The nutritional supplement creatine has been widely used by body builders and athletes for many years. This joint article between Physio Matters and Red Pepper Nutrition examines the increase in research looking at creatine in rehabilitation and health. This research has now come to the attention of the wider public and especially those affected by neurological injury, who are keen to know more about creatine’s use in rehabilitation.
Here, our Specialist Neuro Physiotherapist, Kirsty Agnew, and Sian Riley, Expert Rehabilitation Dietitian from Red Pepper Nutrition, delve into the research on the potential benefits of creatine in neuro rehabilitation.
What is creatine?
Creatine is an amino acid found in foods such as meat and fish and can also be taken as a nutritional supplement. Creatine is often associated with athletes to help them promote greater physical strength and muscle growth.
Is creatine supplementation safe?
Creatine is one of the most widely researched supplements with an encouraging safety record in healthy adults when taken at the recommended doses and sourced from a reputable supplier .
What does creatine do?
Creatine increases body and muscle mass, promoting muscle growth, strength and power. It aids energy transfer in tissues with high energy requirements such as skeletal muscle and the brain . As a result, it could offer health benefits in rehabilitation and ageing through increased muscle mass and neuronal function.
So, is creatine’s supplementation only for athletes and ‘gym goers’? Or does this supplement have its place in the wider population and specifically in rehabilitation after neurological injury?
Creatine and rehabilitation
A common problem during rehabilitation is sarcopenia, where muscle mass, quality and strength decrease with ageing and immobility. Research shows this could be improved through creatine supplementation, potentially offering an important treatment option in rehabilitation . In particular, research  found that creatine supplementation alongside exercise was required to prevent sarcopenia in elderly populations, reinforcing the need for a holistic and multidisciplinary response to rehabilitation.
Creatine and the brain
The brain is a metabolically active organ needing a constant energy supply. Creatine is stored in the brain and is essential for supplying energy for neuronal activity. Creatine supplementation can increase creatine content in the brain by 5-15%, reducing mental fatigue and improving cognitive function, especially in stressed or sleep-deprived situations [1,4].
Creatine and mental health
Low levels of dietary creatine have been linked to depression with an inverse relationship shown between creatine intake and depression (5). Creatine supplementation also shows promising results in the treatment of depression (6).
Creatine in Acquired Brain Injury (ABI)
Brain injury causes direct damage to brain tissue. Secondary damage in the surrounding tissues subsequently occurs due to a reduction in the supply of oxygen and vital nutrients. This includes a lack of creatine , which can further exacerbate damage to the brain.
Animal studies  have shown that a higher creatine level prior to brain injury may play a protective role in reducing this secondary brain damage. Studies have hypothesised that creatine supplementation in those at risk of a brain injury could reduce secondary damage should an injury occur . This would be relevant to sports persons who participate in high-risk sports where head injuries are common.
Furthermore, there have been promising research outcomes in children and adolescents following a traumatic brain injury (TBI). This research showed that provision of creatine after a TBI can reduce symptoms of impaired cognition and fatigue, whilst improving communication .
Creatine in stroke
A stroke occurs when there is a blockage or rupture of a blood vessel that would normally supply the brain with oxygen and essential nutrients. This causes direct damage to brain tissue.
It is vital that this supply of oxygen and nutrients (including creatine) is quickly reintroduced to the brain following a stroke. This minimises any secondary brain damage in the surrounding tissue.
Research in animals has demonstrated that an increased dietary intake of creatine prior to a stroke can reduce the amount of damage that occurs to the brain tissue .
Our expert summary – what is the verdict?
Physio Matters’ Specialist Neuro Physiotherapist, Kirsty Agnew, said: “As a Physiotherapist, I have previously had an awareness of the benefits of creatine with regards to building or maintaining muscle mass. However, I find it really interesting to think about creatine in the context of the brain and nervous system. Research into this area is clearly in its infancy. But to think that a widely available supplement could reduce the level of damage following injury to the brain is very positive and exciting! If creatine is shown to provide both muscular and neurological benefits, this could play a significant role in neurological rehabilitation. I will certainly be keeping a close eye on any more developments in the research!”
Sian Riley, Expert Rehabilitation Dietitian from Red Pepper Nutrition added: “We eat food, not nutrients, and as a dietitian I usually advocate a ‘food first’ approach. Creatine is found naturally in meat, fish and dairy foods so these should be included as part of a balanced diet as they also contain many other nutrients. One thing to be aware of is that creatine supplements are likely to lead to an increase in weight through muscle growth and fluid changes. This weight gain needs to be sensitively managed in those requiring weight losses, and people with body image issues, disordered eating and/or participating in weight sensitive sports.
Nevertheless, the research around creatine is promising and demonstrates the importance of optimising nutrient levels in the body, particularly in rehabilitation where nutrient stores may be reduced. Vegans, vegetarians, and those on restricted diets, may not be able to meet creatine needs through their diet, so creatine supplements may be of benefit. Creatine supplements are widely available, inexpensive and could offer a nutritional treatment to further improve rehabilitation, when seen in a wider context of health.”
Please do continue this discussion through sharing of latest research around creatine, rehabilitation, and health.
To find out more information about creatine, follow the studies below.
 International Society of Sports Nutrition position stand: creatine supplementation and exercise, J Int Soc Sports Nutr 4, 6 (2007)
 Review – Use of creatine in the elderly and evidence for effects on cognitive function in young and old, Amino Acids;40(5):1349-62 (2011)
 Muscle Atrophy and sarcopenia in the elderly: Is there a role for creatine supplementation? Biomolecules, 9:642 (2019)
 Beyond muscle: the effects of creatine supplementation on brain creatine, cognitive processing, and traumatic brain injury, European Journal of Sport Science 19:1, 1-14 (2018)
 Dietary creatine intake and depression risk amongst US adults, Transl Psychiatry 10, 52 (2020)
 Creatine for the treatment of depression, Biomolecules 9, 9 406 (2019)
 Dietary supplement creatine protects against traumatic brain injury Annals of Neurology, 48, 5, 723 -729 (2000) Abstract only accessed.
 Prevention of traumatic headache, dizziness and fatigue with creatine administration Acta Paediatr, 97, 1, 31-34 (2008)
 Improved reperfusion and neuroprotection by creatine in a mouse model of stroke Journal of Cerebral Blood Flow & Metabolism, 27, 3 (2007)