Physiology & Behavior 271 (2023) 114354

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Physiology & Behavior

journal homepage: www.elsevier.com/locate/physbeh

Review

Water temperature during the cold pressor test: A scoping review

Selina Fanninger a, Paul L. Plener a, b, c, Michael J. M. Fischer d, Oswald D. Kothgassner a, b,
Andreas Goreis a, b, *
a
Department of Child and Adolescent Psychiatry, Medical University Vienna, Vienna, Austria
b
Comprehensive Center for Pediatrics (CCP), Medical University of Vienna, Vienna, Austria
c
Department of Child and Adolescent Psychiatry and Psychotherapy, University of Ulm, Ulm, Germany
d
Center for Physiology and Pharmacology, Medical University of Vienna, Vienna, Austria

A R T I C L E I N F O A B S T R A C T

Keywords: The cold pressor test (CPT) is a commonly used method to induce pain and stress in experimental settings.
Cold pressor Previous research has found that the temperature of the water used in the test significantly affects outcome
Laboratory pain measures such as pain tolerance. Variations in CPT protocols, specifically regarding temperature, have been
Experimental pain
criticized. Hence, our objective is to investigate water temperature and associated methodological factors
Laboratory stress
Experimental stress
through a scoping review of the CPT in adults.
Methodology Among 331 included trials, the most commonly reported temperature was 1◦ C (33.8◦ F). Reporting of the
water temperature was adequate (93% of all trials), but a precise range within which the temperature was
maintained was reported only in 27% of all trials. Pain measurement was the primary focus for most studies
(90%), predominantly utilizing pain tolerance as the main outcome (78%). Water circulation was reported in
44% of studies, and 10% reported manually agitating the water. The most common maximum immersion time (i.
e., ceiling time) was 180 s; notably, 64% of trials lacked information on participant awareness of this limit
specification. The limb most immersed was the hand (76%).
Overall, multiple methodological factors significantly impacting outcome measures were inconsistently
implemented or reported. For future studies, we advocate for precise standardization of the water temperature
used during the CPT. We suggest using 1◦ C (33.8◦ F), especially when assessing pain tolerance. A cooling
apparatus allowing precise temperature control and continuous water circulation is advised. At the bare mini­
mum, the temperature should be monitored continuously. While other decisions regarding the implementation of
the CPT may differ depending on the specific aims of the respective study, it remains essential to standardize the
water temperature and to provide a comprehensive report of the experimental protocol.

1. Introduction
The cold pressor test (CPT) has been used increasingly in the study of
pain and physiological stress in laboratory settings. However, the
apparent lack of agreement on a standard protocol has been criticized (e.
g., [1]). The CPT is conducted by immersing a limb, usually the hand, in
ice-cold water. Given that extreme cold poses a threat to survival, it is
crucial for living beings to have the ability to sense and avoid extremely
low temperatures. The cold-water immersion activates nociceptors in
the skin, which transmit ascending signals through A-δ and C fibers to
the somatosensory cortex [2]. This type of acute pain, usually perceived
as mild to moderate, is similar to naturally occurring types of pain (e.g.,
holding an ice cube or postoperative pain [3,4]). Sudden exposure to
cold further activates the sympathetic nervous system (SNS), leading to
cardiovascular changes, such as increased heart rate, blood pressure,
and respiratory rate [5]. In the context of the CPT, the increase in blood
pressure has been referred to as the “pressor response”, from which the
name of the test was derived [6].
In addition to activating the SNS, the CPT concurrently acts as a
potent physiological stressor by activating the endocrine hypothalamic-
pituitary-adrenal (HPA) axis, which releases glucocorticoids involved in
the body’s ability to coordinate physiological and behavioral responses
during stress [7]. The HPA axis response is particularly robust during the
Socially Evaluated CPT (SECPT), an adapted version of the standard CPT
protocol that includes a standardized social-evaluative threat alongside
cold water immersion [8,9]. From a stress-oriented standpoint, the

* Corresponding author at: Department of Child and Adolescent Psychiatry, Medical University of Vienna, Währinger Gürtel 18-20, Vienna 1090, Austria.
