R e s e a r c h a r t i c l e T h e U s e o f A r n i c a T a b l e t s b y R u n n e r s i n t h e 9 0 K i l o m e t e r C o m r a d e s M a r a t h o n ABSTRACT: Background: Arnica is a homeopathic remedy which is sometimes used before and after long distance running in the b e lie f that it reduces delayed onset muscle soreness (DOMS). However, the specific details o f its use among athletes is not known. Therefore the aim o f this study was to determine the usage patterns o f Arnica tablets am ongst participants in the 1999 ninety-kilom eter Comrades ultra-marathon road race in South Africa. M ethods: Every third runner registering f o r the race in Pietermaritzburg in the three-day (25 hour) pre-race registration period was approached and asked to complete a questionnaire on their use o f Arnica tablets (n - 785; males = 85% and fem a les = 15%). Results: Ten percent o f the total study population who agreed to p a rti­ cipate in the study (n = 730) had used Arnica tablets in the previous six months. The average reported dose by these athletes was seven tablets p e r day. The m ost common reason f o r using Arnica tablets was to decrease pain o r stiffness after a race or training run. Only a small group (22%) rated the efficacy o f Arnica tablets as “totally effective”, suggesting that a large num ber o f users o f Arnica did not rate the efficacy highly. There was a po o r relationship between the perceived efficacy after ingesting Arnica tablets and the reported dosage (r = 0.28). The m ajority o f the respondents (63%) believed that Arnica tablets contained anti-inflam matory agents. Conclusions: While 10% o f the runners used Arnica, only one fifth o f these runners rated the treatment as completely effective f o r the prevention o f DOMS. Therefore education on the advantages and disadvantages o f using these tablets has become important. KEYW O RD S: ARNICA TABLETS, LONG DISTANCE RUNNING, M U SC LE SORENESS, HOMEOPATHY CYNTHIA M BAUER', BSc Physio, BSc Med, B.A MICHAEL I LAMBERT2, PhD LINDSAY M WEIGHT3, PhD 1 Faculty of Health Sciences, Departm ent of Physiotherapy, University of C a p e Town. M R C / U C T Research Unit for Exercise Scien ce an d Sports M edicine, Sports Scien ce Institute of South A fric a , Department of H um an Biology, Faculty of Health Science, University of C a p e Town. Department of H um an B iology, Faculty of Health Science, University of C a p e Town. INTRODUCTION T h ere is gro w in g an e cd o tal ev id en c e o f the use o f h o m e o p ath y am o n g st sp o rts ’ p articip a n ts, in p articu la r lo n g d istan ce ru n n ers an d o th e r en d u ra n ce athletes. A rn ica tablets are freq u en tly u sed as a p ro p h y lac tic ag e n t b oth b efo re and after long d istan c e ru n n in g in th e b e lie f th at th e tre a tm e n t re d u c e s d e la y e d o n s e t m u s c le so re n e s s (D O M S ). H o w ev er, alth o u g h h o m eo p ath s o ften use A rn ica tab lets fo r th e tre a tm e n t o f so ft tissue C O R R E S P O N D E N C E TO: A sso c iate P ro fess o r M ik e L am b ert M R C /U C T R esearch U n it fo r E x ercise S cien ce an d S p o rts M ed icin e, P.O. B o x 115, N ew la n d s 7925 So u th A frica Tel: (0 2 1 )6 5 0 - 4 5 5 8 Fax: (021) 6 8 6 -7 5 3 0 E m ail: m la m b e rt@ sp o rts.u ct.ac .z a trau m a, th ere is eq u iv o cal ev id en c e o f its efficacy [L okken e t al, 1995; Ja w a ra et al, 1997], O n e v ie w p o in