BRIEF REVIEW
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EFFECTS OF COLD WATER IMMERSION AND CONTRAST
WATER THERAPY FOR RECOVERY FROM TEAM SPORT:
A SYSTEMATIC REVIEW AND META-ANALYSIS
TREVOR R. HIGGINS,1,2 DAVID A. GREENE,1
AND
MICHAEL K. BAKER1
1
School of Exercise Science, Australian Catholic University, Sydney, Australia; and 2Department of Sport Performance,
Australian College of Physical Education, Sydney, Australia
ABSTRACT
Higgins, TR, Greene, DA, Baker, MK. Effects of cold water
immersion and contrast water therapy for recovery from
team sport: a systematic review and meta-analysis.
J Strength Cond Res 31(5): 1443–1460, 2017—To enhance
recovery from sport, cold water immersion (CWI) and contrast water therapy (CWT) have become common practice
within high level team sport. Initially, athletes relied solely on
anecdotal support. As there has been an increase in the
volume of research into recovery including a number of
general reviews, an opportunity existed to narrow the focus
specifically examining the use of hydrotherapy for recovery
in team sport. A Boolean logic [AND] keyword search
of databases was conducted: SPORTDiscus; AMED;
CINAHL; MEDLINE. Data were extracted and the standardized mean differences were calculated with 95% confidence interval (CI). The analysis of pooled data was
conducted using a random-effect model, with heterogeneity
assessed using I2 . Twenty-three peer reviewed articles (n =
606) met the criteria. Meta-analyses results indicated CWI
was beneficial for recovery at 24 hours (countermovement
jump: p = 0.05, CI: 20.004 to 0.578; All-out sprint: p =
0.02, 20.056 to 0.801) following team sport. The CWI was
beneficial for recovery at 72 hours (fatigue: p = 0.03, CI:
0.061–1.418) and CWT was beneficial for recovery at 48
hours (fatigue: p = 0.04, CI: 0.013–0.942) following team
sport. The CWI was beneficial for neuromuscular recovery
24 hours following team sport, whereas CWT was not beneficial for recovery following team sport. In addition, when
evaluating accumulated sprinting, CWI was not beneficial
for recovery following team sports. In evaluating subjective
measures, both CWI (72 hours) and CWT (24 hours) were
beneficial for recovery of perceptions of fatigue, following
Address correspondence to Trevor R. Higgins, thiggins@acpe.edu.au.
31(5)/1443–1460
Journal of Strength and Conditioning Research
Ó 2016 National Strength and Conditioning Association
team sport. However neither CWI nor CWT was beneficial
for recovery, of perceptions of muscle soreness, following
team sport.
KEY WORDS performance, hydrotherapy, fatigue, ice bath
INTRODUCTION
I
n team sports, habitual activity that consists of multiple
training sessions, competition games, and recovery
over a week occur each week of the season (46).
These multiple training sessions can consist of dedicated conditioning sessions incorporating skills and unit
practices, resistance training sessions, functional training
and team runs involving strategy and game patterns (7,46).
This cycle extracts an ever-increasing physical toll from athletes, impacting muscle contractibility at the point of fatigue,
because of metabolic disturbances followed by structural disruptions within the muscle fibers (2,50,53).
In the context of team sports, during general preparation
and specific preparation phases of a periodized program,
metabolic disturbances and structural disruptions are essential (28). They are required for the development of adaptation to a given workload and consequently enhancement of
athletic performance during these periods of the training
program (28). However, during the competition phase of
a season, the focus is on the maintenance of a player’s physiological condition as opposed to its development (28).
Maintenance becomes problematic during the competition
phases of team sport as structural disruptions have a recovery
period of between 3 and 7 days (28). With time periods of
less than 72 hours between games/training sessions, players
are exposed to additional training stimuli before they are
fully recovered leading to the development and accumulation of fatigue (46). As fatigue has been defined as a reduction
in physical and or functional performance (46), the management of these structural disruptions becomes essential in
relation to athletic performance.
To enhance and/or accelerate recovery of the structural
disruptions associated with team sport, a number of hydrotherapy protocols have been adopted in the field of professional sport (4,5,19,35,43). Hydrotherapy is a broad-based
VOLUME 31 | NUMBER 5 | MAY 2017 |
1443
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Recovery From Team Sport
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Figure 1. Flowchart of outcomes of search strategy.
term in sport science and includes immersion in hot or cold
water, ice massage, hot and/or cold showers, exercise in
water, or various combinations of these interventions
(4,5,19,35,43). The professional sporting community in general believes that hydrotherapy accelerates the recovery process of athletes, bringing about a faster return to an optimal
functioning state. However, supporting evidence in the sport
science literature is inconsistence and despite its popularity,
support for hydrotherapy remains equivocal.
A number of factors explaining the inconsistencies
between results across the sport science literature have been
1444
the
raised. Halson and Leeder et al.
(19,35) stated that when evaluating recovery from sporting
performance a number of factors need to be taken into
account (19,35). Initially, athletes will respond differently
to different types of physiological stressor. Non–weight bearing activities such as swimming
and cycling will generate different physiological disturbances
than weight-bearing activities
such as running (19,35). Furthermore, sports involving collision/impact events would
elicit additional physiological
disturbances again (19,35).
Therefore, evaluation of recovery modalities should be conducted using physiological
stressors similar to the sporting
activities for each specific athletic population (19,35).
Training status of participants also needs consideration.
Because of high training status
and subsequent adaptation
processors, well-trained, professional, elite level athletes
may have blunted responses
to physiological stressors in
comparison with untrained or
recreational athletes (19,35).
Results from evaluations of
recovery protocols with participants of either high training or
untrained cannot be routinely
transferred to differing participants
(19,35).
Therefore,
recovery protocols should be
evaluated with participants of
an appropriate training status
(19,35).
When evaluating hydrotherapy, biochemical markers,
subjective measure of muscle pain and fatigue, neuromuscular performance and sporting performance have routinely
been used as measures for recovery from fatigue (19,35). To
date, conflicting findings have been reported across studies
providing no clear indications as to the beneficial effect of
hydrotherapy toward recovery from biochemical markers,
subjective measures, neuromuscular recovery, and sporting
performance in team sport.
