Hot or Cold? Understanding Thermotherapy for Pain and Recovery

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For anyone experiencing musculoskeletal pain, thermal applications offer a safe, non-pharmacological, and economical therapeutic intervention. They're simple to implement and have relatively minor side effects.

Hot or Cold? Understanding Thermotherapy for Pain and Recovery

When you're dealing with aches, pains, or injuries, reaching for a heating pad or an ice pack is often an instinct. But have you ever wondered when to use hot versus cold, and why? The science behind thermal applications is constantly evolving, and what we once thought was gospel for injury treatment is now being re-evaluated.

Let's dive into the world of hot and cold therapy, and discover how these simple tools can be powerful tools in your journey to pain relief and recovery.

The Warm Embrace of Heat Therapy

There's a reason a warm bath or a cozy heating pad feels so good when your muscles are stiff. Research supports the use of heat to manage both acute and chronic musculoskeletal pain (Clijsen et al., 2022; Dablainville et al., 2025; Lubrano et al., 2023; McGorm et al. 2018; Wiecha et al., 2025). Think of it as a gentle hug for your body!

How does heat help?

  • Improved blood flow: Heat opens up your blood vessels, bringing fresh, oxygen-rich blood to the area.

  • Muscle regeneration: Enhanced blood flow and tissue warmth can contribute to faster muscle repair.

  • Increased range of motion: Warm tissues are more pliable, making it easier to move stiff joints.

  • Pain relief: Heat has a mild analgesic (pain-relieving) effect, helping to soothe discomfort.

Common ways to apply heat include deep moist heat packs, heating pads, hot baths, saunas, or even heated garments.

The Chilling Truth About Cold Therapy

For a long time, "RICE" (Rest, Ice, Compression, Elevation) was the go-to acronym for acute injuries. We were told to ice everything to reduce inflammation. However, recent research is challenging this traditional approach, especially concerning ice.

What we know about cold therapy:

  • Mild pain relief: Cold can act as a temporary analgesic by numbing the area.

  • Reduced blood flow: Cold constricts blood vessels, which can initially reduce swelling.

  • Reduced metabolic demand: Tissues need less oxygen and nutrients when cooled.

While cold therapy might offer temporary pain relief for chronic pain and delayed-onset muscle soreness (DOMS) (Garcia et al., 2021; Wiecha et al., 2025), there's limited evidence from strong clinical trials supporting its widespread use for acute musculoskeletal injuries. In fact, a growing body of research suggests that ice can actually delay healing, increase swelling, and potentially cause further damage to injured tissues (Racinais et al., 2024).

Out with the Old, In with PEACE & LOVE!

Given the evolving understanding of inflammation and healing, the traditional RICE protocol for acute injuries is being replaced by a more nuanced approach: PEACE & LOVE. This new acronym encourages optimal loading and aims to support the body's natural healing processes rather than hindering them (Dubois & Esculier, 2020).

PEACE: Immediately After Injury

These are the first steps you should take when you experience an acute injury:

  • Protect: Avoid activities that aggravate the injured structure for the first few days.

  • Elevate: Raise the injured limb above your heart to help reduce swelling.

  • Avoid Anti-inflammatories: Steer clear of over-the-counter or prescription anti-inflammatory medications, and avoid ice, as they can slow down tissue healing.

  • Compress: Apply gentle compression to the injured area with a bandage to help manage swelling.

  • Educate: Understand the risks of overtreatment and empower yourself with knowledge about your injury and recovery.

LOVE: A Few Days After Injury & Beyond

Once the initial acute phase passes, it's time to focus on progressive recovery:

  • Load: Gradually introduce controlled movement and weight-bearing to facilitate healing and strengthen the injured tissues.

  • Optimism: Maintain a positive outlook! Your mindset can significantly influence your perception of pain and the speed of your recovery.

  • Vascularization: Gradual loading and progressive return to activity will encourage blood flow and nutrient delivery to the injured tissues.

  • Exercise: Engage in activity-based exercises to restore range of motion, strength, and proprioception (your body's sense of its position in space).

Ice Baths (Cold-Water Immersion)

If ice is generally discouraged for acute injuries, what about the growing popularity of ice baths and whole-body cryotherapy?

It's true that controlled stress can promote adaptation in the body. While ice baths may delay healing in the context of acute injury, they are being explored for their potential benefits in other areas. Figures like "The Iceman" Wim Hof have popularized cold-water immersion for its potential to modulate immune responses. Research in this area suggests that controlled cold exposure might help individuals learn to regulate their immune systems, offering hope for those with chronic inflammatory disorders like rheumatoid arthritis and inflammatory bowel disease (Zwaag et al., 2022). This is a fascinating area of ongoing research, and its applications differ significantly from treating an acute sprain.

Practical Application Notes: When to Use What

To summarize, here's a quick guide for applying thermal therapies:

Local Application of Cold/Ice:

  • How: Typically 15 minutes or less (e.g., cold compress, ice pack, ice massage).

  • When: Primarily for acute pain in areas of inflammation.

  • Avoid: Generally not recommended for chronic inflammation or directly after acute injury (as per PEACE & LOVE).

Local Application of Heat:

  • How: Often 10-5 minutes (e.g., compress, "magic bag").

  • When: Used for both acute and chronic pain.

  • Avoid: Not recommended over areas of acute inflammation.

