The effects of cryotherapy on strength

preservation and reduction of muscle soreness

post intense exercise in moderately fit men
Kinesiology 326, Spring 2014
Anthony Rogosic, Tyler Rogosic, Marguerite Montjoy, Jordan Riding, Erin
Silversmith, Ghazal Razavi, Tim St John, Jordan Webb

Abstract:
Background: It is known that intense exercise causes Delayed Onset Muscle Soreness (DOMS)
and Exercise Induced muscle damage (EIMD). Cryotherapy may lessen the symptoms of EIMD
through physiological processes including vasoconstriction, decreasing vascular permeability,
decreasing tissue hypoxia, and acting as a temporary anesthetic. Aim: The aim of the study is to
assess and evaluate the effectiveness of cryotherapy to preserve strength and reduce soreness
within 48 hours following physical activity. Hypothesis: Post-exercise cryotherapy will
significantly preserve force and decrease perceived muscle soreness. Subjects: 8 male subjects,
moderately fit and physically active at least 4 hours per week, with mean age 22.5 1.1 years,
height 176.8 4.7 cm, body mass 80.0 8.1 kg, BMI 25.8 3.0 kg/m, body fat 13.0 4.5 %,
SKF BF 20.7 4.8%. Results: Peak knee extension torque was unchanged (p > 0.05) across the
ice (232.0 44.0 ft/lbs) and no ice trials (213.2 30.2 ft/lbs). Perceived muscle soreness
significantly decreased (p < 0.05) across days in ice group from 4.0 1.3 to 3.5 0.93, and
significantly increased in the no ice group from 4.3 1.4 to 4.5 1.1 on the soreness scale.
Conclusion: The results of the study found that post workout cryotherapy was effective in
reducing perceived muscle soreness and may aid in force preservation, although no significant
change was shown.
Introduction:
Intense exercise including a combination of concentric and eccentric contractions can
lead to delayed-onset muscle soreness (DOMS) and exercise-induced muscle damage (EIMD).
Since muscle damage occurs on both a mechanical and chemical level there are various methods
for quantifying data associated with EIMD (Oakley et al., 2013). Muscle soreness can be
measured using a perceived soreness scale with levels from 0-6 (Vickers A., 2001). Further
analysis can be derived from blood tests including creatine kinase and neutrophils as indicators
of muscle damage. Intense exercise causes microscopic tears within the muscle cells, which
leads to decreased strength post-exercise (Oakley et al., 2013). Damage at the cellular level
stimulates the inflammatory response in which neutrophils are activated to repair the damage.
Increased neutrophil circulation in the blood is associated with temporarily increased levels of
pain and muscle damage due to free radicals that further disrupt the cell membrane (Oakley, et
al., 2013). This secondary cause of muscle damage initiates the release of enzymes into the
bloodstream. The enzyme most commonly used as a biochemical marker for tissue damage is
Creatine Kinase (CK) because it is found solely in the muscle cells (Oakley et al., 2013).
Cryotherapy has been used for many years to reduce inflammation and soreness as a
result of EIMD. One physiological effect of cryotherapy is vasoconstriction, which reduces the
blood flow to the muscle tissue reducing onset of inflammation and swelling (Ciolek, 1985).
More specifically, cryotherapy causes a decrease in vascular permeability, reducing the rate at
which fluids leak into extracellular spaces. The reduced temperature of the blood increases blood
viscosity, which further decreases blood flow to the damaged area (Ciolek, 1985). Cryotherapy
also decreases tissue hypoxia. When tissue damage occurs, secondary damage can result from a
lack of oxygen being transported to surrounding tissues. Research has shown that a reduction in
temperature by as little as 10 C can halve the rate of chemical reactions, lowering the oxygen
demands of the affected area (Olson and Stravino, 1972). Lower oxygen demands will reduce the
risk of secondary damage resulting from tissue hypoxia. Lastly, cryotherapy has been shown to
2

