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Biomarkers of tissue injury in high-intensity interval running: a systematic

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DOI: 10.33233/rbfex.v20i4.4752

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 How to cite: Sales TD, Mello DB, Romão WS, Nunes RAM, Neves EB, Castro JBP et al. Biomarkers of tissue injury in high-intensity
interval running: a systematic review. Rev Bras Fisiol Exerc 2021;20(4):490-502. doi: 10.33233/rbfex.v20i4.4752 490

RBFEx Revista Brasileira de

ISSN Online: 2675-1372
Fisiologia do Exercício
Systematic Review

Biomarkers of tissue injury in high-intensity interval

running: a systematic review

Biomarcadores de lesão tecidual em corrida intervalada de alta intensidade:

uma revisão sistemática

Thiago Dias Sales1,2 , Danielli Braga de Mello3 , Wagner Siqueira Romão1,3 , Rodolfo de Alkmim
Moreira Nunes1 , Eduardo Borba Neves2 , Juliana Brandão Pinto de Castro1 ,
Rodrigo Gomes de Souza Vale1,4
1. Universidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ, Brazil
2. Comissão de Desportos do Exército, Rio de Janeiro, RJ, Brazil
3. Escola de Educação Física do Exército, RJ, Brazil
4. Universidade Estácio de Sá, Cabo Frio, RJ, Brazil

ABSTRACT
Introduction: The improvement of aerobic and anaerobic capacity in athletes of different sports is related
to high-intensity exercise performance, which causes cellular microlesions and leads to an inflammatory
process necessary for muscle adaptation. Biochemical markers, such as creatine kinase (CK) and lactate
dehydrogenase (LDH), have been used to measure muscle and inflammatory damage to identify the phy-
siological response and improving sports performance. Objective: To describe the changes in the CK and
LDH biomarkers after high intensity interval running. Methods: It was conducted a systematic review
following the PRISMA guidelines and registered on PROSPERO (CRD42020201678), with a literature sear-
ch, in February 2021, in the Medline, Lilacs, Scopus, SPORTDiscus, CINAHL, Web of Science, ScienceDirect,
Cochrane, and Scielo databases. We used the descriptors “HIIT”, “L-Lactate Dehydrogenase”, “Creatine Ki-
nase” and their synonyms, available in the Descritores em Ciências da Saúde (DeCS) and Medical Subject
Headings (MeSH). Results: From the 80 studies found, 6 met the inclusion criteria. Of these, four studies
showed significant increases in CK and LDH simultaneously, while one study observed a significant in-
crease only in CK and the other study only in LDH. The increases in biomarkers occurred at different mag-
nitudes. The studies’ protocols and the sample characteristics showed high heterogeneity. Conclusion:
High-intensity interval running can acutely elevate CK and LDL levels, making them excellent markers for
injury risk and exercise load dosing.

Keywords: high-intensity interval training; creatine kinase; lactate dehydrogenase.

RESUMO
Introdução: A melhora da capacidade aeróbia e anaeróbia em atletas de diferentes modalidades esportivas
está relacionada à realização de exercícios de alta intensidade, que causam microlesões celulares e levam
a um processo inflamatório necessário para adaptação muscular. Marcadores bioquímicos, como creatina
quinase (CK) e lactato desidrogenase (LDH) vêm sendo utilizados para a mensuração de danos musculares
e inflamatórios a fim de identificar a resposta fisiológica e auxiliar na melhora do desempenho esportivo.
Objetivo: Descrever as alterações nos biomarcadores CK e LDH após a execução de corrida intervalada em
alta intensidade. Métodos: Foi realizada uma revisão sistemática, seguindo as recomendações do PRISMA
e registrada na PROSPERO (CRD42020201678), com uma busca na literatura em fevereiro de 2021, nas bases
Medline, Lilacs, Scopus, SPORTDiscus, CINAHL, Web of Science, ScienceDirect, Cochrane e Scielo, utilizan-
do os descritores “HIIT”, “L-Lactate Dehydrogenase”, “Creatine Kinase” e seus sinônimos, disponíveis nos
Descritores em Ciências da Saúde (DeCS) e Medical Subject Headings (MeSH). Resultados: Dos 80 estudos
encontrados inicialmente, 6 atenderam aos critérios de inclusão. Destes, quatro estudos apresentaram au-
mento significativos de CK e LDH simultaneamente, enquanto 1 estudo observou aumento significativo
apenas de CK e o outro estudo apenas de LDH. Os aumentos nos biomarcadores ocorreram em magnitudes
diferentes. Os protocolos dos estudos e as características da amostra mostraram alta heterogeneidade.
Conclusão: A corrida intervalada de alta intensidade pode elevar os níveis CK e LDL de forma aguda, o que
torna os mesmos excelentes marcadores para o risco de lesão e dosagem das cargas do exercício.

