The Cold Facts on Icing

If you’re an athlete, there is a good chance that you have been told to ice your muscles after exercising. Icing is commonly thought to alleviate inflammation and soreness, as well as help to heal injuries caused by muscle overuse more quickly.1 There are different types of icing techniques popular in the world of athletics, ranging from a simple ice pack or frozen gel to cryotherapy and cold therapy chambers.2 Despite its wide use, there is some controversy regarding whether cold therapies are beneficial to the muscles or causing more harm than good.

Inflammation is an acute physiological response that is needed for tissues in the body to heal after exercising. Those opposing ice therapies claim that icing a sore muscle reduces its blood flow and slows the natural process of alleviating inflammation. While there is evidence that icing can help to reduce soreness in the short term after a workout, this reduction in the immune response can prevent the muscles from healing as quickly as they otherwise would.3 Many researchers have studied these countering views on the subject.


Figure 1. Cryotherapy machine [6]


One study aimed to see if topical cooling could improve recovery in eccentric contraction-induced muscle damage.4 They used a sample of 11 college male baseball players and put them into two groups; a control group and a group receiving topical cooling. The subjects used a barbell to complete 6 sets of 5 eccentric arm contractions. Those individuals in the cooling group received the ice 0, 3, 24,48, and 72 hours after the exercise for 15 minutes each. This was then repeated four weeks later. The researchers then analyzed the muscle hemodynamic changes, muscle damage markers, inflammatory cytokines, subject pain levels, and isometric muscle strength. The results showed that the subjects pain was similar between the two groups in the short term, but was greater in the later periods after the workout. The measured creatin kinase and myoglobin were significantly greater in the cooling group in the 48 and 72 hour periods than the control group. The cooling also resulted in higher hemoglobin concentration.4

Another study was conducted using 42 moderately active college aged males.5 The researchers had the subjects do 5 sets of 20 drop jumps, followed by lower body immersion in cold water. Three groups were used; one having a water temperature of 5 degrees Celsius, one with 15 degrees Celsius, and one control group. Measurements were taken on isometric knee extensor torque, countermovement jump, muscle soreness, and creatin kinase directly following exercise and 24, 48, 72, 96, and 168 hours after. The results for the countermovement jump showed that the warmer water group recovered more quickly than the colder water group. Creatin kinase remained elevated in all group except the warmer group, which returned to baseline at 72 hours. The subjects reported lower muscle soreness in the warmer water group as well.5

The research shows that icing sore muscles can be beneficial shortly after working out, but that people will possibly experience the same soreness later in time compared to people who don’t ice. It also makes it seem like using only slightly cold ice packs and water is more effective than using extreme cold. Athletes who ice should consider the amount of time they ice and the temperature they use when choosing cold therapies after a workout to avoid possible long term soreness and to improve with training.


Questions to Consider:

  • Do you think that using experienced athletes or people who only exercise occasionally was a more effective method of research?
  • Have your experiences with ice therapies been positive or negative?
  • What could a future study do differently to see the effects of icing on exercise?



  1. Cluett, J. (2019, September 25). How to Properly Ice an Injury. Retrieved from


  1. Gotter, A. (2017, February 2). Treating Pain with Heat and Cold. Retrieved from


  1. Aschwanden, C. (2019, February 5). Athletes love icing sore muscles, but that cold therapy might make things worse. Retrieved from


  1. Tseng, C.-Y. (2013). Topical Cooling (Icing) Delays Recovery From Eccentric Exercise–Induced Muscle Damage. Journal of Strength and Conditioning Research27(5), 1354–1361.


  1. Vieira, A. (2016). The Effect of Water Temperature during Cold-Water Immersion on Recovery from Exercise-Induced Muscle Damage. International Journal of Sports Medicine37(12), 937–943.


  1. (n.d.). 5 Cryotherapy Side Effects Therapists Should Watch For. Retrieved from







Elevation Masks for Endurance Training: Stamina or Scam?

Endurance athletes across the globe are always looking for a way to gain an edge on their opponents. Some methods that have been adopted by elite and amateur athletes alike are altitude and respiratory muscle training. Altitude training involves training at high altitudes where oxygen is more limited than at sea level. Respiratory muscle training involves strengthening the muscles that are required for breathing. Both types of training involve creating a hypoxic condition for the body, meaning that the tissues are not receiving an adequate supply of oxygen. Exposure to hypoxic conditions stimulates the production of erythropoietin in the kidneys, which increases production of red blood cells. This creates an increase in the oxygen carrying capacity of the blood and has been correlated to an increase in endurance performance [1].These training techniques are said to increase aerobic capacity (VO2max), endurance, lung function, and overall performance in athletes [2]. 

