Although whole-body cryotherapy is a fantastic experience for most people, there are some people for whom cryotherapy is not safe. Although in this country, whole body cryotherapy and cryostimulation is available in gyms and medispas, in many countries it is regarded as a medical therapy. Hence, whole-body cryotherapy should follow strict guidelines and indications.
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Certain medical conditions prohibit the use of cryotherapy. These include:
Cryoglobinaemia – this is a medical condition whereby patients have a large number of cold-sensitive antibodies. These proteins become insoluble when the body temperature drops and clump together causing restricted blood flow.
Raynaud’s syndrome – a condition where blood flow to the extremities is unusually cold sensitive.
Claustrophobia – as although the window of the chamber can be open and the door can be pushed open easily the chamber is still a confined space.
Hypothyroidism – this condition increases sensitivity to cold temperatures. Cardiovascular system disease – people unstable angina, peripheral vascular disease and cardiac failure would be unsuitable for whole body cryotherapy as it causes constriction of the peripheral blood vessels
Acute respiratory tract disease – these may be worsened by exposure to cold air and relative lack of humidity.
Severe wasting diseases – people with muscle wastage may not be able to tolerate cold temperatures.
Severe anaemia
Pregnancy
Seizure disorders
Wound healing problems
DVT – again, this will have affected the peripheral blood vessels adversely, so people who have had a DVT should not undergo cryotherapy.
Alcohol or drug use – both of these can adversely affect the normal physiological response to cold.
When performed in the appropriate setting with controlled conditions of temperature and humidity whole-body cryotherapy is a safe procedure. It has been shown to have no adverse effect on heart or lung function. However, it has been shown to cause a very slight, and some have suggested clinically irrelevant, increase in blood pressure. So, out of an abundance of caution, we choose to measure clients’ blood pressure prior to entering the Cryo chamber.
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Dr J Hugh Coyne
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Retrieved studies used for this scoping review are available upon reasonable request and will be made available to researchers who provide a sound proposal. Proposals should be directed to fabien.legrand@univ-reims.fr (corresponding author).
Over the two last decades, whole-body cryotherapy/cryostimulation (WBC) has emerged as an exciting non-pharmacological treatment influencing inflammatory events at a cellular and physiological level, which can result in improved sleep quality, faster neuromuscular recovery after high-intensity exercise, and chronic pain relief for patients suffering different types of diseases (fibromyalgia, rheumatism, arthritis). Some evidence even suggests that WBC has benefits on mental health (depression, anxiety disorders) and cognitive functions in both adults and older adults, due to increased circulating BDNF levels. Recently, some safety concerns have been expressed by influential public health authorities (e.g., FDA, INSERM) based on reports from patients who developed adverse events upon or following WBC treatment. However, part of the data used to support these claims involved individuals whose entire body (except head) was exposed to extreme cold vaporized liquid nitrogen while standing in a narrow bathtub. Such a procedure is known as partial-body cryotherapy (PBC), and is often erroneously mistaken to be whole-body cryotherapy. Although having similarities in terms of naming and pursued aims, these two approaches are fundamentally different. The present article reviews the available literature on the main safety concerns associated with the use of true whole-body cryotherapy. English- and French-language reports of empirical studies including case reports, case series, and randomized controlled trials (RCTs) were identified through searches of PubMed, Scopus, Cochrane, and Web of Science electronic databases. Five case reports and two RCTs were included for a total of 16 documented adverse events (AEs). A critical in-depth evaluation of these AEs (type, severity, context of onset, participant’s medical background, follow-up) is proposed and used to illustrate that WBC-related safety risks are within acceptable limits and can be proactively prevented by adhering to existing recommendations, contraindications, and commonsense guidelines.
Cryotherapy or cryostimulation is a short exposition to extremely low temperatures. The term “cryostimulation” was recently coined to refer to the use of cold exposure among healthy participants (e.g., athletes), whereas the term “cryotherapy” is restricted to the therapeutic use of cold in the management of injuries, disorders, of painful conditions.
