Heat, Cold, and Therapy: Treating Yourself Safely & Effectively
It has been said that “A physician who treats himself has a fool for a patient”.[1] But of course, that was a different age –an age of professional courtesy –and he never had to deal with obtaining referrals or prior authorizations for medical care!
Let me state at the outset that although this fool treats himself regularly, and has for years, I do rely on my internist, urologist, dermatologist, and ophthalmologist for consultation and treatment.
I should also state that although I am a product of a traditional medical education, I have incorporated a few aspects of what is called “Complementary and Alternative Medicine” (CAM) into my own practice. I believe in a good diet (Mediterranean, MIND, DASH among others, I make sure that I obtain a good night’s sleep every night and exercise every day, I meditate, and I have given up on all of the worthless supplements I have tried over the years.
And at the same time, I believe that much of what is regarded as CAM is a sham. Things like homeopathy, naturopathy, Reiki and many others fall into this category. The US seems to specialize in this kind of stuff.
We boaters and sailors need to treat ourselves for two reasons:
First our primary care providers are unfamiliar with many of the problems we face on the water, and second there may be long periods of time when we are responsible for treating ourselves and our crew. So, after that long disclaimer, let’s get into the treatment of minor injuries. (Obviously, you should not treat major injuries unless you are in the middle an ocean in which case you hopefully have a good first aid book and medicine chest. If so, good luck and God bless.)
Acute injuries
The most important time for the management of most minor musculoskeletal injuries is the first 24 hours. It is then that there is damage to blood vessels with the accumulation of blood causing compression of adjoining tissues which in turn causes secondary “hypoxic” injury and further tissue damage to the soft tissues. Therefore, the initial effort should be to reduce further bleeding and swelling. The accepted method is captured in the acronym RICE:
R Rest
I Ice
C Compression
E Elevation [2]
Rest is fairly straightforward. And so is compression (not too tight) and elevation. All three are meant to decrease bleeding and swelling. But what about ice? Ice immediately after an injury is used to reduce inflammation, reduce bleeding by constricting small blood vessels, and reduce tissue destruction (so-called necrosis). There are a number of regimens, but application of 20 minutes every 2 hours for at least 6 hours is a start. Do not apply ice or ice packs directly to the skin (or you can have a freezing “burn”). Also avoid in people who have known peripheral vascular problems (poor blood circulation) or cold allergy.
So, in most acute injuries to the musculoskeletal system, ice is the way to go, not heat. Reusable cold packs, crushed ice in a baggie, vapocoolant sprays, are all available on a boat. The types of injuries that would be appropriate would include an acute muscle strain, ankle ligament sprain, patellofemoral pain (especially in you hiking sailors!), IT band syndrome, among others. Does it help with pain? Yes, somewhat. Localized analgesia occurs when the skin temperature drops below 15 degrees C (59 F). One way to deliver cooling to muscles in the arm or leg is with ice massage. You can buy one, but it is simple to make your own ice massager. Just take a Styrofoam cup and fill it with water to the top. Place it in the freezer and once it is frozen solid cut about an inch all the way around from the top exposing an inch of the ice. Then you can grasp the cup and massage with the exposed ice.
But hold on. Dr. Gabe Mirkin, the physician who developed the RICE protocol many decades ago, has “recanted” as far as the “I” is concerned. Holy moly. His new “theory” is that healing requires inflammation and that since icing (cryotherapy in the trade) decreases inflammation and constricts blood vessels reducing blood flow to the injured tissue, it is counterproductive. Has his late recantation had an effect on the sport medicine profession and trainers? Yes and no. It has certainly changed the recommendations of some trainers.
For those of you who have read the prior blog on shoulder injuries, I discussed my attendance at Philadelphia Phillies baseball fantasy camp many years ago. I remember vividly the issue of icing. For anyone who pitched even one inning they were required to ice down their pitching arm – ice was placed in a sling and they sat for 10-15 minutes. [The reason I recall this so vividly is because I was sitting with the pitchers, icing down my groin muscles with an ice massager because of the …well, probably too much information!]. In any case, the current recommendations for pitchers, both youth and adult, is for them to forgo icing and simply engage in aerobics to increase the blood supply to the arm and promote healing. That is, after you pitch, you run. But I believe that we have to distinguish between muscle soreness (as in pitchers or any similar activity) and an acute injury.
