102

PMRvoL2 N04 IS)9L

From the Oe parl111cnt lor Nat urlwilktnHlc. lJnive rsiUitsklinikum Steglilz. Berlin. Gc:-rm<my
Increase of Heart Rate Variation and WeD-Being
After External Cold Water Application
H. -J. Rudolph and M. Bi.ihrirtg
Key-words: /\ulonolltic 11crvous systl'" ' !teart rate variation - rPspiralory jiequency lhennorequlatory
response - cold - pllysiutlwmmJ.
Summary: In physiotherapy exl<'rn<ll <tpplicalions of cold wa ter a re established to be effective in the
prevention and treat nwnt of many clistw-;es . We tried to improve our understanding of this phenomenon
by investigating t hc rmoregulalory <111cl cnrdiorespiralory responses after mild cold stress.
: The examination was carried out in 12 healthy ma le caucasians (age 24 to 4 7 years). Hearl rale
i Ouctua lions were rC('Orcled bdor<' and ancr appli cation or t horacic cold wet s heet packs (randomized
cross-over t r ial. control with thoracic dry s heet packs ). The degree of s inus a rrhythmia was determined
by the mean successive clillerenn oll wul to-beat intervals and the mean respiratory s inus arrhythmia
' double a mplitude. Uelore and artn treatment well -being was estima ted on a graded eleven -point scale.
ranging from completely exhaust<'d to totally refreshed.
With thoracic cold wet sheet packs !-.ignilkant increases or mean s u ccessive difference a nd respiratory
s inus arrhythmia double amplituclt Wt'rt' round after 20 and 30 min. After 60 min bot h paramete rs s howed
base line values. lmprovcnwnl or well scor e was s igniilcantly better wilh cold wet s heet packs .
Our results suggest that cardiac pamsympathetic activity temporarily increases afte r an external cold
waler application. This seems to lw followed by enhanced regen eration. thereby enabling the described
changes or well -being.
Introduction
Being involved in a n effort to inJ -
prove our understanding of ( hE t>f-
fectivencss or nat ural remedies
a nd hydrotherapy. we report in
this article on phys iological
changes aller application or cold
wet sheet packs. On the one ha nd .
external cold water applications
are certainly quite unspecific. hut
they a re. on the other hand. very
beneficial in the prevention and
treatment of many (I. 2.
3). and furthe rmore helpful in the
development or physiological
toughness, thereby increasing
physical and mental health (4).
Heart rate. respiratory frequency
and skin temperature <'an he re-
Author's address:
H.-J. RUDOLPH. M.D ..
Krankenhaus Moabit.
IV. Innere Ableilung.
TurmstraJ3e 21 .
D-W-1000 Berlin 21. Germany.
g; t n ll-d as s tandard variables of
physiological research. Additional
inl(Jrmation is de-
ri ved from analy-
sis or heart rate
variation. Respi-
mlory s inus ar-
rhythmia (RSA).
its major compo-
nent . re presents
that cycl ic varia-
! ioll or beat-to-
IW<II int erva ls,
wllilh is entra ined
1 o respiration (5.
G. 7): and cur-
rcllti.V RSA ampli-
t uck. ns well as re-
lattcl s tatistical
dcscriptives. are
olll'n used as indi-
cators or cardiac
p<t r<.tsympa thetic
nostril air
temperature (()
40
30
20
0
beat- to- beat
interval (mse<:l
1500
1000
500
0
10
cording. Longer registrations ad-
ditionally show modulations by
20 30 40 ')0
60
.. ... _ ... ....... ....... ....... ........... ..
10 20 30 40
50 60
time (sec)
activity (8. 9. 10.
I I). F'igure I gives
mt example of a
Oll<' minute re-
Figure 1. One minute recording of nostril air tempera-
ture (indicating the rhythm of respiration) and cardi-
ac beat-to-beat intervals.
103
PMRvoL2 N0 4 I992
s lower rhythms ( 12. 13. 14). as well as ins tanta-
neous a nd delayed responses after exposure to or ap-
plication of environmental factors (1 5. 16. 17. 18).
Effects of thera peutic cold water a pplications on
heart rate varia tion a nd respiratory s inus arrhyth-
mia . however. have not yet been reported.
Subjects and Methods
From Augus t 1990 to J a nua ry 199 1 12 heal t hy male
volunteers were examined in a ra ndomized cross-
over t rial (for ant hropometric da ta see Table 1). Night
workers were excluded. and tiring aclivilies as well
as co!Tee. alcoholic beverages a nd tobacco products
were forbidden for 4 hours before examination.
