冷冻疗法在运动医学领域的研究进展综述

张晓亚，高 颀

（北京体育大学，北京 100084）

ZHANG Xiao-ya，GAO Qi

（Beijing Sport University, Beijing 100084,China）

冷冻疗法在运动医学领域的研究进展综述

张晓亚，高 颀

（北京体育大学，北京 100084）

运用文献资料法以 “cryotherapy”、“cryostimulation”、“Cold-water immersion”、“ice pack”、“hydrotherapy”、“cooling”为关键词在PubMed、EBSCO等外文数据库，百链云中外数据库和中国知网（CNKI）中文数据库进行检索，通过系统的文献检索与分析，对局部冷冻疗法进行介绍，经过检索和筛选，共计81篇中英文文献被录入，总结其对机体的影响以及在运动医学领域的研究进展。结论：冷冻疗法在运动医学领域的突出贡献值得运动和康复工作者关注，尤其在运动损伤治疗与康复、运动疲劳消除、体能恢复及运动表现方面的有利影响已得到了广泛认同和应用。

冷冻疗法；损伤；延迟性肌肉酸痛；疲劳；本体感觉

ZHANG Xiao-ya，GAO Qi

（Beijing Sport University, Beijing 100084,China）

冷冻疗法即冷疗（Cryotherapy）是将比人体体温低的诸如冷水、冰、蒸发冷冻剂等物理因子作用于患部而进行治疗的一种物理疗法[1]，主要包括全身冷冻疗法（Whole Body Cryotherapy,WBC）和局部冷冻疗法（Local Cryotherapy）。本文以 “Cryotherpy”、“Cryostimulation”、“Cold-water Immersion”、“Ice Pack”、“Hydrotherapy”、“Cooling”为关键词在PubMed、EBSCO、百链云和中国知网（CNKI）等数据库进行检索共计81篇中英文文献，主要针对局部冷冻疗法进行阐述（下文所述的冷冻疗法如没有特殊说明即指局部冷冻疗法）。

在医学领域，国外应用冷冻疗法已有很长的历史[2]，西方“医学之父”希波克拉底 （公元前460－公元前377年）曾建议用冰或雪作为一种治疗手段。冷冻疗法在我国是70年代兴起的，20世纪70年代后期至80年代，在全国许多医院形成热点[3]，当时的应用和研究主要集中在五官、口腔、皮肤以及肿瘤科。近些年来，欧美和日本等国家把冷冻疗法运用于运动员日常训练后的身体恢复，并取得很好成效[1]，此后，冷冻疗法作为一种重要的恢复手段出现在运动医学领域。

1 冷冻疗法介绍

1.1 冷水浸泡（Cold-water Immersion，CWI） 冷水浸泡方法简单易行、温度能够得到有效控制、安全性能高、高效且具有持续效应[4]，因此，CWI是冷疗中最普遍的治疗方式[5]。Nathan G在比较冷水浸泡、冷热交替浸泡、热水浸泡和热中性水浸泡4种不同形式的影响时证明，冷水浸泡和冷热交替浸泡在促进疲劳消除上更有效[6]。

CWI一般指人体特定部分浸泡在温度低于15℃的冷水中，利用水温的落差对机体产生冷刺激，引起神经肌肉的生理学改变。尽管达到最佳治疗效果应采用的温度还没有统一[7－8]，但通常人们认为15℃为人体冷痛感的起始温度，其中CWI的温度通常建议为10～14℃。持续时间应根据治疗情况而定，如：Nathan G认为，5～15min、10～15℃的冷水浸泡可增强疲劳恢复过程中的运动表现能力[6]。

1.2 冰敷和冰按摩 利用冰袋、冰背心和冰疗仪器等对人体的局部进行挤压与按摩，可以降低局部的组织温度，降低急性损伤的炎症反应，减少局部组织液的渗出，降低疼痛感。冰敷被广泛应用于控制炎症、疼痛和肿胀，是急性闭合性损伤时的紧急处理方法之一，且为避免因长时间冰敷造成的机体代谢水平下降继发缺氧性损伤，通常建议冷疗时间不超过20min。Kuo CC等人认为[9]，对于软组织损伤而言，10min是最佳冰敷时间，但同时要兼顾患者的伤病情况，随时调整干预时间。

