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The Somatic Arts and Sciences Institute

3-Hours Continuing Education

SASI Course: EMS003

The Somatic Arts and Sciences Institute

P.O. Box 3181
NCBTMB Approved
Merced, CA 95344
(209) 777-6305
Provider #450872-08
Table of Contents

Instructions…………………………………………………………………………………………………..……… 3

Educational Objectives……………………………………………………………………….………………….… 3

Chapter 1: The Hot Stone Massage…………...…………...………………………………………..…………….4

Chapter 2: The Science Behind Hot and Cold Stone Therapy……………………………………...…………24

Chapter 3: Unhealthy temperatures and injury treatment………………………………………………...……42

Summary of Hot Stone Massage…………………………………………………………………………………61

Course Completion: Certificate of Completion and Transcript……………………………………………...…63

Course Evaluation and Errata.………………………………………………………………….……….……..…64

Help and Technical Support Line……………………………………………………………………….…...……64

Bibliography (Sources)………………………………………………………………………………………..…...65

APPENDIX I Thermotherapy Study………………………………………………………………………………68

APPENDIX II Ice Massage versus Conventional Icing: a comparison on the effectiveness of each in the
inflammation phase of healing……………………………………………………………………………….……84

APPENDIX III Human thermoregulation and the cardiovascular system………………………………….…92

Fundamentals of Hot Stone Massage
Thanks for downloading this Somatic Arts and Sciences continuing
education course. You are looking at the plain text version of the course,
which can be printed out if you like.

Target Audience
This continuing education course has been designed to meet the
educational needs of massage therapists.

Degree of Difficulty
Beginner/Entry Level

Course Description
The course shows the student how hot stone techniques can be
incorporated into holistic therapeutic practice, which will be of great value to
practitioners of body working therapies. Safety measures,
contraindications and proper care and cleaning of the stones is also

Educational Objectives
Upon completion of this home study continuing education course, the
massage practitioner should be able to:
Describe the physiological benefits of hot stone therapy
List the appropriate range of temperature for safe use of stones.
Describe the motions used when incorporating hot stones in a
Identify the contraindications for hot stone therapy.

This course is presented for educational purposes only. It was developed
and marketed specifically for massage therapists that are required to obtain

continuing education hours for licensing purposes. The author is not giving
medical, legal or other professional advice.

This course is classified as “Cognitive” learning, meaning that there is no

hands on portion.

The Somatic Arts and Sciences Institute strives to provide the most up to
date and accurate material possible, however research and new
discoveries continue daily and we assume no responsibility for errors or
omissions due to the rapid advancement of science.

Chapter 1 The Hot Stone Massage

A hot stone massage is a variation of the typical massage, which uses
smooth, water-heated stones on points around the body. Hot stone
massages aredeeply soothing and relaxing and act to release tight

Hot Stone massages are easy to perform, very therapeutic, and highly
lucrative, making them an excellent addition to the massage practice.

History of the Massage

This is not a new treatment; people have been using hot stones for therapy
for literally, thousands of years.

The Japanese use stones to warm their abdomens to aid digestion and the
Chinese have been rubbing themselves with hot stones to relieve muscular
pain for about 2,000 years. It was also used as an ancient healing tradition
in India when river stones were warmed in hot coals or hot water.

Both the Ancient Romans and the Native Americans used heated stones to
generate steam for saunas.

This shouldn’t surprise anyone, after all, stones were among the first tools
used by humans, and anthropologists have found decorative stones
ranging from ornate to semi-precious quality among the buried remains of
countless primitive cultures. As a species we seem to like rocks.

The modern hot stone massage became popular after Mary Nelson, a
massage therapist, introduced a massage technique in 1993 called La
Stone Therapy using hot stones.

It has since become widespread across the United States.

Hot Stone Massage is so popular now that you would have difficulty finding
a Day Spa that does not include some form of Hot Rock Massage.

Many massage schools are now including hot stone massage in their core
curriculum-but some don’t, which is why we offer this basic course.

The Stones
The stones that are most often used in hot stone massages are smooth
basalt rock from volcanoes. The basalt stones are usually fine-grained as a
result of rapid cooling of lava on the Earth’s surface. As a result, these
basalt stones retain heat very well.

Stones that are artificially smoothed in a tumbler may also be used. River
stones, smoothed by many years of submersion are commonly used by
massage therapists for their ease in gliding across the skin.

Mexican Pebble is a variety of stone that can be purchased very

inexpensively at a landscape supply store, or at a stone quarry and it
makes an excellent stone for massage use.

Do not be fooled by it’s crude appearance. When you see it at the

landscape supply store it looks like this:

Mexican Pebble at the landscape supply company The same stones at the Day Spa
I know it doesn’t look like the fancy black polished stones you see in the
spa brochures. Don’t worry, it will once you wash it, heat it up and put your
oil on it.

Various sizes, shapes and weights of the stones are used during the hot
stone massage depending on whether you are using it as a stationary
stone or as a tool for bodywork.

The larger stones are generally used as stationary stones, placed on the
sacrum and other areas, whereas the smaller hand sized stones are used
as tools to perform petrissage.

Some therapists like to use very small stones to place on the face or even
between the toes of the client.

The number of stones needed during a hot stone massage can vary. For a
typical full body massage, you’ll want to use approximately 40 to 50 stones,
most of which should be the size of the palm of your hand. It is possible to
use fewer stones, but you will need to constantly keep them reheated. If
you do not want to constantly reheat stones, make sure you consider this
factor when you are stocking your massage stones.

Most stones in the Hot Stone massage should be used in the hand and
worked over the body, in effleurage and petrissage strokes

Some will be stationary stones, placed on strategic places on the body and
left there for as long as it is convenient. Good places for stationary stones
include the palms of the hands, the feet, the sacrum, along the spine and
on the Charka Points.

Precautions must be taken with stationary stones.

Stationary stones should be cooler than the ones moving along the body,
or they should be wrapped in linen before being placed on the body.
Stationary stones are more likely to burn your client than a moving stone,
so take the necessary precautions.

I will be going over a simple routine for using hot stones in a massage later
in this module, but for now let’s just get the science out of the way.

The Therapeutic Quality of the Hot Stones

Hot Stone massage is generally thought of as a pampering Spa treatment,
but it is actually very therapeutic.

Heat has always been used in various forms for therapeutic use. Sunlight,
heated sand, and heated water were initially used as an effective means of
therapy for ailments and pain. Early users of heat therapy also obtained
heat from hot stones and coals, open fire, and irons. The earliest hot water
containers consisted of hollow dried fruits and the bladder or skin of

Heat therapy, also called thermotherapy, is the application of heat to the

body for pain relief and health. It can take the form of a hot cloth, hot water,
ultrasound, heating pad, hydrocollator packs, whirlpool baths, and of
course, Hot Stone massage. It can be beneficial to those with arthritis and
stiff muscles and injuries to the deep tissue of the skin. Heat may be an
effective self-care treatment for conditions like rheumatoid arthritis.1

Heat therapy accomplishes it’s therapeutic works by means of a

physiological phenomenon known as vasodilatation (see below).

These therapeutic effects include increasing the extensibility of collagen

tissues; decreasing joint stiffness; reducing pain; relieving muscle spasms;
reducing inflammation, edema, and aids in the post acute phase of healing;
and increasing blood flow. The increased blood flow to the affected area
provides proteins, nutrients, and oxygen for better healing.2

Heat therapy is useful for muscle spasms, myalgia, fibromyalgia,

contracture, bursitis.3

Heat therapy can be used for the treatment of headaches and migraines.
Many people who suffer from chronic headaches also suffer from tight
muscles in their neck and upper back. The application of constant heat to
the back/upper back area can help to release the tension associated with
headache pain. The placement of stationary stones for a hot stone
massage meets this need nicely.

Applying hot stones on the body increases the temperature of the skin and
muscle tissue to improve circulation and calm the nervous system.

Thermotherapy for treating rheumatoid arthritis, from Cochrane Library
Prentice, William E. Arnheim’s Principles of Athletic Training: a Competency Based Approach. New York. McGraw-Hill. 2008.
Raj, P. Pritvi, Practical Management of Pain. Mosby. 2.000. ISBN 978-0-8151-2569-3.
Israel, Beth. “Pain”. 2005. Date Assessed: 28 April 2009.

As a result, hot stone massages are deeply relaxing and act to rebalance
the body and mind. As the superficial muscles relax, a therapist can also
massage the deeper muscles.

The heat of the basalt stones release muscle tension faster than a classic
Swedish massage.

Vasodilation refers to the widening of blood vessels.4 It results from
relaxation of smooth muscle cells within the vessel walls, particularly in the
large veins, large arteries, and smaller arterioles. The process is essentially
the opposite of vasoconstriction, which is the narrowing of blood vessels.

When blood vessels dilate, the flow of blood is increased due to a decrease
in vascular resistance. Therefore, dilation of arterial blood vessels (mainly
the arterioles) decreases blood pressure. The response may be intrinsic
(due to local processes in the surrounding tissue) or extrinsic (due to
hormones or the nervous system). Additionally, the response may be
localized to a specific organ (depending on the metabolic needs of a
particular tissue, as during strenuous exercise), or it may be systemic (seen
throughout the entire systemic circulation).

Because heat is a vasodilator, it should be avoided in tissues with
inadequate vascular supply, in case of acute injury, in bleeding disorders
(because heat would increase bleeding), in tissues with a severe lack of
sensitivity, in scars. Hot stone massages are not recommended for those

Are prone to blood clots

Suffer a skin disease or rash

Have an open wound

Have just undergone surgery or chemotherapy

"Definition of Vasodilation". 27 April 2011. Retrieved 13 January 2012.

Hot stones should not be applied on bruises, open wounds, tumors,
hernias, fractures and inflamed skin. Pregnant women should also
seek advice from their doctor before having a hot stone massage.

Preparations for the Hot Stone massage

In addition to the massage table, linens and oils that you are used to using
for a Swedish massage you will need some specialized equipment for your
Hot Stone massage.

Obviously you will need the stones, which we have discussed already. You
will also need a heating unit to warm your stones, a storage container for
the stones and you will need some form of container to hold room
temperature water, for cooling stones that are too hot to use immediately.
Optionally you may want tongs or spoons to use to remove the stones from
the bottom of the heating unit, as they can be much hotter than the ones on
the top.

The Heating Unit

Do not believe that you have to spend a lot of money purchasing a special
stone heater from a specialty supply catalog for your hot stone practice.

An ordinary kitchen roaster works just fine. I suggest the 16-quart variety,
as it is large enough to hold enough stones to do two or more massages.

These “heaters” are no different than the roasters used to cook turkeys!
They average about $35-$40 and can be purchased at any store that sells
kitchen appliances.

You will need to begin heating your stones at least 1 hour before the
scheduled massage. The stones should be placed in the heating unit,
which is also filled with water.

You will find it is very helpful to place a small white towel in the bottom of
the heater, so that you can see the stones. The inside of the heater is
black and filled with water, and the stones are black, so placing a white
towel inside makes it easier for you to find them.

Temperatures vary by heating unit, but a safe range is 125-150 degrees

Fahrenheit. While this seems very hot, they cool quickly, and if they are
too hot you can douse them quickly in the container of room temperature
water to cool them. Remember that anything over 100 degrees will feel
warm to your client (that is warmer than normal human body temperature)
so do not worry about the stones being too cool.

An important rule is that if a stone is too hot to hold in your hand, it is too
hot to use on your client. The palm of your hand has a great deal more
temperature tolerance than a persons back, so keep that in mind.

You can apply a stone to your forearm (like you would a baby bottle) to test
it. Remember most of the stones you are using are going to be moving on
the clients skin, so they are more tolerable than the stationary stones,
which just sit on key areas. Stationary stones must be a little cooler or
covered in an extra layer of linen.

You should check in with your clients by asking them if the temperature is
ok, just like you ask about pressure in a standard massage.

Application of the Hot Stone massage

Draping for the Hot Stone massage should be minimal. Diaper Draping is
preferred. A good way to start your hot stone massage is by placing two
warm palm sized stones in the clients hands. This establishes contact with
them and keeps the contact going even when you leave their side to get
more stones.

As long as a stone is in contact with the client, you are in contact.

Once you have placed the stones in the hand you can get two more and
use them to effleurage any other area, like the back, the arms, the legs,

Ensure that you have applied product to the skin of the area you are going
to massage with the stone, and that you have applied product to the stones
as well. They need to glide over the skin smoothly to be enjoyable to the
client. This motion also allows you to use a stone that would be a little too

hot to rest on their skin, but will actually be very pleasant when gliding
quickly over it.

The direction of the gliding movements should be toward the heart, similar
to an effleurage you would use during a Swedish massage.

No pressure or weight is needed when applying these gliding

strokes-the heat does all the work.

In this regard the hot stone massage can be a relaxing change of

pace for you too.

The direction of the gliding movements should be toward the heart, similar
to an effleurage you would use during a Swedish massage.

The stones can be used to effleurage and to petrissage as well. Care
should be taken when using the stones as tools for removing adhesions to
not bruise the client.

Stones penetrate tissue far more deeply than fingers and thumbs, and they
are not yielding. After the stones have been used to perform effleurage
and petrissage on the back the therapist can place stationary stones on the
back to continue to work on the client while the arms and legs are attended

Remember that stationary stones should be cooler than the ones used for
gliding movements, especially if they are placed directly on the skin.

Care must be taken that the stones do not come loose and slide down to hit
the clients neck or the back of the head. Keeping the stones further down
on the back, like in the photo above or the diagram below, can prevent this.

A large flat stone placed on the sacrum can feel very good to the client.
The broad flat shape of the sacrum is very accommodating to weight and
can take the stones comfortably.

There are two basic patterns for placing the stationary stones on the back,
and it really doesn’t matter which one you choose.

You will notice that on both patterns there is one stone that is larger than
the others on the sacrum and that there are no stones so high on the back
that they might slip forward and fall onto the neck.

The arms and the legs can be effleuraged with stones of the common
variety, or if you are lucky enough to find some longer, flatter stones you
can use them as shown below.

You can customize your hot stone massage by finding a variety of stones
that can be used as different tools.

You can customize your hot

stone massage by finding a
variety of stones that can be used
as different tools.

You will want at least five or six

large flat stones to use as
stationary stones for the sacrum,
sternum and back, and at least
three or four tools to use for
petrissage and flattening, like in
the picture shown to the right.

You will want at least five or six large flat stones to use as stationary stones
for the sacrum, sternum and back, and at least three or four tools to use for
petrissage and flattening, like in these.

Another option that is available is to place stones on the table, covered by

linen, and then encourage your client to lie on top of them as you are
working on their front.

The idea here is to allow the stones to be stationary, and still working on
the muscles of the back while laying on them. You must cover them with
additional linens; the client will be laying on them and they are stones after

A truly effective Hot Stone massage included a nice mixture of stationary
stones and stones in motion, being used to effleurage and petrissage.

You will only want to try this if

your massage table is sufficiently
soft enough to allow the stones to
“sink in” a bit.

The table pictured has a memory

foam pad, which allows the client
to lie on the stones comfortably.

Cold Stone Therapy

Okay I know this course is entitled “Fundamentals of Hot Stone Massage”
but I would be remiss if I didn’t introduce you to the other side of the stone-
the Cold Stone Massage.

Hot Stone therapy is built on the principle of vasodilatation, and as you

would expect, Cold Stone therapy makes use of the opposite reaction-

Vasoconstriction is the narrowing of the blood vessels resulting from

contraction of the muscular wall of the vessels, particularly the large
arteries and small arterioles. When blood vessels constrict, the flow of
blood is restricted or decreased, thus, retaining body heat or increasing
vascular resistance. On the surface this makes the skin turn paler because
less blood reaches the surface, reducing the radiation of heat. On a larger

level, vasoconstriction is one mechanism by which the body regulates and
maintains mean arterial pressure.

Cold stones are primarily effective as a decongestant on various parts of

the body. They help relieve swelling in the circulatory system, and this
benefit makes cold stone massage a potential treatment for several
ailments. In particular, the injuries related to sports are perfect examples.
Most professional athletes have had to apply an icepack to some part of
their body at least once in their career because of the swelling that goes
hand in hand with pushing the body’s limits. The cold stones can help
release the accumulation of blood in their tissues and muscles the same
way that an icepack can.

Because cold stones help relieve the congestion of body fluids, they can
also be used on the sinuses to help alleviate pressure due to frequent colds
or allergies. In any case where cold stones are used on the face, it's
important that the therapist use a cloth under the stone to prevent
discomfort from the stone being in direct contact with the skin. Other
benefits of this type of massage include decreasing muscle spasms,
stimulation of the nervous system and increased tissue metabolism.

While the general the effect of hot stone massage is to create a feeling of
relaxation, the cold stones are helpful for invigorating the tissues and blood

Physiological benefits of cold stone massage

One of the benefits of cold stone massage is that it can provide a deep
state of relaxation, a release of tension, as well as, a reduction of swelling
and inflammation due to scar tissue, trauma or injuries to muscles.

Cold stones are critical in stone massage work as they decrease soreness
when working on deeper muscles, and draws heat away from the body.

Cold stone massages are also known for helping to alleviate:

Anxiety/Depression-Stones that are cold help the mind to focus on the body
and what it is experiencing rather than the mental/stress issues of life.

PMS-Stones are placed on the abdomen and/or on the back to help

alleviate pain, bloating and swelling associated with a menstruation

Sinusitis-Cold stones are placed on the face (or on a cloth that is on the
face to prevent skin damage) to help reduce congestion and nasal swelling

High Blood Pressure (with Increased Circulation)- When cold marble

stones are placed in certain positions on the body, blood circulation
increases and high blood pressure can decrease

Fatigue-By relieving bloating, inflammation and swelling, and therefore

increasing circulation, other benefits of this therapy is an increase energy
levels and stamina

Selection of the Cold Stones

The important thermal quality that is best to look for in any type of massage
stone, be it for hot or cold stone therapy, is its ability to resist thermal
change. This is to say that if you are using a stone for cold stone therapy, it
should have the ability to retain the cold for a long enough period of time to
prove useful in a massage setting. Various stone can be used for cold
stone therapy work. Sedimentary and basalt stone works but the industry
favorite for cold stonework is marble.

Marble retains cold very well but it is also the most expensive to purchase.
The basalt stones we use for the hot stone massage are usually already
round and perfectly smooth, but unfortunately marble doesn’t come so
easily packaged. It must be shaped and polished so that it has a texture
that is smooth enough to use against bare skin. This is why marble stone
sets are typically more expensive than a basalt stone set.

If you are going to be using cold stones you will want to keep in mind that,
just as hot stones can burn, cold stones can desensitize the skin. While the
cold stones will not desensitize the skin as quickly as ice does, it still can
cause a massage client to loose enough feeling to the area that they
wouldn't notice that soft tissue manipulations were too deep, and therefore
would not let you know if you were actually causing damage.

With this in mind, you would have to pay careful attention to the
appearance of the skin. As with heat, cold can cause structural damage
that may go unnoticed due to the anesthetic effect that cold as on a
person's skin, but later it could be red and have “burned” look to it.

Alternating between hot and cold stones
I am sure some of you reading this are already thinking, “Can I use both hot
and cold stones in the same massage?”

The answer is yes. Alternating between hot and cold stones can provide an
exhilarating experience, but it is not one that everyone will enjoy or benefit

Alternating between heat and cold will cause the blood vessels to alternate
between dilation and constriction. The end result of this will be a dramatic
increase in circulation to that area. For this reason this type of massage
should not be used if the client has circulatory problems.

Short and Long Hot Applications

A short hot application on the skin, which lasts less than 5 minutes,
produces a stimulatory response on circulation, as blood flow through the
area is increased due to dilated blood vessels. In a long hot application,
which is longer than 5 minutes, circulation is actually depressed as the
movement of blood is decreased due to congestion produced by the first 5
minutes' exposure to heat.