Data were recorded in s upine pos ition before and a f-
ter a pplication of thoracic cold wet or dry s heet packs
(a pplication according to [ 19]. wa ter tempera ture 16
to 17 C. s tarting time 14. 00 o'clock. after lunch) .
From the fifteenth minute before till the s ixt ieth
minute after a pplica tion of thoracic packs. every 4 to
I 0 min cardiac beat-to-beat intervals a nd nos tril a ir
temperatures (indica t ing t he rhythm of respira tion)
were recorded s imulta neous ly for one minute each.
us ing a cardiotachometer (Epicon. Munich. Genna-
ny) and a thermosens or (dit.t.o). SubC'I avicular s kin
temperatures were measured continuous ly wi t h a
second thermosens or (Simonsen & Wee!. Albert-
s lund. Denmark). Before and a fter treat ment estima-
tions of well-being were requested to be ma rked on a
graded eleven-point scale. ranging from completely
exha usted to totally refreshed.
Evaluation was done on a n IBM-compatible persona l
computer . The degree of s inus arrhythmia was de-
tennined by the mean s uccessive difference of beat-
to-beat intervals . earlier descri bed by Eckoldt et al.
(20). and the mean respira tory sinus arrhythmia
double a mplitude. calculated automatically by a
modified peak-t rm.1gh method (21). Fourier trans for-
ma tions have not yet been done. Statistics were com-
put ed with SPSS/ PC+ Software (SPSS Inc .. Chicago.
USA).
Results
Time courses of respira tory frequency. respira lmy
sinus a rrhythmia double ampli tude. mean s ucces-
s ive difference a nd s ubclavicular skin temperature
a re depicted in Figures 2 and 3. After application of
Figure 2. Time courses q{respiraloryJrequency. mean
successive d fLTerence and respiratory sinus WThyt h-
mia double amplitude before and c{/ler application of
thoracic packs. Medians. C{lLarliles. Asterisks al Lh.e
lower quarliles indicate sign!f!cant clflTerences us. L11e
fiji h mimLi e be.for<" d ry sheet packs. all he upper quar-
t iles us. I he .fiJi 11 minute cold wet sheet packs.
I kl wnn nwdians p:roup di ITCrl'rlt'('S a re indicated (cold wet dry
-. llet' l racks).
Wilt oxons mal('lled p;tirs signed r nnks l e:-;l. z p ..:; 0. 1. 2 p
O.lJG. 2 p < 0.02!1. 2 p 5 0.0 I .
Table 1. Antll roponwtric dalo qf twel ve fleollfly male
caucasia ns.
Median
Range
RF (min-
1
)
18
15
12
9
6
-15
age (yrs) weight (kg) height (em)
29.5 74.5 182.0
24 - 47 54.0 - 103.0 170.0 - 198.0
Respiratory Frequency
0 15 30 45 60
Mean Successive Difference
MSD !l'nSecl
70
...
60
50
40
30
20
10
-15 0 15 30 45 60
Respiratory Sinus Arrhythmia Double Amplitude
2A (rmec)
180
160
140
120
100
80
60
40
20
-15 0 15
0 Dry SM.t Poct.s (n-12)
e Cold Wet SM.t Pook.s ln-12)

30 45 60
t (min)
104
PMRvoL2N04 t99L
Subcloviculor Sk. 1n T emperoture
T (()
37
36
35
34
33
32
31
30
29
28
27
No
12
10
8
4
2
0
0 Or,. :;._, >oc,_, (n 11)
@> Coo Wet s--1 ?oc<.> (n- 11)
-15
0 15 J(;
60
Number Of Sleep1ng vc ,'lieers
Dry sr-t Poct.1 (n. 1])
1111 Cold Wet Sheet Poet.> (n- 1] )
15 10 . 5 0 5 10 15 20 25 30 40 4 5 ')0 55 60
thoracic cold wei s heet packs. initially.
frequency, hearl rate and s u bdavicu Ia r s kin temper
ature decreased. respiratory sinus arrhythmia dou
ble amplitude and mean s uccessive difference (t h('
latter with 2p = 0.0844 only) increased significantly.
In the following minutes respiratory frequency. IT
spiratory s inus arrhythmia double amplitude. mean
s uccessive difference and subclavicular s kin tem-
perature retun1ed to base line values. heart rate con
linued declining s lightly. No s ignificant group differ-
ences (cold wet vs. dry sheet packs) were round in
respiratory frequency. heart rate. respiratory sinus
arrhythmia double amplitude and mean s uccessivc
difference up to the fifteenth minute. But 20 and 30
min afler application of thoracic packs. respiratory
sinus arrhythmia double amplitude and mean suc-
cessive difference increased s ignificantly. for a sec-
ond lime. with cold wet sheet packs only. At this
time. respiratory frequency and heart rate remained
unchanged. Table 2 summarizes the results.
