Effects of Immediate and Delayed Repeated Cold Exposure After Physical Exertion: a Randomised Controlled Trial
Phase: NA
Conditions: Delayed Onset Muscle Soreness (DOMS), Inflammation, Muscle Pain, Muscle Damage
Sponsor: University of Applied Sciences and Arts of Southern Switzerland

 
 
 
 
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Clinical Investigation Plan (CIP) 
EFFECTS OF IMMEDIATE AND DELAYED REPEATED COLD EXPOSURE AFTER PHYSICAL 
EXERTION: A RANDOMISED CONTROLLED TRIAL 
 
Type of investigation: 
Clinical investigation concerning medical devices (MD). 
Categorisation: 
Category according to Art 6 ClinO-MD A1 
Registration: 
NCT06813690 
Identifier: 
2024-D0116 
Principal Investigator and 
Sponsor, or Sponsor-
Investigator: 
Dr. Ron Clijsen 
University of Applied Sciences of Southern Switzerland SUPSI 
Rehabilitation and Exercise Science Laboratory (RES Lab) 
Weststrasse 8  
7302 Landquart 
+41 81 300 01 75 
 
Thim van der Laan jr 
Thim van der Laan AG 
Weststrasse 8 
7302 Landquart 
+41 81 300 01 70 
Sponsor representative (if the 
Sponsor is not located in 
Switzerland) 
- 
Medical Device: 
Axanova Cold Hot Pearls Compresses 
Basic UDI-DI (GMN): 764011364_PG_04_RF 
CIP Version and Date: 
Version 06 (03.03.2025) 
 
CONFIDENTIALITY STATEMENT 
The information contained in this document is confidential and the property of University of 
Applied Sciences of Southern Switzerland SUPSI, Rehabilitation and Exercise Science 
Laboratory (RESLab). The information may not - in full or in part - be transmitted, reproduced, 
published, or disclosed to others than the applicable Competent Ethics Committee(s) and 
Regulatory Authority(ies) without prior written authorisation from the sponsor except to the extent 
necessary to obtain informed consent from those who will participate in the Investigation. 
Originally in German, translated into English 

 
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Signature Page 
 
 
ID number of the 
investigation: 
2024-D0116 
Title: 
Effects of immediate and delayed repeated cold exposure after 
physical exertion: a randomised controlled trial 
 
The Sponsor, the Principal Investigator and the Statistician have approved the CIP version [6 (dated 
03.03.2025),], and confirm hereby to conduct the investigation according to the CIP, the current version of 
the World Medical Association Declaration of Helsinki, ISO14155 norm [2024], ICH-GCP as far as 
applicable, and the local legally applicable requirements. 
The Investigator has received the ICF and consider it appropriate for use. 
 
 
 
Sponsor: 
 
Name: Thim van der Laan jr.  
 
 
Place/Date 
 
Signature 
 
 
Principal Investigator: 
 
Name: Dr. Ron Clijsen 
 
 
Place/Date 
 
Signature 
 
 
 

 
 
 
 
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TABLE OF CONTENTS 
SYNOPSIS 
4 
ABBREVATIONS 
8 
1 BACKGROUND AND RATIONALE 
9 
2 INVESTIGATION OBJECTIVES AND DESIGN 
9 
2.1 Hypothesis and primary objective 
9 
2.2 Primary and secondary endpoints 
10 
2.3 Investigation design 
11 
2.4 Investigation intervention 
11 
3 INVESTIGATION POPULATION AND INVESTIGATION PROCEDURES 
12 
3.1 Inclusion and exclusion criteria, justification of Investigation population 
12 
3.2 Recruitment, screening and informed consent procedure 
12 
3.3 Investigation procedures 
13 
3.4 Withdrawal and discontinuation 
14 
4 STATISTICS AND METHODOLOGY 
15 
4.1. Statistical analysis plan and sample size calculation 
15 
4.2. Handling of missing data and drop-outs 
17 
5 SAFETY 
17 
5.1 Definition and Assessment of (Serious) Adverse Events and other safety related 
events 
17 
5.2 Documentation and reporting in Medical Device Category A clinical investigations 18 
5.2.1 Foreseeable adverse events and anticipated adverse device effects 
19 
5.2.2 Reporting of Safety related events 
19 
5.3 Radiation 
20 
5.4 Amendments (Art. 15 ClinO-MD) 
20 
5.5 Notification and reporting upon completion, discontinuation or interruption of the 
Investigation 
20 
5.6 Insurance 
21 
6 FURTHER ASPECTS 
21 
6.1 Overall ethical considerations 
21 
6.2 Risk-benefit assessment 
21 
7. QUALITY CONTROL AND DATA PROTECTION 
22 
7.1 Quality measures 
22 
7.2 Data recording and source data 
23 
7.3 Confidentiality and coding 
23 
7.4 Retention and destruction of Investigation data and biological material 
24 
8  MONITORING AND REGISTRATION 
24 
9. FUNDING / PUBLICATION / DECLARATION OF INTEREST 
25 
10. REFERENCES 
26 
 
 
 

 
 
 
 
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SYNOPSIS 
Sponsor / 
Sponsor-
Investigator 
Thim van der Laan AG 
Thim van der Laan jr.  
Weststrasse 8, CH-7302 Landquart 
 
University of Applied Sciences and Arts Southern Switzerland (SUPSI)  
Dr. Ron Clijsen  
Weststrasse 8, CH-7302 Landquart 
Title 
Effects of immediate and delayed repeated cold exposure after physical exertion: a 
randomised controlled trial 
Short Title / 
Invesigation ID 
Local cooling and recovery 
Protocol Version 
and Date 
Version 06 of date (03/03/2025) 
Registration 
ClinicalTrials.gov PRS 
Category and 
Rationale 
Category according to Art 6 ClinO-MD A1. 
This study investigates whether repeated, local cold applications have a positive effect on 
recovery after a muscle soreness protocol. The test subjects are not given medication, nor are 
tissue samples taken. Minimally invasive techniques are used (venous blood sampling).  
Name of the MD, 
Unique Device 
Identification 
(UDI), name of 
the manufacturer 
Axanova Cold Hot Pearls Compresses 
Basic UDI-DI (GMN): 764011364_PG_04_RF 
Axanova AG 
Stage of 
development: 
Post-market stage 
Background and 
Rationale  
Sporting activity is characterized by factors of the type, duration and intensity of exertion. 
Depending on the extent of these factors and the associated recovery time, damage to the 
muscles, inflammation and fatigue in the nervous system occur. Energy substrate degradation 
and local swelling also occur. Therefore, rapid regeneration after intensive sports has become 
all the more important. According to the meta-analysis by Bleakley et al. 2012, cold is 
considered to be one of the most effective recovery methods after sporting activity to delay 
delayed onset muscle soreness (DOMS).  The DOMS are microscopic tears in muscle tissue 
called exercise-induced muscle damage, which can lead to delayed onset muscle soreness. 
DOMS usually peak between 24 and 48 hours – sometimes up to 72 hours – after exercise 
and are characterized by muscle shortening, increased passive stiffness, swelling, decrease 
in strength and power, localized muscle soreness, and altered proprioception. 
The physiological background of cryotherapy is based on the removal of body heat by reducing 
tissue temperature. This is reflected in a reduced perception of muscle pain, so that the body 
feels more "awake" after training and causes less fatigue. In addition, due to the cold, the body 
lowers the heart rate and cardiac output, inducing vasoconstriction. The results are smaller 
vessel diameters, a reduced incidence of oedema and an improved oxygen supply to the cells. 
In order to maintain the body's core temperature, the central metabolism also increases, which 
promotes the transport of waste products. All these effects, in composition, could reduce the 
inflammation caused by exercise by reducing the death or damage of hypoxic cells and 
minimizing damage to secondary tissues by reducing the infiltration of leukocytes and 
monocytes. (Bleakley et al. 2012, Hohenauer E et al. 2015, Hubbard et al. 2004, Ostrowski et 
al 2018). Postoperative cryotherapy utilizing ice packs, cooling, or continuous cryotherapy 
devices reduced visual analogue scale pain scores and analgesic consumption in 
approximately half of the prior art research studies comparing these outcomes to the control 
group (no cryotherapy) (11 [44%] out of 25 studies on pain and 11 [48%] out of 23 studies on 
opioids). However, an effect in increasing range of motion (3 [19 %] out of 16) or reducing 
swelling (2 [22 %] out of 9) was reported less frequently. (Kunkle et al. 2021). The study 
induced here is intended to provide new data, especially in the reduction of swelling and 
inflammation values, and to confirm the reduction of pain by cold application of the Axanova 
Cold Hot Pearls Maxi Pack. 

