THE EFFECTS OF CRYOTHERAPY OVER THE LATERAL ANKLE
ON STATIC
AND DYNAMIC BALANCE

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
Amber Fisher

Research Advisor, Dr. Thomas F. West
California, Pennsylvania
2009

iii
ACKNOWLEDGEMENTS

I would like to thank so many people for supporting me
this year. First, I would like to thank my parents and my
sister for always supporting me in whatever I decided to
do. I would also like to thank the rest of my family, such
as my grandmother, all my aunts, uncles, and cousins who
have came and visited me. I would also love to thanks my
friends both old and new ones that I have made. They have
helped me through so many things, and have always been
there to listen, talk and just be a friend. My friends who
have helped me with this project, a big thank you!! There
are so many memories that will never be forgotten!!!
The people at Lynchburg College also deserve a big
thanks, they have helped me become who I am today and
helped me on my career path to become an athletic trainer,
they is nothing I can say to express my gratitude towards
all of you! The staff at California University of
Pennsylvania all deserves a big thank you. Especially Dr.
Thomas F. West, my chairperson who has helped me so much
with this project and my committee members Dr. Marc
Federico and Dr. Laura Miller. Thank you both for being on
my committee and all the feedback you have given me.
Lastly, I would like thank the people at Avella High

iv
School. They have made this year a very memorable one, so
many good and fun memories at this place. They have
listened to me and have always made me laugh and feel
better at the end of the day. Thank you to everybody!!

v
TABLE OF CONTENTS

Page
SIGNATURE PAGE

. . . . . . . . . . . . . . . ii

AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii
TABLE OF CONTENTS .
LIST OF TABLES

. . . . . . . . . . . . . . . vii

LIST OF FIGURES .
INTRODUCTION .
METHODS .

. . . . . . . . . . . . . v

. . . . . . . . . . . . . . viii

. . . . . . . . . . . . . . . 1

. . . . . . . . . . . . . . . . . 7

Research Design
Subjects .

.. . . . . . . . . . . . . 7

. . . . . . . . . . . . . . . . 7

Preliminary Research . . . . . . . . . . . . . 8
Instruments .

. . . . . . . . . . . . . . . 9

Procedures . . . . . . . . . . . . . . . . . 10
Hypothesizes . . . . . . . . . . . . . . . . 12
Data Analysis
RESULTS .

. . . . . . . . . . . . . . . 13

. . . . . . . . . . . . . . . . . 14

Demographic Data .

. . . . . . . . . . . . 14

Hypothesis Testing .

. . . . . . . . . . . . 15

DISCUSSION . . . . . . . . . . . . . . . . . 19
Discussion of Results .
Conclusions .

. . . . . . . . . . . 19

. . . . . . . . . . . . . . . 26

Recommendations . . . . . . . . . . . . . . . 27

vi
REFERENCES. . . . . . . . . . . . . . . . . . 29
APPENDICES .

. . . . . . . . . . . . . . . . 32

APPENDIX A: Review of Literature. . . . . . . . . 33
Introduction . . . . . . . . . . . . . . . . 34
Cryotherapy .

. . . . . . . . . . . . . . . 35

Balance . . . . . . . . . . . . . . . . . . 40
Previous Research . . . . . . . . . . . . . 48
Summary . . . . . . . . . . . . . . . . . . 53
APPENDIX B: The Problem . . . . . . . . . . . . 55
Definition of Terms . . . . . . . . . . . . . 56
Basic Assumptions . . . . . . . . . . . . . . 57
Limitations of the Study . . . . . . . . . . . 57
Significance of the Study . . . . . . . . . . . 58
APPENDIX C: Additional Methods .
Informed Consent Form (C1) .

. . . . . . . . 59

. . . . . . . . . 60

IRB: California University of Pennsylvania (C2) . . 64
Individual Data Collection Sheet (C3) . . . . . . 70
BESS and STAR Pictures (C4)

. . . . . . . . . 72

Demographic Sheet(C5) . . . . . . . . . . . . 76
REFRENCES

. . . . . . . . . . . . . . . . . 78

ABSTRACT

. . . . . . . . . . . . . . . . . 82

vii
LIST OF TABLES
Table

Title

Page

BESS Test Firm Condition . . . . . . . . 16

BESS Test Foam Condition . . . . . . . . 17

Star Excursion Balance Test . . . . . . . 18

viii
LIST OF FIGURES

Figure Title

Page

BESS Test Ground Ice and No Ice . . . . . . 21

BESS Test Foam Ice and No Ice . . . . . . . 25

SEBT Ice and No Ice . . . . . . . . . . . 25

BESS Double Leg Firm

. . . . . . . . . . 73

BESS Single Leg Firm

. . . . . . . . . . 73

BESS Tandem Firm . . . . . . . . . . . . 73

BESS Double Leg Foam

. . . . . . . . . . 74

BESS Single Leg Foam

. . . . . . . . . . 74

BESS Tandem Foam . . . . . . . . . . . . 75

SEBT . . . . . . . . . . . . . . . . . 75

INTRODUCTION

Cryotherapy is one of the most commonly used
modalities in athletic training today. This modality is
used on a daily basis around the country in various
athletic training rooms.1-12 Many studies have shown the
effectiveness of cryotherapy on pain relief, decreasing
inflammation, preventing hypoxic injury, and decreasing
muscle spasms.1-14 Fewer studies have examined the effect of
cryotherapy on performance measures such as balance.
Balance is an intrinsic part of athletic ability and
being able to balance while performing is highly important
from both the standpoint of performance and injury
prevention. Many athletes use a form of cryotherapy prior
to participating in sports and during breaks from playing.
There have been many conflicting reports about whether
there is a decrease in balance, which leads to a decrease
in performance from the application of cryotherapy prior to
participating in sports.15-18
Cryotherapy is defined as the application of a cold
modality to an area of the body.3 The skin, subcutaneous
tissues, and muscles are cooled through cryotherapy via

2
conduction and/or convection.1 That is how the skin and
underlying tissues and structures loses heat and how
cryotherapy modalities work. The effects that cryotherapy
has on the body are many and include alteration of
sensation, temperature, metabolism, and nerve function and
conduction.1-14
Balance can be defined as the ability to maintain an
upright stance and maintain equilibrium without falling.15
Balance is an intrinsic part of everyday activity and
highly important in athletics. If an athlete does not have
good balance then they cannot perform at their highest
level. Balance is a combination of center of balance,
postural control, and center of pressure and base of
support. Maintaining balance also includes both sensory and
motor components both of which have the potential to be
affected by cryotherapy.15
Proprioception can be described as being able to
detect changes in specific joint position and being able to
adapt to that change.16 It can be considered an intrinsic
part of balance. It is a combination of input from
mechanoreceptors that are contained within the joint,
ligaments, tendons and the skin which work together to give
the sense of change in joint position. Proprioception has
been shown in studies to improve after balance training

3
activities, which can lead to better performance and
decreased risk of injuries.16-20,22
There are two types of balance that are used every
day, static and dynamic. Static balance is used when a
person is remaining in a position for period of time and is
maintaining balance. To maintain static balance the goal is
to minimize the amount of movement in the subjects’ center
of balance. Static balance can be observed on a stable and
unstable surface to determine an athlete’s static balance
ability. Dynamic balance is being able to maintain postural
stability while moving. This type of balance is used most
often in athletics, and is the most important one to be
able to have. If an athlete cannot be balanced and run then
they will not be able to perform at their highest
ability.16-22
There are many reliable ways to test both static and
dynamic balance; two of the most common are the Balance
Error Scoring System (BESS) and the Star Excursion Balance
Test(SEBT). The BESS test is considered a reliable
assessment tool to obtain static balance results.16,18,20 This
test used 3 stances in two different surfaces. Mistakes are
counted as scores. The SEBT is often used to assess dynamic
balance in athletes. This test consists of having a stargrid laid out on the floor in eight directions. The test

4
foot is placed directly in the middle of the star while the
other foot reaches out as far as possible and touches the
farthest point with their toes.16,18,20,24 The SEBT has been
proven to be a reliably method of determining dynamic
balance in numerous studies.27
Nerve function plays an important role in how
cryotherapy may affect balance. The nerves that are
affected first by cryotherapy would be the cold and pain
nerve receptors, since the first sensations felt are cold
and pain. Mechanoreceptors respond to different stimulus.
They are a type of superficial receptors that respond to
touch and pressure and responds rapidly to changes in
stimulus. Thermo receptors are also a type of superficial
receptor that responds quickly to changes in temperature.
Deep receptors include Golgi tendon organs (GTO) and muscle
spindles. GTO help with proprioception and detect changes
in muscle length and tension along with the muscle
spindles.

