Serum Creatine Kinase Response on Exercise Induced Delayed Onset Muscle Soreness: A Pilot Single Blind Randomized Clinical Trial
Selvaraj Sudhakar1, Jibi Paul2, Senthil Selvam P3, Mahendranath P4
1Associate Professor, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute,
Maduravoyal, Chennai– 600095, Tamil Nadu, India.
2Professor, Faculty of Physiotherapy, Dr. M. G. R. Educational and Research Institute,
Maduravoyal, Chennai– 600095, Tamil Nadu, India.
3Professor, School of Physiotherapy, VELS Institute of Science, Technology and Advanced Studies,
Pallavaram, Chennai - 600043, Tamil Nadu, India
4Associate Professor, Department of Pathology, A.C.S Medical College and Hospital,
Dr. M. G. R. Educational and Research Institute, Velappanchavadi, Chennai - 600 077, Tamil Nadu, India.
*Corresponding Author E-mail: sudhakar.physio@drmgrdu.ac.in
ABSTRACT:
Objective: To investigate the effects of diclofenac phonophoresis and autogenic inhibition muscle energy technique on serum creatine kinase level compared to control group on delayed onset muscle soreness in novice athletes. Materials and Methods: Forty eight novice athletes were recruited based on selection criteria and simple random sampling technique through lottery method was used to participate in this single blind multi group repeated measures design, a pilot randomized clinical trial. After collection of demographic data, the athletes were allotted to the group based on the chits what they have picked. Group A subjects were treated with diclofenac phonophoresis, Group B subjects were treated with autogenic inhibition technique and Group C subjects were control group. An Epley formula was used for the calculation of one repetition maximum for elbow flexor muscle followed by 80 % 1 RM was calculated for all the subjects. Blood samples were collected at the baseline and 24 hours, 48 hours, 72 hours and 96 hours after inducing delayed onset of muscle soreness. Creatine kinase biochemical marker was considered as a dependent variable and values displayed in the instrument were noted. Result: On comparing creatine kinease level, there exists no significant difference between the three groups at the baseline and 48 hour measurements at (P > 0.05) and statistically significant difference was found between three groups at 24 hours,72 hours and 96 hours at (P < 0.05). Anova with repeated measures showed that the creatine kinase measures an overall changes within three groups at (P < 0.05). Conclusion: Autogenic inhibition is an effective muscle energy technique to reduce the creatine kinase level following eccentric exercise and can facilitate the recovery faster and prepare the novice athletes for early participation in sports.
KEYWORDS: Delayed Onset Muscle Soreness, Repetition Maximum, Creatine Kinase, Phonophoresis, Autogenic Inhibition Muscle Energy Technique.
NTRODUCTION:
Delayed Onset Muscle Soreness (DOMS) is the impression of inconvenience and firmness in the muscles, regularly after taking part in intense physical activity that ordinarily increments in force in the initial 24 hours after exercise, crests from 24 to 72 hours at that point dies down, so that by 5-7 days post practice it is no more[1,2,3]. Delayed onset muscle soreness named as sort one muscle strain damage [4,5]. DOMS is related with the presentation of new and high power muscle work, especially eccentric contractions[6] and lesser degree by isometric work[7]. Clarkson et al., (1986) analyzed isometric, eccentric and concentric work and found that eccentric work brought about more noteworthy level of DOMS than isometric work[8].
The force, speed, and span of eccentric contraction expected to create considerable levels of DOMS and different markers of post exercise muscle impairment vary. Some utilizes a dead weight resistance technique and thereby the subject reduces the weight and thereby more weighs to be removed as the subject fatigues. For instance unconventional biceps curl[9] Muscle exhaustion can be survived if maximal contraction can be performed all through by each subject, for instance by using isokinetic exercises machine[10]. The prime contraction is set at one repetition maximum (1 RM) for concentric activity.
