Study of Red Ginseng Preparation HRG80 for Relieving Muscle Pain/Soreness and Supporting the Neuromuscular Performance of Elite Weightlifters in Intense Resistance Exercise: An Open-Label, Randomized, Crossover Trial

    


    


    Figure 4: (a) – Effect of RG tablets or capsules on the maximal number of push-ups on the uneven bars (PUB) Test (mean ± SD) of athletes over the time of

treatment with tablets, capsules, and negative control from Day 1 to Day 10. (b) - The changes from the baseline (day 1) of PUB score (mean ± SD) of athletes over

the time of treatment with tablets and capsules vs. negative control from Day 1 to Day 10. The efficacy of RG capsules vs. tablets and negative control (assessed

by two-way between–within ANOVAs) was revealed by an interaction effect (p = 0.006 and p=0.0005 correspondingly), indicating a different response over time

between RG capsules and control with the maximal difference on day 7 (p< 0.05), while the interaction effect of tablets vs negative control was insignificant

(p=0.0725). The significance of the difference is expressed by symbols *p <0.05.

    

Efficacy Outcome Measures

A perceptual measure of fatigue: One of the three efficacy measures used in this study was muscle soreness, frequently utilized to monitor fatigue in athletes after training. It was assessed by an advanced and validated modification [25] of MHQ [24], including the questions related to muscles of upper and lower sites [25]. A scale from 1 to 5 was used to quantify the soreness level of 9 different muscles/muscle sites from both sides of the body: left and right quadriceps, groin, chest, shoulder, calf, hamstrings, gluteus, lower back, upper back. A measure of Lower Body muscle soreness (LB) was calculated from the sum of the left and right quadriceps, groin, calves, hamstrings, and gluteus soreness. A measure of the Upper Body (UB) soreness was calculated from the average of the left and right chest, shoulder, lower back, and upper back muscle soreness. Finally, whole-body soreness was calculated from the total muscle soreness ratings from all muscles/muscle regions. The athletes were monitored for muscle soreness during a 10-day in-season period (phases A, B, and C) to get a control curve of changes in muscle soreness score from the “baseline” (day 1).

Psychomotor and Physical Performance: Tests to Measure Strength Ability

Barbell Squat (shoulder position): This test assesses the legs’ absolute (maximum) strength (gluteal muscles; quadriceps femoris; posterior thigh muscles; adductors).The test requires a standard 20 kg bar, two locks, a frame for the barbell, and enough plates to perform maximum effort with the ability to vary weights in the 5 kg range. When carrying out squats with a barbell with top weight, a prerequisite is using a frame with safety beams or having two assistants who insure the subject and provide assistance if necessary. The subject sits down under the power rack barbell, takes it on his shoulders in a low or high position, and takes a step back. The athlete must squat to a 90° angle and fully extend the legs. Assistants are located on both sides of the bar and are ready to assist the subject at any time.

The first warm-up approach was accomplished with light or medium weights relative to the strength capabilities of the subject, followed by a rest of 1 minute. A warm-up weight is set, presumably allowing the athletes to perform the exercise from three to five repetitions. After execution and rest for 2 minutes, the weight was increased by 5 kg or 10-20% for lower limb exercises. After implementation and rest for 2-4 minutes, the weight was increased by another 5 kg or 10-20% for lower limb exercises. The test continues until the maximum possible weight is selected. The maximum weight of the rod was considered as the final result.

Push-Ups on the Uneven Bars

The athlete stands facing the ends of the bars, jumps up, assumes a support position, bends his arms at an angle of 90°, and then straightens his arms again. The maximum number of push-ups is taken into account as the final result. The athlete repeated as many push-ups as possible.

Efficacy Endpoints

The primary endpoints for assessment of the efficacy of RG preparations were:

A difference in changes in muscle pain/soreness scores from the baseline (day 1)over the time to the last day (day 10) of treatment compared to the negative control (no treatment),

A difference in changes in psychomotor/physical performance tests scores from the baseline over the time to the last day of treatment compared to the negative control (no treatment); time frame: 1, 3, 7, and 10 days.

The secondary endpoints for assessment of the efficacy of Red Ginseng Energy Chewable Tablets were differences in changes in muscle pain/soreness and physical performance test scores from the baseline over the time to the last day of treatment compared to Red Ginseng Energy Capsules.

