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Can Water Temperature and Immersion Time Influence the Effect of Cold Water Immersion on Muscle Soreness? A Systematic Review and Meta-Analysis

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Background Cold water immersion (CWI) is a technique commonly used in post-exercise recovery. However, the procedures involved in the technique may vary, particularly in terms of water temperature and immersion time, and the most effective approach remains unclear. Objectives The objective of this systematic review was to determine the efficacy of CWI in muscle soreness management compared with passive recovery. We also aimed to identify which water temperature and immersion time provides the best results. Methods The MEDLINE, EMBASE, SPORTDiscus, PEDro [Physiotherapy Evidence Database], and CENTRAL (Cochrane Central Register of Controlled Trials) databases were searched up to January 2015. Only randomized controlled trials that compared CWI to passive recovery were included in this review. Data were pooled in a meta-analysis and described as weighted mean differences (MDs) with 95 % confidence intervals (CIs). Results Nine studies were included for review and meta-analysis. The results of the meta-analysis revealed that CWI has a more positive effect than passive recovery in terms of immediate (MD = 0.290, 95 % CI 0.037, 0.543; p = 0.025) and delayed effects (MD = 0.315, 95 % CI 0.048, 0.581; p = 0.021). Water temperature of between 10 and 15 °C demonstrated the best results for immediate (MD = 0.273, 95 % CI 0.107, 0.440; p = 0.001) and delayed effects (MD = 0.317, 95 % CI 0.102, 0.532; p = 0.004). In terms of immersion time, immersion of between 10 and 15 min had the best results for immediate (MD = 0.227, 95 % 0.139, 0.314; p < 0.001) and delayed effects (MD = 0.317, 95 % 0.102, 0.532, p = 0.004). Conclusions The available evidence suggests that CWI can be slightly better than passive recovery in the management of muscle soreness. The results also demonstrated the presence of a dose–response relationship, indicating that CWI with a water temperature of between 11 and 15 °C and an immersion time of 11–15 min can provide the best results.
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SYSTEMATIC REVIEW
Can Water Temperature and Immersion Time Influence
the Effect of Cold Water Immersion on Muscle Soreness?
A Systematic Review and Meta-Analysis
Aryane Flauzino Machado
1
Paulo Henrique Ferreira
2
Je
´ssica Kirsch Micheletti
1
Aline Castilho de Almeida
3
I
´talo Ribeiro Lemes
1
Franciele Marques Vanderlei
1
Jayme Netto Junior
1
Carlos Marcelo Pastre
1
Published online: 18 November 2015
Springer International Publishing Switzerland 2015
Abstract
Background Cold water immersion (CWI) is a technique
commonly used in post-exercise recovery. However, the
procedures involved in the technique may vary, particularly
in terms of water temperature and immersion time, and the
most effective approach remains unclear.
Objectives The objective of this systematic review was to
determine the efficacy of CWI in muscle soreness man-
agement compared with passive recovery. We also aimed
to identify which water temperature and immersion time
provides the best results.
Methods The MEDLINE, EMBASE, SPORTDiscus,
PEDro [Physiotherapy Evidence Database], and CEN-
TRAL (Cochrane Central Register of Controlled Trials)
databases were searched up to January 2015. Only ran-
domized controlled trials that compared CWI to passive
recovery were included in this review. Data were pooled in
a meta-analysis and described as weighted mean differ-
ences (MDs) with 95 % confidence intervals (CIs).
Results Nine studies were included for review and meta-
analysis. The results of the meta-analysis revealed that
CWI has a more positive effect than passive recovery in
terms of immediate (MD =0.290, 95 % CI 0.037, 0.543;
p=0.025) and delayed effects (MD =0.315, 95 % CI
0.048, 0.581; p=0.021). Water temperature of between
10 and 15 C demonstrated the best results for immediate
(MD =0.273, 95 % CI 0.107, 0.440; p=0.001) and
delayed effects (MD =0.317, 95 % CI 0.102, 0.532;
p=0.004). In terms of immersion time, immersion of
between 10 and 15 min had the best results for immediate
(MD =0.227, 95 % 0.139, 0.314; p\0.001) and delayed
effects (MD =0.317, 95 % 0.102, 0.532, p=0.004).
Conclusions The available evidence suggests that CWI
can be slightly better than passive recovery in the manage-
ment of muscle soreness. The results also demonstrated the
presence of a dose–response relationship, indicating that
CWI with a water temperature of between 11 and 15 C and
an immersion time of 11–15 min can provide the best results.
Key Points
Cold water immersion (CWI) can be slightly betterthan
passive recovery in management of muscle soreness.
The findings suggest a dose–response relationship,
indicating that CWI at a temperature between 11 and
15 C for 11–15 min can provides the best results for
both immediate and delayed effects.
A potential risk of bias was identified by
methodological quality assessment of the studies
included, identifying a need for higher-quality
studies to affirm that the dose–response relationship
of the results can be reliably reproduced.
Electronic supplementary material The online version of this
article (doi:10.1007/s40279-015-0431-7) contains supplementary
material, which is available to authorized users.
&Carlos Marcelo Pastre
pastre@fct.unesp.br
1
Departamento de Fisioterapia, Faculdade de Cie
ˆncias e
Tecnologia, Universidade Estadual Paulista, 305 Roberto
Simonsen, Presidente Prudente, Sa
˜o Paulo 19060-900, Brazil
2
Discipline of Physiotherapy, Faculty of Health Science,
The University of Sydney, Sydney, NSW, Australia
3
Departamento de Fisioterapia, Centro de Cie
ˆncias Biolo
´gicas
e da Sau
´de, Universidade Federal de Sa
˜o Carlos, Sa
˜o Carlos,
Brazil
123
Sports Med (2016) 46:503–514
DOI 10.1007/s40279-015-0431-7
1 Background
Several post-exercise recovery techniques are currently
employed in an attempt to return the body to its pre-
exercise state [1,2]. Cold water immersion (CWI) has
become popular in sports [3,4]asitisalow-cost
technique that is easily performed in different situations
[5] and has been found to alleviate physiological and
functional deficits associated with exercise-induced
muscle damage [6]. Compared with controlled inter-
ventions and other traditional recovery techniques, CWI
achieves positive muscle soreness reduction results fol-
lowing a range of exercise types [7,8]. Yet the specific
mechanisms associated with CWI response are unknown
[9,10].
Despite its widespread use, significant procedural vari-
ations in CWI exist [11,12]. Investigations have suggested
that physiological changes are temperature dependent [13],
causing alterations in the body [14]. However, other factors
may influence recovery. Studies claim that the magnitude
of these mechanisms depends on the intensity of the cold
and how it affects the body [15]. Pastre et al. [16] attribute
response variation to differences in the application of CWI,
such as water temperature, immersion time and type of
CWI, being able to cause changes in blood flow [14],
metabolic activity [17], and nerve conduction velocity
(NCV) [18].
In recent years, the number of studies focusing on CWI
has increased, and major systematic reviews have been
performed to compare the effects of CWI and other
soreness recovery strategies [8,12]. However, the focus
of these systematic reviews [8,12] was to analyze the
effects of CWI on muscle soreness, regardless of their
application strategy. Thus, the dose–response relationship,
aimed at finding the best dosage, including analysis of
temperature and duration of immersion, has not yet been
investigated. Glasgow et al. [10] showed that studies
focusing on different CWI application strategies can
contribute to determining the risks and benefits for
athletes.
A systematic review involving the dose–response rela-
tionship will clarify the most effective method of appli-
cation of CWI for post-exercise muscle soreness.
Therefore, the purpose of this systematic review was to
determine the efficacy of CWI on the management of
muscle soreness compared with control intervention (pas-
sive recovery). An analysis of which dosage of application
provides the best results, focusing on water temperature
and immersion time, was also undertaken.