All of these nerves and receptors are affected by

applications of cryotherapy so therefore skin touch,
temperature, and pain are all decreased and proprioception
is decreased via the deep receptors.13
There have been numerous studies that have shown
conflicting results on whether cryotherapy has an effect on
static and dynamic balance. A study performed by Wassinger

5
et al., examined proprioception and throwing accuracy in
baseball players after applying cryotherapy. The results of
this study demonstrated a decrease in shoulder
proprioception and accuracy after applying cryotherapy to
the shoulder.27 In a study performed by Richendollar et al.,
the researchers examined the effect of cryotherapy on three
different functional performance exercises and on active
warm-ups following cryotherapy treatments. The results of
this study showed that ice bag application had decreased
maximal performance in all three of the tests.27 Another
study done by Cross et al. examined functional performance
after ice immersion. The three functional tests that were
performed were the shuttle run, the hop test, and the
single-leg hop test. The results of this test showed that
ice immersion does have an impact on functional
performance.16
Miniello et al. examined lower leg immersion and
whether it affected dynamic balance in females. The results
of this study showed that lower leg immersion does not
affect dynamic stability.28 A study conducted by Berg et al.
explored peroneal reaction time in subjects following a
cryotherapy treatment. The results of this study showed
that there was no significant change in peroneal reaction
time after treatment at any time.28

6
In a study that was performed by Evans et al., the
researchers were examining agility after applying
cryotherapy. The results of this study showed that ice
immersion of the foot and ankle did not alter agility to a
significant degree.6
Balance is major component of athletic ability and if
it is decreased from cryotherapy then professionals who use
this common modality on regular bases needs to be aware of
the possible effect on athletic performance. Therefore, the
purpose of this research is to determine whether
cryotherapy decreases an athlete’s static and dynamic
balance, which in turn could impact the player’s athletic
ability and injury risk.

METHODS

The purpose of this study was to examine the effects
of cryotherapy on both static and dynamic balance. 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 research was a quasi-experimental, within
subjects, repeated measures design.

The independent

variable in this study was cryotherapy condition with two
levels. The first level was with cryotherapy and the other
will be without cryotherapy. The dependent variables were
the scores of the BESS and of the SEBT. The BESS test
measured static balance while the SEBT test will measure
dynamic balance.

Subjects

The subjects that participated in this study were 20
healthy volunteers. They were physically active individuals

8
from California University of Pennsylvania over the age of
18. Physically active can be defined as participating in
moderate to intense exercise at least 3 days a week. The
subjects were screened to make sure they have had no
previous head injury or lower extremity injury within six
months, or any neurovascular condition. There was also a
checklist on the information sheet to rule out any
contraindications such as Raynauds, cold allergy, ect.
There was a mix of both males and females.
Each subject performed three separate sessions on
three days for approximately an hour each day.

The study

was approved by the Institutional Review Board at
California University of PA (Appendix C2).

All subjects in

the study signed an Informed Consent Form (Appendix C1)
prior to participation in the study.

Each participant’s

identity remained confidential and will not be included in
the study.

Preliminary Research

A pilot study was performed on 3 subjects so the
researcher could become familiar with the conducting the
BESS and SEBT and determine the amount of time needed to
take to perform the treatments and the two tests. The

9
results of the pilot study showed that no changed needed to
made to the methods.

Instruments

The instruments that were used were a demographic
sheet (Appendix C5), an ice bag, the BESS test and the
SEBT. Information that was gathered in the demographic
sheet was age, sport played, gender, last head injury (if
any), last lower extremity injury, a checklist of
contraindications and any neurovascular disorders that may
interfere with balance.
The BESS test consisted of 3 different stances on two
different surfaces to test static balance (Picture can be
shown of three stances in Appendix C4). The two surfaces
are a flat surface and an unstable surface, which was being
tested using a foam pad. The three stances are: double leg,
single leg, and tandem. The area to stand is about shoulder
width apart and marked off by a square. The subject held
each stance for 30 seconds with their hands on their iliac
crest and maintains the posture as stable as they were
able. Mistakes were counted and added as a point. Mistakes
include taking hands off the iliac crest, heels off the
ground, moving out of the box, jumping around, and heel

10
touching the ground in the single leg stance.15,17,19,21,26
Intratest reliability has been shown for this test to be
from .78 to .96.17
The SEBT is a way to test a subject’s dynamic balance
(Picture can be shown of set-up in Appendix C4). The setup
for this test consisted of laying out a star shaped marked
area in 8 directions. The directions were anterior,
posterior, medial, lateral, anterior medial, anterior
lateral, posterior medial, and posterior lateral. The
subject stood in the middle of the star with their dominant
leg and reached out as far as possible in each direction.
The researcher then measured the distance reached; this can
be repeated and averaged. Reliability of this test has been
shown to be from .67 to .87.26

Procedures

The subjects reported on day one to complete paperwork
and sign consent forms. Day one also consisted of a
practice day. The subjects learned how to perform both the
BESS test and the SEBT. The researcher explained the study
and the tests. Each subject got one trial for both the BESS
and the SEBT. The results were recorded.

11
Day two, subjects came in and participated in either
the cryotherapy condition or the no cryotherapy condition.
At the beginning of each test session prior to either the
cryotherapy condition or the no cryotherapy the subjects
participated in a pre-trial testing to get their baseline
measurement for that day. The subjects with the cryotherapy
condition sat for 20 minutes with an ice bag over the ankle
and foot with a compression wrap. The subjects were sitting
up in a supine position with their legs straight out in
front of them. The compression wrap has been shown to cause
a greater decrease in temperature than just ice bag alone
and many athletic trainers use wraps to hold the ice bag in
place over the ankle joint.1,2,8,14 The subjects sat with the
ice bag applied for 20 minutes. The subjects without the
cryotherapy condition also sat for 20 minutes prior to
beginning the tests also with a compression wrap applied
and will also sit up in a supine position with their legs
out in front of them. Immediately following the application
of cryotherapy or no cryotherapy the subjects performed
either the BESS test or the SEBT. Whichever one was
performed first, the other immediately followed. After
these two tests the subject sat for 10 minutes to allow rewarming to occur, to see if there are any changes. They
were in the same position supine with their legs straight

12
in front of them. Then the subject performed the two tests
again in reverse order.
Day three consisted of the same routine as day two
with the subjects performing the opposite treatment
condition. The order of the tests remained the same to
eliminate confusion and to create an easier research
environment.

Hypotheses

The following are the hypotheses suggested by the
researcher prior to performing the study.
1. Cryotherapy will have a negative effect on static
balance doing the ground stances as measured by the
BESS test.
2. Cryotherapy will have a negative balance on static
balance during the unstable stances as measured by the
BESS test.
3. Cryotherapy will have a negative effect on dynamic
balance as measured by the Star Excursion Balance
Test.

13
Data Analysis

All data was analyzed by SPSS version 16.0 for
Windows. The data was analyzed to determine if cryotherapy
had an effect on static or dynamic balance. The research
hypothesis was analyzed using repeated measures
Multivariate Analysis of Variance. The analysis was
examined to determine if the application of cryotherapy had
a negative effect on static balance in both the stable and
foam surface and dynamic balance. An alpha level of 0.05
was utilized to determine statistical significance.

