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Whole-body cryotherapy (WBC) involves short exposures to air temperatures below -100°C. WBC is increasingly accessible to athletes, and is purported to enhance recovery after exercise and facilitate rehabilitation postinjury. Our objective was to review the efficacy and effectiveness of WBC using empirical evidence from controlled trials. We found ten relevant reports; the majority were based on small numbers of active athletes aged less than 35 years. Although WBC produces a large temperature gradient for tissue cooling, the relatively poor thermal conductivity of air prevents significant subcutaneous and core body cooling. There is weak evidence from controlled studies that WBC enhances antioxidant capacity and parasympathetic reactivation, and alters inflammatory pathways relevant to sports recovery. A series of small randomized studies found WBC offers improvements in subjective recovery and muscle soreness following metabolic or mechanical overload, but little benefit towards functional recovery. There is evidence from one study only that WBC may assist rehabilitation for adhesive capsulitis of the shoulder. There were no adverse events associated with WBC; however, studies did not seem to undertake active surveillance of predefined adverse events. Until further research is available, athletes should remain cognizant that less expensive modes of cryotherapy, such as local ice-pack application or cold-water immersion, offer comparable physiological and clinical effects to WBC.
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Open Access Full Text Article
http://dx.doi.org/10.2147/OAJSM.S41655
Whole-body cryotherapy: empirical
evidence and theoretical perspectives
Chris M Bleakley1
François Bieuzen2
Gareth W Davison1
Joseph T Costello3
1Sport and Exercise Science Research
Institute, Faculty of Life and Health
Sciences, University of Ulster,
Newtownabbey, Northern Ireland;
2Research Department, Laboratory
of Sport, Expertise and Performance,
French National Institute of Sport
(INSEP), Paris, France; 3S chool of
Exercise and Nutrition Sciences and
Institute of Health and Biomedical
Innovation, Queensland University of
Technology, Brisbane, Australia
Correspondence: Chris Bleakley
Ulster Sports Academy, University of
Ulster, Newtownabbey, County Antrim,
BT370QB, Northern Ireland
Tel +44 28 9036 66025
Email c.bleakley@ulster.ac.uk
Abstract: Whole-body cryotherapy (WBC) involves short exposures to air temperatures
below –100°C. WBC is increasingly accessible to athletes, and is purported to enhance recovery
after exercise and facilitate rehabilitation postinjury. Our objective was to review the efficacy
and effectiveness of WBC using empirical evidence from controlled trials. We found ten
relevant reports; the majority were based on small numbers of active athletes aged less than
35 years. Although WBC produces a large temperature gradient for tissue cooling, the relatively
poor thermal conductivity of air prevents significant subcutaneous and core body cooling.
There is weak evidence from controlled studies that WBC enhances antioxidant capacity and
parasympathetic reactivation, and alters inflammatory pathways relevant to sports recovery.
A series of small randomized studies found WBC offers improvements in subjective recovery
and muscle soreness following metabolic or mechanical overload, but little benefit towards
functional recovery. There is evidence from one study only that WBC may assist rehabilitation
for adhesive capsulitis of the shoulder. There were no adverse events associated with WBC;
however, studies did not seem to undertake active surveillance of predefined adverse events.
Until further research is available, athletes should remain cognizant that less expensive modes
of cryotherapy, such as local ice-pack application or cold-water immersion, offer comparable
physiological and clinical effects to WBC.
Keywords: whole-body cryotherapy, cooling, recovery, muscle damage, sport
Introduction
Cryotherapy is defined as body cooling for therapeutic purposes. In sports and
exercise medicine, cryotherapy has traditionally been applied using ice packs or
cold-water immersion (CWI) baths. Recently, whole-body cryotherapy (WBC) has
become a popular mode of cryotherapy. This involves exposure to extremely cold
dry air (usually between 100°C and 140°C) in an environmentally controlled
room for short periods of time (typically between 2 and 5 minutes). During these
exposures, individuals wear minimal clothing, gloves, a woolen headband cover-
ing the ears, a nose and mouth mask, and dry shoes and socks to reduce the risk of
cold-related injury. Although it was originally developed to treat chronic medical
conditions, such as multiple sclerosis and rheumatoid arthritis,1 WBC is being
increasingly employed by athletes. Its purported effects include decreased tissue
temperature, reduction in inflammation, analgesia, and enhanced recovery follow-
ing exercise. WBC is typically initiated within the early stages (within 0–24 hours)
after exercise and may be repeated several times in the same day or multiple times
over a number of weeks.
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Bleakley et al
WBC is becoming increasingly accessible for athletes.
It is considerably more expensive than traditional forms of
cryotherapy, but it is not clear whether it offers any addi-
tional clinical effect. A recent review by Banfi et al2 found
observational evidence that WBC modifies many important
biochemical and physiological parameters in human athletes.
These include a decrease in proinflammatory cytokines, adap-
tive changes in antioxidant status, and positive effects on
muscular enzymes associated with muscle damage (creatine
kinase and lactate dehydrogenase). They also concluded that
exposure to WBC is safe and does not deleteriously effect
cardiac or immunological function. However, when this
review2 was published, few randomized trials examining
the efficacy of the treatment had been completed. Further,
the conclusions were predominantly based on lower-quality
observational studies, which did not include a control group
and therefore should be treated with caution.
A common supposition is that the extreme nature of
WBC offers significant advantages over traditional methods
of cooling, such as CWI or ice-pack application. Recently,
there has been a large increase in the volume of research
investigating the effects of WBC. Our aim is to update the
evidence base, with a particular focus on reviewing empiri-
cal evidence derived from controlled studies. The objectives
were: 1) to quantify the tissue-temperature reductions associ-
ated with WBC and compare these with traditional forms of
cryotherapy; 2) to examine the biochemical and physiologi-
cal effects of WBC exposure compared to a control, and to
determine any associated adverse effects; and 3) to consider
the strength of the clinical evidence base supporting its use
in sports recovery and soft-tissue injury management.
Materials and methods
A literature search was undertaken using Medline, Embase, and
the Cochrane Controlled Trials Register up to October 2013.
For our first objective, we sourced any studies quantifying
temperature reductions associated with WBC. We extracted
data (mean ± standard deviation) on skin, intramuscular, and
core-temperature reductions induced by WBC. No restrictions
were made on the temperature-measurement device. For com-
parison, we used a convenience sample of studies reporting
tissue-temperature reductions induced by ice-pack application
(crushed ice) and CWI based on durations of 10 minutes and
5 minutes, respectively. These durations were selected as they
align well with current clinical practice.3,4
For our second objective, we focused on studies fulfilling
the following inclusion criteria: controlled studies comparing
WBC intervention to a control group (observational studies
and studies using within-subject designs were excluded); the
temperature of exposure had to have been at least 100°C,
though there were no restrictions placed on the number of
exposures; participants could be healthy, or recovering from
exercise or soft-tissue injury at the time of the intervention; no
restrictions were made on participants’ age, sex, or training
status. We extracted all data relating to biochemical, physi-
ological, or performance/clinical outcomes.
Key study characteristics were extracted by the primary
researcher and tabulated. Outcomes were subgrouped into
biochemical, perceived sensation, and performance-based
measures. We were particularly interested in between-group
differences based on follow-up scores. Where possible, effect
sizes (standardized mean differences [MDs] and 95% confi-
dence intervals [CIs]) were calculated from group means and
standard deviations, using RevMan software (version 5.2;
Nordic Cochrane Centre, Copenhagen, Denmark).
Characteristics of controlled studies
Key study characteristics5–14 are summarized in Table 1.
Three studies8,10,13 used randomized controlled designs, with
all incorporating high-quality methods based on computer-
generated randomization, allocation concealment, and blinded
outcome assessment. The remainder of the studies5–7,9,11,12,14
used controlled or crossover designs, with washout periods
varying between 37 and 16 weeks.5
The majority of studies were undertaken using young,
active participants with mean ages under 35 years. Just under
40% of participants were females. Four studies recruited
high-performance athletes.5–8 In three studies,9,10,12 the objec-
tive was simply to examine the effect of WBC compared to
an untreated control intervention using a sample of healthy
participants. Six studies5–8,10,11 used WBC either in the early
stages after exercise or intermittently throughout a particular
training block. One study13 investigated the clinical effective-
ness of WBC using a sample of participants with adhesive
capsulitis of the shoulder joint.
