UTF-8'en' (Sport Science Review) Cryotherapy and Its Correlates To Functional Performance. A Brief Preview

Sport Science Review, vol.
XXII,
Sport no. 3-4,
Science 2013,
Review, vol.229 - 254No. 3-4, August 2013
XXII,
DOI: 10.2478/ssr-2013-0012
Cryotherapy and its Correlates to

Functional Performance.
A Brief Preview
Márcio Luís Pinto DOMINGUES1
O bjective: To search the English language literature for original

research addressing the effect of cryotherapy on motor performance
and recovery. Data Sources: We searched MEDLINE, the Physiotherapy
Evidence Database, SPORT Discus, Pubmed, and the Cochrane Reviews
database, from 1976 to 2009 to identify randomized clinical trials of
cryotherapy, systematic reviews, original articles and methods of cryotherapy.
Key words used were cryotherapy, return to participation, cold treatment, ice,
injury. Data Synthesis: Brief review including assessment of cryotherapy as
a tool of performance and a recovery method. Conclusions: Most studies
suggest that a short rewarming time would be beneficial (a couple minutes),
which is very reasonable in sports. Also, cooling techniques differ in its result
accordingly to the procedures and objectives used. Finally, the type of tissue
cooled plays a large role (ie. Joint vs. Muscle).
Keywords: cryotherapy, performance, cold
1 Faculty of Sports Science, University of Coimbra, Portugal
ISSN: (print) 2066-8732/(online) 2069-7244 229

© 2013 • National Institute for Sport Research • Bucharest, Romania
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Download Date | 5/9/18 3:15 PM
Cryotherapy and its Corelates
Introduction
Athletes consistently work to improve motor performance and delay the

onset of fatigue (Amusa, Toriola, 2003; Bompa, 1999). The underlying causes of
fatigue and exercise limitation have been extensively studied (Amman, Dempsey,
2008; Hargreaves, 2008; McKenna, Hargreaves, 2008; Noakes, 2000). Skill
development, weight training, cardiorespiratory exercises and stretching are just
a few of the many activities used to enhance achievement.
A wide range of recovery modalities are now used as integral parts of

the training programmes of elite athletes to help attain this balance (Coffey,
2002; Thiriet, Gozal, Wouassi, Oumaru, Gelas & Lacour, 1993; Barnett,
2006; Simjanovic, Hooper, Leveritt, Kellmann, & Rynne, 2008). Achieving an
appropriate balance between training and competition stresses and recovery is
important in maximising the performance of athletes.
It’s been a while since Grant and Hayden published their classic articles on
cryokinetics. Since the work of Kowal (1983), cryotherapy’s depressive effects
on the body’s physiological systems have generated concern among many
health care practitioners about its effect on motor activity. Since many forms
of cryotherapy are used by sports medicine clinicians before or during athletic
participation, a more knowledgeable understanding of the immediate and
delayed effects of cryotherapy on functional performance is necessary. We will
try to determine, within the existing literature, the effects that cryotherapy has
on functional performance and also in the recovery as a method of enhancing
performance.
Cryotherapy´s physiological action
While humans maintain body core temperature within a strict homeostatic

range, skin and peripheral muscle temperature may experience a wide temperature
variation. Cryotherapy application is a valuable therapeutic resource, since the
cold is a state that compounds less molecular movement which preserves the
integrity of the cell. Human body responds to it with a series of systemic and
local responses that vary between local reduced metabolic rate and the reduced
needs of oxygen to the cell. It is a widely accepted component of treatment
for acute injuries due to its hypalgesic effects (Evans, Ingersoll & Worrell,
1995), therefore it has recently re-entered the later stages of rehabilitation as a
contributing modality.
However, previous research (Rubley, Denegar, Buckley, Newell, 2003) has

suggested that cryotherapy may also reduce muscle strength, nerve conduction
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Sport Science Review, vol. XXII, No. 3-4, August 2013
velocity, and proprioception, all of which are important to function in an athletic

environment. It is commonly accepted that it produces physiological answers
such as anaesthesia, heat reduction, reduced muscle spasm (Knight, 1995; Bompa,
1999), stimulates relaxation, allows for early mobilization, develops the range of
movement, decrease in muscle tension over longer application, reduction of the
metabolism (Knight, 1995), breaks the cycle pain-spasm-pain (Bompa, 1999),
reduction of circulation and inhibition of inflammation (Knight,1979; Knight,
1995, Swenson, Swärd & Karlsson, 1996), reduction of post traumatic treatment
and reduction in the regeneration phase of rehabilitation.
Results of studies on cold and blood flow vary considerably, however it

