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Ice or Heat: Exploring the Logic


Man Getting Into Cold Water

Patients often ask whether to use ice or heat for an injury. While it seems like a simple question, the answer depends on the injury's specifics, the patient's overall health, and other factors. Let's dive into the reasoning behind our recommendations.


Article Index:

 

Introduction


Embracing Inflammation: A Beneficial Response


Inflammation can be beneficial in certain cases. Studies have shown that when muscle fibers are damaged, such as during an acute injury or strain/sprain, inflammatory cells (macrophages) quickly move to the affected area. These cells help remove damaged tissue and promote muscle fiber regeneration. For both the public and practitioners, understanding this complex process is crucial for making informed decisions about injury treatment.


A Macrophage

Macrophages: Key Players in the Healing Process


Macrophages constantly patrol your bloodstream, ready to spring into action when needed. Upon injury, your body releases histamines, which increase blood flow to the affected area, bringing in more macrophages. These cells digest damaged tissue through phagocytosis, and fluid fills the vacated space, causing inflammation and swelling.


About 24 hours later, non-phagocytosing macrophages release Insulin-like Growth Factor (IGF-1), promoting the formation of new tissue. These precursor cells eventually merge to replace the damaged tissue, facilitating healing and regeneration (see 3D illustration of a macrophage cell).


The inflammatory process is essential for healing, as it relies on the movement of fluid in and out of the injured tissue. Any disruption to this process can slow down healing, highlighting the importance of understanding the body's intricate responses to injury.


 

The Flames of Inflammation

Acute & Chronic Inflammation


Differentiating between normal (acute) inflammation and abnormal (chronic) inflammation is crucial.


Acute Inflammation, occurs immediately after an injury, whether from trauma, strain, sprain, infection, or intense physical activity. This short-term inflammation accelerates the healing process and indicates that the body is actively repairing itself.


Chronic Inflammation, on the other hand, involves the body attacking its own tissues, leading to autoimmune conditions such as rheumatoid arthritis, hay fever, asthma, and celiac disease. This prolonged, uncontrolled inflammation can be harmful, potentially contributing to heart disease. Chronic inflammation also increases myostatin production, which hinders tissue regeneration.


If you suspect chronic inflammation, it is advisable to undergo testing. Standard blood tests like C-reactive protein (CRP) and erythrocyte sedimentation rate can provide your doctor with valuable information about potential inflammatory conditions.


The type of inflammation you're experiencing will influence our recommendations for using ice or heat as part of your treatment.


 

Using Ice

Using an Ice Pack on a Knee Injury

The Role of Ice and Heat in Injury Treatment: Striking a Balance


Ice is beneficial for reducing pain and controlling swelling after an acute injury or surgery. However, it can also impede muscle tissue regeneration by suppressing inflammation and slowing the healing process.


Swelling-induced pain (nociceptive pain) results from increased pressure on nerve endings. Managing pain is crucial, as it affects sleep, exercise adherence, and overall functioning. Using ice to control inflammation is a delicate balancing act, as it can also delay healing.


For severe pain, we recommend icing within the first 72 hours after an acute injury. If you don't experience significant swelling or acute pain, it's better to avoid ice.


We also advise against applying heat to an injured area immediately after an injury. While heat therapy can improve blood flow, it may exacerbate inflammation and increase pain. A moderate level of inflammation is necessary for healing, but excessive inflammation can be counterproductive.


 
A Don't Sign

When to Avoid Ice Therapy


Refrain from using cold therapy if the person:


  • Is unconscious, unable to communicate, or lacks sensation in the injured area. Surprisingly, ice has been used on unconscious individuals before.

  • Exhibits rash or blister formation when exposed to cold temperatures.

  • Suffers from circulatory problems, such as peripheral artery disease or severe varicose veins. Cold therapy can further reduce blood flow in these conditions.

  • Has Raynaud's Disease, rheumatoid arthritis, gouty arthritis, or kidney malfunctions. These conditions can be aggravated by cold therapy.

  • Has a known hypersensitivity to cold, such as cold urticaria, where exposure to cold can cause severe reactions like hives or anaphylaxis.

