Effects of Korean Herbal Medicine on the Recovery of Exercise-Induced Fatigue and Exercise Performance: Narrative Review of animal experiments in Korea

Seungyong Lee; Byung-Cheul Shin; Changwon Kho; Lee, Seungyong; Shin, Byung-Cheul; Kho, Changwon

doi:10.13048/jkm.24069

JKM > Volume 45(4); 2024 > Article

Lee, Shin, and Kho: Effects of Korean Herbal Medicine on the Recovery of Exercise-Induced Fatigue and Exercise Performance: Narrative Review of animal experiments in Korea

Review Article

The Journal of Korean Medicine 2024; 45(4): 244-263.

Published online: December 1, 2024

DOI: https://doi.org/10.13048/jkm.24069

Effects of Korean Herbal Medicine on the Recovery of Exercise-Induced Fatigue and Exercise Performance: Narrative Review of animal experiments in Korea

Seungyong Lee¹

, Byung-Cheul Shin¹^{, 2}

, Changwon Kho¹^{, 3}^{, *}

¹School of Korean Medicine, Pusan National University, Yangsan, Republic of Korea

²Department of Korean Medicine Rehabilitation, Korean Medicine Hospital Pusan National University, Yangsan, Republic of Korea

³Division of Applied Medicine, School of Korean Medicine, Pusan National University, Yangsan, Republic of Korea

Correspondence to: Changwon Kho, Division of Applied Medicine, School of Korean Medicine, Pusan National University, Yangsan, 50612, Republic of Korea (C. Kho), E-mail: khochangwon@pusan.ac.kr (C. Kho)

Received May 2, 2024 Revised July 10, 2024 Accepted November 12, 2024

Abstract

Objectives

Many athletes utilize herbal medicines to enhance their performance. However, studies comprehensively analyzing the impact of Korean herbal medicine (KHM) on exercise performance enhancement are lacking. This study aimed to explore the basis of animal experimental studies on KHM in improving athletic ability and anti-fatigue effects and derive an evidence-based relationship between exercise and KHM intake.

Methods

We conducted a systematic search of articles within the Oriental Medicine Advanced Searching Integrated System (OASIS) database. Animal-controlled experimental studies exploring exercise performance and fatigue recovery effects after administering KHM were selected and analyzed. Data were categorized based on exercise methods and outcomes, examining the effects of different KHM.

Results

Through experimental research analysis, the effect of KHM on exercise was focused on muscle strength, cardiopulmonary endurance, and anti-fatigue, among basic components of exercise ability. For example, when administering Allii tuberosi semen and Ginseng Radix to an animal model, remarkable muscle strength enhancements were observed. Administration of Allii tuberosi semen, Ginseng Radix, Cervi Parvum Cornu, Ssanghwa-tang, Kyeongok-go, Yukmijihwang-tang, Jakyak-gamcho-tang, and Sogunjung-tang resulted in cardiovascular endurance improvements. Furthermore, Cervi Parvum Cornu, Ganoderma, Ssanghwa-tang, Dangguibohyul-tang, Ssangbohwan, Bojungikgi-tang, Bojungikgi-tang, Jakyak Gamcho-tang, and Sogunjung-tang were effective for fatigue recovery after exercise. We examined the impact of KHM on muscle strength, cardiovascular endurance, and fatigue recovery during exercise.

Conclusions

This systematic review of animal-controlled experimental studies establishes a robust evidence-based relationship between KHM consumption and enhanced athletic abilities, offering valuable insights for athletes exploring natural strategies for performance enhancement.

Keywords: Korean herbal medicine, muscle strength, cardiopulmonary endurance, anti-fatigue

Introduction

In the contemporary landscape, athletes frequently use health supplements and drugs to enhance performance, consequently leading to drug misuse and illegal substance consumption in various fields, including sports. Korean herbal medicine (KHM) emerges as a promising alternative to replace performance-enhancing doping, circumventing side effects and legality concerns. In contrast to doping, which involves the use of specific substances to enhance performance, consuming herbal medicines yields substantial effects on performance enhancement without the accompanying risks and side effects associated with doping. As a result, investigations on the selection and utilization of herbal medicine for optimizing exercise performance are a burgeoning area of research in Korea. Notably, KHM has gained popularity among athletes, with 53.5% of males and 62.2% of females using it for exercise recovery and other purposes.¹⁾

KHM, originating from China, has been an integral part of Korean health practices for approximately 5,000 years. While KHM has been employed to address various health concerns, including gastrointestinal, heart, gynecological, and musculoskeletal diseases, research on its impact on exercise remains limited. Studies by Chen et al.²⁾ and Selami et al.³⁾ have delved into the impact of herbal medicine on sports and exercise; however, their emphasis on pharmacological efficacy leaves a gap in conclusive evidence regarding its actual effectiveness. Considering the widespread use of KHM by athletes for exercise support, a comprehensive systematic review is crucial to lay the groundwork for future clinical studies.

