European Journal of Pharmacology 728 (2014) 161–166
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European Journal of Pharmacology journal homepage: www.elsevier.com/locate/ejphar
Immunopharmacology and inﬂammation
Effects of anatabine and unilateral maximal eccentric isokinetic muscle actions on serum markers of muscle damage and inﬂammation Nathaniel D.M. Jenkins, Terry J. Housh, Kristen C. Cochrane, Haley C. Bergstrom, Daniel A. Traylor, Robert W. Lewis Jr., Samuel L. Buckner, Richard J. Schmidt, Glen O. Johnson, Joel T. Cramer n Department of Nutrition and Health Sciences, University of Nebraska–Lincoln, 211 Ruth Leverton Hall, Lincoln, NE 68583-0806, USA
art ic l e i nf o
a b s t r a c t
Article history: Received 12 September 2013 Received in revised form 27 January 2014 Accepted 28 January 2014 Available online 6 February 2014
The purpose of this study was to examine the effects of anatabine supplementation in conjunction with unilateral, maximal eccentric isokinetic muscle actions on serum markers of muscle damage and proinﬂammatory cytokines in humans. Seventeen men (mean7S.D. age¼22.4 7 3.2 yrs) participated in this double-blinded, placebo-controlled, crossover study. Participants were randomly assigned to two 10-day conditions (anatabine and placebo) separated by a 2–4 week washout period. After seven days of supplementation, blood was sampled immediately prior to PRE, immediately following POST, and 24, 48, and 72 h after 6 sets of 10 repetitions of unilateral, maximal eccentric isokinetic forearm ﬂexion exercise. Concentrations of serum creatine kinase, lactate dehydrogenase, myoglobin, high sensitivity c-reactive protein, and TNF-α were measured. Creatine kinase, myoglobin, and lactate dehydrogenase increased (Po0.05), while high sensitivity c-reactive protein and TNF-α did not change (P40.05) after the eccentric exercise during both conditions. Lactate dehydrogenase was higher (Po0.05) during the anatabine condition. The primary ﬁndings of this study were two-fold: (a) anatabine had no beneﬁcial effects on traditional markers of muscle damage (creatine kinase, lactate dehydrogenase, and myoglobin) compared to placebo after the eccentric exercise protocol, and (b) the eccentric exercise protocol did not elicit increase in the pro-inﬂammatory cytokines (c-reactive protein and TNF-α). Future studies are needed to examine the effects of anatabine on naturally-occurring inﬂammation that is common with aging or obesity. Furthermore, additional research is needed to examine the relationship between muscle damage and inﬂammation after eccentric exercises of different modes, durations, and intensities. & 2014 Elsevier B.V. All rights reserved.
keywords: Anatabine Supplementation Eccentric muscle damage Muscle function Cytokines
1. Introduction Heavy eccentric exercise induces structural damage to skeletal muscle that is characterized by z-line streaming and a disorganization of myoﬁlaments (Friden et al., 1981; Newham et al., 1983), interruption of the excitation contraction coupling process (Proske and Morgan, 2001), and inﬂammatory responses (Clarkson et al., 1992; Houghton and Onambele, 2012). Sarcolemmal disruption (Peake et al., 2005) occurring after muscle damage facilitates the release of intercellular enzymes and muscle proteins such as creatine kinase, myoglobin, and lactate dehydrogenase into the interstitial ﬂuid, followed by uptake into the lymphatic system and eventual release into circulation (Brancaccio et al., 2010; Nosaka et al., 2003). In fact, it is common to observe abnormally high n
Corresponding author. Tel.: þ 402 4722690; fax: þ 402 4720522. E-mail addresses: [email protected]
(N.D.M. Jenkins), [email protected]
(J.T. Cramer). http://dx.doi.org/10.1016/j.ejphar.2014.01.054 0014-2999 & 2014 Elsevier B.V. All rights reserved.
