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The Recovery Magic Tool — a systematic research summary of exercise recovery modalities.

Thomas Solomon, PhD.

Updated on: 13^th July 2021.

Optimal recovery is found with a well-planned and monitored training load combined with good nutrition, sleep, and rest. But folks “do their recovery” with many other popular lines of recovery “magic”. As a supplement to my recovery magic article, this tool is an up-to-date summary of all known scientific evidence for the most popular lines of recovery magic, derived from systematic reviews of the literature. It is designed to be a useful resource for scientists, practitioners, coaches, and athletes to help inform their choices for using recovery approaches that supplement good nutrition, sleep, and rest. I will aim to keep it up-to-date as new evidence emerges.

High-quality robust evidence comes from randomized controlled trials. But, cherry-picking an experimental trial to confirm a bias is not a valid scientific pursuit for informing practice. In the world of science, we have a tool that examines all the cherries in a standardised way — a systematic review. When the studies included in a systematic review are of high enough quality, a meta-analysis of all the available evidence can be completed, and an overall can be calculated along with a (which tells us the range of values the real effect size is likely to fall if the intervention is repeated) and a heterogeneity score (which tells how variable the effect size is). In simple words, a meta-analysis evaluates all the cherries simultaneously to produce a summary statistic based on all available evidence which enables overall conclusions to be made to inform decisions in changing practice. A systematic review that contains a meta-analysis of all known randomized controlled trials, sits right at the top of the evidence-based decision-making pyramid. Therefore, decision-making based on a systematic review is far more robust than decision-making based on a single randomised controlled trial.

In the world of recovery, there is a sufficient number of well-conducted randomised controlled trials that permits systematic reviews and meta-analyses, allowing overall conclusions to be made. To help inform your decisions in using various recovery modalities, I have created a resource that summarises the evidence and brings clarity where there is obscurity in this often snake-oil doused world of recovery magic. And, I will aim to keep each topic up-to-date when scientific advances are made.

Before diving in, remember that “feeling” ready to go is different from actually being ready to unleash your maximal potential. And, before making any decisions, always make a cost-benefit analysis, where “cost” includes a combination of financial costs, time costs, performance impairment, and harm to health:

If there is no benefit, there is no point using the magic.
If there is a benefit and no cost, use it; you’d be foolish not to.
If the cost outweighs the benefit, do not proceed.

Firstly, the essential tools in your toolbox:

and and

Plus, all the other magic:

Sleep is not magic, it is real. Sleep is non-negotiable — without it, you will perish. Sleep is a necessary part of your recovery toolbox, and I have written deep-dive articles on this topic:
→ “Sleep: a five-letter word to supercharge your recovery.”
→ “Sleep will supercharge your recovery. But what about napping and your chronotype?”

Should you use sleep for recovery — what do the systematic reviews say?
Always! Getting sufficient daily sleep is an essential part of recovery — for an in-depth overview of the evidence, please read my articles on sleep and napping. But, to summarise:
→ Sleep restriction reduces recovery from and adaptation to exercise, and reduces performance.
→ Sleep extension boosts several facets of recovery, including performance.
→ Daily sleep time can be “topped-up” by taking a day-time nap, which can make some people feel refreshed. Systematic reviews indicate that napping might help performance, particularly in athletes with sleep deprivation, but there is a low to moderate quality of evidence and a moderate to high risk of bias in the very few studies that have been published. Plus, due to these factors, no meta-analysis has yet been able to quantitatively summarise the effect sizes. Therefore, at this time, the direct effects of napping on recovery (or performance) are unclear and it is recommended that effort be placed on optimising your sleep hygiene to boost the quantity and quality of your nightly sleep (tips for achieving this can also be found in my article, “Sleep: a five-letter word to supercharge your recovery”).

A research summary of exercise recovery products. Thomas Solomon at Veohtu.

Systematic reviews of sleep for recovery:
Here is the list of systematic reviews I have summarised above:

To Nap or Not to Nap? A Systematic Review Evaluating Napping Behavior in Athletes and the Impact on Various Measures of Athletic Performance.
Lastella M, Halson SL, Vitale JA, Memon AR, Vincent GE.
Nat Sci Sleep. 2021

Benefits of Daytime Napping Opportunity on Physical and Cognitive Performances in Physically Active Participants: A Systematic Review.
Souabni M, Hammouda O, Romdhani M, Trabelsi K, Ammar A, Driss T.
Sports Med. 2021

Sleep Interventions Designed to Improve Athletic Performance and Recovery: A Systematic Review of Current Approaches.
Bonnar D, Bartel K, Kakoschke N, Lang C.
Sports Med. 2018

Nutrition is food. Food is not magic, it is real. Food is non-negotiable — without it, you will die. Food is a necessary part of your recovery toolbox and I have previously written deep-dive reviews of recovery nutrition, which include summaries of the current systematic reviews:
→ “Recovery nutrition starts with a healthy eating pattern.”
→ “The “post-exercise nutrition window” is your between-session period for nutrient optimisation.”
→ “Eating carbohydrate replenishes muscle glycogen.”
→ “Eating protein supports muscle protein synthesis to repair and build tissue.”
→ “Carbohydrate plus protein is your recovery superpower.”
Plus, I have written a deep-dive review of training nutrition, examining the concepts of fat oxidation rates, fat burning, and “fueling for the work required”:
→ “What are fat oxidation rates and why do they matter?”
→ “Increasing fat burning during exercise — acute manipulations of carbohydrate availability.”
→ “Chronic dietary manipulation of carbohydrate availability — 100-years of the low-carb, high-fat diet epic.”
→ “Does a low-carb, high-fat diet offer a performance advantage to an endurance athlete?”
→ “Understanding the “carb wars” using context and perspective.”

Should you use nutrition for recovery — what do the systematic reviews say?
Always! High-quality nutrition is an essential component of your recovery. For in-depth overviews of the evidence, please read my articles on healthy eating, the post-exercise nutrition window, carbohydrate and muscle glycogen, protein and muscle protein synthesis, and combining carbohydrate with protein. But, to summarise:
→ Maintaining a healthy eating pattern and sufficient energy availability will keep your health and recovery on track.
→ Careful timing and adequate dosing of certain nutrients between your sessions, especially carbohydrate for replenishing muscle glycogen and protein for maximising muscle protein synthesis, will also enhance the recovery of your performance.
→ And, combining carbohydrate with protein between your sessions can augment the effects.
→ But, there is no need to stress. Eating a wide variety of foods of a whole range of colours across and within all the food groups, distributing meals across the day, and including nutrient-dense foods containing all macronutrients (carbs, fats, and protein) at every meal/snack opportunity, will keep most athletes and nonathletes on track. → Furthermore, your “urgency” to refuel is dependent on the time since you last ate and the time until your next workout. For example, if your next workout is not for several days, then immediate post-exercise carbohydrate intake is not urgent for replenishing glycogen — your following meals will take care of that just fine. Alternatively, if your pre-workout meal was high in protein then immediate post-exercise protein intake is also not urgent.

Systematic reviews of nutrition for recovery:
Here is the list of systematic reviews I have summarised above:

Pre-Sleep Casein Supplementation, Metabolism, and Appetite: A Systematic Review.
Dela Cruz J, and Kahan D.
Nutrients. 2021

Performance effects of periodized carbohydrate restriction in endurance trained athletes – a systematic review and meta-analysis.
Gejl KD, Nybo L.
J Int Soc Sports Nutr. 2021

Does Protein Supplementation Support Adaptations to Arduous Concurrent Exercise Training? A Systematic Review and Meta-Analysis with Military Based Applications.
Chapman S, Chung HC, Rawcliffe AJ, Izard R, Smith L, Roberts JD.
Nutrients. 2021

Protein supplementation increases adaptations to endurance training: A systematic review and meta-analysis.
Lin YN, Tseng TT, Knuiman P, Chan WP, Wu SH, Tsai CL, Hsu CY.
Clin Nutr. 2020

Coingestion of Carbohydrate and Protein on Muscle Glycogen Synthesis after Exercise: A Meta-analysis
Margolis LM, Allen JT, Hatch-McChesney A, Pasiakos SM.
Med Sci Sports Exerc. 2020

Effects of pre-sleep protein consumption on muscle-related outcomes - A systematic review.
Reis CEG, Loureiro LMR, Roschel H, da Costa THM.
J Sci Med Sport. 2020

A review of the ketogenic diet for endurance athletes: performance enhancer or placebo effect?
Bailey CP, Hennessy E.
J Int Soc Sports Nutr . 2020

Fruit supplementation reduces indices of exercise-induced muscle damage: a systematic review and meta-analysis.
Doma K, Gahreman D, Connor J.
Eur J Sport Sci. 2020

The Effect of Ingesting Carbohydrate and Proteins on Athletic Performance: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Kloby Nielsen LL, Tandrup Lambert MN, Jeppesen PB.
Nutrients. 2020

The Role of Muscle Mass Gain Following Protein Supplementation Plus Exercise Therapy in Older Adults with Sarcopenia and Frailty Risks: A Systematic Review and Meta-Regression Analysis of Randomized Trials.
Liao CD, Chen HC, Huang SW, Liou TH.
Nutrients. 2019

Impact of cow's milk intake on exercise performance and recovery of muscle function: a systematic review.
Alcantara JMA, Sanchez-Delgado G, Martinez-Tellez B, Labayen I, Ruiz JR.
J Int Soc Sports Nutr. 2019

Chocolate milk for recovery from exercise: a systematic review and meta-analysis of controlled clinical trials.
Amiri M, Ghiasvand R, Kaviani M, Forbes SC, Salehi-Abargouei A.
Eur J Clin Nutr. 2019

An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis.
Dupuy O, Douzi W, Theurot D, Bosquet L, Dugué B.
Front Physiol. 2018

The Effect of Whey Protein Supplementation on the Temporal Recovery of Muscle Function Following Resistance Training: A Systematic Review and Meta-Analysis.
Davies RW, Carson BP, Jakeman PM.
Nutrients. 2018

Post-exercise Ingestion of Carbohydrate, Protein and Water: A Systematic Review and Meta-analysis for Effects on Subsequent Athletic Performance.
McCartney D, Desbrow B, Irwin C.
Sports Med. 2018

Supplementation Strategies to Reduce Muscle Damage and Improve Recovery Following Exercise in Females: A Systematic Review.
Köhne JL, Ormsbee MJ, McKune AJ.
Sports (Basel). 2016

Effects of protein supplements on muscle damage, soreness and recovery of muscle function and physical performance: a systematic review.
Pasiakos SM, Lieberman HR, McLellan TM.
Sports Med. 2014

Effects of protein in combination with carbohydrate supplements on acute or repeat endurance exercise performance: a systematic review.
McLellan TM, Pasiakos SM, Lieberman HR.
Sports Med. 2014

Protein supplementation augments the adaptive response of skeletal muscle to resistance-type exercise training: a meta-analysis.
Cermak NM, Res PT, de Groot LC, Saris WH, van Loon LJ.
Am J Clin Nutr. 2012

Effects of ingesting protein in combination with carbohydrate during exercise on endurance performance: a systematic review with meta-analysis.
Stearns RL, Emmanuel H, Volek JS, Casa DJ.
J Strength Cond Res. 2010

Rest is what comes in between every stimulus. It takes “time” between sessions for homeostatic restoration to be achieved in order for you to be ready for your next session — time is important — it takes a time period of rest to recover from exercise. During an interval session, easy minutes between hard efforts are the rest-intervals that allows you to get ready to go again. Between days of life, sleep hours are your rest-intervals to help you get ready for tomorrow. In between hard training days, your easy days are your rest-intervals that facilitate adaptation. And, during a training block, easy weeks are your rest-intervals that allow for full recovery and adaptation.

Rest is not magic. Rest is non-negotiable — without it, you will become chronically stressed. Balancing your acute (recent) and chronic (long-term) training load is essential (you can learn about that in my previous posts at veohtu.com/trainingload and veohtu.com/trimp). Optimal training load management keeps your performance on an upward trajectory with good planning, designing, and reviewing of what you will do and what you have done — be the architect of your training. But, you also need to rest your mind.

Should you use rest for recovery — what do the systematic reviews say?
Absolutely! Having sufficient periods of rest is an essential part of your recovery toolbox — for an in-depth overview of the evidence, please read my article on resting your body and your mind to get ready to go again. But, here is a summary:
→ Motivation during a work-out is unaffected by prior cognitive fatigue but perception of effort (RPE) is increased.
→ Prior mental fatigue may affect decision making related to the energy cost of continuing to exercise during a subsequent work-out.
→ There is a small to moderate detrimental effect of prior cognitive fatigue on subsequent exercise performance.
→ Cognitive tasks lasting less than 30-minutes have similar negative effects on subsequent performances as tasks equal to or longer than 30-minutes.
→ Prior mental fatigue has a greater negative effect on muscle strength than aerobic endurance, but the effect on maximal anaerobic power is negligible.
→ It is best to have a calm and rested mind during the hours prior to a workout or race that requires your “A”-game level of performance.

Systematic reviews of rest for recovery:
Here is the list of systematic reviews I have summarised above:

Effects of Prior Cognitive Exertion on Physical Performance: A Systematic Review and Meta-analysis.
Brown DMY, Graham JD, Innes KI, Harris S, Flemington A, Bray SR
Sports Med. 2020

Cognitive fatigue effects on physical performance: A systematic review and meta-analysis.
McMorris T, Barwood M, Hale BJ, Dicks M, Corbett J.
Physiol Behav. 2018

Imagine if you round up all the foods you eat and stack them in one pile on the left and then round up all the pharmaceutical drugs in the world and pile them up on the right — both piles of things are pretty well-regulated. Then, somewhere in between is a muddy and foggy area — this is supplements — a world with a “loose” framework of regulation.

