Secondary Logo

The Effects of Multiple Daily Applications of Ice to the Hamstrings on Biochemical Measures, Signs, and Symptoms Associated With Exercise-Induced Muscle Damage

Oakley, Elizabeth T.; Pardeiro, Rafael B.; Powell, Joseph W.; Millar, Audrey L.

Journal of Strength and Conditioning Research: October 2013 - Volume 27 - Issue 10 - p 2743–2751
doi: 10.1519/JSC.0b013e31828830df
Original Research
Free

Oakley, ET, Pardeiro, RB, Powell, JW, and Millar, AL. The effects of multiple daily applications of ice to the hamstrings on biochemical measures, signs, and symptoms associated with exercise-induced muscle damage. J Strength Cond Res 27(10): 2743–2751, 2013—There is inconclusive evidence for the effectiveness of cryotherapy for the treatment of exercised-induced muscle damage (EIMD). Small sample sizes and treatment applications that did not correspond to evidence-based practice are limitations in previous studies that may have contributed to these equivocal findings. The purpose of this study was to examine the effectiveness of daily multiple applications of ice on EIMD throughout the 72-hour recovery period, an icing protocol that more closely resembles current clinical practice. Thirty-three subjects were assigned to either the cryotherapy group (n = 23) or control group (n = 10). The EIMD was induced through repeated isokinetic eccentric contractions of the right hamstring muscle group. The experimental group received ice immediately after induction of EIMD and continued to ice thrice a day for 20 minutes throughout the 72 hours; the control group received no intervention. Isometric torque, hamstring length, pain, and biochemical markers (creatine kinase [CK], alanine aminotransferase, and aspartate aminotransferase [AST]) were assessed at baseline, 24, 48, and 72 hours. Both groups demonstrated a significant change (p < 0.05) in all dependent variables compared with that at baseline, but there was no difference between groups except for pain. The cryotherapy group had significantly (p = 0.048) less pain (3.0 ± 2.1 cm) compared with the control (5.35 ± 2.5 cm) at 48 hours. Although not statistically significant, the cryotherapy group had a greater range of motion and lower CK and AST means at 72 hours compared with that of the control group. Repeated applications of ice can decrease the pain associated with EIMD significantly at 48 hours post EIMD. Although the results may not be unique, the methodology in this study was distinctive in that we used a larger sample size and an icing protocol similar to current recommended treatment practice.

Department of Physical Therapy, Andrews University, Berrien Springs, Michigan

Address correspondence to Elizabeth Oakley, oakleye@andrews.edu.

Back to Top | Article Outline

Introduction

Strenuous or unaccustomed exercise may result in transitory and repairable injury to the involved muscles, especially when the exercise involves intense eccentric contractions. Common responses to overuse or intense training in the involved muscles of the trained and untrained individual are delayed-onset muscle soreness (DOMS), swelling, decreased strength, and range of motion (ROM) (18). Symptoms vary in intensity and duration and are influenced by the type and arduousness of the activity and the individual's level of training. Although this condition is self-limiting, it can temporarily effect function and interrupt training (1,18).

Many studies (1,5,18) have been done to examine the effects of various interventions in decreasing the signs and symptoms of exercise-induced muscle damage (EIMD). A review article by Howatson and Van Someren (18) examined the efficacy of various interventions in the prevention and treatment of EIMD. These interventions ranged from nutritional and pharmacological substances, to various physical agents such as electrical stimulation and cryotherapy. They concluded that the lack of consistency in the dosage and frequency for the physical agents used in these studies contributed to the lack of unequivocal findings for effectiveness. They further mention that “very few studies used evidence-based guidelines in the application of the interventions.” (18) This is especially evident in many of the cryotherapy studies that often used only 1 or several applications of ice within the first 24 hours for the treatment of EIMD. Current treatment guidelines for acute injury recommend the use of ice as soon as possible after the injury and several times a day for 15–20 minutes throughout the 72-hour recovery period (6,15). We were unable to find a cryotherapy study that followed these clinical guidelines of application for the treatment of EIMD. Similarly, Burgess and Lambert (5) in their review article on the effects of cryotherapy on EIMD commented on the small sample size and varying methods of application as limitations in the studies they reviewed. They ascertained that there was inconclusive evidence for the effectiveness of cryotherapy for the treatment of EIMD. Thus, finding interventions and techniques that will minimize the signs and symptoms of EIMD or reduce recovery time continues to be of interest. Specifically, cryotherapy studies using evidenced-based treatment applications with larger sample sizes need to be done to address the weaknesses of these previous studies to determine effectiveness. Therefore, a study examining the effectiveness of daily multiple applications of ice on EIMD throughout the 72-hour recovery period that reflects current recommended treatment practice is warranted.