Ultrasound is much of the time utilized in the recovery of soft tissue injuries. The procedure of applying ultrasound incorporates the utilization of coupling medium to encourage the infiltration of ultrasonic waves into the body tissues[11]. It also induces the medication into the tissues by a technique called phonophoresis. Drug delivery therapeutic ultrasound procedure is done in the similar process as ultrasound with the exception that medication is used utilized in alternative to the coupling medium[12]. The process enabling medicine to be induced into fundamental tissues during drug induced ultrasound therapy will help to cause a change in tissue permeability. Moreover, the drug can be constrained far from the transducer into the body by the radiation waves produced by the ultrasonic beam[13]. The spill created by ultrasound changes cell permeability and upgrades tissue dispersion[14,15] and sound waves expands the active vitality of the atoms empowering the medication to diffuse all the more effectively into the underlying tissues.
Autogenic inhibition is one of the muscle energy technique (MET) based on the concept of post isometric relaxation (PIR) intercession that can be utilized to extend or stretch the muscles and the outer fascia which needs adaptability[9,16]. Autogenic inhibition requires the patient to develop a force by actuating the focused muscles and tendons in contrast to the counter force applied and make the patient relax then a passive stretch is applied by the therapist. Autogenic inhibition occur when certain muscles are inhibited from contracting due to the activation of the Golgi tendon organ (GTO) and the muscle spindles. These two musculotendinous proprioceptors located in and around the joints and muscles respond to changes in muscle tension and length, which helps manage muscular control and coordination.[17].
In contrast, skeletal muscle contains isoenzymes of creatine kinase (CK) which may be released into the blood stream following a delayed onset muscle soreness. Although, reports of elevations in CK-MM found primarily in skeletal muscle in subjects with skeletal muscle damage exist in the literature and increase in these levels along with elevations of intracellular molecules indicate damage to the sarcolemma following eccentric exercise[18]. The extensive reviews of the literature reveal that, there is paucity of studies on role of various Physiotherapy modalities and manual techniques in ameliorating the DOMS in terms of biochemical markers.
MATERIALS AND METHODS:
Recruitment and Allocation:
The research protocol was approved by the university researchers and institutional ethics committee (2017/0151/PT17D006) and Helsinki declaration, revised 2013 guidelines was strictly followed in the study[19]. A nMaster 2.0 power analysis software was used for repeated measures indicated that an alpha of .05, an effect size of 0.8, a power of 80%, and a sample size of 48 were needed. Forty eight novice athletes were recruited based on selection criteria and simple random sampling technique through lottery method was used to participate in this single blind multi group repeated measures design, a pilot randomized clinical trial[20]. The pilot study was conducted from September 2018 to November 2018 at Dr. M.G.R. Educational and Research Institute, Chennai. The study sample size was 16 per group to be sufficiently powered to conduct a pilot study[21]. Male novice athletes[22] with age group between 18-25 years, who were not under any specific training protocol and no recent history of upper extremity musculoskeletal injury were taken as inclusion criteria for the study and athletes, who had elevated creatine kinase parameters at baseline measurements were excluded from the study[23]. After collection of demographic data, the athletes were allotted to the group based on the chits what they have picked. Group A subjects were treated with diclofenac phonophoresis, Group B subjects were treated with autogenic inhibition technique and Group C subjects were control group.
