Physical Therapy in Sport 15 (2014) 228e233

Contents lists available at ScienceDirect

Physical Therapy in Sport

journal homepage: www.elsevier.com/ptsp

Original research

Cold water immersion in the management of delayed-onset muscle

soreness: Is dose important? A randomised controlled trialq
Philip D. Glasgow a, Roisin Ferris b, Chris M. Bleakley b, *
a
Sports Institute Northern Ireland, University of Ulster, Jordanstown, Newtownabbey, Co. Antrim BT37 0QB, United Kingdom
b
Ulster Sports Academy, University of Ulster, Jordanstown, Newtownabbey, Co. Antrim BT37 0QB, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Background: Cold Water Immersion (CWI) is commonly used to manage delayed onset muscle soreness
Received 4 April 2013 (DOMS) resulting from exercise. Scientific evidence for an optimal dose of CWI is lacking and athletes
Received in revised form continue to use a range of a treatment protocols and water temperatures.
23 October 2013
Objectives: To compare the effectiveness of four different water immersion protocols and a passive
Accepted 16 January 2014
control intervention in the management of DOMS.
Design: Randomised controlled trial with blinded outcome assessment.
Keywords:
Setting: University Research Laboratory.
Eccentric exercise
Ice bath
Participants: 50 healthy participants with laboratory induced DOMS randomised to one of five groups:
Muscle soreness Short contrast immersion (1 min 38
C/1 min 10
C  3), Short intermittent CWI (1 min  3 at 10
C);
10 min CWI in 10
C; 10 min CWI in 6
C; or control (seated rest).
Main outcome measures: muscle soreness, active range of motion, pain on stretch, muscle strength and
serum creatine kinase.
Results: 10 min of CWI in 6
C was associated with the lowest levels of muscle soreness and pain on
stretch however values were not statistically different to any of the other groups. There were no sta-
tistically significant differences between groups for any other outcomes.
Conclusion: Altering the treatment duration, water temperature or dosage of post exercise water im-
mersion had minimal effect on outcomes relating to DOMS.
Ó 2014 Elsevier Ltd. All rights reserved.

1. Introduction resolution of symptoms within 5e7 days) experimentally induced

Muscular pain commonly results after unaccustomed or eccen-
tric exercise and is commonly described as delayed onset muscle
soreness (DOMS) (Armstrong, 1990). Symptoms include a reduction
in the ability of the muscle to generate force, decreased range of
motion (Clarkson & Sayers, 1999), and pain that is exacerbated by
movement (Newham, 1988). DOMS is often cited by athletes and
coaches as being detrimental to recovery and performance.
Although the physiological mechanism underpinning DOMS has not
been fully elucidated, it may relate to primary mechanical damage
that occurs to muscle cells during exercise (Proske & Morgan, 2001)
and a marked but transient inflammatory response (Chatzinikolaou
et al., 2010). Due to its transitory nature (peak soreness 24e72 h and
q Research conducted at Ulster Sports Academy, University of Ulster.
* Corresponding author. Room 15E01, Ulster Sports Academy, University of Ulster,
Jordanstown Campus, BT370QB, United Kingdom. Tel.: þ44 (0) 2890366025.
E-mail addresses: c.bleakley@ulster.ac.uk, chrisbleakley@hotmail.com (C.
M. Bleakley).
DOMS has been used as a model of myogenic pain to investigate the
effects of various therapeutic modalities.
Over the past decade, cold water immersion (CWI) has become
one of the most popular strategies to manage or prevent DOMS.
Immediately after exercise, athletes will immerse themselves in
water baths which may vary from temperature controlled spas to
large containers filled with water. Contrast Water Therapy (CWT),
alternating cold and warm water immersion, is also often offered to
athletes as an alternative to cryotherapy and is commonly used
within the sporting community. Clear physiological evidence to
support these practices has not yet been fully elucidated (Bieuzen,
Bleakley, & Costello, 2013; Bleakley, Glasgow, & Webb, 2012;
Bleakley, McDonough, Gardner, Baxter, Hopkins, & Davison, 2012).
In practice there are large variations in the CWI protocols
employed, particularly in terms of the duration of immersion and
water temperature (Bieuzen et al., 2013; Bleakley, Glasgow, et al.,
2012; Bleakley, McDonough, et al., 2012).
One proposed mechanism is that CWI induces a pumping effect
on the vasculature which stimulates blood flow, nutrient and waste

