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Sports Med 2006; 36 (9): 747-765
R
EVIEW
A
RTICLE
0112-1642/06/0009-0747/$39.95/0
2006 Adis Data Information BV. All rights reserved.
Physiological Response to
Water Immersion
A Method for Sport Recovery?
Ian M. Wilcock,1 John B. Cronin1 and Wayne A. Hing2
1 Institute of Sport and Recreation Research New Zealand, Division of Sport and Recreation,
Faculty of Health and Environmental Sciences, Auckland University of Technology,
Auckland, New Zealand
2 School of Physiotherapy, Faculty of Health and Environmental Sciences, Auckland University
of Technology, Auckland, New Zealand
Contents
Abstract ....................................................................................747
1. Water Immersion as a Recovery Strategy ...................................................748
1.1 Cryotherapy ........................................................................748
1.2 Thermotherapy ......................................................................749
1.3 Contrast Therapy ....................................................................749
1.4 Water Immersion per se ..............................................................749
2. Hydrostatic Pressure ......................................................................750
2.1 Water Pressure.......................................................................750
2.2 Weightlessness and Perceived Fatigue .................................................751
2.3 Fluid Shifts ...........................................................................752
2.4 Exercise-Induced Muscle Oedema ....................................................753
2.5 Cardiac Response ...................................................................754
2.6 Peripheral Resistance and Blood Flow ..................................................756
2.7 Summary of Findings .................................................................757
3. Temperature ............................................................................757
3.1 Cold Temperature Effects.............................................................757
3.2 Hot Water Temperatures ..............................................................758
3.3 Contrasting Temperature .............................................................760
4. Conclusions and Recommendations .......................................................761
Recovery from exercise can be an important factor in performance during
Abstract
repeated bouts of exercise. In a tournament situation, where athletes may compete
numerous times over a few days, enhancing recovery may provide a competitive
advantage. One method that is gaining popularity as a means to enhance
post-game or post-training recovery is immersion in water. Much of the literature
on the ability of water immersion as a means to improve athletic recovery appears
748 Wilcock et al.
to be based on anecdotal information, with limited research on actual performance
change. Water immersion may cause physiological changes within the body that
could improve recovery from exercise. These physiological changes include
intracellular-intravascular fluid shifts, reduction of muscle oedema and increased
cardiac output (without increasing energy expenditure), which increases blood
flow and possible nutrient and waste transportation through the body. Also, there
may be a psychological benefit to athletes with a reduced cessation of fatigue
during immersion. Water temperature alters the physiological response to immer-
sion and cool to thermoneutral temperatures may provide the best range for
recovery. Further performance-orientated research is required to determine
whether water immersion is beneficial to athletes.
Water immersion has been used in some cultures 1. Water Immersion as a
Recovery Strategy
for centuries as a means of health restoration.[1,2]
Recently, water immersion has gained popularity as There are four different methods of using water
a means to improve recovery from exercise, al- immersion in recovery: (i) cryotherapy; (ii) ther-
though much of its use is based on anecdotal infor- motherapy; (iii) contrast therapy; and (iv) water
mation.[2] For example, Netball New Zealand[3] rec- immersion per se. Cryotherapy, thermotherapy and
ommends that during the course of tournament-type water immersion per se are immersion in water at a
events, players should perform 5 minutes of water constant temperature, whereas contrast therapy is
immersion (contrast therapy) after games to aide immersion in alternating extremes of temperature.
recovery and performance. There is some basis for
the use of water immersion (non-exercising) to en- 1.1 Cryotherapy
hance recovery from exercise as it can produce
beneficial physiological changes within the body. Cryotherapy is immersion in cold water. No spe-
These physiological changes have been attributed cific water temperature range has been determined
principally to effects of hydrostatic pressure and for cryotherapy. Low and Reed[4] state that the sen-
temperature. Exercise in water is also used as a sation of cold pain begins at 15°C, and some re-
recovery session by some sport teams. However, the search has used temperatures of ≤15°C for the study
focus of this article is the physiological response of of cold-water immersion compared with thermoneu-
the body during non-exercise immersion. This arti- tral water[5,6] and in performance studies.[7-9] There-
cle will briefly describe the water immersion recov- fore, for the purpose of this article, cryotherapy was
ery strategies used in the laboratory and in the field. considered to be immersion in water of ≤15°C. In
Thereafter, the effect that hydrostatic pressure may the field, cryotherapy normally consists of putting
have on the body in thermoneutral water, and the bags of ice in a container (such as a plastic drum)
effect that cold and hot water temperature has on the full of water in which an athlete stands to immerse
body, will be examined. This information may assist their legs. In performance research, the duration of
athletes, trainers, physiotherapists and coaches in immersion time varies from 15 to 20 minutes.[7,8,10]
determining whether to adopt water immersion as a However, in the field, immersion time may be as
recovery strategy or assist in developing water im- little as 30 seconds as a result of the ability of an
mersion recovery protocols. individual athlete to withstand cold discomfort. For
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 749
a large number of athletes, or team sports, this 1.3 Contrast Therapy
method can be impractical because of the time re- Contrast therapy is a post-exercise recovery
quired to treat all of the athletes. method that has recently gained popularity.[14] Con-
trast therapy necessitates alternating temperature
1.2 Thermotherapy immersion, from a hot to cold bath and vice versa.
Protocols vary (see table I) but generally consist of
Thermotherapy refers to immersion in water that 30–300 seconds of one temperature extreme, imme-
diately followed by 30–300 seconds of the contrast-
raises the core body temperature. This increase in
ing temperature. This is repeated a number of times
core temperature occurs in water with a temperature
and lasts for 4–30 minutes. Vascular ‘pumping’
>36°C.[5,11,12] Facilities that provide a heated pool
caused by the variation in temperature has been
are required to perform thermotherapy. Anecdotally,
proposed as the mechanism that could improve re-
there are numerous teams that are based in facilities covery.[14-16] Whether such a contention is supported
that provide heated baths/spas and who perform by the literature will be discussed in section 3.3.
