Ice or Heat for Pain?

As personal trainers, we have well-acquainted ourselves with the PRICE protocol; pressure and ice help to reduce the swelling associated with acute injuries. And when it comes to muscle tension, moist heat applications are recommended. However, as of late, there has been some conflicting research about how effective icing certain injuries really is, and also some debate about whether chronic pain would benefit more from ice or heat application. Let’s look at what we know.

PRICE Principle

Acute injuries are common and might occur in the course of a fitness client’s journey with you as their personal trainer. They include muscle strains, ligament sprains, contusions (or bruises), subluxations or partial dislocations, full dislocations, and bone fractures. The NFPT’s official recommendation for acute injuries is to employ the PRICE protocol. This acronym stands for:

Protect the injury from further damage. Depending on the injury, stabilizing it with a splint or even an ACE bandage may help prevent it from additional damage.

Rest is necessary for the body to begin the healing process. Excessive movement can increase swelling with increased blood circulation. The research seems to support this rest being limited to immediately after the injury (the day of) but some restricted and thoughtful movement to restore mobility may be in order in the short term following the injury. Known as optimal loading, employing appropriate functional movement to encourage healing may be a more useful step than extended immobility.

Ice, or cryotherapy, is conventionally applied to constrict blood vessels and minimize a swelling response, and also to numb the pain or provide an analgesic effect. Placing a barrier like a thin towel between an ice pack or bag of crushed ice and the skin will prevent skin damage and discomfort. The ice pack can be taped in place, but should be left on for only 20 minutes at a time. Note well that recent research points to ice inhibiting the healing process of inflammation and circulation. Use only to mitigate pain and not to reduce swelling.

Compression wraps should be applied to the injured area when it’s not being iced, to further minimize swelling. Narrower bands should be used for children and adult wrist injuries. Wider bands of 4″ are appropriate for knees and elbows, while 6″ bands are available for thigh injuries.

Elevation is helpful to further reduce blood flow to the injury and minimize swelling. Elevating the injured area above the heart when possible is ideal.

The PRICE protocol should be employed for the first 4-5 days of injury in most cases, and then the injury should be re-evaluated for healing (or a determination made if swelling was present, whether it was edema or hematoma).

This has been the generally accepted sports medicine approach to dealing with acute injuries in the short term, although most of the support for each approach has been largely anecdotal or inferred from research studying other medical conditions.

The entire PRICE protocol itself has not been rigorously researched, and the available material is largely focused on ankle sprain injuries. Conclusions on meta-analyses point to, well, inconclusiveness. It seems that every injury is unique and outcomes employing the PRICE protocol seem to vary. So we do our best with the information we have and employ this methodology until someone learns a better way, if one exists.

Heat Therapy

We apply heat with muscle tension and trigger point syndromes are the underlying cause of pain and discomfort. This kind of pain tends to be chronic and mild but can certainly be jarringly painful and sharp when left unchecked too long and unaccompanied by stress and anxiety.

Adding a moisture barrier or even being submerged in water is said to improve the ability of the heat to penetrate the muscles in need. A wet towel under a heating pad is what I normally recommend.

Therapeutic Contrasting

A little-a-dis, a little-a-dat! Alternating between ice and heat may have some benefit to the healing process by stimulating tissue without too much stress. This should not be used for the beginning stages of an injury, but maybe more appropriate for repetitive tissue damage such as tendonitis, shin splints, or even carpal tunnel.

There’s not much harm in trying it but it may also not produce any results. To try it, alternate 3-6 periods of intensifying heat and cold. Start with 2 minutes of heat, followed by 1 minute of cool, then 2 minutes of higher heat followed by, 1 minute of colder cold, etc.

Why Apply Ice or Heat Anyhow?

Utilizing ice or heat are both reasonable approaches when managing acute and chronic pain because they are non-invasive, inexpensive, and easy to implement and adhere to. When applied properly, they can be effective and may reduce the need for medications. However, applying them to an inappropriate condition will likely just worsen symptoms or just not help at all.

Occasionally, the waters are a bit muddied by circumstance and knowing which approach to take might be a bit tricky. As mentioned above, acute soft tissue damage benefits from icing, so for certain, attempting to ice a stiff or tight muscle will only make matters worse.

Say it’s two hours after a workout that didn’t include an adequate cooldown and your client’s right lower back starts to ache and throb a bit. Since nothing obvious took place and the pain came on following earlier activity, the pain is more likely to be tension or trigger point pain than acute injury. Moist heat is probably a good first step to soothe the aching muscles.

How about the reverse? An achey back (or muscle) seems to improve once someone starts exercising. This is almost always a case of a tight muscle that starts to “loosen up” with the warmth of circulation and blood flow. This is not the kind of pain that would benefit from icing!

Most back discomfort is mysterious and unable to be attributed to a single cause. I can personally attest to this as a chronic low back pain sufferer for over two decades now. I have a diagnosis of a legit back condition, but many folks with bona fide pathologies like mine have no pain whatsoever and don’t even know anything is amiss.

This is where chronic pain management becomes as much a guessing game as pinpointing the source of pain in the first place. Sometimes you have to just experiment and find what works. However, research suggests that when it comes to back pain, the body can’t really tell the difference between hot and cold. Back muscles can run deep, and heating or cooling the body externally can rarely penetrate as deeply as though painful muscles (if that’s where the problem is).

And when someone has lived with chronic pain as long as I have (in varying degrees over the years) it points to the neurological system being somewhat amped up artificially. Ice seems to aggravate the nerves and stimulate them even more, which is not going to produce less pain. (I can attest to this as well as I recall walking around with an icepack in the waistband of my shorts for a week thinking it would help. Nope. I couldn’t even stand up straight).

How Should Trainers Decide on Ice or Heat Applications?

We’ve discussed four plausible scenarios:

1. Acute Trauma: PRICE principle to initiate the healing process (for now, this makes the most sense)
2. Repetitive Soft Tissue Damage: Suggest Therapeutic Contrasting if all else has failed
3. Chronic muscle tension/trigger point syndrome: Moist heat applications to soothe muscles
4. Chronic low back pain: Heat is probably the way to go for some moderate relief.

---

References

C M Bleakley, 1,3 P Glasgow, 2,3 D C MacAuley. PRICE needs updating, should we call the POLICE? Br J Sports Med 2012; 46 :220–221. doi:10.1136/bjsports-2011-090297

van den Bekerom, M. P., Struijs, P. A., Blankevoort, L., Welling, L., van Dijk, C. N., & Kerkhoffs, G. M. (2012). What is the evidence for rest, ice, compression, and elevation therapy in the treatment of ankle sprains in adults?. Journal of Athletic Training, 47(4), 435–443. doi:10.4085/1062-6050-47.4.14 Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3396304/#i1062-6050-47-4-435-b19

https://www.painscience.com/articles/icing-exceptions.php