Garret B., Christine C., Sara K.
Our patient presents with a subacute ankle sprain. Swelling has recently subsided, but the patient is still having significant pain. Contrast bath was used for pain relief and transition from cryotherapy to thermotherapy. Since this was the patients first time, we decided to do a 3 to 1 ratio of hot to cold for 20 minutes. We ended with cold to help regulate the patient’s pain. Upon the next visit, we will observe for signs of swelling, at which point we will change the hot to cold ratio if needed.
From the little research regarding contrast bath, we found evidence both supporting and refuting this modality.
Supporting Evidence: Petrofsky et al found that superficial blood flow to the foot increased significantly with contrast bath. The plantar surface of the foot had more significant findings than the dorsal surface. Fiscus et al, found similar results stating that while it was unlikely that intramuscular temperature changed, there were still peripheral changes in blood flow. During the cold phase, vasoconstriction simply returned to baseline and didn’t drop below the resting temperature. This is relevant because the significant increase in blood flow brings added nutrients and oxygen to the healing tissues. Denegar et al found that contrast bath decreased patient’s pain level on a visual analog scale. They also showed that patient preference for hot , cold, or contrast therapy will effect patients perception of pain relief. Nearly half of the subjects preferred cold or contrast bath.
Refuting Evidence: Higgins et al, found that the warm whirlpool caused significantly greater increase in temperature than contrast bath. Contrast bath showed no fluctuation in temperature after 11 minutes whereas the warm whirlpool had a gradual increase for the whole 30 minute treatment. Myrer et al, had similar findings where the intramuscular temperature for contrast bath had slight increases in temperature, whereas the control group (hot whirlpool) had significant temperature increases. Therefore, contrast bath provides little to no physiological effect in the intramuscular tissues. According to Cote et al, contrast bath is believed to be able to reduce edema through a pumping action caused by vasodilation and vasoconstriction, however, there is no evidence to support this theory. Contrast bath was found to be contraindicated when trying to control edema and it actually caused an increase in edema for post-acute ankle sprains. Heat alone and contrast bath both caused an increase in edema during this study.
Overall, we found that the research regarding contrast bath was insufficient. We believe that more research needs to be done for this modality in the future in order to validate and regulate its use in the clinic. While it was found that thermotherapy produces similar results, contrast bath seems to be a good way to transition from cryotherapy to thermotherapy once the acute phase has passed. Contrast bath could also be a preferred modality for patients. We chose this for our patient due to his lack of edema and persistent pain.
References
Cote, Debra, William Prentice, Daniel Hooker, and Edgar Shields. "Comparison of Three Treatment Procedures for Minimizing Ankle Swelling." Physical Therapy. 68.7 (1988): 1072-1076. Web. 19 Jan. 2012.
Denegar, Craig, et al. "Preferences for Heat, Cold, or Contrast in Patients with Knee Osteoarthritis Affect Treatment Response." Clinical Interventions in Aging 5 (2010): 199-206. PubMed. Web. 19 Jan. 2012.
Fiscus, Kimberly, Thomas Kaminski, and Powers Michael. "Changes in Lower-Leg Blood Flow During Warm-, Cold-, and Contrast-Water Therapy." Archives of Physical Medicine and Rehabilitation. 86.7 (2005): 1404-1410. Web. 19 Jan. 2012.
Higgins , Diana, and Thomas W Kaminski. "Contrast therapy does not cause fluctuations in human gastrocnemius intramuscular temperature." Journal of Athletic Training. 33.4 (1998): 336-41. Web. 19 Jan. 2012.
Myrer, J. W., Draper, D. O., & Durrant, E. (1994). Contrast therapy and intramuscular temperature in the human leg. Journal of athletic training, 29(4), 318-22.
Petrofsky, J, E III Lohman, S Lee, Z de la Cuesta, L Labial , R Iouciulescu, B Moseley, and R Korson. "Effects of contrast baths on skin blood flow on the dorsal and plantar foot in people with type 2 diabetes and age-matched controls.." Physiotherapy Theory & Practice. 23.4 (2007): 189-97. Web. 19 Jan. 2012.
Ginny Rogers and Heather Cameron
ReplyDeleteContrast Bath
Refuting Evidence:
The study by Higgins et al. looked at the effectiveness of cold water immersion (CWI) and contrast bath therapies compared to passive recovery methods of rugby players following game simulation and a week-long training protocol. It is common in rugby for players to engage in vigorous strengthening and conditioning sessions several times a week in addition to playing in games during the season. Although there was not significant evidence to recommend one hydrotherapy modality over another to facilitate recovery, results of this study refuted the use of contrast bath compared to CWI or control for helping rugby players recover during a typical week of practices and competitive play.
According to this study, contrast bath was least effective in minimizing the effects of delayed-onset muscle soreness (DOMS) when compared to CWI and control. Higgins et al. found that muscle soreness scores were 40% below baseline scores for subjects in the contrast bath group, compared to 20% and 24% below baseline for control and CWI groups respectively. While the mechanism of contrast bath is thought to remove metabolic waste through successive cycles of immersion in hot and cold water to facilitate a muscle pump action, Higgins et al. suggested that time spent in each temperature could be insufficient for changing the temperature of the muscle tissue required to achieve a vasoconstriction/vasodilatation pump effect.
