Whole-body Cryotherapy, Ice Baths and Warm-Down

Whole-body Cryotherapy, Ice Baths and Warm-Down. What is the evidence in terms of recovery and performance?

Athelete’s and weekend warriors alike often use strategies to prevent or reduce delayed onset muscle soreness (DOMS). DOMS is described as muscle pain, tenderness and stiffness after high-intensity or unaccustomed exercise that lead to muscle damage. ¹ Cryotherapy has traditionally been applied using ice packs or cold-water immersion (CWI). ² It is suggested that by reducing the temperature and blood flow in skeletal muscle, cryotherapy reduces the metabolic rate of inflammation in tissues within and around the injured site. Protecting neighbouring cells against ischaemia. ³ Whole-body cryotherapy (WBC) was originally developed in Japan Dr. Yamauchi to treat chronic medical conditions, such as multiple sclerosis and rheumatoid arthritis, however has recently become popular amongst athletes. ²

Cryotherapy is typically initiated within the early stages (0–24 hours) after exercise.² CWI participants are generally submerged in a seated position to the midsternal level in cold-water baths (14–18°C) for up to 10 minutes. ⁴

WBC involves a single or repeated exposure to extremely cold dry air (usually between −100°C and −140°C) in a specialised chamber for two to four minutes. ¹

Autonomic nervous system

Intense exercise increases sympathetic activity and heart rate, and decreases heart-rate variability. Prolonged sympathetic activity is thought to be detrimental for recovery. ² WBC and CWI has an initial sympathetic effect, however, its summative effect seems to be parasympathetic. ²

Using CWI before and after supramaximal exercise performed in the heat after a single exercise session significantly restored the impaired parasympathetic function to almost pre-exercise levels. ⁴ Likewise, WBC enhances short-term autonomic recovery after intense exercise. ² WBC may be effective in relieving soreness through receptor sensitivity and nerve conduction velocity. ⁴

Tissue temperature reduction

Optimal analgesia is associated with skin temperatures of less than 13°C. CWI and WBC did not reach the critical temperatures necessary to optimise analgesia. However, local cooling can have an addi­tional excitatory effect on muscle activation. This has been observed in both healthy and injured adults and can be an important adjunct to therapeutic exercise. ²

Exposure to –110°C like that of WBC, creates a large thermal gradient between the skin and the environment (∼140°C). Studies have reported similar skin tempera­tures associated with a 4-minute WBC exposure at −110°C (thigh, 17.9°C±1.4°C; knee, 19.0°C±0.9°C) and a 4-minute CWI at 8°C (thigh, 21.3°C±1.2°C; knee, 20.5°C±0.6°C). ²

Interestingly, the largest skin-temperature reductions were associated with crushed-ice application where bony regions such as the patella generally experienced the largest cooling effect. ²

Adipose tissue

Subcutaneous adipose tissue (or the amount of fat you have) has a very low thermal conduc­tivity and has an insulating effect on the body. ² Cooling time needs to be increased as skinfold thickness increases. A 20-minute treatment will produce a typical effect in patients with skinfolds of less than 20mm where as patients with skinfolds between 20 and 30mm require nearly twice as long 38-minutes to produce the same outcome. ⁵ The current common clinical practice of applying cold for 10 to 30 minutes is only adequate for relatively lean patients. ⁵

Perceived and Functional Recovery

The potential psychological benefits of using cold exposure to reduce the subjective feeling of DOMS play an important in the athlete’s recovery. ⁴ WBC and CWI improved sub­jective outcomes, such as perceived recovery and muscle soreness. ^{2 3}

Ziemann et al recorded improved functional recovery associated with WBC within a group of elite tennis players. The athletes incorporating twice-daily exposure to WBC at a 5-day training camp had greater shot accuracy during two testing sessions, compared to an untreated control. ²

