Cryotherapy applied to a joint may not necessarily have the same effects on balance and physical performance that have been demonstrated in applications involving muscle.
By Emily E. Williams, ATC, and Giampietro L. Vairo, PhD, ATC
Cryotherapy is a commonly used modality in sports medicine and rehabilitation. A typical clinical aim is to elicit an analgesic response in patients suffering from acute or persistent pain associated with musculoskeletal injury.1 This is achieved by decreasing nociceptor afferent nerve conduction velocity, which is proposed to be correlated with depth of cold penetration.2 Furthermore, cryotherapy depresses the excitability of free nerve endings and peripheral nerve fibers,1,3 which raises an individual’s pain threshold and contributes to analgesia.4 This response is augmented by mitigation of the muscle spasms that amplify pain; this mitigation occurs by diminishing the sensitivity of the muscle spindles that detect static tension load and the rate of tension change within the muscle.1,5
Studies suggest cryotherapeutic agents can reach tissues at a depth of approximately 1 to 3 inches5 and that their analgesic effect can be expedited or heightened by the common practice of applying concomitant compression with an elastic bandage or plastic wrap (Figure 1).5-7 However, current evidence suggests the depth of penetration, which is dependent on the type of cold modality used, varies from 1 to 3 cm;8-10 overlying adipose and related tissue composition and thickness factors may also contribute (Figure 2).10,11
Cryotherapy and proprioception
The physiological mechanisms that underpin cryotherapeutic analgesia are also associated with potential decreases in proprioception and neuromuscular control.4,12-14 Although many studies, mostly focused on the ankle, have examined such outcomes, the differences in experimental design and methods present challenges in producing consistent findings, drawing comparisons between studies, and thus determining a consensus to guide clinical practice effectively. An appraisal of the recent related literature revealed that cold water immersion of the foot and ankle complex yields the greatest decreases in skin temperature and sensory nerve conduction velocity and increase in motor nerve conduction velocity compared with an ice bag and ice massage (Figure 3).5,8 Hopper et al15 subsequently reported a decrease in ankle joint proprioception after cold water immersion; conversely, LaRiviere et al16 observed no such finding in a similar investigation.
Hopkins et al17,18 reported increases in neuromuscular activity after cooling the ankle joint, a finding the authors suggested may have resulted from altered afferent input from the skin and joint receptors that would influence supraspinal drive.19 This particular observed response may represent a unique protective mechanism to maintain joint stability, involving inhibition of proprioceptive influences by the Golgi tendon organs, a process that increases neuromuscular demand as necessary to preserve motor control and safeguard the joint.17-20
Although studies of joints other than the ankle are less common, some have demonstrated stimulating findings. Uchio et al,21 for example, reported a decrease in knee proprioception after the use of a cooling pad on the knee for 15 minutes, while Wassinger et al13 observed decreases in active joint position replication, path of motion replication, and throwing accuracy at the shoulder after a 20-minute ice bag application.
Balance and physical performance
Potential negative implications for proprioception and neuromuscular control subsequent to cryotherapy may adversely affect physical performance4,12-14 and increase susceptibility to injury;2 however, contradictory evidence makes it a challenge to interpret the clinical relevance of research findings.
Balance is a clinical measure commonly used to gauge neuromuscular control, a component of physical performance capacity, and a predictor of lower extremity injury.14 The effect of cryotherapy on balance is currently unclear. Various authors22,23 have reported that static balance, measured by center of pressure (COP) excursions, is negatively affected following cryotherapy, while others do not confirm such accounts. For instance, Kernozek et al23 found that decreased static balance following lateral ankle sprain was further diminished after cold water immersion. The authors suggested the modality-skin interface and depth of cold penetration increased the area of anatomy being affected by afferent and efferent pathway impairments. In contrast, however, Rubley et al24 reported no negative effects on static balance after cold water immersion of the ankle in healthy participants. Moreover, Miniello et al25 observed no decreases in dynamic balance during a jump landing subsequent to cold water immersion of the ankle in healthy women. Similarly, Williams et al2 noted an absence of static and dynamic balance deficits, respectively measured by COP excursions and a balance reach task, after an ice bag application to the circumference of the ankle, both with and without concomitant compression, in young healthy participants. The conflicting results could also be attributed to the differing modalities of choice in the previous studies.