t is th a t h o m e o p ath y ’s long history and continued su ccessfu l use w o rld w id e co n v in cin g ly d em o n strates its efficacy in th e treatm en t o f injuries and w o u n d s [L okken e t al, 1995]. A n altern ativ e v ie w p o in t is th a t the lack o f convincing scientific evidence is a m a jo r reaso n w hy h o m e o p ath y is g en e rally n o t accep ted b y th e m ed ical co m m u n ity [L ockie, 1998]. D esp ite the d iscrep an cy b e tw e e n the v ie w p o in ts o f th e p ra c titio n e rs o f h o m e o p a th y an d m ed icin e, th e use o f h o m e o p ath ic re m e ­ dies, am o n g them A rn ica tab lets, is still w id esp read . N o stu d ies co u ld be fo u n d to e stab lish th e d etails on th e use o f A rn ica tablets. T h erefo re the m ain aim o f th is study w as to d e te rm in e th e p re v a le n c e o f u sag e o f A rn ica tablets in a g ro u p o f u ltra -e n d u ra n ce athletes. A seco n d ary aim w as to d e te rm in e th e p erc ep tio n s o f its efficacy, c o n stitu e n ts, d o sag e and th e m o st c o m m o n ly used co m m ercial b ran d in this g ro u p o f ru nners. T h is may serv e to d eterm in e w h eth e r th e reaso n s fo r u sin g A rn ica are m a tch e d by th eir p u rp o rte d effects. METHODS E th ic a l a p p ro v a l f o r th e stu d y w as o b ta in ed fro m th e E th ic s an d R esearch C o m m itte e o f th e F acu lty o f H ealth S c ie n c e s , U n iv e r s ity o f C a p e . T h e q u e stio n n a ire w as ev a lu a ted in a p ilo t stu d y a d m in is te r e d to 63 m a ra th o n ru n n e rs w h o w e re m e m b e rs o f a Jo h a n n esb u rg ru n n in g club, w h erea fter p o o rly c o n stru c te d a n d /o r am b ig u o u s q u estio n s w ere id en tified an d m o d ified . R e g istra tio n fo r th e 1999 C o m ra d e s m a ra th o n to o k p la c e a t tw o v en u e s d u rin g th e th ree d ay s b e fo re the race. A n a ttem p t w as m ad e to targ et every th ird ru n n e r reg isterin g in P ieterm aritzb u rg . T h e s e ru n n e rs w e re a p p ro a c h e d an d 14 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) mailto:mlambert@sports.uct.ac.za Table 1: Characteristics of the study population. Respondents Declined* Total Males 623 (85%) 54 (98%) 6 7 7 (86%) Females 107(15% ) 1 (2%) 108 (14%) Total 730 55 785 ‘ these runners declined to answer the questionnaire and participate in the study. Table 2: Prevalence of Arnica tablet users in the study population (n=730). Users Non-users Total All respondents 72 (10%) 658 (90%) 730 Genders: Males 22 (31%) Females 50 (69%)* ‘ Significantly higher in female compared with male (p<0.05). Table 3: The source from whom the respondents (n = 72) heard about Arnica. Source of advice Number % Other runners 20 28 Physiotherapists 8 11 Homeopaths 8 11 Pharmacists 6 8 Medical doctors 5 7 Other 20 28 (Wife 4 6) (Respondents could indicate > than 1 source. Not all respondents answered this question) Table 4: Reported reasons for using Arnica (n=72). Reported reason % Used after a race/run to minimize pain/stiffness 61% Used before a race/run to minimize pain/stiffness 41% To improve the ability to train harder 4% Other purposes related to running 11% Purposes unrelated to running 36% "Sore muscles" not related to running 8% ask ed to co m p lete the q u estio n n a ire . T h e nam e, C o m rad es m arath o n 1999 race n u m b er and g en d e r o f th o se ru n n ers w ho d