Muscle damage and Biomarkers

Two studies reported an enhanced cytokine profile in athletes who used WBC after training exposures. WBC increases nor-epinephrine, which could have an additional analgesic effect. ² Others found little effect of WBC on various markers of muscle damage after exercise training. ² Equally, CWI has little to no effect on markers of inflammation or muscle damage after exercise. ³ Although CWI reduces clinical signs of inflammation such as limb swelling/oedema. ³

In one study after no intervention muscle thickness increased after 24 hours (P < 0.05) and was significantly higher compared with the WBC group at 24 and 96 h (P < 0.05).  When using submaximal muscle function test, participants using WBC compared with 3 min at 21 °C lifted a greater load (P < 0.05, Cohen’s effect size: 1.3, 38%). WBC after resistance exercise allowed the athletes to complete more work during subsequent training sessions, which could enhance long-term training adaptations. ⁶

Active recovery

Active recovery in the form of a low-intensity ‘warm down’ such as 10 minutes cycle or jog is a common strategy that athletes use to recover by removing metabolic by-products in their muscles.³ One study compared the effects of CWI and active recovery on inflammatory and cellular stress responses in skeletal muscle from exercise-trained men 2, 24 and 48 h during recovery after acute resistance exercise. CWI is no more effective than active recovery for minimising the inflammatory and stress responses in muscle after resistance exercise. ³ Nevertheless, CWI consistently improves perceptions of fatigue and muscle soreness and enhances recovery of muscle function/performance following exercise compared with active recovery. ³

Take Home Messages:

1. WBC leads to tissue-temperature reductions that are comparable to CWI. Ice packs are most effective at tissue cooling ²
2. Intense exercise typically results in an increase in sympathetic activity and if prolonged is thought to be detrimental for recovery. ² WBC and CWI restore the impaired parasympathetic function to almost pre-exercise levels. ⁴
3. Although WBC improves the perception of recovery and soreness, this does not seem to translate into enhanced functional recovery. ²
4. Periodic use of CWI may assist athletes when they need to recovery quickly between training sessions or competitive events. ³
5. Athletes should remain conscious that less expensive modes of cryotherapy, such as local ice-pack application or CWI, offer comparable physi­ological and clinical effects to WBC. ²

Loulou Negoescu
Physiotherapist

Featured in the Top 50 Physical Therapy Blog

Resources

1. Costello JT, Baker PR, Minett GM, Bieuzen F, Stewart IB, Bleakley C. Cochrane review: Whole-body cryotherapy (extreme cold air exposure) for preventing and treating muscle soreness after exercise in adults. J Evid Based Med. 2016; DOI:10.1111/jebm.12187.
2. Bleakley CM, Bieuzen F, Davison GW, Costello JT. Whole-body cryotherapy: empirical evidence and theoretical perspectives. Open Access J Sports Med. 2014; 5:25-36. DOI:10.2147/OAJSM.S41655.
3. Peake JM, Roberts LA, Figueiredo VC, Egner I, Krog S, Aas SN, et al. The effects of cold water immersion and active recovery on inflammation and cell stress responses in human skeletal muscle after resistance exercise. The Journal of Physiology. 2017; 595(3):695-711. DOI:10.1113/JP272881.
4. Buchheit M, Peiffer JJ, Abbiss CR, Laursen PB. Effect of cold water immersion on postexercise parasympathetic reactivation. Am J Physiol Heart Circ Physiol. 2009; 296(2):H421-7. DOI:10.1152/ajpheart.01017.2008.
5. Otte JW, Merrick MA, Ingersoll CD, Cordova ML. Subcutaneous adipose tissue thickness alters cooling time during cryotherapy. Archives of Physical Medicine and Rehabilitation. [cited 2017/05/23]; 83(11):1501-1505. DOI:10.1053/apmr.2002.34833.
6. Ferreira-Junior JB, Bottaro M, Vieira A, Siqueira AF, Vieira CA, Durigan JL, et al. One session of partial-body cryotherapy (-110 degrees C) improves muscle damage recovery. Scand J Med Sci Sports. 2015; 25(5):e524-30. DOI:10.1111/sms.12353.

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