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Patterson, C.W. and Hewat, R. (2009)

CRYOTHERAPY AS A PREVENTATIVE METHOD FOR DELAYED ONSET MUSCLE SORENESS

Delayed onset muscle soreness (DOMS) is an injury occurrence that affects a wide population, regardless of age, gender or athletic ability. DOMS is characterised by the individual suffering pain, muscle swelling, and a reduction in both range of motion and muscular strength that occurs 2-4 days post intensive exercise which can take up to 7 days to recover from. A range of treatments have been used to alleviate the symptoms of DOMS and their impact on athletes including warm-ups, cool downs, stretching and massaging, as well as anti-inflammatory drugs. Using 8 healthy university student volunteers (4 males; 4 females), this study aimed to investigate the use of a post-exercise cryotherapy treatment on the effect of DOMS in the bicep. The findings showed only one significant difference between treated and untreated limbs during the duration of the study, that of the upper arm girth with a fully relaxes bicep muscle, 72 hours after the DOMS inducement protocol. The study found that there were differences in the arm girths and muscle strengths at various points during the 72-hour testing period, indicating that DOMS or a DOMS-like response was generated in the bicep. The results would indicate that while cryotherapy is an appropriate and successful tool in the management and prevention of sports injuries, it has little effect on these components when combined in the manner as seen in DOMS.

Delayed onset muscle soreness (DOMS) is defined as muscular pain felt between 24 and 72 hours post exercise, usually an intense exercise session with high resistance eccentric exercises (Ernst, 1998; Connolly et al., 2003; Hilbert et al., 2003; Maes & Kravitz, 2004; Sellwood et al., 2007). DOMS is further characterised by muscular swelling which when combined with the pain causes a reduced in a joint’s range of motion (RoM) which can take between 5 and 7 days post exercise to return to their normal levels (Ernst, 1998; Eston & Peters, 1999; Connolly et al., 2003; Hilbert et al., Maes & Kravitz, 2004). McArdle et al. (2006) lists a range of potential causes for DOMS, including muscle spasms and minute tears of the muscles’ contractile components. The most prominent theory to the cause of DOMS is through exposing muscles to a force exceeding what the muscles are comfortably able to endure (Maes & Kravitz, 2004). The chances of suffering from DOMS are increased when an individual has been absent from training, the intensity of the training is of a greater increment than the body can handle, and/or when there is a large eccentric exercise component (Clerk & Eston, 1992; Sellwood et al., 2007).

With the potential for DOMS to occur within a 72-hour period and have a negative influence on an individual’s training, Connolly et al. (2003) has provided a comprehensive review of treatment and prevention methods commonly used for DOMS. Post-exercise massage is a component of many an athlete’s cool-down and recovery procedure and as such has been investigated in relation to preventing DOMS from occurring. Ernst (1998), admitting their methodological flaws, stated that massage, hypothetically, may have an effect on reducing if not preventing DOMS. In a follow-up study removing the highlighted methodological flaws of Ernst (1998), Hilbert et al. (2003) tested the use of a single post exercise 20-minute massage on the suffering of DOMS. Throughout the 48-hour study period, both muscle strength and RoM measures showed no significant difference between the massage and control controls, a trend which was continued for the majority of pain and discomfort measures (Hilbert et al., 2003). In terms of soreness and pain, by the 48th hour post-DOMS inducement, the massage group has less reported pain perception than the control group by only the intensity of perceived soreness after 48 hours was a significant difference between the two population sample groups. Some studies have combined the post-exercise massage treatment with other treatments, such as warm-ups and stretching (Rodenburg et al., 1994) or the variations of massage treatments, such as underwater water-jet massage (Viitasalo et al., 1995) or ice massage (Yackzan et al., 1984). Rodenburg et al. (1994) and Viitasalo et al. (1995) found positive results of their respective treatments although they did indicate some potential issues that mean the results are yet to be conclusive due to the lack of evidence from controlled studies.