thermotherapy after training. However, compared
with thermoneutral immersion, little research has 1.4 Water Immersion per se
been conducted on the physiological or performance
effect of hot water immersion. An immersion dura- Water immersion per se is both the easiest
tion of 10–20 minutes has been suggested by method of application in the field and, compared
Brukner and Khan[13] to aide athletic recovery and with the other water immersion modes, widely
rehabilitation, although this time period does not researched (physiologically). No resources are re-
appear to be based on research and is unsubstantiat- quired to heat or cool the water, only a container,
ed. bath or pool in which to immerse athletes. The
Table I. Examples of contrast therapy protocols
Study Temperature (°C) Application time Repeats Order
cold hot
Research
Coffey et al.[17] 10 42 1 min cold: 2 min hot 5 Start cold, end hot
Cote et al.[18] 10–15 39–41 1 min cold: 3 min hot 4 Start hot, end hot
Hamlin and Magson[19] 8–10 38 1 min cold: 1 min hot 3 Start cold, end hot
Hamlin and Sheen[20] 8–10 38 1 min cold: 1 min hot 3 Start cold, end hot
Higgins and Kaminski[21] 15 40 10 min hot, then 5 Start hot, end cold
1 min cold: 4 min hot
Kuligowski et al.[22] 13 39 3 min hot: 1 min cold 6 Start hot, end cold
Sanders[16] 15 38 3.5 min hot: 30 sec cold 3 Start hot, end cold
Vaile et al.[23] 8–10 40–42 1 min cold: 2 min hot 5 Start cold, end hot
Text
Briggs[24] 10–15 NA 3 min hot: 1 min cold 5 ×/h Start hot, end cold
Brukner and Khan[13] 15 40 4 min hot: 1 min cold 3–7 Start hot, end cold
Clover[25] 13–18 38–43 4 min hot: 1 min cold 15–20 min
Walsh[26] 10–18 38–44 10 min hot, then 30 min total Start hot, end hot
1 min cold: 4 min hot
Zuluaga et al.[27] NA 45 3 min hot: 1 min cold NA Start cold, end cold
NA = data not available.
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
750 Wilcock et al.
temperature widely used in this mode ranges from 2.1 Water Pressure
cool to thermoneutral, which for this review is con- Air exerts pressure equally on all sides of the
sidered to range from 16 to 35°C. Research into the body. At sea level, the pressure exerted around the
physiological effect of water immersion generally body equates to approximately 1013Pa. Water is
has concentrated on the use of thermoneutral immer- >800 times denser than air; consequently, at an
sion and has ranged in immersion time from 5 equal depth, water will create a greater pressure than
minutes to 6 hours. This article only considered the air.[30] Due to this greater density, water produces
effect of immersion over a maximum of 30 minutes the same pressure at a depth of only 10m as the
to replicate a time similar to post-exercise recovery entire atmosphere of air at sea level.[30]
sessions. Unlike cryotherapy, thermotherapy or con- When immersed in water, hydrostatic pressure
acts on the body in relation to the depth of immer-
trast therapy, the main effect of water immersion per
sion. The amount of pressure that acts on a body is
se comes from the effect of hydrostatic pressure and
equal to:
perhaps to a lesser degree buoyancy, rather than
P = Patm + g•ρ•h
temperature. The few studies into water immersion
where P = water pressure; Patm = atmospheric pres-
as a performance recovery method have concen- sure (standard sea level 1013 hPa); g = gravity (9.81
trated on cryotherapy, thermotherapy and contrast m/sec2); ρ = water density (1000 kg/m3) and h =
therapy, combining both temperature and hydrostat- height of the water (m).
ic pressure effects.[7,8,16,17,28,29] To gain greater un- Water pressure does not correlate to the total
derstanding of water immersion, the effects of hy- weight of the water in a vessel, only to the depth. If
drostatic pressure and temperature would be best the wall of a container is solid then the walls of the
studied in isolation and provide the focus for the container exert a pressure on the water equal to the
remainder of this article. pressure of the water at that depth. This means that
water pressure is a force per unit area and is trans-
mitted equally throughout the water at a given level.
2. Hydrostatic Pressure
On a body immersed in water, the pressure varies
relative to depth. A body part such as a foot im-
When a body is immersed, water exerts a com- mersed at a depth of 1m would have 981Pa extra
pressive force on the body called hydrostatic pres- pressure acting on it, whereas at hip level (0.1m),
sure. This pressure can cause the displacement of only an extra 98.1Pa. To relate this external pressure
fluids within a person from the extremities towards to blood pressure measurement, for every 1cm depth
the central cavity. This displacement of fluid may of immersion, the pressure increases by 0.74mm Hg.
increase the translocation of substrates from the The proportional change in pressure with depth
muscles, increase cardiac output, reduce peripheral causes an upward squeezing action on the body,
resistance and increase the ability of the body to which at 1m depth (74mm Hg) is almost equal to
transport substrates. Additionally, the antigravity normal diastolic blood pressure (80mm Hg).
effect caused by buoyancy may reduce perception of The human body is mostly water with the addi-
fatigue and aide energy conservation. The following tion of some oil (fats) and proteins. Because water is
sections (sections 2.1–2.7) will explore the physio- essentially non-compressible, it occupies the same
logical effects of hydrostatic pressure during volume regardless of pressure.[31] When external
thermoneutral immersion. pressure on the body increases, gas and fluid sub-
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 751
stances are displaced to lower pressure areas.[30,32,33]
Therefore, a person standing in water experiences
compression on the body acting inwards and
upwards. During hip-level immersion, this ‘squeez-
ing’ causes the displacement of fluid from the lower
extremities of a person into the thoracic region.
During head-out immersion, hydrostatic pressure on
the central cavity reduces the residual air volume of
the lungs increasing the displacement of fluids into
the thorax.[32] It is the movement of these fluids that
may enhance the ability of an athlete to recover from
exercise.
2.2 Weightlessness and Perceived Fatigue
h
P
atm
+
h
• ρ •
g
P
atm
Fig. 1. Water upthrust. g = gravity; h = height; ρ = water density;
Patm = atmospheric pressure
(
standard sea level 1013 hPa
)
.