Palavras-chave: treinamento intervalado de alta intensidade; creatina quinase; lactato desidrogenase.

Received: May 4, 2021; Accepted: July 12, 2021.

Correspondence: Thiago Dias Sales, Comissão de Desportos do Exército, Almirante Floriano Peixoto, s/n Urca
22291-090 Rio de Janeiro RJ. [email protected]
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Rev Bras Fisiol Exerc 2021;20(4):490-502

Introduction

High-intensity interval training (HIIT) is a widely used and effective training

method in many sports, including endurance and sprint/power events [1]. According
to different combinations of work intensity and session length, HIIT uses different
work interval protocols, including long interval (2-4 min of work/session at sub-
maximal intensity, LI-HIIT), short interval (< 45 s of work/session at submaximal
intensity, SI-HIIT), sprint interval (> 20-30 s of work/session close to maximum in-
tensity, SIT), and repeated sprint exercises (≤ 10 s of work/session close to maximum
intensity, RST). When the number of repetitions is increased, HIIT protocols can be
implemented with high (16 min work) or low (4 min work) session volume (HV-HIIT
or LV-HIIT) [2].
HIIT requires an integration of several physiological systems. The contribu-
tions of ATP-phosphocreatine (PCr) and the glycolytic metabolic pathway are ne-
cessary to achieve high exercise intensity, while an oxidative metabolic pathway is
predominant to maintain high exercise intensity as long as possible [3].
High-intensity exercises have benefits for athletes of different modalities [4]
and are related to a series of aerobic and anaerobic adaptations, such as the increa-
se in the dimensions of mitochondria, greater tolerance to blood pH, and increased
anaerobic capacity [5]. However, strenuous, high-intensity exercise can have unfavo-
rable effects when the workload is not controlled [6], which can cause severe dama-
ge to muscle tissue. Some enzymes are used as indicators of tissue damage. Among
these enzymes, creatine kinase (CK) and lactate dehydrogenase (LDH) are capable
of stimulating inflammation and muscle damage because of the physical stimulus
suffered by the body [7].
CK is an intramuscular enzyme that accelerates the resynthesis of ATP and its
increases are noticed in blood dosages after strenuous activities [8]. Generally, the
peak concentration occurs between 24 and 48 hours after exercise and returns to ba-
seline values between 48 and 120 hours, depending on the peak magnitude [9].
LDH is an enzyme that is in the cytoplasm of most cells and is responsible for
catalyzing the reaction that results in the conversion of pyruvate to lactate [10]. Like
CK, LDH is associated with muscle injuries [11].
The time of detection of CK in the blood is dependent on the level of training,
type, intensity, and duration of the exercise. CK values vary widely between indivi-
duals and may change according to sex, age, amount of muscle mass, race, level of
training, and climatic condition. Likewise, LDH has post-exercise variations and can
also change with the training level of the individual [12].
The understanding of the dynamics of expression of these biochemical
markers and its functional criteria can help in the training load adjustments, and
thereafter to adaptations in the athletes’ organism facing this type of exercise [13].
Thus, studies that investigate the acute effects of physical exercise on inflammatory
markers, usually done with blood collection before and immediately after physical
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Rev Bras Fisiol Exerc 2021;20(4):490-502

activity, are important for the relationship between training and performance [14].
Therefore, the present study aimed to describe the changes in CK and LDH
biomarkers after high-intensity interval running.

