Unless you live, work or play in the coldest regions of the country, cold-weather related pathologies will be seen only rarely by massage therapists. It is probably more likely the massage therapist on a skiing vacation or mountain climbing while on holiday might get frostbite, frostnip or chilblains. If the massage therapist is working in a ski resort or mountaintop lodge, there may be the occasional traveler coming in for a massage. He or she may not have active frostbite or another cold-related pathology, but it may be in his or her history, so it is important to be familiar with how extreme cold can affect the body both during and after exposure.

Common Cold Weather Pathologies

If exposed to persistent cold temperatures, the body tries to maintain warmth to the vital organs by constricting blood vessels in the extremities, making them particularly vulnerable to injury. In temperatures below freezing, ice crystals may form in interstitial fluids, body tissue and blood cells. Cells may rupture and tissue may freeze. Lack of adequate circulation to the extremities can itself cause damage. The most common cold-related pathologies are hypothermia, frostnip, chilblains, frostbite and trenchfoot.

  • Hypothermia – Hypothermia is when the body’s core temperature drops below 95.0°F degrees (35.0°C). Hypothermia ranges from mild to severe depending on how low the temperature goes and the length of time it continues. Symptoms can include shivering, confusion, lack of coordination, pale skin, and blueness of extremities (ears, nose, lips, fingers, toes). In severe hypothermia, major organs may fail and death can occur.
  • Frostnip – Frostnip, also referred to as first-degree frostbite, affects only the topmost surface of the skin. This outermost layer freezes, causing itching and pain. The skin may show patches of red, white and yellow discoloration and become numb. This does not usually cause permanent damage.
  • Frostbite– Frostbite is broken up into four classifications, or degrees.
    1. First-degree frostbite is referred to as frostnip, described above.
    2.  Second-degree is similar to first, but the skin remains frozen longer, though not deeper and may produce blisters 1-2 days after becoming frozen.
    3.  Third-degree frostbite extends the damage into the underlying tissue, including muscles, tendons, blood vessels and nerves. The area feels cold and hard to the touch. Blood-filled blisters may appear – at first with a purplish hue, eventually turning black. Amputation may be needed to prevent gangrene.
    4. Fourth-degree frostbite extends even deeper, into the bone and will most likely result in tissue loss and amputation.
  • Trenchfoot – Trenchfoot is caused by prolonged exposure of feet to cold, damp and unsanitary conditions. The name came about during World War I, when solders fought “trench warfare,” often standing in trenches partially filled with water for long periods of time. The tissue does not freeze, but may turn deep red or blue and show signs of necrosis (decaying skin). There may be open sores, blisters or fungal infections. If left untreated, gangrene may set in and amputation may be necessary. If treated in a timely manner, there will usually be a complete recovery.
  • Chilblains – Chilblains is a pathology often confused with both frostbite and trenchfoot. It occurs in individuals with a predisposed sensitivity to cold and humidity. Exposure to cold damages capillaries, resulting in itching, redness, inflammation and even blisters. Chilblains may be symptomatic of some other underlying pathology.

All of the above pathologies may result in life-long sensitivity to cold and heat. They can also lead to various degrees of infection, tissue damage and even amputation or death. All but the worst will usually have full recovery anywhere from days to months after the initial injury.

Some individuals will be more prone to cold weather injury, such as those taking beta-blockers, persons with diabetes or anyone with peripheral neuropathy. Conditions such as extreme cold, wet clothing, clothing that is too tight or inadequate for a cold climate, smoking, drinking alcohol, certain medications and exposure to cryogenic chemicals can contribute to injuries from cold.

The Treatment of Cold Pathologies

The best thing for someone to do when cold temperatures start causing possible tissue damage is to remove the individual from the situation and begin gently – and slowly – re-warming the body. The location should have stable warmth without the possibility of refreezing temperatures, which will only cause more damage.

Warming should be done without applying movement to the tissue. That means no rubbing, massaging or shaking. Do not rub the affected area with snow or apply any kind of direct heat to the area. Excessive movement will cause the ice crystals to injure sensitive body tissue. The best way is to provide blankets or other kind of wrap for passive heat. Having a warm body lay next to the cold-affected one can also help.

Professional rescuers can apply more active warming techniques, such as immersion into water that is between 40-42°F or the introduction of intravenous fluids.

If damage is deep, the frozen tissue may separate from the rest of the body. Surgery may eventually be required to remove remaining dead tissue.

Massage therapists should ask clients if injuries related to cold weather are in their histories. If the answer is yes, caution should be taken with the use of any body-centered therapies using heat or cold (such as hot/cold stone massage, cryotherapies or those using hot-packs), as the client may have either increased or decreased sensitivity to temperature variations and will be unable to give appropriate feedback to the therapist.


The only real way to prevent tissue injury from cold is to keep the body warm and dry. While it may be more comfortable to stay inside, it may be more fun to experience nature, even in the extremes of winter. Some helpful hints to avoid injury from cold, include:

  • Dress warmly and appropriately for the climate you are in.
  • Clothing should be comfortable and not restrictive. Don’t tie laces so tight as to cut down on healthy circulation.
  • Don’t stay out in cold weather too long. If at all possible, take breaks in a warmed area and allow your body to return to a healthy core temperature.
  • If you will be walking in cold, wet places, make sure your footwear will keep you dry and warm. Carry an extra pair of dry socks with you and make sure you change socks every day.
  • Replace wet clothing with dry as soon as possible.
  • Maintain overall energy with a healthy diet and regular exercise.

Getting a massage on a regular basis will help as well, by improving circulation and reducing toxins in the body. If you need to be out in the cold for long periods of time, keeping the body healthy and strong is perhaps the most important thing you can do. Weekly, biweekly or even monthly massage is one of the best defenses you can have.

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