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Effects of Cold Water Immersion (CWI) on Delayed Onset Muscle Soreness
(DOMS) in Athletes: a Critically Appraised Topic
Clinical Scenario:
Delayed onset muscle soreness (DOMS) is a common experience by numerous athletes that has traditionally been treated with cold water immersion (CWI) therapy. However, the effectiveness of this treatment is highly inconclusive, as research on the topic increases. Focused Clinical Question:
In an active population, what is the effect of using CWI compared to nonimmersion rest on the effects of DOMS following an exercise bout? Summary of Key Findings: All three studies showed no significant difference between subjects who underwent CWI compared to those who did not. One study did find a potentially clinically important difference in plasma chemokine ligand (CCL2) concentration while another found differences in perceived soreness. The third study did find improvements in peak power output (PPO) after CWI in severe temperatures (~5
o
C). Clinical Bottom Line: Evidence does not exist to support the use of CWI in the treatment of DOMS as each study reported no statistically significant difference between CWI and nonimmersion rest. However, athletes may find the minimal improvements in DOMS symptoms as important in their training. Strength of Recommendation:
Grade B evidence shows no statistical support for the use of CWI in the
treatment of DOMS. Keywords:
delayed onset muscle soreness, cold water immersion, ice baths, cryotherapy, recovery, athlete, lower extremity Clinical Scenario
Although delayed onset muscle soreness (DOMS) is such a common experience among all levels of athletes, much of this training antagonist remains unknown. Specifically, modes of development, treatment, and impact on performance all remain undefined.
1
Delayed onset muscle soreness is common
at the beginning of training plans when new exercises are introduced and/or athletes have come off of a period of reduced training.
1
Symptoms may range from slight muscle tenderness all the way to performance-inhibiting pain.
1 Cryotherapy methods, such as cold water immersion (CWI) through the use of ice baths, are commonly believed to relieve pain and reduce inflammation due to the vasoconstrictive effects.
2
Although CWI has been used by athletes for decades, many meta-analyses are noting the trivial effects on the reduction of muscle soreness.
3 Thus, examining different studies that show the difference in outcome measures of groups who use cryotherapy compared to those who do not can provide insight into the true importance, or lack thereof, in utilizing CWI. Therefore, the purpose of this paper is to examine the level of benefits CWI brings to subduing the manifestations of DOMS in athletes, if any.
Focused Clinical Question
In an active population, what is the effect of using CWI compared to nonimmersion rest on the indicators of DOMS following an exercise bout?
Summary of Search, “Best Evidence” Appraised, and Key Findings
The literature search identified 9 studies. Of the 9 studies, 1 was excluded as a duplicate study, 5 studies were excluded based on their title or abstract, and no studies were excluded based on lack of relevance to this critically appraised topic (CAT) (Figure 1).
Three randomized controlled trials (RCT) met the inclusion and exclusion criteria (Table 1).
All studies compared CWI, each including a group immersed in 5-6
o
C amongst other CWI methods, with nonimmersion recovery. Perceived muscle soreness ratings with a visual analogue
scale (VAS)
4,5
or 10-point scale
3
were used by each study as an outcome measure. Levels of 1
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creatine kinase (CK)
3,5
or CCL2
4
in the blood were also used by each study to signify extent of muscle damage. Each study had other outcome measures in addition to these listed (Table 2).
In the included studies, all researchers agree that CWI does not show significant benefits in reductions in DOMS. However, it does not pose negative effects to recovery and the perception of athlete’s on CWI may aid in a placebo effect of the recovery method. In addition, severe CWI
(at temperatures around 5
o
C) may pose the most benefits, although not statistically significant.
The author independently used the PEDro scale to analyze the quality of each article. The average score for included articles was 7/10.
Figure 1 – Search Strategy.
Table 1 Summary of Study Designs of Articles Retrieved
Level of Evidence
Study Design
Number Located Reference
1b
Randomized, double-blinded controlled trial 1
Glasgow et al.
