The subject of whether it’s better to use cold or heat to treat pain and injuries comes up pretty frequently in my office. The answer depends on the situation and what you’re trying to accomplish.

The basic rule is to apply cold packs when you want to reduce inflammation and to use heat if you wish to increase circulation.

But, how do you know when you need to reduce inflammation versus increase circulation?

Well, if you’re having symptoms intense enough that you’re looking for something to ease them, there’s an excellent chance that you have inflammation and cold packs are going to be the way to go.

If you’re just stiff and sore from either being too sedentary (maybe you sat around more than you’re used to) or maybe you worked out hard and although you don’t have an actual injury, your muscles are sore from the exertion, then heat can be helpful. It helps to flush out the muscles with fresh blood, improving oxygenation and removal of metabolic waste products that can contribute to soreness.

When in doubt though, I highly recommend starting with cold. If you use cold when you would do better with heat, there’s really no harm done. You might get a little stiffer, but that’s about it.

On the other hand, applying heat to inflamed tissues tends to increase and prolong inflammation.

I have heard some experts recommend using heat to reduce pain because heat increases the firing of nerves that can block pain signals from reaching the brain. While this is true, this pain-relieving effect primarily occurs while the heat is being applied. Since there’s also a tendency for heat to increase inflammation, when the heat is removed, the symptoms not only return, but often worsen and become more lasting.

Again, when in doubt, start with cold. Most people don’t like how cold packs feel when they’re on, but once removed, not only does the discomfort of the cold fade, but usually so do the painful symptoms (although it may take more than one application of cold packs).

If cold doesn’t seem to be helping after a few applications, it may be worth giving heat a try, but avoid it if there’s any noticeable swelling, as that is a definite indication of inflammation.

What about alternating cold and heat? In my experience, this approach really doesn’t seem to have much advantage over just using one or the other according to the circumstances. In fact, I suspect in some cases it actually reduces the effectiveness of both the cold and the heat applications.

In terms of duration and frequency, the same rules of thumb applies to both cold and heat. The recommended duration depends on the thickness of the tissue. In large, muscular areas like the low back or hip, about 15 to 20 minutes is the suggested duration. For smaller areas with less soft tissue like the ankle or wrist, about 10 minutes is recommended. Anything in-between is usually fine with 10 to 15 minutes.

Most cold gel-packs will warm up on their own during use, so they don’t have too many problems with over treatment. But be careful with applying actual ice in a regular plastic bag, as leaving it in place too long could result in frost bite.

If you have been applying some form of topical analgesic that has a cooling sensation, such as Biofreeze, wash it off of the skin thoroughly before using a cold pack on the area, as that too can lead to frost bite.

For heat, moist heat is generally considered a better choice than a dry heating pad. Not only does the moist heat help reduce dehydration of the tissue, but most moist heat options will lose heat on their own which avoids over treatment. If you still choose to use an electric heating pad, it’s best to get one with an automatic shut off so that if you fall asleep or otherwise lose track of treatment time you won’t overheat the tissue.

The usual recommendation for how frequently to apply cold or heat is once every two hours you’re awake, but at least as long as it takes for the tissue to return to normal temperature (compare how the area feels compared to nearby areas or the opposite side of the body or limb).

In my experience, people often underestimate the usefulness of cold or heat (especially cold). I’ve seen numerous cases over the years in which simply starting the use of cold packs or switching from heat to cold has made a huge improvement in symptoms within a day or two when even prescription medication was having little effect.

As discussed, heat does have a place in easing stiffness and soreness, but cold can really be your friend with more severe pain associated with inflammation. It may not feel good while it’s on, but that few minutes at a time of discomfort can really speed recovery.

Until next time…

George F. Best, D.C.