The Effects of Aging

on the Skin Blood Response

to Warm, Cold, and Contrast Warm
and Cold Baths
Jerrold Petrofsky, PhD, PTA, JD
Everett Lohman III, PT, DPTSc, OCS
Scott Lee, MD
Zaldy de la Cuesta, BS, DPT
Louie Labial, BS, DPT
Raluca Iouciulescu, BS, DPT
Brian Moseley, BS
Rachel Korson, BS
Abdul Al Malty, PT, MPT

Jerrold Petrofsky, Everett Lohman III, and Abdul Al Malty are affiliated with the
Department of Physical Therapy, School of Allied Health, A119 Nichol Hall, Loma
Linda University, Loma Linda, CA 92350.
Zaldy de la Cuesta, Louie Labial, and Raluca Iouciulescu are affiliated with the
Department of Physical Therapy, Azusa Pacific University, 901 East Alosta, Azusa,
CA 91702.
Brian Moseley, Rachel Korson and Scott Lee are affiliated with the Department of
Endocrinology, Loma Linda University, School of Medicine, Loma Linda, CA 92350.
Address correspondence to: Jerrold Petrofsky, Professor and Director of Research,
A119 Nichol Hall, Loma Linda University, Loma Linda, CA 92350 (E-mail: jpetrofsky
@llu.edu).
The authors wish to acknowledge Hye Jin Suh for valuable assistance in preparing
this manuscript.

Physical & Occupational Therapy in Geriatrics, Vol. 25(3) 2007

Available online at http://potg.haworthpress.com
© 2007 by The Haworth Press, Inc. All rights reserved.
doi:10.1300/J148v25n03_02 19
20 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

ABSTRACT. Objectives: To examine the effects of aging on the ability

of contrast baths to increase the circulation in the skin of the foot com-
pared with immersion in a continuous warm water bath of the same tem-
perature as the warm component of the contrast bath.
Methods: A laser Doppler flow meter was used to assess skin blood
flow on the dorsal and plantar aspects of the foot during immersion in a
warm bath (100⬚F (37.8⬚C)) compared with contrast baths with a ratio
of 3 minutes of warm (100⬚F (37.8⬚C)) and 1 minute of cold (60⬚F
(15.6⬚C)); the cycle was repeated for 16 minutes. Fourteen participants
whose average age was 55.1 ± 9.1 years were examined and compared
with 12 younger participants whose average age was 23.9 ± 5.8 years.
Results: For both groups of participants, the use of alternating hot and
cold bath temperatures elicited an increase in skin blood flow above that
which was found with warm water immersion alone. The greatest re-
sponse was in the younger participants. For the older participants, skin
blood flow was approximately one-third less than that seen in the youn-
ger participants with either continuous warm water immersion or con-
trast baths. These same results were seen on the dorsal and plantar aspects
of the foot, indicating diminished circulation in both areas with aging.
Conclusion: We conclude that contrast baths do increase circulation
in the skin in the foot of older individuals but the response was less than
that of younger people. doi:10.1300/J148v25n03_02 [Article copies avail-
able for a fee from The Haworth Document Delivery Service: 1-800-
HAWORTH. E-mail address: <docdelivery@haworthpress.com> Website:
<http://www.HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights
reserved.]

KEYWORDS. Cardiovascular, circulation, contrast bath, heat, aging

INTRODUCTION

Hydrotherapy is a common physical therapy modality (Stanton et al.,

2003; Umphred, 1995). One type of hydrotherapy that has been used for
hundreds of years is called contrast baths. It is believed that by alternat-
ing hot and cold baths, additional vasodilatation occurs in the limb
and creates a pumping action that will allow edema to decrease in the
cells (Cameron, 2004; Hecox et al., 1994). Only recently have studies
shown there is better blood flow in the limb after immersion in contrast
baths compared with continuous immersion in warm water at the same
 Petrofsky et al. 21

