IMPACT OF SELF-STRETCHING TECHNIQUES

WITH CRYOTHERAPY VS SELF- STRETCHING

TECHNIQUES WITH TENS, ON ALLEVIATING
DELAYED ONSET MUSCLE SORENESS (DOMS) OF
QUADRICEPS MUSCLE FOLLOWING STRENUOUS
EXERCISE.

NARENDHIRAN G
BACHELOR OF PHYSIOTHERAPY
CHAPTER DESCRIPTION PAGE NO
1 Introduction
 Aim and objective of the study
 Need and background of the study
 Hypothesis
2 Review of literature
3 Methodology
 Inclusion criteria
 Exclusion criteria
 Outcome measure
4 Procedure
5 Data analysis and interpretation
6 Result
7 Discussion
8 Conclusion
9 Limitations and recommendations
10 References
11 Appendix
Introduction

Delayed Onset Muscle Soreness (DOMS) is a common phenomenon experienced by

individuals following unaccustomed or strenuous exercise, characterized by muscle pain,
stiffness, and reduced range of motion. DOMS typically peaks within 24 to 72 hours post-
exercise and can significantly impair physical performance, daily activities, and exercise
adherence. While DOMS is considered a natural response to eccentric muscle contractions
and microtrauma within muscle fibers, its management remains a challenge in sports
medicine and rehabilitation.

Physiotherapy interventions aimed at mitigating DOMS and promoting muscle recovery have
garnered considerable attention in recent years. Among these interventions, self-stretching
techniques, and adjunct modalities such as cryotherapy and Transcutaneous Electrical Nerve
Stimulation (TENS) have shown promise in alleviating DOMS symptoms and accelerating
recovery. Self-stretching exercises aim to improve muscle flexibility, reduce muscle tension,
and enhance blood flow to the affected muscles, thereby promoting tissue repair and reducing
soreness. Cryotherapy, involving the application of cold therapy, has been shown to attenuate
inflammation, reduce pain perception, and minimize muscle damage following exercise-
induced stress. Similarly, TENS therapy, which delivers electrical stimulation to nerve fibers,
modulates pain signals, promotes the release of endorphins, and enhances blood circulation,
offering potential benefits in managing DOMS.

While previous studies have investigated the efficacy of individual physiotherapy modalities
in DOMS management, limited studies have directly compared the effectiveness of different
interventions, particularly when combined with self-stretching techniques. Therefore, there is
a need for rigorous scientific research to clarify the comparative effectiveness of these
interventions in alleviating DOMS and facilitating muscle recovery, particularly in the
context of quadriceps muscle soreness following strenuous exercise.

This introductory narrative sets the stage for a comprehensive exploration of DOMS
management strategies within the realm of physiotherapy. By examining the comparative
effectiveness of self-stretching techniques, cryotherapy, and TENS therapy, this research aims
to provide insights that can inform evidence-based practice and optimize outcomes for
individuals experiencing DOMS-related discomfort. Through a synthesis of existing
knowledge and empirical investigation, this research seeks to advance our understanding of
DOMS management, ultimately enhancing the quality of care and promoting the well-being
of athletes and individuals engaged in physical activity.
Physiology of Delayed Onset Muscle Soreness (DOMS)

To effectively address DOMS and develop strategies for its management, it is crucial to
understand the underlying physiological mechanisms that contribute to its onset and
progression. DOMS is primarily associated with eccentric muscle contractions, which occur
when a muscle lengthens under tension. This type of muscle action often leads to greater
mechanical stress and microtrauma within muscle fibers compared to concentric contractions,
where the muscle shortens under tension.

The microtrauma induced by eccentric exercise is believed to disrupt the structural integrity
of muscle fibers, leading to the release of inflammatory mediators, activation of pain
receptors, and initiation of the inflammatory response. This inflammatory cascade involves
the recruitment of immune cells, such as neutrophils and macrophages, to the site of muscle
damage, where they phagocytose cellular debris and produce pro-inflammatory cytokines.
These cytokines contribute to the inflammatory process and sensitization of nociceptive nerve
endings, resulting in the perception of pain and soreness.