Although this remains somewhat controversial as regards soreness after athletic events, I believe the consensus is that for most new (acute) injuries that we encounter, especially of the arms and legs, the RICE protocol with the “I” is still the way to go, e.g. muscle strains, ligament sprains, and most bruises.
Chronic and Repetitive Injuries: Heat or Cold?
When I recently injured my back. I tried ice first. It was only weakly helpful and so I changed to heat. It was much more effective, and I continued with heat intermittently for the next few weeks. How does heat work?
Heat (technically thermotherapy) is especially good for non-inflammatory muscle and joint pain, e.g. acute soreness due to over-exertion, stiffness secondary to osteoarthritis and pain related to muscle cramping –when localized, the muscle cramping or knots are referred to as “trigger points.” Often it is exceedingly difficult to distinguish muscle pain from joint pain –especially in the neck and back—but fortunately heat works well for both joint and muscle pain.
It is not generally effective for a fresh injury especially if there is redness, swelling, and sensitivity to touch. That is where ice comes in!
How does heat work? It increases blood flow to the area which promotes healing by bringing in nutrients and removing breakdown products. And it is reassuring –it just feels good. So, for subacute and chronic injuries, try heat. This is especially true for neck and low back pain.
For repetitive injuries of the arm or leg rest, rest, rest may be most important of all. You can try heat or ice but repetitive injures are due to tissue stress or damage but not a significant amount of inflammation so either may work. But resting the injured area is key.
What about DOMS?
DOMS stands for Delayed Onset Muscle Soreness - something most of have had in our lifetime but never had a name for it. It is that distinctive muscle pain that occurs the day after intense or unfamiliar exercise and which peaks at 24 to 72 hours. It is not an acute injury per se and it is different from the routine post exercise soreness which is present during and immediately after muscular activity. Its cause is unknown although it is usually associated with eccentric (lengthening) exercise causing microtrauma to the muscle. You should look upon DOMS as a warning sign to back off of that activity. Although it is generally self-limited there is no good treatment. The anti-inflammatories like ibuprofen are often tried but it does not appear to be an inflammatory problem. Ice and heat have been tried but are not effective.
Medication?
Non-steroid anti-inflammatories (NSAIDs) have a definite role to play.
It is important to distinguish acetaminophen (paracetamol) [Tylenol in the US and Canada] from the common NSAIDs. Although paracetamol is helpful for mild to moderate pain, and helps with fever, it has essentially no anti-inflammatory effect.
NSAIDs like ibuprofen, naproxen, and diclofenac help with pain and fever but also have anti-inflammatory properties. One downside is that they may irritate the GI tract. They also should not be taken chronically without acknowledgement from your primary care provider. But for short term use they can be very helpful and may certainly be combined with heat or ice.
Diclofenac topical gel has recently become over-the-counter in the US and is an excellent choice especially if the tissue in question is near the surface of the skin. I have used it personally for many conditions and I have prescribed it successfully in patients with carpal tunnel syndrome (the median nerve in question is a short distance under the skin) and it may help with conditions like Dupuytren’s contracture in the early stages since the tissue knot also lies just beneath the skin surface. But if the tissue is too deep the medication will not be able to reach it, even if you rub it in well and use it twice a day.
Therapy?
Certainly. For chronic and repetitive injuries and DOMS there are a host of therapies which can be tried including:
Physical therapy
Massage
Myofascial release
Acupuncture
Ultrasound
TENS
And many others
If you have tried treating yourself and are getting nowhere [and you are near medical care] then I would recommend a formal evaluation before starting any of the above, for two reasons. 1. Confirm that there is nothing more sinister underlying the prolonged symptoms and 2. The evidence or science behind the above treatment modalities for these conditions is weak or non-existent. And this non-existent science includes both what is happening to the muscle or ligament or joint as well as how effective these treatments actually are. There are simply very few good reliable studies which demonstrate that they are effective. If you really are interested in how muddled these treatments are check out this website. [3]
[1] Sir William Osler (1849-1919), a Canadian physician and one of the founders of The Johns Hopkins Hospital
[2] In the first 72 hours there is an analogous 4 letter acronym that you should keep in mind to avoid: HARM H=heat and heat rubs; A=Alcohol; R=running or any moderate activity; and M=massage of muscles and soft tissues
[3] The site PainScience.com is both comprehensive and even-handed. It has everything you want to know about heat, cold, and the treatment of pain.