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Finger cold-induced vasodilation test does not

predict subsequent cold injuries: A lesson from the
2018 Canadian Forces Exercise

Wendy Sullivan-Kwantes, Katy Moes, Robert Limmer & Len Goodman

To cite this article: Wendy Sullivan-Kwantes, Katy Moes, Robert Limmer & Len Goodman
(2019) Finger cold-induced vasodilation test does not predict subsequent cold injuries:
A lesson from the 2018 Canadian Forces Exercise, Temperature, 6:2, 142-149, DOI:
10.1080/23328940.2019.1574200

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TEMPERATURE
2019, VOL. 6, NO. 2, 142–149
https://doi.org/10.1080/23328940.2019.1574200

PRIORITY REPORT

Finger cold-induced vasodilation test does not predict subsequent cold injuries:
A lesson from the 2018 Canadian Forces Exercise
Wendy Sullivan-Kwantes, Katy Moes, Robert Limmer, and Len Goodman
Department of National Defence, Toronto Research Centre, Research and Development, Toronto, ON, Canada

ABSTRACT ARTICLE HISTORY

A cold–induced vasodilation (CIVD) test was administered to 113 Canadian Armed Forces (CAF) Received 5 November 2018
soldiers (age 25.6 ± 6 yrs) during pre-deployment to a Canadian Arctic training exercise. The Revised 8 January 2019
incidence and rates/types of subsequent peripheral cold injuries, as well as the relationship of Accepted 10 January 2019
CIVD responses against other hypothesized/reported risk factors (smoking, gender, age, ethnicity KEYWORDS
and prior cold injury), were analyzed. Although there was a wide range of CIVD RIF (resistance Arctic; cold weather injuries;
index to frostbite) scores (mean = 5.0 ± 1.5), there were no systematic relationships between RIF frostbite; cold-induced
and injury type/location and rate, and the other risk factors analyzed. The absence of physiological vasodilation; Canadian
links to cold injury occurrence suggests that in a military cold deployment setting, other factors Armed Forces; military
are in play, which might include clothing, training, leadership and doctrine. These factors should operations; cold
be examined in future work.

Introduction layering knowledge, energy conservation strate-

gies, and CWI symptom reporting). However,
Incidences of cold weather injuries (CWI), including
other, non-modifiable inherent physiological
frostbite and frostnip (precursor tissue injury to frost-
risk factors may also contribute, such as inter-
bite) during military operations has been a medical
individual differences in cold-induced vasodila-
issue that dates back decades, and continues to be
tion (CIVD) response [6].The CIVD reflex is an
a challenge for Canadian Armed Forces members
acute autonomous local neuro-cardiovascular
participating in Arctic field exercises during the win-
adaptation which involves the cyclic opening
ter months [1–4]. CAF units deployed to the north
and closing of arterio-venous anastomoses
often face extreme cold weather, frequently experien-
located in the fingers and toes, allowing blood
cing daily lows approaching −35°C and below, with
flow to periodically enter the peripheral tissues,
wind chill equivalent temperatures lower than −60°C
maintaining blood flow, and thus, minimizing
[5]. These conditions can make even simple tasks,
cold- induced tissue freezing [1].
such as erecting shelter, preparing and consuming
In 2005, Daanen & Van Der Struijs [6] charac-
rations, and operating specialized equipment (espe-
terized peripheral tissue’s ability to withstand cold
cially equipment requiring fine motor dexterity and
exposure by re-introducing the concept of
thus un-gloved hands) extremely challenging.
a “resistance index” (RIF) of frostbite based on
Since 2016, data has been collected on the
the CIVD response. The authors observed that
health risks and human performance challenges
low RIF values were linked to high occurrence of
on Arctic exercises and notably, a high incident
local cold injuries during military deployments,
rate of cold weather injuries [3] was found. Many
and suggested that the CIVD test and resultant
modifiable risk factors can contribute to CWI,
RIF score could be employed as a risk tool to
such as inadequate protective clothing (which
predict an individual’s risk of incurring frostbite.
has not improved markedly over this time frame
They also reported that RIF scores were higher (i.e.
for CAF members in Arctic deployments), as well
better) in Caucasians and smokers and that sub-
as behavioral factors (e.g., successful clothing
jects who experienced higher pain after 10 min

CONTACT Wendy Sullivan-Kwantes wendyskwantes@gmail.com; wendy.sullivan-kwantes@drdc-rddc.gc.ca

© 2019 Defence Research and Development Canada (DRDC).