RESULTS

The purpose of this study was to examine whether
cryotherapy applied over the lateral ankle had an effect on
static and dynamic balance. Static balance was tested by
the BESS on two different surfaces and dynamic balance was
tested via the SEBT. The following section includes:
demographic information, hypothesis testing, and additional
information.

Demographic Information

Twenty physically active college students’ from
California University of Pennsylvania with a mean age of
21.7± 2 years acted as subjects in this study. The subjects
volunteered to participate and included 10 males and 10
females.

Subjects completed a demographic sheet containing

information such as age, previous lower extremity injury,
previous head injury, previous cryotherapy use, and
cryotherapy contraindications (Appendix C5).

The

demographic sheet was completed voluntarily with the
researcher present before each study was started. Subjects
also completed the IRB approved consent form at this time.

15
Hypothesis Testing

The following three hypotheses were tested in this
study. All hypotheses were tested with the level of
significance at the ≤.05 level.
Hypothesis 1: Cryotherapy will have a negative effect
on static balance as measured by the BESS test on the firm
condition.
A 2x3 repeated measures ANOVA was used to examine the
effects of the condition (ice and no ice) and time
(pretest, posttest, 10 minutes posttest) on BESS firm
surface scores. The mean test scores under each condition
can be found in Table 1.

A significant effect was found

for the interaction between time and condition
(F(2,38)=14.53,p<.001)). The interactive effect showed that
subjects had decreased performance on the BESS test during
the testing immediately following ice application scores
improved after the rewarming period.
Conclusion: Hypothesis 1 was supported. Balance was
negatively affected in the firm condition of the BESS test
immediately following application of cryotherapy.

16
Table 1:

Mean number of errors during BESS on firm surface

Ice
No ice
Time
Mean (SD)
Mean (SD)____________
Pre
5.0
(2.39)
3.8
(1.8)
___________________________________________________________
Post
7.2
(2.2)
3.6
(1.5)
___________________________________________________________
10 post
•

5.7

(2.3)

3.6

(1.9)

Test time x condition p<.001

Hypothesis 2: Cryotherapy will have a negative effect
on static balance as measured by the BESS test on a foam
surface.
A 2x3 repeated measures ANOVA was used to examine the
effects of the condition (ice and no ice) and time
(pretest, posttest, 10 minutes posttest) on BESS foam
surface scores. The mean test scores under each condition
can be found in Table 2.

A significant effect was found

for the interaction between time and condition
(F(2,38)=26.27,p<.001 ). The interactive effect showed that
subjects had decreased performance on the BESS test during
the testing immediately following ice application scores
improved after the rewarming period.
Conclusion: Hypothesis 2 was supported. Balance was
negatively affected in the foam condition of the BESS test
from the application of cryotherapy.

Table 2: Number of errors during BESS on foam surface
Ice
No Ice
Time
Mean SD
Mean SD
___________________________________________________________
Pre
6.9
(2.4)
6.5
(2.6)
___________________________________________________________
Post
10.1
(2.5)
6.1
(1.9)
___________________________________________________________
10
8.1
(2.3)
5.6
(2.4)
•

Test time x condition p<.001

Hypothesis 3: Cryotherapy will have a negative effect
on dynamic balance as measured by the SEBT.
A 2x3 repeated measures ANOVA was used to examine the
effects of the condition (ice and no ice) and time
(pretest, posttest, 10 minutes posttest) on SEBT distances
reached. The mean test scores under each condition can be
found in Table 3.

A significant effect was found for the

interaction between time and condition
(F(2,38)=218.76,p<.001). The interactive effect showed that
subjects had decreased performance on the SEBT during the
testing immediately following ice application and scores
improved after the rewarming period (Table 3).
Conclusion: Hypothesis 3 was supported. Balance was
negatively affected in the SEBT test from the application
of cryotherapy.

Table 3: Reaching distance during SEBT (cm)

Ice
Time

Mean

No Ice
Mean
SD

Pre
572.7
(66.3)
588
(68)
___________________________________________________________
Post
559.1
(72.6)
593.9
(73.2)
___________________________________________________________
10
577.9
(72.4)
*Test time x condition p<.001

591.2

(68.1)

DISCUSSION

The following section is divided into these
subsections: Discussion of Results, Conclusions, and
Recommendations.

Discussion of Results

The purpose of this study was to examine the effect of
cryotherapy applied over the lateral ankle on static and
dynamic balance. Static balance was measured by the BESS
test on two different surfaces while dynamic balance was
measured by the SEBT. Physically active college students
voluntarily participated in this study. This topic was
chosen because the researcher has been interested in
cryotherapy and balance and there have been many
conflicting reports whether cryotherapy may cause a change
in balance. This study demonstrated that there is a
significant effect of cryotherapy on balance comparing the
times and conditions from the ground and foam stances in
the BESS test and from the SEBT test.
The researcher’s first hypothesis was that there would
be a negative effect on balance after applied to the

20
lateral ankle on static balance on the firm surface in the
BESS test. The results supported the hypothesis. The data
analysis found a significant difference between the time
and condition with the firm stances on the BESS test. The
mean for the ice application pre-test was 4.95 (in number
of mistakes) and the post-test mean was 7.15 and 10 minutes
after the post test was 5.65.(Figure 1) There was a
significant difference between the pre and post test
scores. This shows that the application of cryotherapy over
the lateral ankle caused a decrease in the athlete’s
balance for a short duration.

The average mean for the no

ice condition for the pre test was 3.75, the post-test was
3.55 and the 10 minutes post test was 3.6. (Figure 1).
Comparing the no ice condition to the ice condition the
results show that there is a difference between the two.
The subjects’ scores were lower in the ice condition from
the pre to the post test. This indicates a decrease in
performance. They improved from the post test to the 10
minutes post test but still did not return to baseline
measurements. The no ice condition the scores remained
approximately the same with slight improvements throughout
the three tests. If there would be no effect, the effects
would be approximately the same with both the ice and no
ice condition, they would both get slightly better during

21
the course of the three tests but the opposite occurs
during the ice trial. This demonstrated ice application
caused a significant decrease in balance from immediately
post after and is still affecting the subject 10 minutes
past the post-trial.
__________________________________________________________I

BESS Test Ground Ice and No Ice
8
Mean Number of Mistakes

7
6
5
4
Ice
3
No ice
2
1
0
Pre

Post

Ten

Time

Figure 1. BESS Test Ground Ice and No
___________________________________________________________

The researcher’s second hypothesis was that there
would be a negative effect on balance in the foam stances
from the BESS test. The 2x3 repeated ANOVA showed a
significant difference between time and condition with the
foam surface using the BESS test. The average means for
mistakes in the ice condition in the pre test was 6.9, and

22
the post test after the ice application was 10.2 and the 10
minutes after the post test was 8.05(Figure 2). The mean
for the no ice condition for the pre-test was 6.55 and for
the post-test was 6.05 and the 10 minute after the post
test was 5.55(Figure 2). The foam condition was considered
to be harder to most subjects so the initial mistakes were
higher and the mistakes made after icing were greater. The
pre-test and the post-test mistakes on the foam test
averaged about 3 mistakes higher and the 10 minute posttest mistakes decline from the immediate post after testing
but still did not return to baseline pre-test measurements.
The number of mistakes made for the no ice condition
remained about the same for the foam condition with no
significant fluctuations. This implies that if ice had no
effect then the same would have been expected to happen
with the ice condition, for mistakes to either stay the
same or decrease.

These results showed that ice applied to

the lateral ankle caused a decrease in balance on the foam
surface.

23
___________________________________________________________
12

BESS Test Foam Ice and No ice

Mean Number of Mistakes

10
8
6
Ice

No Ice
2
0
Pre

Post

Ten

Time

Figure 2.