Respiratory muscle training can be done using an elevation mask, which is designed to simulate the conditions of training at altitude while training at sea level (figure 1). Elevation masks cover the nose and mouth, restricting air flow and making respiration more difficult for the athlete. They often have values that allow for adjustments to the amount of oxygen that enters the mask. The Elevation Mask 2.0 by Training Mask LLC is one type of mask that uses values and can simulate altitudes ranging from 914 m to 5486 m [2]. But the question is – do these masks really cause physiological changes in the body to improve stamina and endurance?


Figure 1. The Elevation Mask 2.0 (Training Mask LLC, Cadillac Michigan) that can be used by athletes during training in hopes of improving performance [2]. It consists of a silicone mask and neoprene head strap, with adjustable resistance caps to change the amount of air flow.


Many studies have attempted to test these masks and determine if respiratory muscle training is actually beneficial to endurance athletes. Acclimating to high altitude occurs as the body increases the amount of red blood cells, which has been shown to improve sea-level running performance [1]. However, this hematological effect has not been consistently shown in studies that used elevation training masks. In addition to the volume of red blood cells, significant changes have not been observed in blood lactate concentration in people wearing the mask during training. These trends indicate that elevation masks may work as respiratory muscle training devices but do not accurately simulate the physiological changes that occur in the body at high altitudes [2]. 

Increased aerobic capacity, or ability to pump oxygenated blood to the muscles during exercise, is one of the main goals of endurance training. By participating in any sort of endurance training program, VO2max can be improved as the body adapts to the demands being placed on it. However, the goal of altitude and respiratory muscle training is to further enhance this ability to reach peak performance levels. Studies have shown that increases in VO2max for groups wearing a mask compared to increases in control groups are not significant [2]. In contrast, ventilatory threshold, which refers to the point during exercise where the rate of ventilation increases faster than the rate of oxygen uptake, and power output show a significant increase in experimental groups wearing a mask compared to control groups [3]. These findings indicate that wearing the elevation mask may help improve the function of the cardiovascular system during exercise.

Ventilatory threshold (VT) has been shown to correlate to the amount of work the muscles can maintain without fatigue. When the VT is surpassed, the muscles do not receive the necessary amount of oxygen and fatigue begins to set in. Therefore, increasing the VT for an endurance athlete should result in better performance [4]. In addition to endurance based metrics, respiratory muscle training has been shown to improve deep breathing and increase ventilatory efficiency throughout exercise[3,5]. 

Although there seems to be trends present in studies involving elevation masks and endurance training, there are limitations to what can be concluded. Most of the studies evaluated had limited sample sizes and the duration and intensity of the exercise regimes varied between studies. However, the studies do seem to imply that elevation masks may be beneficial to endurance performance through respiratory muscle training. By making it more difficult for the athlete to inhale and exhale, the body does appear to undergo physiological changes to adapt to the lower levels of oxygen. This adaptation may result in increased VO2max, VT, and power output over time. It seems that using an elevation mask does not cause any of the hematological changes in the body that occur when a person actually reaches a higher altitude. So although endurance performance may increase as a result of using the mask, it does not directly mimic the conditions of elevation training.


Questions to Consider:

  • Prior to reading this article, had you heard of professional athletes using altitude training or elevation masks to improve their performance? And if so, what sport did these athletes participate in?
  • Do you think amateur athletes and non-athletes could benefit from using an elevation mask in daily life?
  • Have you ever experienced altitude sickness? If so, what symptoms did you have?



  1. de Paula, P., Niebauer, J. (2012). Effects of high altitude training on exercise capacity: fact or myth. Sleep Breath 16, 233–239.
  2. Porcari, J. P., Probst, L., Forrester, K., Doberstein, S., Foster, C., Cress, M. L., & Schmidt, K. (2016). Effect of Wearing the Elevation Training Mask on Aerobic Capacity, Lung Function, and Hematological Variables. Journal of sports science & medicine, 15(2), 379–386.
  3. Kido, S., Nakajima, Y., Miyasaka, T., Maeda, Y., Tanaka, T., Yu, W., Maruoka, H., & Takayanagi, K. (2013). Effects of combined training with breathing resistance and sustained physical exertion to improve endurance capacity and respiratory muscle function in healthy young adults. Journal of physical therapy science 25(5), 605–610.
  4. Graef, J.L., Smith, A.E., Kendall, K.L. et al. (2008). The relationships among endurance performance measures as estimated from VO2PEAK, ventilatory threshold, and electromyographic fatigue threshold: a relationship design. Dyn Med 7(15).
  5. Granados, J., Gillum, T., Castillo, W., Christmas, K., Kuennen, M. (2016). “Functional” Respiratory Muscle Training During Endurance Exercise Causes Modest Hypoxemia but Overall is Well Tolerated. Journal of Strength & Conditioning Research 30(3), 755-762.