In all studies, the WBC intervention involved a brief
exposure to an acclimatization chamber or prechamber
before entering a therapy chamber at –110°C to –195°C for
2.5–3 minutes. The total number of treatment sessions varied
between one session on a single day12 up to 20–24 sessions
over a period of weeks.5,13
Results
Tissue-temperature reductions
Table 2 shows the relative temperature reductions associated
with typical applications of ice packs, CWI, and WBC.12,15–29
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Whole-body cryotherapy
Table 1 Study characteristics
Study design Participants WBC
(control)
Outcomes
Higher values in WBC
(vs control)
Lower values in
WBC (vs control)
No between-group
differences
Mila-Kierzenkowska
et al5
Crossover study
(4-month washout)
n=9 Olympic-level kayakers
undertaking a 10-day training cycle
(all female, mean age 23.9±3.2 years)
Cointerventions
Antioxidant supplementation
n=9 exposed to –120°C to –140°C
for 3 minutes; 20 sessions in total:
twice per day over a 10-day period
(n=9 no WBC)
Catalase
TBARS
Superoxide dismutase
Glutathione peroxidase
Hausswirth et al6
Randomized crossover
study (3-week washout)
n=9 well-trained runners undertaking
a simulated 48-minute trail run (all
male, mean age 31.8±6.5 years)
n=9 exposed to –110°C for 3 minutes;
3 sessions in total: immediately,
24, and 48 hours postexercise
(n=9 seated rest)
Strength Pain
Tiredness
Creatine kinase
Pournot et al7
Randomized crossover
study (3-week washout)
n=11 trained runners undertaking
a simulated 48-minute trail run (all
male, mean age 31.8±6.5 years)
n=11 exposed to –110°C for
3 minutes; 4 sessions in total:
immediately, 24, 48, and 72 hours
postexercise
(n=11 seated rest)
IL-1ra CRP IL-1β
IL-6
IL-10
TNFα
Leukocyte count
Ziemann et al8
Randomized
controlled trial
n=12 professional male tennis players
undertaking moderate-intensity
training for 5 days (all male, mean age
20±2 years control, 23±3 years WBC)
n=6 exposed to –120°C for 3 minutes;
10 sessions in total: twice per day over 5
days (n=6 no WBC)
IL-6
Tennis-stroke
effectiveness
TNFαCreatine kinase
Leukocyte count
Cortisol
Testosterone
Miller et al9
Controlled trial
n=94 healthy participants (46 male,
48 female, mean age 37.5±3.1 years
WBC, 37.9±2.1 years control)
n=46 exposed to –130°C for
3 minutes; 10 sessions in total:
1 session per day over 10 days
(n=48 no WBC)
Total antioxidant status
Superoxide dismutase
Uric acid
TBARS
Costello et al10
Randomized
controlled trial
n=36 healthy participants (24 male,
12 female, mean age 20.8±1.2 years)
n=16 exposed to –110°C for
3 minutes; 2 sessions in a single day,
2 hours apart (n=16 exposed to 15°C)
Joint positional sensea
MVIC
Costello et al10
Randomized
controlled trial
n=18 participants (4 female,
14 male, mean age 21.2±2.1 years)
undertaking 100 high-force maximal
eccentric contractions of the left
knee extensors
n=9 exposed to –110°C for 3 minutes;
2 sessions in a single day, 2 hours
apart (n=9 exposed to 15°C)
MVIC
Pain
Peak power output
Fonda and Sarabon11
Randomized crossover
(10-week washout)
n=11 participants (all male, mean age
26.9±3.8 years) undertaking high-load
and eccentric lower-limb exercises
n=11 exposed to –140°C to –195°C
for 3 minutes; 6 sessions in total:
1 per day over 6 days (n=11 no WBC)
Pain at rest
Pain on squat
Creatine kinase
Lactate dehydrogenase
Aspartate aminotransferase
Performanceb
Hausswirth et al12
Controlled trial
n=40 healthy participants (all
male; mean age 33.9±12.3 years
control, 34.6±11.5 years WBC,
33.3±13.8 years PBC)
n=15 exposed to –110°C WBC for
3 minutes; n=15 exposed to –160°C
PBC for 3 minutes; (n=10 seated rest)
Norepinephrine
Dopamine (WBC)
Heart-rate variability
Epinephrine
Dopamine (PBC)
(Continued)
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Bleakley et al
Table 1 (Continued)
Study design Participants WBC
(control)
Outcomes
Higher values in WBC
(vs control)
Lower values in
WBC (vs control)
No between-group
differences
Ma et al13
Randomized
controlled trial
n=30 participants with adhesive
capsulitis of the shoulder joint
(24 female, 6 male, mean age
57.2±6.6 years)
n=15 exposed to –110°C for
4 minutes; 24 sessions in total:
2 sessions per day, 3 times per week
over 4 weeks plus standard physiotherapy
treatment (n=15 standard physiotherapy
treatment only)
ROM
Function
Pain
Schall et al14
Randomized crossover
(1-week washout)
n=11 participants (all female, mean
age 20.3±1.8 years) undertaking
a 3-minute-maximum swimming
exercise bout
n=9 exposed to –110°C for 3 minutes;
1 session immediately after exercise
(n=9 30 minutes of passive recovery)
Indices of heart-rate variability
Metabolic recovery (lactate
VO2 peak)
Subjective recovery
Performance (subjective
judging in synchronized
swimming)
Notes: aAbsolute, relative, and variable error; bcountermovement jump, power, strength.
Abbreviations: WBC, whole-body cryotherapy; vs, versus; TBARS, thiobarbituric acid reactive substances; IL, interleukin; ra, receptor antagonist; CRP, C-reactive protein; TNF, tumor necrosis factor; MVIC, maximum voluntary
isometric contraction; PBC, partial body cryotherapy; ROM, range of movement.
Table 2 Tissue-temperature reductions by cooling modalities
Ice pack
(10 minutes)
CWI
(4–5 minutes,
8°C–10°C)
WBC
(3 minutes)
Skin
temperature
18b,15 6.2 (0.5)24 3.5–8.727
20a,16 8.4 (0.7)25 6.7b,28
20b,17 9.0 (0.8)26 8.1 (0.4)c,12
2018 12.1 (1.0)25
22a,b,19 10.3 (0.6)26
25.7–26.420 13.7 (0.7)12
19.4b,29
Intramuscular
temperature
(2 cm depth)
1.76 (1.37)21 1.7 (0.9)25 1.2 (0.7)25
2.0a,16
2.0a,b,19
2.7b,15
3.88 (1.83)22
Core
temperature
0a,16 0.2 (0.1)24 029
023 0.4 (0.2)25 0.3 (0.2)25
Notes: aData extracted from graphs with permission: Arch Phys Med Rehabil,
2001;82, Jutte LS, Merrick MA, Ingersoll CD, Edwards JE. The relationship between
intramuscular temperature, skin temperature, and adipose thickness during cryo-
therapy and rewarming. 845–850.16 © 2001 with permission from Elsevier; and
Merrick MA, Jutte LS, Smith ME. Cold modalities with different thermodynamic
properties produce different surface and intramuscular temperatures. J Athl Train.
2003;38:28–33.19 bstandard deviation not available. cPBC. All values are degrees
celsius (means ± standard deviation).
Abbreviations: CWI, cold-water immersion; WBC, whole-body cryotherapy;
PBC, partial body cryotherapy (head out).
The largest skin-temperature reductions seemed to be associ-
ated with ice-pack application. The skin-temperature reduc-
tions associated with CWI and WBC seemed to vary slightly
across studies. Two studies25,26 reported similar skin tempera-
tures 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).
Table 2 clearly highlights that subcutaneous tissue temperature
reductions were consistently small regardless of the cooling
medium. Intramuscular temperatures at 2 cm depth were rarely
cooled below 2°C. Again, there were trends that ice packs
induced slightly larger intramuscular temperature reductions
in comparison to CWI and WBC. Core-temperature reductions
were consistently small across all cooling modes.
Inammatory biomarkers
Pournot et al7 compared a WBC intervention to a passive
control after an intense simulated trail run using high-level
athletes. Levels of inflammatory biomarkers (interleukin
[IL]-1β, IL-1 receptor antagonist [ra], IL-6, IL-10, tumor
necrosis factor [TNF]-α, and leukocytes) during the 4-day
recovery period were generally similar in each group. The
largest between-group differences were higher IL-1ra imme-
diately after the first exposure, and lower concentration of
C-reactive protein at 24, 48, 72, and 96 hours postexercise
within the WBC condition. In a small study, Ziemann et al8
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Whole-body cryotherapy
randomized professional tennis players to undertake twice-
daily WBC or no intervention during a 5-day training camp.
Two of the participants in this study could not be randomized
due to contraindications to WBC and were therefore prese-
lected for the control intervention. Their results showed an
enhanced cytokine profile within the WBC group, with lower
levels of TNFα and a higher concentration of IL-6.