Although various clinical balance measures can be useful to gauge proprioception and neuromuscular control aptitude indirectly, task-specific testing offers a more discrete mode of measuring physical performance capacity. The single-leg vertical hop test for height represents such a reliable measure and has been described as closely simulating the functional demands required and experienced during sports.26 Some studies have reported decreases in single-leg vertical hop for height performance after application of cryotherapy to the ankle in the forms of cold water immersion and an ice bag;5,12 researchers have suggested these decreases result from decreased muscle spindle activity in the triceps surae and impaired nerve conduction velocity.5,26 However, Williams et al2 noted a lack of single-leg vertical hop for height deficit following ice bag application to the ankle both with and without concomitant compression. Similarly, other studies demonstrated no significant decreases in functional performance on a variety of measures, including the single-leg and double-leg
vertical hop, 6-m hop, and shuttle run.15,26,27
Evans et al28 measured physical performance during execution of additional task-specific tests (shuttle run, carioca drill, and single-leg 6-m hop) and found no related decrements after lower leg cold water immersion. In a similar study, Fischer et al29 examined physical performance using the shuttle run and a semicircle cocontraction test and the single-leg vertical hop for height following ice bag application to the hamstring muscles. Unlike Evans et al,28 they reported that cold therapy was associated with decreases in shuttle run and cocontraction test outcomes; they also found cold was associated with a deficit in single-leg vertical hop for height, a finding that differs from the aforementioned results of Williams et al.2 The conflicting results of the three previously mentioned studies could potentially have resulted from the cold modality of choice, ie, cold water immersion versus ice bag application.2,28,29
Joint vs muscle
To an extent these contrasting outcomes may also be potentially explained by the differences between cryotherapy applied to a joint and cryotherapy applied to a muscle.2 Cryotherapy applied to a joint has not been definitively associated with modifications to joint position sense that may potentially yield proprioceptive insufficiencies;13,30 by contrast, applying cryotherapy to muscle has been shown to hinder muscle spindle sensitivity, synthesis of adenosine triphosphate production, and calcium release,12 all of which potentially contribute to muscle inhibition.17,18 In turn, muscle inhibition, contributes to balance and physical performance deficits. Similarly, modification of muscle spindle proprioceptive attributes has been the theoretical basis for the acute physical performance deficits that have been observed following exposure to a session of stretching.31
Conversely, Hopkins et al18 found that cryotherapy at the ankle joint heightened adjacent muscle activity and reflex amplitude, which facilitated greater force production at the ankle complex. Furthermore, cryotherapy appears to increase musculoarticular stiffness,32 which has been associated with heightened muscular performance at a joint.20 These biophysical mechanisms potentially provide insight and a foundation for the different responses elicited between cryotherapy applied to a joint versus a muscle.
In studies5,29 exploring cryotherapy applied to muscle tissue, further physical performance decrements were found with concomitant application of compression compared with no compression; however, Williams et al2 noted no such phenomenon at the ankle joint in a similar investigation. These opposing findings may also relate to the dissimilar outcomes produced by icing a joint versus a muscle. Depth of cold penetration is dependent on the structural and material characteristics of the tissues being treated, such as thickness, density, water content, and overlying adiposity.10 The tissues surrounding articular structures, such as the ankle joint, tend not to be as dense and thick as those associated with muscles like the hamstrings, especially at the midbelly; concomitant compression in these thicker denser muscle tissues may be more likely to amplify the biophysical alterations associated with cryotherapy.
In conclusion, cryotherapy is a physical medicine and rehabilitation therapeutic agent commonly used by different clinicians in a variety of practical settings. The targeted therapeutic effect of this modality, an analgesic response, occurs as the result of afferent sensory information being relayed more slowly to the central nervous system. Although such a biophysical mechanism may raise concerns about potential detrimental effects on proprioception and neuromuscular control, evidence suggests such outcomes may be dependent on injury status as well as the specific structure or tissue being treated. Regarding the latter, cryotherapy applied to a joint, regardless of whether concomitant compression is used, may not necessarily result in the type of balance and physical performance deficits that have been demonstrated in applications involving muscle. This suggests that practices such as cryotherapy before physical activity may potentially be used without diminishing performance capacity or heightening susceptibility to injury in healthy individuals; however, this may not be true with applications to muscles, in which cryotherapy has been shown to elicit proprioception and neuromuscular control impairments that are increased with the use of concomitant compression. This hypothesis requires thorough study and may not currently pertain to populations suffering from neuromusculoskeletal injury or dysfunction.
Although the literature provides some insight, there are many factors that limit our comprehension of phenomena related to cryotherapy and, thus, any clinical implications. For example, most of the evidence to date has been based on healthy cohorts, immediate rather than delayed effects, and has not explored discrepancies between the sexes or between dominant and nondominant limbs. Therefore, continued study on the influence of such factors is necessary to reach a definitive determination of the effects of cryotherapy on associated biophysical mechanisms and physical performance capacity. This is the type of sound information practitioners will need to guide clinical critical decision-making.
Emily E. Williams, ATC, is a licensed athletic trainer who practices part time in southeastern Virginia, and is currently pursuing her doctor of physical therapy degree at Old Dominion University in Norfolk, VA. Giampietro Vairo, ATC, PhD, is the clinical education coordinator for the athletic training major and codirector of the Sports Medicine Clinical Research Agenda among the departments of kinesiology, orthopaedics & rehabilitation, and intercollegiate athletics at The Pennsylvania State University in State College.
Acknowledgments: We would like to thank Sayers John Miller III, PhD, in the Department of Kinesiology at The Pennsylvania State University in State College, and Wayne Sebastianelli, MD, at Penn State Hershey Bone and Joint Institute in State College for their intellectual contributions and support.
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