Aside from therapeutic treatments, one of the most researched DOMS treatment or proposed preventative methods is the use of nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, flurbiprofen, aspirin, and naproxen (Connolly et al., 2003; Maes & Kravitz, 2006). While some studies saw that the NSAIDs have had an effect in alleviating DOMS symptoms, others have shown that these drugs are ineffective in alleviating the symptoms of DOMS (Connolly et al., 2003; Maes & Kravitz, 2006). Connolly et al. (2003) highlights that within the range of studies investigating DOMS and NSAIDs, there is a difference present in doses, the timing of treatments in relation to DOMS inducement, and NSAID type as being responsible for the varied findings. Unfortunately, Maes & Kravitz (2004) also notes the associated negative side effects of NSAID treatments, namely gastrointestinal distress and hypertensive effects which question the appropriateness of using NSAIDs as a DOMS treatment. An alternative to the NSAIDs is using nutritional supplementation, although this approach indicates the clear inconsistency of DOMS treatments without a conclusive result being stated (Connolly et al., 2003). The theory is that anti-oxidant rich supplements, those which include vitamins C and E in vast amounts, reduce the free radical production associated with the inflammatory response. Additional supplementary studies have investigated the use of coenzyme-Q and L-carnitine which has been identified of a potential cause of increasing the magnitude of the DOMS symptoms suffered by the athlete. The issue with this approach is that it requires forward planning as it utilises a gradual build-up in eccentric exercises over a six-week period and therefore negates the causes of DOMS as suggested by Cleak & Eston (1992) and Sellwood et al. (2007). It seems that no matter what treatment method is attempted, there is no consensus to the most effective, if not fully conclusive, method for DOMS treatment or prevention.

Cryotherapy treatments are extensively used as a part of a post exercise regimen to reduce the after effects of exercise, especially in the professional sporting environment. These treatments submerge either the whole body, an individual limb, or a limb segment in a combination of ice and cold water to quickly cool the exercised muscle (Connolly et al., 2003; Yanagisawa et al., 2003; Penailillo et al., 2006; Bailey et al., 2007; Sellwood et al., 2007). The cooling of the site causes vasoconstriction that limits the flow of blood to the cooled site which causes less fluid build-up in the muscles that ultimately reduces the swelling at the site (Connolly et al., 2003; Sellwood et al., 2007). The additional benefits of the reduced blood flow include a reduction in any bruising that may occur, due to less blood being lost at the location of the hematoma, and a decrease in the biochemical components of muscle injury (Connolly et al., 2003; Bailey et al., 2007; Sellwood et al., 2007). It should be noted that in the majority of these studies, a common methodology employed is to assign cryotherapy treatment to half the participants which means that individual differences, such as anthropometric differences or training experiences, may also influence the stated results. No study yet, to the authors knowledge, has induced DOMS in a population and only provided a cryotherapy treatment to one of the limbs where it was induced thus eliminating the influential differences from between-participant methodological approaches. By using the alternative method of comparing a treated limb to an untreated limb, the aim of the study was to evaluate the use of a single post-exercise cryotherapy treatment as a method for preventing the onset of DOMS.

Eight university students (4 males; 4 females; age = 21.25 ± 0.7 years old; height = 1.70 ± 0.11m; mass = 69.5 ± 16.03kg) volunteered to participate in this study. All participants reported in good healthy with no current injuries and were given an familiarisation session where the completion of which without pain or injury was required for continued participation in the study. Throughout the study, participants were asked not to participate in other studies or training that could have an impact on the study’s findings. The study was granted ethical clearance by an independent ethics board at Edinburgh Napier University, which acted as a venue for the study. The inducement of DOMS took place in the university’s weights room, located directly across the hall from the physiology laboratory where the cryotherapy treatment and performance tests were conducted.

The familiarisation session consisted of two stages, firstly the collection of baseline measures for muscle girths, elbow flexion RoM, and peak torques measured during the elbow flexion-extension motions. Muscle girths were measured at three locations along the upper arm, notated as the insertion point, the origin point, and the muscle belly (Figure 1). These points were approximate locations of the muscle-tendon junction, the origin being immediately distal to the anterior deltoid and the insertion immediately proximal to the olecranon process of the ulna, with recordings made with the arm abducted to 90° and the elbow fully extended. The muscle belly measurement was recorded with the muscles relaxed and contracted by measuring the girth with the elbow flexed and fully extended (Figure 1). These positions for the girth measurements was marked with a permanent marker pen, which was reapplied if necessary over the following days, to ensure the same location was measured each time.