In the incident of the short hot application the reaction of the body is
considered to be an "intrinsic" response, where the reaction is a direct
result of the heat, which is transferred to the body. In the long hot
application, the response of the body is a "reactive" one, where your body
creates a reflex as a result of its protective reaction to the hot application.
This reflex in the body occurs to prevent the observation we made in the
above paragraph that the peripheral circulation although individually small,
is collectively large enough in its capacity to hold the blood of central
circulation if it is diverted away from the heart.

Short and Long Cold Applications

In a short cold application, which is less than 1 minute, the effect is
stimulating to the circulation, though this would initially seem to be
contradictory. On its initial contact with the skin, the effect is immediately
depressive as the blood vessels instinctively constrict. This momentary and
brief vasoconstriction is important, but insignificant, since it is quickly
followed by a vasodilation that last for 20 to 60 seconds

The "reactive" response of the body occurs to prevent serious instant
vasoconstriction, which occurs in disorders such as Raynaud's disease.
Subsequent longer applications of cold greater than 1 minute result again
in vasoconstriction. In long cold applications of greater than 1 minute, the
effect on the circulation is thus depressive -- an "intrinsic" response of the
body to cold.

Effects on the Metabolism

Thermotherapy and cryotherapy affects metabolism as a result of
circulatory changes in the body or an area of the body. Even though
thermotherapy and cryotherapy appears to be as simple as moving blood
around, the effects on body tissues is profound.

In the case of stimulatory effects of alternating thermotherapy and

cryotherapy on metabolism, the following events take place in the body
under a short cold or hot application. When the skin first encounters
temperature changes, there is a temporary increase in blood pressure
where the body responds by increasing circulation to the area. This
increased superficial circulation results in increased blood supply to the
muscles and tissues as the blood vessel widen to allow the blood to reach
the capillaries on the skin. Subsequently, blood pressure drops. Heart rate,
respiration rate, oxygen absorption, and carbon dioxide secretion all

Additional changes in metabolism occur under a short cold application.

These include an increase in tissue tone, increase in peripheral white blood
cell (WBC) counts, increase in peripheral red blood cell (RBC) counts, and
a decrease in blood sugar levels. In addition, nitrogen absorption and
excretion by the kidneys are also increased. For both short and long hot
applications, the following changes in metabolism occur: decrease in tissue
tone, decrease in peripheral WBC count, decrease in peripheral RBC
count, and an increase in blood glucose levels.

Introducing your clients to Hot or Cold Stones

If you would like to introduce your current clients to the joy of Hot Stone
massage an easy way to do it is to warm up the stones and ask them if
they would like a free sample of the stones. You can add the use of hot
stones to just one body part, like kneading the trapezius. This gives them
an idea of how good it would feel, but leaves them wanting more.

Cleaning Your Stones
The downside to incorporating hot stones in your massage practice is the
amount of work it takes to clean up after the massage.

Let’s get one thing perfectly clear-rubbing a warm stone covered with an
organic carrier oil on a persons skin is like opening up a vacation resort for
bacteria in your massage room. Sanitation measures have to be taken to
keep your room free from disgusting pathogens. Hopefully you are already
practicing good hygiene, but if you are going to be using hot stones you will
have to take it up a notch.

The massage stones must be cleaned after each client, without exception!
While this may seem like a “no-brainer” you would be surprised how many
day spas take the short cut of just putting them back in the heater, thinking,
“Well it’s hot water, that kills germs, right?”

Wrong. Very wrong. Ewwww.

Not only do the stones have to be cleaned after being used on a client, the
water in the heater must be changed between each client and the inside of
the warmer has to be disinfected too.

While this may sound extreme it makes perfect sense. You have to put
your hands into the water of the heater to get the stones you use during the
massage. Each and every time you put your hands in that water, you are
contaminating it with the cooties of the person you are working on. Just
because you don’t put the stones back in the heater after using them, it
doesn’t mean you can skip the step of cleaning the heater.

If this sounds like a lot of work, well, it is. The sad truth is that this is why
we charge more money for a hot stone massage. It is more work for us.
Not only do we have to pay way more attention while we are doing the
massage (to avoid burning our clients) we have to do a lot more work after
the session, so don’t feel bad charging and extra $20 or more in addition to
your regular rate for the hour of hot stone work.

Washing the stones in hot soapy water with antibacterial dish soap is
sufficient for cleaning the hot stones. What I always did to save time was
prepare a third container of hot soapy water before the massage, and I

would just drop the stones I used into it so they would be there waiting
when I was done.

The stones should then be rinsed in hot water, air-dried on a towel and if
possible, wiped down with a disinfectant, Quats5 or even alcohol. The water
in the heater should be changed after each use, and the water reservoir
should be washed with antibacterial soap and water, rinsed and sprayed
with disinfectant. The towel that is at the bottom of the heater must be
replaced with a clean one.

When it comes to cleaning the stones, light water soluble oil is easier to
remove than a crème, gel or lotion. While these make great massage
mediums, they become sticky messes when added to the water of the
stone heater.

When I worked at an upscale spa we were constantly pressured to get the

client out of the room on time, since we only had a few minutes to wash our
hands and change the linens before the next client arrived for their service.

As you can imagine, this caused a great deal of grief when the service
scheduled was a hot stone massage, and naturally, it led to cutting corners
in the proper sanitation of the stones.

We solved the problem by incorporating two things.

1. There was a large supply of stones available. We procured hundreds

of stones for the massages from a local vendor of garden supplies
and these stones were placed in tubs in a storeroom that was easily
accessible by the three massage therapists that worked on any given
day. We had enough stones so that we could easily wait until the
end of the day to wash them so we didn’t have to worry about using
the same ones twice.
2. Each massage room had two stone-heaters. When we looked at our
schedule in the morning we could see what time we had hot stone
massages. If there were ever two back to back (rare-but it
happened) we would turn on both heaters, one for the massage we
were doing and one for the following massage.

Quaternary ammonium compounds

These two simple steps made it possible for us to smoothly incorporate
proper hygiene in a rapid paced business. Yes it cost the spa a little more
initially to set up redundant heaters and excess stones, but it was worth it in
the long run.

Demonstration Video
If you feel like you need to see a demonstration you can see a very good
one here. If you downloaded this course as a pdf document you can click
this link here:

If you are reading it embedded in our website the link to the video page is
below the embedded book.

Chapter 2: The Science Behind Hot and Cold Stone Therapy

Thermotherapy Definition/Description
Thermotherapy consists of application of heat or cold (cryotherapie) for the
purpose of changing the cutaneous, intra-articular and core temperature of
soft tissue with the intention of improving the symptoms of certain
conditions. Cryotherapy and thermotherapy are useful adjuncts for the
treatment of musculoskeletal injuries and soft tissue injuries. Using ice or
heat as a therapeutic intervention decreases pain in joint and muscle as
well as soft tissues and they have opposite effects on tissue metabolism,
blood flow, inflammation, edema and connective tissue extensibility.
Thermotherapy can be used in rehabilitation facilities or at home.

The goal of thermotherapy is to alter tissue temperature in a targeted
region over time for the purpose of inducing a desired biological response.
The majority of thermotherapies are designed to deliver the thermal therapy
to a target tissue volume with minimal impact on intervening or surrounding

Heat: By increasing the temperature of the skin/soft tissue, the blood flow
increases by vasodilatation. The metabolic rate and the tissue extensibility
will also increase. Heat increases oxygen uptake and accelerates tissue
healing, it also increases the activity of destructive enzymes, such as
collagenase, and increases the catabolic rate.

Cold: By decreasing the temperature of the skin/soft tissue, the blood flow
decreases by vasoconstriction. It will be followed afterwards by a
vasodilatation which will prevent against hypoxic damage (hunting reflex: If
the cold pack is left on the skin for more than 10 minutes, the blood vessels
will dilatate). The tissue metabolism will decrease just like the neuronal
excitability, inflammation, conduction rate and tissue extensibility. At joint
temperatures of 30°C or lower, the activity of cartilagedegrading enzymes,
including collagenase, elastase, hyaluronidase, and protease, is inhibited.
the decreased metabolic rate limits further injury and aids the tissue in
surviving the cellular hypoxia that occurs after injury.

Both applications can reduce the pain, but when we need to use which
application is still the question. Therefore, patient’s preference can be
taken into consideration when deciding which thermotherapy tool to use.

Heat: Heating of superficial tissues can be achieved using hot packs, wax
baths, towels, sunlight, saunas, heat wraps, steam baths/rooms. We can
also get the heat in the deeper tissues through electrotherapy (ultrasound,
shockwave and infrared radiation).

Cold: Cooling is achieved using ice packs, ice baths, cooling gel packs,
cold air and sprays.

In the literature, they describe cryotherapie (ice application) as an effective

treatment for soft tissue injuries. It reduces the swelling, and it will improve
the range of motion. However, there are still some doubts if it is actually
effective for pain relief. So the application of ice may be useful for a variety
of musculoskeletal pains, yet the evidence for its efficacy should be
established more convincingly.

Exercise in warm water, usually called hydrotherapy or balneotherapy, is a

popular and effective treatment with a pain relief effect for many patients
with painful neurologic or musculoskeletal conditions. The warmth of water
may block nociception by acting on thermal receptors and
mechanoreceptors, thus influencing spinal segmental mechanisms. It gives
positive effects on cutaneous barrier homeostasis and a anti-inflammatory
activity. In addition, the warmth may enhance blood flow and muscle
relaxation. The hydrostatic effect may also relieve pain by reducing
peripheral edema and by dampening sympathetic nervous system activity.

Mechanism of Action
Skin blood flow is controlled by two branches of the sympathetic nervous
system: a noradrenergic vasoconstrictor system and a cholinergic active

vasodilator system. These dual sympathetic neural control mechanisms
affect the major aspects of thermoregulatory responses over most of the
human body’s surface.

VC = vasocondtriction, VD = vasodilatation

During periods of hypothermia, falling core and skin temperatures lead to

reflexive increases in sympathetic active vasoconstrictor nerve activity to
reduce skin blood flow and conserve body heat. During periods of heat
stress, increasing core and skin temperatures lead to reflexive increases in
sympathetic active vasodilator nerve activity to increase skin blood flow.

The effect of heat on pain is mediated by heat sensitive calcium channels.

These channels respond to heat by increasing intracellular calcium. This
generates action potentials that increases stimulation of sensory nerves
and causes the feeling of heat in the brain. These channels are part of a
family of receptors called TRPV receptors. TRPV1 and TRPV2 channels
are sensitive to noxious heat, while TRPV4 channels are sensitive to
normal physiological heat. Their multiple binding sites allow a number of
factors to activate these channels. Once activated, they can also inhibit the
activity of purine pain receptors. These receptors, called P2X2 and P2Y2
receptors, are mediated pain receptors and are located in the peripheral

small nerve endings. For example, with peripheral pain, heat can directly
inhibit pain. However, when pain is originating from deep tissue, heat
stimulates peripheral pain receptors which can alter what has been termed
gating in the spinal cord and reduce deep pain.

Previous studies have suggested that temperature can affect the exchange
between Ca2+ and Na+ in neural cells. They have documented an increase
in both pain threshold (PTH) and pain tolerance (PTO) with the use of

True or not true?Disadvantage: when you heat skin, vasodilatation (VD)

distracts blood from soft tissue underneath and poor muscle circulation
decreases metabolism in the muscles…

Increased superficial tissue temperature results in the release of chemical

mediators, such as histamine and prostaglandins, which result in
vasodilation. These vasodilatory mechanisms do not significantly affect
blood flow in skeletal muscle since skeletal muscle blood flow is heavily
influenced by other physiologic and metabolic factors. Exercise is the best
means to increase blood flow to skeletal muscle.

The treatment depends on the type of application and the type of disease.
There are 3 phases of the healing process: the inflammatory phase, the
proliferation phase and the remodeling phase.

The first phase, known as the inflammatory phase, protects the injured area
from further injury while the body contains the damaged tissue. During this
phase, cryotherapy can help to reduce swelling. Never use heat during this
phase because heat increases the blood flow into the injured area and
increases the amount of swelling. The inflammatory phase has a duration
of 2 days.

During the second phase, the proliferation phase, new tissue and scar
tissue are formed. Heat can now be applied to the injured area to facilitate
the healing process.

The third and final phase, the remodeling phase, is the process of returning
to health: the restoration of structure and function of injured or diseased
tissues. The healing process includes blood clotting, tissue mending,

scarring and bone healing. Heat therapy can also be used during this

Physiological Effects
Many of the local physiologic effects of heat and cold have been studied
thoroughly. For instance, heat increases skin and joint temperature,
improves blood circulation and muscle relaxation and decreases joint
stiffness. Cold will numb the pain, decrease swelling, constrict blood
vessels and block nerve impulses to the joint.

Deep heating is thought to lessen nerve sensitivity, increase blood flow,

increase tissue metabolism, decrease muscle spindle sensitivity to stretch,
cause muscle relaxation, and increase flexibility. Heat stimulates the
cutaneous thermo receptors that are connected to the cutaneous blood
vessels, causing the release of bradykinin which relaxes the smooth
muscle walls resulting in vasodilation. Muscle relaxation occurs as a result
of a decreased firing rate of the gamma efferents, thus lowering the
threshold of the muscle spindles and increasing afferent activity. There is
also a decrease in firing of the alpha motorneuron to the extrafusal muscle
fibre, resulting in muscle relaxation and decrease in muscle tone.

A very important note that needs to be made is that thermotherapy is safe
for people with a normal skin sensation. When a patient has problems with
thermal sensitivity, it could be dangerous. They cannot feel if they are being
burned due to the application.

There are still a lot of contradictions if the use of thermotherapy is effective;
however, worldwide it is used to reduce the pain.

While there is good evidence that exercise relieves pain, improves function,
and is cost-effective, evidence supporting the use of non-exercise
physiotherapeutic interventions is much weaker. There is some support for
the efficacy of thermotherapy, transcutaneous electrical neuromuscular
stimulation (TENS), and massage. But there is little evidence to support the
efficacy of electrotherapy, acupuncture or manual therapy.

For knee osteoarthritis (OA), ice massage is reported to improve joint

movement, pain and function; ice packs can reduce swelling and improve

movement but may not relieve pain. In rheumatoid arthritis (RA), heat or
cold packs are reported to have no effect on edema, pain, movement, stre

Despite conflicting evidence, the simple form of thermotherapy is widely

recommended for many musculoskeletal conditions because it is a safe,
effective, easy-to-apply and well-liked therapy based on anecdotal reports,
expert opinion and patient preferences. Interventions that can be self-
administered (thermotherapy, TENS, massage) are more likely to be cost-
effective and less burdensome and hence much more attractive long-term
management options. Complex thermal therapeutic modalities (heating
deeper tissues) require special equipment, supervision and need to be
delivered by a therapist, making them less accessible, more costly and
higher risk.

An example of Thermotherapy
Osteoarthritis is a degenerative joint disease that affects mostly the weight-
bearing joints in the knees and hips. As the affected joint degenerates pain
and restriction of movement often occur. Inflammation can also occur
sometimes resulting in edema of the joint with OA. Treatment focuses on
decreasing pain and improving movement.

To determine the effectiveness of thermotherapy in the treatment of OA of

the knee. The outcomes of interest were relief of pain, reduction of edema,
and improvement of flexion or range of motion (ROM) and function.

Two independent reviewers selected randomized and controlled clinical

trials with participants with clinical and/or radiological confirmation of OA of
the knee; and interventions using heat or cold therapy compared with
standard treatment and/or placebo. Trials comparing head to head
therapies, such as two different types of diathermy, were excluded.

Randomized and controlled clinical trials including participants with clinical

or radiographical confirmation of OA of the knee and interventions using
heat or cold compared to standard treatment or placebo were considered
for inclusion.

Study results were extracted by two independent reviewers. Outcomes

were continuous in nature (pain, strength, improvement) and were
analyzed by weighted mean difference using a fixed effects model.
Graphical data were used when table data were not available.

Three randomized controlled trials, involving 179 patients, were included in
this review. The included trials varied in terms of design, outcomes
measured, cryotherapy or thermotherapy treatments and overall
methodological quality. In one trial, administration of 20 minutes of ice
massage, 5 days per week, for 3 weeks, compared to control demonstrated
a clinically important benefit for knee OA on increasing quadriceps strength
(29% relative difference). There was also a statistically significant
improvement, but no clinical benefit in improving knee flexion ROM (8%
relative difference) and functional status (11% relative difference). Another
trial showed that cold packs decreased knee edema.

Ice massage compared to control had a statistically beneficial effect on

ROM, function and knee strength. Cold packs decreased swelling. Hot
packs had no beneficial effect on edema compared with placebo or cold
application. Ice packs did not affect pain significantly, compared to control,
in patients with OA. More well designed studies with a standardized
protocol and adequate number of participants are needed to evaluate the
effects of thermotherapy in the treatment of OA of the knee.

Thermotherapy (heat treatment) for treating osteoarthritis of the knee

To answer this topic, scientists found and analyzed three studies. Over 170
people with osteoarthritis continue to take their medications but used hot,
cold or ice packs/towels with or without massage or no treatment. The
studies were not of high quality but this Cochrane review provides the best
evidence we have today.

What is thermotherapy and how might it help osteoarthritis of the knee?

Osteoarthritis (OA) is the most common form of arthritis that can affect the
hands, hips, shoulders and knees. In OA, the cartilage that protects the
ends of the bones breaks down and causes pain and swelling.
Thermotherapy involves applying heat or cold to joints to improve the
symptoms of osteoarthritis and can be done with packs, towels, wax, etc.
Heat may work by improving circulation and relaxing muscles, while cold
may numb the pain, decrease swelling, constrict blood vessels and block
nerve impulses to the joint. Thermotherapy can be used in rehabilitation
programmes or at home.

One study showed that massaging with ice for 20 minutes, 5 days a week
for 2 weeks, improved muscle strength in the leg, the range of motion in the
knee and decreased time to walk 50 feet compared to no treatment.

Another study showed that ice packs for 3 days a week for three weeks
improved pain just as well as no treatment.

Another study showed that cold packs for 20 minutes for 10 periods
decreased swelling more than no treatment. Hot packs for the same
amount of time had the same effect on swelling as no treatment.

No side effects were reported in the studies, but in general, studies report
that thermotherapy is safe when applied carefully.

Since the studies were small and of low quality firm conclusions cannot be
made. There is "silver" level evidence that ice massage could be used to
improve range of motion and strength of the knee and function in people
with osteoarthritis of the knee. Cold packs may be used to decrease

Cryotherapy Definition/Description
Cryotherapy, also known as ice application, is the simplest and oldest way
to treat injuries. Its use is worldwide spread because of its effectiveness,
convenience low cost and ease of transportation.

Ice is believed to control pain by instigating local anesthesia. It also

decreases edema, nerve conduction velocities, cellular metabolism and
local blood flow. The effect of the cryotherapy depends on the method, the
duration, the temperature of the ice and the depth of the subcutaneous fat.

Application Methods
The most common method of cryotherapy is the use of ice packs. There
are different types of ice used in ice packs. The most common types are ice
packs made with cubed, crushed and wetted ice.

The study of Joseph H. Dykstra et al. sais that wetted ice is better to lower
surface temperature during treatment and maintaining the lower
temperature during recovery. It’s also more effective in lowering the
intramuscular temperature during treatment. We may conclude that wetted
ice is best for treating injuries and rapidly inducing local anesthesia.

Ice application is often used to treat soft tissue injuries. Yet, there is little
evidence of the positive effects of cryotherapy. Therefore, many more high
quality trials are needed to provide guidelines in the treatment of soft-tissue

For more information, see APPENDIX II Ice Massage versus Conventional

Icing: a comparison on the effectiveness of each in the inflammation phase
of healing

Hydrotherapy-Balneotherapy Definition/Description
Hydrotherapy is a definition for exercise in warm water and is a popular
treatment for patients with neurologic and musculoskeletal conditions. The
goals of this therapy are muscle relaxation, improving joint motion and
reducing pain. This therapy is been used for thousands of years. (Level of
evidence A1)

Therapeutic effects
1) The warmth of water blocks nociception by acting on thermal receptors
and mechanoreceptors, thus influencing spinal segmental mechanisms.
2) Warm water stimulates blood flow positively, which leads to muscle
3) the hydrostatic effect may relieve pain by reducing peripheral edema and
by dampening the sympatic nervous system activity.
4) Water exercises against resistance improves muscle strength. ( Levels
of evidence A1,A2)

Difference between aquatic exercise and balneotherapy

Balneotherapy is hydrotherapy but without exercise and is also called “Spa
therapy”. It is frequently used in alternative medicine as a disease cure and
is very popular for treatment of all types of arthritis.

