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Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units



Localized cooling is widely used in treating soft tissue injuries by modulating swelling, pain, and inflammation. One of the primary outcomes of localized cooling is vasoconstriction within the underlying skin. It is thought that in some instances, cryotherapy may be causative of tissue necrosis and neuropathy via cold-induced ischaemia leading to nonfreezing cold injury (NFCI). The purpose of this study is to quantify the magnitude and persistence of vasoconstriction associated with cryotherapy.


Data are presented from testing with four different FDA approved cryotherapy devices. Blood perfusion and skin temperature were measured at multiple anatomical sites during baseline, active cooling, and passive rewarming periods.


Local cutaneous blood perfusion was depressed in response to cooling the skin surface with all devices, including the DonJoy (DJO, p = 2.6 × 10−8), Polar Care 300 (PC300, p = 1.1 × 10−3), Polar Care 500 Lite (PC500L, p = 0.010), and DeRoyal T505 (DR505, p = 0.016). During the rewarming period, parasitic heat gain from the underlying tissues and the environment resulted in increased temperatures of the skin and pad for all devices, but blood perfusion did not change significantly, DJO (n.s.), PC300 (n.s.), PC500L (n.s.), and DR505 (n.s.).


The results demonstrate that cryotherapy can create a deep state of vasoconstriction in the local area of treatment. In the absence of independent stimulation, the condition of reduced blood flow persists long after cooling is stopped and local temperatures have rewarmed towards the normal range, indicating that the maintenance of vasoconstriction is not directly dependent on the continuing existence of a cold state. The depressed blood flow may dispose tissue to NFCI.

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  1. 1.

    Adie S, Naylor JM, Harris IA (2010) Cryotherapy after total knee arthroplasty: a systematic review and meta-analysis of randomized controlled trials. J Arthroplast 25:709–715

    Article  Google Scholar 

  2. 2.

    Airaksinen OV, Kyrklund N, Latvala K, Kouri JP, Grönblad M, Kolari P (2003) Efficacy of cold gel for soft tissue injuries a prospective randomized double-blinded trial. Am J Sports Med 31:680–684

    PubMed  Google Scholar 

  3. 3.

    Barber FA (2000) A comparison of crushed ice and continuous flow cold therapy. Am J Knee Surg 13:97

    CAS  PubMed  Google Scholar 

  4. 4.

    Barber FA, McGuire DA, Click S (1998) Continuous-flow cold therapy for outpatient anterior cruciate ligament reconstruction. Arthroscopy 14:130–135

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Bassett FH III, Kirkpatrick JS, Engelhardt DL, Malone TR (1992) Cryotherapy-induced nerve injury. Am J Sports Med 20:516–518

    Article  PubMed  Google Scholar 

  6. 6.

    Bleakley C (2004) The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. Am J Sports Med 32:251–261

    Article  PubMed  Google Scholar 

  7. 7.

    Bleakley CM (2006) Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. Br J Sports Med 40:700–705

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  8. 8.

    Brown WC, Hahn DB (2009) Frostbite of the feet after cryotherapy: a report of two cases. J Foot Ankle Surg 48:577–580

    Article  PubMed  Google Scholar 

  9. 9.

    Clough G, Chipperfield A, Byrne C, de Mul F, Gush R (2009) Evaluation of a new high power, wide separation laser Doppler probe: potential measurement of deeper tissue blood flow. Microvasc Res 78:155–161

    Article  PubMed  Google Scholar 

  10. 10.

    Cohn B, Draeger R, Jackson D (1989) The effects of cold therapy in the postoperative management of pain in patients undergoing anterior cruciate ligament reconstruction. Am J Sports Med 17:344–349

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Curl WW, Smith BP, Marr A, Rosencrance E, Holden M, Smith TL (1997) The effect of contusion and cryotherapy on skeletal muscle microcirculation. J Sports Med Phys Fit 37:279

    CAS  Google Scholar 

  12. 12.

    Faul F, Erdfelder E, Buchner A, Lang A-G (2009) Statistical power analyses using G* Power 3.1: tests for correlation and regression analyses. Behav Res Methods 41:1149–1160

    Article  PubMed  Google Scholar 

  13. 13.