significantly reduce pain (Clarke et al., 1958). Cooling to temperatures below 20 C has been
shown to induce a limited anesthetic effect due to a slowed nerve conduction velocity, reducing
pain associated with muscle damage (Clarke et al., 1958).
Various methods exist for implementing cryotherapy in a clinical setting. Ice packs can be
directly applied to the damaged area for 15-20 minutes combined with compression and
elevation. Ice massage is another possible method in which a block of ice is applied with
pressure and movement over the affected muscle group. A third method of cryotherapy is ice
immersion, in which the extremity or muscle group is fully immersed in an ice bath. This is
optimal for distal extremities including hands and feet, but is less tolerable than other treatments
(Ciolek, 1985).
Previous literature provides equivocal evidence for the effectiveness of cryotherapy for
the treatment of EIMD. White & Wells (2013) explained that cryotherapy can be effective
because it induces vasoconstriction, which reduces the rate of local metabolism and
inflammation. Oakley et al., (2013) showed a statistically significant decrease in pain with
cryotherapy post-exercise. Their results further indicated that cryotherapy results in a greater
range of motion, and lower creatine kinase (CK) and aspartate aminotransferase (AST) (Oakley
et al., 2013). On the contrary, in a study done by Stubbe et al. (2010), it was found that ice did
not alter functional recovery or pain. It is believed that the lack of evidence-based guidelines
within past studies has resulted in inconclusive findings (Oakley et al., 2013).
Our primary aim is to observe the acute effects of cryotherapy post-exercise as a means
of confirming previous findings by Oakley et al., (2013), that alterations in soreness and strength
preservation are observed. Results will be based on the assumption that muscle damage has
occurred through a series of intense body-weight exercises. We hypothesize that post-exercise
cryotherapy will significantly preserve force and decrease perceived muscle soreness.
Methods:
Subjects
All subjects were prepared to participate in maximal leg strength exercise and physical activity
with proper exercise attire. 8 subjects (all male) were defined as moderately fit and physically
active at least 4 hours per week. The mean age, height, and mass of the subjects were 22.5 1.1
yrs, 176.8 4.7 cm, and 80.0 8.1 kg. The mean BMI and body fat (%) were 25.8 3.0 (kg/m)
and 13.0 4.5%. All subjects who participated had no knee or leg ailments or any pre-existing
health conditions. During the experimental period, subjects were asked to not undergo leg
strength exercises in the past two days before and during the study. Each subject had to sign a
health history questionnaire and a contract explaining their volunteer responsibilities.
Experimental Design
Subjects arrived at the Human Performance Laboratory (ACD 115) at CSU San Marcos to
perform a two-week study of a total of four visits. Before testing, height, weight, BIA, and body
composition using skinfolds at three sites were measured. All subjects used the isokinetic
dynamometer to examine maximal leg strength for both legs. The isokinetic dynamometer
includes 1 set of 5 maximal leg flexion and extension at 30 degrees range of motion. Subjects

familiarized themselves with the isokinetic dynamometer through detailed explanation of

protocol and student example.
Prior to testing, subjects performed a 5-minute warm-up on the bike, as the isokinetic
dynamometer was prepared (randomized order of each leg). Subjects gave maximal effort and
strength for leg flexion and extension, focusing only on the changes in peak torque during these
tests. Post-testing, subjects participated in a mini-boot camp of body weight leg exercises,
located at the campus track. The post-workout was designed to create muscle damage and
soreness. The subjects were then randomized again to receive ice or no ice for 20 minutes on the
quadriceps, hamstrings, and calves after exercise. We provided each subject with a perceived
soreness scale, asking them to note the appropriate level present during the next couple of days.
48 hours later, subjects were asked to return to the laboratory for the same isokinetic
dynamometer testing and procedure. During testing, we looked at the effects of cryotherapy with
maximal leg force. The study then continues with the same protocol the following week,
alternating the ice or no ice intervention post-workout.
Peak Torque
Peak torque is the maximal muscular force output used during a repetition. Peak torque was set
at 30 degrees ROM, which represents a muscles highest strength capability. All other data
regarding the isokinetic dynamometer was not used due to the fact that we are simply analyzing
the effects and changes cryotherapy has on maximal force. During the subjects all-out 5
repetition leg extension and flexion, we focused only on the peak torque generated.
Soreness
Muscle soreness was measured using a perceived soreness scale with values from zero (complete
absence of soreness), to six (severe pain that limits ability to move). Subjects recorded soreness
24 hours and 48 hours post-exercise.
Figure 1: Perceived soreness scale (Vickers A., 2001)