In addition to inflammation, DOMS is associated with other physiological changes, including

oxidative stress, disruption of calcium homeostasis, and activation of satellite cells involved
in muscle repair and regeneration. The accumulation of reactive oxygen species (ROS) during
eccentric exercise can lead to oxidative damage to cellular components, aggravating muscle
injury and contributing to DOMS symptoms. Similarly, disturbances in calcium handling
within muscle fibers can impair contractile function and exacerbate muscle damage, further
amplifying DOMS-related discomfort.

Despite the acute inflammatory response and tissue damage associated with eccentric
exercise, these physiological processes also play a crucial role in muscle adaptation and
remodeling. The repair and regeneration of damaged muscle fibers, accompanied by an
increase in muscle protein synthesis and fiber hypertrophy, contribute to the development of
muscle strength and resilience over time. This phenomenon, known as the repeated bout
effect, refers to the decrease of DOMS and muscle damage following repeated exposure to
eccentric exercise, suggesting that the muscle adapts to better withstand mechanical stress
and minimize subsequent injury.

Despite the adaptive nature of the repeated bout effect, individuals may still experience
DOMS under certain conditions, particularly when exposed to novel or unfamiliar exercise
stimuli. Factors influencing the severity and duration of DOMS include the intensity and
duration of exercise, the degree of muscle lengthening, the presence of eccentric overload,
and individual susceptibility to muscle damage. Additionally, factors such as age, sex, fitness
level, nutritional status, and genetic predisposition may also influence an individual's
susceptibility to DOMS and their ability to recover from exercise-induced muscle damage.
Given the multifactorial nature of DOMS and its impact on physical performance and well-
being, effective management strategies are essential to minimize discomfort, facilitate
recovery, and optimize exercise adherence. In the following sections, we will explore various
physiotherapy interventions aimed at mitigating DOMS symptoms and promoting muscle
recovery, with a particular focus on self-stretching techniques, cryotherapy, and TENS
therapy.

Self-Stretching Techniques for DOMS Management

Self-stretching exercises are commonly recommended as part of a comprehensive warm-up

or cool-down routine to improve flexibility, enhance joint range of motion, and reduce the
risk of injury during exercise. In addition to their preventive benefits, self-stretching
techniques have also been explored as a potential strategy for alleviating DOMS and
accelerating muscle recovery following strenuous exercise.

The rationale behind incorporating self-stretching exercises into DOMS management

protocols lies in their ability to target specific muscle groups affected by DOMS, promote
blood flow to the affected tissues, and alleviate muscle tension and soreness. By gently
elongating the muscle fibers and surrounding connective tissue, self-stretching may help
alleviate muscle stiffness and discomfort associated with DOMS, allowing for improved
mobility and function.

Several types of self-stretching techniques have been investigated for their potential efficacy
in DOMS management, including static stretching, dynamic stretching and proprioceptive
neuromuscular facilitation (PNF) stretching. Static stretching involves holding a muscle in a
lengthened position for a prolonged period, typically 15-30 seconds, to increase muscle
length and flexibility. Dynamic stretching, on the other hand, involves moving a joint through
its full range of motion in a controlled manner, using momentum and muscle activation to
stretch the muscles dynamically.

Proprioceptive neuromuscular facilitation (PNF) stretching techniques incorporate both

passive and active muscle contractions to enhance flexibility and neuromuscular
coordination. These techniques often involve a combination of stretching and contracting
muscle groups in a specific sequence, followed by relaxation and passive stretching to further
elongate the muscles.

While self-stretching techniques offer potential benefits for DOMS management, the optimal
timing, duration, and frequency of stretching exercises remain areas of debate. Some studies
suggest that incorporating stretching into both pre-exercise and post-exercise routines may
help reduce the severity and duration of DOMS, enhance recovery, and improve exercise
performance. However, conflicting evidence exists regarding the effectiveness of stretching
in preventing or alleviating DOMS, with some studies reporting no significant difference
compared to control groups.