There are not much studies that describe the difference in therapy effects
between aquatic exercise and balneotherapy without exercise. Compared
to balneotherapy, exercise in water is more effective for the treatment of
musculoskeletal diseases than passive immersion. There are no long-term
effects, so to keep the disease stable, it is necessary to frequently
participate in water exercises.

It is not clear what exact the effect is of balneotherapy in musculoskeletal
diseases because the studies involving this subject have poor
methodological quality, which makes it difficult to determine the individual
effect in this therapy.

(Level of evidence A1)

Hydrotherapy in patients with rheumatoid arthritis
The study of A. Billberg confirms that temperate pool exercise has a
significant effect on endurance and flexibility of the muscles, in upper and
lower extremities in patients with RA. To gain this endurance and flexibility,
exercises against resistance (Eccentric and concentric exercises) are
necessary. Recent studies also indicate that patients with low muscle
function can improve their muscle endurance with low impact exercises.
The vitality of patients with Rheumatoid arthritis who participate in
exercises in water is significantly improved after the hydrotherapy session.

Two trials compared hydrotherapy to land-based exercise and failed to find

any long term differences in quality of life, health status, pain or functional
scores. When we compare aquatic exercises to no exercise at all, there is a
significant improvement in reducing pain in patients who participated in
aquatic exercises.

Normal human body temperature

Normal human body temperature, also known as normothermia or
euthermia, depends upon the place in the body at which the measurement
is made, the time of day, as well as the activity level of the person.

Different parts of the body have different temperatures. Rectal and vaginal
measurements, or measurements taken directly inside the body cavity, are
typically slightly higher than oral measurements, and oral measurements
are somewhat higher than skin temperature. The commonly accepted
average core body temperature (taken internally) is 37.0 °C (98.6 °F). The
typical oral (under the tongue) measurement is slightly cooler, at 36.8° ±
0.4 °C (98.2° ± 0.7 °F), and temperatures taken in other places (such as
under the arm or in the ear) produce different typical numbers. Although
some people think of these averages as representing the normal or ideal
temperature, a wide range of temperatures has been found in healthy

The body temperature of a healthy person varies during the day by about
0.5 °C (0.9 °F) with lower temperatures in the morning and higher
temperatures in the late afternoon and evening, as the body's needs and
activities change. Other circumstances also affect the body's temperature.
The core body temperature of an individual tends to have the lowest value
in the second half of the sleep cycle; the lowest point, called the nadir, is
one of the primary markers for circadian rhythms. The body temperature
also changes when a person is hungry, sleepy, or cold.

Temperature control (thermoregulation) is part of a homeostatic

mechanism that keeps the organism at optimum operating temperature, as
it affects the rate of chemical reactions. In humans the average internal
temperature is 37.0 °C (98.6 °F), though it varies among individuals.
However, no person always has exactly the same temperature at every
moment of the day. Temperatures cycle regularly up and down through the
day, as controlled by the person's circadian rhythm. The lowest
temperature occurs about two hours before the person normally wakes up.
Additionally, temperatures change according to activities and external

In addition to varying throughout the day, normal body temperature may

also differ as much as 0.5 °C (0.9 °F) from one day to the next, so that the
highest or lowest temperatures on one day will not always exactly match
the highest or lowest temperatures on the next day.

Normal human body temperature varies slightly from person to person and
by the time of day. Consequently, each type of measurement has a range
of normal temperatures. The range for normal human body temperatures,
taken orally, is 36.8±0.5 °C (98.2±0.9 °F). This means that any oral
temperature between 36.3 and 37.3 °C (97.3 and 99.1 °F) is likely to be

The normal human body temperature is often stated as 36.5–37.5 °C

(97.7–99.5 °F). In adults a review of the literature has found a wider range
of 33.2–38.2 °C (91.8–100.8 °F) for normal temperatures, depending on
the gender and location measured.

Natural rhythms

Body temperature normally fluctuates over the day, with the lowest levels
around 4 a.m. and the highest in the late afternoon, between 4:00 and 6:00
p.m. (assuming the person sleeps at night and stays awake during the
day). Therefore, an oral temperature of 37.3 °C (99.1 °F) would, strictly
speaking, be a normal, healthy temperature in the afternoon but not in the
early morning. An individual's body temperature typically changes by about
0.5 °C (0.9 °F) between its highest and lowest points each day.

Body temperature is sensitive to many hormones, so women have a

temperature rhythm that varies with the menstrual cycle, called a
circamensal rhythm. A woman's basal body temperature rises sharply after
ovulation, as estrogen production decreases and progesterone increases.
Fertility awareness programs use this predictable change to identify when a
woman can become pregnant. During the luteal phase of the menstrual
cycle, both the lowest and the average temperatures are slightly higher
than during other parts of the cycle. However, the amount that the
temperature rises during each day is slightly lower than typical, so the
highest temperature of the day is not very much higher than usual.
Hormonal contraceptives both suppress the circamensal rhythm and raise
the typical body temperature by about 0.6 °C (1.1 °F).

Temperature also varies with the change of seasons during each year. This
pattern is called a circannual rhythm. Studies of seasonal variations have
produced inconsistent results. People living in different climates may have
different seasonal patterns.

Increased physical fitness increases the amount of daily variation in


With increased age, both average body temperature and the amount of
daily variability in the body temperature tend to decrease. Elderly patients
may have a decreased ability to generate body heat during a fever, so even
a somewhat elevated temperature can indicate a serious underlying cause
in geriatrics.

Measurement methods
Different methods used for measuring temperature produce different
results. The temperature reading depends on which part of the body is
being measured. The typical daytime temperatures among healthy adults
are as follows:

Temperature in the anus (rectum/rectal), vagina, or in the ear (otic) is about
37.5 °C (99.5 °F)

Temperature in the mouth (oral) is about 36.8 °C (98.2 °F)

Temperature under the arm (axillary) is about 36.5 °C (97.7 °F)

Generally, oral, rectal, gut, and core body temperatures, although slightly
different, are well-correlated, with oral temperature being the lowest of the
four. Oral temperatures are generally about 0.4 °C (0.7 °F) lower than
rectal temperatures.

Oral temperatures are influenced by drinking, chewing, smoking, and

breathing with the mouth open. Cold drinks or food reduce oral
temperatures; hot drinks, hot food, chewing, and smoking raise oral

Axillary (armpit), tympanic (ear), and other skin-based temperatures

correlate relatively poorly with core body temperature. Tympanic
measurements run higher than rectal and core body measurements, and
axillary temperatures run lower. The body uses the skin as a tool to
increase or decrease core body temperature, which affects the temperature
of the skin. Skin-based temperatures are more variable than other
measurement sites. The peak daily temperature for axillary measurements
lags about three hours behind the rest of the body. Skin temperatures are
also more influenced by outside factors, such as clothing and air

Variations due to outside factors

Many outside factors affect the measured temperature as well. "Normal"
values are generally given for an otherwise healthy, non-fasting adult,
dressed comfortably, indoors, in a room that is kept at a normal room
temperature (22.7 to 24.4 °C or 73 to 76 °F), during the morning, but not
shortly after arising from sleep. Furthermore, for oral temperatures, the
subject must not have eaten, drunk, or smoked anything in at least the
previous fifteen to twenty minutes, as the temperature of the food, drink, or
smoke can dramatically affect the reading.

Temperature is increased after eating or drinking anything with calories.
Caloric restriction, as for a weight-loss diet, reduces overall body
temperature. Drinking alcohol reduces the amount of daily change, slightly
lowering daytime temperatures and noticeably raising nighttime

Exercise raises body temperatures. In adults, a noticeable increase usually

requires strenuous exercise or exercise sustained over a significant time.
Children develop higher temperatures with milder activities, like playing.

Psychological factors also influence body temperature: a very excited

person often has an elevated temperature.

Wearing more clothing slows daily temperature changes and raises body
temperature. Similarly, sleeping with an electric blanket raises the body
temperature at night

Sleep disturbances also affect temperatures. Normally, body temperature

drops significantly at a person's normal bedtime and throughout the night.
Short-term sleep deprivation produces a higher temperature at night than
normal, but long-term sleep deprivation appears to reduce
temperatures.Insomnia and poor sleep quality are associated with smaller
and later drops in body temperature.Similarly, waking up unusually early,
sleeping in, jet lag and changes to shift work schedules may affect body

Thermoregulation explained
Thermoregulation is the ability of the body to keep its temperature within
certain boundaries, even when the surrounding temperature is very
different. A thermoconforming organism, by contrast, simply adopts the
surrounding temperature as its own body temperature, thus avoiding the
need for internal thermoregulation. The internal thermoregulation process is
one aspect of homeostasis: a state of dynamic stability in an organism's
internal conditions, maintained far from equilibrium with its environment
(the study of such processes in zoology has been called ecophysiology or
physiological ecology). If the body is unable to maintain a normal
temperature and it increases significantly above normal, a condition known
as hyperthermia occurs. For humans, this occurs when the body is
exposed to constant temperatures of approximately 55 °C (131 °F), and
any prolonged exposure (longer than a few hours) at this temperature and

up to around 75 °C (167 °F) death is almost inevitable. Humans may also
experience lethal hyperthermia when the wet bulb temperature is sustained
above 35 °C (95 °F) for six hours. The opposite condition, when body
temperature decreases below normal levels, is known as hypothermia.

Whereas an organism that thermoregulates is one that keeps its core body
temperature within certain limits, a thermoconformer is subject to changes
in body temperature according to changes in the temperature outside of its
body at a certain temperature.

It was not until the introduction of thermometers that any exact data on the
temperature of animals could be obtained. It was then found that local
differences were present, since heat production and heat loss vary
considerably in different parts of the body, although the circulation of the
blood tends to bring about a mean temperature of the internal parts. Hence
it is important to identify the parts of the body that most closely reflect the
temperature of the internal organs. Also, for such results to be comparable,
the measurements must be conducted under comparable conditions. The
rectum has traditionally been considered to reflect most accurately the
temperature of internal parts, or in some cases of sex or species, the
vagina, uterus or bladder.

Occasionally the temperature of the urine as it leaves the urethra may be of

use in measuring body temperature. More often the temperature is taken in
the mouth, axilla, ear or groin.

As in other mammals, thermoregulation is an important aspect of human

homeostasis. Most body heat is generated in the deep organs, especially
the liver, brain, and heart, and in contraction of skeletal muscles. Humans
have been able to adapt to a great diversity of climates, including hot humid
and hot arid. High temperatures pose serious stresses for the human body,
placing it in great danger of injury or even death. For humans, adaptation to
varying climatic conditions includes both physiological mechanisms
resulting from evolution and behavioural mechanisms resulting from
conscious cultural adaptations.

There are four avenues of heat loss: convection, conduction, radiation, and
evaporation. If skin temperature is greater than that of the surroundings,
the body can lose heat by radiation and conduction. But, if the temperature
of the surroundings is greater than that of the skin, the body actually gains

heat by radiation and conduction. In such conditions, the only means by
which the body can rid itself of heat is by evaporation. So, when the
surrounding temperature is higher than the skin temperature, anything that
prevents adequate evaporation will cause the internal body temperature to
rise. During sports activities, evaporation becomes the main avenue of heat
loss. Humidity affects thermoregulation by limiting sweat evaporation and
thus heat loss.

The skin assists in homeostasis (keeping different aspects of the body

constant, e.g. temperature). It does this by reacting differently to hot and
cold conditions so that the inner body temperature remains more or less
constant. Vasodilation and sweating are the primary modes by which
humans attempt to lose excess body heat. The brain creates much heat
through the countless reactions which occur. Even the process of thought
creates heat. The head has a complex system of blood vessels, which
keeps the brain from overheating by bringing blood to the thin skin on the
head, allowing heat to escape. The effectiveness of these methods is
influenced by the character of the climate and the degree to which the
individual is acclimatized.

In hot conditions
Eccrine sweat glands under the skin secrete sweat (a fluid containing
mostly water with some dissolved ions), which travels up the sweat duct,
through the sweat pore and onto the surface of the skin. This causes heat
loss via evaporative cooling; however, a lot of essential water is lost.

The hairs on the skin lie flat, preventing heat from being trapped by the
layer of still air between the hairs. This is caused by tiny muscles under the
surface of the skin called arrector pili muscles relaxing so that their
attached hair follicles are not erect. These flat hairs increase the flow of air
next to the skin increasing heat loss by convection. When environmental
temperature is above core body temperature, sweating is the only
physiological way for humans to lose heat.

Arteriolar vasodilation occurs. The smooth muscle walls of the arterioles

relax allowing increased blood flow through the artery. This redirects blood
into the superficial capillaries in the skin increasing heat loss by convection
and conduction.

Note: Most animals cannot sweat efficiently. Cats and dogs have sweat
glands only on the pads of their feet. Horses and humans are two of the
few animals capable of sweating. Many animals pant rather than sweat
because the lungs have a large surface area and are highly vascularised.
Air is inhaled, cooling the surface of the lungs and is then exhaled losing
heat and some water vapour.

In hot and humid conditions

In general, humans appear physiologically well adapted to hot dry
conditions. However, effective thermoregulation is reduced in hot, humid
environments such as the Red Sea and Persian Gulf (where moderately
hot summer temperatures are accompanied by unusually high vapor
pressures), tropical environments, and deep mines where the atmosphere
can be water-saturated. In hot-humid conditions, clothing can impede
efficient evaporation. In such environments, it helps to wear light clothing
such as cotton, that is pervious to sweat but impervious to radiant heat
from the sun. This minimizes the gaining of radiant heat, while allowing as
much evaporation to occur as the environment will allow. Clothing such as
plastic fabrics that are impermeable to sweat and thus do not facilitate heat
loss through evaporation can actually contribute to heat stress.

In cold conditions
The minute muscles under the surface of the skin called erector pili
muscles (attached to an individual hair follicle) contract (piloerection), lifting
the hair follicle upright. This makes the hairs stand on end, which acts as
an insulating layer, trapping heat. This is what also causes goose bumps
since humans do not have very much hair and the contracted muscles can
easily be seen.

Arterioles carrying blood to superficial capillaries under the surface of the

skin can shrink (constrict), thereby rerouting blood away from the skin and
towards the warmer core of the body. This prevents blood from losing heat
to the surroundings and also prevents the core temperature dropping
further. This process is called vasoconstriction. It is impossible to prevent
all heat loss from the blood, only to reduce it. In extremely cold conditions,
excessive vasoconstriction leads to numbness and pale skin. Frostbite
occurs only when water within the cells begins to freeze. This destroys the
cell causing damage.

Muscles can also receive messages from the thermo-regulatory center of
the brain (the hypothalamus) to cause shivering. This increases heat
production as respiration is an exothermic reaction in muscle cells.
Shivering is more effective than exercise at producing heat because the
animal remains still. This means that less heat is lost to the environment
through convection. There are two types of shivering: low-intensity and
high-intensity. During low-intensity shivering, animals shiver constantly at a
low level for months during cold conditions. During high-intensity shivering,
animals shiver violently for a relatively short time. Both processes consume
energy, however high-intensity shivering uses glucose as a fuel source and
low-intensity tends to use fats. This is a primary reason why animals store
up food in the winter.

Mitochondria can convert fat directly into heat energy, increasing the
temperature of all cells in the body. Brown fat is specialized for this
purpose, and is abundant in newborns and animals that hibernate.

The process explained above, in which the skin regulates body

temperature is a part of thermoregulation. This is one aspect of
homeostasis — the process by which the body regulates itself to keep
internal conditions constant.

Chapter 3: Unhealthy temperatures and injury treatment

Unhealthy extremes in temperature

Hot stone massage should be avoided if you suspect the client has a fever
or another health issue that could be interfering with their thermoregulation.

A temperature setpoint is the level at which the body attempts to maintain
its temperature. When the setpoint is raised, the result is a fever. Most
fevers are caused by infectious disease and can be lowered, if desired,
with antipyretic medications.

An early morning temperature higher than 37.2 °C (> 98.9 °F) or a late
afternoon temperature higher than 37.7 °C (> 99.9 °F) is normally
considered a fever, assuming that the temperature is elevated due to a
change in the hypothalamus's setpoint. Lower thresholds are sometimes
appropriate for elderly people. The normal daily temperature variation is
typically 0.5 °C (0.9 °F), but can be greater among people recovering from
a fever.

As a person's temperature increases, there is, in general, a feeling of cold

despite an increase in body temperature. Once body temperature has
increased to the new set-point temperature, there is a feeling of warmth.

A fever can be caused by many medical conditions ranging from benign to

potentially serious. Some studies suggest that fever is useful as a defense
mechanism as the body's immune response can be strengthened at higher
temperatures; however, there are arguments for and against the usefulness
of fever, and the issue is controversial. With the exception of very high
temperatures, treatment to reduce fever is often not necessary; however,
antipyretic medications can be effective at lowering the temperature, which
may improve the affected person's comfort.

Fever differs from uncontrolled hyperthermia, in that hyperthermia is an

increase in body temperature over the body's thermoregulatory set-point,
due to excessive heat production or insufficient thermoregulation.

A wide range for normal temperatures has been found. Fever is generally
agreed to be present if the elevated temperature is caused by a raised set
point and:

Temperature in the anus (rectum/rectal) is at or over 37.5–38.3 °C (99.5–
100.9 °F)

Temperature in the mouth (oral) is at or over 37.7 °C (99.9 °F)

Temperature under the arm (axillary) or in the ear (otic) is at or over 37.2
°C (99.0 °F)

In healthy adult men and women, the range of normal, healthy

temperatures for oral temperature is 33.2–38.2 °C (91.8–100.8 °F), for
rectal it is 34.4–37.8 °C (93.9–100.0 °F), for tympanic membrane (the ear
drum) it is 35.4–37.8 °C (95.7–100.0 °F), and for axillary (the armpit) it is
35.5–37.0 °C (95.9–98.6 °F). Harrison's textbook of internal medicine
defines a fever as a morning oral temperature of >37.2 °C (>98.9 °F) or an
afternoon oral temperature of >37.7 °C (>99.9 °F) while the normal daily
temperature variation is typically 0.5 °C (0.9 °F).

Normal body temperatures vary depending on many factors, including age,

sex, time of day, ambient temperature, activity level, and more. A raised
temperature is not always a fever. For example, the temperature of a
healthy person rises when he or she exercises, but this is not considered a
fever, as the set-point is normal. On the other hand, a "normal" temperature
may be a fever, if it is unusually high for that person. For example,
medically frail elderly people have a decreased ability to generate body
heat, so a "normal" temperature of 37.3 °C (99.1 °F) may represent a
clinically significant fever.

Febricula is an old term for a low-grade fever, especially if the cause is

unknown, no other symptoms are present, and the patient recovers fully in
less than a week.

An organism at optimum temperature is considered afebrile or apyrexic,

meaning "without fever". If temperature is raised, but the setpoint is not
raised, then the result is hyperthermia.

Hyperthermia occurs when the body produces or absorbs more heat than it
can dissipate. It is usually caused by prolonged exposure to high
temperatures. The heat-regulating mechanisms of the body eventually

become overwhelmed and unable to deal effectively with the heat, causing
the body temperature to climb uncontrollably. Hyperthermia at or above
about 40 °C (104 °F) is a life-threatening medical emergency that requires
immediate treatment. Common symptoms include headache, confusion,
and fatigue. If sweating has resulted in dehydration, then the affected
person may have dry, red skin.

