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Contrast Hydrotherapy

Exercising tissues with quick temperature changes for injury recovery, especially repetitive strain injuries

updated (first published 2009)
by Paul Ingraham, Vancouver, Canadabio
I am a science writer and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I was the Assistant Editor of ScienceBasedMedicine.org for several years. I’ve written hundreds of articles and several books, and I’m known for readable but heavily referenced analysis, with a touch of sass. I am a runner and ultimate player. • more about memore about PainScience.com
Photograph of vintage water faucets labelled hot and cold, representing cryotherapy and thermotherapy.

Ice packs and heating pads are familiar rehabilitation tools, but many people have never heard of therapeutic contrasting: quickly changing tissue temperature from hot to cold and back again. This is usually achieved with hot and cold water, either dunking a limb or even immersing the whole body. The technique is most familiar to serious athletes, who believe — without much justification, I’m afraid — that it helps them get back in the game quicker.

For injury recovery, contrasting is a good, cheap, safe, and simple idea, and I promise that it feels better than it sounds, when it’s done right. The point is to force your tissues to adapt to the sudden changes, which is stimulatory and requires a lot of metabolic activity and circulatory gymnastics. Basically, contrasting constitutes an extremely gentle tissue workout: stimulation without stress, and strong sensations without movement, which can be particularly helpful for a body part that badly needs some rest while it heals.

Contrasting is not strong medicine, but it is at least safe, cheap, easy

Contrasting probably has some minor medical benefits, but it’s certainly not going to work any miracles. There is no reason to believe that contrasting would make a large difference in healing. In particular, it will probably not meaningfully “accelerate healing” from tissue traumas like sprains and strains.

What does the science say? Not much, unfortunately — just a handful of studies, mostly about athletic recovery, and mostly notable for failing to turn up anything promising.1 Even icing alone is barely studied!2

If contrasting promotes recovery from exercise, it can’t be much. That fits a general pattern: nothing seems to help with recovery from exercise, I’m afraid.3 This article focusses on contrasting for recovery from injury, which is definitely unproven, but more reasonable and plausible, costs nothing, and almost perfectly risk-free. But …

Safety first! (Things I must say, even though they are pretty dang obvious)

Limb contrasting is extremely safe in general, and what little danger there is can be avoided with an ounce of common sense. Don’t burn yourself.

Please avoid contrasting the freshest injuries that are still hot, swollen, and/or red, because the heat may aggravate the inflammation more than the cooling phase can control. You should use just ice on a fresh injury (note an important exception: back pain should not be iced, because it is usually not an “injury” per se). Please wait about three days for an injury like an ankle sprain to calm down a bit before you start contrasting it.

With rapid changes in circulation, there is a small risk of getting dizzy or fainting. This is unlikely when you’re working just with limbs, but be aware of the possibility. Full body contrasting is a different matter. See below.

Comparing contrasting to icing and heating: what’s the difference?

The rationales for contrasting, icing and heating are all nearly identical. Normal icing and heating are simply mild forms of contrasting, because you alternate between applying the ice or the heat and then removing it to let the tissues warm up or cool down. Contrasting just exaggerates this — so it is a refinement and/or hybrid of icing and heating.4

Even though contrasting is very closely related to icing and heating, it does have a couple of noteworthy advantages.

First, icing can be irritating to muscles and/or the nervous system. Like heat, contrasting is usually more soothing, but it’s also more “balanced” — it’s pleasant to cool off after heating, and pleasant to warm up after cooling.

Second, it is possible to create a literally bigger effect with contrasting. It is hard to ice your entire forearm or calf. It is quite easy to dunk them. By immersing a much larger section of your body, you can make more of a splash. Literally and figuratively.

And one disadvantage: while icing and heating are useful almost anywhere on the body, contrasting some anatomy is inconvenient or awkward to the point of pointlessness.

What is contrasting particularly good for? (If anything?)