Methods

Protocol and registration

This systematic review it was conducted according to the Preferred Repor-
ting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations
[15] and registered in the International Prospective Register of Systematic Reviews
(PROSPERO) as number CRD42020201678.

Inclusion criteria
We included studies that met the following inclusion criteria [16]: Popula-
tion: running practitioners; Exposure of interest (independent variable): high-inten-
sity interval running; Outcome (dependent variable): biomarkers of tissue damage
CK and LDH in individuals of both sexes. We excluded studies of systematic reviews,
meta-analyses, case studies, and studies with a publication date before the year 2011,
considering a systematic review published on this issue in 2012 [17].

Search strategy
A systematic literature search was conducted in February 2021, without a lan-
guage filter, in the databases National Library of Medicine (Medline), Lilacs, Scopus,
SPORTDiscus, Cumulative Index to Nursing and Allied Health Literature (CINAHL),
Web of Science, ScienceDirect, Cochrane, and Scielo. We used the descriptors “HIIT”,
“L-Lactate Dehydrogenase”, “Creatine Kinase” and their synonyms, available in Des-
critores em Ciências da Saúde (DeCS) and Medical Subject Headings (MeSH). The
following search phrase was obtained using the Boolean operators “AND” betwe-
en descriptors and “OR” between synonyms: (“High Intensity Interval Training” OR
“High-Intensity Interval Trainings” OR “Interval Training, High-Intensity” OR “In-
terval Trainings, High-Intensity” OR “Training, High-Intensity Interval” OR “Trainin-
gs, High-Intensity Interval” OR “High-Intensity Intermittent Exercise” OR “Exercise,
High-Intensity Intermittent” OR “Exercises, High-Intensity Intermittent” OR “High-
-Intensity Intermittent Exercises” OR “Sprint Interval Training” OR “Sprint Interval
Trainings”) AND (“Creatine kinase” OR “Kinase, Creatine” OR “ATP Creatine Phos-
photransferase” OR “Creatine Phosphotransferase, ATP” OR “Phosphotransferase,
ATP Creatine” OR “Creatine Phosphokinase” OR “Phosphokinase, Creatine” OR “ADP
Phosphocreatine Phosphotransferase” OR “Phosphocreatine Phosphotransferase,
ADP” OR “Phosphotransferase, ADP Phosphocreatine” OR “Macro-Creatine Kinase”
OR “Macro Creatine Kinase”) AND (“L-Lactate Dehydrogenase” OR “Dehydrogenase,
L-Lactate” OR “L Lactate Dehydrogenase” OR “Lactate Dehydrogenase” OR “Dehy-
drogenase, Lactate”).
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Rev Bras Fisiol Exerc 2021;20(4):490-502

Additionally, references of the selected studies and other sources were explo-
red to maximize the search. Two independent evaluators selected the studies. A third
researcher resolved the disagreements between the evaluators. This procedure was
performed in all phases of the present study.

Data collection process

We extracted the following data from the studies: profile of participants,
sex, age, height, total body mass (TBM), body fat percentage (BF%), body mass index
(BMI), maximum oxygen consumption (VO2max), assessment protocols, biochemical
analyzes of CK and LDH, and study results.

Methodological quality analysis

Methodological quality was assessed through the Tool for the assEssment of
Study qualiTy and reporting in EXercise (TESTEX). This tool has a 15-point scale, each
item equals 1 point. The following domains were evaluated: 1) Eligibility criteria spe-
cified; 2) Randomization specified; 3) Allocation concealment; 4) Groups similar at
baseline; 5) Blinding of evaluator; 6) Withdrawals from the study <15%; reported ad-
verse events; reported session attendance; 7) Intention-to-treat analysis; 8) Primary
and secondary between-group statistical comparisons reported; 9) Point measures
for all results; 10) Activity monitoring in control groups; 11) Relative exercise inten-
sity remained constant; 12) Exercise energy expenditure reported [18].