Muscle damage
There was evidence from three studies6,8,11 that WBC does
not affect markers of muscle damage after exercise. These
studies found few differences between WBC and control
groups in creatine kinase, lactate dehydrogenase, and aspar-
tate aminotransferase during recovery from exercise-induced
muscle damage (EIMD),11 intense running,6 or 5 days of
moderate-intensity tennis training.8
Oxidative stress
Miller et al9 examined oxidative stress and antioxidant
function using a group of nonexercising participants. The
results showed an increase in antioxidant status associated
with WBC in comparison to the untreated control group;
however, there were only small between-group differences
in relation to lipid peroxidation. As oxidative stress and
antioxidant function were quantified at two different sites (ie,
vascular and intracellular), it is difficult to conclude a strong
relationship between WBC and free radical production. In
a crossover study, Mila-Kierzenkowska et al5 examined
antioxidant status in Olympic kayakers undertaking training
cycles both with and without WBC stimulation (twice per
day). Results showed an attenuation of oxidative stress as
measured by lipid peroxidation in the WBC group over the
course of a 10-day training bout. This finding did not align
with the majority of the athletes’ enzymatic profiles (super-
oxide dismutase and glutathione peroxidase), which were
also surprisingly lower in the WBC condition in comparison
to the exercise-only condition.
Autonomic nervous system
Hausswirth et al12 reported significant increases in nor-
epinephrine concentrations in the immediate stages after
cryostimulation compared to resting controls. They found
similar between-group differences in resting vagal-related
heart-rate variability indices (the root-mean-square differ-
ence of successive normal R–R intervals, and high-frequency
band). An interesting caveat was that the magnitude of these
effects was reduced when participants substituted WBC for
a partial body cryostimulation that did not involve head
cooling. Another randomized study12 examined the effects
that WBC has on autonomic function, with a primary focus on
parasympathetic reactivation after two maximal synchronized
swimming bouts. Comparisons were made against active,
passive, and contrast water-therapy conditions. The WBC
condition (3 minutes at 110°C) had the largest influence
on parasympathetic reactivation, with large increases across
a range of similar heart-rate variability indices.
Perceived and functional recovery
Using a randomized controlled design, Costello et al10 found
that 3-minute exposures at 110°C had little effect on joint
positional sense and muscle function compared to control
exposures at 15°C. A follow-up study within the same report10
examined the effectiveness of WBC compared to resting con-
trol using a subgroup of participants exposed to EIMD: results
showed few differences between groups in terms of participants’
strength, power, and muscle soreness. Fonda and Sarabon11 also
investigated the effects of WBC on functional recovery after
EIMD, but incorporated a more intense cooling dose based on
temperatures of 195°C, using a liquid nitrogen system, and
treatment up to 6 days postexercise. These investigators also
found few significant differences between groups in relation to
strength and power output; however, they reported significantly
lower muscle soreness in favor of WBC. It is important to con-
sider that Costello et al10 incorporated a randomized controlled
design, allocation concealment, and blinded outcome assessor,
and was less open to selection and reporting bias.
Two studies investigated the effects of WBC on functional
recovery after running- or sporting-based activities. Hausswirth
et al6 found that undertaking WBC immediately and at 24 and
48 hours after intense trail running resulted in significant
improvements in strength, pain, and subjective fatigue compared
to untreated controls. Ziemann et al8 also recorded improved
functional recovery associated with WBC within a group of elite
tennis players. They found that athletes incorporating twice-daily
exposure to 120°C during a 5-day training camp had greater
shot accuracy during two testing sessions, compared to an
untreated control. These findings may be subject to detection
bias, as blinded outcome assessors were not employed.
Schaal et al14 found that compared to a passive control,
a single WBC exposure (3 minutes at 110°C) enhanced
subjective and metabolic recovery (based on blood lactate and
VO2max) after intense bouts of swimming. This study found
few differences when comparisons were made to an active
recovery condition. Figures 1 and 2 provide a summary of the
effects of WBC on perceived and functional recovery after
exercise when compared to control intervention.
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Bleakley et al
Clinical outcomes
One study13 examined the effectiveness of WBC on recovery
from a musculoskeletal injury. Participants with adhesive cap-
sulitis were randomized to receive either physiotherapy alone or
physiotherapy in addition to WBC. After 4 weeks of treatment,
both groups improved in terms of pain, shoulder function, and
range of movement (ROM). Between-group comparisons were
significantly in favor of WBC for all outcomes; in most cases,
these were clinically meaningful with large mean differences in
ROM (MD 13° abduction, 95% CI 9.2°–16.8°; MD 5° external
rotation, 95% CI 3.2°–6.7°), pain (MD, 1.2 cm, 95% CI 0.8–1.6,
based on a 10 cm visual analog scale), and shoulder function
(MD 4 points, 95% CI 3.1–4.9, based on a 30-point scale). Of
note, this study13 did not continue outcome assessment beyond
the 4 weeks of treatment; therefore, any long-term effective-
ness is unclear.
Discussion
This review examined the biochemical, physiological, and
clinical effects of WBC. We found that most of the research in
Study or subgroup
1.3.1 pain at rest 24 hours
Costello
10
Fonda
11
Hausswirth
6
1.3.2 pain at rest 48 hours
Costello
10
Fonda
11
Hausswirth
6
1.3.3 pain at rest 72 hours
Costello
10
Fonda
11
1.3.4 pain at rest 96 hours
Costello
10
Fonda
11
1.3.5 pain on movement 24 hours
Fonda
11
1.3.6 pain on movement 48 hours
Fonda
11
1.3.7 pain on movement 72 hours
Fonda
11
1.3.8 pain on movement 96 hours
Fonda
11
1.3.9 tiredness at 24 hours
Hausswirth
6
1.3.10 tiredness at 48 hours
Hausswirth
6
Standardized mean difference
IV, fixed, 95% CI
−4 −2 0 2 4
Favors WBC Favors control
Figure 1 Forest plot of perceived sensation.
Abbreviations: IV, inverse variance; CI, condence interval; WBC, whole-body cryotherapy.
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Whole-body cryotherapy
this area has been undertaken using small groups of younger
(predominantly male) participants. In over half of the stud-
ies, the primary objective was to determine mechanisms of
effect associated with WBC based on biochemical markers.
A small number of studies focused on perceived recovery
and performance-based measurement after various sport and
exercise exposures. Only one study investigated the clinical
effectiveness of WBC based on participants with significant
musculoskeletal injury.
Tissue-temperature reduction
The premise of cryotherapy is to extract heat from the body
tissue to attain various clinical effects. To optimize these
effects, the best evidence suggests that a critical level of tissue
Study or subgroup
1.2.1 jump height 24 hours
Fonda11
1.2.2 jump height 48 hours
Fonda
11
1.2.3 jump height 72 hours
Fonda
11
1.2.4 jump height 96 hours
Fonda
11
1.2.5 strength 24 hours
Fonda11
Hausswirth6
1.2.6 strength 48 hours
Fonda11
Hausswirth6
1.2.7 strength 72 hours
Fonda11
1.2.8 strength 96 hours
Fonda11
1.2.9 tennis performance (shot accuracy)
Ziemann8
Standard mean difference
IV, fixed, 95% CI
−4 −2 0 2 4
Favors WBC Favors control
Figure 2 Forest plot of performance outcomes.
Abbreviations: IV, inverse variance CI, condence interval; WBC, whole-body cryotherapy.
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Bleakley et al
cooling must be achieved.30,31 As such, a key objective of this
review was to determine the magnitude of tissue-temperature
reductions associated with WBC and to compare with tra-
ditional forms of cooling (ice pack, CWI) used in sport and
exercise medicine.
There is a supposition that because of its extreme
temperatures (–110°C), WBC offers an enhanced cool-
ing effect over traditional forms of cryotherapy. It is clear
that exposure to –110°C creates a large thermal gradient
between the skin and the environment (140°C). However,
heat transfer depends on a number of additional factors. For
example, thermal conductivity or heat-transfer coefficient
(k = W/m2K) is the ability of a material to transfer heat.
Ice has a much higher heat-transfer coefficient (2.18 k)
compared to both water (0.58 k) and air (0.024 k), mean-
ing that it is a more efficient material for extracting heat
energy from the body. Ice application also exploits phase
change (change from solid into liquid), further enhancing
its cooling potential. Although water and air are not the
best media to transfer heat, a potential advantage is that
they facilitate large surface areas of the body to be cooled
simultaneously.
Comparisons across empirical studies suggest that the
largest skin-temperature reductions are usually associated
with crushed-ice application. Temperature reductions
associated with CWI and WBC seem less intense, and in
some reports these did not reach the critical temperatures
necessary to optimize analgesia.30 Of note, intramuscular
temperature reductions seem to be negligible, regardless
of the mode of cooling. To date, only one study25 has
examined the effect of WBC on intramuscular temperature,
and future research addressing this gap in the literature is
warranted.
