|Year : 2020 | Volume
| Issue : 1 | Page : 1-5
The effectiveness of cryotherapy in the management of sports injuries
Sami Awadh Alharbi
Department of Physical Therapy, Hafer Al Batin Central Hospital, Hafar Al Batin, Eastern Province, Kingdom of Saudi Arabia
|Date of Submission||25-Aug-2020|
|Date of Decision||04-Sep-2020|
|Date of Acceptance||08-Sep-2020|
|Date of Web Publication||18-Oct-2020|
Mr. Sami Awadh Alharbi
Department of Physical Therapy, Hafer Al Batin Central Hospital, Hafar Al Batin, Eastern Province
Kingdom of Saudi Arabia
Cryotherapy is widely applied and accepted as a beneficial treatment for soft-tissue injury and postoperative management. It is the one of the most effective interventions for pain management and swelling in acute sports injuries. However, the most efficient Cryotherapeutic agent remains unknown. This paper analyzes different methods of application of cryotherapy in sports injury rehabilitation based on recent scientific evidences. This information will assist health-care practitioners who are involved in sports injury and postoperative management.
Keywords: Acute stage, clinical studies, rehabilitation, sports injury
|How to cite this article:|
Alharbi SA. The effectiveness of cryotherapy in the management of sports injuries. Saudi J Sports Med 2020;20:1-5
| Introduction|| |
Cryotherapy is one of the most effective interventions for pain management and swelling in acute sports injuries. It is a simple intervention, which is inexpensive and widely applied in musculoskeletal cases and postoperative management such as anterior cruciate ligament reconstruction (ACLR), lateral epicondylitis, ankle sprain, and knee arthroplasty.,,,, Cryotherapy is a combination of two terms: Cryo = cold/ice and therapy = treatment. The application of ice to any part of the body aims to remove the heat source, decreasing the temperature of tissues. Presently, the term indicates different methods of treatment, designed to reduce the temperature of the body surface, therefore cooling the site of injury without interruption of tissue. The results of cooling eliminate heat and decrease the inflammation and vasoconstriction of the area treated. The most efficient preapplication temperature for a cryotherapy agent is between 10°C and 15°C.
The cold treatment for sports injuries is widely used, but the scientific evidence about the effectiveness of this treatment is anecdotal. In addition, experimental trials and clinical studies have been limited. Thus, treatment remains experimental and somewhat inaccurate. Moreover, there are several devices and methods of application, and which case each is most effective in is not yet known., In contrast, the operative technique provides a more standardized approach to examine the role of cold compression in postoperative pain, edema, and return to function. Hence, randomized controlled trials have a better methodological quality, which improves the validity of outcomes. However, it appears that the reports of such studies in the literature are contradictory. It is, therefore, paramount that every treatment proposed and provided to athletes should be supported by strong scientific evidence. The aim of this literature review is to describe the published clinical results regarding the application of cryotherapy in sports injuries and postoperative management.
| Pathophysiologic Effect of Cryotherapy|| |
There are several advantages of cryotherapy in sports injuries and operative procedures. These include decreasing edema; reducing pain; decreasing blood flow, which leads to vasoconstriction; decreasing muscle spasms; decreasing inflammation; reducing metabolism process; and slowing nerve conduction velocity, as illustrated in [Table 1].,
In sports medicine, cold therapy is used almost exclusively in the acute stage and in the stage of rehabilitation of soft-tissue injury. However, the basis for applying ice at each phase is totally different. Immediately after injury, the ice decreases the metabolism, thus reducing the secondary oxygen deficiency and degree of tissue damage. By contrast, in the rehabilitative stage, cryotherapy is used almost exclusively for pain relief, facilitating earlier and more intense exercise. Furthermore, some studies reported the indications and contraindications of cryotherapy. It can be used with acute injuries, trauma, chronic pain, muscle soreness, and inflammation. Conversely, its use should be avoided in bradycardia, Raynaud's phenomenon, nerve and tissue damage, and delayed wound healing. In addition, some precautions should be taken in conditions such as cold allergies, circulatory insufficiency, and diabetes., A study found that the main result of long-term local cooling of tissue is the induction of vasoconstriction, which may lead to hypoxia. Prolonged exposure to cold causes vasoconstriction, which may cause injuries that normally fall within nonfreezing cold injury category. In addition, long-term vasoconstriction can cause reperfusion injury when blood flow is returned to the affected tissue.
