EFFECT OF RE-WARMING ON FUNCTIONAL AGILITY IN COLLEGIATE ATHLETES AFTER CRYOTHERAPY TREATMENT A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Colleen Joyce Frickie Research Advisor, Dr. Rebecca Hess California, Pennsylvania 2011 ii iii AKNOWLEDGEMENTS I want to take this opportunity to recognize those that played an important role in the completion of this thesis. To start I want to thank my family, for always supporting and guiding me through the paths I have chosen. You have always encouraged me to be who I am, which lead me to become an athletic trainer. Also a special thank you to my research assistant, Ryan Wildenhain, thank you for being there for me through everything this year. Dad, Mom, Justin, Amanda, Ryan and my grandparents, Fred and Martha Frickie, Ralph and Jane Huff: I love you all. The Lynchburg College community also deserves a big thank you. The athletic and athletic training families allowed me grow into who I am with encouragement and support. I can honestly say, Lynchburg changed my life. To my mentors, Dr. Pat Aronson and Tom Bowman, who have helped guide me to become the athletic trainer that I am today. Finally, I would like to thank those that helped directly with this thesis. Dr. Rebecca Hess, my thesis chair, for pushing me to go above and beyond what I thought I could complete. And to my committee members: Dr. Scott Hargraves and Mr. Adam Annaccone. Dr. Thomas West, for his knowledge in how to complete a thesis in less than a year. To the members of the California University of Pennsylvania soccer teams, I really appreciate your time and effort to participate in my study. Lastly, to McGuffey School District, especially the athletic director, Mike Malesic, I will never forget my first athletic training position. Thank you to all. iv TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . . ii AKNOWLEDGEMENTS . . . . . . . . . . . . . . . . iii TABLE OF CONTENTS LIST OF TABLES INTRODUCTION METHODS . . . . . . . . . . . . . . . iv . . . . . . . . . . . . . . . . vii . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . 6 Research Design. . . . . . . . . . . . . . . . 6 Subjects . . . . . . . . . . . . . . . . . . 7 Preliminary Research. . . . . . . . . . . . . . 8 Instruments. . . . . . . . . . . . . . . . . 9 T-test . . . . . . . . . . . . . . . . . . 9 Warm-Up Protocols . . . . . . . . . . . . . . 10 Procedures. . . . . . . . . . . . . . . . . . 13 Hypotheses. . . . . . . Data Analysis RESULTS . . . . . . . . . . . 15 . . . . . . . . . . . . . . . . 16 . . . . . . . . . . . . . . . . . . . 17 Demographic Data . . . . . . . . . . . . . . . 17 Hypothesis Testing . . . . . . . . . . . . . . 18 Additional Findings . . . . . . . . . . . . . . 20 DISCUSSION . . . . . . . . . . . . . . . . . . 22 Discussion of Results . . . . . . . . . . . . . 22 Conclusions . . . . . . . . . . . . . . . . . 26 v Recommendations . . . . . . . . . . . . . . . 27 REFERENCES . . . . . . . . . . . . . . . . . . 29 APPENDICES . . . . . . . . . . . . . . . . . . 34 APPENDIX A: Review of Literature . . . . . . . . . 35 Introduction . . . . . . . . . . . . . . . . . 36 Cryotherapy . . . . . . . . . . . . . . . . . 36 Physiological Response . . . . . . . . . . 37 Thermodynamic Properties of Cryotherapy . . . 40 Methods and Application Techniques . . . . . 41 Compression Application . . . . . . . . . . 45 Pre-Activity Warm-Up. . . . . . . . . . . . . . 47 Types of Warm-Ups . . . . . . . . . . . . . 48 Factors Included in Warm -Up Protocols . . . . 49 Methods of Stretching . . . . . . . . . . . 51 Effect of Stretching on Performance Components . . . . . . . . . . . . . . . . 54 Functional Assessment . . . . . . . . . . . . 59 Effects of Cryotherapy on Function . . . . . . . . 63 Sensory Effects . . . . . . . . . . . . . . 64 Effects on Strength and Muscular Ability Effects on Performance Tests . . . . 69 . . . . . . . . . 71 Summary . . . . . . . . . . . . . . . . . . . 74 APPENDIX B: The Problem . . . . . . . . . . . . . 77 Statement of Problem. . . . . . . . . . . . . . 78 vi Definition of Terms . . . . . . . . . . . . . . 79 Basic Assumptions . . . . . . . . . . . . . . . 80 Limitations of the Study . . . . . . . . . . . 81 Delimitations of the Study . . . . . . . . . . . 81 Significance of the Study . . . . . . . . . . . 82 APPENDIX C: Additional Methods . . . . . . . . . . 83 Informed Consent Form (C1) . . . . . . . . . . . 84 Individual Data Collection Sheet (C2) . . . . . . . 87 Agility T-test Diagram (C3) . . . . . . . . . . . 89 Short Warm-up Protocol (C4) . . . . . . . . . . . 91 Long Warm-up Protocol (C5) . . . . . . . . . . . 93 IRB Application: Cal U (C6) . . . . . . . . . . . 96 Cryotherapy Set Up (C7) . . . . . . . . . . . . 108 REFERENCES . . . . . . . . . . . . . . . . . . 111 ABSTRACT . . . . . . . . . . . . . . . . . . . 117 vii LIST OF TABLES 1. Demographic Data. . . . . . . . . . . . . . . 18 2. Descriptive statistics for warm-up conditions . . . 19 3. Descriptive statistics between warm-up and gender . 21 1 INTRODUCTION The application of ice is one of the most commonly used modalities to treat athletic injuries. The physiological responses to this modality can be beneficial to facilitate rehabilitating injuries by reducing tissue temperature, metabolism, inflammation, pain and muscle spasms.1-14 When cryotherapy is utilized to take advantage of the physiological responses, further decisions about the type of cold therapy must be decided, such as, ice bag, cold whirlpool, cold immersion, gel pack, or frozen peas.1-14 Due to the ability to undergo the physical property changes during treatment,1-4 evidence shows ice bag, cold whirlpool, and ice-water immersion are superior in tissue cooling efficiency over ice massage, gel packs or frozen peas.1,5,6 In comparing the more effective methods of cryotherapy, ice bags are commonly used for cryotherapy due to its effectiveness, convenience, low cost, and ease of transportation.7 To increase the effectiveness of an ice bag treatment, factors that also need to be considered include the type of ice, amount of ice, time of application, and compression application.5-12 2 Recent evidence shows that cryotherapy treatment can inhibit an athlete’s ability to perform maximally after treatment.15-19 Cross et al15 used pre-activity ice immersion on the lower extremity and then tested functional ability to perform a shuttle run, 6-meter hop test and single-leg vertical jump. Main results showed a decreased ability to perform the shuttle run and vertical jump tests.15 Functional ability was also researched after a cold whirlpool treatment utilizing a counter movement vertical jump, T-test, 40-yard dash and active range of motion.16 Patterson et al16 measured performance tests during the recovery period over 32 minutes. The results demonstrated that functional test performance can be reduced after cold whirlpool treatments, but will regain performance levels gradually. Further, after 32 minutes, not all performance measures returned to full ability. The authors suggested that the timing of returning athletes to play should be carefully considered after cold whirlpool treatments.16 Studies suggest that cryotherapy treatments showing impaired performance could leave athletes at risk for injury. In order for an athlete to prepare to play in competition, proper warm-up and/or pre-activity exercise is widely accepted. Typically, pre-activity exercise includes 3 a warm-up and stretching exercises to enhance performance and prevent injuries.20-39 Performing a warm-up before activity is most beneficial from temperature-related physiological responses, including increasing core temperature, blood flow, and preparing the body for exercise.20 The stretching method utilized in the warm-up protocol has also been shown to influence the effectiveness of the warm-up protocol.20-37 Static and dynamic stretching techniques are widely used for pre-participation warm-ups. Static stretching is when the muscle is stretched to a point of discomfort and then held at that point for an extended period of time.21,22 Recent research has shown acute, static stretching might decrease performance ability and not reduce risk of injury.22-27 Dynamic stretching utilizes full range of motion movements with the body’s own weight and force production.20 Fletcher23 defines dynamic warm-up as a controlled movement through the active range of motion for each joint.23 A comparison of four stretch protocols resulted in significant improvement in sprint times when active dynamic stretching was utilized before testing.23 After concluding that dynamic stretching was better than both static and no stretching in improving agility, Little et al28 suggested 4 that static stretching can be used, but in combination with other exercises is most favorable to minimize decreasing effects on power-based performance.28 During athletic competitions, individuals who are treated with cryotherapy often want to return to play as soon as possible. With the known detrimental effects from cryotherapy on performance ability,15-19 it may not be in the best interest of the athletes to return to play without overcoming the physiological responses from the cold treatment. Richendollar et al17 investigated the effects of re-warming after ice bag application to the anterior thigh on performing functional tasks. Anterior thigh was chosen to examine the effects of cold application to a major muscle group, such as the quadriceps, on functional performance.17 Treatment with the ice bag significantly decreased performance in all three performance tests, including single leg vertical jump, shuttle run and 40-yard sprint. The 6.5 minute warm-up after ice application significantly increased performance on all three tests. The warm-up consisted of a 3-minute jog, 3-minute stretch, and 10 2-legged vertical jumps. The study suggests, even when a with a warm-up is implemented, the subject may not able to return to maximal performance level.17 Further research needs to be conducted to determine the warm-up criteria 5 that will allow performance ability to return to the level of maximal performance level. It would be beneficial to have a protocol for an active warm-up that would counter the negative effects of cryotherapy so athletes could return to play at a maximal functional performance level. Key elements to maximal functional performance may include strength, power, speed, and agility. Agility is a measurable component of functional performance and is crucial for optimal athletic performance.21,40-42 During high level competitions, when athletes suffer an injury, they are commonly treated with ice bags on the sidelines. It would be beneficial for clinicians to know the amount of re-warming necessary to return an athlete full agility performance level in order for them to return to the competition. Therefore, the purpose of the study was to investigate warm-up lengths on functional agility, measured using the T-test, after ice bag application to the anterior thigh. 6 METHODS The primary purpose of this study was to examine the effect of re-warming on functional agility in collegiate athletes after cryotherapy treatment. The following is included in this section: (1) research design, (2) subjects, (3) preliminary research, (4) instruments, (5) procedures, (6) hypothesis, and (7) data analysis. Research Design This study was a quasi-experimental, within-subject repeated measures design. The independent variables were the agility test (pre and post) and the level of re-warming (no warm-up, short warm-up, long warm-up) after cryotherapy treatment. The dependent variable was time on functional agility test (T-test). Measurements were administered on three separate days. An advantage of this design was that each subject acted as their own control in the no warm-up condition. 7 Subjects Healthy National Collegiate Athletic Association (NCAA) Division II men’s and women’s soccer players were presented with the opportunity to participate in this study. Twenty-three athletes (10 male, 13 female) volunteered to participate after being presented with the opportunity by the researcher. The purpose and concept of the study was explained verbally and with written documents before any testing began. Subjects who participated were volunteers without any obligation by coaches or faculty. Volunteers were eliminated from the study if they were currently not participating in practice or competitions due to an injury, and/or any contraindications to cold therapy, such as Raynauds, cold allergy, etc.2 All subjects read and sign the informed consent form (Appendix C1) prior to any participation in this study. Information was gathered in the demographic review included age and gender, preferred kicking leg, and was completed as a part of the individual data collection sheet (Appendix C2) prior to testing. 8 Preliminary Research Preliminary research was conducted to gather information about the testing sessions. Using a longer, 16.5-minute long warm-up protocol was considered, as the 12-minute warm-up protocol was chosen for testing. The warm-up protocols included selected components from previous research to increase validity of this study.17,28 The T-test that was used to measure agility performance has been closely examined in previous research to determine its reliability and validity in measuring leg power, leg speed and agility.40 Final testing location was determined to be on air-filtered floors rather than in a gymnasium with hardwood floors due to availability. It was also determined that the intermittent sprint and agility section, which was a part of the long warm-up, would be changing directions in a square formation in order to fit in the available testing location. Further details for time and familiarization about setting up the cryotherapy treatment, conducting the warm-up protocols, and T-test were also examined in the preliminary research. 