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ORIGINAL ARTICLE
Objectives: To determine the impact of the application of cryotherapy on nerve conduction velocity (NCV),
pain threshold (PTH) and pain tolerance (PTO).
Design: A within-subject experimental design; treatment ankle (cryotherapy) and control ankle (no
cryotherapy).
See end of article for Setting: Hospital-based physiotherapy laboratory.
authors’ affiliations Participants: A convenience sample of adult male sports players (n = 23).
........................ Main outcome measures: NCV of the tibial nerve via electromyogram as well as PTH and PTO via pressure
Correspondence to: algometer. All outcome measures were assessed at two sites served by the tibial nerve: one receiving
K P George, Research cryotherapy and one not receiving cryotherapy.
Institute for Sport and Results: In the control ankle, NCV, PTH and PTO did not alter when reassessed. In the ankle receiving
Exercise Sciences, 15–21
Webster Street, Liverpool L3
cryotherapy, NCV was significantly and progressively reduced as ankle skin temperature was reduced to
2ET, UK; k.george@ljmu. 10˚C by a cumulative total of 32.8% (p,0.05). Cryotherapy led to an increased PTH and PTO at both
ac.uk assessment sites (p,0.05). The changes in PTH (89% and 71%) and PTO (76% and 56%) were not different
between the iced and non-iced sites.
Accepted 4 December 2006
Published Online First Conclusions: The data suggest that cryotherapy can increase PTH and PTO at the ankle and this was
15 January 2007 associated with a significant decrease in NCV. Reduced NCV at the ankle may be a mechanism by which
........................ cryotherapy achieves its clinical goals.
C
ryotherapy has been accepted for decades as an effective, involved with the study. Written informed consent was
inexpensive and simple intervention for pain manage- obtained, and ethical approval was granted through the
ment after many acute sport injuries.1 2 It is widely Manchester Metropolitan University, Manchester, UK. The
believed that the therapeutic application of cryotherapy leads to study conformed to the Declaration of Helsinki. Inclusion
a reduction in pain and swelling, but the physiological basis for criteria required the subjects to be young (20–29 years), male
this effect is still incompletely understood.3 4 Saeki5 and other and physically active. Exclusion criteria prevented the recruit-
authors concluded that pain relief with cold application could ment of subjects who were having/had central and/or periph-
be due to many mechanisms including altered nerve conduc- eral nervous system disorders, overweight (body mass index
tion velocity (NCV), inhibition of nociceptors, a reduction in .30), skin problems and/or allergic response on to exposure
muscle spasms and/or a reduction in metabolic enzyme activity cold conditions.
levels.6–8
NCV can be altered by gender, age and, more pertinently,
Research design
skin temperature.9 On this basis it is plausible to propose that
All subjects were fully familiarised before to testing, at which
cryotherapy could reduce pain via an alteration in NCV.
time the experimental (EXP; cryotherapy) and control (CON)
Alternatively, cryotherapy could also be effective as a counter-
ankles were determined randomly by the toss of a coin. All data
irritant to pain via diffused noxious inhibitory controls, pain
collection occurred in one visit to the laboratory (ca 3 h) where
gate theory, suppressed nociceptive receptor sensitivity or via
the room temperature was held constant between 21˚C and
the analgesic descending pathway of the central nervous
system such as endorphins.1 5 10 11 Evaluation of a counter- 24˚C. Both ankles were subjected to the same measurement
irritant role is difficult to directly evaluate, but if cryotherapy protocols at the same time, but the order of testing between
can reduce pain threshold (PTH) and pain tolerance (PTO) EXP and CON ankle was again randomised by the toss of a coin.
independent of any effect on NCV then these processes may be For the EXP ankle this meant measures of NCV, PTH and PTO
more important. at baseline before ice application and then at skin temperatures
The aim of the current study, therefore, was to assess of 15˚C and 10˚C with ice cooling and a skin temperature of
changes in NCV, PTH and PTO concomitantly as ankle skin 15˚C with re-warming after ice removal. Chesterton et al12
temperature was reduced via cryotherapy. We hypothesise that reported that to achieve a desirable physiological response
cryotherapy reduces skin temperature to a level that decreases (reduction in pain) with cryotherapy requires that the skin
NCV, and that changes in NCV, are associated with an increase tissue is cooled to specific temperature levels (,13.2˚C). This
in PTH and PTO. specifically drove the rationale for the choice of temperatures
assessed in this research design.
