Cryotherapy effects on knee proprioception and quadriceps performance in healthy college students

Abstract

BACKGROUND:

Cryotherapy is widely utilized for therapeutic purposes, yet its specific effects on knee joint proprioception and quadriceps muscle performance in healthy individuals remain unclear. This study addresses this gap by examining the impact of a 20-minute cryotherapy session on knee joint proprioception and related muscle parameters in a cohort of healthy college students.

OBJECTIVES:

To investigate the effects of cryotherapy on knee joint proprioception and quadriceps muscle peak moment, work and power in healthy college male and female students.

METHODS:

Thirty-two healthy students, aged 19–23, underwent a 20-minute cryotherapy session using Cryogel packs applied to the anterior thigh and knee. An isokinetic dynamometer measured knee joint proprioception and quadriceps muscle parameters before, immediately after, 10-min, and 20-min post-cryotherapy.

RESULTS:

Proprioception values did not significantly differ between genders or post-tests ( $p>$ 0.05). However, the female group exhibited significantly lower moment, power, and work values compared to males ( $p<$ 0.05). No significant differences were observed within or between post-tests in moment, power, and work for both genders ( $p>$ 0.05).

CONCLUSIONS:

A 20-minute cryotherapy application demonstrated no adverse effects on knee joint proprioception or quadriceps muscle metrics in healthy college students, supporting the safety of cryotherapy in this context.

Keywords

Cryotherapy isokinetics knee joint muscle strength proprioception

1. Introduction

Exercise is any physical activity involving force generation by an activated skeletal muscle. Adequate muscle performance during exercise, along with flexibility and accurate proprioception are required to prevent injuries during various dynamic tasks [1]. Muscle performance may be assessed in terms of the physical parameters like moment, power, and work [2]. Reduced and/or impaired muscle performance may contribute to joint instability, impaired balance, increased risk of injury, increased disability, and morbidity [3]. It is very important to use a reliable and accurate testing tool for the assessment of muscular performance parameters to determine an individual’s abilities and limitations [4]. Isokinetic dynamometry is a highly accurate tool for measuring muscle performance. Its use has grown in popularity due to its ability to precisely capture dynamic muscle strength [5, 6]. Moreover, tests conducted using isokinetic devices are highly accurate and reproducible [7].

Proprioception is an important body sense that encompasses joint position and movement. This sense determines a person’s ability to detect joint angles and movements [8]. Proprioceptors help maintain static and dynamic stability through modulating muscle activity according to the incoming proprioceptive signals regarding external environments and forces [9]. An impaired proprioception feedback can disturb neuromuscular joint control and balance, which increases the risk of injuries and falls [10]. Proprioception can be measured using various methods, such as passive motion threshold (PMT), directional motion perception (DMP), joint position sense (JPS), reflex muscle contraction latency (RCHL) as recorded by electromyography, and unstable boards for both assessment and training [11].

Cryotherapy, which is the application of cold using ice packs or similar modality to lower the tissue surface temperature, has been widely used by clinicians to treat acute injuries, reduce pain, inflammation, stiffness, muscle spasm, and delayed-onset muscle soreness, and to shorten recovery time. Although its effect on muscular function has limited evidence [1, 12, 13, 14], prolonged cooling has been shown to reduce post-exercise soreness in recreational athletes when applied for six hours [15] and in professional football players when applied for three hours [16]. Despite the positive effects of cryotherapy applications mainly in acute inflammatory conditions, cooling may negatively affect muscle repair [17], proprioception accuracy [18], and may impede natural adaptive responses to heavy training [19, 20, 21, 22, 23]. Burke et al. [24] and Yamane et al. [22] analyzed the outcome of cryo-immersions with varying durations (3–10 min) on muscle soreness and strength recovery. However, their results concerning effects on muscle soreness and strength recovery were not consistent.