The efficacy of self-stretching techniques in DOMS management may vary depending on

various factors, including the type and intensity of stretching, individual flexibility and
conditioning, and the specific muscles targeted. Additionally, the presence of other
interventions, such as cryotherapy or TENS therapy, may influence the outcomes of
stretching exercises and their impact on DOMS symptoms. Further research is needed to
elucidate the mechanisms underlying the effects of self-stretching on DOMS and to
determine the optimal parameters for incorporating stretching into DOMS management
protocols.

Cryotherapy for DOMS Management

Cryotherapy, or cold therapy, involves the application of cold temperatures to the body to
reduce pain and inflammation, promote tissue healing, and enhance recovery following injury
or exercise-induced stress. Cryotherapy modalities commonly used for DOMS management
include ice packs, cold water immersion, cryo-chambers, and cryogenic sprays, each offering
unique benefits and considerations in terms of application and efficacy.

The rationale behind using cryotherapy for DOMS management lies in its ability to modulate
the inflammatory response, reduce pain perception, and minimize muscle damage associated
with eccentric exercise. During cryotherapy, the body undergoes intricate physiological
responses to cold stimuli. Initially, skin temperature decreases as heat dissipates,
accompanied by peripheral vasoconstriction to conserve heat. Despite this, the thermal after
drop phenomenon causes an initial rise in core temperature. Throughout the session,
alternating cycles of vasodilation and vasoconstriction occur, facilitating heat exchange and
thermal regulation. This characteristic feature caused is known as the “Lewis hunting
reaction.” These dynamic responses are essential for the body's adaptation to cold stress
during cryotherapy, enhancing its therapeutic effectiveness.
Additionally, cryotherapy may help decrease nerve conduction velocity, thereby reducing
pain sensation and discomfort associated with DOMS.

Several studies have investigated the effects of cryotherapy on DOMS symptoms and muscle
recovery, with mixed findings regarding its efficacy and optimal application protocols. Some
studies have reported significant reductions in pain, muscle soreness, and markers of muscle
damage following cryotherapy interventions, suggesting potential benefits for DOMS
management. However, other studies have failed to demonstrate significant differences
compared to control conditions or alternative interventions, raising questions about the
consistency and magnitude of cryotherapy effects on DOMS.

The effectiveness of cryotherapy in DOMS management may depend on various factors,

including the timing and duration of cold exposure, the method of application, and individual
differences in tolerance and responsiveness to cold temperatures. For example, early
application of cryotherapy immediately following exercise may help attenuate the
inflammatory response and minimize muscle damage, whereas delayed application may
primarily target pain relief and symptom management. Similarly, the duration and frequency
of cryotherapy sessions may influence its efficacy in promoting muscle recovery and
alleviating DOMS symptoms, with longer durations and multiple sessions potentially
yielding greater benefits.

Despite the potential benefits of cryotherapy for DOMS management, there are practical
considerations and contraindications that warrant attention. Cryotherapy modalities such as
cold-water immersion and cryo chambers may require specialized equipment and facilities,
limiting their accessibility and feasibility for certain individuals. Additionally, individuals
with circulatory disorders, cold intolerance, or sensory impairments may be at increased risk
of adverse effects from cryotherapy, including skin damage, frostbite, and exacerbation of
underlying conditions.

Transcutaneous Electrical Nerve Stimulation (TENS) Therapy for

DOMS Management

Transcutaneous Electrical Nerve Stimulation (TENS) therapy involves the application of low-
frequency electrical currents to the skin via surface electrodes, aiming to modulate pain
signals, promote the release of endorphins, and enhance blood circulation. TENS therapy has
been used extensively for pain management in various clinical settings, including
musculoskeletal injuries, neuropathic conditions, and postoperative rehabilitation. In the
context of DOMS management, TENS therapy offers potential benefits for alleviating pain,
reducing muscle soreness, and facilitating recovery following strenuous exercise.

