Cramping: A Case Study – The Perfect Storm, Part 2

By Coach John Hughes

Four people contacted me recently about cramping problems.

RBR reader Tom J. e-mailed an excellent set of questions on cramping. He has a history of cramping on the bike, which he can usually prevent with a mineral supplement prescribed by his physician. However, “6 to 12 hours later I seize up big time! … Pure agony.”

In Part 1, I discussed his problems, which are common to many roadies, and what scientists know about cramps.

In his e-mail he asked, “We know that Coenzyme Q10, magnesium, sports drinks, pickle juice and other things help alleviate, reduce, or squelch cramping, correct?”

Let’s look at the scientific evidence about each of these supplements.

Supplements

A dietary supplement isn’t subject to the same scientific scrutiny as a medication. Supplements are a billion dollar industry. The objective of these companies is to make money, not to help the athlete. The Food and Drug Administration doesn’t regulate supplements. This means that a supplement doesn’t have to go through rigorous testing to demonstrate either that the supplement provides the claimed benefit or that the supplement is safe. Further, supplements aren’t tested for purity.

As an example, when Scott Moninger raced for Mercury he bought an amino acid supplement that he thought didn’t contained any banned substances. He failed a drug test so he had the supplement tested. Each 500 mg capsule also contained 28 mg of the drug 19-norandrosterone. This amount isn’t just slight contamination! (Cycling News)

One study tested 240 supplements made in the US of which 45 (18.8%) tested positive for a banned substance!

While you may not be concerned with failing a drug test, be aware that any supplement may contain substances not listed on the ingredients, substance which may have effects you didn’t anticipate including effects that may be hazardous to your health.

Buyer beware!

With any supplement start by assessing the claims of the alleged benefits.

Coenzyme Q10 (CoQ10)

Let’s start with a simple example. CoQ10 is an antioxidant that is made in the human body. As you age your body produces less. The Mayo Clinic doesn’t list CoQ10 as a way to prevent or treat muscle cramps; however, CoQ10 is sometimes prescribed to reduce muscle pain associated statins, drugs that are used to lower cholesterol. If CoQ10 helps with that kind of pain it should help with cramps, shouldn’t it? According to Harvard Health, “There is no convincing medical evidence to suggest that Coenzyme Q10 prevents muscle pain in people taking statins.”

There’s no scientific evidence that spending money on CoQ10 will help your cramps.

Mineral depletion

According to the Mayo Clinic, “Too little potassium, calcium or magnesium in your diet can contribute to leg cramps. Diuretics — medications often prescribed for high blood pressure — also can deplete these minerals.”

As I discussed last week electrolyte loss doesn’t seem to be a cause of cramping in athletes; however, a dietary deficiencies, not sweat loss of minerals may cause cramps. If you are concerned that you might be deficient in one or more electrolyte, ask your health care professional to do a simple blood test. If you’re low, then ask how you could change your diet to rectify this or if you should take a supplement.

Tom had his blood tested and he was low in magnesium. He now takes prescribed doses of magnesium daily and is careful not to take more because of possible side effects. According to the National Institute of Health too much magnesium may result in nausea and vomiting, muscle weakness, irregular heartbeat, low blood pressure, respiratory distress and cardiac arrest.

Sports drinks

According to CSP News, which covers the convenience store industry, Gatorade Perform sold $1,642 million in a year. Powerade Ion4 sold $332 M and Gatorade G2 sold $155M. The top 20 drinks sold a total of $2 billion!

Sports drinks are marketed as electrolyte replacement drinks to get you to buy and drink them.

What are the scientific evidence supporting sports drinks as a way of preventing cramps and other problems?

In Part 1 I cited an excellent paper on Exercise Associated Muscle Cramps (EAMC) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3445088/ which was published in the National Center for Biotechnology Information PubMed (NCBI PubMed) a database of 26 million peer reviewed scientific articles. The paper cites four separate studies, “sweat rate and sodium/fluid losses are often not different in athletes who develop EAMC” from athletes who do not cramp.” In another study, “when carbohydrate-electrolyte fluids were ingested at a rate that matched sweat loss, EAMC still occurred in 69% of athletes.”

Sports drinks don’t even match the electrolytes of sweat. One liter of most sports drink contains significantly less sodium, potassium and other electrolytes than found in a liter of sweat. Why? If they contained enough electrolytes, they’d taste bad, just like your sweat does.

If you are tempted to drink more of your favorite sports drink to compensate for the relatively low amounts of electrolytes, don’t! Drinking too much sports drink just like drinking too much water can lead to hyponatremia (low blood sodium), a potentially dangerous condition. Because the sodium concentration in a sports drink is less than the sodium concentration in your blood, drinking more sports drink dilutes your blood sodium concentration just like drinking water does.

Drink to satisfy your thirst, not more.

Electrolyte replacement supplements

These supplements are like sports drinks: marketed to make you think you’re buying a product that will prevent cramps!

The paper on EAMCs demonstrates that electrolyte replacement fluids don’t prevent cramps. If electrolytes in a drink don’t prevent cramps, why would electrolytes in a pill? According to the American College of Sports Medicine (ACSM) 2015 paper on Nutrition and Athletic Performance, “In general, vitamin and mineral supplements are unnecessary for the athlete who consumes a diet providing high-energy availability from a variety of nutrient-dense foods.”

If you choose to use an electrolyte replacement supplement, then read the label to see if it contains electrolytes in the proportions found in sweat.

My RBR column on What Electrolytes Do You Really Need? has a table listing the amounts of the different electrolytes in a liter of sweat.

