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updated 7/12/10

(Almost) Never Use Ice on Low Back Pain!

An important exception to conventional wisdom about icing and heating

by Paul Ingraham, Vancouver, Canada MORE
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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 exception to this rule of thumb. If you have low back pain, you almost always need heat instead of ice, especially the type of low back pain that flares up from time to time for no good reason.

The bottom line is patient preference: if ice feels “right” to the patient, it’s okay. But there are good reasons to err on the side of heat, and ice should only be used on the back by patients who clearly prefer it (for whatever reason), or when there is definitely a fresh injury. This in-depth article explores every possible aspect of this single tricky icing issue. There are three closely related articles available as well: one all about icing, another just about heating, and a short and highly digestible “cheatsheet” overview of the whole ice-heat confusion debacle.

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, 2008

In fact, ice does not provide “significant” pain relief for “many types of back pain,” and most episodes of back pain are not caused by muscle strain, are not inflamed “injuries” per se, and should not be iced as if they are.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 or joint damage.

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 rule unthinkingly can get you into trouble, and this one simply doesn’t apply to low 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 particular reason to avoid heat. And if there’s no inflammation, what exactly would you ice?

Icing low back pain may actually hurt

Just like heating can aggravate inflammation, ice can also have unpleasant effects. Icing the back or neck sometimes aggravates back pain symptoms, particularly when it is unwanted. Sometimes there will be an immediate sensation of increasing spasm as ice is applied, but usually it will only feel somewhat unpleasant. But then, in the minutes and hours afterwards, stiffness and pain will increase — usually not dramatically, but who needs any increase in symptoms?

Ice is not evil. Often no ill effect is felt, and many people — perhaps even most — get mild benefit from icing, just as they do from heating. But many people do not enjoy icing their back, and some of them 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 generally dislike 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 in part to ignorance of the role of trigger points, and to unjustified confidence that back pain is inflammatory in nature and will respond well to ice.

And heating back pain actually helps (or at least does no harm)

Heat is no miracle therapy. I’ve never seen anyone “cured” of chronic back pain by heat. But it does help, and it is certainly preferred over ice. After many years of clinical experience, it seems clear to me that a significant majority of patients prefer to heat their back pain. They recoil from cold, and seek out hot baths and jacuzzis, steaming showers, heating pads, and so on.

Trigger points are also probably the main reason that heat is useful, rather than harmful. They seem to respond quite positively to heat — wherever trigger points occur, in the low back or otherwise, patients almost invariably describe heat as one of the few things that reliably takes the edge off. Heated trigger points don’t generally actually go away — heat alone does not cure serious back pain — but their intensity certainly eases.

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 certainly does occur, and in these cases the role of heat is even more clearly positive, and the role of ice even more clearly negative. Wherever heat is applied to the skin, it triggers a mild reflex that reduces 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.

How to tell the difference between muscle strain and non-inflammatory back pain

There is really only one back pain situation where icing is clearly the way to go, and that is in the case of a true muscle strain or other traumatic injury of the low back muscles. There has to be superficial inflammation to cool off.

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 ripping and tearing of muscle tissue — can occur only during a significant exertion, like lifting something you shouldn’t. But, believe it or not, 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!

Many, many smart people who would otherwise avoid ice nevertheless go right ahead and ice their backs 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!

What if you just aren’t sure if your back pain involves a true muscle strain or not?

Telling the difference can be tricky for both patients and health care professionals alike, but basically it comes down to whether there was an accident involving forces that could realistically have actually damaged you. Here’s a quick checklist:

Did it hit you suddenly during strong stretching or a moment of athletic intensity? Were you lifting something way too danged heavy and/or awkward? In other words, did you have an “oh, shit” moment?

Is there a spot in the muscle that’s extremely sensitive to poking? (It may even be little bit deformed — is there a bump or a depression?)

Is the skin flushed and hot? Does it look puffy?

What about necks?

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

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

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 when they’ve been hurt badly.

However, without a clear and recent injury (almost always a car or skiing accident), 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?

Yes. “Never” is too strong a word, of course. I admit this happily, and yet people still send me hate mail — yes, seriously — about this article because they think I take too strong a position. Please don’t do that. I’m actually quite a reasonable person. The “never” in the title is just for mild dramatic effect to make a point.

Indeed, many people do find that ice feels pleasant and has a positive effect on their back pain. Probably faith is the active ingredient in many of those cases, not ice. 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 or trigger points, let alone how those things interact with ice. That belief can outweigh all other factors, and I am not going to tell anyone who is enjoying their ice that they are wrong!

