SaveYourself.ca helps you solve pain problems

updated 9/18/07

(Almost) Never Ice Low Back Pain!

A common and important exception to conventional wisdom about icing and heating injuries

by Paul Ingraham, Vancouver, Canada MORE

Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.


Got back pain? This article is a great place to start, but you might be better off reading Save Yourself from Low Back Pain!

Always ice an injury, right? Er, no — there is one important and common exception to this rule of thumb. If you are have low back pain, you almost always need heating instead of icing, especially if you have chronic low back pain that flares up from time to time.

Back pain is rarely an injury — that is, it rarely involves any inflammation that can be helped by ice, but instead almost always involves muscular trigger points (knots) that are usually aggravated by ice and helped by heat. For this reason, the great majority of people with back pain prefer heat, and have negative reactions to ice. For similar reasons, most neck pain should also not be iced.

Table of Contents

Unconventional wisdom

This advice — the entire point of this article — runs against the grain. A lot of people, patients and professionals alike, get confused about when and why to use heat or ice.1 And, unfortunately, it is particularly common for doctors and other health care professionals to botch this with low back pain cases, glibly and incorrectly recommending ice massage or the application of ice gel packs.

Patients and health care professionals alike get confused about when and why to use heat or ice.

Here is a typical example from a prominent website, spine-health.com, which emphasizes several incorrect points. I repeat, this information is wrong, and this is an example of bad information:

… ice massage therapy is quick, free, easy to do, and it can provide significant pain relief for many types of back pain. In a world of sophisticated medical care, a simple ice massage can still be one of the more effective, proven methods to treat a sore back … Most episodes of back pain are caused by muscle strain. The large paired muscles in the low back (erector spinae) help hold up the spine, and with an injury the muscles can become inflamed and spasm, causing low back pain and significant stiffness.

www.Spine-Health.com

In fact, ice cannot provide pain relief for “many types of back pain,” and most episodes of back pain are not caused by muscle strain, are not “injuries” per se, and should not be iced.2 Back pain experts like Dr. Richard Deyo have clearly explained that about 85% of back pain patients have “idiopathic [unexplained] low back pain,”3 not muscular strain.

The “no heat” rule

Many people are familiar with the “no heat” rule. The reason for it is simply to avoid aggravating damaged, inflamed tissue with heat. Health care professionals are often taught, “When in doubt, prescribe ice.”

It’s a sensible rule of thumb because it is appropriate in the majority of cases. But using any such rule unthinkingly can get you into trouble, and this one simply doesn’t apply to back pain very well, especially flare ups of chronic low back pain, for several reasons.

The most important reason is simply that inflammation is rarely a factor in back pain!

Using any rule of thumb unthinkingly can get you into trouble!

In the case of some fresh back injuries — such as a lumbar whiplash in a car accident, or a severe attack of pain when trying to lift something heavy — the muscles themselves may be damaged, traumatized and inflamed, and in this case heat might exacerbate the inflammation, and ice might help. But this is rare! The vast majority of back pain is not traumatic in nature, no tissue is damaged, and inflammation is either minimal or nonexistent.

So there is no reason to avoid heat. And if there’s no inflammation, what exactly would you ice?

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Icing low back pain may actually hurt

Icing the back will often aggravate back pain symptoms. Sometimes there will be an immediate sensation of increasing spasm as ice is applied, but usually it will simply feel somewhat unpleasant. In the minutes and hours afterwards, stiffness and pain will increase — usually not dramatically, but who needs any increase in symptoms?

Sometimes, no ill effect is felt, and a few people even report a benefit. (I’ll say more about these exceptions below.) But most people do not enjoy the process of icing their back, and feel worse during and/or afterwards. Why?

This is because the majority of low back pain is probably not caused by inflammation or any kind of trauma, but by the pain of muscular trigger points, also known as “muscle knots”4 — a ubiquitous muscle dysfunction that is not well known to most health care professionals. Trigger points should never be underestimated — they are quite capable of causing severe back pain.

The majority of low back pain is probably caused by the pain of muscular trigger points, also known as “muscle knots.”

And trigger points hate the cold! Chilling the skin is actually a well known risk factor for the formation and aggravation of trigger points.5 How do you feel stepping into a cold shower? Cold applied to the skin stimulates a reflex that causes muscles to contract. This is probably how trigger points are aggravated by cold, and there may be other neurological factors.