Although all participants underwent the same training protocol, the study’s results showed that subjects in the contrast bath group had higher rate of perceived exertion (RPE) scores than both control and CWI groups. RPE scores of the contrast bath group were 25% higher than CWI group scores, and 10% higher than the scores of the control group. This suggests that players that undergo contrast bath therapy could have more difficulty staying motivated to endure week after week of hard practice and competition.
Supporting Evidence:
DeleteThe study by Stanley et al. looked at the effect hydrotherapy had on performance and cardiac parasympathetic reactivation of cyclists. Cold water immersion (CWI) and contrast water immersion (CWT) were compared to passive recovery following bouts of cycling in elite athletes.
According to the results of Stanley et al, both CWT and CWI decreased participant rate of perceived exertion (RPE) scores. However, the authors suggested that this effect was strictly confined to the participant psyche in that average time-trial performance did not improve following either intervention in either hydrotherapeutic group.
The results of this study did not find CWT to improve cardiac parasympathetic reactivation following the cyclic intervals. Instead, CWT had an effect that was slightly above that of the control group, and similar to that in which thermoneutral water had previously been cited for in other studies. CWI was found to have a more profound effect on increasing hydrostatic pressure to stimulate venous return, baroreceptor loading, and increased cardiac parasympathetic activation post exercise.
Stanley et al. demonstrated that CWT could improve athlete perception of recovery following bouts of high-intensity cycling, but did not have substantial effects on cardiac parasympathetic recovery nor capability to improve performance.
Both studies examined had small sample sizes (Higgins et al. n=24, Stanley et al. n=18) which did not attribute the necessary power to either study’s results to make the findings significant. Results for high-level athletes were mixed regarding the benefits of contrast water/bath therapy. More research is needed on the mechanism and effects of contrast water/bath therapy to better understand its role as a therapeutic modality.
References:
1. Higgins T.R, Climstein M, Cameron M. Evaluation of hydrotherapy, using passive tests and power tests, for recovery across a cyclic week of competitive rugby union. Journal of strength and conditioning research. 2013;27(4):954–965. doi:10.1519/JSC.0b013e318260ed9b.
2. Stanley J, Buchheit, M, Peak, J. M. The effect of post-exercise hydrotherapy on subsequent exercise performance and heart rate variability. European journal of applied physiology. 2012-03;112:951-61.
doi: 10.1007/s00421-011-2052-7.
Contrast Baths: Use Them or Lose Them?
DeleteA Review of a Randomized Control Trial
Hydrotherapy is something that physical therapists are very familiar with; however, there is little information published about using it as a recovery therapy in athletes. Many athletes have very demanding schedules and must use their therapy time to their best advantage. In addition, conflicting information on the use of cold water suggests more research is needed. This paper investigates the effects of ice baths, contrast baths, and passive recovery on performance during intermittent team games (high impact anaerobic exercise) in rugby players.
Members of an under 20 rugby team were recruited to take place in this study, excluding those with an injury or illness or already part of a training squad. The 26 individuals were divided into three groups: a control, ice bath (most common post-workout treatment, five minutes), and contrast bath (control, 7 cycles of 60 seconds for each temperature). The three groups completed a pretest phosphate decrement test (also known as a phosphate recovery test, measuring the ability to recover to prior levels after anaerobic activity) one week before the first game in the trial. Each participant then used the assigned recovery technique after each practice, workout and game for the next four weeks. One week after the last game, a posttest phosphate decrement level was taken, as well as self-reports about how rested the players felt, how tight they felt, and whether they though the treatment was beneficial. The pretest and posttest consisted of seven sets of seven second sprints with 21 seconds recovery time in between, measuring the distance of each sprint, and a 300 meter sprint.
Results that were considered positive were an increase in recovery during the sprints (subjects were able to run further), a decrease in 300 meter sprint time and self-reported positive results. Within groups, there was no significant difference between the pretest and posttest of phosphate decrement or the 300 meter sprint. However, for contrast baths against ice baths, there was a medium to large effect size for the 300 meter sprint and a large effect for the phosphate decrement test. Similarly, contrast baths had a medium to large effect on the 300 meter test as compared to the control, but a trivial effect on the phosphate decrement test. Ice baths compared to the control had a trivial effect size with the 300 meter sprint and a negative medium effect with the phosphate decrement test.
These results suggest that contrast baths are better than ice baths and passive recovery for rugby and maybe other intermittent team sports (high impact anaerobic activity). They also suggest that 5 minute ice baths may need to be reconsidered due to their low and possibly negative effects on recovery time.
Climstein, Mike, Heazlewood, Tim I., & Higgins, Trevor R. (2011). A Random Control Trial of Contrast Baths and Ice Baths for Recovery During Competition in U/20 Rugby Union. Journal of Strength and Conditioning Research, (25), 1046-51.