Statistical Analysis

All the data were recorded in standardized case report forms and tabulated in an Excel dataset (Supplemental Tables S1, S2, and S3), which was used in statistical analysis by Prism software (version 3.03 for Windows; Graph Pad, San Diego, CA, USA).

Statistical analysis was conducted using “observed” data for timeto- event outcomes of the intent-to-treat population, defined as all randomly assigned participants who received at least one dose of the study product.

The mean outcomes were evaluated at baseline (Supplemental Table 4), days 1 of phases B and C vs. phase A by the Student’s parametric independent-measures t-test (variables with normal distribution according to the D’Agostino & Pearson omnibus normality test).

Within-group repeated measures analysis of variables was conducted with one-way ANOVA (data with normal distribution) test.

Evaluation of the efficacy of study preparation was achieved by comparison of mean changes from the baseline (differences before and after treatment of particular participant) between treatments using two-way between–within ANOVA (Supplemental Table 2) in which an interaction effect indicates a different response over time between the treatments and negative control or between two treatments (capsules vs tablets) and would therefore indicator a treatment effect, as well as by multiple comparison t-test (one unpaired test per row). The level of statistical significance was set at 5% in all methods.

Results

Between-group comparisons showed no significant difference at the baseline day one on all three phases A (visit 2), B (visit 5), and C (visit 8) of the trial, (Figure 1 and Supplement Table S4).

Muscle soreness significantly increased (p< 0.05, within group, repeated measures ANOVA, Supplement Table S2) from baseline (day 1) over time from days 6^th to 10^th of phase A of the study used as a negative control (Figure 2a). When the same 20 athletes took one Red Ginseng Energy Chewable Tablet daily (daily dose 100 mg RG) for 10 consecutive days - a significant decrease in muscle soreness score was observed (p< 0.05, within group, repeated measures ANOVA, Supplement Table S2), (Figure 2a). The pain ameliorating effect of Red Ginseng Energy capsules (daily dose 400 mg RG) was insignificant (Figure 2a).

A significant increase in muscle soreness score, measured as a change from baseline (day 1) over time, was observed on days 6, 7, 8, 9, and 10 of phase A (negative control), while the pain relief effect of Red Ginseng Energy Chewable Tablet daily (daily dose 100 mg HRG80) was significant on days 5, 6, 7, 8, 9 and 10, compared to control (assessed by two-way between–within ANOVAs and multiple comparison test, (Figure 2b), and Supplementary table S2). When the same athletes took two Red Ginseng Energy Capsules daily (daily dose 400 mg HRG80) for 10 consecutive days - a significant decrease in muscle soreness score, measured as a change from baseline (day 1) over time from baseline (day 1) was found for days 8, 9 and 10, (Figure 2b). No statistically significant difference was observed in the effects of two capsules vs. one tablet (Figure 2b) using two-way between–within ANOVAs; however, the impact of tablets vs. control was significant on the 5^th day of the treatment, while the effect of capsules vs. control was observed three days later - on 8^th day.

All athletes performed Barbell Squats (BS) and Push-ups on the uneven bars (PUB) as measures of neuromuscular performance to monitor fatigue, Figures 3 and 4. The capsule uptake results in an increase in physical performance in the PUB test compared to tablets or control (assessed by two-way between–within ANOVAs and multiple comparison tests) with maximal effect on the 7^th day of treatment.

Discussion

In an effort to improve the bioavailability of ginsenosides and, accordingly, the efficacy of Reg Ginseng preparations, we compared the γ-cyclodextrin based complexes containing red ginseng preparation HRG80 with the γ-cyclodextrin free dosage form. The efficacy outcomes measures were relieving fatigue, assessed as muscle pain/soreness, and neuromuscular performance in elite weightlifters during regular, intense resistance exercise for 10 days.

Both RG preparations were effective in subjective assessment of fatigue and objective measure of physical performance. Furthermore, in this study, we demonstrated that one “Red Ginseng Energy” chewable tablet containing 100 mg of red ginseng preparation HRG80 is (daily dose 100 mg HRG80) is as effective as two “Red Ginseng Energy” capsules containing 200 mg of red ginseng preparation HRG80 (daily dose 400 mg HRG80).

The results of this study provide evidence of the efficacy of Red Ginseng Energy” chewable tablet for relief of muscle soreness and supporting the neuromuscular performance of healthy subjects in intense resistance exercise.