BESS Test Foam Ice and No Ice

___________________________________________________________

The researcher’s third hypothesis was that there would
be a negative effect on dynamic balance from cryotherapy as
tested by the SEBT. The 2x3 repeated ANOVA showed a
significant difference between time and condition with the
SEBT test. The average distance reached in centimeters for
the ice condition for the pre-test was 572.7, the post-test
was 559.1, and the 10 minute test was 577.9. (Figure 3).
The average distance reached for the no ice condition for
the pre-test was 588, the post test was 593.9 and 10
minutes after was 591.2(Figure 3). For the ice condition

24
the distance dropped significantly from the pre test to the
post test. The 10 minute post test, the average distance
went back to up higher then baseline pre-testing. The
average distance reached (centimeters) for the no ice
condition for the pre-test was 588, the post test was
593.9, and the 10 minute post test was 591.2(Figure 6). The
distance reached in the three trials of the no ice
condition remained relatively stable with no significant
differences. The results of this analysis also showed that
ice applied to the lateral ankle caused a significant
decrease in dynamic balance using the SEBT test, and that
it takes longer than 10 minutes for the effects of ice to
completely wear off.

25
___________________________________________________________

SEBT Ice and No Ice
600

Distance Reached (cm)

590
580
570
Ice
560

No Ice

550
540
Pre

Post

Ten

Time

Figure 3. SEBT Ice and No Ice Condition

The results of this study was different to the results
of some other studies that showed no decrease in
performance from the application of cryotherapy.1-4,6,15,16,20,26
There are many reasons why the results of this study could
have been different. One of these reasons is that other
studies mostly examined functional performances as a whole
and not static and dynamic balance separately. Another
reason is that the application of cryotherapy was applied
to different areas of the body such as the peroneals or the
quadriceps muscle. Some of the other studies looked at
certain muscle groups and their reaction not the whole body

26
responding to balance.1-6,9,10,12,18 There were also studies
that found similar results as this study. Some of them
looked at different functional performances following the
application of cryotherapy. These studies mostly examined
different functional activates and not just balance alone
but still found a decrease in performance.4-6,15,16,20,26

Conclusions

The significance of these results is that
professionals that use cryotherapy on a daily basis may
need to re-think how they apply cryotherapy to their
athletes prior to practice or games. The results have shown
that cryotherapy has a negative effect on both static and
dynamic balance immediately post application and 10 minutes
after the post-test. The amount of mistakes made for static
balance

were increasing and distance reached for dynamic

balance was decreasing from the immediate post test but
still have not quite returned to normal.
There have been studies that have shown that poor
balance can be an indicator of injury. Therefore applying
cryotherapy to an athlete and sending them right back to
play could possibly lead to further injury. Even after 20

27
minutes after removing cryotherapy the results have not
quite returned to baseline measurements.

Recommendations

The results of this study demonstrate that cryotherapy
application to the lateral ankle caused a significant
decrease in both static and dynamic balance. Even in the 10
minute post trial testing of both static and dynamic
balance showed a deficit, the scores were recovering from
the immediate post trial but still did not return to
baseline.

Certified Athletic Trainers or other

professionals who are applying cryotherapy to a subject
prior to participating in sports or recreational activities
should make sure to not put them in immediately after using
cryotherapy. A suitable warm-up of at least 10 minutes
should be implemented; they may not be fully recovered from
the cryotherapy but well on their way back to baseline.
Further research that could be done would be to see
how long it takes for results to return to baseline
following the application of cryotherapy. Also, one other
area that could be examined would be what time of warm-up
could be used to decrease the detrimental effects of
cryotherapy on balance.

Another area of future research

28
could include looking at healthy subjects and injured
subjects to see if there are similar results or if one is
worse than the other. Finally, a future study could look at
different time applications of cryotherapy to see if
shorter time application still causes a negative effect on
balance or less of a decrease on balance.

29
REFERENCES
1.

Merrick MA, Knight KL, Ingersoll CD, Potteiger JA.
The effects of ice and compression wraps on
intramuscular temperatures at various depths J Athl
Train. 1996; 28(3): 236-245.

Richendollar ML, Darby LA, Brown TM. Ice bag
application, active warm-up and 3 measures of maximal
functional performance. J Athl Train. 2006;41(4):364370.

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.

Hopkins TJ. Knee joint effusion and cryotherapy alter
lower chain kinetics and muscle activity. J Athl
Train. 2006; 41(2):177–184.

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.

Evans T, Ingersoll CD, Knight KL, Worrel T. Agility
following the application of cold therapy. J Athl
Train. 1995; 30(3) 231-234.

Denegar CD, Saliba E, Saliba S. Therapeutic Modalities
For Musculoskelatal Injuries 2nd Edition. Human
Kinetics;2006.

Yeargin S. Pre-cooling improves endurance performance
in the heat. Clin J Sport Med.2008; 18(2): 177-178.

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.

10.

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.

11.

Hubbard TJ, Denegar CR.Does cryotherapy improve
outcomes with soft-tissue injury?. J Athl Train.
2004;39(3):278–279.

12.

Brodowicz GR. Comparison of stretching with ice,
stretching with heat, or stretching alone on hamstring
Flexibility. J Athl Train. 1996;31(4) 324-327.

13.

Kennet J, Hardaker N, Hobbs S, Selfes J. Cooling
efficiency of 4 common cryotherapeutic agents. J Athl
Train. 2007; 32(3)343-348.

14.

Palmer J. Ankle and thigh skin surface temperature
changes with repeated ice pack application .J Athl
Train. 1996;31(4)319-323.

15.

Richendollar ML, Darby LA, Brown TM. Ice bag
application, active warm-up and 3 measures of maximal
functional performance. J Athl Train.2006; 41(4)364370.

16.

Cross KM, Wilson RW, Perrin DH. Functional performance
following an ice immersion to the lower limb. J Athl
Train. 1996; 31(2): 113-116.

17.

Miniello S, Dover G, Powers M, Tillman M, Wikstrom E.
Lower leg cold immersion does not impair dynamic
stability in healthy women. J Sport Rehab. 2005;
14(3): 234-47.

18.

Berg CL, Hart JM, Palmieri-Smith R, Cross KM,
Ingersoll CD. Cryotherapy does not affect peroneal
reaction following sudden inversion. J Sport Rehab
2007; 16 (4): 285-295.

19.

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): 446-51.

20.

Bernier JN, Perrin DH, Rijke A. Effect of unilateral
functional instability of the ankle on postural sway
and inversion and eversion strength. J Athl Train
1997; 32(3):226-232.

21.

Lee AJY, Lin WH. 12 week biomechanical ankle platform
system training on postural stability and ankle
proprioception in subjects with unilateral functional
ankle instability. Clin Biom. 2008; 23: 1065-1072.

22.

Peterka RJ .Sensorimotor integration in human postural
control. J Neurophysiol. 2002; 88: 1097-1118.

23.

Hardy L, Huxel K, Brucker J, Nesser T. Prophylactic
ankle braces. J Athl Train. 2008;43(3): 347-351.

24.

Wilkstrom EA, Tillman MD, Smith AN, Borsa PA. A new
force-plate technology measure of dynamic postural
stability: the dynamic postural stability index J Athl
Train. 2005; 40(4)305-309.

25.

Hrysomallis C. Preseason and midseason balance ability
of professional Australian footballers. J Strength
Condition Res, 2007; 22(1): 210-215.

26.

Wassinger CA, Myers JB, Gatt JM, Conley KM, Lepart SM.
Proprioception and throwing accuracy in the dominant
shoulder after cryotherapy. J Athl Train. 2007;
42(1):84–89.

27.

Richendollar ML, Darby LA, Brown TM. Ice bag
application, active warm-up and 3 measures of maximal
functional performance. J Athl Train.2006; 41(4)364370.

28.

