Feb 11, 2015

New Research Continues to Support the Ending of an “Ice-Age”.

-Thanks for pic, WebMD.com

Hating on cryotherapy or “icing” musculoskeletal injuries seems to be the flavor of the month thing to do. Decades of conventional wisdom has told us that everything should be iced immediately after injury. RICE & PRICE were so-so nice we thought. However, when held under the light of scientific inquiry the evidence for cryotherapy was found to be on thin ice.

This blog post today isn’t going to be a rehash of previous arguments against cryotherapy. Here is a recent post by Josh Stone, MA, ATC where he gave his top 10 reasons to cease the cryotherapy craze. Instead, today I am going to discuss a recently published study on cryotherapy. This study by Selkow et al1 was just published early online by the Journal of Athletic Training. 

What did they investigate?

The authors wanted to investigate the effect of repeated cryotherapy treatments on microvascular perfusion after a bout of eccentric exercise. Why eccentric exercise? They did this because it has been previously shown in the literature that eccentric exercise results in increased blood flow just like the vasodilation associated with musculoskeletal injury. Therefore, this study would look directly at a very common clinical scenario (using cryotherapy on an acute episode of local inflammation.).

In this article the authors used a single-blind randomized controlled trial study design. They recruited 18 healthy subjects for this study and divided them into three separate groups (intervention, sham, and control.). If you are looking to find a good level of evidence when it comes to studies this is grade A stuff. The investigators were the ones blinded to the intervention not the subjects. I can imagine it would be difficult to blind a subject from whether or not they were receiving cryotherapy and that is why the authors didn’t use a double-blinded study design.

How did they investigate it?

The authors used microbubble infusion via an intravenous catheter that was measured using ultrasound imaging. This allowed the investigators to determine blood flow/local perfusion. After establishing a baseline, the subjects performed an eccentric exercise protocol. Within 1 minute of finishing the eccentrics the subjects were provided with the intervention (ice, sham, or control) depending on their random group allocation. 

After applying the intervention, perfusion was once again measured using the microbubbles and ultrasound. This began within 30seconds of completing the intervention. After this the participants returned 10, 24, and 48 hours after the initial intervention to reassess pain using a visual analog scale (VAS) before undergoing another intervention session (the same as the first, depending on their group placement). This closely mimicked what may be seen in an athletic training or by a person following traditional RICE advice at home.

Kind of like this...but not quite.

So What Did They Find Out?

The authors found out that there was NO difference in the amount of microvascular perfusion between the different intervention groups. This means a sham ice modality, doing nothing at all, and a bag of ice all had the exact same influence when it came to perfusion levels. In other words, the cryotherapy treatment was useless in terms of influencing perfusion. However, there was a difference between pain levels as assessed using the VAS. This was not much of a surprise considering cryotherapy has previously been noted for its ability to influence pain levels.

What does this all mean?

It is just another piece of evidence to support the idea that icing may not be doing what we thought it was doing. Specifically, cryotherapy does not seem to make a big difference in local blood flow after injury. Especially when considered in the light of an eccentric exercise model in this case. However, cryotherapy still remains a viable modality to alter pain perception within patients. While cryotherapy may not fix anything it may still be an option to modulate pain or suffering associated with experiencing a musculoskeletal injury.


I want people to realize that ice does currently have a time and a place. However, that place may not be where we once thought it was. Despite cryotherapy not changing bloodflow it does a great job of modulating pain. Additionally, cryotherapy has recently been found to be a great modality for treating arthrogenic muscle inhibition...Specifically in the quadriceps after knee injury. So ice is still cool for some mechanisms! Remember that! 

  1. Selkow, N. M., et al. (2015). "Blood Flow After Exercise-Induced Muscle Damage." J Athl Train.


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