    Faul F, Erdfelder E, Lang A-G, Buchner A (2007) G* Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39:175–191

    Article  PubMed  Google Scholar 

  14. 14.

    Flack VF, Afifi AA, Lachenbruch PA, Schouten HJA (1988) Sample size determinations for the two rater kappa statistic. Psychometrika 53:321–325

    Article  Google Scholar 

  15. 15.

    Fleiss JL (1986) Design and analysis of clinical experiments. Wiley, New York, pp 1–31

    Google Scholar 

  16. 16.

    Francis TJ (1984) Non freezing cold injury: a historical review. J R Nav Med Serv 70:134–139

    CAS  PubMed  Google Scholar 

  17. 17.

    Francis TJ, Golden FS (1985) Non-freezing cold injury: the pathogenesis. J R Nav Med Serv 71:3–8

    CAS  PubMed  Google Scholar 

  18. 18.

    Hamlet MP (2001) Nonfreezing cold injury. Wilderness Med Mosby, St. Louis, pp 129–134

    Google Scholar 

  19. 19.

    Hodges GJ, Zhao K, Kosiba WA, Johnson JM (2006) The involvement of nitric oxide in the cutaneous vasoconstrictor response to local cooling in humans. J Physiol 574:849–857

    PubMed Central  CAS  Article  PubMed  Google Scholar 

  20. 20.

    Irwin MS (1996) Nature and mechanism of peripheral nerve damage in an experimental model of non-freezing cold injury. Ann R Coll Surg Engl 78:372–379

    PubMed Central  CAS  PubMed  Google Scholar 

  21. 21.

    Jia J, Pollock M (1999) Cold nerve injury is enhanced by intermittent cooling. Muscle Nerve 22:1644–1652

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Johnson JM, Kellogg DL (2010) Local thermal control of the human cutaneous circulation. J Appl Physiol 109:1229–1238

    PubMed Central  Article  PubMed  Google Scholar 

  23. 23.

    Knight KL (1995) Cryotherapy in sport injury management. Human Kinetics, Champaign, pp 1–20

    Google Scholar 

  24. 24.

    Knobloch K, Grasemann R, Spies M, Vogt PM (2008) Midportion achilles tendon microcirculation after intermittent combined cryotherapy and compression compared with cryotherapy alone: a randomized trial. Am J Sports Med 36:2128–2138

    Article  PubMed  Google Scholar 

  25. 25.

    Knobloch K, Kraemer R, Lichtenberg A, Jagodzinski M, Gosling T, Richter M, Krettek C (2006) Microcirculation of the ankle after cryo/cuff application in healthy volunteers. Int J Sports Med 27:250–255

    CAS  Article  PubMed  Google Scholar 

  26. 26.

    Konrath GA, Lock T, Goitz HT, Scheidler J (1996) The use of cold therapy after anterior cruciate ligament reconstruction a prospective, randomized study and literature review. Am J Sports Med 24:629–633

    CAS  Article  PubMed  Google Scholar 

  27. 27.

    Lee CK, Pardun J, Buntic R, Kiehn M, Brooks D, Buncke HJ (2007) Severe frostbite of the knees after cryotherapy. Orthopedics 30:63–64

    PubMed  Google Scholar 

  28. 28.

    MacAuley D (2001) Do textbooks agree on their advice on ice? Clin J Sport Med 11:67–72

    CAS  Article  PubMed  Google Scholar 

  29. 29.

    McGuire DA, Hendricks SD (2006) Incidences of frostbite in arthroscopic knee surgery postoperative cryotherapy rehabilitation. J Arthrosc Relat Surg 22:1141.e1–e6

    Google Scholar 

  30. 30.

    Meeusen R, Lievens P (1986) The use of cryotherapy in sports injuries. Sports Med 3:398–414

    CAS  Article  PubMed  Google Scholar 

  31. 31.

    Minson CT (2010) Thermal provocation to evaluate microvascular reactivity in human skin. J Appl Physiol 109:1239–1246

    PubMed Central  Article  PubMed  Google Scholar 

  32. 32.

    Moor Instruments. Tissue blood flow and temperature monitoring with moorVMS-LDF. Moor Instruments

  33. 33.