9 Instruments The instruments that were used in this study included the T-test and warm-up protocols. T-test Agility was measured using a standard T-test. The Ttest has resulted to have high reliability (r=0.94) for testing agility,40 and therefore only one trial is necessary in each treatment condition. Before testing, subjects were allowed to walk through the T-test course to familiarize themselves with the set up and requirements on each day. Testing took place indoors at a college multipurpose room on air-filtered floors to eliminate extraneous variables and maintain consistent surface and climate conditions. The T-test uses four cones (1 foot tall each) placed on the court in a T-shape (Appendix C3). An automatic laser timer, Speed Trap II Timer, was used to record time to the 1/1000th sec and eliminate human error.43 The method of assessing agility followed the T-test set up as outlined in previous research directly investigating the T-test by Paulo et al.40 Before each Ttest was conducted the subject was reminded to touch the cone when changing directions, not to cross their feet (or 10 grapevine), and to perform at maximal level. To start, the subject began with both feet behind the starting cone A. Start time was initiated from the subject crossing the laser at the first cone. The subject sprinted forward 9.14m (10 yards) to cone B, lateral shuffled left 4.51m (5 yards) to cone C, lateral shuffled right 9.14m (10 yards) to cone D, lateral shuffled left 4.51m (5 yards) back to cone B, and ran backward 9.14m (10 yards) returning to cone A. Time stopped stop when the athlete crossed the line breaking the laser. Individual times were recorded in a data sheet to later be analyzed. Decreased time represented improved agility performance. Warm-Up Protocols The warm-up protocols were adjusted using selected components of previous research.17,28 The warm-ups were adapted to examine various lengths of each warm-up. In order to use a combination of both static and dynamic stretching in both warm-ups, the active warm-up from Richendollar et al17 and the warm-up from Little et al28 were adapted to create a short (6.5 minutes) and long (12 minutes) warm-up. The short warm-up used selected components from previous research, including a combination of jogging, 11 static and dynamic stretching (Appendix C4).17 The components were aimed to simulate a jog and stretch that an athlete might perform quickly before returning to competition for 6.5 minutes. The short warm-up consisted of light jogging (3 minutes), five common static stretches (butterfly, figure-4, spinal twist, foot grab and calf) and one dynamic stretch (10 double-leg jump-tucks).17 The short warm-up was adjusted from Richendollar et al by having the gastrocnemius static stretched in the push-up position and quadriceps static stretching only in the side-lying position. Each static stretch was held for 15 seconds on each side, except for the quadriceps, which were held for 30 seconds each side. Again, from selected components of a previous research study, the long warm-up protocol included jogging, static stretching, dynamic stretching, and intermittent sprint and agility (Appendix C5).28 The long warm-up aimed to simulate a full jog and stretch that an athlete might perform during halftime before returning to competition for 12 minutes. Each stretching method targeted major lower extremity muscles that are used for the agility test. First, jogging section included light jogging, side stepping, back jogging, and light jogging, which totaled two minutes. Static stretching included five common stretches (figure-4, 12 foot grab, spinal twist, butterfly, and calf) totaling 4.5 minutes. Dynamic stretching included, open and close gates, lateral lunges, forward walking lunges, straight-leg march, and heel-to-toe walking, to total three minutes. Agility and sprint included 10 double-leg jump-tucks and three running exercises. The three running exercises started at three-quarter speed 10m forward + 5m sidestepping, repeated twice. The second running exercise included 10m forward at three-quarter speed + 20m forward at full pace. The final running exercise was 30m forward at full pace. Adjustment were made from Little et al’s warm-up protocol and stretching components in order to include both static and dynamic, generally by decreasing the time allotted for each area of jogging, static, dynamic and sprint. The order of warm-up conditions for each subject was randomly assigned. The no warm-up condition allowed for one minute between cryotherapy treatment and agility performance with no stretching or unnecessary movements. The no warm-up condition aimed to simulate the athlete returning to play in competition after cooling down using an ice bag without any proper re-warming session. After each warm-up session, two minutes was allowed for a recovery period before performing maximal T-test. 13 Procedures This study was approved by the California University of Pennsylvania Institutional Review Board (IRB) (Appendix C6). Athletes at California University of Pennsylvania men’s and women’s soccer teams were targeted to participate in the study through email contact and pre-practice discussion. Each athlete was verbally presented the purpose of the study. Without the presence of coaching staff, an informed consent form (Appendix C1) was reviewed for further explanation of subjects’ qualifications, as well as the risks and benefits of involvement in the study. Each subject reported to the athletic training facility on three separate days with at least 24 hours between performance sessions. On each test day, the subjects were instructed to wear athletic shoes and comfortable conditioning clothes. Each day consisted of a pre-warm up, a daily baseline T-test (pretest), a standard cryotherapy treatment, one of three warm-up conditions (no warm-up, short warm-up, long warm-up), and performance of a maximal T-test (posttest) to assess agility. The orders of the three warm-up conditions were randomly assigned. Between pre-warm up, cryotherapy, warm-up condition and agility testing, the athlete was allowed 2 minutes to 14 prepare. One re-trial T-test performance was allowed for the baseline T-test and/or maximal T-test if subjects failed to complete the task as described. All data, including the date, age, self-selected leg preference, order of level re-warming condition, T-test times, and observations were recorded on an individual data collection sheet (Appendix C2). A pre-warm up was allowed to prepare the subjects to perform the baseline T-test. The pre-warm up consisted of an individual warm up for 10-15 minutes, including 3-5 minutes of light jogging, followed by stretching. These pre-warm up guidelines were taken from the study that evaluated the reliability and validity of the T-test.42 Following the pre-warm up, the subjects performed a baseline T-test and proceeded to the cryotherapy treatment. Each cryotherapy session was administered at the site of the testing procedures. Cryotherapy procedures included procedures from previous research to increase effectiveness of treatment using an ice bag (Appendix C7). Before testing began the subject was asked to choose the leg that he or she felt most comfortable kicking a soccer ball, the selfselected leg identified which leg would be iced during cryotherapy treatment. Subjects wore shorts and sat for a 30-minute ice bag treatment on the anterior thigh of the 15 subject’s self-selected leg. The ice bag contained wetted ice as defined by Dykstra et al7 with 2000mL of ice and 300mL of room temperature water. Compression was applied using plastic wrap. To insure consistency, compression pressure was measured at the beginning of the treatment session between 40-45mmHg using a blood pressure cuff, as identified by Janwantanakul.8 However, controlling for exact amount of compression did not affect tissue temperature outcomes because increasing the amount of compression only increases the rate of cooling compared to no compression applied.8 Following the cryotherapy treatment, each subject completed the warm-up condition assigned as explained in the instruments subsection, followed by performing a maximal performance T-test. Results for pretest and posttests (T-test times) were recorded for each condition. Hypotheses The following hypotheses were based on previous research and the researcher’s review of the literature: 1. Re-warming protocols (short and long warm up) will cause significant improvement in functional agility (T-test) after cryotherapy treatment. 16 2. The long warm-up protocol will cause significant improvement in functional agility (T-test) when compared to the short warm-up protocol after cryotherapy treatment. Data Analysis A within-subjects repeated measures ANOVA was used to determine the differences within subjects on two tests (pre- and post-test) and among three conditions (no rewarming, short warm-up and long warm-up). A Paired-Sample T-test was also performed, as a Post-Test, to determine the differences among the three levels of re-warming (no rewarming, short warm-up and long warm-up). All data was analyzed using SPSS version 18.0 at an alpha level of ≤0.05. 17 RESULTS The purpose of the study was to investigate the length of re-warming exercise on functional agility after cryotherapy treatment. Agility was measured using the Ttest with three separate re-warming conditions (no warm-up, short warm-up, and long warm-up). The following section includes: demographic data, hypothesis testing, and additional findings. Demographic Data Twenty-three subjects volunteered to participate in this study. Before testing began, three volunteers were eliminated from the study due to injury and schedule conflicts. Further, after Day 1 of testing was completed, three more individuals dropped out of the study due to injury and schedule conflicts. A total of 17 subjects (6 male, 11 female), mean age of 19.41 ± 1.064, completed this study. All of the subjects were volunteers and collegiate athletes, participating in NCAA Division II soccer at California University of Pennsylvania. During the time of testing, the subjects who 18 completed this study did not have any injury that prevented them from participating in practice or competitions due to an injury, and/or did not have any known contraindications to cold therapy, such as, Raynauds, cold allergy, etc.1 A total of 16 athletes self-selected their right leg for treatment, one athlete selected left leg. Demographic data were collected by the researcher at the beginning of the study (Table 1). Table 1. Demographic Data Total (n=17) Age Minimum Maximum Mean SD (yrs) 18 21 19.41 1.064 (yrs) 18 20 19.33 .816 (yrs) 18 21 19.45 1.214 Male (n=6) Age Female (n=11) Age Hypothesis Testing Hypothesis testing was performed using data from 17 subjects who completed three testing sessions each. Descriptive statistics for the three warm-up conditions (no 19 warm-up, short warm-up, and long warm-up) are shown in Table 2. Using a within-subjects repeated measures ANOVA, the two hypotheses were tested at an alpha level of ≤ 0.05. For final analysis, the change in agility times was computed between pre- and post-test agility times (posttest – pretest). A positive difference indicates a deficient posttest agility time. A negative difference indicates an improved posttest agility time. Table 2. Descriptive statistics for warm-up conditions Minimum Maximum Mean SD No Warm-Up -.16 2.14 .6471 .57116 Short Warm-Up -.47 .71 .0635 .33582 -1.11 .47 -.2341 .38466 Long Warm-Up Hypothesis 1: Re-warming protocols (short and long warm up) will cause significant improvement in functional agility (T-test) after cryotherapy treatment. Hypothesis 2: The long warm-up protocol will cause significant improvement in functional agility (T-test) when compared to the short warm-up protocol after cryotherapy treatment. 20 Conclusion: A within-subjects repeated measures ANOVA was calculated comparing the three levels of warm-up conditions (no warm-up, short warm-up and long warm-up). A significant effect was found (F(2,32) = 19.316, P < .001). Follow-up analysis using Paired-Sample T-tests, used as a Post-Hoc, were significant among all three pairs (Control – Short, Control – Long, and Short – Long). The short warm-up was significantly better than no warm-up. The long warm-up was significantly better than no warm-up and the short warm-up, providing the best change in agility time. Additional Findings A warm-up x gender between-subjects ANOVA was calculated to examine the effect of warm-up (no warm-up, short warm-up, and long warm-up) and gender (male and female). There was no significant main effect found (F(2,30) = 2.494, P = .100). Descriptive statistics between warm-up and gender are shown in Table 3. The change in agility time (posttest – pretest) was not influenced by gender. 21 Table 3. Descriptive statistics between warm-up and gender. Gender Warm-Up Male No Warm-Up .4217 .52943 Short Warm-Up .1333 .41515 -.0567 .34396 No Warm-Up .7700 .57853 Short Warm-Up .0255 .29958 -.2341 .38466 Long Warm-Up Female Long Warm-Up Mean SD 22 DISCUSSION Discussion of Results The effect of functional agility was investigated using different re-warming lengths after ice bag application to the anterior thigh. The main findings were that no warm-up, the short warm-up (6.5 minutes), and the long warm-up (12 minutes) were all significantly different. No warm-up and short warm-up produced slower change in posttest scores on the agility test, indicated by the average difference being positive when compared to the long warm-up. The short warm-up showed a significantly better agility time with an average change of .0635 seconds compared to no warm-up at .6471 seconds. The long warm-up showed the best improvement in agility time, shown with average change of -.2341 seconds being a faster posttest agility time. These findings are consistent with findings of a previous study by Richendollar et al.17 Richendollar et al examined effects of re-warming after ice bag application on the anterior thigh. Uninjured male subjects, participating in physical activity, intramural or varsity athletics at 23 least 3 times a week volunteered for the study. The cryotherapy conditions were no ice/no warm-up, no ice/warmup, ice/no warm-up, and ice/warm-up. Functional performance tests included an agility shuttle run, single-leg vertical jump and 40-yd sprint. Treatment with ice bag decreased performance in all three performance tests,17 which is consistent with our study, which also decreased agility performance. Additionally, when implementing the warm-up after icing, performance ability statistically increased ability on all three performance tests. Even though the 6.5-minute warm-up did not return participants to the preice level of performance, it is worth noting the improvement.17 We used the 6.5 minute warm-up adapted from Richendollar et al for our study as the short warm-up, which also showed a significant improvement in performance after ice bag application, compared to the no warm-up. Richendollar et al17 also made conclusions regarding effects from the active warm-up. When the active warm-up was implemented, with no ice, all three performance tests showed improvement.17 Little et al28 used another warm-up that included jogging, side stepping, back jogging, dynamic stretching and intermittent sprint and agility runs, which also showed an improvement in agility. No differences were shown in sprint time or vertical jump.28 When conducting 24 Little et al’s warm-up in our study as the long warm-up, after ice bag application, improvement in agility performance, compared to both no warm-up and the short warm-up, was significant. Performance ability has also been shown to decrease after cryotherapy in other studies.15-19 Similar to Richendollar et al,17 Patterson et al16 stated after cold whirlpool treatment, functional tests, including vertical