(min) of immersion had lower RIF scores and
therefore were possibly at risk for cold injuries.
Since CIVD is presumed to play a role in provid-
ing protection against CWI’s [1,6], it follows that
the utilization of the RIF might have application in
a military context by predicting the predisposition
of individual soldiers for incurring CWIs during
military exercises in extreme cold conditions.
Recognizing the differences in their study popula-
tion, the Arctic clothing used, the operational tasks
(intensity and types), and duration of cold exposures,
the main purpose of this study was to replicate the
work of Daanen & Van Der Struijs [6] in a Canadian
operational context, and test the hypothesis that RIF
scores predict who would sustain a CWI during an
extreme cold exposure deployment.
Methods
This study was granted approval by the Human
Research Ethics Committee of Defence Research and
Development Canada (DRDC), Toronto Research
Centre (TRC).
113 volunteers were recruited from the Canadian
Armed Forces (CAF) OPERATION NUNALIVUT
2018 (OP NU 2018) training exercise, and any mem-
ber aged 18–65 without pre- existing health conditions
or previous cold-induced injury involving the hands
and fingers was eligible to participate. Volunteers read
the study information and were given the opportunity
to ask questions before providing written, voluntary
consent to participate in the thirty minute CIVD test.
Participants were assured that while pain, numbness,
and discomfort are normal responses, the chance of
permanent finger tissue damage as a result of the
CIVD test is very remote [6,7]. Prior to beginning
the CIVD test, all participants completed a short sur-
vey regarding their previous cold weather experiences.
All CIVD testing was performed at Canadian
Forces Base (CFB) Shilo, MB, CA in a temperature-
controlled room (22 ± 1°C), set up with tables to
accommodate 30 participants at one time. The
volunteers reported to the indoor testing site in the
morning after consuming a normal breakfast., Upon
arrival, oral temperature was measured to rule out
fever (>37.8°C).
The CIVD procedure used is well documented
[1,6–12]. A thermistor (ACR Systems Incorporated
Surrey, British Columbia) was attached to the
TEMPERATURE 143
third finger of the left hand. It was secured to the
middle of the palmar surface of the distal phalanx
using a single layer of transparent, waterproof tape
(3MTMTransporeTM Surgical Tape). The thermistor
was connected to a portable data logger capable of up
to 8 independent signal inputs (ACR Systems
Incorporated SmartReaderPlus 8 Surrey, British
Columbia), and one logger was shared for groups of
up to six participants. Temperature data obtained
from the thermistors was measured and stored at
a rate of once every 8 seconds.
Each participant was assigned an individual dou-
ble-walled polystyrene foam cup filled with small ice
cubes (1cm3) and cold water, to create a volume of
approximately 400 ml of a 0–0.5°C ice slurry, accord-
ing to the methods described by Daanen and Struijs
[6]. Following five min of baseline temperature mea-
surement, participants submerged their finger past
the proximal interphalangeal joint, with their elbow
supported such that their wrist and hand were sus-
pended in a relaxed and comfortable position. Every
two min, each participant stirred their own ice slurry
bath using their free hand and a provided pen, to
ensure uniform temperature throughout the ice slurry
solution [1]. Every five min, they rated their level of
finger pain using a Numeric Pain Distress scale [6],
which is a 10-point scale from “0” (no pain) to “10”
(unbearable pain). Participants were instructed to
maintain submersion for 30 min, but were
free to withdraw their finger if the test became
intolerable. After 30 min, participants were instructed
to withdraw their finger from the water bath, but
temperature and pain scale ratings were measured
for another 10 min.
Approximately one month following the baseline
CIVD screening test, participants embarked on the
OP NU 2018 training course in northern Nunavut,
Canada. This exercise involved a six day field sur-
vival component, during which participants were
outside for 14–18 hours per day, completing var-
ious manual tasks, commuting on snowmobile, and
nights were spent in either snow shelters or small
heated tents. Over the 6-day field exercise, the
average daily high was – 30.3°C, the average daily
low was −39.8°C, and average windchill equivalent
temperature was – 44.6°C [13] During the course,
participants were monitored by field medics and
any suspected CWI was referred to the course med-
ical officer for diagnosis. In the event of injury, the
144 W. SULLIVAN-KWANTES ET AL.
location, severity and mechanism of injury and
other details were recorded by the participant and
medical team. All cold weather injuries were
recorded, but injuries to the fingers and toes were
of particular interest, as the CIVD response only
occurs in the extremities (9).
Individual CIVD response curves for each
volunteer’s CIVD test were constructed from the
raw finger thermistor temperature data, and
plotted as a function of time (min) (Figure 1).
These data were then used to calculate
a Resistance Index of Frostbite (RIF) ratings, as
described by Yoshimura and Iida [7] and Daanen
and van der Struijs [6], and modified slightly. The
rational for modifying the RIF was to ensure that
all values of Tmin, Tonset, and Tmean are included in
the calculation for the number of points. For
example, in the ranges noted in previous papers,
values for Tmin between 1.5 and 1.6 would not be
included. The modifications were as follows:
The three variables utilized to construct the RIF
were:
RIF ¼ Tmin þ Tonset þ Tmean
Figure 1. Fingertip temperature response to 30 mins of immersion in ice slurry. Tmin= minimum finger temperature before CIVD
reaction; Tonset= time immersed before CIVD reaction begins; Tmean= average temperature from 5−30 mins of immersion. RIF is
calculated using Tmin, Tonset, and Tmean.
Where:
Tmin = the minimum skin temperature prior to
CIVD response
Tmin ≤ 1.55°C = 1 point
1.55°C < Tmin <4.05°C = 2 points
Tmin ≥ 4.05°C = 3 points
Tonset = onset time of CIVD (determined by exam-
ining graphs and consensus by investigators)
Tonset > 11.5 min = 1 point
11.5 min >Tonset > 7.5 min = 2 points
Tonset < 7.5 min = 3 points
Tmean = mean finger temperature from minute 5–30
Tmean ≤ 4.0°C = 1 point 4.0°C>
<Tmean < 7.05°C = 2 points
Tmean ≥ 7.05°C = 3 points
RIF scores could range from 3–9, with 3 being the
weakest response to cold (high risk of frostbite),
and 9 being the strongest reaction (low risk of
frostbite).
Statistical analyses were performed using
GraphPad Prism (version 7.00 for Windows,
GraphPad Software, La Jolla California USA,