1466-853X/$ e see front matter Ó 2014 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ptsp.2014.01.002
 P.D. Glasgow et al. / Physical Therapy in Sport 15 (2014) 228e233
transportation through the body (Wilcock, Cronin, & Hing, 2006).
This is thought to be achieved using short CWI’s repeated on either a
single day (Sellwood, Brukner, Williams, Nicol, & Hinman, 2007), over
a period of consecutive days (Eston & Peters, 1999; Yanagisawa,
Niitsu, Yoshioka, Goto, Kudo, & Itai, 2003) or with brief alternate
immersions in cold and warm water (often referred to as Contrast
Immersion) (Wilcock et al., 2006). Others advocate longer, contin-
uous immersions in cold water (Banfi & Melegati, 2008; Vaile, Halson,
Gill, & Dawson, 2008); although this approach has traditionally been
reserved for reducing pain, swelling, metabolism and inflammation
associated with acute sprains and strains, it may have some rationale
post exercise, particularly in sports associated with physical contact,
soft tissue trauma and/or exercise induced muscle damage (EIMD).
A psychological mechanism may also be possible; this may be less
dependent on dose as the rationale is that CWI simply makes the
body feel more ‘awake’, leading to a reduced sensation of fatigue after
exercise (Cochrane, 2004; Wilcock et al., 2006).
Evidence from clinical trials on the effectiveness of CWI for
sports recovery remains equivocal. A recent Cochrane review
(Bleakley, McDonough, Gardner, Baxter, Hopkins, & Davison, 2012)
found some evidence that CWI is superior to passive intervention at
reducing muscle soreness (no intervention/rest) but found no
studies comparing different treatment dosages. Further definitive
conclusions were limited due to poor methodological quality
relating to inadequate randomisation, allocation concealment and
blinding of outcome assessor (Bleakley, Glasgow, et al., 2012;
Bleakley, McDonough, et al., 2012).
The purpose of this study was to provide high quality evidence
to inform post exercise recovery strategies using CWI. Continued
disparity in this area and vague guidelines for its use after sport
mean that athletes could risk employing more extreme tempera-
tures or longer immersion times, before determining actual benefit
or risk. Our primary objective was to compare the effectiveness of
four commonly used CWI strategies and a passive control, in the
management of DOMS using a randomised controlled design with
blinded outcome assessment.
2. Methods
2.1. Study design
This was a randomised controlled trial using a blinded outcome
assessor. There were 5 separate outcome variables (muscle sore-
ness, active range of motion, pain on stretch, muscle strength,
serum creatine kinase), with repeated measures over five time
points [Baseline (0 h) and then at 24 h, 48 h, 72 h, 96 h]. All research
was undertaken at the Ulster Sports Academy (University of Ulster)
between January and February 2011. Approval for this study was
granted by the University of Ulster Research Ethical Committee. All
participants signed a letter of informed consent and were advised
of their right to withdraw from the study at any time.
2.2. Participants
Healthy participants (age range: 18e35 years; height
1.79  0.06 m; body mass 81.9  17 kg) were recruited from the
student population at the University of Ulster (N ¼ 50; 32 male, 18
female). Participants were asked to refrain from commencing any
unaccustomed physical activity during the week of the study but
were advised to continue their normal levels of physical activity.
Participants were excluded from the study if any of the following
contraindications applied: Skin allergy, broken skin, open wounds,
abnormal or altered skin sensation, epilepsy, asthma, chlorine al-
lergy, cold allergy, Raynaud’s disease, peripheral vascular disease,
cryogobinaemia or under the influence of alcohol.
229
2.3. DOMS induction
At baseline (0 h), DOMS was induced to the non-dominant knee
flexors using a standing hamstring curl machine (Samson Equip-
ment, USA). Initially, the concentric one repetition maximum
(1 RM) was established and this weight was used during the in-
duction protocol. During testing, the weight was raised by an
experimenter to the starting position (90
knee flexion) and par-
ticipants lowered the weight eccentrically over 3 s (speed ¼ 30
degrees$s1) by following the researcher instructions (counting
‘3,2,1’ aloud). Participants undertook three sets of eccentric
hamstring contractions to fatigue (fatigue was defined as the point
at which the participant could no longer control the descent of the
weight), with 1 min rest between sets.
2.4. Sequence generation
We used a computer generated randomisation sequence to
randomise participants. Group allocation was printed on a card, and
placed in sequentially numbered opaque envelopes. After written
consent had been obtained and baseline assessment, participants
were randomised to one of the five groups from the numbered
envelopes (n ¼ 10 per group). Participants were not informed as to
which intervention was considered therapeutic throughout the
duration of the study.
1. Short contrast immersion: 1 min water immersion in 38
C
followed by 1 min CWI in 10
C (repeated 3 times)
2. Short intermittent CWI: 1 min CWI in 10
C followed by no
immersion for 1 min (repeated 3 times)
3. 10 min CWI in 10
C
4. 10 min CWI in 6
C
5. Control group: seated rest, no immersion
Participants attended on five consecutive days [Baseline (0 h), 24 h,
48 h, 72 h, 96 h], during which the intervention was applied on the first
three days. The first treatment was initiated within 5 min of the
completion of DOMS induction. Each water immersion was completed
using a CET cryotherapy spa (CET, Dromore, UK). Participants were
immersed up to waist level in a standing position. For each group, the
water temperature was thermostatically controlled at the relevant
level, and water jets were active for the entire period of immersion.
2.5. Measurements
Five outcome measurements were assessed. A single investi-
gator was responsible for all outcome assessments; they were
blinded to group allocation, and participants were advised not to
reveal their group allocation to them. Subjective muscle soreness
was the primary outcome with secondary outcomes of: Active
range of motion (AROM), Pain on stretch (POS), Concentric peak
torque (CPT) and Creatine Kinase (CK) level. The study was
completed over 5 consecutive days. All outcomes were measured at
baseline (0 h) and at 24 h, 48 h, 72 h, 96 h post exercise. Outcome
recording at baseline was undertaken prior to any DOMS induction
or treatment intervention. Outcome recording was consistently
completed over a 10 min period following a standardised order
(muscle soreness, AROM, POS, CPT, CK).
2.5.1. Muscle soreness
Participants were asked to rate the hamstring muscle soreness
felt during everyday activity. Pain was measured using a 10 cm
visual analogue scale (VAS) with terminal descriptors ‘no pain’ and
‘maximum pain.’ The distance from the ‘no pain’ descriptor was
230 P.D. Glasgow et al. / Physical Therapy in Sport 15 (2014) 228e233