Figure 1. Locations of where the origin point (green), the insertion point (blue) and the muscle belly (purple) were measured at with the elbow flexed and extended

Elbow RoM was determined as the difference between the maximal flexion and extension angles recorded using an isokinetic dynamometer (Cybex HUMAC NORM Testing and Rehabilitation System; Cybex International Inc.; New York, USA)1, the same device that was used throughout the study for calculating generated torques from the bicep curls (Figure 2). The participants performed a single set of five individual bicep curls at a rate of 60° per second (Isabell et al., 1992), which was then repeated on the other arm with the order determined by a randomised draw. The baseline tests were then repeated immediately after DOMS-inducement, immediately after the cryotherapy treatment was performed and then again after 24 hours, 48 hours, and 72 hours after DOMS-inducement. The second stage of the familiarisation session was to familiarise the participant with the method for DOMS inducement, which would occur 5 days following the familiarisation session, using a series of bicep curls with incrementally increasing weights attached to the barbell until the participant’s maximal lifted weight for a single rep was identified (1RM).

Figure 2. Definitions of full flexion and extension angles (left) for bicep curls using the isokinetic dynamometer set-up (right). Taken from CSMi Solutions website (http://www.csmisolutions.com/products/isokinetic-extremity-systems/humac-norm/patterns-gallery)

The DOMS-inducement protocol consisted of three sets of ten slow repetitions of the eccentric phase of the bicep curl, with each repetition lasting no longer than 5 seconds as measured by a metronome (Ciccone et al., 1991) and using a weight equivalent to the participants 1RM. Between each set a rest period of 1 minute was used while two members of the research team moved the barbell back to the eccentric phases’ starting position between repetitions so that the desired motion was isolated from the bicep curl. The inducement protocol was immediately followed by the same series of measures performed in the baseline tests during the familiarisation session, which was then followed by the initial cryotherapy treatment.

The cryotherapy treatment protocol was applied to one arm of the participant only, the choice of arm for the treatment was determined using a random draw such that four participants had their preferred limb treated and the other four had their non-preferred limb treated. The participants were required to submerge their selected arm into a container filled with ice and water at a temperature of between -0.5°C and 1°C, as monitored through an infrared thermometer (Testo 830-T1; Testo Ltd.; Chicago, USA), for a total period of 15 minutes. To avoid frostbite or hypothermia from submerging the limb in the ice-cooled water, the 15 minutes were broken down into 5 repetitions of 3 minutes of submersion with a 30 second rest period in between each submersion, during which the participant was asked to move their fingers and clench and unclench their fist to promote blood flow to the extremities. A set of muscle girth measurements were taken immediately after the cryotherapy treatment.

Figure 3. The eccentric phase of the bicep curl

The gathered data was collated in a Microsoft Excel spreadsheet (Microsoft Excel 2007; Microsoft Corporation; Redmund, WA, USA) before being imported in SPSS statistical software package (SPSS statistical software, Version 16.0.2.; SPSS Inc.; Chicago, USA) for processing and analysis. The data was analysed using a two-way ANOVA to identify whether any significant differences occurred between the test timing (between-day differences) and between the treated and untreated limb. Individual significant differences were identified through use of paired samples t-tests with a 95% confidence level thus meaning any p-value ≤0.05 being identified as a significant difference.

There was no clear trend for muscle girths, with the traces increasing and decreasing at different times during the 72-hour period (Figure 1). Only the relaxed muscle belly girth showed a significant difference between treatment limbs with this difference identified 72-hours post DOMS-inducement (Table 1). A variety of between-day differences were identified for the muscle girths at the flexed muscle belly and bicep insertion points (Table 1). The peak torque traces were the only ones which showed a distinct trend, where the torques decreased post-inducement before incrementally increasing over the following 72-hours (Figure 2). There was no significant differences found between the treatment and non-treatment limbs however some of the between-day differences showed a significant difference for both the treatment and non-treatment limbs (Table 1). Although insignificant, elbow RoM showed a difference in their traces between the two limbs.

Figure 4. Muscle girth measures over the 72-hour period

Figure 5. Elbow range of motion and peak torques over the 72-hour period

Table 1. Significant differences between treatment limbs, and between data collection sessions

The aim of the study was to investigate whether the use of a single post-exercise cryotherapy treatment could prevent the onset of DOMS. The findings of the study over the 72-hour period would indicate that DOMS was induced by the exercise protocol used in the study and while showing some changes in the between-day analysis, there was only a single result stating a significant difference between the treated and untreated limbs. The results would indicate that the single post exercise cryotherapy treatment is not an effect method for preventing DOMS but can, potentially, be used as a method for alleviating some of the symptoms suffered in DOMS.