In a medical setting, mild hyperthermia is commonly called heat exhaustion

or heat prostration; severe hyperthermia is called heat stroke. Heat stroke
may come on suddenly, but it usually follows the untreated milder stages.
Treatment involves cooling and rehydrating the body; fever-reducing drugs
are useless for this condition. This may be done through moving out of
direct sunlight to a cooler and shaded environment, drinking water,
removing clothing that might keep heat close to the body, or sitting in front
of a fan. Bathing in tepid or cool water, or even just washing the face and
other exposed areas of the skin, can be helpful.

With fever, the body's core temperature rises to a higher temperature

through the action of the part of the brain that controls the body
temperature; with hyperthermia, the body temperature is raised without the
consent of the heat control centers.

Hyperpyrexia is a fever with an extreme elevation of body temperature
greater than or equal to 41.5 °C (106.7 °F). Such a high temperature is
considered a medical emergency as it may indicate a serious underlying
condition or lead to significant side effects. The most common cause is an
intracranial hemorrhage. Other possible causes include sepsis, Kawasaki
syndrome, neuroleptic malignant syndrome, drug effects, serotonin
syndrome, and thyroid storm. Infections are the most common cause of
fevers, however as the temperature rises other causes become more
common. Infections commonly associated with hyperpyrexia include:
roseola, rubeola and enteroviral infections. Immediate aggressive cooling
to less than 38.9 °C (102.0 °F) has been found to improve survival.
Hyperpyrexia differs from hyperthermia in that in hyperpyrexia the body's
temperature regulation mechanism sets the body temperature above the
normal temperature, then generates heat to achieve this temperature, while
in hyperthermia the body temperature rises above its set point due to an
outside source.

Hypothermia is a condition in which the body's core temperature drops
below that required for normal metabolism and body functions. This is
generally considered to be less than 35.0 °C (95.0 °F). Characteristic
symptoms depend on the temperature. In mild hypothermia there is
shivering and mental confusion. In severe hypothermia there may be
paradoxical undressing, where a person removes their clothing, as well as
an increased risk of the heart stopping.

Body temperature is usually maintained near a constant level of 36.5–37.5

°C (97.7–99.5 °F) through biologic homeostasis or thermoregulation. If a
person is exposed to cold, and their internal mechanisms cannot replenish
the heat that is being lost, the body's core temperature falls. This can occur
due to excessive cold or health problems that decrease a person's ability to
generate heat.

The treatment of mild hypothermia involves: warm drinks, warm clothing

and staying active. In those with moderate hypothermia minimizing
movement is recommended along with heating blankets and warmed
intravenous fluids. In severe hypothermia extracorporeal membrane
oxygenation (ECMO) or cardiopulmonary bypass may be useful. In those
without vitals signs cardiopulmonary resuscitation (CPR) is indicated along
with the above measures. In those whose heart has stopped rewarming is
typically continued until a persons temperature is greater than 32 °C (90 °F)
before rewarming is deemed ineffective.

It is the cause of at least 1500 deaths a year in the United States. One of
the lowest documented body temperatures from which anyone has
recovered was 13.0 °C (55.4 °F) in a near-drowning incident involving a 7-
year-old girl in Sweden in December 2010. Hypothermia is the opposite of
hyperthermia, which is present in heat exhaustion and heat stroke.

Hypothermia is often defined as any body temperature below 35.0 °C (95.0

°F). With this method it is divided into degrees of severity based on the
core temperature.

Another classification system, the Swiss staging system, divides

hypothermia based on the presenting symptoms which is preferred when it
is not possible to determine an accurate core temperature.

Other cold-related injuries that can be present either alone or in
combination with hypothermia include:
Chilblains, superficial ulcers of the skin that occur when a predisposed
individual is repeatedly exposed to cold.
Frostbite, the freezing and destruction of tissue.
Frostnip, a superficial cooling of tissues without cellular destruction.
Trench foot or immersion foot, caused by to repetitive exposure to water at
non-freezing temperatures.
The normal human body temperature is often stated as 36.5–37.5 °C
(97.7–99.5 °F).[6] Hyperthermia and fever, are defined as a temperature of
greater than 37.5–38.3 °C (99.5–100.9 °F).

Signs and symptoms vary depending on the degree of hypothermia, and

may be divided by the three stages of severity. Infants with hypothermia
may feel cold when touched, with bright red skin and unusual lack of

Symptoms of mild hypothermia may be vague, with sympathetic nervous

system excitation (shivering, hypertension, tachycardia, tachypnea, and
vasoconstriction). These are all physiological responses to preserve heat.
Cold diuresis, mental confusion, and hepatic dysfunction may also be
present. Hyperglycemia may be present, as glucose consumption by cells
and insulin secretion both decrease, and tissue sensitivity to insulin may be
blunted. Sympathetic activation also releases glucose from the liver. In
many cases, however, especially in alcoholic patients, hypoglycemia
appears to be a more common presentation. Hypoglycemia is also found in
many hypothermic patients, because hypothermia may be a result of

Low body temperature results in shivering becoming more violent. Muscle
mis-coordination becomes apparent. Movements are slow and labored,
accompanied by a stumbling pace and mild confusion, although the person
may appear alert. Surface blood vessels contract further as the body
focuses its remaining resources on keeping the vital organs warm. The
subject becomes pale. Lips, ears, fingers, and toes may become blue.

As the temperature decreases, further physiological systems falter and
heart rate, respiratory rate, and blood pressure all decrease. This results in
an expected heart rate in the 30s at a temperature of 28 °C (82 °F).

Difficulty speaking, sluggish thinking, and amnesia start to appear; inability

to use hands and stumbling are also usually present. Cellular metabolic
processes shut down. Below 30 °C (86 °F), the exposed skin becomes blue
and puffy, muscle coordination very poor, and walking almost impossible,
and the person exhibits incoherent/irrational behavior, including terminal
burrowing (see below) or even stupor. Pulse and respiration rates decrease
significantly, but fast heart rates (ventricular tachycardia, atrial fibrillation)
can also occur. Atrial fibrillation is not typically a concern in and of itself.
Major organs fail. Clinical death occurs.

Paradoxical undressing
Twenty to fifty percent of hypothermia deaths are associated with
paradoxical undressing. This typically occurs during moderate to severe
hypothermia, as the person becomes disoriented, confused, and
combative. They may begin discarding their clothing, which, in turn,
increases the rate of heat loss.

Rescuers who are trained in mountain survival techniques are taught to

expect this; however, some may assume incorrectly that urban victims of
hypothermia have been subjected to a sexual assault.

One explanation for the effect is a cold-induced malfunction of the

hypothalamus, the part of the brain that regulates body temperature.
Another explanation is that the muscles contracting peripheral blood
vessels become exhausted (known as a loss of vasomotor tone) and relax,
leading to a sudden surge of blood (and heat) to the extremities, fooling the
person into feeling overheated.

Terminal burrowing
An apparent self-protective behaviour known as terminal burrowing, or
hide-and-die syndrome, occurs in the final stages of hypothermia. The
afflicted will enter small, enclosed spaces, such as underneath beds or
behind wardrobes. It is often associated with paradoxical undressing.
Researchers in Germany claim this is "obviously an autonomous process of
the brain stem, which is triggered in the final state of hypothermia and

produces a primitive and burrowing-like behavior of protection, as seen in
hibernating animals." This happens mostly in cases where temperature
drops slowly.

The rate of hypothermia is strongly related to age in the United States.

Hypothermia usually occurs from exposure to low temperatures, and is

frequently complicated by alcohol consumption. Any condition that
decreases heat production, increases heat loss, or impairs
thermoregulation, however, may contribute. Thus, hypothermia risk factors
include: substance abuse (including alcohol abuse), homelessness, any
condition that affects judgment (such as hypoglycemia), the extremes of
age, poor clothing, chronic medical conditions (such as hypothyroidism and
sepsis), and living in a cold environment. Hypothermia occurs frequently in
major trauma, and is also observed in severe cases of anorexia nervosa.

Alcohol consumption increases the risk of hypothermia by its action as a
vasodilator. It increases blood flow to the skin and extremities, making a
person feel warm, while increasing heat loss. Between 33% and 73% of
hypothermia cases are complicated by alcohol.

Water immersion
Hypothermia continues to be a major limitation to swimming or diving in
cold water. The reduction in finger dexterity due to pain or numbness
decreases general safety and work capacity, which consequently increases
the risk of other injuries.

Other factors predisposing to immersion hypothermia include dehydration,

inadequate rewarming between repetitive dives, starting a dive while
wearing cold, wet dry suit undergarments, sweating with work, inadequate
thermal insulation (for example, thin dry suit undergarment), and poor
physical conditioning.

Heat is lost much more quickly in water than in air. Thus, water
temperatures that would be quite reasonable as outdoor air temperatures
can lead to hypothermia in survivors, although this is not usually the direct
clinical cause of death for those who are not rescued. A water temperature
of 10 °C (50 °F) can lead to death in as little as one hour, and water

temperatures near freezing can cause death in as little as 15 minutes. A
notable example of this occurred during the sinking of the Titanic, when
most people who entered the −2 °C (28 °F) water died within 15–30

The actual cause of death in cold water is usually the bodily reactions to
heat loss and to freezing water, rather than hypothermia (loss of core
temperature) itself. For example, plunged into freezing seas, around 20%
of victims die within 2 minutes from cold shock, (uncontrolled rapid
breathing, and gasping, causing water inhalation, massive increase in
blood pressure and cardiac strain leading to cardiac arrest, and panic);
another 50% die within 15–30 minutes from cold incapacitation (inability to
use or control limbs and hands for swimming or gripping, as the body
"protectively" shuts down the peripheral muscles of the limbs to protect its
core), and exhaustion and unconsciousness cause drowning, claiming the
rest within a similar time.

Atrial fibrillation and Osborn J waves in a person with hypothermia. Note
what could be mistaken for ST elevation.
Accurate determination of core temperature often requires a special low
temperature thermometer, as most clinical thermometers do not measure
accurately below 34.4 °C (93.9 °F). A low temperature thermometer can be
placed in the rectum, esophagus or the bladder. Esophageal
measurements are the most accurate and are recommended once a
person is intubated. Other methods of measurement such as in the mouth,
under the arm, or using an infrared ear thermometer are often not accurate.

As a hypothermic person's heart rate may be very slow, prolonged feeling

for a pulse could be required before detecting. In 2005, the American Heart
Association recommended at least 30–45 seconds to verify the absence of
a pulse before initiating CPR.[45] Others recommend a 60 second check.

The classical ECG finding of hypothermia is the Osborn J wave. Also,

ventricular fibrillation frequently occurs below 28 °C (82 °F) and asystole
below 20 °C (68 °F). The Osborn J may look very similar to those of an
acute ST elevation myocardial infarction. Thrombolysis as a reaction to the
presence of Osborn J waves is not indicated, as it would only worsen the
underlying coagulopathy caused by hypothermia.

Appropriate clothing helps to prevent hypothermia. Synthetic and wool
fabrics are superior to cotton as they provide better insulation when wet
and dry. Some synthetic fabrics, such as polypropylene and polyester, are
used in clothing designed to wick perspiration away from the body, such as
liner socks and moisture-wicking undergarments. Clothing should be loose
fitting, as tight clothing reduces the circulation of warm blood. In planning
outdoor activity, prepare appropriately for possible cold weather. Those
who drink alcohol before or during outdoor activity should ensure at least
one sober person is present responsible for safety.

Covering the head is effective, but no more effective than covering any
other part of the body. While common folklore says that people lose most of
their heat through their heads, heat loss from the head is no more
significant than that from other uncovered parts of the body. However, heat
loss from the head is significant in infants, whose head is larger relative to
the rest of the body than in adults. Several studies have shown that for
uncovered infants, lined hats significantly reduce heat loss and thermal

Children have a larger surface area per unit mass, and other things being
equal should have one more layer of clothing than adults in similar
conditions, and the time they spend in cold environments should be limited.
However children are often more active than adults, and may generate
more heat. In both adults and children, overexertion causes sweating and
thus increases heat loss.

Building a shelter can aid survival where there is danger of death from
exposure. Shelters can be of many different types, metal can conduct heat
away from the occupants and is sometimes best avoided. The shelter
should not be too big so body warmth stays near the occupants. Good
ventilation is essential especially if a fire will be lit in the shelter. Fires
should be put out before the occupants sleep to prevent carbon monoxide
poisoning. People caught in very cold, snowy conditions can build an igloo
or snow cave to shelter.

The United States Coast Guard promotes using life vests to protect against
hypothermia through the 50/50/50 rule: If someone is in 50 °F (10 °C) water
for 50 minutes, he/she has a 50 percent better chance of survival if wearing

a life jacket. A heat escape lessening position can be used to increase
survival in cold water.

Babies should sleep at 16-20 °C (61-68 °F) and housebound people should
be checked regularly to make sure the temperature of the home is

Treatment ranges from noninvasive, passive external warming to active

external rewarming, to active core rewarming.[10] In severe cases
resuscitation begins with simultaneous removal from the cold environment
and management of the airway, breathing, and circulation. Rapid
rewarming is then commenced. Moving the person as little and as gently as
possible is recommended as aggressive handling may increase risks of a

Hypoglycemia is a frequent complication and needs to be tested for and

treated. Intravenous thiamine and glucose is often recommended, as many
causes of hypothermia are complicated by Wernicke's encephalopathy.
The UK NHS advises the lay public against putting a person in a hot bath,
massaging their arms and legs or using a heating pad.

Rewarming can be done with a number of different methods including
passive external rewarming, active external rewarming, and active internal
rewarming. Passive external rewarming involves the use of a person's own
ability to generate heat by providing properly insulated dry clothing and
moving to a warm environment. It is recommended for those with mild

Active external rewarming involves applying warming devices externally,

such as a heating blanket. These may function by warmed forced air (a
Bair Hugger is a commonly used device), chemical reactions, or electricity.
In wilderness environments, hypothermia may be helped by placing a hot
water bottle in both armpits and groin. These methods are recommended
for moderate hypothermia. Active core rewarming involves the use of
intravenous warmed fluids, irrigation of body cavities with warmed fluids
(the chest or abdomen), use of warm humidified inhaled air, or use of
extracorporeal rewarming such as via a heart lung machine or
extracorporeal membrane oxygenation. Extracorporeal rewarming is the
fastest method for those with severe hypothermia. Survival rates with

normal mental functioning have been reported at around 50%. Chest
irrigation is recommended if bypass or ECMO is not possible.

Rewarming collapse (or rewarming shock) is a sudden drop in blood

pressure in combination with a low cardiac output which may occur during
active treatment of a severely hypothermic person. There was a theoretical
concern that external rewarming rather than internal rewarming may
increase the risk. These concerns were partly believed to be due to "after-
drop", a situation detected during laboratory experiments where there is a
continued decrease in core temperature after rewarming has been started.
Recent studies have not supported these concerns, and problems are not
found with active external rewarming.

Warm sweetened liquids can be given provided the person is alert and can
swallow. Many recommend that alcohol and drinks with lots of caffeine be
avoided. As most people are moderately dehydrated due to cold-induced
diuresis, warmed intravenous fluids to a temperature of 38–45 °C (100–113
°F) is often recommended.

In those without signs of life cardiopulmonary resuscitation (CPR) should
be continued during active rewarming. For ventricular fibrillation or
ventricular tachycardia, a single defibrillation should be attempted. People
with severe hypothermia however may not respond to pacing or
defibrillation. It is not known if further defibrillation should be withheld until
the core temperature reaches 30 °C (86 °F). In Europe epinephrine is not
recommended until the temperature reaches 30 °C (86 °F) while the
American Heart Association recommended up to three doses of
epinephrine before 30 °C (86 °F) is reached. Once a temperature of 30 °C
(86 °F) is reached, normal ACLS protocols should be followed.

It is usually recommended not to declare a person dead until their body is
warmed to a near normal body temperature of greater than 32 °C (90 °F),
since extreme hypothermia can suppress heart and brain function.
Exceptions include if there is an obvious fatal injuries or the chest is frozen
so that it cannot be compressed. If a person was buried in an avalanche for
more than 35 minutes and is found with a mouth packed full of snow

without a pulse stopping early may also be reasonable. This is also the
case if a persons blood potassium is greater than 12 mmol/l.

Those who are stiff with pupils that do not move may survive if treated
aggressively. Survival with good function also occasionally occurs even
after the need for hours of CPR. Children who have a near-drowning
accidents in water near 0 °C (32 °F) can occasionally be revived even over
an hour after losing consciousness. The cold water lowers metabolism,
allowing the brain to withstand a much longer period of hypoxia. While
survival is possible, mortality from severe or profound hypothermia remains
high despite optimal treatment. Studies estimate mortality at between 38%
and 75%.

In those who have hypothermia due to another underlying health problem,

when death occurs it is frequently from that underlying health problem.

Basal body temperature

Basal body temperature is the lowest temperature attained by the body
during rest (usually during sleep). It is generally measured immediately
after awakening and before any physical activity has been undertaken,
although the temperature measured at that time is somewhat higher than
the true basal body temperature. In women, temperature differs at various
points in the menstrual cycle, and this can be used in the long-term to track
ovulation both for the purpose of aiding conception or avoiding pregnancy.
This process is called fertility awareness.

Core temperature
Core temperature, also called core body temperature, is the operating
temperature of an organism, specifically in deep structures of the body
such as the liver, in comparison to temperatures of peripheral tissues. Core
temperature is normally maintained within a narrow range so that essential
enzymatic reactions can occur. Significant core temperature elevation
(hyperthermia) or depression (hypothermia) that is prolonged for more than
a brief period of time is incompatible with human life.

Temperature examination in the rectum is the traditional gold standard

measurement used to estimate core temperature (oral temperature is
affected by hot or cold drinks and mouth-breathing). Rectal temperature is
expected to be approximately one Fahrenheit degree higher than an oral
temperature taken on the same person at the same time. Ear

thermometers measure eardrum temperature using infrared sensors. The
blood supply to the tympanic membrane is shared with the brain. However,
this method of measuring body temperature is not as accurate as rectal
measurement and has a low sensitivity for fevers, missing three or four out
of every ten fevers in children. Ear temperature measurement may be
acceptable for observing trends in body temperature but is less useful in
consistently identifying fevers.

Until recently, direct measurement of core body temperature required

surgical insertion of a probe, so a variety of indirect methods have
commonly been used. The rectal or vaginal temperature is generally
considered to give the most accurate assessment of core body
temperature, particularly in hypothermia. In the early 2000s, ingestible
thermistors in capsule form were produced, allowing the temperature inside
the digestive tract to be transmitted to an external receiver; one study found
that these were comparable in accuracy to rectal temperature

Chilblain, Frostnip and Frostbite

Chilblain (aka pernio) is a medical condition that is often confused with
frostbite and trench foot. Chilblain is the mildest form of cold injury and
develops on the feet, hands, and face. Athletes participating in winter
sports like skiing, snowboarding, and extreme snowball fighting are usually
unaware of the injury, thinking it’s just normal tingling from the cold but later
noticing a persistent burn and itching that can develop into blisters.

The condition is caused by cold exposure damaging the capillary beds in

the skin, which in turn causes redness, itching, blisters, and inflammation.
This common cold weather sports injury can be avoided by keeping the
hands and feet warm (duh) while participating in outdoor sports in winter.

Frostbite is the medical condition where localized damage is caused to skin

and other tissues due to freezing. Frostbite is most likely to happen in body
parts farthest from the heart and those with large exposed areas. The initial
stages of frostbite are sometimes called frostnip.

At or below 0 °C (32 °F), blood vessels close to the skin start to constrict,
and blood is shunted away from the extremities via the action of glomus
bodies. The same response may also be a result of exposure to high
winds. This constriction helps to preserve core body temperature. In

extreme cold, or when the body is exposed to cold for long periods, this
protective strategy can reduce blood flow in some areas of the body to
dangerously low levels. This lack of blood leads to the eventual freezing
and death of skin tissue in the affected areas. There are four degrees of
frostbite. Each of these degrees has varying degrees of pain.