Coinciding with t he second increase of res pi ra lory s i
nus arrhythmia double amplitude and mean succes-
sive difference. s ubclavicular skin temperature rose
above base line values. In addition drowsiness set in
at Lhat time. and after about 30 min. most subjects
s lept (Fig. 3). Although. no group differences wer<'
Figure 3. Time courses of subclavicular skin Lempero
Lure and Lhe number ofsleeping volunteers before and
after application of thoracic packs. Medians. quar
tiles. Asterisks at the upper quarliles indicate signi]l
cant dUferences vs. the fijlh minute before dry sheet
paclcs. at. the lowerquarliles vs. lhefijih minute
cold wet sheet. paclcs. Between medians group dUJer-
ences are inclicaled (cold wel vs. dry sheet paclcs).
Wil coxon's matched-pairs test. +2 p s 0. I . 2 p "
0.05. ** 2 p $ 0.025. 2 p $ 0.0 I.
Table 2. Respiratory Ji'equencies (IW). lwari rates (HR). mean successive dU]erences (MSD) and double
amplilucles (2A) q{respiratory sinus orrllytlunia5 minutes before and 20 as wello.s 30 minutes after application
qf dry (DSP) and cold wet sh(;>e/ packs (('WSP). Medians, Wilcoxon's matched-pairs signed-ranks Lest. wil.hin
DSP and CWSP subgroups asterisks indicate significant df{ferences us. 5th minute before appl.ication Q{
DSP/ CWSP (2 p 0. I.* 2 p O.Of;. ** 2 0.025. *** 2 p 0.01).
5th minute before DSP/ CWSP 20th minute after DSP/CWSP 30t h minute after DSP/ CWSP
Variable DSP CWSP DSP vs. CWSP DSP CWSP DSP vs. CWSP DSP CWSP DSP vs. CWSP
RF 13.6 14.8 2p>0.100) 13.8 13.3 2p>0.100) 13.9 14.5 2p>0.100)
(breaths/min)
HR 62.5 63.1 2p>0.100) 58.6* * 58.3** 2p>0.100) 59.1 00.9 2p>0.100)
(beats/min)
MSD 37.2 28.9 2p>0.100) 33.1 51.1 * * * 2p=0.0342 34.8 41 .9** 2p=0.0414
(msecl
2A 67.8 69.2 2p>0.100) 70.8
122.1
2p=0.0150 74.5 100.2 + 2p=0.0022
(msec)
found in the number of sleeping
volunteers. quality of s leep was
apiJarcnlly different and well-be-
ing score improved s ignifica ntly
more after thoracic cold wet s heet
packs (Media n + 3.0 vs. + 1.0
[Fig. 4]).
Discussion
With acute cold s tress. an initial
reduction of respiratory frequency
has been known for a long lime
(22). We als o observed this phe-
nomenon a fter a pplication of cold
we( s heet packs: however. s imilar
changes were found with dry
s heet packs. s uggesting an addi-
tiona l effect of the arousal reac-
tion (23) . induced by our manipu-
lalions.
Changes of heart rate with acute
cold stress primarily depend on
the site of application (24. 25): ln-
n cases have been reported with
the cold ha nd test. but decreases
' with the cold face test (26): 1 min
head-out immersions in cold wa-
ter produced increases of heart
rate and decreases of mean suc-
ccssive difference (27) . After appli-
cation of thoracic cold wet sheet
packs. we found an initial de-
crease of heart rate. but no group
differences (cold wet vs. dry s heet
packs ). indicating absence of im-
mediate effects of thoracic cold
wd s heet packs on heart rate.
Even mean s uccessive difference
and respira tory s inus a rrhythmia
do11ble a mplitude showed s imila r
limc courses in the first 10 min of
cold wet or dry s heE't packs. in-
creasing with lowf'r
frequency and heart rat e. as de-
scribed by Hirsch . Bishop (6) and
Schlomka (28) respectively.
In contradisl inction. the second
innease of mean s uccessive dif-
ference and respirato1y s inus a r-
rhythmia double amplitude.
20 min after application of cold
wet s heet packs. can neither be
expla ined on the basis of s imila r
cha nges under control condi tions.
nor in reference to decreases of re-
s piratory frequency or heart rate.