Some studies have shown that cryotherapy has an effect on proprioception [25, 26]. Cooling can affect nerve conduction velocity, resulting in instability and decreased control of the joint. The depth of cooling is seen as the primary factor influencing nerve conduction velocity [26]. The proprioception accuracy of the ankle joint decreases with cooling and compression, potentially leading to poorer sport performance [27, 28]. Various protocols across multiple studies have been used to measure cryotherapy’s effect on proprioception, with varying results [29, 30, 31, 32]. Most studies involve active measurements of joint position sense, with only one used passive joint sense as a measurement of proprioception [29, 33].

According to a recent systematic review [14], some high methodologically randomized controlled trials have reported that cryotherapy has a positive effect on athletic strength, while the majority of the studies concluded that there is negative, very little, or no effect at all of cryotherapy on muscular strength. They concluded that there is no clear evidence upon the positive or negative effects of cryotherapy on proprioception accuracy and neuromuscular control. The results of the aforementioned reports are conflicting. Therefore, this study aimed to investigate the effects of cryotherapy on knee joint proprioception and quadriceps muscle peak moment, total work and power in healthy college male and female students.

2. Methods

2.1 Participants

Thirty-two healthy college students from both genders voluntarily participated in this study with mean age of 20.5 years. The sample size estimated by the G^*Power 3.1 software (University of Düsseldorf, Germany), which was 32 individuals based on $=$ 0.05, power $=$ 0.80, and effect size $=$ 0.22. To be eligible, subjects had to be normal healthy male of female students aged between 19 to 25 years and able to perform pain-free complete knee range of motion. Subjects were excluded from the study if they have recent history of knee joint injury and/or surgery, any contraindication to cryotherapy (e.g., hypersensitivity to cold), previous history of recent lower limb injuries, metabolic or vascular disease with a neurological component such as diabetes or recent history of inner ear infection with associated balance and coordination problems [34].

Official approvals were obtained from the ethics committee of scientific research of Taibah University (CMR-PT-2023-02). Each student was informed about the study objectives stressing on confidentiality of collected data and getting a written consent of the subject to share in the study.

2.2 Study design

This study is a single group pre- and post-test repeated measures experimental design. The measurements were recorded for isokinetic moment, power, work, and joint position sense (active repositioning test) during four separate trials, before cold application, immediately after cold application, 10-min, and 20-min after cold application.

2.3 Measurements

2.3.1 Muscle moment, power and work measurements

Isokinetic measurement of peak moment, power and work was done using the Biodex system 4 Pro Multijoint system isokinetic dynamometer (Biodex Medical Inc., Shirley, NY) before and after application of cryotherapy. After a 5 to 10-min warm up, explanation, and familiarization, each subject was seated and stabilized to the isokinetic chair using straps. Concentric isokinetic protocol was set at a velocity of 60^∘C/s. Each subject was directed to perform four maximal repetitions of knee extension at angular velocity of 60^∘C/s with a rest period of 30-s between repetitions. Verbal and visual encouragement was provided during the test to facilitate a maximal effort [35]. The peak moment, average work and power were recorded for each participant.

2.3.2 Active joint sense measurement

Proprioception accuracy measured through active repositioning test was assessed by the Biodex system 4 Pro Multijoint system isokinetic dynamometer (Biodex Medical Inc., Shirley, NY) before and after cryotherapy application. The Isokinetic active repositioning test showed a high reliability and validity in assessment of active joint position sense [36]. Active movements give more precise estimate of joint angle with well-established validity and reliability as a measure of proprioception [37, 38]. After sitting on the Biodex chair and setting the target angle at 45^∘C each participant was asked to reproduce the preset angle actively while blindfolded [39, 40]. The absolute error in degrees was calculated as the difference between the preset angle and the angle reached by the participant after repeating the test three times and obtaining the mean of the three trials and this absolute error was used in statistical analysis. Three trials were used since repetitive active movement significantly increases repositioning error [41]. The same joint position sense test was used for all subjects since there was no correlation between different tests that measure proprioception in the knee [42].