Experimenting with contrasting should be standard part of rehab from many musculoskeletal injuries, but especially repetitive strain injuries in the extremities. Repetitive strain injuries often need far more rest to recover from than people realize, and any technique for stimulating tissue without stressing it is valuable. Contrasting is also much easier and more practical and effective to apply to the limbs, so the best common candidates for contrasting are:

Knees are a little trickier, but still easy enough to contrast with a little creativity, so two more good candidates are the runner’s knee conditions, iliotibial band syndrome and patellofemoral syndrome.

Hips and shoulders are much more awkward to contrast, and also broader, thicker, and often more padded with fat, so it is harder to change their temperature. The hip joint itself is probably almost completely immune to contrasting, for instance, so there is almost no point in contrasting hip problems. Of course, contrasting is even less convenient or worthwhile for trunk trouble, like back pain.

Ligament sprains are very slow healing, and often become chronically painful, long after it seems like they should have healed. Although it’s doubtful that contrasting will “accelerate healing” from a sprain, it may be worth doing it anyway — after the initial swelling has died down — for the hope of some minor benefits.

How to contrast: delivery systems and procedures

There are many ways to heat up and cool your body parts, and I encourage you to use your imagination and all the tools at your disposal. Bear in mind that immersion is always better than a flow or spray: whenever possible, you want to surround the body part. The major delivery systems for temperature are:

Contrasting should follow the following basic pattern: three to six alternations between heating and cooling. More is probably getting to be a waste of time. Less than three is probably not worth bothering with either. (More on dosing below.)

  1. about 2 minutes of heating: comfortably hot
  2. about 1 minute of cooling: cool, not cold (unless you’re tough)
  3. about 2 minutes of heating: hotter!
  4. about 1 minute of cooling: colder!
  5. about 2 minutes of heating: hot as you can handle
  6. about 1 minute of cooling: cold as you can handle

Cold sounds nasty to a lot of people, but you’ll be surprised at how tolerable it is when you’re properly pre-warmed.5

A few tips and rules of thumb for contrast bathing

Contrasting different body parts

Here are a whole bunch of specific examples and suggestions for using the best delivery systems for different body parts. Obviously, not every possible solution is covered here. I don’t think I’ve ever looked at this list without thinking of something else. Be creative.

Is the shower good enough for contrasting?

You can take a contrast shower. Whole body contrasting is nice and probably healthful in some general ways, but has limited value for rehabilitating from injuries, which require more intense temperatures, more accurately applied. Immersion of the body part is always the best. Intense heating of only the arm by dipping it in hot water, for instance, tends to cause much greater capillary dilation in the arm than the hottest shower.

The hottest and coldest showers are generally just too hot and too cold to tolerate on large areas of your body … or even just from the splashing if your trying to spray just one part of your body.

A detachable shower head, however, allows you to focus the spray enough to achieve a reasonably good effect.

Dosage: how much contrast hydrotherapy is enough?

Precision with dosage of contrasting is not particularly important. Heat and cool in roughly one-minute doses. But if you stick to the idea of “make it good and hot, and then make it good and cold” you’re doing it right.

And how many times should you cycle between hot and cold? Just a single time — one dose of hot, one dose of cold — is a minimal help. Three times is much more of a help, and is probably a good number. Six times is just tedious! There are practical considerations.

And how many times per day? Roughly once per day.8 It’s helpful, but it’s not so good that you should be spending half your day doing it!

This may be powerful medicine in some situations: don’t underestimate its usefulness just because it sounds a bit odd! Try it, have fun, enjoy the sensations, and you may find it more effective at helping you heal than medications or therapy.

The thermal workout

Another interesting application of contrasting is the “thermal workout.” Full body contrasting — switching back and forth between hot tub and pool, for instance — can be surprisingly exhausting and physiologically potent.

It can even be dangerous, so for pity’s sake please be careful and use some common sense:

Seriously, do not even think about trying this without going slow and taking it easy. This is one of those ideas that desperately needs a medical disclaimer! If you get into trouble doing this, it’s not because I didn’t warn you! Those warnings you see around public hot tubs and saunas? They are not for nothing!

