Whole Body Cryotherapy: Counterproductive to Tissue Healing for Exercise-Induced Muscle Damage

Cryotherapy has been used for many years by healthcare professionals, coaches and athletes to minimize swelling and decrease pain following musculoskeletal damage.¹ However, a recent systematic review concluded there is “insufficient evidence to suggest the use of ice/cryotherapy improves clinical outcomes.”² As such, the acronyms ICE, RICE,^3,4 PRICE and POLICE⁵ have recently been questioned because of their inclusion of cryotherapy.^2,3,5,6

CRYOTHERAPY FOR PAIN

Several studies have reported positive findings supporting the use of ice for reducing pain.^1,7-9 Intermittent applications (i.e. three, 10 minute applications with 10 minute recovery intervals) resulted in more effective pain reduction than common 20 minute applications.^1,10 Intermittent applications of cryotherapy combined with compression have also been shown to be effective in both reducing pain and achieving sustained, deep circulation flow reductions during recovery.¹⁰

CRYOTHERAPY FOR EXERCISE-INDUCED SORENESS

1. COLD WATER IMMERSION

While Cold Water Immersion (CWI) has been linked with increased heart rate, blood pressure, respiratory minute volume and metabolism, it has been shown to decrease end tidal carbon dioxide partial pressure and cerebral blood flow.¹¹ Increases in peripheral catecholamine, free-radical-species formation and oxidative stress have also been reported.¹¹ In addition, CWI has been shown to attenuate immunomodulating chemokine CCL2 plasma concentration¹², which promotes healing by stimulating macrophage activity¹³. Furthermore, CWI has been linked with decreased tissue oxygenation,¹⁴ a factor considered predictive of tissue healing.¹⁵

Nevertheless, several studies report modest improvements in enhanced function with brief applications of CWI following exercise or training.^14,16-18 A recent systematic review and meta-analysis concluded, “available evidence suggests that CWI can be slightly better than passive recovery in the management of muscle soreness”.  Furthermore, a dose-response relationship suggests that CWI between 11°C and 15°C at an immersion duration of 11-15 min leads to optimal outcomes.¹⁹ Notably, these findings are consistent with a 2015 meta-analysis of 36 studies that concluded there is a significant improvement in the symptoms associated with Delayed Onset Muscle Soreness (DOMS) following CWI. Nevertheless, no improvements in objective recovery variables were found following CWI during a 96-hour recovery period.²⁰ While Yeung  et al found CWI attenuated a reduction in tissue oxygenation by 4% and decreased muscle soreness 24 hours after testing, CWI had no effect on muscle performance during subsequent exercise.¹⁴

2. WHOLE BODY CRYOTHERAPY

Whole Body Cryotherapy (WBC) is a relatively new trend that attempts to cool the entire body in a short period of time in order to improve blood flow, metabolism, recovery following workouts and pain secondary to a number of conditions. However, WBC has not been cleared or approved by the Food and Drug Administration (FDA), as there is “very little evidence about its safety or effectiveness in treating the conditions for which it is being promoted.”²¹ More specifically, there is insufficient evidence to determine whether WBC decreases muscle soreness or improves recovery following exercise better than passive rest or no WBC in young-adult males.²² Moreover, 24 hours after eccentric exercise, WBC was ineffective at reducing muscle soreness or enhancing muscle force recovery.²³ In a more recent study on professional soccer players, WBC increased testosterone 2 and 24 hours post activity, but it did not change athletic performance.²⁴

3. ICE MASSAGE

While ice massage has been shown to reduce plasma creatine kinase, it was found to be ineffective at reducing factors associated with muscle damage.²⁵  In addition, ice massage was unable to enhance muscle recovery in male exercisers unaccustomed to eccentric training.²⁵

CRYOTHERAPY: SWELLING & INFLAMMATION

Several studies have reported reductions in swelling with cryotherapy secondary to vasoconstriction and post capillary venous flow.^26-29 However, a correlation between skin temperature reductions and systemic vasoconstriction have only been observed following hyperbaric gaseous cryotherapy and not topical ice pack application.³⁰ A systematic review concluded that icing may decrease motor performance and reverse lymphatic flow, thereby increasing extra vascular inflammation.³¹ In another systematic review, icing was found to not have any greater effect on swelling and range of motion than electrical stimulation or no form of cryotherapy.³² A number of studies have also suggested that prolonged cryotherapy may place tissue at significant risk for non-freezing cold injury (NFCI), a condition characterized by tissue necrosis and neuropathy due to prolonged vasoconstriction and ischemia, which persists even after tissue re-warming.^26,33