Although the popularity of hydrotherapy for recovery
has increased in team sport, a number of questions have
TM
Journal of Strength and Conditioning Research
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Reference
Bahnert et al. (1)
Buchheit et al. (6)
Delextrat et al. (9)
N
Gill et al. (18)
Higgins et al. (24)
Higgins et al. (2013a)
Higgins et al. (2013b)
Higgins et al. (21)
Ingram et al. (27)
Jones et al. (30)
Juliff et al. (31)
King and Duffield (32)
Kinugasa et al. (33)
Montgomery et al. (2008a)
Montgomery et al. (2008b)
Pointon et al. (2012a)
Pointon et al. (2012b)
Pournot et al. (44)
10 (F)
23 (M)
26 (M)
24 (M)
24 (M)
24 (M)
11 (M)
10 (M)
10 (F)
10 (F)
12 (NR)
29 (M)
29 (M)
10 (M)
10 (M)
41 (NR)
Rowsell et al. (48)
Rowsell et al. (47)
Rupp et al. (49)
Takeda et al. (52)
Webb et al. (55)
20 (M)
20 (M)
13 (M)
9 (F)
20 (M)
21 (M)
Status
Age
Phase
BMI
In season
Summer workout program
24
18–20.2
24.9
24.2
23.9
31.9
AFL
Football
Basketball
Pro/Semi-Pro
Academy
Premier League
AFL
American Football, n =
18; volleyball, n = 10;
basketball, n = 2
Semi-Pro
Collegiate athletes
23 (64.2)
12–17
23 (63)
22 (62)
24.2 (62.9)
NR
In season
In season
In season
Rugby
Rugby
Rugby
Rugby
Rugby
Athletes
7s Rugby
Netball
Netball
Football
Basketball
Basketball
Rugby Union/League
Rugby Union/League
Football, Rugby,
volleyball
Football
Football
Football
Elite
Under 20
Under 20
Under 20
Under 20
Team games
Premier
Elite
Trained
School Soccer Academy
State
State
Trained
Trained
Elite
NR
25 (63)
19 (6,1)
19.5 (6,1)
19.5 (6,1)
19.5 (6,1)
27.6 (66)
20 (62)
18.5–20.7
19.5 (61.5)
14.3 (6,1)
19.1 (62.1)
19.1 (62.1)
21 (61.7)
19.9 (61.1)
21.5 (64.6)
In season
In season
In season
In season
In season
NR
NR
Preseason
Midseason
3 football games
Preseason
Preseason
NR
NR
NR
SAIS
SAIS
Division 1
15.9 (6,1)
15.9 (6,1)
19.9 (61.1)
Preseason
Preseason
Out of season
N/A
N/A
23.8
Rugby
Rugby League
Collegiate
NRL Professional
20.3 (6,1)
23.6 (62.6)
In season
In season
28.2
28.8
23.7
29.1
25.8
25.5
25.5
25.5
23.9
27.05†
23.1
22.4
19.6
26.1
24.1
26.3
24.5
23.4
TM
*BMI = body mass index: estimated via mean scores only; M = male; AFL = Australian Football League; F = female; NR = not recorded; Rugby = Rugby Union; SAIS = South
Australian Institute of Sport; N/A = BMI estimate unable to be calculated as participants height missing; NRL = National Rugby League; Football (inclusive of soccer) Athletes
(nonclassified team sport athletes).
†BMI score published.
the
Dawson et al. (8)
Getto and Golden (17)
44 (M)
104 (M)
8 (M)
8 (F)
17 (M)
13 (M)
Team sport
Journal of Strength and Conditioning Research
1445
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TABLE 1. Participant characteristics.*
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the
Journal of Strength and Conditioning Research
Reference
Bahnert
et al. (1)
Buchheit
et al. (6)
Delextrat
et al. (9)
TM
Dawson
et al. (8)
Getto and
Golden (17)
Gill et al. (18)
Higgins
et al. (24)
Higgins et al.
(2013a)
Interventions
CWI
CWT
Compression
garments
Hot Shower
Sauna
Hydromassage
CWI
Effleurage
massage
CWI
Stretch
Pool walk
CWT (shower)
CWI
Active recovery
Active recovery
CWT
Compression
garment
CWI
CWT
CWI
CWT
Control
Temperature
Time frame
NA
6–118 C
6–118 C
388 C
8 min
1 min
2 min
NA
33–438 C
2 min
85–908 C
368 C
128 C
2 min
2 min
2 min
30 min
Seated rest
118 C
Fruit and water/
soft drink
Seated rest
15 min
458 C/128 C 2 min/1 min
108 C
10 min
8–108 C
40–428 C
Seated rest
1
4
4
NA
Baseline
timeframe
Data point
timeframe
10 min
8 min
1 min
2 min
12 h
Physiological
stressor
NR
NR
23 AFL games
Game 1
Game 2, post 48 h
2 club football
matches
1-wk before
first game
Immediately
postgame
Postintervention,
24-h† postgame
Basketball game
5
15 min
Seated rest
Seated rest
2 min
Total
immersions
12 Western Australia
State AFL games
5/4
1
3
45-h prematch 15-h post
48-h post
1-wk
Immediately
pretreatment
postconditioning
routine
24–28 h post
3.5-h pregame Immediately post
Conditioning routine
4 NPC
Rugby games
36-h post
48-h post
10–128 C
10–128 C
38–408 C
108 C
5
1
1
5
min
min
min
min
1
7
10–128 C
38–408 C
1 min
1 min
5
2
120 and 72 h
Pregame 1
1-h pregame
48-h post
96-h post
4 U/20
Premier rugby games
Immediately post
Simulated rugby
game
24-h post
48-h post
Recovery From Team Sport
1446
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TABLE 2. Study protocols.*
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CWI
Seated rest
CWT
Higgins et al.
(21)
CWI
Seated rest
Jones et al.
(30)
Active recovery
Seated rest
Seated rest
Contrast shower
1 min
1 min
5
Kinugasa et al. CWT
(33)
CWI/Cycling
Montgomery
CWI
et al.
