydrate-amino acid supplement
containing HMB immediately following each therapy session
perceived no muscle soreness. The support for her
perception of having no muscle soreness while using the
supplement is bolstered by her experiencing muscle
soreness on the one occasion when the supplement was
not used following physical therapy.
Although the patient chose to use the carbohydrate-amino
acid supplement to prevent muscle soreness during
physical therapy, there are several other potential benefits
that may have assisted in her post-surgical recovery.
Previous studies have shown that when essential amino
acids are consumed along with a high glycemic
carbohydrate following exercise, there is a greater gain in
muscle protein synthesis over that induced by exercise or
nutritional supplementation alone.20 This increase in muscle
protein synthesis in conjunction with physical therapy would
lead to muscle hypertrophy and aid the patient in regaining
strength and rebuilding atrophied muscles. As many elderly
patients may also suffer from some degree of malnutrition,
an anabolic nutritional supplement may also provide basic
nutritional benefits.
Manninen21 has described the optimal recovery drink as
composed of high glycemic carbohydrates, protein
hyrdrolysate and supplemental L-leucine. The purpose of
these ingredients is to provide carbohydrate/protein to
induce an optimum insulin response, provide protein
hydrolysate as a source of amino acids for protein synthesis
and L-leucine as an insulintrophic amino acid. The present
composition provides a high glycemic mix of simple and
complex carbohydrates to make the drink isotonic so it
empties quickly out of the stomach and is absorbed rapidly.
It preferably utilizes free-form essential amino acids as they
can be absorbed rapidly and because the non-essential
amino acids can be made by the body and are not rate
limited in protein synthesis.9 The essential amino acids
serve as a protein source to potentiate the induction of
insulin. Furthermore, the essential amino acids contains
L-lysine, one the most potent insulinotrophic amino acids,
in addition to L-leucine and L-phenyalanine, which are
somewhat less potent and L-methionine and L-valine which
are moderately potent. L-leucine’s effect on muscle is
though to be due largely to it being metabolized into
ketoisocaproate, which is metabolized into HMB and
ultimately the end product HMG-CoA, which supports
muscle membrane repair through increased intramuscular
cholesterol synthesis. Therefore, the downstream
metabolite HMB is included in this composition to bypass
other metabolic pathways and promote greater conversion
into HMG-CoA. For these reasons, this composition offers
several advantages over Manninen’s proposed optimal
recovery drink.
A recent study investigated the benefits of using an anabolic
nutritional supplement on malnourished rats that were
recovering from a bone fracture. Those rats receiving an
anabolic supplement consisting of 30% protein with
conditionally essential amino acids showed greater
improvements in bone mineralization, body mass and
muscle mass than those receiving protein alone.22 Essential
amino acid supplementation has been shown to have a
similar effect on muscle and bone in osteoporotic rats.23
Therefore, nutritional supplementation of orthopedic
patients with anabolic supplements may augment
musculoskeletal recovery following corrective surgery for
bone fractures and other orthopedic procedures.
Injuries or disease that require long periods of immobility
during recuperation can have a deleterious effect on
muscles. The muscles enter a catabolic state and other
tissues, such as the immune system and injured tissue,
use the amino acids released from the degradation of
muscle. This results in muscle atrophy and physical
weakness. Once healed, the patient must be rehabilitated
through physical therapy to regain muscle mass and
strength. Previous studies have demonstrated that essential
amino acid-carbohydrate supplements can help prevent and
reverse the catabolic effects of prolonged inactivity and the
resulting loss of muscle protein.24-26
A study on muscle recovery following six weeks of nonweight
bearing inactivity demonstrated that after 12 weeks
of physical therapy, muscle function had improved
significantly, but was still less than weight bearing inactive
normal controls.27 This study also documented that therapy
patients often do experience muscle soreness during
physical therapy; and demonstrated a positive correlation
between the degree of DOMS and the resulting progress
in muscle recovery and strength. This study showed that
the patients who experienced the most muscle soreness
during the study were the ones who showed the greatest
improvement in muscle strength at the end of the study.
The reasoning for this was that those who worked the
hardest and experienced the most DOMS gained the most
benefit from therapy. Patients who did not experience a
significant degree of DOMS had the least muscle strength
at the end of the study. These latter patients may have
intentionally performed their physical therapy at a lower
intensity to avoid the discomfort of muscle soreness.