The mechanism involved in EIMD is thought to be both mechanical and chemical in nature. After strenuous exercise, involving intense eccentric muscle contractions, microscopic muscle damage at the cellular level occurs, which contributes to the temporary decrease in strength postactivity. This muscle damage initiates the inflammatory response, which triggers the release of several chemical mediators that are responsible for the pain, swelling, and tenderness associated with EIMD (1,18,27,32). Several studies have identified the presence of inflammatory markers, such as neutrophils, cytokines, macrophages, and other mononuclear cells, after exercise-induced injury (3,9,22,24–26,28,36). Neutrophils are activated by chemotactic agents as early as 2 hours after injury. Elevated circulatory neutrophil levels are found in the blood before increased concentration levels in the tissue. As the neutrophils marginate and enter the tissue, circulatory neutrophil levels decrease and disintegrate at the site after 24 hours (23,25,26,28,36). Although they contribute positively to the healing process, these inflammatory agents and their byproducts can contribute to elevated pain, inhibit short-term muscle recovery, and perhaps induce further microscopic muscle damage. In particular, neutrophils generate free radicals that are thought to heighten the damage to the cell membrane (1,18,27,32). The resultant cellular damage releases enzymes into the circulation. These enzymes have been identified in the literature as the cytosolic proteins creatine kinase (CK), alanine aminotransferase (ALT), and aspartate aminotransferase (AST), which are indirect biochemical markers for this damage (3,25,26,28,31,32,37). Creatine kinase is the most commonly measured protein in EIMD studies because it is found exclusively in muscle tissue (32).

Cryotherapy is commonly used to treat symptoms associated with inflammation (7,20). The physiological effects attributed to ice are a decrease in pain, swelling, muscle spasm, and secondary hypoxic injury (7,22). Secondary hypoxic injury occurs when healthy tissue surrounding the injured area is deprived of oxygen because of the disruption of blood vessels and increasing pressure from edema. Therefore, injury to the healthy tissue results in a greater total amount of damaged tissue. Application of ice within minutes of the initial trauma has been recommended to obtain the greatest effect for decreasing secondary hypoxic injury (22). Many studies have examined the effectiveness of cryotherapy on minimizing the inflammatory response and associated cellular damage from EIMD (5). To date, the effect of cryotherapy on the signs and symptoms of DOMS remains inconclusive.

A review article, Burgess and Lambert (5) examined the effectiveness of cryotherapy on muscle recovery after EIMD. Thirteen studies met their inclusion criteria. Although there was some evidence that showed a decrease in CK, muscle soreness, and stiffness, the authors felt that overall the results were inconclusive on the effectiveness of cryotherapy in improving EIMD recovery. Additionally, 2 other review articles by Barnett (1) and by Howatson and van Someren (18), noted similar findings and pointed out that many cryotherapy studies used short applications of ice and small sample sizes that may contribute to the apparent lack of effectiveness in some studies. Further, both articles cited studies that suggested that cryotherapy might have a negative impact on muscle adaptation to training.

When looking at the individual studies cited in the review articles by Burgess and Lambert (5), Barnett (1), and by Howatson and van Someren (18), the following studies used either >1 treatment application of ice the first day or 1 treatment of ice daily throughout the duration of the study. Of these studies that examined the effects of ice on the signs and symptoms of EIMD, very few found any significant effect on the functional symptoms or biochemical measures of EIMD (11,13–15,17,21,29,33,35,39,40). Only 3 studies reported a significant effect on ≥1 of the following variables: ROM, CK, or pain (8,14,17,40). These studies used upper extremity muscle groups, mainly the biceps muscle, to compare responses with icing protocols. The frequency of ice application varied in these studies and did not resemble typical recommended clinical guidelines. Gulick et al. (14), Denegar and Perrin (8), and Yangisawa et al. (40) iced once immediately after EIMD. Departing from this was Howatson et al. (15) who iced 3 times immediately post EIMD and then once again at 24 and 48 hours. Another exception was the study by Isabell et al. (21) in which ice was applied immediately after and at 2-hour intervals on the first day and then once every 24 hours thereafter. Studies on the effectiveness of cold immersion (CI) were also inconclusive (11,13,16,33,35). Some studies found that CI was effective in diminishing the loss of muscle force, decreasing soreness and decreasing levels of CK, whereas other studies found no effect. Similarly, the frequency at which CI was administered varied among these studies.