Achey Breaky Muscles

Athletic expertise is not required for one to feel the aching and lasting effects of delayed-onset muscle soreness (DOMS). The aftermath of these effects can often exist along a spectrum ranging from significant muscle tenderness to debilitating pain.¹ In addition, the duration of these effects can exist along a spectrum ranging from 24 to 72 hours.¹ A common misconception correlates a good workout with the subsequent symptoms of DOMS, however, that is just not the case. With that being said, DOMS will often occur in accord with performing new exercises or increasing the intensity and/or duration of a current exercise.¹


The lingering soreness and stiffness as a result of DOMS can often cause individuals to seek methods that will ultimately reduce these symptoms and accelerate their return to the gym. Unfortunately, many of the treatment options on the market have mixed outcomes due to the individualized nature of exercise. Some may obtain adequate results through methods, such as massage or ibuprofen, while others may not; whereas, some methods prove to be completely ineffective, such as cryotherapy and stretching.¹ Furthermore, let’s give a look at a newly proposed treatment for DOMS and whether its results are promising.


Blood-flow restriction (BFR) training is often used at physical therapy as a passive way to regain strength without adding heavy weight. The venous blood supply is terminated at the area of injury, which in turn reduces the amount of oxygen at the site, activates anaerobic metabolism, and encourages muscle hypertrophy.² This proves to be an effective technique for restrengthening the muscle of patients who strictly lift lighter loads.² But, where is the crossover between BFR and DOMS?

Figure 1. BFR machine.[8]

BFR is thought to provide an alternative training method that will achieve similar muscle gains to resistance training with heavy loads while also minimizing the effects of DOMS. It has been postulated that BFR training may attenuate DOMS by preventing calcium-mediated proteolysis³ and by recruiting fast-twitch motor units.⁴ However, it has also been hypothesized that BFR training may induce muscle damage through ischemia-reperfusion (lack of oxygen in the tissues) or through the reduction of neutrophils that aid in inflammatory response.⁵


A 2019 study wished to examine the effects of BFR training on DOMS by using 25 untrained females and submitting them to isokinetic forearm flexion training, where half performed a bicep curl with a BFR cuff at a load reflecting a 30% eccentric-peak torque and the other half at a load reflecting a 30% concentric-peak torque.⁶ The findings revealed neither eccentric or concentric movements with a BFR cuff resulted in DOMS after the 7 days of training.⁶ These results were inconsistent with other studies that showed an increase in DOMS with concentric exercises.⁶ Is this inconsistency due to the low number of participants, the lack of diversity, or the duration of the experiment being only 7 days?


In contrast, a 2017 study compared the effects of BFR training and resistance training on DOMS by using 17 male participants and assessing their elbow-flexor muscle strength for 7 days in one of four training techniques: heavy load, light load, intermittent high-pressure BFR, and continuous low-pressure BFR.⁷ From this, the researchers found DOMS was significantly greater in BFR training (both intermittent high-pressure and continuous low-pressure) than in resistance training (both in heavy and light load).⁷


Much like the other methods of muscle recovery, BFR training may not be the most effective way to minimize DOMS. Exercise can be highly variable and strongly impacted by genetics, which may be the reason a consistent and reliable technique for treating DOMS has yet to be discovered.


Watch this youtube video to learn more about DOMS.⁸

Questions to consider

  • Based on the study mentioned in this article, do you think their findings are an accurate representation of the effects of BFR training on DOMS?
  • How have your opinions regarding DOMS changed with this post?
  • Did the video help you understand DOMS in an easily digestible way?



