Acute Inflammation in Physical Activity and Recovery

Acute inflammation is a normal response to tissue damage, typically associated with pain, redness, and swelling;^[1] all things that interfere in physical movement. So, naturally, it’s something we want to get rid of so we can return to play and feel more comfortable. But inflammation has a purpose and a place in the short-term. Whenever muscle or vascular tissue are injured, the immune system is immediately stimulated, moving white blood cells by increased vasodilation and blood flow to the injury site. Inflammatory mediators are released by cells as a way of resolving the injury; however, there is always a chance of further injury and a cyclical continuation of incomplete healing and inflammation.^[2] This incomplete restoration of tissue after inflammation can lead to a variety of chronic diseases including cancers.^[1]

Exercise and normal “wear and tear” itself causes a degree of inflammation. Inflammatory mediators, such as prostaglandins, are normally produced in response to repetitive motion of tendon cells. As an example, running an ultramarathon is naturally going to produce inflammatory cytokines and prostaglandins in the tendons of the feet, legs, and hips;^[3] these same prostaglandins are produced at the onset of an injury. As much as these mediators cause inflammatory processes, they also support healing. A part of the inflammatory process is the rebuilding of tissue by fibroblasts and collagen synthesis. The actual process of inflammation can be beneficial if the tissues are allowed to repair and recover. However, being exposed to additional stressors or factors that promote inflammatory pathways plays a role in that cyclical and chronic inflammatory state that can cause chronic health issues.^[4] The body’s stress response and cortisol secretion help to mediate inflammation. Low levels of cortisol act directly on macrophage migration inhibitory factor (MIF), a proinflammatory cytokine, while higher levels of cortisol lead to decreases in MIF secretion.^[1] MIF is involved in the upregulation of the inflammatory mediators cyclooxygenase‑2 (COX‑2) and prostaglandins. This demonstrates the need for recovery both in exercise regimens and in stressful lifestyles. This applies to most people who are physically active, but is much more difficult for professional athletes who typically have more than one training session per day. Regardless, recovery is critical for proper bodily functioning. However, for someone who is training for a specific event or season, “recovery” is subjective, and anti-inflammatories are often used to push through extra workouts or to ease discomfort.

Acute Inflammation

Consider acute inflammation in terms of blisters and calluses. Let’s say you’re newly taking up golfing and want to put in some time at the driving range. As you’re hitting golf balls, your hands are repeatedly subject to friction against the handle of the golf club. At the end of the day, you notice that the friction on your hands has given you blisters. You decide to let these blisters heal because they’re painful! This is inflammation after all: redness, swelling, increased fluid to the area, painful to touch. You allow the tissue to recover as fluid gradually drains away and your skin regrows underneath. As you continue playing golf throughout the season, you notice that you don’t get blisters like you did on day one; now you’re noticing that all the areas on your hands that experience repeated friction have developed hard calluses. These calluses have developed as a way of protection. From experience, your skin “knows” that you will be continuing to do damage to that area. The skin thickens like a protective shield. In this way, short-term inflammation is beneficial; the key is in allowing the tissue to heal. Once the tissue recovers from the injury, it will continue to become stronger, increasing fibrin and collagen deposition while the skin tissue underneath remodels.

Now, imagine that after that first day at the driving range, you decide to go back the very next day. Your hands are sore and almost raw, but you take a few ibuprofen capsules to manage the pain and you get out there, swinging the club around. The most likely scenario is that the blisters will burst, making your now-open tissues susceptible to infection. In addition, your hands may start bleeding; you might create new blisters from having to adjust your grip, and by the end of the day (and after the ibuprofen wears off), you’re in far worse pain, and with more tissue damage, than you were at the start of the day. This process can be relatable to many types of stress or injury. Stress in itself is actually a good thing. Your body has the ability to recover from short-term stress. Having to deal with that stress and recovering will make the system stronger in the long run. But when a person is chronically stressed, overworking, taking zero vacation time, not utilizing meditative or mindfulness tools, and continuously exposed to stressful people or events, the body is always on high-alert mode, secreting cortisol more frequently. Long-standing, the body is depleted of key nutrients and energy. Sleep, meditation, self-care, vacations; these are all so important in allowing the body to heal so that you are recovered enough to handle any new stress that comes your way.