Dietary supplements are intended to meet dietary demands that cannot be met with food (this is different to sports supplements, which are compounds intended to be “essential” for optimal athletic performance). In the US, the FDA regulates supplements separately to foods and drugs. In the US, the companies selling the supplements are responsible for evaluating the safety and labeling of their products before marketing while the FDA is responsible for taking action against any adulterated or misbranded product after it reaches the market. In the UK, supplements including vitamins, minerals, amino acids, fatty acids, and plant-extract herbal supplements are regulated as foods by the FSA. These supplements are not allowed to make medicinal claims for preventing/treating disease — if they do, they are regulated as drugs. In the UK, companies selling supplements are responsible for ensuring that food supplements are safe for consumption and that labelling is accurate.

Functional claims about a specific product are usually made in line with a specific functional dose of the active ingredient. If a product doesn’t contain sufficient dose then it definitely won’t have the intended effect. Since the FDA/FSA do not systematically monitor supplements on the market, you need confidence in knowing exactly what’s in the bottle of pills or potion you are taking. As an athlete, quality control is essential! Without it, you may harm your health or take a contaminated product. And this is where things start to fall apart… Several reports have found major discrepancies between claimed contents and actual content (e.g. ephedra and CBD supplements), while even some drugs, like DHEA, have slipped through the net and been sold as dietary supplements. Nonetheless, the dietary supplement business is booming!

Eating real food and following healthy eating pattern on most days will provide you with all the nutrients you need to stay healthy, recover adequately, and perform optimally. But, large-scale studies of dietary intake in athletes (here, here, and here) show that healthy eating practices are not necessarily commonplace. Such surveys show that while some athletes consume levels of vitamins and minerals that meet or exceed recommended daily allowance (RDA), other athletes do not. Typically, however, the intake of most vitamins and minerals is positively associated with total caloric intake. Therefore, specific groups of athletes with low daily caloric intake may be at greater risk of specific vitamin and mineral deficiencies.

Although we know that a healthy eating pattern of real food will adequately meet the needs of an athlete, the supplement world is enticing. So, it is perhaps not surprising that a 2007 IAAF/World Athletics report found that 85% of elite track and field athletes use dietary supplements. “Is this the reason they’re so good?”, said the chicken to the egg. Well, this chicken also recalls Sanya Richards-Ross saying on the Clean Sport Collective podcast that she “never took a vitamin pill during her career”... a career that saw her win 10 golds at World Championship events and the Olympics.

So, why do athletes take dietary supplements? To fulfil their purpose, that is “to meet dietary demands that cannot be met with food”? Or is it to vastly exceed minimum amounts under the pretence that more is always better? Or perhaps athletes assume that supplements are effective, safe, and legal? Question one can philosophise over for many moons… One of the most popular types of dietary supplements that athletes take are antioxidants. In fact, foods that are high in antioxidants often get labelled by nutrition “gurus” as superfoods. Since the phrase “oxidative stress” sounds awful and sounds like it is not good for us humans, particularly when it can cause tissue damage and immune dysfunction, then the natural thought process is that oxidising free radicals flying around the body must be stopped ASAP, with an antioxidant. Since every one of your sessions increases the levels of free radicals like reactive oxygen species (ROS) or reactive nitrogen species (RNS) in your muscles and in the circulation, it is perhaps intuitive to many folks that taking an antioxidant supplement is an “essential” part of being an athlete — to prevent oxidative stress. Indeed a 2015 narrative review from Andrea Braakhuis and Will Hopkins concluded that the acute intake of some antioxidants may be beneficial but that chronic intakes of most antioxidants have a harmful effect on performance.

That was a rather long intro but this is a rather important topic. So, what does a systematic analysis of the literature say?

Should you use dietary supplements for recovery — what do the systematic reviews say?
→ Vitamin C (ascorbic acid) or vitamin E (tocopherol) supplementation (or combined) over several weeks have no positive/ergogenic effect on VO₂max, endurance performance, or muscle strength, nor the recovery of performance. Vitamin C alone may attenuate the oxidative stress and inflammatory response to a single bout of exercise but does not affect exercise-induced muscle damage (creatine kinase, CK), feelings of muscle soreness, or muscle strength. Vitamin E alone does not protect against exercise-induced lipid peroxidation, oxidative stress, or muscle damage (creatine kinase, CK).
→ Some evidence shows that vitamin C and/or vitamin E supplementation can be detrimental to training-induced gains in muscle strength, suggesting that muscle adaptations to training may be dependent on free radical (ROS/RNS) signalling.
→ N-Acetylcysteine (NAC), an antioxidant, has the potential to influence redox during and following exercise and thereby lessen oxidative stress but its effects on performance are highly variable, from beneficial to harmful. NAC also has a high risk of causing gastro-intestinal symptoms including diarrhoea.
→ General antioxidant supplementation (inc N‐acetylcysteine and cherry juice) at low levels does not block the adaptive cellular responses to exercise but supplementation does suppress cell-signalling pathways associated with muscle hypertrophy and blocks the increase in antioxidant enzymes triggered by exercise. Antioxidant supplementation, even at high doses, results in small-to-trivial and clinically-irrelevant reductions in exercise-induced muscle soreness.
→ Vitamin D supplementation does not affect exercise-induced muscle damage or muscle strength adaptations to resistance training. More research is needed to answer questions relevant to the recovery of performance but current evidence suggests that vitamin D supplementation for at least 2-months does not increase performance.
→ Fish oil supplementation (DHA and/or EPA) may reduce the inflammatory response to exercise but has no effects on feelings of muscle soreness, endurance performance, muscle force, or training adaptations. Although there is evidence for preservation of strength, there is a high risk of bias in the studies.
→ Probiotics or prebiotics (or synbiotics — combined pro/prebiotics) have no evidence to suggest an effect on recovery or performance. However, probiotics may help reduce the risk of respiratory tract infection and exercise-induced gastrointestinal symptoms in both athletes and physically-active nonathletes.
→ Magnesium supplementation does not affect muscle strength or aerobic/anaerobic performance but few studies exist, there is a high risk of bias, and the strength of the evidence is weak.
→ Selenium supplementation may help prevent deficiencies in athletes engaged in high-volume or high-intensity training but it does not suppress muscle damage, enhance recovery (or performance), and may even dampen exercise-induced mitochondrial adaptations.
→ Glutamine supplementation does not affect recovery or aerobic performance, nor does it modulate the immune system or body composition.
→ Polyphenol supplementation, especially with quercetin, for at least 7-days, may benefit aerobic performance (mean power output during a time trial). Effects on recovery have not been examined systematically but polyphenols might enhance exercise capacity (although the strength of evidence is weak) while having no effect on training-induced adaptations in muscle strength, peak power output, and VOmax.
→ Red Ginseng has no effect on the recovery of feelings of fatigue following exercise or on aerobic/anaerobic performance and antioxidant function. But, the experimental studies are few and small.
→ Honey ingestion around a single exercise session induces similar performance benefits when compared to other carbohydrate sources. Furthermore, honey may boost performance when compared to carbohydrate-free comparators. Some evidence suggested that several weeks of honey supplementation may help prevent immunological perturbations caused by training and perhaps also improve markers of bone formation. But, the evidence is weak and few studies exist.
→ Fruit ingestion following exercise may help mitigate some biomarkers of muscle damage, inflammation and oxidative stress, with improved muscle function following exercise-induced muscle damage. Due to the lack of studies, it is not possible to prescribe precise types of fruit or dosages.
→ Blackcurrants, which have a high polyphenol content, do not improve recovery but may enhance performance when taken 2-hours prior to exercise. But the effects are small and the heterogeneity between studies is huge (in fact, the confidence interval crosses zero, and therefore the effect is not significant, in all but one study).
→ Pomegranate ingestion for at least 2-weeks may help lessen feelings of post-exercise muscle fatigue and soreness, and reduce muscle damage (creatine kinase, CK; and lactate dehydrogenase, with some evidence for lowering of inflammatory and oxidative stress biomarkers and increased activity of antioxidant enzymes. Pomegranate may also help increase muscle strength. But the effects are small to negligible and are less pronounced following eccentric exercise, when the pomegranate is low in polyphenol content, and when pomegranate is administered less than 1-hour before exercise. Furthermore, neither of the two systematic reviews (Urbaniak et al. and Ammar et al.) presents effects sizes or a forest plot summary, limiting the ability to have confidence in the authors’ conclusions.
→ Curcumin, the main phenolic compound in turmeric, may lessen exercise-induced muscle soreness and damage (decreased creatine kinase, CK), have anti-inflammatory and antioxidant effects. Curcumin may have a small effect on the recovery of performance when taken at a dose of 150–1500 mg/day before and during exercise. Regrettably, however, the experimental studies have a moderate to high risk of bias and neither of the two systematic reviews (Suhett et al. and Fernández-Lázaro et al.) presents effects sizes or a forest plot summary, limiting the ability to have confidence in the authors’ conclusions.
→ Cocoa flavanols may help lessen exercise-induced oxidative stress and improve mitochondrial efficiency but with no effect on performance.
→ Citrulline (a non-essential amino acid found in watermelon) when taken pre-exercise may reduce RPE and post-exercise feelings of soreness for up to 24-hours (with moderate to large effects), but no qualitative synthesis was performed and effects were driven by singular studies.
→ Nitrate-rich beetroot juice may have a moderate effect on some markers of exercise-induced muscle damage (e.g. feelings of muscle soreness and the restoration of isometric strength and countermovement jump performance) but these effects typically only manifest 48 to 72-hours after exercise — most athletes will have trained again in that window.

I know this section is long but there is a monster amount of data! So…
To summarise…
→ Vitamin C, vitamin E, polyphenols, flavonoids, omega-3s are all commonly-taken, self-prescribed, and easily-accessible antioxidant supplements. They are cheap to purchase, over-the-counter, with no questions asked. They must be safe, right? While it is very difficult to overdose on most of these, vitamin E, a fat-soluble vitamin that is stored in the body, can be “overdosed”.
→ Most supplements that claim ergogenic benefit to performance/recovery are not supported by robust scientific evidence.
→ Blunting the inflammatory or oxidative stress response following a workout is not necessarily a good thing because the acute inflammatory response is part of the signal required to prompt exercise adaptations. Supplements often provide “megadoses” of individual compounds that exceed a threshold for blunting beneficial adaptations — doses of antioxidant provided by 5-portions of fruit and veg do not exceed that threshold.
→ Remember that muscle soreness is a sign of damage and of increases in free radicals and inflammatory compounds, i.e. the repair process that leads to adaptation. Yes, the accumulation of excess free radicals (reactive oxygen/nitrogen species) in the absence of your powerful internal antioxidant responses will lead to oxidative stress and tissue dysfunction and, eventually, disease. But, the acute low-level increase in free radicals following a workout is a powerful stimulus that drives your adaptations to said workout. Armed with that knowledge, do you still feel the need to pop an antioxidant pill after every session? Blunting exercise-induced free radical production with antioxidant supplementation will suppress your training adaptations. "Don't shoot the messenger" — don’t take an antioxidant after every session.
→ Never assume that a supplement is safe, effective, or legal. You are the only person responsible for what goes into your body. If you are using a supplement, take responsibility for it… Do you know what is in it? Do you know where it came from? Is it safe? Make sure you are not inadvertently taking a substance listed on the WADA prohibited list and ensure that the products you use have been tested by Informed Sport or Informed Choice to ensure the products are providing what they say they do and are not contaminated with WADA-prohibited substances.
→ The above-described evidence from the studies of whole foods (honey, fruits, cocoa, turmeric, etc) highlights the importance of a “food first” approach, which has merit not only for healthy eating but also for sports recovery and performance.
→ Consuming antioxidants is an important part of healthy eating for helping to prevent disease. Real foods, like berries, fruits, nuts, chocolate, and vegetables, all contain adequate levels of antioxidants (as shown by this crazy study that analyzed 3100 foods/drinks).
→ Despite the lack of robust effect, many athletes take dietary supplements. One of the most comprehensive evaluations studied the effect of ~7-months of vitamin/mineral supplementation providing 100 to 5000 times the RDA on exercise performance in nationally-ranked athletes at the Australian Institute of Sport — supplementation did not affect any measure of performance, including strength, anaerobic power, or aerobic endurance, when compared to athletes whose vitamin and mineral RDAs were met by normal dietary intake. This was supported by two further studies (here and here).
→ If you are healthy, weight stable, not habitually eliminating foods or food groups from your diet, and do not have a clinically-diagnosed deficiency in a specific nutrient/hormone/vitamin, taking a vitamin/mineral/antioxidant is unlikely to provide any benefit to your health nor enhance your recovery.
→ Furthermore, several systematic reviews have confirmed that vitamin/mineral supplementation strategies do not treat colds, influenza, nor do they lower the risk of chronic diseases like cancer and cardiovascular disease. For some lighter reading on this topic, please see examine.com.
→ Yes, some people do have nutrient deficiencies — older-aged folks, vegetarians, and pregnant women are at particular risk of deficiencies and should consult their doctor for blood tests and advice.
→ Some athletes are also at risk of deficiencies, especially if they do not adhere to a healthy eating practice or if they compete in weight category sports — women competing in dance, gymnastics, or endurance running are documented to have an increased prevalence of nutrient deficiencies — such folks should consult their doctor for blood tests to diagnose any possible deficiencies. A 2017 review provides excellent info on blood test selection for athletes.
→ Nutrient deficiencies can be remedied with supplementation but assessing nutritional intake and nutrient status can be tricky, particularly because athlete-specific reference ranges do not exist. So, get professional guidance from your doctor and a registered dietician/nutritionist. An excellent review of nutritional assessment in athletes was published out of Louise Burke’s lab in 2017.
→ And, finally, always remember that a multivitamin is a supplement to not a replacement for healthy eating. As Wyatt Brown elegantly wrote in his article for examine.com, “If you eat a balanced diet, as you should, taking a multivitamin might have for sole result to make your urine more expensive”.

