“What should I use?

“Cold or heat?”

This is the common question coming from a client who has been recently injured or one who deals with chronic joint pain.

Treating pain and/or inflammation with hot and cold can be extremely effective. The nice part is it should be available for all to use because the treatment is inexpensive. The confusing part is knowing when should you use heat therapy and when to use cold therapy…or when to use both.

  • Cold treatment reduces inflammation by decreasing blood flow. Timing is important here and needs to be applied within 48 hours after an injury.
  • Heat treatment promotes blood flow and helps muscles relax towards resting tension.. Use in situations of chronic pain.
  • Alternating heat and cold may help reduce exercise-induced muscle pain also known as D.O.M.S.

The choice between hot and cold can depend on the type and cause of the pain.

Cold Therapy

Cold therapy, also known as cryotherapy, involves the application of cold treatment that removes heat and decreases the temperature of the tissues within contact. It is often applied via crushed ice, gel packs, ice massage, cold compression units and vapocoolant sprays.

Physiological effects of cold include; decreasing blood flow, swelling and metabolism, and can act as a local anesthetic.

Acute musculoskeletal injuries such as ankle sprains commonly receive cold therapy, as the inflammatory response of heat, swelling, redness and pain would logically benefit from the direct application of a cold substance.  

People with sensory disorders that prevent them from feeling certain sensations should not use cold therapy at home because they may not be able to feel if damage is being done. This includes diabetes, which can result in nerve damage and lessened sensitivity.

Cold treatment reduces blood flow to an injured area. This slows the rate of inflammation and reduces the risk of swelling and tissue damage.

It also numbs sore tissues, acting as a local anesthetic, and slows down the pain messages being transmitted to the brain.

Ice can help treat a swollen and inflamed joint or muscle. It is most effective within 48 hours of an injury.

Rest, ice, compression and elevation (RICE) are part of the standard treatment for sports injuries.

Note that ice should not normally be applied directly to the skin.

Types of cold therapy

  • a cold compress or a chemical cold pack applied to the inflamed area for 20 minutes, every 4 to 6 hours, for 3 days.
  • immersion or soaking in cold, but not freezing water
  • massaging the area with an ice cube or an ice pack in a circular motion from two to five times a day, for a maximum of 5 minutes, to avoid an ice burn

In the case of an ice massage, ice can be applied directly to the skin, because it does not stay in one place

A cold compress can be made by filling a plastic bag with frozen vegetables or ice and wrapping it in a dry cloth.

What is ice useful for?

A cold compress applied within 48 hours of an injury can help reduce inflammation.

  • osteoarthritis
  • a recent injury
  • gout
  • strains
  • tendinitis, or irritation in the tendons following activity
  • chronic inflammation
  • migraines (cold compress on forehead

For osteoarthritis, it is recommended to use an ice massage or apply a cold pad 10 minutes on and 10 minutes off.

When Not To Use Ice

  • there is a risk of cramping, as cold can make this worse
  • the person is already cold or the area is already numb
  • there is an open wound or damaged skin
  • the person has some kind of vascular disease or injury, or sympathetic dysfunction, in which a nerve disorder affects blood flow
  • the person is hypersensitive to cold

Ice should not be used immediately before activity. ideally, you may need the muscle tissue to be increased in temperature

It should not be applied directly to the skin, as this can freeze and damage body tissues, possibly leading to frostbite.

Professional athletes may use ice massage, cold water immersion, and whole-body cryotherapy chambers to reduce to delayed onset muscle soreness (DOMS). DOMS commonly shows it’s head 24 to 48 hours after exercise.

However, cryotherapy is primarily a pain-reliever. It will not repair tissues.

Ice and back pain

Ice is best used on recent injuries, especially where heat is being generated.

It may be less helpful for back pain, possibly because the injury is not new, or because the problem tissue, if it is inflamed, lies deep beneath other tissues and far from the cold press.

Back pain is often due to increased muscle tension, which can be aggravated by cold treatments.

For back pain, heat would be a wiser choice.

Heat therapy

  • Dry heat aka. ‘conducted heat’ includes sources like heating pads, hot water bottle, warm towels, saunas and to some degree red light therapy like the sun or lamp) . This type of heat is easy to apply.
  • Moist heat aka. ‘convection heat’ includes sources like steamed towels, moist heating packs or hot baths. Moist heat has the benefit of possibly less time required to be effective and the ability to penetrate deeper into the tissue

Applying heat to an inflamed area will dilate the blood vessels, promote blood flow, and help sore and tightened muscles relax.

Improved circulation can help eliminate the buildup of lactic acid waste occurs after some types of exercise. Heat is also psychologically reassuring, which can enhance its analgesic properties.