Therefore, in this study, we aimed to systematically analyze controlled experimental studies that tested the effects of KHM on fatigue recovery and exercise performance improvement by comparing and summarizing changes in exercise ability and anti-fatigue effects based on actual value that represents the fundamental elements of athletic ability.

Materials and Methods

1. Search strategy and terms

We searched relevant research articles published in Korea until January 2024 using the Oriental Medicine Advanced Searching Integrated System (OASIS), an electronic database. The search employed a combination of keywords such as exercise, muscle strength, endurance, fatigue, and Korean herbal medicine. Studies investigating the effects of KHM on exercise performance and anti-fatigue capabilities were selected from the search output by the abstract. The complete search strategies in this study are presented in Figure 1.

2. Criteria for inclusion and exclusion

Inclusion criteria encompassed controlled animal studies that investigated the impact of KHM on exercise performance and fatigue. Exclusion criteria were review studies, studies with inadequate data, studies lacking statistically significant outcomes, those without control groups, those using inappropriate plant parts for medicinal purposes, and studies not linked to KHM, exercise performance, or anti-fatigue effects.

3. Outcomes measures

This study employed easily quantifiable indicators, such as muscle strength, cardiovascular endurance, and anti-fatigue levels, to strategically assess the influence of KHM on exercise. Utilizing a robust analytical strategy, the comparison of these indicators effectively demonstrated and clarified the effectiveness of KHM in enhancing exercise performance. The results identified specific KHM formulations as effective based on their impact on muscle strength, cardiorespiratory endurance, and anti-fatigue properties when consumed.

4. Data extraction

Figure 1: Flow diagram showing search strategy and obtained literature.

Results

1. The selection of eligible studies

The comprehensive search yielded a total of 166 articles; 158 were retained after excluding 8 duplicate articles. Among these, 55 studies not pertinent to herbal medicines were excluded. Additionally, 65 studies were excluded, comprising studies utilizing substances other than KHM, 12 studies unrelated to muscle-related exercises, 50 studies unrelated to exercise-induced fatigue, 1 study unrelated to exercise, and 2 studies unrelated to exercise-related energy metabolism. Subsequently, 23 articles were excluded based on criteria such as human-based research, having insufficient sample sizes (fewer than four samples per experimental group), lacking statistically significant outcomes, absence of control groups, missing experimental values, or utilizing substances not aligned with Korean medicine practices. Finally, 14 articles that conducted controlled experimental studies focusing on exercise recovery and effectiveness following KHM administration were selected and analyzed. This selection procedure is summarized in Figure 1.

2. Modern Korean herbal medicine research related to exercise

1) Effects on muscle strength

In KHM, Allii tuberosi semen is known for its warm, pungent, and sweet taste. It is believed to tonify the liver and kidney, fortify essence, warm the waist and knees, and address conditions including erectile dysfunction, seminal emission, urinary frequency, urinary incontinence, and sore back and knees.⁵⁾

Initial data extraction included study conditions, intervention drugs, outcomes measured, author conclusions, and other pertinent information. This information was then organized into a tabular format for subsequent analysis. The selected studies mainly analyzed basic primary motor skills for exercise, such as muscle strength, cardiovascular endurance, and anti-fatigue levels. As a predictive indicator for future motor ability, the anti-fatigue level is attracting attention for the evaluation of exercise-induced fatigue substances in the blood.⁴⁾ Therefore, these indicators were used and analyzed to evaluate the effect of KHM on exercise.

3. Data analysis

Studies were further classified and analyzed based on the intervention methods or conditions. Each medicinal substance employed in the studies was divided and evaluated in relation to exercise protocols and outcome measures. This analysis aimed to determine whether these interventions had a controlled experimental impact, shedding light on the potential of KHMs to enhance exercise outcomes and alleviate exercise-induced fatigue.

In modern medicine, Allii tuberosi semen has shown effects including enhancing male sexual function,⁶⁾ alleviating Alzheimer’s disease,⁷⁾ exerting anti-cancer properties,^8,9) and promoting hair growth.¹⁰⁾ After administering an extract of Allii tuberosi semen to mice, grip tests demonstrated a statistically significant increase in muscle strength, with the extent of improvement depending on the treatment period and concentration.^11,12) In particular, when administered at a concentration of 10 mg for 120 days, muscle strength exhibited a 2.47-fold improvement compared with the control group (control group 0.096±0.009 kg vs. treated group 0.237±0.053 kg; p<0.01).