2.4 Cryotherapy application

After completing the testing procedures, each participant was positioned in long sitting position and a cryogel pack at a temperature of $-$ 2^∘C Celsius was positioned over the knee joint area for 20-min and was maintained in place by using elastic straps. To avoid frostbite, the cold pack was kept within a thin cold pack cover. The skin temperature was measured before and after application. After cold application, isokinetic measurement of moment, power, work, and active repositioning were undertaken immediately, after 10-min, and 20-min.

2.5 Statistical analysis

Statistical analysis was conducted using SPSS for windows, version 22 (SPSS, Inc., Chicago, IL). The independent $t$ -test was used to compare between female and male groups regarding age, weight, height and body mass index (BMI). Data were screened for normality, and homogeneity of variance. The Shapiro-Wilk test showed that the data were normally distributed, and Levene’s test illustrated their homogeneity ( $p>$ 0.05). This exploration was done as a pre-requisite for parametric data analysis. So, the differences between both groups regarding the pre-test, post-immediate test, post-10-min test, and post-20-min test values of average knee proprioception, and quadriceps moment, power and work were tested by using the repeated measures analysis of variance (ANOVA). The alpha level was set at alpha level of 0.05 for all statistical tests.

3. Results

In relation to age, and BMI there were no significant differences between female and male groups ( $p=$ 0.776, 0.096 respectively). However, the body weight, and height of female group were significantly lower than male group ( $p=$ 0.001), as demonstrated in Table 1.

Table 1
The participants’ demographic characteristics

Groups	Male group, $n=$ 17 Mean $\pm$ SD	Female group, $n=$ 15 Mean $\pm$ SD	$p$ -value
Age, year	21.47 $\pm$ 1.08	20.80 $\pm$ 0.94	0.776
Weight, kg	73.64 $\pm$ 23.57	59.27 $\pm$ 12.38	0.001^*
Height, cm	171.59 $\pm$ 7.39	159.13 $\pm$ 6.61	0.001^*
BMI, kg/m²	21.31 $\pm$ 6.18	18.56 $\pm$ 3.43	0.096

Data are illustrated as mean $\pm$ standard deviation (SD); $p$ value $>$ 0.05 means non-significant difference; ^*p value $<$ 0.05 means significant difference.

Table 2

Descriptive statistics of the knee proprioception of both groups

Variables		Male group, $n=$ 17 Mean $\pm$ SD	Female group, $n=$ 15 Mean $\pm$ SD	$p$ -value
Proprioception	Pre-test	2.56 $\pm$ 1.97	3.02 $\pm$ 2.09	0.525
	Post immediate test	3.78 $\pm$ 2.01	4.77 $\pm$ 3.30	0.326
	Post 10-min test	3.06 $\pm$ 7.59	3.00 $\pm$ 2.02	0.932
	Post 20-min test	3.30 $\pm$ 2.60	2.18 $\pm$ 1.85	0.542

Data are illustrated as mean $\pm$ standard deviation (SD), ^*p value $<$ 0.05 means significant difference.

Table 3

Descriptive statistics of the moment, power and work of both groups

Variables		Male group, $n=$ 17 Mean $\pm$ SD	Female group, $n=$ 15 Mean $\pm$ SD	$p$ -value
Moment (Nm)	Pre-test	171.18 $\pm$ 9.93	98.73 $\pm$ 10.57	0.001^*
	Post-immediate test	175.39 $\pm$ 7.69	96.80 $\pm$ 8.18	0.001^*
	Post 10-min test	175.18 $\pm$ 7.59	98.40 $\pm$ 8.08	0.001^*
	Post 20-min test	174.81 $\pm$ 7.14	99.33 $\pm$ 7.60	0.001^*
Power (Watt)	Pre-test	91.45 $\pm$ 6.11	51.87 $\pm$ 6.50	0.001^*
	Post-immediate test	92.92 $\pm$ 5.26	51.93 $\pm$ 5.60	0.001^*
	Post 10-min test	92.37 $\pm$ 5.26	52.13 $\pm$ 5.60	0.001^*
	Post 20-min test	93.00 $\pm$ 5.38	55.87 $\pm$ 5.73	0.001^*
Work (J)	Pre-test	150.38 $\pm$ 8.93	89.67 $\pm$ 9.51	0.001^*
	Post-immediate test	154.97 $\pm$ 7.89	87.60 $\pm$ 8.40	0.001^*
	Post 10-min test	153.35 $\pm$ 7.62	89.67 $\pm$ 8.11	0.001^*
	Post 20-min test	153.98 $\pm$ 6.98	91.40 $\pm$ 7.44	0.001^*