jump, T-test and 40-yard dash decreased. Cross et al15 reported decrease ability to perform the shuttle run and single-leg vertical jump test after ice immersion. However, results also showed no difference when performing the 6meter hop test. Within the same study, following the same treatment protocols before functional tests shows that maybe the effect of cryotherapy has to do with which skills was being measured.15 Contrary to studies producing similar results to our study15-19, Evans et al41 showed no statistical difference in any of the three agility tests measured after cold immersion treatment. Interestingly, cold therapy treatments consisted of ice immersion to the level about 8cm above the lateral malleolus, which only submerged the foot and ankle.41 The contrast in results compared to our study and other studies,15-19 shows that after differing cryotherapy 25 treatment locations can have different effects on performance. Cross et al15 used a cryotherapy treatment submerging a single-leg lower leg to the level of the fibular head in a cold whirlpool. Patterson et al16 also used a cold whirlpool for cryotherapy treatment, with bilateral lower leg immersion to the level of the fibular heads. Both of these studies supported cryotherapy decreasing performance ability,15,16 similar to Richendollar et al.17 These findings suggest cooling on the anterior thigh (quadriceps)17 or lower leg (gastrocnemius and soleus),15,16 which are a major muscular areas of the lower extremity, produces greater decreases in performance than cryotherapy applied to a more distal join region, such as the ankle.41 Physiological responses of cryotherapy1-14 and warming up20-39 have been individually researched as well. Cryotherapy is used commonly as a modality to facilitate rehabilitating injuries by reducing tissue temperature, metabolism, inflammation, pain and muscle spasms.1-14 These habilitating responses to cryotherapy are an explanation for the decrease in performance immediately post treatment. Warm-ups are widely used to prepare for activity for temperature-related physiological responses, including increasing core temperature and blood flow.20 Although 26 tissue temperature was not measured in this study, it is plausible that partaking in a warm-up after cryotherapy treatment is beneficial by allowing the tissue to counter the diminishing temperature-related responses of cold therapy with increasing temperature-related responses from the warm-up. It is also important to consider the time span between cryotherapy and warm-up condition during the testing sessions. During the control in our study, when no warm-up was conducted after ice bag application, athletes were allowed one minute to prepare for the maximal performance (posttest) T-test. With supporting evidence that after cryotherapy, performance abilities will regain gradually,16 it is plausible that time allotted to complete the short warm-up (6.5 minutes), or the long warm-up (12 minutes), allowed for additional muscular re-warming. Conclusions Re-warming after ice bag application to the anterior thigh will increase agility performance ability in Division II collegiate soccer athletes. Further, after cryotherapy, a 12-minute warm-up will show more improvement in agility performance compared to a 6.5-minute warm-up. Additionally, 27 gender does not appear to relate to the effectiveness of the warm-up protocol when it is implemented after cryotherapy to prepare for maximal agility performance. Recommendations Our findings suggest that there is a difference between no warm-up, a short warm-up (6.5 minutes) and a long warm-up (12 minutes) when it is implemented after cryotherapy to prepare for maximal agility performance. As previous researchers discussed, when performance ability is compromised due to cold therapy, it can increase the risk of injury.20 Therefore, by implementing a longer warm-up Certified Athletic Trainers can instruct athletes appropriately to counter the detrimental cryotherapy effects before returning to play. As there are limited studies that have investigated re-warming protocols after cryotherapy, further research is needed in this area. There are limited studies that have consistent cryotherapy treatment methods, therefore it would be beneficial to uniform cryotherapy method when assessing functional ability and re-warming lengths. Moreover, when lengths of warm-ups are examined a control condition should be utilized with no ice to determine if the maximal length of 28 warm-up is enough time to return to full level of performance. The site of cryotherapy treatment should also be investigated, comparing major muscular areas to various joints of the lower extremity. Further, expanding future studies to include a variety of performance measures, such as power, speed, strength and balance, would be beneficial for clinicians to help assess athletes’ functional ability when investigating lengths of re-warming after cryotherapy. 29 REFERENCES 1. Kennet J, Hardaker N, Hobbs S, Selfes J. Cooling efficiency of 4 common cryotherapeutic agents. J Athl Train. 2007;42(3):343-348. 2. Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins; 2008, Ch 13,14. 3. Knight, K. Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics; 1995. 4. Merrick MA, Jutte LS, Smith, ME. Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. J Athl Train. 2003;38(1):28-33. 5. Zemke JE, Anderson JC, Guion WK, McMillian J, Joyner AB. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Orthop Sports Phys Ther. 1998;27(4):301-307. 6. Myrer JW, Measom G, Fellingham GW. Temperature changes in the human leg during and after two methods of cryotherapy. J Athl Train. 1998;33(1):25-29. 7. Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael TJ, Baker RJ. Comparisons of cubed ice, crushed ice and wetted ice on intramuscular and surface temperature changes. J Athl Train. 2009;44(2):136-141. 8. Janwantanakul P. Cold pack/skin interface temperature during ice treatment with various levels of compression. Physiotherapy. 2006;92(4):254-259. 9. Janwantanakul P. The effect of quantity of ice and size of contact area on ice pack/skin interface temperature. Physiother. 2009;95:120-125. 10. Tomchuk D, Rubley MD, Holcomb WR, Guadagnoli M, Tarno JM. The magnitude of tissue cooling during cryotherapy with varied types of compression. J Athl Train. 2010;45(3):230-237. 30 11. Palmer J, Knight KL. Ankle and thigh skin surface temperature change with repeated ice pack application. J Athl Train. 1996;31(4):319-323. 12. Merrick MA, Knight KL, Ingersoll CD, Potteigher JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Athl Train. 1993;28(3):236-245. 13. Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trails. Am J Sport Med. 2004;32:251-261. 14. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft-tissue injury? J Athl Train. 2004;39(3):278-279. 15. Cross KM, Wilson RW, Perrin, DH. Functional performance following an ice immersion to the lower limb. J Athl Train. 1996;31(2):113-116. 16. Patterson SM, Edermann BE, Doberstein ST, Reineke DM. The effects of cold whirlpool on power, speed, agility and range of motion. J Sports Sci & Med. 2008;7:387394. 17. Richendollar ML, Darby LA, Brown TM. Ice bag application, active warm-up and 3 measures of maximal performance. J Athl Train. 2006;41(4):364-370. 18. Ruiz DH, Myrer JW, Durrant E, Fellingham GW. Cryotherapy and sequential exercise bouts following cryotherapy on concentric and eccentric strength in the quadriceps. J Athl Train. 1993;28(4):320-323. 19. Wassinger CA, Myers JB, Gatti JM, Conley KM, Lephart SM. Proprioception and throwing accuracy in the dominant shoulder after cryotherapy. J Athl Train. 2007;42(1):84-89. 20. Shellock FG, Prentice WE. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Sports Med. 1985;2:267-278. 31 21. Clark MA, Lucett SC. NASM Essential of Sports Performance Training, 1st ed. Baltimore: Lippincott Williams & Wilkins; 2010, Ch 3,4. 22. Unick J, Kieffer HS, Cheesman W, Feeney A. The acute effects of static and ballistic stretching on vertical jump performance in trained women. J Strength Cond Res. 2005;19(1):206-212. 23. Fletcher IM, Jones B. The effect of different warm-up stretch protocols on 20 meter sprint performance in trained rugby union players. J Strength Cond Res. 2004;18(4):885-888. 24. Faigenbaum AD, Bellucci M, Bernieri A, Baker B, Hoorens K. Acute effects of different warm-up protocols on fitness performance in children. J Strength Cond Res. 2005;19(2):376-381. 25. Faigenbaum AD, Kang J., McFarland J, Bloom JM, Ratamess NA, Hoffman JR. Acute effects of different warm-up protocols on anaerobic performance in teenage athletes. Pediatric Exercise Sci. 2006;17:64-75. 26. Papadopoulos G, Siatras Th, Kellis S. The effect of static and dynamic stretching exercises on the maximal isokinetic strength of the knee extensors and flexors. Isokinetics Exercise Sci. 2005;13:285-291. 27. Woolstenhulme MT, Griffiths CM, Woolstenhulme EM, Parcell AC. Ballistic stretching increases flexibility and acute jump height when combined with basketball activity. J Strength Cond Res. 2006;20(4):799-803. 28. Little T, Williams AG. Effects of differential stretching protocols during warm-ups on high-speed motor capacities in professional soccer. J Strength Cond Res. 2006;20(1):203-207. 29. Marek SM, Cramer JT, Fincher AL, Massey LL, Dangelmaier SM, Purkayastha S, Fitz KQ, Culbertson JY. Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output. J Athl Train. 2005;40(2):94-103. 32 30. Bazett-Jones DM, Wincester JB, McBride JM. Effect of potentiation and stretching on maximal force, rate of force development, and range of motion. J Strength Cond Res. 2005;19(2):421-426. 31. Sale, DG. Postactivation potentiation: Role in human movement performance. Exterc. Sports Sci. Rev. 2002;30:138-143. 32. Schiefelbein NJ. A qualitative systematic review of dynamic warm-up protocols [master’s thesis]. California, PA: California University of Pennsylvania; 2008. 33. Papadopoulos C, Kalapotharakos V, Noussios G, Meliggas K, Gantiraga E. The effect of static stretching on maximal voluntary contraction and force–time curve characteristics. J Sport Rehab. 2006;15:185-194. 34. Yamaguchi T, Kojiro I. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. J Strength Cond Res. 2005;19(3):677-683. 35. McMillian DJ, Moore JH, Hatler BS, Taylor DC. Dynamic vs. static-stretching warm-up: the effect on power and agility performance. J Strength Cond Res. 2006;20(3):492-499. 36. Faigenbaum AD, McFarland JE, Kelley NA, Ratamess NA, Kang J, Hoffman JR. Influence of recover time on warmup effects in male adolescent athletes. Pediatric Exercise Science. 2010;22:266-277. 37. Siatras TH, Papadopoulos G, et al. Static and dynamic acute stretching effect on 15gymnasts’ speed in vaulting. Pediatric Exercise Sci. 2003;15383-391. 38. Bishop D. Warm up 1: Potential mechanisms and the effects of passive warm up on exercise performance. Sports Med. 2003;33(6):439-454. 39. Bishop D. Warm up 2: Performance changes following active warm up and how to structure the warm up. Sports Med. 2004;33(7):483-498. 40. Paulo K, Madole K, Garhammer J, Lacourse M, Rozenek R. Reliability and validity of the T-test as a measure of 33 agility, leg power, and leg speed of college-aged men and women. J Strength Cond Res. 2000;14(4):443-450. 41. Evans T, Ingersoll CD, Knight KL, Worrel T. Agility following the application of cold therapy. J Athl Train. 1995;30(3):231-234. 42. Prentice WE. Rehabilitation Techniques for Sports Medicine and Athletic Training. 4th ed. McGraw Hill; 2004, Ch 13,17. 43. User’s Guide, Test Center-System. Draper, UT: Brower Timing Systems; 2010, p. 20. 34 APPENDICES 35 APPENDIX A Review of Literature 36 REVIEW OF LITERATURE Cryotherapy is commonly accepted as a modality to treat a wide variety of injuries. Cryotherapy can be used to immediately manage injuries by reducing tissue temperatures, metabolism, inflammation, pain and muscle spasms.1-14 Cryotherapy has been shown to inhibit an athlete’s ability to perform directly after treatment.15-19 During athletic competitions, individuals who are treated with cryotherapy often want to return to play as soon as possible. Although, including a warm-up before returning to play after a cryotherapy treatment has been studied,15 there has not been research investigating lengths of warm-up criteria in the same situation. Therefore, the purpose of this review of the literature is to discuss cryotherapy, pre-activity warm up, functional assessment, and the effect of cryotherapy on function. Cryotherapy Cryotherapy can be defined as ―cold therapy‖1,2 and is one of the most commonly used modalities in athletic training.1,2 Cryotherapy causes a physiological response when it is applied that can be beneficial for 37 rehabilitation after an injury.1-14 The ability for cryotherapy to be effective is determined by the physical property changes it undergoes during treatment sessions.1-4 Other factors such as, method of cold therapy, type of ice, and compression, also influence the effectiveness of the cryotherapy treatment.1,2,5-14 Physiological Response The physiological effects of cryotherapy can be broken down into nine categorizes: decreased temperature, tissue destruction, increased or decreased inflammation, decreased metabolism, decreased or increased pain, decreased muscle spasm, increased tissue stiffness, decreased arthrogenic muscle inhibition, and decreased circulation. All of these responses are discussed in depth by Knight in the textbooks, Therapeutic Modalities: The Art and Science1 and Cryotherapy in Sport Injury Management.2 Decreased temperature begins immediately by heat moving away from the tissue and into the cold modality. As the temperature changes throughout the tissue, it is not consistent or immediate in all the areas. Tissue cooling is gradual as the heat is withdrawn from each layer of tissue, starting with the surface, then to subcutaneous and then intermediate tissues. Tissue will remain decreased in 38 temperature after application due to a thermal gradient that is developed in the tissue during application.1,2 Many factors influence the depth and length decreased tissue temperature will be sustained. Tissue destruction is used to destroy and remove tissue, such as to remove warts, using extreme temperatures (-4ºF to 94ºF).1 Tissue temperature also plays a direct role in its metabolism; the greater reduction in temperature, the greater decrease in metabolism.1 Cryotherapy has been used to delay or decrease inflammation during the inflammatory phase of acute trauma. More accurately, using cryotherapy to decrease inflammation is more effective in cases of treating post-surgical wounds, arthritis, and subcutaneous medicine injections.1 An undisputable use of cryotherapy is for pain management. In order to decrease pain, cold therapy must reach the point of numbness in the injured area. Before becoming numb, pain