2 Methods
This systematic review was registered in an international
database of systematic reviews in health and social care
(registration number CRD42015016573; http://www.crd.
york.ac.uk/PROSPERO/).
2.1 Search Strategies
Studies were selected after searching five databases
[MEDLINE, EMBASE, SPORTDiscus, PEDro (Physio-
therapy Evidence Database), and CENTRAL (Cochrane
Central Register of Controlled Trials)] from the earliest
record of each database to 21 January 2015. The terms and
keywords used to search optimization were related to
randomized controlled trials: cold water immersion and
post-exercise recovery (see details in Electronic Supple-
mentary Material Appendix 1). The reference list of eli-
gible clinical trials was searched by hand to complement
the electronic searches. No restrictions were applied to the
sample conditions (age, sex, exercise level) or language of
the studies.
2.2 Study Selection
The studies selected involved CWI treatment with human
participants and assessed post-exercise muscle soreness.
CWI was defined as immersion in water with a temperature
B15 C[5,11,14]. To be eligible, studies had to (1) be
randomized controlled trials comparing CWI and control
condition post-exercise; (2) be studies that used a single
session of exercises; (3) apply CWI within 1 h of the end of
the exercise; and (4) include only one immersion on the
first day. Studies using intermittent immersions or more
than one immersion on subsequent days were excluded.
The control condition was considered as passive recovery,
in which the subjects remained seated, without any attempt
to accelerate recovery [1]. Exercise protocols performed on
a single day were considered as a single exercise session,
regardless of the duration or types of exercises.
The study selection process was conducted by title,
followed by abstract, and full text (Fig. 1). These steps
were performed independently by two authors (ACA and
JKM) and consensus was used to solve disagreements.
2.3 Data Extraction
Outcome data, including final values of means and standard
deviations and sample size were extracted by two review-
504 A. F. Machado et al.
123
ers (AFM, JKM). The data extraction process was per-
formed using a standardized form that included details such
as characteristics of participants, exercise procedures, CWI
procedures, outcome measures, and methodological char-
acteristics. Disagreements between authors regarding data
extraction were resolved by consensus.
Some studies included multiple observations. In such
cases, data were extracted at a clinically relevant timepoint
in order to analyze immediate effects (up to 24 h post-
exercise) and delayed effects (after 24 h post-exercise). For
the delayed effects, the peak soreness of the control group
was considered in order to minimize interference caused by
the intervention. Soreness scores were converted to a
common 0–10 scale.
2.4 Quality Assessment
All studies included were assessed for methodological
quality. This process was performed by two independent
reviewers (AFM and JKM) using the PEDro scale [19,20].
Each study was assessed for random allocation, concealed
allocation, baseline comparability, blinding participants,
therapists and assessors, adequate follow-up, intention-to-
treat, between-group comparison, point estimates, and
variability. A score C7 was considered ‘high quality’, a
score of 5 or 6 was considered ‘moderate quality’, and B4
was considered ‘poor quality’. If trials had already been
assessed and listed on the PEDro database, such scores
were adopted. Methodological quality was not an inclusion
criterion.
2.5 Data Synthesis
Analyses of the temperature and immersion time were
performed separately. The stratification process was based
on two aspects: physiological and information on previous
studies. Regarding the physiological aspect, the relation-
ship between exposure to cold and changes in NCV [18]
and blood flow [14] are described but the magnitude
remains uncertain with small variations [21]. Regarding the
characteristics of previous studies, Bleakley et al. [12]
observed that approximately 75 % of studies involving
CWI used water temperatures between 10 and 15 C and
the average of time of exposure was approximately 12 min.
Thus, after verifying similar values to those found by the
authors, and due to the interest in exploring outcomes from
a range of temperatures and times, the following criteria
were established:
A median of 12 C was observed for water temperature.
Studies with water temperatures below the median,
temperatures of 5 and 10 C, were categorized as
Fig. 1 Flow chart for selection
of studies. CENTRAL Cochrane
Central Register of Controlled
Trials, CWI cold water
immersion, PEDro
Physiotherapy Evidence
Database
Effects of Different Protocols of Cold Water Immersion on Muscle Soreness 505
123
‘severe cold’ (5–10 C). Studies with temperatures
above 10 C were categorized as ‘moderate cold’
(11–15 C).
For immersion time, a median of 14 min was observed.
Studies that used immersion times below the median, 5
and 10 min, were categorized as ‘short immersion’
(5–10 min). The remainder of the studies used a CWI
of 14 min, except for two studies that used 15 and
20 min. Thus, studies with immersion times of up to
15 min (11–15 min) were categorized as ‘medium
immersion’ and studies with an immersion time above
15 min (16–20 min) as ‘longer immersion’, due to
amplitude of times.
It is noteworthy that the entire descriptive analysis
process was conducted prior to execution of the meta-
analysis.
2.6 Data Analysis
Comprehensive Meta-Analysis software, version 2.2.04
(Biostat, Englewood, NJ, USA) was used for all analysis
and pooled estimates were calculated using a random–ef-
fect model, due to the heterogeneity of the studies (repre-
sented by I
2
). Data were pooled in meta-analyses and
described as weighted mean differences (MDs) with 95 %
confidence intervals (CIs). The immediate and delayed
effects were calculated in order to analyze the effect of
CWI, independent of water temperature and duration of
immersion. In case of more than one intervention group per
study, the group that represented the lowest effect size was
used.
3 Results
The database search identified 258 studies and 17 were
chosen for full-text review. Of these articles, eight were
excluded: one was not a single exercise session, one used a
cryotherapy technique other than CWI, and six did not
feature an appropriate immersion based on the inclusion
criteria. Figure 1shows the schematic process of the study
selection based on a PRISMA flow diagram.
Assessment of the methodological quality of the studies
included using the PEDro scale reported a mean of 4.2.
Three studies [2224] were considered as ‘moderate
quality’ and another six studies as ‘poor quality’ [2,9,25
28]. Due to the type of intervention, blinding was often not
possible but 44.4 % of the studies described adequate fol-
low-up procedures (see details in Electronic Supplemen-
tary Material Appendix 2). Figure 2shows the number of
clinical trials that fulfilled each criterion.
The nine eligible studies were published between 2007
[9] and 2015 [22]. These studies comprised a total of 169
participants (male, n=141; female, n=28). The health
conditions of the participants, i.e., the level of exercise,
fluctuated between physically active and athletes.
The studies were from Australia [2,23,24,27], the UK
[9,22,28], and the USA [25,26]. All were randomized
controlled trial-type studies, while six were parallel-group
trials [9,22,2528], and three used a crossover design [2,
23,24]. Exercise protocols consisted primarily of exercises
that required high physical ability with possible subsequent
onset of soreness, such as shuttle running [9,22], downhill
running [25], an Australian Football match and training
[23,27], high-intensity intervals [2,24], and counter-
movement jumps [28].
Interventions were varied. Water temperature ranged
from 5 [25]to15
C[2] and immersion time varied
between 5 [24] and 20 [25] min. Eight studies [2,9,2224,
2628] used passive recovery in which participants had to
remain seated with minimal movement, while one did not
report such information [25]. Immersion depth ranged from
immersion of the lower limbs [9,25,28] to immersion of
the whole body, excluding only the head and neck [24]. It
was observed that seven [2,9,22,23,2527] of eight
studies that evaluated delayed effect found peak soreness at
24 h post-exercise, and only one [23] found peak soreness
at 48 h post-exercise.
The characteristics of the included studies are summa-
rized in Table 1.