Systematic reviews of dietary supplements for recovery or performance:
Here is the list of systematic reviews I have summarised above:

The Effect of Nitrate-Rich Beetroot Juice on Markers of Exercise-Induced Muscle Damage: A Systematic Review and Meta-Analysis of Human Intervention Trials.
Jones L, Bailey SJ, Rowland SN, Alsharif N, Shannon OM, Clifford T.
J Diet Suppl. 2021

Selected root plant supplementation reduces indices of exercise-induced muscle damage: A systematic review and meta-analysis.
Doma K, Devantier-Thomas B, Gahreman D, Connor J.
Int J Vitam Nutr Res. 2020

Effect of citrulline on post-exercise rating of perceived exertion, muscle soreness, and blood lactate levels: A systematic review and meta-analysis.
Rhim HC, Kim SJ, Park J, Jang KM.
J Sport Health Sci . 2020

The effect of dietary (poly)phenols on exercise-induced physiological adaptations: A systematic review and meta-analysis of human intervention trials.
Martinez-Negrin G, Acton JP, Cocksedge SP, Bailey SJ, Clifford T.
Crit Rev Food Sci Nutr. 2020

Effects of vitamin C on oxidative stress, inflammation, muscle soreness, and strength following acute exercise: meta-analyses of randomized clinical trials.
ighi NC, Schuch FB, De Nardi AT, Pippi CM, de Almeida Righi G, Puntel GO, da Silva AMV, Signori LU.
Eur J Nutr. 2020

Omega-3 Polyunsaturated Fatty Acid Supplementation for Reducing Muscle Soreness after Eccentric Exercise: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Lv ZT, Zhang JM, Zhu WT.
Biomed Res Int. 2020

Are There Benefits from the Use of Fish Oil Supplements in Athletes? A Systematic Review.
Lewis NA, Daniels D, Calder PC, Castell LM, Pedlar CR.
Adv Nutr. 2020

Fruit supplementation reduces indices of exercise-induced muscle damage: a systematic review and meta-analysis.
Doma K, Gahreman D, Connor J.
Eur J Sport Sci. 2020

The Role of Selenium Mineral Trace Element in Exercise: Antioxidant Defense System, Muscle Performance, Hormone Response, and Athletic Performance. A Systematic Review.
Fernández-Lázaro D, Fernandez-Lazaro CI, Mielgo-Ayuso J, Navascués LJ, Córdova Martínez A, Seco-Calvo J.
Nutrients. 2020

The effect of fish oil supplementation on the promotion and preservation of lean body mass, strength, and recovery from physiological stress in young, healthy adults: a systematic review.
Heileson JL, Funderburk LK.
Nutr Rev. 2020

The effect of New Zealand blackcurrant on sport performance and related biomarkers: a systematic review and meta-analysis.
Braakhuis AJ, Somerville VX, Hurst RD.
J Int Soc Sports Nutr. 2020

Effects of curcumin supplementation on sport and physical exercise: a systematic review.
Suhett LG, de Miranda Monteiro Santos R, Silveira BKS, Leal ACG, de Brito ADM, de Novaes JF, Lucia CMD.
Crit Rev Food Sci Nutr. 2020

Probiotics, prebiotics and synbiotics: useful for athletes and active individuals? A systematic review.
Calero CDQ, Rincón EO, Marqueta PM.
Benef Microbes. 2020

Modulation of Exercise-Induced Muscle Damage, Inflammation, and Oxidative Markers by Curcumin Supplementation in a Physically Active Population: A Systematic Review.
Fernández-Lázaro D, Mielgo-Ayuso J, Seco Calvo J, Córdova Martínez A, Caballero García A, Fernandez-Lazaro CI.
Nutrients. 2020

The Effects of Strength Training Combined with Vitamin C and E Supplementation on Skeletal Muscle Mass and Strength: A Systematic Review and Meta-Analysis.
Dutra MT, Martins WR, Ribeiro ALA, Bottaro M.
J Sports Med. 2020

Supplementation of Probiotics and Its Effects on Physically Active Individuals and Athletes: Systematic Review.
Möller GB, da Cunha Goulart MJV, Nicoletto BB, Alves FD, Schneider CD.
Int J Sport Nutr Exerc Metab. 2019

The effects of vitamin C and E on exercise-induced physiological adaptations: a systematic review and Meta-analysis of randomized controlled trials.
Clifford T, Jeffries O, Stevenson EJ, Davies KAB.
Crit Rev Food Sci Nutr. 2019

Effect of pomegranate fruit supplementation on performance and various markers in athletes and active subjects: a systematic review.
Urbaniak A, Skarpańska-Stejnborn A.
Int J Vitam Nutr Res. 2019

Honey Supplementation and Exercise: A Systematic Review.
Hills SP, Mitchell P, Wells C, Russell M.
Nutrients. 2019 J

Antioxidant Supplementation and Adaptive Response to Training: A Systematic Review.
Pastor R, Tur JA.
Curr Pharm Des. 2019

Effects of pomegranate supplementation on exercise performance and post-exercise recovery in healthy adults: a systematic review.
Ammar A, Bailey SJ, Chtourou H, Trabelsi K, Turki M, Hökelmann A, Souissi N.
Br J Nutr. 2018

The effect of glutamine supplementation on athletic performance, body composition, and immune function: A systematic review and a meta-analysis of clinical trials.
Ramezani Ahmadi A, Rayyani E, Bahreini M, Mansoori A.
Clin Nutr. 2019

Cocoa Flavanol Supplementation and Exercise: A Systematic Review.
Decroix L, Soares DD, Meeusen R, Heyman E, Tonoli C.
Sports Med. 2018

Antioxidants for preventing and reducing muscle soreness after exercise.
Ranchordas MK, Rogerson D, Soltani H, Costello JT.
Cochrane Database Syst Rev. 2017

Performance and Side Effects of Supplementation with N-Acetylcysteine: A Systematic Review and Meta-Analysis.
Rhodes K, Braakhuis A.
Sports Med. 2017

Polyphenols and Performance: A Systematic Review and Meta-Analysis.
Somerville V, Bringans C, Braakhuis A.
Sports Med. 2017

Effects of Vitamin D Supplementation on Serum 25-Hydroxyvitamin D Concentrations and Physical Performance in Athletes: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
Farrokhyar F, Sivakumar G, Savage K, Koziarz A, Jamshidi S, Ayeni OR,Peterson D, Bhandari M.
Sports Med 2017

Red Ginseng as an Ergogenic Aid: A Systematic Review of Clinical Trials.
Lee NH, Jung HC, Lee S.
J Exerc Nutrition Biochem. 2016

A Systematic Review of the Role of Vitamin D on Neuromuscular Remodelling Following Exercise and Injury.
Minshull C, Biant LC, Ralston SH, Gleeson N.
Calcif Tissue Int. 2016

Effects of vitamin E supplementation on exercise-induced oxidative stress: a meta-analysis.
Stepanyan V, Crowe M, Haleagrahara N, Bowden B.
Appl Physiol Nutr Metab. 2014

The effects of magnesium supplementation on exercise performance.
Newhouse IJ, Finstad EW.
Clin J Sport Med. 2000

Inflammation is the loss of function in a tissue that is painful/sore, swollen, red, and hot. Inflammation sounds pretty terrible and sounds like it is not good for us humans, so, naturally, many people surmise that if inflammatory compounds are flying around the body then that cannot be a good thing. Since every work-out causes an acute inflammatory response, which is detectable in muscles as a feeling of soreness and in the blood and muscles as an increase in proinflammatory cytokines, it has become intuitive to many folks that taking an anti-inflammatory drug is an “essential” part of being an athlete — to help alleviate post-exercise feelings of muscle soreness and to help “speed up” recovery.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are a very popular type of drug, most commonly taken for their pain-killing benefits. Let’s be honest, who hasn’t thought, “I need a painkiller” when they have a headache? NSAIDs include common generic/brand-name drugs like aspirin, ibuprofen/Advil/Motrin/Nurofen, naproxen/Aleve, etc, while analgesic (painkilling) drugs like paracetamol/acetaminophen/Panadol/Tylenol also sometimes get stuffed under the NSAID category because they have similar effects. All of these can be self-prescribed and are cheap to purchase and easily-available, over-the-counter, with no questions asked.

NSAIDs work by rapidly-inhibiting cyclooxygenase (COX) enzymes. Aspirin, ibuprofen, and naproxen are “nonselective”, which means they inhibit all forms of COX enzyme, COX1 and COX2. Inhibiting COX1, which is expressed in all tissues, reduces the levels of prostaglandins that are the cause of inflammation and fever and the associated feelings of soreness. COX2 is predominantly found in gastrointestinal and kidney cells, inhibition of which increases the risk of the gastric/kidney issues associated with NSAIDs. Paracetamol/acetaminophen works via a different mechanism, which is less clearly understood — although it might inhibit COX enzyme activity, paracetamol does not reduce tissue inflammation, while its painkilling effects likely manifest via effects on serotinergic- and endocannabinoid-signalling. Paracetamol/acetaminophen tends not to have the side effects associated with aspirin or ibuprofen and, while it is safe at recommended doses, it can be toxic to the liver, especially when mixed with alcohol.

So, using NSAIDs to blunt or prevent exercise-induced muscle soreness certainly has some rationale. Which is why many folks use them. A 2018 survey of recreational endurance athletes found that 68% (2 in 3) had used NSAIDs (predominantly ibuprofen) in the past 12-months, 45% (1 in 2) immediately before or after a session. The majority surveyed expected anti-inflammatory and/or painkilling benefits despite more than half of the respondents expecting an adverse effect in their liver or kidney, while only 26% (1 in 4) used an NSAID under the guidance of a doctor or pharmacist. This high prevalence of NSAID use has also been reported in Ironman triathletes, Ultrarunners, and world-class footballers. In 2020, a survey of 806 recreational “Parkrunners” (a weekly 5km event in the UK), found that 88% (9 in 10) had used an NSAID (mostly ibuprofen) in the past 12-months and that, alarmingly, 1 in 4 had experienced an adverse drug reaction (usually gastrointestinal), and 1 in 5 of the NSAID users had a pre‐existing contraindication yet still used NSAIDs. The study also found that the longer the race, the more likely a person was to take an NSAID during the event, which was also common (1 in 2) in Ironman triathletes and Ultrarunners (who reported taking NSAIDs during a race to prevent pain and fatigue). To summarise these athlete surveys, the prevalence of NSAID use is high, ibuprofen is the most common, knowledge of effects/side-effects is poor, clinical advice is rarely sought, and use is justified to treat an injury or reduce during-exercise and/or post-exercise soreness/pain.

The folks who reason their journey to using an NSAID as a core component of training, fail to acknowledge that the acute inflammatory response to each work-out is what drives muscle adaptations to training. So, is it also reasonable to assume that regular use of an NSAID alongside training may blunt the recovery of your performance and your training adaptations?

There is some experimental evidence to support this sentiment. In cell cultures, prostaglandins stimulate hypertrophic signalling and muscle cell hypertrophy while in humansCOX enzymes are certainly involved in muscle protein metabolism, as is the production of prostaglandins in muscle following exercise. Further work has found that a single over-the-counter dose of either ibuprofen or paracetamol/acetaminophen may prevent resistance exercise-induced increases in muscle protein synthesis in young recreationally-active men, without suppressing muscle soreness or creatine kinase (CK, a marker of muscle damage) and without blunting exercise-induced increases in muscle inflammation. Longer-term studies in rodents have shown that chronic COX-inhibitor consumption attenuates muscle hypertrophy and regrowth from atrophy. While in humans, high doses of ibuprofen (but not aspirin) have been found to blunt training-induced increases in hypertrophy and strength in younger previously-inactive adults. But, over-the-counter doses of ibuprofen or paracetamol/acetaminophen have not been shown to inhibit training-induced hypertrophy or strength gains in older and previously-inactive men.

To summarise the exercise data, it appears that using NSAIDs or paracetamol may not mitigate exercise-induced inflammation or feelings of soreness but do impair training-induced increases in muscle protein synthesis, hypertrophy, and strength, at least in younger adults. But what about the role of NSAIDs during more severe muscle damage? One study has shown that muscle damage was reduced with daily diclofenac sodium/Voltaren administration for 2-weeks prior to and during 2-weeks of daily eccentric stair-stepping training, in young untrained adults who understood. A similar outcome was found following daily ibuprofen administration for 14-days prior to severe electrical stimulation-induced muscle damage of the quadriceps, which improved the regeneration of muscle despite a lack of effect on feelings of soreness or restoration of muscle strength/power.

That was a somewhat lengthy narrative of experimental studies and, as is probably becoming clear, the topic of NSAIDs and exercise is bewildering...

Because of the vast importance of understanding the risks and the benefits of drugs that are nonchalantly quaffed down by many athletes, there are several narrative reviews that have tried to unravel the complexity of the topic — I have also included them below since they provide most useful insight on top of the current systematic analyses.