may be increased for the first few minutes of cold application, but patients will become accustomed to the cold pain. Cryotherapy decreasing pain directly effects how it decreases muscle spasms. Muscle spasm is defined as muscle tightness. One theory of how cold decreases muscle spasm is by breaking the pain—spasm— pain cycle. By decreasing pain, the spasms also deminish.1 39 By decreasing the temperature of tissues, this directly causes tissues to become less elastic and increase stiffness. Some clinicians follow the notion of the possibility of further injury, indicating to not allow exercise after cryotherapy.1 This is supported by studies showing a decrease in muscular strength and functional ability post-cryotherapy treatments.16,17 Other studies have shown that implementing cryokinetics as a part of a rehabilitation can be beneficial because cryotherapy does not decrease gross motor movement ability.1,20 Recent research also supports cryotherapy decreasing arthrogenic muscle inhibition (AMI). When there is tissue damage in a joint, the reflex of muscles surrounding the joint or area diminish.1 In a recent study by Hopkins et al21, the main findings support cryotherapy facilitating the motor neuron pool, stimulating motor neuron recruitment, by decreasing the AMI.21 Cryotherapy can have both positive and negative effects based on its many physiological responses. When determining therapeutic goals during rehabilitation, all of the physiological responses need to be factored in when considering how a patient can most benefit from a method of cryotherapy.1,2 40 Thermodynamic Properties of Cryotherapy The effectiveness of cryotherapy is established by its ability to undergo thermodynamic phase changes during application.3 During various application techniques of cold modalities, each method undergoes various phase changes, which directly determine cooling efficiency.3,4 Two recent studies examined cooling efficiency using different cryotherapy methods with various thermodynamic properties.3,4 Merrick et al3 measured surface and intramuscular temperatures from three cold modalities: ice bag, Wet-Ice and Flex-i-Cold. Each subject received all treatments on separate treatment days, in a random order. Results indicated on surface and 1cm subadipose depths, the ice bag and Wet-Ice were colder than the Flex-i-Cold treatment. At the 2cm subadipose depth, all cold treatments were not statistically different from one another. Before making conclusions, Merrick et al discuss the importance of thermodynamic changes during the application of cold modalities in order to cool tissues. The transfer of heat in cold modalities takes place from the warmth in the tissues transferring heat to the modality. Another aspect of heat transfer is the mode of heat transfer, conduction, convection, evaporation or a combination. Merrick et al 41 continued by concluding that cold modalities with different thermodynamic properties do have an influence on the temperatures from cold modality treatments.3 Kennet et al4 expanded research by examining four common cryotherapeutic agents: crushed ice, gel pack, frozen peas and ice-water immersion. Each participant received all four separate treatments, which involved measuring skin temperatures and thermal imaging. Skin temperature results showed crushed ice reduced skin surface temperatures significantly more than a gel pack and frozen peas. In addition, cooling efficiency was decreased more with the crushed ice and ice-water immersion than a gel pack and frozen peas. Kennet et al wrapped up the study by discussing the clinical relevance of using crushed ice and ice-water immersion is the most effective for cooling efficiently.4 Methods and Application Techniques When cryotherapy is utilized for treatment, further decisions about the type of cold therapy must be decided, such as, ice bag, cold whirlpool, cold immersion, or ice massage. Factors that also need to be considered when using the ice bag method are the type of ice, amount of ice, and time of application. 42 Methods of cryotherapy application are examined in a study by Zemke et al7 and Myrer et al.8 Zemke et al researched two methods, ice bag and ice massage. Two randomly assigned groups of seven subjects received a 15minute treatment. Ice massage was applied over a 4 x 4 cm area, and the ice bag was laid on the treatment area. Intramuscular temperatures were measured every 30 seconds for the duration of the treatment. Initially, results showed the technique of ice massage decreased tissue temperature significantly more when compared to ice bag treatment. Between 6-7 minutes of treatment, temperature produced from the ice bag treatment decrease below temperatures from the ice massage. It is also important to note, no compression was applied with the ice bag treatment. Another limitation to mention is no posttreatment temperatures were measured.7 In the study by Myrer et al, they compared temperatures during and after treatment of either a crushed-ice pack or cold whirlpool immersion. Subjects were randomly selected for either a 20 minute crushed-ice pack or 30-minute cold whirlpool treatment. Both groups had temperatures measure for an additional 30 minutes for 30 minute post-treatment. Between the two groups, there was no significant different in intramuscular temperature during 43 treatment. However, results also showed, with the ice pack, subcutaneous temperatures are reduced more during treatment, but also re-warmed more quickly post-treatment. In conclusion, Myrer et al state, for rapid tissue temperature reduction, using a crushed-ice pack is better than a cold whirlpool. However, the authors also suggests, in order to keep a significant, prolonged decrease in tissue temperature, such as for cryokinetics, it is more effective to administer a cold whirlpool over an ice pack.8 To investigate types of ice, Dykstra et al9 compared tissue temperatures produced with cubed, crushed and wetted ice. Surface and intramuscular temperature were collected during a 20-minute treatment period and 20-minute recovery period. In the results section, the authors revealed cubedice and wetted-ice reduce temperatures more than crushedice treatments. Also, wetted-ice treatment is more effective in reducing temperatures overall during treatment and recovery, while crushed-ice shows the least amount of temperature difference. Dykstra et al conclude by advising clinicians to utilize the results from the study when purchasing ice machines and recognizing type of ice treatment with making ice bags.9 Amounts of ice and size of surface area covered during an ice bag treatment was examined by Janwantanakul10 by 44 measuring surface temperature. He used twenty college-aged, healthy males, who each received four treatment conditions with varying amount of ice in the ice bag, which directly correlated to surface area covered. Despite the surface area covered, results illustrated ice pack with at least 0.6 kg of ice significantly increases cooling magnitude than a 0.3 kg of ice. From this research, it can be concluded when applying an ice bag treatment, it should hold enough ice to maximize the effects of the treatment, which means having at least 0.6 kg of ice in the bag.10 Length of application time for a cryotherapy treatment can also influence its effectiveness. Palmer and Knight,11 when investigating this topic, used three different amounts of time for ice bag application: 20, 30, and 40 minutes. The authors also included a practical simulation of participants exercising and showering to increase skin temperature prior to treatment. Testing protocol referred to these periods as exercise, ice application, activity, first rewarming, ice application and second rewarming. Temperatures were measured during ice application and rewarming phases. Results showed there were greater temperature differences for 30-minute and 40-minute periods of application time than for 20-minute treatments. In conclusion, the study by Palmer and Knight supports the 45 concept of reapplying ice, for at least 30 minutes, immediately following an injury, as well as, any time following showering, changing clothes, moving around, in order to reduce tissue temperatures.11 Compression Application When using an ice bag to apply a cryotherapy treatment, an important factor includes adding compression. To increase the effectiveness of adding compression, the amount of compression and method of application also need to be considered. In a study exploring intramuscular temperatures at three depths, Merrick et al12 used four treatment set ups (control, only compression, only ice, and ice plus compression) to examine tissue temperatures. The treatment outcomes showed significantly that only compression produced slightly higher tissue temperatures. Most importantly, ice plus compression reduced tissue temperatures significantly more than ice alone.12 Other variables when using ice bags include the amount of compression and methods of application. Janawantanakul13 researched surface temperatures with different amounts of compression using an elastic bandage. All forty healthy females received five compression conditions at 0, 14, 24, 34, and 44 mmHg. The main results showed significant 46 decrease in temperature correlating with increasing amounts of compression. The author concludes by stating more compression decreases the amount of time for tissue cooling.13 Methods of applying compression were examined in a study by Tomchuk et al14 with surface and intramuscular temperatures on the posterior lower leg. The procedures included 2 depths (surface and intramuscular, at 2 cm below the surface), 3 compression types (no compression, Flex-iWrap, and elastic wrap) and 13 time measurements (0-90 minutes). The results showed that at 10 minutes and on, elastic wrap and Flex-i-Wrap decreased surface temperatures greater than no compression. Elastic wrap also decreased temperatures significantly more than Flex-i-Wrap, at 25 minutes and on. The final differences remained for 50 minutes post-application. In conclusion, clinicians should use elastic wrap for acute injury care with cryotherapy application to more effectively reduce tissue temperatures.14 Clinically, adding compression to cryotherapy with an ice bag has been established as an important factor. In conclusion, by decreasing tissue temperature, adding compression to the application of an ice bag is more 47 effective than only ice to reduce metabolism of an injured area.12-14 Pre-Activity Warm-Up Including a warm-up before activity and athletic competitions is widely accepted as a method to enhance performance capabilities. The types of warm-ups used in competitive sports include passive and active warm-ups or general warm-ups.22-24 Essential factors when structuring a warm-up can determine the effectiveness of facilitating performance abilities. Variables that can manipulate a warm-up to be effective also include, intensity, duration and allowed recovery periods.24 Stretching techniques, such as, calisthenics, static, ballistic, potentiation, dynamic and combinations of each that are incorporated within a warm-up protocol could also influence the level of success of the warm-up.22,25-41 Combinations of these methods incorporated in various warm-up protocols have claimed to increase performance ability, however there have also been claims that other techniques can lead to a short-term decrease in ability to perform. 48 Types of Warm-Ups With the basic knowledge of various warm-up techniques, an individual will better understand the purpose and function of including a pre-activity warm-up before competition. A warm-up can be broadly divided into passive, general, or specific techniques.22 General and specific warm-up techniques are used mainly before sports competitions due to the benefits from the physiological response of the body.22,23 Passive warm-up aims to raise muscle temperature or core temperature using an external factor, such as shower, saunas, or heating pads.23 However, active warm-ups, both general and specific, are widely accepted as pre-activity exercise needed before competition. The purpose of an active warm-up is to increase blood flow to the extremities, increase heart rate and increase body core temperature by jogging, stretching, cycling, functional movements and/or sports-specific drills.22-25,42 Active warm-ups are used because of the physiological responses, mainly the increase in muscle temperatures.22,23 General warm-up will also increase levels of dissociation of oxygen from hemoglobin and myoglobin, lower activation energy rates of metabolic chemical reaction, increase blood flow, reduce muscle viscosity, increase sensitivity of 49 nerve receptors and increase the speed of nerve impulses.22,42 With these physiological responses, it is also believed that warm-up will also decrease risk of injury during activity.22,42 Factors Included in Warm-Up Protocols Aspects of warm-up protocols are crucial to producing a successful pre-activity routine to optimize performance ability. Intensity, duration and recovery are three factors that can be manipulated in the structure of a warm-up in various degrees to achieve similar physiological and performance changes.24 Bishop24 reviewed literature to address warm-up protocol elements, starting with intensity. Intensity of a warm-up has been previously researched and its effects on performance. Increasing the workload greater than ~60% VO2max has shown a decrease in high-energy phosphate concentration and therefore has compromised short-term performance ability. A warm-up intensity of ~40-60% VO2max is acceptable to raise muscle temperature, while limiting phosphate depletion. For moderate level athletes, it may be possible to increase intensity of a warm-up to ~70% VO2max for intermediate performance, but only with careful consideration. In conclusion, Bishop states that a 3-5 50 minute warm up of moderate intensity will have the ability to improve short-term performance.24 The factor of duration must be carefully weighed to balance increasing muscle temperature with causing minimal fatigue. Previous research has shown that rising muscle temperatures plateau between 10-20 minutes of exercise. Therefore, Bishop provides the guideline of duration to be the same, 10-20 minutes in combination with the intensity suggestion of ~60% VO2max.24 Recovery time throughout phases of the warm-up is necessary to maximal ability to perform. Time to recover is necessary for the energy system to restore phosphocreatine (PCr) to replenish. Without allowing the muscle temperatures to decline significantly, or VO2 to reach baseline measurements again, recovery times should be sufficient in less than five minutes.24 Other factors that need to be considered when structuring a warm-up protocol are environmental factors, athletic ability of individuals, performance task required, and length of performance.24 Warm-ups prior to activity have been considered to prevent the likelihood of musculoskeltal-associated injuries.22 Warm-up protocols can also utilize various stretching methods and sports-specific exercises to further enhance benefits and performance. 