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Alternating hot and cold water immersion for athlete recovery: A review

Article  in  Physical therapy in sport: official journal of the Association of Chartered Physiotherapists in Sports Medicine · February 2004
DOI: 10.1016/j.ptsp.2003.10.002

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 Physical Therapy in Sport 5 (2004) 26–32
www.elsevier.com/locate/yptsp

Literary review

Alternating hot and cold water immersion

for athlete recovery: a review
Darryl J. Cochrane*
Department of Management, Sport Management and Coaching, Massey University, Private Bag 11 222, Palmerston North, New Zealand

Abstract
Objectives. The aim of this review was to investigate whether alternating hot – cold water treatment is a legitimate training tool for
enhancing athlete recovery. A number of mechanisms are discussed to justify its merits and future research directions are reported.
Alternating hot– cold water treatment has been used in the clinical setting to assist in acute sporting injuries and rehabilitation purposes.
However, there is overwhelming anecdotal evidence for it’s inclusion as a method for post exercise recovery. Many coaches, athletes and
trainers are using alternating hot – cold water treatment as a means for post exercise recovery.
Design. A literature search was performed using SportDiscus, Medline and Web of Science using the key words recovery, muscle fatigue,
cryotherapy, thermotherapy, hydrotherapy, contrast water immersion and training.
Results. The physiologic effects of hot – cold water contrast baths for injury treatment have been well documented, but its physiological
rationale for enhancing recovery is less known. Most experimental evidence suggests that hot– cold water immersion helps to reduce injury
in the acute stages of injury, through vasodilation and vasoconstriction thereby stimulating blood flow thus reducing swelling. This shunting
action of the blood caused by vasodilation and vasoconstriction may be one of the mechanisms to removing metabolites, repairing the
exercised muscle and slowing the metabolic process down.
Conclusion. To date there are very few studies that have focussed on the effectiveness of hot– cold water immersion for post exercise
treatment. More research is needed before conclusions can be drawn on whether alternating hot– cold water immersion improves
recuperation and influences the physiological changes that characterises post exercise recovery.
q 2003 Published by Elsevier Ltd. All rights reserved.
Keywords: Recovery; Training; Post exercise; Hydrotherapy; Regeneration; Immersion

1. Introduction accelerate the recovery process (Calder, 1996). There has

been an increase in the use of modalities such as massage,
Recovery is an important aspect of any physical floatation, hyperbaric oxygenation therapy and acupuncture
conditioning programme however, many athletes train with little scientific evaluation of its use and effectiveness
extremely hard without giving their body time to recover for exercise recovery. Alternating hot –cold water immer-
which can lead to over reaching, burnout or poor sion is one technique that is very popular and is practised
performances (Mackinnon and Hooper, 1991). Without the with increased frequency in aiding recovery after physical
necessary recovery interventions it is very difficult for an training and competition (Calder, 2001a). Anecdotal reports
athlete to maintain a high level of performance on a daily or from coaches, medical personnel and athletes suggest that
this method of water immersion has positive effects on
weekly basis. As athletes look for the leading edge, rest is
subsequent performance.
frequently overlooked for increases in overload, intensity
The aim of this review was to source the literature and
and volume.
provide the scientific rationale and mechanisms of using
Recently a lot of emphasis has been placed on speeding
alternating hot –cold water immersion for post exercise
up the recovery process so athletes can proceed to do
recovery.
successive bouts of training or competition without the
associated fatigue or burn out effects. Numerous physical,
psychological and nutritional methods have been used to 2. Therapeutic modalities