 
 
 
 
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Risk / Benefit 
Assessment 
In this examination, the risk can be classified as minimal. The product is applied as 
recommended by the manufacturer. The muscle soreness protocol is a protocol that has 
already been described in the scientific literature.  
Objective(s) 
The aim of this study is to investigate how local, repeated cold applications affect the recovery 
phase according to a muscle soreness protocol.  
Recovery is assessed at 24-hour intervals (up to 72 hours according to the muscle soreness 
protocol).  
Endpoint(s) 
Primary endpoints:  
• 
Sore muscles (VAS 0 – 10 cm) 
• 
Inflammation levels (blood sinking velocity, C-reactive protein, creatine kinase) 
• 
Muscle swelling (in cm using ultrasound)  
• 
Maximum Voluntary Isometric Thigh Contraction (in kg) 
Secondary endpoints  
• 
Surface temperature of the skin (in °C) 
• 
Thermal Perception 
Investigation 
Design 
Randomized, controlled trial 
Statistical 
Considerations 
Repeated measure ANOVA, n=45 subjects 
Inclusion- / 
Exclusion 
Criteria 
Inclusion Criteria 
• 
Young, healthy adults between the ages of 18 and 30  
• 
No surgical interventions on the musculoskeletal system in the trunk area and lower 
extremities  
Exclusion criteria 
• 
Current pain conditions: Subjects with acute pain conditions. 
• 
Current inflammatory conditions: Presence of inflammation or known inflammatory 
diseases. 
• 
Medication intake (excl. anticonception drugs): Subjects taking medication, with the 
exception of anticonception drugs. 
• 
Pregnant subjects: Women who are pregnant or breastfeeding. 
• 
Competitive athletes: Test subjects who practice competitive sports. 
• 
Children/adolescents: Subjects under 18 years of age or over 30 years of age. 
• 
Non-intact skin conditions (e.g. psoriasis): Skin conditions, such as psoriasis or other 
non-intact skin conditions. 
• 
Known circulatory disorders: Presence of known circulatory disorders. 
• 
Cold allergy (Raynaud's syndrome): Allergy to cold or the presence of Raynaud's 
syndrome. 
• 
Previous operations on the upper body or legs: Operations in the areas of the body 
examined. 
• 
Disturbed perception in the thigh: Disturbances in the sensation of temperature or 
touch in the thigh area. 
• 
Diagnosed diseases: Presence of diagnosed diseases that could affect participation 
in the examination. 
• 
Smoking: When the subject smokes. 
Number of 
Participants with 
Rationale 
The study is planned with 3 study arms. The average initial VAS score after pain induction 
varies depending on the examination and is an approximation of an initial value of 4.73 ± 2.39. 
A reduction in the VAS score after cold application was assumed to be an average of 47%. 
After taking into account the dropout rate of 10% and splitting into 3 randomized groups, a 
patient count of 15 subjects per study arm is considered statistically appropriate. The results 
were determined using the PASS 2023 version 23.0.1 software. 
Intervention 
The product "Cold Hot Pearls Maxi Pack" of the company Axanova AG is used for testing. This 
product has a gel bead filling that can be used for cold and heat applications. According to the 
manufacturer, the cold compresses must be stored in a freezer for at least 1 hour before they 
can be used. The cold pack can then be placed on the affected area on the fleece side, but for 
a maximum of 20 minutes in the same place.  

 
 
 
 
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In our study, there are 2 cooling groups:  
The first group starts cooling immediately after the muscle soreness protocol.  
The second group starts cooling 24 hours after the muscle soreness protocol.  
Control 
Intervention 
The control group will not receive an intervention according to the muscle soreness protocol.  
Investigation 
procedures 
Subject recruitment  
The test subjects are recruited at the University of Physiotherapy THIM in Landquart and the 
University of Applied Sciences and Arts Southern Switzerland in Landquart.  
The subject information and the declaration of consent are given to the test subjects. In the 
subject information there is a checklist that the test persons must fill out in order to check the 
inclusion and exclusion criteria.  
If the subjects agree with the information, have completed the checklist and signed the 
consent, they will be summoned to make an appointment for the measurement.  
Investigation Protocol 
As soon as the signed consent of the test person has been received and an appointment has 
been made, the following procedure is followed. The anthropometric data of the subjects will 
be collected and group randomization will be carried out. Afterwards, the baseline 
measurements are carried out and the measurement of the skin temperature is started. Then 
the muscle soreness protocol (6 x 12 to 15 one-legged knee extensor protocol with a 2-minute 
break between sets) is completed. Cooling group A then receives the first 20-minute cooling 
of the thigh group.  
Cooling group B and the control group leave the laboratory 20 minutes after the muscle 
soreness protocol. The measurement of skin temperature is stopped within all groups 20 
minutes after the muscle soreness protocol.  
Cooling group B begins cooling the thigh muscles 24 hours after the muscle soreness protocol. 
Both cooling groups perform cooling of the thigh muscles 3 x / day for the duration of the data 
collection (up to 72 hours according to the muscle soreness protocol).  
At intervals of 24, 48 and 72 hours, the primary endpoints of the study are collected again. 
These include: muscle soreness, inflammation levels, muscle swelling, maximum voluntary 
isometric contraction of the thigh muscles.  
Measurement of sore muscles 
The level of ventrally felt muscle soreness symptoms is measured using a VAS scale (0 – 10 
cm). The test subjects rate the perceived muscle soreness in both ventral thighs in a 90° knee 
flexion position. The measurement takes place during the baseline measurement and, 24 
hours, 48 hours and 72 hours after the intervention. 
Inflammation levels 
The inflammation values (blood sedimentation rate, C-reactive protein, creatine kinase) are 
determined by venous blood sampling. The measurement takes place during the baseline 
measurement and, 24 hours, 48 hours and 72 hours after the intervention. 
Muscle swelling 
The measurement of muscle swelling of the quadriceps femoris muscle is carried out by 
ultrasound measurement. The measurement is carried out in a resting position and a cross-
section of the muscle is recorded. The measurement takes place during the baseline 
measurement and, 24 hours, 48 hours and 72 hours after the intervention. 
Measurement of maximum voluntary isometric thigh muscle contraction (MVIC)  
MVIC is performed on an ergometer chair for biomechanical measurements and is given in kg.  
The measurement takes place during the baseline measurement and, 24 hours, 48 hours and 
72 hours after the intervention. 
Surface temperature 
The surface temperature is measured using the iButton system. These sensors are glued to 
the skin for the duration of the measurement. The button sensors store the current temperature 
information and can then be read out via a computer. These measurements are started during 
the baseline survey, for the duration of the muscle soreness protocol, and up to 20 minutes 
after the muscle soreness protocol.   
Detection of thermal perception 
The thermal perception of the participants is recorded immediately after exposure to cold using 
the standardized Thermal Perception Scale (-4 to +4). This scale ranges from -4 ("extremely 
cold") to +4 ("extremely warm"), with 0 being considered neutral. The evaluation is carried out 

 
 
 
 