The thermal properties of biological tissue mean that it
is fundamentally difficult to cool below the skin surface.
Subcutaneous adipose tissue has a very low thermal conduc-
tivity (0.23 k; by comparison, muscle has a value of 0.46 k),32
causing it to have an insulating effect on the body. To our
knowledge, the largest intramuscular temperature reduc-
tion (1 cm depth) reported in the clinical literature is 7°C33;
interestingly, this was observed with an 8-minute ice-pack
application in a sample of healthy participants with very low
levels of adipose tissue (0–10 mm skin folds at the site of
application). We have also recently demonstrated34 that the
magnitude of temperature reduction also varies by body part,
with bony regions such as the patella generally experiencing
the largest reductions in tissue temperature.
Adverse events
We found no evidence of adverse effects within the current
review. However, in accordance with previous reviews in
this area,4,35 the majority of included studies did not seem to
undertake active surveillance of predefined adverse events.
Westerlund36 noted that no adverse effects had occurred
during 8 years of WBC use within a specialist hospital in
Finland. In recent years, a small number of isolated prob-
lems associated with WBC (eg, skin burns on the foot) have
been publicized within the media; these events have been
attributed to oversights during preparation, such as entering
the chamber with wet skin or clothing. The skin surface has
been reported to freeze from 3.7°C to –4.8°C,37 with serious
cellular damage and cryotherapy skin burns occurring at a
threshold of around –10°C.38 As few studies have reported
skin-temperature reductions beyond 15°C with WBC, exces-
sive tissue-temperature reductions seem unlikely, provided
adequate procedures for patient preparation are followed,
and relevant contraindications are adhered to: uncontrolled
hypertension, serious coronary disease, arrhythmia, circula-
tory disorders, Raynaud’s phenomenon (white fingers), cold
allergies, serious pulmonary disease, or the obstruction of
the bronchus caused by the cold.36
Biomarkers
There is evidence from animal models to suggest that cryo-
therapy can have a consistent effect on some important cellular
and physiological events associated with inflammation after
injury. These include cell metabolism, white blood cell activ-
ity within the vasculature, and potentially apoptosis.39–44 Few
studies have replicated these effects within human models.
We highlighted two studies reporting an enhanced cytokine
profile in athletes who used WBC after single7 or multiple
training exposures.8 This should be regarded as preliminary
evidence based on methodological limitations, including pseu-
dorandomization and a risk of multiplicity. Others6,8,11 found
little effect of WBC on various markers of muscle damage
after various forms of exercise training. Evidence from recent
reviews suggests that CWI3 and contrast water immersion35
have little to no effect on markers of inflammation or muscle
damage after exercise. To our knowledge, only one study has
quantified the biochemical effects of local ice-pack applica-
tion within human subjects with significant injury. Using the
microdialysis technique, Stålman et al45 reported that local
icing and compression post-knee surgery resulted in a sig-
nificantly lower production of prostaglandin E2 and synovial
lactate compared to an untreated control group.
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Whole-body cryotherapy
Oxidative stress
There is evidence that CWI can induce oxidative stress
and a possible increase in free radical species formation.46
Free radicals are produced both as a by-product of cellular
metabolism in aerobic systems and from various environ-
mental sources. When free radical production exceeds
antioxidant protection capacity and repair mechanisms,
oxidative stress occurs, resulting in damage to such macro-
molecules as proteins, lipids, and deoxyribonucleic acid. The
relative risk of oxidative stress appears to increase during
periods of metabolic stress, where there is a disruption to
the prooxidant/antioxidant equilibrium. A related concept is
that brief repeated exposure to cold temperatures can benefit
athletes by activating adaptive homeostatic mechanisms
in accordance with the hormetic dose–response model.5
Indeed, others have reported improvements in antioxidant
capacity associated with regular exposure to cold-water
swimming.46
Evidence from controlled studies on the effect of WBC on
antioxidant capacity is equivocal. One study5 reported a lower
production of oxidative stress when intense exercise was
undertaken in conjunction with WBC, compared to exercise
alone. Surprisingly, these findings did not fully align with
the athlete’s antioxidant profiles, as the WBC group had a
lower concentration of superoxide dismutase and glutathione
peroxidase over the 10-day training period. Although Miller
et al9 found clearer evidence that WBC increases antioxidant
activity in the absence of exercise, a limitation was that oxida-
tive stress and antioxidant function were not quantified at the
same site, and as such this makes it difficult to determine the
mechanisms associated with oxidative stress. Furthermore,
both these studies5,9 quantified oxidative stress using the thio-
barbituric acid reactive substances (TBARS) assay, which
has a number of limitations.47 For example, the TBARS assay
claims to quantify the amount of malondialdehyde formed
during the lipid-peroxidation process; a primary problem is
that other substances such as biliverdin, glucose ribose, and
2-amino-pyrimidines all have the ability to be absorbed at
or close to the same spectroscopic wavelength as TBARS
(532 nm), and as such the assay generally reports inaccurate
malondialdehyde concentrations when compared with more
sophisticated techniques. Future studies should focus on
the specific cell-signaling events leading to the increase in
antioxidant protein expression and incorporate at least two
or more indices of oxidative stress to confirm cell damage. In
addition, direct measures of free radical production, such as
electron paramagnetic resonance spectroscopy, would allow
for a more accurate quantification of free radical generation
and oxidative damage.
Autonomic nervous system
Finding efficient ways to influence the autonomic nervous
system is a growing field in sports recovery. Intense exercise
typically results in an increase in sympathetic activity,
resulting in increased heart rate and decreased heart-rate
variability. However, prolonged sympathetic activity is
thought to be detrimental for postexercise recovery. As such,
parasympathetic reactivation is currently considered to be an
important indicator of systemic recovery, and often quantified
using various indices of heart-rate variability.48
A small number of controlled studies have investigated
the potential for using WBC to facilitate parasympathetic
reactivation after exercise. Although there is evidence that
WBC has an initial sympathetic effect,12 its summative effect
seems to be parasympathetic. Indeed, Schaal et al14 reported
that WBC enhances short-term autonomic recovery after
intense exercise based on a two- to threefold increase in
heart-rate variability. This response is thought to be medi-
ated by the baroreflex, which is triggered by cold-induced
vasoconstriction and an increase in central blood volume.49
As such, parasympathetic reactivation is not exclusive to
WBC, and others50–52 have replicated these autonomic effects
through CWI.
Clinical outcomes
We found conflicting evidence for the effect of WBC on
correlates of functional recovery following sport. There was
however clearer evidence that WBC could improve sub-
jective outcomes, such as perceived recovery and muscle
soreness. This aligns with findings from a recent Cochrane
review4 concluding that CWI has little effect on recovery
postinjury beyond reductions in muscle soreness. Similarly,
although there is consistent evidence to show that cold packs
and/or crushed ice provides effective short-term analgesia
after acute soft-tissue injury and postsurgery,53–55 there is
little evidence to show any effect on functional restoration
or swelling.
For the current review, we found one study13 concluding
that WBC has a clinically important effect on recovery from
musculoskeletal injury (adhesive capsulitis). The underpin-
ning mechanisms for these effects are difficult to determine.
Perhaps an important consideration is that this study13 used
WBC in conjunction with standardized physiotherapy inter-
vention involving manual therapy and joint mobilization.
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34
Bleakley et al
It is possible that WBC produced a local analgesia, or acted
as a counterirritant to pain, which facilitated mobilization.
Optimal analgesia is associated with skin temperatures of
less than 13°C,30 a threshold that has been attained using
standard WBC exposures in some reports.12,36 We also know
that WBC increases norepinephrine,2 which could have an
additional analgesic effect.56 Local cooling can have an addi-
tional excitatory effect on muscle activation; this has been
observed in both healthy and injured adults,57–60 providing
further evidence that cooling can be an important adjunct to
therapeutic exercise.
Benets, harms, and recommendations
for future research
When assessing therapeutic interventions, it is important
to compare any benefits with possible risks and harms. In
accordance with previous reviews,2 we found that WBC
can modify many important biochemical and physiological
parameters in human athletes. We also found trends that
WBC can improve subjective recovery and muscle soreness
following metabolic or mechanical overload. This evidence
should still be regarded as preliminary, and further high-
quality randomized studies are recommended.
It is difficult to reach a definitive conclusion on possible
risks associated with WBC, as studies have not undertaken
active surveillance of predefined adverse events. This should
be addressed within future studies; the constant pressure to
maximize sporting performance means that athletes often
experiment with extreme exposures and interventions.