appears that blood flow increases with superficial cold application and decreases
when cold is applied to large skin surface areas. Motor performance is affected
by temperature with a critical temperature being around 18 degrees Celsius,
above and beneath which muscle performance decreases (Scott, Ducharme,
Haman and Kenny, 2004). They examined the effect of prior warming by both
active and, to a greater extent, passive warming, may predispose a person to
greater heat loss and to experience a larger decline in core temperature when
subsequently exposed to cold water. Thus, functional time and possibly survival
time could be reduced when cold water immersion is preceded by whole-body
passive warming, and to a lesser degree by active warming.
Several studies have aimed to establish if the use of cryotherapy adversely

affects various measures which play a role in functional performance. Much has
been written about the effects of cryotherapy on individual physiological systems,
such as the nervous system (Mecomber & Hermnan, 1971; McMaster, 1977;
McMaster, 1982; Kowal, 1983; Buchheit, Peiffer, Abbiss & Laursen, 2008) and
the muscular system (Mecomber & Hermnan, 1971; McMaster, 1977; McMaster,
1982; Crowley, Garg, Long, Van Someren & Wade, 1991; Mattacola & Perrin,
1993; Giesbrecht, Wu, White, Johnston & Bristow, 1995; Cross, Wilson & Perrin,
1996; Gatti, Myers & Lephart, 2000; Duck, Kaminski, Horodyski & Bauer, 2000;
Atnip & Mcrory, 2004). However, investigators disagree as to whether muscle
cooling has an effect on force production (Burke, Holt, Rasmussen MacKinnon,
Vossen, Pelham, 2001; Cornwall, 1994; Hatzel and Kaminski, 2000; Kimura,
Thompson, 1997); Mattacola & Perrin, 1993; Verducci, 2000), joint position
sense (Thieme, Ingersoll, Knight, Ozmun, 1996; Uchio, Ochi, Fujihara, Adachi,
Iwasa, Sakai, 2003), or performance (Cross, Wilson & Perrin,1996; Evans,
Ingersoll, Knight & Worrell, 1995).
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Chart of references
Cryotherapy has been shown to have no effect on joint position sense or

sensory perception and therefore, proprioception appears to be unaffected by
the use of cold in the treatment of athletic injuries, namely, sensory perception
of the foot and ankle following therapeutic applications of heat and cold
(Ingersoll et al., 1992).
Another study was designed to determine the effect of ice immersion on

ankle joint position sense. Three different pretest conditions of no ice immersion,
5 min of ice immersion, and 20 min of ice immersion were administered to
31 subjects prior to joint angle replication testing with an electrogoniometer
(LaRiviere & Osternig, 1994). Power and isokinetic strength, both appear to
be decreased immediately following the application of various cryotherapeutic
modalities (Ferretti et al., 1992); ankle strength (Hatzel & Kaminski, 2000);
plantar flexor muscle group (Mattacola & Perrin, 1993); sensory and nervous
system (Ruiz, Myrer, Durrant & Fellingham, 1993).The performance detriments
can be attributed to a loss of electrically evoked force generation and contractile
capacities (Davies & Young, 1985), similar results were found with maximal
isometric grip strength, when the forearm was immersed in 10º C water for
durations between 5 and 20 minutes (Douris, Mckenna, Madigan, Cesarski,
Costiera & Lu, 2003).
Knowledge concerning the use of heat and/or cold upon muscular

performance would help in the design of exercise programs. However, most
research pertaining to strength changes and cryotherapy has primarily been
limited to isometric contractions (Mattacola & Perrin, 1993; Cornwall, 1994;
Johnson & Bahamonde, 1996; Sanya & Bello, 1999). Conflicting results regarding
the effects of cold on isometric strength have been reported by investigators
(McGowin, 1967; Coppin, 1978; Bergh & Ekblom, 1979; Barnes & Larson, 1985;
Howard, Kraemer, Stanley, Armstrong, & Maresh, 1994). The results of these
studies, unfortunately, are equivocal and strength has been shown to increase
(Mattacola & Perrin, 1993; Cornwall, 1994; Sanya & Bello, 1999) and decrease
(Johnson & Bahamonde, 1996). Also, Knight and Adolp (2003), sustained that
while ankle ROM was affected (increased), joint cooling had no affect on lower
chain kinetics during a functional, resisted exercise.
Speed and agility, both which are essential to athletic participation have not
been studied in great detail (Bergh & Ekblom, 1979; Cross et al, 1996; Evans
et al, 1995; Richendollar et al, 2006). A study, however, have demonstrated
that following a cold treatment in which muscle was directly cooled, functional
performance may be impaired (Cross et al, 1996).
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We know that dynamic muscular control mechanism may be altered

