President’s Message
Philip L. Cohen, MD
Spring 2017
Hot vs. Cold?
Years ago, my late dear friend Ulrich Botzenhardt, Chefarzt (Director) of the Rotes Kreuz Hospital in Bremen, Germany, showed me his clinic’s brand-new cryotherapy chamber. After assuring me that there was an escape hatch and a panic button, Ulrich persuaded me to sample for myself the -110 degree Celsius chamber. It feels bracing, to be sure, but –surprisingly – not frigid. And it feels very good when you get out.
I doubt most American rheumatologists are aware that treating RA patients with graded periods of extreme cold (as low as -160 degrees Celsius) is an established therapy in Europe, supported by substantial literature (175 hits on Medline for RA cryotherapy). A leading device, the Icelab Zimmer Medizinsysteme (www.wholebody-cryotherapy.com) consists of three chambers (-10, -60, and -110 degrees Celsius). Patients (in their skivvies) spend a few minutes in each chamber, progressing to the coldest, and exit in reverse order. Longer periods are prescribed for successive therapies, which are typically given bid. There is an interesting video on the website, with patient testimonials. It is notable that there are dozens of Icelab devices, but they are mostly located in central Europe, and none are in North America.
In a meta-analysis, Guillot and colleagues reviewed six studies of whole body cryotherapy of 257 RA patients and concluded that there was significant efficacy, speculating that decreased intrajoint temperature might decrease levels of cytokines and enzymes (1). They recommended that “cryotherapy should be included in RA therapeutic strategies as an adjunct therapy.” In another meta-analysis, Peres and colleagues concluded that cryotherapy was useful and might substitute in part for physical therapy (2). So maybe there is something to chilling of inflamed tissues.
Now, I’ve lost count of the number of times patients have asked me whether to apply hot or cold to their sore neck, back, or extremity. Patients seem to have strong notions on this subject, but scientific data are hard to come by.
For example, regarding the question of cold applications (icepacks, melted vs. solid ice, and others) vs. heat in the form of heating pads, hot water bottles, etc., there are surprisingly few studies for such common treatment modalities. Most are for acute injuries or sprains, only a few concern the kind of back, neck, or joint pain we encounter in rheumatology practice. Garra et al. bravely conducted a study comparing the addition of a 30 minute application of either cold or hot packs to ibuprofen therapy and found a small, apparently equivalent benefit of both (3). They concluded “choice of heat or cold therapy should be based on patient and practioner preferences and availability”. Several small studies have favored heat for chronic back pain, and mechanisms have been quite speculative (4). The ACR recommends heat applications for OA, but supporting data are scant (5).
Perhaps it’s time to study the question of cold vs. hot in a more rigorous way. Couldn’t be that hard….
References:
Philip L. Cohen, MD
Spring 2017
Hot vs. Cold?
Years ago, my late dear friend Ulrich Botzenhardt, Chefarzt (Director) of the Rotes Kreuz Hospital in Bremen, Germany, showed me his clinic’s brand-new cryotherapy chamber. After assuring me that there was an escape hatch and a panic button, Ulrich persuaded me to sample for myself the -110 degree Celsius chamber. It feels bracing, to be sure, but –surprisingly – not frigid. And it feels very good when you get out.
I doubt most American rheumatologists are aware that treating RA patients with graded periods of extreme cold (as low as -160 degrees Celsius) is an established therapy in Europe, supported by substantial literature (175 hits on Medline for RA cryotherapy). A leading device, the Icelab Zimmer Medizinsysteme (www.wholebody-cryotherapy.com) consists of three chambers (-10, -60, and -110 degrees Celsius). Patients (in their skivvies) spend a few minutes in each chamber, progressing to the coldest, and exit in reverse order. Longer periods are prescribed for successive therapies, which are typically given bid. There is an interesting video on the website, with patient testimonials. It is notable that there are dozens of Icelab devices, but they are mostly located in central Europe, and none are in North America.
In a meta-analysis, Guillot and colleagues reviewed six studies of whole body cryotherapy of 257 RA patients and concluded that there was significant efficacy, speculating that decreased intrajoint temperature might decrease levels of cytokines and enzymes (1). They recommended that “cryotherapy should be included in RA therapeutic strategies as an adjunct therapy.” In another meta-analysis, Peres and colleagues concluded that cryotherapy was useful and might substitute in part for physical therapy (2). So maybe there is something to chilling of inflamed tissues.
Now, I’ve lost count of the number of times patients have asked me whether to apply hot or cold to their sore neck, back, or extremity. Patients seem to have strong notions on this subject, but scientific data are hard to come by.
For example, regarding the question of cold applications (icepacks, melted vs. solid ice, and others) vs. heat in the form of heating pads, hot water bottles, etc., there are surprisingly few studies for such common treatment modalities. Most are for acute injuries or sprains, only a few concern the kind of back, neck, or joint pain we encounter in rheumatology practice. Garra et al. bravely conducted a study comparing the addition of a 30 minute application of either cold or hot packs to ibuprofen therapy and found a small, apparently equivalent benefit of both (3). They concluded “choice of heat or cold therapy should be based on patient and practioner preferences and availability”. Several small studies have favored heat for chronic back pain, and mechanisms have been quite speculative (4). The ACR recommends heat applications for OA, but supporting data are scant (5).
Perhaps it’s time to study the question of cold vs. hot in a more rigorous way. Couldn’t be that hard….
References:
- Guillot X. et.al. 2014 Cryotherapy in inflammatory rheumatic diseases – a systematic review. Expert Reviews of Clinical Immunology 10:281-294.
- Peres D. et.al. 2016. The practice of physical activity and cryotherapy in RA – a systematic review. European Journal of Physical and Rehabilitation Medicine (published ahead of print).
- Garra G et.al. 2010. Heat or cold packs for neck and back strain – a randomized controlled trial of efficacy. Acad Emerg Med 17:484-489.
- Malanga GA, Yan N, Stark J. 2015. Mechanism and efficacy of heat and cold therapy for musculoskeletal injury. Postgraduate Med. 127:57-65.
- Hochberg MC et.al. 2012. American College of Rheumatology 2012 recommendations for the use of nonpharmacological and pharmacological therapy in osteoarthritis of the hand, hip, and knee. Arthritis Care and Research 64:465-474