51 Methods of Stretching Stretching techniques have evolved over the years. The general purposes of stretching are to improve performance abilities, decrease risk of injury during activity, and improve flexibility.26 Research has been done to investigate the various methods of stretching, including techniques called static, ballistic, proprioceptive neuromuscular facilitation (PNF), dynamic and potentiation.22,25-41 Static stretching is when the muscle is stretched to a point of discomfort and then held at that point for an extended period of time.25,26 Static stretching can be done individually, or partner assisted. This traditional method is used by all ages to possibly increase flexibility and range of motion, decrease risk of injury and enhance performance abilities.22 This method of stretching is theorized to increase flexibility by decreasing muscle spindle activity and motor neuron excitability.25 Recently, research has show that acutely, static stretching might decrease performance ability and not reduce risk of injury.26-30 Careful consideration should be advised when using only static stretching for pre-activity warm-ups. Ballistic stretching is one of the oldest stretching methods. Ballistic stretching consists of repeated bouncing movement, near the end of the range of motion, intending to 52 further increase flexibility by stretching the musculoskeletal tissue.22,25 Ballistic stretching is not widely used in contemporary warm-up routines because it is thought to cause microdamage to tissue and reduce performance ability.22 In a recent study however, Unick et al’s26 research showed that static and ballistic stretching might not decrease performance ability in trained women.26 Proprioceptive neuromuscular facilitation (PNF) stretching technique involves alternating and combinations of contraction and relaxation of both agonist and antagonist muscles.22 PNF was originally used by physical therapist to increase flexibility. Techniques used include slow-reversal-hold, contract-relax, and hold-relax. All three methods have been shown to improve flexibility.12,22 Dynamic stretching is using full range of motion movements with the body’s own weight and force production.22 Fletcher defines dynamic warm up as a controlled movement through the active range of motion for each joint.31 Fletcher did a study investigating the different warm-up stretch protocols on 20-meter sprint performance using trained rugby players. With four stretch protocols, including passive static stretch (PCC), active dynamic stretch (ADS), active static stretch (ASST) and static dynamic stretch (SDS), each subject performed a 20-meter 53 sprint before and after each stretching protocol. Results showed significant decrease on sprint performance after both stretching protocols that included static stretching. With the active dynamic stretching protocols, sprint times significantly improved. In conclusion, Fletcher suggests that using static stretching might decrease short sprint performance ability.31 In a master’s thesis, Scheifelbein conducted a systematic review of dynamic warm-up protocols. Dynamic warm-ups have shown to increase athletic performance and it is necessary try to develop suggestions and guidelines for dynamic warm up protocols.32 Potentiation or postactivation potentiation is a newly developing technique aimed to increase flexibility and muscle temperature before activity.33 The parameters for the protocol are unclear. Recent studies have used half-squats with varying loads, electrical muscles stimulation and plyometrics. Sale33 defined some of the conditions as evoked twitches, evoked titanic contraction and sustained maximal voluntary contraction. Bazett-Jones et al34 researched potentiation and stretching, determining fatiguing effects could be a detrimental factor in being able to prepare for activity or competition.34 54 Effect of Stretching on Performance Components The stretching component of a warm-up is crucial to having an effective warm-up. It is important to know how the stretching components can influence an athlete’s ability to perform in competition. Athletes need to be able to perform movements that require muscle activation, flexibility, strength, speed, power, and agility. Research has shown positive, negative and neutral results for these performance variables depending on various warm-up and specific stretching protocols.26-31,33-39 Looking at muscle activation, in the rectus femoris muscle, a significant difference after static stretching decreased EMG activity compared to a non-stretching warm up. However, conclusions were drawn that even though EMG activity decreased, it did not reveal a decrease in maximal voluntary contraction in the rectus femoris. Therefore, performance was not compromised when utilizing static stretching in a warm up.36 In measuring flexibility, there is mixed evidence comparing static and dynamic stretching. No significant difference was shown with hip and knee flexibility measurements after any of the testing protocols between static and dynamic stretching methods.29 Specifically when trained women were tested, no flexibility scores showed any 55 significant difference between static or dynamic stretching.29 Also, in children, no difference in flexibility was found.27 However, a study to note is when a 6-week pre-activity routine was implemented, flexibility showed significant improvement in all groups, including ballistic and static stretching groups. Unfortunately, dynamic stretching was not included so there was no data to compare the two common stretching techniques.30 Improved flexibility is key to increasing performance ability, however, it appears that no significant difference can be made in the short term with a specific stretching method. Strength can influence a warm up protocol, specifically by the stretching techniques utilized. Strength measures of the vastus lateralis and rectus femoris decreased after both PNF and static stretching.35 For practical application, implementing PNF or static stretching for strength gain may not be feasible.35 Papadoupolos28 also found knee extensor and flexor muscles showed a significant decrease in isokinetic torque performance, measuring strength, after static stretching exercises, compared to dynamic stretching. The study supports using other stretching techniques besides static stretching in order to reach optimal strength production.29 56 Sprinting and general speed is an advantage in athletic competitions. In teenage athletes, after dynamic and combination stretching warm-ups, 10-yard sprint performance significantly improved.28 Two variables, the 10meter speed acceleration and 20-meter flying sprint, increased with dynamic compared to no stretching, in a study specifically involving soccer players.37 Fletcher et al31 examined a 20-meter sprint performance, with trained rugby players, after four stretch protocols, (1) passive static stretch, (2) active dynamic stretch, (3) active static stretch, and (4) passive dynamic stretch. Both stretching methods that included static stretching, increased sprint time, which is a decrease in performance level. The active dynamic stretch group significantly improved by having lower sprint times. Short sprint performance may be decreased by static stretching being included in a warm up with potential negative effects.31 Power is one of the most important components for optimal performance. A high level of power means increased amount of force moved quickly, combining strength and speed.43 Leg extension power significantly improved after dynamic stretching as opposed to nonstretching or static stretching. Conclusions suggest since static stretching for 30 second periods does not hinder or increase performance, 57 and dynamic stretching enhances performance, it should be utilized.38 Indirect power measures are common assessment techniques when comparing static and dynamic stretching, as a part of a warm up routine. When throwing a weighted medicine ball as an indirect power measurement, dynamic stretching in consistently increasing power performance compared to static stretching.28,39 Jumping ability, either vertical jump or long jump can be used as a tool for assessing power indirectly. When static stretching techniques are tested, dynamic stretching and combination of static and dynamic methods have increased vertical jump performance, in children and teenager athletes.27,28 Further, in children, static stretching showed a decrease vertical jump performance.27 There has also been research showing static and ballistic stretching creates no difference in jumping ability, and might not decrease performance ability.26 Static stretching does not necessarily decrease performance, including power ability, but dynamic stretching should be used to most effectively prepare individuals for high-speed performance, for sports such as soccer.37 In athletics, agility is a combination of speed and power being used to change directions quickly.25 Children have shown decreased shuttle run speed, as a measure of 58 agility, after static stretching.27 In a study specifically involving soccer players, stretching methods were combined with jogging, sidestepping, back jogging and intermittent sprint and agility runs to prepare the athletes for performance tests. In assessing agility using a zig-zag test, dynamic stretching was better than both static and no stretching for decreasing time, and therefore improving agility.37 Stretching methods utilized within a warm up can be a determining factor in a successful warm up that facilitates improving performance. In analyzing performance components, Stretching methods used within a warm up protocol have not shown a difference on muscle activation36 and flexibility,27,29 unless the warm up was implemented for an extended period of time.30 Performance components including strength, speed, power, and agility showed improvements with dynamic stretching methods incorporated in warm up protocols compared to static or no stretch methods.27-29,31,3739 Static stretching decreased strength ability.29,31,35 Concluding, dynamic stretching techniques should be incorporated as a component in a warm up protocol before activity in order to obtain optimal performance. 59 Functional Assessment Before an athlete is able to properly progress through rehabilitation or return to participation, the clinician should have him or her perform certain tasks to isolate specific areas of weakness.43 By using specific functional tests, the clinician can objectively measure an athlete’s progress, set specific goals, and return to play criteria.43 In a textbook by National Academy of Sport Medicine (NASM) for Essentials of Sports Performance Training, the editors outline clearly what needs to be covered in a sports performance assessment prior to activity and further building with a training program.37 Performance areas that need to be objectively assessed include posture, balance and stability, strength, power, speed, agility, quickness and conditioning.25 Posture and movement assessment is an important aspect to assess structural alignment and integrity of the human movement system. The NASM categorizes postural assessment into alignment (static posture) and function (transitional or dynamic posture) assessment sections.25 Prentice defines these groups as static, semidynamic and dynamic balance.43 The purposes of assessing individuals and working to improve balance and stability are to identify weak or 60 abnormal areas, isolate the weak areas, develop measurable progress to assist in return to play criteria and goal setting, and train individuals in proper techniques.43 As defined by NASM, posture evaluation starts with static posture looking at alignments and structural integrity from the front, side and back. The next step is to look at transitional and dynamic posture using basic functions such as squatting, pushing, pulling, jumping and balancing. These assessment exercises include specific positions and movements to evaluate compensations from probable overactive and underactive muscles that can be addressed in a training program.25 To objectively assess balance, trained evaluators can use computerized-interface forceplate technology, such as, Chattecx Balance System, NeuroCom EquiTest, Pro Balance Master or Smart Balance Master.43 Subjective assessments can be beneficial for on-field evaluations and when the computer programs are not available. The Romberg test and The Balance Error Scoring System (BESS) both look at an individual’s balance ability subjectively.43,44 The standard Romberg test is considered positive if the person sways or falls when standing with feet together, hands on iliac crests and eyes closed. The BESS test is completed in three positions (singe-leg, double-leg and tandom) on both firm 61 and foam surface with eyes closed, 20 seconds each position. Errors are tallied during the six trials, such as hands moving off iliac crest, opening eyes, step, stumble, fall, lifting forefoot or heel, or remaining out of position for more than 5 seconds. A total BESS score is calculated and can be used in combination with a previously measured baseline. Posture and movement assessment include a wide variety of evaluation including, static posture, transitional or dynamic posture, and balance.43,44 Strength and power are essential components in any training program and therefore also needs to be assessed regularly. Specific goals and areas being evaluated determine the assessment technique that will be utilized to evaluate strength and power, due to the wide range of techniques available. For upper or lower extremity strength evaluation, objectively an isokinetic dynamometer can be used, such as, a Cybex, Kin-Com, or Biodex.43 Isokinetic machines can work maximally through a range of motion and can work at various set velocities to simulate functional activity. Variables can be set for speed of testing and joint position of the athlete.43 Other strength and power measures can be evaluated less objectively with one-max bench press and maximum pull-ups or push-ups.25 62 Power is a crucial element in training. Power consists of a large amount of force generated quickly, and the combination of strength and speed. Without the ability to create powerful movements, it will limit an athlete’s ability to perform optimally.43 Assessment of power is more indirect. Power movements are assessed by measurements with an objective number, such as distance of a throw using a weighted medicine ball and height of a jump are common techniques.25 Examples of power assessments include rotation medicine ball throw, overhead medicine