You might consider the above-described lengthy narrative of experimental studies combined with other scientists’ narrative reviews to be an epic cherry-picking expedition. And, you would be correct. So, let’s see what the systematic reviews say.

Should you use NSAIDs for recovery — what do the systematic (and narrative) reviews say?
→ First off, never forget that NSAIDs and analgesics are drugs. As with all drugs, there are side-effects, drug-drug interactions, and food/alcohol-drug interactions, the risks of which are increased in people with certain conditions. Widespread availability can easily lead to misuse and even abuse. Never self-prescribe a drug without medical advice and if you are unsure, always consult your doctor.
→ Second, always remember: Acute inflammation is your friend. Chronic inflammation is your foe.
→ Every work-out triggers an acute inflammatory response — this is normal, not pathological. Interestingly, the measurable increase in proinflammatory cytokines in the blood following a work-out is remarkably similar to that seen in a patient with sepsis (an acute bacterial infection in the blood). The major difference is that the former makes you happy and strong while the latter, which is more severe and accompanied by an inadequate anti-inflammatory response, can put you in intensive care.
→ Yes, the accumulation of acute inflammation with impaired anti-inflammatory responses will cause chronic inflammation and tissue dysfunction and, eventually, disease. But, the acute increase in inflammatory molecules following a workout is one of the most powerful mediators for driving your training adaptations. And, your internal anti-inflammatory response prevents acute inflammation having a rager and developing into chronic inflammation. Now, armed with that truth, does it sound like you are supposed to be popping NSAIDs after every session?
→ The systematic reviews show there is reasonably good-quality evidence that anti-inflammatory drugs (both non-selective COX and selective COX-2 inhibitors) may enhance performance and muscle weakness in older-aged people with an acute inflammatory condition and that nonselective Cox inhibitors (NSAIDs) may enhance training-induced increased in muscle strength in older-aged people. This benefit in older folks is very likely to be due to the lowering of ageing-related chronic inflammation but mechanisms are unknown at this time and the evidence does not allow for accurate dosing prescriptions.
→ In healthy and younger adults, the systematic reviews concluded that the level of evidence for a benefit of NSAIDs on strength, endurance, and post-exercise muscle soreness is low, but that there is a high degree of bias — the NSAID doses used are often well above over-the-counter dosing and highly-variable, as are the type of exercises performed.
→ The narrative reviews highlight that the potential adverse effects of NSAIDs should not be ignored — they are numerous and account for 30% of adverse drug reactions hospitalisations (in a survey of 18,820 patients). Furthermore, NSAID use during exercise has been associated with hyponatremia, reduced renal blood flow, and gastrointestinal bleeding. And, some evidence shows that chronic NSAID use may affect bone consolidation, potentially delaying the healing of stress fractures — which is not surprising since prostaglandins, the product of COX enzyme activity, which is inhibited by NSAIDs) are required for bone metabolism.
→ But this is not to say that NSAIDs are useless. Painkillers and anti-inflammatories have their place for dealing with acute pain but only under the guidance of a physician. A reliance on using drugs like NSAIDs to treat daily pain is not something you should be self-diagnosing. Persistent muscular or joint soreness and/or injuries must be examined by a medical doctor and a qualified sports physiotherapist.
→ Sports medicine physicians often use NSAIDs to treat pain in athletes but due to their negative consequence on the long-term healing process, the duration of use is typically short, and the specific type of injury and level of dysfunction and pain should always be considered.
→ Masking the pain associated with sport, may be to the detriment of healing and repair (following injury/damage) and/or adaptation and growth (during training). Therefore, self-prescribed treatment of pain with NSAIDs to accelerate the return to training is unwise.
→ Based on current evidence, taking the occasional anti-inflammatory or analgesic drug is unlikely to impede your training adaptations or affect muscle growth but they lack efficacy for alleviating exercise-induced muscle soreness. Taking such a drug to mask pain or an injury so that you can train is also not prudent.
→ The widespread use of NSAIDs and painkillers in athlete populations is not justified by the evidence. Neither is popping such drugs every day so you “feel” more recovered after every session. Acute inflammation is your friend — “Don't shoot the messenger”.

Systematic reviews of NSAIDs for recovery or performance:
Here is the list of systematic reviews I have summarised above:

Effect of Non-Steroidal Anti-Inflammatory Drugs on Sport Performance Indices in Healthy People: a Meta-Analysis of Randomized Controlled Trials.
Cornu C, Grange C, Regalin A, Munier J, Ounissi S, Reynaud N, Kassai-Koupai B, Sallet P, Nony P.
Sports Med Open. 2020

Impact of drugs with anti-inflammatory effects on skeletal muscle and inflammation: A systematic literature review.
Alturki M, Beyer I, Mets T, Bautmans I.
Exp Gerontol. 2018

Narrative reviews:
List ordered newest to oldest.

Analgesic and anti-inflammatory drugs in sports: Implications for exercise performance and training adaptations.
Lundberg TR, Howatson G.
Scand J Med Sci Sports. 2018

Effects of prostaglandins and COX-inhibiting drugs on skeletal muscle adaptations to exercise.
Trappe TA, Liu SZ.
J Appl Physiol. 2013

The use of nonsteroidal anti-inflammatory drugs for exercise-induced muscle damage: implications for skeletal muscle development.
Schoenfeld BJ.
Sports Medicine. 2012

Non-steroidal anti-inflammatory drugs for athletes: An update.
Ziltenera JL, Leala S, Fournier PE.
Ann Phys Rehabil Med. 2010

Prophylactic Use of NSAIDs by Athletes: A Risk/Benefit Assessment.
Warden SJ.
Phys Sportsmed. 2010 “Scientific evidence for such benefits is sparse, and athlete rationale for using prophylactic NSAIDs for their preemptive analgesic and anti-inflammatory effects appears at odds with current understanding of the underlying pathology of many sports related injuries”

Non-steroidal anti-inflammatory drugs, cyclooxygenase-2 and the bone healing process.
Vuolteenaho K, Moilanen T, Moilanen E.
Basic Clin Pharmacol Toxicol. 2008

Nonsteroidal Antiinflammatory Drugs in Tendinopathy: Friend or Foe.
Magra M, Maffulli N.
Clin J Sports Med. 2006

The paradox of “active recovery” can be somewhat confusing since recovery, that is the restoration of homeostasis and performance, takes time and rest. Easy effort sessions in between your carefully-planned days of homeostatic mayhem help you recover in a sense by allowing adequate time to pass between hard days. But, easy effort sessions in themselves are sessions that disrupt homeostasis and require time to restore such.

The world is full of gadgets and pills and potions that claim recovery benefits by “lowering lactate”, “increasing blood flow”, “clearing toxic metabolites”, “suppressing muscle soreness”, and “boosting feelings of recovery”. But it is best not to forget the most powerful stimulus of all — moving. Going for a gentle stroll after a session is a form of active recovery. Sitting down and resting is a form of passive recovery.

A 2018 narrative review from Bas Van Hooren and Jonathan Peake suggested that while many athletes perform an active “cool-down” including 5- to 15-min of low- to moderate-intensity exercises within an hour of completing a session or race, it may only be effective for restoring performance when the next bout is up to 20-min later. For subsequent bouts that are longer than 4-hours later, an active cool-down is likely not effective for boosting sports performance later that day or in the following days. However, a narrative review albeit credible does not use a standardised systematic approach to evaluating the literature. Furthermore, they aimed to examine the effects of a cool-down on later-in-the-day performance, not between-session active recovery. So, what do the systematic approaches say?

Should you use active recovery — what do the systematic reviews say?
→ Note that some researchers have referred to modalities like massage, foam rolling, cold exposure, etc as “active” recovery. For this post, I am referring to moving one's ass through the medium of light activities like walking/jogging, cycling, etc.
→ Between sessions, active recovery is very effective for reducing post-exercise feelings of delayed onset muscle soreness (DOMS), especially in the short-term (<6-hours) but is less effective at lowering the perceived feeling of fatigue than other recovery modalities.
→ On days, in between heavier sessions, active recovery interventions lasting 6- to 10-minutes have consistently positive effects on performance and self-reported feelings of recovery.
→ The appropriate intensity for active recovery sessions on days between heavier sessions is unknown at this time. From a running perspective, all good coaches agree that low-to-moderate intensity exercise is favourable on days in between harder work.
→ Within sessions, active recovery during rest-intervals tends to reduce the restoration of running sprint performance and elevate feelings of perceived effort when compared to passive recovery. For cycling, however, there is a large heterogeneity between studies so it is unclear whether passive or active rest-intervals are more appropriate.
→ Among the studies selected in the various systematic reviews, the definition of “active recovery” is vague. In some cases referring to walking, jogging, cycling, or swimming at a low- to moderate-intensity while in other cases referring to the use of devices or modalities that are designed to facilitate recovery.
→ Since we have known for many moons that the best way to increase muscle contraction, blood flow, and cardiac output is to move. Contracting muscles with gentle walking/cycling/swimming etc or even some light jogging will increase your heart rate and massively increase blood flow in your limbs, elevating venous return — no device can mimic the magnitude of change seen with these physiological parameters during exercise.
→ A feeling that you are not recovering, and/or performance markers that indicate such, are sometimes induced by a lack of rest in between sessions. Being active as a form of “recovery” is not always the best course of action and indeed the phrase “active recovery” is somewhat paradoxical. If you feel that you need rest, i.e. passive rest, then don’t move, just sit down and do something relaxing.

Systematic reviews of active recovery:
Here is the list of systematic reviews I have summarised above:

Effect of active versus passive recovery on performance-related outcome during high-intensity interval exercise.
Perrier-Melo RJ, D'Amorim I, Meireles Santos T, Caldas Costa E, Rodrigues Barbosa R, DA Cunha Costa M.
J Sports Med Phys Fitness. 2021

The Use of Acute Exercise Interventions as Game Day Priming Strategies to Improve Physical Performance and Athlete Readiness in Team-Sport Athletes: A Systematic Review.
Mason B, McKune A, Pumpa K,Ball N.
Sports Med. 2020

Effect of active versus passive recovery on performance-related outcome during high-intensity interval exercise: a systematic review.
Perrier-Melo RJ, D'amorim I, Meireles Santos T, Caldas Costa E, Barbosa RR, da Cunha Costa M.
J Sports Med Phys Fitness. 2020

A Systematic Review on the Effectiveness of Active Recovery Interventions on Athletic Performance of Professional-, Collegiate-, and Competitive-Level Adult Athletes.
Ortiz RO Jr, Sinclair Elder AJ, Elder CL, Dawes JJ.
J Strength Cond Res. 2019

A systematic review examining the physiological, perceptual, and performance effects of active and passive recovery modes applied between repeated-sprints.
Madueno MC, Guy JH, Dalbo VJ, Scanlan AT.
J Sports Med Phys Fitness. 2019

Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis.
Bieuzen F, Bleakley CM, Costello JT.
PLoS One. 2013 Yes, I know this doesn’t look like an active recovery review but some of the studies selected used active recovery as a comparator to contrast water therapy.

Stretching sessions as a means of increasing flexibility is a mainstay in sports that require feats of bendiness like gymnastics — following her many years of gymnastics training and competition in her youth, 20-years on, my wife could still easily sell herself as a human slinky. But extreme levels of bendiness is not a useful pursuit for a runner. Nonetheless, stretching exercises have existed since the dawn of textbooks and are regularly recommended for the purported aim of preventing injury, reducing muscle soreness, and even enhancing performance.

Recent thoughts have centred around the effects of static stretching on performance outcomes. Indeed some data show that pre-lifting static stretching may reduce the number of repetitions achieved and the total volume of training while consequently blunting hypertrophy gains resulting from resistance training in previously untrained folks. But it gets more complex than that...

Some data shows that performance is differentially affected by varying types of pre-session stretching protocols (e.g. static, ballistic, vs. proprioceptive neuromuscular facilitation) while other work has shown that static stretching of hamstrings (i.e. the antagonist muscle) between sets of squats can increase biceps femoris (hamstring) muscle thickness. Then there is the timing of stretching. For example, inter-set quadriceps stretching has negatively impacted the neuromuscular performance of knee extension exercise in resistance-trained men. But, in previously untrained folks, inter-set stretching may help facilitate increases in muscle strength and hypertrophy during the early phase of a resistance training programme. And other data show that static stretching sessions aimed at increasing flexibility on the days between lifting sessions may even augment strength gains during resistance training in novice lifters. Confused?

Well, this rather complex scene has received attention from several narrative reviews. One such review by James Nuzzo was even so bold to propose, “The Case for Retiring Flexibility as a Major Component of Physical Fitness”, who argues that flexibility can be maintained or improved by exercise modalities besides stretching that cause more robust health benefits — for example, resistance training. But, flexibility is not always the goal of stretching. Namely: stretching in addition to a warm‐up protocol may reduce the incidence of muscle strains but likely does not affect the incidence of overuse injuries, sentiments that have been echoed elsewhere. Other narrative reviews (here and here) have concluded that stretching probably suppresses muscle strength but that the variety of stretching protocols make it difficult to accurately conclude.

So, some patterns are emerging but, while narrative reviews are interesting and thought-provoking, we can do better by turning to the highest level of evidence — systematic reviews of randomised controlled trials. So, what do they say…?