Exercise
The body weight leg exercises took approximately 20-30 minutes. The workout began with a
warm-up, which included 200m side shuffles, 25 jumping jacks with a squat at every 5th, and 15
lateral lunges. The exercise was divided into 2 series of 3 sets with a 1-2 minute rest in between.
The first series consisted of 15 lunge jumps, 12 lunge hops, and 12 pulse lunges on each leg. The
4

second series consisted of 15 jump squats and 100m shuttle squats. Ice intervention post-workout
was given accordingly.
Statistical Analysis
All data was presented as a mean value standard deviation, as well as analyzed using SPSS
software Version 18.0 (SPSS). Statistical comparisons were produced by a one-way analysis of
variance (ANOVA) with repeated measures to examine differences between peak torque. A twoway ANOVA with repeated measures was used to examine ice and no ice intervention across
days. Statistical significance was recorded as p<0.05.
Table 1: Anthropometric data (mean SD) for all subjects (n=8)
Age (years)

Height (cm)

Body Mass (kg)

BMI (kg/m)

Body Fat %

SKF % Fat

22.5 1.1

176.8 4.7

80.0 8.1

25.8 3.0

13.0 4.5

20.7 4.8

Results:
All subjects were adherent to the protocol, but due to time conflicts and the school obligations of
our subjects and researchers, only 8 subjects were able to partake in the study. Perceived
soreness (p<0.05) showed a significant difference for ice and no ice treatments across days,
while peak KE and KF torque exhibited no significant difference (p>0.05) between groups.
Perceived soreness
The perceived soreness for all participants had a baseline equal to 0 and increased for both ice
intervention and no ice intervention. There was a statistically significant change (p=0.03) of
perceived soreness after ice intervention from 24 hours to 48 hours. Table 2 shows the perceived
soreness for icing after physical activity 24 hours after (4.0 1.3) and 48 hours after (3.5 0.93).
Compared to ice intervention, subjects with no ice intervention increased their perceived
soreness 24 hours after (4.3 1.4) to 48 hours after (4.5 1.1). Figure 2 shows how the
perceived soreness for ice decreased from day 1 to day 2, while subjects with no ice intervention
display an increase from day 1 to day 2.
Table 2: Perceived soreness (mean SD) for all subjects
Baseline

24 hours

48 hours

Ice

4.0 1.3

3.5 0.93

No Ice

4.3 1.4

4.5 1.1

Figure 2: Mean values for perceived muscle soreness, for ice and no ice, from Day 1 to Day 2.
Peak torque
Comparing the baseline peak knee extension (KE) torque for the right leg (216.2 26.5 ft/lbs),
subjects increased after the ice intervention (232.0 44.0 ft/lbs), but slightly decreased with no
ice intervention (213.2 30.2 ft/lbs). Repeated measure ANOVA revealed no significant
difference of ice on peak KE torque of R leg (p=0.12). The baseline for peak KE torque for L leg
(203.2 39.1 ft/lbs) increased for both ice intervention (219.6 42.9 ft/lbs) and no ice (205.7
38.9 ft/lbs), but showed no effect of ice on peak KE torque for L leg (p=0.06). Peak knee flexion
(KF) torque for R leg had a baseline equal to 111.9 18.1 ft/lbs, but revealed no significant
difference (p=0.59), as the peak KF torque increased for both ice (114.9 16.9 ft/lbs) and no ice
(113.1 18.1 ft/lbs). In addition, peak KF torque for L leg showed no significant change
(p=0.31) from baseline (107.8 15.9 ft/lbs) to ice and no ice intervention equal to 113.0 13.0
ft/lbs and 108.5 14.8 ft/lbs, respectively. Figure 3 represents the average knee peak torque for
extension and flexion for both legs and peak torque changes between baseline, ice, and no ice.
Table 3: Peak torque (mean SD) for baseline ice intervention and no ice intervention.
Peak Torque

Baseline (ft/lbs)

Ice (ft/lbs)

No Ice (ft/lbs) Significance (P)