METHODS
Subjects Abbreviations: ANOVA, analysis of variance; CON, control; EMG,
A convenience sample of 23 volunteers from local sports clubs electromyogram; EXP, experimental; NCV, nerve conduction velocity; PTH,
were informed individually about the purpose, nature and risks pain threshold; PTO, pain tolerance
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366 Algafly, George
Ice application
EXP CON
45 After baseline measures, ice was applied to lower the tissue
* * * temperature on the EXP ankle. Crushed ice has been found to
40 **
35 be most effective in reducing skin temperature compared with
NCV (m/s) 30 other cold modalities,12 16 and was hence used in this study. At
25 the specific skin temperatures noted (15˚C and 10˚C), the ice
20 pack was removed and all variables were reassessed.
15
10
5
Data analysis
0 Descriptive statistics (mean (SD)) were used to summarise the
PRE 15°C 10°C 15°C data for NCV, as well as for PTO and PTH, at both assessment
Timeline sites on the EXP and CON ankles. Data for NCV, PTO and PTH
at both iced and non-iced sites were analysed using repeated-
Figure 1 The impact of ice application on nerve conduction velocity in measure two-way analysis of variances (ANOVAs) with the
experimental (EXP) and control (CON) ankles (data are mean (SD)). timeline (pre (baseline), 15˚C, 10˚C and 15˚C) and ankle (EXP
Timeline: pre, baseline; 15˚C, skin temperature cooling; 10˚C, skin
temperature cooling; 15˚C, skin temperature with passive warming. and CON) as repeated factors. For each significant F ratio, post
*Significant difference between EXP and CON ankles as well as between hoc comparisons of group means were made using the Tukey
pre and 10/15˚C measurements in EXP ankle (p,0.05). **Significant honestly significant difference test. Pearson product–moment
difference between 15 and 10˚C measurements in the EXP ankle (p,0.05). correlations were then performed on the association between
changes (delta scores from baseline to 10˚C) in NCV with PTO
Protocols and PTH. For all statistical tests, differences were considered to
Skin temperature was measured using a Digital Thermometer be significant if p,0.05. Data analysis was performed using the
(Chavin Arnoux, France). An electrode was placed on the iced SPSS V.10 software package.
area of leg where NCV, PTH and PTO were measured. The
thermistor was applied directly to the skin so temperature RESULTS
measures reflected skin changes with heat loss rather than the Nerve conduction velocity
direct effect of ice on the thermometer. The average ice application time for skin temperature to reach
In this study, NCV measurement was acquired by using a 10˚C was 26 min (range 20–31 min). For NCV, significant main
portable electromyogram (EMG) system (Medtronic Keypoint, effects for ankle (EXP vs CON: F = 5.4, p = 0.02) and timeline
Copenhagen, Denmark). Anode and cathode electrodes were (pre, 15˚C, 10˚C and 15˚C: F = 31.8, p,0.005), as well as the
fixed to the fifth toe and the two EMG electrodes were placed ankle–timeline interaction, (F = 27.8, p,0.005) were demon-
over the tibial nerve. Proper placement of the EMG head would strated. Figure 1 presents the pattern of response, and post hoc
result in the contraction of muscles of the fifth metatarsal once analysis stated that NCV for the EXP ankle was significantly
stimulated. The active electrode was placed above the flexor depressed from baseline as ankle skin temperature decreased in
retinaculum and medial to the medial malleolus for both a progressive fashion. At both 15˚C and 10˚C NCV was also
medial and lateral plantar nerves. The ground electrode was significantly lower in the EXP ankle than in the CON ankle
placed on the dorsum of the foot. The stimulus intensity needed (p,0.05). Data for NCV did not differ across the timeline in the
to obtain the maximal amplitudes is usually three times the CON ankle (p.0.05; fig 1). The change in NCV with ice
sensory threshold. Lateral plantar stimulation was applied application from baseline (pre) to 10˚C represented a 33%
orthodromically by means of a ring electrode on the fifth toe. reduction.