5
Randomized, controlled trial
2
Crystal et al.
4
Anderson et al.
3
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Clinical Bottom Line
Evidence does not exist to support the use of CWI in the treatment of DOMS as each study reported no statistically significant difference between CWI and nonimmersion rest. However, there may be a clinically important difference in the perceived soreness,
5
CCL2 concentrations,
4
and PPO
3
after CWI in
severe temperatures (~5
o
C). Strength of Recommendation:
Grade B evidence
6
does not support the use of CWI for the treatment of
DOMS. Search Strategy
A computerized search was completed in November 2020 (Figure 1). Terms Used to Guide Search Strategy
Patient/Client group: DOMS, delayed onset muscle soreness
Intervention/Assessment: icing, ice bath
Comparison: No terms listed (compared to rest)
Outcome: soreness, recovery, muscle recovery
Sources of Evidence Searched
Academic Search Ultimate
CINAHL Plus
Health Source – Consumer Edition
Health Source – Nursing/Academic Edition
MEDLINE
SPORTDiscus
Inclusion and Exclusion Criteria Inclusion Criteria
Compared CWI with nonimmersion rest on the lower extremities
Written in the English language
Written in the last 10 years (2011-2020)
Human Subjects Exclusion Criteria
Compared to massaging with foam rollers instead of nonimmersion rest
Systematic Reviews
Results of Search
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Three relevant studies were located using these search terms (Table 1). Validity of the selected studies was determined using the PEDro scale (Tables 2 and 3). Crystal et al.
4
Glasgow et al.
5
Anderson et al.
3
Study Design
Randomized, controlled trial
Randomized, double-blinded controlled trial
Randomized, controlled trial
Participants
20 recreationally active males (mean age 21.2 +
2.3 yrs; height 1.78 +
0.05 m; mass 76.4 +
9.6 kg; VO
2peak
= 58.9 +
8.6 ml kg
-
1
min
-1
) unaccustomed to cryotherapy
50 healthy patients (32 male, 18 female; age range 18-35 yrs; height 1.79 +
0.06 m; body mass 81.9 +
17 kg)
9 male recreational team sport players (age
range 21-27; mean age 24 +
2 yrs; height 1.78 + 0.09 m; body mass 77.6 +
14.2 kg)
Interventions Investigated
1.CON* group:
stood quietly in laboratory for 20 min
2.Cryotherapy group:
immersed in cryotherapy tank with 5 + 2
o C water for 20 min
1.CON* Group: nonimmersion, seated rest
2.Short Contrast Immersion
: 1 min water immersion in 38
o
C followed by 1 min CWI* in 10
0
(repeated 3x)
3.Short Intermittent CW*I:
1 min CWI* in 10
o
C followed by no immersion for 1 min (repeated 3 times)
4.10 min CWI* in 10
o
C 5.10 min CWI* in 6
o
C
1.CON* group:
nonimmersion, seated rest
2.CWI
14
o
C
group:
12 min immersion in moderate water temperature 14 + 1
o
C
3.CWI
5
o
C
group
: 12 min immersion in severe water temperature 5
+ 1
o
C
Outcome Measures
Inflammatory cytokine CCL2*:
from venous blood samples from an antecubital vein, 2mL
Isometric Knee Extensor Strength:
torque of the non-dominant leg on a HUMAC Norm dynamometer
Perceived Soreness:
while walking down a
flight of stairs using the VAS*
Swelling:
of the non-dominant thigh measured with a tension-controlled tape measure Muscle Soreness
: during everyday activities using a VAS*
ROM*:
AKE* Pain on Stretch
: during AKE* ROM* with
a VAS
Muscle Strength:
CPT* using a KinCom AP2 isokinetic dynamometer Serum CK*:
from finger-prick samples
PPO*:
using 10 sec peak power cycling test on a cycle ergometer
MPO*:
mean of the 6 PPO measures
Lactate levels:
from finger-prick sample
CK* levels:
from finger-prick samples
Muscle Soreness:
10-point scale from 1 (not sore) to 10 (very, very sore) while subject is standing
Main Findings
No significant therapeutic effects of cryotherapy on any of the variables measured (p=0.116). Lower CCL2* concentration following cryotherapy compared to control was noted.