Clinically, patients with injuries are instructed to ice multiple times a day within the first 24–72 hours to control symptoms (6,19). None of the previously identified studies replicated typical clinical recommendations. Therefore, the purpose of this study was to examine the effectiveness of ice on the functional symptoms (perceived muscle soreness, active knee extension [AKE], and hamstring force) and biochemical markers (CK, ALT, and AST) of EIMD using a more frequent and regular application of ice packs to the hamstring muscle. Our hypothesis was that multiple applications of ice packs daily, throughout the 72-hour period of the study, would decrease muscle soreness, minimize the loss of knee extension, hamstring force production, and muscle damage as demonstrated by minimal change in the elevation of plasma levels of CK, ALT, and AST.

Back to Top | Article Outline

Methods

Experimental Approach to the Problem

This study is a 2-group, controlled experimental study. A sample of convenience was obtained and a combination of random and matched assignment was used for this controlled trial. Matched assignment was used to control for age and gender, as some literature has found a difference in response to EIMD and cryotherapy interventions by both attributes. The first subject was randomly assigned to either the control or experimental group. If the next subject's gender and age matched a previously assigned subject, they were placed in the opposite group; otherwise, the subjects were randomly assigned to either the experimental (n = 20) or control (n = 10) group. An unequal group design, using an approximate 2:1 ratio, was used to increase the size of the experimental group and thus the statistical power (which has been identified as a weakness in many studies on this topic).

Based on recommendations found in the literature, the following dependent variables were measured on all the subjects at baseline, 24, 48, and 72 hours: plasma CK, ALT, AST, soreness, hamstring length, and isometric force output (3,7,21,33). Measurement of the biochemical markers would allow indirect evaluation of tissue damage and its response to the intervention over time. Perceived soreness, hamstring length, and isometric force are the most common clinical measures of EIMD and may change even without concurrent changes in biochemical markers. Both types of measures allow comparison with previous studies on DOMS/EIMD.

Once baseline measures were collected, EIMD was induced in the hamstrings by repeated eccentric hamstring contractions performed on an isokinetic dynamometer. The subjects in the experimental group received a 20-minute crushed ice-pack treatment on the right hamstring area immediately after EIMD and at 24 and 48 hours after the reassessment of the dependent variables. The experimental group was instructed to ice for 20 minutes 3 times a day over the ensuing 72 hours. This more frequent application of cryotherapy reflects current clinical practice and, as noted, has not been used in this regularity in previous studies. The subjects were asked to refrain from participating in any physical activity or any other form of intervention for the treatment of painful symptoms during the study, and subjects' compliance to this request was checked at each visit. The experimental procedure is summarized in Figure 1.

Figure 1

Figure 1

Before implementation of the study, the researchers participated in training to ensure standardization of all procedures. The same researcher performed the same measures on each subject to avoid intertester measurement error. Although statistical reliability assessments were not calculated for ROM in this study, the measures were practiced until the variability was within 2–3 degrees, which is consistent with the ROM studies. Instructions to the subjects were standardized to reduce potential error. Laboratory temperature was consistent throughout tests, and follow-up test times were within 30 minutes of 24 hours from the previous test.

Back to Top | Article Outline

Subjects

Thirty-three (17 men, 16 women; 24.0 ± 4.0 years) trained and untrained individuals participated in this study. This study was approved by the university's Institutional Review Board (IRB) before implementation, and informed, written voluntary consent was obtained from all the subjects in accordance with IRB guidelines. The subjects filled out a health questionnaire to screen for any medical or physical contraindications to exercise or ice. Exclusion criteria included, but were not limited to weight training in the past 2 weeks, any adverse reactions to cold, pertinent cardiopulmonary conditions, or lower extremity joint problems. The latter 2 would restrict measurement. The 2-week limit for previous weight training was used to decrease the potential for the effect of prior eccentric activity on EIMD (18).

Back to Top | Article Outline

Range of Motion of Knee Extension

The 90–90 AKE test was used to assess knee extension. Gajdosik and Lusin (12) found the reliability of the AKE to be 0.99 for test-retest measurements. The subjects were positioned supine on a table and asked to bend and bring the right knee up toward their chest with the opposite extremity flat on the table. The right hip was positioned and held in 90° of hip flexion. The subject was then asked to straighten the knee as far as possible without pain. A piece of paper was placed on 1 side of the goniometric scale to prevent bias when aligning the goniometer. Once the goniometer was positioned, the goniometer was turned around, and the value was determined and recorded by the researcher performing the measurement. Extension was recorded to the nearest degree, with 90° being complete extension, and lower numbers reflecting the inability to extend the knee completely.

Back to Top | Article Outline

Perceived Soreness

Perceived muscle soreness was assessed using a 10-cm horizontal line visual analog pain scale (VAS) with pain descriptors at each end (0 = no pain; 10 = worst imaginable pain). The subjects were asked to report on the soreness they felt while actively extending the knee for the 90–90 test. The subject identified a point on the line with a corresponding number value that best described the intensity of soreness. Bijur et al. (2) found that the intraclass correlation coefficient (ICC) for VAS scores was 0.97 (95% CI = 0.96–0.98) for evaluating the perceived intensity of acute pain.