Conclusion

• Daily intake of Red Ginseng preparations ameliorates the progression of fatigue, measured as muscle soreness, in athletes after repeated heavy physical loads for 10 consecutive days.

• γ-Cyclodextrinbased dosage form of red ginseng preparation HRG80 are almost 4 fold active of cyclodextrin free HRG80 preparation: one” Red Ginseng Energy” chewable tablet containing 100 mg of red ginseng preparation HRG80 is (daily dose 100 mg HRG80) is as effective (or more effective) as two “Red Ginseng Energy” capsules containing 200 mg of red ginseng preparation HRG80 (daily dose 400 mg HRG80).

Supplementary Materials

The following are available online at www.mdpi.com/xxx/s1; supplementary data 1.

Author Contributions

AH contributed to the study execution and good clinical practice, data management, analysis, and study reporting; MDN contributed to the study subjects’ recruitment, implementation of treatment, and data collection; HSA contributed to the overall study management of the study; AP contributed to the study conception, evaluation, design, data analysis, interpretation of the results, drafting and preparation of the manuscript. All authors read and approved the final manuscript.

Funding

This work was partly funded by Europharma USA (Green Bay, WI, USA). The research sponsor was Mr. Terrence Lemerond, Europharma USA Inc., USA.

Acknowledgments

The authors acknowledge the support of Europharma USA (Green Bay, WI, USA) for supplying and characterizing the investigational dietary supplements. The authors thank Nate Paske for technical assistance and Dr. Karen Stepanyan for monitoring the study. The authors are grateful to all participants of the study and Armenian Weighlifting National Team coach Kirakosyan Ervand for supervising Push-ups on the bars and Barbell Squat tests. The authors are thankful to all participants of the study. The datasets used and analyzed in the current study are available from the corresponding author upon reasonable request.

Conflicts of Interest

HAS, MDN, and HSA declare no conflicts of interest. AP has an independent-contractor agreement with Europharma USA and is head of the research and development company Phytomed AB. The funders had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, or in the decision to publish the results.

Institutional Review Board Statement

Supplement 3.

Informed Consent Statement

Supplement 2.

Data Availability Statement

Data are included in the article and supplementary materials.