Ins tead. the lime courses suggest
a n interaction with l hermoregula-
1 ion: After application of thoracic
('old wct s hed packs . thoraco-cu-
105
taneous vaso-
constriction eli-
minis hes a l the
lime of s ubcla -
vicular s kin
temperature re-
normalization
(29). Subse-
quently. vasodi-
la tation s tarts
at the t ime of
s u bclavicular
s kin tempera-
ture rise above
base line values
(29}: and the
switch in ther -
moregulation
a pparently trig-
gers an increase
in cardiac para-
sympathetic ac-
tivity.
Relevance of
our Ilndings
totally
r efreshed
c
0
i5
<IJ
E
2 -'j
I
4
- c. -
completely
exhausted
PMRvoL2N041992
Weii - Be1ng before and after
Dry/Cold Wet Sheet Pocks
2p 0.0254 I
*

0

'Q0 0
Cold Wet
Sheet Pocks
can be detived F'igure 4. v\le/l -1Jcill9 score at about 20 min before and
from r ecently 65 min qjler upplicoiion q{ lhoracic packs. Medians.
published evi- AsLerislcs inclimle si911!flca11/ cl!lTerences in ihe Lime
dence, s uggest- cotLrse.
ing t hat heart Wikoxon's m; lll' l hd p; tirs sig)H<I ranks (csl. +2 p 0. I. 2 p
rate variation at 0.05. 2 p < o.o2s *"' 2 p o.o 1.
rest also reflects
s ufficiency or lack of regenera t i\t
capacity (30) . This concept aclcli
lionally provides a natural expln-
nation for the described improv('
ment of well-being after a ppli(' ;l
lion of thoracic cold wet s lw <'l
packs.
Acknowledgements
This work was s upported by t h('
Rut- & Klaus-Bahlsen-Founclation
and the Kneipp-Werke. Gemtanv.
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t27) 13nnl;c I<. l ' lcw II , l 'l\:
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/\rrh_y( 11 1111!' Vllll clt'l' :Okl d; l i.!fnqn<' lll'. Ill HI
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I2!=Jl liaicr II : l'il ysiologi,.,<l tt' t:nnull; tl.(<'ll
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1
l HO.
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(:30) /\ l w l 1111. 1\r;lltsc I{ , lkrgl'r 1{. 1\l lt:-<s<' ll
rlnr f D. l )rcth 1{, 1\.0l'Jli' l llll Ill': J)ifl,rtll lt'"
La JJ gzl' il v(' r l utl ltIJ dl' l' dti'OIIOiropl' l l I kr;
kunl rollt wii hnnd ki'lrp;r l il'htT l{nht. 111
fkrndl i '. , Jcsdl k < l l (nbl : Spcll'lll! ll i Mc d
iZill , 1'1" IIIHI <'CJ i tii'.L Mfllt( 111'11 ,
Zll,t!.sdt wtrd I , I I . "i(i7
106
PMRvoL:! N<> 1 1q ! J:L
Literature Review
Brief literature extracts
T lti :-; stTiion is a ITJ.!u l ar fcaltllT n l 0 111 JCIII I'n<l l . II :-; i 1ir11 1:-; t o rc p nrt 0 11
-. tudi< ...; in phy:-; ical mcdi ci n<' nn cl rvh:d)i ]il <tlitt n (I' M!{) w l 1i<'l1 n '<'l' llll.v
dJlJII' <I rccl in <wceptecl j ourllnls wh i<' l l : lrt' ll(ll :-.pcr i: llil.<'<l ill I ' MI{. Tllis is
Ill('; il tl I 0 be Of Sel\l i (' t' tO th<)S<' or I Ill r l'l';tdt r:-. WIIO ll.t\'V 1 II 1 l r cU'l 'l'SS
In mcdil'allibr ;JI-i('S mip:Jtl hi!\'<' missc' cl wha l w"" print ed i n t l w
N Engl J Mecl . Lwwet. Ann llll Me(] , lAMA. Br Ml'd , I. l'l<' .
