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Cold-
and
Hot-Pack
Contrast
Therapy:
Subcutaneous
and
Intramuscular
Temperature
Change
J.
William
Myrer,
PhD;
Gary
Measom,
RN,
PhD;
Earlene
Durrant,
EdD;
Gilbert
W.
Fellingham,
PhD
Objective:
To
investigate
the
temperature
changes
in
sub-
cutaneous
and
intramuscular
tissue
during
a
20-minute
cold-
and
hot-pack
contrast
therapy
treatment.
Design
and
Setting:
Subjects
were
randomly
exposed
to
20
minutes
of
contrast
therapy
(5
minutes
of
heat
with
a
hydrocol-
lator
pack
followed
by
5
minutes
of
cold
with
an
ice
pack,
repeated
twice)
and
20
minutes
of
cold
therapy
(ice
pack
only)
in
a
university
laboratory.
Subjects:
Nine
men
and
seven
women
with
no
history
of
peripheral
vascular
disease
and
no
allergy
to
cephalexin
hydro-
chloride
volunteered
for
the
study.
Measurements:
Subcutaneous
and
intramuscular
tissue
temperatures
were
measured
by
26-gauge
hypodermic
needle
microprobes
inserted
into
the
left
calf
just
below
the
skin
or
1
cm
below
the
skin
and
subcutaneous
fat,
respectively.
C
ontrast
therapy,
the
repeated
alternation
of
thermother-
apy
and
cryotherapy,
is
a
common
treatment
for
post-
acute
soft
tissue
injury.'1-3
Though
long
used,
scientif-
ically
validated
parameters
for
temperature,
sequence
order,
time
for
heat
and
cold,
and
total
treatment
time
have
not
been
established.
Myrer
et
al'4
was
the
only
previous
study
found
that
investigated
the
effects
of
contrast
therapy
on
intramuscu-
lar
temperature.
Myrer
et
al
studied
the
intramuscular
temper-
ature
change
experienced
1
cm
below
the
skin
and
subcutane-
ous
fat
in
the
lower
leg
over
a
20-minute
treatment.
The
treatment
was
a
4-minute
hot
immersion
(40.6°C)
followed
by
a
1-minute
cold
immersion
(15.6°C)
repeated
four
times.
They
concluded
that
"contrast
therapy
as
studied
is
incapable
of
producing
any
significant
physiological
effect
on
the
intramus-
cular
tissue
temperature
1
cm
below
the
skin
and
subcutaneous
tissue."14
We
propose
that,
for
most
of
the
physiologic
effects
attrib-
uted
to
contrast
therapy
to
occur,
substantial
fluctuations
in
tissue
temperature
must
be
produced
with
the
alternations
from
the
heat
to
the
cold
or
vice
versa.
Because
our
primary
investigation
failed
to
prove
the
effectiveness
of
the
most
accepted
regimen
for
contrast
therapy,
it
is
critical
to
determine
whether
other
protocols
produce
the
fluctuations
we
feel
are
necessary
to
manifest
the
physiologic
effects
attributed
to
contrast
therapy.
J.
William
Myrer
is
an
associate
professor
of
physical
education,
Gary
Measom
is
an
assistant
professor
of
nursing,
Earlene
Durrant
is
a
professor
and
department
chair
of
physical
education,
and
Gilbert
W.
Fellingham
is
an
associate
professor
of
statistics
at
Brigham
Young
University
in
Provo,
UT
84603-2717.
Results:
With
contrast
therapy,
muscular
temperature
did
not
fluctuate
significantly
over
the
20-minute
period
compared
with
the
subcutaneous
temperature,
which
fluctuated
from
80C
to
140C
each
5-minute
interval.
When
subjects
were
treated
with
ice
alone,
muscle
temperature
decreased
70C
and
subcu-
taneous
temperature
decreased
170C
over
the
20-minute
treat-
ment.
Conclusions:
Our
results
show
that
contrast
therapy
has
little
effect
on
deep
muscle
temperature.
Therefore,
if
most
of
the
physiologic
effects
attributed
to
cold
and
hot
contrast
therapy
depend
on
substantial
fluctuations
in
tissue
tempera-
ture,
contrast
therapy
needs
to
be
reconsidered
as
a
viable
therapeutic
modality.
Key
Words:
cryotherapy,
thermotherapy,
rehabilitation
The
purpose
of
this
in
vivo
study
was
to
investigate
the
temperature
change
in
subcutaneous
and
intramuscular
tissue
during
a
20-minute
cold-
and
hot-pack
contrast
therapy
treatment.