* Tel.: þ 64-6-350-5799; fax: þ64-6-350-5661. Ice packs, whirlpools, baths, heat packs, infra-red lamps,
E-mail address: [email protected] (D.J. Cochrane). paraffin wax and ice massage are various techniques of
1466-853X/$ - see front matter
doi:10.1016/j.ptsp.2003.10.002
 D.J. Cochrane / Physical Therapy in Sport 5 (2004) 26–32 27

cryotherapy and thermotherapy that have been used in the The increased blood flow allows an increased supply of
sports medicine and rehabilitation fields for the treatment of oxygen, antibodies and the ability to clear metabolites
acute injuries (Prentice, 1999). Additionally, contrast baths, (Zuluaga et al., 1995).
warm and cold packs have also played a major role in injury Myrer et al. (1994) proposed that if contrast therapy is
management but increasingly these modalities are now used reported to produce physiologic effects (vasodilation and
for post exercise recovery. Warm spas with cold plunge constriction of local blood vessels, changes in blood flow,
pools or contrast hot – cold baths and showers are common reduction in swelling, inflammation and muscle spasm)
practises used by athletes after training or exercise. significant fluctuations of muscle temperature must be
According to Calder (1996) the contrast hot – cold water produced by the alternating hot – cold contrast treatments.
technique is thought to speed recovery by increasing the Participants immersed their right leg into a hot (40.6 8C)
peripheral circulation by removing metabolic wastes and whirlpool for 4 min followed by a cold (15.6 8C) whirlpool
stimulating the central nervous system. Calder (2001b) for 1 min, and this was repeated four times (Myrer et al.,
further claims that contrast hot – cold increases lactate 1994). This protocol did not produce any significant
clearance, reduces post exercise oedema and enhances differences in intramuscular temperature 1 cm below the
blood flow to the fatigued muscle. Additionally, it is thought skin in the gastrocnemius muscle. In a subsequent study,
to slow down the metabolic rate and revitalise and energise Myrer et al. (1997) changed the modality of the contrast
the psychological state. therapy to cold and hot packs. The exposure duration was
extended to 5 min for both the hot –cold treatment. The
rationale for using the packs was to give deeper penetration,
3. Physiology of cooling and heating greater heat transfer and elicit superior temperature
fluctuations. The results verified their previous study that
There is a general consensus that the application of cold hot – cold contrast treatment does not produce the required
ice or water immersion decreases skin, subcutaneous and physiologic effects required to induce intramuscular tem-
muscle temperature (Enwemeka et al., 2002; Myrer et al., perature changes. Wertz (1998) and Higgins and Kaminski
1997; Hartvickson, 1962; Johnson et al., 1979; Lowden and (1998) have also reported similar results. Lehmann et al.
Moore, 1975). The decrease in tissue temperature is thought (1974) suggested that for the physiologic effects to take
to stimulate the cutaneous receptors causing the sympathetic place the muscle temperature must reach at least 40 8C,