Should you use stretching for recovery — what do the systematic reviews say?
→ Note that this post is aimed at examining the role of stretching in the recovery of performance. It is not relevant to the use of stretching for rehabilitation from injury or surgery, nor is it specific to appropriate warm-up protocols.
→ Stretching is very useful for increasing flexibility, which is important in some sports.
→ High levels of flexibility is probably not so useful for running but it certainly is for hurdlers, steeplechase racers, and OCR athletes, in whom having a high range of motion in all joints is a useful facet for obstacle completion.
→ Stretching either before or after exercise (or both), does not produce clinically important reductions in delayed-onset muscle soreness (DOMS).
→ The evidence that stretching might reduce injury risk in runners, is of very low quality, high risk of bias, and shows large heterogeneity between study designs.
→ Flexibility training alongside resistance/endurance training programmes may enhance muscle performance but again the quality of evidence is low.
→ The evidence recommends against static stretching immediately prior to strength, power, speed, or agility activities — "don't shoot the messenger" with a pre-session/race static stretch.
→ Pre-exercise static stretching has either no effect or a detrimental effect on endurance performance.
→ Dynamic exercises are a suitable alternative to static stretching as part of a warm-up.
→ The negative effect of pre-exercise static stretches is lost if they precede dynamic exercises during a warm-up.
→ Strong evidence supports the use of dynamic exercises on subsequent muscular performance for strength- and power-dominant activities since they have either positive or neutral effects.
→ Since the potentially-detrimental effects of static stretching on muscle contractility likely only persist for a few minutes and are overridden by subsequent dynamic exercises, a static stretch embedded into a dynamic routine that raises muscle temperature (i.e. a “warm-up”) is very unlikely to have any harmful effect on performance. So, if you fancy a quick quad stretch on the start line because it feels good, do not stress over it.

Systematic reviews of stretching for recovery:
Here is the list of systematic reviews I have summarised above:

The Effectiveness of Post-exercise Stretching in Short-Term and Delayed Recovery of Strength, Range of Motion and Delayed Onset Muscle Soreness: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.
Afonso J, Clemente FM, Nakamura FY, Morouço P, Sarmento H, Inman RA, Ramirez-Campillo R.
Front Physiol. 2021

Do alterations in muscle strength, flexibility, range of motion, and alignment predict lower extremity injury in runners: a systematic review.
Christopher SM, McCullough J, Snodgrass SJ, Cook C.
Arch Physiother. 2019

Acute Effects of Static Stretching on Muscle Strength and Power: An Attempt to Clarify Previous Caveats.
Chaabene H, Behm DG, Negra Y, Granacher U.
Front Physiol. 2019

Acute Effects of Dynamic Stretching on Muscle Flexibility and Performance: An Analysis of the Current Literature.
Opplert J, Babault N.
Sports Med. 2018

Influence of chronic stretching on muscle performance: Systematic review.
Medeiros DM, Lima CS.
Hum Mov Sci. 2017

The effects of stretching on performance.
Peck E, Chomko G, Gaz DV, Farrell AM.
Curr Sports Med Rep. 2014

Effects of stretching on performances involving stretch-shortening cycles.
Kallerud H, Gleeson N.
Sports Med. 2013

Does pre-exercise static stretching inhibit maximal muscular performance? A meta-analytical review.
Simic L, Sarabon N, Markovic G.
Scand J Med Sci Sports. 2013

Stretching to prevent or reduce muscle soreness after exercise.
Herbert RD, de Noronha M, Kamper SJ
Cochrane Database of Systematic Reviews. 2011

Cold water immersion is very popular and involves popping oneself in 10 to 15^oC water for up to 15-minutes. Jumping into ice cold water does two things: First, you yell some expletive like, “By the beard of Zeus”. Second, your autonomic nervous system immediately goes nuts — cold water immersion induces shivering (aka muscle contraction)-induced heat production, plus a robust increase in epinephrine (adrenaline), heart rate, and breathing rate — just like exercise — the opposite of rest

.

CrossFit athletes plunging their arms into ice water after crushing Murph... Mo Farah lowering himself into an ice-cold water tub after a lengthy interval workout... Social media “influencers” heading for their weekly cryo-chamber visit... Wim Hof climbing mountains in the winter in his underpants... These images are all visually-stimulating and even quite exciting but why do they do it?

Cold water immersion after a session lowers core body temperature back to normal. After the initial shock of entering the low temperature, the parasympathetic nervous system is activated to help “calm shiz down” (the physiological responses of cold water immersion have been systematically reviewed in the Br J Sports Med). For some folks, cold water immersion lowers the feeling of fatigue and lessens the feeling of muscle soreness — it “feels” like recovery. Subjective feelings of recovery (less muscle soreness) using cold water immersion have been confirmed in runners recovering from a half-marathon (but objective measures (creatine kinase, testosterone, and muscle function) were not improved). Some folks even find cold water immersion exhilarating (I am in this camp) because of the literal adrenaline rush. While others hate it. But, I even know athletes who hate cold water yet still jump in because they think they are supposed to.

With regards to the restoration of performance, there are several proposed mechanisms and many experimental studies examining acute and chronic effects of cold water immersion on both strength and endurance exercise modalities. When you delve into the individual studies, you find a mixed bag of outcomes but the adaptive biochemical and functional responses have been very well summarised in a 2018 narrative review in Sports Med. Fortunately, there are a sufficient number of high-quality experimental studies that can be systematically reviewed and meta-analysed to help you learn how to effectively use such cold immersion in practice.

Should you use cold water immersion for recovery — what do the systematic reviews say?
→ Cold water immersion after a session/race can be effective for reducing muscle soreness and feelings of fatigue (when compared to passive recovery, aka rest) while helping to reduce ratings of perceived exertion (RPE) or even restore physical performance between races/sessions that are just hours apart. That said, if excessive muscle damage has occurred (eccentric exercise), muscle weakness is not remedied with cold water immersion.
→ Some evidence also shows increased mitochondrial biogenesis following short-term cold water treatment.
→ The current optimal protocol is to immerse the entire body, excluding the head, in the water at a temperature of between 10 and 15^oC for 5- to 15-minutes. A narrative of the practical applications can be found in Shona Halson’s 2011 review in the International Journal of Sports Physiology and Performance
→ Icing the local area of sore muscle does not have the same acute benefit as cold water immersion.
→ There is insufficient evidence to determine whether whole‐body cryotherapy (single or repeated exposure(s) to extremely cold dry air below ‐100^oC in a specialised chamber) reduces self‐reported muscle soreness or improves subjective recovery after exercise.
→ Some data indicate that the benefits of cold water immersion are only conferred when standing not sitting due to the greater hydrostatic pressure.
→ Cold/hot-water contrast therapy may confer similar or additional benefits, but more research is needed.
→ Recent work also indicates that body composition may affect the rate of lowering of core temperature when immersed in cold water and should, therefore, be considered when designing your cold water immersion strategy.
→ But THE MOST IMPORTANT THING to know about cold water immersion is the difference between its acute vs. chronic effect. While cold water immersion may help rapidly recover performance, the caveat is that it also reduces training adaptations by blunting molecular signalling in muscle and suppressing muscle protein synthesis while blunting strength gains following resistance training. The inhibitory effect of cold therapy on endurance training adaptations is less pronounced, but regular cold therapy does not improve endurance performance. So, using cold water immersion daily is not advisable — "don't shoot the messenger". Sure, after your hard effort or lifting session, go stand in that cold lake (if ambient conditions permit and adequate warm/dry facilities are available), just not every day or you run the risk of preventing the improvements you are sweating so hard to achieve!

Systematic reviews of cold therapy for recovery:
Here is the list of systematic reviews I have summarised above:

The Effects of Regular Cold-Water Immersion Use on Training-Induced Changes in Strength and Endurance Performance: A Systematic Review with Meta-Analysis.
Malta ES, Dutra YM, Broatch JR, Bishop DJ, Zagatto AM.
Sports Med. 2020

The effects of cryotherapy on athletes' muscle strength, flexibility, and neuromuscular control: A systematic review of the literature.
Kalli K, Fousekis K.
J Bodyw Mov Ther. 2020

Effects of local cryotherapy for recovery of delayed onset muscle soreness and strength following exercise-induced muscle damage: systematic review and meta-analysis.
Nogueira NM, Felappi CJ, Lima CS, Medeiros DM.
Sport Sciences for Health. 2019

Can Water Temperature and Immersion Time Influence the Effect of Cold Water Immersion on Muscle Soreness? A Systematic Review and Meta-Analysis.
Machado AF, Ferreira PH, Micheletti JK, de Almeida AC, Lemes ÍR, Vanderlei FM, Netto Junior J, Pastre CM.
Sports Med. 2016

The Effect of Post-Exercise Cryotherapy on Recovery Characteristics: A Systematic Review and Meta-Analysis.
Hohenauer E, Taeymans J, Baeyens JP, Clarys P, Clijsen R.
PLoS One. 2015

Whole-body cryotherapy (extreme cold air exposure) for preventing and treating muscle soreness after exercise in adults.
Costello JT, Baker PR, Minett GM, Bieuzen F, Stewart IB, Bleakley C.
Cochrane Database Syst Rev. 2015

Cooling and performance recovery of trained athletes: a meta-analytical review.
Poppendieck W, Faude O, Wegmann M, Meyer T.
Int J Sports Physiol Perform. 2013

Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis.
Bieuzen F, Bleakley CM, Costello JT.
PLoS One. 2013

Cold water immersion and recovery from strenuous exercise: a meta-analysis.
Leeder J, Gissane C, van Someren K, Gregson W, Howatson G.
Br J Sports Med. 2012

Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: systematic review and meta-analysis.
Torres R, Ribeiro F, Alberto Duarte J, Cabri JM.
Phys Ther Sport. 2012

Many folks love a good soak in a warm bath. During the closing miles of a long winter run, I always daydream of how high I can stack the bubbles when I get home… Lying in warm water can be truly relaxing.

As a four-eyed ginger youngster in the 80s, I played football and lived for 3 pm on a Saturday. When the FA Cup rolled around each year, I used to be enamoured by the post-match drinking celebrations in the dressing rooms — everyone was so happy. But there is another memory firmly etched in my neurons — the massive bathtubs.

It was totally normal (and occasionally televised) for 11 men to get bollock-naked and take a bath... simultaneously, in the same filthy tub. I asked everyone why they did it; my coaches, my parents, my teammates. In return, I was treated to all sorts of wild answers, my favourite response being an Irish-accented, “they just love it”, from my Grandad. My tiny eight-year-old brain concluded that they just had to get clean before dinner and this was the most efficient method. But, was the seemingly inadvertent immersion in the steamy H₂O having beneficial effects besides impromptu Saturday afternoon man-porn? Well, let’s take a look at the evidence...

Should you use hot water immersion for recovery — what do the systematic reviews say?
→ Hot water immersion studies have typically immersed subjects for between 15 and 25-minutes with water between 35 and 45^oC.
→ Experimental hot water immersion studies have typically compared hot water immersion to cold water immersion or contrast water therapy (hot and cold), or both. Some studies have also made comparisons to passive recovery (rest), active recovery (light jogging/spinning), or others means of magic.
→ There is no systematic review solely examining the effect hot water immersion on recovery but the above-cited reviews did include hot water immersion studies in their analysis.
→ Although the current evidence (here, here, here, and here) shows that hot water immersion is probably not beneficial for lessening exercise-induced delayed onset muscle soreness (DOMS) and/or feelings of fatigue when compared to cold water immersion, contrast water therapy, or passive recovery, no systematic review exists. However, a narrative review from McGorm et al. nicely summarises these sentiments.
→ It is also important to remember that we are talking about recovery from your training sessions — none of the studies I refer to here is relevant to the recovery from injury, illness, and disease.
→ Very recent work, published in 2020, found that hot-water immersion during recovery from a single bout of resistance exercise did not further increase muscle protein synthesis rates or augment the postprandial incorporation of dietary amino acids into muscle in young people. Thus, the sentiments floating around that post-lifting heat-therapy causes more hypertrophy are not looking credible — it is probably the vasodilation caused by the post-session heat that simply makes muscles appear to be massive.
→ So, diving into your warm bath after a session is not going to have any magic effect on your performance but it probably won’t hurt. But do keep in mind that your core temperature rises when you work out and needs to return to normal for you to recover and stay healthy. For this reason, be sensible and use warm baths when you fancy some R&R and getting warm after a chilly session.

Should you use contrast water therapy for recovery — what do the systematic reviews say?
→ Contrast water therapy studies have typically used intermittent immersions in cold (10 to 15^oC) and hot (35 to 45^oC) at 1:1 to 3:1 time duration ratios.
→ There is currently insufficient research to determine optimal immersion durations, water temperatures, or time ratios (in the case of contrast therapy).
→ The systematic review by Bieuzen et al. (2013) found that contrast water therapy lessened exercise-induced muscle damage and feelings of soreness when compared to passive recovery (rest) and hot water immersion, but not when compared to other recovery modalities like active recovery or cold water immersion.
→ Although the review from Bieuzen et al. focussed on muscle damage, the authors also conducted a sub-group analysis of performance finding that contrast water immersion may slightly improve recovery of muscle strength but not muscle power when compared to passive recovery or hot water immersion.
→ However, Bieuzen et al. (2013) concluded that “Overall the study quality in this review was low. The majority of studies had a high risk of bias making the validity of most of the results uncertain.”.
→ Therefore, it is not currently possible to be confident in knowing whether or not using contrast water immersion is of any benefit.