Similarly, Morindae Radix has a slightly warm, sweet, and pungent taste. In KHM, this herb is acknowledged for its ability to enhance kidney function, alleviate conditions related to dispelling wind-dampness, and strengthen muscles and bones. Moreover, this herb is renowned for its efficacy in addressing concerns such as erectile dysfunction, premature semen discharge, infertility caused by a cold uterus, irregular menstruation, and abdominal coldness.⁵⁾ In modern medicine, Morindae Radix exhibits anti-inflammatory effects,¹³⁾ enhances sexual function in men,¹⁴⁾ provides benefits for osteoporosis,¹⁵⁾ and displays antioxidant activity.¹⁶⁾ Morindae Radix extract was orally administered to mice for 90 and 120 days, followed by a grip strength test. The results showed a statistically significant increase in muscle strength was observed at specific concentrations (90 days: control group 0.111±0.007 kg vs. 1 mg treated group 0.116±0.005 kg; p<0.01, vs. 10 mg treated group 0.143±0.007 kg; p<0.01, vs. 100 mg treated group 0.141±0.051 kg; p<0.01, 120 days: control group 0.109±0.006 kg vs. 10 mg treated group 0.133±0.018 kg; p<0.05).¹⁷⁾ However, when comparing the increase in muscle strength results, Allii tuberosi semen administered at 10 mg for 90 days showed approximately six times more improvement than Morindae Radix.

Ginseng Radix is sweet, slightly warm, and bitter and plays a vital role in tonifying the original Qi and stabilizing the mind. Ginseng Radix addresses a wide range of symptoms, such as stemming from overwork, impotence, loss of appetite, vomiting, diarrhea, persistent cough, forgetfulness, palpitations, dizziness, erectile dysfunction, frequent urination, diabetes, irregular menstruation in women, and imbalances in Qi, blood, fluid, and emotions.⁵⁾ Recent studies highlight its potential in treating obesity,¹⁸⁾ functioning as an antioxidant,¹⁹⁾ demonstrating anticancer properties,²⁰⁾ enhancing liver function,²¹⁾ and addressing concerns related to osteoporosis²²⁾ and male fertility.²³⁾ Following the oral administration of ginseng extract to mice for 30 and 60 days, a grip strength test revealed a statistically significant increase in muscle strength in certain concentration treatment groups (30 days: control group 0.103±0.004 kg vs. 1 mg treated group 0.128±0.003 kg; p<0.01, vs. 10 mg treated group 0.133±0.006 kg; p<0.01, vs. 100 mg treated group 0.152±0.007 kg; p<0.01, 60 days: control group 0.109±0.006 kg vs. 10 mg treated group 0.162±0.037 kg; p<0.05).²⁴⁾ Specifically, when comparing the enhanced muscle strength outcomes following the 30-day oral administration of 100 mg Allii tuberosi semen, the ginseng extract treatment group exhibited a 1.25-fold increase in muscle strength compared with the Allii tuberosi semen treatment group.

1) Effects on cardiorespiratory endurance

Ssanghwa-tang is used to address weakness caused by a dual deficiency of the heart and kidney.²⁵⁾ It warms and tonifies yang, making it a distinctive prescription for treating heart-kidney deficiency and weakness due to deficiency of essence, blood, and qi, and overexertion and fatigue.²⁶⁾ Recently, Ssanghwa-tang has been reported to inhibit breast cancer development, reducing malignancy and incidence of cancer cells²⁷⁾ and revealing antioxidant and anti-aging enzyme activity.²⁸⁾ Moreover, Ssangwha-tang fermented by Lactobacillus fermentum showed potential in treating osteoporosis by inhibiting osteoclast formation.²⁹⁾ Fermented fungal Ssanghwa-tang also has effects on hepatotoxic treatment and fatigue recovery.³⁰⁾ After analyzing the increase in swimming time in animal models as an indicator of improved cardiorespiratory endurance, the swimming time of mice orally administered Ssanghwa-tang concentrate increased significantly compared with the control group.³¹⁾ In particular, mice that were orally administered Ssanghwa-tang concentrate for 9 days exhibited a significant increase in swimming time (control group 261.7±16 sec vs. treated group 862.2±8.9 sec; p<0.001), approximately three times longer than the control group.³¹⁾

Yukmijihwang-tang is renowned for countering kidney yin deficiency and inadequate kidney essence.³²⁾ It can address various symptoms, such as stunted growth in children, lumbar-genu asthenia due to liver-kidney deficiency in adults, spontaneous sweating, night sweating, dizziness, seminal emission, tinnitus, bloody stool, severe thirst, abnormal urination, sore throat, and toothache.³³⁾ Recent studies have shown that Yukmijihwang-tang treats brain damage caused by brain tension,³²⁾ protects hippocampal nerve cells to improve and protect memory, and regulates the expression of genes involved in growth and degeneration.^34–36) Yukmijihwang-tang also demonstrates anti-inflammatory properties,³⁷⁾ protects against skin damage caused by photoaging,³⁸⁾ enhances fertility,³⁹⁾ and relieves conditions including prostatic hyperplasia,⁴⁰⁾ hyperlipidemia,⁴¹⁾ and constipation.⁴²⁾ In an experimental study, mice treated with Yukmijihwang-tang for 2 weeks demonstrated significantly reduced oxygen consumption (control group 26.12±1.45 mL/(kg×min) vs. treated group 19.29±0.89 mL/(kg×min); p<0.005) compared with the water placebo group.⁴³⁾