Current recommendations for WBC parameters, including
optimal air temperatures and the duration and frequency of
exposure, are largely based on anecdote. It is imperative
that safe guidelines are developed using evidence-based
information. Future studies should also determine whether it
is necessary to alter the dose of therapy based on the nature
of the injury, the severity, or the level of chronicity.
WBC is often regarded as a superior mode of cooling,
due to its extreme temperatures. However, there is no strong
evidence that it offers any distinct advantages over traditional
methods of cryotherapy. There is much evidence to show that
CWI and ice-pack application are both capable of inducing
clinically relevant reductions in tissue temperature, and
that they also provide important physiological and clinical
effects.3,4,30,46,50,55 Future research should directly compare
the relative effectiveness of WBC, CWI, and ice-pack
application. An important limitation is that WBC is currently
significantly more expensive and much less accessible than
either CWI or ice packs.
Conclusion
WBC induces tissue-temperature reductions that are
comparable to or less significant than traditional forms of
cryotherapy. Controlled studies suggest that WBC could have
a positive influence on inflammatory mediators, antioxidant
capacity, and autonomic function during sporting recovery;
however, these findings are preliminary. Although there is
some evidence that WBC improves the perception of recovery
and soreness after various sports and exercise, this does not
seem to translate into enhanced functional recovery. Only
one study has focused on recovery after significant muscu-
loskeletal injury, and long-term implications are unclear.
Until further research is available, athletes should remain
cognizant that less expensive modes of cryotherapy, such as
local ice-pack application or CWI, offer comparable physi-
ological and clinical effects to WBC.
Disclosure
The authors report no conflicts of interest in this work
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... Exposure of the damaged muscle to cold (cryotherapy) is believed to retard the secondary injury process (Merrick et al., 1999;. Cryotherapy, the reduction of tissue temperature by the withdrawal of heat from the body (Michlovitz, 1990), refers to a range of cooling modalities such as local ice application to the skin (Yackzan et al., 1984;Gulick et al., 1996;Oakley et al., 2013;Nogueira et al., 2019), cold water immersion (CWI) of a large part of the body (Lane and Wenger, 2004;Yeargin et al., 2006;Vaile et al., 2007Vaile et al., , 2010Peiffer et al., 2008;Rowsell et al., 2009Brophy-Williams et al., 2011;Leeder et al., , 2019Webb et al., 2013;Garcia et al., 2016;Wilson et al., 2018), whole body cryotherapy (Banfi et al., 2009Costello et al., 2011Ziemann et al., 2012;Fonda and Sarabon, 2013;Guilhem et al., 2013;Bleakley et al., 2014;Ferreira-Junior et al., 2015;Vieira et al., 2015;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019; WBC) and more recently phase change material (PCM) cooling (Clifford et al., 2018;Kwiecien et al., 2018Kwiecien et al., , 2020aBrownstein et al., 2019;Mullaney et al., 2020), that are employed in various contexts. The most popular cryotherapy modality used following exercise is CWI involving immersion of a large surface area of the body, typically immersion of at least the legs up to at least the umbilicus, in cold water. ...
... However, evidence to support its use for accelerating recovery of strength loss following exercise remains equivocal Poppendieck et al., 2013;Hohenauer et al., 2015;Machado et al., 2015). Comparably, some studies suggest that WBC might be beneficial in accelerating subjective recovery of soreness Ziemann et al., 2012;Fonda and Sarabon, 2013;Bleakley et al., 2014;Rose et al., 2017), strength loss , and might mitigate the signs of functional overreaching (Schaal et al., 2015). However, more recently, there remains little evidence to support improvements in functional recovery (Bleakley et al., 2014;Lombardi et al., 2017;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019). ...
... Comparably, some studies suggest that WBC might be beneficial in accelerating subjective recovery of soreness Ziemann et al., 2012;Fonda and Sarabon, 2013;Bleakley et al., 2014;Rose et al., 2017), strength loss , and might mitigate the signs of functional overreaching (Schaal et al., 2015). However, more recently, there remains little evidence to support improvements in functional recovery (Bleakley et al., 2014;Lombardi et al., 2017;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019). On the contrary, local ice application does not improve the symptoms associated with soreness or strength loss (Nogueira et al., 2019). ...
... Exposure of the damaged muscle to cold (cryotherapy) is believed to retard the secondary injury process (Merrick et al., 1999;. Cryotherapy, the reduction of tissue temperature by the withdrawal of heat from the body (Michlovitz, 1990), refers to a range of cooling modalities such as local ice application to the skin (Yackzan et al., 1984;Gulick et al., 1996;Oakley et al., 2013;Nogueira et al., 2019), cold water immersion (CWI) of a large part of the body (Lane and Wenger, 2004;Yeargin et al., 2006;Vaile et al., 2007Vaile et al., , 2010Peiffer et al., 2008;Rowsell et al., 2009Brophy-Williams et al., 2011;Leeder et al., , 2019Webb et al., 2013;Garcia et al., 2016;Wilson et al., 2018), whole body cryotherapy (Banfi et al., 2009Costello et al., 2011Ziemann et al., 2012;Fonda and Sarabon, 2013;Guilhem et al., 2013;Bleakley et al., 2014;Ferreira-Junior et al., 2015;Vieira et al., 2015;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019; WBC) and more recently phase change material (PCM) cooling (Clifford et al., 2018;Kwiecien et al., 2018Kwiecien et al., , 2020aBrownstein et al., 2019;Mullaney et al., 2020), that are employed in various contexts. The most popular cryotherapy modality used following exercise is CWI involving immersion of a large surface area of the body, typically immersion of at least the legs up to at least the umbilicus, in cold water. ...
... However, evidence to support its use for accelerating recovery of strength loss following exercise remains equivocal Poppendieck et al., 2013;Hohenauer et al., 2015;Machado et al., 2015). Comparably, some studies suggest that WBC might be beneficial in accelerating subjective recovery of soreness Ziemann et al., 2012;Fonda and Sarabon, 2013;Bleakley et al., 2014;Rose et al., 2017), strength loss , and might mitigate the signs of functional overreaching (Schaal et al., 2015). However, more recently, there remains little evidence to support improvements in functional recovery (Bleakley et al., 2014;Lombardi et al., 2017;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019). ...
... Comparably, some studies suggest that WBC might be beneficial in accelerating subjective recovery of soreness Ziemann et al., 2012;Fonda and Sarabon, 2013;Bleakley et al., 2014;Rose et al., 2017), strength loss , and might mitigate the signs of functional overreaching (Schaal et al., 2015). However, more recently, there remains little evidence to support improvements in functional recovery (Bleakley et al., 2014;Lombardi et al., 2017;Rose et al., 2017;Broatch et al., 2019;Krueger et al., 2019). On the contrary, local ice application does not improve the symptoms associated with soreness or strength loss (Nogueira et al., 2019). ...
... Comme l'immersion en eau froide, la diminution de la température musculaire et cutanée, provoquant la diminution des influx nerveux responsables de la douleur, serait à l'origine de l'effet antalgique immédiat. L'effet positif sur les douleurs musculaires à plus long terme serait associée à une atténuation de l'inflammation associées aux dommages musculaires (Costello et al. 2012a;Costello et al. 2012b;Bleakley et al. 2014). Enfin, les auteurs n'excluent pas l'effet placebo évoqué précédemment dans cette partie . ...
... Based on the additional effect of hydrostatic pressure and the greater thermal conductivity of water, CWI was expected to lead to a larger decrease in muscle temperature (19) and to attenuate muscle soreness to a greater extent than WBC (40). ...
... L'absence d'effet de cette technique est confirmée par Dupuy et al.(Dupuy et al. 2018) que ce soit en ce qui concerne les effets sur les douleurs musculaires (5 études incluses) ou la perception de la fatigue (1 étude incluse).vi. Vêtements de compressionPlusieurs revues et méta-analyses se sont intéressées à l'efficacité des vêtements de compression avec un exercice traumatisant comparativement à un groupe contrôle ne réalisant pas cet exercice(Hill et al. 2014; MacRae et al. 2011; Marques-Jimenez et al. 2016;Dupuy et al. 2018;Bieuzen et al. 2014). Les résultats sont relativement consistants et mettent en évidence une diminution des douleurs musculaires lorsque les participants portent des vêtements de compression (chaussettes ou corps entier) jusqu'à 96 h après l'exercice. ...