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as a subjective self-assessment in order to document the individual temperature perception. 
Participants will be informed about the scale in advance. Since this is a purely subjective 
assessment, there is no risk for the participants. 
Investigation 
Duration and 
Schedule 
Planned start of measurements: 01/2025  
Planned end of measurements: 07/2025  
Investigator(s) 
Dr. Ron Clijsen 
Dr. Erich Hohenauer  
Vanessa Wellauer 
 
Contact / Director of Studies 
Clijsen Ron, PhD University of Applied Sciences Southern Switzerland Physiotherapy 
Graubünden Weststrasse 8, 7302 Landquart +41 81 300 01 75 ron.clijsen@supsi.ch 
Investigation 
Center(s) 
University of Applied Sciences Southern Switzerland Physiotherapy Graubünden 
Rehabilitation Research Laboratory RESlab SUPSI Landquart, Weststrasse 8 7302 Landquart 
Data privacy 
The data are only accessible to the head of the study (Ron Clijsen) and persons of the KEK 
(in case of any quality controls on site). The data is coded numerically (001, 002, 003, etc.). 
Only the study leader can solve the code. All data is stored in the laboratory of the University 
of Applied Sciences and Arts Southern Switzerland in Landquart.  
Ethical 
consideration 
Athletes could benefit from these results as they receive information on how they could 
increase their athletic performance or recovery by applying cold after exercise. The 
methodological approach is based on the current scientific literature. The risk can be 
considered minimal because the product is used as prescribed.  
Compliance 
statement 
This investigation will be conducted in full compliance with the CIP, the current version of the 
Declaration of Helsinki, ISO 14155 [2024], ICH-GCP (as far as applicable) as well as all 
national legal and regulatory requirements.  
 
 
 

 
 
 
 
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ABBREVATIONS 
AE 
Adverse Event 
AIP 
Azure Information Protection 
ASR 
Annual Safety Repot 
BASEC 
Business Administration System for Ethical Committees 
ClinO 
Ordinance on Clinical Trials in Human Research (in German: KlinV, 
in French: OClin, in Italian: OSRUm) 
CRF 
Case Report Form 
CTCAE 
Common Terminology Criteria for Adverse Events 
CATHEDRAL Delayed Onset Muscle Soreness 
eCRF 
electronic Case Report Form 
FADP 
Federal Act on Data Protection (in German: DSG, in French: LPD, 
in Italian: LPD) 
FOPH 
Federal Office of Public Health 
GCP 
Good Clinical Practice 
HRA 
Human Research Act (in German: HFG, in French: LRH, in Italian: 
LRUm) 
I 
International Conference on Harmonisation 
ISO 
International Organisation for Standardisation 
MDR 
Medical Device Regulation 
MVIC 
Maximum Voluntary Isometric Contraction 
SAE 
Serious Adverse Event 
SDV 
Source Data Verification 
SSL 
Secure Sockets Layer 
SUE 
Serious Unexpected Events 
TLS 
Transport Layer Security 
UAE 
Unanticipated Adverse Event 
 
 
 

 
 
 
 
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1 
BACKGROUND AND RATIONALE  
Sporting activity is characterized by factors of the type, duration and intensity of exertion. 
Depending on the extent of these factors and the associated recovery time, damage to the 
muscles, signs of inflammation and fatigue in the nervous system occur, as well as energy 
substrate degradation and local swelling. Therefore, rapid regeneration after intensive sports has 
become all the more important. According to the meta-analysis by Bleakley et al. 2012, cold is 
considered one of the most effective recovery methods after sporting activity to delay delayed 
onset muscle soreness (DOMS).  The DOMS are microscopic tears in muscle tissue called 
exercise-induced muscle damage, which can lead to delayed onset muscle soreness. DOMS 
usually peak between 24 and 48 hours – sometimes up to 72 hours – after exercise and are 
characterized by muscle shortening, increased passive stiffness, swelling, decrease in strength 
and power, localized muscle soreness, and altered proprioception. 
The physiological background of cryotherapy is based on the removal of body heat by reducing 
tissue temperature. This is reflected in a reduced perception of muscle pain, so that the body 
feels more "awake" after training and causes less fatigue. In addition, due to the cold, the body 
lowers the heart rate and cardiac output, inducing vasoconstriction. The results are smaller vessel 
diameters, a reduced incidence of oedema and an improved oxygen supply to the cells. In order 
to maintain the body's core temperature, the central metabolism also increases, which promotes 
the transport of waste products. All these effects, in composition, could reduce the inflammation 
caused by exercise by reducing the death or damage of hypoxic cells and minimizing damage to 
secondary tissues by reducing the infiltration of leukocytes and monocytes. (Bleakley et al. 2012, 
Hohenauer E et al. 2015, Hubbard et al. 2004, Ostrowski et al 2018). Postoperative cryotherapy 
using ice packs, cooling, or continuous cryotherapy devices reduced pain scores on the visual 
analogue scale and analgesic consumption in about half of the prior art research studies 
comparing these outcomes to the control group (no cryotherapy) (11 [44%] of 25 studies on pain 
and 11 [48%] of 23 studies on opioids). However, an effect in increasing range of motion (3 [19 
%] out of 16) or reducing swelling (2 [22 %] out of 9) was reported less frequently. (Kunkle et al. 
2021). The study induced here is intended to provide new data, especially in the reduction of 
swelling and inflammation values, and to confirm the reduction of pain by cold application of the 
Axanova Cold Hot Pearls Maxi Pack. 
2 
INVESTIGATION OBJECTIVES AND DESIGN  
2.1 Hypothesis and primary objective 
The aim of this study is to investigate whether repeated, local cold applications have a positive 
impact on recovery compared to no intervention. Furthermore, it will be investigated whether 
cooling, which has been carried out immediately after the exertion, has a more positive influence 
on the recovery compared to refrigeration that has started 24 hours after the exertion. The ability 
to recover is determined on the basis of the following parameters: muscle soreness, inflammation 
levels, muscle swelling and maximum voluntary isometric contraction of the thigh muscles.   
 
• 
H0A: There is no significant difference between repeated cold applications and the control 
intervention in terms of recovery capacity.   
• 
H1A: There is a significant difference between repeated cold applications and the control 
intervention in terms of recovery capacity.  

 
 
 
 
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• 
H0A: There is no significant difference between immediate cold applications and delayed cold 
applications in terms of recovery. 
H1A: There is a significant difference between immediate cold applications and delayed cold 
applications in terms of recovery. 
2.2 Primary and secondary endpoints 
Primary endpoints 
Muscle soreness 
A visual analogue scale (VAS) is used for the quantitative assessment of muscle soreness. The 
muscle soreness of the test subjects is measured on both ventral thighs in 90° knee flexion within 
2 seconds. Participants perform a squat at a 90-degree angle and use a hand-held glide scale to 
choose a value between 0 and 10 cm, with 0 representing no discomfort and 10 representing 
maximum discomfort. This scale is designed without visible numerical indicators to minimize 
repetition bias. Measurements are taken during baseline and 24, 48, and 72 hours after the 
intervention. The examination staff records the selected value in centimetres to document the 
level of the muscle soreness symptoms felt ventrally. 
 
Inflammation levels 
The general inflammation values are determined on the basis of 3 parameters. These are the 
blood sinking rate, the C-reactive protein and the creatine kinase. These parameters are 
determined by means of a venous blood draw.  
 
Muscle swelling 
Swelling of the ventral thigh muscles is performed using ultrasound diagnostics. The test subjects 
are in a lying position. Subsequently, a cross-sectional image of the thigh muscles is created and 
the distance from the femur to the outer boundary of the muscles is measured.  
 
Maximum voluntary isometric muscle contraction  
This parameter is measured using an ergometer chair in 90° hip flexion. The test subjects have 
to try to stretch their thigh as much as possible for 3 seconds. The maximum deflection is used 
to determine the maximum voluntary isometric muscle contraction.  
 