E-mail address: andreas.goreis@meduniwien.ac.at (A. Goreis).

https://doi.org/10.1016/j.physbeh.2023.114354
Received 12 June 2023; Received in revised form 7 September 2023; Accepted 14 September 2023
Available online 17 September 2023
0031-9384/© 2023 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
S. Fanninger et al.
response to the CPT involves adaptive multisystem mechanisms that
prepare and enable the body to cope with noxious stimuli, serving as
warning signals to prevent injury or tissue damage.
Pain researchers often aim to investigate the cold pain threshold (the
latency until the noxious stimulus is first perceived as painful) or pain
tolerance (usually recorded as the maximum time of immersion or,
rarely, as the latency from threshold to termination). Such temporal
measurements in response to the CPT may be accompanied by subjective
measures of pain intensity (e.g., indicated on visual analog scales). Pain
threshold, tolerance, and intensity have been shown to vary significantly
between individuals. Apart from possible methodological confounds,
this variability is attributed to various factors, including genetic, phys­
iological, psychological, and situational influences, as well as their in­
teractions [10–12]. These findings highlight the importance of
considering these factors during the planning, execution, or interpreta­
tion of CPT studies. When assessing other outcomes, researchers
commonly measure autonomic or cardiovascular responses (e.g., heart
rate, blood pressure) and, less frequently, parameters indicating HPA
axis activation (e.g., salivary cortisol) as indicators of physiological
reactivity in response to the CPT [4,13,14]. Another core difference in
CPT paradigms is whether a predefined time cut-off is established to
terminate the cold water immersion, primarily to ensure participant
safety. This cut-off may act as a “ceiling” for trials focusing on pain
tolerance. In these cases, highly pain-tolerant participants may reach the
maximum immersion time, even though reaching this limit is not the
primary objective when assessing pain tolerance. If the goal is stan­
dardized exposure and a consistent response evaluation across partici­
pants, fixed latency paradigms are conducted, wherein participants
undergo a predetermined, often shorter, duration of exposure. The fixed
latency paradigm is associated with lower subjective pain ratings
compared to the pain tolerance paradigm, suggesting that these para­
digms do not impose the same demands on participants [15].
Historically, the CPT was first described by Hines and Brown [16] as
a method for measuring autonomic reactivity and predicting the future
development of hypertension in apparently normotensive individuals. It
was not until 1941 that Wolf and Hardy described its application as a
pain stimulus in experimental settings. Since the 1970s, it has occa­
sionally been used as a laboratory stressor; increasingly so with the
introduction of the SECPT in 2008 [8]. In a more recent guideline [17],
procedures for conducting the standard CPT are recommended. These
include immersion of the dominant hand and forearm into a continu­
ously circulating water bath at 1 ± 0.3◦ C until unbearable or until the
trial is terminated at 120 s. However, this guideline [17] has only been
cited 25 times (SCOPUS, as of August 2023). Adherence to specific
guidelines and—more importantly—the feasibility of those guidelines
are, therefore, unclear.
1.1. Objective of the current review
A pivotal element—the water temperature used during the
CPT—was found to influence outcome measures significantly. However,
the CPT protocol has been insufficiently standardized [1,18–20]. For
example, a temperature variation of 2◦ C or more within a single trial has
been demonstrated to introduce a confounding factor [20]. Besides
ensuring a stable temperature, the challenge lies in finding a tempera­
ture that reliably and consistently induces pain or stress while ensuring
participant safety. To date, few studies have empirically evaluated the
differential effects of water temperature or conducted a review of the
CPT methodology [19–24]. Furthermore, with the exception of one re­
view including 22 studies [20], the research synthesis of CPT method­
ology is limited to its adaptation for children [4,21]. With 10◦ C, the
water temperature recommended for use in children differs vastly from
temperatures typically used in studies of adults.