One significant consequence of water pressure system, allowing for a greater relaxation of gravita-
being proportional to the immersion depth is that the tional muscles and conservation of energy. Such
body will weigh less when immersed in a liquid i.e. greater relaxation would appear to reduce perceived
it is easier to lift a rock in water than it is on dry land. fatigue. A number of studies (see table II) have
This is because water exerts a net upward force on observed lower perception of fatigue after exercise
the body immersed in it. This upward force helps to during and after water immersion. While two au-
support all or part of the weight of the body im- thors[17,23] did not observe any significant difference
mersed in it. The upward force exerted by a fluid on in perceived fatigue, both did observe a moderate
any object placed in it is called buoyancy or hydro- effect of lower sense of fatigue with water immer-
static upthrust. sion compared with other recovery modes (Cohen’s
The force created by upthrust is calculated as: effect size = 0.50–0.89).
F = h•ρ•g•AThe decrease in the perception of fatigue may
taking the calculation further, F = V•ρ•galso be due to reduced neuromuscular responses
F = m/g during water immersion.[35-37] During water immer-
where h = height; ρ = water density; g = gravity; A = sion, electromyographic activity produced during
base area; V = immersed volume; and m = mass. maximal contractions have been observed to reduce
Hence there is a net upward pressure, giving rise by 11–35%.[35,36] In their 2002 study, P¨
oyh¨
onen and
to an upward force equal to upward pressure times Avela[35] also observed a 13% decrease in maximal
horizontal base area (as shown in figure 1). In other voluntary contraction force during immersion. Im-
words, any body partly or wholly immersed in a
mersion may modify the peripheral processes asso-
liquid, experiences an upthrust that is equal to the
ciated with contraction and change central and/or
weight of the liquid displaced (Archimedes Princi-
neural command contractions,[37] or trigger inhibito-
ple). The greater the body density, the less buoyancy
ry mechanisms. The reduced perception of fatigue
a person has, which is why people with higher fat
may come then not only from a reduction in the
mass (less density) are more buoyant than those who
neuromuscular activation required to maintain pos-
are lean. The effect of buoyancy is a reduction in the
gravitational forces that act on the musculoskeletal ture but also due to an overall reduction in neural
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
752 Wilcock et al.
transmissions. However, more research is required
on whether water immersion does reduce neural
efficiency, whether such reductions are due to
weightlessness or hydrostatic pressure[35] and if
there are any post-immersion effects.
2.3 Fluid Shifts
Under normal conditions, the body is comprised
of 50–60% fluid, which is located either in the
intracellular, interstitial (between cells) or intravas-
cular (blood plasma) space (see figure 2). Typical
intracellular, interstitial and plasma volumes are
35–40%, 11–15% and 4–5%, respectively, of body-
weight.[38] Fluid within these compartments acts as a
vehicle for the transport and exchange of materials,
such as metabolic wastes and nutrients, between the
body and the external environment.
Movement of fluid and materials between the
intravascular and extravascular space occur in the
vascular capillaries. Fluid and substance movement
across the capillaries occur via three processes: (i)
diffusion; (ii) vesicular transport; and (iii) filtration-
reabsorption. Diffusion is the movement of fluid/
substances from a high concentration to a low con-
centration, whereas vesicular transport is active
transport (requiring adenosine triphosphate) of sub-
stances across the vascular membrane. Diffusion
occurs along all of the capillary membrane and
accounts for the largest exchange of fluids and sub-
stances, whereas vesicular transport and filtration
account for a small portion of fluid movement.[39]
Filtration-reabsorption is the net movement of fluid
due to the capillary-interstitial pressure gradient.
Filtration is the net movement of fluid into the
interstitial space at arteriolar ends of the capillaries,
which is then reabsorbed at the venular ends of the
capillaries. Approximately 2–4L of this fluid per
day is not reabsorbed by the capillaries through
filtration-reabsorption, but moves through the lym-
phatic vessels and drains into the subclavian
veins.[40] Disruption in the balance of filtration-reab-
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Table II. Water immersion and perception of fatigue
Study Scale Exercise Recovery Measurement timing Main findings
Coffey et al.[17] 20-point RPE Maximal sprints 15 min contrast therapy, 4, 8, 12, 16, 20 min post- No significant difference between
recovery scale active or passive sprint. Pre- and post-second recoveries
set of sprints
Kuligowski et al.[22] 12cm graphic pain DOMS-inducing arm curl 24 min warm water, cold 0, 24, 48, 72, 96h post- ↓ pain perception with cold water
scale water, contrast therapy or exercise and contrast therapy
control
Nakamura et al.[34] 5-point fatigue scale 10 min of submaximal 10 min in 30°C or 38°C Not specified ↓ fatigue for 30°C bathing
cycling water bath, or control
Sanders[16] 10-point CR scale Repeated Wingate test 12 min contrast therapy, 3 and 7 min during recovery ↓ fatigue at all times with contrast
active or passive Post-recovery therapy
Post second exercise bout
Vaile et al.[23] 10cm VAS score DOMS-inducing leg press 15 min contrast therapy (i) 0 Both groups had increased pain. No
or control (ii) 24h significant difference
(iii) 48h
(iv) 72h
Viitasalo et al.[28] 10cm VAS score Strength, plyometric and 20 min warm water Over 2 days post-training ↓ DOMS during immersion week
sprint training over 3d immersion or control
CR = Borg category ratio scale; DOMS = delayed onset of muscle soreness; RPE = rating of perceived exertion; VAS = visual analogue scale; ↓ = decreased.
Physiological Response to Water Immersion 753
Intracellular
space
Interstitial
space
Intravascular
space
Cell
Venous end
of the
capillary
Intravascular
space
Arterial
end of the
capillary
Lymphatic
system
FiltrationReabsorption
Diffusion
and vesicular
transport
Diffusion
and vesicular
transport
Fi
g
. 2. Schematic dia
g
ram showin
g
the intracellular-intravascular movement of fluid.
sorption, through effects such as physical trauma, blood and haematocrit densities (–1.5% and –1.0%,
lymph blockage or changes in pressure gradients, respectively). While plasma dilution occurred in
can cause an abnormal increase in interstitial fluid in these studies, the intravascular fluid shift was also
localised areas, a condition called oedema, swelling, accompanied by a plasma protein shift of albumin.
