Objective: To determine if ice-water immersion after eccentric quadriceps exercise minimises the symptoms ofdelayed-onset muscle soreness (DOMS).
Design: A prospective randomised double-blind controlled trial was undertaken. 40 untrained volunteersperformed an eccentric loading protocol with their non-dominant leg.Interventions: Participants were randomised to three 1-min immersions in either ice water (5¡1°C) or tepidwater (24°C).
Main outcome measures: Pain and tenderness (visual analogue scale), swelling (thigh circumference),function (one-legged hop for distance), maximal isometric strength and serum creatine kinase (CK) recordedat baseline, 24, 48 and 72 h after exercise. Changes in outcome measures over time were compared todetermine the effect of group allocation using independent t tests or Mann–Whitney U tests.
Results: No significant differences were observed between groups with regard to changes in most painparameters, tenderness, isometric strength, swelling, hop-for-distance or serum CK over time. There was asignificant difference in pain on sit-to-stand at 24 h, with the intervention group demonstrating a greaterincrease in pain than the control group (median change 8.0 vs 2.0 mm, respectively, p = 0.009).
Conclusions: The protocol of ice-water immersion used in this study was ineffectual in minimising markers ofDOMS in untrained individuals. This study challenges the wide use of this intervention as a recovery strategyby athletes.
Ice-water immersion and delayed-onset muscle soreness: a
randomised controlled trial
Kylie Louise Sellwood, Peter Brukner, David Williams, Alastair Nicol, Rana Hinman
See end of article forauthors affiliations........................
Correspondence to:Dr K L Sellwood, SportsPhysicians ACT, Deakin,ACT 2600, Australia;firstname.lastname@example.org
Accepted 9 January 2007Published Online First29 January 2007........................
Br J Sports Med2007;41:392397. doi: 10.1136bjsm.2006.033985
Objective:To determine if ice-water immersion after eccentric quadriceps exerciseminimises the symptoms of
delayed-onset muscle soreness (DOMS).Design:A prospective randomised double-blind controlled trial was undertaken.40 untrained volunteers
performed an eccentric loading protocol with their non-dominant leg.Interventions:Participants were randomised to three 1-min immersions in either ice water(51C) or tepid
water (24C).Main outcome measures:Pain and tenderness (visual analogue scale), swelling (thigh circumference),
function (one-legged hop for distance), maximal isometric strength and serum creatine kinase (CK) recorded
at baseline, 24, 48 and 72 h after exercise. Changes in outcome measures over time were compared to
determine the effect of group allocation using independent t tests or MannWhitney U tests.Results:No significant differences were observed between groups with regard to changes in most pain
parameters, tenderness, isometric strength, swelling, hop-for-distance or serum CK over time. There was a
significant difference in pain on sit-to-stand at 24 h, with the intervention group demonstrating a greater
increase in pain than the control group (median change 8.0 vs 2.0 mm, respectively, p = 0.009).Conclusions:The protocol of ice-water immersion used in this study was ineffectual in minimising markers of
DOMS in untrained individuals. This study challenges the wide use of this intervention as a recovery strategy
elayed-onset muscle soreness (DOMS) is pain or dis-
comfort that typically occurs 12 days after unaccus-
tomed eccentric loading of skeletal muscle,13and
generally resolves within a week of the inciting activity.4
Recreational and elite athletes experience DOMS after unac-
customed exercise involving an eccentric muscle-loading
component, and this occurs often after introduction of a new
phase or type of training. It is well documented that eccentric
contraction produces greater muscle damage and strength
deficits than concentric or isometric contractions.56This
damage is evident as disruption of the normal banding patterns
(alignment) of skeletal muscle and broadening or complete
disruption of sarcomere Z lines.79Muscle cell damage allows
release of enzymes including creatine kinase (CK), with serum
CK consistently increased within 13 days of eccentric exer-
cise,51011and contributes to strength deficits seen in
DOMS.91213Oedema or swelling, as a result of production of
prostaglandin E2, has been observed in eccentrically exercised
muscle at 24, 48 and 72 h.1417Prostaglandin E2 also sensitises
the group IV afferent fibres of muscle connective tissue,
responsible for transmitting dull aching pain to the central
nervous system.18This sensitisation in DOMS may result in
allodynia.4 9 1922
Owing to a wide range of clinical features associated with
DOMS, such as strength deficits and stiffness of adjacent joints,
as well as the lack of understanding of the underlying
pathophysiology, many recovery strategies have been used by
athletes, coaching staff and health professionals alike, in an
attempt to minimise the symptoms and signs of this syndrome.