Thesis
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L’organisation du circuit professionnel impose actuellement au joueur de tennis de haut niveau une planification annuelle des entraînements et des compétitions très dense. Ainsi, une gestion appropriée et équilibrée de la fatigue et de la récupération apparait primordiale afin de permettre au joueur de tennis élite d’être performant lors des compétitions mais aussi d’éviter la survenue d’épisodes de fatigue sévère, de surmenage, de blessures ou de maladies. Les connaissances issues de la littérature scientifique incitent à adapter et planifier spécifiquement la récupération en fonction du contexte (discipline, période d’entraînement, type de fatigue, statut de l’athlète). Pourtant, les joueurs ont actuellement recours de façon relativement empirique à des stratégies de récupération diverses, incluant l’application de froid. Cependant, peu d’études se sont intéressées aux effets de ces méthodes de récupération sur les réponses à la charge induite par le tennis pratiqué à haut niveau. Il semble nécessaire de déterminer l’efficacité de chaque technique de récupération dans ce contexte afin d’identifier quelles stratégies répondent le mieux à la nécessité de récupérer. La première partie de ces travaux de thèse a donc eu pour objectif de décrire, sur une période de 15 mois et dans un cadre écologique, les contenus et la charge de travail induite par l’entraînement, les pratiques de récupération et leurs impacts sur la fatigue subjective des joueurs de tennis élites. À court terme, il apparait que les contenus d’entraînement, regroupés et leur charge associée n’impactent pas différemment la fatigue perceptive rapportée. Au sein des stratégies de récupération utilisées par les joueurs, les techniques par le froid (cryothérapie corps entier, immersion en eau froide, bain contrasté) sont les plus représentées. Les modèles statistiques utilisés montrent que ces techniques de récupération par le froid sont les seules associées à une diminution significative des sensations de douleurs musculaires 12-16h post-entraînement. Notre seconde étude a comparé l’efficacité de ces différentes techniques de récupération par le froid dans des conditions de fatigue accumulée, simulant celles induites lors de compétitions professionnelles de tennis. Ces travaux montrent que l’enchaînement de trois jours de matchs de tennis d’1h30, induit une fatigue significative mais modérée. En effet, les paramètres de fatigue neuromusculaire (centrale et périphérique), physiologique diminuent significativement lors du premier jour, mais ne sont pas modifiés en réponse aux matchs de tennis des jours suivants. Au cours des quatre jours de protocole, l’immersion en eau froide et de la cryothérapie corps entier permettent de limiter l’augmentation des sensations de douleurs musculaires. Ces résultats valident l’intérêt d’utiliser les techniques de récupération par le froid pour diminuer les sensations de douleurs musculaires de joueurs de tennis élites en période d’entraînement. Dans le cadre précis de compétitions réalisées sur surface dure (hors Grands Chelems), l’utilisation quotidienne des techniques de récupération par le froid seront alors conseillées pour limiter l’accumulation des sensations de douleurs musculaires.
... This is undoubtedly likely to change depending on the method of cryotherapy used. Indeed, an important point to note is the impact of the thermal gradient created between the skin and the surrounding environment (Bleakley et al. 2014). The thermal conductivity, or heat-transfer co-efficient, is much greater for ice (2.18 k), when compared with water (0.58 k) and air (0.024 k), suggesting a greater ability for the removal of heat from the body using ice. ...
... The thermal conductivity, or heat-transfer co-efficient, is much greater for ice (2.18 k), when compared with water (0.58 k) and air (0.024 k), suggesting a greater ability for the removal of heat from the body using ice. However, despite these values, water and air may be more efficient through greater surface area contact (Bleakley et al. 2014). Therefore, the thermal properties and rate of heat exchange, temperature and duration of cooling, and size of area exposed to cooling should all be carefully considered. ...
Article
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For centuries, cold temperatures have been used by humans for therapeutic, health and sporting recovery purposes. This application of cold for therapeutic purposes is regularly referred to as cryotherapy. Cryotherapies including ice, cold-water and cold air have been popularised by an ability to remove heat, reduce core and tissue temperatures, and alter blood flow in humans. The resulting downstream effects upon human physiologies providing benefits that include a reduced perception of pain, or analgesia, and an improved sensation of well-being. Ultimately, such benefits have been translated into therapies that may assist in improving post-exercise recovery, with further investigations assessing the role that cryotherapies can play in attenuating the ensuing post-exercise inflammatory response. Whilst considerable progress has been made in our understanding of the mechanistic changes associated with adopting cryotherapies, research focus tends to look towards the future rather than to the past. It has been suggested that this might be due to the notion of progress being defined as change over time from lower to higher states of knowledge. However, a historical perspective, studying a subject in light of its earliest phase and subsequent evolution, could help sharpen one's vision of the present; helping to generate new research questions as well as look at old questions in new ways. Therefore, the aim of this brief historical perspective is to highlight the origins of the many arms of this popular recovery and treatment technique, whilst further assessing the changing face of cryotherapy. We conclude by discussing what lies ahead in the future for cold-application techniques.
... Complications include local pain more in the periungual area, temple, plantar areas, eyelids, lips, mucous membranes, tingling and numbness, especially on the fingers, edema, especially on the eyelids, lips, labia, and prepuce, more in infants and the elderly, cryoblister formation, and syncope (vasovagal reaction) in anxious patients along with occasional headache (migraine type) after the treatment of the head and neck area [10]. Common protracted complication includes hypopigmentation, especially in dark-skinned individuals, atrophic scar, and local hypoesthesia due to nerve damage, especially in areas, where the nerves lie superficially, such as the sides of fingers, angle of jaw, post-auricular area, sides of tongue and ulnar fossa of elbow, milia formation, and cicatricial alopecia [10,11]. Absolute contraindications include blood dyscrasias of unknown origin, cold intolerance, Raynaud's disease, cold urticaria, cryoglobulinemia, lesions in areas of compromised circulation, sclerosing basal cell carcinoma (BCC), or recurrent BCC or squamous cell carcinoma located in high-risk areas such as the temple or nasolabial folds [10][11][12]. ...
... Common protracted complication includes hypopigmentation, especially in dark-skinned individuals, atrophic scar, and local hypoesthesia due to nerve damage, especially in areas, where the nerves lie superficially, such as the sides of fingers, angle of jaw, post-auricular area, sides of tongue and ulnar fossa of elbow, milia formation, and cicatricial alopecia [10,11]. Absolute contraindications include blood dyscrasias of unknown origin, cold intolerance, Raynaud's disease, cold urticaria, cryoglobulinemia, lesions in areas of compromised circulation, sclerosing basal cell carcinoma (BCC), or recurrent BCC or squamous cell carcinoma located in high-risk areas such as the temple or nasolabial folds [10][11][12]. Previously our team had conducted numerous clinical trials and invitro studies [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] over the past 5 years now we are focussing on surveys the idea of this survey stemmed from the current interest in our community. So the aim of our survey was to access the knowledge, attitude and awareness of cryosurgery among dental students. ...
... A rapid increase of body temperature after the end of the low temperature exposure causes increases in the blood flow, leading to better removal of waste metabolites and inflammatory mediators released by damaged tissue [10]. In addition, CWI may reduce muscle tension and fatigue, reduce joint pain, and improve general well-being, thus ensuring better sports performance [11]. Other popular methods of cold therapy include ice packs and wholebody cryotherapy (WBC) sessions [12]. ...
... In order to attain the aim of the study, an attempt was made to determine the role of short cold-water immersion, which preceded rest in a sitting position at room temperature, in the modulation of the inflammatory response to submaximal exercise. The beneficial effect of CWI as a post-exercise regeneration method has been presented in many studies [10,11,44]. Several studies report that cold exposure is supposed to aid recovery by attenuating exercise-induced inflammation. ...
Article
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Cold-water immersion (CWI) after exercise is a method used by sportsmen to improve recovery. The aim of the study was to assess the effect of a 3 min CWI on the inflammatory state by measuring levels of interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor α (TNF-α), and transforming growth factor β1 (TGF-β1), and activities of α1-antitrypsin (AAT) and lysosomal enzymes, including arylsulfatase (ASA), acid phosphatase (AcP), and cathepsin D (CTS D), in the blood of healthy recreational athletes. Male volunteers (n = 22, age 25 ± 4.8 yr) performed a 30 min submaximal aerobic exercise, followed by a 20 min rest at room temperature (RT-REST) or a 20 min rest at room temperature with an initial 3 min 8 ◦C water bath (CWI-REST). Blood samples were taken at baseline, immediately after exercise, and after 20 min of recovery. The IL-6, IL-10, and TNF-α levels and the AAT activity increased significantly immediately after exercise. The IL-6 level was significantly higher after CWI-REST than after RT-REST. No changes in the activities of the lysosomal enzymes were observed. The effect of a 3 min CWI on the level of inflammatory markers during post-exercise recovery was limited. Thus, it might be considered as a widely available method of regeneration for recreational athletes.