(2008a)
Compression
garment
Static stretching
and legs raised
Stretches
C
C
C
C
5 min
2
1 min
1 min
5 min
1 min
1 min
15 min
5
2
3
1
108 C
108 C
10 min
25 min
1
388 C,
158 C
1 min
7
388 C,
188 C
1 min
7
1 min
1 min
10 min
108 C
108 C
38–398 C
128 C
388 C
128 C
118 C
5 min
1 min
2 min
1 min
2 min
1 min/2 min
1 min
48-h post
72-h post
1-h pregame
118 C
1 min
96-h post
144-h post
1-wk post
Presimulation
Simulated Rugby
game
3 3 90 min field
training days
2 simulated rugby
games
Postsimulated
24-h post
48-h post
Presimulated 7 24-h post
s
Simulated team sport
Presimulated
netball
circuit
Simulated netball
circuit
Immediately
postcircuit
Simulated 7s Rugby
0.5-h post
24-h post
Pre-ISE
2
5
3
3
5
5
Immediately
postcircuit
ISE
24-h post
2-h prematch
Immediately
postmatch
24-h post
7-d pretourney 10-min post
4–6 h
Stretches
Immediately post
3 3 90 min football
matches
3 3 3 d basketball
tournament
6-h post
Pregame
24-h post
7-d pretourney 10-min post
3 3 3 d basketball
tournament
6-h post
the
Seated rest
TM
24-h post
(continued on next page)
1447
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Compression
garment
10–128 C
38–408 C
1-h pregame
Journal of Strength and Conditioning Research
King and
Active recovery
Duffield (32)
CWI
CWT
CWI
2
10–128
38–408
108 C
10–128
38–408
CWI
CWT
Montgomery
et al.
(2008b)
5 min
108 C
Ingram et al.
(27)
CWI
CWI/active
recovery
Juliff et al. (31) CWT
108 C
Seated rest
CWT
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Higgins et al.
(2013b)
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CWI
Seated rest
9.28 C
9 min
2
Pre-ISE
Pointon et al.
(2012b)
CWI
Seated rest
8.98 C
9 min
2
Pre-ISE
Pournot et al.
(44)
CWI
Seated rest
108 C
15 min
368
108
428
108
348
C
C
C
C
C
15 min
90 s
90 s
1 min
1 min
5
5
5
1 min
1 min
15 min
5
5
1
Pre-Yo-Yo
TWI
CWT
Preexercise
protocol
TM
Rowsell et al.
(48)
CWI
TWI
NA
Rowsell et al.
(47)
Rupp et al.
(49)
CWI
TWI
CWI
NA
Seated rest
108 C
348 C
128 C
Takeda et al.
(52)
Webb et al.
(55)
CWI
Seated rest
158 C
10 min
1
Pretraining
CWI
NA
10–128 C
5 min
1
24-h
pregames
8–108 C
40–428 C
1 min
2 min
3
CWT
90 min
Before first
game
7-d pregame
10-min post
2-h post
24-h post
10-min post
2-h post
24-h post
Immediately
Post
1-h post
24-h post
90 min
Pregames 2, 3 and
4
22-h postgame 4
22-h post
43 games
Immediate post
24-h post
48-h post
Posttraining 24-h
post
1-h post
ISE
ISE
Intermittent exercise
protocol
4 3 football games
4 3 football games
Yo-Yo test
Rugby simulation
training
3 3 competitive NRL
games
18-h post
42-h post
*CWI = cold water immersion; AFL = Australian Football League; CWT = contrast water therapy; NPC = National Provincial Championship; TWI = thermoneutral water immersion;
NRL = National Rugby League; football (includes soccer); ISE = intermittent sprint exercise.
†22h–24h.
Recovery From Team Sport
1448
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Pointon et al.
(2012a)
the
TM
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been raised with regard to its suitability (10,54). Initial
concerns have included heat applied in contrast therapy
increasing inflammation and edema (10). The initial
impact of heat may have a detrimental effect on recovery
with increased inflammation and edema (10). However,
the authors speculated the initial heat would be offset by
the subsequent application of cold, although the benefits of
a single continuous immersion would exceed those of
intermittent immersions (10).
In addition, Versey et al. (54) speculated that hydrotherapy may blunt the chronic adaptation processes. It was theorized that hydrotherapy could disrupt mechanisms of
fatigue, which may be a prerequisite for adaptation, sought
by athletes and training staff, in the development of fitness
(54). However, benefits associated with recovery in the acute
stages, specifically increases in frequency, intensity, or duration of training could offset the potential detrimental effects
through a blunted adaptation response (54).
In an attempt to clarify the efficacy of recovery methods,
a number of reviews/meta-analyses have subsequently
been conducted (5,35,43). Authors from these reviews
have drawn to the reader’s attention limitations that currently exist in recovery research, in particular, the practice
of comparing results from trained and untrained participants. It was highlighted that interpretation and transfer
of both data and results between untrained and trained
participants are difficult (43). In addition to limitations
associated with varying training status of participants, the
variation between different exercise stressors was also
raised. The nature of physiological stress will vary considerably between different types of exercise stressors (35).
Further to this, the potential for reduced performance will
vary depending on the exact exercise stressor that an athlete is recovering from (19,35). Furthermore, it was identified that weight-bearing activities, including running and
weight training respond differently, in physiological stress
and recovery response, to non–weight bearing activities
such as cycling and swimming (19).
Despite raising these issues, the reviews included articles
encompassing both a range of participants and a range of
exercise stressors. With the increase in research into
recovery, the opportunity prevails to extend the work
initiated by these reviews, and to narrow the focus on
specific methods and athletic populations. It has been
identified that team sport comprises a number of highintensity repeat efforts, including a multitude of directional
changes, jumping efforts, and physical impacts/collisions
(9,52), and that each event adds to the physiological stress
confronting the athletes’ ability to recover (9,52). Therefore,
limiting studies to those evaluating recovery in team sport is
essential to be able to evaluate the true beneficial effect of
recovery interventions in team sport.
Furthermore, although there are vast arrays of recovery
modalities, actively used, including stretching, massage,
electrical stimulation, active recovery, and compression
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garments, the implementation of hydrotherapy for recovery
has grown in popularity in team sport, without clear
scientific support (1). Therefore, the purpose of this article
was to systematically review the available research evaluating hydrotherapy for recovery in team sport. This critical
appraisal of recovery methods is necessary to inform the
translation of this evidence base into guidelines for enhancing recovery in team sport athletes, currently absent from the
sport science literature.
METHODS
Design
The systematic review was carried out following the
recommendations outlined in the Preferred Reporting
Items for Systematic Reviews and Meta-Analysis statement (37). A computerized literature search of online
databases was undertaken by one author (T.R.H.),
between September 9, 2014 and September 20, 2014.