Such strategies include massage,23 24stretching225and anti-
inflammatory medications.26 27Studies to date have demon-
strated mixed results of these treatments on DOMS, mostly
with minimal analgesic effects, and inconsistent effects on
strength, joint range and CK levels.
Cryotherapy has long been used to treat musculoskeletal
soreness with the expectation that decreased tissue tempera-
ture will result in constriction of local blood vessels, thus
diminishing inflammatory response and oedema associated
with musculoskeletal trauma.3Complete ice-water immersion
of the affected muscle theoretically maximises the therapeutic
effect of the reduced temperature. Accordingly, ice-water
immersion is frequently used in sports medicine, particularly
among high-level athletes, in an effort to minimise DOMS.22 31
Anecdotal reports suggest that ice-water immersion may have a
positive effect on muscle soreness after an intense or
unaccustomed training session, allowing athletes to continue
to train at peak intensity over subsequent days. Several studies
have investigated cold-water immersion in the prevention of
DOMS,28 29and results regarding the benefit of this practice are
inconclusive. These studies have methodological limitations in
their use of small sample sizes, inadequate blinding, resistance-
trained subjects and variable eccentric exercise protocols,
making it difficult to evaluate the effectiveness of this
treatment. Furthermore, the ice-water immersion studies to
date have used treatment protocols that are of limited clinical
relevance owing their use of repeated immersions over several
days after exercise.2830Current practice among high-level sports
in Australia is to use 1 min immersion in ice water, followed by
1 min out for a total of three cycles immediately after exercise.
Despite its widespread use, this ice-water immersion protocol
has not been evaluated, and evidence attesting to its efficacy is
The aim of this study was to evaluate the efficacy of a
commonly used protocol for ice-water immersion for the
prevention of DOMS, using the rigour of a randomised
Abbreviations:CK, creatine kinase; DOMS, delayed-onset musclesoreness; VAS, visual analogue scale
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controlled trial. It was hypothesised that, compared with tepid
water, ice-water immersion would minimise pain, swelling,
functional and strength deficits, and muscle damage after
eccentric quadriceps exercise.
A randomised controlled trial was performed to compare the
effects of ice-water (51C) and tepid-water (24C) immer-
sion on markers of DOMS after a bout of unaccustomed
eccentric quadriceps exercise.
Participants responded to poster advertisements distributed
throughout the Schools of Physiotherapy and Medicine,
University of Melbourne, Melbourne, Victoria, Australia.
Adults aged.18 years were eligible for inclusion. Exclusion
criteria included a history of eccentric quadriceps exercise in the
past 3 months, a history of quadriceps muscle tear, neurological
disease involving the lower limbs, current lower-limb musculo-
skeletal injury and inability to understand English. Participants
with potential vascular problems for which ice-water immer-
sion is contraindicated (eg, diagnoses of diabetes or Raynauds
disease) were also excluded.
The University of Melbourne Human Research Ethics
Committee approved the study and all participants provided
written informed consent. All outcome assessments were
performed at The Centre for Health Exercise and Sports
Medicine. The non-dominant quadriceps only was used tomaximise the likelihood of DOMS occuring.
Randomisation and maskingThe randomisation sequence was generated using a randomnumbers table and allocation was concealed using sequentiallynumbered opaque envelopes held at a central location. Theinvestigator responsible for the outcome assessments wasblinded to group allocation, and participants were advised notto reveal their group allocation to the investigator. Participantswere blinded as to which intervention was consideredtherapeutic.
Eccentric exercise protocolThe exercise protocol was carried out on a seated leg extensionmachine using the test leg only. The one-repetition maximumweight lifted concentrically was determined for each partici-pant. In all, 120% of the one-repetition maximum wascalculated and used as the weight to be lowered eccentricallyusing the test leg. Each participant completed 5 sets of 10repetitions in total, with a 1 min rest allowed in between eachset.
