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Cold Stress Test

Exams and Signs

Historical Overview

  • The cold pressor test is commonly used to evaluate the digital response to cold stress.1
  • Vascular problems in the upper extremity affect approximately 10% of the population and 20-30% of premenopausal women.1

Description

  • The cold pressor test provides information about the autonomic and vasomotor response to cold stress. Patients with abnormal responses should repeat the test after a sympathetic block with local anesthesia.

Pathophysiology

  • Abnormal perfusion of the upper extremity is caused by a pre-existing congenital abnormality or results from trauma.1
  • Abnormal perfusion of the upper extremity leads to vascular insufficiency, which can lead to cellular ischemia, cell injury and cell death.1 Cold intolerance may arise from vascular problems, which in some cases are linked to vascular injury, Raynaud’s disease or Raynaud’s phenomenon.

Instructions

  1. 1. Record digital pulp temperatures and blood pressures of both hands at room temperature.
  2. 2. Ask the patient to submerge both hands in cold water at 8°C for 20 minutes.
  3. 3. Record the pulp temperatures and blood pressures of both hands during immersion.
  4. 4. Rewarm the hands for 20 minutes and record pulp temperatures and blood pressures.

Variations

  • The severity of cold intolerance can be measured by using the Cold Intolerance Symptom Severity (CISS) questionnaire.2
  • A more recent alternative to the cold pressor test is the cold pressor arm wrap.3

Related Signs and Tests

  • Allen test
  • Doppler
  • Arteriography

Diagnostic Performance Characteristics

  • It is important to keep the water temperatures exact to ensure reliable results, as small variations in temperature can have a significant effect on tolerance time and pain intensity.4 Gender differences have also been observed; male subjects were more tolerant of colder temperatures than were women.4

Additional Information

Definition of Positive Result
  • A positive result occurs when the patient experiences pain, cold intolerance and/or skin changes after submerging his/her hands in the cold water. Measurements of pulp temperatures and blood pressures do not return to baseline.
Definition of Negative Result
  • A negative result occurs when the patient does not experience pain, cold intolerance and/or skin changes after submerging his/her hands in the cold water.  Measurements of pulp temperatures and blood pressures return to baseline.
Comments and Pearls
  • Use laboratory studies, including a complete blood count (CBC), erythrocyte sedimentation rate (ESR) and C-reactive protein, to check for an underlying autoimmune disease and/or connective tissue disorders.1
Diagnoses Associated with Exams and Signs
References
  1. Culp R, Jacoby S.  Musculoskeletal Examination of the Elbow, Wrist and Hand: Making the Complex Simple.  New Jersey: SLACK Incorporated, 2012.
  2. Ruijs AC, Jaquet JB, Daanen HA, Hovius SE.  Cold intolerance of the hand measured by the CISS questionnaire in a normative study population.  J Hand Surg Br 2006;31(5):533-6.  PMID: 16808991
  3. Porcelli AJ. An Alternative to the Traditional Cold Pressor Test: The Cold Pressor Arm Wrap. J Vis Exp 2014;83:e50849. PMID: 24457998
  4. Mitchell LA, MacDonald RA, Brodie EE. Temperature and the cold pressor test. J Pain 2004;5(4):233-7. PMID: 15162346
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