Therefore, our objective is to examine the water temperature used
during the CPT in adults, describing the degree of variation across
studies and time. Furthermore, we address other relevant factors related
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Physiology & Behavior 271 (2023) 114354
to the experimental configuration as well as conduct. Ultimately, the
current review aims to conclude with recommendations for designing
and conducting future studies that employ the CPT.
2. Method
2.1. Search strategy
We searched MEDLINE, PubMed, and Google Scholar using the
search term combination “cold pressor test” AND tolerance AND pain
and the combination “cold pressor test” AND “socially evaluated”. No
limits on publication year were imposed. The literature search
concluded in March 2023, thus including studies up to this date. Due to
the impracticality of including all published CPT trials to date, we
applied a more restrictive search strategy with the aim of selecting a
representative subsample for the purpose of our review. Specifically,
studies that utilized a CPT or SECPT paradigm in adult participants were
included. We excluded variants of the CPT that do not include cold water
immersion (e.g., arm wrap or forehead cold pressor). Studies with the
primary aim of comparing different water temperatures were excluded.
In the case of multiple studies drawing data from the same dataset, only
the study published the earliest was included (secondary data was,
therefore, excluded). A Google Scholar alert was set up to allow for the
inclusion of newly published articles. In addition, we cross-referenced
our findings with the supplementary materials provided by Treister
et al. [25], who identified 122 studies using the search term “cold
pressor test” AND “tolerance” AND “pain” for their review focusing on
data analyses in CPT studies. 119 of the records provided by Treister
et al. [25] were included in our review. Details regarding the literature
search were recorded in a PRISMA flow diagram [26], which is pre­
sented in Fig. 1. The search and application of exclusion criteria were
performed by the first (SF) and last author (AG). Disagreements were
discussed and resolved with a third author (ODK). The study was re­
ported according to the PRISMA-ScR checklist [27], which is provided in
Supplementary Table 1.
2.2. Data extraction
The following characteristics of eligible studies were coded: whether
the study reported a water temperature at all (yes/no) and the specific
water temperature stated (in ◦ C). Whenever necessary, we calculated the
arithmetic mean of the water temperature (e.g., if a range of 0–1◦ C was
reported, the mean temperature was coded as 0.5◦ C). Furthermore, we
extracted information on whether the primary objective of each study
was to address pain, stress, both, or other variables, as well as the
outcome measures used. Additionally, we coded the type of cooling
equipment utilized, whether the water was circulated, how the tem­
perature was controlled, and which limb was immersed. In instances
where there was a predetermined cut-off time (ceiling time), we recor­
ded this information, as well as whether participants were informed of
this prior to the CPT trial. We assigned studies to one of five categories
according to sample characteristics: healthy (all participants were
described as “normal”, “apparently healthy”, “healthy”, or the sample
consisted of undergraduates); somatic disease (the sample included
patients with somatic diseases, including chronic pain, may include a
healthy control group); mental health disorder (the sample included
patients with mental health disorders, may include comorbid somatic
diseases or a healthy control group) or addiction (the sample included
patients with current or recent substance dependence, may include co­
morbid psychiatric and somatic diseases or a healthy control group).
When samples were mixed, i.e., including participants with comorbid­
ities or multiple groups with different diagnoses, the study was assigned
to the category that best described the primary diagnosis, the majority of
participants’ diagnoses, or the primary research question of the study.
Although subsuming the last four categories as “clinical” represents an
artificial dichotomization of a continuous variable, this classification
S. Fanninger et al.
Fig. 1. Flowchart illustrating the literature search and selection process.
was utilized for simplicity and to facilitate analysis. Lastly, we noted
whether the immersion time was fixed (fixed latency paradigm) or if
participants were instructed to keep their limb in the water until it
became unbearable (tolerance paradigm).