InterventionsWater immersion was carried out immediately after theeccentric exercise protocol. Participants stood submerged tothe level of the anterior superior iliac spines. Participantsrandomised into the treatment group were immersed inmelting iced water at 51C. Those in the control group wereimmersed in tepid water at 24C. Participants remained in thebath for 1 min, followed by 1 min out of the bath. This cyclewas repeated three times.
Outcome measuresAll outcome measures were recorded at baseline, and 24, 48 and72 h after the eccentric exercise protocol.
Pain and tenderness in the test leg quadriceps muscleusing the visual analogue scaleThe visual analogue scale (VAS) was an unmarked horizontal100 mm line with the terminal descriptors no pain andworst pain possible. Pain was rated with a single vertical lineon the scale for the activities of sit to stand, passive quadriceps
Table 1Characteristics of participants in the study
Control(n = 20)Intervention(n = 20) t Value p Value
Age (years) 21.0 (3.1) 21.4 (4.3) 0.63*Height (m) 1.67 (0.08) 1.68 (0.08)20.176 0.85Weight (kg) 64 (9) 63 (11) 0.330 0.35BMI (kgm2) 23 (2) 22 (3) 0.731 0.14Male:female 4:16 7:13 0.29
BMI, body mass index.*Values are mean (SD).MannWhitney U test.Pearsonsx2.
Table 2Results of MannWhitney U test for baseline comparisons of outcome measuresbetween control and intervention groups
Control (n = 20) Intervention (n = 20) p Value
Pain (mm)Sit-to-stand 0.0 (0.00.8) 0.0 (0.00.0) 0.24Passive stretch 1.0 (0.05.0) 2.0 (0.09.5) 0.42Hopping 0.5 (0.03.0) 0.0 (0.02.0) 0.69Running 0.0 (0.01.0) 0.0 (0.00.0) 0.43Isometric strength 8.0 (0.022.5) 4.5 (1.317.5) 0.84
Tenderness (mm)Mid-belly 5.5 (0.015.3) 3.0 (0.09.0) 0.43Musculotendinous 1.0 (0.07.8) 1.0 (0.04.5) 0.88
Circumference (mm)Mid-belly 555 (531569) 540 (489570) 0.21Musculotendinous 407 (391426) 394 (369415) 0.28*
Serum CK (IUl) 119.5 (64.0133.0) 106.0 (71.8186.5) 0.47Hop (m) 1.9 (1.72.1) 1.8 (1.62.3) 0.94Torque (N.m) 145.2 (113.3162.3) 132.6 (120.2158.0) 0.71
CK, creatine kinase.Data reported as median (interquartile range).*Independent t test.
Ice-water immersion and DOMS393
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stretch, one-legged hop-for-distance test, running and maximal
Tenderness was assessed using a pressure algometer (Pain
Diagnostics and Thermography, Italy) exerting a standard
force of 6 lbcm2, at two reference points marked on the thigh
along a line drawn from the anterior superior iliac spines to
the superior pole of the patella. One point was at the mid-
point of this line (representing the mid-belly of the rectus
femoris), and the other at 5 cm above the superior pole of the
patella (representing the musculotendinous junction).
Participants were asked to rate their tenderness at each point
on a VAS.
Measures of thigh circumference were used to indicate swelling
of the quadriceps muscle at each of the two reference points
marked as above. The mean of three measures was determined
at each point.