Data are illustrated as mean $\pm$ standard deviation (SD), ^*p value $<$ 0.05 means significant difference.

There was a statistically significant difference between-subjects effect (groups; $F=$ 0.125, $p=$ 0.726), and no significant difference within-subjects effect (time; $F=$ 0.397, $p=$ 0.031), and the interaction effect (time^*group; $F=$ 0.779, $p=$ 0.515). Subsequently, multiple pairwise comparison tests were conducted to identify the source of significance regarding group interactions (female versus male) and time (pre-test versus post-tests) factors.

The pre-test, post-immediate test, post 10-min test, and post 20-min test values of the proprioception of female group were not significantly different than male group ( $p>$ 0.05), as showed in Table 2. In female and male groups, there were no significant differences between the pre-test and post-immediate test ( $p>$ 0.05), pre-test and post 10-min test $p>$ 0.05), pre-test and post 20-min test ( $p>$ 0.05), post-immediate test and post 10-min test ( $p>$ 0.05), post-immediate test and post 20-min test ( $p>$ 0.05), or post 10-min test and post 20-min test ( $p>$ 0.05).

The pre-test, post-immediate test, post 10-min test, and post 20-min test values of moment, power and work of female group were significantly lower than male group ( $p=$ 0.001), as showed in Table 3. There were no significant differences between the pre, post-immediate test, post 10-min test, and post 20-min test values of moment, power and work in both groups ( $p>$ 0.05). Also, there were no significant differences between post-tests and each other ( $p>$ 0.05).

4. Discussion

In the current study, the effect of cryotherapy on quadriceps muscle moment, power, work and knee proprioception immediate, post 10-min, and post 20-min in males and females was investigated. The main finding of this study shows that there is no effect of cryotherapy on knee extensor muscle moment, power, or work during isokinetic concentric test at 60^∘C/s, and cryotherapy does not affect knee joint proprioception accuracy in males and females.

Regarding muscle strength variables, the results of the current study are in agreement with a study by Rubely et al. [43], who found that submaximal isometric-force production of hand muscles was not affected by 15-min ice bath, they stated that cryotherapy does not impair the motor control of the digits and they argued that analgesic effect of cryotherapy before strength training will not impair exercise performance. In another study carried out by Aboeleneen et al. [1] found no significant effect for cryotherapy application on quadriceps muscles moment or knee proprioception. They recommended that pre-exercise cooling is safe and will not impair neuromuscular performance. Kim et al. [44] investigated the effect of knee cooling on isokinetic dynamic and static quadriceps muscle strength in healthy students. They could not find any change in quadriceps strength immediately, 20, and 40-min after cooling, and the normal muscle performance and proprioception are requirements for optimal joint stability. So, if the proprioception accuracy is not affected by cooling the tissues, as confirmed by the current study findings, it may be logic that dynamic muscle moment will not be negatively influenced by the cryotherapy applications [44].

The lack of effect of cryotherapy on quadriceps muscle moment, power and work may be explained by the large size of the quadriceps muscle, so the change in muscle temperature may not be enough to induce a change in the muscle strength. Furthermore, the proprioception accuracy together with strength of muscle affect joint stability. Without proper action of joint and muscle proprioceptors, joint stability and in turn muscle performance including moment, power and work will be disturbed [44]. As in the current study, proprioception was confirmed to be not affected by cold application, it may be of logic that cryotherapy will not affect muscle performance as represented by moment, power and work.