or inflammation. Stocks et al.[44] suggested that the increase in the
It is well documented that water immersion extracellular fluid volume ultimately comes at the
causes a rise in central blood volume, which in- expense of intracellular fluid, although further in-
creases with the depth of immersion.[33,41-43] The vestigation and verification of this hypothesis is
increase in central blood volume is due to two required. Such fluid shifts would increase the intra-
effects: haemodilution (increased diffusion and re- cellular-intravascular osmotic gradients and some
absorption) and blood displacement. During immer- intracellular constituents, such as metabolic wastes,
sion at hip level, haemodilution occurs as a result of may leave the cells and interstitial space to maintain
negative transcapillary pressure in the legs. This an osmotic balance.[44,47] It is possible then that
pressure gradient causes a fluid shift from the inter- immersion may cause improvements in the translo-
stitial to intravascular space in the legs.[42,44,45] cation of substrates, which may help to increase the
With immersion above hip level, additional in- ability of an athlete to recover, as reduced transpor-
creases in central blood expansion results as blood tation time could increase clearance of waste sub-
from the abdomen, which acts as a blood reservoir, strates.[16,17,34,48]
is displaced.[42] Norsk et al.[46] studied changes in
plasma concentration during head-out immersion 2.4 Exercise-Induced Muscle Oedema
and observed significant decreases in haematocrit
and haemoglobin concentration with an associated
Apart from assisting the possible removal of sub-
6.5 ± 1.9% (mean ± standard error [SE]) increase in
stances, the gradient between internal tissue hydro-
plasma volume. Hinghofer-Szalkay et al.[47] ob-
static pressure and capillary filtration pressure may
served similar results when using plasma densitom-
also improve the reabsorption of interstitial fluids,
etry to measure transvascular fluid shifts during
reducing oedema.[29,49] An increase in the pressure
immersion to the neck. After 30 minutes of ther-
gradient between the interstitial compartment of the
moneutral immersion, the six men in the study had
legs and the intravascular space caused by hydro-
plasma volume increases of 11 ± 3%, with decreased
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
754 Wilcock et al.
static pressure should reduce oedema in a similar reduction in muscular inflammation may improve
contractile function as well as lowering the levels of
fashion to compression stockings.[50,51]
inflammatory cells and muscle enzymes circulating
Exercise causes a shift of plasma from the blood in the blood.[23,65] Reducing oedema may, therefore,
into the muscles, with this fluid movement being decrease secondary damage to tissue, which in turn
relative to the intensity of the exercise.[52-57] The may increase the ability of an athlete to recover from
mode of exercise does not appear to be a factor but muscle damaging exercise.[23,66]
rather the respondent increase in mean arterial pres-
sure.[53] Researchers have observed that cycling at 2.5 Cardiac Response
intensities of 30–120% of maximal oxygen uptake
decreased blood plasma by 5–17% as fluid shifted The predominant effect of water immersion and
intramuscularly.[54-58] However, during resistance the associated increase in central blood volume ex-
training, plasma decreases of 8–14% have been ob- pansion is an increase in cardiac pre-load. Central
served in relation to an intensity range of 40–70% blood volume expansion increases atrial pre-load
one repetition maximum (1RM).[53] The decrease in and stroke volume. Increasing the depth of immer-
plasma volume observed by Knowlton et al.[53] dur- sion causes greater stroke volume increases. Com-
ing the resistance training correlated highly with an pared with non-immersion, at the level of the hips
increasing mean arterial pressure (r = –0.98). How- stroke volume has been reported to increase by
ever, fluid shifts from the vascular space reflected 12–37%,[32,33] this increases to 38–67% at the level
movement into active but not inactive muscle during of the xiphoid process[5,12,32,33,45] and 28–95% during
exercise.[59] Using magnetic resonance imaging, head-out immersion.[32,33,41,67-69] The effect size be-
pre- and post-resistance exercise (six sets of 10RM tween each level of immersion from these studies
squats) Ploutz-Synder et al.[59] observed an increase ranged from moderate to very large (0.75–3.95).
in the cross-sectional area of the vasti and adductor When immersed in thermoneutral water to the
muscle groups coinciding with a 22% decrease in level of the hips, heart rate has a tendency to de-
plasma volume (measured by Evans blue dye). The crease by approximately 4–6%.[32,33] Increasing
coefficient of determination between the plasma depth of immersion to the xiphoid process has de-
decrease and volume increase in the adductor and creased heart rates by 11–18% compared with non-
vasti muscle groups was strong (r2 = 0.75, p = immersion.[5,12,32,33,45,70,71] However, rather than a
0.0157). Muscles that were less active during squats linear decrease in heart rate with increasing immer-
(rectus femoris and the hamstring muscle groups) sion depth, the decrease in heart rate during head-out
had smaller non-significant increases in their cross- immersion (3–15%)[6,32,33,41,42,67-70] is less than that
sectional area. observed during immersion to the xiphoid process.
Oedema in response to exercise or muscle dam- Individual heart rate response to immersion var-
age may increase both the transport route and com- ies and decreases in heart rates have been non-
pression of localised capillaries, reducing oxygen significant in some studies.[5,41,42,68] While non-sig-
delivery to localised cells. With excessive muscle nificant, a negative effect on heart rate was still
oedema, such an increase in transportation time can apparent in the immersed subjects of these studies
cause an increase in cellular damage or death.[49,60-62] (see table III). The explanation for heart rate vari-
A positively increased pressure gradient can reduce ance may be due to conflicting physiological feed-
cellular infiltration by leukocytes and monocytes back systems. Increasing mean arterial pressure
decreasing further tissue degeneration.[23,63,64] Such causes arterial baroreceptors to bring about a reflex
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 755
Table III. Cardiac response of thermoneutral immersion compared with non-immersion (p < 0.05 unless otherwise stated)
Study Immersion Change in Change in Change in cardiac
duration (min) stroke volume (%) heart rate (%) output (%)
Hip level immersion
Farhi and Linnarsson[32] 11.9 –3.9 14.0
L¨
ollgen et al.[33] 37.0 –5.7 29.2
Xiphoid process immersion
Farhi and Linnarsson[32] 64.2 –10.5 48.0
L¨
ollgen et al.[33] 67.1 –11.4 48.1
Bonde-Petersen et al.[5] 15 38.7 –14.5 NS 19.1
Gabrielsen et al.[45] 10 50.8 –10.6 32.6
Gabrielsen et al.[70] 10 –14.1
Watenpaugh et al.[71] 30 –18.3
Weston et al.[12] 15 50.0 –11.0 31.5
Head-out immersion
Arborelius et al.[41] 10 28.3 –3.3 NS 28.9
Farhi and Linnarsson[32] 79.1 –6.6 66.0
L¨
ollgen et al.[33] 79.5 –11.4 59.1
Gabrielsen et al.[70] 10 –15.3
Johansen et al.[42] 5–6.9 NS
10 –8.6
15 –8.6
Park et al.[67] 30 54.7 –1.4 53.2
Shiraishi et al.[69] 30 62.1 –8.6 52.4
Sramek et al.[6] 10 –8.0
Yun et al.[68] a 20 52.5 –1.7 NS 49.4
Yun et al.[68] b 20 56.4 –6.3 NS 48.7
Yun et al.[68] c 20 95.3 –2.3 NS 101.7
a Subjects = breath-hold divers (mean age 55y).
b Subjects = housewives (mean age 55y).
c Subjects = housewives (mean age 22y).