Table 4Changes in pain and tenderness ratings (on 0100 mm visual analogue scale)overtime at 24, 48 and 72 h after exercise, by group
Pain (mm) Control (n = 20) Intervention (n = 20) z Score p Value
Sit-to-stand24 h 2.0 (0.08.8) 8.0 (2.534.0)22.61 0.009*48 h 2.5 (0.310.5) 11.5 (1.526.0)21.97 0.0572 h 0.0 (0.02.0) 1.0 (0.010.5)21.57 0.12
Passive stretch24 h 4.5 (20.88.5) 12.5 (3.537.3)22.59 0.01048 h 4.0 (0.010.0) 10.5 (6.324.5)22.04 0.04172 h 0.5 (23.53.8) 4.5 (0.07.8)21.68 0.093
Hopping24 h 7.0 (2.09.5) 13.5 (5.526.5)21.32 0.1948 h 5.5 (1.010.5) 11.5 (3.325.0)21.69 0.09372 h 1.0 (20.86.3) 3.5 (0.07.8)21.23 0.22
Running24 h 4.0 (0.012.8) 17.5 (3.526.0)22.08 0.03848 h 6.5 (1.015.8) 17.0 (3.829.8)21.71 0.08872 h 1.0 (0.04.0) 1.0 (0.011.8)20.99 0.32
Isometric contraction24 h 9.0 (1.520.8) 25.0 (8.540.5)21.83 0.06848 h 1.0 (25.819.5) 16 (1.044.0)21.92 0.05472 h24.5 (213.810.8) 4.0 (23.817.8)21.69 0.091
Tenderness mid-belly (mm)24 h 4.5 (0.011.5) 7.5 (0.319.8)20.96 0.3448 h 4.0 (0.011.8) 8.0 (3.020.3)21.27 0.2072 h 0.0 (22.88.5) 5.5 (0.016.5)21.57 0.12
Tendernessmusculotendinous (mm)24 h 1.0 (21.57.5) 4.5 (0.513.3)21.88 0.06148 h 3.5 (20.810.8) 3.0 (0.010.8)20.42 0.6772 h 0.0 (23.83.0) 0.0 (20.88.5)21.02 0.31
CK, creatine kinase.Values are median (interquartile range).*p,0.01.
Table 3Within group comparisons of pain scores over time, reported as median(interquartile range)
Pain (mm) Baseline 24 h z Score p Value
Passive stretchControl (n = 20) 1.0 (0.05.0) 6.0 (2.316.0)21.995 0.046Intervention (n = 20) 2.0 (0.09.5) 16.5 (4.056.0)23.827,0.001
Maximal isometric contractionControl (n = 20) 8.0 (0.022.5) 26.5 (8.341.8)22.919 0.004Intervention (n = 20) 4.5 (1.317.5) 38.0 (13.855.0)23.679,0.001
Serum CK (IUl)Control (n = 20) 120 (64133) 150 (117221)23.584,0.001Intervention (n = 20) 106 (72187) 180 (89306)23.361 0.001
Mean (SD) maximal isometric strength (N.m)Control (n = 20) 147 (40) 129 (30)23.173 0.002Intervention (n = 20) 148 (52) 136 (40)22.240 0.025
CK, creatine kinase.
394Sellwood, Brukner, Williams, et al
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Functional performanceThe one-legged hop-for-distance test31 32was used to assessquadriceps function. The maximum distance obtained fromthree hopping attempts was recorded. Maximal isometricquadriceps strength was also evaluated using a KinComisokinetic dynamometer (Chattecx Corporation, Chattanooga,Tennessee, USA). Isometric testing was performed at 60kneeflexion. The peak force obtained from three attempts wasrecorded in newtons (N), and multiplied by the lever armlength in metres (m) to obtain the peak torque in N.m.
Serum CKSerum CK samples were obtained as a marker of muscledamage. Samples were analysed using an Olympus2 vial CKreagent (Integrated Sciences, New South Wales, Australia;Catalogue Number OSR6179; 4624 ml R1, 466 ml R2).
Sample sizeWe aimed to detect a 25% reduction in pain at 48 h with ice-water immersion. A previous study reported a mean increase inpain of 69 mm on the VAS at 48 h in individuals receiving nointervention after eccentric exercise.25Assuming a mean(SD)increase in pain of only 52(16) mm in the intervention group,30 participants in all were required to demonstrate a significantdifference between groups using an independent t test(significance level of 0.05 and 80% power). The sample sizewas increased to 40 to allow for any dropouts or missing data.
Data analysisData were analysed using SPSS software version 14 on anintention-to-treat basis. Data were checked for normality beforeanalysis. Groups were compared at baseline with regard toparticipants characteristics and outcome measures usingMannWhitney U tests,x2tests, and independent t tests. Thelast observation carried forward was used to impute datamissing at reassessment. To assess whether DOMS hadoccurred, Wilcoxons signed ranks tests were used to determinesignificant changes in variables within groups from baseline to
24 h using analevel of 0.05. To evaluate the effects of theintervention, changes in scores for each outcome weredetermined between baseline and the subsequent threereassessments. Changes in outcome measures over time werecompared between groups using independent t tests or MannWhitney U tests. A more conservativealevel of 0.01 was used toprotect against type 1 error, given the multiple comparisonsperformed on the dataset.