Table 1
Muscle soreness, AKE ROM, Pain on Stretch, Peak Torque and CK.

Baseline (0 h) Follow up (hrs) Summary of within/between

subjects effects [F (df); P values]
24 h 48 h 72 h 96 h

Muscle soreness (10 cm VAS) Time: F (2.295,

Contrast WI 0.65 (1.53) 1.88 (1.42) 2.77 (1.83) 1.94(1.50) 0.99(1.16) 103.267)a ¼ 32.311; P ¼ 0.000
Intermittent CWI 10
C 0.11(0.26) 1.4(1.12) 2.95(1.71) 1.81(1.70) 0.82(1.17) Group*Time: F (9.179,
10 min at 10
C 0.21(0.35) 2(1.86) 3.4(3.19) 1.42(1.94) 1.01(1.49) 103.267)a ¼ 0.935; P ¼ 0.499
Control 0.3(0.95) 2.03(1.67) 3.39(2.41) 2.69(2.52) 1.22(1.24) Group: F (4, 45) ¼ 2.375;
10 min at 6
C 0(0) 0.39(0.75) 1.35(2.35) 0.34(0.71) 0(0) P ¼ 0.066
AKE ROM (degrees) Time: F (2.834,
Contrast WI 29.2(9.28) 32.3(14.94) 37.1(12.99) 29.1(14.12) 26.1(9.94) 127.571)a ¼ 11.696; P ¼ 0.000
Intermittent CWI 10
C 38.5(14.05) 39.5(11.25) 44.9(11.54) 37.6(11.35) 38.4(13.76) Group*Time: F (11.335,
10 min at 10
C 32.1(10.08) 35.7(11.95) 39.7(14.37) 35.9(11.88) 31.5(12.90) 127.517)a ¼ 0.521; P ¼ 0.890
Control 34.7(8.25) 37.6(10.99) 44.5(16.26) 40.7(15.10) 35.6(13.40) Group: F (4, 45) ¼ 0.966;
10 min at 6
C 30.1(11.10) 37.6(15.29) 39.6(18.47) 34.2(13.59) 33.5(13.59) P ¼ 0.435
Pain on Stretch (10 cm VAS) Time: F (2.738,
Contrast WI 3.05(2.49) 3.58(2.89) 4.6(2.56) 3.6(2.38) 2.36(1.92) 117.722)a ¼ 16.451; P ¼ 0.000
Intermittent CWI 10
C 2.35(1.75) 2.62(1.26) 3.81(1.34) 2.67(1.68) 1.63(1.25) Group*Time: F (10.951,
10 min at 10
C 2.77(2.57) 3.58(2.70) 4.43(2.97) 2.18(2.70) 1.85(2.30) 117.722)a ¼ 1.007; P ¼ 0.444
Control 2.04(2.36) 3.18(2.31) 5.25(2.40) 4.42(2.96) 2.72(2.74) Group: F (4, 45) ¼ 1.267;
10 min at 6
C 0.65(1.18) 1.8(2.32) 2.78(2.45) 1.79(2.55) 1.26(2.05) P ¼ 0.298
Hamstring Peak Torque (N) Time: F (4, 180) ¼ 9.563;
Contrast WI 297.40(72.20) 266.40(47.45) 279.50(80.57) 286.50(65.30) 318.50(79.34) P ¼ 0.000
Intermittent CWI 10
C 317.40(85.05) 293.50(92.33) 281.30(94.19) 292.60(81.40) 301.90(66.06) Group*Time: F (16,
10 min at 10
C 307.30(82.48) 276.10(69.13) 278.00(79.06) 287.70(77.70) 292.70(66.34) 180) ¼ 0.856; P ¼ 0.620
Control 326.70(68.67) 299.90(75.00) 266.60(94.18) 273.30(84.54) 312.40(76.26) Group: F (4, 45) ¼ 0.52;
10 min at 6
C 303.50(78.87) 263.10(74.90) 266.80(81.62) 286.00(93.79) 304.80(103.55) P ¼ 0.995
Creatine Kinase (U/L)b Time: F (1.511,
Contrast WI 255.90(163.67) 415.70(334.79) 1497.30(2237.69) 2652.80(3957.17) 1903.20(2461.20) 67.984)a ¼ 15.935; P ¼ 0.000
Intermittent CWI 10
C 690.18(1164.92) 587.09(1137.86) 959.90(1148.34) 2028.53(1944.10) 2612.90(2728.89) Group*Time: F (6.043,
10 min at 10
C 184.55(147.43) 204.42(89.06) 876.75(1212.98) 1436.85(2062.15) 2001.02(3375.97) 67.984)a ¼ 0.564; P ¼ 0.759
Control 268.07(366.63) 606.34(589.54) 1620.10(1658.09) 3716.90(4263.08) 3066.15(4067.33) Group: F (4, 45) ¼ 0.317;
10 min at 6
C 461.56(739.66) 459.67(619.35) 1741.44(3525.90) 2262.69(4757.84) 2002.02(3030.88) P ¼ 0.865