In contrast, other studies found that cryotherapy may have positive/negative effect on muscle moment [12, 35]. Farokhi et al. [12] found that knee extension moment increased immediate and post 30-min of cold pack application in the experimental group at 30^∘C/s and 120^∘C/s [12]. However, a possible explanation is that participant learning effect led to increased muscle strength. In their study, participants were not familiarized with the isokinetic testing at different speeds, whereas in the present study participants were familiarized with the isokinetic test before starting the test. Pietrosimone et al. [45] detected an increased isometric strength of quadriceps muscle 20-min post knee cooling, and this improved strength was maintained till 45-min. The authors only investigated eleven healthy subjects and such a small number may affect statistical power and in turn affect differences detected between study groups. Also, the current study disagreement with the previous studies may be explained by using samples of participants with different characteristics [46, 47]. Some studies investigated possible effects of cold application on patients after surgeries or patients with arthritic conditions that result in neural inhibition of knee musculature. So, any improvement in muscle variables may be related to that the cold application may break the muscle inhibition effect and in turn increase muscle’s excitability and strength. This is not the case in normal participants who do not have any neural inhibition. So, cryotherapy may not change the state of excitability and contraction of the muscles [44].

On the other hand, Rhodes and Alexander [35] found that there is a reduction in knee extension moment after 20-min of ice application over the quadriceps muscle. The authors referred to that altered muscle mechanical characteristics and anesthetizing muscles and joint mechanoreceptors may increase muscle stiffness and decrease force output. Reduced moment of quadriceps muscle after cryotherapy may be attributed to a combination of decreasing nerve conduction velocity, changing soft tissue properties and altering neuromuscular response.

The current study showed that cryotherapy for 20-min using ice pack does not change the proprioception accuracy of the knee joint during active repositioning test. A possible explanation is that the cooling does not affect muscle spindles which is responsible for joint positioning sense. In addition, the nerve fibers of the proprioception (i.e., Ia and II) may not be affected by ice pack application due to the high conductive velocity of the large myelinated sheath of Ia and II [48]. In other words, the amount of cooling might not be enough to affect the high conductive velocity of the large myelinated sheath that is responsible to conduct the proprioception. Another explanation could be that the muscle spindles in hamstring muscle which was not involved in the application of cold pack were sending information to central nervous system regarding the joint position during the active reproduction test.

The results of the current study are consistent with previous research [12, 31, 49]. A study by Satavi-Farokhi et al. found that with using the joint repositioning test, the application of cryotherapy for 15-min does not affect the proprioception of knee joint [12]. In addition, the current study’s findings agree with a study by Costello et al, in which they used cold water immersion for 30-min [49]. They found that there was no significant change in the joint position sense at the knee joint. Moreover, another study investigated the effect of cryotherapy for 20-min on the knee joint at three different starting positions (i.e., 90^∘C, 60^∘C, and 30^∘C). It found that cryotherapy does not impair proprioception accuracy [50]. Marouvo et al. [51] investigated the effect of cooling on shoulder proprioception in badminton athletes after a 15-min of cryotherapy. They concluded that there was no negative effect for cryotherapy on joint position sense and force sense immediately and after 30-min of application. In addition, similar results were obtained by several studies which have investigated the effect of cryotherapy on different joints such as the hand [52], ankle [31, 53], and the shoulder joint [54]. Therefore, the current study adds more certainty that applying cryotherapy over the knee joint and quadriceps for 20-min will not impair the proprioception accuracy in both males and females. So, it was safe to use cryotherapy during competition or sport related activity.