The mechanism of action underlying TENS therapy involves the activation of sensory nerves
and the subsequent modulation of pain transmission pathways within the central nervous
system. When electrical currents are applied to the skin, they stimulate sensory nerve fibers,
leading to the generation of action potentials and the transmission of impulses to the spinal
cord and brain. These impulses can interfere with pain signals traveling along nociceptive
pathways, thereby reducing pain perception, and providing symptomatic relief.
In addition to its analgesic effects, TENS therapy has been shown to trigger the release of
endogenous opioids, such as endorphins and enkephalins, which act as natural painkillers and
mood enhancers. The activation of opioid receptors within the central nervous system can
produce analgesia and induce feelings of euphoria and well-being, further contributing to the
pain-relieving effects of TENS therapy. Moreover, TENS therapy may enhance blood
circulation to the affected area, promoting the delivery of oxygen and nutrients to damaged
tissues and facilitating the removal of metabolic waste products.

Several studies have investigated the efficacy of TENS therapy for DOMS management, with
mixed findings regarding its effectiveness and optimal parameters. Some studies have
reported significant reductions in pain, muscle soreness, and markers of inflammation
following TENS interventions, suggesting potential benefits for DOMS symptom relief and
muscle recovery. However, other studies have failed to demonstrate consistent or significant
effects of TENS therapy on DOMS, raising questions about its clinical utility and optimal
application protocols.

The effectiveness of TENS therapy in DOMS management may be influenced by various

factors, including the frequency, intensity, and duration of electrical stimulation, as well as
individual differences in pain sensitivity and responsiveness to TENS. High-frequency TENS,
delivered at frequencies above 50 Hz, is thought to activate large-diameter sensory nerve
fibers, thereby producing rapid pain relief through then pain gate mechanism. Conversely,
low-frequency TENS, delivered at frequencies below 10 Hz, is believed to stimulate
endorphin release and produce longer-lasting analgesic effects through the activation of
opioid receptors.

Optimizing the Physiotherapy Interventions for DOMS

Management

While self-stretching techniques, cryotherapy, and TENS therapy offer potential benefits for
DOMS management, optimizing their efficacy requires careful consideration of various
factors, including intervention parameters and individual characteristics. By incorporating
evidence-based principles and personalized approaches, physiotherapists can tailor
interventions to address the unique needs and preferences of individuals experiencing
DOMS-related discomfort.

To optimize the efficacy of self-stretching techniques, physiotherapists should consider the

specific muscles affected by DOMS, the severity of symptoms, and individual flexibility and
conditioning. Tailored stretching routines may involve a combination of static and dynamic,
targeting both agonist and antagonist muscle groups to improve overall flexibility and
mobility.
When implementing cryotherapy for DOMS management, physiotherapists should carefully
consider the timing, duration, and method of cold application, considering individual
preferences and tolerances. Early application of cryotherapy immediately following exercise
may help attenuate the inflammatory response and minimize muscle damage, whereas
delayed application may primarily target pain relief and symptom management.

Similarly, optimizing the efficacy of TENS therapy for DOMS management requires
attention to electrode placement, stimulation parameters, and individual responsiveness to
electrical stimulation. Ensure proper electrode placement over relevant muscle groups or
trigger points, adjusting stimulation intensity and frequency based on individual pain
thresholds and preferences. High-frequency TENS may be preferred for rapid pain relief and
acute symptom management, whereas low-frequency TENS may be more suitable for
promoting endorphin release and longer-lasting analgesic effects.

In addition to intervention-specific considerations, physiotherapists should also address

broader factors influencing DOMS management, such as exercise prescription,
biomechanical alignment, nutritional support, and psychosocial factors. By adopting a
holistic and interdisciplinary approach, physiotherapists can collaborate with other healthcare
professionals to optimize outcomes and promote the well-being of individuals experiencing
DOMS-related discomfort. Through ongoing assessment, monitoring, and adjustment of
treatment plans, physiotherapists can empower individuals to effectively manage DOMS
symptoms, enhance recovery, and achieve their fitness and performance goals.
By synthesizing existing knowledge and empirical evidence, this research aims to advance
our understanding of DOMS management strategies within the realm of physiotherapy,
informing evidence-based practice and optimizing outcomes for individuals experiencing
DOMS-related discomfort. Through interdisciplinary collaboration and personalized
approaches, physiotherapists can empower individuals to effectively manage DOMS
symptoms, enhance recovery, and achieve their fitness and performance goals, ultimately
promoting the well-being of athletes and individuals engaged in physical activity.
 ABSTRACT

AIM OF THE STUDY:

To compare the efficacy of self-stretching techniques combined with
cryotherapy versus self-stretching techniques combined with Transcutaneous
Electrical Nerve Stimulation (TENS) in alleviating Delayed Onset Muscle
Soreness (DOMS) of the quadriceps muscle following strenuous exercise.

