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
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Kennet J, Hardaker N, Hobbs S, Selfes J. Cooling
efficiency of 4 common cryotherapeutic agents. J Athl
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2.

Knight KL, Draper DO. Therapeutic Modalities: The Art
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Knight, K. Cryotherapy in Sport Injury Management.
Champaign, IL: Human Kinetics; 1995.

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Merrick MA, Jutte LS, Smith, ME. Cold modalities with
different thermodynamic properties produce different
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Zemke JE, Anderson JC, Guion WK, McMillian J, Joyner
AB. Intramuscular temperature responses in the human
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Myrer JW, Measom G, Fellingham GW. Temperature changes
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Dykstra JH, Hill HM, Miller MG, Cheatham CC, Michael
TJ, Baker RJ. Comparisons of cubed ice, crushed ice
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8.

Janwantanakul P. Cold pack/skin interface temperature
during ice treatment with various levels of
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Janwantanakul P. The effect of quantity of ice and
size of contact area on ice pack/skin interface
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Tomchuk D, Rubley MD, Holcomb WR, Guadagnoli M, Tarno
JM. The magnitude of tissue cooling during cryotherapy
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Palmer J, Knight KL. Ankle and thigh skin surface
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Merrick MA, Knight KL, Ingersoll CD, Potteigher JA.
The effects of ice and compression wraps on
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Train. 1993;28(3):236-245.

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Bleakley C, McDonough S, MacAuley D. The use of ice in
the treatment of acute soft-tissue injury: a
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J Sport Med. 2004;32:251-261.

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Hubbard TJ, Denegar CR. Does cryotherapy improve
outcomes with soft-tissue injury? J Athl Train.
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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Sale, DG. Postactivation potentiation: Role in human
movement performance. Exterc. Sports Sci. Rev.
2002;30:138-143.

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Schiefelbein NJ. A qualitative systematic review of
dynamic warm-up protocols [master’s thesis].
California, PA: California University of Pennsylvania;
2008.

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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

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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.