Fire and Ice Notes

ãMatt Callison • Sports Medicine Acupunctureâ • 10.29.16

Fire and Ice: The Great Debate on the Use of Cold and Heat in the Rehabilitation of Musculoskeletal Injury

Even though cold and heat therapy are probably the most commonly applied therapeutic modalities for injury rehabilitation, whether to use cold or heat is a topic of ongoing debate. Methods

• Sciencedirect • Medline/PubMed • PEDro • Google scholar • ProQuest • American Journal of Sports Medicine Archives • Cochrane Library: Cochrane Register of Controlled Trials • Journal of Chinese Medicine (Archives) • American Journal of Chinese Medicine (Archives) • Keywords: Musculoskeletal, acute trauma, chronic injury, inflammation, moxa, thermotherapy,

cryotherapy. Common Theme

• More randomized clinical trials (RCTs) are needed to determine a standardization of when to use ice and when to use heat for the management of acute and chronic musculoskeletal injury and delayed onset muscle soreness (DOMS).

• Due to a lack of clinical evidence, the decision of whether to use cold or heat applications for these conditions is based on empirical evidence.

Articles: References 1-8.

The Merck Manual states: “The choice between therapies is empiric: if heat does not work, cold is applied.” 9

Primary Injury • The amount of tissue damage and the body’s immediate reaction to the initial trauma is termed

the primary injury.10 • This phase usually lasts no longer than the first 3 minutes after the initial trauma. • Vascular changes occur immediately at the injury site; blood vessels vasoconstrict and local

blood flows ceases.11 • With acute trauma, pain is immediately felt and the initial reaction is to hold the injured area. • Eight Principles: Yin, Cold, Deficient, External

Inflammatory Response (Days 0-3) Begins minutes after the Primary Injury.

Three Primary Objectives • Defend the body against foreign substances.


• Dispose of dead and dying tissue so that repair can take place. • Promote the regeneration of normal tissue. Five Cardinal Signs of Inflammation • Pain • Redness • Swelling or edema • Heat • Loss of function

“The magnitude of the inflammatory response depends on the severity of the injury, the degree of contamination, the degree of the vascularization of the injured tissue as well as patient factors such as preexisting immunodeficiency, diabetes or steroid use.” 12 Four Primary Stages of the Inflammatory Response

• Vasodilation and Increased Microvascular Permeability • Cellular Activation • Swelling: Hemorrhage and Edema • Pain and Spasm Cycle

Eight Principles – Yang, Excess, Hot, External Vasodilation and Increased Microvascular Permeability

• Blood vessels that vasoconstrict in the Primary Injury, vasodilate to increase blood flow. • Local capillaries become permeable to allow leukocytes out from the vessels and migrate into the

injury site. • Due to vessel permeability, protein-rich fluid leaks into the injured tissues that contributes to

swelling. Cellular Activation

• Cellular debris from the injury activates an immune response resulting in the sudden and extended release of inflammatory mediators that control and regulate the inflammatory process.

• Macrophages and neutrophils engage in phagocytosis, the destruction and ingestion of the unwanted cellular debris. The by-products of phagocytosis, damaged cells, extravasated blood results in free proteins deposited into the injury site.

• Dead cells from the primary injury release enzymes that are designed to digest cellular debris. These enzymes are non-selective and digest nearby living cells that further contributes to the swelling and fluid accumulation.

• In acute trauma, the inflammatory response, vasodilation and enzymatic reactions can increase the local temperature, ranging from 102-113˚ F (39-45˚ C).13

Swelling: Hemorrhage and Edema • Fluid accumulation (exudate) occurs due to damaged blood vessels, vascular permeability and

increased cellular debris. This process begins within hours and can continue for days after the primary injury.

Oncotic Pressure • Free proteins in the exudate increases interstitial tissue pressure, oncotic pressure, which pulls

fluid out of the local capillaries causing edema to accumulate in the injured area. The result is more fluid accumulation that can cause further tissue damage.

Pain and Spasm Cycle Nociceptors (specialized pain nerve endings) induce the pain-spasm cycle in two ways:

1. Damaged nociceptors from the primary injury induce a reflexive contraction of the nearby muscle tissue.

2. Fluid accumulation increases pressure on nearby hypersensitive nociceptors resulting in pain. Muscle tissue goes into spasm. Nociceptors signal more pain, increased tension is produced.