Risk of bias analysis

The A Cochrane Risk Of Bias Assessment Tool for Non-Randomized Studies
of Interventions (ACROBAT-NRSI) was used to assess the risk of bias of the inclu-
ded studies. This tool analyzes seven domains: 1) Bias due to confounding; 2) Bias
in selection of participants into the study; 3) Bias in measurement of interventions;
4) Bias due to departures from intended interventions; 5) Bias due to missing data;
6) Bias in measurement of outcomes; 7) Bias in selection of the reported result [19].
For each domain, the studies were classified as uninformed, low, moderate, severe, or
critical risk of bias. For a study to be classified as “low risk”, it should be classified as
low risk in all domains. A study is classified as “critical risk” if it presents a critical
risk in at least one of the seven domains of the tool.

Results

Initially, 80 articles were identified in the searched databases (Medline = 19;

Lilacs = 2; Scopus = 0; CINAHL = 31; SPORTDiscus = 0; Web of Science = 22; ScienceDi-
rect = 0; Cochrane = 6; SciELO = 0). Four studies were included manually. After using
the eligibility criteria, six studies were included in this review (Figure 1).
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Rev Bras Fisiol Exerc 2021;20(4):490-502

Figure 1 - Flow diagram of the studies included in the systematic review

The sample characteristics and protocols of the included studies are summa-
rized in Table I. The sample had a total of 84 participants, 64 male and 20 not infor-
med. Among the characteristics of the subjects, all six studies showed age, total body
mass, and height. Only Cipryan [20] did not present the BMI. Three studies showed
aerobic capacity (VO2max) [20-22]. Only Cipryan [20] and Santos et al. [23] presented
the body fat percentage (BF%). Four studies used HIIT protocols [19-22,24] and two
used tests that resemble HIIT protocols [23,25].
Table II presents the biochemical variations and the results of the included
studies. The protocols were slightly different concerning the times when data were
collected in each study and the number of collections performed. Two studies collec-
ted only pre and post-test [23,25], Aloui et al. [25] performed pre and post measure-
ments twice, each at a different time of the day (morning and afternoon). Another
three studies [21,22,24] checked CK levels in 3 periods, Farias-Junior et al. [21] and
Brandão et al. [22] in pre, 24, and 48 h, and Dorneles et al. [24] in pre, post, and 30
min. Cipryan [20] collected data in four phases: pre, post, 3, and 24h.
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Rev Bras Fisiol Exerc 2021;20(4):490-502

Table I - Sample characteristics and protocols

VO2max
Study Participants Protocol
(mL∙kg-1∙min-1)
Dorneles et al., 22 M (10 N, 12 O) NI HIIE: 10 × 60 s (85–
2016 [27] Age.: N: 26.5 ± 6.11; O: 27.41 ± 9.20 90% PMax)/75 s (50%
Height: N: 1.73 ± 0.06; O: 1.75 ± 0.04 PMax)
TBM: N: 66.07 ± 7.61; O: 98.82 ± 13.15*
BMI: N: 22.00 ± 1.63; O: 31.99 ± 3.93*
Aloui et al., 2017 111 students NI Intermittent test
[28] Age: 21.00 ± 0.48 (YYIRT) in two hours
Height: 1.81 ± 2.28 of the day (07:00 and
TBM: 72.75 ± 1.79 17:00), with rest ≥ 36
BMI: 22.15 ± 0.54 hours between tests,
in random order
Cipryan, 2017 [23] 12 M 57.2 ± 6.3 3 × 12min, effort/rest;
Age: 22.8 ± 1.7 effort at 100% VO2m-
Height: 1.84 ± 0.78 ax
, rest at 60% VO2max,
TBM: 77.0 ± 8.4 with: HIIT1: 15/15s;
BF%: 9.9 ± 4.0 HIIT2: 30/30s; HIIT3:
60/60s
Farias-Junior et 15 M 39.0 ± 4.1 HIIE: (10 × 1 min a
al., 2019 [24] Age: 28.9 ± 5.0 100% VO2max/1 min re-
Height: 1.7 ± 0.1 covery)
TBM: 87.1 ± 16.2
BMI: 29.2 ± 3.8
Santos et al., 2018 9A NI Teste Rast = 6
[26] Age: 16.5 ± 1.5 maximum sprints of
Height: 1.7 ± 0.1 35m with 10s interval
TBM: 59.2 ± 11.4 between them
BF%: 12.6 ± 4.0
BMI: 19.6 ± 2.5
Brandão et al., 15 M 51.4 ± 5.7 HIIT1: 15s effort (130%
2020 [25] Age: 28.0 ± 8.0 vVO2max)/15s passive
Height: 1.7 ± 0.1 rest, until exhaustion
TBM: 73.9 ± 17.5
BMI: 24.9 ± 4.8 HIIT2: 30s effort (130%
vVO2max)/30s passive
rest, until exhaustion
M = men; N = normal weight; O = overweight; A = athletes; Age in years; Height in meters; TBM = total
body mass (kg); BMI = body mass index (kg/m2); BF% = body fat percentage (%); min = minutes; HIIE
= high intensity interval exercise; HIIT = high intensity interval training; YYIRT = Yo-Yo intermittent
recovery test; CK = creatine kinase; LDH = lactate dehydrogenase. *difference between groups; NI =
not informed