3.1 Analysis of Water Temperature
Seven studies [9,2328] provided data related to the
immediate effects of CWI. The subgroup analysis of the
pooled results is shown in Fig. 3. A general analysis of the
Fig. 2 Number of trials meeting individual PEDro [Physiotherapy
Evidence Database] criteria
506 A. F. Machado et al.
123
Table 1 Characteristics of the included studies
Study, year Study
design
Characteristics
of participants
a
Exercise
protocol
CWI group Control
group
Soreness assessment Time of assessment Time of analysis and
soreness values
b
PEDro
score
Leeder
et al.
[22],
2015
Parallel
groups
N=24
Male; well-
trained
21 ±3 years
Intermittent
shuttle
running
14C; 14 min; n=8
TI: immediately post-
exercise
WL: DNR
BP: standing
Remained
seated;
14 min;
n=8
VAS =0–200 mm
Squat at 90 knee
flexion
24, 48, 72 h post-
exercise
24 h post-exercise
(CG: 5.5 ±2.6;
CWI: 4.8 ±1.5)
6
Crystal
et al.
[25],
2013
Parallel
groups
N=20
Male
21.2 ±2.3 years
Downhill
run
5±2C; 20 min; n=10
TI: immediately post-
exercise
WL: up to top of the thigh
BP: DNR
Position:
DNR;
n=10
VAS =0–100 mm
Leg soreness while
walking down the
stairs
Immediately, 1, 6, 24,
48, 72 h post-
exercise
1 h post-exercise
(CG: 3.2 ±1.7;
CWI: 4.5 ±2.0)
24 h post-exercise
(CG: 4.8 ±2.8;
CWI: 7.0 ±1.5)
4
Getto and
Golden
[26],
2013
Parallel
groups
N=23
13 male; 10
female
Age: DNR
Exhaustive
exercise
session
10 C; 10 min; n=7
TI: immediately post-
exercise
WL: up to level of chest
BP: seated
Remained
seated;
10 min;
n=8
VAS =0–60
Calves, quadriceps,
hamstrings, hip
adductors, hip
abductors, and low
back
Immediately post-
exercise and
immediately and
24 h post-
intervention
Immediately post-
intervention (CG:
1.99 ±2.56; CWI:
1.75 ±0.78)
24 h post-exercise
(CG: 1.7 ±1.8;
CWI: 2.7 ±1.88)
3
Elias et al.
[27],
2013
Parallel
groups
N=24
Male; Australian
Football
players
19.9 ±2.8 years
Australian
Football
match
12 C; 14 min; n=7
TI: within 12 min post-
exercise
WL: up to xiphoid process
BP: seated with legs
stretched out
Remained
seated;
14 min;
n=8
VAS =0–100 mm
DNR
Immediately, 1, 24,
48 h post-exercise
1 h post-exercise
(CG: 0.66 ±0.16;
CWI: 0.45 ±0.1)
24 h post-exercise
(CG: 0.75 ±0.14;
CWI: 0.47 ±0.07)
4
Elias et al.
[23],
2012
Crossover N=14
Male; Australian
Football
players
20.9 ±3.3 years
Australian
Football
training
12 C; 14 min; n=14
TI: within 12 min post-
exercise
WL: up to xiphoid process
BP: seated with legs
stretched out
Remained
seated;
14 min;
n=14
VAS =0–100 mm
DNR
Immediately, 1, 24,
48 h post-exercise
1 h post-exercise
(CG: 0.54 ±0.19;
CWI: 0.30 ±0.12)
24 h post-exercise
(CG: 0.79 ±0.08;
CWI: 0.34 ±0.13)
5
Stanley
et al.
[24],
2012
Crossover N=18
Male; cyclists
27 ±7 years
High-
intensity
interval
session
14.2 ±0.6 C; 5 min;
n=18
TI: 20 min post-exercise
WL: body excluding head
and neck
BP: DNR
Remained
seated;
10 min;
n=18
VAS =1–10
Leg soreness
Immediately post-
intervention
Immediately post-
intervention (CG:
5.4 ±0.9; CWI:
4.5 ±0.9)
5
Effects of Different Protocols of Cold Water Immersion on Muscle Soreness 507
123
Table 1 continued
Study, year Study
design
Characteristics
of participants
a
Exercise
protocol
CWI group Control
group
Soreness assessment Time of assessment Time of analysis and
soreness values
b
PEDro
score
Brophy-
Williams
et al. [2],
2011
Cross-
over
N=8
Male; well-
trained
20.9 ±1.2 years
High-
intensity
interval
session
15 ±1C; 15 min; n=8
TI: immediately post-
exercise
WL: up to mid-sternum
BP: DNR
Remained
seated;
15 min;
n=8
VAS =0–7
DNR
24 h post-exercise 24 h post-exercise
(CG: 0.94 ±1.19;
CWI: 3.92 ±0.91)
4
Jakeman
et al.
[28],
2009
Parallel
groups
N=18
Female; athletes
19.9 ±0.97
years
Counter-
movement
jumps
10 ±1C; 10 min; n=9
TI: within 10 min post-
exercise
WL: up to level of the
superior iliac crest
BP: seated with leg at 90
to the torso
Remained
seated;
10 min;
n=9
VAS =0–10
Unweighted squat at
90 knee flexion
1, 24, 48, 72, 96 h
post-exercise
1 h post-exercise
(CG: 1.1 ±1.2;
CWI: 1.6 ±0.8)
48 h post-exercise
(CG: 3.8 ±0.9;
CWI: 3.0 ±0.9)
3
Bailey
et al. [9],
2007
Parallel
groups
N=20
Male; healthy
22.3±3.3 years
Intermittent
shuttle
running
10 ±0.5 C; 10 min;
n=10
TI: immediately post-
exercise
WL: up to level of iliac
crest
BP: seated
Remained
seated;
10 min;
n=10
VAS =1–10
General whole-body
soreness; palpation of
major muscle group
Immediately, 1, 24,
48, 168 h post-
exercise
1 h post-exercise
(CG: 5.13 ±1.62;
CWI: 3.15 ±1.42)
24 h post-exercise
(CG: 6.12 ±1.98;
CWI: 4.23 ±0.84)
4
BP body position, CWI cold water immersion, CG control group, DNR data not reported, PEDro Physiotherapy Evidence Database, TI time of immersion, VAS Visual Analog Scale, WL water
level
a
Age data are mean ±standard deviation
b
Soreness values converted to a common 0–10 scale
508 A. F. Machado et al.
123
immediate effects shows a significant pooled effect for
CWI (MD =0.290, 95 % CI 0.037, 0.543; p=0.025).
When subgroups were analyzed, it was observed that
studies using a water temperature of between 11 and 15 C
(moderate cold) produced better results than those using
water between 5 and 10 C (severe cold). Therefore, tem-
peratures higher than 10 C present the best results for
immediate effect on muscle soreness (severe cold:
MD =0.144, 95 % CI -1.299, 1.526, p=0.875; moder-
ate cold: MD =0.273, 95 % CI 0.107, 0.440, p=0.001).
Eight studies [2,9,22,23,2528] were included in the
analysis of water temperature on delayed effects, with
pooled results showing a tendency similar to immediate
effect results (Fig. 4). Overall pooled results, independent
of water temperature, showed a statistically significant
difference in favor of CWI (MD =0.315, 95 % CI 0.048,
0.581; p=0.021). Analysis of subgroups revealed that
water at temperatures of between 11 and 15 C were more
effective than temperatures of B10 C (severe cold:
MD =0.057, 95 % CI -1.483, 1.598, p=0.942; moder-
ate cold: MD =0.317, 95 % CI 0.102, 0.532, p=0.004).