Miniello S, Dover G, Powers M, Tillman M, Wikstrom E.
Lower leg cold immersion does not impair dynamic
stability in healthy women. J Sport Rehab. 2005;
14(3): 234-47.

APPENDICES

APPENDIX A
Review of Literature

REVIEW OF THE LITERATURE

Cryotherapy is one of the most commonly used
modalities in athletic training.

Cryotherapy has been

shown to have multiple effects on the body, both externally
and internally.

Athletic participation requires many

abilities to perform at a high level, including speed and
balance. These two components are critical in athletes who
wish to perform at their best.
Many athletes prior to participating in sports use
some form of cryotherapy to help them participate fully
without pain.

The research is unclear as to whether this

treatment will decrease overall athletic performance.

The

purpose of the literature review is to examine cryotherapy,
balance and the effect that cryotherapy has on static and
dynamic balance. This review will be discussed in the
following sections: (1) Cryotherapy, (2) Balance, (3) The
Effects of Cryotherapy on Performance, and (5) a Summary.

Cryotherapy

Cryotherapy is defined as “the use of ice or cold in a
therapeutic setting.”

Cryotherapy is one of most commonly

used modalities in athletics today.1,

2,4,6

Athletic trainers

use some form of cryotherapy daily for athletes before and
after participating in their respective sports. The main
purposes of using cryotherapy on injuries are to decrease
pain, decrease muscle spasm, and to decrease farther harm
from acute injuries.1,2,4,6,8-10,13
The skin, subcutaneous tissues, and muscles are cooled
through cryotherapy via conduction and/or convection2. Heat
goes from areas of high heat to areas of low heat. This
means that heat from the skin, which is warmer than the
cold modality, gets absorbed into the cold modality. The
deeper tissues lose their heat by giving their heat to the
superficial layers which continues to give heat to the cold
modality.2 That is how the skin and underlying tissues and
structures looses heat and how cryotherapy modalities work.
The effects that cryotherapy has on the body are many and
include alteration of sensation, temperature, metabolism,
and nerve function and conduction.1-14

36
Tissues Affected by Cryotherapy
The main external structures that cryotherapy has an
effect on is the skin, sub cutanous tissues, and muscles.2-5,
7-9,11-13

A study performed by Merrick et al. compared

different modes of cryotherapy on surface temperature, 1 cm
and 2 cm below the subject’s skin. Using four different
cold modalities, the researchers found that using an ice
bag and Wet-Ice, which is a reusable ice pack that adds
compression via elastic bands, caused the greatest decrease
in both surface and sub adipose tissue levels. The surface
temperature for all the trials was approximately 31 degrees
Celsius. The average post-test temperature for both the ice
bag and wet-ice was 6.35 degrees Celsius at the surface
temperature. At the 1 cm sub adipose level the baseline
temperature was about 35 degrees and after treatment the
temperate dropped to around 27 degree. At the 2-cm sub
adipose level the baseline temperature was around 36
degrees and the temperature dropped to an average of 31.5
degrees. Skin temperature was shown to drop the fastest and
by the most degrees when compared to the sub adipose
levels.2
This data is supported by a study performed by Palmer
et al., which studied skin temperature changes after
multiple applications of cryotherapy. This study

37
demonstrated that skin temperature dropped very fast and as
soon as the ice bag was applied and that temperature
changes were greater after having ice on for 40 minutes
compared to only 20 minutes.5 After removing the ice there
is an initial temperature rise followed by a slow return to
baseline temperature.13 The superficial muscles, and sub
adipose tissues return to baseline measurements
approximately 20 minutes prior to deeper tissues.2,5,8
Cryotherapy has also been shown to decrease muscle
spasms.1,2,6,8,9,11,13 Cryotherapy has shown to decrease these
spasms through reflex mechanisms, which make the muscle
spindles not as sensitive allowing them to relax and
therefore relieve the spasm.13
Internal structures that are affected by applying
cryotherapy include: blood vessels, nerves, and
mechanoreceptors.

Alteration of the function of

mechanoreceptors will potentially affect sensation.

As a

tissue cools, there are usually four sensations that are
felt while applying Cryotherapy.

This altered sensation

starts out as extreme cold, and then changes to an aching
pain, followed by a pins and needles sensation and then
eventually it becomes numb.13
Different nerve types also are affected by cooling.
The nerves that are affected first would be the cold and

38
pain nerve receptors, since the first sensations felt are
cold and pain. As heat is taken away from the skin,
muscles, and nerves, the nerve impulses are slowed down
which causes a decrease in sensation.5,13 Sensation can be
divided into superficial and deep sensation. Superficial
involves touch, temperature, and pain from the skin, which
are from superficial receptors, which transmit these
signals to the brain. Mechanoreceptors are responses to
different stimulus as well. They are a type of superficial
receptors that respond to touch and pressure and responds
rapidly to changes in stimulus. Thermo receptors are also a
type of superficial receptor that responds quickly to
changes in temperature. Deep sensation involves joint and
muscle positions, pressure, and proprioception from
muscles, joint capsules, and ligaments.5,13

Deep receptors

include Golgi tendon organs (GTO) and muscle spindles. GTO
help with proprioception and detect changes in muscle
length and tension along with the muscle spindles. All of
these nerves and receptors are affected by applications of
cryotherapy so therefore skin touch, temperature, and pain
are all decreased and proprioception is decreased via the
deep receptors.13
Blood vessels are affected through cryotherapy because
decreasing the temperature causes a decrease in the

39
metabolic rate of the tissue and the need for oxygen.
Therefore since the need for oxygen is considerably less,
blood vessels constrict so not as much oxygenated blood
goes to the area.1-13

Methods of applying cryotherapy
There are many methods of applying cryotherapy. Some
of the most common example includes: ice bags, ice packs,
gel packs, cold whirlpool and compression units. In a study
performed by Merrick et al., the researchers compared 3
types of cryotherapy to examine which had the deepest
surface and deep cooling temperatures. The researchers used
an ice bag, Wet-Ice, and Flexi-Cold. Wet-Ice is a type of
compression unit that ice is applied in and then applied to
the skin with its elastic wraps. Flexi-Cold is a type of
gel pack just applied to the skin. In this study the
results showed that using ice bags and Wet-Ice, produced
similar results and had the most rapid temperature loss and
the coldest temperature.2
Another study, performed by Kennett et al., examined
four commonly used cryotherapy modalities and how well they
cooled. The four modalities used were: crushed ice, gel
pack, frozen peas, and ice water immersion. The results of
this study showed that using crush iced produced the lowest

40
temperature followed by ice immersion.14 The results of
these two studies show that ice bags are the best available
form of cryotherapy if you want the quickest and coolest
drop in temperature. Ice bags are also the cheapest and
easiest forms of cryotherapy to use and can be conformed to
almost any area of the body.14
Cryotherapy is the most commonly modality in sports
medicine today and had been shown to be effective in
treating soft tissue injuries.9 There are a wide variety of
applications, such as ice bags, compression units, cold
whirlpools, and gel packs. Each type has different
temperature penetrations with ice bags with compression
allowing the deepest and the coolest temperature.2,5,13,14

Balance

Balance can be defined as “the state of bodily
equilibrium or the ability to maintain the center of body
mass over the base of support.”24 Balance is an intrinsic
part of everyday activity and highly important in
athletics. If an athlete does not have good balance then
they cannot perform at their highest level. Balance is a
combination of center of balance, postural control, center

41
of pressure and base of support. Maintaining balance also
includes both sensory and motor components.