Jakyak-gamcho-tang has been used as an analgesic and sedative for sudden abdominal pain and muscle spasms in the extremities and offers anti-inflammatory, antitussive,⁴⁴⁾ and anti-anxiety effects and panic disorder relief.⁴⁵⁾ Jakyak-gamcho -tang was also reported to improve colitis and show anti-diabetes, neuroprotection, and antithrombotic effects.⁴⁶⁾ Mice administered orally with 30% ethanol extract of Jakyak gamcho-tang had an approximately 2.3-fold increase in swimming time (control group 10.8±1.46 min vs. treated group 25±2.52 min; p<0.05) compared with the control group.⁴⁶⁾

Hwangkeegunjung-tang, extracted by adding Astragali Radix to Sogunjung-tang, is used to treat spontaneous sweating induced by consumptive diseases and Qi deficiency.⁴⁷⁾ A normal mice group administered with Hwangkeegunjung-tang 1 h before exercise had decreased oxygen consumption after swimming compared with the saline control group (control group 1396.8±68.9 mL/kg^0.75/h vs. treated group 1170.3±74.9 mL/kg^0.75/h; p<0.05).⁴⁸⁾

Similar to the improvements in muscle strength, cardiorespiratory endurance increased not only when KHM was administered but also when KHM herbs were consumed. Allii Tuberosi semen and Morindae Radix extracts, which enhance muscle strength, also have effects in boosting cardiorespiratory endurance, as evidenced by significantly increased swimming times in mice groups receiving these extracts.^11,12,17) Similar to the earlier observed muscle strength increase, the swimming time (for each group administered Allii Tuberosi semen and Morindae Radix on 10 mg for 90 days showed statistically significant improvement compared with the control group control group 4.15±0.53 min vs. Allii Tuberosi semen Morindae Radix treated group 9.44±0.95 min; p<0.01, vs. treated group 8.78±0.56 min; p<0.01). Interestingly, even in enhancing cardiorespiratory endurance, the effect of 90-day 10 mg of Allii Tuberosi semen administration was approximately 1.6 times greater than that of Morindae Radix.

Similarly, the mice groups that received 30 and 60 days of Ginseng Radix extract administration exhibited significantly increased swimming times compared with the control group (30 days: control group 5.6±0.39 min vs. 1 mg treated group 7.06±0.42 min; p<0.05, vs. 10 mg treated group 7.67±0.51 min; p<0.01, vs. 100 mg treated group 8.59±0.5 min; p<0.01, 60 days: control group 5.56±0.88 min vs. 100 mg treated group 9.14±1.95 min; p<0.05).²⁴⁾ However, when comparing swimming time with the group administered the same dose of Allii Tuberosi semen for 60 days, the swimming time in the Allii Tuberosi semen-treated group increased up to 1.81 times more than that in the Ginseng Radix-treated group. This effect was also mirrored in red ginseng extract administration before exercise; the treatment group showed significantly prolonged exhaustion times during exercise compared with the control group.⁴⁹⁾

In KHM, Cervi Parvum Cornu is warm, sweet, and salty; it can invigorate kidney yang, essence, and blood and foster robust muscles and bones. It has also been reported to treat erectile dysfunction, seminal emission, infertility due to a cold uterus, mental fatigue, chills, tinnitus, dizziness, back and knee pain, muscle and bone weakness, menorrhagia, menstrual spotting, and vaginal discharge.⁵⁾ Recent studies have been reported to exert anti-osteoporosis effects,⁵⁰⁾ bone growth promotion,⁵¹⁾ anti-inflammatory properties,⁵²⁾ nerve cell regeneration,⁵³⁾ memory improvement,⁵⁴⁾ and immune enhancement.⁵⁵⁾ Mice administered with fermented Cervi Parvum Cornu and Cervi Parvum Cornu water extracts had significantly increased swimming time compared with the saline group (control group 14.11±1.81 min vs. Cervi Parvum treated group 99.83±3.8 min; p<0.001, vs. fermented Cervi Parvum Cornu treated group 100.44±4.63 min; p<0.001).⁵⁶⁾ Mice receiving 100 mg of Cervi Parvum Cornu extract had approximately a 7-fold increase in swimming time in the control group compared with the saline group.