In contrast, some studies have suggested that cryotherapy may impair proprioception accuracy when applied over the knee joint [30, 55]. For instance, Alexander et al. found an impairment in the proprioception accuracy after applying crushed ice for 20-min [55]. In addition, Oliveira et al. reported a significant reduction in the proprioception accuracy after applying cold pack over the quadriceps and the knee joint [30]. The aforementioned mentioned studies have recruited small number of participants. (fifteen and eleven, respectively), which might not be enough to detect the effect of cryotherapy on knee joint proprioception. Whereas the current study and other studies with similar findings, recruited a larger sample size.

One of the limitations of this study is that the results may not be generalized to other joints as the knee was the only tested joint. Another limitation is that this study was only performed on healthy participants and not injured individuals or athletes. Therefore, future research should investigate the effect of cooling in injured individuals and athletes and target other joints. The current study measured only the surface skin temperature and did not measure the intramuscular temperature to assure adequate lowering of muscle temperature. Further study should evaluate the eccentric muscle strength, as it might be associated with certain types of musculoskeletal injuries [44]. Additionally, the study’s design did not include a sham group, which may present a limitation. In the absence of a placebo-controlled environment, it is challenging to conclusively isolate the effect of cooling application from the psychological or placebo responses that might influence the outcome measures. Finally, this study adopted only one angle for repositioning error (i.e., 45^∘C) and only one proprioception test (active repositioning test). Therefore, the upcoming research work is required to include multiple angles for proprioception error testing and other forms of proprioception tests.

5. Conclusion

The results of this study show that cryotherapy does not affect knee extensor muscle strength nor knee proprioception accuracy in healthy individuals. Therefore, using cryotherapy before or during physical activity is safe.

Author contributions

CONCEPTION: M.M.A., A.A., M.S.A. O.K.

PERFORMANCE OF WORK: M.M.A., R.A., and Y.A.

INTERPRETATION OR ANALYSIS OF DATA: M.M.A., A.A., M.S.A., R.A. and O.K.

PREPARATION OF THE MANUSCRIPT: M.M.A, and A.A.

REVISION FOR IMPORTANT INTELLECTUAL CONTENT: Y.A., A.A., R.A., and O.K.

SUPERVISION: A.A., M.S.A., and O.K.

Ethical considerations

All participants in this study signed an informed consent form approved by Taibah University. The study was conducted in accordance with the Declaration of Helsinki and approved by Ethics Committee of scientific research of Taibah University (Approval number: CMR-PT-2023-02).

Funding

The authors report no funding.

Footnotes

Acknowledgments

The authors have no acknowledgment.

Conflict of interest

The authors have no conflicts of interest to report.

References

Aboeleneen

Darwesh

Embaby

, et al. Short-term effect of cryotherapy on knee joint proprioception and quadriceps isometric strength in healthy young females. Bulletin of Faculty of Physical Therapy. 2018.

Knuttgen

. Force, work, and power in athletic training. Sport Science Exchange. 1995.

Horlings

Van Engelen

Allum

, et al. A weak balance: the contribution of muscle weakness to postural instability and falls. Nature clinical practice Neurology. 2008.

Thompson

Bemben

. Reliability and comparability of the accelerometer as a measure of muscular power. Med Sci Sports Exerc. 1999.

Fagher

Fritzson

Drake

. Test-retest reliability of isokinetic knee strength measurements in children aged 8 to 10 years. Sports health. 2016.

Ferri-Morales

Alegre

Basco

, et al. Test-retest relative and absolute reliability of knee extensor strength measures and minimal detectable change. Isokinetics Exerc Sci. 2014.

Osternig

. Isokinetic dynamometry: implications for muscle testing and rehabilitation. Exercise and Sport Sciences Reviews. 1986.

Furmanek

Słomka

Juras

. The effects of cryotherapy on proprioception system. BioMed Research International. 2014.

Hoffman

Payne

. The effects of proprioceptive ankle disk training on healthy subjects. Journal of Orthopaedic & Sports Physical Therapy. 1995.

10.

Ferlinc

Fabiani

Velnar

, et al. The importance and role of proprioception in the elderly: a short review. Materia socio-medica. 2019.

11.