Based on published studies and the observed results in
this case report, it is fair to speculate that orthopedic
patients, as well as other ambulatory patients, could benefit
from an amino acid-carbohydrate supplement that was able
to provide both anabolic properties and prevent muscle
soreness during physical therapy. Such post surgical
supplementation should allow both the bone and
surrounding muscle tissue to experience improved postoperative
healing. Additionally, supplementation should also
allow the therapist to increase the intensity of the therapy
without limiting subsequent activities due to DOMS. This
would allow the patient to perform better during physical
therapy due to lack of muscle soreness resulting from
reloading muscles, and atrophied muscles should respond
to the exercise by showing increased hypertrophy and gains
in strength.
Further studies need be carried out using the present
carbohydrate-amino acid supplement to determine if bone
and tissue repair can be improved following surgery. Also,
if patients can undergo more intense physical therapy
without the undesirable discomfort from DOMS, they will
be able to recoup more muscle strength at a faster rate
during rehabilitation. Such nutritional therapy would be very
beneficial to patients with injuries as it could help maintain
muscle mass during convalesce and enhance
musculoskeletal repair. This could enable the patient to be
in better physical condition upon entering rehabilitation and
perform both qualitatively and quantitatively better when
undergoing physical therapy.
Additionally, as the population grows older and life spans
increase, orthopedic injuries will increase proportionately.
Any adjunct nutritional therapy that results in a more
successful outcome following surgery and faster return to
normal activities would be of enormous benefit to both the
healthcare system and patients.
Acknowledgements
The amino acid – carbohydrate supplement was provided
by Southwest Immunology, Inc., P.O. Box 8262, Ennis, TX
75119.
References
- Connolly DAJ, Sayers SP, McHugh MP. Treatment
and prevention of delayed onset muscle soreness. J
Strength Cond Res 2003; 17:197-208.
- Cheung K, Hume PA, Maxwell L. Delayed onset
muscle soreness. Treatment strategies and
performance factors. Sports Med 2003; 33: 45-164.
- Crenshaw AG, Thornell LE, Friden J. Intramuscular
pressure, torque and swelling for the exercise-induced
sore vastus lateralis muscle. Acta Physiol Scand
1994; 152: 265-277.
- Evans GFF, Haller RG, Wyrick PS, et al. Submaximal
delayed-onset muscle soreness: correlations between
MRI imaging findings and clinical measures.
Radiology 1998; 208: 815-820.
- MacLean DA, Graham TE, Saltin B. Branched-chain
amino acids augment ammonia metabolism while
attenuating protein breakdown during exercise. Am
J Physiol 1994; 267: E1010-E1022.
- Blomstrand E, Saltin B. BCAA intake affects protein
metabolism in muscle after but not during exercise in
humans. Am J Physiol Endocrinol Metab 2001; 281:
E365-E374.
- Coombs JS, McNaughton LR. Effects of branchedchain
amino acid supplementation on serum creatine
kinase and lactate dehydrogenase after prolonged
exercise. J Sports Med Phys Fitness 2000; 40: 240-246.
- Shimomura Y, Yamamoto Y, Bajotto G, et al.
Nutraceutical effects of branched-chain amino acids
on skeletal muscle. J Nutr 2006;136: 529S-532S.
- Tipton KD, Gurkin BE, Matin S, Wolfe RR.
Nonessential amino acids are not necessary to
stimulated net muscle protein synthesis in healthy
volunteers. J Nutr Biochem 1999; 10: 89-95.
- Thyfault JP, Carper MJ, Richmond SR, Hulver MW,
Potteiger JA. Effects of liquid carbohydrate ingestion
on markers of anabolism following high-intensity
resistance exercise. J Strength Cond Res 2004;18:
174-179.
- Millard-Stafford M, Warren GL, Thomas LM, Doyle JA,
Snow T, Hitchcock K. Recovery from run training:
efficacy of a carbohydrate-protein beverage. Int J
Sport Nutr Exerc Metab 2005;15: 610-624.
- Bird SP, Tarpenning KM, Marino FE. Liquid
carbohydrate/essential amino acid ingestion during
a short-term bout of resistance exercise suppresses
myofibrillar protein degradation. Metabolism 2006a;
55: 570-577.
- Bird SP, Tarpenning KM, Marino FE. Effects of liquid
carbohydrate/essential amino acid ingestion on acute
hormonal response during a single bout of resistance
exercise in untrained men. Nutrition 2006b; 22: 367-375.