Sensory Components of Balance
Postural stability is controlled through a combination
of visual, vestibular, and proprioceptive neural input,
which comes from the central nervous system.15-17,

19,21,23,24

Information is gathered from these three inputs and is
processed to establish the motor controls to follow. After
deciding on the appropriate motor control it is followed
through via muscles activity.16
Postural stability is dependent on the athlete’s base
of support, the larger the base of supports the better the
balance. Base of support can be defined as the area of the
body that is making contact with the ground or environment.
In many sports athletes are rarely on two feet for long
period of time, making their base of support very small.
Therefore the inputs from visual, vestibular, and
proprioceptive sources must be interpreted and acted on
quickly so that motor commands can maintain equilibrium in
the body.16
Proprioception can be described as being able to
detect changes in specific joint position and being able to
adapt to that change.15 It is a combination of input from

42
mechanoreceptors that are contained within the joint,
ligaments, tendons and the skin which work together to give
the sense of change in joint position. Proprioception has
been shown in studies to improve after balance training
activities, which can lead to better performance and
decreased risk of injuries.15-17,19,21,25
Visual input is an important part of balance.
Information is gained through vision and goes to the brain
to be analyzed and put into motor commands. Visual input is
important but not necessary in healthy individuals. In
healthy subjects, with their eyes closed, subjects can
still maintain balance with little change in movement. In
subjects that have lower extremity injuries or instability
vision plays an important part in maintaining balance.
Paying attention while focusing on the visual inputs is
another aspect of vision integration. While focusing on
solely balancing subjects have been shown to balance more
effectively than when there are distractions surrounding
the subject.21
The vestibular sensory component also plays an
essential role in balance. It is a part of the hearing
system and contributes to equilibrium and movement. Signals
from the vestibular system send outputs to the eyes and to

43
muscles. The signals to the muscles help keep correct
posture to maintain balance.16,18

Components of Balance
There are two types of balance that are used everyday,
static and dynamic. Static balance is used when a person is
remaining in a position for period of time and is
maintaining balance. To maintain static balance the goal is
to minimize the amount of movement in the subjects’ center
of balance. Static balance can be observed on a stable and
unstable surface to determine an athlete’s static balance
ability. In a study done by Bressel et al., they compared
static balance of athletes in three different female sports
to see if different sports played a role in static balance.
The results of this study showed that gymnastic athletes
had a better static balance score than the basketball group
but no statistical differences in other comparisons.15
Another study performed by Onate et al., determined that
static balance can be changed just by changing the
environment around the test subject. The study took a
sample of baseball athletes and took a controlled baseline
measurement using the Balance Error Scoring System (BESS),
in the athletic training room. The researchers took another
measurement in the sidelines off the baseball field during

44
practice on a level surface. The results of comparing these
two tests showed that there was an increase in the scores
from the controlled setting to an uncontrolled setting.21
Dynamic balance is being able to maintain postural
stability while moving. This type of balance is used most
often in athletics, and is the most important one to be
able to have. If an athlete cannot be balanced and run then
they will not be able to perform at their highest ability.
A study performed by Lee and Lin examined dynamic balance
training on ankle instability over a period of twelve
weeks. Ankle instability was defined as having at least one
severe lateral ankle injury, and feelings of giving away.
Center of balance and neuromuscular ability was examined
pre and post training. Center of balance is considered the
center of the base of support when 25% of weight is equally
in four quadrants.23 What was found was that dynamic balance
training reduced ankle instability, increased neuromuscular
ability and improved center of balance. In a study
performed by Gribble et al. the authors examined dynamic
balance and the influence on time of day. Testing was
performed using the Star Excursion Balance Test (SEBT) over
a period of 48-hours using 3 separate times over the two
days. The results of this study showed that time of day had
an impact on dynamic balance, showing that mornings

45
produced the best score. Activities that require dynamic
activity would best be performed in the morning shortly
after waking.19 Another study examined ankle braces while
performing the Star Excursion Balance Test(SEBT), to see if
dynamic balance is changed from wearing ankle braces. The
results showed that wearing ankle braces had no decrease in
dynamic balance performance.23
There are many valid and reliable ways that both
static and dynamic balance can be tested. Some of these
include the BESS, the SEBT, and the Chattecx Balance System
and the Biodex Balance System. While the Chattecx Balance
System and the Biodex Balance System are both reliable and
accurate they are expensive to use and require proper
training. The BESS test and the Star Excursion are just as
reliable and accurate and require little to no money and
are simple to perform.
The BESS test is considered a reliable assessment tool
to obtain static balance results.15,

17,21

This test used 3

stances in two different surfaces. The three stances used
are double-leg stance, single leg and tandem stance both on
a firm and foam surface, all with eyes closed. This test
can be used as a clinical test after a head injury,
assuming there were baseline measurements taken, to see if

46
balance was affected. Mistakes are measured using this test
and counted as the score.
Using a similar environment to use this test is
important. In a study performed by Onnate et al., the used
the BESS test in a controlled clinical site (athletic
training room with only the subject and testers) and on the
sidelines of the baseball field (with multiple people and
practice going on) to see if the results changed. The study
found that there was a major statistical increase in the
mistakes made on the sidelines compared to the clinical
setting. If this test is going to be used, as head injury
test baseline measurements should be taken on the field
where the athlete most likely will be when a head injury
occurs.19
The SEBT is often used to assess dynamic balance in
athletes. This test consists of having a star-grid laid out
on the floor in eight directions. The lines are 45 degrees
away from each other. The test foot is placed directly in
the middle of the star while the other foot reaches out as
far as possible and touches the farthest point with their
toes.15,19,24,26

The distance is then recorded used as needed.

The Star Excursion Balance test has been proven to be a
reliably method of determining dynamic balance in numerous
studies.27

47
The Chattecx Balance System is a force platform
connected to a computer and can measure both static and
dynamic balance. It can measure both static and dynamic
balance in single and double leg stances. The Balance
System measures the subject’s center of balance and
determines how far away they move from their center of
balance during the testing. In the static testing the
platform remains flat and still and in the dynamic stance
the platform is tilted in various positions.27 This balance
platform is a very reliable way to test static and dynamic
balance but it expensive while the BESS and the Star test
are equally as reliable and cheap and easy to test.27
The Biodex Balance System tests both static and
dynamic balance as well. The machine consists of a platform
with a safety harness to ensure the subject does not fall.
This machine also measures postural sway, center of
balance, and postural stability. In the static testing the
platform remained still, while the subject maintained
balance. The dynamic portion consisted of making the
platform shake and tilting the platform anterior and
posterior.23
Balance is an intrinsic and complicated part of
athletics. Input is gained through visual, vestibular and
proprioceptive input that is used to determine proper

48
commands to execute which keeps a person balanced. Balance
is a combination of both static and dynamic balance and is
critical in everyday activities and more so in athletics.
Propcrioception, center of balance, and mechanoreceptors
are all part of maintaining both static and dynamic
balance.

Cryotherapy and Balance

There have been numerous studies examining cryotherapy
and cryotherapy’s effect on numerous aspects of
performance. There have been many contradicting results
from these studies; some results show an impact while some
show no difference.15-17,19-25
In a study performed by Wassinger et al., they
examined propriocetion and throwing accuracy in baseball
players after applying cryotherapy.

The subjects that were

used were 22 healthy college students, none that were
participating in a throwing sport.

All the subjects

participated in a pre-test, post-test experiment. The
independent variable was cryotherapy. The dependent
variables were the Active joint position replication
(AJPR), and Path of Motion Replication (PJMR), and the
Functional Performance index, which is what the researchers

49
used to determine proprioception and throwing accuracy. The
AJPR was determined using an isokinetic dynamometer. Pads
were placed on various parts of the body to analyze the
movements of the shoulder. Subjects were blindfolded and
asked to move into certain position. When they reached that
position they were asked to maintain it for 10 seconds, and
it was repeated without using the dynamometer. The PJMR
also used the dynamometer and moved into position at a
certain speed in a specific path. This was also repeated
without the dynamometer. The results of this study showed
that there was a decrease in shoulder proprioception and
accuracy after applying cryotherapy to the shoulder. The
conclusions drawn from this study was that if a subject who
is participating in a throwing sport that uses cryotherapy
to the shoulder should perform a proper warm-up to regain
accuracy and proprioception in throwing.27
In the study performed by Richendollar et al., the
researchers were examining the effect of cryotherapy on
three different functional performance exercises and on
active warm-ups following cryotherapy treatments. There
were 4 different treatment conditions that were tested.
They were no ice/no warm-up, ice/no warm-up, no ice/warmup, and ice/warm-up. They tested the effects of jogging,
stretching and vertical jumps in each of these treatment

50
conditions. The independent variables of this study were
ice/no ice and warm-up/no warm-up.