All 6 studies, each with a different exercise protocol and time of collection,
evaluated CK. Five of these studies showed a significant increase in CK [21-25]. Only
Cipryan [20] did not observe a significant difference in this biomarker at any time.
Three studies observed a significant increase immediately after exercise [23-25]. Dor-
neles et al. [24] also found a significant increase 30 min after the test. Farias-Junior et
al. [21] and Brandão et al. [22] found changes 24 and 48 hours after the work perfor-
med, with variation at 48 hours only in the 30/30 protocol.
In the studies by Cipryan [20], Farias-Junior et al. [21], and Brandão et al. [22],
the increase in CK peaked 24 hours after exercise, while the peak occurred in 30 mi-
nutes in Dorneles et al. [24].
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As for LDH, 5 of the 6 studies [20,22-25] found a significant increase after

high-intensity interval running, and 4 studies [20,23-25] observed increases only im-
mediately after the test. Brandão et al. [22] found a significant increase in LDH only
24 h after exercise. Farias-Junior et al. [21] found no significant difference in LDH at
any time.
Farias-Junior et al. [21] and Brandão et al. [22] found an LDH peak 24 h after
the protocol was performed. Dorneles et al. [24] and Cipryan [20] observed LDH peak
immediately after exercise.

Tabela II - Biochemical variations and main results

Study Biochemical variations Results
Dorneles 3 moments (Pre, Post, and 30min) This type of exercise was
et al. CK pre (U/L) HIIE: N= 135 ± 15*; O= 188 ± 17* well tolerated and may have
[24] CK post (U/L) HIIE: N= 180 ± 25#; O= 225 ± 30# important implications for
CK 30min (U/L) HIIE: N= 185 ± 25#; O= 230 ± 30# the generation of anti-in-
flammatory effects throu-
LDH pre (U/L) HIIE: N= 238 ± 12; O= 226 ± 7 gh a low-volume session,
LDH post (U/L) HIIE: N= 270 ± 13#; O= 275 ± 9# helping to control chronic
LDH 30min (U/L) HIIE: N= 251 ± 9; O= 253 ± 9 low-grade inflammation in
obesity.
Aloui et 2 moments (pre and post); Periods (morning and after- Performance was impaired
al. [25] noon) in the morning compared
CK (U/L) pre: morning = 170.63 ± 16.01; afternoon = 222.27 to the afternoon, associa-
± 1.81 ted with an oxidative res-
CK (U/L) post: morning = 268.18 ± 27.09#; afternoon = 320 ponse of patent variation,
± 15.64*# as well as biochemical
measures.
LDH (U/L) pre: morning = 264.54 ± 24.27; afternoon =
363.18 ± 6.21
LDH (U/L) post: morning = 420.90 ± 28.61#; afternoon =
458 ± 23.30*#
Cipryan 4 moments (Pre, Post, 3h, and 24h) The results indicated that
[20] CK (μkat/L) pre: 15/15 = 3.12 ± 1.80; 30/30 = 3.54 ± 2.10; the 15/15 and 60/60 proto-
60/60 = 3.72 ± 2.11 cols can be preferred to the
CK (μkat/L) post: 15/15 = 3.81 ± 1.76; 30/30 = 4.42 ± 2.03; 30/30 protocols to maximize