ball throw, standing soccer throw, double-leg and single-leg vertical jumps, double- and single-leg horizontal jumps.25 Most movements in sports are explosive, and therefore, training needs to include assessing and improving the ability to perform powerful movements.43 Speed, agility and quickness are all generally correlated with athleticism. In competitive sports it is essential to be able to change directions quickly without losing speed.25 Linear speed can be measured with simple sprint distance.25 Multidirectional speed, or agility, can be measured objectively by timing drills, such as, the Ttest, the box, 5-10-5 test and other agility drills. The Ttest has been researched specifically to examine its effectiveness of measuring agility, leg power, and leg 63 speed in college-aged men and women. A total of 304 subjects performed four sports tests, (a) 40-yd dash (leg speed), (b), counter-movement vertical jump (leg power), (c) hexagon test (agility) and (d) T-test. The reliability across all three variables was a 0.98 for the T-test, indicating that it is a highly reliable test to assess agility, leg power, and leg speed.45 All of these measurements of function will help clinicians evaluate areas of weakness to progress through rehabilitation and return to play programs. In order to progress returning an athlete to play or meeting specific goals that have been set, clinicians need to know what factors can influence functional movements in all areas of posture, balance strength, power, speed, agility and quickness. Effects of Cryotherapy on Function In order to use cryotherapy, an understanding of how the treatment will affect function and performance must be addressed. Cold treatments can causes changes in sensory perception, joint position sense and proprioception during and after application.18,46-49 Other components of function that can potentially be compromised after cryotherapy 64 treatment include, muscular activation, strength, and various performance tests, such as, agility, flexibility, speed and power.15-17,19,20,50-53 Sensory Effects Many times cold and hot treatments are followed by exercise as rehabilitation measures. Sensory perception,46 joint position sense18,47-49 and proprioception47 could be effected due to the temperature changes and therefore potentially effect performance ability. The concern is if performance ability is compromised, then it could also increase risk of injury after cryotherapy treatment.18,46-49 Previous research has examined the effects of cryotherapy on sensory perception, joint position sense, and proprioception.18,46-49 Sensory perception examined in the foot and ankle after heat and cold therapy treatments was investigated by Ingersoll et al.46 Twenty-one subjects immersed their right foot in water for treatments at temperatures 1ºC and 40ºC. After each treatment dependent variables were measured for topagnosis (loss of ability to localize the site of tactile sensations)54, two-point discrimination and postural balance. In evaluating the data, there was no significant difference between any of the treatments. In conclusion, 65 Ingersoll stated that hot and cold therapeutic treatments can be combined with therapeutic exercises without interfering with sensory perception in the foot. A limitation by only immerging the foot up to the ankle malleolus, leaves room for further research pertaining to sensory perception after heat and cold therapy treatments.46 Ankle joint position sense was measured after ice immersion for 0, 5, and 20 minute treatments, by LaRiviere and Osternig.47 Thirty-one subjects were treated and then tested on an electrogoniometer for joint angle replication. There was no statistical difference between conditions, trials or angles. The authors conclude by stating that it is possible that the joint position receptors are not affected by ice immersion.47 Two studies examined proprioception after cryotherapy.18,48 Theime et al48 investigated knee proprioception after a 20-minute application of ice over their left leg with two ice packs. Proprioception was measured by blindfolding the subjects and testing three sections of knee ROM: 90º to 60º, 60º to 30º and 30º to full extension. There was no significant difference between ice treatment and control trials on proprioception ability. There was a statistical difference between the times of the ROM sectors. In the discussion, the authors discuss the 66 possibilities for the time differences because (1) the type of receptors at different points in the ROM, (2), difference in the muscle receptors, and (3), gravity assisting sectors 60º to 30º and 30º to full extension. Similar to research testing with ice treatment on the ankle in regards to joint position sense by LaRiviere et al47, Theieme et al’s follow the same findings related to the knee. In conclusion, this study supports using cooling to facilitate exercise for rehabilitation of injuries.48 Proprioception was also researched in the upper extremity by Wassinger et al.18 The study explored cryotherapy effects on the shoulder proprioception and throwing accuracy. Subjects were physically active college students and were all evaluated for active joint position replication, path of joint motion replication and throwing accuracy. Proprioception measurements and functional measurements were assessed on separate days. Each measurement was assessed three times, 2 trials before and 1 after ice treatment. The two pretests were used for learning controls. Main findings did not show any difference after cryotherapy treatment for active joint position replication. However, there was a decreasing difference in functional throwing performance after cryotherapy application. The authors conclude by stating 67 this information can be used when assessing an athlete to return to play after treatment. Wassinger et al’s study is influential to clinical practice because it shows specific elements of rehabilitation that can be effected by cryotherapy treatment.23 The findings on functional ability follow prior research findings as well, when it was found that cryotherapy effected functional ability.15-19 In a review of literature by Costello and Donnelly49, the authors examined literature that has produced original research concerning joint position sense (JPS) after cryotherapy treatment. The intention was to be able to give recommendations about returning athletes to play after cryotherapy. The review used 7 articles pertaining to the topic and the outcome measures and numbers, ages, sexes of subjects were extracted. Studies includes were evaluated using the PEDro scale, which averaged a 5.4 out of 10, ranging from 5 to 6. Three joints were used in assessments: 2 ankle, 3 knee and 2 shoulder. The modality used for evaluating JPS was mostly unilateral active joint repositioning. As an active test, active joint repositioning is thought to be more functional that passive testing. Cryotherapy had a negative effect on JPS in 3 of the studies, and 4 of the studies had no effect. All analyzed studies used pre-test and post-test study design 68 method with a cryotherapy application. Of the studies that reported no change, they all used superficial cubes ice bags and two were done on the shoulder. In conclusion, the authors reported there is limited evidence that address the effect of cryotherapy on joint position sense. Costello et al advise clinicians to use caution with returning patients to activity immediately after cryotherapy until further research is done.49 There has been research aimed to evaluate the effect of cryotherapy on sensory perception, joint position sense and proprioception. Measurements of sensory perception has not shown a decrease after hot or cold therapeutic treatments.46 Further, joint position sense has also not shown to decrease in the ankle, knee, or shoulder after cryotherapy treatment, supporting using cooling to facilitate exercise for rehabilitation of injuries.23,47,48 Shoulder proprioception showed decrease in throwing accuracy after cryotherapy treatment.23 In reviewing the literature, authors suggest joint position sense after cryotherapy has showed limited amount of evidence supporting effects on sensory effects. Although various rehabilitation components have decreased function after cooling23, clinicians can use caution when returning 69 patients to activity immediately after cryotherapy treatment.49 Effects on Strength and Muscular Ability Understanding an effect on muscular strength and ability after a cryotherapy treatment is necessary before implementing treatment with patients. Several studies examined the muscular effects with cryotherapy treatment on muscular activity50, concentric and eccentric strength16, motor recruitment51 and after simulated injuries.52 To investigate muscle activity, Berg et al50 researched reactions of the ankle to sudden inversion after a cryotherapy treatment. Participants’ peroneal muscles were measured for the amplitude of EMG activity over time with sudden inversion on the platform. Main findings supported conclusions that cryotherapy does not affect peroneal muscle reaction after sudden inversion.50 Further examination by Ruiz et al16 researched the effect from cryotherapy on concentric and eccentric strength of the quadriceps. Strength measurements were taken using a kinetic communicator (Kin-Com) after four different 2-set cryotherapy treatments, including, ice and exercise, ice and rest, no ice and exercise and no ice and rest. The main findings showed a significant decrease in 70 strength immediately post-treatment. In conclusion, Ruiz et al make a point to mention the risk cryotherapy may cause an athlete to return to play immediately after a cryotherapy treatment. The authors also noted the strength reduction may only be short-term. In addition, exercise post-treatment may also help with recovery of concentric strength.16 Hopkins51 analyzed changes in motor recruitment during functional lower chain kinetic movement after joint effusion and cryotherapy treatment. Participants were divided into three treatment groups, including, normative, effusion/control and effusion/cryotherapy. Each subject was evaluated using an Omnikinetic device to measure kinetic data during a semirecumbent stepping motion against a set resistance. After data was analyzed, results showed decreases in peak torque and peak power after effusion. With the cryotherapy and normative groups, there was no decrease of peak torque and peak power over time. In conclusion, Hopkins’ results support using cryokinetics in a rehabilitation program to restore motor deficiencies.51 Another study, Isabel et al52, looked at perceived pain, ROM, strength, and serum CK levels after cryotherapy and exercise treatment for delayed onset muscle soreness (DOMS) in the upper arm. Methods of treatment included ice 71 massage alone, ice massage with exercise and exercise alone. Main results showed no significant difference between mode of treatment on any of the dependent variables.52 With conflicting results showing significant decrease in strength ability immediately post-cryotherapy treatment16, but also studies with no changes in muscular activity50, motor recruitement51, returning an athlete to competition or progressing rehabilitation exercises need to proceeded with caution. Effects on Performance Tests There have been many studies performed addressing how cryotherapy affects various performance tests. Results have shown significant decreases15,17,19 in performance, but also shown no significant differences17,20,53 after cryotherapy treatments. Components of performance ability that have been investigated include agility, stability, vertical jump, sprint, power, and flexibility.15,17,19,20,53 Two studies have shown no significant decrease in function after cold immersion.20,53 Using three agility tests, no statistical difference was shown in any of the tests post cold immersion treatment. These results could be because the cold therapy treatments consisted of ice 72 immersion to the level about 8 cm above the lateral malleolus, which only submerged the foot and ankle.20 Stabilization was also assessed after cold immersion treatment, finding no decrease in muscle activity or time to stabilize.53 Both groups of authors suggest cryotherapy should continue to used for treating musculoskeletal injuries.20,53 Cross et al17 also used a Pre-activity ice immersion treatment on the lower extremity, but received varying results when performing numerous functional tests. Participants were from Division III soccer and football athletic teams. Main results showed decrease ability to perform the shuttle run and single-leg vertical jump test, but no difference when performing the 6-meter hop test. Within the same study, following the same treatment protocols before functional tests shows that maybe the effect of cryotherapy has to do with which skills was being measured.17 There is supporting evidence that when measuring impaired functional performance, due to a cold whirlpool treatment, performance ability will regain baseline levels gradually. Patterson et al19 utilized examining functional performance before and after cold whirlpool treatment immersing bilateral lower legs to the fibular head. The 73 functional testing included a counter movement vertical jump, T-test, 40-yard dash and active ROM. Results showed significant decreases immediately following treatment in all of the functional tests, including, the vertical jump, T-test and 40-yard dash. All of the decreased performances were below normal for significant amount of time. Authors suggest since the functional performance increased over time, the timing of returning athletes to play should be carefully considered after cold whirlpool treatments.19 Increasing performance ability after cryotherapy conditions can be accelerated by adding a warm-up. Richendollar et al15 investigated four ice treatment conditions on the ability to perform functional fitness tests: single leg vertical jump, shuttle run and 40-yard sprint. The cryotherapy conditions were no ice/no warm-up, ice/no warm-up, no ice/warm-up and ice/warm-up. A warm-up consisted of a 3-minute jog, 3-minute stretch, and 10 2legged vertical jumps. Treatment with ice bag, on the anterior thigh, decreased performance in all three performance tests. Also, adding the warm-up statistically increased performance on three tests. However, the warm-up used did not return participants to the pre-ice level of performance. Richendollar et al expressed that a warm-up after ice bag application was detrimental on the effects of 74 icing on functional performance.15 Richendollar et al’s study shows, with the warm-up lasting 6.5 minutes, even though the subject is not able to return to maximal performance level, there is a decrease of injury risk because an athlete is better able to perform than without a warm-up.15 These studies have all evaluated