Cold therapy for rheumatoid arthritis and chronic inflammatory arthritis
Evidence review
Overview
Most controlled cold-therapy evidence in rheumatoid arthritis comes from whole-body cryotherapy (WBC), a 2-3 minute cold-air chamber exposure at -166 to -202 F, which is a different method from a home cold plunge. A single-blinded RCT in 56 patients with active RA found WBC added to inpatient treatment reduced pain by 1.31 points on a 0-10 scale, and uncontrolled series report lower DAS28 and pain. When WBC was compared with local cold or conventional physical therapy, however, pain and disease activity improved similarly in all groups. Water-based data are limited to a cold mist shower crossover trial (modestly lower weekly pain) and a feasibility study of exercise with cold-water immersion that reported no flares.
Key findings
- WBC (cold-air chamber, not water) RCT, n=56 active RA: between-group pain difference -1.31 (95% CI -2.1 to -0.53, p=0.002) (Klemm 2022).
- WBC vs local cryotherapy RCT, n=60 active RA: pain fell most at -166 F but disease activity did not differ; 15% discontinued WBC; WBC judged not superior to local cold (Hirvonen 2006).
- WBC vs conventional rehabilitation, n=44 and n=50: similar improvements in pain and DAS28 in both groups (Gizińska 2015; Sadura-Sieklucka 2019).
- Uncontrolled WBC series, n=60 (48 RA): DAS28 3.9 to 3.4 and pain VAS 51.4 to 37.9 (p<0.01); 21.7% stopped for adverse effects (Braun 2009).
- WBC at -166 F, 3 min daily for 10 days, n=48 vs non-randomized controls: improvement in 31 of 48, with significant reductions in pain, morning stiffness, joint swelling, CRP and corticosteroid/NSAID use (Ploss 2005).
- Cold mist shower crossover (water-based), n=121 inflammatory arthritis: weekly pain VAS 2.0 vs 2.4 (p=0.006) (Hinkka 2017).
- Exercise plus cold-water immersion feasibility, n=18 RA: no dropouts or symptom flares (Peres 2023).
Every study we reviewed
7 found benefit · 3 mixed results · 3 found no effect
Each study was checked on PubMed. The colored edge shows the direction of the result. The research library lists 27 studies on rheumatoid arthritis, across all heat and cold therapies, including case reports and older work not graded here.
Effects of cold mist shower on patients with inflammatory arthritis: a crossover controlled clinical trial.
Hinkka H et al. Scand J Rheumatol. 2017. PubMed 27575584 · DOI · Free full text
- Who
- patients with chronic inflammatory arthritis during 1-week rehabilitation periods
- What
- whole-body cold mist shower (water-based home treatment) vs control period
- Measured
- pain VAS, sleep quality VAS, depression scale (DEPS), adverse effects
- Result
- Past-week pain VAS 2.0 vs 2.4 (p=0.006); treatment effect significant after controlling for period and sequence (LRT p<0.0001); sleep quality 2.3 vs 2.7 (p=0.058); DEPS no difference (4.5 vs 4.1, p=0.29). No significant side effects.
- Limitations
- 1-week periods; small absolute difference (0.4 cm VAS); cold mist differs from immersion; inflammatory arthritis types not specified in abstract
Effects of an Exercise Program and Cold-Water Immersion Recovery in Patients with Rheumatoid Arthritis (RA): Feasibility Study.
Peres D et al. Int J Environ Res Public Health. 2023. PubMed 37372715 · DOI · Free full text
- Who
- patients with rheumatoid arthritis (17 women), mean age 55
- What
- individualized intermittent exercise program followed by cold-water immersion recovery
- Protocol
- 3/wk
- Measured
- acceptability, joint counts (ultrasound), HAQ, SF-36, pulse wave velocity
- Result
- No dropouts and no symptom aggravation; heart rate 70.2 to 66 bpm (p<0.05) and pulse wave velocity 8.9 to 7.0 m/s (p<0.001) after 9 sessions.
- Limitations
- uncontrolled; cannot separate cold-water effect from exercise; small
Whole-body cryotherapy for the treatment of rheumatoid arthritis: a monocentric, single-blinded, randomised controlled trial.