fibres to vasoconstrict which decreases the swelling and however, the above studies reported muscle temperatures
inflammation by slowing the metabolism and production of below 40 8C. More research is required to investigate the
metabolites thereby limiting the degree of the injury required physiologic effects associated with using deep heat
(Enwemeka et al., 2002). treatments in hot –cold contrast therapy.
Superficial tissues can remain cool up to four hours from
ice packs or cold water immersion (Beltisky et al., 1987;
Hocutt et al., 1982; McMaster et al., 1979). The mechanism 4. Recovery
of this process still remains unclear. Enwemeka et al. (2002)
found that cold pack treatment up to 20 min significantly Recovery is defined as ‘the return of the muscle to its pre
decreased superficial tissue temperature by dulling and exercise state following exercise’ (Tomlin and Wenger,
reducing the sensation of pain. They concluded that cold 2001). Aerobic metabolism remains elevated in the recovery
pack treatment limits the amount of swelling in acute phase after exercise. Known as excess post-exercise oxygen
injuries by slowing the metabolic rate by shunting less blood consumption (EPOC) it assists in replenishing the body
to the cold superficial area. Earlier research has shown that stores (Bahr and Maehlum, 1986). EPOC consists of a fast
metabolites are cleared by the blood exchange from and slow component (Gaesser and Brooks, 1984). The fast
superficial to deep tissue. Incoming warm blood is diverted component restores 70% of ATP and PCr energy stores
to the deeper tissues thereby slowing down the cooling within 30 s (Hultman et al., 1967) and reloads plasma
effect of the deep tissues (Pugh et al., 1960). A cooling haemoglobin and muscle myoglobin (Bahr, 1992). The slow
effect also decreases nerve conduction velocity in super- component is observed after strenuous exercise and has
ficial tissues by slowing the rate of firing of muscle spindle been associated with increased cardiac and respiratory
afferents and reflex responses thus decreasing muscle spasm functions, elevated core temperature and removal of
and pain (Prentice, 1999; de Jesus et al., 1973). metabolic waste products (Gaesser and Brooks, 1984;
Thermotherapy has shown to increase tissue temperature, Sahlin, 1992). Dependent on the exercise intensity it may
increase local blood flow, increase muscle elasticity, cause take up to 24 h for the slow component to return to its
local vasodilation, increase metabolite production and resting levels (Gaesser and Brooks, 1984). Phosphagen
reduce muscle spasm (Prentice, 1999; Brukner and Khan, stores take 3 – 5 min to fully recover (Hultman et al., 1967)
2001; Zuluaga et al., 1995). Additionally, superficial compared to an hour or more for the resting return of lactate
heating decreases sympathetic nerve drive which causes and pH. The rise in lactate production and Hþ accumulation
vasodilation of local blood vessels and increases circulation. can disrupt the muscle contractile processes and the existing
28 D.J. Cochrane / Physical Therapy in Sport 5 (2004) 26–32