Before excluding papers, all authors (T.R.H., D.A.G., and
M.K.B.) met to review the papers. Papers were excluded
immediately when each author agreed. If there was a disagreement on the suitability of an article, a meeting was
called with authors presenting arguments, either for or
against a paper’s inclusion/exclusion. If agreement was
still absent, the decision with most authors in support
was adopted. Capture dates were limited to individual
databases dates for online availability. Databases searched
included: SPORTDiscus with Full Text (1998–2014);
AMED–The Allied and Complementary Medicine Database (1995–2014); CINAHL Complete (1998–2014);
MEDLINE Complete (1997–2014). Search strategy
included a combination of Boolean logic [AND] keyword
search (Interventions, recovery, team sport) (Figure 1). A
hand search was also conducted by one author (T.R.H.).
The hand search included searching through the reference
lists of articles identified in the database search. Papers
included in the hand search were the articles identified
to be included in this systematic review and published
reviews on recovery.
Studies were excluded if they were not evaluating
recovery, evaluated performance without a recovery intervention, adaptation to a training protocol, assessing recovery
of acute or chronic injury.
Interventions
To be included, studies were required to use a physiological
stressor associated with team sport. This could include
competitive games, simulated competitive games, team
training, or combinations of the above. Studies were to
include comparison between postexercise recovery modalities associated with hydrotherapy and at least one other
group, and examined a time period of no less than 24-hour
postphysiological stressor.
Studies that used general or non–sporting specific physiological stressors, evaluated a single limb/body section,
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Recovery From Team Sport
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Figure 2. Forest plot for cold water immersion vs. control in countermovement jumps.
evaluated the immediate response (,24 hours), without
extending to 24 hours or beyond, and following hydrotherapy were excluded (6,8).
and subjective measures of performance, and/or muscle
soreness, power, acceleration, fitness tests, neuromuscular
performance, or passive assessments.
Study Populations
Data Extraction
Studies comprised of male participants, female participants,
or both were included. Participants were required to be
reported as free from injury or illness and further classified as
either/or well-trained, athletic, elite/semi-elite, professional/
semiprofessional, and academy/institute team athletes. Studies evaluating untrained, recreational athletes or athletic
status not disclosed were excluded.
Data relating to types of interventions (cold water immersion [CWI], contrast water therapy [CWT], thermal-neutral
water immersion), physiological stressor (competitive game,
simulated game, team training), data collection time points,
mean totals, and SDs, were extracted by one author (T.H.).
Where insufficient information was provided, attempts to
contact the authors through e-mails were made to obtain
the missing data.
Outcome Measures
Studies were required to measure the effect recovery
interventions on one or more outcome measures. Measures
could include biochemical markers, physical performance,
Assessment of Methodological Quality
To be included, studies were to meet the minimum quality
threshold, defined as having met all the inclusion criteria.
Figure 3. Forest plot for contrast water therapy vs. control in countermovement jumps.
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Figure 4. Forest plot for cold water immersion vs. control in one all-out sprint.
Further quality assessment was conducted using a modified
Delphi Scale (11,26) and Jadad Scale (36).
Meta-analysis
All meta-analysis calculations were conducted with the
Comprehensive Meta-Analysis software (Version 2.2.057;
Biostat Inc., Englewood, New Jersey, USA). A p-value of
,0.05 was considered statistically significant for all analyses.
Statistical heterogeneity was assessed using the I2, which
describes the percentage of variability in effect estimates that
is due to heterogeneity rather than chance (35). To assess for
the presence of publication bias, visual inspection of funnel
plots was used to investigate the relationship between effect
size and sample size.
The standardized mean differences (mean difference
between recovery intervention and control groups divided
by pooled SD) were calculated across variables including
neuromuscular performance (jump performance, sprint
times, agility), subjective measures of fatigue and muscle
soreness, biochemical markers, repeat effort tests, and
game performance markers, with a 95% confidence interval (CI) (35). For the purposes of meta-analysis, the direction of change for some studies was reversed to ensure
consistency of directionality between the tests; reduced
times in sprints indicated improvement in recovery,
whereas increased subjective values of fatigue or muscle
soreness indicated improvement in recovery. The analysis
of pooled data was conducted using a random-effect model
allowing for the calculation of the direct probability of
a treatment effect.
RESULTS
Identification and Selection of Studies
The original search produced 10,276 articles. After reviewing
the titles and abstracts as well as conducting a hand search
through the reference lists of manuscripts, the total number
of articles was reduced to 396. Further elimination of papers
based on the eligibility criteria provided the final total of
papers at 23 (Figure 1).
Figure 5. Forest plot for cold water immersion vs. control in accumulated sprinting.
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Figure 6. Forest plot for cold water immersion vs. control in muscle soreness.
Cohort Characteristics
Physiological Stressor
Across the included studies a combined total of 606
participants (506 men; 47 women; 53 not reported) participated in the trials. Three studies evaluated both male and
female participants, 2 studies evaluated female participants
only, and 19 studies evaluated male participants only.
A further 2 studies did not report the gender of the
participants. Participants were recruited from 8 different
team sports (AFL [n = 2], American Football [n = 1], Basketball [n = 4], Netball [n = 2], Football [n = 5], Futsal [n =
1], Rugby Union [n = 10], Rugby League [n = 3], Volleyball
[n = 2]), with one study describing participants as team sport
athletes. Four of the included studies recruited participants
from multiple sports, whereas the rest of the studies recruited participants from only one of the above-mentioned
team sports (Table 1). Thirteen of the studies were conducted during the competition phase of the sporting calendar. Five studies were carried out during the preseason phase
of the sporting calendar and 2 studies were conducted during the off-season phase of the sporting calendar. Six studies
did not report the phase of the sporting calendar in which
they were conducted (Table 1).
Seven studies incorporated team training sessions as their
physiological stressor with 11 studies incorporating competition games as the physiological stressor. Six studies
incorporated both competition games and team training
sessions as the physiological stressors and 6 studies incorporated simulated team sport games as the physiological
stressor (Table 2). Hydrotherapy interventions applied
included CWI (n = 21), contrast water therapy (n = 13)
and showers (n = 2). Several studies included additional
recovery interventions that included compression garments
(n = 4), saunas (n = 1), massage (n = 2) and active recovery
(n = 5). Control protocols included seated rest (n = 20),
thermoneutral water immersion (n = 3), nutritional intake
(n = 1), placebo (n = 1), stretching (n = 3), and several
groups evaluating response of more than one recovery intervention without a control group.
Studies used a range of times for immersion when
applying CWI including a total time immersed of 10 minutes
(n = 12), which included 7 studies applying 2 cycles of 5minute immersions and 1 study applying 5 cycles of 2minute immersions. Additional immersion times included
Figure 7. Forest plot for contrast water therapy vs. control in muscle soreness.
