Which Is More Effective... Hot Or Cold For Back Pain?

We Answer Another Question... This Time About Which Is Best - Hot Or Cold?

The Short Answer – Whether it is better to use hot or cold for back pain, is one of medicine’s more surprising mysteries. The evidence suggest both work. The theory suggests only heat should be relevant for back pain.

We look at both options and ask ‘why choose?’ But if you do, heat (thermotherapy) has to get the vote….

Hot and cold therapy has been recommended for injuries, strains and permanent painful conditions for many, many years.

Frequently this has been without any real review of the clinical evidence, but is based on plenty of anecdotal evidence, because past patients have said it worked.

The clinical rationale between hot (thermotherapy) or cold therapy (cryotherapy) is fairly straightforward –

Heat –

  • Heat is renowned for relaxing stiff and sore muscles, as well as helping to increase flexibility
  • Heat dilates blood vessels, facilitating an increased blood flow, increasing oxygen delivery and vital healing anti-bodies to the Injured area.
  • Heat can block some of the sensory pain signals to the brain by overwhelming it with other sensory signals.

Cold –

  • Rather than increasing the blood flow, cold slows the blood flow which serves to reduce inflammation.
  • The ice is thought to actively numb nerves around an injury, reducing the number of pain messages sent to the brain

Both hot and cold therapies benefit from 3 other main advantages –

  • They are relatively inexpensive, compared to physio or chiropractic sessions.
  • It’s easy to apply at home
  • There are very few side effects

They also both benefit from a substantial ‘placebo effect’, improving results considerably. 

We’ve discussed ‘The Placebo And Pain Relief’ at length in another article, but in short, the brain is an incredibly powerful tool for pain relief.

It regulates what pain you feel and how much. For evidence of this you need only stub your toe and feel searing pain. The brain tells you that was ‘unfortunate’ by sending pain messages.

Cut your entire foot off though and the brain recognises danger to life and you feel no pain. A combination of adrenaline and the brain’s response to keep your mind clear to aid your chances of survival, mean you wont feel the real pain until you back in a hospital bed being treated.

We see this more specifically with gout, where heat should offer no benefits whatsoever, but some patients still report improvement in symptoms. This is because they expect it work and the warmth feels nice. Technically the hot pad has done nothing.

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Hot or Cold For Back Pain – The Data

The difficult part with making a scientific judgement here is the sheer lack of testing with hot vs cold effects.

The closest trial we have to doing this is the one in 2014 by Malanga et al which reviewed a number of trials and came to the conclusion that

…” RCTs have shown that heat-wrap therapy provides short-term reductions in pain and disability in patients with acute low back pain and provides significantly greater pain relief of DOMS than does cold therapy.”
(RCTs stand for ‘randomized clinical trials’ and DOMS stands for ‘delayed onset muscle soreness’)

Garra et al published in Academic Emergency Medicine a trial aimed at finding out specifically which was more effective (hot or cold therapy), but could only conclude that both showed

“…mild yet similar improvement in the pain severity.” 

It was also further complicated by the fact both groups were given ibuprofen, which made it impossible to assess how much of the improvement was down to the drugs and how much was down to the hot or cold treatment.

And The Winner Is….

The lack of serious clinical data comparing the two means we have to rely to some extent on a combination empirical evidence and strong theory.

There is a clinical saying that goes ‘ice for injuries and heat for muscles’. The main impetus behind this is the feeling that only fresh injuries really benefit from ice treatment.

This is why a lot of athletes have an ice bath immediately after competing, catching any tiny trauma’s while they are still fresh.

Furthermore, there is significant debate around whether reducing inflammation around back injuries has any benefit anyway.

If you have rheumatoid or osteoarthritis, then the inflammation in your joints is a major source of the pain, so reducing it is priceless. (Cold therapy)

But in a muscle strain around your back, how much benefit there is to reducing inflammation is very much now being called in to question.

Furthermore, given how close the spine is to the heart (which keeps the blood warm) and how many muscles/fat/bone may lie between you and the injury, there is significant doubt as to how cool you can get your back anyway.

Icing toes/ ankles/ knees/ elbows etc are easy because they already cooler than your main torso because of the distance from the heart pumping warm blood.

However, trying to cool a muscle inside your spine would be like trying to cool down your kidneys or lungs!

This is the debate that rages today – yes ice definitely works on many injuries, but not necessarily on your back.

So if you had to pick just one for non-specific back pain, then your best option may well be Heat Therapy.

Cold therapy still has a vital place in many areas of pain relief – and can still be effective in reducing back pain. But if it was a choice of hot or cold for back pain – then hot wins.

The Final Word –

There is sufficient evidence to suggest that heat pads (thermotherapy) definitely work for back pain.

The same is less clear cut for cold therapy (cryotherapy) though. A lot of people who say it works use both, approximately half an hour apart.

This is the most common option that patients take up – a combination of both.

However, if the choice is hot or cold for back pain, then it has to be hot for the muscles.

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References Used –

1. Malanga GA, Yan N, Stark J. (2014). Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate Medicine Journal.
2. Garra G, Singer AJ, Leno R, Taira BR, Gupta N, Mathaikutty B, Thode HJ. (May 2010). Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Academic Emergency Medicine.

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