RESULTSTable 1 summarises the characteristics of participants in thestudy. No significant difference was noted between theparticipants in the two treatment groups at baseline withregard to age, height, weight or body mass index. Participantsin both groups reported similar scores on all outcome measuresat baseline and there were no significant differences betweengroups (table 2).
Exercise protocol and DOMSThe eccentric exercise protocol was successful in producingDOMS as indicated by the significant changes from baseline to24 h in pain with passive stretch, pain with maximal isometriccontraction, serum CK and muscle strength (table 3). Pain withpassive stretch was significantly increased in both groups at24 h after eccentric exercise compared with baseline (p = 0.046for controls and p,0.001 for the intervention group), as waspain with maximum isometric contraction (p = 0.004 andp,0.001, respectively). Both groups showed a significantincrease in serum CK at 24 h (p,0.001 and p = 0.001,respectively), and a significant decrease in maximum isometricstrength (p = 0.002 and 0.025, respectively).
Effect of ice-water immersion on outcome measuresTable 4 shows that participants in the intervention groupdemonstrated a greater increase at 24 h in pain on sit-to-standthan those in the control group (median change 8.0 vs 2.0 mmrespectively, p = 0.009). No significant differences were evidentbetween control and intervention groups at any time point with
Table 5Comparison of changes in other outcome measures across time (24, 48 and 72 hafter exercise)
Control (n = 20) Intervention (n = 20) z Score p Value
Serum CK (IUl)24 h 42.0 (10.397.0) 38.0 (13.878.3)20.24 0.8148 h 24.0 (214.071.3) 11.0 (24.523.5)21.25 0.2172 h 17.0 (24.558.3) 8.5 (231.533.8)21.07 0.29
Thigh circumference mid-belly (mm)24 h 1.7 (6.5) 2.4 (7.2)20.322 0.7548 h 1.1 (7.0) 4.0 (5.7)21.436 0.1672 h 2.1 (5.9) 2.2 (6.1)20.053 0.96
Thigh circumference musculotendinous (mm)24 h 2.0 (5.1) 1.3 (5.4) 0.420 0.6848 h 1.7 (6.1) 1.0 (5.9) 0.368 0.7272 h 2.8 (5.5) 1.0 (5.1) 1.076 0.29
One-legged hop for distance (m)24 h20.08 (0.08)20.07 (0.11)20.492 0.6348 h20.08 (0.09)20.05 (0.13)20.996 0.3372 h20.08 (0.11)20.03 (0.12)21.366 0.18
Maximal isometric strength (N.m)24 h217.4 (20.5)211.5 (22.5)20.858 0.4048 h25.5 (22.1)24.4 (19.5)20.159 0.8872 h 1.8 (22.1)20.3 (28.3) 0.267 0.79
p,0.01.Values are either median (interquartile range) or mean (SD).
Ice-water immersion and DOMS395
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regard to all other pain measures. No significant differences
were evident between control and intervention groups at anytime point with regard to serum CK, thigh circumference, one-
legged hop for distance or isometric strength (table 5).
Despite the lack of scientific evidence supporting the use of ice-water immersion to prevent DOMS in the sporting environ-
ment, it remains widely used in clinical practice as a recovery
technique.22 33Although treatment protocols vary with regard to
the duration and frequency of immersions and the temporalrelationship with exercise, anecdotal evidence suggests that the
most commonly used protocol in Australia involves 1 min ice-
water immersion followed by 1 min out of water for a total of
three cycles, applied immediately after a bout of exercise. Weaimed to test the efficacy of this common clinical protocol. Our
double-blind randomised controlled trial demonstrated that in
a group of untrained healthy volunteers, ice-water immersion
produced no significant change in most markers of DOMS. Theonly exception to this was pain on concentric quadriceps
contraction at 24 h, which was actually increased in the
intervention group compared with controls, contrary to the
hypothesis at the study outset. However, the small magnitudeof this difference in pain between groups is of questionable
Serum CK is accepted widely as a marker of muscledamage.11 3436In the current study, a peak median CK increase
of 170% from baseline occurred at 24 h. This suggests that the
eccentric exercise protocol used was successful in eliciting
muscle damage, although peak increases up to 600% have beenreported in other studies with more aggressive eccentric
quadriceps loads.2563738Increases in pain and reductions in
quadriceps strength at 24 h in both groups further attest to the
success of the exercise protocol in inducing DOMS.