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Figure 8. Forest plot for cold water immersion vs. control in measures of fatigue.
a single 15-minute immersion (n = 2), 5-minute immersion
(n = 7) either as a single 5-minute immersion (n = 3) or 5
cycles of 1-minute immersion (n = 4). Temperatures for cold
water ranged between 5 and 158 C with most studies applying cold water between 10 and 128 C (n = 20). Hot/warm
water temperatures ranged between 38 and 428 C in most
studies (n = 13) applying CWT with immersion times of
between 1 and 3 minutes (Table 2).
Data collection time points included baseline, within
1 hour (n = 18), 24 hours (n = 18), 48 hours (n = 8), 72 hours
(n = 1), 96 hours (n = 2) and 7 days (n = 3), postexercise
stressor. Six studies included other data collection points.
Countermovement Jump
The results showing the effect of hydrotherapy as a recovery
modality, on countermovement jumps (CMJ), are displayed
in Figures 2 and 3. Overall, results for CMJ indicated that
CWI was beneficial for recovery of neuromuscular recovery
24 hours following the exercise stressor (p = 0.05, CI: 20.004
to 0.578). However, at all other time points, CWI did not
enhance neuromuscular recovery (1 hour: p = 0.39, CI:
20.202 to 0.514; 48 hours: p = 0.56, CI: 20.244 to 0.451;
72 hours: p = 0.38, CI: 20.360 to 0.954). Furthermore, results
for CMJ indicated CWT did not enhance neuromuscular
recovery at any time points following the exercise stressor
(1 hour: p = 0.07, CI: 20.004 to 0.863; 24 hours: p = 0.46 CI:
20.227 to 0.498; 48 hours: p = 0.39, CI: 20.191 to 0.489).
Best Sprint
The results showing the effect of hydrotherapy as a recovery
modality, on a one all-out maximal sprint test, are displayed
in Figure 4. When evaluating performance of all-out sprint
performance, CWI enhanced recovery 24 hours following
the exercise stressor (p = 0.02, CI: 20.056 to 0.801). However, overall results for one all-out maximal sprints indicated
that CWI had minimal effect on enhancing recovery as measured in one all-out sprint performance 1 hour, 48 hours, and
beyond 90 hours following the exercise stressor (1 hour: p =
0.07, CI: 20.039 to 0.873; 48 hours: p = 0.15, CI: 20.159 to
1.068; .90 hours: p = 0.15, CI: 20.093 to 0.591). When
evaluating the effect of CWT as a recovery modality with
a one all-out maximal sprint test, data from only one study at
each time point was available; therefore, a meta-analysis was
unable to be conducted.
Accumulated Sprint Time
The results showing the effect of hydrotherapy as a recovery
modality, on accumulated sprint time, are displayed in Figure 5. Overall, results indicated that at 24, 48, and 72 hours
Figure 9. Forest plot for contrast water therapy vs. control in measures of fatigue.
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Figure 10. Forest plot for cold water immersion vs. control in measures of creatine kinase.
following the exercise stressor, CWI was not beneficial in
enhancing recovery when evaluated with accumulated
sprinting (24 hours: p = 0.29, CI: 20.189 to 0.637; 48 hours:
p = 0.44, CI: 20.171 to 0.392; 72 hours: p = 0.07, CI: 20.062
to 1.209). No studies examining accumulated sprinting evaluated the effects of CWT.
Muscle Soreness
The results showing the effect of hydrotherapy as a recovery
modality, on muscle soreness, are displayed in Figures 6 and
7. Combined results for perceptions of muscle soreness, indicated that CWI did not enhance participants perception of
muscle soreness (1 hour: p = 0.20, CI: 20.192 to 0.920; 24
hours: p = 0.08, CI: 20.092 to 1.936; 48 hours: p = 0.41, CI:
21.632 to 4.011; 72 hours: p = 0.09, CI: 20.121 to 1.555).
Furthermore, as with the findings with CWI, CWT did not
enhance perceptions of muscle soreness, following exercise
stressor (24 hours: p = 0.12, CI: 20.233 to 2.082; 48 hours:
p = 0.25, CI: 20.999 to 3.803).
Subjective Measures of Fatigue and Effort
The results showing the effect of hydrotherapy as a recovery
modality, on participants’ subjective measures of fatigue and
effort are displayed in Figures 8 and 9. Combined results for
perceptions of fatigue indicated that CWI enhanced athletes’
perception of fatigue and recovery 72 hours following the
exercise stressor (p = 0.03, CI: 0.061–1.418). However, in
contrast, CWI did not enhance athletes’ perception of
fatigue and recovery at all other time points (24 hours: p =
0.44, CI: 20.264 to 0.611; 48 hours: p = 0.28, CI: 20.309 to
1.063; .90 hours: p = 0.16, CI: 20.240 to 1.422). As with
CWI at 72 hours, at 48 hours CWT enhanced athletes perceptions of fatigue and recovery following exercise stressor
(p = 0.04, CI: 0.013–0.942) but did not enhance perceptions
of fatigue and recovery 24 hours or 72 hours following exercise stressor (24 hours: p = 0.59, CI: 20.373 to 0.661; 72
hours: p = 0.08, CI: 20.082 to 1.408).
Flexibility/Range of Motion
Although flexibility and/or range of motion has anecdotal
support to indicate recovery, there was lack of studies to
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conduct a meta-analysis. Data from only 2 studies were
available for evaluation of each hydrotherapy intervention.
Biochemical Markers
A number of markers were used across studies including
creatine kinase (CK), interleukin-6 (IL-6), aspartate aminotransferase (AST), C-reactive protein (CRP), lactate
dehydrogenase (LDH), and lactate and pH. With the
exception of CK, a dearth of studies evaluating IL-6,
AST, CRP, and LDH were available for meta-analyses to
be conducted. The results showing the effect of hydrotherapy as a recovery modality on CK are displayed in
Figure 10. Overall, results for CK indicated that CWI did
not enhance clearance levels of CK 24 hours following the
exercise stressor (p = 0.06, CI: 20.009 to 0.658). There
were insufficient data available at additional time points
to conduct a meta-analysis beyond 24 hours with CWI.
Furthermore, there was insufficient data on CWT to conduct a meta-analysis at any time point (27,38,48).
