Hot and Cold Therapy

Hot and Cold Therapy

Treatments for sports injuries will depend on the individual and the severity of the injury. Also, it is important to take into consideration the individual’s medical history. Please note that the following is general information and NOT personal advice.

The information gathered is based on the research available at the time of writing this blog.

Superficial Heat Therapy

Applying heat superficially triggers increased blood flow by widening the blood vessels. It may decrease some types of pain and may increase joint range of movement.

There is a moderate level of evidence that heat wraps decrease low back pain for a short period of time in individuals with pain for less than three months. It has been shown that doing exercise as well as applying heat will have additional benefits of decreasing pain and improving movement when compared to using heat therapy alone.

Heat therapy increases blood flow and therefore it is not a recommended treatment within the first 48-72 hours of injury. Whilst swelling is a natural and important part of any healing process, heat therapy is not recommended for swelling management as the heat will encourage more fluid and blood to the local area.

Please refer to our soft tissue healing blog for more information on the healing process.

In general, research suggests that heat therapy is recommended for symptom relief of persistent pain (more than three months) and muscle spasm.

Heat treatments may include, hot water bottle, grain-filled soft bags or packs, warm baths, heat wraps, heat pads, saunas, infra-red lamps and more.

Be aware of skin damage via burns or blisters. Always check the temperature (we advise warm not hot) and put a layer between the skin and the warm pad/bag.

Contraindications, which means not advised for any person with any of the following (with a moderate to strong evidence base):

Acute injury Inflammation
Pregnancy (around the area of the womb or pelvis)
Impaired sensation
Haemorrhagic conditions
Impaired circulation
Infection Tuberculosis
Deep vein thrombosis Thrombophlebitis
Skin disease Damaged or at-risk skin

Precaution is recommended to be taken for older adults with an increased body mass index (BMI) and diabetes as the heat can accumulate under the skin and cause burns or skin damage.

Superficial Cold Therapy

In research, cold therapy has been found to be effective for early treatment of acute sports injuries.

The principles of treating acute injury can be taken from the following acronym P.O.L.I.C.E. Previously known as P.R.I.C.E (protect, rest, ice, compress, elevate):

P – protect
Protect from further injury.
Walking aids, splints, casts, bandages, or time resting the area may be appropriate for a short period of time

O – optimise
Optimise for a better outcome.
Graded rehabilitation programmes have shown to be beneficial for early recovery. There is “no one size fits all” and so an individual may require face-to-face assessment of the injury for a specific programme and advice

L – loading
Complete rest should be limited to a short period of time unless the individual has sustained a fracture or severe injury and then immobilisation may be required
graded mechanical loading (weight bearing) has shown to improve functional outcomes

I – ice
Ice treatment is recommended for 10 minutes or less for the first 72 hours.
Make sure there is a layer between the ice and skin to avoid ice burns

C – compress
For swelling management.
Although clinical studies demonstrating the benefits are lacking, some people may find it useful for supporting the joint in the acute stages of injury

E – elevate
For swelling management.
Although clinical studies demonstrating the benefits are lacking, some people may find that elevation encourages them to actively rest the area for a short period of time.

It has been recommended that following an acute sports injury, the above principles should be followed for the up to 72 hours. The idea of following these guidelines is to optimise the individuals return to full function as quickly as possible.

Cold therapy may be beneficial for inflammatory causes.

Cold therapy may slow nerve conduction and thus reduces pain (by blocking the sensation of pain).

Cold therapy may include, cold towels, cold gel packs, ice packs and more.

Research has suggested that cold therapy is contraindicated for those who have:

Cognitive or communication problems
Cold urticaria (skin reaction) or hypersensitivity
Raynaud’s disease/vasospasm
Impaired circulation
Cryoglobulinemia (a type of inflammation of the blood vessels)
Hemoglobulinemia (excess of haemoglobin in the blood plasma)
Haemorrhagic conditions (a defect in blood clotting)
Persistent wound (not healing as expected, taking longer than three months to heal)
Superficial regenerating nerve (injury to a nerve near to the surface of the skin)
Hypertension (high blood pressure)
Infection Tuberculosis

Precaution advised if using cold therapy with compression: Anyone using cryotherapy cuffs (with compression) then be aware not to cut off the circulation and nerves are not jeopardised.
If you have impaired sensation or are using cold therapy on an area with minimal subcutaneous fat or areas with superficial nerves, then the application should be kept to less than 10 minutes.

Note that induced nerve injury is reported to be most common when applied with compression and therefore it is important to check capillary refill time (circulation of the blood without compromise).

If treating a skin burn, then please seek urgent medial advice. It is important to avoid excessive cooling of the area as it may increase the severity of injury and increase tissue hypoxia (tissues not receiving adequate oxygen).

It has been recommended that re-warming time of the tissue should be at least twice as long as the treatment time (1:2). 1:6 is preferential for icing protocol (for example, 10 minutes on the area and 60 minutes off for re-warming).

Be aware that following local cold therapy, and especially if considering activity, it may decrease muscle strength, dexterity, proprioception and local pain awareness.

Superficial Heat and cold therapy combination

Research suggests that: Heat and cold stimulate an alteration in local blood flow, metabolic activity and increase the pain threshold. However, these effects have been shown to decrease after 30-60 minutes (please note this research is of low methodological quality).

When superficial heat or cold is considered in the management of knee osteoathritis it is recommended that the individual experiments to identify the method that offers them the greatest relief and that contrast between cold and heat therapy is an option for pain or symptom reduction purposes.

It may be that an individual’s preference may change depending upon the circumstance. So please be mindful about what feels best for your symptoms depending on the nature of your injury. For example, if a person has pain from muscle spasm then it may be that they prefer heat because it improves the symptoms and movement. If a person has discomfort from inflammation then it may be that they prefer cold because it improves the symptoms.

Please seek specific advice for your circumstances.

Bleakley, C,M., Glasgow, P., MacAuley, D, C (2012). PRICE needs updating, should we call the POLICE. Br J Sports Med. Vol 46 No 4

Denegar, C, R., Dougherty, D,R., Friedman, J,E., Schimizzi, M,E., Clark, J,E., Comstock, B,A., and Kraemer, W,J (2010). Preferences for heat, cold, or contrast in patients with knee osteoarthritis affect treatment response. Clinical Interventions in Aging. 5:199-206

French, S, D., Cameron, M., Walker, B,F., Reggars, J,W., and Esterman, A,J (2006). Superficial heat or cold for low back pain. Cochrane Database of Systematic Reviews. Issue 1

Lane, E., and Latham, T (2009). Managing pain using heat and cold therapy. Paediatric nursing. 21(6):14-18

Rennie, S (2010). Electrotherapy agents. Contraindications and precautions: An evidence-based approach to clinical making in physical therapy. Physiotherapy Canada. Canadian physiotherapy association. 62(5):1-83

Robertson, V., Ward, A., Low, J., and Reed, A (2006). Electrotherapy Explained. Principles and Practice. 4th Edition. Elsvier, London

Veenman, P and Watson, T (2008). Physiotherapy perspective on pain management. Veterinary Nursing Journal, 23:4, 29-35

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