Data were entered into a spreadsheet by the first (SF) and last author
(AG). From the included trials, 70 (20%) were chosen at random and
coded independently by a research assistant naïve to the aim of the
current study. The inter-rater reliability coefficient Cohen’s κ was 0.97,
indicating almost perfect agreement between raters [28]. Prior to data
analysis, the present study was preregistered with the Open Science
Framework (osf.io/hqfks, doi: 10.17605/OSF.IO/HQFKS). For compre­
hensive data underlying our analyses, please refer to Supplementary
Table 2.
2.3. Statistical analyses
To summarize study characteristics, we computed descriptive mea­
sures (e.g., Mode, M, SD). We explored temperature as a function of time
by fitting linear regression models. To compare water temperatures
between healthy and clinical samples, we conducted a Mann-Whitney U
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Physiology & Behavior 271 (2023) 114354
test. Analyses were performed in R (version 4.2.3). The package ggplot2
[29] was used to visualize data.
3. Results
330 studies were included, of which one study reported results of two
independent CPT trials [30]. Thus, our final sample comprises 331 CPT
trials (all further references to “studies” or “trials” refer to these 331
included trials). In most studies (93%), water temperature was reported,
while in the remaining studies, temperature specifications were absent.
In 27% of studies, a specified temperature range was maintained, while
in the remaining studies, the level of precision concerning temperature
maintenance remains unclear. The most frequently used temperature
was 1◦ C (in 22% of trials), followed by 2◦ C and 4◦ C, accounting for 19%
and 11% of the trials, respectively. The mean temperature was 2.43◦ C
with a standard deviation of 2.11◦ C, and temperatures ranged from -2 to
12◦ C. Linear regression models were fitted to explore mean temperature
as a function of time, indicating that temperature increased in healthy
samples (b = 0.06, SE = 0.02, p < .001) but not in clinical studies (b =
0.01, SE = 0.02, p = .56; Fig. 2).
S. Fanninger et al.
Fig. 2. Distribution of the temperature over time, categorized by sample type. Higher contrast symbolizes overlapping data points. The lines visualize tempera­
ture trends.
To analyze differences in the mean temperature used in clinical
studies (M = 2.20◦ C, SD = 2.04◦ C) and studies including only healthy
participants (M = 2.53◦ C, SD = 2.14◦ C), a Mann-Whitney U test was
conducted (W = 9113.5; p = .14). The results showed no statistically
significant difference between the groups.
In 45% of studies, no information regarding the circulation of the
water was given, 44% reported circulation, and 10% stated that the
water was manually stirred, shaken, or mixed. The mechanical circula­
tion rate of a device was reported in only six trials (2%).
The majority of the included studies utilized the CPT to measure pain
(90%), while only 6% aimed to measure stress; in 0.9% of studies, pain
and stress were mutually assessed. The remaining studies had other
objectives. In most trials, the sample solely consisted of healthy in­
dividuals (68%), followed by participants with somatic diseases (17%),
substance dependence (8%), and mental health disorders (7%).
The limb most commonly immersed was the hand (76%), followed
by the forearm (18%) and one foot or both feet (5%). In trials involving
hand immersion, the non-dominant hand was most commonly utilized
(29%), followed by the left hand (16%), right hand (14%), and dominant
hand (13%). In the remaining studies, hand immersion involved both or
a combination of hands (11%), or the specific hand was not specified
(19%). In one study, either the index finger or hand was immersed [31];
in another, it was merely stated that a “limb” was immersed [32].
Most studies employed the tolerance paradigm (89%), while only
11% employed a fixed latency paradigm. In 80% of trials, a maximum
time of immersion (ceiling time) was set, ranging from 18 s to 900 s. The
most frequent durations were 180 s and 300 s, accounting for 24% and
18% of trials, respectively. Most often, it was not reported whether
participants were informed of the maximum immersion time or cut-off
prior to the CPT (64%); in 18% of studies, participants were informed,
4
Physiology & Behavior 271 (2023) 114354
and in 15% of studies, they were unaware of the ceiling time. The most
common outcome measure was pain tolerance (259 times), followed by
pain intensity (171 times) and pain threshold (142 times). Outcomes less
often employed were blood pressure (46 times), heart rate (42 times),
pain unpleasantness (30 times), salivary cortisol (21 times), and mea­
sures of subjective stress (15 times).