No significant interaction between groups on any of the variables measured. Lower levels of muscle soreness noted in the 10 min CWI* 6
o
C group
PPO* was greater in both CWI* groups compared to CON* 72 hours after exercise
(d=.28-30). MPO* was higher in CON* compared with both CWI (p=.04 for both) 72 hours after exercise. CWI
5
o
C
was more effective than CWI
14
o
C
at restoring PPO* to
baseline levels 24 to 48 hrs post exercise and more effective than CON* 24 to 72 hrs. Lactate, CK*, and perceived muscle soreness showed no significant difference between groups.
Level of Evidence
1b
1b
1b
Validity Score
PEDro 6/10
PEDro 9/10
PEDro 6/10
Conclusion
CWI* had minimal impact on recovery and is not supported by the results as having large benefits. Water temperature or dosage had minimal effect on outcomes. CWI* has minimal impact on recovery. If it is going to be used. 10 min of CWI* at 6
o
C may pose the
most benefits, although not much. Repeated bouts of exercise are initially impaired directly after 5 and 14
o
C CWI*, but PPO* may be improved by 72 hours after exercise. PPO* is also more benefitted with severe CWI* than moderate. CWI* is not recommended for acute recovery and still does not show substantial benefits for recovery overall. 89
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Table 2 Characteristics of Included Studies
Abbreviations: CON, control; CWI, cold water immersion; CCL2, plasma chemokine ligand 2; VAS, visual analogue scale; AKE, active knee extension; CPT, concentric peak torque; PPO, peak power output; MPO, mean power output; CK, creatine kinase
Crystal et al.
4
Glasgow et al.
5
Anderson et
al.
3
1.Eligibility criteria specified (yes/no)
yes
yes
yes
2. Subjects randomly allocated to groups (yes/no)
yes
yes
yes
3. Allocation was concealed (yes/no)
no
yes
no
4. Groups similar at baseline (yes/no)
yes
yes
yes
5. Subjects were blinded to group (yes/no)
no
yes
no
6. Therapists who administered therapy were blinded (yes/no)
no
no
no
7. Assessors were blinded (yes/no)
no
yes
no
8. Minimum 85% follow-up (yes/no)
yes
yes
yes
9. Intent to treat analysis for at least 1 key variable (yes/no)
yes
yes
yes
10. Results of statistical analysis between groups reported (yes/no)
yes
yes
yes
11. Point measurements and variability reported (yes/no)
yes
yes
yes
Overall Score (out of 10)
6/10
9/10
6/10
Table 3 Results of PEDro Scale for Each Article
Note: Item 1 was not included in overall score Best Evidence
As described in Table 1, the studies selected for inclusion in this CAT were identified as the best evidence. The authors of these level 1 studies considered the use of CWI in the treatment of DOMS in comparison with nonimmersion rest. Implications for Practice, Education, and Future Research
The studies included in this CAT were conducted to identify the effect of CWI compared with nonimmersion rest on the effects of DOMS after an exercise bout in a healthy population. Cryotherapy has been considered a recovery modality to assist with fatigue and DOMS for decades.
2
Although it has been considered to reduce pain, swelling, and inflammation, the benefits of CWI are still unclear, with many research studies showing contradictory evidence.
3 Therefore, after years of ice packs and ice baths
as the norm, researchers are now looking to find if there is truly any evidence behind these traditional recovery methods. 91
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The researchers of the 3 studies examined in this CAT found CWI to be an ineffective treatment for the symptoms of DOMS. In the highest-quality study available, researchers randomized 50 healthy participants into 5 different treatment groups, including a control group, in order to test different CWI modalities.
5
After statistical analysis, they reported no statistical difference between treatment groups.