PROCEDURE:
Group A consist of 16 subjects received diclofenac phonophoresis (Technomed Electroson 709 therapeutic ultrasound unit). The medicated phonophoresis coupling medium consist of 1% diclofenac sodium topical gel[24] which is a non steroidal anti-inflammatory drug for topical use and a technique applied parallel to the non dominant biceps brachii muscle at 24 , 48 ,72 and 96 hours after induction of DOMS with parameters of 3 MHz frequency, pulsed mode , 1:4 ratio with an intensity of 0.8 watts/cm2 for a duration of 8 minutes[25,26]. Group B consist of 16 subjects received autogenic inhibition muscle energy technique with non dominant biceps brachii muscle involves the affected elbow being held in extension at the easy barrier. The investigator holds the subject's wrist in order to restrain a light effort to flex the elbow for 7-10 seconds after which, following relaxation phase of 10 seconds, the arm is extended to or through, the new resistance barrier[27]. All subjects have performed 15 repetition per session at 24, 48, 72 and 96 hours after induction of DOMS. Group C consist of 16 subjects no therapy was administered. Rest advised for the control group. An Epley formula[28] was used for the calculation of one repetition maximum followed by 80 % 1 RM was calculated for all the subjects. Shortening contractions of elbow flexors were followed by lengthening contractions for 5 seconds. During elbow flexion movement, investigator provided assistance to the subject and elbow extension movement was done by the subject without any assistance and verbal encouragement was given. All subjects have performed four sets, one set consisting of ten repetitions with a rest period of 3-5 minutes between each set[27].
Measurement of Creatine Kinase (CK):
International Federation of Clinical Chemistry (IFCC) outlined a principle by (Wroblewski and Ladue) and utilizes a modified recommended methodology[29]. Erba Chem 5 plus v2 instrument was used for the analysis, 2 ml blood samples were collected from all the subjects using a disposable syringe and the serum separated. Then 50 micro liters of serum added to1 ml of CK reagent, and incubated at 37 degree Celsius for 180 seconds in an incubator. Agappe diagnosis kits were used for the analysis, following the standard protocol and readings displayed in the instrument were noted. The normal concentrations of creatine kinase in the blood for males are 20 to 200 units per litre (U/L)[30]. Blood samples were collected at the baseline, 24 hours, 48 hours, 72 hours and 96 hours after inducing DOMS. In this study, all novice athletes baseline parameters were within the reference range and none of them were dropped out.
Statistical package for social science SPSS version 20.0 IBM (Armonk, NY: IBM Corp.) were used to analyze the demographic data. Shapiro-Wilk test was used for testing normality of data as the study sample size is below 50 (n < 50). Novice athletes demographic features were displayed in [Table 1]. The descriptive data were analysed and their distributions are expressed in terms of mean±standard deviation. Repeated measures ANOVA was adopted to analyse the statistical differences within the groups and one way analysis of variance was used to find out the difference between the groups. p-value less than 5% (0.05) was considered to be significant[31].
Table 1: Demographic characteristics of the subjects recruited in Group A, Group B and Group C
|
Parameters |
Group A |
Group B |
Group C |
p value |
|
N |
16 |
16 |
16 |
- |
|
Age |
21.6 ± 2.7 |
20.6 ± 3.0 |
21.3± 2.8 |
0.81 |
|
Height (cm) |
161 ± 3.5 |
162 ± 5.8 |
162 ± 3.9 |
0.68 |
|
Weight (kg) |
62.5 ±3.1 |
61.7 ± 3.5 |
62.2 ± 3.2 |
0.62 |
|
BMI(Kg/m2) |
23.3±2.7 |
23.9 ± 3.5 |
23.4 ± 1.6 |
0.88 |
|
Abbreviations: cm-centimetre; kg-kilogram; BMI-Body Mass Index |
||||
RESULTS:
Forty eight novice athletes were recruited for the study. One way analysis of variance test was used to compare the mean values between diclofenac phonophoresis (Group A), autogenic inhibition technique (Group B) and control group (Group C). On comparing creatine kinease levels, there exists no significant difference between the three groups at the baseline and 48 hour measurements (P>0.05) and, statistically significant difference was found between three groups at 24 hours,72 hours and 96 hours (P<0.05). [Figure 1]. Anova with repeated measures showed that the creatine kinase measures an overall changes within three groups at (P < 0.05). [Table 2].