4. Discussion
The present review indicates that reporting of the water temperature
in the 331 included CPT studies was generally adequate (93% reported a
specific temperature). Still, a range was specified in only 27% of stud­
ies—a finding that raises concerns about continuous water temperature
monitoring and maintenance. The temperature most frequently reported
was 1◦ C (33.8◦ F), with an overall tendency towards higher temperatures
(M = 2.43◦ C, SD = 2.11◦ C). There was a wide variation in the temper­
atures used across studies (range: -2–12◦ C). We found an increase in the
temperature used over time in studies involving healthy participants (p
< .001), while no such increase was observed in clinical trials (p = .56).
This difference could be attributed to the broader range of applications
that have emerged, especially in studies with healthy subjects, which
may also have led to the use of more diverse water temperatures. No
significant difference was found when comparing the overall mean
temperatures between clinical and healthy participants (p = .14).
The type of device used to cool and circulate the water also plays a
crucial role as it determines the uniformity of the cold stimulus, and
uncirculated water leads to longer tolerance times [4,20,33]. In our
review, we found that 44% used stirring or pumping devices, and 10%
manually stirred, shook, or mixed the water. 45% did not provide any
information regarding circulation, implying the absence of a circulation
S. Fanninger et al.
method. This is relevant as the thickness of the unstirred layer around
the participant’s immersed limb affects the rate at which the cold
stimulus reaches the skin. Continuous circulation minimizes the thick­
ness of the unstirred layer, leading to better thermal equilibration. Thus,
the device should allow for circulation and precise temperature control
to maintain a constant temperature throughout the test and across
participants. In studies that used ice to cool the water, containers with
constructions such as mesh screen barriers to avoid direct contact be­
tween the skin and ice were highlighted as advantageous when other
forms of cooling were unfeasible (e.g., [34,35]).
The majority of studies (90%) focused on the investigation of pain,
with only a small percentage (6%) addressing stress. This discrepancy
can be attributed to the only recent emergence of the SECPT [8],
whereas the standard CPT is primarily used to assess pain or adjacent
outcomes.
One hand was immersed most often (73%), followed by the forearm
(17%) and one foot or both feet (5%). The remaining studies utilized
different variations, such as immersing both hands or feet. In the context
of specific limb immersion, it is important to consider spatial summa­
tion, the phenomenon in which the size and area of the body part
immersed in cold water affect the pain stimulus’s perceived intensity.
There have been conflicting statements about whether immersion of the
hand, for example, produces significantly different results compared to
immersing the forearm up to the elbow [4,36–38]. However, spatial
summation was found when experimentally comparing heat stimuli
applied to a skin area of 100 cm2 to that of 225 cm2 [39]. Given these
findings, extending this phenomenon to cold stimuli is plausible, thereby
suggesting the likelihood of spatial summation effects during cold water
immersion.
The non-dominant hand was immersed most frequently (in 29% of
all trials involving hand immersion), followed by the left (16%), right
(14%), and dominant (13%) hand. In the remaining studies, hand im­
mersion included both hands or a combination of hands (11%), or it was
not specified (19%). Previous research has indeed shown that handed­
ness and which hand was subjected to cold affected pain tolerance, with
a significantly higher pain tolerance in the dominant hand in right-
handed participants only [40]. However, subsequent research has not
replicated these findings, making it difficult to formulate a strong
recommendation regarding the preferred hand for CPT trials. Further­
more, the choice of hand may vary depending on specific research
questions. For instance, if continuous pain intensity reporting on a me­
chanical visual analog scale is integral to any CPT study, it appears
sensible to immerse the non-dominant hand [4].