Contrast Application (Alternating Hot & Cold):

  • How: Alternate cold (e.g., 3 minutes) with heat (e.g., 1 minute).

  • When: Useful for subacute pain (the phase between acute and chronic).

Key Takeaways

For anyone experiencing musculoskeletal pain, thermal applications offer a safe, non-pharmacological, and economical therapeutic intervention. They're simple to implement and have relatively minor side effects. By understanding the nuances of hot and cold therapy, and embracing the PEACE & LOVE protocol for acute injuries, you can make informed choices to support your body's natural healing process and get back to feeling your best!

References and Sources

Allan, R., Malone, J., Alexander, J., Vorajee, S., Ihsan, M., Gregson, W., Kwiecien, S., & Mawhinney, C. (2022). Cold for centuries: a brief history of cryotherapies to improve health, injury and post-exercise recovery. European journal of applied physiology, 122(5), 1153–1162. https://doi.org/10.1007/s00421-022-04915-5

Cashin, A. G., Furlong, B. M., Kamper, S. J., De Carvalho, D., Machado, L. A., Davidson, S. R., Bursey, K. K., Abdel Shaheed, C., & Hall, A. M. (2025). Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials. BMJ evidence-based medicine, bmjebm-2024-112974. Advance online publication. https://doi.org/10.1136/bmjebm-2024-112974

Chaillou, T., Treigyte, V., Mosely, S., Brazaitis, M., Venckunas, T., & Cheng, A. J. (2022). Functional Impact of Post-exercise Cooling and Heating on Recovery and Training Adaptations: Application to Resistance, Endurance, and Sprint Exercise. Sports medicine - open, 8(1), 37. https://doi.org/10.1186/s40798-022-00428-9

Clijsen, R., Stoop, R., Hohenauer, E., Aerenhouts, D., Clarys, P., Deflorin, C., & Taeymans, J. (2022). Local Heat Applications as a Treatment of Physical and Functional Parameters in Acute and Chronic Musculoskeletal Disorders or Pain. Archives of physical medicine and rehabilitation, 103(3), 505–522. https://doi.org/10.1016/j.apmr.2021.06.015

Dablainville, V., Mornas, A., Normand-Gravier, T., Al-Mulla, M., Papakostas, E., Olory, B., Fermin, T. M., Zampeli, F., Nader, N., Alhammoud, M., Bayne, F., Sanchez, A. M. J., Cardinale, M., Candau, R., Bernardi, H., & Racinais, S. (2025). Muscle regeneration is improved by hot water immersion but unchanged by cold following a simulated musculoskeletal injury in humans. The Journal of physiology, 10.1113/JP287777. Advance online publication. https://doi.org/10.1113/JP287777

Dubois, B., & Esculier, J. F. (2020). Soft-tissue injuries simply need PEACE and LOVE. British journal of sports medicine, 54(2), 72–73. https://doi.org/10.1136/bjsports-2019-101253

Garcia, C., Karri, J., Zacharias, N. A., & Abd-Elsayed, A. (2021). Use of Cryotherapy for Managing Chronic Pain: An Evidence-Based Narrative. Pain and therapy, 10(1), 81–100. https://doi.org/10.1007/s40122-020-00225-w

Hyldahl, R. D., & Peake, J. M. (2020). Combining cooling or heating applications with exercise training to enhance performance and muscle adaptations. Journal of applied physiology (Bethesda, Md. : 1985), 129(2), 353–365. https://doi.org/10.1152/japplphysiol.00322.2020

Lubrano, E., Mazas, P. F., Freiwald, J., Krüger, K., Grattagliano, I., Mur, E., Silva, R. Q., Maruri, G. R., & de Medeiros, L. S. (2023). An International Multidisciplinary Delphi-Based Consensus on Heat Therapy in Musculoskeletal Pain. Pain and therapy, 12(1), 93–110. https://doi.org/10.1007/s40122-022-00419-4

McGorm, H., Roberts, L. A., Coombes, J. S., & Peake, J. M. (2018). Turning Up the Heat: An Evaluation of the Evidence for Heating to Promote Exercise Recovery, Muscle Rehabilitation and Adaptation. Sports medicine (Auckland, N.Z.), 48(6), 1311–1328. https://doi.org/10.1007/s40279-018-0876-6

Racinais, S., Dablainville, V., Rousse, Y., Ihsan, M., Grant, M. E., Schobersberger, W., Budgett, R., & Engebretsen, L. (2024). Cryotherapy for treating soft tissue injuries in sport medicine: a critical review. British journal of sports medicine, 58(20), 1215–1223. https://doi.org/10.1136/bjsports-2024-108304

Wiecha, S., Cieśliński, I., Wiśniowski, P., Cieśliński, M., Pawliczek, W., Posadzki, P., Prill, R., Zając, J., & Płaszewski, M. (2025). Physical Therapies for Delayed-Onset Muscle Soreness: An Umbrella and Mapping Systematic Review with Meta-meta-analysis. Sports medicine (Auckland, N.Z.), 55(5), 1183–1212. https://doi.org/10.1007/s40279-025-02187-5

Zwaag, J., Naaktgeboren, R., van Herwaarden, A. E., Pickkers, P., & Kox, M. (2022). The Effects of Cold Exposure Training and a Breathing Exercise on the Inflammatory Response in Humans: A Pilot Study. Psychosomatic medicine, 84(4), 457–467. https://doi.org/10.1097/PSY.0000000000001065