3.2 Analysis of Immersion Time
Figure 5shows the results of analysis of immediate effect
in relation to immersion time. Overall, CWI was more
effective than the control condition (MD =0.290, 95 % CI
0.037, 0.543; p=0.025). Three categories were used for
subgroup analysis: short, medium, and longer immersion.
The medium immersion category, which had duration of
between 10 and 15 min, was responsible for the best results
in terms of immediate effects. Although there is only one
study featuring ‘longer immersion’ [25] it was observed
that the effect of such treatment was less beneficial than
passive recovery (short immersion: MD =0.646, 95 %
-0.360, 1.652, p=0.208; medium immersion:
MD =0.227, 95 % 0.139, 0.314, p\0.001; longer
immersion: MD =-1.300, 95 % CI -2.927, 0.327,
p=0.117).
In terms of delayed effects, the overall pooled effects of
CWI described in the eight studies analyzed were positive
(MD =0.315, 95 % CI 0048, 0581, p=0.021) (Fig. 6).
As with the immediate effects, an immersion time of
between 11 and 15 min produced the best results (short
immersion: MD =0.728, 95 % CI -0.561, 2.017,
p=0.268; medium immersion: MD =0.317, 95 % 0.102,
0.532, p=0.004; longer immersion: MD =-2.200, 95 %
CI -4.169, -0.231, p=0.029).
4 Discussion
The results of the meta-analysis of CWI as a post-exercise
recovery technique and reliever of muscle soreness were
statistically consistent, and revealed the following findings:
(1) independent of time and temperature, CWI produces
Fig. 3 Forest plot illustrating
the effects of cold water
immersion versus passive
recovery on muscle soreness
(immediate effect, stratified by
water temperature). CI
confidence interval, CWI cold
water immersion
Effects of Different Protocols of Cold Water Immersion on Muscle Soreness 509
123
Fig. 4 Forest plot illustrating
the effects of cold water
immersion versus passive
recovery on muscle soreness
(delayed effect, stratified by
water temperature). CI
confidence interval, CWI cold
water immersion
Fig. 5 Forest plot illustrating
the effects of cold water
immersion versus passive
recovery on muscle soreness
(immediate effect, stratified by
water immersion time). CI
confidence interval, CWI cold
water immersion
510 A. F. Machado et al.
123
generally positive results in terms of both immediate and
delayed effects; (2) immersion in water at temperatures
between 11 and 15 C appeared to produce a greater
reduction of muscle soreness after exercise; and (3)
11–15 min appeared to be the optimal immersion time for
the relief of muscle soreness caused by exercise.
The findings regarding CWI, independent of immersion
temperature and time, are in accordance with previous
reviews, such as the studies by Leeder et al. [8] and
Bleakley et al. [12]. The authors claim that the technique is
capable of altering blood flow, thereby causing vasocon-
striction and redirection of the blood [14]. The real effects
of CWI have not yet been fully elucidated [4], but it has
been speculated that this technique is able to reduce lym-
phatic and capillary cell permeability [14,29], resulting in
decreased fluid diffusion, which may assist in the reduction
of the inflammatory process caused by exercise [14].
This technique can also reduce nerve velocity conduc-
tion and muscle spasm [18]. This mechanism is derived
from decreasing the transmission rate of neurons due to
reduction in acetylcholine production [14]. Studies also
suggest that CWI can affect the exchange between Ca
2?
and Na
2?
in neural cells [18], which may lead to a delay in
action potential generation [30], contraction speed, and
force-generating capacity [31], reducing the dynamic
contractile force by 4–6 % for every 1 C reduction in
muscle temperature [6]. These changes may result in
decreased sports performance if the exercise is performed
immediately after CWI [14,15,32].
The reduction in soreness could also be explained by the
same factors that are associated with analgesia, which
occurs in response to the reduction in the pain–spasm cycle
[32]. Algafly and George [18] showed that cooling that is
able to reduce the skin temperature by 10–13 C can pro-
mote a reduction of 10–33 % in NVC. However, the same
temperature reduction is considered beneficial for
analgesia.
While the effects of CWI have been widely investigated,
opinions vary with regard to method of application [16].
The variance in effects caused by temperature change
observed in this review revealed that CWI was more
effective in terms of both immediate and delayed effects
when temperatures were in the ‘moderate cold’ category
(11–15 C). The benefits of ‘moderate cold’ temperatures
have not been discussed in clinical studies. However, it has
been shown that immersion at very low temperatures can
Fig. 6 Forest plot illustrating
the effects of cold water
immersion versus passive
recovery on muscle soreness
(delayed effect, stratified by
water immersion time). CI
confidence interval, CWI cold
water immersion
Effects of Different Protocols of Cold Water Immersion on Muscle Soreness 511
123
cause adverse effects that are interpreted by the body as
noxious stimuli [33], such as nerve damage [34]. Regarding
water temperature, a beneficial and safe lower limit for skin
temperature remains uncertain [34]. It has been suggested
that severe cold can produce hyperventilation, leading to
blood acidosis [14]. In extreme situations, severe cold can
cause loss of consciousness or even death [14].
A study by Getto and Golden [26] claims that short
immersions are less efficient at lessening muscle soreness
caused by exercise, due to limited muscle temperature
reduction [5]. Such a statement confirms the findings of this
study, which indicate that medium immersions of between
11 and 15 min produce better results than short immersions
(B10 min). Additionally, during the immediate effect,
there is the presence of the category ‘longer immersion’,
which is responsible for the worst results. Although pooled
results were not available for this category due to an
insufficient number of studies (n=1), it compared unfa-
vorably with passive recovery. The study in question [25]
considered the use of a very low temperature (5 C) for
20 min. Davis and Pope [35] claimed that an application of
10 s at low temperatures was required for CWI to produce
harmful stimulation and pain. Such effects can be exacer-
bated during long immersion conditions [36,37], causing a
greater depression of sensory and motor NCV, and pro-
ducing superficial nerve damage [31]. Vaile et al. [38] state
that the best responses result from faster cooling, but there
are difficulties in defining the limit and exact magnitude.
Accordingly, it is important to analyze studies by sub-
divisions of water temperature and immersion time. The
limited number of studies, however, does not allow the
implementation of closed protocol comparisons. The rela-
tionship between the two variables could allow objective
inferences about the most effective recovery model to be
used.
As in the study by Crystal et al. [25], which showed that
exposure to a low temperature for longer durations com-
pared unfavorably with passive recovery, other studies
have reported unfavorable results for CWI for various other
reasons. Getto and Golden [26] used a scale that involved
six different points, including the low back, to analyze
soreness. This type of evaluation considers a larger number
of soreness points than other studies and can result in
participant confusion in relation to the effects of CWI.
Jakeman et al. [28] found no significant difference between
CWI and a control group following counter-movement
jumps. These authors justify the absence of results favor-
able to CWI based on variation of time related to analgesic
mechanisms, which can last from a few minutes to hours,
and further report these mechanisms as uncertain [28]. The
main methodological difference that can be considered as a
hypothesis for divergence in the results refers to the sam-
ple. Evidence suggests that there are sex-specific
physiological responses after body cooling [39]. In our
systematic review, studies with female participants were
not found to have differences favoring CWI [26,28].
Overall, the studies selected for this review show similar
models of inducing stress, represented by physical activi-
ties featuring high intensity of effort. This factor is relevant
to data interpretation, as different types of stress provide
different outcomes, as previously explained. For example,
the characteristics of injuries induced in localized eccentric
exercise can differ from those sustained during sporting
activities, and respond differently to the application of
CWI [7,40].