temperature as the warmest water temperature used for the contrast bath
(Fiscus, Kaminski, & Powers, 2005; Petrofsky & Laymon, 2006a). In
both studies, no consideration was given to the age of the participants,
even though vascular endothelial function has been shown to be re-
duced in older people (Anderson, Edvinsson, & Edvinsson, 2003;
Franzoni et al., 2004; Minson et al., 2002).
While there is some evidence of a reduction in the ability of blood
vessels to vasoconstrict with age, largely due to sympathetic ganglionic
failure (Dinenno, Dietz, & Joyner, 2002; Thompson, Holowatz, &
Kenney, 2005), there is a well-documented reduction in the ability
of blood vessels to vasodialate associated with the aging process
(Anderson, Edvinsson, & Edvinsson, 2003; Franzoni et al., 2004; Minson
et al., 2002). This is especially true of the foot (Evans, Rendell &
Bartek, 1993), an area where ulceration in the elderly and especially
those with diabetes is common (Petrofsky et al., 2005c). The mecha-
nism of impaired vasodilatation with aging is caused by several things,
including a reduction in the release of nitric oxide, a potent vasodilator
normally released by vascular endothelial cells (Musicki et al., 2005;
Stansberry et al., 1997). This is possibly due to an increase in the cellu-
lar stores of arginase 1, an enzyme which reduces the availability of
arginine, the precursor of nitric oxide (White et al., 2006). There are
also other unidentified agents impaired with ageing (Franzoni et al.,
2004). Sympathetic neuronal traffic and ␤ adrenergic receptor sensi-
tivity are reduced with ageing (Schutzer & Mader, 2003), as is a de-
creased response to autonomic stress and reduced heart rate variability
(Konrady et al., 2001; Siebert, Drabik, Lango, & Szyndler, 2004).
Although the skin blood flow response to global heating and anoxia
have been shown to decrease with age (Petrofsky, Lee, & Cuneo,
2005a), few studies have examined the effect of age on the response of
skin blood flow to local heat. Schubert (2000) noted there is impaired
vasodilatation to local heat in older people. Magerl and Treede (1996)
found a diminished axon-axon reflex increase in skin blood flow during
local heating in older compared with younger individuals. While some
of the response was due to impaired release of vasodilator agents by
vascular endothelial cells, at least some of the diminished response has
been attributed to impaired nociceptive transmission in the elderly
(Iwate et al., 2002) since these receptors mediate the local vasodilation
in response to heat (Magerl & Treede, 1996). If the response of the skin
to local heat was diminished, it would seem logical that the response of
the skin to contrast baths would also be diminished with age. The pur-
pose of the present investigation was to test the hypothesis that both the
22 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

skin blood flow response to warm water bath immersion and contrast
baths are diminished in an older population compared with younger
people. Blood flow was measured on both the dorsal and plantar aspects
of the foot with a laser Doppler flow meter (Petrofsky et al., 2005c). Stud-
ies show that a laser Doppler flow meter is a reliable method of analysis
of skin blood flow (Orlandi, Rossi, & Finardi, 1988). The contrast bath
ratio was three minutes warm and one minute of cold. This is a common
protocol used in physical therapy (Campion, 1998; Cameron et al., 2003;
Fiscus et al., 2005). Since the blood flow response to contrast baths di-
minishes with each successive change in bath temperature (Fiscus et al.,
2005), only four changes in bath temperature were examined here. Fi-
nally, since the blood flow response to local heat can be altered by sym-
pathetic outflow due to global temperature changes on the body (Petrofsky
et al., 2005c; Divert, 2001), subjects rested in a controlled temperature
room for 20 minutes before the study was undertaken.

METHODS

Participants

Twenty-six subjects participated in this study. The participants were

subdivided into two groups: Group A, the older group, had 14 partici-
pants while Group B had 12 younger participants. Both groups were
screened by the medical staff at the lab and did not have a history of dia-
betes, were non-smokers and did not have heart disease. There was no
statistical difference between the groups for height and weight whereas
age was significantly different (p < 0.01). The average age, heights, and
weights of the groups were 55.1 ± 9.1 years, 175.4 ± 15.3 cm, and 87.1 ±
9.4 kg for the older group and 23.9 ± 5.8 years, 176.9 16.9 cm, 84.1 ±
9.8 kg for the younger group, respectively.
All experimental procedures and methods were explained to each
subject, who then signed an Informed Consent approved by the Institu-
tional Review Board of Loma Linda University.