Extension Right Leg

216.2 26.5

232.0 44.0

213.2 30.2

0.12

Extension Left Leg

203.2 39.1

219.6 42.9

205.7 38.9

0.06

Flexion Right Leg

111.9 18.1

114.9 16.9

113.1 18.1

0.59

Flexion Left Leg

107.8 15.9

113.0 13.0

108.5 14.8

0.31

Figure 3: Mean + SD Peak torque for extension and flexion in right and left legs.
Discussion:
What our findings say about the effects of cryotherapy on perceived muscle soreness
The aim of this experiment was to assess and evaluate the effectiveness of cryotherapy on the
treatment of exercise-induced muscle damage (EIMD). According to the results, the utilization of
cryotherapy to promote recovery directly following physical activity shows beneficial
therapeutic results. The data demonstrated that 20 minutes of cryotherapy (in the form of ice
packs) applied to the quadriceps, hamstrings, and calves directly after a leg workout, decreased
subjects perceptions of muscles soreness and preserved muscular strength. Compared to ice
intervention results, subjects with no ice intervention displayed an increase in perception of pain
from day 1 to day 2. These findings suggest that there is a significant reduction in soreness
related to the application of cryotherapy immediately following muscular damage caused by
intense exercise. This study attempted to examine the effect cryotherapy had on peak torque.
Findings demonstrate that there was no significant difference between ice and no ice groups,
although there was a trend that showed a minor preservation in peak torque. The primary
findings of the present study support our hypothesis, that post-exercise cryotherapy will
significantly decrease perceived muscle soreness and aid in the preservation of peak torque, this
is due to the bodys natural physiologic response to ice (Ciolek, 1985).
How our findings are comparable with other literature
There is limited research that addresses the benefits of cryotherapy on the treatment of exerciseinduced muscle damage. The findings of our current study confirm the findings presented by
Oakley et. al., (2013) that cryotherapy is an effective method to decrease muscle soreness and to
preserve muscle performance, after intense training. This is important because of the controversy
surrounding the effectiveness of cryotherapy -- Stubble et al (2010) -- on the treatment of EIMD
and DOMS. The findings presented by the current study can be applied in clinical and
competitive sport settings, to decrease patients and athletes perceived muscle soreness and
preserve their muscular strength and performance for subsequent days of therapy or practice.

Limitations that could affect interpretation of results

This study had various limitations that may influence, but are not likely to adversely affect our
conclusions. Possible limitations of this study include sample size, skill level, and measures used
to collect data. One particular limitation was the limited sample size of this study, which
consisted of 8 moderately active males. In future studies, a larger sample size with greater
variation in gender and skill level may be more beneficial by allowing a greater range of data to
be used for interpretation.
Another potential limitation presented in this study is the possibility of developing muscle
memory. Performing the same set of exercises repeatedly trains the muscles to reproduce the
same movements (Nielson et al., 2014). Exercises that cause greater perturbation of the muscles
will elicit muscle memory shortly after learning (Nielson et al., 2014). An increase in muscle
memory from week 1 to week 2 of training could be a source of error in this study, reducing the
amount of EIMD that the subjects experienced. To properly evaluate muscle soreness, it would
be important in future studies to have variations amongst workouts to prevent muscle memory
from occurring.
The isokinetic dynamometer machine was used to measure strength in this study. Our subjects
unfamiliarity with the isokinetic dynamometer machine could have been a limitation because of
the learning curve they experienced during their first trial. Data accuracy may be reduced in the
starting point of the study due to inexperience with the machine, however, this is unlikely
because all subjects underwent a practice trial before data was recorded. Furthermore, data
derived from blood tests could have better evaluated the effects of ice on muscle damage. Blood
tests can detect circulating neutrophil and creatine kinase concentration, providing accurate
measurements of muscle damage and the process of healing that occurs on subsequent days
(Oakley et al., 2013). Blood tests are costly and more invasive than our selected variables, and
therefore were avoided for the purposes of this lab.
Small, square ice packs were used in this study to perform cryotherapy. The size of these ice
packs and amount of time spent icing are both limitations that could have affected interpretation
of our results. In future studies more forms of cryotherapy such as ice immersion, or ice massage
may be more beneficial for maximal results, especially if repeated several times, for up to 72
hours post-exercise. Although this study had various limitations, they are not likely to alter our
conclusions because our soreness data showed a significant change with a p-value (0.003) far
below =0.05, which would not have been affected by the limitations enough to alter significance.
Also, preservation of force was not a significant result of treatment, so there is no risk of making
a false-positive assumption (Type I error) due to the effects of the aforementioned limitations.
What we can conclude from the present findings
The results of the study found that post workout cryotherapy was effective in reducing perceived
muscle soreness across days. This can have valuable implications for those who experience
muscular pain post exercise. Both trained and untrained individuals struggle with perceived
muscle soreness. This can either lead to people not working out, or they may become
discouraged because of the amount of soreness they experienced. Cryotherapy can alleviate the
muscle soreness and allow for people to continue their training without disruptions. Cryotherapy
can also be used in a clinical environment in order to aid patients in their treatments.
8

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