Heat or Cold Therapy—which is best to treat my chronic pain?

Heat and cold therapy are simple and accessible pain management tools that should be included in the treatment arsenal of anyone with a chronic pain. From my observations, many people who struggle with chronic pain tend to use heat most often, because in general it feels more comfortable and relaxing. But should heat always be your go to? Let’s take a look.


The use of cold therapy

Traditionally, ice is recommended for “acute” or new injuries. An example of this would be a sprained ankle. You step on your dog’s tennis ball, you scream in pain, your ankle blows up to the size of an elephant, and eventually the old adage R.I.C.E. pops into your head (Rest. Ice. Compress. Elevate). You’re not even sure where this protocol came from. But you know you are supposed to slap a bag of frozen peas on that ankle and hope for the best.

Understanding what happens after an injury

When an injury occurs, blood rushes to the area bringing along a cascade of natural inflammatory molecules. These travel to the injured area to initiate the healing response. The result is the red, hot, painful blob where you ankle used to be.

This increased blood flow and local soft tissue damage results in compression on nerves in the area. These nerves send the memo to the brain – “yo, we are messed up down here! Would someone grab this chick an ice pack?” (This of course is my oversimplified way of describing the incredible science behind the transmission of pain signals, memory, and learned habits).

Benefits of cold therapy

The application of ice to your ankle at this point causes local vasoconstriction or reduction in the size of blood vessels. This will help to reduce the risk of the area swelling more and allow the excess fluid to return to circulatory system once the body has done its job.

More recent research suggests that the overuse of ice can actually delay or block the natural inflammatory process, slowing down the body’s innate healing system. So while ice is the traditional go-to, more research is warranted as to how and when we utilize it.

Other benefits of cold therapy include decreased pain by reducing sensation from the aggravated nerve endings.

Overall, cold therapy helps us experience less pain and can prevent excess and prolonged swelling with a recent injury. But here we are talking about chronic pain- pain that is not new. How does this change things?

Cold therapy for chronic pain

Your chronic pain may have originally started from an injury such as the one outlined above. It may have started without any injury at all.

As always, with chronic pain things are a bit more complicated.

As we learned ice can be helpful in blocking the nerve signal for pain. Instead of the area of your body screaming “PAIN PAIN PAIN SO MUCH PAIN” at you, it will now yell, “HOLY COW WE ARE FREEZING DOWN HERE”. When in significant pain, often times people find the latter message more appealing.

Plus, if the painful area is “numb” from the use of ice, the nerves can’t communicate for a temporary period. That can be a nice break for you and your brain regardless of if the pain is acute or chronic.

The role of inflammation

Inflammation is another buzzword in the chronic pain world. I believe that the majority of people with chronic pain have an increased level of inflammation in their body. This means that systemwide, the body is getting signals of “we are hurt or malfunctioning” in the absence of an actual injury or disease process.

Cold therapy has been found to reduce inflammation locally. Cold therapy alone cannot address underlying, widespread inflammation in the body though. Perhaps this limitation is behind the increasing popularity of “whole-body cryotherapy”. With this treatment, brave souls enter a chamber that exposes their body to extremely cold temperatures for a few minutes. More on that at a later date if I ever dare to try it.

Is “cool” okay or does it need to be “cold”?

For treatment of chronic pain, I generally actually prefer cool over cold temperatures. The use of ice will eventually numb the area thus blocking pain signals. But sometimes that level of cold is not tolerated well because it can overwhelm your already overwhelmed nervous system.

Remember that the use heat or cold therapy will not “cure” your chronic pain. If the temperature does not feel tolerable to you, change it until it is. Get out of the mind set that “pushing through it” will help…anything. The chronic pain cycle you are stuck in could in part be due to this type of mindset.

The goal of using these modalities is to decrease your pain and improve your comfort. Therefore, applying a cool compress may be more soothing than gutting it out using an ice bag until you are numb. Listen. To. Your. Body.

