Should You Take Painkillers To Exercise?

The use of painkillers to keep exercising through the pain barrier is common practice in the fitness world.

NSAID's (Non-steroidal anti-inflammatories) are legal in sports and many professional athletes use them routinely to train and compete. 

The benefits of exercise for physical and mental health are widely documented, but does taking painkillers in order to stay active start to do more harm than good?

There's a study which showed that ultramarathon runners who took Ibuprofen before their race had higher levels of endotoxins (LPS) and inflammatory markers in the blood, compared to the runners who competed drug-free.

Interestingly, both groups reported similar levels of perceived exertion and post-race muscle soreness (DOMS) in the week following the race.

Why would the runners have got these blood results after consuming Ibuprofen before their race?

First, let's look at the study....

The researchers looked at Ibuprofen use during the 160Km Western States Endurance Run. They included 29 ultramarathoners who consumed 600mg and 1200mg Ibuprofen the day before and on race day respectively, and a control group of 25 runners who avoided all medications. Blood and urine samples were collected the morning before and immediately after the race, and competitors rated their DOMS (muscle soreness) during the week following the event. 

Results

• Race times and RPE (rate of perceived exertion) didn't vary significantly between the Ibuprofen users and non-users
• Post-race DOMS and serum creatinine kinase levels weren't significantly different between the two groups
• Ibuprofen use was associated with higher levels of LPS (lipopolysaccharide), C-reactive protein (CRP), and plasma cytokine levels for interleukins, granulocytes, monocytes and macrophages 

Conclusions

• Ibuprofen usage compared to non-usage didn't result in better race times or how hard the race felt
• There were similar levels of post-race muscles soreness and muscle damage between the two groups
• The runners who took Ibuprofen had higher levels of endotoxins (LPS) and inflammatory markers in their blood compared to the non-users

In other words, Ibuprofen usage didn't help the runners to perform or feel better during and after the race. There wasn't a significant difference in muscle damage either between the two groups, but those who took Ibuprofen had more markers of gut damage and inflammation after the race.

Obviously this was an extreme endurance event, and we need to be careful about translating the study results literally to the average recreational exerciser. The study group sizes were also small.

But there are things that we can take from the study that will help us to decide whether taking painkillers to continue exercising through the pain barrier is a good idea or not.

What Is Inflammation?

We often hear the word 'inflammation' but do you know what it is and why we get it?

The 4 Steps of Inflammation

1. Acute inflammatory response to infection, tissue injury or some form of stress
2. Recruitment of cells - small signalling proteins called cytokines act like first responders and tell the immune system to mount a defence
3. Elimination of the microbe
4. Resolution and healing

Lipopolysaccharides (LPS) can induce an inflammatory response from our cells.

What's LPS?

Gram negative bacteria in our gut naturally produce LPS as a waste by-product. An over-abundance of gram negative bacteria in our gut can lead to gut dysbiosis, 'leaky gut' (a permeable gut wall) and potentially IBS (Irritable Bowel Syndrome) or IBD (Irritable Bowel Disease).

If LPS escapes from the gut, say through an excessively permeable gut wall ('leaky gut'), it can attach to specific receptors on the cell wall. This triggers a chain reaction in the cell that results in the production of Nuclear Factor Kappa Beta (NFKB).

You can think of NFKB as the gas pedal of inflammation. 

NFKB tells the cell nucleus to produce more pro-inflammatory proteins, such as Interleukins (eg. IL-1, IL-6), COX, and TNF-alpha.

IL-1 signals the production of CRP (C-reactive protein) - a classic inflammatory marker

IL-6 signals the production of monocytes and lymphocytes, which are white blood cells forming part of the immune system response.

COX is an enzyme involved in the production of prostaglandins, which are hormones that promote the inflammatory response.

So you can see how gut health and the gut microbiome are integral to the inflammatory response.

The 5 Cardinal Signs of Acute Inflammation

Acute inflammation is the body's immediate response to infection, tissue injury or stress. It's a necessary, healthy and helpful function that helps the body to eliminate harmful bacteria, viruses and other foreign substances.

The 5 cardinal signs of acute inflammation are:

• Pain - a signal that tells you something is wrong and to be careful
• Heat - from increased blood flow
• Redness - from dilation of the blood vessels in the damaged area
• Swelling - fluid building in the surrounding tissue causing oedema
• Loss of function - immobilising the injured area to prevent further damage

Once the injury has healed inflammation should subside. Sometimes inflammation persists even after the initial injury has healed, leading to chronic inflammation.