N ¼ 10 in each group at all follow ups.

Values are mean (SD).
b
Log transformation of data undertaken prior to analysis.
a
Degrees of freedom adjusted using GreenhouseeGeiser epsilon.

measured in centimetres and represented a pain score out of a
maximum of 10.
2.5.2. Active range of motion (AROM): knee extension
Participants were positioned supine with a stabilisation belt
around their pelvis to minimise compensatory movements. Par-
ticipants started the test with their test leg in 90 degrees of hip
flexion/90
knee flexion. Participants were asked to extend their
knee as far as possible and AROM at the knee joint was measured
using a universal goniometer.
2.5.3. Pain on stretch (POS)
Participants rated pain during the AROM test; again a 10 cm VAS
was used with terminal descriptors ‘no pain’ and ‘maximum pain’.
2.6. Statistical analysis
We used SPSS (version 19; SPSS Inc, Chicago, IL) to conduct the
analysis. Normal distribution and homogeneity of data were
assessed visually (histograms; QQ plot linearity) and statistically
using the ShapiroeWilk procedure. Changes in variables over time
(Baseline (0 h), 24 h, 48 h, 72 h, 96 h) were compared between
groups using a Repeated Measures Analysis of Variance (ANOVA).
The assumptions of homogeneity of covariance were tested by
Mauchly sphericity test. When this was significant, the Greenhouse-
Geiser epsilon was used to adjust the degrees of freedom to increase
the critical value of the F-ratio. Effect sizes based on the absolute
mean differences between groups (MD) [(þ95% confidence intervals
(CI)] were calculated to describe any trends in the data. The alpha
level was set at P < 0.01 for all analyses.