Two categories of cryotherapy/cryostimulation devices should be clearly distinguished from one another: (1) Whole-Body Cryotherapy (WBC), delivered inside entire-body cryogenic chambers called “cryochambers” where air temperature is lowered to − 50° to – 150 ℃, and (2) Partial-Body Cryotherapy (PBC), delivered in can-shaped barrel coolers called “cryosaunas” filled with a mixture of air and liquid nitrogen mist at about − 190 ℃.
The differences between WBC and PBC mainly involve the exclusion of the head in PBC treatment, different ways to create cold (nitrogen vapor directly injected inside the cryosauna for PBC, versus refrigerated air injected into the cryochamber usually from an outdoor air-conditioner in the case of WBC), as well as different device sizes and mobility possibilities.
Importantly, WBC and PBC also strongly differ in that the PBC approach simultaneously imposes two different types of stress on participants: cold and hypoxia. Such a combination of constraints may lead to the activation of different cell signaling cascades compared to a cold stimulus alone [1].
The last difference between WBC and PBC relates to the thermal homogeneity within the cryogenic units, with cryosaunas displaying a higher degree of heterogeneity in temperature from the bottom to the top, and from the wall to the center of the cabin.
The effectiveness of WBC has been established in the treatment and rehabilitation of several diseases like multiple sclerosis, arthrosis, chronic back pain, or fibromyalgia [2–5]. We also know that WBC is widely used in sports medicine [6], in case of injury and to recover faster after physical exercise and training [7], and may have a potentially positive effect on affective disorders [8, 9], deterioration of cognitive functions [10], poor sleep quality [11], and metabolic disorders as well [12]. The potential mechanisms of action still remain quite unclear. However, the influence of WBC via alleviation of inflammatory processes and reduction of oxidative stress has been reported [13, 14].
With the increasing number of cryocenters, the number of WBC sessions delivered has multiplied in France and worldwide. According to the French Society of Whole-Body Cryotherapy, the number of cryotherapy sessions delivered in France was estimated to be over one million for the year 2019 (approximately 200 cryocenters nationwide, with an average of 5000 sessions per year in each center), 40% of them being WBC sessions. In Poland, where whole-body cryotherapy is covered under the national health fund, the number of reimbursed WBC sessions was estimated to be around 650,000 sessions per year over the last decade. The high number of exposures may result in an increased number of complications despite taking precautions (window and/or camera allowing continuous monitoring over the treatment time, cold protection equipment, security door for fast exit).
Surprisingly, only a few cases of complications have been reported in the literature to date. Part of the reason for this are the precautionary measures taken over the last two decades for safety and security (see list of absolute contraindications jointly released and implemented by the Bad Voslau consensus (Additional file 1: 15, Appendix 2) and the International Institute of Refrigeration [16]). However, the lack of evidence on adverse events is thought to be underestimated due to either underreporting or a lack of uniform reporting standards. The present consortium emerged in response to calls by several experts for further investigations on WBC safety [17], and our aim here was to critically analyze each reported case of WBC-induced adverse events using well-established reporting standards.
To do so, the Common Terminology Criteria for Adverse Events (CTCAE) grading system [18] was used for assessing the seriousness of any adverse event, which allowed to distinguish between « minor» (Grade 1 or Grade 2) and « serious» (Grade 3, Grade 4, or Grade 5) adverse events in the present review. As can be seen in Additional file 1: Appendix 1, adverse events classified into the Grade 3 (or more) category define severe complications requiring at least hospitalization or invasive healing therapy, while Grade 1 and Grade 2 adverse events require no or non-invasive interventional procedures. As the weight of scientific evidence for a causal relationship in each of the cases to be presented differs somewhat, a judgment has been made at the end of each section. This assigned associations to one of four categories: (1) convincing evidence for a causal relationship, (2) probable evidence, (3) possible evidence, and (4) insufficient evidence. « Convincing» and « probable» evidence for a causal disease/exposure relationship should result in policy recommendations, while « possible» and « insufficient» evidence indicate the need for more research.
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