eclin ed to c o m p lete th e q u e s tio n ­ naire w ere reco rd ed w h ere p ossible. T h e sam p le g ro u p w as div id ed into th e fo llow ing subgroups: ru n n ers w ho a g re e d to a n s w e r th e q u e s tio n n a ire versu s th o se ru n n ers w ho d eclin ed , m ale versu s fem ale, and ru n n ers w h o had p re v io u sly h ea rd o f A rn ic a ta b le ts versus ru n n ers w ho h ad not. T h o se ru n ­ ners w ho rep o rted h av in g p rev io u sly used A rn ica tablets w ere fu rth er analysed as a subgroup. T h ey w ere req u ired to an s w e r q u estio n s on th e ir p ercep tio n s o n th e efficacy o f A rn ica tab lets, the c o n s titu e n ts o f th e ta b le ts an d th e ir d o sa g e used. T h e efficacy o f A rn ica w as assessed by asking th e su b jects to ev alu ate th e ir efficacy o n a scale o f “0 ” (ab so lu tely no) to “7 ” (ab so lu tely yes). D ata are expressed as ab so lu te values, p erc en ta g es and m ean s (stan d ard d ev ia­ tio n [SD ]). T h e C h i sq u ared statistic w as used to d eterm in e sig n ifican t d ifferen ces b e tw e e n g ro u p s fo r th e p re v a le n c e data. A n in d e p en d e n t t-test w as used to d e term in e d ifferen ces b etw een groups fo r all param etric variables. A S p earm an ’s c o rrela tio n co e ffic ie n t w as ca lc u lated to d eterm in e the rela tio n sh ip betw een the d o sa g e o f A rn ica tablets and the p e rc e iv e d effic a c y o f th e tre a tm e n t. S tatistical sig n ifican ce w as accep ted as P < 0.05. RESULTS T h e g en eral ch a racteristics o f the total stu d y p o p u latio n and su b -p o p u latio n s are show n in T able 1. T h e total re sp o n ­ d e n t p o p u latio n w as n = 7 30 (m ale 85% , fem a le 15%). T w en ty -n in e p ercen t o f th is p o p u la tio n h ad h ea rd o f A rn ica tab lets prev io u sly (m ales 22% , fem ales 7% ). T h is rep resen ts 26% o f th e m ale p o p u la tio n an d 50% o f the total fem ale p o p u la tio n w hen the d ata w ere stratified fo r gender. O f th e ru n n ers w ho h ad h ea rd o f A rn ica tablets, the m o st co m m o n b ran d w as W eleda (P h arm a N atu ra) (71% ), B io fo rce (7% ), and “o th e r” (4% ). T h e resp o n d en ts w ere allo w ed to in d icate m o re th a n o n e b ra n d . T w en ty fo u r p erc en t o f th e su b jects w ere n o t able to id en tify a specific bran d . O f those su b je c ts w h o h a d h e a rd o f A rn ic a tablets, 34% (n = 72) h ad used them in th e p rev io u s six -m o n th p erio d . T h is rep resen ts 10% o f th e total sa m p le o f ru n n ers. T h e se d ata a re su m m a riz e d in T able 2. T h ere w as a sig n ifican tly h ig h e r p rev alen ce o f use am o n g fem ale (6 9 % ) c o m p a re d w ith m a le (3 1 % ) [P<0.05] resp o n d en ts. T h o s e ru n n e rs w h o u se d A rn ic a tab lets p rev io u sly w ere ad v ised fro m a v a rie ty o f so u rc e s (T ab le 3). R e sp o n d en ts freq u en tly in d icated that they w ere advised fro m m o re than o n e source. T h e c o m m o n so u rces in this stu d y p o p u la tio n w ere o th e r ru n n ers (2 8 % ), p h y sio th erap ists (11% ), h o m e o ­ p a th s (1 1 % ), p h a r m a c is ts (8 % ) an d d o cto rs (7% ). T w enty eig h t p e rc e n t had b e e n a d v ise d b y a n o th e r so u rc e , o f w h ich “ w ife” w as th e m o st freq u en t (6% ) in this sub-group. T h e m ain reaso n s fo r w h ich A rn ica tab lets w ere