The dependent variables

were the functional performance, jogging, stretching and
vertical jumps. The subjects used in this study were 24
uninjured mean from 18-24 years old. The results of this
study showed that ice bag application had decreased maximal
performance in all three of the tests. The warm-up protocol
following ice application offset the effects of ice
application but did not return the subject to no-ice ice
and warm-up results.

The conclusion is that if ice is

applied to the anterior thigh prior to practice than a
proper warm-up should be done prior to playing and that no
icing and a proper warm-up increases the subjects
performance.27
Another study done by Cross et al. examined functional
performance after ice immersion. The three functional tests
that were performed were the shuttle run, the hop test, and
the single-leg hop test. The subjects that participated in
this study were 20 Division 3 male college athletes. The
subjects were assigned into the control or the experimental
group. The independent variable of this study was ice
immersion or no ice immersion. The dependent variable was
performance on the functional tests. The results of this
test showed that the vertical jump, and shuttle run scores

51
decreased in experiment group but had no effect in the
control group. There was no effect in the hop test. The
conclusion is that ice immersion does have an impact on
functional perfomance.16
Miniello et al. examined lower leg immersion and
whether it affected dynamic balance in females. The
subjects were 17 healthy women who all participated in a
pre-test, post-test study. The researchers used EMG to
analyze activity and stabilization of lower leg muscles
after a jump landing. The independent variable was lower
leg immersion in cold whirlpool and the dependent variables
were dynamic stability. The results of this study showed
that lower leg immersion does not affect dynamic stability.
The conclusions drawn from this study were that using coldwater immersion in athletes would not have an effect on
dynamic stability.28
A study conducted by Berg et al. explored peroneal
reaction time in subjects following a cryotherapy
treatment. The study done was a repeated measures design
using 27 healthy volunteers. The subjects participated in
both a control and treatment group. The reaction times were
measured at baseline, immediately post treatment, and at 15
and 30 minutes post-treatment. The inversion of the ankle
was caused by a trap door mechanism and the peroneal

52
reaction time was measured. The independent variable was
cryotherapy and the dependent variable was peroneal
reaction time. The results of this study showed that there
was no significant change in peroneal reaction time after
treatment at any time. The conclusions was that cryotherapy
over the lateral ankle has no affect on the reaction time
of the peroneals.18
In a study that was performed by Evans et al. the
researchers were examining agility after applying
cryotherapy. The study performed was a pre-test, post-test
design. There were 24 male subjects that participated in
the study. Subjects participated in a control and treatment
setting. Agility was measured using the concontraction,
carioca, and the shuttle run test. The concontraction test
is performed by having a rubber tube attached to a belt,
which is around the subject’s waist, while the other end is
attached to a wall. The subject then performs a semi-circle
around the room with the rope taunt. The point of this test
is to replicate rotational forces that use stabilization at
the ankle. The cryotherapy treatment consisted of foot and
ankle ice immersion for 20 minutes. The results of this
study showed that ice immersion of the foot and ankle did
not alter agility to a significant degree. The conclusions

53
of this study were that ice immersion of the ankle and foot
does not decrease the ability to perform agility movements.6
Many of the studies were performed on lower extremity,
mostly lower leg and ankle, except for the shoulder
proprioception research study. There are many conflicting
results of previous studies done on cryotherapy and
performance. Three have shown that there is an effect from
using cryotherapy while three have shown that there is no
effect. More research needs to be done to have more
conclusive evidence whether cryotherapy affects
performance.

Summary

Cryotherapy is the most commonly used modality is
athletic training today. Many studies have shown it to be
an effective way to decrease pain, secondary hypoxic
injury, and muscle spasms and to decrease edema.1-14 Three
studies have shown cryotherapy to have a negative effect
and three studies have shown it to have no effect on
performance.
Therefore more research needs to be applied to this
field to try and obtain conclusive results on whether
cryotherapy decreases an athlete’s static and dynamic

54
balance, which in turn could impact the player’s athletic
ability and injury risk.

APPENDIX B
The Problem

56
THE PROBLEM

The purpose of the study is to examine the effects of
cryotherapy on static and dynamic balance. There have been
conflicting reports about whether cryotherapy has an effect
on static and dynamic balance. Some research has found that
cryotherapy decreases balance performance while some has
found that there is no difference. This is important to
know because if there is an effect on either of these two
components performance may be declined.

Definition of Terms
The following definitions of terms will be defined for
this study:
1) Cryotherapy – the application of a cold modality
2) Balance- the ability to maintain upright and in a
position of equilibrium
3) Static Balance-balance maintained while standing
without moving as measured by the BESS test
4) Dynamic Balance- balance maintained while performing
as measured by the SEBT.
5) Rewarming- the tissues reaction after a
cryotherapuetic modality is removed, blood flow

57
increases to the area and the tissues begin to rewarm, may be increased by activity
6) Physically active-participating in moderate to intense
exercise at least 3 times per week

Basic Assumptions
The following are basic assumptions of this study:
1) The subjects will honestly complete the demographic
sheet about prior injury history.
2) All subjects are volunteers with no coercion by
coaches or faculty.
3) The subjects will fully understand the instructions
given to them during the study and perform to their
best ability.

Limitations of the Study
The following are possible limitations of the study:
1. The subjects are volunteers and are limited to
physically active subjects from California University of
Pennsylvania and therefore it is not randomized
2. There may be a practice effect while performing the
BESS and Star tests.
3) Testing done in the lab is not sport specific tests.

58
4) There might be a re-warming effect between performing
the two tests.

Significance of the Study
This is important to study because many athletic
trainers apply a form of cryotherapy to athletes prior to
participating in sports and even during halftime at games.
Knowing whether cryotherapy causes a detrimental effect on
either static or dynamic balance may cause professionals to
re-evaluate applying cryotherapy immediately before or
during participation in athletics. If there is an effect we
can know that there should be some time of warm-up after
applying cryotherapy to counteract some of the effects. If
there aren’t any effects from cryotherapy then we know that
it is safe to put athletes immediately back to play after
using cryotherapy.

APPENDIX C
Additional Methods

APPENDIX C1
Informed Consent Form

61
Informed Consent Form
1.
Amber Fisher, who is a Graduate Assistantship Athletic
Training Student at California University of Pennsylvania ,
has requested my participation in a research study at
California University of Pennsylvania. The title of the
research is The Effect of Cryotherapy over the Lateral
Ankle on Static and Dynamic Balance.
2.
“I have been informed that the purpose of this study
is To determine if cryotherapy has an impact on static and
dynamic balance in physically active subjects from
California University of Pennsylvania. I understand that I
have been asked to participate along with 19 other
individuals because I have no previous head injury or lower
extremity injury within the last 6 months nor do I have any
neurovascular disorders which could interfere with balance
and because I am physically active, as defined as
participating in moderate to intense exercise at least 3
times a week.”
3.
“My participation will involve applying an ice bag to
my lateral ankle for 20 minutes and without applying an ice
bag with a compression wrap and then partaking in two
balance tests. The two tests are the Balance Error Scoring
System and the Star Excursion Balance Test. I will be
tested immediately after removing the ice bag and 20
minutes after applying the ice bag. My participation in
this study will consist of an orientation meeting with a
practice trial of each test and two meeting days for
testing.”
4.
“I understand there are foreseeable risks or
discomforts to me if I agree to participate in the study.
The possible risks and/or discomforts include possible ice
injury and/or injuries do to falling from loss of balance.
To minimize these risks the researcher will be asking me
questions about prior cryotherapy use and cold allergy. The
researcher will also stand by closely during the balance
testing in case I need help or begin to fall.”
5. “I understand that, in case of injury, I can expect to
receive treatment or care in Hamer Hall’s Athletic
Training Facility. This treatment will be provided by the
researcher, Sonia Masse, under the supervision of another
Certified Athletic Trainer, either of which whom can
administer emergency and rehabilitative care. Additional

