Fire and Ice: The Great Debate on the Relative Value of Heat and Ice in Musculoskeletal Therapy - a Narrative Review

A B S T R A C T In contemporary musculoskeletal therapy it is common to apply topical cooling agents such as ice, particularly in the context of the RICE (Rest, Ice, Compression and Elevation) protocol. Traditional Chinese medicine (TCM) practice, however, has tended, for two millennia, to use heat rather than cold to treat musculoskeletal injuries, due to the traditional belief that enhancing circulation is likely to be beneficial, while impeding circulation is likely to be deleterious. This narrative review examines the evidence to support the use of ice alone (not as part of the RICE protocol) and the use of heat in the treatment of acute soft tissue injuries, rheumatoid arthritis, osteoarthritis and low back pain. Conclusions: Ice, applied to muscles, appears to have a local anaesthetic rather than an analgesic action. Evidence on the efficacy of ice in reducing oedema is contradictory. Insufficient evidence was found to support the assertion that ice can reduce muscle spasm, however there is evidence that heat can. In rheumatoid arthritis neither heat nor cold showed evidence of benefit. Knee oedema associated with osteoarthritis showed no significant improvement from ice massage, whereas knee oedema following arthroplasty improved with ice packs but not with hot towels. For low back pain there is moderate evidence of significant short- term benefit from heat wraps but insufficient evidence to draw conclusions on the use of cold. Low back pain studies comparing heat and cold yielded conflicting evidence. K E y W o R d S ice, heat, cryotherapy, thermotherapy, musculoskeletal, moxibustion.