In this episode of the Active Ingredients Podcast, Donny and I discuss the efficacy of cryotherapy to help people recover from strenuous exercise. Donny talks about his experience with cryotherapy as an athlete and we discuss what we learned from a dozen a half articles that investigated the effect of cryotherapy in mostly two forms: cold water immersion and nitrogen cooled air in a standing chamber.
Don't worry, you don't need to go to this far!
The Big Takeaway
The body of research is still growing, and it’s still contentious as to whether cooling therapies are effective in reducing muscle soreness, inflammation, and various aspects of sports performance as the design of many of the trials vary which makes it difficult to draw clear conclusions. However, there is a leading trend from the research that cold water immersion can be effective at reducing post-exercise soreness (DOMS) which supports those who have been using it in an athletic setting and those who may be considering using it.
How Can I Use Cryotherapy to Help Me Recover from Soreness?
For cold-water immersion, studies find small to medium effects on improving DOMS anywhere between 48-96 hours following 10-15 minute immersion in 11°C-15°C water after strenuous exercise.
For nitrogen cooled chambers/whole-body cryotherapy, researchers have found mixed results on improving DOMS anywhere between 24-96 hours after strenuous exercise though the reduction in soreness may not be as pronounced as with cold-water immersion. Manufacturers typically recommend around 3 minute applications with temperatures ranging -100°C to -195°C.
From a cost perspective, we find that cold-water immersion is the more economical choice, but slightly less convenient.
At the moment, there is inconsistent evidence supporting improvement in aspects of performance, but some individuals may experience a benefit in returning to baseline performance levels sooner as a result of cryotherapy.
What is the Theory Behind Cryotherapy?
The application of cold causes blood vessels to constrict and is thought to slow down the process of cellular metabolism and damage. This is supposed to help reduce inflammation (swelling and pain). Prolonged application of cold is also an analgesic which further helps in pain control. While these ideas have been the long accepted explanation for the effects of any form of cold therapy, some authors in the studies we looked at pointed to some evidence in animal studies where the application of cold may be detrimental to muscle repair and lead to more deposition of scar tissue, which would make muscle tissue less compliant.
How is the Effectiveness of Cryotherapy Studied?
Most studies we read set out to investigate the effect of cryotherapy in the form of cold water immersion and nitrogen cooled air in a standing chamber. Researchers utilized exercise protocols known to induce muscle damage and measured the following before and after the exercise at various times to to determine how effective cryotherapy was:
Levels of inflammatory markers and proteins in the blood (indicators of muscle damage/breakdown)
Post-exercise soreness levels (DOMS pain levels)
Muscle strength and performance (e.g. % maximum contraction, jump heights)
Our Cryotherapy Article Summaries
We read through a dozen and a half articles to educate and inform us about cryotherapy. Below are the short summaries of what we got out of each study. Remember, always be sure to check with your medical professional if you are uncertain what you should be doing because exposure to extreme cold can be dangerous to some. To see a chiropractic expert that can help guide you through this process, come see your local Kirkland Chiropractor Dr. Frank Wen
Olivier D, Wafa D, Dimitri T, Laurent B, Benoit D. An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis. Frontiers In Physiology, Vol 9 (2018) [serial online]. 2018
The Take Away: The authors investigate the effect of many different types of treatment on DOMS, perceived fatigue, and inflammatory markers of muscle damage by looking at data from 140 studies. In this study they investigate cold water immersion and cold air cryotherapy separately. In regards to cold water immersion, they find a small effect on improving DOMS and that 11-15 minutes at 11°C-15°C was most effective. Cold water immersion in temperatures lower than 15°C have shown to be effective at reducing inflammatory markers. In regards to cold air cryotherapy the authors find that it produces a small effect in reducing DOMS that is best when performed within 24hrs after strenuous exercise, but results vary greatly as echoed in other systematic reviews. Temperatures for cold air cryotherapy ranged from -30°C to -195°C, but the authors cite the Fonda study that demonstrated a positive effect in the -140°C to -195°C range.
Glasgow P, Ferris R, Bleakley C. Original research: Cold water immersion in the management of delayed-onset muscle soreness: Is dose important? A randomised controlled trial. Physical Therapy In Sport [serial online]. November 1, 2014;15:228-233.