following cryotherapy. Piedrahita, Oksa, Rintamäki and Malm (2009) designed
a study to find out if local leg cooling affects muscle function and trajectories
of the upper limb during repetitive light work as well as capability to maintain
dynamic balance, they found that local leg cooling did not affect upper limb
muscle function or trajectories, but ability to maintain dynamic balance was
reduced. Gatti, Myers and Lephart (2000) postulated that cryotherapy negatively
affects functional performance specific to the dominant shoulder. In contrast,
another study concluded a that 5 min cold water immersion intervention lowered
muscle temperature but did not affect isokinetic strength or 1-km cycling
performance (Peiffer, Abbiss, Watson, Nosaka & Laursen, 2008); however it is
unlikely however to significantly lower the temperature in the deeper articular
structures with superficial cryotherapy (Enwemeka, Allen, Avila, Bina, Konrade
& Munns, 2002; Merrick, Jutte & Smith, 2003).
Some studies reflect a positive association between cryotherapy and

performance (Catlaw, Arnold & Perrin, 1996; Sanya, & Bello, 1999). One
study reflected a positive association between the effect of icing the arm and
shoulder between weight-pulling sets on work, velocity, and power. Verducci
(2000) found that interval cryotherapy between weight-pulling sets is associated
with increased work, velocity, and power, similar results were found in baseball
pitchers (Verducci, 1997) and Burke, Macneil, Holt, Mackinnon, Rasmussen,
(2000) found positive results in maximum isometric force production, velocity
and power, between sets. Also the effects of a 20-min focal knee joint cooling
intervention on quadriceps central activation ratio (CAR) in healthy volunteers
were higher than the control group in weight-bearing explosive strength or
power that decreased toward baseline measures (Pietrosimone & Ingersoll,
2009), and a decrease in vertical impulse (Kinzey, Cordova, Gallen, Smith &
Moore, 2000), further, joint cryotherapy may provide increased PL activity
during the rewarming period following joint cooling (Hopkins, Hunter &
McLoda, 2006). Patterson, Udermann, Doberstein, Reineke (2008) suggested
functional performance was affected immediately following and for up to 32
minutes after cold whirlpool treatment. It was also evident that there is a gradual
performance increase for each measure of functional performance across time.
Therefore, the consequences should be carefully considered before returning
athletes to activity following cold whirlpool treatment and further work should
consider whether joint cooling may affect other areas of sensorimotor control.
Myrer, Measom and Fellingham (2000) developed a study, the first designed
specifically to examine the effect of exercise on intramuscular rewarming after
a standard crushed-ice-pack treatment, they found that moderate walking
significantly enhanced rewarming of the triceps surae. Involuntary activation
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during the rewarming phase following joint cooling is also well documented
(Hopkins et al., 2001; Hopkins & Stencil, 2002; Krause et al., 2000).
Whilst there is some evidence that stretching and massage may reduce
muscle soreness, there is little evidence indicating any performance benefits.
Electrical therapies and cryotherapy offer limited effect in the treatment of
Exercise-Induced Muscle Damage (EIMD). However, inconsistencies in the
dose and frequency of these and other interventions may account for the lack
of consensus regarding their efficacy. Both as a cause and a consequence of
this, there are very few evidence-based guidelines for the application of many
of these interventions (Howatson & van Someren, 2008), however, one study
concludes that cold water immersion after stretch-shortening exercise (SSE)
accelerates the disappearance of the majority of indirect indicators of EIMD.
Prior bouts of eccentric exercise provide a protective effect against

subsequent bouts of potentially damaging exercise. Further research is warranted
to elucidate the most appropriate dose and frequency of interventions to
attenuate EIMD and if these interventions attenuate the adaptation process.
This will both clarify the efficacy of such strategies and provide guidelines
for evidence-based practice. Another study adds that cryotherapy significantly
improved immediate range of motion in enhancing supine, extended-leg, hip
flexion decreasing pain perception, interfering with muscle spasm, and possibly
causing reflex vasodilation (Minton, 1993).
Cooling methods
Different methods of cryotherapy have different effects on muscle tissue.