62
services needed for prolonged care past thee days will be
referred to the attending physician at the Downey Garofola
Health Services located on campus.”
6. There are no feasible alternative procedures available
for this study.
7. I understand that the possible benefits of my
participation in the research is to help determine
the effects of cryotherapy over the lateral ankle on static
and dynamic balance. This study can help athletic trainers
decide how and when to use cryotherapy and if it causes a
decrease in balance after application which could lead to a
decrease in performance.
8. I understand that the results of the research study
may be published but my name or identity will not be
revealed. In order to maintain confidentially of my
records, Amber R Fisher will maintain all documents in a
secure location in which only the student researcher and
research advisor can access. Each subject will be given a
specific number to represent his or her name.
9. I have been informed that I will not be compensated
for my participation.
10. 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
Amber R Fisher
Fis6490@cup.edu
302-228-25874
Thomas F. West, PhD, ATC
west_t@cup.edu
724-809-1321
11. I understand that written responses may be used in
quotations for publication but my identity will
remain anonymous.
12. 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

63
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.
13. This study is (will be) approved by the California
University of Pennsylvania Institutional Review Board.
14. The IRB approval dates for this project are from:
January 2009 to May 2009.
Subject's signature___________________Date:___________
Other signature:______________________Date____________

APPENDIX C2
Institutional Review Board –
California University of Pennsylvania

Appendix C3
Individual Data Collection Sheet

71
Data Collection Sheet
Subject # ________________________Balance Error Scoring System
Trial 1
Stances

Firm

Foam

Double Leg
Single Leg
Tandem
Total
Trial 2
Stances

Firm

Foam

Double Leg
Single Leg
Tandem
Total
Star Excursion Balance Test
Direction
Anterior
Anterior Medial
Anterior Lateral
Medial
Lateral
Posterior Medial
Posterior Lateral
Posterior
Total

Distance Trial 1

Distance Trial 2

APPENDIX C4
Pictures of the BESS and SEBT Test

73
___________________________________________________________

Figure 4. BESS Test Double Leg Stance Firm
_____________________________________________________________________________
____________________________________________________________

__________________________________________________________

Figure 5 BESS Test Single Leg Stance
Figure 6 BESS Test Tandem Stance

74
___________________________________________________________

Figure 7. BESS Test Double Leg Foam
___________________________________________________________

___________________________________________________________

Figure 8.
. BESS Single Leg Foam
___________________________________________________________

75
___________________________________________________________

Figure 9. BESS Tandem Foam

__________________________________________________________

Figure 10. Star Excursion Balance Test
___________________________________________________________

Appendix C5
Demographic Information

77
Demographic Information

Age: __________________________
School year: __________________
Gender: _________________
Sport: ___________________
Injury History:
Any history of lower extremity injury, is so, date of last
injury, type and severity:
Any history of head injury, if so, date of last injury,
type, and severity?
Any neurological disorder that affect balance?

Have you used ice before as an injury treatment? Yes/no

Contraindications for application of ice:(yes or no if
known condition)
Raynauds phenomenon: yes/no
Cold allergy: yes/no
Poor circulation: yes/no
Diminished sensation: yes/no
Long-lasting/slow healing wounds: yes/no
Denegar, C.R, Saliba E, Salibe S. Therapuetic Modalities
for Musculoskelatal Injuries Second Edition 2006; Human
Kinetics

78
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1.

Merrick MA, Knight KL, Ingersoll CD, Potteiger JA.
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Richendollar ML, Darby LA, Brown TM. Ice bag
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Merrick MA, Jutte LS. Smith ME. Cold modalities with
different thermodynamic properties produce different
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Hopkins JT. Knee joint effusion and cryotherapy alter
lower chain kinetics and muscle activity. J Athl
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Evans T, Ingersol CD, Knight KL, Worrel T. Agility
following the application of cold therapy. J Athl
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Denegar CR, Saliba E, Saliba S. Therapeutic Modalities
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Ingersoll CD, Knight KL, Merrick MA. Sensory
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applications of heat and cold. J Athl Train 1992;
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Brodowicz, GR. Comparison of stretching with ice,
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Flexibility. J Athl Train. 1996;31(4) 324-327.

13.

Kennet J, Hardaker N, Hobbs S, Selfes J. Cooling
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Train. 2007; 32(3)343-348.

14.

Palmer J. Ankle and thigh skin surface temperature
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Richendollar ML, Darby LA, Brown TM. Ice bag
application, active warm-up and 3 measures of maximal
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16.

Cross KM, Wilson RW, Perrin DH. Functional performance
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Train. 1996; 31(2): 113-116.

17.

Miniello S, Dover G, Powers M, Tillman M, Wikstrom E.
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Berg CL, Hart JM, Palmieri-Smith R, Cross KM,
Ingersoll CD. Cryotherapy does not affect peroneal
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Bernier JN, Perrin DH, Rijke A. Effect of unilateral
functional instability of the ankle on postural sway
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Peterka RJ. Sensorimotor integration in human postural
control. J Neurophysiol. 2002; 88: 1097-1118.

23.

Hardy L, Huxel K, Brucker J, Nesser T. Prophylactic
ankle braces. J Athl Train. 2008;43(3): 347-351.

24.

Wilkstrom, EA, Tillman MD, Smith AN, Borsa PA. A new
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Hrysomallis C. Preseason and midseason balance ability
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26.

Wassinger CA, Myers JB, Gatt JM, Conley KM, Lepart SM.
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42(1):84–89.

27.

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81
ABSTRACT
Title:

THE EFFECTS OF CYROTHERAPY OVER THE LATERAL
ANKLE ON STATIC AND DYNAMIC BALANCE

Researcher:

Amber R Fisher, ATC, PES

Advisor:

Dr. Thomas F. West

Date:

May 2009

Research Type: Master’s Thesis
Context:

There has been conflicting results from the
effects of cryotherapy on performance. There
have been reports that there is no
difference on performance following the
application of ice and some have shown a
difference in performance. Previous studies
have not looked at both static and dynamic
balance in a physically active population.

Objective:

The purpose of this study was to examine the
effects of cryotherapy on static and dynamic
balance in a physically active population as
measured by the Balance Error Scoring System
(BESS) and the Star Excursion Balance Test
(SEBT).

Design:

Quasi-experimental, within subjects,
repeated measure design.

Setting:

Controlled laboratory setting.

Participants:

20 physically active college students, who
volunteered, with no current injury or cold
contraindications

Interventions: Subject were tested on 3 different days. The
first day was a practice trial for the two
tests. The second day was either under the
ice trial or no ice trial. Each consisted of
a pre-trial of both BESS and SEBT. The
subjects then sat with ice or no ice for 20
minutes over the lateral ankle and then
conducted an immediate post trial, and 10
minutes following the trial they repeated
the two tests again. The subject repeated

82
the opposite trial on the following day
following the same format.
Main Outcome Measures: Number of mistakes during the BESS
tests in each the firm and firm ground and
the total distance reached were gathered for
the SEBT.
Results:

The results showed that there was a
significant difference from the application
of cryotherapy comparing time and condition
on static balance in both the firm and foam
condition and on dynamic balance. The
differences remained even after a 10 minute
re-warming period, but gradually returning
back to baseline measurements.

Conclusions:

Professionals using cryotherapy on clients
prior to participating in physical activity
should not send them to participation
immediately after application without a
proper warm-up.

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