• dr puisan

Hot and Cold (no, not a Katy Perry song)

"You...change your a girl...changes clothes..."

No, not quite like that.

This post discusses instead about hot vs cold pack compression.

Hot versus Cold.

Ever wondered when and on what sort of occasion should you apply warm compress or a cold compress?

Are you confused with the conflicting information that you have read online or being told by someone who was told by someone else?

Why does one injury needs ice while another needs warm compress?

Or perhaps you are puzzled at why certain times at physiotherapy sessions cold and/or warm pack were applied?

Let's try to clear up SOME of the confusion and get down to the nitty-gritty details of warm versus cold therapy.

When I say warm therapy, it comprises of warm compress, warm towels, heat producing electrotherapeutic modalities and basically anything that provides heat/warmth.

In same manner, when I say cold therapy, it includes ice,  cold compress, cold producing electrotherapeutic modalities and the likes.

Let's start with cold pack and it's indications:

- Anything that is an active inflammation.

Active inflammation such as acute injuries for example:

1) acute (newly occurring) muscle strains/tears

2) acute ligamentous sprains/tears 

3) acute flare of arthritic joints which includes knee osteoarthritis

4) new bruising due to contusions to soft tissue 

5) delayed onset of muscle soreness (DOMS)

In a nutshell, anything that is causing pain suddenly and there is increase warmth in the painful area, you will not go too wrong by applying cold compress.


Now let's look into the reason WHY cold pack is useful for the above conditions:

- When in acute soft tissue injuries, there will be bleeding and hematoma (blood clot).  Sometimes the bleeding takes a while to stop which is why you will experience swelling and if superficial enough, bruising at the skin. With the new injury, there will be onslaught of inflammatory cells and chemicals that aid in the future process of regeneration of normal tissues. However problem arises when the swelling and inflammation causes severe pain and disability that the person suffering from the injury is unable to proceed with early rehabilitation (or even just daily activities of living). Therefore, ice compression helps in constriction the blood vessels thus reducing the amount of cumulated swelling and controls the amount of inflammatory cells entering the injured area.

- With the reduction in swelling and amount of inflammatory cells, so does with the pain felt by the injured person.

- Ice compression also to a certain degree, slows the nerve conduction of pain signals to and from the injured area to the brain thus it will be interpreted as reduction in pain.

- When it comes to Delayed Onset of Muscle Soreness (DOMS), the pain felt is due to micro trauma to the muscles caused by the exercise/physical activity thus it will react exactly like an acute injury only to a much MUCH lesser extend and has a much quicker resolution in pain. Depending on pain tolerance, sometimes ice compression is not even necessary but if the discomfort is affecting daily activities, I advice to ice it to ease the symptoms.

Let's proceed with warm pack and it's indications:

1) Tight or spastic muscles

2) Stiff joints - chronic and non-flared up arthritis

3) Any musculoskeletal discomfort or aches and pains that does not have any symptoms of acute inflammation --> that is no increase warmth of the achy area, no swelling and definitely no excessive pain.

Now let's look into the reasons for the above indications.

- In muscles that are tight or spastic (spasms), ideally one would try to stretch it out. However stretching out tight muscles from the get go can be tough therefore warm compress is helpful in this situation. Warm compress increases blood flow to the area thus "warming up" the muscle for stretching making the process much easier. Sometimes a warm compress can be applied pre-stretching even without any muscle tightness or spasm as it helps get you into the stretch faster. This is also the basis of Hot Yoga/Bikram Yoga where the heated surrounding helps you get into the yoga pose easier.

- With stiff joints esp in chronic osteoarthritis (which is why a lot of knee osteoarthritis patients attending physiotherapy sessions, they will almost always start with warm towels or compress prior to exercise therapy), the warm compress helps to increase blood circulation to the region (which includes the surrounding muscles) which eases the movement of the joints for easier and more conducive physical therapy. However, sometimes this becomes an issue as arthritic joints tend to flare (becoming acutely inflamed) with overuse of the joints (i.e. Walking too much for a person with knee osteoarthritis), and in itself needs cold compress. It is best to go with the symptoms.

- In fact, as long as there are no symptoms of acute injuries/inflammation, warm compress may help reduce musculoskeletal aches and pains. Many do prefer warm compress over cold as it is more comfortable (as long as the compress is not too hot). would you apply you cold and/or warm pack?

- For acute injuries or inflammations, ice compress for 20minutes and can be repeated every 2 hours. But note of caution using ice compress --> it is advice to protect your skin with a towel before applying the ice as direct cold contact to skin can cause a phenomenon known as ice burn (which is equally as painful as a heat burn).

- For those who are just returning to sports after an injury, I usually advice a cold compress over the previously injured region almost immediately after sports/activities to eliminate possible discomfort or swelling. There is an option of tapering the cold compress off as participation in the sports become more regular and pain free.

- For warm compress, apply over applicable area(s) for 15-20min (but be careful with the heat to not burn the skin) prior to stretching (for tight muscles) or for physical therapy/activities (in arthritic joints).

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