OBJECTIVE OF THE STUDY:

The study aims to compare self-stretching with cryotherapy versus self-
stretching with TENS for quadriceps DOMS post-exercise. Objectives include
symptom alleviation, functional recovery, and long-term effects, exploring
participant satisfaction to inform clinical practice.

BACKGROUND OF THE STUDY:

Delayed Onset Muscle Soreness (DOMS) poses challenges for post-exercise
recovery. Self-stretching, cryotherapy, and TENS are common interventions.
Their comparative efficacy in quadriceps DOMS remains uncertain. Clarifying
effectiveness is crucial for optimizing recovery strategies in athletes and
rehabilitation.

HYPOTHESIS
Null Hypothesis:
There is no significant difference in the effectiveness of self-stretching
combined with cryotherapy compared to self-stretching combined with
Transcutaneous Electrical Nerve Stimulation (TENS) in alleviating Delayed
Onset Muscle Soreness (DOMS) of the quadriceps muscle following strenuous
exercise.
Alternate Hypothesis:
There is a significant difference in the effectiveness of self-stretching combined
with cryotherapy compared to self-stretching combined with Transcutaneous
Electrical Nerve Stimulation (TENS) in alleviating Delayed Onset Muscle
Soreness (DOMS) of the quadriceps muscle following strenuous exercise.

METHODOLOGY:
The study will be an Experimental study of comparative type aiming to
assess the efficacy of interventions for managing Delayed Onset Muscle
Soreness (DOMS) of the quadriceps muscle following strenuous exercise.
Participants with consistent exercise backgrounds will be randomly assigned to
one of two intervention groups: Group 1 will receive self-stretching combined
with cryotherapy for the quadriceps, while Group 2 will receive self-stretching
combined with Transcutaneous Electrical Nerve Stimulation (TENS). The
standardized quadriceps-focused exercise protocol will include a cardiovascular
warm-up, dynamic stretching, and specific quadriceps exercises. Outcome
measures, including assessments of pain, muscle function, and range of motion,
will be conducted pre- and post-exercise at specific intervals.

INTERVENTION GROUPS:
1. Group 1: Participants in this group will receive self-stretching combined with
cryotherapy for the quadriceps muscle.
2. Group 2: Participants in this group will receive self-stretching combined with
Transcutaneous Electrical Nerve Stimulation (TENS) for the quadriceps muscle.

INTERVENTION PROTOCOL:
- Both intervention groups will undergo a standardized quadriceps-focused
exercise protocol, which will include a cardiovascular warm-up, dynamic
stretching, and specific quadriceps exercises.
- Cryotherapy will involve the application of cold therapy/ to the quadriceps
muscle following exercise. This may include ice packs, cold water immersion,
or other cryotherapy modalities.
- TENS therapy will involve the application of Transcutaneous Electrical Nerve
Stimulation to the quadriceps muscle following exercise. TENS electrodes will
be placed strategically to target the quadriceps muscle, and electrical stimulation
will be applied according to a predefined protocol.

OUTCOME MEASURES:
- Assessments of pain intensity using visual analogue scales or numerical
rating scales.
- Measurements of muscle function, including strength and endurance, using
standardized functional tests such as the isokinetic dynamometer or squat
repetitions.
- Evaluation of range of motion of the quadriceps muscle using goniometry or
other appropriate measurement tools.
- Follow-up assessments will be conducted at specific intervals post-exercise to
evaluate the long-term effects of the interventions.