METHODS
Sixteen
college
students
(9
men,
age
=
25.2
±
3.4
yr,
wt
=
82.9
±
12.7
kg,
calf
skinfold
=
17.2
7.5
mm,
calf
girth
=
38.8
±
2.4
cm;
7
women,
age
=
21.1
2.5
yr,
wt
=
58.3
±
9.6
kg,
calf
skinfold
=
20.9
+
8.0
mm,
calf
girth
=
35.2
±
2.4
cm)
volunteered
as
subjects
and
signed
Brigham
Young
University's
approved
consent
form.
We
verbally
screened
subjects
for
a
history
of
peripheral
vascular
disease
or
allergy
to
cephalexin
hydrochloride
(Keftab,
Dista
Products,
Indianap-
olis,
IN).
To
minimize
the
risk
of
infection,
we
administered
one
500-mg
dose
of
cephalexin
hydrochloride
immediately
before
the
experiment.
Each
subject
was
instructed
to
take
three
similar
doses
at
6-hour
intervals
following
the
conclusion
of
the
experiment.
All
subjects
participated
in
both
treatments
(contrast
and
control).
The
experimental
design
was
stratified
to
ensure
that
eight
subjects
would
begin
with
contrast
and
that
the
other
eight
would
begin
with
the
control
treatment.
For
all
subjects,
we
measured
height,
weight,
and
maximum
calf
girth
of
the
left
lower
leg.
The
skinfold
of
the
posterior
left
lower
leg
was
measured
with
a
Lange
Skinfold
Caliper
(Cambridge
Scientific
Industries,
Ltd,
Cambridge,
MD),
and
we
divided
this
measurement
by
two
to
determine
the
depth
of
subcutaneous
fat
over
each
subject's
gastrocnemius.
Subjects
assumed
a
prone
position
on
a
standard
examining
table.
A
4
X
4-cm
area
of
skin
was
shaved
over
the
left
medial
calf.
We
cleansed
this
area
thoroughly,
first
with
a
10%
povidone-iodine
238
Volume
32
*
Number
3
*
September
1997
(Betadine,
Purdue
Frederick,
Norwalk,
CT)
scrub
and
then
with
a
70%
isopropyl
alcohol
swab.
Subcutaneous
and
muscle
tissue
temperatures
were
mea-
sured
with
26-gauge
hypodermic
needle
microprobes
(Physi-
temp
MT-26/2
and
MT-26/4,
Physitemp
Instruments,
Inc,
Clifton,
NJ).
The
microprobes
were
sterilized
in
a
gas
auto-
clave
using
ethylene
oxide,
following
hospital
sterilization
procedures.
The
intramuscular
microprobe
(MT-26/4)
was
inserted
from
the
side
into
the
left
medial
calf.
The
sensor
tip
of
this
probe
was
positioned
in
the
center
of
the
lower
leg
to
a
depth
of
1
cm
below
the
subcutaneous
fat
and
skin.
Both
microprobes
were
inserted
using
sterile
technique.
We
mea-
sured
the
appropriate
vertical
distance
down
from
the
posterior
surface
of
the
lower
leg
with
a
caliper
to
ensure
that
the
probe
was
inserted
at
the
proper
depth.
14
A
second
probe
(MT-26/2)
was
inserted
just
below
the
skin,
perpendicular
to
the
first,
so
that
its
sensor
tip
was
approximately
0.5
cm
distal
to
the
sensor
tip
of
the
first
probe
(Fig
1).
The
microprobes
were
then
connected
to
a
digital
monitor
(Bailey
Instruments
BAT-12,
Physitemp
Instruments,
Inc)
and
after
3
minutes
the
baseline
intramuscular
and
subcutaneous
temperatures
were
recorded.
The
control
(ice)
treatment
group
had
a
1.8-kg
ice
pack
(approximately
25
X
30
X
5
cm)
placed
directly
over
the
triceps
surae
muscle
group
for
20
minutes
(Fig
2).
The
contrast
group
first
had
a
5-minute
application
of
a
standard
hydrocol-
lator
pack
(25
X
30
cm)
consisting
of
hydrophilic
silicate
gel
encased
in
a
canvas
outer
cover
(Tropic
Pac,
JA
Preston
Corporation,
Jackson,
MI).