www.graphpad.com). An alpha level of 0.05 was
used for all statistical analyses. The differences in
RIF scores between injured and non-injured
between RIF scores and incidence of CWI was
determined using a t-test. A one-way analysis of
variance (ANOVA) was used to determine the
response pattern between CWI location and RIF
score. Additional ANOVAs were used to examine
the differences between RIF scores and smoking
behaviour, ethnicity, and military rank.
A Pearson’s product-moment correlation coeffi-
cient (PPMCC) test was used to estimate the cor-
relation between RIF and age, as well as RIF and
oral temperature. An ANOVA test was used to
examine the changes in Borg Pain Rating through-
out the 40-minute test. A PPMCC test was used to
examine the correlation between pain ratings
and RIF.
Two survey questions were used to examine the
relation between self-assessed cold tolerance and
RIF. Question 1 (How do you generally feel in the
cold?) used a 4-point scale between 1 (“Very
Uncomfortable”) and 4 (“Very Comfortable”), for
5 different locations (whole body, ears, toes, fin-
gers, and face). The ratings from each location
were totaled, and then compared to the RIF score
using a PPMC. Question 3 inquired, “Are you
exceptionally sensitive to the cold?”. A t-test was
used to compare the RIF scores of those who
answered “Yes” with those who answered “No”.
Results
109 of 113 participants completed the CIVD test
(Mean age = 25.6 ± 5.8 years). Four participants
Figure 2. Borg pain rating every 5 min during 30 min of finger immersion (0–3 mins) and 10 mins of recovery (30–40 mins).
TEMPERATURE 145
withdrew from the test (two due to discomfort;
two due to scheduling conflicts) and are not
included in the final analysis. All but one of the
participants was male. The mean RIF score of all
the participants was 5.0 ± 1.5.
Ratings of pain were highest 5 min after finger
immersion and decreased over time, with a small
increase initially after withdrawal at 35 min (Figures
1 and 2). Pain rating correlated weakly and negatively
with RIF scores, with strongest correlations shown at
35 min (r =−0.445) and 40 min (r =−0.290).
34 participants declined to identify their ethni-
city. A t-test was performed to compare RIF scores
the remaining participants (n =75, Mean RIF =
5.2 ± 1.5) with the total group mean (n =109,
Mean RIF = 5.0 ± 1.5), and no significant differ-
ence was found. Of those who provided their eth-
nicity, 60 identified as Caucasian. In the Non-
Caucasian group (n =15), 5 responded as Asian,
4 as Aboriginal, 4 as mixed ethnicity, and 2 as
African descent. A t-test was then performed to
examine differences in RIF between Caucasian and
Non-Caucasian participants, which revealed no
significant difference. An ANOVA, followed by
Tukey’s multiple comparisons test, was done to
examine differences between the subgroups within
the Non-Caucasian participants, and found no
significant differences.
104 participants completed the survey in its
entirety. A t-test found no difference in RIF between
those who answered “No” to the question #3 regard-
ing sensitivity to cold (n =92, RIF =5.0 ± 1.5) and
those who answered “Yes” (n =13, RIF =4.7 ± 1.0).
A PPMCC found no significant correlation between
RIF and total comfort score in Question 1 (r =−0.08).
146 W. SULLIVAN-KWANTES ET AL.