- Indirect muscle-damage markers:

- Maximal voluntary isometric contraction torque
- Range of motion
- Serum creatine kinase activity

- Assessment of muscle pain:

- Visual Analog Scale (VAS)
- Category Ratio-10 Scale (CR-10) when applying static pressure and
palpation at different sites (3, 9, and 15 cm above the elbow crease)
- Pressure-pain thresholds (PPTs) at 50 sites (pain mapping)
PROCEDURE
STANDARDIZED QUADRICEPS-FOCUSED EXERCISE PROTOCOL.

Warm-Up:
The subject is asked to engage in 5-10 minutes of light cardio activity, such as
walking, jogging, or cycling, to increase blood flow to the muscles and prepare
them for exercise.

DYNAMIC STRETCHING:
The subject is instructed to perform dynamic stretching exercises to further
warm up the muscles and improve flexibility.
Leg swings
1. The subject is asked to stand beside a stable support and hold onto it for
balance.
2. Keeping the leg straight, the subject is instructed to swing one leg forward
and backward in a controlled manner.
3. The subject is asked to perform 10-15 swings on each leg, gradually
increasing the range of motion.
4. The subject is reminded to engage the quadriceps and hips and maintain
control to prevent injury while improving flexibility.

MAIN WORKOUT:

1. BARBELL SQUATS:
- Perform 3 sets of 6-8 reps with a 3-second eccentric contraction.
- The subject is directed to use a weight that challenges them to control the
descent phase (eccentric contraction) of the squat.
 - Stand with feet shoulder-width apart, holding the barbell across the upper
back.
- Keeping the chest up and core engaged, the subject is asked to lower the
body slowly over a period of 3 seconds by bending the knees and pushing the
hips back as if sitting into a chair, emphasizing the eccentric phase.
- Lower until thighs are parallel to the ground, then push through the heels to
return to the starting position.

2. LEG PRESS:
- Perform 3 sets of 8-10 reps with a 3-second eccentric contraction.
- The subject is instructed to use a challenging weight that allows for
controlled eccentric contractions.
- Sit on the leg press machine with feet shoulder-width apart on the platform.
- Release the safety bars and lower the platform slowly over a period of 3
seconds until knees are at a 90-degree angle, emphasizing the eccentric phase.
- Push through the heels to extend the legs and lift the weight, then slowly
lower it back down with control.

3. DUMBBELL LUNGES:
- Perform 3 sets of 8-10 reps per leg with a 3-second eccentric contraction.
- The subject is directed to hold a dumbbell in each hand by their sides.
- Take a large step forward with one leg, lowering the body slowly over a
period of 3 seconds until both knees are bent at a 90-degree angle, focusing on
the eccentric contraction.
- Push through the front heel to return to the starting position, then repeat on
the other side.

4. LEG EXTENSIONS:
- Perform 3 sets of 10-12 reps with a 3-second eccentric contraction.
- The subject is asked to use a weight that challenges them during the
eccentric phase.
 - Sit on the leg extension machine with knees bent at a 90-degree angle.
- Extend the legs to lift the weight, then lower it back down slowly over a
period of 3 seconds with control, focusing on the eccentric contraction.

By incorporating a 3-second eccentric contraction into each repetition,

quadriceps can be effectively targeted while also inducing DOMS. Ensuring
proper form is maintained throughout each repetition to prevent injury and
maximize the effects of eccentric training.

BASELINE ASSESSMENT PROCEDURE:

Indirect Muscle-Damage Markers:

Introduction: Indirect muscle-damage markers provide objective measures
to assess the physiological impact of strenuous exercise on muscle tissue,
which is pertinent to understanding the efficacy of interventions in
alleviating DOMS.

- Maximal Voluntary Isometric Contraction (MVIC) Torque:

Justification: MVIC torque is a reliable indicator of muscle strength and
function, essential for assessing the effectiveness of interventions in
restoring muscle function post-exercise.

Procedure:
 Set up the isometric dynamometer according to manufacturer
instructions.
  Instruct the participant to sit comfortably and stabilize themselves
using handles or straps.
 Align the dynamometer axis with the tested joint (e.g., knee for
quadriceps assessment).
 Demonstrate the MVIC test procedure and provide verbal
instructions.
 Guide the participant through a brief warm-up and familiarization
trials.
 Instruct the participant to exert maximum force against the
dynamometer for 3-5 seconds.
 Record the peak torque value displayed on the dynamometer.
 Repeat the test for each assessed muscle group (e.g., quadriceps).