Pain was the only parameter significantly influenced by the
treatment in our study, and contrary to expectation, ice-water
immersion actually increased the severity of pain after 24 h ofeccentric exercise. It is unclear why pain increased in
participants subjected to ice-water immersion. A noxious cold
stimulus such as ice-water immersion is known to evoke varied
sensory experiences in humans including cold, pain, ache andprickling, which are mediated by thermoreceptors and noci-
ceptors.39Temperatures,15C are associated with additional
perceptions of pain and ache as well as cold, and peak painsensation occurs at a temperature of approximately 3C for at
least 10 s.39Application of noxious cold stimulus for.1 min
may also stimulate vascular and muscle nociceptors. The ice-
water immersion group in the current study may have thereforeexperienced a significant painful stimulus at the time of
immersion. The experience of pain is determined by both
physiological and psychological influences, and the meaning or
context that a subject attaches to a particular stimulus caninfluence the subjective interpretation of the pain they experi-
ence.40 41Thus, the ice-water immersion group may have had a
heightened subjective interpretation of discomfort on performing
the sit-to-stand activity (which was the first outcome reassessedat 24 h) secondary to both their expectation of being sore as a
result of the exercise on the previous day and the significant
additional pain experienced during immersion.
Contrary to the research hypothesis, the ice-water immersion
protocol used in the current study did not influence CK levels. It
is likely that a bout of immersion immediately after exercise as
used in the current study would not have had a sustained effecton vessel permeability and was therefore unlikely to influence
CK efflux from the damaged muscle on subsequent days. This
may also explain why there was no effect on swelling over
The lack of a treatment effect for other outcomes may be due
to the eccentric exercise protocol inducing only low levels of
muscle damage. This is reflected by relatively low pain scores,
small percentage strength deficits and small CK increases after
exercise (tables 4 and 5). In comparison with other studies,
which have demonstrated mean VAS scores of up to 71 mm
after exercise with 10 sets of 10 maximal hamstring contrac-
tions,25for example, the control group in the current study
achieved only a maximum of 27 mm of pain (on isometric
contraction at 24 h), and the intervention group a maximum of
38 mm (again on isometric contraction at 24 h). The strength
deficits observed in this study were also small compared with
other studies of DOMS which demonstrated 2540% strength
reduction at 24 h and increases in mean CK of 278600% above
baseline25630. Thus, because of the small strength deficits
induced, there was limited capacity for the treatment to be
effective, which is likely to have contributed to the non-
With all physical activity there is a psychological component
that can enhance performance,42particularly in elite athletes
who use many different types of recovery strategies that have
little evidence behind them. What may be considered beneficial
by one athlete as a recovery technique is not necessarily of any
perceived benefit to another. Over time, athletes develop their
own rituals of preparation and recovery that they use before
and after every competition performance or training bout. The
perceived psychological benefit of using a familiar recovery
technique may have a greater influence on performance than
perhaps the actual physiological benefit of that technique.
Although the present study used a control intervention in tepid
water to account for these potential placebo effects of ice-water
immersion, the study sample did not include athletes, so it is
possible that different results would be obtained in a group of
The main strength of this study was the use of a rigorous
double-blind randomised control design, which included a
control intervention (tepid water bath) to assess the effects of
temperature alone with few confounders. Another strength of
this study is that it evaluated a clinically feasible treatment
regimen that is commonly used in Australia.
What is already known on this topic
NIce-water immersion is a commonly used treatment in
sporting populations, believed to limit the inflammatory
response after muscle damage mainly through a
NPrevious literature evaluating the effect of ice-water
immersion on eccentrically induced muscle damage
contains conflicting results involving poorly justified
protocols of immersion that are also impractical to apply.