Overall, CWI and contrast water therapy (CWT) were found to be effective in
reducing the physiological and functional deficits associated with delayed onset
muscle soreness (DOMS), including improved recovery of isometric force and
dynamic power and a reduction in localised oedema. While one study says hot
water immersion (HWI) was effective in the recovery of isometric force, it was
ineffective for recovery of all other markers compared to PAS (Vaile, Halson,
Gill, Dawson, 2008a), another research relates no effect at all (Stanley, Kraemer,
Howard, Armstrong & Maresh, 1994). These authors in 2008b developed a study
where all cold water immersion protocols were effective in reducing thermal
strain and were more effective in maintaining subsequent high-intensity cycling
performance than active recovery.
Although it isn’t the purpose of this research paper, in fact we know DOMS
as a particular state of muscular tenderness that can evolve in debilitating pain
(Powers & Howley, 2004). Cryotherapy may not have effect on this particular
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situation (Yackzan, Adams & Francis, 1984; Weber, Servedio & Woodwall,
1994), instead exercise must be encouraged in order to allow the most affected
muscle groups to recover (Cheung, Hume & Maxwell, 2003), particularly
eccentric exercises (Weber, Servedio, Woodwall, 1994; Bakhtiary, Safavi-Farokhi
& Aminian-Far, 2006). Although a study (Paddon-Jones, 1997) suggests that
the use of cryotherapy immediately following damaging eccentric exercise may
not provide the same therapeutic benefits commonly attributed to cryotherapy
following traumatic muscle injury.
We should also take into account the amount of adipose over the therapy
site as a significant factor in the extent of intramuscular temperature change that
occurs during and after cryotherapy (Myrer, Myrer, Measom, Fellingham & Evers,
2001). Preliminary evidence suggests that intermittent cryotherapy applications
are most effective at reducing tissue temperature to optimal therapeutic levels
confirmed by Bleakley, McDonough and MacAuley (2006).
When we talk about core and skin temperature we need to evaluate different
cryotherapy modalities. Zemke, Anderson, Guion, McMillan and Joyner (1998)
refer that ice massage appears to cool muscle more rapidly than ice bag, whereas
during the application of 4 cryotherapy modalities (ice pack, gel pack, frozen
peas, mixture of water and alcohol) the ice pack and mixture of water and
alcohol was significantly more efficient in reducing skin surface temperature
than the gel pack and frozen peas (Kanlayanaphotporn, Janwantanakul, 2005).
It has been noticed that ice massage produces a significant drop in intramuscular
temperature (Lowdon & Moore, 1975), and to a decrease in core temperature
(Palmieri, Garrison, Leonard, Edwards, Weltman & Ingersoll, 2006). A study
valuating and comparing the ability of wet ice (WI), dry ice (DI), and cryogenic
packs (CGPs) to reduce and maintain the reduction of skin temperature directly
under the cooling agent, found no significant differences in mean skin temperature,
15 minutes after removal of the cold modality (time 30) was significant for WI
only (Belitsky, Odam & Hubley-Kozey, 1987). On the other hand, cooling rates
were nearly identical between ice-water immersion and cold-water immersion,
either mode of cooling is recommended for treating the hyperthermic individual
(Clements, Casa, Knight, McClung, Blake, Meenen, Gilmer & CaldwellIce, 2002).
Armstrong, Crago, Adams, Roberts and Maresh (1996) and McDermott, Casa,
Ganio, Lopez, Yeargin, Armstrong and Maresh (2009) refute the theory that ice
water immersion is an inefficient cooling modality addressing the efficiency of
whole-body cooling modalities in the treatment of exertional hyperthermia.
When the physiological processes produced by cryotherapy are examined

in experimental situations, some of these reactions differ from expectations
(Meeusen, 1986). Skin, subcutaneous, intramuscular and joint temperature
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changes depend on application method, initial temperature and application time.

Drinkwater (2008) claims that there isn’t a standard method to investigate the
effects of cooling, so protocols range across a variety of temperatures (10-42
ºC), temperature assessment methods (skin, intramuscular), cooling mediums (air,
water immersion), muscle fibre type (species, fast or slow twitch), contraction
type (evoked or voluntary, isometric or dynamic), and isolated versus intact fibres.
Precooling and performance
We need to clarify the effects of pre-cooling on the improvement in

exercise performance and the effects of post-exercise cooling on recovery.
We know that metabolism remains elevated for several minutes immediately
following exercise (Powers & Howley, 2004). While pre-cooling has received
much research attention, the mechanisms resulting in enhanced performance
remain equivocal and moreover, pre-cooling has previously only been considered
effective for endurance performance. Ingram, Dawson, Goodman, Wallman
and Beilby, (2009) demonstrated that cold following exhaustive simulated team
sports exercise offers greater recovery benefits than Contrast Water Immersion
(CWI) or control treatments. There are very few studies that have focused on
the effectiveness of hot–cold water immersion for post exercise treatment in a
physiological basis, there isn’t enough research (Cochrane, 2004).
Precooling studies (Marino, 2002) confirm that increasing body heat is a