2) Effects on anti-fatigue

Dangguibohyul-tang reinforces the Qi and blood and is effective in treating hemolytic anemia.^57,58) Other effects of Dangguibohyul-tang included inhibiting proliferation of the human colon cancer cell line, HCT116, inducing apoptosis as anticancer effects;⁵⁹⁾ promoting hair growth and preventing hair loss,⁶⁰⁾ and showing antioxidant and skin anti-inflammatory effects. Dangguibohyul-tang also affects bone formation, neovascularization, and muscle fatigue.⁶¹⁾ Studies on Angelicae Gigantis Radix, a component of Dangguibohyul-tang, have reported its anti-inflammatory, antioxidant, and protective effects against muscle fatigue.⁶¹⁾ Furthermore, studies on Astragali Radix have reported its antioxidant effects, promotion of neovascularization in ischemic injury, inhibition of lipid peroxidation, improvement of muscle fatigue, and protective effects against muscular atrophy.⁶¹⁾ After swimming, the Dangguibohyul-tang treatment rat group showed significantly reduced indicators of fatigue, such as blood lactate (control group 3.0±0.16 mmol/L vs. treated group 2.4±0.11 mmol/L; p<0.05) and lactate dehydrogenase (LDH) (control group 586.3±32.5 mU/L vs. treated group 422.0±23.8 mU/L; p<0.01) concentrations, compared with the control group. Conversely, blood creatine phosphokinase (CPK) (control group 121.8±9.5 U/L vs. treated group 83.8±9.2 U/L; p<0.05) and free fatty acid (FFA) (control group 816.1±34.8 mEq/L vs. treated group 698.5±28.5 mEq/L; p<0.05), indicators of anti-fatigue ability, showed a significant decrease in the Dangguibohyul-tang group compared with the control group.⁶²⁾

Ssangbohwan targets the lower body, gradually alleviating cold and weakness, and proves effective against tinnitus, essence and blood deficiency, and dryness-heat.⁶³⁾ In mice treated with Ssangbohwan before exercise, blood LDH (control group 586.3±32.5 mU/L vs. treated group 468.3±28.7 mU/L; p<0.05) and CPK (control group 121.8±9.5 U/L vs. treated group 91.6±9.3 U/L; p<0.05) concentrations after the swimming test were significantly lower than those in the control group.⁶²⁾

Bojungikgi-tang has been used to treat symptoms such as fever, sweating, headache, chills, Qi deficiency, speech difficulty, fatigue, pale complexion, diarrhea, prolapse, and uterine hypothyroidism.¹⁾ It has demonstrated effectiveness against various conditions, including lung tuberculosis, iron-deficiency anemia, late-onset hypogonadism, diabetes, Guillan-Barre syndrome, angina pectoris, allergic rhinitis, irritable bowel syndrome, ulcerative colitis, diarrhea, gastroptosis, and anal prolapse.⁶⁴⁾ Plasma lactic acid content (control group 62.4±3.5 mg/dL vs. treated group 49.2±3 mg/dL; p<0.05) and blood creatine phosphokinase activity (control group 773.2±52.1 U/L vs. Bojungikgi-tang treated group 495.3±104.5 U/L; p<0.05, vs. Bojungikgi -tang with Acanthopanacis Cortex treated group 502.3±113.6; p<0.05) were significantly reduced immediately after the swimming test in the mouse group treated with Bojungikgi-tang and an additional component, Acanthopanacis Cortex.⁶⁵⁾

Jakyak-gamcho-tang, known for its effect on improving cardiorespiratory endurance, has also shown anti-fatigue effects. A mice group administered 30% ethanol extract of Jakyak gamcho-tang exhibited significantly lower blood LDH (control group 1576.7±113.3 m/L vs. treated group 559.0±100.4 m/L; p<0.001) and lactate (control group 75.2±6.0 mg/dL vs. treated group 31.1±4.1 mg/dL; p<0.01) concentrations after the swimming test compared with the saline group.⁴⁶⁾

A mice experimental group that received Hwangkeegunjung-tang or Hwangkeegunjung-tang supplemented with Ginseng Radix 1 h before the swimming test had significantly lower blood lactate (control group 72.4±6.3 mg/dL vs. Hwangkeegunjung-tang treated group 54.0±5.6 mg/dL; p<0.05, vs. Hwangkeegunjung-tang supplemented with Ginseng Radix treated group 47.9±5.0 mg/dL; p<0.01), LDH (control group 1396.0±73.7 IU/L vs. Hwangkeegunjung-tang treated group 1183.2±49.6 IU/L; p<0.05, vs. Hwangkeegunjung-tang supplemented with Ginseng Radix treated group 1129.2±43.2 IU/L; p<0.01), and FFA (control group 877.9±39.3 mEq/L vs. Hwangkeegunjung-tang treated group 578.3±27.2 mEq/L; p<0.05, vs. Hwangkeegunjung-tang supplemented with Ginseng Radix treated group 604.8±12.9 mEq/L; p<0.05) levels than the group that received saline after the exercise test.⁴⁸⁾

Mice orally administered with 10 mg Morindae Radix extract for 120 days and subjected to swimming tests exhibited significantly lower blood LDH (control group 147.5±10.6 mg/dL vs. treated group 130.0±7.1 mg/dL; p<0.05) levels than the distilled water-administered group.¹⁷⁾