serum creatine kinase (i.e. 410,000 IU L 1) and myoglobin (i.e. 41000 IU L 1) concentrations following eccentric muscle actions of the forearm ﬂexors (Clarkson et al., 1992; Nosaka et al., 2003). In addition, there is production and release of pro-inﬂammatory cytokines such as tumor necrosis factor-alpha (TNF-α) and c-reactive protein, which attracts lymphocytes, monocytes, and neutrophils (Houghton and Onambele, 2012; Ostrowski et al., 1999) to the damaged tissue (Tidball, 2005). Pro-inﬂammatory cytokine concentrations may be related to the amount of delayed onset muscle soreness and recovery from muscle damage (Northoff and Berg, 1991; Richards and Gaulder, 1998; Smith et al., 2000). Consequently, studies have examined the efﬁcacy of interventions such as anti-inﬂammatory drugs (Nieman et al., 2006), cryotherapy (Pournot et al., 2011), massage therapy (Crane et al., 2012), and dietary supplementation (Childs et al., 2001; Houghton and Onambele, 2012; Michailidis et al., 2013; Serra et al., 2012) to reduce markers of muscle damage and the pro-inﬂammatory cytokine responses from eccentric-induced muscle damage.
N.D.M. Jenkins et al. / European Journal of Pharmacology 728 (2014) 161–166
Anatabine, a minor tobacco alkaloid with a similar chemical structure to nicotine, has demonstrated (Paris et al., 2011, 2013) anti-inﬂammatory properties and the ability to regulate cytokine production via inhibition of Signal Transducer and Activator of Transcription 3 (STAT3) and NFkB phosphorylation. For example, anatabine reduced the prevalence and severity of experimentallyinduced autoimmune thyroiditis and limited the associated increases in interleukin-1 (IL-1) receptor type 2 and interleukin18 in mice (Caturegli et al., 2012). Anatabine also reduced NFkB activation and suppressed amyloid beta production, which are both associated with plaque deposits in the brain during the overproduction of pro-inﬂammatory cytokines and Alzheimer’s disease (Paris et al., 2011). Anatabine has also been shown to inhibit the production of IL-1β, interleukin-6, and TNF-α induced by lipopolysaccharides in mice and in human blood (Paris et al., 2013). Thus, anatabine may minimize the pro-inﬂammatory cytokine responses, which in theory, may attenuate the muscle damage response after heavy eccentric exercise. To our knowledge, no previous studies have examined the effects of anatabine supplementation on humans in vivo. Therefore, the purpose of this study was to examine the effects of anatabine supplementation in conjunction with unilateral, maximal eccentric isokinetic muscle actions on serum markers of muscle damage and pro-inﬂammatory cytokines in humans. Based on previous animal studies (Paris et al., 2011, 2013), we hypothesized that, compared to a placebo, anatabine would attenuate the increases in serum markers of muscle damage and pro-inﬂammatory cytokines over a 72-h period after eccentric exercise.
2. Materials and methods 2.1. Participants Twenty-seven men (mean7S.D. age¼21.972.9 yrs; body mass¼ 82.4720.5 kg; height¼ 182.675.8 cm) volunteered to participate in this investigation; however, only 17 (mean7S.D. age¼22.473.2 yrs; body mass¼79.9716.6 kg; height¼ 182.476.3 cm) men ﬁnished the study. Ten participants did not complete the study or were considered non-compliant and were excluded from the analyses for the following reasons: a serious adverse event unrelated to the supplement, but related to the exercise protocol (n¼1), noncompliance with supplement consumption (n¼3), an adverse event related to the supplement, but unrelated to the exercise protocol (n¼1), and unspeciﬁed reasons or reasons unrelated to the study (n¼5). Prior to any testing at visit 1, participants signed an informed consent form and completed a health history questionnaire. Each participant was free from current or ongoing neuromuscular diseases or musculoskeletal injuries involving the wrist, elbow, and shoulder joints. None of the participants had acute infections nor had they engaged in any upper-body resistance training during the 6 months prior to enrollment. In addition, none of the participants reported smoking, use of smokeless tobacco, or use of creatine within 9 weeks prior to enrollment. All of the participants were instructed to maintain their normal dietary habits and refrain from anti-inﬂammatory or pain medications throughout the duration of the study. This study was approved by the university Institutional Review Board for the protection of human participants.