  • Is experiencing an acute asthma attack or has a history of cold-induced asthma. Cold can trigger bronchospasms and worsen breathing difficulties.

  • Has cardiovascular conditions, such as angina or heart failure. Extreme cold can cause vasoconstriction, potentially increasing cardiac workload and exacerbating symptoms.

  • Is pregnant. Applying cold therapy to the abdomen or lower back should be avoided as it may pose risks to the developing fetus.



These guidelines ensure the safe and effective use of cold therapy, minimizing the risk of complications and enhancing recovery.


 

How to Ice!


Optimizing Cold Therapy: Tips for Effective Icing


To make the most of cold therapy while avoiding potential drawbacks, consider these suggestions:


  • Elevate the Injured Area: Keep the injured area elevated above heart level to reduce swelling and promote blood flow away from the injury, using gravity to assist.

  • Regular Icing Intervals: Apply ice every two to three hours, ensuring the area warms up and is no longer numb between applications.

  • Prevent Frostbite: Avoid placing the ice pack directly on your skin. Use a thin towel as a barrier to protect your skin from frostbite.


Ice Pack on a Knee Injury

Icing with an Ice Pack: Guidelines for Safe Application


  1. Use a Barrier: Place a thin cloth over the injured area to prevent direct contact between the ice pack and your skin.

  2. Apply the Ice Pack: Position the ice pack on the affected area.

  3. Monitor Sensations: Keep the ice pack in place until the area feels numb. You will first feel cold, followed by a burning sensation, then aching, and finally numbness. If numbness doesn’t occur, you may need to ice longer, but do not exceed 15-20 minutes to avoid frostbite.

  4. Timing Between Sessions: Allow at least one hour between icing sessions to ensure your tissues have ample time to warm up.


Foot in a Bucket of Ice

Ice Massage: An Alternative Approach to Icing


Ice massage can be an excellent alternative to traditional icing. Here’s how to do it:


  1. Prepare the Ice: Fill small paper cups with water and freeze them.

  2. Expose the Ice: Peel back the top of the cup to reveal the ice.

  3. Hold the Cup: Use the paper-covered bottom part of the cup as a handle.

  4. Massage the Area: Gently massage the ice over the injured area in small circular motions, letting the ice melt and using a towel to catch the dripping water. Limit sessions to 7-9 minutes to avoid tissue damage.


During the ice massage, you will feel cold, followed by a burning sensation, then aching, and finally numbness.


 

Heat Therapy

We All Love Heat


The Right Time for Heat Therapy


While heat therapy can be comforting, using it too soon after an acute injury can lead to complications and extend recovery time.


Heat therapy should only be applied after the acute inflammatory response has subsided. Avoid using heat within the first 72 hours of an acute injury, especially when tissue damage and swelling are present, as it may worsen the injury. Cold therapy is generally more effective and appropriate during this initial period.


For non-acute injuries, heat therapy can be used almost immediately.


Benefits of Heat


Using Heat Therapy After Inflammation Subsides


Once inflammation has diminished, heat therapy can be applied to enhance flexibility, alleviate muscle cramps, reduce arthritic symptoms, and accelerate healing by increasing blood flow.


The strength of heat therapy lies in its ability to penetrate deeply and improve circulatory and neurological function. Enhanced circulation delivers oxygen and nutrients to the area while removing waste products. Additionally, heat stimulates sensory receptors in the skin, which can decrease pain signal transmission to the brain, reducing muscle spasms and acute pain episodes.


Heat Application: For minor, superficial injuries, apply heat therapy for 10 to 20 minutes. For chronic injuries, heat therapy may need to be applied for 20 to 35 minutes.


 

A Don't Sign

When to Avoid Heat Therapy


Refrain from using heat therapy if the person:


  • Is unconscious, unable to communicate, or lacks sensation in the injured area. It is crucial to ensure the individual can feel and respond to heat to prevent burns or further injury.

  • Has an open wound or severe skin condition, such as dermatitis or psoriasis. Heat can exacerbate these conditions and increase the risk of infection.