The Take Away: The authors in this study investigate the effect of various dosages of cold water immersion (CWI) on DOMS. They used 50 participants and split them into Short contrast immersion (1 min 38°C /1 min 10°C x 3), Short intermittent CWI (1 min x 3 at 10°C), 10 min CWI in 10°C, 10 min CWI in 6°C or control (seated rest). DOMS was induced in the hamstrings using a standing curl machine. The participants were submerged up to the waist for the CWI applications. The authors find that treatment duration, water temperature, or dosage of post exercise water immersion had no significant difference in effect on DOMS, but there may be a trend that 10 minutes or more may be associated with less soreness.
Snyder J, Ambegaonkar J, Winchester J. Cryotherapy for Treatment of Delayed Onset Muscle Soreness. INTERNATIONAL JOURNAL OF ATHLETIC THERAPY AND TRAINING [serial online]. 2011:28.
The Take Away: The authors review 15 studies to determine the effectiveness of cryotherapy on alleviating DOMS. The studies they looked at utilized cold-water immersion, ice massage, and ice packs. The authors conclude that is unclear if cryotherapy is effective due to mixed results from the studies.
Clifford T, Abbott W, Kwiecien S, Howatson G, McHugh M. Cryotherapy Reinvented: Application of Phase Change Material for Recovery in Elite Soccer. International Journal Of Sports Physiology & Performance [serial online]. May 2018;13(5):584-589.
The Take Away: In this study, the researchers investigate phase change material (PCM) to cool the body. This material is capable of maintaining a temperature of 15°C for 3 hours and can be fitted into various wraps for different parts of the body. In this study, the researchers tested the efficacy of PCM cooled to 15°C on the quadriceps muscles of a team of elite soccer players for 3 hours after a match. The control was PCM at ambient temperature. The researchers investigated muscle soreness, countermovement jump height, and maximum voluntary isometric contraction (MVIC) of the quadriceps 84 hours before the match and at 12, 36, and 60 hours after the match. The authors found that PCM helped restore MVIC close to baseline levels, slightly increased countermovement jump height over baseline levels, and reduce muscle soreness at 36 and 60 hours. They conclude that PCM can be a novel alternative to CWI due to its portability.
Crystal N, Townson D, Cook S, LaRoche D. Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise. European Journal Of Applied Physiology [serial online]. October 2013;113(10):2577-2586.
The Take Away: The authors compare a 20 minute ice water bath (5°C /41°F) to no treatment on inflammatory markers (CCL2 - Chemokine Ligand 2, one byproduct of muscle cell damage), strength, swelling, and soreness after a 40-minute downhill run which is known to induce inflammation and damage to muscles. They found no significant difference in the maximum voluntary contraction for the knee extensors, no significant difference in soreness levels, no significant difference in thigh girth, and no significant difference in CCL2 levels between the two groups. They conclude that 20 minute ice baths are not effective in helping in exercise recovery.
Klich S, Krymski I, Michalik K, Kawczyński A. Effect of short-term cold-water immersion on muscle pain sensitivity in elite track cyclists. Physical Therapy In Sport [serial online]. July 2018;32:42-47.
The Take Away: The authors study the effect of cold water immersion (CWI) on pain pressure threshold (PPT) of the anterior and posterior thigh and calves of elite cyclists. The cyclists were subjected to 3 maximum sprints after a 20 minute warm-up on the bike to induce muscle soreness, lowering pain pressure thresholds. PPT was measured before the workout, immediately after the workout before CWI, 1 hour after CWI, and 12 hours after CWI. The cold water immersion was performed once with the lower extremity submerged for 5 minutes in 5°C of water. The authors find that CWI may can help restore a degree of pain pressure threshold in the thighs of elite cyclists.
Elias G, Wyckelsma V, Varley M, McKenna M, Aughey R. Effectiveness of Water Immersion on Postmatch Recovery in Elite Professional Footballers. INTERNATIONAL JOURNAL OF SPORTS PHYSIOLOGY AND PERFORMANCE [serial online]. 2013:243.
The Take Away: The authors of this study compare the effect of a 14-minute cold water bath (12° C), contrast baths (7 x 1-min in 12° C / 7 x 1-min in 38° C), and no bath had on repeated sprint times, static jumping, counter movement jumping, soreness, and fatigue on Australian Footballers after a regular match. It was found that cold water bath was able to restore sprinting speed, mitigate declines in jumping performance, and reduce soreness and fatigue 48 hours later compared to contrast baths and no baths.