NS = non-significant.
to slow the heart, most likely to prevent abnormally Regardless of an individual’s heart rate response,
the increase in stroke volume ultimately causes an
high blood pressure levels. Opposing this sympa-
increase in cardiac output. Observed cardiac outputs
thetic response, an increased atrial stretch caused by (see table III) vary but have been reported to be
the greater central blood volume (most notably approximately 14–29% at hip level,[32,33] 19–48% at
when the water level rises above the hips) stimulates the height of the xiphoid process[5,12,32,33,45] and
atrial stretch receptors and increases heart rate 29–66% at head-out immersion.[32,33,41,67,69] Yun et
through a neural reflex called the Bainbridge re- al.[68] observed larger increases in cardiac output
flex.[72] Individual physiological variables (such as (102%) during head-out thermoneutral immersion,
heart size) would then determine the dominant re- but was the only study in which the subjects were
flex. Generally speaking, however, the mean heart both female and Korean. Subjects used in immer-
rate of subjects appears to decrease during short- sion research have for the most part been male and
term thermoneutral immersion. European.
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
756 Wilcock et al.
2.6 Peripheral Resistance and Blood Flow resistance would seem to occur during head-out
immersion only.[41,43,67,68] While studies of immer-
Accompanying the increased cardiac output dur- sion at a depth under chin level have shown a
ing immersion is a decrease in peripheral resistance decrease in peripheral resistance and increased
implying that peripheral vasodilation oc- blood flow (with small to very large effect sizes;
curs.[5,12,41,67,68] Total peripheral resistance (TPR) –0.59 to –2.62) the findings of these studies com-
has been measured indirectly using the following pared with non-immersion have been non-signifi-
calculations: cant.[5,12]
TPR = (MAP – CVP)/ ˙
Q[67,68]
With the increase in cardiac output, some reduc-
TPR = (MAP – right atrial pressure)/ ˙
Q[41]
tion in peripheral resistance and vasodilation, in-
TPR = MAP/ ˙
Q[5,12]
creased blood flow may result throughout the body.
where MAP = mean arterial pressure, CVP = central
During erect head-out immersion, dogs have re-
venous pressure and ˙
Q = cardiac output.
sponded with large increases (>50%) in blood flow
Decreases in peripheral resistance of 27–51%
have been reported[41,67,68] during head-out water through the liver, intestinal tract, pancreas, spleen,
immersion. Immersions at lower depths do not seem renal cortex and skeletal muscle.[73] If the responses
to reduce peripheral resistance. Gabrielsen et al.[70] displayed by dogs can be extrapolated to humans,
determined intramuscular blood flow using a count- greater organ and muscle blood flow may allow
ing signal between two cadmium-telluride detectors improved removal of metabolites and an increased
to measure the washout of injected 113Xenon-saline ability to replenish energy stores. However, such
(k). From the determined blood flow, peripheral extrapolation may not be possible. Blyden et al.[74]
resistance was determine as TRP = MAP/k. Muscu- observed that the clearance of lidocaine (lignocaine)
lar vascular resistance did not change significantly in humans was unaltered by immersion to the neck,
with immersion to the xiphoid process but decreased indicating no change in splanchnic blood flow. Ep-
by approximately 15% with immersion to the neck. stein et al.,[75] using the clearance of p-aminohip-
Similarly, Gabrielsen et al.[70] observed that during puric acid and inulin to determine changes in renal
immersion to the xiphoid process, blood flow did plasma flow and glomerular filtration rate, sup-
not significantly increase but increased by 49 ± 16% ported the findings of Blyden et al.[74] With greater
(mean ± SE) during head-out immersion. Bonde- cardiac output, lower peripheral resistance and vaso-
Petersen et al.[5] and Weston et al.[12] also observed dilation (at head-out immersion at least), it could be
no significant decrease in total peripheral resistance logically assumed that an increase in blood flow
during immersion to the xiphoid process. through the muscles and perhaps the organs would
A direct method of measuring venous tone during occur. Results from Epstein et al.[75] and Blyden et
immersion is occlusion plethysmography. Echt et al.[74] imply that renal blood flow is unaffected,
al.[43] used this method to determine venous elastici- although their research only analysed the clearance
ty during a 3-hour immersion to the neck of subjects. of certain chemicals not actual blood flows. Other
In the first 15 minutes of immersion, the venous metabolites, notably blood lactate, have an in-
volume elasticity coefficient reduced from 16.6 to
creased clearance rate when subjects have been par-
13.5mm Hg/mL/100g tissue, a decrease of 19%.
tially immersed in water,[16,17,19,34] indicating that
Venous tone slowly reduced a further 30% by the
blood flow through the muscle beds increase.[74]
third hour of immersion and persisted for 1 hour
Whether blood flow increases to organs other than
post-immersion. However, reduction in peripheral
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 757
the kidneys is unknown and requires further investi- 3. Temperature
gation.