Back to Top | Article Outline

Biochemical Markers: CK, ALT, AST, and Neutrophils

Two 5-ml vacutainers of blood were collected each time from the antecubital area using standard techniques by a trained phlebotomist. The blood was allowed to clot and then centrifuged to separate the serum. The serum was stored at 4° C for not >3 days before analysis.

The analyses of CK, ALT, and AST were performed as specified by the Diagnostic Chemicals Limited (Oxford, CT, USA) package insert instructions, and were carried out at 37° C. All measurements were made using a Model 340 Spectrophotometer, Sequoia-Turner Corporation (Mountain View, CA, USA). Reagents for the analysis of CK, ALT, and AST were obtained from Diagnosticts Chemicals Limited. Quality control was checked by using Lyphocheck Assayed Chemistry Controls level 1 and level 2 from Bio-Rad Laboratories (Irving, CA, USA).

Back to Top | Article Outline

Isometric Force Production of Hamstrings

An isokinetic dynamometer was used to measure maximal isometric voluntary contraction of the hamstring muscle. The subjects were seated in the dynamometer chair with the right hip and knee flexed to 90° and stabilized with straps at the hip, thigh, and ankle. The dynamometer was set on the isometric mode, and the subjects were asked to maximally contract their right hamstring muscle 3 times, with a 5-second hold for each rep and a 60-second rest between repetitions. An average of the 3 repetitions was recorded in foot/pounds and converted to Newton meters (N.m). Shelley et al. (34) found test-retest ICC values for isokinetic strength testing for the quadriceps ranging between 0.92 and 0.97 at various speeds.

Back to Top | Article Outline

Eccentric-Exercise Protocol

The subjects remained seated as above, and the dynamometer was switched to the eccentric mode. The subjects performed 5 warm-up eccentric contractions, followed by a fatiguing bout of 5 sets of 10 eccentric repetitions of the hamstring muscle with a 1-minute rest between sets. This protocol was chosen based on a previous unpublished study done by Dukes and Ronto (9), which demonstrated effectiveness in eliciting the desired response.

Back to Top | Article Outline

Intervention-Ice Protocol

The subjects in the experimental group received a 20-minute ice treatment immediately postexercise and at 24 and 48 hours after the reassessment of all dependent variables. A moistened towel was placed over the subject's right hamstring muscle, and a plastic bag filled with crushed ice was placed on top, and then covered with a towel. A researcher monitored the subject during this first treatment for potential abnormal responses to the icing (of which there were none).

At the conclusion of the first treatment, the subjects were given an icing log and instructed to ice for 20 minutes, at least 3 times per day for the next 72 hours. The subjects were also asked to report any unusual signs or symptoms immediately to the investigators. To improve interpretation of the results, the subjects in both groups were asked not to do any other therapeutic intervention for pain (such as taking an anti-inflammatory). Subjects' compliance to this request and icing protocol was checked, and recorded, at each session by verbal questioning.

Back to Top | Article Outline

Statistical Analyses

Means and SDs were calculated for all variables. Independent t-tests were used to compare groups before the intervention. To determine the differences in response to the intervention by groups, repeated measures (mixed model) analyses of variance (ANOVAs) were calculated for all dependent variables. Differences were considered significant if at p ≤ 0.05. Because the ANOVA is a robust test, it was also used to analyze the VAS data. If there was a significant difference in the variances, as reflected by Mauchly's test of sphericity, the Greenhouse-Geisser correction was used for the ANOVA results. Linearity was examined using within-subject contrasts, with any nonlinear findings identified after the initial within-subject effects. As normal post hoc comparisons are not possible with a repeated-measures ANOVA for the time component, the changes from baseline to each of the repeat measures (24, 48, and 72 hours) were calculated using paired t-tests. Because of the increased possibility of type 1 decision-making errors with multiple comparisons, a Bonferroni adjustment was made with the statistical significance set at p ≤ 0.017 (based on the formula α/# comparisons [10]). A posttest analysis of observed power was calculated. Power over time was 0.728 for knee extension ROM, 0.919 for torque, and 0.924 for CK in UL. Power for time by group was much less, 0.1–0.3, depending on the variable.

Back to Top | Article Outline

Results

Thirty-three (17 men, 16 women; 24.0 ± 4.0 years) subjects participated in this study. Because of missed appointments by subjects and failure to obtain an adequate blood sample volume to test all biochemical parameters, the n varies in some assessments. There were no significant differences between the groups for baseline measures, including age, height, and weight. Initial changes in the dependent variables for all individuals confirm that EIMD was incurred by the eccentric exercise. See Table 2 for a summary of the dependent variables, presented by groups.