Inflammatory Response and Secondary Injury Inflammation in response to injury is a normal function however, it is the by-products of the inflammatory response and the associated collateral damage, known as the secondary injury, that can alter healing and delay rehabilitation of the injury.14-17

• Enzymes destroy normal cells that increases fluid accumulation. • Fluid accumulation compresses local blood vessels and decreases blood flow. • Inflammatory by-products results in a stasis or sludging in the local and adjacent blood vessels

that decreases blood flow.18 • Muscle spasm compresses blood vessels decreasing oxygen delivery to the local tissues. • These ischemic and hypoxic conditions result in cell necrosis and increased fluid accumulation. • “Blood is not nourishing qi and qi is not moving the blood”

Fibroplasia – The Repair Stage (Days 4-28) • As the inflammatory response subsides and the debris from the injury site has been removed,

tissue regeneration begins. • Capillaries begin to grow into the wound (angiogenesis). • Fibroblasts lay down an unorganized connective tissue foundation that will eventually become

scar tissue. Scar tissue is avascular and acellular. • The injury is transitioning from yang, hot and excess toward a relative state of yin, cold and

deficient. • Heat applications are important to use during this stage to increase yang qi and to promote the

circulation of qi and blood. Rehabilitation (Days 15-60)

• The rehabilitation phase generally begins 15-60 days after the primary injury. • Maturation of collagen tissue and continued improvements in soft tissue strength, range of motion

and function. • Blood vessel proliferation is complete. • Eight Principles transform from the yin, cold and deficient of the fibroplasia stage to the normal

function of the soft tissue. • Heat applications are important to use during this stage to promote the circulation of qi and blood.

Heat and Cold Applications

• Thermotherapy is the therapeutic application of any substance that adds heat to the body resulting in increased tissue temperature.

• Cryotherapy is the therapeutic application of any substance that removes heat from the body resulting in decreased tissue temperature.

Thermotherapy and Cryotherapy Basics


Thermotherapy (heat therapy) is a universal treatment for pain and discomfort and is useful in treating contusions, strains, sprains, bursitis, muscle spasm and tendinopathies after the inflammatory response has been controlled.19 Common heat applications in an acupuncturist’s office: • Moxibustion • Hydrocollator Packs • TDP Lamps Moxibustion

• The primary historical use for moxibustion is for cold syndromes. The contraindication for moxibustion is the presence of a heat condition because this therapy adds heat to the body.

• Using moxibustion for excess heat and deficient heat conditions is still contraindicated in all standard TCM texts of today.

• Direct moxibustion induced an inflammatory response of leukocyte migration and the enhancement of microvascular permeability, which is considered one of the host defense mechanisms.20-21

• The treatment of moxibustion was found to be associated with the increase of superoxide dismutase (SOD) in the skin.22

• Enzymatic and neutrophil destruction of muscle cells during the secondary injury could be largely prevented by the addition of superoxide dismutase (SOD).23

• A pro-inflammatory cytokine, interleukin 6 (IL-6) has been shown to be markedly reduced with moxibustion treatment. IL-6 is a common blood marker that is measured to assess the magnitude of the inflammatory process seen in acute trauma, rheumatoid and osteoarthritis.24

• A recent study of direct moxibustion applied to GV4 reduced circulating IL-6 in a collagen-induced arthritis (CIA) mouse model.25

Moxibustion and Tendinopathy • Chronic tendinopathies are frequently labeled as tendinitis, but an increasing body of

evidence supports the idea that chronic tendon conditions do not commonly involve inflammation and therefore, it would be more appropriate to categorize many of these injuries as a tendinosis.26-28

• A review of surgical cases demonstrated that an inflammatory process was not evident in cases diagnosed as tendinitis. In fact, fibroblast cells far out numbered inflammatory cells in all of the surgical cases.29-30

• Moxibustion to tendinosis is remarkable in decreasing pain and increasing function of the tissue.

