There are a whopping 35 million visits to emergency departments across the country annually for injuries. A majority of these are musculoskeletal injuries managed with X-ray imaging, splinting and possible orthopedic surgery consults. Most acute pain from stable fractures and sprains can be managed with standard medication like acetaminophen, ibuprofen and narcotics.
The larger debate among emergency physicians and orthopedic surgeons centers is around which additional non-pharmacological treatment strategy is better for pain reduction and healing – cold or heat therapy.
There is limited data comparing the two modalities in head-to-head trials. Individually, both have demonstrated reduction in acute pain in small studies. I’ve found that most doctors will recommend patients use one or the other based on their own anecdotal experience.
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What is the science behind heat and cold application for pain management?
Application of cold therapy like an ice pack signals the brain to trigger a complex physiological response. The muscular wall of blood vessels contracts in a process known as vasoconstriction. This vasoconstriction reduces blood flow to the affected area, which effectively limits inflammation and tampers pain.
Cold therapy options include:
- ice packs
- ice baths
- coolant spray
- ice massage
Heat therapy, on the other hand, relaxes blood vessel wall muscles via vasodilation, which widens their diameter and increases blood flow. Heat therapy enhances circulation and flow of healing nutrients to the injured area. Similar to cold therapy, it also has been shown to reduce pain. In fact, a systematic review of 32 randomized-control trials featuring over 1,000 study participants demonstrated that both cold and heat were effective in reducing pain.
Heat therapy options include both dry and moist heat options:
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General rule: 20 minutes on, 20 minutes off
As a rule of thumb, you should apply cold or heat therapy for 20 minutes, then take a 20-minute break.
In general, cold and hot therapy is a great option for many patients. However, never apply cold or hot directly to an open wound. Patients with chronic medical problems such as diabetes, dermatitis, multiple sclerosis and vascular disease should exercise caution or consult their doctor first.
The bottom line: Both ice and heat are an option. I personally recommend using a 20-minute cold therapy sessions for acute injury pain. Ice works very well to both reduce pain and swelling. After 72 hours, switch over to heat to increase blood flow, enhance healing and reduce stiffness in the affected area.
Michael Daignault, MD, is a board-certified ER doctor in Los Angeles. He studied Global Health at Georgetown University and has a Medical Degree from Ben-Gurion University. He completed his residency training in emergency medicine at Lincoln Medical Center in the South Bronx. He is also a former United States Peace Corps Volunteer. Find him on Instagram @dr.daignault