transport and metabolic pathways can become less efficient Active recovery often requires additional energy that
(Tomlin and Wenger, 2001).The use of passive (no exercise, further depletes precious energy stores therefore, if passive
massage, contrast hydrotherapy) or active recovery (light recovery is proven to increase glycogen resynthesis contrast
exercise) for replenishing fuel stores and removal of hydrotherapy may be justified as a post training tool.
metabolic wastes has implications for accelerating post However, most athletes have the tendency to spend more
exercise recovery rates. time in the warm water immersion thus off setting the
purported benefits as dehydration and neural fatigue are
4.1. Metabolic removal in active and passive recovery accentuated.
Additionally, if competition is conducted at night
Lactate production is evident when training or compet- recovery could be compromised if other engagements
ing, however, the amount produced is dependent on the such as team debriefing, after match functions or press
duration and intensity of the exercise and the length of the conferences take priority. Conducting hot –cold contrast
recovery interval. The ability to clear lactate in the recovery training may not be any more beneficial than complete rest.
phase relies on the working muscle to quickly remove, Sanders (1996) used a contrast-temperature protocol
tolerate and/or buffer Hþ (Sahlin and Henriksson, 1984). involving hot –cold plunge pools to measure the recovery
hot – cold immersion may have some merit in aiding of lactate levels in elite women hockey players after a
recovery if waste products are cleared faster. However, series of Wingate tests. A comparison of lactate clearances
the mechanism by which active recovery promotes lactate following passive rest, light exercising (active recovery)
removal is not clearly understood. This process is complex and the contrast immersion protocol was undertaken.
as it depends on a range of factors for example, local blood Results indicated that lactate levels were recovered equally
flow, chemical buffering, movement of lactate from muscle fast by using either the contrast water immersion or the
to blood, lactate conversion to pyruvate in liver, muscle and active recovery protocol. However, the lactate recovery
heart (McArdle et al., 2001). following passive rest was significantly slower. In sports
Research has shown that lactate removal is increased medicine contrast baths have been used to treat subacute
when active recovery periods are implemented compared to soft tissue and joint injuries by alternating hot –cold, thus
passive rest for continuous or repeated bouts of exercise promoting vasodilation/vasoconstriction causing a ‘pump-
(Hermansen and Stensvold, 1972; Weltman et al., 1979; ing’ action to reduce swelling of the injured site
Cortes et al., 1989). Dodd et al. (1984) found that a recovery (Rivenburgh, 1992; Prentice, 1999). This ‘pumping’ action
period of moderate continuous intensity facilitated lactate may explain the possible anecdotal reports of reduced post
removal faster than passive recovery. Additionally, a exercise stiffness and the accelerated return to basal and
combination of high intensity (65% VO2 max) and low metabolic resting levels. However, the removal of
intensity (35% VO2 max) was no more beneficial than a metabolites and reduced swelling from the mechanical
recovery of low intensity (35% VO2 max) for 40 min. force of alternating hot –cold immersion is unproven and
There is conflicting evidence on the effect that active and contentious. Myrer et al. (1997) suggested that
passive recovery has on muscle glycogen synthesis. Choi the significant skin temperature fluctuations from the
et al. (1994) have shown active recovery delays glucose hot – cold contrast packs caused vasoconstriction and
synthesis after high intensity (130% VO2 max) intermittent vasodilation thereby initiating subcutaneous response
cycling in untrained males. However, Futre et al. (1987) and mechanical shunting. Conversely, they argue that the
found no statistical differences between passive and active increase in local blood flow would not reduce oedema, as
recovery for muscle glycogen synthesis. Whatever the swelling reduction requires the removal of debris and fluid
outcome there are implications to the type of recovery performed by the lymphatic system. Since the lymphatic
implemented in post training. system requires muscle contraction or gravity to move fluid
It appears that no further gains are elicited when contents, it is unlikely this mechanism can be substan-
performing the intensity of the recovery period above tiated, as lymph flow is independent of circulatory
lactate threshold, as it may prolong the clearance of lactate changes.Tomasik (1983) studied the effect of blood
by accumulating more (Dodd et al., 1984; Gladden, 1989). electrolytes and lactic acid levels in participants that
From isotope tracer studies, Brooks (2000) suggested that underwent 30 min of hydromassage or control (no hydro-
lactate produced in fast twitch muscle fires can be massage) after 15 min of sub-maximal cycling. The
transported to other fast twitch or slow muscle fibres for investigation found that the hydromassage intervention
pyruvate conversion, which undergoes chemical reactions was able to return haematocrit, plasma potassium and lactic
for aerobic energy metabolism. This shuttling allows for acid levels to resting levels faster than those who received
both production and removal of lactate. Signorile et al. no hydromassage. However, the acquired effects of
(1993) claimed that during recovery from low intensity hypergravity and proprioception from the underwater jets
cycling, lactate clearance may be enhanced by active to assist the clearance of waste products were not
muscles causing a pumping action and adjacent muscles discussed. Unfortunately the studies of Tomasik (1983)
providing oxidative metabolism to removing metabolites. and Sanders (1996) have relied on measurements of blood
 D.J. Cochrane / Physical Therapy in Sport 5 (2004) 26–32 29