2 冷冻疗法对机体的影响

2.1 冷冻疗法对血管和血流的影响 冷冻疗法可以刺激治疗部位血管收缩[10]，使血流速度和红细胞流速降低、白细胞滚动和粘附数量降低[11－12]，从而降低炎症反应。Thorlacius H、Smith TL也分别证实损伤发生后，局部冷冻疗法不会影响小动脉的舒张功能[13]，但可引起小动脉收缩[14]。闭合性软组织损伤后，功能性毛细血管密度明显降低，微血管的通透性显著增加，此种改变可经过20min的局部冷疗恢复到未受伤时的水平，使营养灌注、物质交换等功能恢复正常[11]。Westermann S等人也认为[15]，冷疗可以完全恢复由于肿瘤坏死因子-α（TNF-α）引起的毛细血管功能障碍。其次，冷冻疗法可通过静水压和水温双重作用促进机体疲劳恢复，静水压可提高心输出量、改变肌肉血流、加快代谢废物的移除[16-18]，除此之外还可降低氧、营养物质和激素运输至疲劳肌肉的时间，加快营养供应，促进疲劳恢复[16－17]。

2.2 冷冻疗法对细胞代谢和细胞因子的影响 冷冻疗法可以影响损伤恢复过程中重要的细胞反应以及一些生理活动的发生，包括：减轻肿胀、缓解疼痛、减少细胞对氧的需求、降低代谢活动[19－20]、减慢神经传导速率、提高疼痛阈值和疼痛耐受程度[17]，以及减少肌肉坏死和细胞凋亡[11，12，15,22,23]。其次，冷冻疗法可以通过增加抗炎性细胞因子释放，同时抑制促炎性细胞因子的释放，减轻炎症反应。进行冷疗后，白细胞介素-1β表达降低、转化细胞生长因子-β1表达升高，以此减弱无菌性炎症反应，加速肌纤维修复，并且持续性冷疗效果优于间歇性冷疗效果[24－25]。

2.3 冷冻疗法对神经肌肉控制的影响 冷冻疗法会抑制神经肌肉的传递[26]、降低肌梭敏感性[27]、降低肌肉感知位置的能力[28]、增加组织硬度[28]；还可通过降低横桥之间的交互作用，影响酶促反应释放能量的过程，从而降低肌肉表现[29—30]。再者，冷冻疗法可短时改变肌肉组织反射性抑制的出现，恢复运动神经元池的可用性[31]，因此可改变康复训练过程中受伤关节周围的肌肉没有办法完全激活的状况。

3 冷冻疗法在运动医学领域的应用

3.1 冷冻疗法是急性闭合性软组织损伤的常见处理措施 在运动医学领域的治疗方法中，除了暂时制动和应用止痛、抗炎药物[32]，为了加快闭合性软组织损伤的康复进程，常用的措施还包括局部冷疗[33－34]。肌肉拉伤是急性闭合性软组织损伤中常见的一种运动损伤，常常发生在休闲性体育或专业体育运动中[35－37]。2007年12月12日～14日，在英国体育局举办的肌肉拉伤相关问题讨论会上，通过热烈的讨论专家们一致认为，冷疗是肌肉损伤早期有效且重要的干预方式[38]。Mark A等人认为[39]急性骨骼肌损伤时，可利用冰对组织的冷却作用，降低受伤组织的代谢率，从而治疗损伤，并发现冰敷配合加压包扎在降低肌肉温度上的效果强于只做冰敷。Gregson W 和Mawhinney C也认为冷疗对治疗运动性肌肉损伤和损伤后的康复过程有促进作用，且冷刺激的温度越低效果越明显（8℃和22℃对比）[40－41]。

由此可知，局部冷疗是闭合性软组织损伤早期的有效处理方法，可通过抑制炎性反应、减轻肿胀和疼痛、降低代谢活动从而加快损伤组织恢复。在临床应用中，应根据肌肉损伤的性质、损伤类型、损伤深度以及表层脂肪的厚度不同而做出相应改变[42]。