The previous sections have considered the physi-
ological response that thermoneutral immersion in
2.7 Summary of Findings water can have on a person. This article has concen-
trated on the immersion of subjects in thermoneutral
Hydrostatic pressure during water immersion water because of the abundance of research in this
aids the return of fluid from the muscles into the area. Colder, warmer or a variation in water temper-
blood.[29] If plasma volume increases due to a fluid ature may alter these physiological responses, pro-
shift from the interstitial space, the translocation of viding either additional benefits or detriment to any
metabolic waste may be improved due to blood possible recovery enhancement.
dilution and improved diffusion gradients.[38] Addi-
tionally, the increase in blood volume increases 3.1 Cold Temperature Effects
stroke volume and cardiac output, increasing blood
flow through the body. Improved diffusion gradients Thermoneutrality is considered to occur in a
and increased blood flow through the body could small range (35°C) in which subjects can maintain
increase the ability of an athlete to metabolise waste their core temperature for at least 1 hour.[77] Critical
products and enhance recovery from exercise by cold temperatures at which an individual cannot
reducing transport time of substrates.[76] The in- maintain core temperature for an hour ranges from
creased clearance of blood lactate in subjects that 30 to 34°C depending on cutaneous fat.[78] However,
have been immersed in water following exer- core temperatures can be maintained during head-
cise[16,17,19,20,34] would support such a theory. Sports out immersion at temperatures as low as 18°C for up
that cause a large depletion in muscle energy stores to 30 minutes.[78,79]
or cause large increases in metabolites (high-intensi- Cooler temperatures do have some effect on the
physiological responses of the body. As water tem-
ty anaerobic power-endurance or endurance sports)
perature decreases, heart rate reduces,[6,12] which
may therefore benefit from water immersion, espe-
decreases cardiac output.[5,6,67] Additionally, arterial
cially in tournament situations where an athlete may blood pressure and peripheral resistance also in-
compete a number of times within a few days. crease.[5,6,67] The increase in peripheral resistance is
Hydrostatic pressure may also aide the reduction due to blood being redirected from the periphery to
exercise-induced muscle oedema. Excessive muscle maintain core temperature.[5,80] Oxygen consump-
oedema may cause capillary constriction and in- tion and metabolism also increase to maintain core
crease substrate transportation time leading to temperatures.[6,67]
greater cellular damage or death. Reduction of oede- Reduced permeability of cellular, lymphatic and
ma may therefore improve nutrient delivery and capillary vessels due to localised vasoconstriction
speed recovery from exercise that has induced mus- reduces fluid diffusion into the interstitial
cle damage. Where fluid shifts could improve athlet- space.[81,82] This reduced fluid diffusion can assist in
ic recovery physiologically, buoyancy may provide reducing acute inflammation from muscle dam-
a psychological enhancement to recovery as some age.[18] This in turn can reduce pain, swelling and the
studies have observed a lower perception of fatigue loss of force generation that is also associated with
in immersed subjects. inflammation.[83] Hence, cold is often used in the
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
758 Wilcock et al.
treatment of inflammation to improve the rehabilita- ally, sudden severe cold immersion of a large por-
tion process.[18] tion of the body can produce hyperventilation,
which may cause ventilation to increase up to five
One metabolite that is used as a marker of muscle times the resting rate.[94] The decrease in arterial
damage is the level of creatine kinase in the carbon dioxide caused by hyperventilation may lead
blood.[84] Exercise-induced injury is thought to in- to blood acidosis and impaired consciousness, even
crease the permeability of cells increasing the diffu- in fit young people.[94,95] Additionally, sudden cold
sion of myoproteins such as creatine kinase into the immersion can cause tachycardia and acute periph-
extracellular space.[81,82,85] Cold water immersion eral vasoconstriction producing sudden loss of con-
decreases the level of creatine kinase in the blood sciousness, convulsions, ventricular ectopy, cardiac
after exercise-induced muscle damage.[81,86] Lower arrest and death.[94,95]
creatine levels are attributed to a decrease in cellu- While rare, some people also have cold hypersen-
lar, lymphatic and capillary permeability caused by sitivity and can be at risk if body parts are suddenly
vasoconstriction induced by the cooler tempera- immersed in cold water. Conditions consist of aller-
ture.[81,82] However, caution is warranted when ap- gic and possible anaphylactic reactions, Raynaulds
plying the presence of creatine kinase in the blood as phenomenon, and paroxysmal cold haemoglobin-
an indication of muscle damage. Levels of creatine uria.[95,96] Allergic reactions can consist of rashes
kinase in the blood reflect not only creatine kinase and wheals, which may advance into anaphylaxis.
release rate but also the removal rate. Exercise- The signs and symptoms of fully developed anaphy-
induced haemoconcentration or haemodilution and laxis include hypotension, syncope and vascular col-
alterations of tissue clearance due to blood-flow or lapse and can lead to death.[95,96] Raynaulds phe-
function will affect creatine concentration in the nomenon is peripheral vasoconstriction that leads to
blood. Creatine kinase may not then accurately indi- numbness, tingling and burning pain,[97] while par-
cate muscle damage or fatigue.[85]
oxysmal cold haemoglobinuria is a rare and poten-
Neural components are also affected by the cold. tially life-threatening affliction that causes the re-
Cooling of tissue decreases the rate of transmission lease of haemoglobin from red blood cell into the
along neurons by decreasing the production of ace- urinary system causing acute transient anaemia.[98]
tylcholine[87] and possibly stimulates superficial in- While cold hypersensitivity is rare, care should
hibitory cells that regulate the impulse of pain per- be taken when using cold immersion on athletes.
ception to the CNS.[88] Reduction of nerve impulse Very cold water temperatures may be best only in a
transmission by cold has two effects: (i) reduced localised manner to treat acute injuries and reduce
level of pain perception (analgesia); and (ii) reduc- inflammation, rather than being used as a recovery
tion in muscle spasm.[88,89] While reduction in pain strategy.
may be of benefit, a reduced neural transmission
may decrease muscular contractile speed[87,90,91] and
force-generating ability of an athlete post-applica- 3.2 Hot Water Temperatures
tion.[91-93] Performance may then be initially inhib-
ited if exercise is performed shortly after cold im- Considering the use of thermotherapies such as
mersion. hot baths in physiotherapy, there is a lack of re-
There are risks to athletes whom may be im- search-based literature on the effect that superficial
mersed in cold water, dependent on the temperature heat application has on a person. Apart from basic
extreme and amount of the body immersed. Gener- physiological responses, much of the literature
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 759
comes from texts that cite other texts or is based on studies that have analysed the effect of the superfi-
anecdotal information. cial application of heat, flexibility was not enhanced
unless accompanied with stretching.[108-111] A report
Superficial application of heat increases subcuta- by Bigos et al.[112] on back pain and thermal applica-
neous and cutaneous tissue temperature while tissue
tions concluded that not enough data existed to
temperature at depths >2cm remains unchanged.[99]
recommend the use of heat in pain reduction. More
An increase in superficial tissue temperature causes
recent research[113-115] has observed that pain may be
an increase in the cutaneous blood flow, over short
reduced if heat is applied continuously (8 hours/day)
durations, due to peripheral vasodilation.[5,80] Heart
over a long term (2–5 days). However, research is
rate also increases in response to hot water immer-
sion.[5,12] This increase in heart rate may reduce lacking in the short-term application of heat and
stroke volume due to lack of cardiac filling time, but possible effects on pain.