What this study adds
NThis study challenges the use of ice-water immersion in
athletes, given that for eccentric exercise-induced muscle
damage, ice-water immersion offers no benefit for pain,
swelling, isometric strength and function, and in fact may
make athletes more sore the following day.
396Sellwood, Brukner, Williams, et al
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Future research may involve repeating the current study with
a more damaging eccentric exercise protocol to be able to
determine significant differences between treatment and
placebo interventions for all outcome measures.
Future research may focus on specific groups of elite athletes
who regularly use ice-water immersion and develop reliable
functional measures for each group that may demonstrate more
subtle objective deficits resulting from muscle soreness. It
would be valuable to assess athletes in their chosen sport to
determine the specific muscle symptoms that result from an
intense competition performance as it may be possible to
identify a reliable model of sports-induced muscle damage, and
reliable outcome measures that are affected by muscle soreness.
From this, the effects of various interventions such as ice-water
immersion could be properly assessed in sports-induced muscle
In conclusion, this study challenges the use of this interven-
tion as a recovery strategy by athletes given that ice-water
immersion to minimise or prevent symptoms of muscle damage
after eccentric exercise is ineffectual in young, relatively
untrained individuals. Given that trained athletes are relatively
well protected against DOMS, ice-water immersion is likely to
offer them even less benefit for the minimal soreness they may
experience after eccentric exercise.
ACKNOWLEDGEMENTSWe thank St Vincents Pathology, Victoria Parade, Melbourne, Victoria,Australia, for blood analysis of serum CK.
Kylie Louise Sellwood,Sports Physicians ACT, Deakin, AustraliaPeter Brukner, David Williams, Alastair Nicol, Rana Hinman,University ofMelbourne, Melbourne, Victoria, Australia
Competing interests: None declared.
REFERENCES1Ebbeling C, Clarkson P. Exercise-induced muscle damage and adaptation.SportsMed1989;7:20734.2Lund H, Vestergaard-Poulsen P, Kanstrup I,et al.The effect of passive stretchingon delayed onset muscle soreness, and other detrimental effects followingeccentric exercise.Scand J Med Sci Sports1998;8:21621.3Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness. Treatmentstrategies and performance factors.Sports Med2003;33:14564.4Armstrong R. Mechanisms of exercise-induced delayed muscular soreness: abrief review.Med Sci Sports Exerc1984;16:52938.5Schwane J, Johnson S, Vandenakker C,et al.Delayed-onset muscular sorenessand plasma CPK and LDH activities after downhill running.Med Sci Sports Exerc1983;15:516.6Golden C, Dudley G. Strength after bouts of eccentric or concentric actions.MedSci Sports Exerc1992;24:92633.7Friden J, Sjostrom M, Ekblom B. Myofibrillar damage following intense eccentricexercise in man.Int J Sports Med1983;4:1706.8Stauber W. Eccentric action of muscles: physiology, injury and adaptation. In:Kandolph KB, eds.Exercise and sports sciences reviews. Baltimore, MD: Williamsand Wilkins, 1989;17:15785.9Proske U, Morgan D. Muscle damage from eccentric exercise: mechanism,mechanical signs, adaptation and clinical applications.J Physiol2001;537:33345.10Clarkson P, Tremblay I. Exercise-induced muscle damage, repair, andadaptation in humans.J ApplPhysiol1988;65:16.