performance ability on the lower extremity after cryotherapy treatment, but have shown different results.15,17,19,20,53 Cryotherapy has shown a decreased function with a variety of the size of the treatment area covered, the mode of application and the task required to perform post-treatment.15,17,19 Without specific guidelines to the effects of cryotherapy before performance assessments, decreased function is still a unfavorable possibility. Even with supporting evidence that adding a warm-up can counter the detrimental cryotherapy effects,15 research has not been conducted to determine post-cryotherapy warm-up guidelines to return to full performance ability. Summary Cryotherapy is a commonly used modality by athletic trainers during competitions. Many studies have shown the 75 physiological responses that are beneficial for rehabilitation after an injury.1-14 By undergoing certain physical property changes, treatment sessions can be more effectively used.1-4 Cryotherapy effectiveness can be increased by utilizing certain methods of cold therapy, the type of ice, and the amount of ice and compression.1,2,5-14 Utilizing a pre-activity warm up is also a common practice for before athletic competitions and practices. A warm up that will successfully enhance performance and decrease risk of injuries can have many influencing variables. The type of warm-up, intensity, duration, recovery periods, and stretching techniques can all factor into formulating a proper pre-activity warm up. Looking at the effect of stretching techniques on performance, generally, research has supporting using a dynamic stretching component incorporated in a warm up protocol.2729,31,37-39 Functional ability is a major area for assessing athletes’ ability to participate in activity or competition when rehabilitating an injury.43 By being able to objectively assess posture, balance, stability, strength, power, speed, agility and quickness, a clinician can set specific goals and return to play criteria.25,43 The difficulty arises when an athlete wants to immediately 76 return to play after a cryotherapy. Clinicians cannot ignore the effects of cryotherapy that have shown to decreased ability to perform optimally and therefore leaves risk of injury possible for athletes.15,17,19 One study showed a short warm-up (6.5 minutes) after cryotherapy treatment significantly improved performance ability. However, the participants did not return to pre-ice performance with only 6.5 minutes of warming up.15 Therefore, more research is needed to gain conclusive data on what is necessary in a warm-up to be able to return an athlete to play after a cryotherapy treatment. 77 APPENDIX B The Problem 78 THE PROBLEM Statement of the Problem Cryotherapy is one of the most commonly used modalities in sports medicine even though it has the potential to negatively impact performance. There has been conflicting evidence on the effect cryotherapy has on effecting performance.15-20,50-53 Specifically, when testing agility, two other studies have shown cryotherapy to decrease agility performance using a large lower extremity treatment area for cold whirlpool17,19 and an ice bag on the anterior thigh.15 There has also been varying research to support the most effective warm-up protocols before high performance activities.22,25-41 It is known that dynamic warmups are successful at increasing performance in areas of strength, speed, power and agility compared to warm up incorporating only static stretching or no stretching warm ups.27-29,31,37-39 The purpose of the present study was to investigate the effect of re-warming on functional agility performance after cryotherapy treatment. It is important to examine the relationship between varying warm-up protocols on agility performance after cryotherapy treatment to help guide clinical practice. Additionally it will be beneficial for 79 clinicians to know what type of warm-up protocol will help return athletes to be able to maximally perform after cryotherapy. Definition of Terms The following definitions of terms were defined for this study: 1. Cryotherapy- the application of cold therapy.1,2 2. Wetted Ice- ice and water added together in an ice bag and used with a dry interface.9 3. Functional Agility- the ability to change direction or orientation of the body based on internal or external information quickly and accurately without significant loss of speed.25 Agility is a measurable component of functional performance and is crucial for optimal performance.20,25,43,45 4. T-test- a reliable and valid measure of agility, leg power, and leg speed.45 5. Re-warming- a second warm up period prior to returning to competition, after which they have already participated in competition and had a period of cooling, by either inactivity or cryotherapy treatment. 80 6. Dynamic Stretching- utilizes full range of motion movements with the body’s own weight and force production.22 Fletcher31 defines dynamic warm-up as a controlled movement through the active range of motion for each joint.31 7. Static Stretching- when the muscle is stretched to a point of discomfort and then held at that point for an extended period of time.22,26 8. Collegiate Athlete- individuals that are identified by the NCAA as an athlete that have completed at least one full season. Basic Assumptions The following are basic assumptions of this study: 1. The subjects will be honest when they complete their demographic sheets. 2. All subjects are volunteers without any obligation by coaches or faculty. 3. The subjects will fully understand the directions and perform to the best of their ability during testing sessions. 4. The subjects will follow the instructions for the process during each portion of the testing sessions. 5. The T-test is reliable and valid to test agility. 81 6. The equipment will be calibrated and set up identically each testing session and time will be measured accurately. Limitations of the Study The following are possible limitations of the study: 1. The subjects were volunteers and limited to the soccer teams from California University of Pennsylvania. 2. Results of this study are limited to non-injured athletes. Delimitation of the Study The following statement reflects the delimitations of the study: 1. The study is limited by completing agility assessment on hardwood, gymnasium floors, which potentially, is not familiar for the soccer athletes. 2. The research study is limited to the effects of ice bag treatment placed on the anterior thigh and testing agility performance. 82 Significance of the Study The scope of this study is to investigate the length of re-warming exercise on agility performance after cryotherapy treatment. With the effect of cryotherapy, lengths of warm-up to prepare to return to play needs to be determined in order for the athlete to be able to return to play without a decrease in performance and increase risk of injury. When athletes suffer an injury, they are commonly treated with ice bags. Previous research has found that cryotherapy can be detrimental to performance ability.15-19 When performance ability is compromised due to cold therapy, it can increase risk of injury.22 Warming up before activity can improve performance ability mostly from temperature-related physiological responses, including increasing core temperature, blood flow, and preparing the body for exercise.22 Research also demonstrates that warming up can counter the cryotherapy response which inhibits factors of performance ability.15 Agility is a measurable component of functional performance and is crucial for optimal athletic performance.20,25,43,45 It is essential for clinicians to know the amount of time re-warming exercise should be conducted to return an athlete to full functional agility performance level in order for them to return to competition. 83 APPENDIX C Additional Methods 84 APPENDIX C1 Informed Consent Form 85 Informed Consent Form 1. Colleen J Frickie, ATC has requested my participation in a research study at California University of Pennsylvania. The title of the research is “Effect of Rewarming on Functional Agility in Collegiate Athletes After Cryotherapy Treatment”. 2. I have been informed that the purpose of the research is to investigate the effect of re-warming on functional agility performance after cryotherapy treatment. 3. My participation will involve a light warm-up, performing the T-test, completing a cryotherapy treatment (ice application) and completing several warm-up protocols before performing a follow up T-test. The pre warm-up is light exercise allowing me to get prepared to perform the baseline T-test. The T-test is used to measure functional agility, in which I will sprint, lateral shuffle and run backward in a T-shape, as directed by the researcher. The cryotherapy treatment will involve an ice bag being wrapped to my anterior thigh for 30 minutes. The warm-up protocols will involve jogging, static stretching, dynamic stretching, and agility exercises. All testing, treatment and warm-ups will take place in the gymnasium of Hamer Hall on three separate days for approximately one hour each day, with at least 48 hours between testing sessions, for all subjects. 4. I understand there are foreseeable risks or discomforts to me if I agree to participate in the study. The possible risk of falling during the T-test or during the warm-ups will be minimized by the researcher. The risk is no more than normal physical activity that normal collegiate athletes would experience during practice or competition. I would not be included in the study if I had any known contraindications to cold therapy or cold allergy. 5. Any injuries or prolonged soreness that may occur during testing can be treated at the athletic training room at Hamer Hall provided by the researcher, Colleen J Frickie, ATC, or another Certified Athletic Trainer, either of whom can administer emergency and rehabilitative care. 7. I understand that there are no feasible alternative procedures available for this study. 8. I understand that the possible benefits of my participation in the research are contributions to existing research and may aid in identifying what level of a warm-up protocol will help return athletes to maximal performance ability after ice application. 9. I understand that the results of the research study may be published but that my name or identity will not be revealed. In order to maintain confidentiality of my records, Colleen J Frickie, will maintain all documents in a secure location in which only the researcher and research advisor can access them. 86 10. I have been informed that I will not be compensated for my participation. 11. I have been informed that any questions I have concerning the research study or my participation in it, before or after my consent, will be answered by: Colleen J Frickie, ATC 947 Cross St Apt #1 California, PA 15419 703.795.6416 Fri0405@calu.edu Rebecca Hess, PhD B6 Hamer Hall California University of Pennsylvania California, PA 15419 724.938.4359 Hess_ra@calu.edu 12. I understand that written responses may be used in quotations for publication but my identity will remain anonymous. 13. I have read the above information. The nature, demands, risks, and benefits of the project have been explained to me. I knowingly assume the risks involved, and understand that I may withdraw my consent and discontinue participation at any time without penalty or loss of benefit to myself. In signing this consent form, I am not waiving any legal claims, rights, or remedies. A copy of this consent form will be given to me upon request. Subjects signature ________________________________________ Date ___________ Other signature (if appropriate)______________________________ Date ___________ 14. I certify that I have explained to the above individual the nature and purpose, the potential benefits, and possible risks associated with participation in this research study, have answered any questions that have been raised, and have witnessed the above signature. 15. I have provided the subject/participant a copy of this signed consent document if requested. Investigator’s signature ____________________ Date ________ Approved by the California University of Pennsylvania IRB: Start date: 2/15/11, End date: 2/14/12. 87 Appendix C2 Individual Data Collection Sheet 88 Individual Data Collection Sheet Subject Number: _______ Age : __________ Gender: Female / Male Dominant Leg: R / L DAY 1 Date: ___________ Observation Notes: WUP (circle one) Pre-Warm Up No WUP / SWUP / LWUP 10-15 min Baseline T-test Re-trial 1 Time: ____________ Time: ____________ Cryotherapy Tx Re-warming WU 30min 0 min / 6.5 min / 16 min T-test Re-trial 1 Time: ____________ Time: ____________ DAY 2 Date: ___________ WUP (circle one) Pre-Warm Up No WUP / SWUP / LWUP 10-15 min Baseline T-test Re-trial 1 Time: ____________ Time: ____________ Cryotherapy Tx Re-warming WU 30min 0 min / 6.5 min / 16 min T-test Re-trial 1 Time: ____________ Time: ____________ DAY 3 Date: ___________ WUP (circle one) Pre-Warm Up No WUP / SWUP / LWUP 10-15 min Baseline T-test Re-trial 1 Time: ____________ Time: ____________ Cryotherapy Tx Re-warming WU 30min 0 min / 6.5 min / 16 min T-test Re-trial 1 Time: ____________ Time: ____________ 89 APPENDIX C3 Agility T-test Diagram 90 Agility T-test diagram This image has been taken from Topend Sports Network website.55 Cone A to B = Sprint Forward Cone B to C = Lateral Shuffle Left Cone C to D = Lateral Shuffle Right Cone D to B = Lateral Shuffle Left Cone B to A = Run backwards 91 APPENDIX C4 Short Warm-Up Protocol 92 Short Warm-Up Protocol Phase 1: Jogging Each subject will jog at a light, comfortable pace around the gymnasium for 3 minutes. Phase 2: Static Stretching Each subject will individually perform each stretch for the allotted amount of time. For each stretch, the subjects are instructed to hold the position at the end of the range of motion without causing any pain. Phase 3: Dynamic Stretching Each subject will complete 10 double-leg jump-tucks in place. The subjects will be instructed to complete 10 jumps in a row, with no break in between. The subjects will also be instructed to use both arms for counter movement and jump as high as possible. A breakdown of each phase and times for each stretch is as follows: Time 3 min 3 min 30 sec 6.5 min Phase 1 LIGHT JOGGING 2 STATIC STRETCHING Butterfly Figure-4 Spinal Twist Foot Grab Calf 3 DYNAMIC STRETCHING Double-Leg Jump-Tucks Position Time 3 min Seated Seated Seated Side-lying Push-Up 30 sec 15 sec 15 sec 30 sec 15 sec 2 sec Reps Target Areas x1 x1 x2 x2 x2 x2 Adductors Hamstring Lower Back & Gluts Quadriceps Gastroc & Soleus x10 TOTAL TIME 6.5 min The short warm-up protocol has been taken from the active warm-up routine developed by Richendollar et al.15 93 APPENDIX C5 Long Warm-Up Protocol 94 Long Warm-Up Protocol Phase 1: Jogging Each subject will jog at a light, comfortable pace around the gymnasium for 2 minutes total. This will include 45 seconds light jogging, side stepping 15 seconds on each side, back jogging for 15 seconds and another 45 seconds light jogging. Phase 2: Static Stretching Each subject will individually perform each stretch for the allotted amount of time. For each stretch, the subjects are instructed to hold the position at the end of the range of motion without causing any pain. Phase 3: Dynamic Stretching Each subject will complete five dynamic stretches. Each exercise will be performed in a walking pattern for the allotted time. Each stretch is performed for a total of 1 minute each. Phase 4: Sprint and Agility This phase is aimed to include incremental intermittent sprint and agility exercises to prepare the body for agility performance. Following 10 doulbe-leg jump-tucks, each subject will start at three-quarter running pace and increase intensity to be full speed for the final exercise. Time for these is estimated on each exercise, when each exercise is complete the subject will rest for the remaining of the 20 seconds. 