(Almost) Never Use Ice on Low Back Pain!

An important exception to conventional wisdom about icing and heating

Always ice an injury, right? Er, no — there is one important exception to this rule of thumb. If you have low back pain, you almost always need heat instead of ice, especially the type of low back pain that flares up from time to time for no good reason.

The bottom line is patient preference: if ice feels “right” to the patient, it’s okay. But there are good reasons to err on the side of heat, and ice should only be used on the back by patients who clearly prefer it (for whatever reason), or when there is definitely a fresh injury. This in-depth article explores every possible aspect of this single tricky icing issue. There are three closely related articles available as well: one all about icing, another just about heating, and a short and highly digestible “cheatsheet” overview of the whole ice-heat confusion debacle.

Table of Contents

• Unconventional wisdom
• The “no heat” rule
• Icing low back pain may actually hurt
• And heating back pain actually helps
• How to tell the difference between muscle strain and non-inflammatory back pain
• What about necks?
• Never ice? Isn’t that a little extreme?
• The mind game — how ice and heat are dominated by your opinion
• But we come back to erring on the side of heat
• Skeptical? Use the experimental method!
• Further Reading
• Notes

Unconventional wisdom

This advice — the entire point of this article — runs against the grain. A lot of people, patients and professionals alike, get confused about when and why to use heat or ice.1 And, unfortunately, it is particularly common for doctors and other health care professionals to botch this with low back pain cases, glibly and incorrectly recommending ice massage or the application of ice gel packs.
Patients and health care professionals alike get confused about when and why to use heat or ice. Here is a typical example from a prominent website, spine-health.com, which emphasizes 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.

In fact, ice does not provide “significant” pain relief for “many types of back pain,” and most episodes of back pain are not caused by muscle strain, are not inflamed “injuries” per se, and should not be iced as if they are.2 Back pain experts like Dr. Richard Deyo have clearly explained that about 85% of back pain patients have “idiopathic [unexplained] low back pain,”3 not muscular strain or joint damage.

The “no heat” rule

Many people are familiar with the “no heat” rule. The reason for it is simply to avoid aggravating damaged, inflamed tissue with heat. Health care professionals are often taught:

When in doubt, prescribe ice.

It’s a sensible rule of thumb because it is appropriate in the majority of cases. But using any rule unthinkingly can get you into trouble, and this one simply doesn’t apply to low back pain very well, especially flare ups of chronic low back pain, for several reasons.
The most important reason is simply that inflammation is rarely a factor in back pain!
Using any rule of thumb unthinkingly can get you into trouble! In the case of 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 may be damaged, traumatized and inflamed, and in this case heat might exacerbate the inflammation, and ice might help. But this is rare! The vast majority of back pain is not traumatic in nature, no tissue is damaged, and inflammation is either minimal or nonexistent.
So there is no particular reason to avoid heat. And if there’s no inflammation, what exactly would you ice?

Icing low back pain may actually hurt

Just like heating can aggravate inflammation, ice can also have unpleasant effects. Icing the back or neck sometimes aggravates back pain symptoms, particularly when it is unwanted. Sometimes there will be an immediate sensation of increasing spasm as ice is applied, but usually it will only feel somewhat unpleasant. But then, in the minutes and hours afterwards, stiffness and pain will increase — usually not dramatically, but who needs any increase in symptoms?
Ice is not evil. Often no ill effect is felt, and many people — perhaps even most — get mild benefit from icing, just as they do from heating. But many people do not enjoy icing their back, and some of them feel worse during and/or afterwards. Why?
This is because the majority of low back pain is probably not caused by inflammation or any kind of trauma, but by the pain of muscular trigger points, also known as “muscle knots”4 — a ubiquitous muscle dysfunction that is not well known to most health care professionals. Trigger points should never be underestimated — they are quite capable of causing severe back pain.
The majority of low back pain is probably caused by the pain of muscular trigger points, also known as “muscle knots.” And trigger points generally dislike cold! Chilling the skin is actually a well known risk factor for the formation and aggravation of trigger points.5 How do you feel stepping into a cold shower? Cold applied to the skin stimulates a reflex that causes muscles to contract. This is probably how trigger points are aggravated by cold, and there may be other neurological factors.
This anecdote 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 ...

from anonymous client

Yet around the world, doctors are telling their patients to ice their low back pain, due in part to ignorance of the role of trigger points, and to unjustified confidence that back pain is inflammatory in nature and will respond well to ice.

And heating back pain actually helps (or at least does no harm)

Heat is no miracle therapy. I’ve never seen anyone “cured” of chronic back pain by heat. But it does help, and it is certainly preferred over ice. After many years of clinical experience, it seems clear to me that a significant majority of patients prefer to heat their back pain. They recoil from cold, and seek out hot baths and jacuzzis, steaming showers, heating pads, and so on.
Trigger points are also probably the main reason that heat is useful, rather than harmful. They seem to respond quite positively to heat — wherever trigger points occur, in the low back or otherwise, patients almost invariably describe heat as one of the few things that reliably takes the edge off. Heated trigger points don’t generally actually go away — heat alone does not cure serious back pain — but their intensity certainly eases.
Also, for cases of back pain where spasm is more of a factor, heat helps as well. Back spasms are not as common a situation as people think — a lot of so-called back muscle “spasm” is actually just the pain and stiffness caused by trigger points6 — but it certainly does occur, and in these cases the role of heat is even more clearly positive, and the role of ice even more clearly negative. Wherever heat is applied to the skin, it triggers a mild reflex that reduces muscle tone. And so the pain of low back muscle spasms can be eased by applying heat, with minimal or no risk of exacerbating inflammation that either doesn’t exist at all, or is so minor and/or deep that heating is unlikely to aggravate it.

How to tell the difference between muscle strain and non-inflammatory back pain

There is really only one back pain situation where icing is clearly the way to go, and that is in the case of a true muscle strain or other traumatic injury of the low back muscles. There has to be superficial inflammation to cool off.
Bear in mind that most back pain feels like a “true muscle strain of the low back muscles,” but likely is not. A true strain — a 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!
Many, many smart people who would otherwise avoid ice nevertheless go right ahead and ice their backs because they assume that they are the exception, one of the rare cases where actual damage has been done to the back muscles and therefore icing is advisable!
What if you just aren’t sure if your back pain involves a true muscle strain or not?
Telling the difference can be tricky for both patients and health care professionals alike, but basically it comes down to whether there was an accident involving forces that could realistically have actually damaged you. Here’s a quick checklist:

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