- Bird SP, Tarpenning KM, Marino FE. Independent and
combined effects of liquid carbohydrate/essential
amino acid ingestion on hormonal and muscular
adaptations following resistance training in untrained
men. Eur J Appl Physiol. 2006c; 97: 225-238.
- Ohtani M, Maruyama K, Suzuki S, Sugita M, Kobayshi
K. Changes in hematological parameters of athletes
after receiving daily dose of a mixture of 12 amino
acids for one month during the middle- and longdistance
running training. Biosci Biotechnol Biochem
2001; 65: 348-355.
- Kraemer WJ, Ratamess JS, Volek JS, et al. The effect
of amino acid supplementation on hormonal
responses to resistance training overreaching.
Metabolism 2006;55: 282-291.
- Nosaka K, Sacco P, Mawatari K. Effects of amino
acid supplementation on muscle soreness and
damage. Int J Sport Nutr Exer Metab 2006;16: 620-635.
- Van Someren KA, Edwards AJ, Howatson G.
Supplementation with â
hydroxyâ-methylbutyrate
(HMB) and a-ketoisocaproic acid (KIC) reduces signs
and symptoms of exercise-induced muscle damage
in man. Int J Sport Nutr Exer Metab 2005;15: 413-424.
- Paddon-Jones D, Keech A, Jenkins, D. Short-term
beta-hydroxy-beta-methylbutyrate supplementation
does not reduce symptoms of eccentric muscle
damage. Int J Sport Nutr Exerc Metab 2001; 11: 442-450.
- Rasmussen BB, Tipton KD, Miller SL, et al. An oral
essential amino acid-carbohydrate supplement
enhances muscle protein anabolism after resistance
exercise. J Appl Physiol 2000;88: 386-392.
- Manninen AH. Hyperinsulinaemia, hyperaminoacidaemia
and post-exercise muscle anabolism:
the search for the optimal recovery drink. Br J Sports
Med 2006; 40: 900-905.
- Hughes MS, Kazmier P, Burd TA, et al. Enhanced
fracture and soft-tissue healing by means of anabolic
dietary supplementation. J Bone Joint Surg 2006; 88A:
2386-2394.
- Ammann P, Bonjour JP, Rizzoli R. Essential amino
acid supplements increase muscle weight, bone mass
and bone strength in adult osteoporotic rats. J
Musculoskelet Neuronal Interact 2000: 1: 43-44.
- Paddon-Jones D, Sheffield-Moore M, Urban RJ, et
al. Essential amino acid and carbohydrate
supplementation ameliorates muscle protein loss in
humans during 28 days bedrest. J Clin Endocrinol
Metab 2004; 89: 4351-4358.
- Paddon-Jones D, Wolf RR, Ferrando AA. Amino acid
supplementation for reversing bed rest and steroid
myopathies. J Nutr 2005; 135: 1809S-1812S.
- Paddon-Jones D, Sheffield-Moore M, Urban RJ, et
al. The catabolic effects of prolonged inactivity and
acute hypercortisolemia are offset by dietary
supplementation. J Clin Endocrinol Metab 2005; 90:
1453-1459.
- MacIntyre DL, Eng JJ, Allen TJ. Recovery of lower
limb function following 6 weeks of non-weight bearing.
Acta Astronautica 2005; 56: 792-800.
Corresponding Author:
Dennis R. Sparkman, Ph.D.
Southwest Immunology, Inc.
P.O. Box 8262, Ennis, TX 75119
dsparkman(at)swimmunology.com
Dennis R. Sparkman
Southwest Immunology, Inc. Ennis, TX 75119 USA
Abstract
Objective: The current literature offers ample evidence to
support the use of amino acid therapy to prevent muscle
soreness following overuse and to help maintain and restore
muscle tissue following prolonged periods of inactivity. The
purpose of this case report is to demonstrate that a
carbohydrate-amino acid supplement can safely be used
during physical therapy to prevent muscle soreness.
Methods: A 74-year old female underwent elective hip
replacement surgery followed by a week of rehabilitative
physical therapy. The patient elected to use a carbohydrateamino
acid supplement as a means to prevent muscle
soreness following physical therapy and consented to
observation.
Results: During the course of physical therapy the patient
reported no muscle soreness on the days following therapy
while using the carbohydrate-amino acid supplement. The
one occasion where the supplement was not used following
physical therapy, noticeable discomfort due to muscle
soreness was reported.