Apparatus

The blood flow in the skin on the dorsal and plantar aspects of the
foot, as well as the local skin temperature, were measured during immer-
sion of the foot in baths as described in the following paragraphs. Local
skin temperature should be set at that of the bath during immersion. It
 Petrofsky et al. 23

was measured here to assure that the foot remained immersed during the
period that flow was measured.
Whirlpool. Two baths were used to store water. Each bath was in a
stainless steel tank with a turbine motor to stir the water (Cameron et al.,
2004). Water was transferred to smaller baths for every temperature that
the foot was submerged and changed continuously to assure that the
temperature did not vary. The temperature was monitored with thermis-
tor probes on the skin to assure the temperatures were maintained and
that stirring was adequate. Stirring was used to keep skin temperature
from varying from that of the bath. One bath maintained cold water
(60⬚F-15.5⬚C) and the other warm water (100⬚F-37.8⬚C).
Blood Flow. Blood flow was measured by a Laser Doppler flow me-
ter (Biopac Inc., Goletta, CA) which consisted of a 1 cm2 capsule (TSD
140, Biopac Inc., Goletta, CA) which provided infrared light to the area
under the capsule. The reflected light was then received and transmitted
through fiber optic tracks to a laser Doppler controller module (LDF
100 C, Biopac Inc., Goletta, CA). The analysis system, Biopac MP 100,
calculated the frequency shift in the light. The MP 100 Biopac system
(Biopac Inc., Goletta, CA) used the Acknowledge 3.8.3 software to cal-
culate the blood flow, in flux (a unit based on fluctuation in frequency
due to blood flow).
Temperature. Skin temperature was measured just adjacent to and on
the opposite sides of the blood flow sensor. Two temperature sensors
(Yellow Spring Instruments, Yellow Spring, Ohio) were taped lightly to
the skin. The output of the temperature sensors was transduced by a
temperature transducer module (SKT 100C, Biopac Inc., Goletta, CA)
and the data recorded were digitized with a 16-bit A/D Converter at 200
samples/second on a Biopac MP 100 system (Biopac Inc., Goletta, CA).
The temperature transducers were calibrated periodically during the ex-
periments and at the beginning of the study. A third temperature sensor
was placed in the water bath and measured bath temperature. In this
manner, skin and bath temperature could be monitored to assure con-
stant temperature during the immersion period.

Procedures

Participants first entered the lab and rested for 20 minutes. The room
temperature was maintained at 75 ± 2⬚F (23.8 ± 1.2⬚C). Three series of
experiments were conducted on different days to examine blood flow in
the skin on the dorsal and plantar foot during contrast bath immersion.
As a basis for comparison, to examine the effectiveness of contrast
24 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

baths, first, the participants placed their foot in water at 100⬚F (37.8⬚C)
for 16 minutes to see the effect of a warm water bath alone on circula-
tion. The temperatures of the skin and blood flows were monitored over
16 minutes. On another day, the procedure was repeated but the foot
was immersed in a cool bath, 60⬚F (15.6⬚C), to see the effect of the cold
bath on skin blood flow. On a final day, the foot was placed in warm wa-
ter for three minutes and then the cold water for one minute (contrast
baths). This cycle was repeated four times for a total of 16 minutes of
immersion.

Statistical Analysis

Statistical analysis involved the calculations of means, standard

deviations of paired and unpaired t-tests. The level of significance was
p < 0.05.

RESULTS

The results of the experiments are shown in Figures 1-4. The data
comparing the 16-minute hot, 16-minute cold, and 16-minute contrast
baths had the same pattern for the dorsal and plantar foot blood flow re-
cordings. Therefore, for ease in presentation, Figures 1 and 3 show the
mean blood flow data for the group for the hot, cold, and contrast data
on the dorsal foot only. Figures 2 and 4 show the data during the contrast
baths only to compare the dorsal and plantar foot. Data for the older par-
ticipants are shown in Figures 1 and 2 and for the younger participants
in Figures 3 and 4.