2.5.4. Muscle strength (concentric peak torque)

Concentric peak torque (CPT) was measured using a KinCom
AP2 isokinetic dynamometer (Chattanooga Group Inc, USA). Par-
ticipants performed three maximum concentric contractions of the
hamstring (through range from 10 to 80
knee flexion), with 10 s
rest between each repetition. The highest peak torque out of the
three attempts was recorded.
2.5.5. Creatine Kinase (CK)
Serum CK samples were obtained as a marker of muscle dam-
age. A sample of blood was obtained from a finger-prick which was
then analysed using a Reflotron Plus machine (Roche Diagnostics,
Germany).
3. Results
Between January 2011 and February 2011, 50 participants met
the inclusion criteria and provided informed consent to participate
in the study. All 50 participants underwent randomisation and all
received the intervention as allocated. There were no drop outs,
with complete data sets for each outcome at every follow up point.
There were no adverse effects reported. Table 1 summarises out-
comes for each group at baseline and all follow up points. There
were no significant differences between groups at baseline.
Table 1 shows a significant main effect for time for all outcomes
(p < 0.001). Muscle soreness peaked at day 2 post exercise; POS and
limitations in AROM followed the time course. Muscle strength was
 P.D. Glasgow et al. / Physical Therapy in Sport 15 (2014) 228e233
lowest between day 1 and 2 post exercise, whereas CK activity
peaked between day 3 and 4 post exercise.
There were no significant interaction effects (GROUP*TIME) for
AROM (P ¼ 0.890), POS (P ¼ 0.444), muscle strength (P ¼ 0.620),
serum CK levels (P ¼ 0.759) and muscle soreness (P ¼ 0.499). Fig. 1
shows the changes over time for the primary outcome, by inter-
vention group. The largest effect sizes for muscle soreness at 48 h
[MD of 2.05 cm (95% CI 0.4 to 4.5)] based on a 10 cm VAS) and 72 h
post exercise (MD of 1.06 (95% CI 0.2 to 2.32) based on a 10 cm
VAS] were in favour of the 10 min CWI in 6
C group (vs control).
There were further trends in favour of this group over the control,
for POS at 48 h [MD of 1.7 cm (95% CI 0.69 to 4.09) based on a
10 cm VAS] and 72 h post exercise [MD of 0.58 cm (95% CI 1.68 to
2.84) based on a 10 cm VAS].
4. Discussion
Water immersions, such as CWI or CWT are commonly used as a
recovery modality but there is little empirical evidence to support
its use (Bieuzen et al., 2013; Bleakley, Glasgow, et al., 2012; Bleakley,
McDonough, et al., 2012). To date no study has compared different
WI temperatures and treatment durations in the management of
delayed onset muscle soreness. This is also one of the first studies in
this area to use a randomised methodology with parallel group
design, allocation concealment and blinded outcome assessment.
We found that altering the treatment duration, water temperature
or dosage of post exercise water immersion had no significant effect
on outcome relating to DOMS. There were trends that CWI con-
sisting of 10 min immersion in 6
C is most effective, but may only
be associated with lower levels of muscle soreness over the first
96 h post exercise.
We used a hamstring loading protocol based on three sets of
eccentric exercise undertaken to fatigue. This exercise bout was
successful in inducing muscle damage; this was evident from the
significant change over time in all of the dependent variables
measured. Others have also induced significant levels of DOMS
based on eccentric lower limb resistance protocols (Vaile et al.,
2008; Yanagisawa et al., 2003). In the current study, muscle sore-
ness peaked at 48 h post exercise, a pattern that is consistent with
previous studies in this area (Jakeman, Macrae, & Eston, 2009;
Fig. 1. Primary outcome (muscle soreness) by intervention group.
231
Yanagisawa et al., 2003). Pain on passive stretching also peaked at
48 h post exercise, with scores either comparable to (Goodall &
Howatson, 2008; Jakeman et al., 2009), or higher than other
studies in this area (Sellwood et al., 2007).
Intracellular release of CK is commonly used as an indirect
marker of muscle damage. We found a mean peak increase from
baseline of over 600%. Others have reported mean increases from
baseline of between 170% (Sellwood et al., 2007) and 600% (Byrne &
Eston, 2002). Interestingly our CK values peaked at 72 h post ex-
ercise. Although this is comparable to some studies (Rowsell,
Coutts, Reaburn, & Hill-Haas, 2011; Yanagisawa et al., 2003),
others (Bailey, Erith, Griffin, Dowson, Brewer, & Gant, 2007;
Jakeman et al., 2009) have recorded earlier CK peaks at around
24 h post exercise. These variations may be due to the methods of
DOMS inducement employed; early peaks seem to be associated
with more moderate strengthening protocols (Sellwood et al.,
2007) or single bouts of running (Bailey et al., 2007; Jakeman
et al., 2009). In contrast, later peak values, such as those reported
in the current study, seem to be associated with isolated eccentric
loading (Yanagisawa et al., 2003) or intense game exposure
(Rowsell et al., 2011).
