Cold Hyperalgesia Testing

I have often read in the literature the view that Cold Hyperalgesia is suggestive of more “severe” pain states and hence poorer prognosis. For example:

  • Van Oosterwijck et al (2013) reported in their Systematic literature review on the evidence for central sensitisation in chronic whiplash that:
    • The outcome of the processes involved in central sensitization is an increased responsiveness to a variety of stimuli including mechanical pressure, chemical substances, cold temperature, heat temperature and electrical stimuli.
  • Goldsmith et al (2012) conducted a systematic review investigating cold hyperalgesia as a prognostic factor in whiplash associated disorders.
    • There is moderate evidence supporting cold hyperalgesia as a prognostic factor for long-term pain and disability outcome in Whiplash Associated Disorders.
  • Woolf (2011) suggests that Cold Hyperalgesia is suggestive of central hyper excitability/sensitisation.
  • Haanpaa et al (2011), in their guidelines for neuropathic pain assessment:
    • Studies have shown that sensory examination (i.e., pinprick, heat, cold and tactile stimuli) in the painful area could discriminate patients with neuropathic pain from those without neuropathic pain.
  • Kaya et al (2013) in a Systematic Literature Review on Central Sensitisation in Urogynecological Chronic Pelvic Pain report that:
    • Central Sensitisation entails much more than generalized hypersensitivity to pain: It is characterized by an increased responsiveness to a variety of stimuli including mechanical pressure, chemical substances, cold, heat, electrical stimuli, stress, emotions, and mental load. 

So this was all well and good. The issue I had being I could never find how I could go about somewhat confidently assessing cold hyperalgesia in the clinic unless I purchased some expensive equipment! I did realise that I could probably just grab an ice block or icepack from the freezer and pop it on the patients area of pain and see the response. But what response was I looking for e.g. how much pain? Did I need to test other areas?

Pleasingly I recently found a study by Maxwell and Sterling (2013) that helped to answer some of my questions. The study took 63 participants with chronic Whiplash Associated Disorder (WAD) (grade II and III) and tested them for cold hyperalgesia at the cervical spine with both laboratory testing equipment and with 10 seconds of ice application. The patients reported pain intensity on an 11 step numerical rating scale. The authors then compared the ability for 1o seconds of ice to discriminate between cold hyperalgesic and non-cold hyperalgesic sites vs the laboratory equipment. Final results concluded that:

A pain intensity rating of greater than 5 gave a positive likelihood ratio of 8.44 suggesting that, if this value is reported, clinicians could be suspicious of the presence of cold hyperalgesia.

So I plan to begin assessing cold hyperalgesia more regularly in the clinic using this method. Granted more studies need to be done to further validate this clinical test, but I think this is a good starting point. I personally think that we can use cold hyperalgesia testing to compliment our other testing that we might routinely use to assess for neuropathic pain/central sensitisation. In my case I often use:

  • Brushing of cotton wool or a tissue for Allodynia (local and widespread).
  • Using a toothpick or end of a paperclip for sharp hyperalgesia (local and widespread).
  • Neuropathic pain questionnaires such as the LANSS scale, PainDETECT and DN4.

Interested to hear other peoples thoughts.

Thanks for reading.


Goldsmith R, Wright C, Bell SF, Rushton A. Cold hyperalgesia as a prognostic factor in whiplash associated disorders: a systematic review. Man Ther. 2012 Oct;17(5):402-10. doi: 10.1016/j.math.2012.02.014. Epub 2012 Mar 29.

Haanpää M, Attal N, Backonja M, Baron R, Bennett M, Bouhassira D, Cruccu G, Hansson P, Haythornthwaite JA, Iannetti GD, Jensen TS, Kauppila T, Nurmikko TJ, Rice AS, Rowbotham M, Serra J, Sommer C, Smith BH, Treede RD. NeuPSIG guidelines on neuropathic pain assessment. Pain. 2011 Jan;152(1):14-27. doi: 10.1016/j.pain.2010.07.031. Epub 2010 Sep 19.