Conclusions: This case report supports the use of
carbohydrate-amino acid supplementation to prevent
muscle soreness while restoring lean muscle and strength
following physical therapy, even though definite conclusions
cannot be drawn from a single case report design. Current
literature in conjunction with this case report supports the
need for properly designed studies to further investigate
the therapeutic benefits of a carbohydrate-amino acid
supplement as an adjunct to physical therapy and
rehabilitation.
Key Words: Dietary Supplements, Physical Therapy
Modalities, Inflammation, Muscles, and Amino Acids.
Introduction
Following any unaccustomed or prolonged use of the muscles that leads to overuse will inevitably result in muscle soreness. This muscle soreness is referred to as delayed onset muscle soreness or DOMS.1,2 Because DOMS is not a direct manifestation of the resulting disruption of the contractile component of the muscle tissue and muscle membranes, the soreness is not felt immediately. DOMS is a symptom of the damage that occurs when soluble muscle proteins leak into the extra cellular space resulting in local inflammation and the muscle swelling that ensues. Peak levels of DOMS have been shown to coincide with peak levels of edema.3,4 For this reason, the soreness begins to develop gradually following exercise and can last for several days. Although this muscle soreness is most often associated with athletic training, it can affect anyone, especially persons undergoing physical therapy. Because DOMS can have a negative impact on muscle function and reduce one’s ability to perform physical activities, it can curtail further physical activities for days. For the patient requiring physical therapy following surgery or an injury, the muscles can be weakened and/or atrophied from physical inactivity. Such a scenario makes the patient an ideal candidate for experiencing DOMS during physical therapy, even though physical therapists strive to manage therapy intensity to maintain a balance between strength gains and muscle soreness. For this reason, finding an effective intervention to prevent or reduce DOMS while helping to rebuild atrophied muscles would facilitate a patient’s physical therapy and recovery.
The role of oral supplementation of amino acids in the prevention of DOMS is a field of interest for nutritional science that has a direct and practical application in the field of sports medicine. Oral supplementation with 77 mg/ kg branched chain amino acids (BCAA) before exercise has been reported to suppress endogenous muscle protein breakdown.5 This finding was corroborated in another study whereby giving 100 mg/kg of BCAA before, during and after exercise showed a protein sparing effect on muscle proteins.6 Supplementation with 12-g/day BCAA for 2 weeks plus 20 g before and after exercise reduced serum creatine phosphokinase (CPK) for several days following exercise.7 A recent study that investigated administering 5 g BCAA before exercise noted a reduction on DOMS for several days following exercise.8 Previous studies have shown that administering 40 g EAA after exercise results in a change from net protein degradation to net protein synthesis.9
Carbohydrate-amino acid mixtures have also recently been shown to help reduce muscle soreness. When a liquid carbohydrate beverage was consumed 10-minutes before and immediately after exercise, it resulted in a more favorable anabolic response, although it did not alter the catabolic response.10 When a solution of 8% carbohydrate + 2% protein was consumed immediately following exercise, there was a perceived reduction in soreness among athletes.11 Administration of a 6% carbohydrate solution containing 6 g EAA during weight resistance exercise suppressed cortisol release, stimulated insulin release and reduced myofibrillar protein degradation12,13 and increased the anabolic response.14
Mixtures of amino acids have also been reported to reduce DOMS. Mixes of amino acids have been shown to reduce serum CPK activity following exercise.15,16 When an amino acid mixture containing 60% essential amino acids was given at a total daily dose of 7.2 g twice daily on the day of exercise and for 4 days following exercise, there was a statistically significant reduction in both serum CPK levels and DOMS in the days following exercise.17
A recent study has described the use of beta-hydroxy-betamethylbutyrte (HMB) in the prevention of DOMS. In this study administration of 3g HMB/0.3g KIC for 14 days prior to a single bout of eccentric resistance training determined that CPK and DOMS were significantly reduced after 14 days supplementation with HMB/KIC compared to controls.18 One previous study looked at the effects of short term HMB supplementation on eccentric resistance training found that six days supplementation with 40 mg/kg HMB did not reduce DOMS after a single bout of exercise.19
This case report examines the role for using a carbohydrateamino acid supplement containing HMB in the prevention of muscle soreness during post-operative physical therapy.
Patient and methods
The patient was a 74-year old Caucasian female who had undergone elective left hip replacement. She was 5 feet 8 inches tall, weighed 175 lbs.