Back to Top | Article Outline

Range of Motion of Knee Extension

There was a statistically significant change (p = 0.002) within groups overtime for knee extension ROM (Table 1). The change in ROM was quadratic (curvilinear), with a significance of 0.016. Both groups started with similar baseline ROM means and decreased similarly overtime. There was a significant difference (p = 0.048) from baseline ROM measures for both groups at 48 and 72 hours. The largest difference between the means of both groups for ROM occurred at 48 hours, with the control group demonstrating a greater loss of ROM compared with the treatment group. This trend is illustrated in Figure 2. However, the difference between groups was not statistically significant (Table 2).

Table 1

Table 1

Figure 2

Figure 2

Table 2

Table 2

Back to Top | Article Outline

Isometric Force Production of Hamstrings

There was a statistically significant change (p < 0.0005) within groups overtime for isometric force production of the hamstrings (Table 1). Both groups started with similar baseline force production means and decreased similarly overtime. There was a significant difference (p < 0.001) from baseline for both groups at each of the time increments for force production. The largest difference between the means of both groups occurred at 72 hours with the treatment group having greater hamstring force production compared with the control group. Although this difference was not statistically significant, the force production for the treatment group started to rise compared with the control group, which continued to decrease (Table 2).

Back to Top | Article Outline

Perceived Soreness

There was a statistically significant change (p < 0.05) within groups overtime for perceived soreness with both groups experiencing elevated soreness overtime (Table 1). There was a significant difference (p = 0.017) from baseline for both groups at 24, 48, and 72 hours. The largest difference between the means of both groups for perceived soreness occurred at 48 hours with the control group having a greater elevation of pain compared with the treatment group. This difference was found to be statistically significant (p = 0.009; Table 2). Figure 2 shows the difference between means for perceived soreness between groups at 48 hours.

Back to Top | Article Outline

Biochemical Markers: CK, ALT, and AST

There was a statistically significant change within groups overtime for CK in UL (p < 0.001), ALT in UL (p = 0.001), and AST in UL (p = 0.012; Table 1). The levels of all biochemical markers elevated similarly in both groups over time. Changes for both ALT and AST were quadratic in nature (p = 0.042 and 0.019, respectively). There was a significant difference (p < 0.017) from baseline CK and AST measures for both groups at 24 and 72 hours. The largest difference between groups for the mean values of CK occurred at 72 hours, with the control group demonstrating higher levels of CK and AST compared with the treatment group. However, the difference between the 2 groups was not statistically significant (Table 2). There was a significant difference (p = 0.017) from baseline ALT levels for both groups at 72 hours. The mean ALT levels for the treatment group was higher as compared with the control group; however, the difference between the 2 groups was not statistically significant (Table 2).

Back to Top | Article Outline

Discussion

The purpose of this study was to see if multiple daily applications of ice throughout a 72-hour period would decrease soreness, minimize the loss of knee extension, and hamstring force production and minimize the elevation of CK, ALT, and AST. We found that all cytosolic proteins and reported muscle soreness increased from baseline, demonstrating successful generation of EIMD. In addition, knee extension range and force production of hamstrings decreased. These responses to EIMD were similar to that of other studies (10,15,21,27,32,36,39).

There was a statistical and clinically significant difference in reported pain levels between groups at 48 hours. Williamson and Hoggart (38) calculated that a 3-mm change in the VAS pain intensity score was equal to an approximate 6% change. Further, the authors cite references that have identified 30, 33, and 50% pain reduction to be a statistically and clinically meaningful change in pain. The difference between the mean pain levels at 48 hours in our study was clinically significant in that the pain for the control group increased from 2.6 to 5.4 cm, a 108% change in pain intensity, whereas the treatment group increased from 2.7 to 3 cm, an 11% change in pain intensity. Thus, although there was no difference at 72 hours, this suggests that ice was able to control pain effectively and produced a faster relief in pain by 48 hours (Table 2).

Our findings are similar to those of Gulick et al. (14), Denegar and Perrin (8), and Yangisawa et al. (40) who also found a decrease in muscle soreness. Gulick et al. (14) found a significant reduction in pain with one application of ice massage to the wrist extensors delivered immediately postexercise. Pain reduction occurred only at the 20-minute interval postexercise, and there was no sustained effect throughout the remainder of the 72-hour assessment time. The lack of sustainability of pain may be because of the use of only one application of ice immediately after exercise during the entire 72-hour duration of the study. Denegar and Perrin (8) also found reductions in immediate pain, but only looked at 1 application of ice. Similarly, a crossover study by Yangisawa et al. (40) found significant improvement in muscle soreness of the shoulder in 7 male baseball pitchers after 1 ice-pack application given immediately after exercise. This improvement was noted at each of the 2 assessment intervals, immediately after and 24 hours postexercise. Because of the limited duration of their study, the sustainability of the reduction of pain beyond 24 hours cannot be determined.