| Methods of Cryotherapy Application|| |
There are different methods for applying ice therapy, including crushed ice bags, cold packs, cold compression machine, and ice massage. So far, there is contradictory evidence on which of these methods are most effective, the optimal duration of treatment, and whether it should be applied continuously or intermittently. Kennet et al. compared four cryotherapy types including gel pack, crushed ice, water immersion, and frozen peas to investigate the most effective technique in decreasing the skin temperature after 20 min of application. The research found that water immersion and crushed ice resulted in the greatest reduction of skin surface temperature, compared to gel pack and frozen peas, indicating that they are likely to be the most effective clinically.
A study in 2009 used three types of cryotherapy to investigate the effectiveness of cubed ice, crushed ice, and wetted ice on skin surface and intramuscular temperature. The study reported that the crushed ice generated the smallest temperature change, decreasing the temperature by 15.0°C at the skin surface and 4.3°C intramuscularly; the wetted ice generated the greatest temperature change by decreasing the temperature by 17.0°C at the skin surface and 6.0°C intramuscularly; and the cubed ice reduced the temperature by 14.1°C at the skin surface and 4.8°C intramuscularly. Thus, the best technique in decreasing surface temperature was wetted ice, followed by cubed ice and crushed ice.
Cryokinetics is another cryotherapy technique and is followed by active exercise. Bleakley et al. investigated the effectiveness of cryotherapy (intermittent ice with compression) and cryokinetics (intermittent ice with compression and therapeutic exercise) on acute ankle sprain. The study found that the application of cold therapy with exercise is more effective than the application of cold therapy alone.
| Duration of Cryotherapy|| |
So far, there are different recommendations about the duration and interval of the application of ice, for example 10–20 min, or 20–30 min twice a day, or 30–45 min for 2 h after injury. Bleakley et al. studied the effectiveness of the application of ice for 20 min continuously compared to 20 min intermittently (10 min application, 10 min rest, and then applied for another 10 min). The study concluded that the intermittent application of cold therapy resulted in less pain than the continuous application of ice, while there was no difference in terms of swelling in both groups. The results indicated that the intermittent application of cold therapy lessened pain more than the continuous application of ice.,
Myrer et al. proposed that the duration of treatment with cryotherapy should be 20 min. However, this treatment time cannot be given as a standard because the treatment time may vary from case to case and in accordance with the injury severity. In these conditions, there are several factors that influence the degree of surface and deep temperature change during cryotherapy, such as kind of cold agent, site treatment application, and compression and difference sensation from one person to another.
Kind of cold agent
There are different theories on the time and type of cold agent to be used when conducting cryotherapy. Crushed ice, for example, is commonly used directly on the skin or sometimes in a towel. A study in 1998 recommended that ice in a towel should be applied for 40 min. Another study in 1996 revealed that 40 min of cold therapy produced the best outcomes. Thus, the longer the ice is on the affected area, the better the result is with this kind of cryotherapy. In contrast, another study found that the intramuscular temperature dropped dramatically after applying an ice pack for 5 min.
Site treatment application
Before starting the treatment, an important consideration is the area the ice will be applied to, for example the superficial nerve area of the elbow (ulnar nerve) and knee (peroneal nerve) as long as the patient does not feel uncomfortable.
Merrick et al. compared the application of ice with compression with ice alone. Ice compression penetrated the skin to a depth of 1–2 cm. Moreover, the temperature 1 cm under the skin was 26°C, whereas the temperature of skin with ice alone was 28°C. This demonstrates how ice and pressure is a better choice for reducing blood flow to the affected areas. A meta-analysis (2016) compared the effectiveness of cryotherapy compression versus cryotherapy alone in patients who had undergone knee surgery. The study suggests that the cryotherapy compression had a better analgesic effect after knee surgery than cryotherapy alone. In addition, the cryotherapy compression had a more pronounced effect on swelling than cryotherapy alone.