The patient had become progressively immobile over a period of approximately 2-years due to the degenerative left hip. At the time of surgery, the patient was barely able to walk across the room without having to stop to sit and rest. Because a great deal of her time was sedimentary, she had become weak and lost muscle strength.
The patient requested to be provided with a sample of a patent-pending carbohydrate-amino acid dietary supplement that was designed to prevent or significantly reduce muscle soreness following muscle overuse. Her intention was to use the product during her physical therapy to aid in reducing muscle soreness and to help regain muscle strength. Her request was granted and in return permission was obtained from the patient to observe and interview her during the physical therapy.
The patient used a pre-production sample of a carbohydrate-amino acid dietary supplement. A single serving of the supplement contained 44 g of a proprietary blend which consisted of sucrose, maltodextrin, calcium beta-hydroxy-beta-methylbutyrate, L-leucine, Lphenylalanine, L-lysine, L-threonine, L-valine, L-histidine, L-isoleucine, L-methionine). Among the eight essential amino acids, 40% was made up of the branched chain amino acids. The recommended serving of approximately 50 g was mixed with 500 ml of water and consumed immediately following physical therapy.
Results
Following a successful hip replacement and recovery, the patient was moved from the hospital on the fifth day to a local rehabilitation center in the Southwest United States. On the seventh post-operative day, physical therapy was started and consisted of hip abductions, hip extensions, knee raises, knee flexions, ankle pumps, bed supported knee bends and straight leg raises. As therapy progressed, rubber bands were added to add resistance to the exercise routine.
Immediately following each physical therapy session, the patient consumed one dose of the carbohydrate-amino acid supplement. Each day prior to physical therapy the patient was asked to rate the level of muscle soreness in her legs from the previous day’s therapy using a visual analog scale (VAS) of 1 to 10 with one being no soreness and ten being the most severe soreness. Following six of her daily physical therapy sessions, the patient reported no muscle pain, as indicated with a VAS soreness value of 1, when the carbohydrate- amino acid supplement had been used immediately post-therapy the preceding day. Other hip replacement patients in her therapy group were interviewed to determine if they were experiencing muscle soreness in conjunction with the physical therapy regimen. The other patients who were not using any type of supplementation reported that they did experience muscle soreness and discomfort, especially in their thighs. Although physical therapy sessions are not typically conducted on the weekends, her assigned physical therapist was on weekend duty and gave the patients an unscheduled session of physical therapy. Following this session, the patient did not have the carbohydrate- amino acid supplement, which was routinely prepared and brought in daily by a family member. In this one instance where the patient did not receive post-therapy nutritional supplementation, she did report a noticeable amount of discomfort from muscle soreness the following day and reported a VAS soreness value of 4. The patient commented that her thighs were sore and felt some tightness in her muscles. This VAS soreness value when not using the supplement was a noticeable increase over previous values when the supplement was used and the degree of muscle soreness noted is a reasonable value for what one would expect for the level of muscle exertion employed during physical therapy. No further soreness was noted on subsequent therapy sessions when the supplement was used.
Discussion
The present case report observes that a post-surgical patient who used a carbohydrate-amino acid supplement containing HMB immediately following each therapy session perceived no muscle soreness. The support for her perception of having no muscle soreness while using the supplement is bolstered by her experiencing muscle soreness on the one occasion when the supplement was not used following physical therapy.
Although the patient chose to use the carbohydrate-amino acid supplement to prevent muscle soreness during physical therapy, there are several other potential benefits that may have assisted in her post-surgical recovery. Previous studies have shown that when essential amino acids are consumed along with a high glycemic carbohydrate following exercise, there is a greater gain in muscle protein synthesis over that induced by exercise or nutritional supplementation alone.20 This increase in muscle protein synthesis in conjunction with physical therapy would lead to muscle hypertrophy and aid the patient in regaining strength and rebuilding atrophied muscles. As many elderly patients may also suffer from some degree of malnutrition, an anabolic nutritional supplement may also provide basic nutritional benefits.