3.2 冷冻疗法在改善运动性肌肉损伤中的作用 运动所致的肌纤维微细损伤是诱发运动性肌肉损伤的（Exerciseinduced Muscle Damage，EIMD）主要原因[43]，肌小节的破坏可促使细胞间粘附因子-1 （ICAM-1）向损伤组织迁移，同时中性粒细胞、淋巴细胞、单核细胞产生的促炎性细胞因子和自由基增多，进而加重肌肉损伤[44]，这也是发生延迟性肌肉酸痛（Delayed Onset Muscle Soreness，DOMS）的诱因之一[45]。如何有效地缓解DOMS是运动领域研究的热点，在众多的方法中冷疗占据了重要的 地 位。Bleakley C[45]、Leeder J[46]、Jeremyi I[47]和Kuligowski L I[48]均认为，冷水浸泡可缓解训练后出现的DOMS症状。训练过程中肌小节的破坏会促进炎症反应发生以及细胞内肌酸激酶（CK）的释放[49－50]。TNF-α水平升高是大强度抗阻训练后组织修复过程中发生的重要促炎性反应[51]，促炎性进程对肌肉修复和再生很重要，减轻或阻断炎症反应同样会阻碍或延缓修复进程[52]。Townsend J的实验结果显示[53]，与对照组相比CWI不能降低修复过程中TNF-α的释放，说明CWI不会对炎症反应进程产生不良影响。另外，Banfi G[54]和Eston R[58]的实验显示，冷水浸泡后血清总CK浓度下降，表明冷水浸泡有助于降低运动引起的肌肉微损伤。

然而，冷疗对DOMS影响的研究至今没有定论，方法学的差异是造成研究结果不一致的重要原因[45,46,55,56]。Peluaga等人[57]对受试者进行每天1次45min、持续3d的冰袋冷敷后发现，与不经过任何处理的对照组相比，冰袋冷敷不能够降低DOMS引起的压痛反应，出现此结果的原因可能是：1）冰袋的作用范围较小；2）治疗次数少，从而造成治疗效果不明显。除此之外，Eston R和Peters D的实验也没有证明CWI对于肌肉压痛和肌肉力量的丢失有积极影响[58]。Sellwood K的相似实验证实，对于未经任何训练的人群来说，冷水浸泡不能改善DOMS反应[59]，究其原因可能是此实验在对受试者进行离心训练诱发肌肉损伤的程度太轻，因此对冷水浸泡的反应不敏感。另外，Paddon-Jones DJ[60]、Naomi J[61]、Howatson G[62]、Jakeman JR[63]4人不同的实验也得出一致的结论，认为冷疗对于改善肌肉酸痛和肌肉微损伤恢复上没有积极影响。

引起实验结果不一致的原因有很多，受试对象运动水平、造模过程组织的损伤程度、冷疗方式、冷疗温度、持续时间、冷疗频率、冷疗部位等因素都会对冷疗的效果产生影响。总体而言，学者们还是倾向于冷疗对运动引起的肌肉损伤有积极的恢复作用，尤其适用于大强度运动训练后可能引起延迟性肌肉酸痛，因此运动训练后进行冷冻治疗还是被提倡的[64]。

3.3 冷冻疗法对肌肉疲劳恢复的影响 肌肉疲劳状态下继续进行运动是运动损伤的重要原因之一。因此，尽可能高效地促进肌肉做功能力的恢复，是运动领域关注的一个重点。很多研究证明，冷冻疗法可降低疲劳反应、促进疲劳恢复[6,65－67]。Nathan G在比较冷水浸泡、冷热交替浸泡、热水浸泡和热中性水浸泡不同方式对机体的影响时发现，冷水浸泡和冷热交替浸泡在促进疲劳消除上更有效[6]。与此同时，Gregson W[68]也认为冷水浸泡不会降低肌糖原的再合成速率，同样支持冷冻疗法可作为一种促进疲劳恢复的积极手段。冷水浸泡可降低机体热应力反应[69]，对于在热环境中训练的运动员来说，CWI可通过冷却组织、恢复运动表现力、维持高强度耐力性运动的表现能力[70－71]。Roberts LA等人[72]经过实验证实抗阻训练后进行CWI可提高长时间运动训练的适应性，有利于运动员在随后的训练组中完成更多工作。Rowsell GJ[73]也认为高强度间歇跑后进行5次60s浸泡60s休息的冷水浸泡有助于增强随后的循环间歇训练表现。

尽管多数研究赞同冷疗在促进疲劳恢复中发挥着积极作用，Kuligowski LA[48]仍提出了不同的观点，认为冷水浸泡和冷热交替浸泡均不能促进肘关节屈肌群最大随意收缩的恢复。之所以得出此结论，可能的原因有：1）受试者没有经过系统的训练；2）实验中进行的不是全身运动性训练和全身冷水浸泡，而只是单纯地针对上肢，所以冷水浸泡的积极效果没能够显现出来。