11Nosaka K, Newton M, Sacco P. Delayed-onset muscle soreness does not reflectthe magnitude of eccentric exercise-induced muscle damage.Scand J Med SciSports2002;12:33746.12Morgan D, Allen D. Early events in stretch-induced muscle damage.J ApplPhysiol1999;87:200715.13Morgan D, Proske U. Popping sarcomere hypothesis explains stretch-inducedmuscle damage.Clin Exp Pharmacol Physiol2004;31:5415.14Bobbert M, Hollander A, Huijing P. Factors in delayed onset muscle soreness ofman.Med Sci Sports Exerc1986;18:7581.15Friden J, Sfakianos P, Hargens A. Muscle soreness and intramuscular fluidpressure: comparison between eccentric and concentric load.J Appl Physiol1986;61:21759.16Cleak M, Eston R. Muscle soreness, swelling, stiffness and strength loss afterintense eccentric exercise.Br J Sports Med1992;26:26772.17Mekjavic I, Exner J, Tesch P,et al.Hyperbaric oxygen therapy does not affectrecovery from delayed onset muscle soreness.Med Sci Sports Exerc2000;32:55863.18Lanier A. Use of nonsteroidal anti-inflammatory drugs following exercise-induced muscle injury.Sports Med2003;33:17786.19Armstrong R, Ogilvie R, Schwane J. Eccentric exercise-induced injury to ratskeletal muscle.J Appl Physiol1983;54:8093.20Byrnes W, Clarkson P. Delayed onset muscle soreness and training.Clin SportsMed1986;5:60514.21Smith L. Acute inflammation: the underlying mechanism in delayed onset musclesoreness?Med Sci Sports Exerc1991;23:54251.22MacIntyre D, Reid W, McKenzie D. Delayed muscle soreness. The inflammatoryresponse to muscle injury and its clinical implications.Sports Med1995;20:2440.23Tiidus P, Shoemaker J. Effleurage massage, muscle blood flow and long termpost-exercise strength recovery.Int J Sports Med1995;16:47883.24Johagen S, Ackermann P, Eriksson T,et al.Sports massage after eccentricexercise.Am J Sports Med2004;32:1499503.25Johansson P, Lindstrom L, Sundelin G,et al.The effects of pre-exercise stretchingon muscular soreness, tenderness and force loss following heavy eccentricexercise.Scand J Med Sci Sports1999;9:21925.26Donnelly A, Maughan R, Whiting P. Effects of ibuprofen on exercise-inducedmuscle soreness and indices of muscle damage.Br J Sports Med1990;24:1915.27Stone M, Merrick M, Ingersoll C,et al.Preliminary comparison of bromelain andibuprofen for delayed onset muscle soreness management.Clin J Sport Med2002;12:3738.28Paddon-Jones D, Quigley B. Effect of cryotherapy on muscle soreness andstrength following eccentric exercise.Int J Sports Med1997;18:58893.29Eston R, Peters D. Effects of cold water immersion on the symptoms of exercise-induced muscle damage.J Sports Sci1999;17:2318.30Kuligowski L, Lephart S, Giannantonio F,et al.Effect of whirlpool therapy on thesigns and symptoms of delayed-onset muscle sorenss.J Athletic Train1998;33:2228.31Barber S, Noyes F, Mangine R,et al.Quantitative assessment of functionallimitations in normal and anterior cruciate ligament-deficient knees.Clin OrthopRelat Res1990;255:20414.32Ageberg E, Zatterrstrom R, Moritz U. Stabilometry and one-leg hop test havehigh test-retest reliability.Scand J Med Sci Sports, 1998;l8, 198202.33Connolly D, Sayers S, McHugh M. Treatment and prevention of delayed onsetmuscle soreness.J Strength Cond Res2003;17:197208.34Byrnes W, Clarkson P, White J,et al.Delayed onset muscle soreness followingrepeated bouts of downhill running.J Appl Physiol1985;59:71015.35Newham D, Jones D, Clarkson P. Repeated high-force eccentric exercise: effectson muscle pain and damage.J Appl Physiol1987;63:13816.36Balnave C, Thompson M. Effect of training on eccentric exercise-induced muscledamage.J Appl Physiol1993;75:154551.37Byrne C, Eston R. The effect of exercise-induced muscle damage on isometric anddynamic knee extensor strength and vertical jump performance.J Sports Sci2002;20:41725.38Byrne C, Eston R. Maximal-intensity isometric and dynamic exercise performanceafter eccentric muscle actions.J Sports Sci2002;20:9519.39Davis K, Pope G. Noxious cold evokes multiple sensations with distinct timecourses.Pain2002;98:17985.40Hirsch M, Liebert R. The physical and psychological experience of pain: theeffects of labeling and cold pressor temperature on three pain measures incollege women.Pain1998;77:418.41Arntz A, Claassens L. The meaning of pain influences its experienced intensity.Pain2004;109:205.42Brukner P, Khan K. Maximising performance. In:Psychology. Clinical sportsmedicine. Sydney: McGraw-Hill Book Company, 1993.
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