Clinical application of CWI continues to vary dramatically
depending on location, sport and personal preference. Currently
the optimal duration of immersion is not clear (Bleakley, Glasgow,
et al., 2012; Bleakley, McDonough, et al., 2012). In the current study,
we compared a range of popular cooling durations but found no
significant differences for any outcomes. In accordance with a
number of recent studies (Eston & Peters, 1999; Yanagisawa et al.,
2003), we employed serial treatment interventions over a period
of three days. Some areas of athletics promote serial interventions
as a means of inducing larger treatment dose. A subgroup analysis
within a recent Cochrane review found few differences between
single and serial treatments of CWI in the prevention and treatment
of muscle soreness (Bleakley, Glasgow, et al., 2012; Bleakley,
McDonough, et al., 2012).
The basic scientific theory underpinning cryotherapy is that it
decreases metabolic activity, thereby limiting secondary hypoxic
damage and facilitating recovery after soft tissue damage (Merrick,
Jutte, & Smith, 2003). This theory may not translate into a clinical
setting however, as tissue temperature reductions in human
232 P.D. Glasgow et al. / Physical Therapy in Sport 15 (2014) 228e233
subjects are often not large enough to influence metabolic cellular
activity (Bleakley, Glasgow, & Webb, 2012). Indeed many studies
have shown negligible reductions in thigh muscle temperature
with CWI, despite using treatment durations comparable to or
longer than those used in the current study (Gregson et al., 2011;
Myrer, Measom, & Fellingham, 1998). Other clinical studies have
found little evidence of a duration dependent response associated
with water immersion recovery, despite comparing immersion
durations of 6, 12 or 18 min (Versey, Halson, & Dawson, 2011).
Water temperature may be a more important component
determining clinical effectiveness. An interesting trend was that
immersions in lower water temperatures (6
C) were associated
with less muscle soreness throughout the entire follow up period.
Indeed, at 48 h post exercise, control group scores were approxi-
mately 20% higher than the group using 10 min immersions at 6
C
[MD of 2.05 cm (95% CI 0.4 to 4.5)]. Although these reductions
were not statistically significant, they may be clinically relevant. A
Minimal Important Difference (MID) has been defined as “the
smallest difference in score in the domain of interest that patients
perceive as important, either beneficial or harmful, and which
would lead the clinician to consider a change in the patient’s
management” (Guyatt, Osoba, Wu, Wyrwich, Norman, & Aaronson,
2002). A 10e20% difference in muscle soreness may represent an
important effect for an athletic population, particularly those in an
elite sporting environment.
We can only postulate the physiological mechanisms under-
pinning these trends. The hypoanalgesic effects of cold are well
reported and seem to be optimised when skin temperature is
reduced to below 12
C (Algafly & George, 2007; Kunesch, Schmidt,
Nordin, Wallin, & Hagbarth, 1987). The magnitude of skin temper-
ature reductions during immersion is strongly influenced by water
temperature (Hopper, Whittington, & Davies, 1997; Kennet,
Hardaker, Hobbs, & Selfe, 2007; Khanmohammadi, Someh, &
Ghafarinejad, 2011; Leeder, Gissane, van Someren, Gregson, &
Howatson, 2012). It may be that immersion in 6
C reduces skin
temperature to optimal levels fastest. Achieving more effective
short term analgesia may be more conducive to higher levels of
physical activity after exercise which has already been shown to
attenuate painful symptoms relating to DOMS when used in
isolation (Ahmaidi, Granier, Taoutaou, Mercier, Dubouchaud, &
Prefaut, 1996; Reilly & Ekblom, 2005) or in combination with CWI
(Kinugasa & Kilding, 2009).
Throughout the study we ensured that participants were not
informed of the water temperatures employed and we did not state
which intervention was deemed most therapeutic. We must how-
ever acknowledge that the nature of CWI prevents true participant
blinding. Studies which are not blinded or have observational
components may be vulnerable to unintended effects on inter-
vention outcomes such as the Hawthorne effect (Fernald, Coombs,
DeAlleaume, West, & Parnes, 2012). CWI is considered by many
athletes as the touchstone for managing muscle soreness. In the
current study, the extreme sensation associated with immersion in
6
C may have been construed as being more therapeutic and may
partly explain the lower levels of muscle soreness within this
group. Interestingly, we found no differences between groups
based on measures of strength or active range of motion. This
concurs with recent literature whereby CWI (Barnett, 2006;
Bleakley, Glasgow, et al., 2012; Bleakley, McDonough, et al., 2012;
Cheung, Hume, & Maxwell, 2003) seems to enhance perception of
recovery over no intervention (eg. muscle pain and fatigue after
exercise) but few studies report any significant effects on objective
measures of function and sporting performance.