Klemm P et al. Clin Exp Rheumatol. 2022. PubMed 35238767 · DOI
- Who
- patients with active RA during a 16-day multimodal inpatient program
- What
- WHOLE-BODY CRYOTHERAPY (cryo chamber, cold air; not water immersion): 6 applications at -202 F for 3 min over 14 days vs no WBC
- Protocol
- -202 (cryo chamber air) °F · 3 min · 3/wk · 2 wk
- Measured
- pain NRS (primary), disease activity, function, cytokines, analgesic use
- Result
- Between-group pain difference -1.31 +/- 0.4 (95% CI -2.1 to -0.53; p=0.002); disease activity and function improved after intervention but not significant at 12 weeks; 18 of 31 reduced or stopped analgesics by 12 weeks. No WBC-related side effects.
- Limitations
- different modality; single center; single-blinded; background multimodal inpatient therapy
Cryotherapy in inflammatory rheumatic diseases: a systematic review.
Guillot X et al. Expert Rev Clin Immunol. 2014. PubMed 24345205 · DOI
- Who
- RA patients (6 pooled studies) treated with local cryotherapy or whole-body cryotherapy
- What
- LOCAL CRYOTHERAPY OR WHOLE-BODY CRYOTHERAPY (not water immersion)
- Measured
- pain VAS, DAS28
- Result
- Pooled analysis showed significant decreases in pain VAS and DAS28 after chronic cryotherapy; authors call for better-designed RCTs.
- Limitations
- different modalities; pooled effect sizes not given in abstract; low-quality primary studies
Effectiveness of different cryotherapies on pain and disease activity in active rheumatoid arthritis. A randomised single blinded controlled trial.
Hirvonen HE et al. Clin Exp Rheumatol. 2006. PubMed 16870097
- Who
- Patients with active seropositive rheumatoid arthritis (Finland)
- What
- WHOLE-BODY CRYOTHERAPY chamber at -166 F (-110 C) or -76 F (-60 C) vs local cold air (-22 F, -30 C) or local cold packs, plus physiotherapy
- Protocol
- -166 or -76 °F · 2-3 min · 14-21/wk · 1 wk
- Measured
- Pain, disease activity (DAS), global assessments, adverse effects
- Result
- Pain fell in all groups, most in the -166 F WBC group; DAS fell slightly with no significant between-group differences; 6 of 40 (15%) discontinued WBC; authors conclude WBC at -166 F is not superior to local cryotherapy
- Limitations
- Active comparator was local cold, not no treatment; one week; single-blinded; WBC, not cold-water immersion
The effect of cryotherapy on total antioxidative capacity in patients with active seropositive rheumatoid arthritis.
Hirvonen H et al. Rheumatol Int. 2017. PubMed 28698947 · DOI · Free full text
- Who
- Patients with active seropositive rheumatoid arthritis (Finland)
- What
- WHOLE-BODY CRYOTHERAPY chamber at -166 F (-110 C) or -76 F (-60 C) vs local cryotherapy, plus conventional rehabilitation
- Protocol
- -166 or -76 °F · 21/wk · 1 wk
- Measured
- Plasma total antioxidant capacity (TRAP)
- Result
- 1-h TRAP rose by 23.6 (95% CI 4.1-43.2) umol/L after the first -166 F session (p<0.001 within group) but not significantly between groups (p=0.78); no significant within-group change over the week; no evidence of oxidative stress
- Limitations
- Laboratory outcome only; one week; WBC, not cold-water immersion
Acute cold stress in rheumatoid arthritis inadequately activates stress responses and induces an increase of interleukin 6.
Straub RH et al. Ann Rheum Dis. 2009. PubMed 18413439 · DOI
- Who
- Patients with rheumatoid arthritis with or without glucocorticoid therapy (Finland)
- What
- WHOLE-BODY CRYOTHERAPY chamber at -166 F (-110 C) or -76 F (-60 C) vs local cold (-4 to -22 F, -20 to -30 C)
- Protocol
- -166 or -76 °F · 1 wk
- Measured
- Adrenal and sympathetic hormones, IL-6
- Result
- No sympathetic stress response in either group; under glucocorticoids, -166 F produced the smallest hormone responses; without glucocorticoids, -166 F raised plasma IL-6 relative to other groups, and this subgroup showed the best clinical response (numbers not in abstract)
- Limitations
- Mechanistic outcomes; randomization implied by trial design, details not in abstract; WBC, not cold-water immersion
Effects of Whole-Body Cryotherapy in Comparison with Other Physical Modalities Used with Kinesitherapy in Rheumatoid Arthritis.
