(Almost) Never Use Ice on Low Back Pain!

An important exception to conventional wisdom about icing and heating

Paul Ingraham • Sep 29, 2018 • 15m read

Got back pain? This article is a good place to start, but there’s also an extremely detailed general tutorial about low back pain. I also have a basic general article about ice vs. heat — this is specifically about choosing ice or heat for back and neck pain.

Always ice an injury, right? Not always — there is an exception to this rule of thumb. If you have low back pain, you should probably choose to treat it with heat, not ice, especially if it’s the sort of low back pain that flares up from time to time for no apparent reason.

The bottom line is patient preference: if ice feels nice, it will suffice. But there are good reasons to err on the side of heat, and ice should only be used on the backs of patients who clearly prefer it (for whatever reason)… or when there’s a definite, fresh, superficial injury.

• see also:
• Ice vs Heat
• Ice
• Heat
• Depth
• Contrasting
• Ice & Back Pain
• Baths
• Ice Baths

Unconventional wisdom about icing

Icing has a good reputation as a treatment method … which it may not deserve.1 Even if it is helpful, many people are unclear about when and why to use it.2 Unfortunately, it is routine for healthcare professionals to recommend ice massage or ice gel packs for back pain.3 For back pain specifically (and neck pain to some extent as well), it’s particularly likely to fail or even backfire.

Neither icing or heating has much potential to relieve acute back pain. This was shown by a 2010 experiment at a busy emergency department.4 The test was simple: give some patients ice packs, give others heating pads, and compare the results. Which were pretty much the same. Both heat and cold resulted in “mild yet similar improvement in the pain severity.” The researchers 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”? Or lose?

The mind game: the effects of icing and heating are dominated by your opinion

The emergency room experiment was surely dominated by placebo. The only medicine involved was reassurance: the patients expected relief, which is usually good for pain.5 The placebo effect is not as powerful as people think,6 but it was probably the only major factor affecting the outcome in this experiment.

And yet people do react quite differently to ice and heat! We often have strong preferences about this. The only real leverage hot and cold packs have is on our nervous system — alarming or relaxing, soothing or irritating — and that in turn is strongly determined by context and how we feel about it. A lot like back pain itself, actually.7

There’s not much (biological) difference between ice and heat

The body is adept at maintaining a just-right internal temperature, almost no matter what you put on the skin. Even a few millimetres under an ice pack, the tissue temperature drops only a few degrees.8 And the back is thick; most of the muscle and all of the spinal joints are well out of reach.

Also, most of those patients probably had no injury to treat. Most back pain cannot be attributed to any specific cause, let alone a trauma.910

One of the main goals of my career has been to determine the cause of non-specific back pain. And in this I have failed. 
I didn’t know the origin of back pain in those days, and I don’t know now.

Prof. Alf Nachemson, MD, PhD, “A Tribute to Alf Nachemson: The Spine Interview“

Most “strained” backs are not actually damaged — it just feels like it. When people think they’ve “thrown their back out,” there is rarely anything out of place, or nothing that actually hurts.11 Even if there is — like herniated discs (“slipped” discs) — the problem is much deeper than the limited penetrating power of either ice or heat can reach.

So why does it even matter? Why choose either one?

Ice can dial up neurological sensitivity

Back and neck pain are mysterious and hard to explain. As they get chronic, they get even more mysterious. This weirdness is probably because they are often about neurological over-reaction to relatively minor or stale threats.12 Our nervous systems are paranoid about potential spinal hazards, and the bark (pain) is usually worse than the “bite” (actual tissue trouble). Pain will dial up or down in proportion to how “worried” our brains are about the situation. This is “The Mind Game in Low Back Pain.”

Heat is comforting, pleasant, and relaxing. It rarely makes the brain worry.