References

1. Lee SM, Bae BS, Park HW, Ahn NG, Cho BG, Cho YL, et al. Characterization of Korean Red Ginseng (Panax ginseng Meyer): History, preparation method, and chemical composition. J Ginseng Res. 2015; 39: 384-391.
2. Flagg AJ. Traditional and current use of ginseng. Nurs Clin N Am. 2021; 56:109–121.
3. Ratan ZA, Youn SH, Kwak YS, Han CK, Haidere MF, Kim JK, et al. Adaptogenic effects of Panax ginseng on modulation of immune functions. J Ginseng Res. 2021; 45: 32-40.
4. Panossian A, Brendler T. The Role of Adaptogens in Prophylaxis and Treatment of Viral Respiratory Infections. Pharmaceuticals. 2020; 13: 236.
5. Irfan M, Kwak YS, Han CK, Hyun SH, Rhee MH. Adaptogenic effects of Panax ginseng on modulation of cardiovascular functions. J Ginseng Res. 2020; 44: 538-543.
6. Liao LY, He YF, Li L, Meng H, Dong YM, Yi F, et al. A preliminary review of studies on adaptogens: comparison of their bioactivity in TCM with that of ginseng-like herbs used worldwide. Chin Med. 2018; 13: 57.
7. Patel S, Rauf A. Adaptogenic herb ginseng (Panax) as medical food: Status quo and future prospects. Biomed. Pharmacother. 2016; 85: 120–127.
8. Panossian AG, Efferth T, ShikovAN, Pozharitskaya ON, Kuchta, K, Mukherjee PK, et al. Evolution of the adaptogenic concept from traditional use to medical systems: Pharmacology of stress- and aging-related diseases. Med. Res. Rev. 2020; 41: 630–703.
9. EMA/HMPC/321232/2012. Assessment Report on Panax Ginseng C.A. Meyer, Radix. Based on Article 16d (1), Article 16f and Article 16h of Directive 2001/83/EC as Amended (Traditional Use); European Medicines Agency: Amsterdam, The Netherlands, 2014.
10. EMA/HMPC/321232/2012. Community Herbal Monograph on Panax Ginseng C.A. Meyer; Radix European Medicines Agency: Amsterdam, The Netherlands, 2014.
11. Caldwell LK, DuPont WH., Beeler MK, Post EM, Barnhart EC, Hardesty VH, et al. The Effects of a Korean Ginseng, GINST15, on Perceptual Effort, Psychomotor Performance, and Physical Performance in Men and Women. Sports Sci Med. 2018; 17: 92–100.
12. Flanagan SD, DuPont WH, Caldwell LK, Hardesty VH, Barnhart EC, Beeler MK, et al. The Effects of a Korean Ginseng, GINST15, on Hypo-Pituitary- Adrenal and Oxidative Activity Induced by Intense Work Stress. J Med Food. 2018; 21:104–112.
13. Kim JY, Park JY, Kang HJ, Kim OY, Lee JH. Beneficial effects of Korean red ginseng on lymphocyte DNA damage, antioxidant enzyme activity, and LDL oxidation in healthy participants: a randomized, double-blind, placebocontrolled trial. Nutr J. 2012; 11: 47.
14. Mariage PA, Hovhannisyan A, PanossianAG. Efficacy of Panax ginseng Meyer herbal preparation HRG80 in preventing and mitigating stress-induced failure of cognitive functions in healthy subjects: A pilot, randomized, doubleblind, placebo-controlled crossover trial. Pharmaceuticals 2020; 13: 57.
15. Dimpfel W. Mariage PA, Panossian A. Effects of Red and white ginseng Preparations on Electrical Activity of the Brain in Elderly Subjects: A Randomized, Double-Blind, Placebo-Controlled, Three-Armed Cross-Over Study. Pharmaceuticals 2021; 14: 182.
16. Panossian A, Abdelfatah S, Efferth T. Network Pharmacology of Ginseng (Part II): The Differential Effects of Red Ginseng and Ginsenoside Rg5 in Cancer and Heart Diseases as Determined by Transcriptomics. Pharmaceuticals (Basel). 2021; 14: 1010.
17. Choi SY, Kim KJ, Song JH, Lee BY. Ginsenoside Rg5 prevents apoptosis by modulating heme-oxygenase-1/nuclear factor E2-related factor 2 signaling and alters the expression of cognitive impairment-associated genes in thermal stress-exposed HT22 cells. J Ginseng Res. 2018; 42: 225-228.
18. Xu D, Wang C, Zhao W, Gao S, Cui Z. Antidepressant-like effects of ginsenoside Rg5 in mice: Involving of hippocampus BDNF signaling pathway. Neurosci Lett. 2017; 645: 97-105.
19. Elshafay A, Tinh NX, Salman S, Shaheen YS, Othman EB, Elhady MT, et.al. Ginsenoside Rk1 bioactivity: a systematic review. Peer J. 2017; 5: e3993.
20. Pan W, Xue B, Yang C, Miao L, Zhou L, Chen Q, et al. Biopharmaceutical characters and bioavailability improving strategies of ginsenosides. Fitoterapia. 2018; 129: 272-282.
21. Yoo S, Park BI, Kim DH, Lee S, Lee SH, Shim WS, et al. Ginsenoside Absorption Rate and Extent Enhancement of Black Ginseng (CJ EnerG) over Red Ginseng in Healthy Adults. Pharmaceutics. 2021; 13: 487.
22. Ma C, Lin Q, Xue Y, Ju Z, Deng G, Liu W, et al. Pharmacokinetic studies of ginsenosides Rk1 and Rg5 in rats by UFLC-MS/MS. Biomed Chromatogr. 2021; 35: e5108.
23. Ginosyan A, Prazyan A, Davinyan A, Hovhannisyan A. Effect of γ -Cyclodextrin on the Dissolution of Ginsenosides Rg5 and Rk1 from Red Ginseng Chewable Tablets. Glob J Pharmaceu Sci. 2022; 9: 555766.
24. Montgomery PG, Hopkins WG. The effects of game and training loads on perceptual responses of muscle soreness in Australian football. Int J Sports Physiol Perform. 2013; 8: 312-318.
25. Tavares F, Healey P, Smith TB, Driller M. Short-term effect of training and competition on muscle soreness and neuromuscular performance in elite rugby athletes. Journal of Australian Strength & Conditioning. 2018; 26: 11- 17, 2018.