Secondary endpoints 
Superficial skin temperature 
The skin temperature of the thighs is measured using the iButton system. The sensors are glued 
to the skin and continuously measure the temperature of the skin. The data from the sensors is 
then read out on a computer. This measurement is started during the baseline survey, for the 
duration of the muscle soreness protocol, and up to 20 minutes after the muscle soreness 
protocol.   
Thermal Perception 
The thermal perception of the participants is recorded immediately after exposure to cold using 
the standardized Thermal Perception Scale (-4 to +4). This scale ranges from -4 ("extremely 
cold") to +4 ("extremely warm"), with 0 being considered neutral. The evaluation is carried out as 
a subjective self-assessment in order to document the individual temperature perception. 
Participants will be informed about the scale in advance. Since this is a purely subjective 
assessment, there is no risk for the participants. 

 
 
 
 
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2.3 Investigation design  
This study is a single-center, randomized, controlled trial with 3 arms. After the subjects have 
been admitted to the examination, they are divided into one of the 3 groups.  
Group A: immediate cooling according to the muscle soreness protocol 
Group B: delayed cooling according to the muscle soreness protocol (24 hours delayed)  
Group C: Control group  
This examination is a clinical trial of risk category A.  
Group A: immediate cooling 
In this group, cooling starts immediately after the muscle soreness protocol. Cooling is carried 
out 3 x /day both on the day of the muscle soreness protocol and for a period of 72 hours. Both 
thighs are cooled with the "Cold Hot Maxi Pack" from Axanova for a period of 20 minutes.  
Cooling log: Day 1 (muscle soreness log, 3x/day), Day 2 (3x/day), Day 3 (3x/day), Day 4 (3x/day)  
Group B: delayed cooling 
In this group, cooling starts 24 hours after the sore muscle protocol. Cooling is also carried out 3 
x /day for a period of 72 hours. Both thighs are cooled with the "Cold Hot Maxi Pack" from Axanova 
for a period of 20 minutes.  
Cooling log: Day 1 (muscle soreness log, no cooling), Day 2 (3x/day), Day 3 (3x/day), Day 4 
(3x/day).  
Group C: Control group  
This group receives according to the muscle soreness protocol and will not receive any cooling 
intervention, nor any other intervention, for the entire period thereafter.  
Sore muscle protocol  
To induce sore muscles, the test subjects perform one-sided, 6 times 12 – 15 knee extensors on 
an ergometer chair. They straighten and bend the knee as far as possible. They repeated the 
exercise 5 more times after a 2-minute break (a total of 6 rounds). The movement sequences are 
observed and corrected if necessary. A similar protocol has already been successfully used in 
the literature to induce muscle soreness (Ruas et al 2022, Comparison between eccentric-only 
and coupled concentric-eccentric contractions for neuromuscular fatigue and muscle damage). 
In order to increase the significance of the investigation, the subjects are asked not to carry out 
any additional interventions during the experimental phase.  
2.4 Investigation intervention 
The repeated cold applications are carried out by the test subjects independently at home. For 
this, the test subjects receive 6 cold packs to take home (CE-certified Axanova Cold Hot Pearls 
Maxi Pack, Axanova AG). One cold pack is applied per thigh (2 packs per cooling session). The 
packs must be placed in a chest freezer/freezer compartment 1 hour before use. After the 
minimum cooling time has expired, the cold packs are placed on the thighs for 20 minutes with 
the fleece side down (skin contact). There must be at least 4 hours between cold applications. 
The cold packs may only be applied to the skin, without any additional pressure. The 20-minute 
cold application is described by the manufacturer Axanova as follows. We do not change the 
duration of application or form. The applications 24, 48 and 72 hours after the muscle soreness 
protocol are carried out by the test subjects at home and documented with a photo. Study 
participants upload these images directly to a designated cloud-based folder via a secure, 
password-protected link. This ensures that the data is transmitted and stored in encrypted form. 
When the intervention is carried out in the laboratory by the study staff, the temperature of each 

 
 
 
 
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cold pack is checked using an infrared thermometer to document possible temperature 
differences. This measurement is used to record potential variations in the cooling effect without 
influencing the application of the cold pack. 
3 
INVESTIGATION POPULATION AND INVESTIGATION PROCEDURES  
3.1 Inclusion and exclusion criteria, justification of Investigation population 
For this study, n=45 subjects will be recruited 
Inclusion Criteria 
• 
Young, healthy adults between the ages of 18 and 30  
• 
No surgical interventions on the musculoskeletal system in the trunk area and lower 
extremities  
Exclusion criteria 
• 
Current pain conditions  
• 
Current inflammatory states  
• 
Medication intake (excl. anticonception drugs)  
• 
Pregnant subjects  
• 
Athletes  
• 
Children/adolescents 
• 
Non-intact skin conditions (e.g. psoriasis)  
• 
Known circulatory disorders  
• 
Cold allergy (Raynaud's syndrome) 
3.2 Recruitment, screening and informed consent procedure 
Participants are recruited via the websites of the Thim van der Laan (www.physioschule.ch) 
physiotherapy schools and the SUPSI (www.supsi-landquart.ch University of Applied Sciences 
and Arts Southern Switzerland). An electronic advertisement is placed on the screens in the 
building of Thim van der Laan AG in Landquart. The ad texts are based on the guidelines of the 
Ethics Committee of the Canton of Zurich.   
The initial contact is made directly with the head of studies in the research laboratory of the 
University of Applied Sciences and Arts Southern Switzerland. At the first contact, the potential 
participants are informed about the procedure and the risks of the examination, as well as about 
the conditions and the amount of compensation.  
The principal investigator will explain to each participant the nature of the study, its purpose, the 
procedures involved, the expected duration, the possible risks and benefits, and any 
inconveniences it may entail. Each participant is informed that participation in the examination is 
voluntary and that he or she can withdraw from the examination at any time and that withdrawing 
consent will not affect his or her subsequent supervision.   
The study leader then hands over the subject information and the declaration of consent. In the 
subject information there is a checklist that the potential test persons must fill out. This checklist 
checks whether the potential test subjects are suitable for the examination. The test subjects are 
told that they can contact us at any time if questions arise.  
The completed checklist and the signed consent form will be handed over to the Director of 
Studies and checked by him. If all exclusion criteria are checked and the consent form is signed 

 
 
 
 
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and the subject has no more questions, he/she is admitted to the examination. A copy of the 
signed informed consent form will be given to the study participant. The declaration of consent is 
kept as part of the study documents. The original of the signed consent form is kept as a study 
document in a locked filing cabinet.   
After successful completion of the intervention, the participants receive a remuneration of 50 
Swiss francs.   
3.3 Investigation procedures 
Investigation duration:  
Subject to EC approval in 2024. 
Recruitment period: January 2025  
Conduct of the study: February - March 2025 
Statistics and writing of the article: April – July 2025 
 
Individual Investigation duration for each participant 
Phase 
Content 
Time 
Recruitment 
Handing 
out 
patient 
information 
& 
consent,  
explanation of the experiment 
30 min 
Experiment 
Day 1 
Anthropometry, baseline measurement, muscle soreness protocol 
(cooling: group A) 
60 min 
Experiment  
Day 2 
Follow-up measurement 24 hours 
(Cooling: Group A and Group B) 
30 min 
Experiment 
Day 3 
Follow-up measurement 48 hours 
(Cooling: Group A and Group B) 
30 min 
Experiment 
Day 4 
Follow-up measurement 72 hours  
(Cooling: Group A and Group B) 
30 min 
 
 
 