It probably just doesn’t matter all that much, according to the results of a 2010 experiment at a busy emergency department.7

The test was simple: give some patients ice packs, and give other patients some heating pads, and see how they do. Just to level the playing field a little bit, everyone also got 400mg of ibuprofen (anti-inflammatory). The researchers concluded that adding heat or cold to ibuprofen therapy did not change the result. Both heat and cold resulted in “mild yet similar improvement in the pain severity.”

They recommend that the “choice of heat or cold therapy should be based on patient and practitioner preferences and availability.”

What’s going on here? Why didn’t one of them “win”?

The mind game — how ice and heat are dominated by your opinion

The body is incredibly good at maintaining an even internal temperature, no matter what you put on the skin. Even just a few millimetres in, the temperature is practically normal. And so ice packs and heat packs are really not very different. The only significant effect that either of them can have is on your nervous system — alarming or relaxing, soothing or irritating — and that in turn is strongly determined by context and how we feel about it. And that’s the common denominator, the equalizer, the thing that makes both treatments kind of the same and kind of underwhelming, and strongly affected by your confidence — a lot like back pain itself, actually.8

It can be said of either heat or ice: sometimes we like the idea, and sometimes we don’t. A person may think that a ice pack sounds just lovely — or they may think, “Ack, yuck, cold!” And the same with heat. It depends. How we feel about it is affected by many rapidly changing variables. For example, if we’ve been sitting, inadequately dressed, in a chilly examination room at the emergency room, cold is much less likely to seem soothing. But, on the other hand, if a charismatic and reassuring doctor warmly gives us an ice pack … et voila, now the cold pack seems a bit more like needful medicine, and we accept the discomfort as a necessary evil in service of a greater good for our screaming back.

In fact, I’ll bet you 100 bucks that cold packs magically “work” better when given to patients by doctors in hospitals than if they were prescribed by, say, belly dancers.

And so on.

This would explain why the ice/heat confusion is so great, and why the benefits of either treatment will average out to “modest.”

And so 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 obviously are reasons why ice occasionally works.

But I stand by the rule that heat should be preferred, because I still think that ice has the potential to do (minor) harm and to make low back pain worse.

But we come back to erring on the side of heat

Despite the fact that the evidence strongly suggests that both ice and heat are routinely mildly helpful, over the years I have seen many nasty-ish reactions to icing, particularly in the back, particularly when the patient is feeling anxious and vulnerable, and particularly when the patient would rather be heated but is given ice for their own good.

Giving ice to patients in hospital emergency rooms is probably quite safe because of the context, and I suspect you could study icing in that situation in hundreds of patients before seeing a single case go badly, and even then it wouldn’t be very bad. But when a nervous patient who prefers heat is told by a manual therapist that they must go home and ice … things are lot more likely to go sideways. I cannot tell you how many times I have had conversations like this:

PATIENT: My physiotherapist told me to ice, and it’s horrible. My back just seizes up every time!

ME: Why are you still doing it?

PATIENT: He told me I had to.

ME: Would you prefer heat?

PATIENT: Yes!

ME: You have my permission to use heat, if that’s what sounds nicer to you.

PATIENT: Oh thank you thank you thank you!

You could almost turn that conversation inside and out, and make it about a patient who was told to heat but wishes that she could have used ice, but there is one key difference: unwanted ice tends to cause nastier reactions than unwanted heat. Unwanted heat is irritating but doesn’t tend to cause muscle contraction and pain. Ice does. And that’s directly relevant to neck and back pain. Ice is somewhat riskier simply because it tends to have a stronger negative effect on patients who don’t want to be iced.

And that’s why I will continue to tell people to err on the side of heat.

Skeptical? Use the experimental method!

If you’re skeptical about my conclusions, good — that’s a healthy mental habit!

Fortunately, this issue is easy to solve for yourself with experimentation. Keep your mind open, and try starting with gentle warmth. The body knows what it likes and needs to maximize healing. If it doesn’t like heat, you’ll know it: things will 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. 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” — probably trigger points. 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 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.
  7. Garnett. Boston Globe. 2000. Return to text.
  8. For more detail, see another article on SaveYourself.ca, The Mind Game In Low Back Pain: How back pain is powered by fear and loathing, and greatly aided or cured by confidence. Return to text.