  • Suffers from circulatory problems, such as deep vein thrombosis (DVT) or severe varicose veins. Heat can increase blood flow, potentially worsening these conditions.

  • Has a fever. Applying heat can raise the body's temperature further, which is counterproductive when trying to reduce fever.

  • Experiences acute inflammation or swelling. Heat can increase inflammation and swelling, which is detrimental in the early stages of injury or infection.

  • Has a known malignant tumor. Heat therapy may enhance the growth of malignant cells by increasing blood flow to the area.

  • Has diabetes, especially if they suffer from neuropathy. Individuals with diabetes may have impaired sensation, increasing the risk of burns.

  • Suffers from cardiovascular disease. Heat can increase heart rate and blood pressure, potentially exacerbating cardiovascular conditions.

  • Is pregnant. Heat therapy, especially applied to the abdomen or lower back, can increase core body temperature and may pose risks to the developing fetus.


These guidelines ensure the safe and effective use of heat therapy, minimizing the risk of complications and enhancing recovery.



 

Moist Heat or Dry Heat?


Heat Therapy: Finding the Right Fit


The effectiveness of heat therapy varies from person to person. It's essential to experiment and find the most suitable type for your condition. There are two primary types of heat therapy: moist heat and dry heat.


Moist Heat

This includes hot baths, heated whirlpools, hot packs, or hot moist towels. Many users find that moist heat penetrates more deeply and provides better relief.


Hot Towels

The Moist Towel Treatment


  • Prepare the Towel: Dampen an old, clean towel (note that towels may discolor during this process).

  • Heat the Towel: Heat the moist towel in a microwave for one minute. Check the temperature and, if needed, heat for another 30 seconds to a minute.

  • Handle with Care: Carefully remove the moist towel to avoid steam burns.

  • Wrap and Apply: Wrap the heated towel with a dry towel to prevent burns and retain heat. Apply the wrapped towel to the affected area until the muscles relax.

  • Duration: Apply the heat for 10 to 20 minutes.



Woman in Epsom Salt Bath

Epsom Salt Bath

Soaking in an Epsom salt bath offers numerous benefits for the body. Epsom salts (magnesium sulfate) are rich in magnesium, which helps alleviate muscle cramps, ease joint pain, and enhance circulation. Remember that Epsom salt baths are a form of heat therapy, so the same guidelines apply.


To prepare an Epsom salt bath, mix 2 cups of Epsom salts in hot water. Immerse yourself in the bath and let the Epsom salts work their magic.


Epsom Salts in a Bowel

Using Epsom Salts Locally


To soothe sore feet, fill a bucket with hot water, add one cup of Epsom salts, and soak your feet.


For localized treatment, dip a washcloth in Epsom salt water and wrap it around the affected area, such as a foot, hand, or shoulder.


Alternatively, soak a cloth in Epsom salt water, wring it out, and place it over the sore or painful area. Wrap a tensor bandage or towel around the area to retain heat and keep the Epsom-salt-soaked cloth in place.


When used at the appropriate time, heat therapy can be highly effective!


 

Dry Sauna

Dry Heat Therapy Options


Dry heat therapy options include dry saunas, electric heating pads, and heat lamps. While these methods can be highly effective, they may also cause dehydration. Be sure to drink plenty of fluids when using dry heat therapy.


Apply heat for only 10 to 20 minutes. When using saunas, exercise caution to prevent dehydration, as prolonged sessions can increase this risk.


 

Conclusion - Ice or Heat


Understanding when to use ice or heat for an injury is essential for effective treatment and recovery. Both ice and heat therapies have their roles and benefits, but their application depends on the specific circumstances of the injury.


Ice Therapy, is particularly effective in the first 72 hours following an acute injury, as it reduces pain and controls swelling. It's important to balance the benefits of reducing inflammation with the potential drawback of slowing down the healing process. Techniques such as elevating the injured area, applying ice at regular intervals, and using a barrier to prevent frostbite are crucial for optimizing cold therapy.