Systematic reviews of hot water immersion or contrast water therapy for recovery:
Here is the list of systematic reviews I have summarised above:

Contrast water therapy and exercise induced muscle damage: a systematic review and meta-analysis.
Bieuzen F, Bleakley CM, Costello JT.
PLoS One. 2013

A sauna is usually a wooden shack with burning embers that increase the temperature to around 60-80^oC, sometimes evaporating water into the atmosphere (wet sauna, humidity >50%) or not (dry sauna, humidity <20%). In a wet sauna, you will likely feel very sweaty, while in a dry sauna you will not because the low humidity sucks that sweat straight off of you.

Many folks feel relaxed, rested, refreshed, and re-invigorated when they walk out of a sauna. Many also do not. I sit in the latter camp. A sauna gives me a feeling of excess fatigue. The only thing I enjoy about sweating my balls off in a hot box is inhaling the hot humid air, which my asthma-infested lungs find very soothing.

The list of proposed benefits of regular sauna treatment are as long as a piece of string. Some experimental studies indicate that regular sauna treatment can lower stress, anxiety, inflammation, etc etc. But not all studies reach the same conclusions. However, one of the most impressive studies, the Kuopio Ischemic Heart Disease Risk Factor Study, surveyed ~3000 middle-aged Finnish men and women over 20-years, finding an association between sauna use and a reduced risk of hypertension (high blood pressure), stroke, cardiovascular-related mortality (death), and dementia (inc. Alzheimer's disease), even when controlling for age, socioeconomic status, diet, and physical activity.

Yes, the Finns swear by it and I have been privileged to have visited pine-cabin saunas with many a Finn in various parts of their great country — it is indeed true that many apartment buildings even have a sauna in the basement. And, nothing beats giving a scientific talk in front of university academics, several of whom have seen you naked in a sauna just hours previously!

The associative role of sauna in the prevention of chronic disease certainly sounds impressive, which it is, but these data are associations derived from prospective long-term cohort studies where diet, activity, and sauna use are documented with questionnaire-based recall rather than being prescribed using a randomised controlled trial design (which is needed to prove direct causality). Importantly, there does not appear to be any adverse effects of a sauna, so long as you avoid dehydration and heat stress.

But, what about using a sauna to aid the recovery of your performance?

Should you use a sauna for recovery — what do the systematic reviews say?
→ Be mindful that this article is about the recovery from and adaptations to exercise that restore your performance. This article is not specific to the recovery from injury or illness nor is it relevant to the use of sauna as an adjunct for the maintenance of health.
→ Please also be mindful that this article is not about using a sauna for helping with heat acclimation.
→ When you sit in a sauna, your heart rate, breathing rate, sweat rate, oxygen consumption (VO₂), cardiac output, and blood pressure will all increase — similar physiological effects that occur during exercise. But regular trips to the sauna do not induce the same fitness adaptations as your regular training — be wary of any journalist or former cell biologists-turned public health gurus telling you otherwise. Yes, there is a long list of physiological things that change when you expose yourself to an unusually-hot environment, but these acute changes are not necessarily signs of adaptation and improvements, they are simply indications that your body is trying to maintain homeostasis under the stress/stimulus of the heat.
→ Since sitting in a sauna dramatically increases sweat rates, it is important to replace sweat losses with fluid to stay hydrated — dehydration will impair your recovery from and adaptations to your training. It is also important to avoid heat stress. So, exit the hot building if you feel like poop.
→ Most of the sauna research on exercise-related recovery has been done in rodents, which cannot be confidently extrapolated to practice in humans.
→ Few human studies exist and there is currently no systematic review of the literature.
→ One study, which included only 6 subjects and did not clearly-describe their during-study training loads, found that that 3-weeks of daily post-exercise sauna treatments may increase run time to exhaustion at current 5 km race speed (17.1±1.6 kph) in trained male runners.
→ Other studies have found that a post-exercise sauna reduces swimming time trial performance the following day (in 30 trained swimmers and triathletes) and that a muscle voluntary torque (MVC), a marker of muscle strength is reduced following a sauna in untrained folks.
→ If you feel relaxed, rested, refreshed, and reinvigorated when you leave a sauna, then go for it. If you do not, then sauna is not a recovery modality you need to include in your toolbox. Furthermore, it seems unwise to take a sauna immediately before, or the day before, a maximal effort (session or race) — "don't shoot the messenger".

Systematic reviews of using a sauna for recovery:
Here is the list of systematic reviews I have summarised above:
Unfortunately, there are currently no systematic reviews of using a sauna for recovery from exercise.

The local application of heat to an area of tissue that needs recovery has been all the rage since Mr Miyagi suppressed the feeling of pain in Daniel LaRusso leg before he headed back out into the ring to “Crane-kick” Jonny’s face in... That classic story.

“Old school” methods using hot water-perfused garments have found that heat-treatment of the thigh (~52^oC) for 90-mins 5-days/week for 8-weeks may increase knee extensor strength in untrained young healthy adults while just 5 daily 90-min sessions of thigh heat-treatment (54–55°C) following eccentric knee extensor exercise (300 bilateral maximal eccentric contractions), might hasten the recovery of fatigue resistance (but not strength) of the knee extensor in untrained young healthy adults.

Miyagi’s use of heat to dull LaRusso’s leg pain clearly helped him “recover” mid-match but things have advanced since the ole vigorous hand-rub friction-based application of heat and in this new-fangled world of tech, infra-red phototherapy has emerged from the burning embers.

Infra-red phototherapy is like a spy in that it goes by a variety of identities: photobiomodulation, diathermy, infra-red low-level laser therapy, light-emitting diode (LED) therapy, etc. Whatever its name, it involves firing at the muscle of interest with light of an infra-red or near-infrared wavelength — we humans can’t see it.

A narrative review of the literature concluded that there is a potential benefit for infra-red phototherapy in sports performance, particularly for muscle strength/hypertrophy, which might raise its ethical use in line with current WADA rules. Indeed as the number of studies grows, the evidence shows support for a role in boosting the hypertrophic or strength stimulus of weight lifting in untrained men and elderly women. An identical-twin case study also documented the use of infra-red phototherapy for boosting strength and reducing muscle damage. Another case-study found potential endurance-enhancing benefits in one elite runner, but this finding was not confirmed in a small randomised controlled trial.

All the above sounds rather impressive but it is more relevant to performance rather than the recovery of performance. Furthermore, the studies are simply cherry-picked from the literature. We can do better than that. So, what do the systematic reviews say?

Should you use infra-red phototherapy for recovery — what do the systematic reviews say?
→ Despite a potential effect on helping to lower circulating levels of creatine kinase (CK), a biochemical marker of muscle damage, phototherapy is not likely useful for decreasing muscle soreness or pain caused by exercise. It should be also noted that the large between-study heterogeneity of the effect on creatine kinase, precludes a confident conclusion of any effect.
→ Using phototherapy prior to resistance exercise extends time to fatigue, increases total reps, and reduces the decline in maximal voluntary isometric contraction during exercise.
→ The beneficial effects on performance are predominantly found with pre-exercise phototherapy — post-exercise phototherapy does not confer any benefit to recovery or performance.
→ As found in the systematic review by Leal-Junior et al., the largest and most consistent results were found: (i) with red or infrared wavelengths, (ii) when phototherapy was used before exercise, and (iii) with light providing a power output between 50 and 200 milliwatts and doses of 5 and 6 joules per spot. So, these specifications are worth checking if you choose to opt for a phototherapy device.
→ Another important application has been found where daily infra-red heat treatment of quadriceps muscle (which raised muscle temp 4.2 ± 0.29^oC above normal body temperature) for 2-hours daily for 10-days reduced muscle atrophy in the immobilized leg of physically-active and healthy adults. This shows promise for the use of infra-red phototherapy in maintaining muscle mass during prolonged bed rest (injury, illness, hospitalisation) or old age.
→ Overall, there are no documented adverse effects of phototherapy. It does not lessen delayed-onset muscle soreness (DOMS) but it does appear to restore the recovery of muscle strength and even provide an additional stimulus for strength/hypertrophy gains during strength training. Although some work has found that a far-infrared light-emitting sauna may confer benefit for the neuromuscular recovery from maximal endurance exercise, the effects of phototherapy on the recovery of endurance performance have not yet been sufficiently studied to make accurate conclusions.

Systematic reviews of infra-red phototherapy for recovery:
Here is the list of systematic reviews I have summarised above:

Phototherapy on Management of Creatine Kinase Activity in General Versus Localized Exercise: A Systematic Review and Meta-Analysis.
Machado AF, Micheletti JK, Lopes JSS, Vanderlei FM, Leal-Junior ECP, Netto Junior J, Pastre CM.
Clin J Sport Med. 2020

Effect of phototherapy (low-level laser therapy and light-emitting diode therapy) on exercise performance and markers of exercise recovery: a systematic review with meta-analysis.
Leal-Junior EC, Vanin AA, Miranda EF, de Carvalho Pde T, Dal Corso S, Bjordal JM.
Lasers Med Sci. 2015

Effect of low-level phototherapy on delayed onset muscle soreness: a systematic review and meta-analysis.
Nampo FK, Cavalheri V, de Paula Ramos S, Camargo EA.
Lasers Med Sci. 2015

Does phototherapy enhance skeletal muscle contractile function and postexercise recovery? A systematic review.
Borsa PA, Larkin KA, True JM.
J Athl Train. 2013

Compression garments were initially developed to help prevent deep-vein thrombosis and to relieve the symptoms of peripheral vascular disease, a clinical condition where cardiac output is too low for blood to efficiently return to the heart. In the context of recovery, compression garments are marketed to reduce swelling, assist venous return, and prevent blood pooling in the limbs, and can be purchased with a range of compression pressures.

Wearing compression clothing can feel like a massive hug — most of us love a good hug. Many folks also swear they “feel” more recovered when they wear their compression stockings after a good work-out — many of the athletes I have coached echo these sentiments. From a scientific perspective, in recreational basketball players, compression clothing has been shown to improve the feeling of recovery but not performance. While, in rugby players, the recovery of strength following fatiguing exercise was found to be greater in those who wore custom-fitted compression garments. Other experimental studies have found that compression garments may reduce muscle vibrations during running. But, such findings have not always been reproduced and such interventions are typically rather short (the above example used 3-minute runs at 8, 10, and 12 kph). Furthermore, whether reducing muscle vibration extrapolates to better recovery, performance, and/or injury prevention is unclear.

These study examples are simply cherry-picked anecdotes and, as a healthy athlete, you may be wondering why you need something to cause blood to flow when you thought your heart and vascular system were doing a fine job. “Medical grade” compression has indeed been shown to promote blood flow and tissue oxygenation in patients with vascular disease, but what does the science say about the role of compression garments in the recovery of athletic performance?

Should you use compression for recovery — what do the systematic reviews say?
→ Wearing compression garments after exercise may reduce circulating levels of creatine kinase and lactate dehydrogenase (markers of muscle damage), lessen the feeling of delayed onset muscle soreness (DOMS), and promote the feeling of recovery.
→ Wearing compression garments after exercise also has a small to moderate effect on the restoration of muscle strength and power, and a small to trivial effect on the restoration of endurance performance (although cycling is better restored than running).
→ Compression garments seem most effective for recovery from resistance or plyometric exercise (i.e. muscle-damaging bouts), specifically for the restoration of strength performance.
→ Interestingly, there is no effect of compression on the restoration of strength following running.
→ Caution should be made in that there is large heterogeneity in study designs and outcomes between the experimental studies included in the meta-analytic systematic reviews.
→ One systematic review assessed the effects of wearing compression garments during running (by Engel et al. ), finding a trivial effect on time-to-exhaustion and running economy but no effect of compression on time trial performance during ½-marathon, 15 km trail running, 5/10 km runs, or 400 m sprints.
→ The majority of experimental studies have not measured the compression pressure exerted by the garments and simply report the levels indicated by the manufacturer, typically 15 to 35 mmHg. At this time, optimal compression pressures or durations are unknown.
→ Since we have known for many moons that the best way to increase muscle contraction, blood flow, and cardiac output is to move, it is unlikely that the purported role of compression to “improve blood flow” is of any use since no device or tool can simulate the magnitude of change seen with these physiological parameters during exercise.
→ If you are healthy and do not have vascular disease, blood does not pool in your limbs, it flows very well, and the return of venous blood to the heart is just fine, even at rest. Contracting lower limb muscles with gentle walking/cycling/swimming etc or even some light jogging will increase your heart rate and massively increase blood flow in your limbs, elevating venous return — a compression garment will not augment that.
→ Compression garments are not detrimental to post-exercise recovery and, excitingly, appear to lessen feelings of soreness and facilitate the recovery of strength performance. Since compression garments often feel like a big hug, that psychologically-soothing feeling will also be relaxing and restful; two additional ingredients that will get you ready to go again.

Systematic reviews of compression for recovery:
Here is the list of systematic reviews I have summarised above:

Effects of Wearing Compression Stockings on Exercise Performance and Associated Indicators: A Systematic Review.
Mota GR, Simim MAM, Dos Santos IA, Sasaki JE, Marocolo M.
Open Access J Sports Med. 2020

Compression Garments and Recovery from Exercise: A Meta-Analysis.
Brown F, Gissane C, Howatson G, van Someren K, Pedlar C, Hill J.
Sports Med. 2017

Are compression garments effective for the recovery of exercise-induced muscle damage? A systematic review with meta-analysis.
Marqués-Jiménez D, Calleja-González J, Arratibel I, Delextrat A, Terrados N.
Physiol Behav. 2016

Is There Evidence that Runners can Benefit from Wearing Compression Clothing?
Engel F, Holmberg, H, Sperlich B.
Sports Med. 2016

Compression garments and recovery from exercise-induced muscle damage: a meta-analysis.
Hill J, Howatson G, van Someren K, Leeder J, Pedlar C.
Br J Sports Med. 2014

An extension of compression is external counterpulsation (ECP), which was developed to assist venous return in patients with terribly low cardiac output (e.g. those recovering from a stroke, heart attack, or those with peripheral vascular disease) and to promote shear stress (a stimulus caused by increased blood flow that promotes angiogenesis aka the formation of new blood vessels) in patients who are unable to exercise. However, systematic reviews on stroke, angina, and heart failure have found a widespread lack of study quality that prevents clear conclusions regarding the effectiveness of ECP for disease rehabilitation.