60/60 = 4.61 ± 2.06 the training stimulus.
CK (μkat/L) 3h: 15/15 = 3.65 ± 1.62; 30/30 = 4.01 ± 1.97;
60/60 = 4.15 ± 2.07 LDH showed post-exercise
CK (μkat/L) 24h: 15/15 = 4.02 ± 1.97; 30/30 = 4.63 ± 2.05; changes with 90% confiden-
60/60 = 4.75 ± 2.17 ce intervals for HIIT 15/15,
30/30, 60/60.
LDH (μkat/L) pre: 15/15 = 2.38 ± 0.36; 30/30 = 2.28 ± 0.42;
60/60 = 2.35 ± 0.43
LDH (μkat/L) post: 15/15 = 2.90 ± 0.51#; 30/30 = 2.89 ± 0.60#;
60/60 = 2.96 ± 0.48#
LDH (μkat/L) 3h: 15/15 = 2.59 ± 0.40; 30/30 = 2.59 ± 0.49;
60/60 = 2.66 ± 0.47
LDH (μkat/L) 24h: 15/15 = 2.47 ± 0.39; 30/30 = 2.42 ± 0.41;
60/60 = 2.53 ± 0.53
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Table II - Continuation
Study Biochemical variations Results
Farias- 3 moments (Pre, 24h, and 48h) Inactive overweight men ex-
-Junior CK pre (U/L) HIIE: 147.3 ± 48.5 pressed displeasure during
et al. CK 24h (U/L) HIIE: 206.1 ± 76.6# the performance of HIIE,
[21] CK 48h (U/L) HIIE: 198.0 ± 76.4# particularly at the end of
the exercise session when
LDH pre (U/L) HIIE: 323.4 ± 62.0 the metabolic and perceived
LDH 24h (U/L) HIIE: 330.5 ± 60.9 exertion were greater and
LDH 48h (U/L) HIIE: 318.1 ± 43.6 self-efficacy was less than
MICE.
Santos et 2 moments (Pre and Post) The Rast Test promoted oxi-
al. [23] CK (U/L) pre: 278.1 ± 78.64; post: 983.62 ± 339.49# dative stress and muscle
damage, with a significant
LDH (U/L) pre: 326.0 ± 72.65; post: 758.72 ± 135.09# increase in muscle damage
markers (LDH and CK) in
young athletes.
Brandão 3 moments (Pre, 24h, and 48h) The performance values
et al. CK (U/L) pre: 15/15 = 210 ± 170; 30/30 = 220 ± 170 were similar in the H15 and
[22] CK (U/L) 24h: 15/15 = 370 ± 180*; 30/30 = 340 ± 160* H30 protocols. The diffe-
CK (U/L) 48h: 15/15 = 310 ± 230; 30/30 = 230 ± 140# rence between the relative
changes (1%) was greater for
LDH (U/L) pre: 15/15 = 200 ± 60; 30/30 = 190 ± 70 H15 in relation to H30 in the
LDH (U/L) 24h: 15/15 = 270 ± 80*; 30/30 = 250 ± 60* activity of the CK enzyme, an
LDH (U/L) 48h: 15/15 = 240 ± 60; 30/30 = 230 ± 50 important finding, since H15
had a similar performance in
relation to H30.
H = men; N = normal weight; O = overweight; A = athletes; CK = creatine kinase; LDH = lactate dehy-
drogenase; HIIE = high intensity interval exercise; HIIT = high intensity interval training; MICE =
moderate intensity continuous exercise; NI = not informed. *difference between groups; #difference
between moments

Table III presents the assessment of methodological quality, using the TES-
TEX tool. The main methodological flaws observed were related to the reported ran-
domization criteria and the blinding of the evaluators. These items were not scored
in any of the included studies since all studies had a quasi-experimental design.