... The fairly modest quantity of 12 cryotherapy treatments in total could be a factor in the lack of hindrance effect on adaptations. An alternative explanation is that the modality and mechanisms of the cold exposure in WBC is different to that of CWI (Bleakley et al., 2014). Cold water exerts a hydrostatic effect and has a higher thermal conductivity than cold air (White and Wells, 2013). ...
Article
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Despite its potential merit in sport and exercise recovery, the implications of repetitive Whole Body Cryotherapy (WBC) during training programmes require further review due to the possibility of repetitive cold interfering with long term adaptations. This study investigated the impact of two weekly 3 min WBC sessions (30 s at −60 • C, 150 s at −120 • C) on adaptations to a 6 week strength and endurance training programme. Sixteen male participants (mean ± SD age 33.4 ± 9.8 years, body mass 82.3 ± 9.8 kg) randomly allocated into WBC (n = 7) and non-cryotherapy control (CON, n=9) groups completed the programme consisting of two weekly strength and plyometric training sessions and two weekly 30 min runs (70% VO 2 max). Participants were assessed for body fat, VO2 max, muscle torque, three repetition maximum barbell squat and countermovement jump height before and after the programme. Resistance and running intensities were progressed after 3 weeks. Participants in both groups significantly improved muscle torque (WBC: 277.1 ± 63.2 Nm vs. 318.1 ± 83.4 Nm, p < 0.01, d = 0.56; CON: 244.6 ± 50.6 Nm vs. 268.0 ± 71.8 Nm, p = 0.05, d = 0.38) and barbell squat (WBC: 86.4 ± 19.5 kg vs. 98.9 ± 15.2 kg, p = 0.03, d = 0.69; CON: 91.1 ± 28.7 kg vs. 106.1 ± 30.0 kg, p<0.01, d=0.51) following the 6 week programme. For the CON group, there was also a significant reduction in body fat percentage (p = 0.01) and significant increase in jump height (p = 0.01). There was no significant increase in VO2 max for either group (both p > 0.2). There was no difference between WBC and CON for responses in muscle torque, 3RM barbell squat and body fat, however WBC participants did not increase their jump height (p = 0.23). Repetitive WBC does not appear to blunt adaptations to a concurrent training programme, although there may be an interference effect in the development of explosive power. Sports practitioners can cautiously apply repetitive WBC to support recovery post-exercise without undue concern on athletes' fitness gains or long term performance, particularly throughout training phases focused more on general strength development than explosive power.
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Whilst Whole Body Cryotherapy (WBC) has become an emerging tool for sport and exercise recovery, its overall efficacy remains contentious. This thesis addressed a variety of issues concerning the practice. Firstly, the impact of single WBC interventions for treating exercise-induced muscle damage (EIMD) is unclear. Secondly, the influence of inter-individual factors on WBC outcomes post-exercise remains an under-investigated area. Therefore the first main study explored the effects of age and body fat content on responses to WBC following downhill running, a commonly utilised eccentric exercise model for inducing muscle damage. WBC participants underwent cryotherapy (3 minutes, −120°C) one hour post- downhill run and control (CON) participants passively recovered (20°C). Despite the presence of EIMD, WBC significantly blunted (p=0.04) the decrease in muscle torque 24 hours after the downhill run. This response was significantly influenced by age, with young participants (<40 years) retaining their muscle strength more than older participants (≥45 years). WBC may therefore attenuate EIMD and benefit muscle strength recovery following eccentrically biased exercise, particularly for young males. A subsequent downhill run study investigated the influence of WBC timing post-exercise, a factor that could clarify optimal treatment usage. An additional objective was to compare the effects of WBC with cold water immersions (CWI) since the verdict regarding which cold modality is superior for recovery remains an on-going area of controversy. It was revealed that WBC 4 hours post-exercise was ineffective in treating EIMD markers, so applying WBC within one hour after exercise may be preferable to delaying by several hours. However, WBC was no more effective than CWI, meaning that the cost vs. reward implications of WBC treatments would need further reviewing. Finally, the implications of repetitive WBC during training programmes require further evaluation due to the possibility of repetitive cold interfering with long term adaptations. The final study investigated the impact of two weekly WBC treatments on adaptations to a 6 week strength and endurance training programme. It was found that WBC participants significantly improved their muscle strength comparatively to the CON group. However WBC did not improve their jump height (p=0.23) in contrast to the CON group (p=0.01). In conclusion, repetitive WBC does not appear to blunt strength training adaptations, although there may be an interference effect in the development of explosive power.
Article
Study design Single arm, quasi-experimental study design. Background To describe the effects of whole-body cryotherapy on pain, disability, and serum inflammatory markers in patients with chronic low back pain. Methods A quasi-experimental trial was performed on adult patients between 18 and 65 years with chronic low back pain. After obtaining informed consent, participants underwent 20 sessions of whole-body cryotherapy (at −160 °C) during a 5-week time span. Patient reported pain and disability measures (Pain Numerical Rating Scale [PNRS], Oswestry Disability Index [OSI], and Roland Morris Questionnaire [RMQ]) were obtained at each of the twenty sessions. Blood samples were obtained to analyze serum inflammatory markers at baseline, 10th and 20th session. Results Forty-one participants were included in the study. A significant decrease was observed between the initial and final PNRS, ODI, and RMQ scores (p < 0.001). A significant reduction in the PNRS was found after 4 sessions of whole-body cryotherapy (p < 0.001). We observed decreasing values of pro-inflammatory serum marker IL-2 (p = 0.046) and a significant increase in the anti-inflammatory serum marker IL-10 (p = 0.003). No adverse events were reported during the study. Conclusions Whole-body cryotherapy is an effective therapy for pain and disability treatment in chronic low back pain. It also produces changes in serum markers of inflammation, decreasing pro-inflammatory markers and increasing anti-inflammatory markers.
Article
Complementary and alternative medicine therapies can be used as adjuvant or preventive therapy, and have newer applications: cryotherapy, halotherapy, floatation therapy, and compression therapy. Nurse practitioners need to know about these therapies and their applicability to patient populations. Appropriate integration of these therapies is part of holistic care, which they strive to provide.
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While cryotherapy has direct physiological effects on contractile tissues, the extent to which joint cooling affects the neuromuscular system is not well understood. The purpose of the study was to detect changes in ankle dynamic restraint (peroneal short latency response and muscle activity amplitude) during inversion perturbation following ankle joint cryotherapy. A 2x3 factorial design was used to compare reaction time and EMG amplitude data of treatment conditions (cryotherapy and control) across time (pre-treatment, post-treatment, and 30 min post-treatment). Thirteen healthy volunteers (age 23 ± 4 yrs, ht 1.76 ± 0.09 m, mass 78.8 ± 16.6 kg), with no history of lower extremity joint injury participated in this study. Surface EMG was collected from the peroneus longus (PL) of the dominant leg during an ankle inversion perturbation triggered while walking. Subjects walked the length of a 6.1 m runway 30 times. A trap door mechanism, inducing inversion perturbation, was released at heel contact during six randomly selected trials for each leg. Following baseline measurements, a 1.5 L bag of crushed ice was applied to the lateral ankle of subjects in the treatment group with an elastic wrap. A bag similar in weight and consistency was applied to the lateral ankle of subjects in the control group. A repeated measures ANOVA was used to compare treatment conditions across time (p < 0.05). Maximum inversion range of motion was 28.4 ± 1.8° for all subjects. No overall condition by time difference was detected (p > 0.05) for PL reaction time. Average RMS EMG, normalized to an isometric reference position, increased in the cryotherapy group at the 30 min post-treatment interval relative to the control group (p < 0.05). Joint cooling does not result in deficiencies in reaction time or immediate muscle activation following inversion perturbation compared to a control
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The aim of this study was to compare the effects of a single whole-body cryostimulation (WBC) and a partial-body cryostimulation (PBC) (i.e., not exposing the head to cold) on indices of parasympathetic activity and blood catecholamines. Two groups of 15 participants were assigned either to a 3-min WBC or PBC session, while 10 participants constituted a control group (CON) not receiving any cryostimulation. Changes in thermal, physiological and subjective variables were recorded before and during the 20-min after each cryostimulation. According to a qualitative statistical analysis, an almost certain decrease in skin temperature was reported for all body regions immediately after the WBC (mean decrease±90% CL, -13.7±0.7°C) and PBC (-8.3±0.3°C), which persisted up to 20-min after the session. The tympanic temperature almost certainly decreased only after the WBC session (-0.32±0.04°C). Systolic and diastolic blood pressures were very likely increased after the WBC session, whereas these changes were trivial in the other groups. In addition, heart rate almost certainly decreased after PBC (-10.9%) and WBC (-15.2%) sessions, in a likely greater proportion for WBC compared to PBC. Resting vagal-related heart rate variability indices (the root-mean square difference of successive normal R-R intervals, RMSSD, and high frequency band, HF) were very likely increased after PBC (RMSSD: +54.4%, HF: +138%) and WBC (RMSSD: +85.2%, HF: +632%) sessions without any marked difference between groups. Plasma norepinephrine concentrations were likely to very likely increased after PBC (+57.4%) and WBC (+76.2%), respectively. Finally, cold and comfort sensations were almost certainly altered after WBC and PBC, sensation of discomfort being likely more pronounced after WBC than PBC. Both acute cryostimulation techniques effectively stimulated the autonomic nervous system (ANS), with a predominance of parasympathetic tone activation. The results of this study also suggest that a whole-body cold exposure induced a larger stimulation of the ANS compared to partial-body cold exposure.
