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Use of cold in (self)-treatment of pain & trigger points

Spray and stretch methods – as described in several of my books, including those linked to these books.
Click on covers for more information

y previous posting looked (in part) at the protection against the common cold
– with one example involving cold showers.
An earlier posting (February 2008) discussed the use of ice cold wet socks, to help with the symptoms of congestion associated with colds….. and so, what could be more natural in mid-winter than this post that offers a few thoughts on the use of ice and ice-sprays, in treatment and self-treatment of musculoskeletal pain, such as that caused by sprains and by myofascial trigger points.
In short, if there is an acute inflammatory musculoskeletal situation, it makes sense to try to make the process of recovery as painless as possible without actually blocking this natural healing process (represented by inflammation), and without causing any additional problems.

An old physical medicine acronym for management of such problems is RICE:

  • Rest : this applies to the early stages after injury (e.g. sprain), but is not advised as healing progresses
  • Ice: offers pain relief as well as reducing swelling which, if excessive, can slow the healing process
  • Compression: this too reduces swelling, but must not be so tight as to cause throbbing
  • Elevation: helps to reduce swelling

Many experts in sports medicine recommend RICE as a first step towards recovery, however if swelling and pain has not reduced after two days, or so – expert advice should be sought.
If progress towards reduced swelling and pain is obvious, then movement is called for, involving light exercise, light and careful stretching, and/or manual therapy such as massage or positional release. ….and none of these should cause pain.
If they do then whatever provokes it is probably premature or excessive.

The Mayo Clinic supports the use of ice – in inflammatory conditions – such as tendinitis:
“If tendinitis is recent, ice may be a better choice for reducing pain and inflammation. Ice causes narrowing (vasoconstriction) of blood vessels and is helpful in reducing swelling. Reducing swelling also helps reduce the level of some inflammatory substances that can be produced with tissue injury.
If tendinitis is long-standing, either heat or ice can help to improve pain.
In general, a new injury to a muscle or joint that causes swelling and pain is best treated with ice.”

Sources of ice might include:

  • Cold packs filled with gel can be purchased on-line, or from sports stores, as well as many pharmacies. The pack can be kept frozen and ready for use when needed. It should be applied, wrapped in a thin piece of material (toweling for example), rather than directly onto the skin.
  • Frozen food, can be used as a readily available standby – frozen peas for example. This would be applied as in the example above – for 10 to 15 minutes per hour.
  • A plastic drinking cup, filled with water and frozen, can be used for ice massage – with the icy surface applied directly onto the skin. A rotary pattern is recommended, involving constant slow movement to prevent ‘ice-burn’. Five minutes of this, every half hour, should assist in pain control of acute musculoskeletal problems.

Myofascial trigger points
Manual approaches to treatment of myofascial trigger points and the pain and dysfunction they produce include :

Spray and stretch (use of vapocoolant spray during prolonged stretching of muscle housing trigger point)....SEE BELOW

  • Deep tissue work (neuromuscular technique/massage)
  • Procaine (or similar) injections
  • Dry needling (acupuncture)
  • Myofascial release of tissues housing trigger points
  • Manipulation (e.g. articulation or adjustment) of associated joints as appropriate

Individually, each of these methods can partially or totally deactivate triggers. Combined, they results are often more lasting and efficient.

Cold spray and stretch methods for Myofascial trigger points
David Simons, the premier researcher into trigger points has reported that: ‘Spray and stretch is the single most effective non-invasive method to inactivate acute trigger points
He has also said that the stretch component is the important part of this process, and that the spray is for ‘distraction’.

It is important that the coolant spray should be applied before, or during the stretch, and not after the muscle has already been lengthened.


The aim is to chill the surface tissues, while the underlying muscle (housing the trigger point) is being stretched.
• A container is needed of an environmentally friendly vapocoolant spray (such as ‘Gebauer Spray and Stretch’) that has a calibrated nozzle that delivers a fine jet stream.
• If this brand cannot be obtained then fluorimethane is acceptable, and is preferred over ethyl chloride, which is both a health hazard and colder than is needed for this treatment
• The cold jet stream should be strong enough to carry for at least 3 feet (± one meter).
• The person to be treated should be relaxed and warm.
• The spray container should be held 1–2 feet (25 to 50 cms) away from the skin surface, so that the coolant stream meets it at an acute angle.
• Each cold sweep should start just proximal to the trigger point (i.e. nearer the head) moving slowly through the reference zone to cover it, and to extend slightly beyond it.
• The direction of movement is usually in line with the muscle fibers toward their insertion
• Both the trigger and reference areas should be chilled because embryonic points may have developed in the referral zone.
• The optimum speed of movement of the sweep/roll over the skin seems to be about 4 inches (10 cm) per second.
• The sweeps are repeated in a rhythm of a few seconds on, and a few seconds off, until all the skin over the trigger and reference areas has been covered once or twice.
• If during the spraying a ‘cold pain’ develops, or if the application of the creates a referred pain, the interval between applications should be lengthened. Take great care not to frost or blanch the skin.
• During the application of cold, or immediately after, the taut fibers should be passively stretched. The fibers should not be stretched before the cold application.
• Steady, gentle, stretching is usually best, maintained for 20–30 seconds.
• After each series of cold applications, active motion is tested.
• An attempt should be made to restore the full range of motion, but always within the limits of pain, since sudden overstretching can increase existing muscle spasm
• The entire procedure may occupy 15–20 minutes and should not be rushed.
• Simple home exercises that involve passive or active stretching should be applied.

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