Geongak-tang containing Cervi Parvum Cornu is known to reduce fatigue effectively.⁵⁶⁾ Additionally, Cervi Parvum Cornu was reported to be effective for fatigue recovery. In both mice treated with Cervi Parvum Cornu extract or fermented Cervi Parvum Cornu extract, FFA levels were statistically significantly lower after the swimming test exercise than the control group administered with water (control group 961.4±46.6 mg/dL vs. Cervi Parvum Cornu extract treated group 746.1±30.0 mg/dL; p<0.05, vs. fermented Cervi Parvum Cornu extract treated group 492.3±49.4 mg/dL; p<0.001).⁵⁶⁾

In KHM, Ganoderma is characterized by its sweet and slightly bitter taste. It nourishes the heart to tranquilize and tonify the Qi and blood, suppresses coughing, and alleviates panting.⁵⁾ It is also effective against obesity,⁶⁶⁾ oxidation,⁶⁷⁾ chemotherapy-related fatigue,⁶⁸⁾ cancer,⁶⁹⁾ and pancreatitis.⁷⁰⁾ The group of mice administered the Ganoderma extract for 6 weeks showed significantly lower blood lactate levels after running machine exercise compared with the control group (control group 24.2±1.2 mg/dL vs. treated group 20.8±2.3 mg/dL; p<0.05). In addition, blood LDH (control group 349.5±13.1 IU/L vs. treated group 319.3±10.4 IU/L; p<0.05) and other fatigue indicator, ammonia (control group 123.5±2.9 mg/dL vs. treated group 105.3±2.5 mg/dL; p<0.05) levels, were significantly reduced in the Ganoderma extract treatment group compared with the control group.⁷¹⁾ In an additional study on anti-fatigue efficacy using rats, those orally administered fermented Ganoderma extract for 4 weeks exhibited lower blood inorganic phosphorus levels, another fatigue indicator, compared with the saline group after a swimming test (control group 8.19±1.15 mg/dl vs. treated group 7.09±1.36 mg/dl; p<0.05).⁷²⁾ The results of fatigue reduction and exercise performance related to Korean medicine intake are summarized in Table 1.

Discussion

This study systematically analyzed and summarized controlled experimental investigations examining the impact of KHM on enhancing muscle strength, cardiopulmonary endurance, and anti-fatigue, which are fundamental components of exercise ability.

Although KHM may not constitute a large proportion of research on fatigue recovery and exercise performance, the relationship among exercise, physical activity, and health has been recognized since ancient times. With a rising trend among professional athletes to incorporate herbal medicines for improved athletic ability, research exploring the effects of KHM on muscle strength, cardiopulmonary endurance, and anti-fatigue effects has surged. Muscle strength and cardiorespiratory endurance are foundational components of most sports, serving as pivotal determinants of performance. Additionally, anti-fatigue capacity is a crucial factor influencing endurance during exercise and subsequent workouts. Hence, understanding the diverse effects of various KHMs on these attributes is of paramount importance.

Although direct comparisons using uniform criteria are challenging owing to variations in experimental periods, sample sizes, measurement indicators, and capacity across different studies on Korean medicine, this study assessed increased grip strength as an indicator of muscle strength improvement. In this study, the KHMs with comparable findings on muscle strength improvement are Allii tuberosi semen, Morindae Radix, and Ginseng Radix. In a comparative analysis of muscle strength enhancement, the treatment concentration and duration were compared with the control group, revealing the highest strength improvement of 2.54 times with 60-day administration of 10 mg of Allii tuberosi semen.¹¹⁾ Allii tuberosi semen contains Nicotianoside C, daucostrol, adenosine, thymidine, tuberosine B, 7-hydroxy-2,5-dimethyl vernolic acid, 3-methoxy-4-hydroxybenzoic acid, glycosides, and vitamin C.⁷³⁾ Among them, Nicotianoside is a cofactor of nicotinamide adenine dinucleotide (NADH/NAD+). In cells, nicotinamide is incorporated into NAD+ and nicotinamide adenine dinucleotide phosphate (NADP+) and is used in oxidation-reduction reactions, glycolysis, citric acid cycle, and electron transport chain. NAD acts as an electron carrier in energy metabolism.⁷⁴⁾

Regarding cardiorespiratory endurance, swimming time was remarkably elevated by approximately seven times after 7 days of 100 mg/kg of fermented Cervi Parvum Cornu extract administration.⁵⁶⁾ Pantocrine, derived from deer antlers, is recognized for enhancing tension in the peripheral region of the parasympathetic nerve, optimizing the muscle nervous system, normalizing nervous system function, and improving endocrine function.⁷⁵⁾ Thus, it can be assumed that the observed remarkable results in cardiorespiratory endurance were attributable to these pharmacological actions of Cervi Parvum Cornu.