Range of Motion (ROM):

Justification: ROM assessments evaluate joint flexibility and mobility,
providing insights into the impact of interventions on muscle recovery and
flexibility.
Procedure:
 Position the participant in a standardized posture for ROM
assessment (e.g., supine for knee flexion).
 Identify anatomical landmarks and reference points for consistent
measurements.
 Use a goniometer or inclinometer to measure joint angles at the
start and end of ROM.
 Instruct the participant to perform active or passive movements to
their maximum comfortable extent.
 Align the goniometer axis with the joint axis and record the
corresponding angle.
 Repeat the measurement for each assessed joint (e.g., knee flexion
and extension).

Serum Creatine Kinase (CK) Activity:

Justification: Serum CK activity serves as a biomarker of muscle damage,
crucial for assessing the extent of muscle injury and recovery post-
exercise, thereby informing the efficacy of interventions.
Procedure:
 Obtain informed consent and explain the blood collection procedure
to the participant.
 Cleanse the participant's skin with an antiseptic swab at the selected
venipuncture site.
 Use a sterilrre needle and syringe to collect a blood sample from a
peripheral vein.
 Transfer the blood sample into a labeled serum separator tube (SST).
 Centrifuge the SST according to standard protocols to separate
serum from cellular components.
 Transfer the serum aliquot into a labeled storage vial and store it at
the recommended temperature.
 Transport the serum samples to the laboratory for analysis of CK
activity using validated assays.
 Record the CK activity level obtained from the laboratory report.

Assessment of Muscle Pain:

Introduction: Assessing muscle pain perception is essential for
understanding the subjective experience of discomfort, a primary outcome
in evaluating interventions for DOMS relief.

VISUAL ANALOG SCALE (VAS):

Justification: The VAS provides a subjective measure of pain intensity,
vital for assessing the effectiveness of interventions in reducing DOMS-
related pain.
Procedure
 Present the VAS to the participant and explain how to use it.
 Provide verbal instructions for marking the scale, emphasizing the
endpoints.
 Ask the participant to indicate their current level of pain by placing a
mark on the line.
 Measure the distance from the "no pain" end of the line to the
participant's mark.
 Record the distance as the VAS score, ranging from 0 (no pain) to 10
(worst pain imaginable).

-CATEGORY RATIO-10 SCALE (CR-10):

Justification: The CR-10 scale offers a categorical rating system for pain
severity, facilitating a comprehensive evaluation of pain perception post-
intervention.
Procedure:
 Present the CR-10 scale to the participant and explain the numeric
rating system.
 Describe the verbal descriptors corresponding to each numeric value
(e.g., 0 = "no pain," 10 = "worst pain imaginable").
 Ask the participant to select the number that best represents their
current level of pain.
 Record the chosen numeric value as the CR-10 score, ranging from 0
to 10.

PRESSURE-PAIN THRESHOLDS (PPTS):

Justification: PPTs offer an objective measure of pain sensitivity, aiding
in assessing the efficacy of interventions in modulating pain perception
associated with DOMS.
Procedure:
 Prepare a pressure algometer or handheld pressure device for PPT
assessment.
 Identify predetermined anatomical sites for PPT measurement (e.g.,
quadriceps muscle belly).
 Apply the pressure device perpendicularly to the skin at each
identified site.
 Increase pressure gradually at a standardized rate (e.g., 1 kg/cm² per
second).
 Instruct the participant to indicate when they first perceive pressure
as pain.
 Record the pressure value displayed on the device at the onset of
pain.
 Repeat the measurement at multiple sites to create a pain map of the
assessed region.

This adapted baseline assessment procedure aligns with your research

focus on evaluating the impact of self-stretching techniques with
cryotherapy versus self-stretching techniques with TENS on alleviating
DOMS of the quadriceps muscle following strenuous exercise. It
incorporates objective measures of muscle damage markers and subjective
assessments of muscle pain perception to comprehensively evaluate the
efficacy of interventions in managing DOMS.