In contrast, a majority of the cryotherapy studies (10,15,17,21,33,39) found either no change in soreness or increased soreness. The exception was Isabell et al. (21) whose treatment frequency most closely resembled a clinical treatment schedule. Ice massage was applied to the elbow flexors immediately after exercise and at 2, 4, and 6 hours on the first day and then once every 24 hours throughout the 120-hour testing period. Twenty-two men were divided into 4 treatment groups: control, ice massage, ice massage with exercise, or exercise alone. Although not statistically significant, they found that the ice massage group had the highest peak CK levels, highest soreness at rest, and lowest peak total ROM suggesting that the application of ice might be detrimental in the treatment of DOMS. The lack of significant findings may be because of the small sample size in each group (n = 5). Yackzan et al. (39) divided 30 female participants into 3 treatment intervals: group A received a single ice massage immediately after exercise, group B at 24 hours postexercise, and group C at 48 hours postexercise. They found a significant increase in muscle soreness in the treated arm vs. the untreated arm with group B. This may be because of the lack of any intervention until the 24-hour time interval. In addition, muscle soreness has been found to peak at 24–48 hours (1,16,27,32).

We found no significant difference for knee extension ROM and hamstring force production between groups. However, the loss of knee extension ROM from baseline to 48 and 72 hours was greater for the control group. They started at 61.2° and ROM decreased to 49.8° at 48 and 72 hours, an 18.6% change. The treatment group started at 60.6° and dropped to 55.8° at 48 hours and 54.6° at 72 hours, an 8 and 10% change, respectively (Figure 2). Similarly, the loss of hamstring force production in the control group continued to drop at 72 hours, whereas the treatment group started to improve. Continued assessment of these variables beyond 72 hours may have demonstrated a continued trend in favor of ice treatment. None of the studies using an ice application for treatment found any significant improvement in ROM, and only 1 study found a significant improvement in strength (14,15,17,21,39). Yangisawa et al. (40) found a significant improvement in muscle strength with the combination of ice pack and light exercise compared with the ice-only and control group. The combination of these interventions may have contributed to these findings. As previously noted, none of these studies used daily multiple applications of ice throughout the testing period, a possible contributing factor in the apparent lack of findings for these variables.

As established in the literature, CK, ALT, and AST increased from preexercise levels (1,18,27,32). Although not statistically significant, there was a 41.5% difference in the mean for CK at 72 hours, with the mean for the treatment group being lower compared with the control. In addition, we found that there was a 14% difference in the AST mean between groups 72 hours, with the mean being lower for the treatment group. Thus, this trend may have become statistically significant for our study if it was carried out beyond the 72-hour time frame. Furthermore, we believe that these differences may indicate a slight improvement in healing, though we cannot definitively state this.

Our results are similar to those of Isabell et al. (21) and Howatson et al. (15) who did not find a significant difference in CK levels with ice massage to the elbow flexors. Interestingly, an earlier study by Howatson and Van Someren (17) found a significant decrease in CK levels with ice massage at 72 hours compared with the control, yet despite this, there was no difference between groups in muscle soreness. Ice massage was delivered to elbow flexors at the same treatment parameters and same time intervals as their latter study (15), immediately after exercise and again at 24 and 48. One of the differences between these 2 studies was the training of the subjects. One study (17) used 9 resistance-trained male participants and the other (15) used 12 untrained male participants using an isokinetic eccentric protocol with the same exercise parameters. There is evidence (4,19,30) to suggest that prior eccentric training has a lasting protective effect against muscle damage and may account for the varying results between these studies (15,17).

We did not differentiate between trained and untrained subjects except for verbally screening them for any vigorous activity within the past 7 days, which would have excluded them from the study. Thus, subject participation in any previous eccentric activity may have had an influence on our results. Brancaccio et al. (3) noted these additional variables that can influence CK levels: age, gender, race, muscle mass, physical activity, and climatic condition. Although we used a matched assignment for age and gender, in an attempt to control for these variables, the influence of all of the other uncontrolled variables mentioned may contribute to the inconsistent results found in the literature for these biochemical markers of muscle damage and the apparent lack of significance in our study.

Based on the results of our study, we could not accept our original hypothesis that multiple applications of ice every 24 hours would decrease the signs and symptoms of EIMD in the treatment group compared with the control group. However, we did find that the application of an ice pack 3 times a day for 20 minutes throughout the recovery period significantly reduced pain at 48 hours that remained reduced at 72 hours. Further, although not statistically significant, the means for CK and AST were lower and muscle force started to rebound for the treatment group at 72 hours. It appears that the frequency of icing after intense exercise has the potential to influence the progression and rate of healing for the signs and symptoms of EIMD. Although we used a minimum treatment frequency of 3 times per day, it still did not come near to the recommended treatment frequency of icing every 2 hours within the first 24–72 hours. Future studies examining the use of this treatment regime may find significant results.

