Heat or Ice AFTER Manual Therapy: Revisiting the Evidence for Optimal Recovery
Chiropractors often use manual therapy to treat orthopedic conditions, but a common question is whether to apply heat or ice afterward to enhance recovery. This brief review summarizes peer-reviewed research and clinical guidelines. It will also help you clarify when to use each modality, depending on whether the condition is acute or chronic and whether it involves soft tissue or joint structures.
*For this blog, I will focus on using heat or ice after manual therapy. A follow-up discussion will include the use of these treatments before manual therapy.
Should I ICE After Treatment?
Physiological Rationale: Cryotherapy causes vasoconstriction and reduces local blood flow, which can limit edema and the release of inflammatory mediators. It also slows nerve conduction velocity, providing an analgesic effect. By “cooling” treated tissues after manual therapy, clinicians aim to decrease post-treatment soreness, swelling, and secondary tissue damage. Cold therapy has proven to be most beneficial for controlling excessive swelling within the first 6-12 hours post-injury for sprains, strains, contusions, etc. (1-3)
When To Use ICE Therapy
In a neck pain trial, patients received cervical mobilizations with cryotherapy; after 5 weeks, pain and disability improved significantly. Notably, cryotherapy plus mobilization produced greater reductions in neck pain and disability than a similar program that added stretching exercises. (4)
For lateral epicondylitis (tennis elbow), a pilot study combining manual therapy with local cryostimulation (-78°C cold spray) reported improved pain-free grip strength and reduced pain, comparable to exercise programs incorporating ice therapy. (5)
While heat may be the physiologically superior option in many cases, especially for improving mobility, patients who experience increased discomfort immediately following manual therapy may also benefit from ice therapy. Applying ice post-treatment can reduce soreness and limit secondary tissue damage, particularly in diagnoses involving active inflammation.
Should I HEAT After Treatment?
Physiological Rationale: Thermotherapy has the opposite vascular effect of cold – it causes vasodilation, increasing blood flow to the area. The warmth can relax muscles, reduce joint stiffness, and increase connective tissue extensibility. Heat also may activate pain gate mechanisms, providing a comforting analgesic sensation. After manual therapy, heat is often used to soothe tight muscles or to maintain tissue elasticity gains from stretching/mobilization.
When To Use HEAT Therapy
Heat is commonly recommended for chronic or subacute musculoskeletal pain. Clinical guidelines for low back pain notably endorse superficial heat as an effective therapy.
The American College of Physicians (ACP) guideline (2017) states that superficial heat is an appropriate first-line treatment for acute/subacute low back pain, with moderate-quality evidence that heat wraps yield moderate improvements in pain and disability. Likewise, many clinicians use moist hot packs or heating pads AFTER manual therapy for chronic back or neck pain to relax muscle spasms and alleviate soreness. (6)
Applying heat after a manipulation or soft-tissue mobilization for chronic low back or neck pain can further loosen tight muscles and may enhance pain relief.
Importantly, avoid heat in acute injury scenarios. Applying heat in the first 6-12 hours of an acute injury or immediately after an acute injury mobilization is contraindicated, as it can increase bleeding, swelling, and inflammation.
In summary, thermotherapy improves subjective pain and mobility in many chronic or subacute conditions but is less effective for acute inflammation or swelling.
Clinical Guidelines and Professional Guidance
In summary, clinical evidence supports applying ice after manual therapy primarily for acute orthopedic injuries and any inflammation or pain flare-ups, as it provides short-term analgesia and limits swelling.
Applying heat after manual therapy benefits chronic or subacute conditions that aim to reduce pain and stiffness rather than inflammation. Guidelines note modest improvements in pain and mobility from heat in conditions like low back pain.
The choice between cryotherapy and thermotherapy should be tailored to the stage and type of injury: ice for acute (<12 hours), heat for chronic is a valid general rule. Still, exceptions exist based on individual patient responses.
Want to learn more about heat vs. ice? Check out our in-depth blog that breaks down which is best for musculoskeletal injuries.
Deliver Care You Can Stand Behind
Knowing when to apply heat or ice is a simple yet powerful example of evidence-based care. With ChiroUp’s 200+ continually updated protocols, you’re not just staying informed—you’re turning the latest research into better outcomes for every patient.
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1. Malanga GA, Yan N, Stark J. Mechanisms and efficacy of heat and cold therapies for musculoskeletal injury. Postgraduate medicine. 2015 Jan 2;127(1):57-65. Link
2. Wang ZR, Ni GX. Is it time to put traditional cold therapy in rehabilitation of soft-tissue injuries out to pasture?. World journal of clinical cases. 2021 Jun 6;9(17):4116. Link
3. Kwiecien SY. Is it the End of the Ice Age?. International Journal of Sports Physical Therapy. 2023;18(3):547. Link
4. Alfawaz RA, Khan M, Alghadir AH, Iqbal ZA.Cryotherapy with mobilization versus cryotherapy with mobilization reinforced with home stretching exercises in treatment of chronic neck pain: a randomized trial. J Bodyw Mov Ther. 2020;24(4):203–7.
5.Radecka A, Lubkowska A. Direct effect of local cryotherapy on muscle stimulation, pain and strength in male office workers with lateral epicondylitis: non-randomized clinical trial study. Healthcare (Basel). 2022;10(5):879.
6. Qaseem A, Wilt TJ, McLean RM, Forciea MA; Clinical Guidelines Committee of the American College of Physicians. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017;166(7):514–530.