To the authors’ knowledge, this is the first systematic
review and meta-analysis to investigate the effects of dif-
ferent CWI procedures, namely variations in water temper-
ature and immersion time. The strengths of this systematic
review relate mainly to the rationale of the study, which
aims to analyze the dose–response relationship, which is still
poorly investigated in studies of this nature. Despite the
statistically significant effects on muscle soreness favoring
CWI, the small effect size of the intervention should be
considered. It is possible to observe a decrease in muscle
soreness of approximately 5 % in the best situation (upper
limit of delayed effect for moderate cold and medium
immersion). Although this reduction may be small, there is
no evidence to indicate what the minimal clinical difference
detected is in this population, especially in athletes.
One of the limitations of the study is the poor method-
ological quality of the studies included. Future trials should
be attentive to the criteria for the development of a high-
quality study, which would result in surveys with greater
scientific evidence. Other limitations are related to the
sample heterogeneity, due to no restrictions in the search
strategy and the investigation of a single outcome.
Although this is a key outcome in the recovery of an ath-
lete, further studies should consider the dose–response
effect of CWI on other markers of muscle damage, such as
performance, in order to identify the best CWI recovery
strategy based on different and relevant factors.
5 Conclusion
The findings of the present study suggest that CWI may be
slightly better than passive recovery in the management of
muscle soreness. The results also demonstrate the presence
of a dose–response relationship, indicating that CWI pro-
vides the best results at temperatures between 11 and 15 C
for 11–15 min. The low quality of the included studies and
the small size of the intervention effect should be consid-
ered. Higher-quality studies are needed to investigate
whether the dose–response relationship of the results can
be reliably reproduced.
512 A. F. Machado et al.
123
The findings of the study allow athletes using CWI to
have a better understanding of the technique. For those
applying CWI, it enables the use of improved logistics and
therefore results in lower costs due to the most effective
use of immersion time and water temperature.
Compliance with Ethical Standards
Funding This work was supported by The Sa
˜o Paulo Research
Foundation—FAPESP master degree scholarship (Grant Number
2013/12474-7) and FAPESP research internships abroad (Grant
Number 2014/0338-5), and by the National Council for Scientific and
Technological Development—CNPq (Grant Number 482749/2012-1).
Conflicts of interest Aryane Flauzino Machado, Paulo Henrique
Ferreira, Je
´ssica Kirsch Micheletti, Aline Castilho de Almeida, I
´talo
Ribeiro Lemes, Franciele Marques Vanderlei, Jayme Netto Junior,
and Carlos Marcelo Pastre declare that they have no conflicts of
interest relevant to the content of this review.
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... Although cold water immersion has been widely used for recovery purposes, 10 this method proved to be effective only to recover at a perceptual level, which is in agreement with most studies on this topic. 19,21,[72][73][74] On the contrary, cold water immersion was not effective in recovering physical performance and physiological parameters, which is contrary to the conclusions of some studies 21,72,75 but not others. 19,76,77 The different findings between studies may be explained by the high bias and the heterogeneity of studies reported in previous systematic reviews. ...
... 19,76,77 The different findings between studies may be explained by the high bias and the heterogeneity of studies reported in previous systematic reviews. 19,21,73,75,76 For instance, the characteristics of the participants (eg, age, sex, physique trait) and the type of intervention (eg, duration, water temperature) may influence the magnitude of recovery due to the different effects in blood flow and tissue temperature. 18,78 Thus, some new approaches focusing on the individualization of cold water immersion to enhance the benefits in recovery were recently proposed. ...
... In addition, the long-term use of cold water immersion may be potentially harmful to skeletal muscle mass development, in particular when using more aggressive protocols with lower temperatures and higher duration. 78,79 Although there are few studies concerning the long-term implications of using cold water immersion for recovery, none has been conducted in team sports, and it might be wise to use cold water immersion as per the recommendations (ie, water temperature at 11-15°C and duration of 11-15 min), 73,75 and periodically in strictly necessary moments (eg, congested fixtures or after highly harmful exercise). Although the practical suggestions noted to avoid potential harmful effects, the overall high methodological quality of the studies and level of evidence reported reinforce the beneficial use of cold water immersion after football matches, in particular aiming to accelerate perceptive recovery, which is in line with Abaïdia and Dupont 12 and Cullen et al. 15 ...
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Background: Sleep, nutrition, active recovery, cold-water immersion, and massage were recently reported as the most used postmatch recovery methods in professional football. However, the recommendations concerning the effect of these methods remain unclear. Purpose: To systematically review the literature regarding the effectiveness of the most common recovery methods applied to male and female football players (or other team sports) 72 hours postmatches and to provide graded recommendations for their use. Methods: A systematic search of the literature was performed, and the level of evidence of randomized and nonrandomized studies was classified as 1 or 2, respectively, with additional ++, +, and - classification according to the quality of the study and risk of bias. Graded recommendations were provided regarding the effectiveness of recovery methods for physical, physiological, and perceptive variables. Results: From the 3472 articles identified, 39 met the inclusion criteria for analysis. The studies' levels of evidence varied among methods (sleep: 2+ to 1++; nutrition: 2- to 1+; cold-water immersion: 2- to 1++; active recovery: 2- to 1+; and massage: 1- to 1+). Different graded recommendations were attributed, and none of them favored the effective use of recovery methods for physiological and physical parameters, whereas massage and cold-water immersion were recommended as beneficial for perceptive variables. Conclusions: Cold-water immersion and massage can be recommended to recover up to 72 hours postmatch at a perceptive level. However, there is a current need for high-quality research that identifies effective recovery strategies that enhance recovery at the physical and physiological levels.
... The rationale for cryotherapy application after muscle damage has developed over the years due to various positive physiological effects, including inflammatory, vascular, neurological, and metabolic adaptations [4,[7][8][9]. The magnitude of these mechanisms depends on the intensity and time of the cold application and how it impacts the body. ...
... The magnitude of these mechanisms depends on the intensity and time of the cold application and how it impacts the body. Machado et al. [7] showed findings that DOMS has the best improvement with cryotherapy application with temperature between 11 and 15 • C when applied for 11 to 15 min. Furthermore, protocols that involve the body and limbs [10][11][12] (i.e., WBC) may have an advantage in increasing parasympathetic reactivation post-exercise compared to other applications. ...
... To evaluate the quality of the included studies, two authors independently assessed the selected studies using two instruments. The 11-item PEDro scale, which quantitatively includes the following 11 items: (1) eligibility criteria were specified (not used to calculate score); (2) subjects were randomly allocated to groups; (3) allocation was concealed; (4) the groups were similar at baseline regarding the most important prognostic indicators; (5) there was blinding of all subjects; (6) there was blinding of all therapists who administered the therapy; (7) there was blinding of all assessors who measured at least one key outcome; (8) measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups; (9) all subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analyzed by "intention to treat"; (10) the results of between-group statistical comparisons are reported for at least one key outcome; and (11) the study provides both point measures and measures of variability for at least one key outcome. Each of the items was marked as "yes (1)" or "no (0)" and the final score was on a scale from 0 to 10. ...
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Background: There are extensive studies focusing on non-invasive modalities to recover physiological systems after exercise-induced muscle damage (EIMD). Whole-body cryotherapy (WBC) and Partial-body cryotherapy (PBC) have been recommended for recovery after EIMD. However, to date, no systematic reviews have been performed to compare their effects on muscle performance and muscle recovery markers. Methods: This systematic review with metanalysis compared the effects of WBC and PBC on muscle performance, muscle soreness (DOMS), and markers of muscular damage following EIMD. We used Pubmed, Embase, PEDro, and Cochrane Central Register of Controlled Trials as data sources. Two independent reviewers verified the methodological quality of the studies. The studies were selected if they used WBC and PBC modalities as treatment and included muscle performance and muscle soreness (DOMS) as the primary outcomes. Secondary outcomes were creatine kinase and heart rate variability. Results: Six studies with a pooled sample of 120 patients were included. The methodological quality of the studies was moderate, with an average of 4.3 on a 0-10 scale (PEDro). Results: Both cryotherapy modalities induce similar effects without difference between them. Conclusion: WBC and PBC modalities have similar global responses on muscle performance, soreness, and markers of muscle damage.