Table III - Methodological quality of selected studies

Study 1 2 3 4 5 6 7 8 9 10 11 12 Total
Dorneles et al. [24] 1 0 0 0 0 3 1 2 1 1 1 1 11
Aloui et al. [22] 1 0 1 1 0 2 0 2 1 1 1 1 11
Cipryan [20] 0 0 0 1 0 2 0 2 1 0 1 1 8
Farias-Junior et al. [21] 1 1 1 1 0 3 1 2 1 1 1 1 14
Santos et al. [23] 1 0 0 0 0 2 0 2 1 1 1 1 9
Brandão et al. [22] 1 0 0 1 0 3 1 2 1 1 1 1 12
Total 8 0 4 7 0 33 5 28 14 8 14 14 mean 10,83
1 - Eligibility criteria specified; 2 - Randomization specified; 3 - Allocation concealment; 4 - Groups
similar at baseline; 5 - Blinding of evaluator; 6 - Withdrawals from the study < 15%; reported adverse
events; reported session attendance; 7 - Intention-to-treat analysis; 8 - Primary and secondary betwe-
en-group statistical comparisons reported; 9- Point measures for all results; 10 - Activity monitoring
in control groups; 11 - Relative exercise intensity remained constant; 12 - Exercise energy expenditure
reported
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Rev Bras Fisiol Exerc 2021;20(4):490-502

The main sources of bias in the present review were related to the measure-
ment of results and the selection of the reported result, because, according to the
ACROBAT-NRSI tool, the possibility of influencing the measurement of results due
to the non-blinding of the researchers is sufficient for the risk of bias is at least mo-
derate [19]. Thus, all included studies had a moderate risk of bias (Table IV).

Table IV - Risk of bias analysis of selected studies

Study 1 2 3 4 5 6 7 Risk
Dorneles et al. [24] L L L L L M M M
Aloui et al. [25] L L L L NI M M M
Cipryan [20] L M L L NI M M M
Farias-Junior et al. [21] L M L L L M M M
Santos et al. [23] L M L L L M M M
Brandão et al. [22] L L L L L M M M
1 - Bias due to confounding; 2 - Bias in selection of participants into the study; 3 - Bias in measurement
of interventions; 4 - Bias due to departures from intended interventions; 5 - Bias due to missing data;
6 - Bias in measurement of outcomes; 7 - Bias in selection of the reported result. L = low; M = moderate;
NI = not informed