3.4 冷冻疗法对肌肉激活和运动表现的影响

3.4.1 冷冻疗法对肌肉向心收缩能力的影响 Herrera E[74]在研究中发现3种不同冷疗形式（冰袋冷敷、冷水浸泡、冰按摩）均可使感觉神经传导速度和运动神经传导速度减慢，复合动作电位持续时间和复合动作电位延迟时间变长，从而使肌肉表现能力降低。其中，冷水浸泡对感觉和运动速度的影响最明显，对动作表现的影响也最大。而后，Vieira A[75]也比较了冰袋冷敷、冷水浸泡2种不同冷疗方式对肌肉表现和肌肉激活的影响，认为冰袋冷敷和冷水浸泡都会降低肌肉向心收缩的肌肉激活能力和表现能力。

3.4.2 冷冻疗法对肌肉等长收缩力量的影响 Jeremyi I认为[47]冷水浸泡可抑制训练后出现的等长肌力的丧失。Ranatunga的研究发现[76]，25℃冷敷可增加肌肉8%的等长收缩力量，但低于25℃的冷敷会降低等长收缩肌力，这种肌力的下降和冷敷强度相关。冰袋冷敷可增加等长收缩的力矩，加大等长收缩力量。等长收缩力量的增加可能是因为适度冷疗提升了高阈值运动单元募集率[74]。因此，冷冻疗法在静态肌肉收缩的运动项目训练前或比赛前是提倡使用的。

3.4.3 冷冻疗法对爆发力的影响 温度可以通过影响肌肉粘滞性和弹性进而影响肌肉的收缩和放松能力[77—78]。人体运动时肌肉的最适温度为38℃[79]，在达到最佳温度前，肌肉的收缩能力随温度的升高而增强[77]。冷冻疗法可以使肌肉反应速度和收缩速度降低、形态改变、硬度增加[80]。Beelen A认为冷水浸泡会影响运动员的下肢爆发力，表现为垂直纵跳能力下降了23%[81]。研究发现，冷疗在肌肉表现和肌肉电活动中存在剂量效应，温度越低对肌肉表现的影响越明显[27]，等张收缩相比等长收缩运动而言更易受到冷疗的抑制，高速率运动比低速率运动更易受到制约[31，82]。Parouty J等人[83]对10名顶级游泳运动员2次100m比赛间歇进行5min水温为14℃的冷水浸泡，发现冷疗组第2次游泳冲刺能力明显下降，说明在连续训练或比赛的短暂间歇期采用冷冻疗法会降低机体的爆发力。Crowley G[84]和 Sleivert G[85]的实验证实运动前进行下肢冷水浸泡或冰背心预冷却，会降低最大无氧功率和平均无氧功率的输出，降低机体的爆发力和速度耐力。这种无氧能力的下降主要源于组织的温度降低抑制了肌肉的收缩能力。然而，短时间（6～7min）的热身可以使肌肉回温，抵消预冷处理对机体无氧代谢产生的负面影响。

以上研究结果引发运动医学工作者深思，运动员接受冷疗处理后立即回到赛场上是否可取？冷疗虽然可起到镇痛作用，但同样会降低运动能力和本体感觉[86]，更容易造成二次损伤，所以对于动态运动项目的运动员来讲，冷冻疗法的使用要非常谨慎。

3.4.4 冷冻疗法对耐力的影响 Duffield R和 Marino F[87]的实验显示，对在热环境中训练的运动员训练前进行身体预冷却处理（冰背心或冰水浴）可提高机体次最大强度运动表现。相似的，Uckert[88]对长跑运动员进行20min预冷处理（冰背心）后，发现跑步能力提升。由此可见，运动前进行局部预冷处理，对次最大强度或耐力性运动有积极影响，可通过提高机体承受热应激的能力增加机体运动表现[89－90]。预冷处理可降低训练前身体的温度，提高代谢产热的效率，延长身体到达极限温度的时间，因此这种方法对于加强耐力性和抵抗性运动的运动表现有积极作用[75]。

这些结果提醒我们，选择冷疗方法要谨慎，除了要考虑到冷疗形式、冷疗时间，也要考虑到冷疗的时机，并结合训练或康复过程中肌肉将要工作的类型进行取舍。研究证明，对于静力性运动项目或耐力性项目，运动前进行冷疗干预可增加等长收缩肌力，提高运动表现。但不建议在动态运动项目或爆发力运动项目训练前或比赛前应用冷冻疗法，因其会降低肌肉收缩速率、降低肌肉激活及肌肉表现，从而影响运动成绩。