ECP involves a series of pneumatic cuffs placed on the limbs that inflate/deflate sequentially akin to a beating heart to provide a peristalsis-like stimulus to blood vessels, helping blood return to the heart. I spent some time at the Cleveland Clinic in 2009 collecting pilot data using this tech in patients with diabetes. The feeling of wearing an ECP is certainly unique and the patients found it fun, but that project was aborted when the effects on blood glucose control were unimpressive.

Since ECP can moderately increase limb blood flow, it garners interest from athletes, coaches, and sports teams, and “recovery” centres often have some form of ECP device ready to peristaltically-massage your veins. But, what does the evidence say?

Should you use ECP for recovery — what do the systematic reviews say?
→ Currently, there is no systematic review of the evidence in this area, but some research has emerged that attempts to determine the effect of ECP on recovery.
→ Twenty minutes of ECP administered between two bouts on the same day caused a smaller decline in 1.2 km shuttle run performance and increased feelings of recovery in recreationally-active men.
→ Thirty-minutes of ECP following a session better-restored cycling peak power output in 7 National Rugby League players, compared to rest only.
→ On the contrary, 30-minutes of ECP treatment following a session of S.H.I.T. (short high-intensity training) had no effect on the restoration of jump height, mean power during an 8-minute time trial, or feelings of fatigue, in elite triathletes or in team sports players.
→ Similarly, 30-minutes of ECP treatment following a plyometric session did not effect the restoration of jump height or feelings of fatigue, in recreationally active adults.
→ And, competitors in the 161-km Western States race who received a post-race 20-minute session of massage combined with pneumatic compression reported lower feelings of fatigue but their recovery of performance was not improved in a 400 m time-trial 3- and 5-days post-race, compared to competitors who simply rested post-race.
→ Since we have known for many moons that the best way to increase muscle contraction, blood flow, and cardiac output is to move, it is unlikely that the purported role of ECP to “improve blood flow” is of any use to an athlete since vascular function is impeccable in such folks, and no device or tool is able to simulate the magnitude of change seen with these physiological parameters during exercise.
→ That said, some studies show small benefits while others do not. Currently, there are no adverse effects of ECP reported so it won’t harm your recovery. But, far more research is needed to make definitive conclusions.

Systematic reviews of ECP for recovery:
Here is the list of systematic reviews I have summarised above:
There are currently no systematic reviews of ECP for recovery.

The proposed effects of massage include relieving muscle tension, reducing soreness, and improving joint range of motion. The potential benefits of massage are proposed to derive from an increase in parasympathetic activity, skin and muscle temperature, and blood flow. You can read more about this in a narrative review by Weerapong et al. (2015). There is also a psychophysiological response to massage that helps to enhance mood and reduce feeling of fatigue through relaxation. I.e. massage provides the subjective sense of “going through recovery”. Subjective feelings of recovery (less muscle soreness) using massage have been confirmed in runners recovering from a half-marathon, but objective measures (creatine kinase, testosterone, and muscle function) were not improved.

Everyone can agree that a great massage is truly relaxing and even the simple act of seeing a masseur can be relaxing. But every massage is different… I am guessing you have, at some point, also walked away from brutal far-from-relaxing “deep-tissue” massage from He Man, who even informs you, “you’ll be sore for a while” as you hobble away — more soreness and left feeling rubbish — that is the precise reason that the only type of massage I have opted for since my last brutal massage in 2003 is a relaxing one, ideally from my wife.

A sports masseur will tell you that a massage will increase blood flow, reduce DOMS, stop inflammation, and remove lactate (and maybe even some other enticing nouns with a direction of change). But what about the science?

Some work has shown a massage to “relax” the autonomic nervous system by triggering the parasympathetic nervous system (see here and here. Some studies show small increases in limb blood flow during massage but other studies do not, and some studies find that light exercise (hand grip and knee extensions) far more greatly increase blood flow than massage. Some studies find that massage can lower lactate and heart rate following exercise but others find no effect compared to passive rest or even a lower effect compared to light activity (here and here. Massage has been also shown to reduce delayed onset muscle soreness (DOMS) in some studies but not others (see here, here, and here . So, it sounds like a mixed bag. But, where some alarm bells ring is with the use of pre-exercise massage, which blunts muscle strength (see here and here. A couple of narrative reviews have delved into this area and but narrative reviews are not systematic and do not sit at the top of the evidence tree. Furthermore, my above narrative could indeed be cherry-picked. So, what about more robust evidence...

Should you use massage for recovery — what do the systematic reviews say?
→ Caution should be given to having a massage immediately prior to exercise, which can reduce muscle strength and speed — "don't shoot the messenger" with a pre-session or pre-race massage.
→ While a massage can feel bloody good (in the right hands) and can confer psychological benefits associated with relaxation and the perception of “feeling” more recovered, it does not improve the recovery of exercise performance (and a recent randomised controlled trial combining massage with compression after an ultra marathon confirms this, adding further evidence to that which has been systematically reviewed).
→ Importantly, massage does not impair the recovery of performance either. So, if you like it and you find it relaxing, a post-session massage should do no harm.
→ That said, it is not known whether massaging a muscle that is painful (i.e. focussing knots and hot-spots) is a good or bad thing to do. Erring on the side of caution, it is probably wise to remember that causing more pain and soreness should never be a goal of your between-session recovery periods.

Systematic reviews of massage for recovery:
Here is the list of systematic reviews I have summarised above:

Effect of sports massage on performance and recovery: a systematic review and meta-analysis.
Note: this article has a correction: https://bmjopensem.bmj.com/content/7/2/e000614corr1
Davis HL, Alabed S, Chico TJA.
BMJ Open Sport Exerc Med. 2020

Massage Alleviates Delayed Onset Muscle Soreness after Strenuous Exercise: A Systematic Review and Meta-Analysis.
Guo J, Li L, Gong Y, Zhu R, Xu J, Zou J, Chen X.
Front Physiol. 2017

Massage and Performance Recovery: A Meta-Analytical Review.
Poppendieck W, Wegmann M, Ferrauti A, Kellmann M, Pfeiffer M, Meyer T.
Sports Med. 2016

Immunological effects of massage after exercise: A systematic review.
Tejero-Fernández V, Membrilla-Mesa M, Galiano-Castillo N, Arroyo-Morales M.
Phys Ther Sport. 2015

Does post-exercise massage treatment reduce delayed onset muscle soreness? A systematic review.
Ernst E.
Br J Sports Med. 1998

Foam rolling is a self-inflicted myofascial release technique — some folks love it, others hate it. Rolling is a bit like a massage in that it can be very soothing and relaxing but sometimes just as painful, which prompts the obvious thought of “is more pain good when I am supposed to be resting?”.

A huge range of foam rollers and roll-massaging “rolling pins” can be purchased — varied sizes and surface textures. Proponents for foam rolling will tell you it triggers mechanoreceptors, increases blood flow, boosts flexibility, releases endorphins, and alleviates fatigue. But, what foam rolling does at the cellular and molecular level is not currently understood. Despite that, as you are probably aware, foam rolling is hugely popular — many runners own them, every gym hosts them, and some folks consider them a viable replacement for a masseur. But are they useful adjunct for assisting your recovery?

Should you use foam rolling for recovery — what do the systematic reviews say?
→ Foam rolling or rolling massage after an intense work-out may lessen feelings of delayed-onset muscle soreness (DOMS).
→ Foam rolling after a workout may also have a small effect on helping to restore sprint and strength performance.
→ Regular foam rolling may increase range-of-motion but to the same degree as a stretching programme.
→ Before a session, foam rolling may be used as part of a dynamic warm-up to help increase range-of-motion and reduce feelings of muscle stiffness.
→ But, while pre-session foam rolling may cause a small improvement in sprint performance, it has a negligible or even negative effect on other performance markers, including jump height, strength, power, and maximal oxygen uptake — "don't shoot the messenger". Such potential negative effects on performance have been hypothesised to be due to increased parasympathetic activity, impaired neural signalling, and decreased motor unit recruitment. → Evidence shows a tendency for foam rollers to confer larger recovery effects than roller massagers.
→ Because of the heterogeneity of methods used between studies, there is currently no consensus on the optimal foam rolling or roller-massage program, inc. treatment time, pressure, and cadence, which makes one curious as to how somebody can become “certified” in foam rolling. That said, the evidence indicates that 90 seconds per muscle group may be the minimum duration that confers a short-term reduction in feelings of DOMS.
→ Foam rolling does not appear to harm recovery or performance. That said, it is not known whether rolling specific areas that are painful is a good or bad thing to do — siding with caution, it is probably best to remember that causing more pain and soreness should never be a goal of your between-session recovery periods.
→ Foam rolling may help lessen post-session feelings of muscle soreness but has small to non-existent effects on the recovery of performance. Foam rolling is not an essential tool for recovery but neither will it impair your training adaptations.

Systematic reviews of foam rolling for recovery:
Here is the list of systematic reviews I have summarised above:

A systematic review and meta-analysis of the effects of foam rolling on range of motion, recovery and markers of athletic performance.
Skinner B, Moss R, Hammond L.
J Bodyw Mov Ther. 2020

Acute Effects of Foam Rolling on Range of Motion in Healthy Adults: A Systematic Review with Multilevel Meta-analysis.
Wilke J, Müller AL, Giesche F, Power G, Ahmedi H, Behm DG.
Sports Med. 2020

Duration of myofascial rolling for optimal recovery, range of motion, and performance: A systematic review of the literature.
Hughes GA, Ramer LM.
Int J Sports Phys Ther. 2019

Effects of foam rolling on performance and recovery: A systematic review of the literature to guide practitioners on the use of foam rolling.
Hendricks S, Hill H, Hollander SD, Lombard W, Parker R.
J Bodyw Mov Ther. 2020

A Meta-Analysis of the Effects of Foam Rolling on Performance and Recovery.
Wiewelhove T, Döweling A, Schneider C, Hottenrott L, Meyer T, Kellmann M, Pfeiffer M, Ferrauti A.
Front Physiol. 2019

The effects of self-myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and performance: A systematic review.
Cheatham SW, Kolber MJ, Cain M, Lee M.
Int J Sports Phys Ther. 2015

Humans have been firing electricity into their bodies for centuries — it is thought that ancient Egyptians, Greeks, and Romans used electric fish to treat all manner of issues. Emperor Palpatine also used electricity for “treating” his foes. Today, electrical muscle stimulation/electromyostimulation (EMS) or transcutaneous electrical nerve stimulation (TENS, which targets afferent nerves to blunt pain) is used by physiotherapists for rehabilitation. A common application of EMS/TENS is in the rehab phase for patients recovering from a stroke, and systematic reviews conclude that EMS/TENS may enhance the recovery of motor control and increase gait speed in stroke patients. But, the therapeutic benefit of using electrical stimulation in patients who have no or low muscle function should not be taken to mean that it will benefit recovery or performance in a healthy person. After all, sending nerve impulses to muscle cells is a highly-developed attribute in a healthy athlete.

Consumer devices like Compex and Powerdot are common-place in glossy and enticing videos on social media. They are also inexpensive and widely available. Although not a new technology — vigorous EMS was used in East German athlete training camps in the 1970s — with the increasing popularity of consumer devices and even whole-body EMS systems, it is important to understand what EMS does and whether or not it is useful for the recovery of athletic performance.

In physiology labs, EMS is widely used as a “test-tube” biology method to study muscle contraction at the cellular level — we extensively used this “exercise in a dish” approach in my lab. The pulses of current can be fired at different voltages, frequencies, and durations, and this “fine-tuning” of the stimulus can also be achieved in the lab on human muscle and even with some consumer devices. In living humans, applying an electrical current through the skin to a muscle causes involuntary muscle contractions, which are purported by device-selling companies to “increase blood flow” and “flush out metabolic waste products” (akin to alleged outcomes for many other forms of “magic”).

Since we have known for decades that muscle contraction increases blood flow to the muscle and therefore increases delivery and removal of nutrients, these sentiments are certainly not inaccurate. Furthermore, using electrical stimulation to innervate afferent nerves to dull pain may, theoretically, reduce feelings of muscle soreness following exercise. But, is the use of EMS relevant to and useful for recovery, particularly when considering that low-intensity walking/cycling/swimming would do the same thing on multiple muscles plus with the bonus of a light cardiovascular load? A 2011 narrative review, “Does electrical stimulation enhance post-exercise performance recovery?”, concluded that while EMS may enhance post-exercise lactate removal and reduce creatine kinase activity, evidence for restoring (or enhancing) performance is lacking. However, more research has emerged since 2011. And, we can do better than a narrative review.