Among the study results analyzed in this paper, seven indicators (LDH, lactate, CPK, FFA, inorganic phosphate, lactic acid, and glucose levels included in the blood) show the effect of anti-fatigue. Dangguibohyul-tang showed improvement in four indicators of anti-fatigue effect: LDH, lactate, CPK, and FFA.⁶²⁾ Of note, although only two anti-fatigue indicators were analyzed for the use of Jakyak-gamcho-tang (0.35 times LDH and 0.41 times lactate), it demonstrated better improvements compared with Dangguibohyul-tang (0.72 times LDH, 0.81 times lactate).⁴⁶⁾

Among the constituent medicines of Dangguibohyul -tang, Angelicae Gigantis Radix can be seen as a Korean medicine that adds blood, breaks blood stasis, and helps Astragali Radix’s action as a drug that adds Qi.⁵⁹⁾ The effect of reducing LDH, an indicator of Dangguibohyul-tang administration’s cell survival, can be interpreted as a result of inhibition of thrombus production with the help of Angelicae Gigantis Radix.

Examining the relationship between the consumption of Jakyak-gamcho-tang and blood lactic acid concentration, it is noteworthy that Paeoniae Radix, a component of Jakyak-gamcho-tang, is recognized in Korean medicine for its ability to add blood and softening the liver. Top of Form.⁴⁶⁾ The fact that the blood lactic acid concentration can increase in the event of liver disease can be interpreted as a result of the softening liver effect of Paeoniae Radix that decreases the blood lactic acid concentration when Jakyak-gamcho-tang is ingested.

A limitation of this study was that the reviewed articles were animal-based studies. Human studies on the effectiveness of herbal medicine in exercise were not included in this study because not only is the number small, but studies that set the same dose and time according to specific drugs and exercise types are rare. In human clinical trials evaluating the enhancement of exercise capacity with herbal medicine, experiments incorporating Ssanhwa-tang,⁷⁶⁾ Kyungohkgo,⁷⁷⁾ and Bojungikgi-tang,¹⁾ reported a 13.33% reduction in heart rate, 12.08% increase in VO2 max and 10.24% rise in blood creatine,⁷⁶⁾ a 12.88% increase in VO₂ max,⁷⁷⁾ and 20.47% decrease in blood lactate,¹⁾ respectively. These examples show that herbal medicine effectively increases exercise ability in humans; however, more research is needed. Therefore, validating our findings in clinical trials involving humans remains imperative to ascertain clinical effectiveness.

Furthermore, owing to data availability constraints concerning KHM and doping-related research, an exhaustive exploration of this topic is incomplete. Nevertheless, this comprehensive review of existing research holds significance in systematically summarizing the effects of KHM on exercise outcomes and fatigue recovery stemming from exercise. These findings suggest the potential of KHM’s application in sports-related fields, such as various sports supplements using herbal medicines.

Another limitation of this study is that not all KHM consumption leads to muscle strength improvements, as reported in the studies of Lee et al.¹⁷⁾ and Lee et al.¹²⁾ In addition, several studies examining the effect of KHM on exercise recovery have shown inconsistent results, which will require a systematic investigation to establish optimal dosage and duration according to specific medicine and exercise types. There is also a limitation that only research conducted in Korea was used for the review.

Nevertheless, this study can be the basis for the next clinical trial by comprehensively analyzing the effects of herbal medicine. KHM harbors immense potential to rival existing supplements and drugs, effectively augmenting muscle strength, cardiorespiratory endurance, and anti-fatigue capabilities for exercise and recovery. In the future, clinical trials involving humans are imperative to ascertain the clinical effectiveness of KHM for improving muscle strength, cardiorespiratory endurance, and fatigue recovery.

Furthermore, Substances enhancing muscle strength and endurance hold potential not only for exercise efficacy but also for patient rehabilitation. During the recovery phase of patients after injury, KHM can accelerate muscle strength recuperation and enhance cardiorespiratory endurance, potentially conferring anti-fatigue properties. However, additional clinical trials are needed to confirm its clinical effectiveness.

Notes

Authors’ contributions

Seungyong Lee: Conceptualization, Methodology, Investigation, Writing-original Draft.: Byung-Cheul Shin: methodology, Writing-Review: Changwon Kho: Supervision, Project administration, Writing-Reviewing, Editing, Funding acquisition.

Conflicts of interests

The authors have no conflict of interest to declare.

Acknowledgments

We would like to thank Editage (www.editage.co.kr) for English language editing.

This work was supported by a 2-Year Research Grant of Pusan National University.

Fig. 1

Flow diagram showing search strategy and obtained literature.

Table 1

Effects of Korean Medicine on Exercise performance.