| Variation in Cold Sensation between Persons|| |
Myrer et al. stated that the application of cold therapy and the sensation will vary from person to person. Practitioners should be aware, when giving treatment, of the differences in subcutaneous layers in each person. When applying the treatment to a thick layer, for example on the quadriceps, the cold pack should be left on for longer. In contrast, when applying to a thin layer such as the dorsal area of hand, the duration of treatment in this area should be lower. Mancuso et al. studied weather and temperature and their influence on athletes. Injuries are different depending on whether they occur in hot or cold weather. Their study showed that the skin temperature of athletes after training was higher than that of before training. Therefore, for injuries that occur in hot weather, cold therapy will take a longer time to cool down the temperature of the skin compared to injuries that occur in cold weather or before training.
| Cryotherapy Mechanism|| |
Several aspects of cryotherapy mechanism
From the metabolism aspect
Cold therapy provides a decrease in surface temperature, which leads to a reduction in cellular metabolism. This is an important benefit in treatment. When the injury occurs, the cellular metabolism will increase, which will delay the process of healing. By contrast, cold therapy lowers the cellular metabolism, thus helping to shorten the healing time after injury.
From the circulation aspect
Vasoconstriction is the narrowing of the blood vessels when the muscle wall vessels contract. It takes only a few minutes for the vasodilation process to begin. This phenomenon is known as the “hunting response,” often occurring in distant limbs.
Reducing muscle soreness
A study looked at the effectiveness of cold therapy on muscle soreness and suggested that cryotherapy decreased and delayed muscle soreness.
Reduction in stretch reflex
Cold therapy reduces the muscle spindle activation, thus allowing the action of stretching to become more effective.
Decreasing muscle tightness
Cold therapy plays a major role in the destruction of the pain–spasm–pain cycle.
| Results of Cryotherapy|| |
The nociceptor is a receptor of sensory nerves that transmits the signals to give us the sensation of pain. The receptors are located in large numbers in skin and soft tissue of muscles, organs, and joints; the function of these receptors is transmitting the nerve signals that travel through the spinal cord to the brain. Any type of injury or damage, thermal, mechanical, or chemical, is transmitted to the central nervous system. Once the injury occurs, the pain signals are transmitted through two small diameters of fibers: the A delta fiber and the C fiber. The myelinated fiber is a delta, which accelerates pain signals. When the A delta fiber is involved, the pain is commonly described as a sharp stabbing pain or pricking, whereas with the C fiber, the transmitted pain signal is slower and is described as a burning sensation, or a dull and throbbing aching.
When the nociceptors send pain signals through the spinal cord to the brain, pain receptors are recognized; at the same time, the neurotransmitters will initiate the spine reflex, leading to increased muscle tone and contraction. If this continues, muscle spasms can occur, which are painful, and they may result in additional damage to the tissue due to the decreasing levels of blood flow and oxygen (hypoxia) in the tissue. This in turn leads to increased pain, and this action is called the pain–spasm–pain cycle. The pain–spasm–pain action should be interrupted to avoid further tissue damage and reduce the sensation of pain. Here, the role of cryotherapy is to initiate the other receptors which are found in nerve endings known as proprioceptors. The activity of the proprioceptors includes preventing the transmission of sensory nerve receptor signals to the brain. Activation of these receptors in the spinal cord will therefore decrease the muscle tone, promoting blood flow in the tissue and relieving painful muscles.,
Cold therapy helps to decrease edema, swelling, and inflammation. When an acute injury occurs, there is increased accumulation of fluid around the tissues; this is one of the main sources of pain. Cold therapy is “gold” intervention that reduces skin temperature, reduces blood flow to that area, and reduces blood viscosity and the permeability of capillaries, which in turn reduce fluid accumulation.
| Protection, Rest, Ice and Elevation or Protection, Optimal Loading, Ice, Compression and Elevation Rules|| |
Protection, Rest, Ice, and Elevation (PRICE) has been utilized for acute soft-tissue injury for many years. Treatment models for sports medicine must be updated with development research evidence. For example, the use of nonsteroid anti-inflammatory drugs in the management of acute soft injury has been challenged, especially with muscle and ligament injury. At this point, for the protection of acute injuries, resting and avoiding any movement for a specified period of time can cause adverse changes through the biomechanical and morphological mechanics in the tissues. Hence, the practitioner should be practicing the Protection, Optimal loading, Ice, Compression, and Elevation rule for treatment.
