Heat and cold therapy reduce pain in patients with delayed onset muscle soreness: A systematic review and meta-analysis of 32 randomized controlled trials
Wang Y, Li S, Zhang Y, Chen Y, Yan F, Han L, Ma Y. Physical Therapy in Sport. 2021;48:177-187.
https://www.sciencedirect.com/science/article/abs/pii/S1466853X21000055?via%3Dihub
Take-Home Message
Both cold and heat therapy applied within 1 hour of exercise decreases delayed onset muscle soreness during the first day after exercise. However, heat therapy may be ideal for reducing pain after the first day.
Background
Delayed onset muscle soreness is a common complaint following physical activity. Treatment strategies to prevent or reduce pain are crucial to allow people to resume activity. However, it remains unclear which treatment strategy may be ideal.
Study Goal
Wang and colleagues completed a systematic review and meta-analysis to identify the effects of heat and cold therapy to treat delayed onset muscle soreness.
Methods
The researchers searched 9 databases for randomized clinical trials published before December 2020. They identified 4138 studies and then screened them for inclusion. The researchers included clinical trials that treated adults with heat or cold therapy within 1 hour of exercise. After screening, they identified 32 studies for the final analysis.
Results
The 32 studies included 1,098 people. The meta-analysis demonstrated that cold therapy effectively decreased pain associated with delayed onset muscle soreness during the first 24 hours after exercise. However, cold therapy was ineffective for pain after 24 hours post-exercise. These findings were consistent when examined among cold water immersion and other cold therapies (e.g., ice packs, ice massage). The authors found that heat therapy, specifically hot packs, effectively decreased pain associated with delayed onset muscle soreness during the first 24 hours after exercise and after 24 hours.
Viewpoints
Interestingly, the authors found that both cold and heat therapy alleviated pain during the first 24 hours after exercise. However, pain associated with delayed onset muscle soreness often increases after the first day. Hence, heat therapy, especially hot packs, may be ideal for reducing the risk of delayed onset muscle soreness after the first day. Clinicians should note that the treatments were applied shortly after exercise, which may be an essential factor influencing the efficacy of these treatments. It would be interesting to see if newer meta-analysis methods (e.g., network meta-analysis) could offer more insights into whether certain heat therapies are genuinely better than other treatment options. Furthermore, it would be interesting to see if the timing of the intervention is critical. Finally, it should be noted that there was significant variability in the methodologies of the included studies. Hence, additional studies may be needed to clarify the optimal treatment strategies for these modalities (e.g., duration of treatment, tissue temperatures to achieve).
Clinical Implications
If a clinician’s goal is to reduce pain during the first day after exercise, then cold or heat therapy may help. However, if the goal is to reduce pain after the first day, then a heat pack within an hour after exercise may be ideal.
Questions for Discussion
Have you found either heat or cold therapy following exercise to be superior in decreasing the pain associated with delayed onset muscle soreness? What other factors do you feel are important when advocating for one treatment over another?
Written by: Kyle Harris
Reviewed by: Jeffrey Driban
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In my clinical experience I have found that cold therapy is typically the choice for DOMS (delayed onset muscle soreness). I believe this could be out of routine more so than actual benefits. However, cold therapy is typically more challenging and more uncomfortable for the patient so introducing heat therapy as a better solution may benefit athletes the most.
When advocating for cold therapy I think it’s important to note that the benefits of cold therapy come with significant rules. In order for the cold therapy to reach the goal tissue the patient has to stay relatively still so that metabolic heat is not fighting the cold therapy. With heating modalities that metabolic heat wouldn’t be a concern and could even be helpful to the intervention.
Thanks for the great comment Amber! I think you made a great point about there being some element of routine. I have certainly felt this in my clinical practice as well. I think the focus that can ultimately lead all clinicians to have the best results is to use clinical research to help guide our decision-making rather than support the decisions we make. In the end, your comment about making decisions that benefit the patient is something we can all strive to do and continue to keep at the center of our clinical decision-making process. Being that patients may be used to a particular kind of treatment though, how much of a role do you feel the wants of the patients should be considered in a decision such as cold vs. heat therapy?
Personally, I have found that heat therapy works better for me. However, I find most of the athletes I work with will choose cold therapy over heat therapy for reducing pain and muscle soreness. The athletes generally will choose to use normatec boots or get into the cold whirlpool. As Amber commented above, the athletes may choose this therapy more so because everyone else does it and it is routine. When the athletes do use heat therapy, it is usually in conjunction with some other therapy (e-stim, graston, stretching, etc.). Consequently, this usually takes more time and may contribute to why patients choose to use cold therapy.
I think it’s important to note that research shows that for heat therapy to have the best effect, you need to follow it with stretching within 2-3 minutes. I would also look at a patient’s history to see if they have raynaud’s syndrome or allergic reaction or other adverse effects to cold therapies. In this instance, I would advocate using heat. I think it would also be important to utilize all of the evidence-based practice factors (best evidence, patient preferences and clinical experiences) when choosing heat versus cold.