lactate to reflect muscle lactate clearance, which may Viitasalo et al. (1995) investigated the effect of exposure
compromise conclusions on lactate removal (Tomlin and and non-exposure of underwater jet massage (36 –37 8C) on
Wenger, 2001). Further research is needed to establish junior track and field athletes. The experiment used a cross
whether mechanical shunting from the hot – cold immersion over design where two groups of equal size under went a
elicits a possible mechanism for metabolite removal to week of non-exposure and exposure of underwater jet
accelerate post exercise recovery. massage. Three treatments of 20 min were performed over
five days after power, speed and strength conditioning
4.2. Neural recovery sessions. During the exposure week of underwater jet
massage vertical jumping power declined slightly, continu-
It is well established that during exercise there is a ous vertical jumping ground contact time increased, serum
decrease in parasympathetic and increase in sympathetic creatine kinase and myoglobin levels were elevated
activity. The sympathetic excitation causes a release of compared to no water jet treatment. The results indicated
noradrenaline and adrenaline that increases myocardial that the combination of intense speed, power and strength
contractility and accelerates heart rate (McArdle et al., sessions with underwater jet massage increased blood
2001). Additionally, vasodilation occurs in skeletal and markers to release more protein from the muscle to the
heart muscle, blood flow increases from vasoconstriction blood thereby enhancing the neuromuscular system.
of other organs and the airways become dilated. Post
exercise sympathetic activity remains high but with 4.3. Muscle recovery
adequate recovery it returns to resting levels. However,
if a high training load, volume or intensity is repeatedly It has been confirmed that eccentric, intensive and
performed without the necessary rest, sympathetic activity unfamiliar exercises are causes of muscle damage (Clarkson
will become unceasingly high. This often leads to and Sayers, 1999 McHugh et al., 1999; Armstrong, 1984).
overtraining/overreaching when the signs and symptoms Delayed onset of muscle soreness (DOMS) usually
are not detected (Hahn, 1994). transpires 24 –48 h post exercise with symptoms consisting
Neurological recovery of the peripheral nervous system of tender, stiff and sore muscles (Clarkson et al., 1992).
may be augmented by contrast hydrotherapy, massage and Several theories have been presented to explain the
floatation by reducing the load of the sympathetic activity physiological mechanism of DOMS but with little agree-
(Hahn, 1994; Calder, 1996). Athletes who perform hot – ment. They include muscle fibre damage, breakdown of
cold hydrotherapy after training or competition have muscle proteins resulting in inflammation and cellular
reported lighter and less tight muscles with a feeling of degradation (Armstrong, 1984; Smith, 1991; Friden and
mental freshness (Calder, 2001a). This may be associated Lieber, 1992; Byrd, 1992; Clarkson and Sayers, 1999).
to central nervous system relief. However, little is known McHugh et al. (1999) has argued for a combined neural,
on the effects that hot –cold water immersion has on the connective and cellular mechanism. Whatever the proposed
nervous system. Research conducted by Gieremek (1990) mechanism causing DOMS the recovery process is
examined reaction time of simple reflex tasks, the tendon important for regeneration. The symptoms of DOMS
reflex (T reflex) of the Achilles tendon, Hoffman reflex (H normally develop within 24 h and peak between 24– 72 h
reflex) of the soleus and conduction of the tibialis nerve (Cleak and Eston, 1992; Armstrong 1990).
before and after 30 min of jet pressured spa water The symptom of exercise-induced muscle damage (pain,
immersion (34 – 36 8C) in judo fighters and healthy spasm and inflammation) is similar to that of injured muscle
untrained males. He found that for both groups, the therefore cryotherapy has been the primary treatment
underwater jet spa improved the efficiency of both the modality. Kuligowski et al. (1998) studied the effectiveness
central and peripheral nervous system. He supported his of warm, cold whirl pool and contrast therapy for treating
claim from the significant changes of simple reaction delayed-onset muscle soreness 24, 48, and 72 h post
time, T and H reflexes. Gieremek stated that the exercise. The elbow flexors were eccentrically trained to
underwater jets and lukewarm water activated the elicit DOMS. Resting elbow flexion, active elbow flexion
proprioreceptors to increase the excitability to the brain, and extension, perceived soreness and maximal isometric
which stimulated the neuromuscular system. Additionally, contraction were the criteria used to assess what effect the
he justified the periphery efficiency component from the different treatments had on DOMS. They found that
significant increases in neural transmission and the perceived soreness and resting elbow flexion returned to
induced M-response of the H reflex. baseline levels when cold whirlpool and contrast therapy
Gieremek claimed that the reflex and electrophysiologi- were administered, propagating that these treatments were
cal responses elicited from the underwater jet immersion more effective than warm whirlpool and passive resting.
may have improved the speed of the central spread of Contrary, Miller (1992) found that a warm whirlpool was
electrical activation in the nerve, neuromuscular synapses sufficient enough to decrease the perceived pain of DOMS
and the muscle thereby producing a positive post exercise in down hill treadmill running. However, the efficacy of
recovery effect. control and warm whirlpool produced no significant
30 D.J. Cochrane / Physical Therapy in Sport 5 (2004) 26–32