CRYOTHERAPY: TISSUE REPAIR

Various types and/or parameters of cryotherapy have been found ineffective in speeding up recovery following exercise induced muscle soreness.^9,20,34-36 The efficacy of cryotherapy must be questioned, as there is “little evidence to suggest that the addition of ice to compression has any significant effect”.⁷ Another systematic review concluded, “there is insufficient evidence to suggest that cryotherapy improves clinical outcomes in the management of soft tissue injuries.”⁶ Moreover, following 15 minutes of cryotherapy immediately following 3, 24, 48, and 72 hours after exercise, compared to controls, increased factors associated with muscle cell damage (i.e. CK-MB and myoglobin) were found. In addition, investigators found a peak shift in IL-12p70, a cytokine important for stem cell recruitment and tissue regeneration, and subjective increases in fatigue compared to control.

Collectively, this data suggests that cryotherapy may actually delay recovery of eccentric, exercise-induced muscle damage.³⁷ It is perhaps worth noting that warming tissues to 100°F was found to lead to faster recovery and improved performance after muscle soreness, whereas icing was found to delay recovery and performance.³⁶ Remarkably, a double-blind randomized controlled trial found tissue heating via Photobiomodulation therapy (PBMT) improved recovery rates and muscle performance better than PBMT + cryotherapy or cryotherapy alone.³⁸ Moreover, PBMT + cryotherapy and cryotherapy alone did not aide in post-exercise recovery more than placebo.³⁸

CRYOTHERAPY MAY BE COUNTERPRODUCTIVE TO TISSUE HEALING

The use of cryotherapy to reduce inflammation, blood flow and metabolism may not be beneficial for tissue healing. In reality, cryotherapy may reverse lymphatic flow, thereby increasing inflammation, impairing coagulation and leading to cell death.^31,32  Although the increase in vasoconstriction shunts pro-inflammatory factors, it also may limit the reparative actions of cells that serve dual roles. For example, using cryotherapy to inhibit neutrophils may seem like an appropriate strategy as neutrophils aide in tissue degeneration.³⁹ However, neutrophils are also responsible for kick-starting reparative processes that are later managed by macrophages.³⁹ Prostaglandins further contribute to chronic inflammation, but are also responsible for tissue remodeling, angiogenesis, fibrosis⁴⁰ and, ultimately, resolution of inflammation.⁴¹ Similarly, M1 macrophages secrete inflammatory cytokines, while M2 macrophages promote anti-inflammation and repair.⁴²  Interestingly, a number of studies have found that the use of NSAIDs immediately following an injury interrupt both inflammatory and repair processes, resulting in prolonged healing and suboptimal tissue repair.^43-46

In contrast, increasing factors associated with inflammation-repair pathways has been shown to facilitate healing and functional recovery. For example, enhancement of platelets in damaged tissue has been shown to facilitate repair of soft tissue in animal models,^47-49 and in humans with plantar fasciitis,^50-52 rotator cuff recovery,⁵³ hamstring tendinopathy,⁵⁴ lateral epicondylitis,⁵⁵ knee osteoarthritis,^56,57 and ACL reconstruction.⁵⁸ In addition, there are five main growth factors (i.e. IGF-I, TGFb, VEGF, PDGF and bFGF) that are crucial for tendon and ligament repair. Given that many of these factors are unregulated during the inflammatory phase of healing, cryotherapy may be counterproductive.⁵⁸

AUTHORS:

Dr. Craig Hadfield, DPT, Cert. DN
Fellow-in-Training, AAMT Fellowship in Orthopedic Manual Physical Therapy
Physical Therapist, Proactive Rehabilitation and Fitness
Pinedale, WY

Dr. Raymond Butts, PhD, DPT, MS, Dip. Osteopractic, MAACP (UK)
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Atlanta, GA

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