Kaya S, Hermans L, Willems T, Roussel N, Meeus M. Central sensitization in urogynecological chronic pelvic pain: a systematic literature review. Pain Physician. 2013 Jul-Aug;16(4):291-308.

Maxwell S, Sterling M. An investigation of the use of a numeric pain rating scale with ice application to the neck to determine coldhyperalgesia. Man Ther. 2013 Apr;18(2):172-4. doi: 10.1016/j.math.2012.07.004. Epub 2012 Aug 11.

Van Oosterwijck J1, Nijs J, Meeus M, Paul L. Evidence for central sensitization in chronic whiplash: a systematic literature review. Eur J Pain. 2013 Mar;17(3):299-312. doi: 10.1002/j.1532-2149.2012.00193.x. Epub 2012 Sep 25.

Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain.Pain. 2011 Mar;152(3 Suppl):S2-15. doi: 10.1016/j.pain.2010.09.030. Epub 2010 Oct 18. 


About the Author:

Mark is a Specialist Musculoskeletal Physiotherapist who consults at both Insight Physiotherapy and Pain Options, in Perth, Western Australia. He specialises in the assessment and management of persistent/chronic musculoskeletal pain. In addition to his clinical role he maintains regular involvement in education of the profession having held a Teaching Fellow position at the University of Western Australia for 10 years and regularly presenting at courses and seminars through the Australian Physiotherapy Association and private education sector. Mark is also a Facilitator for the Australian College of Physiotherapists Specialisation Training Program and a Sessional Academic at Curtin University. The views expressed on this blog are his own.

7 Comments on "Cold Hyperalgesia Testing"

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  1. Robert Goldsmith says:

    Yes this method shows some promise (there are other methods out there that are similar) but I’m cautious about placing too much emphasis on this finding alone until further research has been done.

    The ‘window’ of sensitivity to cold for predicting outcome from WAD is quite narrow. Based on the data from Serling 2006, those who go on to recover well report pain at 12.7C (6.7)SD, and those who have a poor prognosis reporting pain at 17.4C (7.7). So thats a ‘window’ of 4.7C. Tricky to do with a block of ice and a VAS/NRS (and thats even before you consider the SD’s).

    • Mark Gibson says:

      Hi Robert,

      Thanks for the informative comment.

      I couldn’t agree more with you that we shouldn’t be placing emphasis on this finding alone. As I am sure you are aware there are many other factors in WADs that relate to prognosis. Utilisation of cold hyperalgesia testing, without a thorough clinical examination and use of appropriate screening tools, would be unwise.

      As Sterling and Maxwell (2013) mention:

      Uncertainty regarding a value for a positive test is unlikely to be a significant issue for clinical practice, as prognosis and clinical decisions will not be made on the presence of one factor alone (i.e. cold hyperalgesia). Additional factors of pain and disability levels, psychological factors and demographic factors should also be included in gauging prognosis and decisions about treatment.

      The use of ice as a proxy measure of cold hyperalgesia adds further information to the clinical assessment. The implications of the presence of cold hyperalgesia in terms of alternative management approaches should be considered more strongly if an individual with WAD reports limited clinical improvement, regardless of reported NRS value.

      Thanks again.


  2. Robert Goldsmith says:

    Hi Mark, I completely agree. No clinician is likely to base treatment decisions on CH alone, and rightly so. I’m also not sure how we interpret CH. Many authors are making a link between CH and ‘central sensitisation’ (however you choose to define that). I’m not yet sure how we should be interpreting CH. IT could be a sign of neuropathy, neuroinflammation or a marker for a psychological variable. I hope this becomes clearer as more research is done. It might make it a much more useful sign.

    Nice site & Blog BTW,



    • Mark Gibson says:

      Thanks again Rob for the feedback and information re: this topic and the blog.

      Now that my brain has kicked into gear, and assuming I have the right Robert Goldsmith, I will also say that I enjoyed reading the systematic review of yours that I referenced in this post!

      Best wishes.


  3. ortho run says:

    Merci pour toutes vos information s ainsi que votre site

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