This is a severe stage of the condition and is unlikely to be encountered by

cold weather athletes unless something seriously goes wrong, like they got
stuck on the ski lift or got lost on the mountain and couldn’t get to the hot
chocolate kiosk at the ski lodge before the sun went down.

The first degree of Frostbite is frostnip and only affects the surface of the
skin, which is frozen. On the onset, there is itching and pain, and then the
skin develops white, red, and yellow patches and becomes numb. The area
affected by frostnip usually does not become permanently damaged as
only the skin's top layers are affected. Long-term insensitivity to both heat
and cold can sometimes happen after suffering from frost nip.

If freezing continues, the skin may freeze and harden, but the deep tissues
are not affected and remain soft and normal. Second-degree injury usually
blisters 1–2 days after becoming frozen. The blisters may become hard and
blackened, but usually appear worse than they are. Most of the injuries
heal in one month, but the area may become permanently insensitive to
both heat and cold.

Third and fourth degree frostbite occurs if the area freezes further. The
muscles, tendons, blood vessels, and nerves all freeze. The skin is hard
and feels waxy, and use of the area is lost temporarily, and in severe
cases, permanently. The deep frostbite results in areas of purplish blisters
which turn black and which are generally blood-filled. Nerve damage in the
area can result in a loss of feeling. This extreme frostbite may result in
fingers and toes being amputated if the area becomes infected with
gangrene. If the frostbite has gone on untreated, they might just fall off on
their own. The extent of the damage done to the area by the freezing
process of the frostbite may take several months to assess, and this often
delays surgery to remove the dead tissue.

Massage therapy implications

Massage is actually a great way to help prevent Chillblain, if the affected
areas can be massaged in a safe warm environment when the symptoms

first begin. The increased circulation from the massage can greatly reduce
the amount of discomfort that would be experienced later.

If the Chillblain is in the acute stage (redness, itching, blisters, and

inflammation) massage is contraindicated as it would only further agitate
the skin.

Frostnip and Frostite are both more serious conditions that contraindicate
massage due to the presence of blistering and inflammation to the skin.

Burns and Scalds

A burn is a type of injury to flesh or skin caused by heat, electricity,
chemicals, friction, or radiation. Burns that affect only the superficial skin
are known as superficial or first-degree burns. When damage penetrates
into some of the underlying layers, it is a partial-thickness or second-
degree burn. In a full-thickness or third-degree burn, the injury extends to
all layers of the skin. A fourth-degree burn additionally involves injury to
deeper tissues, such as muscle or bone.

The treatment required depends on the severity of the burn. Superficial

burns may be managed with little more than simple pain relievers, while
major burns may require prolonged treatment in specialized burn centers.
Cooling with tap water may help relieve pain and decrease damage;
however, prolonged exposure may result in low body temperature. Partial-
thickness burns may require cleaning with soap and water, followed by
dressings. It is not clear how to manage blisters, but it is probably
reasonable to leave them intact. Full-thickness burns usually require
surgical treatments, such as skin grafting. Extensive burns often require
large amounts of intravenous fluid, because the subsequent inflammatory
response causes significant capillary fluid leakage and edema. The most
common complications of burns involve infection.

While large burns can be fatal, modern treatments developed since 1960
have significantly improved the outcomes, especially in children and young
adults. Globally, about 11 million people seek medical treatment, and
300,000 die from burns each year. In the United States, approximately 4%
of those admitted to a burn center die from their injuries. The long-term
outcome is primarily related to the size of burn and the age of the person

The characteristics of a burn depend upon its depth. Superficial burns
cause pain lasting two or three days, followed by peeling of the skin over
the next few days. Individuals suffering from more severe burns may
indicate discomfort or complain of feeling pressure rather than pain. Full-
thickness burns may be entirely insensitive to light touch or puncture. While
superficial burns are typically red in color, severe burns may be pink, white
or black. Burns around the mouth or singed hair inside the nose may
indicate that burns to the airways have occurred, but these findings are not
definitive. More worrisome signs include: shortness of breath, hoarseness,
and stridor or wheezing. Itchiness is common during the healing process,
occurring in up to 90% of adults and nearly all children. Numbness or
tingling may persist for a prolonged period of time after an electrical injury.
Burns may also produce emotional and psychological distress.

At temperatures greater than 44 °C (111 °F), proteins begin losing their

three-dimensional shape and start breaking down. This results in cell and
tissue damage. Many of the direct health effects of a burn are secondary to
disruption in the normal functioning of the skin. They include disruption of
the skin's sensation, ability to prevent water loss through evaporation, and
ability to control body temperature. Disruption of cell membranes causes
cells to lose potassium to the spaces outside the cell and to take up water
and sodium.

In large burns (over 30% of the total body surface area), there is a
significant inflammatory response. This results in increased leakage of fluid
from the capillaries, and subsequent tissue edema. This causes overall
blood volume loss, with the remaining blood suffering significant plasma
loss, making the blood more concentrated. Poor blood flow to organs such
as the kidneys and gastrointestinal tract may result in renal failure and
stomach ulcers.

Increased levels of catecholamines and cortisol can cause a

hypermetabolic state that can last for years. This is associated with
increased cardiac output, metabolism, a fast heart rate, and poor immune

Burns can be classified by depth, mechanism of injury, extent, and

associated injuries. The most commonly used classification is based on the
depth of injury. The depth of a burn is usually determined via examination,
although a biopsy may also be used. It may be difficult to accurately

determine the depth of a burn on a single examination and repeated
examinations over a few days may be necessary. In those who have a
headache or are dizzy and have a fire-related burn, carbon monoxide
poisoning should be considered. Cyanide poisoning should also be

The size of a burn is measured as a percentage of total body surface area

(TBSA) affected by partial thickness or full thickness burns.[10] First-
degree burns that are only red in color and are not blistering are not
included in this estimation. Most burns (70%) involve less than 10% of the

There are a number of methods to determine the TBSA, including the "rule
of nines", Lund and Browder charts, and estimations based on a person's
palm size. The rule of nines is easy to remember but only accurate in
people over 16 years of age. More accurate estimates can be made using
Lund and Browder charts, which take into account the different proportions
of body parts in adults and children. The size of a person's handprint
(including the palm and fingers) is approximately 1% of their TBSA.

To determine the need for referral to a specialized burn unit, the American
Burn Association devised a classification system. Under this system, burns
can be classified as major, moderate and minor. This is assessed based on
a number of factors, including total body surface area affected, the
involvement of specific anatomical zones, the age of the person, and
associated injuries. Minor burns can typically be managed at home,
moderate burns are often managed in hospital, and major burns are
managed by a burn center.

Scalding (from the Latin word calidus, meaning hot) is a form of burning
from heated fluids such as boiling water or steam. Most scalds result from
exposure to high-temperature water such as tap water in baths and
showers or cooking water boiled for the preparation of foods. Another
common cause of scalds is spilled hot drinks, such as coffee. Scalds are
generally more common in children, especially from the accidental spilling
of hot liquids. Most scalds are considered first or second degree burns, but
third degree burns can result, especially with prolonged contact. Scalds are
typically far more severe when caused by steam, because it has absorbed
a great amount of latent heat, and is therefore far more effective at heating

Applying first aid for scalds is the same as for burns. First, the site of the
injury should be removed from the source of heat, to prevent further
scalding. If the burn is at least second degree, remove any jewelry or
clothing from the site, unless it is already stuck to the skin. Cool the scald
for about 20 minutes with cool or lukewarm water, such as tap water from a
faucet. Ice should be avoided, as it can do further damage to area around
the injury, as should butter, toothpaste, and specialized creams. With
second-degree burns, blisters will form, but should never be popped, as it
only increases chances of infection. With third-degree burns, it is best to
wrap the injury very loosely to keep it clean, and seek expert medical

First Aid for Burns and Scalds

Appropriate first aid must be used to treat any burns or scalds as soon as
possible. This will limit the amount of damage to your skin.

You may need to apply the following first aid techniques to yourself or to
another person who has been burnt.

First aid for burns

Follow the first aid advice below to treat burns and scalds:

Stop the burning process as soon as possible. This may mean removing
the person from the area, dousing flames with water or smothering flames
with a blanket. Do not put yourself at risk of getting burnt as well.

Remove any clothing or jewellery near the burnt area of skin. However,
don't try to remove anything that is stuck to the burnt skin because this
could cause more damage.

Cool the burn with cool or lukewarm water for 10 to 30 minutes, ideally
within 20 minutes of the injury occurring. Never use ice, iced water or any
creams or greasy substances such as butter.

Keep yourself or the person warm. Use a blanket or layers of clothing, but
avoid putting them on the injured area. Keeping warm will prevent
hypothermia, where a person's body temperature drops below 35ºC (95ºF).
This is a risk if you are cooling a large burnt area, particularly in young
children and elderly people.

Cover the burn with cling film. Put the cling film in a layer over the burn,
rather than wrapping it around a limb. A clean clear plastic bag can be used
for burns on your hand.

Treat the pain from a burn with paracetamol or ibuprofen. Always check the
manufacturer's instructions when using over-the-counter (OTC) medication.
Children under 16 years of age should not be given aspirin.

When to go to hospital
Once you have taken these steps, you will need to decide whether further
medical treatment is necessary. Go to a hospital accident and emergency
(A&E) department for:
Large or deep burns – any burn bigger than the affected person's
Full thickness burns of all sizes – these burns cause white or charred
Partial thickness burns on the face, hands, arms, feet, legs or genitals
– these are burns that cause blisters
All chemical and electrical burns

Also get medical help straight away if the person with the burn:
Has other injuries that need treating
Is going into shock – signs include cold clammy skin, sweating, rapid
shallow breathing and weakness or dizziness
Is pregnant
Is over 60 years of age
Is under five years of age
Has a medical condition such as heart, lung or liver disease, or
Has a weakened immune system (the body's defence system), for
example because of HIV or AIDS, or because they're having
chemotherapy for cancer

If someone has breathed in smoke or fumes, they should also seek medical
attention. Some symptoms may be delayed and can include coughing, a
sore throat, difficulty breathing, singed nasal hair or facial burns.
See recovering from burns and scalds for information on how serious burns
are treated.

Summary of Fundamentals of Hot Stone Massage
Hot Stone massage is a wonderful compliment to any massage practice.
The techniques are easy to perform and to incorporate into an existing
massage business. The equipment is inexpensive and easy to maintain
and the therapeutic and financial benefits are substantial. I hope this
overview of the fundamentals of Hot Stone massage will encourage you to
explore this complimentary modality and to successfully include it in your
catalog of services.

Hot Stone massage began to become popular in America in 1993. We

know Hot Stone massage is popular with Spa customers It is difficult to find
a spa that does not offer it.

A variety of different stones can be used for a Hot Stone massage,

including Volcanic Basalt Stones, Mexican Pebble, and river smoothed
stones. You can often get stones that are good to use in a Hot Stone
massage at a rock quarry or landscape company.

You need about 40-50 stones to do a good job, although you can get by
with less if you have to. The majority of stones in your collection should be
about as big as the palm of your hand.

You can place stationary stones on the Charka points, along the spine or
on the hands. You must take special precautions with stationary stones
because they might burn the client if they are not moving. You can you
keep stationary stones on the soles of the feet by wrapping a scarf or a a
cloth bandage around the foot and the stone.

Hot stone massage is effective because heat has many therapeutic

properties; it relaxes muscles,increases blood circulation, and lowers the
concentration of pain producing toxic metabolites.

Pregnant women should seek a doctor’s advice before getting a Hot Stone
massage, and you should never perform one on a client that you suspect
has a temperature (fever) or difficulty regulating their internal temperature.

You use a 16-Quart Roasterto heat your stones, and you should start
warming them up at least an hour before your appointment. A safe
temperature range for warming your stones is 125-150 degrees. You can

decide if a stone is too hot to use by testing it against your fore arm (like a
baby bottle), and if it is too hot to hold in your hand it is definitely too hot to

You do not have to worry about maintaining contact with your client during
a Hot Stone massage because as long as a Stone is touching the client
you are considered to be in contact. When efflueraging with a stone, you
should move the stones towards the heart. Remember that when you are
using a stone to remove an adhesion stones do not yield like flesh, they
penetrate and can bruise.

To clean your stones you should use an antibacterial soap.

Certificate of Completion and Transcript
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for this course you must complete and pass the quiz.

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Help and Technical Support

We have worked hard to make this course as easy to use as possible, but it
does rely on technology and sometimes there are factors that are out of our
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version, the device you are using etc).

If for some reason you are not able to access the quiz you can call us and
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call if you need to and I will do my best to help you. The number is (209)

Beck, Mark F Theory and Practice of Therapeutic Massage.
Milady 4 edition (2007)

Alison Trulock Hot Stone Massage: The Essential Guide to Hot Stone and
Aromatherapy Massage Sterling Publishing November 4, 2008

M. V. Hurley et al., Non-exercise physical therapies for musculoskeletal

conditions, Best Practice & Research, Clinical
Rheumatology, 2008. 1C

Brosseau L., Yonge K.A., Welch V. et al., Thermotherapy for treatment of

osteoarthritis, the Cochrane library, 2003. 1A

Petrofsky J., Berk L., Lee H., Moist heat or dry heat delayed onset muscle
soreness, Journal of clinical medicine research, 2013. 2B

Scott F. Nadler, DO, FACSM, Kurt Weingand, PhD, DVM, and Roger J.
Kruse, MD; The Physiologic Basis and Clinical Applications of Cryotherapy
and Thermotherapy for the Pain Practitioner, pain physician, 2004. 1A

D. L. Kellogg Jr., In vivo mechanisms of cutaneous vasodilation and

vasoconstriction in humans during thermoregulatory challenges, the
American Physiological Society, 2006. 3A

Hendee W.R., Physics of Thermal Therapy, Fundamentals and Clinical

applications, By Taylor and Francis group, 2013.

Heinrichs K., Textbook of medical physiology, Philadelphia, 1986. (chapter

16: superficial thermal modalities).

Bleakley C.,McDonough S.,MacAuley D., The Use of Ice in the Treatment

of Acute Soft-Tissue Injury: A Systematic Review of Randomized
Controlled Trials, The American Journal of Sports Medicine; 2004. 1A

Tricia J. Hubbard et al., Does Cryotherapy Improve Outcomes With Soft

Tissue Injury? Journal of Athletic Training, 2004. 1A

Ernst E., Fialka V., Ice freezes pain? A review of the clinical effectiveness
of analgesic cold therapy, J pain symptoms manage, 1994. 5

11.0 11.1 Amin A. Algafly, Keith P. George, The effect of cryotherapy on
nerve conduction velocity, pain threshold and pain tolerance, Br J Sports
Med, 2007. 3B

12.0 12.1 Choi YJ et al. Therapeutic effects and immunomodulation of

suanbo mineral water therapy in a murine model atopic dermatitis. 1B

Hiroharu K., Kiichiro T., Effectiveness of Aquatic Exercise and

Balneotherapy: A Summary of Systematic Reviews Based on Randomized
Controlled Trials of Water Immersion Therapies, Journal of epidemiology,
2010. 1A

Eversden L, Maggs F, Nightingale P, Jobanputra P., A pragmatic

randomized controlled trial of hydrotherapy and land exercises on overall
well-being and quality of life in rheumatoid arthritis, BMC Musculoskeletal
Disorders, 2007. 2A

Lacy A. Holowatz et al., Mechanisms of acetylcholine-mediated

vasodilatation in young and aged human skin, The Physiological Society,
2005. 3B

Swenson C et al. Cryotherapy in sports medicine. Scand J Med Sci Sports.

1996 Aug6(4) 1B

17.0 17.1 17.2 Kathleen A. Sluka, PhD, PT, Michelle R. Christy, MPT,
Wendy L. Peterson, MPT, Staci L. Rudd, MPT, Stacie M. Troy, MPT,
Reduction of pain-related behaviors with either cold or heat treatment in an
animal model of acute arthritis, Archives of Physical Medicine and
Rehabilitation, March 1999. 3B

18.0 18.1 Fahey T.D., Athletic training: principles and practice, Mayfield.

19.0 19.1 19.2 Oosterveld F.G.J., Rasker J.J., Effects of local heat and cold
treatment on surface and articular temperature of arthritic knees, American
college of rheumatology, 1994. 1B

William E. Prentice, An Electromyographic Analysis of the Effectiveness of

Heat or Cold and Stretching for Inducing Relaxation in Injured Muscle, The
journal of orthopaedic and sports physical therapy, 1982. 1B

Steven E. Peres, David O. Draper, Kenneth L. Knight, Mark D. Ricard,
Pulsed shortwave diathermy and prolonged long-duration stretching
increase dorsiflexion range of motion more than identical stretching without
diathermy, Journal of Athletic Training, 2003. 2B
22.0 22.1 22.2 Oosterveld F.G., Rasker J.J., Treating arthritis with locally
applied heat or cold, semin Arthritis Rheum., 1994. 5

Chris Bleakley, Suzanne McDonough and Domhnall MacAuley; The Use of

Ice in the TreatmentfckLRof Acute Soft-Tissue Injury: A Systematic Review
of Randomized Controlled Trials; The American Journal of Sports
Medicine; 2004; 32 (1); 251-261 [A1]

Joseph H. Dykstra et al.; Comparisons of Cubed Ice, Crushed Ice, and

Wetted Ice on Intramuscular and Surface Temperature Changes; Journal of
Athletic Training; 2009;44(2); 136–141 [A2]

APPENDIX I Thermotherapy Study

Thermotherapy. An alternative for the treatment of American cutaneous

Liliana López1, Martha Robayo2, Margarita Vargas2 and Iván D Vélez1*

* Corresponding author: Iván D Vélez

Author Affiliations
1 Program for the Study and Control of Tropical Disease, University of Antioquia, Carrera 53 #61-30, Medellín, Colombia

2 Dirección de Sanidad, DISAN, Colombia Army, Bogotá, Colombia

This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (,
which permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properly cited.

Pentavalent antimonials (Sb5) and miltefosine are the first-line drugs for
treating cutaneous leishmaniasis in Colombia; however, toxicity and
treatment duration negatively impact compliance and cost, justifying an
active search for better therapeutic options. We compared the efficacy and
safety of thermotherapy and Meglumine antimoniate for the treatment of
cutaneous leishmaniasis in Colombia.

An open randomized Phase III clinical trial was performed in five military
health centres. located in northwestern, central and southern Colombia.
Volunteers with parasitological positive diagnosis (Giemsa-stained smears)
of cutaneous leishmaniasis were included. A single thermotherapy session
involving the application of 50°C at the center and active edge of each
lesion. Meglumine antimoniate was administered intramuscularly at a dose
of 20 mg Sb5/kg weight/day for 20 days.

Both groups were comparable. The efficacy of thermotherapy was 64%
(86/134 patients) by protocol and 58% (86/149) by intention-to-treat. For
the Meglumine antimoniate group, efficacy by protocol was 85% (103/121
patients) and 72% (103/143) by intention-to-treat, The efficacy between the
treatments was statistically significant (p 0.01 and <0.001) for analysis by
intention to treat and by protocol, respectively. There was no difference

between the therapeutic response with either treatment regardless of the
Leishmania species responsible for infection. The side effects of
Meglumine antimoniate included myalgia, arthralgia, headache and fever.
Regarding thermotherapy, the only side effect was pain at the lesion area
four days after the initiation of treatment.

Although the efficacy rate of Meglumine antimoniate was greater than that
of thermotherapy for the treatment of cutaneous leishmaniasis, the side
effects were also greater. Those factors, added to the increased costs, the
treatment adherence problems and the progressive lack of therapeutic
response, make us consider thermotherapy as a first line treatment for
cutaneous leishmaniasis. Registered NCT00471705

Keywords: Thermotherapy; American cutaneous leishmaniasis; Meglumine

antimoniate; treatment
Leishmaniasis is a group of diseases caused by parasites from the
Leishmania genus. It is transmitted by female insects from the Lutzomyia
genus in America and Phlebotomus in the Old World, affecting humans and
domestic and wild mammals [1,2]. It is endemic in more than 98 countries.
There are 2 million new cases per year, of which 1.5 million present in the
cutaneous form [3].