Moxibustion and Osteoarthritis • Moxibustion can improve the clinical symptoms of knee osteoarthritis such as pain, stiffness

and motor disturbances.31 Hydrocollator

• Hydrocollator packs are insulated pouches of petroleum distillate that are heated in water to a temperature of around 170˚ F. The heat from hydrocollator packs has been shown to penetrate to a depth of 1 centimeter.32

• Moist heat has been shown to be more effective than dry heat with quicker pain relief and faster increase in tissue temperature.33


Far-infrared (FIR) wavelength energy lamps

• Far infrared lamps such as a TDP lamp have been shown to penetrate 0.2mm-0.8mm and therefore is able to pass through the skin to interact with subcutaneous capillaries and cutaneous nerve endings.

Cryotherapy and TCM Cryotherapy is not recognized as a valid treatment strategy in TCM theory. The use of cold, that is, the use of ice, does not appear to be in any historical references for the treatment of musculoskeletal injury. For over two millennia, the traditional belief about the treatment of acute musculoskeletal injury has been that it is better to enhance the circulation of qi and blood than to impede its circulation with cold and potentially cause more harm.

Painful Obstruction Syndrome (Bì Zhèng) When cold invades the channels it retards the circulation: outside the channels, it decreases blood (circulation), inside the channels it impairs the movement of qi that stagnates the blood and this results in pain.” Simple Questions, Chapter 39

Cryotherapy and Sports Medicine Returning to activity after an injury requires adequate repair of damaged tissues. The greater the quantity of damaged or necrotic tissue, the longer the time required for its removal, which delays healing and return to activity. Short-term management techniques that limit the quantity of damaged tissue are highly desirable. Western medical practitioners use numerous modalities for managing acute injury. Of these modalities, none is more commonly used for decreasing the secondary injury than ice.16

Cryotherapy and the Secondary Injury • Several research studies over a 20 year period have shown that cryotherapy applied within 24

hours of acute trauma decreased the amount of inflammatory by-products, which result in swelling, edema and delayed healing time.13-14,16,35-40

• By reducing tissue temperature, cellular metabolism is slowed down and the need for oxygen is lessened, which results in less secondary hypoxic injury to the cells within the injured tissue.13-14,41

Acute Musculoskeletal Injury When choosing a cold application, the practitioner should consider: • Are there are signs of bleeding? What is the state of tissue function? After the injury occurred,

was the person able to raise their arm? Grasp objects? Walk away? • Bleeding and tissue dysfunction leads to a greater inflammatory response and secondary injury. • What is the magnitude of the excess heat. The extent of the inflammatory process and subsequent

secondary injury. Assess and treat the patient’s ability to handle the inflammatory process. • Assess and treat the patient’s ability to handle the inflammatory process.

Excess Heat

Tissue temperature varies directly and proportionally with the degree of inflammatory response.42


Microtrauma • Move qi stagnation and disperse blood stasis, relax the sinews, alleviate pain. Macrotrauma • Clear heat, move qi stagnation and disperse blood stasis, drain fluid accumulation, relax the

sinews, alleviate pain, calm the shen.

Clearing Localized Heat with Chinese Herbal Medicine

My Experience

In a severe inflammatory response, where localized excess heat is apparent and can potentially become worse, ice massage or an ice pack is effective when applied for a short duration. In conjunction with ice: • Internal and external Chinese herbal medicine. • Acupuncture point prescriptions for the injury and the injured patient (every day until the excess

heat is reduced substantially). • Bleeding and Cupping • Bleeding • Dimethylsulfoxide (DMSO) Refer to: Matthew Kester L.Ac., Dipl. OM, MS TCM, MS

BIOL. Botanē www.botanemed.com Ice Applications

• Ice massage and ice pack applications are easy to use and have been shown to create analgesia and lowers blood flow that can lead to edema faster than gel packs.43-44

• Ice massage or ice pack duration: • 20 minutes on • 10 minutes off • 10 minutes on • Use off and on for 1-2 days depending on the amount of cycling excess heat • Research indicates that frozen pea application for 20 minutes can create analgesia but does not

maintain a cool enough temperature to reduce secondary injury cascades.45


Cryotherapy: Cautions and Contraindications • Raynaud’s Disease or Phenomenon • Cold Hypersensitivity (Cold-Induced Urticaria) Questions: • Do you have any unusual responses to cold? • Do develop a rash when cold? • Do you have pain, numbness and color changes in your fingers or toes when exposed to cold? • Research shows after cold exposure is removed, blood vessels continue to maintain

vasoconstriction and do not normalize for several hours. These vessels normalize after exercise and return to normal size much faster than when heat application follows cold therapy.46

• Wolf found that cooling did not just have local effects in decreasing local tissue temperature but also the contralateral extremity after 15 minutes of cryotherapy.47

• The practitioner should consider if the patient’s yang qi will be able to re-establish circulation and warm the tissue after the application of cold. Consider the patient’s age.