Should you use electrical muscle stimulation for recovery — what do the systematic reviews say?
→ Note that these systematic reviews are specific to exercise recovery (or performance) and are not relevant to the management of pain or rehabilitation from injury or illness.
→ Also note that if you have heart problems, epilepsy, wear a pacemaker, or are pregnant, EMS is not advised.
→ A large range of electrical impulse intensities (current), impulse frequencies, impulse durations, and total durations of treatment have been used.
→ The systematic reviews report a medium to high risk of bias in the experimental studies examined.
→ EMS treatment following a session can restore blood lactate levels and suppress the feelings of pain/soreness better than passive recovery (rest) but is poorer than active recovery (moving) for remedying these consequences of exercise.
→ The effects of EMS on the recovery of performance following a session is not different from either passive recovery (rest) or active recovery (moving).
→ Regarding EMS “training” to increase performance, the 2011 systematic review by Filipovic et al. found that a stimulation intensity of ≥50% of a maximal voluntary contraction (MVC) is required to provide a sufficient stimulus that will activate strength adaptations; and, that this can be achieved with an impulse intensity of ≥50 mA combined with a stimulation frequency of 76.4 ± 20.9 Hz and an impulse width of 306.9 ± 105.1 microseconds. They also concluded that EMS treatment must be applied 3x/time for 10-15-mins per session for 4–6 weeks to increase in strength in trained athletes. Their follow-up 2012 systematic review additionally concluded that EMS treatment may increase maximal isometric strength, rate of force development, and power, as well as functional movements like jump height and sprint time. Regrettably, however, neither of their reviews conducts a valid meta-analysis and neither presents a forest plot summary of the effect sizes from the individual studies, which makes it impossible to interpret the validity of their conclusions.
→ The reviews that did conduct a valid meta-analysis and soundly present the effect size data (by Wirtz et al. and Pano-Rodriguez et al.) concluded that whole-body EMS has trivial and non-statistically-significant effects on exercise performance.
→ Recent work shows promise for the use of EMS at maintaining muscle mass in chronic conditions that force muscular inactivity, like during critical care in the ICU and during 5-days of leg immobilisation in healthy people. Therefore, EMS may be useful for preventing muscle atrophy during the rehabilitation from an injury that forces one to be inactive.
→ EMS also shows promise for maintaining muscle mass in older-aged folks, in whom muscle atrophy is an unwanted symptom of aging that reduces functional capacity and quality of life. But EMS is no match for the effects of resistance exercise.
→ Since the increase in blood flow induced by EMS is very small in comparison to light exercise, then some low-intensity activity after a session may be preferable especially given that light effort walking/cycling/swimming more greatly induces the same outcomes as EMS but on multiple muscles simultaneously and have the added benefit of a light cardiovascular stimulus.
→ That said, if time is tight and you cannot cool-down after your hard effort or occasionally don’t have time for your “between-hard-session” easy sessions, then perhaps EMS would be better than nothing — but remember that sometimes rest is good.

Systematic reviews of electrical muscle stimulation for recovery:
Here is the list of systematic reviews I have summarised above:
Note: There is currently only one systematic review examining the effect of EMS on recovery but there are some reviews examining the effect of EMS on muscle strength and sprint performance.

Resistance Exercise, Electrical Muscle Stimulation, and Whole-Body Vibration in Older Adults: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Šarabon N, Kozinc Ž, Löfler S, Hofer C. J Clin Med. 2020

Effects of Whole-Body Electromyostimulation on Strength-, Sprint-, and Jump Performance in Moderately Trained Young Adults: A Mini-Meta-Analysis of Five Homogenous RCTs of Our Work Group. Wirtz N, Dörmann U, Micke F, Filipovic A, Kleinöder H, Donath L. Front Physiol. 2019

Effects of whole-body electromyostimulation on health and performance: a systematic review. Pano-Rodriguez A, Beltran-Garrido JV, Hernández-González V, Reverter-Masia J. BMC Complement Altern Med. 2019

Neuromuscular electrical stimulation during recovery from exercise: a systematic review. Malone JK, Blake C, Caulfield BM. J Strength Cond Res. 2014

Electromyostimulation--a systematic review of the effects of different electromyostimulation methods on selected strength parameters in trained and elite athletes. Filipovic A, Kleinöder H, Dörmann U, Mester J. J Strength Cond Res. 2012

Electromyostimulation--a systematic review of the influence of training regimens and stimulation parameters on effectiveness in electromyostimulation training of selected strength parameters. Filipovic A, Kleinöder H, Dörmann U, Mester J. J Strength Cond Res. 2011

Acupuncture dates back ~2500 years and is inherent to traditional Chinese medicine. It involves inserting needles into specific “acupoints” of the body and is said to “restore the balance of energy flow in the body”. Acupuncture is purported to treat many chronic conditions, including stress, hypertension, and cardiovascular disease — pick a chronic condition and you will easily find a study and, in some cases, a systematic review, showing how acupuncture treats it.

Sounds wonderful but there are some caveats. It is not uncommon for acupuncture to cause an adverse event — the incidence of which ranges from 6% to 15% in countries outside of China and less in studies conducted within China. Some uncommon adverse events are severe, even including death, but the most common are mild — local pain, bleeding, and bruising — all of which have been attributed to the patient’s mental tension, poor clinical practice, and a lack of sterilization.

Besides adverse outcomes, scientists have also examined the high prevalence of positive effects of acupuncture in published works. A systematic review of pain treatment found that all 36 trials (100%) conducted in China found a statistically significant benefit of acupuncture. Compared to the 171 of 252 trials (68%) conducted world-wide which favoured acupuncture over control, this is pretty alarming and may suggest a publication/reporting bias. But, with optimism, this odd finding could simply be that acupuncture is more effective in the country where it is traditionally practised or that Chinese doctors are simply more skilled acupuncturists. However, a 2008 review found that the majority of studies examining the effect of acupuncture on pain used study designs that increase the likelihood of a false positive outcome. So, in terms of pain management, study quality must be questioned. For a great read on the general importance of study design, statistics, and “P-hacking”, I can thoroughly recommend the book, “The Art of Statistics”, by David Spiegelhalter.

With relevance to exercise, some studies have found that acupuncture may reduce exercise-induced delayed-onset muscle soreness (DOMS) while other studies have not found a benefit. Similar dichotomies exist for other aspects of recovery but these are cherry-picked sentiments — what does the entirety of the literature say?

Should you use acupuncture for recovery — what do the systematic reviews say?
→ Note that these systematic reviews are specific to the recovery from exercise and are not relevant to the management of pain or rehabilitation from injury or illness.
→ The 2013 systematic review by Urroz et al. identified only 4 trials and concluded that “given the heterogeneity of the interventions and the paucity of robust RCTs, the pooling of effect sizes across studies for meta-analysis was not considered appropriate”. This means that they were unable to create a summary effect size of all studies.
→ The 2020 systematic review by Chang et al. identified 15 studies, finding no effect of acupuncture on muscle strength and trivial to small effects on exercise-induced delayed onset muscle soreness (DOMS); however, the summary statistic confidence intervals cross zero in all cases, indicating that the effect on DOMS is not statistically significant.
→ The 2020 systematic review by Huang et al. found a small effect of acupuncture on DOMS (7 studies), a moderate effect on creatine kinase (CK, a muscle damage marker), and a small to moderate effect on muscle strength at 72-hours after prior exercise but no effect at 24- or 48- hours after prior exercise (4 studies). Huang et al. also reported a low quality of evidence in all studies included in the analysis.
→ Overall, acupuncture might have a small effect on alleviating DOMS and a small effect on the restoration of muscle strength but only when the next bout is 72-hours later.
→ Within the body of literature, which is small, all reviews noted that many methodological limitations exist, including inadequately powered randomised controlled trials, a lack of thorough and/or standardized reporting of methods, a lack of appropriate placebo-controls, and a lack of blinding of both participants and investigators.
→ Acupuncture is also not without risk. Severe but less-common adverse-outcomes include hospitalisation and death while more-common effects include pain, bleeding, and bruising. Is the risk of hospitalisation and death during recovery worth it? Yes, it is very rare but perhaps consider saving those risks for your sessions. Meanwhile, pain, bleeding, and bruising are unlikely to halt your training but do they sound restful? Perhaps consider saving such things for your sessions/races, not for when you are trying to restore homeostasis to get ready to go again.
→ If you can handle the increased risk of adverse events during your recovery and you do not experience pain, bleeding, or bruising from your practitioner, acupuncture does not harm the recovery of performance and may slightly lessen feelings of muscle soreness. But, please always remember that your recovery time is not supposed to cause more stimulus and further disruption to homeostasis than your training sessions already do — recovery is about restoring homeostasis not smashing it.

Systematic reviews of acupuncture for recovery:
Here is the list of systematic reviews I have summarised above:

Effects of Acupuncture on Delayed-Onset Muscle Soreness: A Systematic Review and Meta-Analysis.
Chang WD, Chang NJ, Lin HY, Wu JH.
Evid Based Complement Alternat Med. 2020

Does Acupuncture Benefit Delayed-Onset Muscle Soreness After Strenuous Exercise? A Systematic Review and Meta-Analysis.
Huang C, Wang Z, Xu X, Hu S, Zhu R, Chen X.
Front Physiol. 2020

Effect of acute acupuncture treatment on exercise performance and postexercise recovery: a systematic review.
Urroz P, Colagiuri B, Smith CA, Cheema BS.
J Altern Complement Med. 2013

Cupping originates from alternative medicine and is used by acupuncturists or other therapists, primarily to treat pain (a systematic review of the use of cupping for the treatment of pain has been published). The method uses a cup made of glass or bamboo to create suction on the skin over the area of interest. “Dry cupping” pulls the skin into the cup without drawing blood. “Wet cupping” lacerates the skin so that blood is drawn into the cup. The result is a hematoma (bruise) under the skin, i.e. a subcutaneous blood clot — damage that needs to be repaired.

We have all seen famous athlete’s sporting their cupping “scars” — it was popularised at the last Olympics when swimmers looked like they’d had a bad session with a massive octopus. Anecdotally, I have heard a couple of folks say they “feel” more recovered when they undergo cupping. But is this framed by images of their sporting heroes sporting their scars? Perhaps. But, some sentiments are certainly anecdotal. So, what does the science say...

Should you use cupping for recovery — what do the systematic reviews say?
→ There are currently no systematic reviews evaluating the effect of cupping on the recovery of performance.
→ The most recent systematic review examining the role of cupping on the treatment of pain concluded that “the total number of RCTs included in the analysis and the methodological quality were too low to draw firm conclusions”.
→ Since there is not currently sufficient experimental evidence to draw a conclusion, we do not know whether cupping is beneficial for the recovery of performance.
→ Neither do we know whether it even has a detrimental effect on the recovery of performance.
→ What we do know is that each cup site causes a bruise (hematoma), which is damage that needs biochemical resources, energy, and time to repair.
→ While cup-marks might look cool, there are too many unknowns to risk using this approach at the expense of your recovery/performance — “don’t risk shooting the messenger” — choose a different route in your quest for coolness.
→ At present, there are also several other restful things you could spend your time doing to optimise your recovery.

Systematic reviews of cupping for recovery:
Here is the list of systematic reviews I have summarised above:
There are currently no systematic reviews evaluating the effect of cupping on recovery.

Disclaimer: I occasionally mention brands and products but it is important to know that I am not sponsored by or receiving advertisement royalties from anyone. I have conducted biomedical research for which I have received research money from publicly-funded national research councils and medical charities, and also from private companies, including Novo Nordisk Foundation, AstraZeneca, Amylin, the A.P. Møller Foundation, and the Augustinus Foundation. I have also consulted for Boost Treadmills and Gu Energy on their research and innovation grant applications. These companies had no control over the research design, data analysis, or publication outcomes of my work. Any recommendations I make are, and always will be, based on my own views and opinions shaped by the evidence available. The information I provide is not medical advice. Before making any changes to your habits of daily living based on any information I provide, always ensure it is safe for you to do so and consult your doctor if you are unsure.

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Exercise physiologist, Dr Thomas Solomon at Veohtu

About the author:
I am Thomas Solomon and I'm passionate about relaying scientific information to the masses and helping folks meet their fitness and performance goals. I hold a BSc in Biochemistry and a PhD in Exercise Science and am an ACSM-certified Exercise Physiologist and Personal Trainer, a VDOT-certified Distance running coach, and a Registered Nutritionist. Since 2002, I have conducted biomedical research in exercise and nutrition and have taught and led university courses in biochemistry, molecular medicine, and exercise physiology. My work is published in over 80 peer-reviewed medical journal publications and I have delivered more than 50 conference presentations & invited talks at universities and medical societies. I have coached and provided training plans for truck-loads of athletes and regular folk, have competed at a high level in running, cycling, and obstacle course racing, and continue to run, lift, and climb as often as possible. To stay on top of scientific developments, I participate in journal clubs and peer-review papers for medical journals, and I invest every Friday in reading what new delights have spawned onto PubMed. In my spare time, I hunt for phenomenal mountain views to capture through the lens, boulder problems to solve, and for new craft beers to drink with the goal of sending my gustatory system into a hullabaloo.

Copyright © Dr Thomas Solomon. All rights reserved.

The Recovery Magic Tool — a systematic research summary of exercise recovery modalities.

Sleep.

Nutrition.

Rest.

Dietary supplements.

Anti-inflammatories and painkillers.

Active recovery / Cool-downs.

Stretching.

Cold water immersion and cryotherapy.

Hot water immersion (or contrast therapy).

Sauna.

Local heat / infra-red phototherapy.

Compression clothing.

External counterpulsation (ECP).

Massage.

Foam rolling.

Electrical muscle stimulation (EMS).

Acupuncture.

Cupping.