The effectiveness of cryotherapy in postsurgical procedures, sports injury, and recovery Kijkunasathian et al. examined the effect of intermittent cold pack (ICP) for post-ACLR compared with a modified Robert Jones bandage (MRJ). The study found that the swelling in the ICP group was less than that in the MRJ group, therefore the study recommended ICP s for post-ACLR management. Another study evaluated the effectiveness of ice compression post-ACLR on experimental and control groups to improve the pain and range of motion (ROM). The study found that ice compression was effective in improving pain and ROM. A systemic review in 2014 investigated the effectiveness of cryotherapy after ACLR, measuring pain and edema as primary outcomes and ROM, hospital stay, quality of life, and patient satisfaction as secondary outcomes. The review showed that the use of cold therapy significantly decreased pain after 48 h of surgery compared to no cold therapy. The effectiveness of cold therapy for other outcomes was limited and did not lead to a final conclusion.
Bleakley et al. investigated the effectiveness of ice therapy on the management of acute ankle sprains. The study found that the application of ice after ankle injury significantly decreased pain, while there was no difference in terms of swelling and function. Another study, a systemic review (1994), compared cryotherapy versus a placebo, and it found no difference in pain relief, swelling, or ROM. Moreover, another study comparing cold therapy with heat therapy and a contrast bath, found significantly less edema with cold packs compared with a contrast bath or heat therapy 3–5 days after injury.
According to the Cochrane systemic review that investigated the effectiveness of whole-body cryotherapy (WBC) for preventing and treating muscle soreness postexercise, the evidence was insufficient to determine whether WBC decreased the muscle soreness or improved self-recovery postexercise compared to no WBC or passive rest. Another systemic review investigated the effectiveness of various cooling applications on recovery after exercise compared to noncooling. The review found that the cryotherapy was effective in decreasing the symptom of delayed-onset muscle soreness, especially the cold-water immersion.
| Conclusion|| |
The evidence showed that cryotherapy was most effective in post-ACLR. Furthermore, it enhances the rehabilitation process, decreases pain, and reduces swelling and edema. Hence, when designing a treatment program for sports injuries, cryotherapy should be one of the basic procedures used.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bettoni L, Bonomi FG, Zani V, Manisco L, Indelicato A, Lanteri P, et al
. Effects of 15 consecutive cryotherapy sessions on the clinical output of fibromyalgic patients. Clin Rheumatol 2013;32:1337-45.
Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med 2007;41:365-9.
Nuhmani S, Khan MH. Lateral ankle sprain: A review. Saudi J Sports Med 2014;14:14.
Waseem M, Nuhmani S, Ram CS, Sachin Y. Lateral epicondylitis: A review of the literature. J Back Musculoskelet Rehabil 2012;25:131-42.
Nuhmani S, Muaidi QI. Patellar tendinopathy: A review of literature. J Clin Diagn Res 2018;12:YE1-6.
Nadler SF, Weingand K, Kruse RJ. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician 2004;7:395-9.
Galiuto L. The use of cryotherapy in acute sports injuries. Ann Sports Med Res 2016;3:1060.
Block JE. Cold and compression in the management of musculoskeletal injuries and orthopedic operative procedures: A narrative review. Open Access J Sports Med 2010;1:105-13.
Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgrad Med 2015;127:57-65.
Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: A systematic review of randomized controlled trials. Am J Sports Med 2004;32:251-61.
Martimbianco AL, da Silva BN, de Carvalho AP, Silva V, Torloni MR, Peccin MS. Effectiveness and safety of cryotherapy after arthroscopic anterior cruciate ligament reconstruction. A systematic review of the literature. Phys Ther Sport 2014;15:261-8.
Khoshnevis S, Craik NK, Diller KR. Cold-induced vasoconstriction may persist long after cooling ends: An evaluation of multiple cryotherapy units. Knee Surg Sports Traumatol Arthrosc 2015;23:2475-83.
Kennet J, Hardaker N, Hobbs S, Selfe J. Cooling efficiency of 4 common cryotherapeutic agents. J Athl Train 2007;42:343-8.
Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael TJ, Baker RJ. Comparisons of cubed ice, crushed ice, and wetted ice on intramuscular and surface temperature changes. J Athl Train 2009;44:136-41.