... a recent meta-analysis suggested that the optimal protocol for use of cWi included a water temperature of 11-15 ºc and a procedure duration of 11-15 min. 27 cWi consisted of three alternating exposures, each including a 5-minute immersion in cold water up to the iliac crest and a 60 second seated rest on a chair at room temperature. Water temperature was maintained at a constant 15 °c by the addition of ice cubes and monitored using a thermometer. ...
... , 26 the temperature and time of the cWi used in this study are recommended for both immediate and delayed effects.27 ...
... In some cases, participants perceived these healing effects to be because of immersing themselves in cold water, which has been shown to reduce muscle soreness [31]. However, in other cases, the physical demands of swimming resulted in the re-strengthening of participant's bodies over time: ...
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... Die Auseinandersetzung mit interventionellen Verfahren zur Optimierung der Regeneration und Erholung sowie zur Prävention von Muskelverletzungen ist in den letzten Jahren vor allem im Leistungs-und Spitzensport zunehmend in den Vordergrund gerückt. Vor allem die CWI, dessen klinische Wirksamkeit anhand systemischer Metaanalysen wissenschaftlich bestätigt werden konnte, gilt dabei als effektives und beliebtes Therapieverfahren [34][35][36][37][38] ...
Thesis
1. Zusammenfassung 1.1. Hintergrund Die Kryotherapie ist ein etabliertes Verfahren zur Prävention und Therapie akuter und überlastungsbedingter Muskelverletzungen. Insbesondere das Verfahren der Kaltwasserimmersionstherapie (CWI), dessen klinische Wirksamkeit anhand sys-tematischer Metaanalysen wissenschaftlich belegt ist, wird zur Optimierung der Muskelregeneration in vielen Sportarten regelhaft angewandt. Die zugrundelie-genden physiologischen Wirkungsweisen sowie die Effekte auf die Skelettmuskula-tur, einschließlich Veränderungen der muskulären Steifigkeit, sind jedoch weitest-gehend ungeklärt. Ziel dieser Studie war es, den Einfluss einer Kaltwasserimmersi-onstherapie auf die passive Muskelsteifigkeit zu untersuchen. 1.2. Material und Methoden Insgesamt wurden 30 gesunde Sporttreibende in drei Gruppen (jeweils n=10) ran-domisiert aufgeteilt: 1) Nach-Belastung (Post-ESU) -Gruppe: Belastung und CWI; 2) Kontroll-Gruppe: Belastung ohne CWI; 3) Vor-Belastung (Pre-ESU) -Gruppe: CWI ohne Belastung. Die passive Muskelsteifigkeit wurde mittels Acoustic radiation force impulse (ARFI) Elastosonographie anhand der Scherwellen-Geschwindigkeit (SWV, m/s), jeweils im M. rectus femoris (RF) und M. vastus intermedius (VI) be-stimmt. Die Messwerte des Ausgangsniveaus (t0) wurden gruppenspezifisch mit den Werten nach der Belastung (t1, für Post-ESU-Gruppe und Kontroll-Gruppe) nach CWI (t2, für Post-ESU-Gruppe und Pre-ESU-Gruppe bzw. Kontrollzeit für Kon-troll-Gruppe) und 60 min nach Intervention (t3, für alle Gruppen) verglichen. Die Be-lastung erfolgte auf einem Fahrradergometer (t=20 min. bei 70% Wmax), die CWI erfolgte bei 12 °C (15 min., sitzend bis Bauchnabelhöhe); für die Kontrollgruppe sitzend (Raumluft, 21 °C). 1.3. Ergebnisse Die Ergebnisse der vorliegenden Arbeit wurden veröffentlicht in: Huettel, M. et al., Effects of Pre- and Post-Exercise Cold-Water Immersion Therapy on Passive Muscle Stiffness. Sportverletz Sportschaden, 2019 [1]. In der Post-ESU-Gruppe zeigte sich kein signifikanter Unterschied zwischen den Messzeitpunkten: Belastung (t1: RF 1,63 m/s; VI 1.54 m/s), CWI (t2: RF 1,63 m/s; VI: 1,53 m/s;) und 60 min. nach Intervention (t3: RF 1,72 m/s; VI 1,61 m/s). In der Kontroll-Gruppe konnte eine signifikante Abnahme der SWV zwischen dem Ausgangsniveau t0 und t1 im VI beobachtet werden, (VI: 1,37 m/s; p=0.004) (RF: 1,59 m/s; p=0,084). Zum Zeitpunkt t2 und t3 konnte keine signifikante Änderung festgestellt werden. Eine signifikante Abnahme der SWV konnte in der Pre-ESU-Gruppe zwischen Ausgangsniveau (t0) und post-CWI (t2) im VI festgestellt werden (p=0,027). 1.4. Schlussfolgerung Die vorliegende Studie zeigt in Abhängigkeit des Anwendungszeitpunktes unter-schiedliche Einflüsse einer CWI auf die Muskelsteifigkeit. Insgesamt kann festge-halten werden, dass bei der Anwendung nach Belastung kein signifikanter Effekt der CWI auf die Muskelsteifigkeit festgestellt werden konnten. Die unterschiedli-chen Effekte, abhängig vom Zustand vor oder nach Belastung, müssen bei der Durchführung bedacht werden, um einen möglichen präventiven und regenerativen Nutzen gewährleisten zu können.
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Heat shock proteins (HSPs) expression protect the cell from stress, this expression varies on tissue and stress level. Here, we investigated the structure and functional expression of HSPs in different chicken organs using meta-analysis. A total of 1253 studies were collected from three different electronic databases from January 1, 2015 to February 1, 2022. Of these studies, 28 were selected based on the specific criteria for this meta-analysis. The results for the expression of HSPs and the comparative expression of HSPs (HSP90, HSP70, and HSP60) in different chicken organs (brain, heart, liver, muscle, and intestine) were analyzed using the odds ratio or the random-effects model (REM) at a confidence interval (CI) of 95%. Compared to the thermoneutral groups, heat stress groups exhibited a significant (P < 0.01) change in their HSP70 expression in the chicken liver (8 trials: REM = 1.41, 95% CI: 0.41, 4.82). The expression of different HSPs in various chicken organs varied and the different organs were categorized according to their expression levels. HSP expression differed among the heart, liver, and muscle of chickens. HSPs expression level depends on the structure and molecular weight of the HSPs, as well as the type of tissue.
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The effectiveness of electrical stimulation (ES) in preventing or treating delayed-onset muscle soreness (DOMS) and its effects on muscle recovery is unclear. The systematic review investigated the benefits or harms of ES on DOMS and muscle recovery. Databases (PubMed, Medline, CENTRAL, EMBASE, CINAHL, PsycINFO, PEDro, LILACS, SPORTDiscus) were searched up to March, 31st 2021 for randomized controlled trials (RCTs) of athletes or untrained adults with DOMS treated with ES and compared to placebo/sham (simulation or without ES), or control (no intervention). Data were pooled in a meta-analysis. Risk of bias (Cochrane Collaboration tool) and quality of evidence (GRADE) were analyzed. Fourteen trials (n=435) were included in this review and 12 trials (n=389) were pooled in a meta-analysis. Evidence of very low to low quality indicates that ES does not prevent or treat DOMS as well as ES does not help to promote muscle recovery immediately, 24, 48, 72, 96 hours after the intervention. Only one study monitored adverse events. There are no recommendations that support the use of ES in DOMS and muscle recovery.
