Whole-Body Cryotherapy in Athletes: From Therapy to Stimulation. An Updated Review of the Literature

ABSTRACT:

Nowadays, whole-body cryotherapy is a medical physical treatment widely used in sports medicine. Recovery from injuries (e.g., trauma, overuse) and after-season recovery are the main purposes for application. However, the most recent studies confirmed the anti-inflammatory, anti-analgesic, and anti-oxidant effects of this therapy by highlighting the underlying physiological responses. In addition to its therapeutic effects, whole-body cryotherapy has been demonstrated to be a preventive strategy against the deleterious effects of exercise-induced inflammation and soreness. Novel findings have stressed the importance of fat mass on cooling effectiveness and of the starting fitness level on the final result. Exposure to the cryotherapy somehow mimics exercise, since it affects myokines expression in an exercise-like fashion, thus opening another possible window on the therapeutic strategies for metabolic diseases such as obesity and type 2 diabetes. From a biochemical point of view, whole-body cryotherapy not always induces appreciable modifications, but the final clinical output (in terms of pain, soreness, stress, and post-exercise recovery) is very often improved compared to either the starting condition or the untreated matched group. Also, the number and the frequency of sessions that should be applied in order to obtain the best therapeutic results have been deeply investigated in the last years. In this article, we reviewed the most recent literature, from 2010 until present, in order to give the most updated insight into this therapeutic strategy, whose rapidly increasing use is not always based on scientific assumptions and safety standards.

INTRODUCTION:

Local and systemic cold therapies (cryotherapies) are widely used to relieve symptoms of various diseases including inflammation, pain, muscle spasms, and swelling, especially chronic inflammatory ones, injuries, and overuse symptoms (Bettoni et al., 2013; Jastrzabek et al., 2013). The beneficial effects of cold as a therapeutic agent have been known for a long time, with ancient population aware about the reinvigorating effects of cold water either taken orally or used for baths. The use of cold, mainly locally, still remains in our daily common activities. A still up-to-date survey of a sample of Irish emergency physicians highlighted the fact that 73% of consultants frequently “prescribe” cold, 7% never suggest to use cryotherapy, and 30% is unsure about the benefits of using cold. Experience (47%) and common sense (27%) were the most frequently declared reasons for using ice, while only 17% referred to scientific reasoning (Collins, 2008).

Forty years ago, following personal observations of Prof. Toshiro Yamauchi (who recognized that the combination of cold and physical exercise was beneficial for clinical outcomes of treatments received by his patients’, affected by rheumatoid arthritis, coming back from mountain localities after winter holidays), whole-body cryotherapy was introduced into clinical practice (Yamauchi et al., 1981a,b).

At present, the use of very cold air in special, controlled chambers may be proposed for treating symptoms of various diseases (Bouzigon et al., 2016). Beside its clinical applications, a brief full body exposure to dry air at cryogenic temperatures lower than −110°C has become widely popular in sports medicine, often used to enhance recovery after injuries and to counteract inflammatory symptoms resulting from overuse or pathology (Furmanek et al., 2014). The number of studies about the use of whole-body cryotherapy (WBC) in sports medicine is growing, however, it is still lower than the topic’s potential if the wide range of application of this methodology is considered. Studies published on athletes had mainly focused on post-training or competitive season recovery. Only a limited number of papers had investigated the effects of WBC used in preparation phase for competitive season to enhance form and performance, or during periods of high intensity of training to limit overuse and overreaching. Studies should be acknowledged to define safety, effectiveness, and efficacy of the treatment in athletes and to discover underlying molecular mechanisms supporting the claimed beneficial effects.

This review article collects the most recent literature (since 2010, Banfi et al., 2010b) on whole-body cryotherapy with the purpose of delivering a complete and updated overview of the newest findings and the directions taken in research in this field. In particular, given the high number of new scientific findings mostly associated with great technological developments of this therapeutic method, this review discusses both technical aspects (i.e., therapeutic protocols, contraindications, thermoregulatory responses) and effects on a wide range of physiological (i.e., hematological, metabolic, energetic, endocrinological, skeletal, muscular, inflammatory) and functional parameters (post-exercise and post-traumatic recovery, pain, performance). We are aware of the limitations of this literature review. Almost all published research included in this review discuss results of using whole-body cryotherapy without providing any insight into molecular mechanisms involved in observed responses to the treatment. Also, although the review takes a non-systematic approach, an alternative meta-analysis would only offer a limited article coverage due to the type and, sometimes, the quality of available papers. Furthermore, we only reviewed reports on the WBC procedures performed in cryochambers (regardless of the cooling system, but considering the operating temperature); we do not consider treatments performed in cryosauna (also named cryocabins). Exposure to cold in a cryosauna cannot be deemed whole-body since during the treatment the head remains outside of the cabin. The two settings were concluded to, activate different molecular pathways and, possibly, exert different outcomes. Indeed, in a cryosauna, cooling is delivered through direct insufflation of liquid nitrogen vapors into the box. Free vapors are heavy and tend to remain within the cabin, below the chin; contrarily, in a nitrogen-cooled cryochamber liquid nitrogen fluxes through pipes inside the chamber’s wall, and thus, there is no free nitrogen within the chamber. These differences also account for different safety standards of these treatments: free nitrogen vapor in a cryosauna could be potentially hazardous due to the risk of asphyxia.

In the present paper we refer to “whole-body cryotherapy,” which is the most commonly used term to define the methodology, but also to “whole-body cryostimulation,” which better describes effects of WBC in improving the metabolic and inflammatory responses as well as in enhancing recovery from exercise and injuries. In contrast, the term “cryotherapy” refers to a real therapy aimed at treating painful symptoms of inflammatory or traumatic conditions.

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