Heat is Superior to Ice for Neck and Back Pain
For both acute and chronic neck and back pain, use superficial heat therapy rather than ice, as moderate-quality evidence demonstrates heat provides meaningful pain relief and functional improvement, while evidence for cold therapy is insufficient. 1
Evidence Supporting Heat Therapy
Acute Pain (Less Than 4 Weeks)
- Heat wraps moderately improve pain relief at 5 days and reduce disability at 4 days compared to placebo, based on moderate-quality evidence from the American College of Physicians guidelines. 1
- Heat therapy outperforms common oral analgesics: heat wraps provide more effective pain relief and improved functional scores compared to acetaminophen or ibuprofen after 1-2 days. 1
- When combined with exercise, heat plus exercise provides greater pain relief at 7 days compared to exercise alone. 1
Chronic Pain (Greater Than 12 Weeks)
- Pulsed heat at 45°C produces significantly more analgesia than steady lower-temperature heat, with rapid onset (<5 minutes) and sustained effect lasting 2+ hours after treatment completion. 2
- Low-level continuous heat as an adjunct to physical therapy significantly reduces pain, improves range of motion, and increases patient compliance with home exercise programs in chronic neck pain. 3
Evidence Against Ice Therapy
The American College of Physicians explicitly states that evidence is insufficient to determine the effectiveness of superficial cold for low back pain. 1
- A randomized controlled trial comparing heat versus cold packs in the emergency department found no significant difference between the two modalities when added to ibuprofen, but both groups showed only mild improvement, suggesting the benefit was primarily from the ibuprofen rather than the thermal therapy. 4
- This study's limitation is that it only evaluated 30-minute single applications, which may be inadequate duration for meaningful thermal effect. 4
Practical Application Guidelines
Heat Therapy Protocol
- Apply heat for 20-30 minutes at a time, 3-4 times daily, as recommended by the American Heart Association. 5
- Use heat wraps or heating pads at body temperature or slightly warmer (approximately 40-45°C for therapeutic effect). 5, 2
- Avoid direct skin contact with heat source to prevent burns. 5
- Do not exceed 30 minutes per application to avoid tissue damage. 5
Contraindications to Heat
- Active inflammation with significant swelling or redness. 5
- Impaired sensation where patient cannot detect excessive heat. 5
Clinical Pitfalls to Avoid
Do not rely on thermal therapy alone—the evidence consistently shows heat works best as part of multimodal treatment including exercise, physical therapy, and appropriate analgesics. 1, 3
Do not use ice as first-line therapy for musculoskeletal neck or back pain, as guideline-level evidence does not support its efficacy, unlike heat which has moderate-quality evidence. 1
Avoid passive heat therapy without concurrent active rehabilitation—heat combined with exercise produces superior outcomes compared to heat alone. 1, 3