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Objective: To update and appraise the efficacy of physiotherapy for adults with cervicogenic headache. Literature survey: Bibliographic searches were conducted up to September 2021 for randomized controlled trials, assessing the efficacy of physiotherapy interventions for adults with cervicogenic headache, in five databases: CINAHL, PEDro, PubMed, Sage Journals and Wiley Online Library. Methods: Data extraction of included trials was conducted by two reviewers according to a standardized extraction form. The PEDro tool and the GRADE approach were used for grading evidence. Results from trials with similar interventions and with similar outcome measures were pooled into separate meta-analyses. A qualitative synthesis was performed for studies that were not pooled into meta-analyses. Synthesis: Fourteen trials were included. Moderate-certainty evidence indicates that manual therapy significantly reduces headache frequency (MD: -0.93 episodes/week; 95%CI: -1.40 to -0.46; 2 RCTs; n=265) compared to sham manual therapy, and headache frequency (MD: -1.23 episodes/week; 95%CI: -1.55 to -0.91; 3 RCTs; n=126) and intensity (MD: -1.63/10; 95%CI: -2.15 to -1.10; 4 RCTs; n=208) compared to no treatment in the short term. At 12-month follow-up, moderate-certainty evidence indicates that manual therapy did not lead to greater reduction in headache intensity (MD VAS 0-10: -0.12; 95%CI: -0.49 to 0.26; 2 RCTs; n=265) nor frequency (MD: -0.32 episodes/week; 95%CI: -0.91 to 0.28; 2 RCTs; n=265) when compared to a sham manual therapy. In the long-term, in one high quality trial, neck exercise significantly reduces headache intensity compared to no treatment (MD: -1.51/10; 95%CI: -2.52 to -0.50; n=100) or to aerobic exercises in another trial of moderate quality (MD: -1.15/10; 95%CI: -2.1 to -0.20; n=180). Conclusions: Manual therapy in the short term and neck exercise in the long term may be efficacious to treat adults with cervicogenic headache. More high quality evidence is needed and future results may change the current conclusions. This article is protected by copyright. All rights reserved.
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Strategies to improve recovery are widely used among soccer players at both amateur and professional levels. Sometimes, however, recovery strategies are ineffective, improperly timed or even harmful to players. This highlights the need to educate practitioners and athletes about the scientific evidence of recovery strategies as well as to provide practical approaches to address this issue. Therefore, recent surveys among soccer athletes and practitioners were reviewed to identify the recovery modalities currently in use. Each strategy was then outlined with its rationale, its physiological mechanisms and the scientific evidence followed by practical approaches to implement the modality. For each intervention, practical and particularly low-effort strategies are provided to ensure that practitioners at all levels are able to implement them. We identified numerous interventions regularly used in soccer, i.e., sleep, rehydration, nutrition, psychological recovery, active recovery, foam-rolling/massage, stretching, cold-water immersion, and compression garments. Nutrition and rehydration were classified with the best evidence, while cold-water immersion, compression garments, foam-rolling/massage and sleep were rated with moderate evidence to enhance recovery. The remaining strategies (active recovery, psychological recovery, stretching) should be applied on an individual basis due to weak evidence observed. Finally, a guide is provided, helping practitioners to decide which intervention to implement. Here, practitioners should rely on the evidence, but also on their own experience and preference of the players.
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Background: It has been demonstrated that pressotherapy used post-exercise (Po-E) can influence training performance, recovery, and physiological properties. This study examined the effectiveness of pressotherapy on the following parameters. Methods: The systematic review and meta-analysis were performed according to PRISMA guidelines. A literature search of MEDLINE, PubMed, EBSCO, Web of Science, SPORTDiscus, and ClinicalTrials has been completed up to March 2021. Inclusion criteria were: randomized control trials (RCTs) or cross-over studies, mean participant age between 18 and 65 years, ≥1 exercise mechanical pressotherapy intervention. The risk of bias was assessed by the Cochrane risk-of-bias tool for RCT (RoB 2.0). Results: 12 studies comprised of 322 participants were selected. The mean sample size was n = 25. Pressotherapy significantly reduced muscle soreness (Standard Mean Difference; SMD = -0.33; CI = -0.49, -0.18; p < 0.0001; I2 = 7%). Pressotherapy did not significantly affect jump height (SMD = -0.04; CI = -0.36, -0.29; p = 0.82). Pressotherapy did not significantly affect creatine kinase level 24-96 h after DOMS induction (SMD = 0.41; CI = -0.07, 0.89; p = 0.09; I2 = 63%). Conclusions: Only moderate benefits of using pressotherapy as a recovery intervention were observed (mostly for reduced muscle soreness), although, pressotherapy did not significantly influence exercise performance. Results differed between the type of exercise, study population, and applied treatment protocol. Pressotherapy should only be incorporated as an additional component of a more comprehensive recovery strategy. Study PROSPERO registration number-CRD42020189382.
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The effects of cold stress on exercise performance and fatigue have been thoroughly investigated only in males, and thus the general understanding of these effects relates only to males. The aim of this study was to determine whether whole-body cooling has different effects on performance during fatiguing exercise in males and females. Thirty-two subjects (18 males and 14 females) were exposed to acute cold stress by intermittent immersion in 14°C water until their rectal temperature reached 35.5°C or for a maximum of 170 min. Thermal responses and motor performance were monitored before and after whole-body cooling. Whole-body cooling decreased rectal, muscle and mean skin temperatures in all subjects (p<0.05), and these changes did not differ between males and females. Cold stress decreased the fatigue index (FI) of a sustained 2-min maximal voluntary contraction (MVC) only in males (p<0.05). There were no sex differences in central and peripheral fatigability, or muscle electromyographic activity. This observed sex difference (i.e., body cooling-induced decrease in the FI of a sustained MVC in males but not in females) supports the view of sex effects on performance during fatiguing exercise after whole-body cooling. Copyright © 2015 Elsevier Inc. All rights reserved.
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This study investigated the effects of two different hydrostatic pressures (seated or standing) during cold water immersion at attenuating the deleterious effects of strenuous exercise on indices of damage and recovery. Twenty four male well-trained games players (age 23 ± 3 years; body mass 81.4 ± 8.7 kg: O2max 57.5 ± 4.9 ml∙kg−1∙min−1) completed the Loughborough Intermittent Shuttle Test (LIST) and were randomly assigned to either a control, seated cold water immersion or a standing cold water immersion (14 min at 14°C). Maximal isometric voluntary contraction, counter-movement jump, creatine kinase, C-reactive protein, interleukin-6 and delayed onset muscle soreness (DOMS) were measured before and up to 72 h following the LIST. All dependent variables showed main effects for time (P < 0.05) following the LIST, indicating physiological stress and muscle damage following the exercise. There were no significant group differences between control and either of the cold water immersion interventions. Seated cold water immersion was associated with lower DOMS than standing cold water immersion (effect size = 1.86; P = 0.001). These data suggest that increasing hydrostatic pressure by standing in cold water does not provide an additional recovery benefit over seated cold water immersion, and that both seated and standing immersions have no benefit in promoting recovery following intermittent sprint exercise
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Despite a general lack of understanding of the underlying mechanisms, cold-water immersion (CWI) is widely used by athletes for recovery. This study examined the physiological merit of CWI for recovery from high-intensity exercise, by investigating if the placebo effect is responsible for any acute performance or psychological benefits. Thirty males (mean ± SD; age 24 ± 5 y; V[Combining Dot Above]O2peak 51.1 ± 7.0 mL·kg·min) performed an acute high-intensity interval training (HIT) session, comprised of 4 x 30-s sprints, immediately followed by one of three 15-min recovery conditions; CWI (10.3 ± 0.2°C), thermo-neutral water immersion placebo (TWP; 34.7 ± 0.1°C) or thermo-neutral water immersion control (TWI; 34.7 ± 0.1°C). An intramuscular thermistor was inserted during exercise and recovery to record muscle temperature. Swelling (thigh girth), pain threshold/tolerance, interleukin-6 concentration, and total leukocyte, neutrophil, and lymphocyte count were recorded at baseline, post-exercise, post-recovery, and 1, 24 and 48 h post-exercise. A maximal voluntary isometric contraction (MVC) of the quadriceps was performed at the same time-points, with the exception of post-exercise. Self-assessments of readiness for exercise, fatigue, vigour, sleepiness, pain, and belief of recovery effectiveness were also completed. Leg strength following the MVC, and ratings of readiness for exercise, pain and vigour, were significantly impaired in TWI compared with CWI and TWP, which were similar to each other. A recovery placebo administered after an acute HIT session is superior in the recovery of muscle strength over 48 h as compared with TWI, and as effective as CWI. This can be attributed to improved ratings of readiness for exercise, pain and vigour, suggesting that the commonly-hypothesised physiological benefits surrounding CWI are at least partly placebo related.
