The Ice Man Cometh

[originally published in KCN, October 2002]

Okay — so there you are,  flat on your back.  “The cat food bag really wasn’t that heavy,” you think to yourself,  but apparently your back didn’t seem to care as it locked up in spasm with knife-like pain half way through the lift that you now realize lacked proper technique.  Perhaps now would be a good time to find the card for that chiropractor your friends have been pestering you to see for the past five years.  “Nahh, it will go away on its own,” you reassure yourself.  “A little rest and heat and I’ll be fine — or is it ice?  No, no, I’m sure it’s heat…maybe.”

What do you do in a situation like this?  The answer, obviously, is to call that chiropractor.  But aside from that, do you use ice or heat?  Or, is it both?  It can be a tad confusing to sort out, as professional opinions oftentimes conflict.  While there are always special cases and circumstances, it’s my recommendation that it’s hard to go wrong with ice.  Use heat at the wrong time, and you could make it worse!

Imagine that your cat food-back pain is like a red, hot sunburn.  The muscles, nerves, and other tissues are swollen and throbbing — kind of like a Ball Park Frank on a hot grill, only not as tasty.   Adding heat to this situation would only stoke the fire — bringing more blood circulation to an already fluid-filled situation.  Ice, on the other hand, would serve to reduce swelling by constricting local blood vessels, ease the pain by slowing nerve transmission, and relax guarded and spastic muscles.

Sure, heat feels good.  It too can reduce pain and is excellent at getting tight, spastic muscles to relax.  The only problem is, because heat dilates blood vessels, heat will pull more blood to the area and cause an increase in  the swelling!  What this means to you, is that while it feels good initially, once you remove the heat, it won’t be long before you actually start to feel worse — it’s called  “rebound effect” and can be a frustrating stumbling block when someone is looking for a quick heal.

So how do you ice?  It can be as simple as putting a few ice cubes in a plastic bag, however, the flexible, gel-filled cold packs are more convenient and versatile, definitely less messy, and will recharge in the freezer quickly.  If you’re in a pinch, a bag of frozen peas will work (although I have one patient who stands by his lima beans).  For the “Do-It-Yourselfers,” I’ve read that you can make your own “gel packs” by placing a 2:1 ratio of water and rubbing alcohol into a Ziploc or “seal-a-meal” bag and freezing it.  Just be sure in all these instances to avoid direct contact of the plastic on your skin — as it is possible to burn your skin with frostbite.  And believe me, ice burns do not look pretty.  Using a paper towel or thin,T-shirt type material will work well.  If you feel this is blocking the coldness, wet down the material.  On the other hand, if you find yourself reaching for your grandmother’s fluffy, pink, embroidered, terry cloth towel — forget it — don’t waste your time.

In order for the ice therapy to work, the ice must initially make the area cold.  And, in fact, this is actually the first of four sign posts that you will encounter while on an ice pack.  After the coldness, comes a burning sensation.  This is then followed by a much shorter aching feeling, and then, finally, you’ll launch into a level of numbness.

How long you ice for and how often seems to vary depending on who you read.  I recommend icing for 15 minutes as often as every hour (I would reduce this time to about 10 minutes in areas with less fat tissue, like elbows for example).  What this effectively means is that at the top of the hour, say 4:00, you would ice until 4:15.  You would then remove the ice and “defrost” for 45 minutes until 5:00, at which time you could then repeat the process.

A word of warning: once you get used to how good ice can feel, human nature will rationalize that if 15 minutes felt good, 30 minutes will feel twice as good.  Not so.  As a matter of fact, if your ice pack is cold enough, your body eventually will kick in an automatic, emergency reflex known as the “hunting reaction.”  What this means is that your body begins to sense that the area you are icing is going to freeze to death.  In a last ditch effort to save the freezing tissue, the body sounds the alarm, and the hunting reaction kicks in.  Massive amounts of blood are pumped to the area you were treating, and all of the wonderful physiologic benefits that you had just garnered from the ice go out the door — which essentially places you in the “Grandma’s Terry Cloth Towel Group.”

So what about heat?  Heat, as one author stated, is the “most misused and overused therapy modality.”  Nonetheless, it does have its place.  Because heat increases blood circulation by opening up blood vessels, it can be invaluable at assisting in the carting away of waste products brought about from an injury, as well as, delivering nutrients that will be needed to rebuild.  Text books generally recommend that it is safe to begin heat therapy 48-72 hours after an injury.  Unfortunately, not every one, for a variety of factors, is a textbook case.  One author has come up with a practical way to judge when to make this “heat shift” by monitoring the “quality” of your pain.  That is, when your pain is such that you cannot find a “pain-free” position, use ice.  If, on the other hand, as your condition progresses, you begin to experience pain only with certain movements, then the application of heat is permissible.  Knowing when to shift to heat is becoming more important, especially since research is suggesting that prolonged use of ice can eventually slow healing.

During the transition phase between obvious ice application and obvious heat application, I often times will recommend that my patients use an ice/heat contrast therapy.  The alternating application of ice then heat creates a “pumping” effect that is quite effective in reducing residual swelling and removing waste products.  You’ll want to use 5 minutes of ice, then 5 minutes of heat, followed by 5 minutes of ice, etc.  I recommend for the subacute injury, ending with ice in most cases.

When it comes to hot packs, moist heat tends to be the most beneficial as it is capable of penetrating deeper into the tissue.  Examples of moist heat include warm moist towels under a hot water bottle, hot tubs, hot showers, and microwavable “grain bags.”

To make an inexpensive grain bag, find an old sock (preferably one that has been washed), fill it with about 2/3 uncooked rice (or other uncooked grain), tie off the open end, and microwave on high for 2-3 minutes (smells may vary).

Aside from using heat to facilitate the healing process as the acute nature of the injury subsides, heat is also good for limbering up stiff joints and muscles.  Generally, people with chronic pain and stiffness will benefit from heat.  Duration and frequency are roughly the same as for ice (15 minutes, as often as every hour).  As is probably obvious, hot packs can burn, so proper precautions must be taken.

Ice or heat?  A confusing issue for many — even doctors.  Recommendations to use heat still abound from doctors pulling from what they learned back when they attended medical school.  A 1987 edition of the American Medical Association’s Family Medical Guide recommends — you guessed it — heat as a self-help treatment measure for back pain.  Gradually, the shift in thinking to initially use ice is taking place, and one day, it will be common knowledge.

Ice really is an excellent anti-inflammatory.  It won’t cause your stomach to bleed, your liver to malfunction, or your kidneys to shut down.   It’s safe, natural, very affordable, and it goes right on the spot where you need it — unlike a pill that has to course through your entire body to bring about its effect.

Now, slowly get up.  Go to the freezer and grab the peas.  Then make an appointment to see that chiropractor.  Oh yea, feed the cat.

sources used for this article:
Jaskoviak.  Applied Physiotherapy, 2nd ed.  American Chiropractic Association.  Arlington, VA.  1993.
Kaiser Permanente website.  Use of Heat and Ice. heat-ice.html.  (09/15/02)
Kunz.  The American Medical Association Family Medical Guide.  Random House. New York.  1987.
Lowe.  Heat or Ice?  Determination Based on the Phase of Healing.  Dynamic Chiropractic.  18 (20). 2000.
M. Steckel website. Ice, Heat, & Epsom Salts.  (09/15/02).
McClure.  Management of Common Extremity Injuries.  Bayfield, CO.  1997.
Take Care website.  What’s best for sprains and strains…Ice or Heat or Both?             (09/15/02)
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