31 October 2019 / 0 comments

Water immersion, specifically cold- and contrast water immersion, is widely used in the performance recovery area. However, based on its working mechanisms there is a clear rationale to use water immersion in rehabilitation as well. When should water immersion for rehabilitation be used, and is there any scientific evidence to back things up?

Let’s start with a summary of the possible indications. Cold-water immersion could be used:

  1. To limit the magnitude of the cardinal signs during inflammation
  2. To limit acute-, chronic- or post-surgical pain
  3. Before, or in conjunction with rehabilitation exercises
  4. To reduce spasticity accompanying central nervous system disorders, like Alzheimer or Parkinson
  5. To treat acute- or chronic muscle spasms

And next, hot water immersion could be used:

  1. For sub-acute or chronic inflammatory conditions like in rheumatoid arthritis.
  2. To reduce subacute pain, for example following musculoskeletal injuries like muscle tears or strains and chronic pain, pain typically lasting longer than 12 weeks
  3. To reduce subacute-or chronic muscle spasms, for example in multiple sclerosis
  4. To decrease range of motion
  5. To reduce joint contractures, for example following anterior cruciate ligament replacement or immobilization

Water immersion has a high potential of generating and optimizing effects in this rehabilitation as well. Available literature though is scarce:

Da Costa Santos and colleagues (2015)1 compared the effect of an ice pack and cold-water immersion on ankle skin surface temperature in athletes. They concluded that the ice pack and cold-water immersion both produced similar and appropriate temperatures but that during the rewarming the skin surface temperature stayed significantly lower following cold-water immersion.

Which is in line with the finding from Rupp and colleagues (2012)2 who aimed to compare the time required to decrease intramuscular temperature 8°C/14.4°F below baseline temperature, and compare intramuscular temperature 90minutes post-treatment between crushed ice and cold-water immersion. The time to reach an 8°C/14.4°F reduction in intramuscular calf muscle was not significantly different. It took 40 minutes with cold-water immersion and 42,5 minutes with the crushed ice. Howeverintramuscular temperature remained significantly colder 90 minutes post-cold water-immersion compared to crushed ice.

It should be acknowledged though that using cold-water immersion over local cryotherapy has an impact on balance and proprioception in patients with an ankle sprain as evidenced by the study of Rao and Vemali (2015).3 Also the therapeutic effects associated with the reduction of motor nerve conduction velocity are most indicated with cold-water immersion according to Herrera and colleagues (2010).4 Dynamic balance exercises later in rehabilitation directly following cold-water immersion should, therefore, be performed with high caution. Preferably these types of activities are conducted during more thermoneutral water immersion while after exercise cold-water-immersion might be advised to lower tissue metabolism.

Water immersion per rehabilitation phase: the acute injury

The primary goal in the early phase is to decrease tissue temperature, decrease metabolism, decrease secondary hypoxic injury, reduce edema formation and facilitate exercise.

In acute injuries, like ligament sprains or tendon ruptures, cold-water immersion should prevail irrespective of whether its joint, muscle or tendon related. There is a direct relationship between lower tissue temperature and tissue metabolism. A slower metabolism results in lower secondary cell injury as found by Merrick and colleagues (1999)5 and prevents non-injured cells at the initial trauma to survive. Moreover, cold is effective in reducing pain and edema, also in the acute phase of an injury, as was evidenced by Schässer and colleagues (2007).6 Several other studies have shown that cold-water immersion has a large effect on the neuromuscular system. It not only reduces the nerve conduction velocity; it also has an ‘anesthetic’ or‘numbing’ effect.

A study of Algafly and colleagues (2007)7 which focused specifically on the effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance showed that cooling a body part clearly reduces the nerve conduction velocity and inhibits nociceptive receptor sensitivity, supporting strongly the use of cryotherapy to minimize pain.

Hot-water immersion in the early stages of an ankle sprain may be counter-effective. A study from Coté and colleagues(1988)8 observed increased edema in 30 patients with first and second-degree ankle sprains when 20 minutes of hot-water immersion was applied each day over three days. The volumetric increase in ankle size was 25% with the hot-water immersion of the foot compared with 3% inpatients receiving cold-water immersion.

Water immersion per rehabilitation phase: the post-acute rehabilitation phase

The primary goals of applying water immersion in this phase are, facilitate exercise, impact pain management, limit the analgesic use and arthrogenic muscle inhibition.

  • CWI should be used primarily after rehab exercises to impact pain management.
  • HWI can be used before exercise to facilitate rehab exercises, and
  • thermoneutral immersion can be used as the environment for aquatic therapy, especially in the early phases of weight-bearing activities.

Arthrogenic muscle inhibition is the clinical impairment caused by an ongoing reflex inhibition following damage to a joint. Performing rehabilitation exercises immediately after cooling results in more significant strength gains than when no cooling was applied, promoting functional recovery as described by Hart and colleagues (2014)9 and Rice and colleagues(2009).10 The step towards aquatic therapy and the use of water immersion to treat diseases is small but beyond the scope of this blog. In case of interest in these particular topics, the papers of respectively Torres-Ronda and colleagues (2014)11 and Mooventhan and colleagues(2014)12 are a good start. Next time we will focus on the application of water immersion in rehabilitation.


  1. Santos, V. B. da C. et al. Effect of cryotherapy on the ankle temperature in athletes: ice pack and cold water immersion. Fisioterapia em Movimento28, 23–30 (2015).
  2. Rupp, K. A., Herman, D. C., Hertel,J. & Saliba, S. A. Intramuscular Temperature Changes During and After 2Different Cryotherapy Interventions in Healthy Individuals. The Journal of Orthopaedic and Sports Physical Therapy (2012). doi:10.2519/jospt.2012.4200
  3. Rao, M.S. & Vemali, D.EFFECTIVENESS OF ICE PACK VERSUS COLD WATER IMMERSION ON STATIC AND DYNAMIC BALANCE IN ANKLE SPRAIN. International Journal of Physiotherapy and Research3, 1239–1243 (2015).
  4. Herrera, E., Sandoval, M. C., Camargo, D. M. & Salvini, T. F. Motor and sensory nerve conduction are affected differently by ice pack, ice massage, and cold water immersion. PhysTher 90, 581–591 (2010).
  5. Merrick, M. A., Rankin, J. M., Andres, F. A. & Hinman, C. L. A preliminary examination of cryotherapy and secondary injury in skeletal muscle. Med Sci Sports Exerc 31,1516–1521 (1999).
  6. Schaser, K.-D. et al. Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats. Am J Sports Med35, 93–102 (2007).
  7. Algafly, A. A. & George, K. P.The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med 41, 365–369; discussion 369 (2007).
  8. Coté, D. J., Prentice, W. E., Hooker, D. N. & Shields, E. W. Comparison of three treatment procedures for minimizing ankle sprain swelling. Phys Ther 68, 1072–1076 (1988).
  9. Hart, J. M., Kuenze, C. M., Diduch,D. R. & Ingersoll, C. D. Quadriceps muscle function after rehabilitation with cryotherapy in patients with anterior cruciate ligament reconstruction. J Athl Train 49, 733–739 (2014).
  10. Rice, D., McNair, P. J. &Dalbeth, N. Effects of cryotherapy on arthrogenic muscle inhibition using an experimental model of knee swelling. Arthritis Rheum 61, 78–83(2009).
  11. Torres-Ronda, L. & Del Alcázar,X. S. I. The Properties of Water and their Applications for Training. J HumKinet 44, 237–248 (2014).
  12. Mooventhan, A. & Nivethitha, L.Scientific Evidence-Based Effects of Hydrotherapy on Various Systems of the body. N Am J Med Sci 6, 199–209 (2014).

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