Horváth

Ferentzi

Schwartz

, et al. The measurement of proprioceptive accuracy: A systematic literature review. Journal of Sport and Health Science. 2023.

12.

Safavi-Farokhi

Bagheri

Ziari

, et al. The Effect of Cryotherapy on Proprioception and Knee Extensor Torque in Healthy Volunteers. Middle East Journal of Rehabilitation and Health Studies. 2021.

13.

Lubkowska

. Cryotherapy: Physiological considerations and applications to physical therapy. Physical Therapy Perspectives in the 21st Century-Challenges and Possibilities (InTech). 2012.

14.

Kalli

Fousekis

. The effects of cryotherapy on athletes’ muscle strength, flexibility, and neuromuscular control: A systematic review of the literature. J Bodywork Movement Ther. 2020.

15.

Kwiecien

McHugh

Howatson

. The efficacy of cooling with phase change material for the treatment of exercise-induced muscle damage: pilot study. J Sports Sci. 2018.

16.

Clifford

Abbott

Kwiecien

, et al. Cryotherapy reinvented: application of phase change material for recovery in elite soccer. International journal of sports physiology and performance. 2018.

17.

Woods

Lowder

. Exercise-induced modulation of macrophage function. Immunol Cell Biol. 2000.

18.

Costello

Donnelly

. Effects of cold water immersion on knee joint position sense in healthy volunteers. J Sports Sci. 2011.

19.

Figueiredo

Roberts

Markworth

, et al. Impact of resistance exercise on ribosome biogenesis is acutely regulated by post-exercise recovery strategies. Physiological reports. 2016.

20.

Fröhlich

Faude

Klein

, et al. Strength training adaptations after cold-water immersion. The Journal of Strength & Conditioning Research. 2014.

21.

Roberts

Raastad

Markworth

, et al. Post-exercise cold water immersion attenuates acute anabolic signalling and long-term adaptations in muscle to strength training. J Physiol (Lond). 2015.

22.

Yamane

Teruya

Nakano

, et al. Post-exercise leg and forearm flexor muscle cooling in humans attenuates endurance and resistance training effects on muscle performance and on circulatory adaptation. Eur J Appl Physiol. 2006.

23.

Yamane

Ohnishi

Matsumoto

. Does regular post-exercise cold application attenuate trained muscle adaptation? Int J Sports Med. 2015.

24.

Burke

Macneil

Holt

, et al. The effect of hot or cold water immersion on isometric strength training. The Journal of Strength & Conditioning Research. 2000.

25.

Herrera

Sandoval

Camargo

, et al. Effect of walking and resting after three cryotherapy modalities on the recovery of sensory and motor nerve conduction velocity in healthy subjects. Brazilian Journal of Physical Therapy. 2011.

26.

White

Wells

. Cold-water immersion and other forms of cryotherapy: physiological changes potentially affecting recovery from high-intensity exercise. Extreme physiology & medicine. 2013.

27.

Herrera

Sandoval

Camargo

, et al. Motor and sensory nerve conduction are affected differently by ice pack, ice massage, and cold water immersion. Phys Ther. 2010.

28.

Fullam

Caulfield

Coughlan

, et al. The effect of cryotherapy application to the ankle joint on dynamic postural stability in an elite athletic population. Br J Sports Med. 2014.

29.

Surenkok

Aytar

Tüzün

, et al. Cryotherapy impairs knee joint position sense and balance. Isokinetics Exerc Sci. 2008.

30.

Oliveira

Ribeiro

Oliveira

. Cryotherapy impairs knee joint position sense. Int J Sports Med. 2009.

31.

Someh

Ghafarinejad

. The effect of cryotherapy on the normal ankle joint position sense. Asian Journal of Sports Medicine. 2011.

32.

De Almeida Lins

de Brito Macedo

Silveira

RAG

, et al. Influence of cryotherapy on balance and joint position sense in healthy subjects: randomized clinical trial. Manual Therapy, Posturology & Rehabilitation Journal. 2015.

33.