95 Long Warm-Up Protocol Time 2 min 1 4.5 min 2 3 min 3 2.5 min 4 12 min Phase JOGGING Jogging Side Stepping Back Jogging Jogging STATIC STRETCHING Butterfly Figure-4 Foot Grab Spinal Twist Calf DYNAMIC STRETCHING Open Gates Close Gates Lateral Lunge Forward Walking Lunge Straight-Leg March Heel-to-Toe SPRINT and AGILITY 10 Double-Leg Jump-Tuck 10m Forward + 5m Forward 10m Forward + 20m Forward 30m Forward TOTAL TIME Position Time Reps Target Areas 45 sec 15 sec 15 sec 45 sec x1 x2 x1 x1 Seated Seated Side-Lying Seated Push-Up 30 sec 30 sec 30 sec 30 sec 30 sec x1 x2 x2 x2 x2 Adductors Hamstring Hip Flexor & Quads Gluteals Gastroc Alternating Alternating One-Way Alternating Alternating Alternating 30 sec 30 sec 15 sec 30 sec 30 sec 30 sec x1 x1 x2 x1 x1 x1 Adductors/Gluteals Adductors/Gluteals Adductors Gluteals/Quadriceps Hamstrings Gastroc 20 sec Alternating 20 sec 20 sec 20 sec 12 min x1 x2 x1 x1 3/4 Speed 3/4 Speed+Full Pace Full Pace The long warm-up protocol has been taken from the warm up protocol routines developed by Little et al.37 96 APPENDIX C6 Institutional Review Board – California University of Pennsylvania 97 IRB Application 98 99 100 101 102 103 104 105 106 107 Institutional Review Board California University of Pennsylvania Psychology Department LRC, Room 310 250 University Avenue California, PA 15419 instreviewboard@cup.edu instreviewboard@calu.edu Robert Skwarecki, Ph.D., CCC-SLP,Chair Ms. Frickie, Please consider this email as official notification that your proposal titled “The Effect of Re-warming on Functional Agility in Collegiate Athletes After Cryotherapy Treatment” (Proposal #10-023) has been approved by the California University of Pennsylvania Institutional Review Board as submitted. The effective date of the approval is 02-15-2011 and the expiration date is 02-14-2012. These dates must appear on the consent form. Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: (1) Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) (2) Any events that affect the safety or well-being of subjects (3) Any modifications of your study or other responses that are necessitated by any events reported in (2). (4) To continue your research beyond the approval expiration date of 02-14-2012 you must file additional information to be considered for continuing review. Please contact instreviewboard@calu.edu Please notify the Board when data collection is complete. Regards, Robert Skwarecki, Ph.D., CCC-SLP Chair, Institutional Review Board 108 APPENDIX C7 Cryotherapy Set Up 109 Cryotherapy Set Up Step 1: Ice bag contained wetted ice as defined by Dykstra et al9 with 2000mL of ice and 300mL of room temperature water. Step 2: Compression was measured to insure consistency at the beginning of the treatment session between 4045mmHg using a blood pressure cuff.13 Step 3: Plastic wrap was applied to secure the ice bag application, ensuring the compression remained within 40-45mmHg, at the beginning of the treatment. 110 Step 4: Athlete sat with minimal movement and leg extended for a 30-minute ice bag treatment. 111 REFERENCES 1. Knight KL, Draper DO. Therapeutic Modalities: The Art and Science. Philadelphia, PA: Wolters Kluwer Health, Lippincott Williams & Wilkins; 2008, Ch 13,14. 2. Knight, K. Cryotherapy in Sport Injury Management. Champaign, IL: Human Kinetics; 1995. 3. Merrick MA, Jutte LS, Smith, ME. Cold modalities with different thermodynamic properties produce different surface and intramuscular temperatures. J Athl Train. 2003;38(1):28-33. 4. Kennet J, Hardaker N, Hobbs S, Selfes J. Cooling efficiency of 4 common cryotherapeutic agents. J Athl Train. 2007;42(3):343-348. 5. Bleakley C, McDonough S, MacAuley D. The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trails. Am J Sport Med. 2004;32:251-261. 6. Hubbard TJ, Denegar CR. Does cryotherapy improve outcomes with soft-tissue injury? J Athl Train. 2004;39(3):278-279. 7. Zemke JE, Anderson JC, Guion WK, McMillian J, Joyner AB. Intramuscular temperature responses in the human leg to two forms of cryotherapy: ice massage and ice bag. J Orthop Sports Phys Ther. 1998;27(4):301-307. 8. Myrer JW, Measom G, Fellingham GW. Temperature changes in the human leg during and after two methods of cryotherapy. J Athl Train. 1998;33(1):25-29. 9. Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael TJ, Baker RJ. Comparisons of cubed ice, crushed ice and wetted ice on intramuscular and surface temperature changes. J Athl Train. 2009;44(2):136-141. 10. Janwantanakul P. The effect of quantity of ice and size of contact area on ice pack/skin interface temperature. Physiother.2009;95:120-125. 112 11. Palmer J, Knight KL. Ankle and thigh skin surface temperature change with repeated ice pack application. J Athl Train. 1996;31(4):319-323. 12. Merrick MA, Knight KL, Ingersoll CD, Potteigher JA. The effects of ice and compression wraps on intramuscular temperatures at various depths. J Athl Train. 1993;28(3):236-245. 13. Janwantanakul P. Cold pack/skin interface temperature during ice treatment with various levels of compression. Physiotherapy. 2006;92(4):254-259. 14. Tomchuk D, Rubley MD, Holcomb WR, Guadagnoli M, Tarno JM. The magnitude of tissue cooling during cryotherapy with varied types of compression. J Athl Train. 2010;45(3):230-237. 15. Richendollar ML, Darby LA, Brown TM. Ice bag application, active warm-up and 3 measures of maximal performance. J Athl Train. 2006;41(4):364-370. 16. Ruiz DH, Myrer JW, Durrant E, Fellingham GW. Cryotherapy and sequential exercise bouts following cryotherapy on concentric and eccentric strength in the quadriceps. J Athl Train. 1993;28(4):320-323. 17. Cross KM, Wilson RW, Perrin, DH. Functional performance following an ice immersion to the lower limb. J Athl Train. 1996;31(2):113-116. 18. Wassinger CA, Myers JB, Gatti JM, Conley KM, Lephart SM. Proprioception and throwing accuracy in the dominant shoulder after cryotherapy. J Athl Train. 2007;42(1):84-89. 19. Patterson SM, Edermann BE, Doberstein ST, Reineke DM. The effects of cold whirlpool on power, speed, agility and range of motion. J Sports Sci & Med. 2008;7:387394. 20. Evans T, Ingersoll CD, Knight KL, Worrel T. Agility following the application of cold therapy. J Athl Train. 1995;30(3):231-234. 113 21. Hopkins JT, Ingersoll CD, Edwards J, Klootwyk E. Cryotherapy and transcutaneous electric neuromuscular stimulation decrease arthrogenic muscle inhibition of the vastus medialis after knee joint effusion. J Athl Train. 2002; 37: 25-31. 22. Shellock FG, Prentice WE. Warming-up and stretching for improved physical performance and prevention of sports-related injuries. Sports Med. 1985;2:267-278. 23. Bishop D. Warm up 1: Potential mechanisms and the effects of passive warm up on exercise performance. Sports Med. 2003;33(6):439-454. 24. Bishop D. Warm up 2: Performance changes following active warm up and how to structure the warm up. Sports Med. 2004;33(7):483-498. 25. Clark MA, Lucett SC. NASM’s Essential of Sports Performance Training, 1st ed. Baltimore: Lippincott Williams & Wilkins; 2010, Ch 3,4. 26. Unick J, Kieffer HS, Cheesman W, Feeney A. The acute effects of static and ballistic stretching on vertical jump performance in trained women. J Strength Cond Res. 2005;19(1):206-212. 27. Faigenbaum AD, Bellucci M, Bernieri A, Baker B, Hoorens K.. Acute effects of different warm-up protocols on fitness performance in children. J Strength Cond Res. 2005;19(2):376-381. 28. Faigenbaum AD, Kang J., McFarland J, Bloom JM, Ratamess NA, Hoffman JR.. Acute effects of different warm-up protocols on anaerobic performance in teenage athletes. Pediatric Exercise Sci. 2006;17:64-75. 29. Papadopoulos G, Siatras Th, Kellis S. The effect of static and dynamic stretching exercises on the maximal isokinetic strength of the knee extensors and flexors. Isokinetics Exercise Sci. 2005;13:285-291. 30. Woolstenhulme MT, Griffiths CM, Woolstenhulme EM, Parcell AC. Ballistic stretching increases flexibility and acute jump height when combined with basketball activity. J Strength Cond Res. 2006;20(4):799-803. 114 31. Fletcher IM, Jones B. The effect of different warm-up stretch protocols on 20 meter sprint performance in trained rugby union players. J Strength Cond Res. 2004;18(4):885-888. 32. Schiefelbein NJ. A qualitative systematic review of dynamic warm-up protocols [master’s thesis]. California, PA: California University of Pennsylvania; 2008. 33. Sale, DG. Postactivation potentiation: Role in human movement performance. Exterc. Sports Sci. Rev. 2002;30:138-143. 34. Bazett-Jones DM, Wincester JB, McBride JM. Effect of potentiation and stretching on maximal force, rate of force development, and range of motion. J Strength Cond Res. 2005;19(2):421-426. 35. Marek SM, Cramer JT, Fincher AL, Massey LL, Dangelmaier SM, Purkayastha S, Fitz KQ, Culbertson JY. Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output. J Athl Train. 2005;40(2):94-103. 36. Papadopoulos C, Kalapotharakos V, Noussios G, Meliggas K, Gantiraga E. The effect of static stretching on maximal voluntary contraction and force–time curve characteristics. J Sport Rehab. 2006;15:185-194. 37. Little T, Williams AG. Effects of differential stretching protocols during warm-ups on high-speed motor capacities in professional soccer. J Strength Cond Res. 2006;20(1):203-207. 38. Yamaguchi T, Kojiro I. Effects of static stretching for 30 seconds and dynamic stretching on leg extension power. J Strength Cond Res. 2005;19(3):677-683. 39. McMillian DJ, Moore JH, Hatler BS, Taylor DC. Dynamic vs. static-stretching warm-up: the effect on power and agility performance. J Strength Cond Res. 2006;20(3):492-499. 40. Faigenbaum AD, McFarland JE, Kelley NA, Ratamess NA, Kang J, Hoffman JR. Influence of recover time on warm- 115 up effects in male adolescent athletes. Pediatric Exercise Science. 2010;22:266-277. 41. Siatras TH, Papadopoulos G, et al. Static and dynamic acute stretching effect on 15gymnasts’ speed in vaulting. Pediatric Exercise Sci. 2003;15383-391. 42. Powers SK, Howley ET. Exercise Physiology, Theory and Application to Fitness and Performance, 6th ed. Boston: McGrawHill; 2007; Ch 3,11,21. 43. Prentice WE. Rehabilitation Techniques for Sports Medicine and Athletic Training. 4th ed. McGraw Hill; 2004, Ch 13,17. 44. Onate JA, Beck BC, Van BL. On-field testing environment and Balance Error Scoring System performance during preseason screening of healthy collegiate baseball players. J Athl Train. 2007;42(4):446-451. 45. Paulo K, Madole K, Garhammer J, Lacourse M, Rozenek R. Reliability and validity of the T-test as a measure of agility, leg power, and leg speed of college-aged men and women. J Strength Cond Res. 2000;14(4):443-450. 46. Ingersoll CD, Knight KL, Merrick MA. Sensory perception of the foot and ankle following therapeutic applications of heat and cold. J Athl Train. 1992;27(3):231-234. 47. LaRiviere J, Osternig LR. The effect of ice immersion on joint position sense. J Sports Rehabil. 1994;3:5867. 48. Thieme HA, Ingersoll CD, Knight KL, Ozmun JC. Cooling does not affect knee proprioception. J Athl Train. 1996;31(1)8-11. 49. Costello JT, Donnelly AE. Cryotherapy and joint position sense in healthy participants: a systematic review. J Athl Train. 2010;45(3):306-316. 50. Berg CL, Hart JM, Palmiere-Smith R, Cross KM, Ingersoll CD. Cryotherapy does not affect peroneal reaction following sudden inversion. J Sports Rehabil. 2007;16(4):285-294. 116 51. Hopkins JT. Knee joint effusion and cryotherapy alter lower chain kinetics and muscle activity. J Athl Train. 2006;41(2):177-184. 52. Isabel WK, Durran ET, Myrer W, Anderson S. The effects of ice massage, ice massage with exercise, and exercise on the prevention and treatment of delayed onset muscle soreness. J Athl Train. 1992;(27)3:208217. 53. Miniello S, Dover G, Powers M, Tillman M, Wikstrom E. Lower leg cold immersion does not impair dynamic stability in healthy women. J Sports Rehabil. 2005;14(3):234-247. 54. Venes, D. Taber’s Cyclopedic Medical Dictionary. 20th ed. Philadelphia: F.A. Davis Company; 2001. 55. Agility T-Test. The Topend Sports Network. http://www.topendsports.com/testing/tests/t-test.htm. Updated January 14, 2011. Accessed November 13, 2010. 117 ABSTRACT TITLE: Effect of Re-Warming on Functional Agility in Collegiate Athletes after Cryotherapy Treatment RESEARCHER: Colleen Joyce Frickie ATC, NASM-PES ADVISOR: Dr. Rebecca Hess DATE: May 2011 RESEARCH PROBLEM: Master Thesis PURPOSE: The purpose of the study was to investigate warm-up lengths on functional agility, measured using the T-test, after ice bag application to the anterior thigh. PROBLEM: With the detrimental effects of cryotherapy on performance ability, lengths of warm-up in preparation to return to play needs to be determined to decrease the risk of injury and increase athletes’ performance. METHODS: This study used a quasi-experimental, within-subjects design. Seventeen Division II collegiate soccer athletes completed three testing sessions that included a prewarm-up, baseline (pretest) agility T-test, ice bag application, level of warm-up condition (no warm-up, short warm-up and long warm-up), and maximal performance (posttest) T-test. FINDINGS: A repeated measures ANOVA revealed a significant difference among no warmup, short warm-up and long warm-up (F(2,32) = 19.316, P < .001). In addition, Paired-Sample T-tests were significant among all three pairs (Control – Short, Control – Long, and Short – Long). The long warm-up demonstrated the best agility time, 118 shown with a difference average of .2341 seconds being a faster agility time. CONCLUSIONS: Re-warming after ice bag application to the anterior thigh will increase agility performance ability in Division II collegiate soccer athletes. Further, after cryotherapy, a 12-minute warm-up will show more improvement in agility performance compared to a 6.5-minute warm-up.