Total time required per subject 
180 min 
 
 
Recruitment 
As soon as the potential test subjects show interest in the study and arrive at the laboratory in 
Landquart, they are sent to the study director. If he is not present or available at that time, 
interested parties are asked to appear on another day. 
The head of the study explains the procedure, the tests carried out, the risks and possible 
inconveniences. In addition, it is explained that participation is voluntary and that withdrawal is 
possible at any time, without giving reasons, without this having a negative impact on future care. 
The test subjects then receive the test subject information, which describes the examination in 
detail and in an understandable way. The document also contains a checklist that must be 
completed. The declaration of consent is also provided and must be signed and returned by the 
Director of Studies before the start of the programme. The doctor checks the completed checklist 
and confirms the consent. 
Baseline measurements  
The room temperature and relative humidity are determined at the beginning of each 
measurement day (Voltcraft MT52 digital multimeter, Hirschau, Germany). Baseline 
measurements include demographic data (age, gender, height). Anthropometric features at the 
beginning of the study included height (GPM Stadiometer, Zurich, Switzerland), body mass, and 
body fat percentage estimation. Body mass and lower body fat percentage were measured using 

 
 
 
 
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a TANITA-TBF 611 scale (Tokyo, Japan). The estimate of the percentage of lower body fat was 
chosen because the cold pack was applied to the thigh, which mainly affects the lower extremities.   
Recovery parameters (see Exact Measurement Method and Primary and Secondary Endpoints) 
are assessed in the same order for each measurement: (1) Inflammation Scores, (2) Muscle 
Swelling, (3) Soreness, (4) Maximum Voluntary Isosomic Muscle Concontraction. The 
measurement method and the equipment used for each specific result are described in Chapter 
3.2.  
Randomization 
The randomization of the subjects will take place on the day of the baseline measurement by 
drawing a lot. It is ensured that the same number of tickets are available for each intervention 
group (5 tickets per group) and test subjects. If the number of subjects in a group exceeds one 
third of the total number of subjects, the lots of this group will be removed. In order to ensure the 
equality of the groups in terms of covariates and gender, the composition of the groups is 
monitored. As soon as half of a group consists of male or female subjects, the tickets for this 
group are removed for future subjects of the same sex. 
The tickets are made of folded paper with the numbers 1, 2 or 3 on them and are placed together 
in a container. The drawing of the lots is carried out by the test persons themselves. After the 
draw, the subjects hand over the unread ticket to the study director, who assigns them to a group. 
Blinding 
Since cold applications are tested in this study, blinding is not possible.  
Sore muscle protocol 
To induce muscle soreness, a one-legged knee extensor protocol is used, which has already 
been used (Ruas et al., 2022). Participants will be instructed to straighten and bend their knee for 
6 sets for 12 – 15 reps, with 2 minutes rest between sets. During the 2-minute break, the 
participants are allowed to sit on the chair. The execution of the knee extensor protocol is visually 
observed by an examiner. Verbal corrections of the execution can be given by the examiner. 
However, no verbal encouragement is given. All training sessions are carried out in the morning. 
If a participant is unable to perform all the repetitions of a set due to extreme fatigue or maximum 
effort, the set can be stopped and a new set can be started after the rest period. However, at least 
12 repetitions per set must be performed. Otherwise, this will be considered an abandonment. 
Intervention 
The subjects in group A (immediate cooling) receive the first cooling on the two thighs immediately 
after the end of the muscle soreness protocol. This cooling is carried out in the supine position. 
After this application, you can leave the laboratory and the measurement of the skin temperature 
is stopped.  
Group B (delayed cooling) and group C (control group) do not receive any cooling (group B) or 
any intervention (group C) immediately after the muscle soreness protocol. However, you will also 
need to spend 20 minutes lying on your back in the lab before the skin temperature measurement 
is completed.   
Follow-up measurements 
Follow-up measurements will be taken for each measurement in the same order as for the 
baseline measurement ((1) Inflammatory markers, (2) Muscle swelling, (3) Soreness of muscles, 
(4) Maximum voluntary isometric contraction). The follow-up measurements take place 24, 48, 
and 72 hours after the muscle soreness protocol in the laboratory in Landquart.   
The measurement method and the equipment used for each specific result are described in 
Chapter 3.2. 
3.4 Withdrawal and discontinuation 

 
 
 
 
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Participants can withdraw from the investigation at any time and without giving reasons. 
Participants will be excluded from the examination if an imminent injury or illness contraindications 
exercise or cold application.   
4 
STATISTICS AND METHODOLOGY 
4.1. Statistical analysis plan and sample size calculation 
Sample calculation 
Before any data collection is carried out, case number planning and sample size calculation is 
necessary in order to obtain valid results. In clinical trials and animal experiments, this is even 
mandatory and is carefully reviewed before approval is granted (MDR, Annex XV, Chapter 1, 
Section 2.1, DIN EN ISO 14155:2021-05). Postoperative cryotherapy utilizing ice packs, cooling, 
or continuous cryotherapy devices reduced pain scores on the visual analogue scale and 
analgesic consumption in about half of the research studies comparing these outcomes against 
their control (no cryotherapy). The average initial VAS score after pain induction varies depending 
on the study and is an approximation of a baseline value of 4.73 ± 2.39. A reduction in the VAS 
score after cold application was assumed to be an average of 47%. After taking into account the 
dropout rate of 10% and splitting into 3 randomized groups, a patient count of 15 subjects per 
study arm is considered statistically appropriate. The results were determined using the PASS 
2023 version 23.0.1 software. 
Numerical Results for Multiarm Tests for the Difference Between Treatment and Control Agents 
Assuming Equal Variance 
Solve for: 
Number of cases 
Group distribution: 
equal to (Nc = N1 = N2 = 
...) 
Test Type: 
T-Test 
Hypothesis: 
H0: δ = 0 vs.   H1: δ ≠ 0 
Number of groups: 
3 
Bonferroni Correction: 
none (divisor = 1) 
 
Comparis
on 
Target 
Strength 
Real 
Number 
of cases Mean μi  Difference δi Standard 
deviation σ 
Alpha 
Control 
 
 
13 
4,72 
 
2,1 
 
vs. A 
0,8 
0,832
33 
13 
2,21 
-2,51 
2,1 
0,05 
vs. B 
0,8 
0,912
87 
13 
1,87 
-2,85 
2,1 
0,05 
Total 
n/a 
n/a 
39 
n/a 
n/a 
n/a 
n/a 
 

 
 
 
 
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Compariso
n 
The group involved in the comparison between the treatment and control shown 
in this report row. The comparison is made on the basis of the difference. 
Test 
Strength 
The desired test strength. Test strength is the probability of rejecting a false null 
hypothesis for this comparison. This test strength refers only to the comparison 
shown in this line. 
Really. TS 
The test strength that is really achieved. 
Ni 
The number of elements in the ith group. The total sample size is displayed in the 
last row of the column. 
μi 
The mean value of the ith group at which the test strength is calculated. The first 
row contains μc, the mean value of the control group. 
δi 
The difference between the ith treatment agent and the control agent (μi – μc) 
for which the test strength is calculated. 
σ 
The standard deviation of the responses within each group. 
Alpha 
The probability of rejecting the null hypothesis that the control mean is equal to 
the treatment mean described in this row. 
 