A total of 50 participants completed this study which represents
one of the largest samples used within CWI research to date
(Bleakley, Glasgow, et al., 2012; Bleakley, McDonough, et al., 2012).
However, as we randomised across five groups, our level of statis-
tical significance for all tests was set at p < 0.01 a priori, to control
for experiment wise error rate (Type 1 error). Although we found
no statistically significant interaction effect (group*time) on our
outcome variables, we have described important trends that may
be clinically relevant. Another potential limitation is that our data
are limited to a 96 h follow up and we cannot make conclusions on
any long term effects. We also acknowledge that our research is
based on a muscle damage model; CWI may have a different effect
in sports associated with other physiological stresses such as:
metabolic cost and energy substrate depletion, hyperthermia,
oxidative stress and nervous system fatigue (Leeder et al., 2012).
Indeed there is some evidence to suggest that CWI is an effective
method for controlling core temperature (DeMartini et al., 2011)
and optimising exercise performance in a hot environment
(Schniepp, Campbell, Powell, & Pincivero, 2002; Yeargin et al.,
2006).
5. Conclusion
CWI remains a popular strategy for post exercise recovery;
however there is little guidance on the most effective water tem-
perature or treatment duration. We found no strong evidence to
suggest an optimal treatment dosage; only trends that longer im-
mersions (10 min) in colder water are associated with less muscle
soreness. This aligns with previous studies in this area which seem
to suggest that CWI has most effect on self reported recovery rather
than objective measures of sporting performance (eg. increased
strength). Coaches and sports practitioners should consider using
CWI; however this should be undertaken as part of a structured
recovery session and be tailored to the specific requirements of
each athlete.
Conflict of interest
This project was part funded by CET Cryotherapy (Dromore, UK).
The results of the present study do not constitute endorsement of
the product by the authors.
Ethical approval
Approval for this study was granted by the University of Ulster
Research Ethical Committee.
Funding
This project was part funded by CET Cryotherapy (Dromore, UK).
References
Ahmaidi, S., Granier, P., Taoutaou, Z., Mercier, J., Dubouchaud, H., & Prefaut, C.
(1996). Effects of active recovery on plasma lactate and anaerobic power
following repeated intensive exercise. Medicine and Science in Sports and Exer-
cise, 28, 450e456.
Algafly, A. A., & George, K. P. (2007). The effect of cryotherapy on nerve conduction
velocity, pain threshold and pain tolerance. British Journal of Sports Medicine, 41,
365e369.
Armstrong, R. B. (1990). Initial events in exercise-induced muscular injury. Medicine
and Science in Sports and Exercise, 22, 429e435.
Bailey, D. M., Erith, S. J., Griffin, P. J., Dowson, A., Brewer, D. S., & Gant, N. (2007).
Influence of cold water immersion on indices of muscle damage following
prolonged intermittent shuttle running. Journal of Sports Sciences, 25, 1163e
1170.
Banfi, G., & Melegati, G. (2008). Effect on sport hemolysis of cold water leg im-
mersion in athletes after training sessions. Laboratory Hematology, 14, 15e18.
Barnett, A. (2006). Using recovery modalities between training sessions in elite
athletes. Does it help? Sports Medicine, 36, 781e796.
Bieuzen, F., Bleakley, C. M., & Costello, J. T. (2013 Apr 23). Contrast water therapy and
exercise induced muscle damage: a systematic review and meta-analysis. PLoS
One, 8(4), e62356.
Bleakley, C. M., Glasgow, P., & Webb, M. J. (2012). Cooling an acute muscle injury:
can basic scientific theory translate into the clinical setting? British Journal of
Sports Medicine, 46, 296e298.
 P.D. Glasgow et al. / Physical Therapy in Sport 15 (2014) 228e233
Bleakley, C., McDonough, S., Gardner, E., Baxter, G. D., Hopkins, J. T., & Davison, G. W.
(2012). Cold-water immersion (cryotherapy) for preventing and treating muscle
soreness after exercise. Cochrane Database Systematic Reviews, 15, CD008262.
Byrne, C., & Eston, R. (2002). Maximal-intensity isometric and dynamic exercise per-
formance after eccentric muscle actions. Journal of Sports Sciences, 20, 951e959.
Chatzinikolaou, A., Fatouros, I. G., Gourgoulis, V., Avloniti, A., Jamurtas, A. Z.,
Nikolaidis, M. G., et al. (2010). Time course of changes in performance and in-
flammatory responses after acute plyometric exercise. Journal of Strength and
Conditioning Research, 24, 1389e1398.
Cheung, K., Hume, P. A., & Maxwell, L. (2003). Delayed onset muscle soreness e
treatment strategies and performance factors. Sports Medicine, 33, 145e164.
Clarkson, P. M., & Sayers, S. P. (1999). Etiology of exercise-induced muscle damage.
Canadian Journal of Applied Physiology, 24, 234e248.
Cochrane, D. J. (2004). Alternating hot and cold water immersion for athlete re-
covery: a review. Physical Therapy in Sport, 5, 26e32.
