Heat vs Cold … What the evidence suggests

Acute soft tissue injury has been managed using the acronym PRICE (Protection, Rest, Ice, Compression, and Elevation) for years, even though there is a lack of evidence demonstrating its efficacy. Although rest is beneficial for acute soft tissue trauma (Bring et al. 2009; Martinez et al. 2007), it should only be limited to immediately after the trauma as long periods of rest are potentially harmful. This is because lack of movement will allow the soft tissue to heal in the static state rather than according to its biomechanical function. In other words, the soft tissue will grow back in a more random, mesh pattern rather than its natural muscle fiber directions.

The goal after any soft tissue injury is to be up and have pain free movement as soon as possible, to find the balance between movement, exercise, traction, and rest (METH). This will improve healing outcomes substantially. The key words here are pain free. Movement too early after injury can initiate bleeding and cause further injury, however prolonged rest can lead to atrophy, contracture, and decrease in neural function of the damaged tissue. Early rehabilitation/mobilization has been shown to be effective in both minor injuries such as an ankle sprain (Jones and Amendola 2007, Kerkoffa et al. 2002, Bleakley et al. 2010) and more invasive procedures such as hip/knee joint replacements (Wellman et al. 2011, Ibrahim et al. 2013). The reason behind this standard medical practice is because progressive mechanical loading restores the strength and structural characteristics of collagen tissues better than prolonged rest (Bring et al. 2009; Martinez et al. 2007). Progressive mechanical loading activates cellular responses, which cause tissue structural changes (Khan and Scott 2009), such as upregulation of key proteins associated with soft tissue healing (Bring et al. 2009, Martinez et al. 2007, Eliasson et al. 2009).

The acronym METH (Movement, Exercise, Traction, and Heat) provides clinicians with an approach to acute soft tissue healing that is not only individualized to the injury itself, but also is in alignment with the natural healing process. Movement, exercise, and traction are all specific to the site of injury, thus allowing the clinician to cater to the unique mechanical stresses and functional activities required of the tissue. So now the question is….

When do you PRICE and when do you METH?

PRICE is best over short term (about 6 – 72 hours maximum) if there is any concern for developing compartment syndrome. From the table above, you can see that PRICE decrease both blood flow and collagen formation (great to fend off compartment syndrome), however it also increases healing time and decreases range of motion (bad for healing outcomes). Fibroblasts, myoblasts, and neurons require movement to build collagen and muscle fibers along lines of stress.

METH is best suited if there are no concerns for developing compartment syndrome and sub-acute injuries (post 6 -72 hours, depending on injury). The heat application encourages blood flow, range of motion, and collagen formation leading to a shorter healing time. This is because the body’s natural response to injury is to warm up the site of injury or systemically during an infection (i.e. fever) and thus we should support this mechanism via nutrition/supplement support (such as natural analgesics which will reduce painful swelling and will not suppress the natural inflammatory reactions that promote healing (unlike anti-inflammatories or steroids)), water intake, mechanotherapies (e.g. massage, exercise, IASTM), and mental/emotional support.

BOTTOM LINE:

METH is best suited for healing acute soft tissue injuries, but we must use our clinical judgement and case history to optimize healing outcomes.

For more specific, evidence based approaches to orthopaedic conditions, click here and for video resources, click here.

References:

Bleakley CM, Glasgow PD, Philips P, et al; for the Association of Chartered Physiotherapists in Sports and Exercise Medicine (ACPSM). Guidelines on the Management of Acute Soft Tissue Injury Using Protection Rest Ice Compression and Elevation. London: ACPSM, 2011:15–21.

Bleakley CM, O’Connor SR, Tully MA, et al. Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. BMJ 2010;340:c1964.

Bring DK, Reno C, Renstrom P, et al. Joint immobilization reduces the expression of sensory neuropeptide receptors and impairs healing after tendon rupture in a rat model. J Orthop Res 2009;27:274–80.

Eliasson P, Andersson T, Aspenberg P. Rat Achilles tendon healing: mechanical loading and gene expression. J Appl Physiol 2009;107:399–407.

Ibrahim MS, Alazzawi S, Nizam I. An evidence-based review of enhanced recovery interventions in knee replacement surgery. Ann R Coll Surg Engl. 2013 Sep; 95(6): 386–389.

Jones MH, Amendola AS. Acute treatment of inversion ankle sprains: immobilization versus functional treatment. Clin Orthop Relat Res 2007;455:169–72.

Kerkhoffs GM, Rowe BH, Assendelft WJ, et al. Immobilisation and functional treatment for acute lateral ankle ligament injuries in adults. Cochrane Database Syst Rev 2002;3:CD003762.

Khan KM, Scott A. Mechanotherapy: how physical therapists’ prescription of exercise promotes tissue repair. Br J Sports Med 2009;43:247–52.

Martinez DA, Vailas AC, Vanderby R Jr., et al Temporal extracellular matrix adaptations in ligament during wound healing and hind limb unloading. Am J Physiol Regul Integr Comp Physiol 2007;293:R1552–60.

Paoloni JA, Milne C, Orchard J, et al. Non-steroidal anti-inflammatory drugs in sports medicine: guidelines for practical but sensible use. Br J Sports Med 2009;43:863–5.

Prins JC, Stubbe JH, van Meeteren NL, et al. Feasibility and preliminary effectiveness of ice therapy in patients with an acute tear in the gastrocnemius muscle: a pilot randomized controlled trial. Clin Rehabil 2011;25:433–41.

Wellman S, Murphy A, Gulcynski D, Murphy S. Implementation of an accelerated mobilization protocol following primary total hip arthroplasty: impact on length of stay and disposition. Curr Rev Musculoskelet Med. 2011 Sep; 4(3): 84–90.