Summary statements 
A parallel 3-group design (with a control group and 2 treatment groups) is used to test whether 
the mean for each treatment group is different from the mean of the control group (H0: δ = 0 
versus H1: δ ≠ 0, δ = μi – μᴄ). The hypotheses are evaluated using two two-sided, two-sample 
methods. Bonferroni-adjusted t-tests with the same variance and an overall (experimental) Type 
I error rate (α) of 0.05. The common standard deviation for all groups is assumed to be 2.1. The 
mean value of the control group is assumed to be 4.72. The treatment means 2.21 and 1.87 with 
at least 80% test strength to be detected in each case. For the test, the (same) group sample size 
needed for each of the three groups (control and treatments) is 13 (39 subjects in total). The 
group sample sizes were calculated using PASS 2023, version 23.0.1. 
Sample size taking into account the dropout rate 
Group 
Dropouts 
Abandonment 
Rate 
Number 
of 
cases/group 
Number of cases 
with drop-out rate 
Number 
of 
abandoned 
participants 
1 - 3 
10% 
13 
15 
2 
Total 
n/a 
39 
45 
6 
Taking into account the drop-out rate 
Taking into account a dropout rate of 10%, the group sizes in each study arm should be 15 
subjects. 
Statistical approach to examine the primary endpoints  
The statistical analysis is performed using IBM SPSS Statistics (version 27, IBM Corp., Armonk, 
NY, USA) and the significance level is set to p <0.05.  
In order to be able to determine the differences between groups, a repeated ANOVA analysis is 
carried out with a factor of 1: time (baseline, 24 hours, 48 hours, 72 hours) and a factor of 2: 

 
 
 
 
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intervention (group A, group B, group C) for the recovery parameters (inflammation values, 
muscle swelling, muscle soreness data, maximum voluntary isometric muscle contraction).   
The examination is discontinued if the participants are intolerant to the local cold application. 
Participants in the IC and DC groups are instructed to cancel a cooling session and contact their 
contact immediately if they experience symptoms such as severe pain/discomfort as a result of 
the cooling. 
4.2. Handling of missing data and drop-outs 
Missing data, missed training sessions or abandonments are noted in the CRF. Data from patients 
who discontinue the examination is collected and stored. Drop-outs are not replaced by the 
recruitment of new participants. If consent is withdrawn, the data already collected will be included 
in the analysis for scientific and safety reasons. These are only anonymised after the analysis 
(Art. 32 ClinO-MD). 
5 
SAFETY 
5.1 Definition and Assessment of (Serious) Adverse Events and other safety related events 
Adverse Event (AE) (Art. 2 para. 57 MDR) 
Any adverse medical event, unintentional illness or injury, or adverse clinical sign (including 
abnormal laboratory findings) in subjects, users, or others, whether or not related to the medical 
device (MP). 
These include events related to the MP or comparator product being studied, as well as the 
associated procedures. For users or other persons, this is limited to events that are related to the 
MP. 
 
Serious Adverse Event (SAE) (Art. 2 para. 58 MDR) 
An adverse event that resulted in one of the following: 
(a) death; 
(b) serious deterioration in the subject's health resulting in any of the following: 
(i) life-threatening illness or injury, 
(ii) permanent impairment of a body structure or function, 
(iii) hospitalization or extension of an existing hospitalization, 
(iv) medical or surgical intervention to prevent a life-threatening illness or injury or 
permanent impairment of a body structure or function; 
(v) chronic illness, 
(c) fetal distress, fetal death, or a congenital physical or mental impairment or birth defect. 
Note: Planned hospitalizations due to a pre-existing condition or a procedure specified in the 
protocol (CIP) without a serious deterioration in the subject's health are not considered SAE. 
 
Device Deficiency (Art. 2 para. 59 MDR) 
Shortcomings of a medical device related to the identity, quality, durability, reliability, safety, or 
performance of an investigational device, including malfunctions, user error, and insufficient 
information from the manufacturer. 
The definition includes defects in both the test product and the comparator product. 
 
Malfunction (ISO14155) 
The failure of an investigational product to perform its intended function in accordance with the 
instructions for use or protocol (CIP). 
 
Defects of the medical device with SAE potential (Device Deficiency with Serious Adverse 
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(Art. 80 para. 1 letter c MDR; ISO14155) 
Any product defect that could have resulted in a serious adverse event if appropriate measures 
had not been taken, no intervention had been made, or if the circumstances had been less 
favourable. 
 
Adverse Device Effect (ADE) (ISO14155) 
An adverse event that maybe, probably, or causally related to the use of an investigational product 
or associated procedures. 
This includes events resulting from inadequate or incorrect instructions for use, from use, 
implantation, installation or operation, or from malfunctions of the test product. This also includes 
events caused by operating errors or intentional misuse. 
 
Serious Adverse Device Effect (SADE) (ISO14155) 
An adverse reaction of the medical device (ADE) that has led to one of the consequences of a 
serious adverse event. 
 
 Unanticipated Serious Adverse Device Effect (USADE) (ISO14155) 
A serious adverse reaction of the medical device (SADE) that has not been identified in its nature, 
frequency, severity or outcome in the current version of the risk report. 
Note: An anticipated serious adverse reaction of the medical device (Anticipated SADE, ASADE) 
is an effect that has already been identified in the risk report in terms of type, frequency, severity 
or outcome. 
 
Causal relationship of SAEs (MDCG 2020-10/1) 
The causal relationship with the medical device or the methods of investigation is assessed by 
the principal investigator and the sponsor as follows: 
 • 
Unrelated: The association with the product or process can be excluded. 
 • 
Possible: The connection with the use of the test product is weak, but cannot be 
completely ruled out. Alternative causes are also possible. Cases where assessment is not 
possible or no information is available are also considered possible. 
 • 
Probable: The association with the use of the investigational product appears relevant 
and/or the event cannot be meaningfully explained by another cause. 
 • 
Causal relationship: The serious event is unequivocally related to the investigational 
product or procedures. 
5.2 Documentation and reporting in Medical Device Category A clinical investigations 
Device defects (DD) and all adverse events (AE), including all serious adverse events (SAE), are 
recorded, fully investigated, and documented in the source document as well as in the 
corresponding Case Report Forms (CRF) throughout the study period, i.e. from the time of patient 
consent to the last CIP-specific procedure, including a safety follow-up phase. 
 • 
Documentation of AEs (including SAEs) by the investigator includes diagnosis or 
symptoms, start and end dates of the event, treatment of the event, resolution of the event, 
assessment of the severity and causal relationship with the medical device and/or the 
examination procedure (Art. 32 ClinO-MD, ISO14155). 
 • 
Documentation of DDs by the auditor includes the description of the event, the start date, 
information about the examination device, actions taken with respect to the examination device 
and the determination of whether the DD has resulted in an AE. The sponsor examines all DDs 
and decides and documents in writing whether they could have led to an SAE (DD with SADE 
potential) (Art. 32 ClinO-MD, ISO14155). 

 
 
 
 
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Reporting of SAEs (Art. 32 ClinO-MD) 
All SUEs are documented and reported immediately (within a maximum of 24 hours) to the 
sponsor/investigator of the investigation. 
If it cannot be ruled out that the SUE that occurred in Switzerland is due to the intervention under 
investigation, the investigator reports it to the Ethics Committee via BASEC within 15 days. 
 
Follow up of (Serious) Adverse Events 
An aftercare plan is created for the affected subjects, ensuring that they receive appropriate 
medical care and support. Communication with the affected subjects is maintained to monitor 
their recovery . 
 
Notification of safety and protective measures (Art. 32 ClinO-MD) 
If immediate safety and protective measures must be taken during the conduct of the 
investigation, the investigator shall inform the Ethics Committee within 7 days of these measures 
and the circumstances that require them. 
5.2.1 Foreseeable adverse events and anticipated adverse device effects 
Predictable AEs during the application of the MD. 
 
Type of event 
 
Description 
 
Mitigation 
or 
Treatment Measures 
 
Probable 
incidence 
Skin 
irritation 
or 
redness 
 
Localized erythema or 
irritation 
at 
the 
application site due to 
pressure or cold. 
 
use protective materials; 
apply soothing creams 
or gels if necessary. 
Medium 
Pain or discomfort 
 
Temporary 
pain 
or 
discomfort 
during 
or 
after application due to 
refrigeration. 
 
Ask 
participants 
to 
report pain. 
Small 
Decreased 
local 
sensitivity 
 
Temporary 
numbness 
or decreased sensitivity 
due to exposure to cold. 
 
inform participants about 
this possibility; Avoid 
prolonged 
use 
to 
prevent complications. 
Medium 
Slight 
swelling 
or 
edema 
 
Localized swelling due 
to prolonged cooling or 
improper use. 
 