This
was
followed
by
a
cold
treatment
similar
to
that
of
the
control
group,
but
for
only
5
minutes.
This
was
repeated
twice
for
a
total
treatment
time
of
20
minutes.
The
hydrocollator
was
thermostatically
controlled
at
75°C
(Model
MZ,
Chattanooga
Corporation,
Chattanooga,
TN).
A
commercial
terry
cloth
cover
and
two
layers
of
toweling
were
used
to
protect
the
subjects
from
excessive
heat
(Fig
3).
After
the
first
hot-pack
application,
the
hydrocollator
pack
was
immediately
returned
to
the
hydrocollator
until
needed
for
the
second
application.
We
recorded
intramuscular
and
subcutaneous
temperatures
every
30
seconds
over
the
entire
treatment
time
and
for
30
minutes
posttreatment.
Imme-
diately
following
the
30-minute
posttreatment
period
of
the
first
treatment
we
began
the
second
treatment.
At
the
conclu-
Fig
1.
Insertion
of
the
subcutaneous
needle
microprobe.
Fig
2.
Placement
of
the
ice
pack,
directly
on
the
skin,
over
the
triceps
surae
muscle
group.
Fig
3.
Placement
of
the
hydrocollator
pack
over
the
triceps
surae
muscle
group,
which
has
been
wrapped
in
a
terry
cloth
cover
over
two
layers
of
toweling.
sion
of
the
second
treatment
and
recovery
period,
we
removed
the
microprobes,
dried
the
limb,
swabbed
the
area
with
70%
isopropyl
alcohol,
and
applied
an
adhesive ban-
dage
over
the
site.
We
recorded
the
dry
and
wet
bulb
temperatures
and
relative
humidity
of
the
room
over
the
duration
of
the
study.
We
performed
a
multivariate
analysis
of
variance
(MANOVA)
(p
<
.05)
on
our
data
to
determine
whether
a
significantly
different
pattern
of
temperature
change
existed,
from
baseline
through
each
5-minute
interval
to
the
end
of
treatment,
between
the
contrast
and
control
groups
and
be-
tween
the
subcutaneous
and
intramuscular
tissue.
We
analyzed
the
magnitude
of
the
temperature
change
from
baseline
in
5-minute
intervals
(5,
10,
15,
and
20
minutes)
for
each
treatment
and
tissue
with
paired
t
tests.
Paired
t
tests
were
also
used
to
analyze
the
rate
of
temperature
change
between
adjacent
5-minute
intervals.
We
used
Pearson's
product-
moment
correlation
to
determine
the
relationship
between
intramuscular
temperature
change
and
gender,
weight,
calf
girth,
and
calf
skinfold
in
the
contrast
and
the
control
groups.
Journal
of
Athletic
Training
239
RESULTS
There
were
significant
differences
between
treatments
and
tissues
in
the
patterns
of
temperature
changes
from
baseline
through
each
5-minute
interval
to
the
end
of
treatment
(F(12,
151)
=
44.0,
p
=
.0001)
(Fig
4).
Muscle
temperature
in
the
contrast
group
did
not
fluctuate
significantly
throughout
the
treatment
after
the
initial
increase
due
to
the
first
hot-pack
application.
Subcuta-
neous
tissue
temperature,
however,
did
fluctuate
significantly
from
baseline
and
between
hot
and
cold
applications
during
the
contrast
treatment
(Tables
1
and
2).
During
the
contrast
treatment,
the
mean
temperature
change
subcutaneously
varied
from
8°C
to
14°C
over
each
5-minute
interval
of
contrast
(p
<
.0001),
while
the
greatest
mean
fluctuation
intramuscularly
was
approximately
0.50C.
The
control
(ice)
group
experienced
significant
temperature
decreases
from
baseline
and
between
5-minute
intervals
throughout
the
20-minute
treatment
(Tables
1
and
2).
The
20-minute
ice
treatment
decreased
intramuscular
and
subcuta-
neous
temperatures
approximately
7°C
and
17°C
respectively
(p
<
.0001).
There
were
no
significant
correlations
between
intramuscu-
lar
or
subcutaneous
temperature
changes
and
gender,
weight,
or
calf
girth
in
the
contrast
and
the
control
groups.
There
was
not
a
significant
correlation
between
skinfold
and
subcutane-
ous
temperature
change
in
either
group.
However,
there
were
significant
correlations
between
skinfold
and
intramuscular
temperature
change
in
both
the
contrast
and
control
groups.