limiting factor during exercise. It seems that it is only beneficial for endurance
exercise of up to 30–40 minutes with related physiological factors (Olschewski
& Bruck, 1988), rather than intermittent or short duration exercise. However,
Marsh and Sleivert (1999) concluded that precooling improves short term cycling
performance. In the motor co-ordination of the working agonist-antagonist
muscle pair of the lower leg there was a dose-dependent response between the
degree of cooling and the amount of decrease in muscle performance as well
as EMG activity changes. A relatively low level of cooling was sufficient to
decrease muscle performance significantly (Oksa, Rintamaki & Rissanen, 1997),
and a decreased immediate shuttle run result questions the implications for
immediate recovery (Cross et al 1996). Future research is required to determine
the physiological basis for the ergogenic effects of precooling on high intensity.
Local leg cooling did not affect upper limb muscle function or trajectories,
but ability to maintain dynamic balance was reduced, although other studies claim
that whole body cooling impairs muscle performance (Crowley, Garg, Lohn,
Van Someren & Wade, 1991; Giesbrecht, Wu, White, Johnston & Bristow, 1995;
Cross, Wilson & Perrin, 1996; Gatti, Myers & Lephart, 2000; Duck, Kaminski,
Horodyski & Bauer, 2000; Atnip & Mcrory, 2004). However, Carman and Knight
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(1992) has shown that habituation takes place if cold treatments, consistent in
temperature, are applied to the same limb, although some studies report no
changes on voluntary motor output (Cornwall, 1994; Evans et al, 1995; Kimura,
Thompson & Gulick, 1997).
Although recent research has been useful describing the effects of pre-
cooling on exercise performance, little has been conducted on the effects
of cooling as a recovery tool from heat stress (Duffield, 2008). Much of the
literature investigating cooling on human performance involves cooling of the
core (Powers & Howley, 2004), though many performance effects relate to
cooling of the periphery (Drinkwater, 2008). The author considers that while
most of these effects occur independently of central activation, purposeful
core cooling for the purpose of improving athletic performance should be used
cautiously to avoid the deleterious effects of peripheral cooling.
On the other side, there are studies that show results depending on the
method used precooling via an ice vest (Duffield, Dawson, Bishop, Fitzsimons
& Lawrence, 2003), cold water immersion (CWI), and ice packs covering the
upper legs (Packs). Castle, Macdonald, Philp, Webborn, Watt and Maxwell
(2006) underpin that the method of precooling determines the extent to which
heat strain was reduced during intermittent sprint cycling, with leg precooling
offering the greater ergogenic effect on peak power output (PPO) than either
upper body or whole body cooling. In the same line of results the study of
Schniepp, Campbell, Powell and Pincivero (2002) showed that a relatively brief
period of cold-water immersion can manifest significant physiological effects
that can impair cycling performance, especially by decreasing heart rate. Also,
significant decreases in tissue temperature have been shown to decrease nerve
conduction velocity, muscle force production, and muscular power (Lee, Warren
& Mason, 1978; Sargeant, 1987).
Previous data show that cooling the joint (not cooling muscle) increases
surrounding muscle activity, reflex amplitude, and allows for increased force
generated around the cooled joint (Krause, Hopkins & Ingersoll, 2000; Hopkins
& Stencil, 2002). Conversely, Duck, Kaminski, Horodyski and Bauer, (2000) in
their study found that single-leg (SL) vertical jump and 40-yard dash performance
were significantly reduced immediately after the application of 10 and 20 minute
cryotherapy treatments in a group of female collegiate athletes.
To examine the effects of different thermoregulatory preparation proce-

dures [warm-up (WU), precooling (PC), control (C)] on endurance performance
in the heat, Ückert and Joch (2007) concluded that the use of an ice-cooling vest
for 20 min before exercising improved running performance, whereas the 20
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min WU procedure had a distinctly detrimental effect. Cooling procedures in-

cluding additional parts of the body such as the head and the neck might further
enhance the effectiveness of PC measures. Also, there may be a psychological
benefit to athletes with a reduced cessation of fatigue.
Duffield, Dawson, Bishop, Fitzsimons and Lawrence, 2003 conclude