Non-Steroid Anti-Inflammatory Drugs (NSAIDs)

We have dozens of products on our shelves that are used to decrease inflammation including ibuprofen, naproxen, and ASA (Aspirin®). We have analgesics to help relieve pain; and a plethora of topical preparations including arnica, diclofenac, and others that elicit hot and cold sensations. Though perhaps we should reconsider how to use these products in order to properly promote healing while promoting tissue strength. Over-the-counter (OTC) anti-inflammatories typically work by blocking cyclooxygenase (COX), an enzyme used to produce prostaglandins from arachidonic acid. Some studies have shown that this inhibition of COX can actually impair tendon healing by interfering in collagen synthesis.^[3] Although the injury may feel temporarily better, this particular inflammatory pathway may have a role in the healing process. NSAIDs, although most commonly prescribed for inflammation, do not inhibit the production of other immune mediators that promote inflammation.^[5] In patients with osteoarthritis and rheumatoid arthritis, NSAIDs could potentiate degradation of joint cartilage.^[5] Additionally, NSAIDs are well-known to have serious side effects, including gastric ulcerations and an increased risk of stroke and cardiovascular events.^[6][7] Overall, there is definitely a time and a place where pain relief is required, and by talking to your doctor, this might be the right choice for you; but it’s important to understand how to manage day-to-day wear and tear from exercise, and avoid reaching for NSAIDs and analgesics on a regular or daily basis. There are many at-home practices and natural therapies to reduce delayed-onset muscle soreness.

Resolution of Inflammation: Healthy Tissue Healing

Recovery between higher-intensity exercise sessions/events is necessary for the body and its tissues to adapt to physical stress. Athletes often adapt to heavy training schedules using cold-water applications and anti-inflammatory applications. Cold-water therapies have been shown to reduce recovery time between training sessions, as well as reduce muscle fatigue and soreness by reducing the buildup of lactic acid.^[8] This applies to the average active individual as well: recovery is necessary to allow muscle tissues to heal, but short-term cold applications can help to reduce pain and soreness postexercise.

Foam-rolling is a great example to help prevent muscle pain, as it provides a massage to the tissues and has been shown to reduce delayed-onset muscle soreness.^[10] Foam-rolling can be conducted with your physiotherapist or at home. Foam rollers are very cost-effective, and use your own body weight to apply pressure to specific muscle groups.

Hydrotherapy, specifically alternating hot and cold application, is a great modality to use for strains, sprains, bruises, and swelling 24 hours or more postinjury.^[9] Alternating hot and cold water temperature in a shower or bath helps to stimulate the immune system, circulation, and healing.^[9] As a general guideline, allow the area or body to be exposed to warm/hot water (never above 110 °F) for three minutes, then switch to cold water for 30 seconds. Repeat this series three to six times, always ending with cold water—except in cases of rheumatoid arthritis, where cold may aggravate symptoms. Other topical applications include arnica gels and hot/cold sensation preparations containing menthol and capsaicin.

Curcumin and Arthritis

Inflammation plays a huge role in arthritis, often discouraging patients from physical activity, due to pain. While arthritis is considered a chronic form of inflammation, patients may be prone to acute pain flare-ups depending on physical activity and movement of the affected joints. Those with arthritic joints would generally benefit from long-term natural anti-inflammatories such as omega‑3 fatty acids, resveratrol, and curcumin.^[5] Curcumin has been used in traditional Indian medicine for thousands of years,^[5] and its anticancer, anti-inflammatory, antioxidant, and hepatoprotective actions have been widely studied.^[1] Curcumin induces interstitial collagenase activity while inhibiting inflammatory mediators. It increases the capacity of antioxidants in the blood, to help attenuate exercise-induced oxidative stress.^[11]

For patients with rheumatoid arthritis, curcumin acts as a protector and anti-inflammatory as it may control hyperplasia of the synovial fibroblasts.^[5] In cases where using NSAIDs is warranted, depending on the injury and doctor’s recommendation, using curcumin in conjunction may reduce the required dose of NSAIDs, promoting a safer concentration of COX‑2 inhibitor drugs.^[5] This is further relevant for patients with sensitive stomachs, as curcumin has no gastrointestinal side effects, in contrast to NSAIDs.^[5]

Conclusion

Overall, there are many options for promoting tissue healing. Rest and recovery of muscles is critical for proper healing and function; as well, it is necessary for optimal sport performance.^[12] It’s important to note that acute inflammation is a self-limiting process, and that although NSAIDs provide pain relieve in the interim, they may not be beneficial for your health on a chronic or regular basis. It is worth investigating other, alternative methods for pain relief while allowing tissue healing, such as hydrotherapy and cold-water applications, and then to work on preventing future injuries. This can be accomplished by regular foam-rolling postexercise, adequate water intake to hydrate muscle tissues, taking rest days during the week, and eating a whole-foods diet including sources of omega‑3 fatty acids.