In Colombia, there has been a reappearance of leishmaniasis. During the

years of 2005–2008, 61,120 new cases were diagnosed. Among these
cases, 34,262 (56.1%) occurred in National Army soldiers Statistical data
(Dirección de Sanidad del Ejército (DISAN)).

Since the 1940s, the pentavalent antimonials (Sb5) (Meglumine

antimoniate and sodium stibogluconate) have been considered first line
medications for the treatment of leishmaniasis. In Colombia, health
authorities recommend a 20 mg Sb5/kg/day dose for 20 days to treat
cutaneous leishmaniasis and 28 days of therapy to treat mucosal
leishmaniasis (ML) and visceral leishmaniasis (VL) [4].

However, the pentavalent antimonials are expensive (approximately $200

per patient), cardiotoxic (P wave prolongation, inverted T waves, ST
elevation and QT prolongation), hepatotoxic (liver enzymes elevation),

nephrotoxic (BUN and creatinine elevation) and can also cause
pancreatitis, leukopenia, thrombocytopenia, arthralgia and myalgia.

These complications, in combination with the parenteral route and the

duration of treatment, cause adherence problems. Antimonials are
contraindicated during pregnancy and lactation, in very young children, in
patients with hypersensitivity to the drug and in patients suffering from
chronic conditions. Some reports have shown a decrease in the sensitivity
of Leishmania parasites to antimonials [3-13]. In the Old World
leishmaniasis caused by L. (L) tropica, the parasite resistance is the main
problem for the use of antimony [14,15]. Therefore, all of the factors
mentioned above reinforce the need for alternative therapies.

Several oral medications have been tested for the treatment of CL, such as
dapsone [16], ketoconazol [17,18], mefloquine [19], allopurinol [20],
miltefosine [21-25] and others [4], none of which are completely effective.
Comparisons of the efficacy of different drugs are complicated by the
different protocols used in each study. According to a recent meta-analysis
of clinical trials for CL, this lack of standardization of methodologies makes
it impossible to obtain conclusive information [4,26,27].

Some studies have shown that it is possible to induce healing of lesions by

treatment with local heat [28-30]. Ethnomedical studies have shown that, in
rural communities of South America and Africa, the empiric application of
caustic materials (powder, hot brown sugar, silver nitrate, oil, battery) or the
cauterization of the lesions with hot metal objects (spoons, knifes) is very
common [31-33]. Currently, we employ the local application of an
instrument, maintained at 50°C, called Thermomed®. This equipment was
used in this study [34].

In addition to the benefits of local treatment, the cost of thermotherapy is

significantly lower than the pentavalent antimony. The antimony cost is
approximately USD 37.2, which must be added on to the patients disability,
medical test before, during and after treatment, and in cases where it is
needed, the electrocardiogram. According to calculations by dermatologist
of the study, the total cost of local heat therapy, does not exceed USD 20

The objective of this study was to evaluate the efficacy and safety of
Thermotherspy compared with Meglumine antimoniate for the treatment of
Cutaneous Leishmnaniosis in Colombia.

Materials and methods

Study design
We conducted an open randomized, phase III clinical trial to compare the
differences in efficacy and safety between thermotherapy and Meglumine

Population and site of the study

The study was conducted between June 2006 and April 2008. The subjects
were adult males enlisted in the Colombian Army. The study took place in
five military health clinics in the northeast, south and central regions of

Inclusion Criteria
Patients included in this study met the following criteria: a) positive
parasitologic diagnosis of leishmaniasis, b) no previous treatment for this
parasitic infection, c) laboratory exams including renal, hepatic and
hematologic testing and d) voluntary agreement to participate in the study.

Exclusion criteria
Patients with the following characteristics were excluded: a) chronic
concomitant diseases, b) lesions compromising the mucosa, c) presence of
10 or more cutaneous lesions with a negative Montenegro test or d)
cutaneous lesions located less than 2 cm from the nasal or oral mucosa,
eyes or near the anal or urogenital orifices.

Thermotherapy (Thermomed®, Thermosurgery Inc. Phoenix-USA).
Following the aseptic preparation of the lesions and local anesthesia with
2% xylocaine, we applied a single session of thermotherapy to the center,
active borders and peripheral area of the lesions. Each thermal application
was at 50°C and lasted for 30 seconds; the number of applications
depended on the size of the lesion. After the thermotherapy session and
over the next 10 days, an antibiotic ointment (fusidic acid) was applied over
the lesions, which were then covered with sterile gauze to prevent
secondary infections. Meglumine antimoniate (Glucantime®, Aventis, Paris,
France) was administered intramuscularly under medical supervision at a

dose of 20 mg Sb5/kg/day for 20 days. All patients of both groups remained
within the military unit for the duration of the treatment.

Data collection and samples

After providing writing informed consent, all patients were given a medical
chart with pertinent demographic information, lesion data and a review of
inclusion/exclusion criteria. We subsequently photographed each lesion.
Histologic samples were taken from all patients to confirm the diagnosis
and to identify the type of Leishmania using PCR-RFLP, according to
published guidelines [35].

Clinical samples were taken from all subjects for the parasitological
confirmation of leishmaniasis by direct microscopic examination, lesion
aspirate samples were taken from each of the patients and were processed
as explained in other publications [35,36]. In brief, the aspirates were
cultured in NNN culture medium, incubated at 26°C, and from the fourth
day on they were observed weekly for one month, in the inverted
microscope in search of promastigotes. The media cultures were labeled
with the code of each participant and were stored on independent racks to
avoid mixing. Each week positive cultures were mass cultured in 50 ml
glass bottles with NNN modified medium, one part was frozen in liquid
nitrogen and is now stored in the PECET Criobank, and the other was used
for species identification; for the DNA extraction, Promastigotes cultures
were centrifuged and washed three times for 5 min at 1000 g in PBS pH
7.6. Parasites were then re-suspended in 200 μl of lysis buffer (10 mM
Tris–HCl, pH 8,5 mM EDTA, 0.5% SDS, 200 mM NaCl, 100 μg/ml
proteinase K) for 90 min at 65°C with moderate agitation. DNA was
precipitated by adding two volumes of absolute ethanol to the lysate and
the solution was mixed by inversion, and centrifuged for 15 min at 10,000 g.
To recover the DNA, the supernatant was discarded and the pellet was
dried for 15 min at 65°C and then re-suspended in 200 μl of water or TE.
Then for the PCR amplification of the Cpb gene. Due to the partial degree
of variability of the Cpb sequence between the Viannia and Leishmania
subgenus, Cpb-specific primers were designed using the primer3plus
software (
webcite). A region of the Cpb gene in L. (V) panamensis, L. (V) braziliensis
and L. (V) guyanensis were amplified with the primers FwNTerBra (5´-
CTACTTGAACGTGCAGAT-3’); while primers FwRGPS (5’-

CAGGTGTTCATGATCGAGCCC-3’) were used for L. (L) mexicana and
L. (L) infantum; To amplify the Cpb region of L. (L) amazonensis the
last pair of primers also amplify for L. (L)Mexicana. After each PCR round,
5 μl of the product were separated in a 1% agarose gel and stained with
0,5 μg/ml of ethidium bromide. DNA products were visualized using a
Chemidoc image analyzer system (Bio-Rad, Hercules, California, USA).

In order to identify the Leishmania species by RFLP, the NEBcutter V2.0

programme (New England Biolab, Ipswich, Massachusetts, USA) was used
to generate species-specific restriction sites. To differentiate L. (V)
panamensis from L. (V) braziliensis, 10 μl of the amplification product was
digested with KpnI (Promega), the mix was incubated for 6 h at 37°C. To
differentiate L. (V) panamensis from L. (V) guyanensis, 10 μl of the
amplification product was digested with NsiI (New England Biolab), this mix
was incubated for 16 h at 37°C. To differentiate L. (L) mexicana from L. (L)
amazonensis, 10 μl of the amplification product was digested, with NarI
(New England Biolab), and the mix was incubated for 6 h at 37°C. To
differentiate L. (L) mexicana from L. (L) infantum, 10 μl of the amplification
product was digested with KpnI (Promega). After digestion, products were
separated in 1% or 2% agarose gel using the same conditions described
above for visualizing the PCR-Cpb amplification products[37,38].

Assignment to the treatment group

Subjects were assigned randomly to treatment groups using a generated
list in blocks of eight (EpiInfo 3.1). Only the clinical coordinator of the study
had access to the list and was in charge of allocating treatments.

Follow-up and outcomes

Subjects receiving Meglumine antimoniate were evaluated at the beginning
and end of treatment, at 6 weeks and at 3 and 6 months after completing
the treatment. Subjects receiving thermotherapy were evaluated on the
same day they started the treatment, at days 10 and 20, at 6 weeks and at
3 and 6 months after the application of heat, although thermotherapy was
applied in an only session the followup of the healing process of the lesions
was carried out three weeks after application, coinciding with the visit of
final treatment of the group that received Meglumine antimoniate. All
patients underwent renal, hepatic, pancreatic and hematologic blood
function tests before, during and after the completion of treatment. The

assessment of side effects was done according to the Common
Terminology Criteria for Adverse Events v.3 (CTCAE)[39].

The treatment response was evaluated clinically. For each lesion, the
following definitions were used:

Initial healing
Complete reepithelialization of all ulcers and complete loss of induration up
to three months after the end of treatment.

Definitive healing
Initial healing criteria without any recurrence six months after the
completion of treatment.

Increase in size of a lesion of more than 50% at the end of treatment or an
absence of clinical response at 6 weeks (lesion size reduction less than
50% compared to the evaluation at the end of treatment), signs of lesion
activity 3 months after the completion of treatment or recurrence or
presence of mucosal leishmaniasis at any time 6 months after the end of

Lesion reactivation in the original site after cicatrization.

Presence of new lesions at an anatomic site different from the original
lesions after the patient was considered healed and after returning to
endemic areas.

In all subjects that had a treatment failure, Meglumine antimoniate was

provided as rescue therapy at a dose of 20 mg Sb5/kg/day for 20 days,
according to the Colombian Ministry of Health guidelines [40].

Sample size calculation

The sample size was calculated assuming a thermotherapy efficacy of
78%, Meglumine antimoniate efficacy of 90%, confidence interval (CI) of
95% and power of 80% (non-inferiority trial). To this sample size number,
we added 20% to account for possible loss of subjects to follow-up. The
total sample size was 144 subjects per group for a total of 288 participants.

Statistical analysis
Data entry and data analysis were performed using ACCESS and SPSS
v.15, respectively. The baseline characteristics of volunteers were
categorized and analyzed by treatment group. The treatment efficacy was
calculated by intention-to-treat and by protocol. The relative risk was
calculated using 2x2 tables. For hypothesis tests in dichotomic variables,
we used the Fisher's Test or X2 test. The student's t-test or the “U of
Mann–Whitney” test was used to analyze continuous data. Potential
confounding factors and interactions were controlled with analysis stratified
by parasite species, number, location, type of lesions and geographic area
where the infection occurred. Statistical survival analysis was performed
using the Kaplan-Meier method and the log rank test to compare the
healing time between both groups. A p value of <0.05 was considered as
stastically significant and CI of 95% was used for data analysis.

We included 292 subjects in the study and randomly assigned 149 to
receive thermotherapy and 143 to receive Meglumine antimoniate. In the
thermotherapy group, two subjects did not want to participate (1%), 13
(9%) did not complete the six month follow-up and a total of 134 (90%)
completed the study. In the Meglumine antimoniate group, 18 (13%) did not
complete the six month follow-up, 2 (1%) withdrew from the Army before
completing the study, 2 (1%) died in combat and 121 (85%) completed the
study, as shown in Figure 1.

Recurrence was reported in 6 (4.1%) and 4 (3%) patients for the
thermotherapy and Meglumine antimoniate groups, respectively. All of
these patients received Meglumine antimoniate as a rescue treatment, and
only one patient, who was assigned to the Meglumine antimoniate group,
required a third treatment with amphotericine B. All recurrences occurred
within 3 months of treatment completion.

Baseline analysis
As shown in Table 1, both groups had similar demographic, clinical and
parasitologic characteristics.

Therapeutic response
Initial healing

Three months after the end of treatment, 64% (95% IC 56–72) of the
thermotherapy group and 78% (95% IC 71–85) of the Meglumine
antimoniate group were healed.

Definitive healing
A total of 7 patients (4.8%) from the thermotherapy group and 7 (5%) from
the Meglumine antimoniate group did not complete follow-up with the 3-
and 6-month evaluations. By protocol, 64% (95% IC 55–73) of patients in
the thermotherapy group and 85% (95% IC 64–80) of patients in the
Meglumine antimoniate group showed definitive healing. By intention-to-
treat, the definitive healing rate in the thermotherapy group was 58.5%
(95% IC 49–66) and 72% (95% IC 78–92) in the Meglumine antimoniate
group, as shown on Table 2. The efficacy analysis between both
treatments showed a statistically significant difference, for the analysis by
protocol the Meglumine antimoniate is 0.33 times more effective than
thermotherapy (RR 1.33 (IC 95% 1.15 – 1.54) p <0.001), when analysis
was carried out by intention to treat, the superiority of the Meglumine
antimoniate maintained, being 0.25 more effective than thermotherapy (RR
1.25 (IC 95% 1.05 – 1.48) p <0.001).

Group analysis
We identified Leishmania species as agents of infection in 167 patients. In
the group treated with Meglumine antimoniate, 32 patients (38%) had
lesions caused by L. (V) panamensis and 52 (62%) by L. (V) brazililensis. In
the thermotherapy group, 24 patients (29%) had lesions caused by L. (V)
panamensis and 59 (71%) by L. (V) brazililensis.

The healing response in the Meglumine antimoniate group, among patients

with L. (V) panamensis and L. (V) braziliensis, was of 72% and 65%,
respectively. In the thermotherapy group, the healing response was 58%
for L. (V) panamensis and 53% for L. (V) braziliensis. There was no
association found between the treatment (Meglumine antimoniate, p = 0.5,
and thermotherapy, p = 0.6) and the Leishmania species identified.

There was also no association between treatment and other variables such
as number, location and lesion type or with the geographical area of
Colombia where the infection occurred (Table 3).


Table 4 shows the systemic and local side effects found in this study.
Frequency and severity of side effects were greater in the Meglumine
antimoniate group. These side effects occurred during and after treatment.
These side effects included fever, myalgia, arthralgia and headache. In the
group treated with thermotherapy, we found an association with local pain,
especially four days after initiating treatment (p = <0.001).

In all laboratory analysis conducted during and at the end of treatment with
Meglumine antimoniate, there were alterations in renal, hepatic, pancreatic
and hematologic tests. There was an association with increased amylase
levels (p < 0.005), which reached grade 3 in some cases[39].

Severe side effects

Three patients experienced serious adverse effects, none of which were
related to medications (2 died in combat and 1 was wounded by a knife).
These three patients were part of the Meglumine antimoniate group.

Survival analysis
The Meglumine antimoniate group experienced significantly fewer failures
to treatment (15%) compared to the thermotherapy group (36%) (log
rank = 9.6, p = <0.001).

This study followed procedures delineated by the GCP. The sample size
was adequate for the study. The follow-up rate was 88% at six months after
treatment, which was higher than estimated when calculating the sample

In the Meglumine antimoniate group, treatment efficacy by protocol and

intention-to-treat were 85 and 72%, respectively. These results
demonstrate a decrease in the rate of efficacy for this age group, which
was reported as 93% during the 1990s [41-43]. This decrease in the
efficacy of antimonials could be related, among other factors, to the
administration of incomplete doses as a consequence of adherence
problems, unavailability of a complete dose to all patients, black market of
medications in rural areas and evidence that men also play a role in the
transmission of American cutaneous leishmaniasis [29]. There was no
statistically significant difference in terms of treatment efficacy with
leishmania species.

Thermotherapy had an efficacy of 64 and 58% per protocol and intention-
to-treat, respectively; these results are comparable to the findings reported
by a study in Kabul, Afghanistan, (CL due to L. (L) tropica) in which the
efficacy per protocol was 69% [44]. In other study made with patients from
other Asian countries (Irán and Kuwait), following the same conditions of
application of local heat and where the isolated specie was L. (L) major, the
intent efficacy of thermotherapy to treat was 48%, two months after
treatment ends[45].

With regard to efficiency, we found that Meglumine antimoniate is

statistically superior to thermotherapy for the treatment of CL in Colombia
(p < 0.001), but we also found that Meglumine antimoniate has been
associated with severe side effects in the musculoskeletal system (myalgia
and arthralgia), fever, headaches [4] and toxicity in organs such as the
kidney, the pancreas and the hematologic and cardiovascular systems.
These effects are not associated with thermotherapy, which only causes
local pain four days after the initiation of treatment.

Systemic treatment with pentavalent antimonials for cutaneous

leishmaniasis caused by L. (V) panamensis and L. (V) braziliensis was
recommended by the WHO in 1990 under the assumption that such
treatment prevents the development of mucosal lesions[46]. However,
subsequent studies conducted in Peru demonstrated that mucosal lesions
may appear despite the use of these therapeutic schemes. In the case of
Colombia, where the predominant parasite species are L. (V) braziliensis
and L. (V) panamensis, the need for all patients to receive systemic
treatment of 20 mg Sb5/kg/day for 20 days is even more controversial,
especially because the incidence of mucosal leishmaniasis is less than
0.5% although it is estimated that, in rural areas far from health centers,
only 10% of the population with CL receives complete treatment with
antimonials [28-30]. Unpublished data (Dirección de Sanidad del Ejército
(DISAN) and Programa de Estudio y Control de Enfermedades Tropicales
(PECET)) documented 12 fatalities related to the use of this therapy, which
is unacceptable for a form of the disease that is not fatal.

Thermotherapy has been evaluated in several American and Old World

countries with efficacy rates of more than 70%. In Colombia, only one
report of thermotherapy used to treat CL was made in an epidemic area of
L. (V) guyanensis. In this region, thermotherapy had an efficacy of 100 and
19% by protocol and intention-to-treat, respectively, although the lack of

follow-up in many patients (81%) decreased the efficacy of the study and
limited the interpretation of results[47].

The facts mentioned previously led us to ponder the convenience of using

local treatments (thermotherapy, paromomicine, cryotherapy, intra-lesion
pentavalent antimony) in combination with patient education on how to
detect early signs and symptoms of mucosal complications so they can be
promptly reported to the physician and addressed with systemic treatment.

The results of the present study show that thermotherapy could be

considered a valid alternative treatment due to its efficacy (>60%) and
safety as well as because it requires a single session and does not require
laboratory monitoring.

Although the equipment required for thermotherapy (ThermoMed) is very

expensive and difficult to access in endemic countries due to its cost, the
expenses related to conventional treatment overweigh the costs of

With the goal of increasing its efficacy, we propose a subsequent clinical

trial to evaluate new schemes of application of local treatment with
thermotherapy; for example, patients may undergo 2–3 sessions or a
combination of local treatments with a low systemic dose.

Although the efficacy rate of Meglumine antimoniate was greater than that
of thermotherapy for the treatment of cutaneous leishmaniasis, the side
effects were also greater. Those factors, added to the increased costs, the
treatment adherence problems and the progressive lack of therapeutic
response, make us consider thermotherapy as a first line treatment for
cutaneous leishmaniasis.

The thermotherapy is also a valid alternative in patients with renal, hepatic

and cardiac illness who cannot receive systemic therapy. It is important to
mention that thermotherapy should not be applied near mucosal areas.

Ethical approval
The protocol was approved by the Bioethics Committee for Human
Research of “Sede de Investigacion Universitaria” (CBEIH-SIU) from the
University of Antioquia and by the Ethics Committee of the General Health

Management of the Colombian Army and and carried out according to
international norms of good clinical practice

Consent informed
Before deciding to participate in the research, All patients signed a
informed consent form in the presence of two witnesses.