that the intermittent use of an ice cooling jacket, both before and during a
repeat sprint cycling protocol in warm/humid conditions, did not improve
physical performance, although the perception of thermal load was reduced.
Longer periods of cooling both before and during exercise (to lower mean
skin temperature) may be necessary to produce such a change. Other studies
refer improvements in performance (Arngrïmsson, Petitt, Stueck, Jorgensen &
Cureton, 2003) reduced thermal and cardiovascular strain and perception of
thermal discomfort in the early portion of the run that appear to permit a faster
pace later in the run. A practical combined precooling strategy that involves
immersion in cool water followed by the use of a cooling jacket can produce
decrease in rectal temperature that persist throughout a warm-up and improve
laboratory cycling time trial performance in warm conditions (Quod, Martin,
Laursen, Gardner, Halson, Marino, Tate, Mainwaring, Gore & Hahn, 2008).
We know that power and functional performance are affected by short-

term cryotherapy application. Power and functional performance was impaired
immediately and 20 minutes after 10-minute ice bag application to the hamstrings,
whereas a shorter duration of ice application had no effect on these tasks. This
study examined the immediate and short-term (20 minute) effects of 3- and
10-minute ice bag applications to the hamstrings on functional performance as
measured by the cocontraction test, shuttle run, and single-leg vertical jump. A
decrease in cocontraction time was observed at 20 minutes post compared with
preapplication during the control condition in which no ice bag was applied.
(Fischer, Van Lunen, Branch & Pirone, 2009). Other studies didn’t show effects
in performance as reported on agility using cold therapy before strenuous
exercise (Evans, Ingersoll, Knight & Worrell, 1995); on eccentric peak torque,
an athlete can reap the beneficial effects of cryotherapy without compromising
eccentric force production or endurance (Kimura, Thompson & Gulick, 1997),
on motor control of the digits (Rubley, Denegar, Buckley & Newell, 2003)
or on increase hamstring length in healthy subjects (Burke, Holt, Rasmussen
MacKinnon, Vossen & Pelham, 2001).
However there has not been great research examining the effects of pre-
cooling on high-intensity exercise performance, particularly when combined
with strategies to keep the working muscle warm. Sleivert, Cotter and Febbraio
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(2001) indicate that pre-cooling does not improve 45-s high-intensity exercise
performance, and can impair performance if the working muscles are cooled.
Joint position sense and neurological effects
Previous studies have suggested that cryotherapy affects neuromuscular

function and therefore might impair dynamic stability. If cryotherapy affects
dynamic stability, clinicians might alter their decisions regarding returning athletes
to play immediately after treatment. Proprioception and throwing accuracy were
decreased after ice pack application to the shoulder. It is important that clinicians
understand the deficits that occur after cryotherapy, as this modality is commonly
used following acute injury and during rehabilitation. This information should
also be considered when attempting to return an athlete to play after treatment
(Wassinger, Myers, Gatti, Conley & Lephart, 2007).
Cryotherapy has also been implicated in decreased afferent proprioception

information at the knee. Therapeutic programs that involve exercise immediately
after a period of cooling should be taken into account because cooling for 15
minutes makes the knee joint stiffer and lessens the sensitivity of the position
sense (Uchio, Ochi, Fujihara, Adachi, Iwasa & Sakai, 2003), consistent with
Thieme (1992) findings. Significant differences were found for joint position
sense (JPS) before and after cold spray application and between JPS scores and
pain. In the study, they showed that knee JPS deficits occurred, and postural
control was adversely affected, with cryotherapy, and caution should be observed
when athletes immediately return to their chosen sport after cryotherapy
application (Surenkok, Aytar, Tüzün & Akman, 2008). Moreover, Gardner,
Aiken, Robinson, Condra and McGinnis (2000) found that postural sway and
balance strategy were not significantly affected following 20 minutes of ankle
ice immersion; also lower leg cold-immersion therapy does not impair dynamic
stability in healthy women during a jump-landing task (Miniello, Dover, Powers,
Tillman & Wikstrom, 2005).
Studies by LaRiviere (1994) in the ankle, knee (Thieme, 1992), and hand
(Williams and Rainham, 1980) showed that therapeutic cold treatments did not
affect proprioception. Another study says that a 20-minute ice treatment had no
effect on joint angle reproduction (Thieme, Ingersoll, Knight & Ozmun, 1996).
Despite these studies, the effect of cooling on proprioception of the knee has
not been studied extensively.
Thieme et al (1996) refer that one possible explanation for the difference
between sectors is that different receptors are active at different points in
the knee’s range of motion. They conclude that cooling the knee joint for
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20 minutes does not have an adverse effect on proprioception and Ingersoll,