DISCUSSION
This is the first systematic review with meta-analyses to
specifically investigate hydrotherapy as a recovery protocol
with well-trained, team sport athletes. Although a number of
reviews have been conducted on hydrotherapy and recovery, all have included considerable variation between training status and physiological stressors of participants. Overall,
results indicated that in enhancing neuromuscular recovery
following team sport, only CWI (24 hours) enhanced
neuromuscular recovery. However, benefits in neuromuscular recovery identified at 24 hours were not evident at any
other time point. In evaluating subjective measures, CWI (72
hours) and CWT (24 hours) enhanced perceptions of
fatigue, following team sport. However, neither CWI nor
CWT was identified as enhancing recovery of perceived
muscle soreness following team sport.
This systematic review with meta-analyses identified 23
articles from the sport science literature that investigated
hydrotherapy for recovery in team sport. Reflecting the
increasing amount of research into recovery, 15 of these
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articles were published after 2011. However, despite this
increase a paucity of scientific research into team sport
recovery still exists. Previously, the need to extend the period
of research in team sport recovery to beyond 48 hours was
identified (8). Despite this recommendation, only 6 of the 23
studies evaluated periods longer than the 48-hour period. As
team sport predominantly involves a cyclic week of competition and multiple training sessions, the effect of common
recovery interventions, specifically hydrotherapy, needs to
be evaluated beyond 48 hours.
Most studies evaluated the effect of hydrotherapy 24
hours following physiological stressor; only 3 studies
extended the research to 72 hours following; and only 3
studies extended research to 90 hours or beyond. In addition,
a number of studies evaluated extended time periods.
Extended time periods included the compounding effect of
3 and 4-day tournaments (38,48,39,47). Extending time
points included evaluating a number of interventions over
an AFL season (1), evaluating a 4-week period of a rugby
union competition and a weekly cycle of simulated rugby
union inclusive of training (23), and finally, an investigation
over several weeks of an NRL competition (55).
Limitations in study designs were also identified. Blinding
of participants in research is problematic, particularly with
hydrotherapy, leaving participants open to the placebo
effect. Unfortunately, blinding of participants from different
interventions is not possible. A randomized, crossover design
may aide against the placebo effect in some cases but not all,
specifically subjective measures of pain or fatigue (1,52).
The CMJ and one all-out sprint running performance are
routinely used as indices of neuromuscular performance (52).
It has been suggested that after exercise-induced muscle
damage, a decline in CMJ and sprinting performance is
a result of compromised neuromuscular function and neuromuscular efficiency (52). Across studies in this review, the
reliability of these tests was reported. However, validity of
the tests, to reflect recovery with well-trained team sport
athletes, was not.
Compromised neuromuscular function has been associated with a number of factors. These factors include
muscle activation and muscle coordination, as the nervous
system may facilitate changes in recruitment patterns
(3,45). With myofibrillar damage or disruption (25) the
nervous system would bypass the more severely damaged
muscle fibers, specifically fast twitch (45). This would then
bring about changes in recruitment patterns and the coordination of muscle activation (25). With the change in
muscle activation and coordination, a slowing of peak
velocity would result (29).
It has been proposed that the CMJ may not be sensitive
enough to evaluate recovery of power in well-trained
athletes (8,23,47). Authors speculated that well-trained athletes may have sufficient motivational drive to record near
maximal efforts in one off all-out tests (6). Others postulated
that the level of exercise-induced muscle damage would be
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less with well-trained athletes because of adaptation processes (23,47). Well-trained athletes would therefore have
a larger portion of functioning motor units and intact muscle
fibers allowing for near maximal efforts (47).
Although results indicated that CWI was beneficial for
recovery, it should be noted that at 1 hour and 24 hours
following team sport activity, irrespective of recovery
intervention, the power of athletes as measured by a CMJ
was still compromised. Athletes recorded below baseline
scores of 5–15% at 1 hour and 3–10% at 24 hours following
team sport activity. The benefits in recovery from both CWI
and CWT, during the first 24 hours, appear to be attenuating
the detrimental effects of team sport. However, by 48 hours,
irrespective of recovery intervention, control and hydrotherapy intervention groups had returned to within 2% of baseline scores for CMJ. Only 2 studies evaluated the
effectiveness of CWI and CWT in CMJ performance beyond
48 hours. In both studies, results were unclear as to whether
CWI or CWT provided any beneficial effect in restoring
CMJ performance (23,48).
In evaluating recovery with one all-out maximal sprinting
performance, CWI (24 hours) was beneficial. However, as
with the CMJ, all participants recorded decrements in scores
for sprinting performances irrespective of recovery intervention. The reported benefits of CWI at 24 hours were in
attenuating the decrements in all-out maximal sprinting
performances. Despite the common use of CWT in team
sport recovery, only one study evaluated the effects CWT
and one all-out sprinting performance. Meaningful evaluation through meta-analysis of CWT was therefore not
possible in this review.
This review noted a dearth of research into recovery of
sprinting performance beyond 24 hours was noted. In
evaluating hydrotherapy and sprinting performance, there
were data from only 2 studies to evaluate the effect of CWI
at 48 hours following team sport with unclear results
identified. Three studies evaluated the effect of hydrotherapy
on sprinting beyond 48 hours following team sport
(23,24,34). However, in each case, different time points were
assessed. The additional time points evaluated were 90 hours
after (48); 96 hours after (24,48); and 144 hours after (23),
discounting any feasibility of conducting a meaningful metaanalysis.
This systematic review and meta-analyses indicated that
within 24 hours following team sport, CWI was beneficial in
attenuating the detrimental effects of fatigue on neuromuscular function. However, beyond 24 hours, the beneficial
effect of CWI in recovery of neuromuscular function was
unclear when evaluated with either a CMJ or one all-out
sprint. Several studies evaluated neuromuscular function
through electromyographic (EMG) measurements (41,42).
Due to methodological differences, additional metaanalysis evaluation was not possible. However, each study
reported that CWI offered greater benefits in recovery of
neuromuscular function of the knee extensors (42).
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However, these results need to be viewed with some level of
caution. It has been suggested that functional tests best
reflect recovery of performance in team sport (8), whereas
these studies using EMG used a seated knee extension testing protocol. Furthermore, hip extensors and knee flexors
have been previously identified as the primary movers in
team sport activities (13,15). Therefore, further research is
required to confirm that a reported recovery of the knee
extensors (42) can be duplicated with a similar recovery
response of the hip extensors and/or knee flexors. In future
research, EMG evaluation of the hip extensors and knee
flexors while performing functional exercises may provide
a greater insight into the effectiveness of either CWI or
CWT in facilitating recovery in neuromuscular function with
well-trained team sport athletes.