u sed b y the resp o n d en ts are d ep icte d in T able 4. R esp o n d en ts co u ld in d ic ate m ore than o n e reaso n for SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 15 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Table 5: Data of the runners who declined to fill in the questionnaire (36% of the total non-responders) compared to the responders. The sample size (n) varies depending on the numbers of responses to the questions. Non-responders Responders Variable n Mean ± SD n Mean ± SD A ge (years) (20) 38 ± 9 (730) 38 ± 9 Comrades 1999 time (min) (19) 544 ± 77 (568) 576 ± 69 Comrades PB (min) (20) 528 ± 79 (645) 542 ± 76 Number of medals (20) 5 ± 4 (646) 6 ± 5 (PB = personal best time) using A rn ica tablets. T h e m ost frequently rep o rted rea so n s fo r u sin g A rn ica tab lets w ere to m in im iz e p ain and stiffness a fte r a r u n /ra c e (6 1 % ) o r b e fo re a ru n /ra ce to red u c e p ain /stiffn ess (41% ). F o u r p erc en t o f th e resp o n d e n ts used A rn ica tab lets to im p ro v e th e ir ab ility to train h ard e r w h ile 1 1% used A rn ica tablets fo r “o th e r” reasons. A rn ica tablets w ere also used fo r co n d itio n s un related to ru n n in g (3 6 % ) o f w h ich 8% listed “ so re m u sc le s” as th e reason. O nly 22% o f th o se ru n n ers w ho had used A rn ica ta b lets p rev io u sly regarded th e ir effects to b e co m p letely effective w h ile 1% fo u n d th em to b e to tally ineffective. T h irty -th ree % o f th e subjects w ere am b iv alen t w h en asked a b o u t the efficacy. T h e ru n n ers w ho had used A rn ica tab lets took an av erag e o f seven tablets p er day fo r an av erag e o f seven days. N in etee n resp o n d e n ts (26% ) w h o used A rn ica tab lets in g ested m ore than seven ta b lets a day and scored th e ir efficacy as 80% . F o rty -o n e su b jects (57 % ) took less than seven tab lets a day and scored th e ir efficacy as 71% . T w elv e u sers (1 7 % ) d id n o t resp o n d to this qu estio n . T h e rela tio n sh ip b etw een th e d o sa g e and perceiv ed efficacy o f A rn ica tab lets w as p o o r (r = 0.28). R u n n e rs b eliev ed A rn ica tab lets c o n ­ tain various su b stan ces. T h e c o m m o n est p e rc e p tio n s w e re th a t A rn ic a ta b le ts h ad an ti-in flam m ato ry p ro p ertie s (63% ), co n tain ed ‘a n ti-sw e llin g ’ ag en ts (38% ) and pain reliev ers (17% ). E leven p ercen t resp o n d ed to “o th e r” as a co n stitu e n t and 19% d id n o t k n o w th e an s w e r to this q u estio n . N o ru n n er listed “ stim u la n ts” as a co n s titu e n t o f A rnica. F ifty -fiv e o f th e ru n n e rs (7 % ) o f th e total study p o p u la tio n w h o w ere ap p ro ach ed , d eclin ed to fill in th e q u e s ­ tio n n a ire. D a ta w h ich w ere o b ta in ed fo r 36% o f th e se “ n o n -re sp o n d ers” w ere th eir age, 1999 C om rades m arathon tim e, P erso n al B est (PB ) C o m ra d es m arathon tim e and to tal n u m b e r o f C o m rad es m arath o n s co m p leted (T able 5). T h ere w as no sig n ific an t d iffe ren ce in th ese p aram eters betw een th o se w h o answ ered th e q u estio n n aire and th o se w ho declined to an s w e r th e q u es tio n n a ire (T able 5). DISCUSSION T h e m ain aim o f th is study w as to d e te r­ m in e th e p rev alen ce o f u sa g e o f A rn ica ta b lets in a g ro u p o f u ltra -e n d u ra n ce ath letes u sin g a se lf-rep