But a chill, especially around the spine, often feels like a hazard. (Unless we’ve been convinced of its necessity, perhaps by a situation like being in the emergency room. In that case, we aren’t likely to perceive it as a threat. But cold often feels menacing and unpleasant enough to drown out any optimism about its benefits.)

Simply put, ice is more likely to make us “tense up” and more sensitive.

Heat is no miracle therapy, no more than ice is. I’ve never seen anyone “cured” of chronic back pain by heat. But it does help, and it is usually more welcome than ice. Once people are cured of the belief that they have an inflamed injury that must be iced, they are happy to seek out more cozy hot baths and jacuzzis, steaming showers, heating pads and hot water bottles.

Trigger points don’t like cold either

Trigger points (often also called “muscle knots”) are probably a major cause and/or compication of most back pain. They may be one way that sensitization manifests in the body.

Trigger points are pressure-sensitive spots associated with pain and stiffness,13 which are common in the low back. Theoretically, they are tiny patches of cramping muscle tissue — an aching micro-cramp, rather than the whole muscle “spasms” that people often think they feel in the back.14

These little monsters are probably aggravated by cold. There is no science whatsoever that directly supports that, just some expert opinion,15 and my own personal and professional experience. It does seems possible that little tiny cramps might get cranky when chilled.

What if you really are injured and inflamed?

In 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 could actually be damaged, traumatized, and inflamed. Heat will probably exacerbate that kind of inflammation, while ice is much more likely to help.

But this situation is rare! Most back pain is not caused by trauma, no tissue is damaged, and so inflammation is either minimal or nonexistent … or just too deep to treat with ice anyway.

But for those rare cases of a bad enough, fresh enough, superficial strain, ice does make sense as a drugless way to take the edge off the pain in the early stages of healing.

The challenge is knowing the difference between back injury and pain without trauma.

Muscle strain versus other kinds of back pain

Although a lot of back pain feels like a “true muscle strain of the low back muscles,” it rarely is. True muscle strain — 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! (Think about it: steak knives are sharp and serrated.)

Telling the difference can be tricky for both patients and professionals, but basically it boils down to whether you suffered a nasty enough accident to have actually damaged tissue. Here’s a checklist.

• Did the pain 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 a little bit deformed — is there a bump or a depression?)
• Is the skin flushed and hot? Does it look puffy?

Without all three of those, either it’s not a serious muscle strain, or the tear isn’t superficial/fresh enough for ice to help anyway.

What about necks?

Almost all of this applies to necks, too … but probably not as strongly.

• Like back pain, most neck pain is not traumatic or inflamed.
• Like backs, necks are irritated by cold, but more frequently. For instance, one of the most common minor pain problems in the world, the common crick in the neck, is routinely brought on by a chilly draft on the skin at night.
• And, like backs, necks tend to prefer heat.

But necks do get injured more often than backs. “Acceleration injury” (whiplash) is more common and more serious than low back muscle strain, and involve large amounts of more superficial tissue damage and inflammation, the pain of which can be relieved by ice in the early stages.

Necks are thinner and therefore easier to ice thoroughly, when ice is called for. So again, when they’ve been hurt badly, icing necks may be more effective than icing backs.

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.

Err on the side of heat

Over the years I have seen some nasty-ish reactions to icing, particularly in the back, when the patient is feeling anxious and vulnerable and would prefer to be heated but is given ice. Some of those reactions seem out of proportion to the limited powers of ice or heat to do anything to back pain. As a result, I have come to believe that unwanted ice tends to cause nastier backfires than unwanted heat, probably because some people just really don’t like being chilled. 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 advise people to err on the side of heat. I’ll close with an anecdote that 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 ...

anonymous client

Yet around the world, healthcare professionals are telling their patients to ice their low back pain, mostly due to their bogus overconfidence that back pain is injurious/inflammatory in nature and thus will respond well to ice.

