Hot & Cold Therapy

1. French, SD et al.A Cochrane review of superficial heat or cold for low back pain. Spine. 2006 Apr 20; 31(9):998-1006.

Heat and cold are commonly used in the treatment of low back pain. The objective of this review of the literature was to assess the effects of superficial heat and cold therapy for low back pain in adults.

Electronic databases were search from inception to October 2005. Nine trials involving 1,117 participants were included.

RESULTS:

• In two trials of 258 participants with a mix of acute and subacute low back pain, heat wrap therapy significantly reduced pain after 5 days, compared with oral placebo.

   

• One trial of 90 participants with acute low back pain found that a heated blanket significantly decreased pain immediately after application.

   

• One trial of 100 participants with a mix of acute and subacute low back pain examined the additional effects of adding exercise to heat wrap and found that it reduced pain after 7 days.

   

CONCLUSIONS:
There is moderate evidence in a small number of trials that heat wrap therapy provides a small short-term reduction in pain and disability in a population with a mix of acute and subacute low back pain, and that the addition of exercise further reduces pain and improves function.

2. Melzack, R et. al.Ice massage and transcutaneous electrical stimulation: comparison of treatment for low-back pain. Pain.1980 Oct; 9(2):209-17.

The purpose of this study was to examine the relative effectiveness of ice massage and TENS for the relief of low-back pain. Patients suffering chronic low-back pain were treated with both ice massage and TENS. The order of treatments was balanced, and changes in the intensity of pain were measured with the McGill Pain Questionnaire (MPQ).

RESULTS:

• Both methods are equally effective: based on the Pain Rating Index of the MPQ, 67-69% of patients obtained pain relief greater than 33% with each method.

   

• The results indicate that ice massage is an effective therapeutic tool, and appears to be more effective than TENS for some patients.

   

• It may also serve as an additional sensory-modulation method to alternate with TENS to overcome adaptation effects.

   

• Evidence that cold signals are transmitted to the spinal cord exclusively by A-delta fibers and not by C fibers suggests that ice massage provides a potential method for differentiating among the multiple feedback systems that mediate analgesia produced by different forms of intense sensory input.

   

3. Nadler, SF et al.The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician. 2004 Jul; 7(3):395-9.

Cryotherapy and thermotherapy are useful adjuncts for the treatment of musculoskeletal injuries. Clinicians treating these conditions should be aware of current research findings regarding these modalities, because their choice of modality may affect the ultimate outcome of the patient being treated. Through a better understanding of these modalities, clinicians can optimize their present treatment strategies.

Although cold and hot treatment modalities both decrease pain and muscle spasm, they have opposite effects on tissue metabolism, blood flow, inflammation, edema, and connective tissue extensibility. Cryotherapy decreases these effects while thermotherapy increases them.

Continuous low-level cryotherapy and thermotherapy are newer concepts in therapeutic modalities. Both modalities provide significant pain relief with a low side-effect profile. Contrast therapy, which alternates between hot and cold treatment modalities, provides no additional therapeutic benefits compared with cryotherapy or thermotherapy alone.

Complications of cryotherapy include nerve damage, frostbite, Raynaud's phenomenon, cold-induced urticaria, and slowed wound healing.

With thermotherapy, skin burns may occur, especially in patients with diabetes mellitus, multiple sclerosis, poor circulation, and spinal cord injuries.

In individuals with rheumatoid arthritis, deep-heating modalities should be used with caution because increased inflammation may occur. Whirlpool and other types of hydrotherapy have caused infections of the skin, urogenital, and pulmonary systems. Additionally, ultrasound should not be used in patients with joint prostheses.

4. Nadler, SF et al.Continuous low-level heat wrap therapy provides more efficacy than Ibuprofen and acetaminophen for acute low back pain. Spine. 2002 May 15;27 (10):1012-7.

The objective of this study was to compare the efficacy of continuous low-level heat wrap therapy [40 C, 8 hours/day] with that of ibuprofen [1200 mg/day] and acetaminophen [4000 mg/day] in subjects with acute nonspecific low back pain. This study was a prospective, randomized, single blind, comparative efficacy trial.

371 Subjects were randomly assigned to heat wrap, acetaminophen or ibuprofen for efficacy evaluation, or to oral placebo or unheated back wrap for blinding. Outcome measures included pain relief, muscle stiffness, lateral trunk flexibility, and disability. Efficacy was measured over two treatment days and two follow-up days.

RESULTS:

• Day 1 pain relief for the heat wrap was higher than for ibuprofen or acetaminophen. Extended mean pain relief (Days 3 to 4) for the heat wrap also was higher than for ibuprofen or acetaminophen.

   

• Lateral trunk flexibility was improved with the heat wrap during treatment vs. acetaminophen and ibuprofen. The results were similar on Day 4.

   

• Day 1 reduction in muscle stiffness with the heat wrap was greater than with acetaminophen.

   

• Disability was reduced with the heat wrap as compared with ibuprofen and acetaminophen on Day 4.