Costello J, Algar L, Donnelly A. Effects of whole-body cryotherapy (-110 °C) on proprioception and indices of muscle damage. Scandinavian Journal Of Medicine & Science In Sports [serial online]. April 2012;22(2):190-198.
The Take Away: The researchers in this study investigate, 1. the effect of WBC on joint control at the knee and strength of the quadriceps without a damaging exercise prior and, 2. the effect of WBC on post-workout soreness and strength in the quadriceps. They find that WBC does not negatively affect joint control at the knee and is not helpful in restoring strength nor in reducing the time it takes to recover from muscle soreness.
Fonda B, Sarabon N. Effects of whole-body cryotherapy on recovery after hamstring damaging exercise: A crossover study. SCANDINAVIAN JOURNAL OF MEDICINE AND SCIENCE IN SPORTS [serial online]. 2013:e270.
The Take Away: The authors investigate the effect of WBC vs. no WBC on inflammatory markers (CK, LDH), pain, jump height, and jump power at 1 hr, 24hrs, 48hrs, 72hrs, 96 hrs, and 120 hrs after making subjects perform a damaging exercise protocol that utilized drop jumps and eccentric hamstring exercises. The application of WBC was 3 minutes in a cryo-cabin between -140°C to -195°C. The authors found statistically significant differences in pain between WBC (lower) and no WBC from 1-72 hrs, and statistically significant differences in jump height and power between WBC and no WBC at some points between 1-96 hrs. However, the differences were not practically significant. The authors conclude that their results are not completely supportive of using WBC for recovery after strenuous training.
Torres R, Ribeiro F, Alberto Duarte J, Cabri J. Literature review: Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: Systematic review and meta-analysis. Physical Therapy In Sport [serial online] 2012:101.
The Take Away: In this systematic review, the authors investigate several types of treatment on muscle soreness and performance. In regards to cryotherapy, the authors selected 10 studies that investigated the effects of cryotherapy after various experimental conditions that induced muscle damage. These were a soccer match, shuttle run, elbow flexor contractions, drop jumps, knee extensions, and countermovement jumps. Four out of the ten studies demonstrated a positive effect of cryotherapy on reducing inflammatory markers, strength, and soreness. The remaining studies demonstrated no significant effect of cryotherapy. While there are some positive findings in helping soreness and strength, the authors note that the studies are too different to be able to conclude if cryotherapy is beneficial.
Ferreira-Junior J, Bottaro M, Bemben M, et al. One session of partial-body cryotherapy (-110 °C) improves muscle damage recovery. Scandinavian Journal Of Medicine & Science In Sports [serial online]. October 2015;25(5):e524-e530.
The Take Away: The authors compare effect of one 3 minute application of -110°C air cryotherapy with the head exposed to no treatment on isometric peak torque and soreness of the quadriceps at 24hrs, 48hrs, 72hrs, and 96 hrs after a damaging exercise protocol (5 sets of 20 drop jumps). They find that peak torque and muscle soreness returned to baseline after 96 hrs and 72 hrs respectively, whereas it did not in the control group. The authors suggest that partial-body cryotherapy may be helpful in helping athletes recover from strenuous exercise.
Abaïdia A, Lamblin J, Dupont G, et al. Recovery From Exercise-Induced Muscle Damage: Cold-Water Immersion Versus Whole-Body Cryotherapy. International journal of sports physiology and performance [serial online]. 2017:402.
The Take Away: The authors compare the effect of cold water immersion to whole-body cryotherapy (nitrogen cooled air) on muscle soreness, muscle strength (eccentric & isometric hamstring strength), single leg countermovement jump height, and double leg countermovement jump height after making subjects induce muscle damage using an eccentric hamstring exercise protocol. The most significant and largest difference between the two therapies was cold water immersion helped to restore more jump height in the single and double leg countermovement jump between 48-72 hours.
Torres R, Silva F, Pedrosa V, Ferreira J, Lopes A. The Acute Effect of Cryotherapy on Muscle Strength and Shoulder Proprioception. Journal Of Sport Rehabilitation [serial online]. November 2017;26(6):497-506.
The Take Away: The authors cite prior studies that demonstrate a negative effect of ice on the integrity of sensory and motor control function. They investigate the effect of ice on joint position sense, force sense, ability to detect passive movement, and maximum force production at the shoulder joint. They find that the application of 15 minutes of an ice pack to the shoulder can decrease the subject’s muscle strength (albeit very small), the subject’s acuity in reproducing a set position of shoulder, along with the ability to detect a change in passive movement. Based on the results, they believe this may increase the risk for injury.