2.2. Experimental design This study used a randomized, double-blinded, placebo-controlled, and crossover design. At visit 1, the participants were randomly assigned to either a supplement (anatabine) or placebo
condition based on their participant number and corresponding randomization code. The participants returned to the laboratory seven days (7 1 day) after visit 1 and completed a bout of unilateral, maximal eccentric isokinetic forearm ﬂexor exercise to induce muscle damage using a standard exercise protocol detailed elsewhere (Beck et al., 2007). Blood draws were performed immediately prior to (PRE), immediately following (POST), and 24, 48, and 72 h after the bout of maximal eccentric exercise in order to quantify serum concentrations of creatine kinase, lactate dehydrogenase, myoglobin, high sensitivity c-reactive protein, and TNF‐α. Serum anatabine concentrations were determined at PRE, and 24, 48, and 72 h after the bout of maximal eccentric exercise (Fig. 3). Following a washout period of 2–4 weeks, participants returned for visit 6 to undergo either the anatabine or placebo condition, whichever condition was not completed during visits 1–5. The procedures during the crossover (visits 6–10) were exactly the same as during visits 1–5, except the participants completed the eccentric exercise with the opposite arm. 2.3. Supplementation The anatabine and placebo dietary supplements were administered as mint-ﬂavored mannitol granulation tablets. Each anatabine tablet contained 3 mg of anatabine, 834 IU vitamin A, and 66 IU vitamin D3. The placebo tablet was identical in ﬂavor and appearance to the anatabine tablet and contained everything in the anatabine tablet except for anatabine. The participants were given a 10 day supply of study product (anatabine or placebo) at visits 1 and 6 and were instructed to self-administer the tablets with food two or three times per day beginning after visit 1 or 6. Table 1 contains the schedule for tablet consumption during each 10 day supplementation period. During the anatabine condition, the participants consumed 6 mg of anatabine during days 1 and 2, 9 mg during days 3 and 4, and 12 mg during days 5 through 10. The participants did not take any study product during the washout period of 2–4 weeks. Compliance was assessed by counting the amount of unused tablets returned at the end of each condition. If a participant consumed less than 70% of the tablets, they were considered noncompliant (n ¼ 2). In addition, one participant's serum anatabine concentrations were 10 ng mL 1 at PRE, 24, and 48 h during the placebo condition, and this participant's data were excluded from analyses. 2.4. Eccentric exercise protocol During visits 2 and 7 (Fig. 1), the participants completed 6 sets of 10 maximal eccentric isokinetic muscle actions of the forearm ﬂexors at 301 s 1 (Beck et al., 2007). The exercised arm (right or left) used during visit 2 was determined at visit 1 using a separate randomization, and the opposite arm was exercised at visit 7. It has been reported (Connolly et al., 2002) that a bout of eccentric exercise in one limb does not confer a protective effect against muscle damage in the opposite limb 2 weeks later. 2.5. Blood sampling procedures Serum concentrations of creatine kinase, lactate dehydrogenase, myoglobin, high sensitivity c-reactive protein, TNF-α, and anatabine were measured from 7.5-mL blood samples taken from the median cubital vein of the non-exercised arm. A trained phlebotomist performed all blood draws. The samples were collected into silicon dioxide dry-coated tubes and centrifuged for 10 min at 3000 r min 1 to separate the serum. The separated samples were frozen and shipped on dry ice to a third party laboratory for analyses (ARUP Laboratories, Salt Lake City, Utah).
N.D.M. Jenkins et al. / European Journal of Pharmacology 728 (2014) 161–166
Lactate dehydrogenase and creatine kinase were detected using quantitative enzymatic assays that had sensitivities of 10 IU L 1 and 7 IU L 1, and coefﬁcients of variation of 0.8% and 1.6%, respectively. Serum myoglobin was detected with electrochemiluminescent immunoassays that had a sensitivity of 21 ng mL 1 and a coefﬁcient of variation of 1.6%. c-reactive protein was detected using quantitative immunoturbidimetry with a sensitivity of 0.1 mg L 1, and a coefﬁcient of variation of 0.7%. TNF-α was detected with a quantitative multiplex bead assay that had a reference range of 0–22 pg mL 1.
t-tests were used to analyze the area under the curve (AUC) for the serum concentrations of creatine kinase, lactate dehydrogenase, myoglobin, high sensitivity c-reactive protein, TNF-α, and anatabine, which were calculated with the standard trapezoidal rule (Table 2) (Kline, 1967). All statistical analyses were performed using IBM SPSS v. 21 (Chicago, IL), and a type I error rate of 5% was considered statistically signiﬁcant for all comparisons.