overall cardiac output increases compared with There are contraindications to immersion in hot
thermoneutral immersion.[12] water. The most obvious is the possibility of burns
The increase in cardiac output and a lower pe- due to high water temperatures. At 45–50°C protein
ripheral resistance allows an increase in subcutane- denaturation occurs and immersion water tempera-
ous and cutaneous blood flow.[5,12,100] An increase in tures should be below this range.[102] Superficial heat
subcutaneous and cutaneous blood flow increases application also causes an inflammatory response
the permeability of cellular, lymphatic and capillary and swelling,[18,116-118] which may prolong recovery
vessels.[101] Increased permeability increases metab- time.[18,91] Cote et al.[18] observed increased oedema
olism, nutrient delivery and waste removal from the in 30 patients with first- and second-degree ankle
cells that can increase healing.[18,102] However, for sprains when 20 minutes of hot water immersion
short-duration superficial application, these changes was applied each day over 3 days. Volumetric in-
are not likely to occur within the muscle, but rather crease in ankle size was 25% with hot water immer-
within the skin.[5,103] Additionally, Bonde-Petersen sion of the foot compared with 3% in patients re-
et al.[5] observed that while subcutaneous and cuta- ceiving cold water immersion. The effect size of this
neous blood flow increased, blood flow through the difference was large (1.95). If heat increases oedema
muscle may decrease compared with thermoneutral in sprains, it can be speculated that in may also
immersion. Lower water temperatures may then increase muscle inflammation.[119]
have greater benefits in substrate transportation
within a muscle. However, the effect size Bonde- Hot water immersion of a large portion of the
Petersen et al.[5] observed in blood flow difference body can produce a potentially dangerous strain on
between thermoneutral and hot water immersion the cardiovascular system causing ectopic beats,
was small (0.29). hypotension, heat syncope, excessive tachycardia
and even death.[120,121] Heat syncope is fainting and
Superficial heat may also increase neural trans-
giddiness due to the collapse of vasomotor control
mission[104] proprioception and improve reaction
and a decrease in blood pressure owing to rapid
time.[9] Other proposed benefits of thermotherapy
vasodilation.[11] Care is warranted with athletes who
include increased muscle elasticity, joint extensi-
have acute injuries, oedema, vascular disease,
bility, analgesia and reduction of muscle
wounds or infections as these can be exacerbated
spasm.[13,17,102,105-107] While a large amount of anec-
with heat application and increase potential
dotal support is available, little research-based evi-
risks.[102]
dence has been found to support these claims. Of
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
760 Wilcock et al.
3.3 Contrasting Temperature during contrast therapy, it would seem unlikely to
cause a great effect at such a slow frequency.
Another point to consider with vaso-pumping is
Contrast therapy has been considered to enhance that intramuscular temperature has not been ob-
athletic recovery through:[14-17]
served to change with alternating contrasts, only
•stimulating area-specific blood flow; subcutaneous temperature.[15,99] A study by Higgins
•increasing blood lactate removal; and Kaminski[21] observed that at a 4cm depth, intra-
•reducing inflammation and oedema; muscular temperature also did not fluctuate with
•stimulating circulation; repeated 1-minute immersions into cold water (after
•relieving stiffness and pain; 4 minutes of warm whirlpool therapy), but gradually
•increasing range of motion; increased by 0.85 ± 0.60°C over 31 minutes. If
•reducing delayed onset of muscle soreness. temperature does not change at deep tissue levels
One reason behind such possible benefits to re- with alternating immersion, any vaso-pumping
covery is that contrast therapy may mimic one of the would then be likely to occur at a subcutaneous level
mechanisms attributed active recovery without the only. To aide recovery and intramuscular waste
same energy demands.[2,14,29,122] Recovery using ac- removal by vaso-pumping, temperature changes
tive low-intensity exercise is considered to enhance would surely be required at a deeper tissue level.
recovery compared with passive modalities.[123-125] Additional to the unlikely vaso-pumping within
One theory for increased recovery is alternating deep tissue, the sudden immersion into an icy bath
muscular contractions acting in a pumping/squeez- from heat may not cause vasoconstriction. During
ing action. Low-intensity repetitive mechanical high body temperatures, as may occur after intense
‘squeezing’ by the muscles during contraction-re- athletic exertion and hot water immersion, the sud-
laxation may increase the translocation and removal den immersion into cold may cause cutaneous vaso-
of metabolites, such as lactate, and reduce intracel- dilation rather than vasoconstriction in a shock re-
lular fluid volume.[125] Much of the research and sponse.[5,126]
literature regarding contrast therapy perpetrate the To date, no research was found that had observed
theory of contrast therapy causing a similar action or measured any form of alternating vasodilation-
with vaso-pumping. Alternating vasoconstriction constriction caused by contrast therapy. If vaso-
and vasodilation is thought to act in a comparable pumping does not occur, another explanation for
way to muscle pumping, increasing blood flow and elevated blood lactate removal during contrast ther-
metabolite removal, enhancing recovery.[14,29,122]
apy must exist. One area that is little discussed in
However, vaso-pumping would seem unlikely to contrast therapy literature that may explain in-
occur at a level that could act effectively in this creased removal of wastes from the body is simply
manner. the hydrostatic pressure caused by immersion in
During contrast therapy, each alternation of tem- water.
perature generally lasts for 30–120 seconds and is
repeated 2–5 times. Vaso-pumping would then oc- Similar to heat application, contrast therapy may
cur at a slow rate and only with 2–5 ‘pumps’ over a be harmful to athletes by causing inflammation.