This anecdote nicely illustrates the danger of cold:

I was receiving a pleasant massage from an RMT for a low back or sacroiliac joint problem. Everything was going well, and I was feeling quite a bit better, when suddenly she put an ice pack directly on my skin. She gave no warning at all, just put it on. It was so startling and unpleasant that my back muscles started to spasm, and all the good she’d done was completely reversed. It was a disaster! Obviously, I never went back there ...

from anonymous client

Yet around the world, doctors are telling their patients to ice their low back pain, due to ignorance of the role of trigger points.

And heating back pain actually helps

After many years of treating severe chronic low back pain, it seems clear to me almost everyone prefers to heat their back pain. The vast majority of back pain patients recoil from cold, and seek out hot baths and jacuzzis, hot showers, heating pads, and so on.

Trigger points are also probably the main reason that heat is useful, rather than harmful. They respond positively to heat just as predictably as they respond negatively to cold. They don’t necessarily go away — heat alone cannot generally cure back pain, although there is the odd miracle — but their intensity often eases.

The vast majority of back pain patients recoil from cold.

Also, for cases of back pain where spasm is more of a factor, heat helps as well. Back spasms are not as common a situation as people think — a lot of so-called back muscle “spasm” is actually just the pain and stiffness caused by trigger points6 — but it is certainly does occur. Wherever heat is applied to the skin, it triggers a mild reflex reducing muscle tone. And so the pain of low back muscle spasms can be eased by applying heat, with minimal or no risk of exacerbating inflammation that either doesn’t exist at all, or is so minor and/or deep that heating is unlikely to aggravate it.

What about necks?

Almost all of this applies to necks. But probably not quite as strongly.

Unlike backs, however, necks are more frequently injured. “Acceleration injuries” — whiplash — are more common and more serious than low back muscle strains, and involve large amounts of tissue damage and inflammation, the pain of which can be greatly relieved by ice.

Like backs, most neck pain is not actually injurious and inflammatory.

Unlike backs, necks are thinner and therefore easier to ice effectively … when ice is called for. To the degree that inflammation may occur in the neck, it is easier to reach with ice — thinner tissues are easier to chill. So again, icing necks may be more effective than backs.

However, generally speaking icing neck pain should be avoided for the same reasons that you should avoid icing back pain.

Er … never ice? Isn’t that a little extreme?

“Never” is a strong word, of course. Some people do find that ice feels pleasant and has a positive effect on their back pain. I am not going to tell them that they are wrong!

First of all, I never mess with a good placebo in progress — I’m sure that in many such cases, faith is the active ingredient. Many people believe in the power of ice with a dogmatic intensity, even though they can’t tell you the first thing about the physiology of inflammation, let alone what ice does to it. That belief can probably outweigh all other factors.

Secondly, I always advise clients to trust their personal experience above all. If ice works for you, go with that. The human body is too complex for absolute rules. There are reasons why ice occasionally works. I suspect the main one is that icing the skin can have a temporary numbing/distracting effect which, under certain circumstances, also might outweigh all other factors. For instance, this is more likely to work in the case of acute pain, when the problem feels “hot,” and it’s simply a pleasure to feel anything sufficiently different from the pain!

Never mess with a good placebo — I’m sure that faith is the active ingredient in cases where icing seems to work.

However, these effects tend to fade quickly over time. It’s common for low back pain patients who initially got a good result from ice to start getting less and less benefit. This probably reflects the fact that ice has no real power to heal most low back pain, but rather is limited to “neurological trickery” — placebo and distraction and the pleasing aesthetics of cooling an area that seems to be hot with pain. There is really only one back pain situation where icing has a more substantive power to actually improve the situation, and that is in the case of a true muscle strain or other traumatic injury of the low back muscles: where there is superficial inflammation to reduce.

Bear in mind that most back pain feels like a “true muscle strain of the low back muscles,” but likely is not. A true strain — a genuine tearing of muscle tissue — can occur only during a significant exertion. Even most traumatic lifting accidents probably do not involve actual muscle tearing — it just seems that way. To tear any muscle, you really have to pull on it very hard!

A true strain can occur only during a significant exertion.