• Moxibustion to points that supplement or circulate yang qi can help to alter the systemic cold effects of ice application.

Cold and Age • With aging, the epidermal barrier decreases its ability to protect the body from the external

environment due to thinning of the epidermis, decreased amount of collagen matrix, loss of water and lipid content.48

• In an interesting epidemiological study of ice-cream factory workers, Italian researchers found an extremely high frequency of carpal tunnel syndrome, epicondylitis and scapulo-humeral periarthritis in workers over the age of 35 in comparison to a control population not exposed to the cold.49

Ice Baths Roberts and his colleagues recruited 21 physically active men who were asked to participate in a strength training exercise circuit 2 days/week for 12 weeks. Following each workout, half of the participants took 10-minute-long post-workout ice baths at 50˚F while the other half actively cooled down on an exercise bike. The participants in the active cool down group experienced a greater increase in muscle strength and mass at the end of the 12 weeks, compared to the ice bath group. In addition, the results showed that the activity of satellite cells and pathways necessary for muscle growth were “blunted” up to two days after partaking in exercise and a subsequent ice bath. Satellite cells, also known as skeletal muscle stem cells are considered indispensable to skeletal muscle regeneration.50

Wim Hof Wim Hof, known as the Ice Man, holds 20 world records, including a world record for the longest ice bath, 1 hr. 52 minutes. Wim describes his ability to withstand extreme cold temperatures as being able to “turn his own thermostat up” through breathing exercises. On average, recruits who underwent training by Hof reported fewer flu-like symptoms than those who did not. Trained recruits also produced lower amounts of several proteins associated with inflammation, and higher levels of an inflammation-fighting protein called interleukin-10.

References 1. Bleakley, Chris, Suzanne McDonough, and Domhnall MacAuley. "The use of ice in the treatment

of acute soft-tissue injury a systematic review of randomized controlled trials." The American journal of sports medicine 32.1 (2004): 251-261.

2. Malanga, Gerard A., Ning Yan, and Jill Stark. "Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury." Postgraduate medicine 127.1 (2015): 57-65.

3. Ibid.


4. Schmidt, Klaus L., and Eckhart Simon. "Thermotherapy of pain, trauma, and inflammatory and degenerative rheumatic diseases." Thermotherapy for Neoplasia, Inflammation, and Pain. Springer Japan, 2001. 527-539.

5. Crystal, N.J., Townson, D.H., Cook, S.B. et al. Eur J Appl Physiol (2013) 113: 2577. 6. Oakley, Elizabeth T., et al. "The effects of multiple daily applications of ice to the hamstrings on

biochemical measures, signs, and symptoms associated with exercise-induced muscle damage." The Journal of Strength & Conditioning Research 27.10 (2013): 2743-2751.

7. Schaser, Klaus-Dieter, et al. "Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats." The American journal of sports medicine 35.1 (2007): 93-102.

8. Collins, N. C. "Is ice right? Does cryotherapy improve outcome for acute soft tissue injury?." Emergency Medicine Journal 25.2 (2008): 65-68.