Pickle juice

Some scientific studies report that pickle juice does relieve cramps while other studies reach the opposite conclusion. The Cooper Institute reports that “there is research showing pickle juice shortens muscle cramp duration, but not because of its high electrolyte concentration. In fact, it takes about 30 minutes for even small volumes (2/3 cup) of pickle juice to leave the stomach (Miller et al., 2010a). Hence, blood electrolyte levels would not increase quickly enough to explain cramp relief. However, the acetic acid in pickle juice is ‘noxious tasting’ and proposed to chemically stimulate a reflex in the back of the throat. This reflex has been shown to decrease activity in the alpha motor neurons, which causes muscle relaxation. You don’t even have to swallow the pickle juice to trigger the reflex, which can relieve cramps in less than 3-4 minutes. It is possible that other noxious tasting substances may also provide relief from exercise-associated muscle cramps.”

In other words it may or may not help you. Other than the taste there are no significant side effects so you could try it.

HotShot

HotShot is a supplement that claims to prevent and alleviate cramps, which came to market in 2016. It was developed by Rod MacKinnon, PhD, who won the Nobel Prize in chemistry in 2003 and Dr. Bruce Bean, a neurobiologist at Harvard. Their research suggests that when an athlete eats or drinks something spicy the ion receptors in the mouth, esophagus and stomach send signals to the spinal cord, which are then transmitted through the nervous system to keep everything operating normally, i.e., don’t cramp. They report that many natural substances including cinnamon, ginger, capsicum (aka red pepper, chili pepper), mustard, wasabi, garlic, cinnamaldehyde (what gives cinnamon its flavor) and others are effective at dealing with cramps.

This is consistent with the research on pickle juice reported by the Cooper Institute.

Bean and MacKinnon have founded a company Flex Pharma to develop a commercial product, HotShot, to deal with cramps the same way these natural substances do. HotShot contains a proprietary mix of these natural substances.

Flex Pharma cites two studies, which demonstrate the effectiveness of HotShot:

In the first study 31 endurance cramp-prone athletes tested HotShot and the prevalence of muscle cramps dropped over 50% both during and after workouts.

In the second study Penn State collaborated with Flex Pharma to test HotShot in a double blind study. Bean and MacKinnon reported that the study demonstrated the effectiveness of HotShot; however, no details were provided.

Does HotShot work? To be valid a study should have a control group of about 30 athletes matched in age, physiology, fitness and history of cramping to the experimental subjects. The experimental group and the control group do exactly the same workout(s) under exactly the same conditions. If the experimental group has significantly fewer cramps than the control group, then HotShot helps. However, the Flex Pharma report doesn’t mention a control group and I couldn’t find a citation of this study in PubMed.

In the second study the Penn State researchers collaborated with Flex Pharma. Hardly objective research. Searching PubMed I couldn’t find the Penn State study — I couldn’t even find it in the Penn State database!

Neither of these studies proves the effectiveness of HotShot.

A HotShot 24 pack is $3.95 per serving and you’re supposed to take one before every workout. Rather than buying HotShot I suggest you head to the spices aisle at your grocery store and get one of more of the natural substances above.

I’m sticking with my diet of cinnamon buns, breakfast burritos, chili for lunch and garlic-rich pasta sauce for dinner to prevent cramps.

Prevention

The paper on EAMCs recommends, “Despite the lack of direct evidence, maintaining hydration and adequate electrolyte levels is a good prevention strategy for individuals susceptible to EAMC. … A common perception is that level of conditioning is a factor in the development of EAMC. There is a strong theoretical basis for performing exercises that target the neuromuscular system to prevent EAMC. Prevention exercises that target muscle spindle and GTO receptors should be implemented to delay neuromuscular fatigue onset and, hence, EAMC. Plyometric exercises may be beneficial to elicit neural adaptations in muscle spindle and GTO receptor firing, enhancing efficiency and sensitivity of reflexive and descending pathways used for neuromuscular control. Endurance training may also serve as an effective means of preventing EAMC by expanding plasma volume and the extracellular fluid compartment and delaying neuromuscular fatigue.” [emphasis added]

What can Tom or any other roadie afflicted with cramps do to prevent them?

• Maintain hydration. The 2015 ACSM paper recommends drinking enough so that dehydration isn’t greater than 2% body weight loss. Drink to satisfy your thirst.
• Eat salt. Sodium is the primary electrolyte lost in sweat.
• Get a medical check-up to be sure you don’t have a related medical problem or a dietary nutritional deficiency.
• Get fitter. You can improve your fitness and reduce the risk of cramping by:
• Building endurance, which increases the volume of your blood and increases blood flow to the skin to provide better cooling.
• Increase specific muscle strength of any cramp-prone muscles, especially as you age.
• Doing plyometrics, which target the neuromuscular system.
• Train for heat by doing fairly hard rides of up to an hour that raise your core temperature.
• Acclimate to heat by leaving the AC off and the windows open.
• Pace yourself in hot conditions. Your muscles at work are the major source of heat and slowing down as it heats up will reduce the total heat load on your body.
• Stretch. Muscles are more prone to cramp when they contract in a shortened position. Stretching to increase range of motion, both during rides and at home, will reduce the risk.

Resources:

Strength Training to Prevent Cramps on my website illustrates exercises for six muscle groups prone to cramping.

My 10-page eArticle Preventing and Treating Cramps explains in detail the causes of cramps, the role of electrolytes and how to break and flush a cramp if one strikes you.

My Summer Riding bundle totaling 66 pages includes How to Handle Cramps, Cycling in the Heat Parts 1 and 2, and Eating and Drinking Like the Pros.