Dorsal Foot Blood Flows: Older Group

When the older participants immersed their foot in the warm water for
a period of 16 minutes, there was a significant increase in blood flow on
the dorsal foot from an initial flow of 22 ± 7 flux to a final flow of 42 ± 8
flux (Figure 1). This increase was significant (p = 0.006). In contrast,
when the foot was placed in cold water, blood flow on the dorsal foot
decreased significantly to 13 ± 3 flux (Figure 1). This decrease from rest
was also significant (p = 0.0003). After immersion of the foot in con-
trast baths, the flow response was quite different. During the first warm
bath immersion, the blood flow increased as it had with the continuous
 Petrofsky et al. 25

FIGURE 1. Blood flow on the dorsal aspect of the foot (flux) during 16 minutes of
continuous warm water immersion (lower panel), four periods of alternating hot
and cold baths (middle panel), and 16 minutes of continuous cold water immer-
sion (upper panel) in the old group of subjects. Each point is the mean ± SD.

warm water immersion seen as the lower panel of Figure 1. But when
the water temperature was changed to cold, the blood flow, over the one-
minute period, was reduced by about 10%. Therefore, when the foot
was placed in the second warm bath, the blood flow in the skin on the
dorsal foot not only increased to the same extent as if there was continu-
26 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

FIGURE 2. Blood flow (flux) in the old participants during 16 minutes of alter-
nating warm and cold baths on the plantar (upper panel) and the dorsal (lower
panel) aspects of the foot. All the flows are shown as the mean ± SD.

ous warm water immersion, but average blood flow for the group was
significantly higher (p = 0.0006) than that seen with continuous warm
water immersion of the foot for the same period of time. As shown in
Figure 1, after 3 minutes of immersion in the warm bath, average blood
flow in the older participants increased from an initial value of 20 ± 6 to
42 ± 7 flux. For the same time period, immersion in a continuous warm
water bath resulted in an average blood flow of 31 ± 7 flux. The greater
flow response with contrast baths compared with continuous warm wa-
ter immersion of the foot was maintained with each succeeding warm
water immersion.
 Petrofsky et al. 27

FIGURE 3. Blood flow on the dorsal aspect of the foot (flux) during 16 minutes of
continuous warm water immersion (lower panel), four periods of alternating hot
and cold baths (middle panel), and 16 minutes of continuous cold water immer-
sion (upper panel) in the young group of subjects. Each point is the mean ± SD.

Plantar Blood Flows: Older Group

When comparing the blood flows on the dorsal to planter aspect of

the foot in Figure 2, for the older group of participants, the greatest in-
crease in the blood flow was on the planter surface of the foot. For
example, comparing the blood flow after 11 minutes on the dorsal
aspect of the foot to the plantar foot, the respective flows were 47 ± 9
28 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

FIGURE 4. Blood flow (flux) in the young participants during 16 minutes of

alternating warm and cold baths on the plantar (upper panel) and the dorsal
(lower panel) aspects of the foot. All the flows are shown as the mean ± SD.

and 116 ± 13 flux. Like the dorsal foot, there was a large increase in blood
flow after immersion in the warmer of the two contrast baths which was
substantially higher than the blood flows obtained during continuous
heating. The blood flows on the plantar foot was always significantly
higher than the dorsal foot at all times (p = 0.009).

Dorsal Foot Blood Flows: Younger Group

For the younger participants, the mean blood flow of the group in the
cold bath was not different than that of the older participants (Figure 3,
p = 0.23). But for warm water immersion for the entire 16-minute
 Petrofsky et al. 29

period (Figure 3), the average blood flow increased in the younger
group on the dorsal foot from an initial average value of 30 ± 6 flux to
a final value of 61 ± 8 flux. The difference in skin blood flow from rest
and throughout the 16 minimum immersion period was significantly
higher in younger participants than that of the older participants (p =
0.02). Further, for the contrast baths, as shown in Figure 3, blood flows
were higher as well at any point during the immersion with the largest
blood flow recorded at the end of the last warm water immersion at
68 ⫾ 5 flux (p = 0.03).

Plantar Blood Flows: Younger Group

The blood flow was substantially higher on the planter aspect of the
foot than the dorsal foot during contrast baths in the younger compared
with the older participants (Figure 4) (p = 0.002). The peak flow recorded
on the planter surface of the foot was 165 ± 11 flux compared with the
peak flow recorded in the older participants of 116 ± 6 flux. Further, the
blood flow was significantly higher on the plantar foot than the dorsal
foot in these participants during contrast bath immersion (p = 0.0002).