Table 2 : Summary of Creatine Kinase (CK) repeated measures ANOVA findings
|
Dependent Variable CK (U/L) |
GROUP A |
GROUP B |
GROUP C |
|||
|
MEAN |
S.D |
MEAN |
S.D |
MEAN |
S.D |
|
|
Baseline |
81.00 |
5.66 |
81.81 |
4.03 |
80.18 |
4.13 |
|
24 Hours |
210.93 |
7.75 |
279.06 |
6.38 |
246.25 |
8.06 |
|
48 Hours |
478.12 |
9.12 |
463.75 |
8.43 |
481.75 |
9.88 |
|
72 Hours |
747.50 |
11.52 |
552.62 |
9.02 |
887.50 |
6.83 |
|
96 Hours |
407.50 |
8.47 |
213.72 |
5.00 |
961.75 |
9.67 |
|
ANOVA f Value |
856.40 |
367.54 |
558.64 |
|||
|
p value |
0.00** |
0.00** |
0.00** |
|||
|
Note: * p >0.05(Not Significant), **p < 0.05(significant), U/L-Unit Per Litre |
||||||
Figure-1: Creatine kinase (CK) mean values at repeated measures
DISCUSSION:
In the eccentric exercise, muscle damage is in higher amount than the concentric exercise[34]. After a set of 80% 1 RM, the creatine kinase level was elevated. Diclofenac along therapeutic ultrasound were administrated for treating DOMS which inhibit the metabolism of arachidionic acid via cyclooxygenase pathway and thus preventing the production of endoperoxides and prostaglandins[35]. A decrease in provocative reaction prompts a reduction in response which cause a decrease in the muscle odema, intramuscular pressure and skeletal muscle enzymatic levels. Diclofenac phonophoresis was applied to the belly of the biceps brachii muscle and creatine kinase level was measured as an assessment parameters at 24, 48, 72 and 96 hours. Autogenic inhibition technique was applied to non dominant elbow flexor which resulted in a reduction of muscle soreness. This occurs due to golgi tendon stretch receptors that are located in the tendon of the agonist muscle. These receptors react to damaging of the biceps muscle by inhibiting further muscle contraction. This is naturally a protective reaction, preventing rupture and has a lengthening effect due to the sudden relaxation of the entire muscle under stretch. Therefore, it shows individuals who participate in an intense exercise has a raised levels of creatine kinase compared to sedentary individuals[36].
In the present study, before induction of Delayed Onset Muscle Soreness (DOMS), the baseline parameters of CK were within the same range in all the three groups. However after induction of DOMS, CK were started to rise in all the three groups, and immediately after intervention, there is variation of recovery with respect of CK in all the groups. It was found that CK values did not differ significantly in the three groups at baseline and at 48 hours. But where as significant differences were observed at 24 hours, after 72 hours and 96 hours. The study found that diclofenac phonophoresis has a mild influence on reducing the creatine kinase level. Whereas, Autogenic inhibition muscle energy technique has better influence on reducing CK activity. This indicates that muscle energy technique used in this study reduces some of the pathological alterations in the skeletal muscle following unaccustomed and strenuous eccentric exercise. Thus it is interesting that increase in plasma CK activity were significantly smaller for the autogenic inhibition group than the control and diclofenac Phonophoresis group.
CONCLUSION:
Autogenic inhibition was a successful muscle energy technique and significantly limiting the elevation of creatine kinase level. While diclofenac phonophoresis and control group demonstrated a lesser effect in altering the creatine kinase enzymatic activity. From this study, it is concluded that autogenic inhibition is an effective technique to reduce the creatine kinase level following eccentric exercise and can facilitate the recovery faster and prepare the novice athletes for early participation in sports.
ACKNOWLEDGEMENT:
I would like to express my deep sense of gratitude to Dr. S. Sudhakar Ph.D. for his helpful comments and all the suggestions made for the successful completion of research work.
CONFLICT OF INTEREST:
None Declared.
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Received on 15.10.2019 Modified on 26.12.2019
Accepted on 07.02.2020 © RJPT All right reserved
Research J. Pharm. and Tech. 2020; 13(8):3638-3642.
DOI: 10.5958/0974-360X.2020.00643.5