o rted q u e s tio n ­ naire. D ata o b tain ed fro m self-rep o rted q u e s tio n n a ire s a re o p en to c ritic is m b ec au se th e resp o n ses are d ifficu lt to validate. F o r this reaso n th e q u e s tio n ­ n aire w as tested in a p ilo t study and any q u estio n s w hich w ere am b ig u o u s o r m isinterpreted w ere adjusted accordingly. T h e ta rg e te d r u n n e rs c o m p le te d th e q u estio n n a ire s in a co n tro lled en v iro n ­ m en t and th e m eth o d o f g ath erin g d ata w as b eliev ed to b e valid. F u rth erm o re, th e sam p lin g p ro ce d u re w as d esig n ed to se lec t su b jects in a sy stem a tic w ay to avoid bias. T h e targ eted ru n n ers w ho dec lin e d to an s w e r th e q u estio n n a ire had s im ila r p o p u la tio n d em o g ra p h ics co m pared to those runners w ho answ ered th e q u estio n n a ire . T h e re fo re it is rea so n ­ ab le to assu m e th a t th e resu lts o f th e ru n ­ ners w ho resp o n d e d to th e q u estio n n a ire in th is study are an ac cu rate re p re se n ­ tation o f the study p o p u latio n (C om rades m arath o n runners). T h e m ain fin d in g o f th e study w as th a t ten p erc en t o f th e total study p o p u ­ lation had used A rn ica tablets in the p rev io u s six m o n th s and tw en ty -n in e p erc en t o f th e total resp o n d e n t study po p u latio n had heard o f A rn ica tablets. F u rth e rm o re , w om en w ere m o re likely to have b een aw are o f A rn ica o r to have used A rn ica ta b lets than m en. A n o th er fin d in g o f th e study w as th a t o n ly 22% o f th e su b jects w h o h ad u sed A rn ica tab lets prev io u sly rated th e ir effec ts as co m p letely effective. T h is fin d in g can be in te rp re ted in tw o w ays. E ith e r th e trea t­ m en t is in effectiv e in m o st cases, or altern ativ ely th e A rn ica is not b ein g used is th e c o rre c t d o sag es o r p o ten cies. A fu n d am e n tal p rin cip le o f h o m eo p ath y is th a t o n e rem ed y d o es n o t n ecessarily h e lp ev e ry p a tie n t w ith a sim ila r c o m p lain t. T h e th e ra p eu tic o b jectiv e o f h o m eo p ath y is to treat th e individual and th e w h o le b o d y an d n o t j u s t th e s p e c ific c o n d itio n [K o e h le r, 1986]. C lassica lly , h o m e o p ath y is b ased on in d iv id u alised tre a tm e n t w ith d ru g s and d o ses selected acco rd in g to th e signs, sy m p to m s and individual te m p eram en t o f th e p atie n t - fac to rs w h ich are not acco m m o d ated in th e stan d ard research p r o to c o ls o f s c ie n c e an d m e d ic in e [W eight, 2000], T his p rin cip le p o ses a p ro b le m fo r c o n d u c tin g a sc ie n tific , d o u b le -b lin d , p la ce b o co n tro lled study, m ak in g th e ev alu atio n o f th e efficacy o f A rn ic a tab lets d ifficult. A s a re su lt there is no c o n sen su s on the efficacy o f A rn ica in th e literatu re. F o r e x a m p le T v eitan et al [1991] assessed th e affect o f a rnica m o n ta n a D 30 tab lets on ru n n ers c o m ­ p e tin g in th e 1990 O slo M a ra th o n . T h o se ru n n ers in g estin g A rn ic a tablets ex p e rien c ed less m u scle stiffn ess and had less m u sc le d am ag e afte r th e rac e as show n by lo w er p la sm a cre atin e activity. H ow ever, th e re w as no d iffe ren ce in the d u ratio n o f so ren ess b etw e en this group and th e g ro u p w h o to o