Back to Top | Article Outline

Practical Applications

Based on the theory that behind the signs and symptoms of EIMD is the onset of inflammation because of muscle damage, ice would be the physical agent of choice because of its anti-inflammatory effects. Clinically, for effective management of symptoms associated with an acute injury, multiple applications of ice are required each day throughout the 72-hour period to obtain the most benefits from this intervention. Multiple 20-minute ice-pack applications is recommended during the first 24–72 hours of injury for effective management of pain and swelling (22,6). In addition, ice is a cost-effective treatment that is easily obtainable and carried out at home. Our study found ice to be effective in managing soreness, especially for the first 48 hours after intense exercise. Thus, we would recommend ice as the modality of choice for the treatment of postexercise soreness. Although the results of this study may not be unique, the methodology in this study was distinctive in that we examined the effect of an icing protocol similar to current recommended treatment practice that previous studies have not. Treatment based on evidence-based practice continues to be of significance for quality of patient care and reimbursement. Because this study addressed some of the weaknesses of previous cryotherapy studies, the results of this study can contribute to coming up with a more unequivocal understanding of the role of cryotherapy in the treatment of EIMD.

Back to Top | Article Outline

Acknowledgments

The authors would like to thank Richard Show and Albert McMullen from the Medical Laboratory Science department at Andrews University in Berrien Springs, Michigan, for analyzing the blood samples for this study.