    Music M, Finderle Z, Cankar K (2011) Cold perception and cutaneous microvascular response to local cooling at different cooling temperatures. Microvasc Res 81:319–324

    Article  PubMed  Google Scholar 

  34. 34.

    Razali NM, Wah YB (2011) Power comparisons of Shapiro–Wilk, Kolmogorov–Smirnov, Lilliefors and Anderson–Darling tests. J Stat Model Anal 2:21–33

    Google Scholar 

  35. 35.

    Rheinecker S (1998) Using ice therapy to alleviate pain and edema. J Am Acad Physician Assist 11:73–81

    Google Scholar 

  36. 36.

    Royston P (1995) A remark on algorithm AS 181: the W-test for normality. J R Stat Soc 44:547–551

    Google Scholar 

  37. 37.

    Schaser K-D, Disch AC, Stover JF, Lauffer A, Bail HJ, Mittlmeier T (2006) Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats. Am J Sports Med 35:93–102

    Article  PubMed  Google Scholar 

  38. 38.

    Schröder D, Pässler HH (1994) Combination of cold and compression after knee surgery. Knee Surg Sports Traumatol Arthrosc 2:158–165

    Article  PubMed  Google Scholar 

  39. 39.

    Singh H, Osbahr DC, Holovacs TF, Cawley PW, Speer KP (2001) The efficacy of continuous cryotherapy on the postoperative shoulder: a prospective, randomized investigation. J Should Elb Surg 10:522–525

    CAS  Article  Google Scholar 

  40. 40.

    Thomas JR, Oakley EHN (2002) Nonfreezing cold injury. In: Pandoff KD, Burr RE (eds) Textbooks of military medicine: medical aspects of harsh environments. Office of the Surgeon General, U. S. Army, Falls Church, VA, pp 467–490

  41. 41.

    Van Ness PH, Towle VR, Juthani-Mehta M (2008) Testing measurement reliability in older populations: methods for informed discrimination in instrument selection and application. J Aging Health 20:183–197

    PubMed Central  Article  PubMed  Google Scholar 

  42. 42.

    Walter SD, Eliasziw M, Donner A (1998) Sample size and optimal designs for reliability studies. Stat Med 17:101–110

    CAS  Article  PubMed  Google Scholar 

  43. 43.

    Warren TA (2004) Intra-articular knee temperature changes: ice versus cryotherapy device. Am J Sports Med 32:441–445

    Article  PubMed  Google Scholar 

  44. 44.

    Woolf SK, Barfield WR, Merrill KD, McBryde AMJ (2008) Comparison of a continuous temperature-controlled cryotherapy device to a simple icing regimen following outpatient knee arthroscopy. J Knee Surg 21:15–19

    Article  PubMed  Google Scholar 

  45. 45.

    (2014) MoorVMS-LDF Specifications. Moor Instruments.

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This research was sponsored by National Science Foundation Grants CBET 0828131, CBET 096998, and CBET 1250659, National Institutes of Health Grant R01 EB015522, and the Robert and Prudie Leibrock Professorship in Engineering at the University of Texas at Austin. We would also like to thank Ms. Natalia Mejia for investing long hours of careful and conscientious work in her critical role in extracting data for this publication, and Dr. Michael Mahometa of the Division of Statistics and Scientific Computation, College of Natural Sciences at the University of Texas at Austin for his help and guidance in statistical analysis of data. Comments by the reviewers have been very helpful.

Conflict of interest

A patent application has been submitted by Dr. Khoshnevis and Dr. Diller to the United States Patent and Trademark Office under the title Improved Cryotherapy Devices and Methods to Limit Ischaemic Injury Side Effects. Ownership rights to this patent reside with The University of Texas System. Dr. Diller has served as an expert witness for both plaintiff and defendant counsel since 2000 in numerous legal cases regarding the safety and design of existing cryotherapy devices.

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Correspondence to Kenneth R. Diller.

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Khoshnevis, S., Craik, N.K. & Diller, K.R. Cold-induced vasoconstriction may persist long after cooling ends: an evaluation of multiple cryotherapy units. Knee Surg Sports Traumatol Arthrosc 23, 2475–2483 (2015).

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  • Cryotherapy
  • Vasoconstriction
  • Tissue blood perfusion
  • Tissue cooling
  • Nonfreezing cold injury