CL, Cutaneous leishmaniasis; ML, Mucosal leishmaniasis; VL, Visceral
leishmaniasis; CTCAE, Common Terminology Criteria for Adverse Events;
CI, Confidence Interval; PECET, Programa de Estudio y Control de
Enfermedades Tropicales; DISAN, Dirección de Sanidad del Ejército.

Competing interest
The authors declare that they have no competing interests.

Authors' contributions
LL coordinated and conducted the field work, participated in the design and
reporting of the study; MR and MV carried out field work (inclusion and
follow-up of volunteers); IV participated in the design, execution and
reporting of the study. All authors read and approved the final manuscript.
IV is guarantor of the paper.

Authors' information
LL MSc. Clinical Trials Coordinator PECET. MR Dermatologist, Colombia
Army. MV Dermatologist, Colombia Army. IV MD MSc PhD. Director
PECET, Professor University of Antioquia - Colombia, member of the "Data
Management Team" TDR/WHO, Clinical Monitor TDR/WHO.

The authors express gratitude to the “Ministerio de Protección Social” and
especially to Dr. Julio Cesar Padilla for his support and co-funding of this
study. We also thank the personnel of the Colombian Army directed by
General Mario Montoya Uribe, who supported and made the execution of
this study possible.

Thanks also to the staff from the “Direccion de Sanidad del Ejercito”,
especially Colonels Erwin Solarte Rodríguez and Fernando Pineda, TC
David Rojas Tirado, TC Gonzalo Godoy Mendez and the Army team of
dermatologists (Coronel Ximena Sánchez, TC Alvaro Sandoval, TC

Gustavo Pérez and MY Claudia Cruz) for their support of the study. Thanks
to the staff of Learning and Control of Tropical Diseases, Dra. Sara
Robledo, Daniel Agudelo and Ronald and Eugenia Pelaez Cardona.
Thanks to Dr. Piere Buffet (Hôpital Pitie Salpetriere in Paris) for reviewing
this manuscript. We would also like to thank all of the patients for their
willingness and commitment to the study.

Funding was provided by the Social Protection Ministry of the Republic of
Colombia, which did not participate in the design, implementation, analysis
or report of this project.

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APPENDIX II Ice Massage versus Conventional Icing: a comparison
on the effectiveness of each in the inflammation phase of healing

Chris Pantellere
Therapeutic Modalities
Dr Sterner
1 December 2008

Ice Massage versus Conventional Icing: a comparison on the effectiveness

of each in the inflammation phase of healing
A. Introduction
Cryotherapy is the application of cold between the therapeutic
temperatures of 32°F and 65°F. For ages, cryotherapy has been an
acceptable modality of choice for acute soft tissue trauma.1 Cryotherapy
has been used since the days of the ancient Greeks and its practice if
evident in today’s health care providers. Cryotherapy is the easiest and
most readily available modality, making cryotherapy one of the most widely
used modalities in the athletic training setting. In previous studies
cryotherapy techniques have shown to alter the effects of the acute
inflammation phase in healing tissues.1,2 Many researchers in the past
have studied the effect of icing techniques with little comparison between
ice massage and conventional icing. The purpose of this paper is to
examine these two different cryotherapy techniques and determine which
would be more effective in treating acute injuries and injuries in the
inflammation phase of the healing process.
B. How does the body react to trauma?
In order to fully understand the effect of cryotherapy on the body’s
healing process, we must first investigate what happens when there is
trauma to bodily tissues. The healing process is broken down into several
different aspects; first the acute inflammatory phase, second the repair
phase, and lastly the remodeling phase.3 For the purposes of this paper
the investigator will focus on the acute inflammation phase.
The acute inflammation phase is the first and one of the most
important phases of healing. If something were to go wrong in the healing
process in this phase, there could be serious setbacks.4 The inflammation
phase is triggered by some sort mechanical trauma ranging from a cut to a
fracture. This mechanical stimulus will cause a release of inflammatory
mediators which will in turn cause a vascular, cellular, and immune
responses which all occur simultaneously. Someone can tell that an

individual is in the acute inflammatory phase by recognizing the cardinal
signs of inflammation.3,4
1. Vascular response
The vascular response is comprised of two segments. In the first
response, which takes place immediately after an injury, there is a
vasoconstriction at the arteriole and venule level which lasts five to ten
minutes.1,3 This vasoconstriction’s purpose is an attempt to slow
hemorrhaging and allow blood platelets to ‘patch up’ the damaged vessels.
This process of the vascular repair is called the clotting cascade.1,3
The second response by the vascular system is triggered by a series
of chemical reactions to cause vasodilation of the vessels. This vasodilation
will bring in more blood to the area as well as, increase the permeability of
the vessel.1 The chemical reaction that triggers this vasodilation attracts
leukocytes which clean up the debris and toxins left behind after the injury.
The increased permeability of the vessel is what allows these large
leukocytes and blood to cross across to the injured area.1,3 This vascular
permeability and influx of blood, proteins, and leukocytes is what causes
edema. Although this edema brings aid to the injured tissue it can also
cause severe trauma. A pressure buildup can occur on healthy tissues and
cause a secondary hypoxic injury due to lack of oxygen. In addition these
leukocytes can kill healthy cells.3
2. Cellular response
The cellular response occurs simultaneously with the vascular
response. Once trauma is detected chemical mediators trigger the vascular
response. Other chemical mediators will also alert the body to send
leukocytes which use phagocytosis to clean and repair the area.1 First to
act are the neutrophils, followed by monocytes and macrophages.1,3
These cells play a large role in the repair of structures and are a cause of
swelling and edema.
3. Immune response
This segment of the inflammatory response is mediated by hormones
and is complimented by the vascular system.1 The lymphatic and vascular
systems are responsible for removing lymph and wastes throughout the
body. In the inflammation phase it will help to remove these wastes and
leukocytes that help clean the area of debris.
C. The physical properties of ice
1. How does ice work?
The common misconception with ice is the way people think it works.
Many believe that ice directly cools the tissues it is in contact with, but in
fact there is a constant reaction going on.3 As ice comes into contact with

the body, there is an obvious difference in body temperatures and the
temperature of the ice. This difference in temperatures will cause the skin
will give heat to the ice in an attempt to warm (melt) the ice.3,4,5 As the
superficial tissue layers are brought to a lower temperature the superficial
layers will draw heat from the deeper tissues in affect cooling the deeper
tissues.4,5 This transfer of kinetic energy between two different
temperatures is called the enthalpy of fusion.3 This energy transfer can be
administered a number of different ways but the most common method is
conduction. Conduction will transfer kinetic energy by coming in direct
contact between the different temperatures, which we commonly see with
After the ice is removed from the area and if the individual remains
sedentary the tissues will continue to cool.4 If an individual begins exercise
or even to walk the tissues will begin to re-warm but if they remain still, five
to ten more minutes of cooling will occur. This will result in a longer effect of
the modality, making it more effective.3,5
2. Factors that affect kinetic energy transfer
Thermal energy can be affected by a number of different variables.
The size of the treatment area will have a huge affect on the effects of ice.4
The larger the treatment area the more energy transfer will occur and will
cause a deeper penetration of the modality.3 The duration of the treatment
time will also affect the rate of cooling. The longer the ice is left on, the
greater the cooling rates of the tissue will occur. The temperature
difference between the ice and tissue will also affect the cooling rates.2,4,5
The greater this temperature difference the faster cooling will take place.
The body itself can also have adverse effects on cooling as well. The
body’s natural insulator is adipose tissue. Adipose tissue retains body
temperature which has affect on the rate of cooling as well as the rate of
penetration.2,3,4,5 Higher levels of fat can prevent deep musculature from
being cooled and requires longer treatment times in order to penetrate as
deep as someone with less adipose tissue.2
D. Physiological responses to ice application
1. Effects of the vascular system
If you recall when an injury occurs there can be a secondary hypoxic
injury due to a vasodilation of the vessels. One of the first effects of ice
application on the body’s systems is a vasoconstriction of the area where
ice is being applied. This vasoconstriction can lower the healthy cells
metabolic rate, therefore lowering the cells need for oxygen.1,2,3,4,5 For
every 1.8°F decrease in tissue temperature metabolic rate will decrease
thirteen percent.3 This vasoconstriction can also influence the amount of

edema formation by limiting the amount of hemorrhaging but it will not
remove it.2,4,5
2. Effects on pain
Pain perception can be altered by cryotherapy’s ability to alter nerve
conduction velocity.6 All types of nerve fibers will be affected by cold
application, particularly their synapses.3,6 One study said reported a
decrease of 33% in nerve conduction velocity of sensory fibers after a 10
degree decrease in skin temperature.6 The same study said, the same
decrease in skin temperature lowered motor nerve firing rates by 14%.6
The decreased sensory fibers will decrease the sensation of pain by the
gate theory.3,6 A decrease in motor nerve fibers firing rates will reduce
muscle spasm caused by injury, theoretically breaking the pain-spasm-pain
cycle.2,4,5,6 Muscle spindle sensitivity will also be affected which will
override the stretch reflex which will also affect spasm.6 The faster the skin
is cooled and nerve conduction velocities are lowered, the faster analgesia
will occur.4,5
3. Proprioception and muscular function
Although sensory fibers are affected through ice application,
proprioception is not altered.6 This is because propriocepive nerves have
very low thresholds and are thickly myelinated, located deep in tissues.6
Since motor nerves and muscle spindles are altered by cold to reduce
spasm and pain, we can expect to see a decrease in muscular function.5,6
One study indicated after a 20 minute cold application eccentric,
concentric, and isokinetic contractions all decreased as did endurance and
power.6 It has been theorized that short term icing can decrease the need
for oxygen while maintaining full muscular ability.6
E. Ice Massage
1. What is ice massage?
Ice massage is a cryotherapy technique that is usually administered
in a manner so the clinician can keep the ice moving.3 Typically, water is
frozen in a cup at 0-2°C then a portion of the cup is removed leaving some
portion of the cup allowing the clinician to grip the modality.7,8 A tool in
which a tongue depressor is frozen into the ice can be used as a grip,
essentially making a round, flat popsicle.9 The ice is then moved in a
circular or longitudinal manner over the affected area.3 Previous studies
have shown that using a treatment area no larger than three times the
surface of the ice so intramuscular temperatures can be lowered enough to
cause metabolic rate.7,8,9,10 The limited amount of ice prevents clinicians
from treating larger areas.
2. Cooling rates and depth of penetration

Almost immediately after ice massage is applied to the skin, the
skin’s temperature begins to drop very rapidly.8 Waylonis reported that in
the first five minutes of ice massage skin temperatures decreased 18.9°C
on the gastrocnemius.8 Another study reported a 26.6°C decrease in skin
temperature after a ten minute application.7 This same study by Bugaj
stated that the rate of skin cooling is 2.7°C by ice massage.7 He also
stated that re-warming took place at 1.9°C.7 However, it seems that ice
massage has more difficulty affecting intramuscular temperatures.8
Waylonis reported the same five minute application of ice massage caused
a 2.6°C decrease at a depth of 2.0cm.8 However, another study reported a
15.9°C decrease at 2.0cm deep for a similar five minute application.7
These studies also attempted ice massage for longer periods of time in an
attempt to further decrease intramuscular temperatures.7,8,9,11 Lowdon
and Moore reported after a ten minute ice massage application to the
gastrocnemius caused a decrease in 18.4°C at 2.0 cm deep.11 They also
said that a fifteen minute application caused a 20.4°C decrease at the
same depth.11 Waylonis has much different results stating, a ten minute
application lowered the temperature 5.2°C at the same depth of Lowdon
and Moore.8 Waylonis also recorded the temperature change at 3 and 4cm
deep.8 A ten minute application resulted in a decrease of 1.4°C at 3.0cm,
and .1°C at 4.0cm deep.7,8
3. Effects on nerve conduction velocity and pain
The circular or longitudinal movements produced on the skin can not
only lower nerve conduction velocities of the pain sensing A-delta and C-
fibers, but it can also stimulate the A-beta fibers.7,8 These large diameter
fibers activate the gate theory, in sense beating the noxious stimuli to the
spinal cord and modulating pain sensation.7,8,11 This decrease in pain will
reduce the spasm caused by the injury.3 Cooling rates can be increased by
applying more pressure with the icing implement.6,7,8,9 Studies have
shown that a decrease in 7.4°C causes a decreased nerve conduction
velocity of 33%.7,8 Ice massage has been shown to lower skin
temperatures 26.6°C on the thigh after a tem minute ice massage
application.8,9 Normal skin temperature is 33°C, a decrease of 26.6°C
would bring skin temperature to 6.4°C. This is well below the 14.4°C which
is when maximum analgesia occurs.7,9
F. Conventional icing
1. What is conventional icing?
Conventional icing is providing cryotherapy through ice bag
application to the injury site. In addition the area is compressed with an
elastic wrap to enhance cooling effects as well as aid in venous and

lymphatic return.9,12,13 Ice can either be crushed or cubed produced by
ice machines storing the ice just above 0°C.3 Before the ice bag is applied
excess air must be taken out of the ice bag so the bag can conform to the
injured area.9 Multiple ice bags can be used allowing larger treatment
areas.12 These ice bags can be wrapped in moist towels.3,9,12 This
provides insulation of the ice bag which helps the ice stay cooler for longer.
This is not necessary for conventional icing but it can help transmission.12
2. Cooling rates and depth of penetration
Ice bag application with compression has been shown to lower skin
temperature 20.3°C after a 20 minute application.13 Another study showed
a 13.1°C reduction after a 20 minute ice bag application without
compression.12 It also seems that conventional icing can penetrate deeper
and more effective than ice massage.9 Although one study states that after
thirty-nine minutes of conventional icing without compression, lowered
tissues 8°C at 2.0cm deep.9 The same study states, that when
conventional icing is added with compression a thirty minute treatment time
lowered intramuscular temperatures 13°C at the same depth.9 Another
study has shown that conventional icing with compression caused a
reduction in 12.7°C at 2.0cm deep.13
3. Effects on nerve conduction velocity and pain
Dependent on adipose tissue levels maximum analgesia is usually
produced within twenty minutes of conventional icing with compression.
One study says conventional icing took nearly forty-five minutes to reach
maximal analgesia.9 It could have been that this study had larger
individuals who may have had more adipose tissue. Studies have shown
that there is little difference between the rates at which nerve conduction
velocities lower between conventional icing and ice massage.6,9 A-beta
fibers are not stimulated as with ice massage application.
G. Discussion
1. Pros/cons of ice massage and conventional icing
Each application of cryotherapy surely has their place when it comes
to management of the inflammation phase of healing.9 Each modality has
positive and negative aspects that will lead a clinician to make a choice
between each technique. With conventional icing, the fact that we can
increase the rate of cooling and aid lymphatic return by adding
compression is the biggest advantage.14 Although we can add
compression to areas after ice massage, the combination of cold and
compression is far more effective in reducing edema.14,15 Another positive
point of conventional icing is that it allows clinicians to treat a larger area
that is injured.3 The small amounts of ice used in ice massage limits us to

use a treatment size no larger than three times the diameter of the ice.7,8,9
Ice massage is a very effective modality in its own sense. Ice massage can
help reduce spasm by activating A-beta fibers as well as lowering the
conduction velocities.6,7,8,9 This is very helpful in treating flat even areas
where there is spasm or pain.7 Ice massage can reduce skin temperatures
faster than conventional icing, but it doesn’t penetrate as deep as deep.9
Even though some studies have shown the ability to cool intramuscular
temperatures as much as 13°C results vary.6,7,8,9 For the most part, ice
massage has shown little effect on intramuscular temperatures.8 This could
be due to different methods of data collection or, differences in the amount
of the subject’s adipose tissue. Certainly there is a need for a standard
protocol to measure temperature changes, as well as an agreed upon
amount adipose tissue levels of test subjects. Ice massage is inexpensive,
easily accessible, and simple enough for a client to use. Patients can take
several ice cups home after they have sustained and injury in practice if ice
massage is preferred. Conventional icing also requires an ice machine
which can be expensive and unreliable if not operating properly.
2. Clinical applications of injuries in the acute inflammation phase
Ice massage although has its disadvantages certainly can be useful
in the primary care of acute injuries. Instances in which ice massage can
be used to manage acute inflammation conditions include: Acute bursitis of
the elbow or the knee, acute strains to superficial tendons (i.e. biceps
femoris, pes anserine muscle group, extensor carpi radialis/ulnaris,
abductor pollicis brevis/longus, and extensor pollicis brevis/longus), volar
plate and collateral ligament trauma of the phalanxes, strains to the
trapezius, as well as the thenar and hypothenar eminences. In addition
compression sleeves can be applied to bursitis conditions as well as,
injuries to the digits of the hand.7,8,9
Conventional icing should be performed on larger areas of the
body.13 Particularly where there are high levels of adipose tissue or where
deep cooling is desired. If the athletic trainer does not have access to
modalities such as electric stimulation, ice, compression, and elevation can
be used immediately after the injury to reduce hemorrhaging and
edema.13,14,15 We can also surround a joint with multiple ice bags in the
case of severe knee injuries.12 The larger the area needed to be treated as
well as, how deep penetration is needed will determine the modality the
clinician uses.3
H. Conclusion
Cryotherapy’s clinical use dates back to the days of the ancient
Greeks when they discovered it can alleviate pain.3 All forms of

cryotherapy provide vasoconstriction, analgesia, altered nerve conduction
velocities, and reduce the chance of secondary hypoxic injury by
decreasing cell metabolism.1,2,3,4,5 Cryotherapy can be administered a
number of different ways, but the therapeutic goals and phase of the
healing process will determine the choice of application.1 Conventional
icing can be used to treat larger, deeper areas, and entails compression
which can help reduce edema.13 Ice massage has proven to cause
analgesia faster than conventional icing but there is also less amount of
penetration and no compression with the ice.9 Previous research has
shown varied results for ice massage and there is a need for standardized
measurements.7,8 Ice massage and conventional icing each have their
own purposes in the inflammation phase of healing. In order to use each
appropriately more research on these forms of cryotherapy must be
administered with standardized methods in order to help clinicians
determine the best course of treatment.

Works Cited
1. Kellett, J. Acute soft tissue injuries-a review of the literature. Medicine & Science in Sports & Exercise. 1986;18(5):489-500.
2. Meeusen R, Lievens P. The Use of Cryotherapy in Sports Injuries. Sports Medicine. 1986;3(6):398-414.
3. Starkey C. Therapeutic Modalities. 3rd ed. Philadelphia, PA: FA Davis; 2004.
4. Swenson C, Sward L, Karlsson J. Cryotherapy in sports medicine. Scandinavian Journal of Medicine and Science in Sports.
5. Tepperman PS, Devlin M. Therapeutic heat and cold: a practitioner’s guide. Postgraduate Medicine. 1983;73(1):69-76.
6. Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. British Journal
of Sports Medicine. 2007;41:365-369.
7. Bugaj R. The Cooling, Analgesic, and Rewarming Effects of Ice Massage on Localized Skin. Physical Therapy. 1975;55(1):11-19.
8. Waylonis G. The Physiologic Effects of Ice Massage. Archives of Physical Medicine and Rehabilitation. 1967;48(1):37-42.
9. Zemke JE, Anderson JC, Guion WK, McMillan J, Joyner AB. Intramuscular Temperature Responses in the Human Leg to Two
Forms of Cryotherapy: Ice Massage and Ice Bag. Journal of Orthopaedics and Sports Physical Therapy.1998;27(4):301-307.
10. Borgmeyer JA, Scott BA, Mayhew JL. The effects of Ice massage on Maximum Isokinetic-Torque Production. Journal of Sport
Rehabilitation. 2004;13:1-8.
11. Lowdon BJ, Moore RJ. Determinants and nature of intramuscular temperature changes during cold therapy. American Journal of
Physical Medicine. 1975;54(5):223-233.
12. Kennet J, Hardaker N, Hobbs S, Selfe J. Cooling Efficiency of 4 Common Cryotherapeutic Agents. Journal of Athletic Training.
13. Merrick MA, Knight KL, Ingersoll CD, Potteiger JA. The Effects of Ice and Compression Wraps on Intramuscular Temperature at
Various Depths. Journal of Athletic Training. 1993;29(3):236-245.
14. Bleakley CM, McDonough SM, MacAuley DC. Cryotherapy for Acute Ankle Sprains: A Randomized Controlled Study of Two
Different Icing Protocols. British Journal of Sports Medicine. 2006;40:700-705.
15. Enwemeka CS, Allen C, Avila P, Bina J, Konrade J, Munns S. Soft Tissue Thermodynamics before, during, and after cold pack
therapy. Medicine & Science in Sports & Exercise. January 2001;34(1):45-50.