Knight and Merrick (1992) concluded that heat and cold applications can be
used prior to therapeutic exercise programs without interfering with normal
sensory perception as do other analgesic and anesthetic agents. Similar results
were presented in a study of Hopkins and Adolp (2003), ankle and knee joint
cryotherapy does not appear to affect normal biomechanics in terms of torque
and power of the lower extremity. Joint cryotherapy is an effective treatment
that will not inhibit normal motor function that dynamically supports the joint.
It’s been known that cryotherapy has direct physiological effects on

contractile tissues, the extent to which joint cooling affects the neuromuscular
system is not well understood. Hopkins, Hunter and McLoda (2006). Although
some studies have yet to confirm an effect in the joint position sense (Dover &
Powers, 2004), others say clinical application of cryotherapy is not deleterious
to joint position sense and assuming normal joint integrity patients may resume
exercise without increased risk of injury of the ankle (Hopper, Whittington &
Davies, 1997). The slowed enzymatic processes and slowed nerve conduction
that impair rate of force development also likely reduce local muscular endurance
during dynamic contractions and impair manual dexterity (<35 ºC). Both the
voluntary and evoked force development capacities of muscle is unimpaired
until cooling is quite severe (<27 ºC). There also exists the hypothesis that the
increased viscosity of the synovial fluid is a factor in decreasing finger dexterity
in the cold. However, this is not the only factor since cooling of the arm, even
when the hands are kept warm, also caused a large decrement in finger dexterity
(LeBlanc, 1956).
Also, Hopkins, Hunter and McLoda (2006) with their study tried to
detect changes in ankle dynamic restraint (peroneal short latency response and
muscle activity amplitude) during inversion perturbation following ankle joint
cryotherapy. They concluded that joint cooling does not result in deficiencies in
reaction time or immediate muscle activation following inversion perturbation
compared to a control.
The extent to which joint cooling affects the neuromuscular system is

not well understood. Mecomber and Herman (1971) noted a decrease in the
amplitude of action potentials, twitch contraction, and nerve conduction time
following maximal tendon taps of precooled Achilles tendons. Consequently, the
resultant force development within the muscle and the myotatic reflex’s protective
mechanism may be negatively influenced. Also, therapeutic cooling decreases
nerve conduction velocity (Halar, DeLisa & Brozovich, 1980). Over this issue,
Mac Auley (2001) performed a systematic literature search on ice therapy in
injuries, concluding that reflex activity and motor function are impaired following
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ice treatment, so patients may be more susceptible to injury for up to 30 minutes

following treatment. It is concluded that ice is effective, but should be applied
in repeated application of 10 minutes to be most effective, avoid side effects,
and prevent possible further injury. Another systematical review considered
cryotherapy alone on return-to-participation measures (Hubbard, Aronson
& Denegar, 2004) and with optimal results following training (Lievens, 1986).
Results of various studies are consistent on the effects on neuromuscular

and pain processes. How can we assess the effect of CWI on postexercise
parasympathetic reactivation? A study shows that CWI can significantly restore
the impaired vagal-related heart rate variability (HRV) indexes observed after
supramaximal exercise. CWI may serve as a simple and effective means to
accelerate parasympathetic reactivation during the immediate period following
supramaximal exercise (Buchheit, Peiffer, Abbiss & Laursen, 2008).
Experimental models designed to reflect the circumstances of elite athletes

are needed to further investigate the efficacy of various recovery modalities for
elite athletes. Other potentially important factors associated with recovery, such
as the rate of post-exercise glycogen synthesis and the role of inflammation in
the recovery and adaptation process also need to be considered in this future
assessment.
Conclusion
Most studies suggest that a short rewarming time would be beneficial (a

couple minutes), which is very reasonable in sports. Also, cooling techniques
differ in its result accordingly to the procedures and objectives used. Finally, the
type of tissue cooled plays a large role (ie. Joint vs. Muscle).
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Table 1
Studies relating cryotherapy and functional performance
Subject Authors Test Results