  1. Cheung K, Hume P, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Med. 2003; 33(2):145-164. DOI: 10.2165/00007256-200333020-00005
  2. Blood-Flow Restriction Training. American Physical Therapy Association. Website. Updated May 24, 2019. Accessed February 20, 2020.
  3. Sudo M, Ando S, Poole DC, Kano Y. Blood flow restriction prevents muscle damage but not protein synthesis signaling following eccentric contractions. Physiol Rep. 2015;3(7):e12449.
  4. Loenneke JP, Fahs CA, Wilson JM, Bemben MG. Blood flow restriction: the metabolite/volume threshold theory. Med Hypotheses. 2011;77(5):748-752.
  5. Curty VM, et al. Blood flow restriction attenuates eccentric exercise-induced muscle damage without perceptual and cardiovascular overload. Clin Physiol Funct Imaging. 2017;38(3):468-476.
  6. Hill EC, Housh TJ, Smith CM, Keller JL, Schmidt RJ, Johnson GO. Eccentric and concentric blood flow restriction resistance training on indices of delayed onset muscle soreness in untrained women. Eur J Appl Physiol. 2019;119(10):2363-2373.
  7. Brandner CR, Warmington SA. Delayed onset muscle soreness and perceived exertion after blood flow restriction exercise. Journal of strength and conditioning research. 2017;31(11):3101-3108. doi:10.1519/JSC.0000000000001779
  8. Should You Still Train Sore? Youtube. Website. Published November 18, 2018. Accessed February 20, 2020.

Personalized Blood Flow Restriction. Owens Recovery Science. ORS. 2020c.

Dry Needling: Is it Worth the Pain?

Arriving at a physical therapy appointment to have a needle stuck deep into the body’s muscles only to leave hobbling and sorer than before doesn’t seem like an effective method for rehabilitation. However, the post-treatment benefits have made dry needling one of the many techniques individuals are using to treat and prevent injury from exercise.

What is Dry Needling?

While wet needling uses hollow needles to inject corticosteroids into muscle [7], dry needling (DN) consists of inserting a fine needle, similar to those used in acupuncture, deep into the muscle without injections. The needle is then twisted and moved around the area without being fully removed from the skin. The needling itself can be uncomfortable, feeling like a pinch, cramp, or deep prick, and can result in local soreness post-treatment. Physical therapists seek to insert the needle into a myofascial trigger point (MTrP) to relieve myofascial pain syndrome (MPS), the most common muscle pain disorder seen in clinical practice [1]. In exercise science, MTrPs are defined as “hyperirritable local point(s) located in taut bands of skeletal muscle or fascia which when compressed causes local tenderness and referred pain” [10]. Potentially caused by muscle overuse [2], this pain is commonly described as having a knot in a muscle and creates localized tenderness, pain to deep touch, and restricted movement [1].

The video above shows a physical therapist performing the dry needling technique on various muscles. Created by Dynamic Physical Therapy, Covington, LA (2013).

Dry needling is used as a rehabilitation technique to decrease the pain MTrPs can cause. The “fast-in and fast-out needle technique” applies high pressure stimulation to the MTrP, often causing a twitch response. These twitch responses are the result of a spinal reflex generated by the activation of nociceptors and mechanoreceptors. These receptors respond to the painful mechanical irritation and stretch the needle causes within the muscle [1]. When this occurs, a single motor unit fires and a visible, isolated contraction – the “twitch” – can be seen. These twitch responses can occur local to the needle or within muscles on the opposite side of the body. This phenomenon has led researchers to believe that the pain associated with MTrPs is due to central nervous system (CNS) changes [1]. 

How is Dry Needling Portrayed in Healthcare?

Healthcare providers, such as MedStar National Rehabilitation Network and ChristianaCare, have been advocates for dry needling. They mention DN is “an effective physical therapy modality…in the treatment of orthopedic injuries” [5] and that it can even be used for preventing pain and injury [4]. There have been many personal accounts of the wonders of dry needling in recovery from nagging injuries. AshleyJane Kneeland, who struggles with muscular pain due to lupus, fibromyalgia, and postural orthostatic tachycardia syndrome, cites DN treatment as relief for her painful spasms and headaches, as well as providing general relaxation [6]. But how effective is dry needling, really? Is there science to back up these claims?

What Does the Science Say?

Elizabeth A. Tough and co-authors performed a meta-analysis in 2009 of seven studies assessing the effectiveness of DN in managing MTrP pain. This study provides an update for the systematic review by Cummings and White, which found no evidence suggesting injections through wet needling generate a better response than dry needling [3]. One study found by Tough et al. suggests DN is more effective in treating MTrP pain than undergoing no treatment, two studies produced contradictory results when comparing DN in MTrPs to DN elsewhere, and four studies showed DN is more effective than other non-penetrating forms of treatment (placebo controls). However, when combining these studies for a sample size of n=134, no statistical significance was found between DN and placebo treatments. 