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About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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Notes

1. Icing is probably not all its cracked up to be. Although it is definitely still valuable as a simple pain-killer for fresh injuries, despite overzealous debunking — it is much less clear that it provides any other kind of help. For much more information, see Icing for Injuries, Tendinitis, and Inflammation: Become a cryotherapy master.
2. 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 loud and clear: 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 demonstrated 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 report after report 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.

3. Here is a typical example from a prominent website emphasizing 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

4. Garra G, Singer AJ, Leno R, et al. Heat or cold packs for neck and back strain: a randomized controlled trial of efficacy. Acad Emerg Med. 2010 May;17(5):484–9. PubMed 20536800 ❐

5. To reduce pain, we need to reduce credible evidence of danger & increase credible evidence of safety.

   Lorimer Moseley. Explainer: what is pain and what is happening when we feel it? TheConversation.com.

6. Placebo is fascinating, but its “power” isn’t all it’s cracked up to be: the power of belief is strictly limited and accounts for only a little of what we think of as “the” placebo effect, which is actually a collection of diverse nonspecific effects and research artifacts For more information, see Placebo Power Hype: The placebo effect is fascinating, but its “power” isn’t all it’s cracked up to be.
7. For more detail, see another article on PainScience.com, The Mind Game in Low Back Pain: How back pain is powered by fear and loathing, and greatly helped by rational confidence.
8. Can heating pads and ice packs affect the deeper tissues they are often intended for? The science is incomplete, but suggests that we can change tissue temperature by a few degrees Celsius up to a couple centimetres, and any fat greatly limits the effect. That’s just enough to affect some superficial muscle and smaller joints, but nothing deeper. See Icing, Heating & Tissue Temperature: How much do ice packs and heating pads change the temperature of deeper muscle and joints?
9. Deyo RA, Weinstein DO. Low Back Pain. N Engl J Med. 2001 Feb;344(5):363–70. PubMed 11172169 ❐ If you go to the trouble of looking that up, you’ll find I 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.”
10. Another Moseley quote:

    The evidence that tissue pathology does not explain chronic pain is overwhelming (e.g., in back pain, neck pain, and knee osteoarthritis).

    Teaching people about pain — why do we keep beating around the bush?, by Lorimer Moseley, 2–3

11. People routinely have no pain despite the presence of obvious arthritic degeneration, herniated discs, and other seemingly serious structural problems like stenosis and spondylolistheses. This surprising contradiction has been made clear by a wide variety of research over the years, but the most notable in recent history is Brinjikji 2015. There are painful spinal problems, of course — which was also shown by Brinjikji et al. in a companion paper — but they are mostly more rare and unpredictable than most people suspect, and there are many fascinating examples of people who “should” be in pain but are not, and vice versa. Spinal problems are only one of many ingredients in back pain.
12. This can be a pathological over-sensitivity (see Sensitization in Chronic Pain), but it’s usually just back business as usual: brains are a bit over-protective of backs, and that’s just how we are.
13. While their nature has been controversial for decades now, their existence and prevalence isn’t: everyone agrees that they are common, and every massage therapists knows that they are found most often in the low back and hips (and the neck and shoulders.) Their importance in back and neck pain is a pet theory of mine, one of the only major pet theories I allow myself, a legacy of my bias as a former massage therapist. I may be wrong about this, but it’s not a crazy idea, and it’s one I’ve built a large case for over many years. See The Complete Guide to Trigger Points & Myofascial Pain for a full discussion of trigger points, and see The Complete Guide to Low Back Pain for an exhaustive discussion of the role of trigger points in back pain. Those pages are both huge books, over 200,000 words total. I do go on.
14. Back spasms are not as common a situation as people think. 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 the word is usually used to refer 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. For more information, see Cramps, Spasms, Tremors & Twitches: The biology and treatment of unwanted muscle contractions.
15. Mense S, Simons DG, Russell IJ. Muscle pain: understanding its nature, diagnosis and treatment. 1st hardcover ed. Lippincott Williams & Wilkins; 2000.