People don't like pain. It seems like every other commercial on TV is for this or that pain reliever - tablet, gelcaps, mineral rub, thermal patch, easy-to-swallow liquid, and even the special herbal formulary translated from an ancient stone tablet somewhere in the Himalayas. The focus on alleviating pain is enormous. Please note, I said the focus is on alleviating pain, not fixing the problem. As chiropractors, we often focus on fixing the source of the problem - that is all well and good, but most people on the street are only worried about getting out of their pain now.
I recently had a patient come in who had hurt his back at work. He was lifting a tub form for a bathroom and felt his middle back seize up. His work doctor sent him to PT, an MRI was performed, and he started exercise. The MRI came back showing bulging discs. After three weeks of heat and exercise, he wasn't feeling any better - so he was sent for a surgical consult. Fortunately, the surgeon recognized this was not a case that warranted surgery, and referred him to me for further evaluation.
The first thing I noted was the dramatic inflammation in his upper back - mostly in the rhomboids and levators - you could see the spasm, and on palpation you could feel the rigidity of the tissues and the heat coming from the area. When we talked about what he had been doing for therapy, he described mostly resistance exercises and home application of a heat pack. As I questioned him further, he admitted the heat felt good while it was on, but overall he was not getting better - if anything, he was now hurting more.
For some reason, it seems a lot of docs are reluctant to recommend cold therapy and want to limit that treatment. I cannot count the number of patients who have said they were instructed not to use cold, but to go with heat. I went back to Jaskoviak's text to review the proper protocols for cold therapy. It was interesting to note he devotes an entire chapter to the application of cold and cold therapies - and he makes the comment that when a patient is not responding to treatment, it often might be because they are improperly using heat at home.
Obviously, cold therapies decrease the local tissue temperature. This, in turn, decreases blood flow, local metabolism and inflammation. With the decreased inflammatory response comes a reduction of histamine and exudates. Ultimately, the application of cold will produce arteriolar vasoconstriction and reduction of edema. All of this helps to reduce spasm and pain.
It often has been said one should only use ice up to 72 hours after an injury. I am not sure this can be supported by the literature. It is true the initial inflammatory reaction might last up to 72 hours, but that does not mean all the inflammation goes away from that point forward. It's quite possible for an injury to remain inflamed for a week or more. I believe common sense dictates cooling therapies are much more effective in treating actively inflamed tissues. Heat might feel good over an area in inflammation, but not everything that feels good is good for you. As in the case of my patient, heat and active exercise only served to increase his spasm and pain. When we had him use ice over the area of spasm, his pain levels dropped quickly and I was able to get a much better adjustment. We also can talk about how cold initially decreases blood flow, but after about five or 10 minutes, actually serves to increase blood flow to an area as the body tries to stabilize the temperature of the skin. It always has been my understanding that this increase in blood flow, instead of bringing inflammation to the tissues, helps to flush out toxins and congestion that are creating pain. But that is another topic for discussion.
Obviously, there are a number of cautions when using cold therapy - vascular compromise, intolerance to cold, etc. - but the proper application of ice has tremendous therapeutic benefits. Heat is not bad, but should be used at the appropriate time. In my office, I rarely use heat other than to warm tight stiff muscles prior to active rehab. Remember, you are responsible for the care you provide your patients. Make sure the treatment you give is appropriate to the condition. Your job as a physician goes beyond just helping people feel better. Cool therapies are not always comfortable, but they can greatly aid the healing process and get your patients better quicker. Take the time to provide the best care you can; your patients will thank you for it.
Click here for more information about Douglas R. Briggs, DC, Dipl. Ac. (IAMA), DAAPM, EMT.
Kymberlie Combs is a licensed massage therapist specializing in prenatal massage and practicing near Philadelphia.