3.5 冷冻疗法在关节源性肌肉抑制的应用 关节损伤后会出现肌肉组织反射性抑制，这种抑制会通过破坏正常的肌肉功能来阻碍正常的关节功能[86]。关节稳定性发生改变后会反过来加重关节损伤，如此形成恶性循环，因此，关节源性肌肉抑制（Arthrogenic Muscle Inhibition,AMI）是一个亟待解决的临床难题。冷冻疗法的目的在于短时改变这种反射性抑制，在康复训练过程中，保证患者运动神经元池的完整性，从而改变患者受伤关节周围的肌肉没有办法完全激活的状况。

起初，人们认为损伤后疼痛感受器被激活从而抑制了肌肉功能，但后来发现，疼痛消失后AMI依旧存在[91-95]。Rice D等人的实验结果显示，膝关节积液后股四头肌激活受到抑制（力矩明显减小），但经过20min的冰袋冷敷后，抑制程度明显降低（力矩相比对照组增加）。Hopkins J的实验虽与Rice D选取的参考指标不同，但结论相同，均认为冷冻疗法可以克服机械感受器感觉信息的改变，恢复运动神经元池的可用性[31]。近期研究证据表明，膝关节或踝关节的冷敷可分别促进股四头肌和比目鱼肌发挥功能[31,95－99]。冷冻疗法在避免肌肉训练过程中出现平台的同时增加肌肉重新获得功能的可能性[34]，这种现象的存在为康复工作者提供了一个信息，即肌肉训练前可先进行20～30min的冷冻疗法[31,95,97－99]。

3.6 冷冻疗法对本体感觉的影响 在预防损伤和损伤康复过程中，本体感觉的作用尤为重要，常见的急性踝关节扭伤和膝关节的损伤与本体感觉的缺失息息相关[100－101]。Joseph T[102]在冷冻疗法对关节位置觉影响的系统综述中提到，入选的7篇文献里，3篇研究认为冷冻疗法后关节位置觉感知下降、错误信息的感觉增加，另外4篇认为冷冻疗法对关节位置觉没有影响。研究的关节部位不同（肩、膝、踝）、冷疗形式不同、评定标准或技术不同等是造成冷疗效果不同的重要原因。Haupenthal D认为[103]本体感觉的好坏可反映在机体对力的大小的感知能力上，冷敷后踝关节背屈肌对等长收缩肌力的感知明显下降。由于冷冻疗法对关节本体感觉影响的相关研究证据不足且结果不一致，所以为了得出明确的结果，更加深入地研究还应继续。尽管研究结果不一致，但仍能给我们一个提示，即运动员在进行动态运动（如旋转、变向、落地、跑动）项目时，运动前的冷疗要谨慎。

4 总 结

冷冻疗法是低温医学中的一部分，有其独特的优势，低温可使人体细胞的生命活动减慢或暂停以及产生自身免疫，因而尽管新的技术不断兴起，但绝不会取代冷冻治疗在运动医学领域中扮演的角色。由于冷冻疗法的效果受冷疗方式、持续时间、使用频率、冷疗温度以及应用时机等因素的影响，因此在选择此治疗手段时应在明确治疗目的的基础上选择治疗方式，为了更好地指导实践，有必要探索出一个最优的治疗策略供康复工作者参考。

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Review of Cryotherapy Study in Sports Medicine

Adopting method of literature consultation, taking "cryotherapy", "cryostimulation", "cold-water immersion", "ice pack", "hydrotherapy" and "cooling" as key words, searching through foreign language database like PubMed and EBSCO, Chinese data base like Blyun and CNKI, this thesis introduces partial cryotherapy through systematical information retrieval and analysis, summarizes its effect on body as well as study progress . Totally 81 Chinese and English articles are selected. Conclusion: outstanding contribution of cryotherapy in sports medicine feld should be emphasized by sports and rehabilitation staff, especially its positive infuence on cure and rehabilitation of sports injury, sports fatigue elimination, physical energy recovery and sports performance should be widely recognized and applied.

cryotherapy; injury; delayed onset muscle soreness; fatigue; proprioception

G804.5

A

1004 - 7662(2015 )04- 0082- 08

2015-03-01

张晓亚，硕士研究生，研究方向：运动损伤的评估、治疗和预防。