No significant differences were detected for the three
Ingersoll, Knight 20-minute 1°C ice immersion treatment to the dominant
dependent measures. Heat and cold do not affect sensory
& Merrick (1992) foot and ankle and 20 minutes of rest
perception
Proprioception Joint position receptors in the ankle are resilient to this type
LaRiviere & 20 minute, 10 degree Celsius cold whirlpool following the office treatment. The affected receptors (i.e., skin and muscle)
Osternig (1994) pre-test of a given functional performance measure were adequately compensated for by other sensors such as
joint receptors
Ferretti, Ishii, Relationships between absolute peak muscle power,
The temperature dependence of muscle power was found to
Power Moia & Cerretelli muscle cross sectional area (the sum of both thigh and
be less than reported in the literature for ATP max
(1992) calf) and muscle high energy phosphate concentration
Results indicated concentric isokinetic strength values were
Mattacola & Effect of cold water submersion (CWS) on isokinetic
lower after cold water submersion for peak torque, average
Perrin (1993) strength of the plantar flexor group
power and total work of the plantar flexor muscle group
Strength Burke, Macneil,
3 different treatment conditions only on their right lower All 3 groups had significant improvements in his extensor
Holt, Mackinnon,
limb: control, cold water immersion, and hot water isometric force production (pre to post), the cold group was
& Rasmussen
immersion significantly greater than that of the control and hot groups
(2000)
Influence of muscle temperature (Tm) on maximal Maximal dynamic strength, power output, jumping, and
Berg & Ekblom
muscle strength, power output, jumping, and sprinting sprinting performances were positively related to muscle
(1979)
performance was evaluated in four male subjects temperature
Speed Significant main effects were noted for both ice and warm-up
Richendollar, Effects of ice bag application to the anterior thigh and
for all functional tests. Ice bag application negatively affected
Darby, & Brown active warm-up, on 3 maximal functional performance

performance on all 3 functional tests; warm-up significantly
(2006) tests
improved post icing performance
Application of a 20-minute ice immersion (13°C) to the Vertical jump and shuttle run scores decreased in the
Cross, Wilson, &
lower leg. Shuttle run, the 6-m hop test, and the single-leg experimental group but not in the control group as a result of
Perrin (1996)
vertical jump the treatment
Agility
Evans, Ingersoll, 20-minute 1°C ice immersion treatment to the dominant Although the mean agility time scores were slightly slower

Unauthenticated
Knight, & Worrell foot and ankle and 20 minutes of rest. Three trials of following the cold treatment, cooling the foot and ankle caused
(1995) each agility test no difference in agility times
253
Márcio DOMINGUES is a finishing PhD Student at the Faculty of Sports Science

within the University of Coimbra. He has published national and international articles
in sport related themes and made several oral communications internationally. Currently
he’s developing two projects related to young sport, migration and talent development.
Corresponding address:
Márcio Luís Pinto Domingues
61 Rua Nova
Horta-Velha
3750-862 Borralha
Portugal
Phone: (+351) 910 973 39 06
E-mail: marcio.domingues@live.com.pt
254
Unauthenticated

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Sport Science Review, vol.

Cryotherapy and its Correlates to

Márcio Luís Pinto DOMINGUES1

O bjective: To search the English language literature for original

Keywords: cryotherapy, performance, cold

1 Faculty of Sports Science, University of Coimbra, Portugal

ISSN: (print) 2066-8732/(online) 2069-7244 229

Athletes consistently work to improve motor performance and delay the

A wide range of recovery modalities are now used as integral parts of

Cryotherapy´s physiological action

While humans maintain body core temperature within a strict homeostatic

However, previous research (Rubley, Denegar, Buckley, Newell, 2003) has

velocity, and proprioception, all of which are important to function in an athletic

Results of studies on cold and blood flow vary considerably, however it

Several studies have aimed to establish if the use of cryotherapy adversely

Cryotherapy has been shown to have no effect on joint position sense or

Another study was designed to determine the effect of ice immersion on

Knowledge concerning the use of heat and/or cold upon muscular

We know that dynamic muscular control mechanism may be altered

Some studies reflect a positive association between cryotherapy and

Prior bouts of eccentric exercise provide a protective effect against

Different methods of cryotherapy have different effects on muscle tissue.

When the physiological processes produced by cryotherapy are examined

changes depend on application method, initial temperature and application time.

Precooling and performance

We need to clarify the effects of pre-cooling on the improvement in

Precooling studies (Marino, 2002) confirm that increasing body heat is a

To examine the effects of different thermoregulatory preparation proce-

min WU procedure had a distinctly detrimental effect. Cooling procedures in-

Duffield, Dawson, Bishop, Fitzsimons and Lawrence, 2003 conclude

We know that power and functional performance are affected by short-

Joint position sense and neurological effects

Previous studies have suggested that cryotherapy affects neuromuscular

Cryotherapy has also been implicated in decreased afferent proprioception

20 minutes does not have an adverse effect on proprioception and Ingersoll,

It’s been known that cryotherapy has direct physiological effects on

The extent to which joint cooling affects the neuromuscular system is

ice treatment, so patients may be more susceptible to injury for up to 30 minutes

Results of various studies are consistent on the effects on neuromuscular

Experimental models designed to reflect the circumstances of elite athletes

Most studies suggest that a short rewarming time would be beneficial (a

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