Take-aways for use of cold therapy for chronic pain:

  • Use cold therapy when pain feels like it may be nerve-related: “shooting”, “aching”, “burning”, or “throbbing” might be words you’d use to describe your pain
  • Don’t use cold therapy if you feel your pain is related to a muscle spasm or stiff joint – this can sometimes make your pain worse
  • Use cold therapy to give your body and brain a break during periods when you experience higher than normal pain
  • Use ice if the area looks red, swollen, and hot
  • Don’t overuse ice, as it can affect the healthy blood flow that reaches the area
  • Try cold therapy for “mystery” pain symptoms that are linked to excess blood flow such as ice applied around the neck when you feel a migraine coming on

The use of heat therapy


There are many benefits to heat therapy, but the science behind it is relatively simple. Applying heat to a painful area will bring more blood flow to that area. This is a desirable way to help reduce muscle spasms or tension and to decrease stiffness in your joints.

I tend to recommend heat to my clients more frequently because I believe (for most) it is more relaxing and enjoyable. As discussed these are factors of vital importance in the treatment of any chronic pain.

Unlike in the ankle sprain scenario outlined above, with chronic pain, the acute inflammatory response has completed (or never occurred in the first place). With chronic pain inflammation tends to be a more widespread issue that can manifest itself in a vulnerable area or areas. This results in the sensation of localized pain. These areas may also not be receiving enough blood flow due to inactivity or muscle soreness. Applying heat can bring more healthy blood cells to the painful area.

Take-aways for use of heat therapy for chronic pain:

  • Use heat when the pain feels more muscular or due to joint stiffness. Words like “tight”, “crampy”, or “in spasm” might come to mind.

My favorite forms of cold or heat therapy

  • Gel iced packs: easy to clean and reuse, comfortable, and can easily conform to different body parts
  • Moist hot packs: heat comes from moisture and not electricity; microwavable packs can be purchased or homemade with the use of rice
  • Inexpensive options can also be found that can be used for both heat or cold therapy

Safe application of heat or cold therapy

Direct use of moderate cold or heat therapy (applying a hot pack or ice to one area of the body) should be utilized for 15-20 minutes at a time. Any period beyond that will be unnecessary in gaining any additional positive effects. It can actual become detrimental to the circulation to that area of the body.

If you are having a particularly painful day try 15 minutes on, 45 minutes off. This will allow your body time to adjust back to its normal temperature in between sessions.

Burns can occur from the application of heat or cold therapy. Avoid by utilizing a pillowcase or wash cloth between the pack and your skin. The source of heat therapy will determine if you need additional layers between it and your skin. Follow the directions that came with your product and pay attention. (Don’t sleep with it on…  I fell asleep with one once and awoke to my necklace being tattooed on my skin, bad news)

Medical diagnoses that may affect your choice

My business works to serve those with “mystery” pain. This means those without a diagnosis that explains their symptoms. This can also mean those with a diagnosis, but the underlying cause of the disease or symptoms is unknown. Your pain may or may not be correlated with each condition you have. But you should always consider your full medical history when deciding on what therapy is right for you.

Here are a few important conditions that should be considered prior to utilizing heat or cold therapy. If you are unsure of the risks, check with your physical therapist or physician first.

Here are examples of some chronic illnesses that could result in heat sensitivity/intolerance:

  • Diabetes – be very cautious with application of heat if you have decreased sensation in your hands and feet as you could burn yourself without realizing it
  • Multiple sclerosis – heat is known to worsen symptoms in those with MS and therefore should be avoided

Here are some examples of medical conditions that could result in cold sensitivity/intolerance:

  • Raynaud’s Syndrome – avoid completely in affected areas due to circulatory concerns
  • Fibromyalgia – may be okay depending on the person, but some find cold too uncomfortable
  • Diabetes – same as the above stated reason for heat

At the end of the day, do you.

Remember, there should always be general safety guidelines that you follow, but you are an individual. There are many aspects that contribute to chronic pain, so there is no guarantee that one form of therapy will be the right one for you.

Always respect and respond to your body’s individual needs.

Even after I fully assess someone, take their history and feel the muscles and joints around the painful area, I still might make the wrong call. As long as you are being safe, allow yourself to try different treatments.

Be present in your body. Despite all of the “best evidence” sometimes what “should work” or “has worked before” will not work now. Pay attention to the way your body is responding to a particular therapy and make changes as needed.

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