While the authors conclude the overall direction of past studies trend towards showing that DN is effective in treating MTrP and MPS [10], there is no significant evidence yet. The lack of statistical significance could be due to low consistency in study design for studies included in the meta-analysis, as each employed varying mechanisms for needle placement, depth, and treatment frequencies, along with there being an overall small sample size. Therefore, further studies are required to significantly conclude that DN is effective in MTrP rehabilitation.

Ortega-Cebrian et al. recognized the limitations in previous studies and thus sought to create a significant evaluation of the ability of DN to decrease pain and improve functional movements. The authors use a myometer (MyotonPro, [8]) and surface electromyography (sEMG) to assess the mechanical properties of muscle in subjects (n=20 M) with quadricep muscle tension and pain [9]. 

The MyotonPro allows researchers to quantify muscle tone and stiffness. While no standards exist for describing these parameters with respect to changes after rehabilitation techniques, researchers found the device to be reliable through inter-rater reliability (comparing values of the MyotonPro to another rater). Pain was assessed by subjects using the Visual Analogue Scale (VAS) and a goniometer was used to measure small range of motion (ROM) improvements. DN was performed by one of two experienced therapists until twitch responses ceased [9].

Authors report that DN resulted in statistically significant pain reduction and an increase in flexion ROM. However, the ROM was very small and could be within the range of measurement error of the goniometer. Also, the p-values reported in-text for these parameters do not match the corresponding table which presents a question of the reliability of author reporting. All sEMG parameters, except for decreased vastus lateralis activity, were not significantly changed by DN, as well as all MyotonPro parameters, besides a decrease in vastus medialis decrement (muscle elasticity) and resistance. In a power analysis performed after the study, authors report needing 198 subjects for statistically significant results – much higher than the 20 subjects used [9]. Therefore this study continues the uncertainty in the benefits of DN, but does present significant subject-reported pain reduction.

Is it Worth the Pain?

So is dry needling worth the pain? After being put to the test through experimental studies, there is no clear evidence that dry needling is more beneficial than alternative rehabilitation methods such as wet needling, placebo needling, or acupuncture [9]. However, while the mechanisms of changes in muscles with trigger points due to dry needling are unknown, subjects do report pain reduction. Dry needling should be taken on a case-by-case basis since current knowledge of widespread benefits is limited. Essentially, if dry needling treatment alleviates pain more than other rehabilitation methods and the pain of the procedure is bearable, why not give it a try?


Questions to Consider:

  • Would you be willing to try dry needling regardless of uncertainties in the literature?
  • Do you believe it is a problem that healthcare providers claim dry needling is effective despite a lack of conclusive evidence?
  • What should future studies do to ensure significant results?



[1] Audette, J. F., Wang, F., & Smith, H. (2004). Bilateral Activation of Motor Unit Potentials with Unilateral Needle Stimulation of Active Myofascial Trigger Points. American Journal of Physical Medicine & Rehabilitation, 83(5), 368–374. doi: 10.1097/01.phm.0000118037.61143.7c. 

[2] Bron, C., & Dommerholt, J. D. (2012). Etiology of Myofascial Trigger Points. Current Pain and Headache Reports, 16(5), 439–444. doi: 10.1007/s11916-012-0289-4. 

[3] Cummings, T., & White, A. R. (2001). Needling therapies in the management of myofascial trigger point pain: A systematic review. Archives of Physical Medicine and Rehabilitation, 82(7), 986–992. doi: 10.1053/apmr.2001.24023. 

[4] Dry Needling®. (n.d.). Retrieved from

[5] Dry Needling. (n.d.). Retrieved from

 [6] Dry Needling: The Most Painful Thing I’ve Ever Loved. (2015, March 25). Retrieved from

[7] Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), 252–265. doi: 10.1179/108331913×13844245102034. 

[8] Muscle Tone, Stiffness, Elasticity measurement device. (n.d.). Retrieved from 

 [9] Ortega-Cebrian, S., Luchini, N., & Whiteley, R. (2016). Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients. Physical Therapy in Sport, 21, 57–62. doi: 10.1016/j.ptsp.2016.02.001. 

[10] Tough, E. A., White, A. R., Cummings, T. M., Richards, S. H., & Campbell, J. L. (2009). Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials. European Journal of Pain, 13(1), 3–10. doi: 10.1016/j.ejpain.2008.02.006.