Chronic Inflammation

The signs of chronic inflammation are less obvious and may include:

• Fatigue or exhaustion
• Poor sleep
• A general feeling of being under the weather but not actually sick
• Frequent minor colds, sniffles or headaches
• Brain fog
• Allergies, such as hay fever
• Skin or respiratory conditions, such as eczema or asthma

Some people may not feel any symptoms if they have a chronic low grade, systemic inflammation, or they could have become used to their symptoms, thinking they're normal or they have to put up with them.

How Do NSAID's Work?

NSAID's such as Ibuprofen and aspirin work to block the COX enzyme and therefore stop the cell from producing prostaglandins. 

This reduces unpleasant symptoms, such as fever and pain, and puts a handbrake on inflammation. 

So far so good! What's the problem with taking NSAID's if it reduces pain and inflammation?

It's important to recognise that inflammation is a vital part of our body's response to infection or injury. Stopping inflammation too quickly can result in delayed healing.

The study mentioned earlier seems to confirm this, with the runners performing on Ibuprofen actually showing higher markers of inflammation in their blood after the race.

To understand why this might happen take a look at the triad of inflammation:

NSAID's work to calm the inflammation corner of the triangle, but what about oxidative stress and organelle dysfunction (sub-optimal cell processes) that also contribute to inflammation?

If we aren't able to clear oxidative stress from our cells, or we have poor cell health, and don't address these issues, we can end up with chronic systemic inflammation or long-term health conditions further down the line. 

NSAID's can mask the signs of this happening until you're really sick,

Side Effects of NSAID's

Taking NSAID's routinely for a long period of time or taking a high dose can have some unpleasant and potentially side effects on the body:

• Digestive upsets, gastrointestinal bleeds and ulcers - prostaglandins help to protect the stomach lining and maintain gut wall integrity
• Cardiovascular episodes - heart attack, stroke
• Kidney dysfunction - blocking the COX enzyme reduces blood flow to the kidneys, impairing their function and making them work harder to excrete waste products

Remember how gut health is linked to inflammation, and that a leaky gut wall allows LPS produced by gram-negative bacteria to escape from the gut into the bloodstream. LPS pushes the inflammation pathways in the cell.

So NSAID's halt the production of pro-inflammatory proteins, like COX and prostaglandins, but they can also damage the gut, leading to more LPS escaping into the bloodstream. LPS triggers the inflammation pathways in the cell. This sets up a situation where the drug both stops inflammation, yet also contributes to it!

POV: Would I Take NSAID's to exercise?

My personal point of view is that I do not exercise or teach on NSAID's or analgesics.

Here are my reasons:

• The negative and harmful effects of NSAID's on the gut. LPS is a marker for systemic inflammation and gut health. LPS levels are often elevated in people with metabolic and autoimmune diseases.
• Pain is NOT always an accurate indicator of physical damage, especially chronic pain, but it IS a signal that my body or nervous system are unhappy. 
• When I'm teaching or exercising I need to feel that first point of tension so I don't push beyond it and potentially overload or injure that muscle.

When my back goes twang, it's usually because of a hyper-vigilant and overly protective nervous system making the muscles spasm painfully, and not from an actual muscle strain.

Therefore the side effects of NSAID's far outweigh any benefits. Dulling pain sensations could lead to me inadvertently straining a muscle and actually injuring myself, which would then take far longer to resolve than simply calming my nervous system. 

Do you agree with my reasons for not exercising on NSAID's or painkillers?

Of course there are occasions when taking NSAID's is helpful, but I believe that it should be at the lowest effective dose and for the least amount of time necessary.

As always, if in any doubt over whether taking NSAID's or analgesics is beneficial please discuss with a medical professional, and do not stop taking prescribed medications without consulting with your doctor first.

Study Link

Nieman DC, Henson DA, Dumke CL, Oley K, McAnulty SR, Davis JM, Murphy EA, Utter AC, Lind RH, McAnulty LS, Morrow JD. Ibuprofen use, endotoxemia, inflammation, and plasma cytokines during ultramarathon competition. Brain Behav Immun. 2006 Nov;20(6):578-84. doi: 10.1016/j.bbi.2006.02.001. Epub 2006 Mar 22. PMID: 16554145. https://doi.org/10.1016/j.bbi.2006.02.001

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