difference on quadriceps flexibility or strength. Likewise nutritional and psychological fatigue. According to Calder
Easton and Peters (1999) concluded that following exhaus- (1995) the site of fatigue for the neurological component is
tive eccentric exercise the cold-water immersion appeared the peripheral nervous system; physiological (muscle cell);
to reduce muscle damage and stiffness but had no effect on nutritional (fluid and fuel stores); and psychological
the perception of muscle tenderness and strength loss. (central nervous system). From the ranking system the
It can be concluded that the research is contradictory to athlete and coach can then identify the appropriate
alleviating the symptoms of DOMS due to variations in the recovery techniques needed to accelerate the recovery,
type, frequency and duration of treatments. which are rehydration and carbohydrate intake for fluid
and fuel stores; hydrotherapy, ‘warm down’ and massage
4.4. Water temperature and ratio of cold to hot for increasing blood flow to fatigued muscles; visualisa-
for hydrotherapy recovery tion, progressive muscular relaxation, meditation, flotation
and massage for psychological fatigue; passive rest,
The common practised ratio of warm to cold bath massage, hydrotherapy, and ‘warm down’ for neurological
duration for injury treatment is normally 3:1 or 4:1, with hot fatigue. The holistic approach for recovery training may
baths ranging from 37 to 43 8C alternating with cold baths give better responses rather than using isolated recovery
temperature ranging from 12 to15 8C (Bell and Horton, techniques. Flanagan et al. (1998) simulated a soccer
1987; Myrer et al., 1994; Brukner and Khan, 2001; tournament to examine the effects of recovery strategies
Halvorson, 1990). The duration of the treatment is normally on young male soccer players. They found those in the
20 –30 min repeated twice daily (Higgins and Kaminski, recovery group did not show any significant decline in 10
1998). It is also well documented that the treatment should and 20 m speed times until the sixth day of competition
finish on the cold treatment to encourage vasoconstriction compared to the control group. However, there was no
for the injured athlete (Bell and Horton, 1987; Prentice, change in vertical jump for both groups during the
1999; Zuluaga et al., 1995; Brukner and Khan, 2001). tournament. The recovery techniques that were employed
Calder (1996) has documented guidelines (water tempera- included; massage, active pool sessions, hot – cold
ture, repetitions and durations) for post exercise contrast showers, stretching, hydration and nutritional plans. The
water recovery that are similar to injury management. consequences of the combined recovery techniques pre-
However, the duration for hot –cold shower (1 – 2 min hot, vented physical drop off, lowered the occurrence of
10 –30 s cold) differs to that of a spa/bath (3 –4 min hot, 30– influenza symptoms and produced a higher rating
60 s cold) with little justification. Higgins and Kaminski of overall wellness.
(1998) and Myrer et al. (1997) found cold exposure of
approximately 1 min was not sufficient enough to signifi-
cantly decrease muscle temperature following warm water 6. Conclusion
immersion, thus nullifying the required physiologic effects.
There is a lack of evidence to support the post exercise Despite the popularity of hot –cold water immersion as a
recovery guidelines especially in the light of injury contrast recovery modality, little research has been conducted. hot –
treatment. Further research is required to investigate the cold contrast therapy for acute injuries has been used to
different hot to cold time ratios. The appropriate mode of explain the purported physiologic effects for post exercise
contrast treatment, the duration and the optimum water recovery. However, the conflict of literature makes it
temperature need to be examined to verify its effectiveness difficult to give a conclusive mechanism. Additionally, the
as a recovery modality. guidelines of the duration spent in each water condition,
the repetitions, temperature, the use of underwater jets, the
learning and training effect of the body adapting to the hot –
5. Holistic approach cold contrast therapy all need to be vigorously investigated
before it can be claimed as an accelerant for aiding
Training and competition creates an overload to stress recovery.
the body, which in turn produces fatigue followed by
improved performance (Calder, 1996). Depending on the
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