Table 1. Mean resistance index to frostbite (RIF) scores. basis by implementing either extra cold weather pro-
N RIF (Mean ± SD) tection or other technical or administrative/training/
All Participants 109 5.0 ± 1.5
doctrinal measures. The other key finding however is
Injury Status
Injured 40 5.1 ± 1.5 the overall rate of CWIs in the study – a 33% casualty
Uninjured 69 4.9 ± 1.4 rate. We suspect that this magnitude of injuries in
Injury Severity
Frostbite 34 4.9 ± 1.4 a temperate temperature deployment would be gen-
Frostnip 6 5.7 ± 2.0 erally considered unacceptable by most militaries.
Injury Location
Non-Extremity 26 5.2 ± 1.7
All Extremities 14 4.9 ± 1.3
Feet 1 4.0 ± 0.0
CWIs
Hands 9 5.3 ± 1.2
Both Hands and Feet 4 4.3 ± 1.3 As we have presented in this study, the RIF-value
Smoking Behaviour of the 14 soldiers that were diagnosed with a CWI
Smoker 47 5.3 ± 1.6 on the extremities was 4.9 ± 1.3. The RIF- value of
Non-Smoker 62 4.8 ± 1.3
Rank the 69 soldiers that were not diagnosed with
Junior NCM 94 5.0 ± 1.5 a CWI was 4.9 ± 1.4. These values were not sig-
Senior NCM 12 5.0 ± 1.3
Junior Officer 3 4.7 ± 0.6
nificantly different. These results conflict with pre-
Ethnicity vious findings from Daanen and van der Struijs [6]
Caucasian 60 5.0 ± 1.5 who reported significantly lower RIF scores in
Non-Caucasian 15 5.9 ± 1.3
Asian 5 5.0 ± 1.0 marines who suffered cold injuries vs. those who
Aboriginal 4 6.5 ± 1.7 did not. RIF scores also did not appear to correlate
Mixed ethnicity 4 6.5 ± 1.3
African 2 6.0 ± 0.0
with injury severity, as there was no significant
Declined to Answer 34 4.7 ± 1.2 difference between those who experienced frost-
bite (N =34, RIF =4.9 ± 1.4) and those who experi-
enced frostnip (N =6, RIF =5.7 ± 2.0).
Of the 109 participants for whom RIF scores
The CIVD response has been shown in tempera-
were calculated, 40 experienced a CWI during the
tures as high as 8°C [14], but in extremely cold and
Arctic training exercise. Mean RIF scores are
windy conditions, the CIVD mechanism may be
shown in Table 1. No significant difference was
unable to prevent freezing and subsequent CWIs
found between the RIF scores of injured and unin-
[15]. Wilson et al. [15] examined the effects of dif-
jured participants . Of the 40 injuries, 14 were
ferent air temperatures and wind speeds on the
sustained in the extremities (hands and feet).
CIVD response in the finger, and found that none
When RIF scores were compared across injury
of their participants exhibited CIVD at air tempera-
locations, no significant differences were found.
tures below −16°C. In the present study, the partici-
No significant difference was found based on
pants spent six days in northern Nunavut, Canada,
smoking behaviour or military rank. No signifi-
experiencing daily temperatures ranging from −23°C
cant correlation was found between RIF and age
to −43°C, with wind chill equivalent temperatures of
(r =0.003), RIF and number of cigarettes smoked
less than −50°C [13] In addition, many of their
per day (r =0.226), or RIF and oral temperature
operational tasks exposed them to higher wind
(r =0.114).
speeds (long snowmobile trips), and compromised
personal protection (removing gloves to perform
fine-motor tasks). It is possible that in this scenario,
Discussion
the cold exposure was too great to be mitigated by
The goal of the current study was to test whether the the CIVD response, thus negating the predictive
RIF could serve as a tool to predict susceptibility to potential of the individual RIF scores.
peripheral CWIs during CAF Arctic Operations with Park and Lee [16] found that self-identified cold
the intention of helping to reduce the incidence of intolerance significantly correlated with a weaker
CWIs during future Arctic Operations. The institution CIVD response. Similarly, Daanen and van der
of the RIF rating would complement other methods of Struijs [6] noted that those with a low RIF score
preventing CWIs – perhaps even on an individual tended to be aware of their susceptibility to CWIs.