Finally, results from across the review indicated that,
irrespective of the recovery intervention, neuromuscular
function returned to near baseline levels within 48 hours of
team sport activity. This may suggest that the effectiveness of
such intervention strategies in enhancing recovery before the
next competition is limited.
Perceptual measures of muscle soreness and fatigue are
widely accepted tools in the monitoring of athlete’s recovery.
It has been proposed that athletes will instinctively regulate
intensity (9) and govern physical workloads (40) according
to their perceptions (9,40). Individually, a number of studies
in this review did report CWI and/or CWT to be more
beneficial in alleviating perceptions of muscle soreness during the acute response (17,22,23,27,39,44,49). Indications
from the meta-analysis were that neither CWI nor CWT
was beneficial in attenuating perceived muscle soreness.
The reported beneficial effects of CWI and CWT with
muscle soreness can be linked with an acute analgesic affect
(16). The mechanisms associated with the acute analgesic
effect of CWI and CWT center primarily on the reduction of
muscle soreness through pain inhibition and lower pain sensation (16,29,44,49). The effect of CWI reduces nerve conduction velocity (16,29,49), which in turn reduces muscle
spindle activity allowing the muscle to relax, and alleviating
the perception of pain (16,49).
There have also been additional mechanisms attributed to
lower perceptions of muscle soreness and fatigue after CWI
and/or CWT. The effect CWI and CWT has on changes in
skin temperature has been associated with enhanced perceptions of recovery (31). Authors discussed the relationship
between changes in skin temperature and human perception
of fatigue and comfort (31). They postulated that the perception of recovery after CWI and CWT is a result of an increase
in skin temperature postimmersions, and that the sensation of
skin warming enhances perceptions of recovery (31). Alternatively, immersion therapy was associated with partial weightlessness and hydrostatic pressure, both inducing inhibitory
mechanisms toward muscle contractions, which allows muscle to relax, reducing stress on muscle, and subsequently
reducing perceptions of muscle soreness (39).
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Although it is believed that hydrostatic pressure generated
during water immersion will impact on recovery mechanisms (19), it was not evident when CWI and thermoneutral
water immersion (TWI) were evaluated jointly (48). As CWI
was identified to be more beneficial than TWI in enhancing
perceptions of recovery (48), this would suggest that the
underlying mechanisms enhancing perceptions of recovery
are associated with the cold temperature rather than hydrostatic pressure.
The authors also postulated that CWI and CWT benefited
perceptions of muscle soreness through the reduction of
inflammation after exercise-induced muscle damage (1). The
reduction in inflammation has been attributed to a number
of mechanisms. Cold therapy has been reported to reduce
edema through vasoconstriction altering lymph evacuation
and lymph flow as well as blood flow (38,49). Reducing
edema would result in a reduction in pressure on pain receptors (9,38,49) and reduced cell necrosis alleviating muscle
soreness (27). Furthermore, reduced cellular permeability
and cellular diffusion has been associated with vasoconstriction (44) reducing both neutrophil migration (27) and
inflammation, subsequently inducing inhibitory influences
on pain (44).
Within this review, it is probable that CWI and CWT
only offered an acute analgesic effect on muscle soreness,
as the beneficial effects toward muscle soreness were not
evident at later time points. Although a number of authors
postulated that benefits of either CWI or CWT within 1–2
hours postimmersions could be expected to occur at later
time points, these beneficial effects of CWI or CWT were
not evident 24 hours following (38,41,42). A rebound effect
in perceptions of muscle soreness from the CWI and CWT
groups were identified following a basketball tournament
(39). If CWI and CWT had an effect on the reported physiological mechanisms, including reduced edema, reduced
cellular metabolism, reduced diffusion, and reduced neutrophil migration, the beneficial effects would be expected
at later time points. In addition, the previously discussed
link between perceptions of pain and fatigue and intensity
regulation was not evident in this review. Individually,
a number of articles did report greater beneficial effects
of CWI and/or CWT with perceptual measures of recovery; however, no beneficial effects in performance measures were reported (1,8,9,23,31,32,48).
Although it was previously suggested repeat effort
testing may be more appropriate in assessing recovery
(8), there has been a subsequent lack of research. In all, 7
studies were identified in this systematic review that evaluated repeat effort performances, which included actual
game performance (6,47), simulated game performance
(6,21,47), and sprint repeat performance (9,27,39). A complete meta-analysis could not be conducted due to variations in study protocols, which included variations in
running speeds, sprinting distances, recording of results
(seconds or meters). Furthermore, as with neuromuscular
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performance and subjective measures, only 2 studies evaluated beyond 48 hours (21,48).
Two of the studies did report some notable findings (6,21).
Although reporting differences in overall running distances
between groups, the volume of high-intensity running
showed no differences (6). This may provide an example
of players regulating intensity when fatigued, as previously
discussed. In attempting to conserve energy for highintensity activities associated with soccer, players reduced
their levels of incidental movement throughout the second
game. This led the authors to postulate that hydrotherapy
was beneficial for recovery when consecutive games of football were played (6).
Additionally, when evaluating performances between
2 simulated games of rugby union, athletes performed allout maximal sprints in times equal to or improved above
baseline scores (21). However, when athletes performed
multitask rugby-specific actions, performances in the second simulated game were (although not significant) below
baseline measures (21). This may in itself reflect the complexity of measuring fatigue and recovery with well-trained
athletes. The level of exercise-induced muscle damage may
not be severe enough, because of adaptations bought about
through training. As such, when using well-trained athletes, these athletes may have significant motor units functioning to record near maximal efforts in all-out maximal
tests (21). As has been previously recommended, repeat
effort testing, which reflects actual game requirements
may be better suited to assess recovery for well-trained
team sport athletes (8).
The studies reviewed in this article that evaluating biochemical markers of muscle damage and inflammation
indicated that team sports elicit a high level of muscle
damage and inflammation, as evident with significant
increases in biochemical markers. Although evaluating
recovery biochemical markers of both muscle damage and
inflammation are routinely assessed, this review highlights
the paucity of research evaluating biochemical responses to
hydrotherapy and recovery from team field sport. The
review identified that CK was the most commonly used
biochemical marker evaluated and the only marker with
sufficient data to apply a meta-analysis. From the metaanalysis, the overall effect of both CWI and CWT was
greater in reducing CK levels at 24 hours after than control
groups; no other time points had sufficient data available to
conduct meta-analyses. In addition, there were insufficient
data across the other biochemical markers, including AST,
myoglobin, CRP, IL-6, LDH, and Fatty Acid-Binding Protein (FABP) to conduct meta-analyses.