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The purpose of the study was to determine the effects of cold water immersion (CWI) performed immediately or 3 h after a high intensity interval exercise session (HIIS) on next-day exercise performance. Eight male athletes performed three HIIS at 90%VO2max velocity followed by either a passive recovery (CON), CWI performed immediately post-exercise (CWI(0)) or CWI performed 3 h post-exercise (CWI(3)). Recovery trials were performed in a counter balanced manner. Participants then returned 24 h later and completed a muscle soreness and a totally quality recovery perception (TQRP) questionnaire, which was then followed by the Yoyo Intermittent Recovery Test [level 1] (YRT). Venous blood samples were collected pre-HIIS and pre-YRT to determine C-Reactive Protein (CRP) levels. Significantly more shuttles were performed during the YRT following CWI(0) compared to the CON trial (p=0.017, ES = 0.8), while differences between the CWI(3) and the CON trials approached significance (p = 0.058, ES = 0.5). Performance on the YRT between the CWI(0) and CWI(3) trials were similar (p = 0.147, ES = 0.3). Qualitative analyses demonstrated a 98% and 92% likely beneficial effect of CWI(0) and CWI(3) on next day performance, compared to CON, respectively, while CWI(0) resulted in a 79% likely benefit when compared to CWI(3). CRP values were significantly lower pre-YRT, compared to baseline, following CWI(0) (p = 0.0.36) and CWI(3) (p = 0.045), but were similar for CON (p = 0.157). Muscle soreness scores were similar between trials (p = 1.10), while TQRP scores were significantly lower for CON compared to CWI(0) (p = 0.002) and CWI(3) (p = 0.024). Immediate CWI resulted in superior next-day YRT performance compared to CON, while delayed (3 h) CWI was also likely to be beneficial. Qualitative analyses suggested that CWI(0) resulted in better performance than CWI(3). These results are important for athletes who do not have immediate access to CWI following exercise.
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High-intensity exercise is associated with mechanical and/or metabolic stresses that lead to reduced performance capacity of skeletal muscle, soreness and inflammation. Cold-water immersion and other forms of cryotherapy are commonly used following a high-intensity bout of exercise to speed recovery. Cryotherapy in its various forms has been used in this capacity for a number of years; however, the mechanisms underlying its recovery effects post-exercise remain elusive. The fundamental change induced by cold therapy is a reduction in tissue temperature, which subsequently exerts local effects on blood flow, cell swelling and metabolism and neural conductance velocity. Systemically, cold therapy causes core temperature reduction and cardiovascular and endocrine changes. A major hindrance to defining guidelines for best practice for the use of the various forms of cryotherapy is an incongruity between mechanistic studies investigating these physiological changes induced by cold and applied studies investigating the functional effects of cold for recovery from high-intensity exercise. When possible, studies investigating the functional recovery effects of cold therapy for recovery from exercise should concomitantly measure intramuscular temperature and relevant temperature-dependent physiological changes induced by this type of recovery strategy. This review will discuss the acute physiological changes induced by various cryotherapy modalities that may affect recovery in the hours to days (<5 days) that follow high-intensity exercise.
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Background and Purpose. Assessment of the quality of randomized controlled trials (RCTs) is common practice in systematic reviews. However, the reliability of data obtained with most quality assessment scales has not been established. This report describes 2 studies designed to investigate the reliability of data obtained with the Physiotherapy Evidence Database (PEDro) scale developed to rate the quality of RCTs evaluating physical therapist interventions. Method. In the first study, 11 raters independently rated 25 RCTs randomly selected from the PEDro database. In the second study, 2 raters rated 120 RCTs randomly selected from the PEDro database, and disagreements were resolved by a third rater; this generated a set of individual rater and consensus ratings. The process was repeated by independent raters to create a second set of individual and consensus ratings. Reliability of ratings of PEDro scale items was calculated using multirater kappas, and reliability of the total (summed) score was calculated using intraclass correlation coefficients (ICC [1,1]). Results. The kappa value for each of the 11 items ranged from .36 to .80 for individual assessors and from .50 to .79 for consensus ratings generated by groups of 2 or 3 raters. The ICC for the total score was .56 (95% confidence interval=.47–.65) for ratings by individuals, and the ICC for consensus ratings was .68 (95% confidence interval=.57–.76). Discussion and Conclusion. The reliability of ratings of PEDro scale items varied from “fair” to “substantial,” and the reliability of the total PEDro score was “fair” to “good.”
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Athletes engage in activities which necessitate utilization of recovery strategies. Although the benefits of cold-water immersion have been extensively studied, active recovery with submaximal effort exercise in water has received more limited consideration. The purpose of this study was to compare the influence of active recovery, cold-water immersion, and passive recovery on speed, power, and perceived soreness after exhaustive exercise. Participants included 23 NCAA Division I athletes, matched by sport, sex and position, then randomized into 3 groups: passive recovery, cold-water immersion, or active recovery. Dependent measures of perceived muscular soreness, maximum vertical jump height and 20-meter sprint time were recorded at baseline, post-exercise and 24-hours post-intervention. Separate repeated measures ANOVA were utilized to analyze the effect of group and time on the dependent measures. Cold-water immersion, active recovery and passive recovery were not found to produce significant differences with respect to recovery of speed, power or perceived soreness. [Athletic Training and Sports Health Care. 2013,5(4), 169-176]
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Background Cold Water Immersion (CWI) is commonly used to manage delayed onset muscle soreness (DOMS) resulting from exercise. Scientific evidence for an optimal dose of CWI is lacking and athletes continue to use a range of a treatment protocols and water temperatures. Objectives To compare the effectiveness of four different water immersion protocols and a passive control intervention in the management of DOMS. Design Randomised controlled trial with blinded outcome assessment. Setting University Research Laboratory Participants 50 healthy participants with laboratory induced DOMS randomised to one of five groups: Short contrast immersion (1 min 38°C/1 min 10°C x 3), Short intermittent CWI (1 min x 3 at 10°C); 10 minute CWI in 10°C; 10 minute CWI in 6°C; or control (seated rest). Main outcome measures muscle soreness, active range of motion, pain on stretch, muscle strength and serum creatine kinase. Results 10 minutes of CWI in 6°C was associated with the lowest levels of muscle soreness and pain on stretch however values were not statistically different to any of the other groups. There were no statistically significant differences between groups for any other outcomes. Conclusion Altering the treatment duration, water temperature or dosage of post exercise water immersion had minimal effect on outcomes relating to DOMS.
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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.