DeMartini, J. K., Ranalli, G. F., Casa, D. J., Lopez, R. M., Ganio, M. S., Stearns, R. L., et al.
(2011). Comparison of body cooling methods on physiological and perceptual
measures of mildly hyperthermic athletes. Journal of Strength and Conditioning
Research, 25, 2065e2074.
Eston, R., & Peters, D. (1999). Effects of cold water immersion on the symptoms of
exercise-induced muscle damage. Journal of Sports Sciences, 17, 231e238.
Fernald, D. H., Coombs, L., DeAlleaume, L., West, D., & Parnes, B. (2012). An
assessment of the Hawthorne effect in practice-based research. The Journal of
the American Board of Family Medicine, 25, 83e86.
Goodall, S., & Howatson, G. (2008). The effects of multiple cold water immersions
on indices of muscle damage. Journal of Sports Science and Medicine, 7, 235e241.
Gregson, W., Black, M. A., Jones, H., Milson, J., Morton, J., Dawson, B., et al. (2011).
Influence of cold water immersion on limb and cutaneous blood flow at rest.
American Journal of Sports Medicine, 39, 1316e1323.
Guyatt, G. H., Osoba, D., Wu, A. W., Wyrwich, K. W., Norman, G. R., & Aaronson, N.
(2002). Methods to explain the clinical significance of health status measures.
Mayo Clinic Proceedings, 77, 371e383.
Hopper, D., Whittington, D., & Davies, J. (1997). Does ice immersion influence ankle
joint positional sense? Physiotherapy Research International, 2, 223e236.
Jakeman, J. R., Macrae, R., & Eston, R. (2009). A single 10-min bout of cold water
immersion therapy after strenuous plyometric exercise has no beneficial effect
on recovery from the symptoms of exercise induced muscle damage. Ergo-
nomics, 52, 456e460.
Kennet, J., Hardaker, N., Hobbs, S., & Selfe, J. (2007). Cooling efficiency of 4 common
cryotherapeutic agents. Journal of Athletic Training, 42, 343e348.
Khanmohammadi, R., Someh, M., & Ghafarinejad, F. (2011). The effect of cryo-
therapy on the normal ankle joint position sense. Asian Journal of Sports Med-
icine, 2, 91e98.
Kinugasa, T., & Kilding, A. E. (2009). A comparison of post-match recovery strategies
in youth soccer players. Journal of Strength and Conditioning Research, 23, 1402e
1407.
233
Kunesch, E., Schmidt, R., Nordin, M., Wallin, U., & Hagbarth, K. E. (1987). Peripheral
neural correlates of cutaneous anaesthesia induced by skin cooling in man. Acta
Physiologica Scandinavica, 129, 247e257.
Leeder, J., Gissane, C., van Someren, K., Gregson, W., & Howatson, G. (2012). Cold
water immersion and recovery from strenuous exercise: a meta-analysis. British
Journal of Sports Medicine, 46, 233e240.
Merrick, M. A., Jutte, L. S., & Smith, M. E. (2003). Cold modalities with different
thermodynamic properties produce different surface and intramuscular tem-
peratures. Journal of Athletic Training, 38, 28e33.
Myrer, J. W., Measom, G., & Fellingham, G. W. (1998). Temperature changes in the
human leg during and after two methods of cryotherapy. Journal of Athletic
Training, 33, 25e29.
Newham, D. J. (1988). The consequences of eccentric contractions and their rela-
tionship to delayed onset muscle pain. European Journal of Applied Physiology,
57, 353e359.
Proske, U., & Morgan, D. L. (2001). Muscle damage from eccentric exercise: mech-
anism, mechanical signs, adaptation and clinical applications. Journal of Physi-
ology, 537, 333e345.
Reilly, T., & Ekblom, B. (2005). The use of recovery methods post exercise. Journal of
Sports Sciences, 23, 619e627.
Rowsell, G. J., Coutts, A. J., Reaburn, P., & Hill-Haas, S. (2011). Effect of post-match
cold-water immersion on subsequent match running performance in junior
soccer players during tournament play. Journal of Sports Sciences, 29, 1e6.
Schniepp, J., Campbell, T. S., Powell, K. L., & Pincivero, D. M. (2002). The effects of
cold water immersion on power output and heart rate in elite cyclists. Journal of
Strength and Conditioning Research, 16, 561e566.
Sellwood, K. L., Brukner, P., Williams, D., Nicol, A., & Hinman, R. (2007). Ice-water
immersion and delayed onset muscle soreness: a randomised controlled trial.
British Journal of Sports Medicine, 41, 392e397.
Vaile, J., Halson, S., Gill, N., & Dawson, B. (2008). Effect of cold water immersion on
repeat cycling performance and thermoregulation in the heat. Journal of Sports
Sciences, 26, 431e440.
Versey, N., Halson, S., & Dawson, B. (2011). Effect of contrast water therapy duration
on recovery of cycling performance: a dose response study. European Journal of
Applied Physiology, 111, 37e46.
Wilcock, I. M., Cronin, J. B., & Hing, W. A. (2006). Physiological response to water
immersion, a method for sport recovery? Sports Medicine, 36, 747e765.
Yanagisawa, O., Niitsu, M., Yoshioka, H., Goto, K., Kudo, H., & Itai, Y. (2003). The use
of magnetic resonance imaging to evaluate the effects of cooling on skeletal
muscle after strenuous exercise. European Journal of Applied Physiology, 89, 53e
62.
Yeargin, S. W., Casa, D. J., McClung, J. M., Knight, J. C., Healey, J. C., Goss, P. J., et al.
(2006). Body cooling between two bouts of exercise in the heat enhances
subsequent performance. Journal of Strength and Conditioning Research, 20,
383e389.