The EMG was set to a frequency of 8 Hz or 1.6 kHz with a
sweep speed of 2 or 5 ms/div and a gain of 5–10 mV. NCV was PTH and PTO at assessment site one (iced)
then calculated by software inherent to the EMG as the time Both PTH1 and PTO1 were significantly altered by ice
difference between the stimulation and the stimulation and application (figs 2 and 3). For PTH1, significant ANOVA F
onset of EMG activity divided by the distance (assessed by ratios were reported for the main effects of ankle (F = 47.5,
callipers) between the fifth-digit ring electrodes to the ankle p,0.005), timeline (F = 56.7, p,0.005) and their interaction
pick-up. (F = 41.3, p,0.005). This was mirrored by statistical outcomes
Both PTH and PTO were assessed by a pressure algometer for PTO1 (ankle: F = 34.5, p,0.005; timeline: F = 53.2,
(Pain Diagnostic and Thermography, Great Neck, NY, USA) by
a single investigator at two different sites of reference for the EXP CON
tibial nerve on the lateral aspect of both the treatment and 12
*
control ankles. The first assessment site (PTH1, PTO1: iced) was 10 **
located posterior to the lateral aspect of the lateral malleolus * *
1 cm to the lower tip of the lateral malleolus, where ice 8
PTH (kg)
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Cryotherapy and nerve conduction velocity 367
PTH (kg)
12 6
10 5
8 4
6 3
4 2
2 1
0 0
PRE 15°C 10°C 15°C PRE 15°C 10°C 15°C
Timeline Timeline
Figure 3 The impact of ice application on pain tolerance at point 1 (iced) Figure 4 The impact of ice application on pain threshold (PTH) at point 2
in the experimental (EXP) and control (CON) ankles (data are represented (non-iced) in the experimental (EXP) and control (CON) ankles (data are
as mean (SD)). PTH, pain threshold. *Significant difference between EXP represented as mean (SD)). *Significant difference between EXP and CON
and CON ankles as well as between baseline (pre) and 10/15˚C ankles as well as between baseline (pre) and 10/15˚C measurements in the
measurements in the EXP ankle (p,0.05). **Significant difference between EXP ankle (p,0.05). **Significant difference between 15 and 10˚C
15 and 10˚C measurements in the EXP ankle (p,0.05). measurements in the EXP ankle (p,0.05).
10
PTH and PTO irrespective of site assessed. 8
6
DISCUSSION 4
Our data support the contention that cryotherapy is an 2
effective, inexpensive and simple intervention for pain manage- 0
ment,1 2 and uniquely provides some insight into the potential PRE 15°C 10°C 15°C
mechanisms by which this may be brought about. Specifically, Timeline
NCV is significantly and progressively reduced concomitantly
with skin temperature at the ankle during cryotherapy. Figure 5 The impact of ice application on pain tolerance (PTO) at point 2
(non-iced) in the experimental (EXP) and control (CON) ankles (data are
Associated with the changes in NCV, we observed significant represented as mean (SD)). *Significant difference between EXP and CON
increases in PTH and PTO at both assessment sites on the ankle ankles as well as between baseline (pre) and 10/15˚C measurements in the
served by the same nerve, even though only the first site EXP ankle (p,0.05). **Significant difference between 15 and 10˚C
received direct ice application. measurements in the EXP ankle (p,0.05).
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368 Algafly, George
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Cryotherapy and nerve conduction velocity 369
14 Hou CR, Tsai LC, Cheng KF, et al. Immediate effects of various physical
therapeutic modalities on cervical myofascial pain and trigger-point sensitivity.
Arch Phys Med Rehabil 2002;83:1406–14.
............... COMMENTARY ...............
K
arl B Fields, MD, graduated from Yale University and the
University of Kentucky Medical School. He completed
family practice residency at Charlotte Memorial Hospital
in Charlotte, NC, and after a stint in private practice completed
a faculty development fellowship at UNC Chapel Hill. He is
residency and sports medicine fellowship director of the Moses
Cone Family Practice Residency in Greensboro, NC as well as
Professor of Family Medicine and Associate Chairman of the
Department of Family Medicine at the University of North
Carolina Medical School in Chapel Hill and an adjunct
professor of sports science at the University of North Carolina
in Greensboro. He developed the sports medicine fellowship
programme in Greensboro in 1992 and received his CAQ in
sports medicine in 1993. Currently he serves as team physician
for Guilford College and consults in the care of several
university and high school teams, running clubs and elite
athletes. He has been a visiting professor for the Australian
Institute of Sport and for the Norwegian Primary Care
Association. He is a past president of the American Medical
Society of Sports Medicine and a member of the American
College of Sports Medicine.
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