Bennell

Wee

Crossley

, et al. Effects of experimentally-induced anterior knee pain on knee joint position sense in healthy individuals. Journal of orthopaedic research. 2005.

34.

Mattacola

Perrin

. Effects of cold water application on isokinetic strength of the plantar flexors. Isokinetics Exerc Sci. 1993.

35.

Rhodes

Alexander

. The effect of knee joint cooling on isokinetic torque production of the knee extensors: considerations for application. International Journal of Sports Physical Therapy. 2018.

36.

Drouin

Valovich-mcLeod

Shultz

, et al. Reliability and validity of the Biodex system 3 pro isokinetic dynamometer velocity, torque and position measurements. Eur J Appl Physiol. 2004.

37.

Contu

Cappello

Konczak

, et al. Preliminary analysis of non-dominant proprioceptive acuity and interlimb asymmetry in the human wrist. 2015 37th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) Anonymous. 3598-3601. IEEE.

38.

Fuentes

Bastian

. Where is your arm? Variations in proprioception across space and tasks. J Neurophysiol. 2010.

39.

Elangovan

Herrmann

Konczak

. Assessing proprioceptive function: Evaluating joint position matching methods against psychophysical thresholds. Physical therapy. 2014. doi: 10.2522/ptj.20130103.

40.

. Clinical evaluation of motion and position sense in the upper extremities of the elderly using motion analysis system. Clinical Interventions in Aging. 2014. doi: 10.2147/CIA.S62037.

41.

Wang

Cheng

. Effects of active fatiguing movement versus passive repetitive movement on knee proprioception. Clinical biomechanics (Bristol). 2010. doi: 10.1016/j.clinbiomech.2010.04.017.

42.

Grob

Kuster

Higgins

, et al. Lack of correlation between different measurements of proprioception in the knee. Journal of Bone and Joint Surgery. British volume. 2002. doi: 10.1302/0301-620X.84B4.0840614.

43.

Rubley

Denegar

Buckley

, et al. Cryotherapy, Sensation, and Isometric-Force Variability. Journal of Athletic Training. 2003.

44.

Kim

Mettler

McCurdy

, et al. Effects of focal knee joint cooling on static and dynamic strength of the quadriceps: Innovative approach to muscle conditioning. International Journal of Environmental Research and Public Health. 2021. doi: 10.3390/ijerph18094890.

45.

Pietrosimone

Ingersoll

. Focal knee joint cooling increases the quadriceps central activation ratio. Journal of Sports Sciences. 2009. doi: 10.1080/02640410902929374.

46.

Loro

Thelen

Rosenthal

, et al. The effects of cryotherapy on quadriceps electromyographic activity and isometric strength in patient in the early phases following knee surgery. Journal of Orthopaedic Surgery. 2019. doi: 10.1177/2309499019831454.

47.

Rice

Mcnair

Dalbeth

. Effects of cryotherapy on arthrogenic muscle inhibition using an experimental model of knee swelling. Arthritis Care and Research. 2009.

48.

Proske

. What is the role of muscle receptors in proprioception? Muscle and Nerve. 2005. doi: 10.1002/mus.20330.

49.

Costello

Donnelly

. Effects of cold water immersion on knee joint position sense in healthy volunteers. Journal of Sports Sciences. 2011. doi: 10.1080/02640414.2010.544047.

50.

Ozmun

Thieme

Ingersoll

, et al. Cooling does not affect knee proprioception. Journal of Athletic Training. 1996.

51.

Marouvo

Tavares

Dias

, et al. The effect of ice on shoulder proprioception in badminton athletes. European Journal of Investigation in Health, Psychology and Education (EJIHPE). 2023. doi: 10.3390/ejihpe13030051.

52.

Williams

Rainham

. Control of finger movements as shown by reducing muscle spindle and joint information. Motor Leaming and Biomechanical Factors in Sport.Toronto, Canada: Pub Division School of Physical and Health Education. 1980.

53.

LaRiviere