Discussion

The present systematic review described the changes in the tissue injury bio-
markers (CK and LDH) after high-intensity interval running. The heterogeneity of
the methods and the characteristics of the samples of the included studies indicate
that the results found must be analyzed with caution. It was observed that, despite
the different protocols used, four of the six studies found a significant increase in CK
and LDH concentrations simultaneously [22-25]. However, the extent of these chan-
ges has not always occurred to the same magnitude.
The CK results were consistent in terms of the behavior observed immediately
after exercise, since five of the six studies showed an increase in CK levels [21-25]. The
cause of this increase is pointed to the damage caused to the muscle fiber structures
[26], more specifically to the sarcolemma membrane [27].
Furthermore, the changes depend on the protocol used, intensity, volume,
frequency, time of post-test collection, number, and physical conditioning of the
samples [28]. Moghadam-Kia et al. [29] mention that the type and duration of exerci-
se are the main factors for variation in CK levels. Strenuous exercises are responsible
for the highest elevation. Gender and race also have a significant contribution to the
variation of this biomarker, with CK levels higher in men than women and in black
people when compared to white people [29,30].
The increase in CK, observed in studies whose protocols involved running,
can be explained by the mechanism of the stretching-shortening cycle, which gene-
rates muscle microlesion in the lower limbs during running [31]. Another explana-
tion for the increase in CK levels may be the characteristic of the exercises to generate
tension, which promotes muscle damage and results in the increase of this enzy-
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me [32]. Besides, the eccentric muscle action implies greater muscle damage [27,30].
Such changes may take a week to return to baseline levels [33].
The CK peak occurs 24 to 96 hours after the onset of activity [27,34,35], which
was observed in three [20-22] of the six included studies, although the Cipryan’s stu-
dy [20] presented the interval 90% confidence, which requires careful analysis of this
result. However, as in Cerqueira et al. [36], another three studies did not show such a
pattern or did not collect at that time [23-25]. At rest, CK levels tend to be higher in
athletes when compared to healthy individuals, despite after exercise, the increase in
CK levels tends to be lower in athletes [3].
Although LDH shows a difference in CK regarding metabolic adaptations to
exercise [27], a similar behavior was observed between the indicators of muscle da-
mage CK and LDH in four [22-25] of the six studies included. This finding can be
explained by the biochemical adaptation to the physical load because when CK levels
remain high, individuals also have an altered LDH [37]. As with CK, the increase of
LDH levels depends on the duration and intensity of the effort [12]. Also, van de Vy-
ver et al. [35] reported a strong correlation between VO2max and the peak values of the
biomarkers CK and LDH.
According to Brancaccio et al. [34], LDH activity seems to be correlated with
the individuals’ training levels and sports performance. A short interval training can
increase the activity of glycolytic and oxidative muscle enzymes, resulting in a slight
increase in LDH. This was found in the study by Klapcińska et al. [37], who verified
that the lack of adaptation to training in untrained people can be observed by the
higher concentration of LDH after a single stimulus. However, the levels of this bio-
marker showed to be higher in athletes at rest [36,37].
Callegari et al. [31] reported that aerobic exercise, such as running, can cause
an increase in LDH from 12 to 24 hours. Bessa et al. [38] observed a significant increa-
se between 3 and 6 hours after intense exercise. As in the previous study [38], another
study showed that the increase in LDH levels, in moderate to intense physical activi-
ty, begins to be noticed from 1 to 3 hours after the end of the exercise, with a peak of
3 to 6 hours and returning to baseline levels in 24h [39].
Such statements confirm the results presented by most of the studies inclu-
ded in the present review and contradict Delsmann et al. [40], who observed that the
increase in LDH can occur for up to 14 days after exercise, with the peak between the
third and fourth days after stimulation. Concomitantly, Shin et al. [41] report that CK
and LDH can help as markers for assessing the degree of muscle damage since such
enzymes demonstrate skeletal muscle deficit, muscle damage, and cell necrosis.
The present systematic review has some limitations. The different moments
of evaluation of the biomarkers, as well as the difference in the HIIT protocols used in
the included studies, hinder a comparative analysis with greater depth. The studies
included in this systematic review were related to healthy individuals. Thus, it is not
possible to declare whether the same results would be valid for unhealthy popula-
tions. Moreover, all studies conducted the experiment with a small number of parti-
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Rev Bras Fisiol Exerc 2021;20(4):490-502

cipants, which may have contributed to greater individual variability. Therefore, the
data evaluated needs to be observed with caution.

Conclusion

Based on the observed evidence, the present study pointed out that the CK
and LDH biomarkers have high levels with high-intensity interval running. It was
found that the measurement of these biomarkers can be a strategic tool for assessing
the exercise load, accumulation of exercise, and intensity of physical activity, risks,
and injury degree.
More research is needed to examine the impact of other types of exercise on
inflammation. It is important that future studies carefully evaluate the intensity
associated with the type and duration of exercise since these aspects influence in-
flammation during intense exercise.

Conflict of interest
The authors declare no conflict of interest with relevant potential.

Financing source
Supported by DECEx/Brazilian Army, EsEFEx, IPCFEx, CDE and CCFEx.

Author’s contributions
Conception and design of the research: Sales TD, Mello DB, Romão WS, Castro JBP, Nunes RAM, Neves
EB, Vale RGS. Data collection: Sales: TD, Mello DB, Romão WS, Castro JBP, Vale RGS. Data analysis and
interpretation: Sales TD, Mello DB, Castro JBP, Nunes RAM, Neves EB, Vale RGS. Writing of the manus-
cript: Sales TD, Mello DB, Romão WS, Castro JBP, Vale RGS. Critical review of the manuscript regarding
important intellectual content: Sales TD, Mello DB, Romão WS, Castro JBP, Nunes RAM, Neves EB, Vale
RGS.

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