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This study sought to a) compare and contrast the effect of 2 commonly used cryotherapy treatments, 4 min of − 110 °C whole body cryotherapy and 8 °C cold water immersion, on knee skin temperature and b) establish whether either protocol was capable of achieving a skin temperature ( < 13 °C) believed to be required for analgesic purposes. After ethics committee approval and written informed consent was obtained, 10 healthy males (26.5 ± 4.9 yr, 183.5 ± 6.0 cm, 90.7 ± 19.9 kg, 26.8 ± 5.0 kg/m 2 , 23.0 ± 9.3 % body fat; mean ± SD) participated in this randomised controlled crossover study. Skin temperature around the patellar region was assessed in both knees via non-contact, infrared thermal imaging and recorded pre-, immediately post-treatment and every 10 min thereafter for 60 min. Compared to baseline, average, minimum and maximum skin temperatures were signifi cantly reduced (p < 0.001) immediately post-treatment and at 10, 20, 30, 40, 50 and 60 min after both cooling modalities. Average and minimum skin temperatures were lower (p < 0.05) immediately after whole body cryotherapy (19.0 ± 0.9 ° C) compared to cold water immersion (20.5 ± 0.6 ° C). However, from 10 to 60 min post, the average, minimum and maximum skin temperatures were lower (p < 0.05) following the cold water treatment. Finally, neither protocol achieved a skin temperature believed to be required to elicit an analgesic effect.
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The aim of this systematic review was to examine the effect of Contrast Water Therapy (CWT) on recovery following exercise induced muscle damage. Controlled trials were identified from computerized literature searching and citation tracking performed up to February 2013. Eighteen trials met the inclusion criteria; all had a high risk of bias. Pooled data from 13 studies showed that CWT resulted in significantly greater improvements in muscle soreness at the five follow-up time points (<6, 24, 48, 72 and 96 hours) in comparison to passive recovery. Pooled data also showed that CWT significantly reduced muscle strength loss at each follow-up time (<6, 24, 48, 72 and 96 hours) in comparison to passive recovery. Despite comparing CWT to a large number of other recovery interventions, including cold water immersion, warm water immersion, compression, active recovery and stretching, there was little evidence for a superior treatment intervention. The current evidence base shows that CWT is superior to using passive recovery or rest after exercise; the magnitudes of these effects may be most relevant to an elite sporting population. There seems to be little difference in recovery outcome between CWT and other popular recovery interventions.
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This study investigated the effect of whole-body cryostimulation (WBC), contrast-water therapy (CWT), active recovery (ACT), and passive condition (PAS) protocols on the parasympathetic reactivation and metabolic parameters of recovery in elite synchronized swimmers who performed 2 simulated competition ballets (B1 and B2) separated by 70 min. After determining maximal oxygen consumption (V̇O(2max400)) and blood lactate concentrations ([La(-)](b400)) during a 400-m swim trial, 11 swimmers performed 1 protocol per week in randomized order. Heart rate variability (HRV) was measured at rest (PreB1), 5 min after B1 (PostB1), before B2 (PreB2), and 5 min after B2 (PostB2). V̇O(2peak) was measured at PostB1 and PostB2, and [La(-)](b) was measured at PostB1, PreB2, and PostB2. PostB1 V̇O(2peak) and V̇O(2max400) were similar, but PostB1 [La(-)](b) was higher than [La(-)](b400) (p = 0.004). Each ballet caused significant decreases in HRV indices. At PreB2, all HRV indices had returned to PreB1 levels in the CWT, PAS, and ACT protocols, whereas the WBC protocol yielded a 2- to 4-fold increase in vagal-related HRV indices, compared with PreB1. WBC and ACT both increased [La(-)](b) recovery, compared with PAS (p = 0.06 and p = 0.04, respectively), and yielded an increased V̇O(2peak) from B1 to B2; however, it decreased after PAS (+5.4%, +3.4%, and -3.6%; p < 0.01). This study describes the physiological response to repeated maximal work bouts that are highly specific to elite synchronized swimming. In the context of short-term recovery, WBC yields a strong parasympathetic reactivation, and shows similar effectiveness to ACT on the metabolic parameters of recovery and subsequent exercise capacity.
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Tournament season can provoke overreaching syndrome in professional tennis players, which may lead to deteriorated performance. Thus, appropriate recovery methods are crucial for athletes in order to sustain high-level performance and avoid injuries. We hypothesized that whole-body cryostimulation could be applied to support the recovery process. To assess the effects of 5 days of whole-body cryostimulation combined with moderate-intensity training on immunologic, hormonal, and hematologic responses; resting metabolic rate; and tennis performance in a posttournament season. Controlled laboratory study. National Olympic Sport Centre. Patients or Other Participants: Twelve high-ranking professional tennis players. Intervention(s): Participants followed a moderate-intensity training program. A subgroup was treated with the 5-day whole-body cryostimulation (-120°C) applied twice a day. The control subgroup participated in the training only. Main Outcome Measure(s): Pretreatment and posttreatment blood samples were collected and analyzed for tumor necrosis factor α, interleukin 6, testosterone, cortisol, and creatine kinase. Resting metabolic rate and performance of a tennis drill were also assessed. Proinflammatory cytokine (tumor necrosis factor α) decreased and pleiotropic cytokine (interleukin 6) and cortisol increased in the group exposed to cryostimulation. In the same group, greater stroke effectiveness during the tennis drill and faster recovery were observed. Neither the training program nor cryostimulation affected resting metabolic rate. Professional tennis players experienced an intensified inflammatory response after the completed tournament season, which may lead to overreaching. Applying whole-body cryostimulation in conjunction with moderate-intensity training was more effective for the recovery process than the training itself. The 5-day exposure to cryostimulation twice a day ameliorated the cytokine profile, resulting in a decrease in tumor necrosis factor α and an increase in interleukin 6.
Article
Cryotherapy is used in various clinical and sporting settings to reduce odema, decrease nerve conduction velocity, decrease tissue metabolism and to facilitate recovery after exercise induced muscle damage. The basic premise of cryotherapy is to cool tissue temperature and various modalities of cryotherapy such as whole body cryotherapy, cold spray, cryotherapy cuffs, frozen peas, cold water immersion, ice, and cold packs are currently being used to achieve this. However, despite its widespread use, little is known regarding the effectiveness of different cryotherapy modalities to reduce skin temperature.
Article
The purpose of this study was to examine the effects of whole-body cryotherapy (WBC) on biochemical, pain, and performance parameters during the 5-day recovery period after damaging exercise for hamstrings. Participants completed a bout of damaging exercise for the hamstring muscles on two separate occasions (control and experimental condition) separated by 10 weeks. During the control condition, subjects received no treatment after the damaging exercise. The experimental condition consisted of WBC everyday during the recovery period. WBC included single 3-min daily exposures to low temperatures (-140 to -195 °C) in the cryo-cabin. During the recovery period, subjects were tested for biochemical markers, perceived pain sensation, and physical performance (squat jump, counter movement jump, maximal isometric torque production, and maximally explosive isometric torque production). Majority of the observed variables showed statistically significant time effects (P < 0.05) in control group, which indicates the presence of muscle damage. Significant interaction between the control and WBC condition was evident for the rate of torque development (P < 0.05). Pain measures substantially differed between the WBC and the control condition after the exercise. Results of this study are not completely supportive of the use of WBC for recovery enhancement after strenuous training.
Article
Background: The basic premise of cryotherapy is to cool injured tissue; however, there is much confusion around how much cooling is adequate, and how this can be achieved clinically. Objectives: Our objective was to review recent literature to determine the rate and magnitude of tissue temperature reduction with cryotherapy. Values were compared with current recommended threshold temperatures deemed necessary for optimal cold induced analgesia (skin temperature