3. Results 2.6. Statistics 3.1. Muscle damage indicators Five separate two-way repeated measures analyses of variance (ANOVAs) (condition [anatabine vs. placebo] time [PRE vs. POST vs. 24 h vs. 48 h vs. 72 h]) were used to analyze serum creatine kinase, lactate dehydrogenase, myoglobin, high sensitivity c-reactive protein, and TNF-α. A two-way repeated measures ANOVA (condition [anatabine vs. placebo] time [PRE vs. 24 h vs. 48 h vs. 72 h] was used to analyze serum anatabine. Follow-up one-way repeated measures ANOVAs and Bonferonni-corrected dependent samples t-tests were used when appropriate. Separate dependent samples
For serum creatine kinase, there was no condition time interaction (P¼ 0.40; partial η2 ¼0.06) and no main effect for condition (P¼ 0.29; partial η2 ¼0.07), but there was a main effect for time (Po 0.01; partial η2 ¼0.39). Serum creatine kinase (collapsed across condition) was greater at 72 h than at PRE (P¼ 0.02), POST (P ¼0.02), 24 (P¼ 0.02), and 48 h (P¼ 0.03). For serum lactate dehydrogenase, there was no condition time interaction (P¼ 0.08; partial η2 ¼ 0.12), but there were main effects for condition (P¼0.001; partial η2 ¼0.30) and time (P¼ 0.02; partial η2 ¼0.26). There were no signiﬁcant differences among the marginal means (collapsed across condition) for PRE, POST, 24, 48, or 72 h. However, the marginal mean for serum lactate dehydrogenase (collapsed across time) was greater in the supplement than in the placebo condition (P¼0.02). For serum myoglobin, there was no condition time interaction (P¼0.27; partial η2 ¼ 0.05) and no main effect for condition (P¼0.51; partial η2 ¼0.08), but there was a main effect for time (Po0.01; partial η2 ¼ 0.418). The marginal mean for myoglobin (collapsed across condition) was greater at 72 h than at PRE, POST, and 24 h (Po0.01). 3.2. Inﬂammatory cytokines There were no condition time interactions (P 40.05; partial η2 ¼0.06–0.08) and no main effects for condition (P 40.05; partial η2 ¼0.01–0.02) or time (P4 0.05; partial η2 ¼0.07–0.10) for high sensitivity c-reactive protein, or TNF-α (Fig. 2). 3.3. Anatabine There was no condition time interaction (P¼ 0.22; partial η2 ¼0.06) and no main effect for time (P ¼0.37; partial η2 ¼0.06), but there was a main effect for condition (P o0.01; partial η2 ¼ 0.475). The marginal mean for anatabine (collapsed across time) was greater during the anatabine condition (P¼ 0.002). 3.4. Area under the curve There were no differences (P 40.05) between the anatabine and placebo conditions for the AUCs of creatine kinase, myoglobin, high sensitivity c-reactive protein, and TNF-α. However, AUCs for lactate dehydrogenase (P¼ 0.03) and anatabine (P o0.01) were greater during the anatabine condition. Table 1 The number of anatabine or placebo tablets (anatabine; mg) consumed at breakfast, lunch, and dinner during each 10-day supplementation period.
Fig. 1. Serum muscle damage indicator responses. The means ( 7 standard errors) for serum lactate dehydrogenase (A), creatine kinase (B), and myoglobin (C) at PRE and POST, and 24, 48, and 72 h after exercise-induced muscle damage.
Days 1 and 2
Days 3 and 4
Breakfast Lunch Dinner
1 (3 mg) 1 (3 mg) 0
1 (3 mg) 1 (3 mg) 1 (3 mg)
2 (6 mg) 1 (3 mg) 1 (3 mg)
Total per day
2 (6 mg)
3 (9 mg)
4 (12 mg)
N.D.M. Jenkins et al. / European Journal of Pharmacology 728 (2014) 161–166
Table 2 The means ( 7S.D.) for the area under the curve for each of the serum muscle damage indicators and pro-inﬂammatory cytokine responses, and anatabine concentrations during the supplement and placebo conditions.
Creatine kinase (IU L ) Lactate dehydrogenase (IU L 1) Myoglobin (ng mL 1) c-reactive protein (mg L 1) Tumor necrosis factor-alpha (pg mL 1) Anatabine (ng mL 1) a
Mean ( 7S.D.)
Mean ( 7 S.D.)