Okay, I hope that’s enough ranting about the dangers to fully cover my butt.

Done safely, even a gentle thermal workout is ideal for wearing yourself out and burning some calories without straining anatomy, and that’s can be a handy component of a rehabilitation or general fitness regimen.9


About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.

What’s new in this article?

Four updates have been logged for this article since publication (2009). All PainScience.com updates are logged to show a long term commitment to quality, accuracy, and currency. more Like good footnotes, update logging sets PainScience.com apart from most other health websites and blogs. It’s fine print, but important fine print, in the same spirit of transparency as the editing history available for Wikipedia pages.

I log any change to articles that might be of interest to a keen reader. Complete update logging started in 2016. Prior to that, I only logged major updates for the most popular and controversial articles.

See the What’s New? page for updates to all recent site updates.

Added a citation about icing science. General editing. Moved several examples and elaborations into footnotes.

Major revision and upgrade. Almost everything improved.

Added section, “The thermal workout.”

Added some contrasting science.

Publication.

Notes

  1. Hing WA, White SG, Bouaaphone A, Lee P. Contrast therapy—a systematic review. Phys Ther Sport. 2008 Aug;9(3):148–61. PubMed #19083715.

    This review of the science of contrast hydrotherapy concludes that there is no science of contrast hydrotherapy: as of 2008, no research had ever been done that provides useful evidence that it works or does not work. Contrasting remains a popular and plausible but untested form of treatment.

    BACK TO TEXT
  2. Collins NC. Is ice right? Does cryotherapy improve outcome for acute soft tissue injury? Emerg Med J. 2008 Feb;25(2):65–8. PubMed #18212134.

    This is a 2008 review of just 6 studies of therapeutic icing, only two of them any good: one with slightly positive results, the other showing no effect. So that’s two studies that showed little or no benefit, which is leaning towards bad news, but it’s just not enough data to clinch it. (Four animal studies showed reduced swelling, but we can’t take animal studies to the bank.) The bottom line is just that “there is insufficient evidence.”

    BACK TO TEXT
  3. PS Ingraham. Delayed Onset Muscle Soreness (DOMS): The biological mysteries of “muscle fever,” nature’s little tax on exercise. PainScience.com. 7893 words. BACK TO TEXT
  4. For instance, where anatomically practical, you could contrast by switching between ice and hot water, or a heating pack and ice water … and so on. BACK TO TEXT
  5. In fact, if you’re hot enough, you can tolerate a great deal of cold — it’s one of the neat things about contrasting. The cold should feel refreshing or “bracing” at the worst. If you think the cold is too intense, tweak the procedure: more time heating, less time cooling, and reduce the contrast. BACK TO TEXT
  6. For instance, when I contrast my arms, I start with two sinks of regular hot and cold tap water — but for the second cycle, I dump a little boiling water into the hot, and add a tray of ice cubs or an ice pack to the cold. Thus the 2nd round of contrasting is much more intense. BACK TO TEXT
  7. So to contrast feet, the best combination of ease and effectiveness is to sit on the edge of the tub and just use the tap. And yet few tub faucets work very well for the whole calf: the position of the tap is usually too awkward, and there’s not quite enough water for so much more area. BACK TO TEXT
  8. More would undoubtedly be better — perhaps three times per day, for a few days, for a situation where contrasting is particularly easy and ideal for the injury — but there are usually strict practical limits on how much contrasting people can do, or should do. BACK TO TEXT
  9. For instance, I often cluster workouts as close together as I dare. If I play competitive sports on Tuesday night, I may be pretty sore the next day and just barely have time for my body to recover for my next strength training workout on Friday. And yet I don’t want to be a lazy butt for three solid days. A thermal workout is a perfect way to poop myself out a bit without loading my tissues up with more stress than they can adapt to. BACK TO TEXT