Manninen21 has described the optimal recovery drink as composed of high glycemic carbohydrates, protein hyrdrolysate and supplemental L-leucine. The purpose of these ingredients is to provide carbohydrate/protein to induce an optimum insulin response, provide protein hydrolysate as a source of amino acids for protein synthesis and L-leucine as an insulintrophic amino acid. The present composition provides a high glycemic mix of simple and complex carbohydrates to make the drink isotonic so it empties quickly out of the stomach and is absorbed rapidly. It preferably utilizes free-form essential amino acids as they can be absorbed rapidly and because the non-essential amino acids can be made by the body and are not rate limited in protein synthesis.9 The essential amino acids serve as a protein source to potentiate the induction of insulin. Furthermore, the essential amino acids contains L-lysine, one the most potent insulinotrophic amino acids, in addition to L-leucine and L-phenyalanine, which are somewhat less potent and L-methionine and L-valine which are moderately potent. L-leucine’s effect on muscle is though to be due largely to it being metabolized into ketoisocaproate, which is metabolized into HMB and ultimately the end product HMG-CoA, which supports muscle membrane repair through increased intramuscular cholesterol synthesis. Therefore, the downstream metabolite HMB is included in this composition to bypass other metabolic pathways and promote greater conversion into HMG-CoA. For these reasons, this composition offers several advantages over Manninen’s proposed optimal recovery drink.
A recent study investigated the benefits of using an anabolic nutritional supplement on malnourished rats that were recovering from a bone fracture. Those rats receiving an anabolic supplement consisting of 30% protein with conditionally essential amino acids showed greater improvements in bone mineralization, body mass and muscle mass than those receiving protein alone.22 Essential amino acid supplementation has been shown to have a similar effect on muscle and bone in osteoporotic rats.23 Therefore, nutritional supplementation of orthopedic patients with anabolic supplements may augment musculoskeletal recovery following corrective surgery for bone fractures and other orthopedic procedures.
Injuries or disease that require long periods of immobility during recuperation can have a deleterious effect on muscles. The muscles enter a catabolic state and other tissues, such as the immune system and injured tissue, use the amino acids released from the degradation of muscle. This results in muscle atrophy and physical weakness. Once healed, the patient must be rehabilitated through physical therapy to regain muscle mass and strength. Previous studies have demonstrated that essential amino acid-carbohydrate supplements can help prevent and reverse the catabolic effects of prolonged inactivity and the resulting loss of muscle protein.24-26
A study on muscle recovery following six weeks of nonweight bearing inactivity demonstrated that after 12 weeks of physical therapy, muscle function had improved significantly, but was still less than weight bearing inactive normal controls.27 This study also documented that therapy patients often do experience muscle soreness during physical therapy; and demonstrated a positive correlation between the degree of DOMS and the resulting progress in muscle recovery and strength. This study showed that the patients who experienced the most muscle soreness during the study were the ones who showed the greatest improvement in muscle strength at the end of the study. The reasoning for this was that those who worked the hardest and experienced the most DOMS gained the most benefit from therapy. Patients who did not experience a significant degree of DOMS had the least muscle strength at the end of the study. These latter patients may have intentionally performed their physical therapy at a lower intensity to avoid the discomfort of muscle soreness.
Based on published studies and the observed results in this case report, it is fair to speculate that orthopedic patients, as well as other ambulatory patients, could benefit from an amino acid-carbohydrate supplement that was able to provide both anabolic properties and prevent muscle soreness during physical therapy. Such post surgical supplementation should allow both the bone and surrounding muscle tissue to experience improved postoperative healing. Additionally, supplementation should also allow the therapist to increase the intensity of the therapy without limiting subsequent activities due to DOMS. This would allow the patient to perform better during physical therapy due to lack of muscle soreness resulting from reloading muscles, and atrophied muscles should respond to the exercise by showing increased hypertrophy and gains in strength.
Further studies need be carried out using the present carbohydrate-amino acid supplement to determine if bone and tissue repair can be improved following surgery. Also, if patients can undergo more intense physical therapy without the undesirable discomfort from DOMS, they will be able to recoup more muscle strength at a faster rate during rehabilitation. Such nutritional therapy would be very beneficial to patients with injuries as it could help maintain muscle mass during convalesce and enhance musculoskeletal repair. This could enable the patient to be in better physical condition upon entering rehabilitation and perform both qualitatively and quantitatively better when undergoing physical therapy.
Additionally, as the population grows older and life spans increase, orthopedic injuries will increase proportionately. Any adjunct nutritional therapy that results in a more successful outcome following surgery and faster return to normal activities would be of enormous benefit to both the healthcare system and patients.
Acknowledgements
The amino acid – carbohydrate supplement was provided by Southwest Immunology, Inc., P.O. Box 8262, Ennis, TX 75119.
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Corresponding Author:
Dennis R. Sparkman, Ph.D.
Southwest Immunology, Inc.
P.O. Box 8262, Ennis, TX 75119
dsparkman(at)swimmunology.com