Analysing the data from this study with the definitions previously stated in research, it can be stated that the participants in this current study did suffer from DOMS (Connolly et al., 2003; Howatson & van Someren, 2003; Sellwood et al., 2007; Howatson et al., 2009). The decrease in RoM and strength production 48 hours post the extensive and unaccustomed eccentric exercise are two of the identifying criteria of the onset of DOMS (Connolly et al., 2003; Howatson & van Someren, 2003; Sellwood et al., 2007; Howatson et al., 2009). The difference between the measured girths prior to and following the inducement protocol indicating the swelling that occurred in the muscle, one of the symptoms that is associated with DOMS (Connolly et al., 2003; Sellwood et al., 2007) with the muscle insertion point recording significant differences in both pain and swelling (Yanagisawa et al., 2003).

Similarly, to the findings of the Hilbert et al. (2003) study into post-exercise massage, this study’s findings indicate an appropriateness for using a post-exercise cryotherapy treatment in alleviating the initial injury potentials from high intensity exercise but having little impact on preventing the onset of DOMS. The post-exercise cryotherapy treatment had the expected affect that the treatment has previously elicited in research by preventing increased muscular pain and swelling, as well as joint stiffness between the pre-treatment and post-treatment tests (Paddon-Jones & Quigley, 1997; Bleakley et al., 2004; Hubbard & Denegar, 2004; Ingram et al., 2007). Paddon-Jones & Quigley (1997) and Ingram et al. (2007) identified that the cryotherapy treatment worked in limiting oedema formation by promoting vasoconstriction, thus lowering blood flow to the area, and decreasing the area’s metabolic rate. Meanwhile, Hubbard & Denegar (2004) and Bleakley et al. (2004) stated that the lowering of tissue temperature through cryotherapy stops the onset of muscle spams and limits the levels of endorphins released by the muscles thus resulting in a decrement of the perceived pain. Many papers are in similar agreement to this study in that cryotherapy has little, if any, effect in eradicating DOMS following an intense bout of exercise (Cleak & Eston, 1992; Eston & Peters, 1999; Cheung et al., 2003; Yanagisawa et al., 2003; Sellwood et al., 2007) though none have been able to comprehensively state a reason behind this agreement.

DOMS shares similar symptoms as muscle damage, for which cryotherapy is a common treatment during the initial inflammation phases (24- to 48-hour period within a potential 6-day post-injury period), however the cryotherapy treatment is continued beyond a single treatment session. Given that the symptoms of DOMS tend to peak at various points in the 72-hour period following the cessation of eccentric exercises. Additionally, Ingram et al. (2007) states that swelling increases to its peak on the fourth day after the exercise which makes the idea that the use of a single post-exercise cryotherapy is going to be unable to prevent DOMS from occurring. In Lehman’s terms, the immediate application of cryotherapy only misses the crucial time period for treating DOMS symptoms and may only have the effect of delaying DOMS occurrence, if it has any effect at all (Penailillo et al., 2006; Bailey et al., 2007). Cheung et al. (2003) summarises that in terms of DOMS, the application of cryotherapy is only relevant for reducing the related swelling symptoms without affecting loss of function and reduced DOMS. On a similar line of thought, Bailey et al. (2007) identifies that cryotherapy as a method that is more beneficial for its analgesic properties than its ability in inhibiting muscle damage due to its inability to remove exercise-induced by-products associated with pain and muscle damage.

In conclusion, the use of a post-exercise cryotherapy treatment can be used to alleviate the initial symptoms of muscle damage but has a minimal influence on DOMS. One potential reason is that DOMS symptoms can occur within a 72-hour period after extensive exercise therefore an initial, immediate post-exercise cryotherapy session may only delay the onset of DOMS but not the magnitude of the symptoms the athlete suffers from. Therefore, should cryotherapy be used to alleviate DOMS then it could be suggested that additional cryotherapy sessions over the 24- to 72- hour period in which DOMS symptoms occur. Although, this suggestion requires further research to prove its effectiveness and until then it would be more reasonable to utilise other suggestion preventative measures in conjunction with cryotherapy.

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The authors would like to thank the other members of the cryotherapy application research group (Jemma Oswald, Emma Fairley, Amy Wicks, Kathryn Wilkie, Peter Jackson, Stanislaw Krzyzaniak, and Russell Wilson) for their assistance during the study’s data collection and analysis phases. The gratitude of the whole research group is expressed to the Sports and Exercise Science department of Edinburgh Napier University, namely Dr Susan Gray and Brendon Ferrier, for their support and advice throughout the study. Finally, the authors would like to thank the participants for volunteering their time for the study to occur.