Back to Top | Article Outline

References

1. Barnett A. Using recovery modalities between training sessions in elite athletes does it help? Sports Med 36: 781–796, 2006.
2. Bijur PE, Silver W, Gallagher EJ. Reliability of the visual analog scale for measurement of acute pain. Acad Emerg Med 8: 1153–1157, 2001.
3. Brancaccio P, Maffulli N, Limongelli FM. Creatine kinase monitoring in sport medicine. Br Med Bull 81–82: 209–230, 2007.
4. Brockett CL, Morgan DL, Proske U. Human hamstring muscles adapt to eccentric exercise by changing optimum length. Med Sci Sports Exerc 33: 783–790, 2001.
5. Burgess TL, Lambert MI. Efficacy of cryotherapy on recovery after muscle damage training. Int Sport Med J 11: 258–277, 2010.
6. Cameron MH. Physical Agents in Rehabilitation. Philadelphia, PA: W.B. Saunders Company, 1999. pp. 139–140.
7. Ciolek JJ. Cryotherapy: Review of physiological effects and clinical application. Cleve Clin Q 52: 193–201, 1985.
8. Denegar CR, Perrin DH. Effect of transcutaneous electrical nerve stimulation, cold, and a combination treatment on pain, decreased range of motion, and strength loss associated with delayed onset muscle soreness. J Athl Train 27: 200–206, 1992.
9. Dukes AC, Ronto WL. Effects of recovery massage on delayed onset muscle soreness and physiological parameters of muscle damage. Master’s thesis, Andrews University, Berrien Springs, MI, 1995.
10. Dunn OJ. Multiple comparison among means. J Am Stat Assoc 56: 54–64, 1961.
11. Eston R, Peters D. Effects of cold water immersion on the symptoms of exercise-induced muscle damage. J Sports Sci 17: 231–238, 1999.
12. Gajdosik R, Lusin G. Hamstring muscle tightness. Reliability of an active-knee-extension test. Phys Ther 63: 1089–1090, 1983.
13. Goodall S, Howatson G. The effects of multiple cold water immersion on indices of muscle damage. J Sports Sci Med 7: 235–241, 2008.
14. Gulick DT, Kimura IF, Sitler M, Paolone A, Kelly J IV. Various treatment techniques on signs and symptoms of delayed onset muscle soreness. J Athl Train 31: 145–152, 1996.
15. Howatson G, Gaze D, van Someren KA. The efficacy of ice massage in the treatment of exercise-induced muscle damage. Scand J Med Sci Sports 15: 415–422, 2005.
16. Howatson G, Goodall S, van Someren KA. The influence of cold water immersions on adaptation following a single bout of damaging exercise. Eur J Appl Physiol 105: 615–621, 2009.
17. Howatson G, van Someren KA. Ice massage: Effects on exercise-induced muscle damage. J Sports Med Phys Fitness 43: 500–505, 2003.
18. Howatson G, van Someren KA. The prevention and treatment of exercise-induced muscle damage. Sports Med 38: 483–503, 2008.
19. Howatson G, van Someren K, Hortobagyi T. Repeated bout effect after maximal eccentric exercise. Int J Sports Med 28: 557–563, 2007.
20. Hubbard TJ, Aronson SL, Denegar CR. Does cryotherapy hasten return to participation? A systematic review. J Athl Train 39: 88–94, 2004.
21. Isabell WK, Durrant E, Myrer W, Anderson S. The effects of ice massage, ice massage with exercise, and exercise on the prevention and treatment of delayed onset muscle soreness. J Athl Train 27: 208–217, 1992.
22. Knight KL. Cryotherapy: Theory, Technique and Physiology. (1st ed.). Chattanooga, TN: Chattanooga Corporation, 1985. pp. 17–22.
23. Lee J, Goldfarb AH, Rescino MH, Hegde S, Patrick S, Apperson K. Eccentric exercise effect on blood oxidative-stress markers and delayed onset of muscle soreness. Med Sci Sports Exerc 34: 443–448, 2002.
24. Lippi G, Schena F, Salvagno GL, Montagnana M, Gelati M, Tarperi C, Banfi G, Guidi GC. Acute variation of biochemical markers of muscle damage following a 21-km, half-marathon run. Scand J Clin Lab Invest 68: 667–672, 2008.
25. MacIntyre DL, Reid WD, Lyster DM, McKenzie DC. Different effects of strenuous exercise on the accumulation of neutrophils in muscle in men and women. J Appl Physiol 81: 47–53, 2000.
26. MacIntyre DL, Reid WD, Lyster DM, Szasz IJ, McKenzie DC. Presence of WBC, decreased strength, and delayed soreness in muscle after eccentric exercise. J Appl Phys 80: 1006–1013, 1996.
27. MacIntyre DL, Reid WD, McKenzie DC. Delayed muscle soreness. The inflammatory response to muscle injury and its clinical implications. Sports Med 20: 24–40, 1995.
28. MacIntyre DL, Sorichter S, Mair J, Berg A, McKenzie DC. Markers of inflammation and myofibrillar proteins following eccentric exercise in humans. Eur J Appl Physiol 84: 180–186, 2001.
29. Nemet D, Meckel Y, Bar-Sela S, Zaldivar F, Cooper DM, Eliakim A. Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: A prospective comparative trial. Eur J Appl Physiol 107: 411–417, 2009.
30. Paddon-Jones D, Muthalib M, Jenkins D. The effects of a repeated bout of eccentric exercise on indices of muscle damage and delayed onset muscle soreness. J Sci Med Sport 3: 35–43, 2000.
31. Panteghini M. Aspartate aminotransferase isoenzymes. Clin Biochem 23: 311–319, 1990.
32. Pyne DB. Exercise-induced muscle damage and inflammation: A review. Aust J Sci Med Sport 26: 49–58, 1994.
33. Sellwood KL, Brukner P, Williams D, Nicol A, Hinman R. Ice-water immersion and delayed-onset muscle soreness: A randomized controlled trial. Br J Sports Med 41: 392–397, 2007.
34. Shelley CR, Paulus LM, Baker R, Millar AL. Concentric isokinetics test-retest reliability and testing interval. Isokinet Exerc Sci 3: 44–49, 1993.
35. Skurvydas A, Sipaviciene S, Krutulyte G, Gailiuniene A, Stasiulis A, Mamkus G, Stanislovaitis A. Cooling leg muscles affects dynamics of indirect indicators of skeletal muscle damage. J Back Musculoskelet Rehabil 19: 141–151, 2006.
36. Smith LL, Keating MN, Holbert D, Spratt DJ, McCammon MR, Smith SS, Israel RG. The effects of athletic massage on delayed onset muscle soreness, creatine kinase, and neutrophil count: A preliminary report. J Orthop Sports Phys Ther 19: 93–99, 1994.
37. Warren GL, Lowe DA, Armstrong RB. Measurement tools used in the study of eccentric contraction-induced injury. Sports Med 27: 43–59, 1999.
38. Williamson A, Hoggart B. Pain: A review of three commonly used pain rating scales. J Clin Nurs 14: 798–804, 2005.
39. Yackzan L, Adams C, Francis KT. The effects of ice massage on delayed muscle soreness. Am J Sports Med 12: 159–165, 1984.
40. Yangisawa O, Miyanga Y, Shiraki H, Shimojo H, Mukai N, Niitsu M, Itai Y. The effects of various therapeutic measures on shoulder strength and muscle soreness after baseball pitching. J Sports Med Phys Fitness 43: 189–210, 2003.
Keywords:

cryotherapy; exercise-induced muscle damage; eccentric exercise

Copyright © 2013 by the National Strength & Conditioning Association.