5 However, the treatment group that had cold water immersion in 6
o
C water for 10 minutes did show lower levels of muscle soreness as well as lower ratings of pain on stretch compared to the control group.
5
These subjective measures may have been due to the perceived recovery of the subjects due to the bias of cryotherapy.
5
However, the other two studies also showed improvements, not statistically significant, in different outcome measures of the groups in the CWI at 5-6
o
C (considered severe).
3,4 One study found improvements in the levels of CCL2
4
while the other found improvements in PPO.
3
Since the methodologies of most research on CWI are not consistent, it makes comparison difficult. In these 3 studies, the mode of DOMS inducement are all different. One used downhill running,
4
another used a standing hamstring curl machine,
5
while another used intermittent bouts of running.
3
The extent of DOMS emitted through each methodology could make a difference in outcome measures. Length of immersion was also completely different between studies. One had subjects immersed for 20 minutes,
4
another had 10 minutes of consistent immersion along with different contrast therapy groups,
5
while the last one used 12 minutes.
3 The study comparing different methods of immersion did not increase immersion time all the way up to 20 minutes to match the first study.
3
Instead the study focused
on different temperatures of immersion.
3
Lastly, perceived muscle soreness was an outcome measure used throughout all studies. However, one study asked subjects to rate their pain on a VAS as they had the subjects walking downstairs.
4 Another asked subjects to rate soreness with a VAS during everyday activities as well as their pain on stretch.
5 The last study asked subjects to rate their soreness on a 1-10 scale while simply standing.
3
All of these activities would elicit different pain responses with soreness, making them hard to compare precisely. Walking downstairs would require more hamstring usage than simply standing or doing everyday activities. Clinicians should use caution when generalizing these results to athletic teams at elite levels. Each study
used recreationally active participants. The subjects were not in a state of high stress from continuous intense training. Thus, the results in the outcome measures may differ for elite athletes in constant training. In addition, although no statistical differences were found when comparing the CWI groups to the control groups, there were differences in means of outcome measures in CWI groups with temperatures around 5
o
C that could be considered a clinically important difference. For situations where every advantage counts in competition, clinicians may consider this as a modality to aid in recovery. However, if time or money is restricted, this mode of recovery should not be given high importance. This mode may not be advantageous for athletes who are aware of the research demonstrating the ineffectiveness of CWI compared to those convinced of CWI’s supposed benefits. Further studies should be conducted of the duration of CWI as well as with elite athletes. This current CAT should be reviewed in 2 years to determine whether additional evidence exists that may alter the clinical bottom line of this clinical question. Acknowledgment 110
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The authors declare no conflict of interest. 150
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References
1.
Cheung, K., Hume, P., & Maxwell, L. (2003). Delayed onset muscle soreness : treatment strategies and performance factors.
Sports medicine (Auckland, N.Z.)
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33
(2), 145–164. https://doi.org/10.2165/00007256-200333020-00005
2.
Hohenauer, E., Taeymans, J., Baeyens, J. P., Clarys, P., & Clijsen, R. (2015). The Effect of Post-Exercise Cryotherapy on Recovery Characteristics: A Systematic Review and Meta-
Analysis.
PloS one
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3.
ANDERSON, D., NUNN, J., & TYLER, C. J. (2018). Effect of Cold (148° C) Vs. Ice (58° C) Water Immersion on Recovery from Intermittent Running Exercise.
Journal of Strength & Conditioning Research (Lippincott Williams & Wilkins)
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4.
Crystal, N. J., Townson, D. H., Cook, S. B., & LaRoche, D. P. (2013). Effect of cryotherapy on muscle recovery and inflammation following a bout of damaging exercise.
European Journal of
Applied Physiology
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(10), 2577–2586. https://doi.org/10.1007/s00421-013-2693-9
5.
Glasgow, P. D., Ferris, R., & Bleakley, C. M. (2014). Cold water immersion in the management of delayed-onset muscle soreness: Is dose important? A randomised controlled trial.
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6.
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medicine-levels-evidence-march-2009/.
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