Rhodiola Rosea: A Physical Therapist’s Tool or Gimmick?

By Dr. Sean M. Wells, DPT, PT, OCS, CNPT, ATC/L, CSCS, NSCA-CPT, Cert-DN

Many patients in my practice come to me asking how they can get more energy for their daily activities. Of course, being a holistic physical therapist I talk with them about sleep hygiene, scheduling, daily aerobic exercise, and nutrition. While many of these interventions help significantly, some of my patients with autoimmune disorders often still struggle with energy and fatigue. I also have a subset of patients in my practice that simply just want more performance for their daily activities as well as for sports. Both of these groups of patients are willing to try almost any dietary supplement, which can be both good and bad: The willingness to try new things is good but many supplements are not regulated and can interact with drugs or cause severe Adverse Events.

Recently I was listening to the Huberman Podcast and Dr Layne Norton was discussing the use of rhodiola rosea. I had heard of this plant before but my last literature review did not yield much to support its use. However, now it appears there is additional literature to support its utilization. Let’s take a look at what this supplement is, how it’s used, and what implications does it have for physical therapy (PT) practice.

Rhodiola rosea is in the crassulaceae family of plants, known for stonecrop and other similar flowering succulents. These plants commonly grow in northern territories like the arctic circle and northern Asia. As such, cultures living in these areas such as Scandinavia and China have been using this plant for many years to address stress and fatigue in the harsh environment. Traditional Chinese medicine practitioners call it hóng jǐng tiān, but Westerns also call it Golden Root, Rose Root, and Orpin Rose. It is commonly labeled as an “adaptogen,” which is a term for a plant, herb, or mushroom that can help your body with stress, anxiety, and fatigue. The term adaptogen is trendy now in the United States but it has been around for decades with Russian and Chinese producers pushing products like ginseng and Ashwagandha. Other sellers of rhodiola utilize the term nootropic, which is a substance that improves focus, clarity of thought, and reduces stress to improve cognitive performance. Regardless of the term used, rhodiola rosea contains up to 140 different compounds, with this study citing these as the most common active compounds: monoterpene alcohols, cyanogenic glycosides, aryl glycosides, phenylethanoids, phenylpropanoids and their glycosides, flavonoids, flavonlignans, proanthocyanidins and gallic acid derivatives. Rosavins and salidrosides are the two predominant substrates in rhodiola rosea used in studies and supplements. Such compounds have been suggested to physiologically alter the HPA-axis and other pathways via corticotropin-releasing hormone (CRH), cortisol, nitric oxide, pro-inflammatory cytokines, free radicals, stress-activated protein kinase (SAPK) and heat shock proteins.

Such physiological responses are why rhodiola rosea has been used both traditionally and in trials to treat fatigue, anxiety, and depression. A recent systematic review analyzed 39 randomized control trials of rhodiola rosea used to treat anxiety, depression, or mood. The authors found a total of 5 RCTs that met inclusion criteria. One trial showed significant improvement in anxiety, another yielded significant results for treatment of mild to moderate depression, while another study did not yield a positive treatment response for major depression. It seems rhodiola may be beneficial in the treatment of mild to moderate depression, but not major depressive disorders. The 2015 Mao et al study showed that rhodiola rosea offered clinically meaningful odds ratios that indicated that patients taking R. rosea had 1.4 times the odds of improvement, and patients on sertraline had 1.9 times the odds of improvement, by week 12 of treatment versus those taking placebo. Other research has shown that Rhodiola rosea acts as a MAO-A and MAO-B inhibitor, showing evidence about the herb’s antidepressant and cognitive enhancing properties. As such, it would seem that rhodiola may have a use in the treatment of anxiety and/or mild/moderate depression, but further data is needed to truly strengthen these findings.

Two other studies analyzed in the systematic review looked at rhodiola rosea use in individuals with burnout or mental fatigue. The first study yielded patients having significant improvements on a standardized burnout scale while on a rhodiola when compared to placebo. The other study looked at 17–19 year old students during the course of a stressful examination period. Rhodiola offered statistically significant improvements in self-reported mental fatigue and statistically significant improvements in general well-being when compared to placebo. It should be noted no performance gains in regards to speed or accuracy of test-taking were improved.

In terms of fitness and muscle performance the data is more varied and of poorer quality. The Hung, Perry, and Ernst 2016 systematic review looked at some of the trials before 2009. This review cited that two trails with small sample sizes (n = 15 and 12) found rhodiola did not improve blood oxygenation after induced hypoxia and skeletal muscle phosphocreatine recovery after exhaustive exercise, respectively. Another study in the review found significant increases in time to exhaustion (increase of 3% on peak VO2 on a cycle ergometer) with 200mg/day rhodiola use. The authors suggested the improvement may be related to the mental improvements related to fatigue, not to metabolic changes. Two other trials in the review yielded a mean C-reactive protein (CRP) level improvement.

A few trials have looked at rhodiola since 2009, with this study finding 1500 mg/day of rhodiola having a small improvement in bench press velocity but not endurance. The sample size in this study was very small and the dosage much higher than other studies (most other studies used ~100-680 mg of rhodiola rosea/day). Another trial of 14 trained male athletes yielded improvements in immediate lactate and creatine kinase enzymes, but no improvements in VO2max or other performance measures. The authors state that rhodiola did improve fatty acid metabolism, which deviates from the above cycle ergometer study that found a VO2 improvement. Again, it was another study with a small sample size and it also had a wide range of “trained” participants from 20-35 years who performed either triathlons, roller skating, and/or track/field. Such variability in sport and a small sample size makes it tough to interpret actual results.

So how do these findings translate in the world of sport and physical therapy? In brief, the sport physio needs to be skeptical of the actual performance benefits of rhodiola rosea. While the supplement appears to be safe, with only 3 mild adverse events (headache and hypersalivation) in 8 trials, the benefits to sports performance may not be present. However, in the world of precision or individualized medicine, a patient or athlete may want to trial rhodiola rosea in their training regime and see if they see actual performance benefits. In this case, most studies used rhodiola on a chronic basis taking on average 300-600 mg of extract per day. If clients are to use rhodiola, I would recommend using a reputable supplement company that is GMP certified, NSF certified, and 3 party independently tested. Obviously supplements are not regulated, and some authors have cited issues with quality control and environmental issues related to rhodiola rosea – caveat emptor.

General PTs and PTs that work with patients that have chronic pain, autoimmune disorders, or other neurocognitive issues with mental fatigue may also want to examine rhodiola use for their clients. Patients with chronic pain often present with mild to moderate depression and anxiety; utilizing rhodiola, in combination with other common physical therapy interventions, may improve a patient’s condition more rapidly than without supplementation. Have we seen a trial regarding this yet? Unfortunately, no, but perhaps this could be an awesome DPT student’s study! Clients with autoimmune and other neurocognitive conditions may see improvements in mental fatigue and resiliency. Such improvements may be the difference between getting out of bed, off the couch, or engaging in social activities – all positive interactions.

In the end, rhodiola rosea offers some promising impacts to our clients, and perhaps this is why traditional medicine practitioners used it; however, I caution PTs that the benefits of this adaptogen may not be as strong for some (athletes) as for others (those with depression).

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