Medicine for the Outdoors
Medicine for the Outdoors

Dr. Paul Auerbach is the world's leading outdoor health expert. His blog offers tips on outdoor safety and advice on how to handle wilderness emergencies.

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Heat or Cold Treatment for Muscle Strain

Applying an ice pack to a muscle strain.
Along with blisters and sprains, muscle strains are among the most common afflictions for active persons in the outdoors. Common medical dogma is to use the “RICE”  approach for sprains and strains of—rest, ice (application of cold), compression, and elevation. This is more applicable to sprains (e.g., an ankle sprain) than to strains, because the sprained body part is usually a limb (ankle, knee, wrist) that is amenable to this approach. Strains more often involve larger muscle groups, such as those in the back, chest, thigh or abdomen, or difficult-to-approach areas, such as the neck or groin.

Prevailing theory for treatment of a muscle strain is that one applies external cold for 24 to 48 hours, and discontinues it after 72 hours, at which time one begins application of external heat. The rationale is that swelling (from leakage of blood and tissue fluid) and inflammation prevail in the first two days, and that after three days, one wishes to increase local circulation and augment reabsorption of the fluid that has collected. There is some science to this, and these recommendations have been around for as long as I can recall.

I just read a paper entitled “Heat or Cold Packs for Neck and Back Strain: A Randomized Trial of Efficacy,” authored by Gregory Garra and his colleagues (Academic Emergency Medicine 2010;17:484-489). The purpose of the study was to compare the pain-relieving benefit of heat versus cold in the treatment of back and neck strains. The authors started out with the scientific hypothesis that there would be no difference between the two temperature modalities. Patients included in the study were 18 years of age or older. All of the patients received 400 milligrams of ibuprofen orally and then were assigned in a random fashion to receive 30 minutes of either a heating pad or a cold pack applied to the injured body region. A variety of methods were used to assess pain before and after therapy.

There were 31 patients in the heat-treated group and 29 patients in the cold-treated group. In the final analysis, there was no difference between the groups either in their demographics or in response to the therapies. The authors admitted that pain relief may have been due to the painkiller anti-inflammatory drug ibuprofen, and not to the heat or cold therapies. However, if there was an additional beneficial effect from the heat or cold, no difference between the two was noted.

So, what can we conclude from this study? Really, not much. The confounding factor of administration of ibuprofen interferes with any direct conclusion about the heat and cold, other than that in combination with ibuprofen, neither appears to offer an advantage over the other.  Indeed, there wasn’t even a control group, which in this case would have been ibuprofen administration alone without adding heat or cold. What if ibuprofen alone generated the same amount of improvement? Furthermore, how about a longer duration of heat/cold therapy? Might that have yielded more or less improvement? What about time to complete resolution of symptoms? It would have been interesting to follow these patients until their pain was completely resolved, to determine if despite the rapid effects upon pain relief, there were any implications to time to total resolution of symptoms (and presumably, healing).

Based on this particular study, I really cannot draw any conclusions, so will stick with the dogma until someone reports something to make me change the traditional approach. My advice to the readers is to stick with cold first for acute muscle strains, then transition to heat after 72 hours.

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About the Author

Dr. Paul S. Auerbach is the world’s leading authority on wilderness medicine.