k th e p laceb o . It w as c o n c lu d e d fro m th is stu d y th a t A rn ica tab lets did not red u c e long term m u sc le d a m a g e b u t did red u c e acu te m u s c le s o re n e s s . In a n o th e r stu d y , V ickers e t al [1998] co n d u c te d a ra n ­ d o m iz e d , d o u b le -b lin d , p la c e b o c o n ­ trolled trial on 519 lo n g -d istan ce ru n n ers to d e te rm in e w h e th e r tre a tm e n t w ith A rn ica 3 0X tab lets d ec reased d elay ed - o n se t m u sc le so ren ess m o re effectively th an p la c e b o fo llo w in g lo n g -d ista n c e ru n n in g . R e s u lts o b ta in e d fro m 4 0 0 ru n n ers led th em to co n c lu d e th a t A rn ica 16 SA J o u r n a l o f Ph ysioth era p y 2001 V o l 57 No 4 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) ta b le ts w ere in e ffe c tiv e in re d u c in g m u scle so ren ess b ased on the fact that the ru n n e rs’ p ercep tio n o f p o st-ex ercise pain w as not d ec reased in the control group. T h erefo re, b ased on these data th ere is no ju stific a tio n to reco m m en d A rn ica tablets b efo re and afte r long d istan ce racing. It is in te restin g to n o te th a t d es p ite the la ck o f clin ic al trial d ata, an d the low (2 2 % ) p erc e p tio n o f efficacy in o u r stu d y , th a t 10% o f th e r u n n e rs still c h o s e to use A rn ica. T h is can p e r­ haps be a ttrib u ted to th e re c e n t surge in c o n s u m e r in te re st an d a c ce p ta n ce o f a lte r n a tiv e m e d ic in e , w h ic h has re s u lte d in a te n d en c y to se lf-m e d ic a te w ith o u t d u e re g a rd o r k n o w le d g e o f the a d v a n ta g es an d d is a d v a n ta g e s o f A rn ic a tab lets. In co n clu sio n , 10% o f the ru n n ers in a m ajo r event in South A frica m ak e use o f A rn ica. O nly o n e fifth o f these ru n ­ ners rate the trea tm e n t as co m p letely effective fo r the prev en tio n o f D O M S, and th erefo re ed u catio n on the a d v a n ­ tages an d d isad v an tag es o f u sing these tab lets h as beco m e im portant. U ltra ­ en d u ran ce athletes need further education on the use o f A rn ica tablets as their ex p ectatio n s fo r u sing A rn ica tablets are n o t m atch ed by the p u rp o rted affects o f th e h o m e o p a th ic a g e n t. F u tu re research sh o u ld d eterm in e w h eth e r the consum ption o f A rnica should be reduced b ecau se o f the p o o r efficacy o r w h eth er the p o o r efficacy is a re su lt o f in co rrect u sag e p attern s. ACKNOWLEDGEMENTS /T h e M edical R esearch C o u n cil an d the / N ellie A tk in so n an d H arry C ro ssley l R esearch F u n d s o f the U n iv ersity o f ,Cape Town and W eleda (P h arm a N atura) s u p p o rte d this study. G ill C o h e n o f the C o m rad es M arath o n A sso c iatio n is th an k ed fo r h er support. REFERENCES Jaw ara N, L ew ith G T, V ickers A J, M u llee M A, Sm ith C 1997 H om eopathic arnica and Rhus toxidendron fo r d elay ed o nset m uscle so re ­ ness. British H om eopathic Journal 86:10-15 K o e h ler G 1989 T h e H a n d b o o k o f H o m e o p a th y : Its P rin c ip le s a n d P ra c tice . H ealing A rt Press, V erm ont L ockie A 1998 T he fam ily g uide to ho m eo p a ­ thy, 2nd edn. 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R unners W orld (SA ) January: 9 -10 SA J o u r n a l o f Physiotherapy 2001 V o l 57 No 4 17 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )