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Contrast baths: what do we know about their use?
PRACTICE FORUM
Contrast Baths: What Do We Know about Their Use? Contrast baths have become an everyday tool in our clinical practice, but what do we really know about this common modality? The authors looked to the literature and devised a survey to answer that question. Here is their report.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
Donna Breger Stanton, MA, OTR/L, CHT, FAOTA Master of Occupational Therapy Program Samuel Merritt College Oakland, California
Jane Bear-Lehman, PhD, OTR, FAOTA Department of Clinical Occupational Therapy Columbia University New York, NY
Mark Graziano, MS, OTR Jacobi Medical Center Bronx, New York
Christine Ryan, MS, OTR Beth Israel Medical Center New York, NY
Contrast baths have had continued presence as a thermal treatment modality in hand therapy clinics for over 70 years. Contrast baths combine alternating hot and cold water applications to increase blood flow and to decrease joint stiffness in a relatively immobile hand.1 They are believed to alleviate pain, stiffness, and edema by externally inducing vasodilatation and vasoconstriction that is usually produced by normally contracting muscles.2 It is believed that alternating water temperature will increase the blood flow to the affected area and induce a ‘‘vascular pumping’’ effect resulting in vasoconstriction, edema reduction, and increased mobility. No uniform procedures or clinical research studies could be located to support the efficacy for the use of contrast baths.2–4 Two clinical research results were published in 19382 and 19503 with similar findings that contrast baths may be useful, but their application is not substantiated by research. Information Correspondence and reprint requests to Donna Breger Stanton, MA, OTR/L, CHT, FAOTA, Assistant Professor, MOT Program, Samuel Merritt College, 450 30th Street, Suite 4738, Oakland, CA 94609; e-mail:. doi:10.1197/S0894-1130(03)00161-3
on the use of contrast baths is included but not emphasized in journal articles, textbook chapters, and various selected Internet articles from medical to healing arts resources.4–24 On the other hand, the physiological and mechanical effects of hot and cold, individually, have been well studied and documented.5–11 Despite the lack of evidence-based research to support their use, contrast baths have had a consistent presence or legacy in the clinic.
PROCEDURES FOR ADMINISTRATION OF CONTRAST BATHS Clinically, contrast baths have been described and administered quite differently in the suggested amount of time immersion in each bath, whether to start in cold versus hot, the duration of the treatment, the actual water temperature used, and the specific exercise instruction during submersion. Several authors advocate the immersion of the hand into hot water initially for 10 minutes, cold for 1 minute, hot water for 4 minutes, and then into cold water for 1 minute for a maximum of 30 minutes.4,9,10 Other authors recommend a shorter immersion time such as 3 minutes each, and others suggest even less time in each such as 30 seconds each for a total of 15 minutes. The most commonly suggested ratio of time in hot water to cold water was from a 4:1 to 3:1 ratio.5,6,11 There was a noticeable variation in which modality is delivered first: hot versus cold; and the type of modality used (e.g., running water, pooled water poured into a basin or sink, tap water, or ice water). The suggested temperature of the hot and cold water was also variable. For example, several authors set the water temperature at extremes from 808 to 1108F for hot and from 508 to 688F for cold.4–8,10–12 Few texts referenced the need to monitor the water temperature during the course or end of treatment. Recently, a prototype device for provision of contrast baths was developed with the ability to maintain constant temperature as patients complete their treatment of contrast baths.21
October–December 2003 343
Another discrepancy is the difference in patient instruction during the use of a contrast bath. Some therapists direct their patients to immerse the hand in water without instruction to exercise; others request patients to complete range-of-motion exercises, or to perform some pumping action exercise by squeezing a soft sponge during this immersion modality.
SURVEY OF HAND THERAPISTS Methods To close the gap in research findings, a survey for hand therapists was carried out.25,26 Three research methods were followed: personal contact with hand
therapists through use of a survey; use of the electronic invisible college; and use of the World Wide Web. To extend our personal contact to the level of an electronic invisible college, we used the American Society of Hand Therapists (ASHT) directory to select therapists to receive a survey regarding contrast baths. These therapists served as our invisible college for our topic of concern.
Subjects A 10% sample of members of the ASHT was asked to participate. These 100 therapists, including occupational and physical therapists, were proportionally selected from the ASHT directory with a random
Survey About the Use of Contrast Baths Among Therapists Practicing in Hand Clinic Please complete the survey below about your current use of contrast baths in your practice of upper limb rehabilitation. We would appreciate your returning this information in the enclosed envelope by February 19, 2002. We thank you for your time and for sharing your information with us. 1. Do you use contrast baths at your facility as a modality to reduce edema? ___ Yes, as a clinic treatment ___ Yes, as a home program ___ We do not use this protocol (skip to question #3) 2. If your facility uses contrast baths, please attach your written protocol. If a written protocol is not available, please fill in or circle the following: a. Start modality with: Hot Cold b. Amount of time in each: Hot:________Cold:_________ c. Temperature of each: Hot:__________Cold:__________ d. End modality with: Hot Cold e. Exercise in water? Yes No f. Please describe what kind of exercise is performed while using contrast baths: g. Duration of the entire modality: __________ 3. If you do not use contrast baths as a modality, please circle reasons that may apply: a. I do not find them to be effective. b. They are not used in the facility. c. I find other modalities more effective, such as _________________ d. There’s not enough supporting research. e. Other: _____________________ 4. In general, how would you rate the effectiveness of contrast baths: Not Effective Highly Effective 1234567 We would appreciate learning more about you and your treatment caseload. 5. This clinic specializes in the treatment of the following disorders (circle all that apply): Fractures Nerve Injuries Tendon Injuries Crush Injuries Arthritis Burns Other: 6. I work in a (please circle): Private practice—therapist owned Hospital—in-patient Hospital—out patient Private Corporation Other: We appreciate your time and your willingness to share information about your use of contrast baths in the treatment of upper limb edema reduction. If you would like a copy of our study results, please let us know how to reach you.
FIGURE 1. Questionnaire.
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JOURNAL OF HAND THERAPY
start and defined replacement strategy (see Figure 1). In ASHT, there are, typically, four occupational therapist members to one physical therapist member.
Results Of the 100 inquiries mailed, 43 were returned (see Table 1). The settings that these therapists work in are private practices (26.8%), outpatient hospitals (39%), private corporations (17%), and physician offices (17%). The majority of these therapists (69.8%) reported they used contrast baths. Most therapists (76%) reported beginning with heat immersion; 54% of the respondents indicated that they ended the procedure with hot water. The amount of immersion time in hot versus cold water varied greatly, with hot water immersion ranging from 10 seconds to 10 minutes and cold water immersion ranging from 10 seconds to 5 minutes. Thirty-two percent of the therapists reported their protocol for hot water immersion was for 3 minutes and 52% instructed immersion in cold water for 1 minute. The reported duration of the entire treatment ranged from as little as 8 minutes to as long as 25 minutes; 24% instructed use of the modality for a total period of 15 minutes. The reported range for hot water temperature varied from 908 to 1158F and the cold water temperatures ranged from 578 to 708F. There seemed to be no preferred hot water temperature reported; however, 50% of the therapists reported using a cold water temperature approximating 608F. Approximately 82% of the therapists who used contrast baths indicated they encouraged the patient to do hand
TABLE 1. Results of the Survey 43% response rate (43 of 100 surveys sent were returned) 69.8% use contrast baths as a home program, in the clinic or both, while 30% do not Duration of modality ranged from 8 to 25 minutes 76% begin the treatment procedure using hot water; 24% report begin the procedure with cold water 54% end the treatment procedure with hot water; 46% end the treatment procedure with cold water 32% report direct their patients to keep their hand immersed in the hot water for 3 minutes for each use of the hot water; others report hot water immersion times that range from 10 seconds to 10 minutes 52% report directing their patients to keep their hand immersed in cold water for only 1 minute; others report cold water immersion times that range from 10 seconds to 5 minutes A wide range of temperatures were reported for use: Hot water varied from 908 to 1158F Cold water varied from 578 to 708F, with 50% using approximately 608F 90% encourage use of exercise while the hand is immersed 69.2% of those who do not use contrast baths feel that there is not enough research supporting their use and find other modalities more effective
exercises while the hand was immersed (e.g., sponge squeezing, tendon gliding). Of the 13 therapists who did not use contrast baths in their clinic or as a home program, the majority of them (69.2%) indicated that they did not use the contrast baths because there was not enough research supporting their use. These therapists indicated that they find other treatment modalities to be more effective such as compression, high-voltage postgalvanic stimulation (HVPG), massage, and active range of motion.
Discussion Despite the lack of clinical research to support their use, contrast baths are commonly used in practice, particularly in the home. Our inquiry shows that the wide procedural variation described in the literature exists in the clinic. Despite vast differences in duration of immersion, duration of treatment time, water temperature, starting or ending water immersion bath, or use of exercise, many find it useful and with positive results, albeit, anecdotal. There is now a CPT code devoted exclusively to this modality.17 Adverse effects have not been reported. There are many clinical studies that could be developed to help give contrast baths an evidence base. One study design could be to control for one variable at a time, such as water temperature constant throughout the treatment or for the variances in timing of water immersion in cold versus warm or the sequence of cold versus warm. The use of range-ofmotion and volume measurements of the hand preand post-contrast bath treatment would make this treatment more objective. Introducing and using consistent and precise tools to document the effect of contrast baths similar to those used to monitor other treatment effects could potentially give contrast baths more acceptance in terms of evidence-based practice.
Conclusion It is known that contrast baths have little evidence to support their use, yet therapists are familiar with them, have a concept of how and when to use them, and have used them for years. Empirical evidence suggests that they have a positive effect on the patient regardless of adherence to precise application of a protocol. The treatment is applauded for its low cost and ease of use.
REFERENCES 1. Lehmann JF, DeLateur BJ. Cryotherapy. In: Lehmann JF (ed). Therapeutic Heat and Cold. 4th ed. Baltimore: Williams and Wilkins, 1990:590–628.
October–December 2003 345
2. Woodmansey A, Collins DH, Ernst MM. Vascular reactions to the contrast bath in health and in rheumatoid arthritis. Lancet. 1938;2:1350–3. 3. Engel JP, Wakim KG, Erickson DJ, Krusen FH. The effect of contrast baths on the peripheral circulation in patients with rheumatoid arthritis. Arch Phys Med Rehabil. 1950;31:135–44. 4. Swanson AB, Swanson GG, Leonard JB. Postoperative rehabilition programs in flexible implant arthroplasty of the digits. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Rehabilitation. St. Louis: CV Mosby, 1995:1372. 5. Cameron M. Physical Agents in Rehabilitation: From Research to Practice. Philadelphia: W.B. Saunders, 1999:191, 203. 6. Hayes KW. Manual for Physical Agents, 5th ed. Englewood, NJ: Prentice-Hall, 2000. 7. Hecox B, Mehreteab TA, Weisberg J. Physical Agents, A Comprehensive Text for Physical Therapists. East Norwalk, CT: Appleton and Lange, 1994:246. 8. Kasch MC, Nickerson E. Hand and upper extremity injuries. In: Pedretti LW, Early MB (eds). Occupational Therapy, Practice Skills for Physical Dysfunction. St. Louis: Mosby, 2001:833. 9. Lehmann JF, DeLateur BJ. Therapeutic heat. In: Lehmann JF (ed). Therapeutic Heat and Cold. 4th ed. Baltimore: Williams & Wilkins, 1990:451. 10. Michlovitz SL. Thermal Agents in Rehabilitation, 3rd ed. Philadelphia: FA Davis, 1996. 11. Post RE, Lee SL, Syen DB. Physical agent modalities. In: Trombly CA (ed). Occupational Therapy for Physical Dysfunction. 4th ed. Baltimore: Williams and Wilkins, 1995:662. 12. Prentice WE, Quillen WS, Underwood F. Therapeutic Modalities for Allied Health Professionals. New York: McGraw-Hill, 1993. 13. Foot Care-Contrast Baths Home Physical Therapy. http:// www.umt.edu/shs/healthlibrary/hlfootcare_contrast.htm. Accessed July 5, 2002.
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JOURNAL OF HAND THERAPY
14. Help for Some Music-Related Injuries, Contrast Bath Hydrotherap. http://www.Ithaca.edu/faculty/nquarrie/contrast. html. Accessed July 5, 2002. 15. Herbal Preparations: Baths-Contrast Bath. http://www. tempestwolf.com/hers/herbs/herbalprep/bath-contrast.htm. Accessed July 5, 2002. 16. Hot and Cold Baths. http://www.brianmac.demon.co.uk/ hcbaths.htm. Accessed July 5, 2002. 17. http://www.accuchecker.com/AccuLibrary/articles/ rehabcontrastbaths.asp. Accessed July 5, 2002. 18. Martin M. The Draw of the Bath. http://seattletimes. nwsource.com/pacificnw/2002/0203/fitness.html. Accessed July 5, 2002. 19. Osteoarthritis. http://www.newstarthealthcare.com/articles/ Kgnw/oaradio.htm. Accessed July 5, 2002. 20. Quarrier N. Contrast Baths for Pain Relief. http://www. ithaca.edu/faculty/nquarrie/topic.html. Accessed July 5, 2002. 21. Sabelman EE, Netter JB, Jaffe DL, Ward M. The Arthritic Hand—A System to Reduce Pain and Increase Function. http://guide.stanford.edu/96reports/96dev7.html. Accessed July 5, 2002. 22. Stavroudis D. Facts About Cumulative Trauma Disorders. http://palimpsest.stanford.edu/waac/wn/wn15/wn15-2/ wn15-211.htm. Accessed July 5, 2002. 23. Stiff Big Toe (Hallus rigidus). http://orthoinfor.aaos.org/fact/ thr_report.cfm?Thread_ID=352&topcategory=Foot. Accessed July 5, 2002. 24. Wnorowski D. Heat and Cold Therapy. http://www.genufix. com/heat_and_cold_therapy.htm. Accessed July 5, 2002. 25. Graziano M, Ryan C. Exploring the Use of Contrast Baths. Submitted in partial fulfillment of the Master of Science Degree in Occupational Therapy, Columbia University, NY, unpublished thesis, 2002. 26. Helewa A, Walker JM. Critical Evaluation of Research in Physical Rehabilitation: Towards Evidence-based Practice. Philadelphia: W.B. Saunders, 2000.
Contrast Baths: What Do We Know about Their Use? Contrast baths have become an everyday tool in our clinical practice, but what do we really know about this common modality? The authors looked to the literature and devised a survey to answer that question. Here is their report.—PEGGY L. FILLION, OTR, CHT, Practice Forum Editor
Donna Breger Stanton, MA, OTR/L, CHT, FAOTA Master of Occupational Therapy Program Samuel Merritt College Oakland, California
Jane Bear-Lehman, PhD, OTR, FAOTA Department of Clinical Occupational Therapy Columbia University New York, NY
Mark Graziano, MS, OTR Jacobi Medical Center Bronx, New York
Christine Ryan, MS, OTR Beth Israel Medical Center New York, NY
Contrast baths have had continued presence as a thermal treatment modality in hand therapy clinics for over 70 years. Contrast baths combine alternating hot and cold water applications to increase blood flow and to decrease joint stiffness in a relatively immobile hand.1 They are believed to alleviate pain, stiffness, and edema by externally inducing vasodilatation and vasoconstriction that is usually produced by normally contracting muscles.2 It is believed that alternating water temperature will increase the blood flow to the affected area and induce a ‘‘vascular pumping’’ effect resulting in vasoconstriction, edema reduction, and increased mobility. No uniform procedures or clinical research studies could be located to support the efficacy for the use of contrast baths.2–4 Two clinical research results were published in 19382 and 19503 with similar findings that contrast baths may be useful, but their application is not substantiated by research. Information Correspondence and reprint requests to Donna Breger Stanton, MA, OTR/L, CHT, FAOTA, Assistant Professor, MOT Program, Samuel Merritt College, 450 30th Street, Suite 4738, Oakland, CA 94609; e-mail:
on the use of contrast baths is included but not emphasized in journal articles, textbook chapters, and various selected Internet articles from medical to healing arts resources.4–24 On the other hand, the physiological and mechanical effects of hot and cold, individually, have been well studied and documented.5–11 Despite the lack of evidence-based research to support their use, contrast baths have had a consistent presence or legacy in the clinic.
PROCEDURES FOR ADMINISTRATION OF CONTRAST BATHS Clinically, contrast baths have been described and administered quite differently in the suggested amount of time immersion in each bath, whether to start in cold versus hot, the duration of the treatment, the actual water temperature used, and the specific exercise instruction during submersion. Several authors advocate the immersion of the hand into hot water initially for 10 minutes, cold for 1 minute, hot water for 4 minutes, and then into cold water for 1 minute for a maximum of 30 minutes.4,9,10 Other authors recommend a shorter immersion time such as 3 minutes each, and others suggest even less time in each such as 30 seconds each for a total of 15 minutes. The most commonly suggested ratio of time in hot water to cold water was from a 4:1 to 3:1 ratio.5,6,11 There was a noticeable variation in which modality is delivered first: hot versus cold; and the type of modality used (e.g., running water, pooled water poured into a basin or sink, tap water, or ice water). The suggested temperature of the hot and cold water was also variable. For example, several authors set the water temperature at extremes from 808 to 1108F for hot and from 508 to 688F for cold.4–8,10–12 Few texts referenced the need to monitor the water temperature during the course or end of treatment. Recently, a prototype device for provision of contrast baths was developed with the ability to maintain constant temperature as patients complete their treatment of contrast baths.21
October–December 2003 343
Another discrepancy is the difference in patient instruction during the use of a contrast bath. Some therapists direct their patients to immerse the hand in water without instruction to exercise; others request patients to complete range-of-motion exercises, or to perform some pumping action exercise by squeezing a soft sponge during this immersion modality.
SURVEY OF HAND THERAPISTS Methods To close the gap in research findings, a survey for hand therapists was carried out.25,26 Three research methods were followed: personal contact with hand
therapists through use of a survey; use of the electronic invisible college; and use of the World Wide Web. To extend our personal contact to the level of an electronic invisible college, we used the American Society of Hand Therapists (ASHT) directory to select therapists to receive a survey regarding contrast baths. These therapists served as our invisible college for our topic of concern.
Subjects A 10% sample of members of the ASHT was asked to participate. These 100 therapists, including occupational and physical therapists, were proportionally selected from the ASHT directory with a random
Survey About the Use of Contrast Baths Among Therapists Practicing in Hand Clinic Please complete the survey below about your current use of contrast baths in your practice of upper limb rehabilitation. We would appreciate your returning this information in the enclosed envelope by February 19, 2002. We thank you for your time and for sharing your information with us. 1. Do you use contrast baths at your facility as a modality to reduce edema? ___ Yes, as a clinic treatment ___ Yes, as a home program ___ We do not use this protocol (skip to question #3) 2. If your facility uses contrast baths, please attach your written protocol. If a written protocol is not available, please fill in or circle the following: a. Start modality with: Hot Cold b. Amount of time in each: Hot:________Cold:_________ c. Temperature of each: Hot:__________Cold:__________ d. End modality with: Hot Cold e. Exercise in water? Yes No f. Please describe what kind of exercise is performed while using contrast baths: g. Duration of the entire modality: __________ 3. If you do not use contrast baths as a modality, please circle reasons that may apply: a. I do not find them to be effective. b. They are not used in the facility. c. I find other modalities more effective, such as _________________ d. There’s not enough supporting research. e. Other: _____________________ 4. In general, how would you rate the effectiveness of contrast baths: Not Effective Highly Effective 1234567 We would appreciate learning more about you and your treatment caseload. 5. This clinic specializes in the treatment of the following disorders (circle all that apply): Fractures Nerve Injuries Tendon Injuries Crush Injuries Arthritis Burns Other: 6. I work in a (please circle): Private practice—therapist owned Hospital—in-patient Hospital—out patient Private Corporation Other: We appreciate your time and your willingness to share information about your use of contrast baths in the treatment of upper limb edema reduction. If you would like a copy of our study results, please let us know how to reach you.
FIGURE 1. Questionnaire.
344
JOURNAL OF HAND THERAPY
start and defined replacement strategy (see Figure 1). In ASHT, there are, typically, four occupational therapist members to one physical therapist member.
Results Of the 100 inquiries mailed, 43 were returned (see Table 1). The settings that these therapists work in are private practices (26.8%), outpatient hospitals (39%), private corporations (17%), and physician offices (17%). The majority of these therapists (69.8%) reported they used contrast baths. Most therapists (76%) reported beginning with heat immersion; 54% of the respondents indicated that they ended the procedure with hot water. The amount of immersion time in hot versus cold water varied greatly, with hot water immersion ranging from 10 seconds to 10 minutes and cold water immersion ranging from 10 seconds to 5 minutes. Thirty-two percent of the therapists reported their protocol for hot water immersion was for 3 minutes and 52% instructed immersion in cold water for 1 minute. The reported duration of the entire treatment ranged from as little as 8 minutes to as long as 25 minutes; 24% instructed use of the modality for a total period of 15 minutes. The reported range for hot water temperature varied from 908 to 1158F and the cold water temperatures ranged from 578 to 708F. There seemed to be no preferred hot water temperature reported; however, 50% of the therapists reported using a cold water temperature approximating 608F. Approximately 82% of the therapists who used contrast baths indicated they encouraged the patient to do hand
TABLE 1. Results of the Survey 43% response rate (43 of 100 surveys sent were returned) 69.8% use contrast baths as a home program, in the clinic or both, while 30% do not Duration of modality ranged from 8 to 25 minutes 76% begin the treatment procedure using hot water; 24% report begin the procedure with cold water 54% end the treatment procedure with hot water; 46% end the treatment procedure with cold water 32% report direct their patients to keep their hand immersed in the hot water for 3 minutes for each use of the hot water; others report hot water immersion times that range from 10 seconds to 10 minutes 52% report directing their patients to keep their hand immersed in cold water for only 1 minute; others report cold water immersion times that range from 10 seconds to 5 minutes A wide range of temperatures were reported for use: Hot water varied from 908 to 1158F Cold water varied from 578 to 708F, with 50% using approximately 608F 90% encourage use of exercise while the hand is immersed 69.2% of those who do not use contrast baths feel that there is not enough research supporting their use and find other modalities more effective
exercises while the hand was immersed (e.g., sponge squeezing, tendon gliding). Of the 13 therapists who did not use contrast baths in their clinic or as a home program, the majority of them (69.2%) indicated that they did not use the contrast baths because there was not enough research supporting their use. These therapists indicated that they find other treatment modalities to be more effective such as compression, high-voltage postgalvanic stimulation (HVPG), massage, and active range of motion.
Discussion Despite the lack of clinical research to support their use, contrast baths are commonly used in practice, particularly in the home. Our inquiry shows that the wide procedural variation described in the literature exists in the clinic. Despite vast differences in duration of immersion, duration of treatment time, water temperature, starting or ending water immersion bath, or use of exercise, many find it useful and with positive results, albeit, anecdotal. There is now a CPT code devoted exclusively to this modality.17 Adverse effects have not been reported. There are many clinical studies that could be developed to help give contrast baths an evidence base. One study design could be to control for one variable at a time, such as water temperature constant throughout the treatment or for the variances in timing of water immersion in cold versus warm or the sequence of cold versus warm. The use of range-ofmotion and volume measurements of the hand preand post-contrast bath treatment would make this treatment more objective. Introducing and using consistent and precise tools to document the effect of contrast baths similar to those used to monitor other treatment effects could potentially give contrast baths more acceptance in terms of evidence-based practice.
Conclusion It is known that contrast baths have little evidence to support their use, yet therapists are familiar with them, have a concept of how and when to use them, and have used them for years. Empirical evidence suggests that they have a positive effect on the patient regardless of adherence to precise application of a protocol. The treatment is applauded for its low cost and ease of use.
REFERENCES 1. Lehmann JF, DeLateur BJ. Cryotherapy. In: Lehmann JF (ed). Therapeutic Heat and Cold. 4th ed. Baltimore: Williams and Wilkins, 1990:590–628.
October–December 2003 345
2. Woodmansey A, Collins DH, Ernst MM. Vascular reactions to the contrast bath in health and in rheumatoid arthritis. Lancet. 1938;2:1350–3. 3. Engel JP, Wakim KG, Erickson DJ, Krusen FH. The effect of contrast baths on the peripheral circulation in patients with rheumatoid arthritis. Arch Phys Med Rehabil. 1950;31:135–44. 4. Swanson AB, Swanson GG, Leonard JB. Postoperative rehabilition programs in flexible implant arthroplasty of the digits. In: Hunter JM, Mackin EJ, Callahan AD (eds). Rehabilitation of the Hand: Surgery and Rehabilitation. St. Louis: CV Mosby, 1995:1372. 5. Cameron M. Physical Agents in Rehabilitation: From Research to Practice. Philadelphia: W.B. Saunders, 1999:191, 203. 6. Hayes KW. Manual for Physical Agents, 5th ed. Englewood, NJ: Prentice-Hall, 2000. 7. Hecox B, Mehreteab TA, Weisberg J. Physical Agents, A Comprehensive Text for Physical Therapists. East Norwalk, CT: Appleton and Lange, 1994:246. 8. Kasch MC, Nickerson E. Hand and upper extremity injuries. In: Pedretti LW, Early MB (eds). Occupational Therapy, Practice Skills for Physical Dysfunction. St. Louis: Mosby, 2001:833. 9. Lehmann JF, DeLateur BJ. Therapeutic heat. In: Lehmann JF (ed). Therapeutic Heat and Cold. 4th ed. Baltimore: Williams & Wilkins, 1990:451. 10. Michlovitz SL. Thermal Agents in Rehabilitation, 3rd ed. Philadelphia: FA Davis, 1996. 11. Post RE, Lee SL, Syen DB. Physical agent modalities. In: Trombly CA (ed). Occupational Therapy for Physical Dysfunction. 4th ed. Baltimore: Williams and Wilkins, 1995:662. 12. Prentice WE, Quillen WS, Underwood F. Therapeutic Modalities for Allied Health Professionals. New York: McGraw-Hill, 1993. 13. Foot Care-Contrast Baths Home Physical Therapy. http:// www.umt.edu/shs/healthlibrary/hlfootcare_contrast.htm. Accessed July 5, 2002.
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JOURNAL OF HAND THERAPY
14. Help for Some Music-Related Injuries, Contrast Bath Hydrotherap. http://www.Ithaca.edu/faculty/nquarrie/contrast. html. Accessed July 5, 2002. 15. Herbal Preparations: Baths-Contrast Bath. http://www. tempestwolf.com/hers/herbs/herbalprep/bath-contrast.htm. Accessed July 5, 2002. 16. Hot and Cold Baths. http://www.brianmac.demon.co.uk/ hcbaths.htm. Accessed July 5, 2002. 17. http://www.accuchecker.com/AccuLibrary/articles/ rehabcontrastbaths.asp. Accessed July 5, 2002. 18. Martin M. The Draw of the Bath. http://seattletimes. nwsource.com/pacificnw/2002/0203/fitness.html. Accessed July 5, 2002. 19. Osteoarthritis. http://www.newstarthealthcare.com/articles/ Kgnw/oaradio.htm. Accessed July 5, 2002. 20. Quarrier N. Contrast Baths for Pain Relief. http://www. ithaca.edu/faculty/nquarrie/topic.html. Accessed July 5, 2002. 21. Sabelman EE, Netter JB, Jaffe DL, Ward M. The Arthritic Hand—A System to Reduce Pain and Increase Function. http://guide.stanford.edu/96reports/96dev7.html. Accessed July 5, 2002. 22. Stavroudis D. Facts About Cumulative Trauma Disorders. http://palimpsest.stanford.edu/waac/wn/wn15/wn15-2/ wn15-211.htm. Accessed July 5, 2002. 23. Stiff Big Toe (Hallus rigidus). http://orthoinfor.aaos.org/fact/ thr_report.cfm?Thread_ID=352&topcategory=Foot. Accessed July 5, 2002. 24. Wnorowski D. Heat and Cold Therapy. http://www.genufix. com/heat_and_cold_therapy.htm. Accessed July 5, 2002. 25. Graziano M, Ryan C. Exploring the Use of Contrast Baths. Submitted in partial fulfillment of the Master of Science Degree in Occupational Therapy, Columbia University, NY, unpublished thesis, 2002. 26. Helewa A, Walker JM. Critical Evaluation of Research in Physical Rehabilitation: Towards Evidence-based Practice. Philadelphia: W.B. Saunders, 2000.