DISCUSSION

In the current investigation, the older participants showed an im-

paired circulatory response to local heat. But the response to contrast
baths, while greater in the younger participants than the older partici-
pants, was greater in both groups than that reported previously (Fiscus
et al., 2005). These authors reported a much smaller increase in blood
flow between the cold and hot baths after the first immersion, and, by
the fourth immersion cycle of hot and cold baths, the effect of the con-
trast baths was negligible compared with the circulatory response of
leaving the foot continuously in warm water. But there are differences
between this study and the current investigation. In their study, the au-
thors measured whole limb blood flow. Their assumption was that the
temperature of the entire limb would be changed by hot and cold alter-
nating baths. Recent studies, however, show that such brief changes in
temperature are restricted to the skin but not muscle or bone (Myrer,
Measom, Durrant, & Fellingham, 1997). Further, in older individuals
where body fat content is usually higher, even if body weight is matched
(due to loss in muscle mass and an increase in body fat), there is less
change in muscle and deep tissue temperature due to bath immersion
30 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

(Petrofsky & Lind, 1975). Increased thickness of subcutaneous fat un-

der the skin provides additional insulating power, protecting deep tissue
from rapid changes in temperature. Whereas skin temperature will
change rapidly in a contrast bath, it takes in excess of 15-20 minutes of
continuous temperature exposure in water to bring deep tissue tempera-
ture (⬚C) in the arm and the leg up or down by more than a few degrees
(Petrofsky & Laymon, 2006a; Petrofsky & Lind, 1975). Thus, while the
skin temperature may oscillate with contrast baths, the deep tissue tem-
perature will be dampened and show only a steady rise in temperature
during contrast baths since the cycle is three times longer in the warm
than the cold bath.
Therefore, the magnitude of the change in blood flow with contrast
baths here was greater than in the previous investigation (Fiscus et al.,
2005). In the current investigation, we only looked at skin blood flow.
Fiscus et al. (2005) looked at whole limb blood flow. In the first few
minutes, only skin blood flow would change with contrast baths. By
looking at limb blood flow, this would mask the response of the skin.
For example, if 50% of flow went to skin and 50% to muscle, in a re-
cording of the whole leg, if skin blood flow doubled, then the whole
limb flow would only increase by 50%. Recordings of skin blood flow
alone would show a doubling in the response. Thus here, the higher
changes in flows reflect the true contribution of skin in the current in-
vestigation and the changes are consistent with previous investigations
of whole limb blood flows. After 15 minutes, when muscle blood flow
increases either with contrast baths or continuous warm baths due to
warming, skin blood flow measurements would not show the increase
in muscle blood flows, and therefore, would show the pulsatle change
with each succeeding bath temperature change. Whole limb recordings
mask the skin change due to a large increase in deep tissue flows and the
eventual heating of muscle. Thus, the previous findings, that contrast
baths are not effective after 15 minutes, are a misinterpretation of the
data by Fiscus et al. (2005).
The lower blood flow response in older individuals in contrast baths,
however, still does not limit their usefulness. While there are far less
benefits from contrast baths in an older population than in a younger
population, the threefold increase in blood flow to the skin on the sur-
face of the foot (both plantar and dorsal) points to a positive benefit of
contrast baths, even in an older population.
Impaired vasodilatation in older people has been linked to defective
vasodilators such as nitric oxide (Franzoni et al., 2004) and reduced ␤
adrenergic receptor function (Schutzer & Mader, 2003). This defect as-
 Petrofsky et al. 31

sociated with age would theoretically place the older group at increased
risk for heat stroke (Evans et al., 1993). Further, weakening of the der-
mal-epidermal barrier can lead to an increased burn incidence (Nilsson,
1987; Wienert et al., 1983). Thus, caution should be exercised in the
warmer bath temperature since prolonged exposure at even 44⬚C can
cause burns in the elderly (Lewandowski, Pegg, Fortier, & Skimmings,
1993).

CONCLUSION

In conclusion, the skin blood flow of the foot in the older subjects
was about one-third less than that of the younger subjects with the sub-
jects at rest. When the foot was immersed in a warm water bath, the skin
blood flow was increased in both groups of subjects, but for the older sub-
jects, the skin blood flow response was diminished to a similar extent
by ageing. While contrast baths offered a clear advantage in increasing
skin blood flow above that observed for continuous warm water immer-
sion in the younger subjects, there was only a small advantage over con-
tinuous warm water immersion in the older subjects.

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Received: 10/21/05
Revised: 06/10/06
Accepted: 06/15/06

doi:10.1300/J148v25n03_02