Telling the difference between muscle strain and non-inflammatory back pain

What if you just aren’t sure if your back pain involves a true muscle strain or not? Many, many people who are otherwise convinced that ice is not a great plan for back pain nevertheless go right ahead and do it because they assume that they are the exception, one of the rare cases where actual damage has been done to the back muscles and therefore icing is advisable.

Telling the difference can be trick for patients and health care professionals alike. Trigger points tend to be regarded as an odd diagnosis, less likely than muscle strain, when in fact exactly the reverse is true.

Many people go right ahead and ice their backs because they assume that they are one of the rare cases where it will work.

If you strongly suspect that you really do have a muscle strain that needs icing, check this article first: it will walk you through confirmation of your diagnosis, or help you to understand and believe that you don’t really have a muscle strain.

And another approach is simply to give heat a chance …

Skeptical? Use the experimental method!

If you’re skeptical, good — that’s a healthy mental habit! Especially when you are reading something like this that argues with mainstream medical opinion.

Fortunately, this issue is easy to solve for yourself with experimentation. Keep your mind open, and try starting with gentle warmth instead of searing heat. The body knows what it likes and needs to maximize healing. If it doesn’t like heat, you’ll know it: things feel worse, and you should obviously stop.

But chances are, if you have low back pain, some heat is going to feel like a big relief — for all the reasons described above. The next time you have a flare-up of back pain, give it a cautious try and let me know how it goes!


Further Reading

Notes

  1. Anecdotally, consider this incident with my father. When I was still in school, and my father had not yet learned to call me before asking a doctor about his aches and pains, he went to a drop-in clinic following a traumatic knee injury. The physician on duty prescribed heat! This is shockingly wrong, but the results spoke louder than any discussion of physiology: his knee swelled dramatically, outrageously, causing severe pain and immobility. This kind of thing is not too surprising, especially from general practitioners, whose incompetence in musculoskeletal health care has been repeatedly proven by medical specialists. Unfortunately, returning to anecdotal evidence again, I see a lot of the same confusion amongst physiotherapists, chiropractors and massage therapists. Not only do I hear almost continuous reports of confused icing and heating advice that my patients receive from other health care professionals, but I also clearly remember many of my student colleagues struggling to learn these concepts, and relying heavily on memory tricks and rules of thumb rather than actually understanding. Sad but true. Return to text.
  2. The case for this is laid out in the introductory (free) sections of my article Save Yourself from Low Back Pain!, and it is made with an extraordinary amount of scientific evidence. Return to text.
  3. Deyo et al. New England Journal of Medicine. 2001. Anyone who actually goes to the trouble to look that up will find that I’ve oversimplified. Here’s the whole story. Deyo writes in full, “Perhaps 85 percent of patients with isolated low back pain cannot be given a precise pathoanatomical diagnosis. The association between symptoms and imaging results is weak. Thus, nonspecific terms, such as strain, sprain, or degenerative processes, are commonly used. Strain and sprain have never been anatomically or histologically characterized, and patients given these diagnoses might accurately be said to have idiopathic [unexplained] low back pain.” In other words, between 70 and 85% of low back pain is unexplained — yet is routinely attributed to minor injuries without any evidence that this is the case. Just because doctors often attribute back pain to “strain” doesn’t mean that they are right. According to Deyo, most of those diagnoses are actually “idiopathic” — trigger points, probably. Return to text.
  4. This is a difficult statement to prove, but easy enough to support. An understanding of the nature of trigger points is the main requirement. See Save Yourself from Trigger Points & Myofascial Pain Syndrome! for a full discussion of trigger points and numerous relevant references, and see Save Yourself from Low Back Pain! for an even more exhaustive discussion of the role of trigger points in back pain. Return to text.
  5. Mense et al. Muscle Pain. 2000. Return to text.
  6. Have you ever had a charlie horse? That is a muscle spasm — incredibly powerful and painful. A muscle contraction does not have to be that powerful to be called a spasm, but generally speaking “spasm” is reserved to whole muscle contractions that are so strong that they hurt and make movement difficult, if not impossible. By contrast, most people with low back pain simply have a high muscle tone — the muscles are contracted more than usual, but not to a degree that “spasm” is really the right word. The cause of most of the discomfort is trigger points, which are small patches of muscle that are in spasm, and very uncomfortable. Again, for more information about how trigger points work, see Save Yourself from Trigger Points & Myofascial Pain Syndrome! Return to text.