\V1 i nvil f' 01 1r r eackr;.. I< C'onl r i l)tl i <' to I <'ol umt l:-;. All <'Ot tt ri iJIIIiOia:-;
:--I IC>l< ld he short I max. 2 typed pa!!,t:-,1 w1d cu, 11 a i11 l l w 111;.1 i n J'i n di n;..(s of llw
-. t t 1rlv ln(lnwecl by a bri PI' enmmenl n 1t l Jw impnrfanc\'. :-. (rell !,!lh
Il l' -.Jtor lcomin.!.!f- or (11(' pari icul ilr :-. I
Smoking causes disc degen-
eration
l'l w objel'l i vC' ol lhis s t udy wc-1-; to
t (l'l crm i 11<' wht l h<'r c I i sl' ck geJII'ra
l tn t L <JS asse!->sed l hrougl1 n t<c\gJl L'i w
l'!' s<tl1<111l'L' imagin.g. i s p:rcatcr 111
" lll(tker s than i n nunsmok er s. Tu
, .,111J rol lor t he mn..;'(i mumnumbcl-ol
polen tia.l ly conrouncling variaiJle;.;,
p : l i r o., or iclf'nli cal I wins cl i scorcl anl
fC)r dg; t r etl c <;IIIOI<ing W('r(' SC!CI' l<'<f
"' ahj <'ds. a na ly!"es reve;lll'd
e;reat er ml'an elise
liPII SCore'S ill IJH' Jumbnr spint:-. cd
"tnoker<; as cnmpar<'cl with nnn
-. rnni<1r s. T he cl ill er en ce was p r C' -
-.t lll ;wross t he enUre lumbar spi11r_
-.tll],gl'sl i ng a mechanism act

l k clli<' MC. Videmon T. Gill K c t al:
!->n 111king and l umbar interver Lebra l
d isC' degener a ti on. an MRJ study of
idl' l l li l'al lv.rins. Spine 1991:1 6:
I () I !1 I 02 1.
Commentary: Al several o<'ca-
sions our Jnu r na! has already Clll -
ph<tsi zecllhc importance or tis k l'<tt' -
l o t' r<'search lot- vertebral
(' Ill' clalu avni lable so rnr clenrly
sltow a st rong and consistent asso
bet ween s muking habi ts
. 111tl IJ<1l'k pain . Yet the nature of this
.1ssot'iution was lefl open to speC'lt-
h t liutt. I s il Lausal or i t r c lalccl tu
Cit !J, r u nl1enl l.hy lire slyiP vcuiables?
l'llt' present study i mplies Lhe lor-
t i ll'!'. It i s a n exceJJ ent example of a
Wl' ll c , mduC' t ed study. ll i s exempln-
ry 111 sclccti np:R con t rol gr oupwher e
.111 possible con founders were con -
I r nlkd for. Therefore only s ntoking
l '<lll e:-. plain I he r el atively h ighe rde -
Of el i:;(' clegenera lion in the
s lllokinggroup. To be enti r ely su r e.
111 a shou lei nnw invesliga tc I h e
Jil l'( \t ;lllisJII by
11 ,, rt ns t 11 <' rl i :-;( .
wilidl "' II HI I\ill ,!!,
f-;. Ernst. V it ' ll l lil
Handicap after stroke
2 [II 7 _\'tars aflcr l ht'ir Slrukt'.
32k su rv ivurs !'rum the
(_ <llltntunily St r o k e Prcded' regist1r
\WI T assessed ror dis<J IJ i l ily . f>a -
t it J ll ti \\I(' IT dilssil kcl : 1s P il her
1110bilc nr i mmuhik. or (]1(' 190 i lll-
nwbii <' pnt i t"nt;.; . onl v ()0 I'Ou ld be
l'll(l'ITC] inl o ;1 trial of physillllll'r<t-
Jl.\'. T hC' major Ccll lSl'S or HII r il inn
\Vl' n rcli ts<l l l o p;.trt il' i p<li <' i JIHI ll1c
ab setlCe of impairment im
mobi li ty. Arllt rilis ancl d uncnl in
wer e common in patients wi ll ! nw-
bi lit y disability. I II II IIOI>i l<' jJ<l l ienl s
wer e older and l wei sullerccl <I more
stve re s lrnke.
Coll en FM. Wncl<' IJT: n l o -
bi lit y probk, mc; a i't er s t rnl<e. In I Dis-
abi l Sl ucl I :191 : I :3: 12 - 15.
Commentary: The lilcrallllT i s nol
en! ircly vicar ahnul how many sur-
vi vor s nf ;.l sl rok C' wi ll be <tblc lo wa l k
nlngc l r nlll w1 opli -
111i s li e

to b leak 5QtV.,, This

:-,lucly shows a rclalivl'ly low f rc
C[LI C' ll <'Y of i mmobi lity fol -
st roke cl i rt'C'tly cl t tt' to sl mke
impai m1ents. N<m- strok c re l:o1tcd
were frequ ent ; 35
1
.!111 had w --
mobi lity . IJemen lia
causPcl mobi l ity problems in 2mh.
Th e authors uf this s tudy s u.!!;,.gesl
that t h ese 2 Pnt it ies may complicate
or prevcll l phys iol hcrapeulic
bil it alio11 o!' s t rokc su rvivors. The
s l udy cle<1rly cm phasi:tcs t hC' n<"cd
l'nr more r esearch i nt o s l rokc IT ha -
bili t ation.
E. Emst. Vicnml