Despite a large overall effect in reducing CK levels,
individual research papers from within the review offered
conflicting results. The beneficial effect of CWI and/or
CWT in reducing CK levels was reported by several papers
(12,20,32), whereas no beneficial effect of CWI and/or CWT
in reducing CK levels was reported in other studies (3,42,48).
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The conflicting results may be related to the time course of
peak CK levels. Most time course responses evaluated were
less than 48 hours, and although 1 study reported peak CK
levels at post-24 hours (18), peak CK levels have been reported to generally occur up to 96 hours postphysiological
stressor (34). The conflicting results may reflect the time
frames of studies missing peak CK levels. Extended time
periods of research would be required to truly evaluate the
effect CWI or CWT has on CK levels.
In addition to the conflicting results into the efficacy of
CWI and/or CWT in enhancing clearance of biochemical
markers discussed, conflicting positions have been raised by
a number of authors. Initially it was stated that enhanced
clearance of CK after rugby union reflected enhanced
recovery (18), in contrast, changes in intracellular proteins
in venous blood were merely a reflection of increased CK
clearance without indicating recovery (44). Importantly,
opposing positions were identified in relation to biochemical
markers and performance. Authors stated that there was no
significant correlation between either muscle soreness or
performance capabilities and plasma concentrations of either
CK or CRP (27), whereas in contrast it was reported that
reduced CK levels indicated recovery (18). It has also been
postulated that the acute elevations of myoglobin and FABP
compared with the sustained elevation of CK made them
a more effective marker (38).
This systematic review identified that team sport does
elicit high levels of muscle damage and inflammation,
whether in a contact or noncontact sport. In addition, when
multiple days of team sport competition and/or training are
conducted, levels of muscle damage and inflammation will
be compounded (38,48). Therefore, the importance of recovery after competition and training cannot be overstated.
However, there is still a dearth of research evaluating CWI
and CWT and biochemical markers, specifically beyond 48
hours, and therefore the efficacy and utility of such therapies
remains unclear. The conflicting results discussed above fail
to provide a definitive answer in relation to the beneficial
effects of either CWI and/or CWT on the subsequent clearance of biochemical markers and enhanced recovery.
In response to previous commentary (19), this review
focused on highly trained team sport athletes. Despite
narrowing the focus of the review to well-trained athletes,
it is accepted that different team sports still have variations to physical and psychological strains. Although
most team sports include contact/collisions, the 2 rugby
codes have a higher incidence of contact, eliciting higher
degrees of muscle trauma (14,15,18,52), Whereas both
football and AFL have greater physiological and biochemical loads placed on athletes as a result of the greater
distances covered in running in competition games
(6,8,27,48). With small court games such as basketball
and netball, athletes are required to perform a higher
number of high explosive jumps and rapid changes in
directions, again eliciting variations in physiological loads
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Recovery From Team Sport
(9,31,38). As postulated by authors within this review,
responses to recovery may be highly individualized
between athletes and between sports (19).
CONCLUSIONS
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This systematic review with meta-analysis has confirmed
well-trained team sport athletes undergo high levels of
physiological, psychological, and mechanical strain, leading
to fatigue, through competition and training. In addition,
that when competition and/or training occurs on successive
days, there is a compounding effect of the physiological,
psychological, and mechanical strain, indicating the presence of residual fatigue (21,38,48). Therefore, the importance
placed on appropriate recovery is not misplaced. Although
CWI and CWT were beneficial in attenuating decrements in
neuromuscular performance 24 hours following team sport,
the indications of this systematic review are that those benefits were not evident 48 hours following team sport.
However, the beneficial effects of CWI and CWT and the
athlete’s improved perceptions of fatigue were supported
with the meta-analysis conducted within this review. The
authors postulated that greater perceptions of recovery
may extend beyond the timeframes evaluated. Those greater
perceptions of recovery may provide athletes with a better
frame of mind enhancing the athlete’s physical performance
at training and competitions. However, at present, supporting evidence that improved the athlete’s perceptions of muscle soreness and fatigue will enhance performance at training
is not available, or was it supported by the pooled evidence
within this review.
Recommendations
From this review, hydrotherapy interventions to attenuate
the detrimental effects of team sport activity should use the
following protocols. The CWI should incorporate 2 3 5 minute immersions of 108 C with 2-minute seated rest in ambient temperature between immersions. The CWT would be
advised to use a protocol incorporating CWI with 108 C, and
warm/hot water immersions at 38–408 C. Total immersion
times for CWT should total not less than 10 minutes with
similar immersion times for both cold and warm/hot used.
Recommendations for immersion of whole body (19) (head
out) should be used, or ensure as much body is immersed as
facilities allow.
As a scarcity of research into recovery from team sport and
hydrotherapy still exists, further research evaluating hydrotherapy for recovery from team sport is required. Research
encompassing team sports should be directed toward various
sports, including, but not limited to, AFL, basketball, football,
netball, and both codes of rugby. It is paramount that future
research incorporates both competition and training and that
research focuses on the period 48 hours following team sport
activity. Only by extending the research beyond the initial 48
hours can the compounding effects of residual fatigue, and
subsequent benefits of hydrotherapy be fully evaluated. In
1458
the
addition, hydrostatic pressure generated with hydrotherapy
and its effect on recovery should be evaluated with the use of
thermoneutral water immersion. Although temperatures for
TWI have been previously defined as 34–368 C (51), authors
who have used TWI in this review have used temperatures of
approximately 258 C. Investigations of the 2 different temperature ranges for TWI is required to clarify the optimal temperature for TWI.
Physical performance measurements including either game
or simulated game performances and functional performance
tests should be used. Furthermore, functional tests need to be
specific to the sport being investigated. It may provide greater
insight into neuromuscular function recovery to incorporate
the use of EMG while performing functional performance
tests. The use of EMG may aide in the identification of altered
motor unit recruitment with well-trained athletes.
Perceptual measures continue to be an important tool in
monitoring an athlete’s response to games, training, fatigue,
and recovery. With this in mind, the association between
perceived recovery and enhanced performance in games
and/or training needs additional exploration. Future research
should include the monitoring of athlete’s perceptions of
fatigue/recovery and the athlete’s physical performance in
competition games and at successive training sessions.
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