Hohenauer E, Taeymans J, Baeyens J, Clarys P, Clijsen R. The Effect of Post-Exercise Cryotherapy on Recovery Characteristics: A Systematic Review and Meta-Analysis. Plos One [serial online]. September 28, 2015;10(9):e0139028.
The Take Away: The authors evaluate and crunch numbers from 36 different studies examining the effect of various cooling strategies on DOMS and Inflammatory Markers (LDH, CK, IL-6, and CRP) after various types of muscle damaging activities. They conclude that cold water immersion cryotherapy is the most effective form of cryotherapy (they looked at studied that looked at ice packs, wraps, cooled air, etc.) in reducing symptoms of DOMS up to 96 hours. The average temperature of the water baths utilized were 10°C with an average time of 14 minutes. There was not enough evidence to demonstrate a reduction in the amount of inflammatory markers. Furthermore, the authors cite studies that suggest that muscle may not be able to be cooled sufficiently enough to decrease inflammation in humans, but where it was achieved in animal studies, it may delay the healing process of damaged muscle and possibly increase scar tissue deposition.
Lorete C, Fontaine R, Welsch L, Hoch J. The Effects of Cold Water Immersion on Postexercise Muscle Soreness and Fatigue. International journal of athletic therapy & training [serial online]. 2016:4.
The Take Away: The authors whittled down 124 articles to 4 that investigated the effect of cold water immersion on soccer and rugby players. They find that there is inconsistent evidence for the application of 10-14 minutes of cold water immersion between 12°C-15°C.
Doeringer J, Colas M, Peacock C, Gatens D. The Effects of Postexercise Cooling on Muscle Performance and Soreness Perception. International journal of athletic therapy & training [serial online]. 2018:73.
The Take Away: In this study the authors study the effect of CWI on muscle soreness, flexibility (Sit N' Reach Box), power(Countermovement Jump Height), agility (5-10-5/Pro Agility), and speed(10m Dash) after subjecting the participants to an exercise protocol involving lower body direction changes, tuck jumps, zig-zag hops, depth jumps, and depth presses. The authors found that the biggest impact of CWI was on pain perception at 24hrs and not so much on performance metrics.
Burgess T, Lambert M. The efficacy of cryotherapy on recovery following exercise-induced muscle damage. International Sportmed Journal [serial online]. June 2010;11(2):258-277.
The Take Away: The authors look at 13 studies to determine the efficacy of cryotherapy (ice massage, ice bag, cold water immersion) on muscle soreness, ROM, muscle function, and proteins associated with muscle damage. While there may be some benefit in reducing muscle soreness and proteins after strenuous exercise they find the data they looked at is equivocal and may not be applicable to elite athletes.
Howatson G, Gaze D, van Someren K. The efficacy of ice massage in the treatment of exercise-induced muscle damage. SCANDINAVIAN JOURNAL OF MEDICINE AND SCIENCE IN SPORTS [serial online]. 2005:416.
The Take Away: The researchers investigate the effect of ice massage on DOMS, muscle strength, creatine kinase, and myoglobin. The authors had subjects perform eccentric exercise of the elbow flexors (3 sets x 10 reps) and applied ice massage with an ice ball for 15 minutes immediately after, 24hrs, and 48hrs after the exercise. They found that compared to a placebo group that received sham ultrasound, there was no significant difference between the two groups in the variables they sought to investigate up to 96 hours after the exercise protocol. The researchers conclude that ice massage may not help speed recovery from exercise as thought.
Costello J, Baker P, Minett G, Bieuzen F, Stewart I, Bleakley C. Cochrane review: Whole-body cryotherapy (extreme cold air exposure) for preventing and treating muscle soreness after exercise in adults. Journal Of Evidence-Based Medicine [serial online]. January 14, 2016
The Take Away: The authors seek out to determine the effectiveness of whole-body cryotherapy (WBC, on reducing muscle soreness after exercise by looking at existing studies. They identify 4 small studies of adequate quality that compare WBC against rest or no WBC. These studies utilized chambers where temperatures were -110C or less with exposure for 3 minutes. No forms other forms of cryotherapy was compared within these studies. The authors find that there may be some benefit from WBC at 1, 24, 48, and 72 hours after but the evidence from these studies is not strong enough for them to feel comfortable supporting its use. They also cite the lack of studies examining the adverse effects that might result from being exposed to such cold temperatures.