In the majority of the included CPT trials (80%), a pre-set maximum
immersion time was used to ensure safety. Pain tolerance, i.e., the total
time the participant keeps their limb in the water, was the most frequent
primary outcome variable (in 78% of included trials). However, pain
tolerance is easily confounded by ceiling effects, and as there is signif­
icant interpersonal variance [10–12], the CPT might not act as a relevant
noxious stimulus for part of the population. Ceiling effects occur when a
substantial proportion of participants endure the cold stimulus until the
predefined cut-off, leading to right-censored data. For instance, in the
seventh wave of the Tromsø study, an ongoing epidemiological study of
health in Norway, a temperature of 3◦ C and a cut-off at 120 s were
utilized—over 25% of the participants reached the maximum time [41].
Indeed, this artificial ceiling may prevent further distinctions between
participants, potentially affecting the interpretability, validity, and
generalizability of pain tolerance. To avoid ceiling effects, using the pain
threshold instead of total tolerance times has been discussed [4].
However, a drawback in using the pain threshold as a measure is that
participants may not consistently indicate when they first experience
pain. Conversely, pain tolerance can be reliably measured as the latency
to withdrawal. Lowering the temperature below freezing would theo­
retically reduce ceiling effects and the lack of differentiation when
reaching cut-off times [42]. However, adding substances like glycerol to
induce freezing-point depression requires extra effort and ethical
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Physiology & Behavior 271 (2023) 114354
standards must be considered. Without more in-depth investigation, the
potential advantages of reducing ceiling effects do not outweigh the
challenge of ensuring participant safety and comparability with the
extensive body of existing evidence.
5. Conclusion
Despite repeated concerns, the CPT paradigm still lacks sufficient
standardization. Critical methodological factors such as the water tem­
perature, the specific range within which this temperature is main­
tained, water circulation, and the rate of circulation, as well as pre-trial
information about maximum immersion time given to participants,
either varied widely across studies or were inadequately reported.
As pain tolerance (the most frequent outcome measure) is susceptible
to ceiling effects, which can be reduced by utilizing lower temperatures,
we highlight—and endorse—the suggested temperature of 1◦ C (33.8◦ F)
in the guidelines by Modir and Wallace [17]. Conversely, immersing
only the hand—not the forearm, as Modir and Wallace [17] sug­
gested—is likely the preferred option as it aligns with previous ap­
proaches and appears to provide a sufficient cold stimulus. If pain
tolerance is the outcome of interest in future studies, stopping rules or
cut-offs of at least 180 s should minimize skewed data due to highly
pain-tolerant individuals. To ensure consistency and comparability of
outcomes within and across studies, a standardized cooling device is
crucial. We recommend a cooling apparatus that offers precise temper­
ature control and allows constant water circulation whenever feasible.
When using ice water, a barrier should be in place to prevent direct
contact between the ice and the hand. At a minimum, continuous tem­
perature monitoring is essential.
Some aspects regarding the implementation of the CPT, such as
which hand to use, may differ depending on specific research questions.
However, we emphasize the importance of standardizing the water
temperature, maintaining it within a narrow range, and providing a
detailed report of the experimental protocol. Further and more sys­
tematic investigation of the effects of water temperature on outcome
variables is warranted due to the limited empirical evidence available
[20,22–24,43]. We recommend utilizing within-subject designs to con­
trol for potential confounding variables arising from interindividual
differences.
The CPT will undoubtedly continue to be a valuable tool in experi­
mental pain and stress research. Despite its widespread use, methodo­
logical differences and inconsistencies limit the comparability of CPT
outcomes. Therefore, it is crucial for researchers planning studies, au­
thors, reviewers, and journal editors handling CPT studies to be well-
versed in conducting or reporting CPT trials. Emphasizing consistency
in water temperature and study protocols is a vital factor in ensuring
comparability and replicability in human pain and stress research.
Funding
This research did not receive any funding.
Declaration of Competing Interest
The authors declare no conflict of interest.
Data availability
No data was used for the research described in the article.
Acknowledgments
The authors would like to thank Rosa List and Leo Kirsch for their
valuable assistance on this project.
S. Fanninger et al.
Supplementary materials
Supplementary material associated with this article can be found, in
the online version, at doi:10.1016/j.physbeh.2023.114354.
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