• The Renaissance Surgeon

Can CBD Enhance Recovery?

Can cannabidiol (CBD) help you perform better or recover faster? The evidence isn’t there yet to say definitively, but research is accumulating, with some promising avenues of investigation. CBD is a nonintoxicating compound that can be extracted from the cannibis sativa plant.


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(Tetrahydrocannabinol, THC, is the intoxicating compound derived from the same plant, used recreationally and medicinally, but with no known performance enhancing properties.) As with many things in sports medicine (hello, platelet rich plasma), widespread adoption of CBD has preceded solid clinical evidence of effectiveness. Add to this the fact that as a nutritional supplement, these products do not undergo the same testing and regulation by the Food and Drug Administration (FDA) as required for medications and you have murky waters indeed.


Survey data indicates that many athletes already utilize CBD for various reasons. 25% of university level athletes report using CBD (Rojas-Valverde). In 2018, the World Anti-Doping Agency removed CBD from its list of banned substances, though the legality of CBD still varies with geography.


CBD pharmacology is complex. It has a variety of mechanisms of action throughout the body, including inhibiting the body from removing endocannabinoids, chemicals that the body naturally produces as part of the endocannabinoid system, which globally participates in homeostasis or maintaining a steady state in the body.


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The majority of research on CBD has not been done on humans (it is ‘pre-clinical’), but shows that CBD has the following properties (Rojas-Valverde):


  • Anti-inflammatory

  • Pain-relieving

  • Anxiety-relieving

  • Neuroprotective (for example, in the brain after concussion)

  • Influences the sleep-wake cycle


This has earned it a role in my starting line-up for postoperative pain control, but what about performance? There’s even less research in sports performance and recovery. I have not found evidence that CBD enhances performance, other than largely theoretical statements that if CBD can reduce anxiety, it may have a role in preventing sports performance anxiety. I think the recovery side is more promising, and I’m eager to see what additional evidence is produced in that arena.


Existing evidence indicates that it may help reduce muscle inflammation and soreness, more so for trained weightlifters than for untrained. An experiment performed at the University of South Carolina randomly assigned trained weightlifters to receive either 1) a solution containing CBD plus medium chain triglycerides (MCT), 2) MCT oil alone or 3) no intervention. The doses were administered immediately after completing four sets of 10 barbell back squats at 80% of single repetition maximum (1RM). (The athletes’ 1 RM was determined a few days before.) They found that CBD decreased soreness and increased rate of recovery. However, the CBD group lifted significantly more weight and were significantly more sore initially.


I’m not sure exactly what to make of this study. There was no placebo in the non-intervention group, though MCT was administered both alone and with CBD, which may help tease out the effects of CBD. Additionally, it’s hard to compare soreness between athletes that squatted 226 pounds and got CBD versus 145 pounds and got no CBD. My conclusion: This study is inconclusive. CBD might reduce soreness, but we can’t say for sure.


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An experiment by German sports medicine researchers in Cologne and Dusseldorf randomly assigned trained weight lifters to receive CBD or placebo after performing 12 barbell back squats at 70% of 1RM as well as drop jumps from a 45 cm box, landing in a deep squat. They measured blood levels of creatine kinase (CK) and myoglobin (myo), markers of muscle damage, at 24, 48 and 72 hours. They also re-tested performance at those time points. They found that at 72 hours (but not earlier), those in the CBD group had lower CK, lower myo and higher back squat performance. The differences were small but significant. The CBD group squatted an average of 261 pounds initially, then 264 pounds at 72 hours, a performance increase. The placebo group squatted 260 pounds initially, then 255 pounds at 72 hours, a slight performance decrease. Gaining 3 pounds versus losing 5 pounds on your squat is not earth-shattering, but I find this study much more exciting in that it has a rigorous, placebo-controlled protocol, backed by laboratory analysis. When differences are that small though, you have to question whether it’s clinically significant or whether it is just the random effect of sampling at various time points.


I recently spoke with Thomas Trojian, MD, a sports medicine expert who has reviewed the potential for CBD therapy in sports in his recent article in Current Sports Medicine Reports. He noted that there is “some justification” for its use as neuroprotection after concussion, but stops short of recommending it. His view: it is unlikely to harm, and “might” be beneficial. (Another challenge in the post-concussion arena is that there is no benefit to starting metabolic neuroprotective interventions such as CBD outside of a 24 hour window.) As far as its role in recovery, he acknowledged the theoretical benefit, and also would welcome more studies along the lines of the German study discussed above. One concern, however, is that CBD (similar to NSAIDs), through its anti-inflammatory effects, might delay recovery from muscle damage. The German researchers found small differences in markers of muscle damage in their study, but more research with robust muscle marker data is needed before we can start recommending athletes take CBD after every lifting session.


 

If you’re considering using CBD, please be careful about where you get it. A lot of CBD products have been found to contain significant amounts of THC when tested by third parties. Many had little or no CBD. You need to make sure you know what you’re ingesting. The Mayo Clinic put out an article that reviews a lot of the issues surrounding CBD. They note that doses of 300 mg have been used safely up to six months. (Both the research studies discussed above used doses less than 100 mg.) But CBD can interact with medications, such as anti-seizure medications and the blood thinner warfarin, and if you take any medications at all, you should check for interactions and check with your prescriber. The authors of the Mayo report provide a checklist to make sure you’re sourcing your CBD from a reputable source:


Does it meet the following quality standards?

a. Current Good Manufacturing Practices (CGMP) certification from the US Food and Drug Administration

b. European Union (EU), Australian (AUS), or Canadian (CFIA) organic certification

c. National Science Foundation (NSF) International certification

Does the company have an independent adverse event reporting program?

Is the product certified organic or ecofarmed?

Have their products been laboratory tested by batch to confirm tetrahydrocannabinol levels <0.3% and no pesticides or heavy metals?