Even though these subjects avoided hazardous situa-
tions, they were more at risk. In our study, the risk
avoidance may also be a plausible explanation for the
absence of a relationship between RIF and CWI
incidence. If those with low RIF scores are aware of
their poor response and heightened risk, they may
behave more cautiously to avoid situations that may
elicit a CWI. However, the relevant survey questions
in the present study showed no relationship between
RIF and self-assessed cold sensitivity.
The CIVD test was performed in fingers, while cold
injuries also occurred at other body locations like the
toes. It has been shown that the physiological beha-
viour of fingers and toes is often unrelated [17] and
therefore the CIVD test in the fingers may not have
been specific enough for other cold injuries [12].
Additionally, a total of 40 soldiers were diagnosed
with CWIs (mean RIF =5.1 ±1.5), however, only the
extremity CWIs are relatable to the CIVD test, as
arteriovenous anastomoses exist only in the fingers
and toes [9]. Thus the relation between RIF and the 26
soldiers who were diagnosed with CWIs on the face,
head, and/or neck cannot be assessed in this study.
Smoking
The relationship between smoking and RIF was
assessed due to the well-documented peripheral
vasoconstriction that occurs temporarily after
tobacco smoking [18]. Previous studies have reported
impaired rewarming in smokers [19,20]. Interestingly,
Daanen and van der Struijs [6] reported increased RIF
scores in smokers compared to non-smokers. In the
present study, there was no significant difference in
RIF scores between smokers and non-smokers, and
no correlation with number of cigarettes smoked
per day. Despite being permitted to smoke ad libitum
until arrival for the study, the acute vasoconstriction
resulting from tobacco smoke did not appear to influ-
ence the CIVD response. Of the 40 participants who
suffered a CWI, 22 were non-smokers and 18 were
smokers, indicating smoking did not increase inci-
dence of CWI in this study, contrary to previous
reports [21–23].
Ethnicity
There was no significant difference in RIF based on
self-identified ethnicity. Previous studies have
TEMPERATURE 147
reported significant differences in RIF [6, 24] and
CIVD response [25–27] across difference ethnicities,
with weaker CIVD responses typically being found in
non-Caucasians. In the present study, the population
was predominantly Caucasian (N =60), which may
have masked potential significant differences with
the underrepresented non-Caucasian group (N =15).
For instance, previous studies have reported lower
CIVD responses in individuals of African descent
[27,28], but the present study had only two partici-
pants of African descent, and found no significant
difference from the Caucasian group.
Pain ratings
Pain is known to vary during typical CIVD tests,
peaking during vasoconstriction and decreasing
during vasodilation [29]. The pain ratings given
during and after the CIVD test showed only
a weak to moderate correlation with RIF. The
strongest correlations were shown at 35 min
(r =- 0.45) and 40 min (r =−0.29). All correlations
were negative, meaning higher pain ratings corre-
lated with lower RIF (higher risk). Daanen and
van der Struijs [6] also found moderate negative
correlations between pain and RIF, noting that
pain could be taken as a warning sign before
a CWI occurs.
Limitations
This study only included one female participant, thus
sex-related differences in RIF were not examined.
While this may be a limitation, a previous study [11]
found CIVD response was not influenced by sex.
Participants were permitted to smoke and consume
caffeine ad libitum until arrival for the CIVD test. As
described above, previous studies have demonstrated
the acute vasoconstriction and CIVD responses of
smoking. While no difference in RIF was found
between smokers and non- smokers, the acute effects
of smoking were not controlled in this study. Kim
et al. [30] also noted a diminished CIVD response
following caffeine consumption, which may have
impacted the RIF scores seen presently. Future studies
should ensure a uniform period of pre-study smoking
and caffeine abstinence in all subjects.
Despite a large sample size and a wide distribu-
tion of CIVD responses, this study did not find
148 W. SULLIVAN-KWANTES ET AL.

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