period of around 2–10 minutes (at a low frequency Compared with cold water immersion, Cote et al.[18]
such as 0.03–0.008Hz). Under active recovery, such observed a 26.5% increase in oedema using contrast
as light-running, muscular pumping would occur at therapy on patients with first- and second-degree
a rate of around 2Hz. If vaso-pumping does occur ankle sprains. The effect size of this difference was
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
Physiological Response to Water Immersion 761
large (2.05). However, Vaile et al.[23] observed that fatigue, which may be due to reduced neuromuscu-
15 minutes of contrast therapy after muscle damag- lar signal magnitudes and energy conservation.
ing eccentric leg presses reduced thigh volume oe- Decreasing water temperature may reduce some
dema significantly over 72 hours compared with of the physiological responses associated with hy-
passive recovery. Mean (± standard deviation) thigh drostatic changes. The body responds to cold by
measurements increased by 2.3 ± 0.8% with passive reducing heart rate and cardiac output, and inducing
recovery compared with 0.6 ± 0.6% in the contrast vasoconstriction. This response reduces peripheral
therapy group. The reason for the benefit observed blood flow and conserves body core temperatures.
in the study of Vaile et al.[23] may be due to the large Additionally, central metabolism increases to main-
portion of the body that was immersed (immersion tain the core temperature, which increases the pro-
to the gluteal fold), rather than the effect of tempera- duction of waste products and erodes energy stores.
ture. A greater physiological response would have However, cold also assists the reduction of oedema
occurred due to the higher hydrostatic pressures by increasing vasoconstriction and lowering periph-
compared with the study of Cote et al.[18] where only eral metabolism, which may reduce secondary cellu-
the foot was immersed. Alternatively, in the study of lar death due to muscular damage. The analgesic
Cote et al.,[18] subjects had acute injuries rather than effect of cold is likely due to reduced neural trans-
induced muscle damage, which may account for the mission magnitude and speed. Heat and contrast
possible effect difference of the contrast therapy. therapy provide lesser possible benefits to the recov-
More research is required before any conclusion can ery process by increasing oedema and increasing the
be drawn on whether contrast therapy is harmful or energy requirement due to an increased metabolic
beneficial to oedema. Other contraindications of rate. Immersion in cool to thermoneutral water may
contrast therapy are likely to include those of both provide the best option for recovery unless muscle
the hot and cold temperatures.[102,120] Care is war- sprains or strains have occurred, in which case cold
ranted when using extremes of temperature in con- water immersion may provide greater benefit. Ex-
trast immersion. tremes of water temperature have contraindications
and cool to thermoneutral immersion may provide
4. Conclusions and Recommendations both a safer and more beneficial immersion temper-
ature range.
Hydrostatic pressure from water immersion
Physiologically speaking, hydrostatic pressure
causes an inward and upward displacement of body
would seem the mechanism that could benefit exer-
fluid. This action reduces oedema, increases ex-
cise recovery. Ultimately, the aim of the recovery
tracellular fluid transfer into the vascular system and
process is to enhance future performance. To date, a
increases cardiac output. Greater cardiac output in-
small amount of research has been conducted into
creases blood flow through the body and in response
the use of water immersion as an exercise recovery
to increased arterial pressure vasodilation may oc-
strategy.[7,8,16,17,23,28,76] The varied methodology and
cur. Increased blood flow through the body may
observations of these studies provide an unclear
assist in the metabolism of waste products that accu-
picture of whether water immersions could provide
mulate during exercise by reducing transport time.
a benefit to exercise recovery. Numerous factors
Additionally, reductions in oedema due to fluid
such as duration, water temperature, immersion
shifts may assist short-term in maintaining muscle
depth, exercise type and intensity, and timing be-
function and assist muscular repair. Weightlessness
when immersed in water decreases the perception of tween exercise and recovery sessions require study.
2006 Adis Data Information BV. All rights reserved. Sports Med 2006; 36 (9)
762 Wilcock et al.
9. Burke DG, Holt LE, Rasmussen RL, et al. Effects of hot or cold
Of the studies conducted, there would appear to be water immersion and modified proprioceptive neuromuscular
no harm in using water immersion as a recovery facilitation flexibility exercise on hamstring length. J Athl
Train 2001; 36 (1): 16-9
strategy and a possible benefit[7,23,28] to future per- 10. Clarke DH. Effect of immersion in hot and cold water upon
formance. Increases in blood plasma fraction recovery of muscular strength following fatiguing isometric
exercises. Arch Phys Med Rehabil 1963; 44: 565-8
(movement of interstitial-intravascular fluid) during
11. Greenleaf JE, Kaciuba-Uscilko H. Acclimatization to heat in
immersion have been observed to take least 10 min- humans. Moffett Feild (CA): National Aeronautics and Space
utes;[42,47] therefore, as a possible recovery strategy, Administration, Ames Research Centre, 1989: 41
12. Weston CEM, O’Hare JP, Evans JM, et al. Haemodynamic
immersions should be of at least 10 minutes dura- changes in man during immersion in water at different temper-
tion. However, more research incorporating per- atures. Clin Sci 1987; 73: 613-6
formance measures and water immersion needs to 13. Brukner P, Khan K. Clinical sports medicine. 2nd ed. Sydney:
McGraw-Hill, 2001
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exercise causes any worthwhile performance bene- athlete recovery: a review. Phys Ther Sport 2004; 5: 26-32
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Acknowledgements 16. Sanders J. Effect of contrast-temperature immersion on recov-
ery from short-duration intense exercise [dissertation]. Can-
The authors would like to thank the Division of Sport and berra: University of Canberra, 1996
Recreation and the Alumni Association of Auckland Univer- 17. Coffey V, Leveritt M, Gill N. Effect of recovery modality on 4-
sity of Technology, Auckland, New Zealand, for financial hour repeated treadmill running performance and changes in
support during the writing of this study. The authors have no physiological variables. J Sci Med Sport 2004; 7 (1): 1-10
18. Cote DJ, Prentice WE, Hooker DN, et al. Comparison of three
conflicts of interest that are directly relevant to the contents of
treatment procedures for minimizing ankle sprain swelling.
this review. Phys Ther 1988; 68 (7): 1072-6
19. Hamlin MJ, Magson P. The effects of post-exercise hydrothera-
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