6345.2 622.0 727.7 5.9 95.4 36.1
( 7 9146.8) ( 7 222.6) ( 7 810.9) ( 7 7.1) ( 7 243.2) ( 7 37.6)
4225.5 537.0 1086.7 5.0 71.4 2.2
( 7 6228.7) ( 7 173.7) ( 7 1229.3) ( 7 9.6) ( 7 133.3) ( 7 4.0)
0.28 0.03a 0.25 0.78 0.52 o 0.01a
0.27 0.43 0.34 0.11 0.12 1.27
A signiﬁcant difference between supplement and placebo groups (Po 0.05).
Fig. 2. Serum pro-inﬂammatory cytokine responses. The means ( 7 standard errors) for serum high sensitivity c-reactive protein (A) and TNF-α (B) at PRE and POST, and 24, 48, and 72 h after exercise-induced muscle damage.
Serum Anatabine (ng·mL-1)
15 10 5
Fig. 3. Serum anatabine concentrations. The means ( 7 standard errors) for serum anatabine concentrations at PRE and POST, and 24, 48, and 72 h after exerciseinduced muscle damage.
The present study was the ﬁrst to examine the effects of anatabine supplementation on humans in vivo. The primary ﬁndings of this study were two-fold: (a) anatabine had no beneﬁcial effects on the traditional markers of muscle damage (creatine kinase, lactate dehydrogenase, and myoglobin) compared to the placebo after the eccentric exercise protocol, and (b) the eccentric exercise protocol did not elicit increases in the proinﬂammatory cytokines (c-reactive protein and TNF-α). In previous studies, the anti-inﬂammatory effects of anatabine have been demonstrated in response to systemic and chronic inﬂammation in rodents during endotoxemia (Paris et al., 2013), Alzheimer's disease (Paris et al., 2013), and auto-immune thyroiditis (Caturegli et al., 2012). In the present study, an acute model of exerciseinduced muscle damage was used to examine the effects of anatabine in humans. While anatabine had no beneﬁcial effects on exercise-induced muscle damage in the present study, it is still unknown whether it is efﬁcacious for reducing exercise-induced inﬂammation. Subsequently, these ﬁndings suggested that there is a dissociation between muscle damage and inﬂammation, such that muscle damage can occur without a systemic inﬂammatory response. The increases of 127 to 4,858 IU L 1, 127 to 211 IU L 1, and 33 to 611 ng mL 1 for creatine kinase, lactate dehydrogenase, and myoglobin, respectively, indicated that this protocol elicited muscle damage that was consistent with previous investigations using similar eccentric exercise (Beck et al., 2007; Cooke et al., 2010; Rawson et al., 2001). Previous studies (Cockburn et al., 2008; Cockburn et al., 2012; Cooke et al., 2010; Samadi et al., 2012; Shimomura et al., 2010; Tokmakidis et al., 2003) have demonstrated the ability of dietary supplement or drug interventions to attenuate exercise-induced increases in creatine kinase, lactate dehydrogenase, and myoglobin. For example, Tokmakidis et al. (2003) found that ibuprofen ingestion prevented increases in creatine kinase after 6 sets of 10 eccentric leg ﬂexion muscle actions. Cockburn et al. (2008) showed that a milk-based carbohydrate and protein supplement attenuated increases in creatine kinase and myoglobin compared to a placebo. Silva et al. (2010) demonstrated that vitamin E supplementation decreased the lactate dehydrogenase response to eccentric upper body exercise when compared to a placebo, although Theodorou et al. (2011) showed no effect of mixed antioxidant supplementation on increases in creatine kinase. Therefore, serum markers of exercise-induced muscle damage can be sensitive to dietary supplement or pharmaceutical interventions. However, in the current study, the anatabine supplement did not attenuate the creatine kinase, lactate dehydrogenase, or myoglobin responses after the eccentric exercise. These results are consistent with the ﬁndings of Jenkins et al. (2013), who demonstrated that anatabine supplementation had no effect on the recovery of muscle strength
N.D.M. Jenkins et al. / European Journal of Pharmacology 728 (2014) 161–166
and soreness following eccentric exercise. It is possible, therefore, that the mechanisms of action for dietary anatabine may be speciﬁc to inﬂammation, rather than markers of muscle damage. Interestingly, our study indicated that there were no increases in c-reactive protein or TNF-α in response to the eccentric exercise protocol in either the anatabine or placebo groups. Tissue damage that occurs in response to unaccustomed eccentric exercise often involves an acute release of pro-inﬂammatory cytokines (Clarkson et al., 1992; Smith et al., 2000; Tidball, 2005). These cytokines are thought to facilitate an inﬂammatory reaction that encourages the presence of monocytes, lymphocytes, and neutrophils (Ostrowski et al., 1999) at the site of muscle damage (Tidball, 2005). Michailidis et al. (2013) demonstrated that N-acetylcysteine supplementation minimized the serum c-reactive protein responses to exerciseinduced muscle damage of the leg extensors. Crane et al. (2012) found that massage therapy attenuated the production of TNF-α in the leg extensors after exercise-induced muscle damage. Therefore, although these pro-inﬂammatory cytokines have responded to exercise-induced muscle damage in previous studies involving the leg extensors (Michailidis et al., 2013; Crane et al., 2012), the present study indicated that 6 sets of 10 repetitions of unilateral, maximal eccentric isokinetic muscle actions of the forearm ﬂexors were unable to increase serum concentrations of the proinﬂammatory cytokines high sensitivity c-reactive protein and TNF-α. Eccentric exercise involving the leg extensors may be more appropriate for experimentally inducing inﬂammatory responses than eccentric exercise involving the forearm ﬂexors. This hypothesis is consistent with Peake et al. (2005) who pointed out that leukocyte counts in response to pro-inﬂammatory cytokines may be directly related to the amount of muscle mass recruited during eccentric exercise. Therefore, given its ability to regulate STAT3 and NFkB phosphorylation (Paris et al., 2013), anatabine may elicit antiinﬂammatory effects in circumstances that are marked by elevated pro-inﬂammatory cytokine concentrations, such as in the recovery from eccentric exercise involving the leg extensors. It is also possible that the lack of pro-inﬂammatory cytokine responses in the present study may have been related to the mode, intensity, and duration of exercise as well as the local vs. systemic nature of the exercise-induced inﬂammation. Hirose et al. (2004) suggested that greater increases in circulating pro-inﬂammatory cytokines occurred following prolonged endurance exercise, despite the fact that isolated eccentric muscle actions of the forearm ﬂexors or leg extensors often result in greater local muscle damage (Paulsen et al., 2012). Peake et al. (2005) indicated that downhill running and eccentric cycling have resulted in greater concentrations of pro-inﬂammatory cytokines than isolated eccentric muscle actions of the forearm ﬂexors or leg extensors due to the intensity and duration of exercise, rather than the amount of muscle damage. Hirose et al. (2004) also reported that concentrations of inﬂammatory cytokines as well as other inﬂammatory mediators were relatively small after eccentric muscle actions of the forearm ﬂexors and suggested that eccentricinduced muscle damage may not be associated with increases in serum pro-inﬂammatory cytokine concentrations. Furthermore, Bessa et al. (2013) demonstrated that an extensive exercise protocol consisting of 6 sets of squat and bench press exercises at 85% of the 1 repetition maximum and 1 h of cycling at 85% of VO2 peak resulted in local muscle inﬂammation, but not systemic inﬂammation measured by circulating inﬂammatory markers. Therefore, although the unilateral, maximal eccentric isokinetic forearm ﬂexion exercise used in the present study caused muscle damage that was consistent with previous studies (Beck et al., 2007; Cooke et al., 2010; Rawson et al., 2001), it was insufﬁcient to elicit a systemic inﬂammatory response measured by serum concentrations of the pro-inﬂammatory cytokines high sensitivity c-reactive protein and TNF-α.
5. Conclusions Anatabine had no beneﬁcial effects on the exercise-induced increases in serum myoglobin, creatine kinase, or lactate dehydrogenase, which are regarded as biomarkers of muscle damage. Although the unilateral, maximal eccentric isokinetic muscle actions of the forearm ﬂexors caused local muscle damage, it was unable to elicit an increase in systemic inﬂammation measured by serum pro-inﬂammatory cytokine concentrations (c-reactive protein and TNF-α). Therefore, it is still unknown whether anatabine is effective for reducing inﬂammation in humans. Future studies should examine the effects of anatabine on the inﬂammation associated with musculoskeletal or joint ailments induced by aging, injury, or autoimmune disorders as well as conditions characterized by low-level pro-inﬂammatory cytokine concentrations such as aging or obesity. Furthermore, research is needed to better characterize the relationship between muscle damage and inﬂammation after eccentric exercises of different modes, durations, and intensities.
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