In
the
ice
group
there
was
a
significant
(p
<
.05)
negative
correlation
between
skinfold
and
temperature
change
for
the
first
15
minutes
of
the
treatment.
That
is,
the
lower
the
skinfold,
the
greater
the
intramuscular
temperature
change
and
Mean
Temperature
Change
Over
Time
0
5
10
15
20
Time
(Minutes)
Fig
4.
Temperature
change
during
the
contrast
and
control
treat-
ments
in
subcutaneous
and
intramuscular
tissue.
Table
1.
Temperature
Change
from
Baseline
Muscle
Subcutaneous
Treatment
Time
(min)
(0C
±
2
SE)
(0C
±
2
SE)
Contrast
baseline
33.31
±
1.43
31.04
±
1.25
5
.74
±
0.35*
8.13
±
1.34*
10
.46
±
0.53
-6.03
±
2.03*
15
.27
±
0.67 5.68
±
1.42*
20
.24
±
1.02
-5.84
±
2.89*
Control
(Ice)
baseline
34.91
±
0.72
32.78
±
0.54
5
-1.94
±
1.43*
-10.87
±
2.23*
10
-3.88
±
1.83*
-13.81
±
1.87*
15
-5.67
±
2.01*
-15.60
±
1.82*
20
-7.09
±
2.04*
-16.97
±
1.91*
*Significant
(p
<
.05)
Table
2.
Temperature
Change
Between
Adjacent
5-Min
Intervals
Muscle
Subcutaneous
Treatment
Interval
(min)
(°C
±
2
SE)
(°C
±
2
SE)
Contrast
baseline
33.31
±
1.43
31.04
±
1.25
0-5
0.74
±
0.35*
8.13
±
1.34*
5-10
-0.28
±
0.59
-14.16
±
2.41*
10-15
-0.19
±
0.41
11.71
±
1.96*
15-20
-0.51
±
0.63
-11.53
±
3.48*
Control
(Ice)
baseline
34.91
±
0.72
32.78
±
0.54
0-5
-1.94
±
1.43*
-10.87
±
2.23*
5-10
-1.94
±
0.54*
-2.94
±
0.65*
10-15
-1.79
±
0.39*
-1.79
±
0.37*
15-20
-1.42
±
0.36*
-1.37
±
0.29*
*
Significant
(p
<
.05)
vice
versa.
In
the
contrast
group
during
the
hot-pack
applica-
tion
there
was
not
a
significant
correlation
between
skinfold
and
intramuscular
temperature
change,
but
during
the
ice-pack
application
there
was
a
negative
correlation
(p
<
.05).
The
dry
and
wet
bulb
temperatures
and
relative
humidity
of
the
room
were
22.7
±
0.58°C,
12.9
±
0.88°C,
and
32.6
±
5.8%,
respectively,
over
the
duration
of
the
study.
DISCUSSION
The
information
concerning
the
use
and
effectiveness
of
con-
trast
therapy
in
sports
medicine
has
largely
been
empirical.
Myrer
et
al'4
was
the
first
study
to
scientifically
examine
the
common
hydrotherapy
contrast
protocol
of
a
4-minute
bath
in
hot
water
followed
by
a
1-minute
bath
in
cold
water,
repeated
four
times.
We
undertook
this
investigation
because
the
results
of
that
first
study
indicated
that
nonsignificant
temperature
fluctuations
oc-
curred
between
hot
and
cold
immersions,
as
well
as
over
the
total
treatment.
In
an
attempt
to
see
if
we
could
produce
the
significant
temperature
fluctuations
we
feel
are
necessary
to
produce
the
physiologic
effects
attributed
to
contrast
therapy,
we
varied
several
factors
from
the
Myrer
et
al'4
study.
We
changed
the
modality
from
hydrotherapy
to
ice
packs
and
hydrocollator
packs.
This
produced
a
greater
temperature
gradient
between
the
heat
and
the
cold
than
that
produced
in
Myrer
et
al.'4
The
greater
the
temperature
gradient,
the
greater
the
heat
transfer.8,15-19
We
also
increased
the
duration
of
each
heat
and
cold
application.
The
longer
the
superficial
heat
or
cold
is
applied,
the
greater
the
total
heat
transfer.8"15-18
Finally,
because
we
know
that
the
depth
that
240
Volume
32
*
Number
3
*
September
1997
we
measure
is
critical
to
the
amount
of
heat
transfer,8"17'19'20
we
measured
the
intramuscular
temperature
at
the
same
depth
as
that
first
study
(1
cm
below
the
skin
and
subcutaneous
fat).