	Dose	Population	Period	Result	Notes
Muscle Strength	Allii tuberosi semen	20 Male ICR mice	30days	30.10%↑ (100mg/0.3ml)	Grip Test
			60days	154%↑(10mg/0.3ml) 30.77%↑(1mg/0.3ml),
			90days	27.88%↑(10mg/0.3ml), 31.73%↑(100mg/0.3ml)
			120 days	146.88%↑(10mg/0.3ml)
	Morindae Radix	20 Male ICR mice	90days	4.50%↑(1mg/0.3ml), 28.83%↑(10mg/0.3ml), 27.03%↑(100mg/0.3ml)	Grip Test
	Morindae Radix	20 Male ICR mice	120 days	22.02%↑(10mg/0.3ml)	Grip Test
	Ginseng Radix	20 Male ICR mice	30days	24.27%↑(1mg/0.3ml), 29.13%↑(10mg/0.3ml), 47.57%↑(100mg/0.3ml)	Grip Test
	Ginseng Radix	20 Male ICR mice	60days	65.31%↑(10mg/0.3ml)	Grip Test
Cardiovascular endurance	Allii tuberosi semen	20 Male ICR mice	30days	98.45%↑(10mg/0.3ml), 81.02%↑(100mg/0.3ml)	Swimming test
			60days	44.66%↑(1mg/0.3ml), 96.30%↑(10mg/0.3ml), 91.07%↑(100mg/0.3ml)
			90days	53.73%↑(1mg/0.3ml), 127.47%↑(10mg/0.3ml), 82.65%↑(100mg/0.3ml)
			120 days	104.76%↑(10mg/0.3ml), 87.86%↑(100mg/0.3ml)
	Morindae Radix	20 Male ICR mice	90days	37.25%↑(1mg/0.3ml), 56.51%↑(10mg/0.3ml), 82.35%↑(100mg/0.3ml)	Swimming test
	Morindae Radix	20 Male ICR mice	120 days	56.40%↑(100mg/0.3ml) 26.07%↑(1mg/0.3ml),	Swimming test
	Ginseng Radix	20 Male ICR mice	30days	38.57%↑(10mg/0.3ml), 53.39%↑(100mg/0.3ml)	Swimming test
		20 Male ICR mice	60days	64.39%↑(100mg/0.3ml)	Swimming test
		40 Male ICR mice	4days	25.57%↑ (50mg/kg)	Treadmill test
	Cervi Parvum Cornu	40 Male ICR mice	7days	607.51%↑	Swimming test
	Cervi Parvum Cornu (fermented)	40 Male ICR mice	7days	611.84%↑	Swimming test
	Ssanghwa-tang	36 ICR mice	1day	26.48%↑	Swimming test
			3days	18.15%↑
			5days	96.79%↑
			7days	57.32%↑
			9days	229.46%↑
	Yukmijihwang-tang	18 male ICR mice	14days	↑	Swimming test
	Yukmijihwang-tang	18 male ICR mice	14days	↓	Oxygen consumption
	Jakyak gamcho-tang	20 male ICR mice	4days	50.46%↑(water extract), 131.48%↑(ethanol extract)	Swimming test
	Sogunjung-tang (+Astragali Radix)	18 male ICR mice	1days	16.22%↓	Oxygen consumption
anti-fatigue	Morindae Radix	20 Male ICR mice	120 days	11.86%↓	LDH
	Cervi Parvum Cornu	40 Male ICR mice	7days	211.77%↑	Blood sugar level
	Cervi Parvum Cornu	40 Male ICR mice	7days	22.39%↓	FFA
	Cervi Parvum Cornu(fermented)	40 Male ICR mice	7days	207.31%↑	Blood sugar level
	Cervi Parvum Cornu(fermented)	40 Male ICR mice	7days	48.79%↓	FFA
	Ganoderma	40 Male ICR mice	42days	13.78%↓	Lactate
				8.63%↓	LDH
				14.71↓	Ammonia
	Ganoderma (fermented)	40 Male ICR mice	28days	13.11%↓	Inorganic phosphorus
	Dangguibohyul-tang	18 Male ICR mice	1day	18.46%↓	Lactate
				28.02%↓	LDH
				31.20%↓	CPK
				14.41%↓	FFA
	Ssangbohwan	18 Male ICR mice	1day	20.13%↓	LDH
	Ssangbohwan	18 Male ICR mice	1day	24.79%↓	CPK
	Bojungikgi-tang (+Acanthopanacis Cortex)	18 Male ICR mice	1day	21.15%↓	Lactic acid
	Bojungikgi-tang (+Acanthopanacis Cortex)	18 Male ICR mice	1day	35.94%↓(Bojungikgi-tang) 35.04%↓(Bojungikgi-tang +Acanthopanacis Cortex)	CPK
	Jakyak gamcho-tang	20 male ICR mice	4days	64.55%↓	LDH
	Jakyak gamcho-tang	20 male ICR mice	4days	58.71%↓	Lactate
	Sogunjung-tang (+Astragali Radix)	18 male ICR mice	1days	15.24%↓	LDH
				25.41%↓	Lactate
				34.13%↓	FFA
	Sogunjung-tang (+Astragali Radix, Ginseng Radix)	18 male ICR mice	1days	19.11%↓	LDH
				33.84%↓	Lactate
				31.11%↓	FFA

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