Monitor application time; 
elevate 
the 
affected 
area; 
Reduce 
application 
time 
for 
subsequent 
applications. 
Small 
 
No SAEs are expected. 
5.2.2 Reporting of Safety related events 
Reporting to the Sponsor: 
All Serious Adverse Events (SAEs), Equipment Defects (DDs) with potential for SAEs, and health 
hazards requiring action will be reported by the investigator (or authorized representative) to the 

 
 
 
 
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sponsor immediately upon becoming aware of the event. DDs are evaluated as to whether they 
could lead to an SAE. 
 
Pregnancies 
Pregnant or breastfeeding women are excluded from participating in the examination. Participants 
who become pregnant during the study must notify the study leader immediately and are not 
allowed to continue participating in the study. However, the examination does not pose a risk to 
pregnant women. 
 
Reporting to the Competent Ethics Committee: 
The sponsor shall immediately notify the Ethics Committee of any SAE in which a causal 
relationship between the event and the clinical trial test procedure has been established (Art. 33 
ClinO-MD). 
To ensure prompt notification, the sponsor may first submit an incomplete notification. 
In the event that safety or health risks arise during the conduct of the investigation that require 
immediate action, the sponsor shall inform the Ethics Committee within 2 days of these measures 
and the circumstances that made them necessary (Art. 34 ClinO-MD). 
 
Periodic safety reporting (Art. 35 ClinO-MD): 
Once a year, the sponsor submits a list of SAEs and DDs to the Ethics Committee and submits a 
report on their severity, the causal relationship with the device and the intervention, and the safety 
of the participants. The sponsor informs the Ethics Committee annually about the general 
progress of the clinical trial. 
 
Materiovigilance reporting to Swissmedic: 
The sponsor is responsible for ensuring that Swissmedic  is informed of serious incidents in 
accordance with Art. 66 MedDO. 
Mate vigilance reports are not sent to the Ethics Committee. 
If the sponsor is not the manufacturer of the device under investigation or the Swiss representative 
of the manufacturer: 
 • 
In the event of incidents, verify that the event has occurred in accordance with Art. 66 
para. 4 MedDO is subject to the reporting obligation (using the instructions 
MU680_20_008e_WL). 
 • 
The sponsor must ensure that reportable incidents are sent to Swissmedic using Form 
MU680_20_015d_FO (materiovigilance@swissmedic.ch). 
 • 
Users are required by law to inform the suppliers of the equipment (Art. 66 para. 4 
MedDO). 
 
5.3 Radiation 
No radiation is included in this examination.   
5.4 Amendments (Art. 15 ClinO-MD) 
Significant changes to the study structure, organisation, protocol and associated study documents 
will be submitted to the Ethics Committee for approval in accordance with Art. 15 ClinO-MD before 
implementation. In addition, a list of non-material changes is reported annually to the EC, together 
with the CSA or the general study progress report. 
5.5 Notification and reporting upon completion, discontinuation or interruption of the 

 
 
 
 
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Investigation 
After the regular conclusion of the investigation, the Ethics Committee will be informed about 
BASEC within 30 days in accordance with Article 38 of the ClinO-MD. 
The sponsor/investigator may terminate the investigation early in certain circumstances, such as: 
 
• 
ethical concerns, 
 
• 
Insufficient participant recruitment, 
 
• 
doubts about the safety of the participants or if the participants are at risk (e.g. if 
the benefit-risk assessment is no longer positive), 
 
• 
Changes in accepted clinical practice that make it no longer make sense to 
continue the investigation, 
 
• 
Early indications of harm or benefit of experimental intervention. 
 
In the event of an early termination or interruption of studies, the Ethics Committee will be 
informed of BASEC within 15 days in accordance with Article 38 of the ClinO-MD. 
 
Within 12 months of completion or termination of the investigation, a final report is submitted to 
the Ethics Committee via BAREC, unless a longer period is provided for in the protocol (Article 
38 ClinO-MD). 
5.6 Insurance 
There is a business liability insurance with Baloise Insurance for Thim van der Laan AG in 
Landquart, where the investigation is carried out.  
6 
FURTHER ASPECTS 
6.1 Overall ethical considerations 
The study is carried out on healthy volunteers. Participants can opt out of the investigation at any 
time without consequences, as indicated in the informed consent form. The sample of healthy 
participants between the ages of 18 and 30 reflects a population that engages in regular physical 
activity, so the results are transferable to the general population. To prioritize the safety of 
participants, vulnerable populations such as pregnant women and those with certain health 
conditions were excluded to minimize possible adverse reactions. The results of this research 
can provide valuable insights into the mechanisms and application of recovery strategies after 
exercise. The use of a randomized controlled trial design is scientifically rigorous and minimizes 
bias. By considering covariates (e.g., gender) in randomization, the study increases internal 
validity and reduces the potential for confounding variables. The informed consent form explicitly 
states that participants will be informed of personal findings and random results relevant to their 
health (e.g. abnormal blood values).   
6.2 Risk-benefit assessment  
There are no health risks associated with participation in this examination. The CE-certified cold 
packs used in this study (Axanova Cold Hot Pearls Maxi Pack, Axanova AG) have been specially 
developed to exert a safe cooling effect on the affected muscle tissue. The product is used 
according to the instructions for use. As stated in the declaration of consent, the instructions for 
use of the CE-certified cold packs (Axanova Cold Hot Pearls Maxi Pack, Axanova AG) refer to 
the possibility of overcooling and the subsequent development of local frostbite due to local cold 
application. Through explicit instructions on use, duration, and frequency, the protocol helps 

 
 
 
 
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ensure that participants use the ice packs correctly, minimizing the risk of adverse effects and 
optimizing the intended appropriate cooling effect on muscle tissue.   
As stated in the informed consent form, participants must expect to fatigue and become sore 
muscles due to the physical exertion from the knee extensor protocol and the measurement of 
the maximum isometric contraction level associated with a medium to high intensity. However, 
these complaints are not considered a significant health risk. The study design aims to ensure a 
safe and controlled practice environment with minimal potential for injury.  
Venous blood samples were taken from a cubital vein by a trained specialist. However, as stated 
in the consent form for blood collection, there is a possibility that bruising, bleeding or swelling 
may occur at the injection site. 
Participation in the study does not bring any direct benefit to the participants. While there is no 
direct personal benefit, participation in this research has the potential to provide valuable data for 
the scientific community. The results could benefit future athletes, people who engage in physical 
activity, and patients by shedding light on the best practices for post-exercise recovery. 
7. QUALITY CONTROL AND DATA PROTECTION 
7.1 Quality measures  
Monitoring is carried out by Dr. Biomed. Ing. Ursula Hohenauer-Küng from the institution THIM - 
The International University of Physiotherapy, Weststrasse 8, 73002 Landquart.  
In her function as a monitor of the examination, Dr. Ursula Hohenauer-Küng ensures that the 
examination is carried out and documented correctly. A detailed description of her activities as a 
monitor is listed below in point 9. This ensures that Dr. Biomed. Ing. Ursula Hohenauer-Küng is 
independent of the study team and is not employed by the examiner of the study. 
For quality assurance, the sponsor, the ethics committee or an independent study monitor can 
visit the research facilities. On such occasions, direct access to the source data and all study-
related files is granted. All parties involved treat the subject data in the strictest confidence.   
 