In
addition,
however,
we
examined
temperature
change
subcutaneously,
just
below
the
skin.
In
spite
of
these
changes,
our
intramuscular
results
remained
the
same
as
the
results
found
in
Myrer
et
al.
14
The
largest
temperature
change
from
the
end
of
one
pack
treatment
to
the
end
of
the
next
was
0.51
±
1.25°C,
compared
with
0.15
+
0.
10°C,
the
temperature
change
from
one
immersion
to
the
end
of
the
next
in
that
first
study.
The
temperature
change
from
the
beginning
to
the
end
of
the
treatment
in
this
study
was
0.24
+
2.03°C;
in
that
first
study
it
was
0.39
±
0.46°C.
Once
again,
contrast
therapy
was
incapable
of
producing
any
significant
physiologic
effect
on
the
intramuscular
tissue
temperature
1
cm
below
the
skin
and
subcutaneous
fat.
It
is
interesting
to
note
that
significant
fluctuations
in
temperature
did
occur
subcutaneously
from
the
end
of
one
pack
treatment
to
the
end
of
the
next
and
from
the
beginning
to
the
end
of
the
treatment
(Tables
1
and
2).
This
could
conceivably
result
in
changes
in
peripheral
circulation
to
the
integument.
Together
with
the
changes
in
sensation
of
heat
and
cold
in
the
skin,
this
perhaps
accounts
for
the
commonly
held
belief
that
contrast
therapy
reduces
edema
through
a
"pumping
mecha-
nism"
resulting
from
vasoconstriction
and
vasodilation.6"2
Even
if
such
a
phenomenon
existed,
increased
blood
flow
to
the
injured
area
would
not
result
in
edema
reduction.6
Edema
reduction
requires
the
removal
of
extravascular
fluid
and
proteins
from
the
injury
site.6'21
This
is
accomplished
by
the
lymphatic
system,
not
the
circulatory
system.
The
lymphatic
system
is
a
passive
system,
and
fluid
movement
is
dependent
upon
gravity
(elevation)
and
external
force
provided
by
mus-
cular
contraction
or
compression.6'222
Circulatory
changes
have
little
effect
on
lymph
flow.
The
effect
of
adipose
as
an
insulator
has
been
mentioned
by
numerous
researchers.
8,16,17,19,23,24
In
the
control
(ice)
treat-
ment
group
our
results
indicated
that
the
amount
of
adipose
was
a
significant
factor
for
15
minutes.
There
was
a
significant
inverse
relationship
between
skinfold
and
temperature
de-
crease.
This
is
very
important
when
you
consider
that
for
75%
of
a
20-minute
cold
treatment
the
amount
of
fat
overlying the
target
tissue
was
a
significant
factor
in
the
temperature
reduc-
tion
accomplished.
In
the
contrast
group
it
was
interesting
to
note
that
only
during
the
cold-pack
application
was
there
a
significant
correlation
between
skinfold
and
temperature
change.
We
saw
that,
as
skinfold
increased,
the
magnitude
of
temperature
fluctuation
during
the
cold
applications
decreased.
The
delay
from
the
change
in
treatment
(heat
to
cold
or
vice
versa)
to
the
change
in
direction
of
temperature
(increase
or
decrease)
was
also
longer
as
the
skinfold
increased.
This
occurred
probably
because
the
temperature
gradient
between
the
ice
and
the
skin
was
greater
than
that
between
the
hydrocollator
and
the
skin.
We
concur
with
other
stud-
ies8
'4,17,24
in
recommending
that
the
percentage
of
body
fat
be
considered
when
using
a
modality
that
involves
heating
or
cooling
via
conduction.
Our
results
indicate
that
if
most
of
the
physiologic
effects
attributed
to
contrast
therapy
depend
on
substantial
fluctuations
in
intramuscular
tissue
temperature,
then
contrast
therapy
needs
to
be
reconsidered
as
a
viable
treatment
modality.
Further
research
using
an
injured
model,
human
or
animal,
would
shed
additional
light
on
the
efficacy
of
contrast
therapy.
ACKNOWLEDGMENTS
We
acknowledge
partial
funding
of
this
project
by
a
Faculty
Fellow-
ship
Grant
from
Brigham
Young
University
College
of
Physical
Education.
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241
