Mechanisms and Efficacy of Heat and Cold Therapies for Musculoskeletal Injury

Jan 22

Mechanisms and Efficacy of Heat and Cold Therapies for Musculoskeletal Injury

The Orthobiologic Institute: TOBI Faculty, Gerard Malanga MD, and colleagues recently published a review article titled “Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury” in Post Graduate Medicine discussing the potential mechanisms and applications of heat and cold therapy. Although many different mechanisms have been described throughout the decades, heat and cold therapies have continued to be used in the treatment of musculoskeletal injuries. However, throughout the general population, and even amongst healthcare professionals, the common question still remains, “Should I ice or heat?”. In his recent publication, Dr. Malanga explains in greater detail the proposed mechanisms of such therapies, and summarizes the evidence for use of such therapies in specific musculoskeletal injuries.


In short, the article describes how cold therapies are thought to reduce blood flow and edema, slow the delivery of inflammatory mediators to the damaged tissue, reduce spasm, and provide a local anesthetic effect through cold-induced neurapraxia.  While, heat therapy has been shown to increase blood flow and supply of nutrients and oxygen, increase elasticity of the tissues, and decrease pain, possibly by activation of the TRPV1 receptors in the brain modulating descending antinociceptive pathways.  However, regardless of the mechanism of action, there is often confusion about which modality is best in certain situations and whether current studies support their use.


Two of the most common indications for the use of cold therapy (aka cryotherapy) are acute ankle sprains and Delayed Onset Muscle Soreness (DOMS). When examining the efficacy of cold therapy for acute ankle sprains, Dr. Malanga’s research revealed multiple systematic reviews that showed marginal evidence supporting the use of ice post ankle sprain, and a majority of randomized controlled trials (RCT) to be greater than 20 years old and of low quality.  However, one article showed an intermittent icing protocol performed for 72-hours post ankle sprain to be associated with significantly less ankle pain on activity when compared to a standard cold therapy protocol. In addition, the use for cold therapy in the treatment and prevention of delayed onset muscle soreness (DOMS) also revealed conflicting results.  One RCT found that localized air-pulsed therapy provided no significant benefit compared to the control group in muscle soreness or function following strenuous exercise.  In contrast, another RCT found that multiple daily applications of ice (20 minutes, 3 times/day for 72 hours) were superior to no-treatment in reducing perceived muscle soreness.


Like cold therapies, heat therapy has also been used in the treatment of many common musculoskeletal conditions.  One of the major uses is for acute and subacute low back pain, and there are multiple RCTs to support its use in patients with these conditions. Dr. Malanga describes three major studies in which the use of heat was associated with greater pain relief, reduced back pain disability scores, and improved range of motion.  Furthermore, heat therapy has also been studied in the treatment of DOMS, and the studies mentioned in the paper (2 RCTs) showed significantly reduced pain, disability, and perceived muscle soreness; particularly with the use of moist heat in older subjects (45-70 years).


The article also examined studies that compared the efficacy of cold and heat therapies.  One RCT showed no difference between a single 30-minute treatment of heat or cold in the management of acute low back pain and neither showed significant reductions in pain.  In contrast, statistically significant reductions in muscle stress reaction markers were seen in healthy young athletes who performed hamstring eccentric exercises after being submersed in warm water compared to submersion in cold water.


Although the article revealed mixed evidence for the efficacy and indications of heat and cold therapy, combining this current evidence with clinical experience, Dr. Malanga sees potential benefit in the use of cold therapy for acute injuries with inflammation, and the use of heat for muscular pain, soreness, joint pain and stiffness. He also identifies the need for more well-designed prospective randomized controlled studies to further support or refute the use of these modalities for treatment of musculoskeletal pain.


Collaboration across a variety of fields is necessary to expand research efforts and continue to improve evidence based medicine in the field of sports medicine. For all of the latest research and protocols in regenerative medicine be sure to attend the 6th Annual TOBI: The Orthobiologic Institute PRP & Regenerative Medicine Symposium with Cadaver Lab June 12-14, 2015 in Las Vegas,, Use Promo Code LINKSAVE300

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