Heat therapy is usually more effective than cold at treating chronic muscle pain or sore joints caused by arthritis.

Types of heat therapy

  • applying safe heating devices to the area. Many heat products are available for purchase online, including electrical heating pads, hot water bottles, hot compress, or heat wrap.
  • soaking the area in a hot bath, between 92 and 100 degrees Fahrenheit or 33 and 37.7 degrees Celsius
  • using heated paraffin wax treatment
  • medications such as rubs or patches containing capsicum, available for purchase online.

Heat packs can be dry or moist. Dry heat can be applied for up to 8 hours, while moist heat can be applied for 2 hours. Moist heat is believed to act more quickly.

Heat should normally be applied to the area for 20 minutes, up to three times a day, unless otherwise indicated.

Single-use wraps, dry wraps, and patches can sometimes be used continuously for up to 8 hours.

What is heat useful for?

Heat is useful for relieving:

A hot bath can provide comfort and relief from some types of pain.

  • osteoarthritis
  • strains and sprains
  • tendonitis, or chronic irritation and stiffness in the tendons
  • warming up stiff muscles or tissue before activity
  • relieving pain or spasms relating to neck or back injury, including the lower back

Applied to the neck, heat may reduce the spasms that lead to headaches.

Heat has the ability to relax muscles, stimulates blood flow, improves circulation, helps increases range of motion.

When not to use heat

Heat is not suitable for all injury types. Any injury that is already hot will not benefit from further warming. These include infections, burns, or fresh injuries.

Heat should not be used if:

  • the skin is hot, red or inflamed
  • the person has dermatitis or an open wound
  • the area is numb
  • the person may be insensitive to heat due to peripheral neuropathy or a similar condition

Ask your doctor first about using heat or cold on if you have high blood pressure or heart disease.

Excessive heat must be avoided.

Here are suggestions for safely using heat therapy devices such as a heating pad, a heat pack, a hand towel soaked in hot water, a warm water soak, or a hot water bottle:

  • Make sure that the temperature is never uncomfortably high; you don’t want to put your skin at risk for burns.
  • Place a cloth or towel between your skin and the heat source to prevent burns.
  • Don’t apply heat to skin that is cut or injured in any way.
  • Never apply heat for longer than 20 minutes at a time.

Suggestions for safely using cold therapy devices such as a cold pack, a bag of frozen vegetables, or a bag of ice:

  • Use a cloth or towel between your skin and the cold source to prevent irritation or damage.
  • Avoid cold therapy if you have circulatory problems.
  • Never leave the cold application on your skin for longer than 20 minutes, and don’t allow your skin to become too cold.

Switching between hot and cold therapy can offer excellent arthritis pain management benefits, as long as each one is used appropriately.

Alternating cold and heat

When cold is applied to the body, the blood vessels contract, vasoconstriction occurs. This means that circulation is reduced, and pain decreases.

Removing the cold causes vasodilation, as the veins expand to overcompensate.

As the blood vessels expand, circulation improves, and the incoming flow of blood brings nutrients to help the injured tissues heal.

Alternating heat and cold can be useful for:

  • osteoarthritis
  • exercise-induced injury or DOMS

Contrast water therapy (CWT) uses both heat and cold to treat pain. Studies show that it is more effective at reducing EIMD and preventing DOMS than doing nothing.

A review of studies has suggested that, for elite athletes, CWT is better at reducing muscle pain after exercise compared with doing nothing or resting.

However, the researchers point out that it may not better than other strategies, such as heat treatment, cold treatment, stretching, or compression. They say that more evidence is necessary.

Bottom line: Cold therapy may be beneficial with acute injuries with inflammation between 48 to 72 hours post injury, while heat therapy is recommended for both acute low back pain and muscle soreness by primarily decreasing pain.

As a general rule of thumb, use ice for acute injuries or pain, along with inflammation and swelling. Use heat for muscle pain or stiffness.

Heat should not be used on a new injury, an open wound, or if the person is already overheated. The temperature should be comfortable. It should not burn.

Ice should not be used if a person is already cold. Applying ice to tense or stiff muscles in the back or neck may make the pain worse.

Heat and cold treatment may not be suitable for people with diabetic neuropathy or another condition that reduces sensations of hot or cold, such as Raynaud’s syndrome, or if they are very young or old, or have cognitive or communication difficulties.

It may be hard to know when the heat or cold is excessive in these cases.

Science has yet to firmly establish the effectiveness of heat and cold therapies, but neither treatment is very potent, and the danger of an adverse reaction, when applied to a particular point on the body, is usually low.

Individuals with chronic pain or a non-serious injury can try either method and find their own best protocol.