Gizińska M et al. Biomed Res Int. 2015. PubMed 26576422 · DOI · Free full text
- Who
- Patients with rheumatoid arthritis (Poland)
- What
- WHOLE-BODY CRYOTHERAPY chamber at -166 F (-110 C) with kinesiotherapy (n=25) vs traditional rehabilitation with other physical modalities (n=19)
- Protocol
- -166 °F · 2 wk
- Measured
- Pain, disease activity, fatigue, walking, HAQ, IL-6, TNF-alpha
- Result
- Both groups improved similarly in pain, disease activity, fatigue and walking with similar falls in IL-6 and TNF-alpha; HAQ improved more with traditional rehabilitation (p<0.05)
- Limitations
- Not randomized; active comparator; WBC, not cold-water immersion
Effects of whole body cryotherapy in patients with rheumatoid arthritis considering immune parameters.
Sadura-Sieklucka T et al. Reumatologia. 2019. PubMed 32226165 · DOI · Free full text
- Who
- Patients with rheumatoid arthritis in rehabilitation (Poland)
- What
- WHOLE-BODY CRYOTHERAPY-based rehabilitation (n=25) vs conventional rehabilitation (n=25)
- Measured
- DAS28, morning stiffness, pain VAS, ESR, CRP, cytokines
- Result
- DAS28, morning stiffness and pain fell in both groups with no significant between-group differences; CRP improved significantly only in the WBC group; no change in IL-6, IL-10, TNF-alpha or MIF
- Limitations
- Groups assigned by rehabilitation method, not randomized; WBC, not cold-water immersion
[Whole-body cryotherapy in patients with inflammatory rheumatic disease. A prospective study].
Braun KP et al. Med Klin (Munich). 2009. PubMed 19337708 · DOI
- Who
- 48 patients with rheumatoid arthritis and 12 with ankylosing spondylitis (Germany)
- What
- WHOLE-BODY CRYOTHERAPY chamber twice daily (mean 15.8 sessions)
- Measured
- DAS28 and pain VAS (RA); BASDAI (AS); discontinuation
- Result
- RA: DAS28 3.9 to 3.4 and VAS 51.4 to 37.9 (both p<0.01); AS: BASDAI 4.4 to 3.1 (p=0.01); 13 of 60 (21.7%) stopped because of adverse effects
- Limitations
- Uncontrolled; German-language; high discontinuation rate; WBC, not cold-water immersion
[Serial whole-body cryotherapy in the criostream for inflammatory rheumatic diseases. A pilot study].
Lange U et al. Med Klin (Munich). 2008. PubMed 18548207 · DOI
- Who
- Patients with active inflammatory rheumatic disease: 4 RA, 3 ankylosing spondylitis, 3 psoriatic arthritis (Germany)
- What
- WHOLE-BODY CRYOTHERAPY in a single-person nitrogen-cooled cold-air unit, 9 sessions in 5 days
- Protocol
- 1.5-2.5 min · 9/wk · 1 wk
- Measured
- Pain, disease activity, function, TNF-alpha, IL-1
- Result
- Pain, disease activity and functional scores improved significantly; TNF-alpha (p<0.01) and IL-1 (p<0.05) fell; headache and cold sensation in two patients after the first session
- Limitations
- Uncontrolled; 10 patients of mixed diagnoses; German-language; open nitrogen-cooled device differs from a chamber and from cold-water immersion
Cryotherapy decreases histamine levels in the blood of patients with rheumatoid arthritis.