Bleakley CM, O'Connor S, Tully MA, Rocke LG, Macauley DC, McDonough SM. The PRICE study (protection rest ice compression elevation): Design of a randomised controlled trial comparing standard versus cryokinetic ice applications in the management of acute ankle sprain [ISRCTN13903946]. BMC Musculoskelet Disord 2007;8:125.
Bleakley CM, McDonough SM, MacAuley DC, Bjordal J. Cryotherapy for acute ankle sprains: A randomised controlled study of two different icing protocols. Br J Sports Med 2006;40:700-5.
Lamb SE, Marsh JL, Hutton JL, Nakash R, Cooke MW, Collaborative Ankle Support Trial (CAST Group). Mechanical supports for acute, severe ankle sprain: A pragmatic, multicentre, randomised controlled trial. Lancet 2009;373:575-81.
Myrer JW, Measom G, Fellingham GW. Temperature changes in the human leg during and after two methods of cryotherapy. J Athl Train 1998;33:25-9.
Tsang K, Buxton B, Guion W. The effects of cryotherapy applied through various barriers. Occup Health Ind Med 1998;2:102.
Palmer JE, Knight KL. Ankle and thigh skin surface temperature changes with repeated ice pack application. J Athl Train 1996;31:319-23.
Zemke JE, Andersen JC, Guion WK, McMillan J, Joyner AB. Intramuscular temperature responses in the human leg to two forms of cryotherapy: Ice massage and ice bag. J Orthop Sports Phys Ther 1998;27:301-7.
Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Athl Train 1993;28:236-45.
Song M, Sun X, Tian X, Zhang X, Shi T, Sun R, et al
. Compressive cryotherapy versus cryotherapy alone in patients undergoing knee surgery: A meta-analysis. Springerplus 2016;5:1074.
Myrer WJ, Myrer KA, Measom GJ, Fellingham GW, Evers SL. Muscle temperature is affected by overlying adipose when cryotherapy is administered. J Athl Train 2001;36:32-6.
Mancuso DL, Knight KL. Effects of prior physical activity on skin surface temperature response of the ankle during and after a 30-minute ice pack application. J Athl Train 1992;27:242-9.
Prentice WE, Quillen WS, Underwood FB. Therapeutic Modalities for Allied Health Professionals. New York: McGraw-Hill Companies; 1998.
Berk L, Bains GS, Akerkar S, Shah J, Al-Dabbak F, Laymon MS. Cold vs. heat after exercise-is there a clear winner for muscle soreness. J Strength Cond Res 2015;29:3245-52.
Glasgow P, Phillips N, Bleakley C. Optimal loading: Key variables and mechanisms. Br J Sports Med 2015;49:278-9.
Kijkunasathian C, Limitlaohaphan C, Saengpetch N, Chanasit P, Sundarathiti P, Waratanarat P. A comparison between modified Robert Jones bandage and intermittent cold pack in arthroscopic anterior cruciate ligament reconstruction: A prospective randomized controlled trial. J Med Assoc Thai 2017;100:287-94.
Dambros C, Martimbianco AL, Polachini LO, Lahoz GL, Chamlian TR, Cohen M. Effectiveness of cryotherapy after anterior cruciate ligament reconstruction. Acta Ortop Bras 2012;20:285-90.
MacAuley D, Best TM. What is the Role of Ice in Soft-tissue Injury Management? Malden, Massachusetts, USA: Blackwell Publishing; 2007. p. 187-207.
Struijs PA, Kerkhoffs GM. Ankle sprain. BMJ Clin Evid. 2010 May 13;2010:1115. PMID: 21718566; PMCID: PMC2907605.
Hohenauer E, Taeymans J, Baeyens JP, Clarys P, Clijsen R. The effect of post-exercise cryotherapy on recovery characteristics: a systematic review and meta-analysis. PLoS One 2015; 10: e0139028; PMID:26413718; http://dx.doi.org/10.1371/journal.pone.0139028
Hohenauer E, Taeymans J, Baeyens JP, Clarys P, Clijsen R. The effect of post-exercise cryotherapy on recovery characteristics: A systematic review and meta-analysis. PLoS One 2015;10:e0139028.