Heat Therapy, should be reserved for after the acute inflammatory response has subsided. It enhances flexibility, alleviates muscle cramps, reduces arthritic symptoms, and accelerates healing by increasing blood flow. Whether using moist or dry heat, finding the right type of heat therapy for your condition is important. Moist heat options like hot baths and moist towels often provide deeper penetration, while dry heat options like saunas and heating pads offer convenience but require careful monitoring to avoid dehydration.


Recognizing the differences between acute and chronic inflammation helps tailor the use of these therapies to individual needs. Acute inflammation aids healing, while chronic inflammation can lead to more severe health issues and requires different management strategies.


 

References

  1. Bleakley, C. M., McDonough, S. M., & MacAuley, D. C. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. The American Journal of Sports Medicine, 32(1), 251-261.

  2. Smart, K. M., Blake, C., Staines, A., & Doody, C. (2010). Clinical indicators of 'nociceptive', 'peripheral neuropathic' and 'central' mechanisms of musculoskeletal pain. A Delphi survey of expert clinicians. Manual Therapy, 15, 80-7.

  3. Deal, D. N., & Tipton, J. (2007). Ice and heat therapy: when to use each. American Academy of Orthopaedic Surgeons.

  4. Hubbard, T. J., & Denegar, C. R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training, 39(3), 278-279.

  5. Nemet, D., Meckel, Y., Bar-sela, S., Zaldivar, F., Cooper, D. M., & Eliakim, A. (2009). Effect of local cold-pack application on systemic anabolic and inflammatory response to sprint-interval training: a prospective comparative trial. European Journal of Applied Physiology, 107(4), 411-7.

  6. Hubbard, T. J., & Denegar, C. R. (2004). Does cryotherapy improve outcomes with soft tissue injury? Journal of Athletic Training, 39(3), 278.

  7. Gallin, J. I., Snyderman, R., & Fearon, D. T. (Eds.). (1999). Inflammation: Basic principles and clinical correlates (3rd ed.). Lippincott Williams & Wilkins, Philadelphia.

  8. Jarvinen, T. A., Jarvinen, T. L., Kaariainen, M., Kalimo, H., & Jarvinen, M. (2005). Muscle injuries: biology and treatment. The American Journal of Sports Medicine, 33(5), 745-764.

  9. Lu, H., Huang, D., Saederup, N., Charo, I. F., Ransohoff, R. M., & Zhou, L. (2010). Macrophages recruited via CCR2 produce insulin-like growth factor-1 to repair acute skeletal muscle injury. The FASEB Journal. doi:10.1096/fj.10-171579

  10. Malanga, G. A., Yan, N., & Stark, J. (2015). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine, 127(1), 57-65.

  11. Petrofsky, J. S., Laymon, M., & Lee, H. (2013). Effect of heat and cold on tendon flexibility and force to flex the human knee. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 19, 661.

  12. Serhan, C. N., & Savill, J. (2005). Resolution of inflammation: the beginning programs the end. Nature Immunology, 6(12), 1191-1197.

  13. Takagi, R., Fujita, N., Arakawa, T., Kawada, S., Ishii, N., & Miki, A. (2011). Influence of icing on muscle regeneration after crush injury to skeletal muscles in rats. Journal of Applied Physiology, 110(2), 382-388.

  14. Bleakley, C., McDonough, S., & MacAuley, D. (2004). The use of ice in the treatment of acute soft-tissue injury: a systematic review of randomized controlled trials. American Journal of Sports Medicine, 32, 251–261.

  15. Thompson, D., Pepys, M. B., & Wood, S. P. (February 1999). The physiological structure of human C-reactive protein and its complex with phosphocholine. Structure, 7(2), 169-77.


 

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DR. BRIAN ABELSON, DC. - The Author


Photo of Dr. Brian Abelson

Dr. Abelson is dedicated to using evidence-based practices to improve musculoskeletal health. At Kinetic Health in Calgary, Alberta, he combines the latest research with a compassionate, patient-focused approach. As the creator of the Motion Specific Release (MSR) Treatment Systems, he aims to educate and share techniques to benefit the broader healthcare community. His work continually emphasizes patient-centred care and advancing treatment methods.





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