Wojtecka-Lukasik E et al. Inflamm Res. 2010. PubMed 20020313 · DOI
- Who
- Patients with rheumatoid arthritis (44) and osteoarthritis (45) (Poland)
- What
- WHOLE-BODY CRYOTHERAPY chamber (20 RA, 17 OA) vs conventional physiotherapy (24 RA, 28 OA)
- Protocol
- -220 to -256 °F · 2-3 min · daily/wk · 4 wk
- Measured
- Blood histamine, neutrophil activation and cartilage-metabolism markers at 3 months
- Result
- WBC reduced blood histamine in RA (p<0.001), lasting at least 3 months; histamine unchanged in OA; other markers changed non-significantly; no changes with physiotherapy
- Limitations
- Laboratory outcomes only; no clinical outcomes in abstract; allocation not described; WBC, not cold-water immersion
The value of systemic cryotherapy in a cold chamber at -110° for disease activity, inflammatory markers and steroid requirement in RA
Ploss G et al. Physikalische Medizin, Rehabilitationsmedizin, Kurortmedizin. 2005. Not in PubMed: source · DOIGerman publication; title and summary translated by SaunaLMN. Original title: Der Stellenwert der systemischen Kryotherapie in der Kältekammer bei –110° auf Krankheitsaktivität, Entzündungsparameter und Steroidbedarf bei der RA
- Who
- 48 patients with RA (ACR criteria) treated (Germany); controls were patients who declined the treatment or had contraindications (e.g. Raynaud phenomenon, claustrophobia), number not stated
- What
- WHOLE-BODY CRYOTHERAPY chamber at -166 F (-110 C), 3 minutes daily for 10 days vs no cryotherapy
- Protocol
- -166 °F · 3 min · 7/wk · 1.5
- Measured
- Clinical response (pain, morning stiffness, joint swelling), ESR, CRP, corticosteroid and NSAID requirement
- Result
- Target criteria improved in 31 of 48 treated patients; significant improvements in pain, morning stiffness, joint swelling and corticosteroid/NSAID use; CRP fell significantly in the treated group, while ESR was comparable with controls
- Limitations
- Not randomized; controls were patients who refused or had contraindications, so groups may differ; control size and effect sizes not given; short follow-up; German-language abstract (translated by us); WBC, not cold-water immersion
Protocols used in the studies
Whole-body cryotherapy trials used cold-air chambers at -166 F (-110 C) to -202 F (-130 C), occasionally -76 F (-60 C) or -220 to -256 F, for 2-3 minutes, from 6 sessions over 2 weeks up to 2-3 sessions daily for 1 week, usually alongside physiotherapy. Water-based studies used whole-body cold mist showers over 1-week periods, or cold-water immersion after exercise 3 times per week for 17 sessions; neither abstract reports water temperature or duration.
What is still unknown
No RCT of cold-water immersion in RA; whether water immersion reproduces chamber cryotherapy effects; whether WBC adds anything over local cold or conventional physical therapy; effect on disease activity beyond short-term pain; durability.
Safety
Cautions for cold therapy in this condition
- Secondary Raynaud's phenomenon is more common in rheumatic disease; cold triggers vasospastic attacks (Ramahi 2022, PMID 35699336). Screen before any cold exposure.
- RA carries increased cardiovascular risk; cold immersion acutely raises systolic blood pressure (Radtke 2016, PMID 26152773).
- Whole-body cryotherapy discontinuation: 15% in a 1-week RCT (PMID 16870097) and 21.7% for adverse effects in an uncontrolled series (PMID 19337708); headache and cold sensation after a first session were reported in a pilot (PMID 18548207).
- No symptom flares were recorded in the cold-water feasibility study (Peres 2023, PMID 37372715) or the cold mist trial (Hinkka 2017, PMID 27575584).
- Whole-body cryotherapy contraindications and adverse events (16 documented across case reports and RCTs) are specific to cold-air chambers and do not transfer directly to cold-water immersion (Legrand 2023, PMID 37770960). See general cold safety entry.
For clinicians
Suggested rationale
Cold is used as an adjunct analgesic in RA: whole-body cryotherapy reduced pain in a randomized trial in active RA (Klemm 2022) but was not superior to local cryotherapy (Hirvonen 2006), and a crossover trial found modestly lower pain with whole-body cold mist showers (Hinkka 2017). The chamber evidence does not directly support home cold-water immersion, for which data are preliminary.
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