9. Beers, MH., Porter S., Jones T. The Merck Manual 18th edition. Merck publishers 2006 10. Järvinen MJ, Lehto MU: The effects of early mobilization and immobilization on the healing

process following muscle injuries. Sports Med 1993;15(2):78-89. 11. Knight KL: Cryotherapy in Sports Injury Management. Champaign, IL, Human Kinetics, 1995. 12. Rodriguez EK Gitajin, IL. Biomechanics of Musculoskeletal Injury. In Biomechanics in

Applications. Edited Dr. Vaclav Klika. InTech. September 2011. 13. Merrick MA, Rankin JM,. A preliminary examination of cryotherapy and secondary injury in

skeletal muscle. Med Sci Sports Exerc. 1999;31:1516-1521 14. Knight K. Cryotherapy in Sports Injury Management. Human Kinetics. 1995. , Merrick MA, 15. Anderson MK, Hall SJ Martin M. Sports Injury Management. 2nd ed. Lippincott Williams &

Wilkins: Philadelphia, PA 2000. 16. Merrick, MA. Secondary Injury After Musculoskeletal Trauma: A Review and Update. Journal of

Athletic Training 2002;37(2)209-217. 17. Toumi, H, Best TM. Inflammatory Response: friend or enemy for muscle injury? Br J Sports Med

2003;37:284-286 doi:10.1136/bjsm.37.4.284 18. Knight K, Effects of Hypothermia on inflammation and swelling. Athl Train. 1976 1;7-10. 19. Lehman JF, DeLateur BJ. Therapeutic Heat and Cold, 3rd ed. Baltimore, Williams and Wilkins,

2002. 20. Masako Okazaki et al, Am. J. Chin. Med. 18,12(1990). Effects of Single Moxibustion on

Cutaneous Blood Vessel and Microvascular Permeability in Mice. 21. T. Seki, S. Takayama, M. Watanabe et al., “Changes of blood flow volume in the superior

mesenteric artery and brachial artery with abdominal thermal stimulation,” Evidence-Based Complementary and Alternative Medicine, vol. 2011, Article ID 214089, 10 pages, 2011.

22. Atsushi Chiba, Hiromoto Nakanishi, and Shiko Chichibu, Am. J. Chin. Med. 25, 143 (1997). 23. Nguyen, HX and Tidball JG. Interactions between neutrophils and macrophages promote

macrophage killing of muscle cells in vitro. J Physiol 547: 125-132, 2003. 24. Reikeras O. (2010). Immune depression in musculoskeletal trauma. Inflammation Research. 59:

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Induced Arthritis Mouse Model. Journal of Acupuncture and Meridian Studies , Volume 5 , Issue 1 , 29 - 33

26. K M Khan, J., Cook, P., Kannus, N. Time to abandon the “tendinitis” myth BMJ 2002; 324 doi: 10.1136/bmj.324.7338.626 (Published 16 March 2002) Cite this as: BMJ 2002;324:626

27. Järvinen M, Jozsa L, Kannus P, et al: Histopathological findings in chronic tendon disorders. Scand J Med Sci Sports 1997;7(2):86-95

28. Khan KM, Cook JL, Bonar F, et al: Histopathology of common tendinopathies: update and implications for clinical management. Sports Med 1999; 27(6):393-408.

29. Perugia L, Postacchini F, Ippolito E: The Tendons: Biology, Pathology, Clinical Aspects. Milan, Italy, Editrice Kurtis, 1997


30. Astrom M, Gentz CF, Nilsson P, et al: Imaging in chronic Achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol 1996;25(7):615-620)

31. Ren XM, Cao JJ, Shen XY, Wang LZ, Zhao L, Wu F, Zhang HM. [Knee osteoarthritis treated with moxibustion: a randomized controlled trial]. Zhongguo Zhen Jiu. 2011 Dec;31(12) 1057-1061. PMID: 22256633.

32. Robertson VJ. Ward AR. The effect of heat on tissue extensibility: A comparison of deep and superficial heating. Archives of Physical Medicine and Rehabilitation 86(4) April 2005.

33. Michlovitz SL: Thermal Agents in Rehabilitation, 2nd ed. Philadelphia, Davis 1990 34. Knight K. Cryotherapy in Sports Injury Management. Human Kinetics. 1995. 35. Lessard LA, Lephart SM, Giannantonio FP, Blanc RO: The efficacy of cryotherapy following

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50. Roberts, L. A., Raastad, T., Markworth, J. F., Figueiredo, V. C., Egner, I. M., Shield, A., Cameron-Smith, D., Coombes, J. S. and Peake, J. M. (2015), Post-exercise cold water immersion attenuates acute anabolic signalling and long-term adaptations in muscle to strength training. J Physiol, 593: 4285–4301.


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Fire and Ice Notes