APPENDIX III Human thermoregulation and the cardiovascular system

Human thermoregulation and the cardiovascular system

José González-Alonso

A key but little understood function of the cardiovascular system is to
exchange heat between the internal body tissues, organs and the skin to
maintain internal temperature within a narrow range in a variety of
conditions that produce vast changes in external (exogenous) and/or
internal (endogenous) thermal loads. Heat transfer via the flowing blood
(i.e. vascular convective heat transfer) is the most important heat-exchange
pathway inside the body. This pathway is particularly important when
metabolic heat production increases many-fold during exercise. During
exercise typical of many recreational and Olympic events, heat is
transferred from the heat-producing contracting muscles to the skin
surrounding the exercising limbs and to the normally less mobile body trunk
and head via the circulating blood. Strikingly, a significant amount of heat
produced by the contracting muscles is liberated from the skin of the
exercising limbs. The local and central mechanisms regulating tissue
temperature in the exercising limbs, body trunk and head are essential to
avoid the deleterious consequences on human performance of either
hyperthermia or hypothermia. This brief review focuses on recent literature
addressing the following topics: (i) the dynamics of heat production in
contracting skeletal muscle; (ii) the influence of exercise and environmental
heat and cold stress on limb and systemic haemodynamics; and (iii) the
impact of changes in muscle blood flow on heat exchange in human limbs.
The paper highlights the need to investigate the responses and
mechanisms of vascular convective heat exchange in exercising limbs to
advance our understanding of local tissue temperature regulation during
exercise and environmental stress.

Heat production in skeletal muscle

Heat is produced in all body cells from the conversion of metabolic energy
into mechanical and thermal energy. This process is very inefficient and
thus approximately 30–70% of the energy liberated during muscle
contraction appears as thermal energy (Edwards et al. 1975; González-
Alonso et al. 2000b; Bangsbo et al. 2001; Krustrup et al. 2001, 2003). Heat
production by dynamically contracting human skeletal muscle increases
abruptly and markedly at the onset of dynamic exercise, increases further

at a lower rate during the early stages of exercise and eventually plateaus if
exercise is of a steady-state nature. When exercise is intense, however,
heat production does not level off, as illustrated in Fig. 1. A doubling in heat
production is seen over 3 min of intense dynamic exercise, with half of the
increase occurring during the first 38 s (González-Alonso et al. 2000b).
Heat production in dynamically contracting muscle in conditions of
unrestricted flow is estimated by measuring the amount of heat
accumulated in the contracting muscles, the amount of heat removed by
the blood to the body trunk and the amount of heat loss from the exercising
limb skin. When looking at each subdivision (in conditions in which heat
exchange with the surroundings of the thigh is minimized by a
thermostatically isolated system and the circulation to the lower leg is
arrested), heat storage in the active quadriceps muscles accounts for the
immediate elevation in heat production, whereas heat removal to the body
trunk via the blood is dominant at the end of exercise.

Rates of total heat production and its subdivisions in terms of storage in the
quadriceps muscle and removal by the blood to the body trunk are depicted
for each 5 s of exercise. Note that heat storage in the quadriceps muscle
accounts for the immediate increase in heat production, decreasing
progressively thereafter. Conversely, heat removal by the blood is nil at the
onset of exercise, increasing progressively thereafter to account for most of
heat production at the end of the 180 s of exercise. (Modified from
González-Alonso et al. 2000b.)

The elevation of total heat production over time in contracting skeletal

muscle is tightly coupled with changes in heat liberation during metabolic
ATP production early in exercise (González-Alonso et al. 2000; Bangsbo et
al. 2001; Krustrup et al. 2001, 2003). As depicted in Fig. 2, the contribution
of anaerobic energy turnover to total energy turnover (i.e. the sum of total
heat production and mechanical power output) is greatest at the onset of
exercise, becoming smaller as the contribution of aerobic energy turnover
increases. In vitro studies have shown that heat production during ATP
utilization varies from 35 to 72 kJ (mol ATP)−1 depending upon whether
creatine phosphate (PCr), glycolysis or oxidative phosphorylation provides
the energy for ATP resynthesis (Wilkie, 1968; Curtin & Woledge, 1978).
Hence, both in vitro and in vivo studies show that muscle heat production
can increase during high-intensity dynamic exercise by a factor of two, with
a shift in ATP resynthesis from primarily PCr catabolism to primarily
oxidative phosphorylation.

Figure 2. Total, anaerobic and aerobic energy turnover during intense
dynamic knee-extensor exercise

Rates of total and aerobic energy turnover and heat liberation for each 5 s
period of intense dynamic knee-extensor exercise. Note that anaerobic
heat liberation accounts for most of the total energy turnover at the onset of
exercise, whereas aerobic heat liberation is dominant after some 45 s of
exercise. (Modified from González-Alonso et al. 2000b.)

Heat storage in body tissues depends upon the interplay among heat
production, heat dissipation and, to a lesser extent, energy exchanged
during mechanical work. Excessive heat accumulation or liberation
compromises the physiological function of cellular and organ systems,
which can lead to impaired human performance (González-Alonso et al.
2008a; Taylor et al. 2008). A well-developed control system is therefore
required to regulate heat exchange within the body and between the skin
and the environment. The two avenues of heat exchange inside the body
are ‘intercellular conductive heat transfer’ and ‘vascular convective heat
transfer’. Heat conductance through tissues in the human body is a slow
process and, in limbs, is primarily dependent upon the temperature
gradient between muscle and skin and the thermal conductivity of muscle.
This avenue of heat exchange is particularly important in conditions of
exercise in cold environments, which produces a large temperature
gradient between deep muscle and neighbouring subcutaneous tissue and
skin (Werner et al. 2008). Conversely, it plays no role when there is not a
temperature gradient between muscle and surrounding skin, as during
exposure to warm environments. In contrast, convective heat transfer
(mass flow) from dynamically contracting limb muscles to the core of the
body and to the surrounding subcutaneous limb tissues hinges upon tissue
blood flow and arteriovenous blood temperature difference (according to
the Fick principle; González-Alonso et al. 2000b). Hence, conditions that
alter either limb tissue blood flow and/or arteriovenous blood temperature
difference, such as exercise and/or environmental stress, are likely to
induce profound changes in convective heat exchange within the exercising
limbs and between the exercising limbs and the body torso. Conversely,
when exercise is performed in ischaemic conditions (e.g. when limb
circulation is arrested by inflation of a cuff), convective heat removal to the

body truck is nil and thus heat accumulates in the muscle (Edwards et al.
1975; Krustrup et al. 2003).

The body of literature discussing the processes involved in heat liberation

from the skin to the environment is very extensive. The reader is referred to
two excellent reviews on the biophysics and physiology of heat exchange
between the body and the environment (Gagge & Gonzalez, 1996; Werner
et al. 2008). On the contrary, the number of studies directly investigating
the processes involved in heat exchange inside the human body,
particularly in contracting limb skeletal muscle, is relatively small due partly
to the complexity of performing the necessary invasive measurements of
tissue blood flow and blood and tissue temperature gradients. The focus of
this paper is on the latter aspect of temperature regulation.

Cardiovascular responses to exercise and environmental stress

The circulatory adjustments to exercise and environmental stress are
integrative responses to a vast collection of external and internal stimuli.
Based on the external stimuli, the haemodynamic responses to
environmental stress and exercise are determined by the magnitude of the
environmental (heat or cold) load and the duration, intensity and type of
exercise. The environmental conditions and the type and intensity of
exercise determine the metabolic and thermal demands for local and
systemic blood flow, whereas exercise duration defines the regulatory
disturbances and constraints in cardiovascular function over time (Rowell et
al. 1996; González-Alonso et al. 2008a; Mortensen et al. 2008). Depending
upon the amount of muscle mass engaged, exercise can generally be
classified as small or large muscle mass exercise. Single-limb exercise,
such as forearm and isolated leg exercise, are examples of small muscle
mass exercise, whereas whole-body exercise, such as cycling, running and
rowing, are considered large muscle mass exercise. The effects of heat
and cold stress during exercise on cardiovascular function are most likely
to differ during small compared with large muscle mass exercise when
exercise intensity is high (Mortensen et al. 2008). From a mechanistic
physiology viewpoint, the combination of intense whole-body exercise and
heat stress poses the greatest challenge to the regulation of temperature,
mean arterial pressure and oxygen delivery to the working muscles, brain
and heart, because in these conditions the cardiovascular system is
pushed faster to the limit of its regulatory capacity (Rowell et al. 1996;
González-Alonso et al. 2008).

Prolonged whole-body exercise in the heat is associated with greater
tachycardia, skin and core hyperthermia, but conflicting systemic and
exercising limb blood flow responses compared with equivalent exercise in
the cold (Claremont et al. 1975; McArdle et al. 1976; Nadel et al. 1979;
Sawka et al. 1979; Montain & Coyle, 1992; González-Alonso et al. 1998,
2000a). The lack of control for subjects’ hydration status, randomization of
the experimental trials and familiarization of the participants with the
experimental conditions might explain, at least in part, the discrepancy in
the blood flow responses in the literature. In this context, people lose more
body water during exercise in the heat due to higher sweat rates and thus
become more dehydrated than during exercise in the cold. The question
then arises as to how distinct levels of dehydration impact upon the
cardiovascular responses to exercise and environmental stress. Figure 3
depicts the results from a study investigating the influence of environmental
temperature and hydration status on the cardiovascular responses to
moderately intense leg cycling (González-Alonso et al. 2000a). Subjects
were randomly tested at 35 and 8°C ambient temperatures when
euhydrated and dehydrated by 1.5, 3.0 and 4.5% of their body weight.
When subjects were euhydrated and core temperature and oxygen uptake
(inline image) were the same during exercise in both environments, cardiac
output was elevated by 1 l min−1 in the heat, accompanied by a higher
heart rate but an unchanged stroke volume. This elevated systemic blood
flow might have been a response to the threefold higher skin blood flow
during exercise in the heat, as the metabolic and thermal demands for
exercising muscle blood flow were apparently the same.

Note that cardiac output was elevated in the heat in normal hydration
conditions, but in contrast to exercise in the cold it declined significantly
with increasing levels of dehydration owing to the greater decline in stroke
volume (González-Alonso et al. 2000a).

*Significantly different from the euhydrated control condition. †Significantly

different from exercise in the cold at the same hydration level

The circulatory responses to a given level of dehydration, however, vary in

cold and hot environments. In contrast to the well-characterized
cardiovascular strain evoked by dehydration during exercise in the heat
(Sawka et al. 1979; Montain & Coyle, 1992; González-Alonso et al. 1998),
graded dehydration up to 4% of body weight loss (i.e. 3 kg for a 70 kg
person) does not reduce cardiac output, skin blood flow, arterial blood

pressure or systemic vascular conductance during exercise in the cold.
Consequently, cardiac output, and possibly active muscle blood flow
(González-Alonso et al. 1998), is lower during moderate intensity exercise
in the heat compared with exercise in the cold when dehydrated by 4%,
which is the opposite response to what occurs in the euhydrated state.
Hydration status can therefore explain part of the discrepancy in the
cardiac output responses to environmental stress and intense whole-body
exercise reported in the literature.

The literature directly comparing the effects of environmental heat and cold
stress on the haemodynamic responses to small muscle mass exercise is
sparse (e.g. Savard et al. 1988), yet evidence in resting limbs is extensive.
Studies in resting limbs generally show that heat stress increases blood
flow to the arms and legs, whereas cold stress reduces limb perfusion (e.g.
Barcroft & Edholm, 1943). A highly controversial issue, however, is whether
these differences in limb perfusion reflect changes only in skin blood flow or
in both muscle and skin blood flow. With respect to heat stress, early
investigations into the partition of limb perfusion between skin and skeletal
muscle in the human forearm led to conflicting results, with some studies
suggesting an elevation in muscle blood flow (Barcroft & Edholm, 1946;
Barcroft et al. 1947), but others not (e.g. Rodie et al. 1956; Detry et al.
1972; Johnson et al. 1976). The negative findings together with the
estimate of maximal skin blood flow of 6–8 l min−1, based on indirect
measures of cardiac output and visceral blood flow during whole-body heat
stress, promoted the idea that increases in skin blood flow with heat stress
accounted fully for the rise in systemic hyperaemia and blood flow
redistribution (Detry et al. 1972; Rowell 1974; Minson et al. 1998). Recent
evidence in the human leg, however, challenges this widely held dogma.
Using 133Xe washout or positron emission tomography techniques, Keller
et al. (2010) and Heinomen et al. (2011) recently showed that passive leg
heating increases calf blood flow by approximately 60–65%. In parallel, we
have shown significant increases in leg tissue blood flow, deep femoral
venous O2 content and muscle oxygenation and a parallel significant
decline in leg arterial–deep venous O2 differences during whole-body heat
stress, both at rest and during mild knee-extensor exercise, with a small
effect or no effect on aerobic metabolism (Pearson et al. 2011). The
enhanced muscle blood flow was closely associated with increases in
arterial plasma ATP concentration and muscle temperature (Pearson et al.
2011), which is in turn coupled to a temperature-mediated release of ATP
from erythrocytes (Kalsi & González-Alonso, 2012). On the other hand,

cold stress has repeatedly been shown to reduce limb blood flow in resting
humans (e.g. Barcroft & Edholm, 1943; Gregson et al. 2011). For instance,
the classic work of Barcroft & Edholm (1943) clearly showed lower forearm
blood flows and deep muscle temperatures when the forearm was
immersed in a water bath at 13, 20 and 25°C compared with higher water
temperatures. Likewise, Gregson and co-workers recently reported a 35–
40% decline in femoral artery blood flow and conductance following 10 min
of cold and temperate water immersion (8 versus 22°C), which evoked
drastic decreases in muscle and skin temperatures, but less cutaneous
vasoconstriction at 8 than at 22°C water temperature, possibly reflecting a
lower muscle blood flow (Gregson et al. 2011). Taken together, growing
evidence from the human leg suggests that heat and cold stress not only
alters blood flow to the skin, but also to the skeletal muscle. These
circulatory adjustments might have important implications for heat transfer
in resting and exercising human limbs.

Muscle blood flow and limb heat liberation

The flowing blood transports heat inside the body in relation to blood
temperature and flow rate. Heat transfer in major arteries and veins
supplying and draining the limbs is bidirectional. In normal resting
conditions, limb muscle and venous blood temperatures are significantly
lower than arterial and core temperature (González-Alonso et al. 1999; He
et al. 2002; Fig. 4). In fact, blood temperature in the limb muscle
microcirculation is normally several degrees lower than core temperature
due to rapid thermal equilibration between tissues and vessels (He et al.
2002). At the level of the major supply vessels, the resulting negative
arteriovenous temperature gradient indicates that more heat is being
transferred from the upper body core to the extremities than vice versa
(Fig. 4). This net body core-to-limbs heat transfer helps limbs to maintain
tissue temperature when their metabolic heat production is low. For
instance, leg inline image is normally about 25 ml min−1 in the resting
state, corresponding to a total leg heat production of 0.5 kJ min−1 based
on the heat equivalent of inline image (Bangsbo et al. 2000). This value is
only half of the 1 kJ min−1 of heat being transferred from the body trunk
to each leg when femoral venous temperature is 0.7°C lower than femoral
arterial blood temperature, resting leg blood flow is 0.4 l min−1 and the
blood specific heat is 3.61 kJ l−1°C−1 (Fig. 4). These simple estimates

demonstrate that more heat is transferred into the resting leg than
produced locally in resting conditions. This implies that limb tissue
temperature will drop if its circulation is arrested and heat dissipation to the
surroundings of the limbs is kept constant. An example of this might occur
during knee or elbow surgery.

Note that muscle (Tm) and femoral venous temperatures (Tfv) are lower
than core (Toes) and femoral arterial blood temperatures (Tfa) at the onset
of submaximal leg cycling exercise (0–3 min for Tfa and 0–8 min for Tm),
but increase very rapidly as exercise progresses. A net heat influx in the
leg is observed at rest (0 min) and during the initial 5.5 min of exercise. A
net heat efflux is seen thereafter. (Modified from González-Alonso et al.

The impact of alterations in limb perfusion on heat exchange between the

body core and limbs can be exemplified from the findings of He et al.
(2002) in the rat hindlimb. To the author's knowledge, comparable limb
thermodynamic data are not available for humans. Femoral artery and vein
blood flow was increased by infusion of the nitric oxide donor sodium
nitroprusside (vasodilatation), normal (control) or reduced by infusion of
noradrenaline (vasoconstriction; Fig. 5). Increases in blood flow were
accompanied by parallel reductions in femoral arteriovenous temperature
difference, thus net limb heat influx was the same. In contrast, when
femoral artery blood flow was reduced, heat influx into the hindlimb was
reduced, accompanying an essentially unchanged arteriovenous
temperature gradient. Therefore, the findings of He and co-workers (2002)
indicate that increasing limb blood flow in resting limbs does not
necessarily increase the net amount of heat being transferred from the
body trunk to the limbs because of compensatory tissue-to-blood thermal
exchange adjustments within the leg tissues. However, reducing blood flow
might have an impact on limb heat transfer. In the resting human leg,
femoral venous blood temperature has been shown to decrease by up to
0.5°C with progressive increases in blood flow from 0.4 to 8 l min−1 evoked
by intrafemoral artery infusion of ATP (González-Alonso et al. 2008b).
Whether similar thermal adjustments to those described in the rat hindlimb
occur in the human leg warrants detailed investigation.

Note that increases in blood flow in the resting hindlimb do not change the
net limb heat influx, because of compensatory changes in femoral

arteriovenous (a-v) temperature differences (drawn from data reported by
He et al. 2002). *Significantly different from control.

Exercise illustrates a different scenario, in which not only limb tissue

perfusion and convective heat exchange, but also heat production
increase. During the initial stages of leg exercise, the temperatures of the
contracting muscle and the outflowing femoral venous blood increase at a
faster rate than the temperatures of the inflowing femoral arterial blood and
the upper body core (González-Alonso et al. 1999), yet a negative femoral
arteriovenous blood temperature gradient prevails during the early stages
of exercise, signifying that more heat is still transferred from the upper body
core to the exercising limbs in normal environmental conditions (Fig. 4).
After a few minutes of exercise (duration will depend on the initial
temperatures and the rate of heat production or exercise intensity), muscle
and venous blood temperature becomes higher than arterial blood and
upper body core temperature. At this point in time, heat transferred from
the exercising limbs to the body torso becomes positive, increasing
thereafter to reach a plateau when exercise is of light-to-moderate intensity.
To date, data on heat exchange in human limbs in different environmental
and exercise conditions are very limited, thus the ideas discussed above
require thorough scrutiny.

Summary and future directions

Our knowledge and understanding of human thermo-regulation and its
interaction with cardiovascular regulation during exercise is largely based
upon data from resting limbs. The observation that a significant amount of
heat produced by the exercising muscles is liberated directly from the skin
of the exercising limbs (González-Alonso et al. 1999) highlights the need to
investigate the responses and mechanisms of vascular heat exchange in
resting and exercising limbs. Quantification of heat production and
convective heat exchange in human limbs is likely to shed new light onto
the role of muscle blood flow in the control of tissue temperature during
environmental stress and exercise.

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