 

 
 
 
 
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7.2 Data recording and source data 
The answers to the checklist, demographic and anthropometric data (gender, age, height, weight, 
estimated lower body fat percentage), room conditions (temperature, relative humidity), muscle 
soreness, and maximum isometric contraction force are manually recorded in the CRF. The data 
is then transferred in Microsoft Excel to the research computer of the research laboratory. 
Activation of the "Track Changes" option is ensured in the Excel file to ensure data protection and 
security. In addition, the Excel file is password-protected and backups are carried out regularly 
after measurements. 
The study participants who run and document the application at home upload the images directly 
to a dedicated folder on Microsoft OneDrive for Business via a secure, password-protected link. 
It uses Azure Information Protection (AIP) to ensure secure transmission (with TLS/SSL 
encryption) and secure storage of data. The uploaded images are only accessible to authorized 
members of the study team, and storage is done in accordance with applicable data protection 
regulations. After the scan is completed or after the retention period has expired, the images are 
securely and completely deleted. 
The blood sinking velocity is determined on site in the research laboratory using the Westergren 
method. The blood samples are then destroyed. The remaining parameters are determined by an 
external laboratory (Dr. Riesch, Buchs). After the blood is taken, the samples are picked up by a 
blood courier during the same day and taken to the medical laboratory, where the standardized 
analyses are performed. The creatine kinase values are determined by the ultraviolet method and 
the C-reactive protein values by the turbidimetric method. The blood samples are destroyed by 
the external laboratory and the reports are sent to us. We keep these reports confidential for a 
period of 10 years. The external laboratory only receives the numerical code of the participants 
(e.g. 001, 002, 003, etc.). No conclusions can be drawn from the external laboratory about the 
test subjects.  
The images for the examination of muscle swelling are stored on an ultrasound machine. Only 
the numerical code is stored in the ultrasound machine and no personal data. It is not possible to 
draw conclusions about the test persons on the basis of the numerical code. The ultrasound 
machine is the property of the research laboratory and is operated only by research staff.  
The key to the code is only with the principal investigator of this study. Only the study leader can 
decipher the code.  
7.3 Confidentiality and coding 
Study and participant data will be treated with the utmost discretion and will only be accessible to 
authorized personnel who need the data to perform their duties as part of the investigation. On 
the CRFs and other study-specific documents, participants are identified only by a numerical 
participant number. No personal data is presented or published. The signed declaration of 
consent and the completed checklist are kept in the original as a study document in a locked filing 
cabinet.    
 
 

 
 
 
 
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7.4 Retention and destruction of Investigation data and biological material 
All study data will be archived for 20 years after the end of the study or premature termination of 
the examination. After this period, all data will be securely destroyed in accordance with the 
applicable data protection regulations and the guidelines of the study protocol. This applies to 
both the electronic data and all biological samples collected during the examination. The 
destruction is carried out in a secure way, for example by encrypting and completely deleting the 
electronic data and by physically destroying biological materials in order to exclude any possibility 
of reconstruction or identification of test subjects. If longer storage is necessary, for example for 
regulatory or scientific reasons, this will be coordinated in advance with the responsible ethics 
committees and authorities. 
8  MONITORING AND REGISTRATION 
The monitoring is carried out by Dr. Ursula Hohenauer-Küng from the institution THIM - The 
International University of Physiotherapy, Weststrasse 8, 73002 Landquart. Dr. biomed. Ing. 
Ursula Hohenauer-Küng ensures that the investigation is properly conducted and documented by 
performing the following activities, provided that they are relevant and necessary for the 
investigation: 
• 
Verify that the investigator has and maintains adequate qualifications and resources 
throughout the duration of the study, that the facilities, including laboratories, equipment, 
and personnel, are suitable for the safe and proper conduct of the study and are 
maintained throughout the duration of the study. 
• 
Review of study interventions 
• 
Ensuring that the conditions for the interventions are acceptable. 
• 
Verify that the study interventions are only made available to those subjects who are 
eligible. 
• 
Ensuring that examinees are given the necessary instructions on the study interventions. 
• 
Verify that the auditor is complying with the approved protocol and, if applicable, any 
approved changes. 
• 
Verify that written informed consent has been obtained prior to each examinee's 
participation in the investigation. 
• 
Ensuring that the auditor and the auditor's audit staff are adequately informed about the 
audit. 
• 
Verify that the examiner is recruiting only eligible examinees. 
• 
Reporting on the subject recruitment rate. 
• 
Verify that the auditor provides all required reports, notifications, applications, and 
submissions, and that these documents are accurate, complete, timely, legible, dated, 
and identify the review. 
• 
Verify that adverse events, concomitant medications and intercurrent diseases are 
reported according to the protocol on the CRFs. 
• 
Ensuring that missed visits by the examinees, tests and examinations that were not 
carried out are clearly identified as such in the examination forms. 
• 
All withdrawals and discontinuations of enrolled subjects from the study are reported and 
explained on the CRFs. 
 
 

 
 
 
 
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Source Data Verification (SDV) is also carried out as part of the monitoring to ensure the accuracy 
and integrity of the study data. This includes the following specific activities: 
• 
Verification of sources and original data: It verifies that all data collected in the CRFs 
matches the original, primary data sources, such as participant data, lab reports, and 
notes from investigations. 
• 
Control of study participants' documentation: Verify that all relevant demographic and 
medical data (e.g., age, gender, medical history, test results) are correctly captured and 
consistent with the original records. 
• 
Verification of informed consent: Ensuring that each participant has written and informed 
consent prior to the start of the study. 
• 
Adverse Event (AE) Review: Confirmation that all adverse events and concomitant 
medications are documented correctly and in accordance with the protocol. 
• 
Control of study interventions: Verification that only eligible participants have received the 
study interventions and that all intervention data has been properly recorded. 
• 
Examination of dropouts and non-perceptions: Verification that all abandonments from 
study visits and non-attendances have been properly noted and declared in the CRFs. 
These measures ensure that the investigation meets the highest standards of data integrity and 
security, and that all recorded data is accurate and reliable. 
9. FUNDING / PUBLICATION / DECLARATION OF INTEREST 
This study is financed by Thim van der Laan AG in Landquart. The auditors are employed by this 
institute and are remunerated for their work on this study in accordance with their employment 
contracts. No further financial support is needed. 
The sponsor shall enter and publish the summary of the study results in a public register in 
accordance with ClinO Art. 65a within one year of completion or termination of the investigation. 
An interruption of more than two years is considered to be an interruption of the investigation. For 
publication in the public register, the sponsor shall also ensure that an easy-to-understand 
summary of the study results is entered in BASEC within one year of completion or termination 
of the study. The entry is made at least in the national language of Switzerland in which the study 
participants were recruited. 
 

 
 
 
 
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10. REFERENCES 
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Cochrane Database Syst Rev, 2, CD008262. doi:10.1002/14651858.CD008262.pub2 
Hohenauer, E., Taeymans, J., Baeyens, J.P., Clarys, P., & Clijsen, R. (2015). The Effect of Post-
Exercise Cryotherapy on Recovery Characteristics: A Systematic Review and Meta-Analysis. 
PLoS One, 10(9), e0139028. doi:10.1371/journal.pone.0139028 
Hubbard, T. J., & Denegar, C. R. (2004). Does Cryotherapy Improve Outcomes With Soft Tissue 
Injury? J Athl Train, 39(3), 278-279. 
Ostrowski, J., Purchio, A., Beck, M., Leisinger, J., Tucker, M., & Hurst, S. (2018). Examination of 
Intramuscular and Skin Temperature Decreases Produced by the PowerPlay Intermittent 
Compression Cryotherapy. J Sport Rehabil, 27(3), 244-248. doi:10.1123/jsr.2016-0244 
Ruas, C., Latella, C., Taylor, J., Gregory Haff, G., Nosaka, K. (2022). Comparison between 
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Chow, S.C., Shao, J., Wang, H., and Lokhnygina, Y. 2018. Sample Size Calculations in Clinical 
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Raton, FL. Pages 86-88. 
 
Machin, D., Campbell, M.J., Tan, S.B., and Tan, S.H. 2018. Sample Sizes for Clinical, Laboratory, 
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Julious, Steven A. 2004. 'Tutorial in Biostatistics. Sample sizes for clinical trials with Normal data.'  
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Zar, Jerrold H. 1984. Biostatistical Analysis (Second Edition). Prentice Hall. Englewood Cliffs, 
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