Guided tour of hot/cold therapy and topical treatment products that provide targeted pain relief at the surface.

By Stuart Wilson, MSPT

In recent years, the desire for alternative methods of pain relief has skyrocketed. Individuals seeking pain relief today have more options than ever—anything from oral NSAIDs to the newly popular topical analgesics, and hot and cold contrast wraps. This article explores the full range of pain-management products currently on the market—from therapeutic tape to iontophoresis—and explores the advantages of each in providing effective pain relief.

Hot and Cold Wraps

Hot and cold wraps are an excellent tool that can be used by rehabilitation professionals to provide therapeutic pain relief, and can also aid in recovery from injuries such as muscle sprains and strains. Elasto-Gel, made by Southwest Technologies Inc, North Kansas City, Mo, are reuseable packs manufactured in a number of shapes and sizes and designed to provide utility for hot or cold therapies. A few of the products in the Elasto-Gel line are made specifically for feet/ankles or knees, but the rest are all-purpose wraps that vary in size. The company’s website offers directions about how to heat or freeze these products.

Because the products are gel, they absorb moisture very easily. This could cause the product to swell and become damaged, particularly if used with a patient who is very sweaty. Likewise, all these wraps are recommended to be hand washed and air dried, which could be time-consuming for a large practice. Those who use gel packs may also notice temperature distribution can be inconsistent.

An aspect of Elasto-Gel products that is attractive is the product’s dual use for hot and cold therapy, which can cut down on materials a clinic might use separately. The packs also can be strapped to a patient, which makes it easier to position the product and enhances patient comfort while they use the product. It is also worth noting that gel packs are easily molded, no matter how cold they are.

The California-based company ProSeries LLC offers the Pro Series Ice Wraps, another wrap intended for injury treatment and pain relief. The company makes reuseable ice packs in a number of shapes for different body parts. Products are designed according to the body part targeted for treatment with adjustable Velcro straps for varying body sizes. It should be noted that this line of products is designed so the company’s product-replacement parts must be used. For example: If the ice pack itself became perforated, a replacement bag would have to be purchased from the company rather than simply using a plastic bag of ice. These products are designed only for icing.

An advantage of ProSeries Ice Wraps is that in addition to cold therapy, patients also receive compression to the site of therapy. Furthermore, the therapist only has to refill the provided ice bags. There is no need for storing gel packs in a freezer. This makes it more convenient for on-field use. My personal preference is to use ice bags, since they are cheap and something a patient can take with them.

Hot and Cold with Pneumatic Compression

The Multi-FLO Combo System, manufactured by Bio Compression Systems, headquartered in Moonachie, NJ, incorporates reuseable cold packs designed in different shapes depending on which part of the body is targeted for treatment. The gel packs are removable and fit into the different-shaped garments. Each garment is designed to be attached to a pump that allows for a low-pressure therapy in addition to the cold therapy.

Multi-Flo Combo System garments are for cold therapy only and can only be used in conjunction with a pump machine. This requires an energy source, which makes it nearly impossible for on-field use at athletic events. These products are designed also for use on one patient at a time, unless the clinic has multiple pump machines. An advantage of using the Multi-Flo Combo System is that it does offer pumping compression—something for which other similar products may not be designed. Compression can aid with the body’s natural lymphatic pump and help remove edema in a timely manner.


Topicals come in a variety of forms that range from gels, creams, lotions, or patches, to sprays that are designed to be applied to the skin for temporary pain relief associated with muscle aches, arthritis, and other conditions.

There are four types of topicals:

1) Rubefacients—Used to increase blood flow to the area and produce a soothing sensation. Additionally, they deplete the chemical Substance P that sends pain signals to the brain. Capsaicin is the compound typically found in rubefacients. Brand names include ArthriCare, Capzasin, Zostrix, and Rock Sauce.

2) Anesthetics—Block pain signals in nerve endings, thus numbing the area. Benzocaine is the active ingredient in the brand names Benzodent, SensiGel, Americaine, and Blistex.

3) Analgesics—Block enzymes that produce inflammation that causes pain. The active ingredient is methyl salicylate, the same ingredient found in aspirin. Brand names include Bengay, Aspercreme, Rock Sauce, and Sportscreme.

4) Counterirritants—These give the skin a hot or cold sensation that creates a distraction from pain. Menthol is typically used as the active ingredient. Brand names include ChinaGel, from Arlington Heights, Ill-based China Gel; Cramergesic (also an analgesic), manufactured by Gardner, Kan-based Cramer Products Inc; BioFreeze, from Akron, Ohio-based The Hygienic Corporation; Tiger Balm, manufactured by Prince of Peace Enterprises Inc, based in Hayward, Calif; and Rock Sauce, manufactured by RockTape, headquartered in Campbell, Calif.

There are a number of different types and brands of topicals that are widely available to the general public. Additionally, many of those listed above fall into more than one category of topicals. The question is, what are the different ways to use topicals, and which one should I use in my clinic?

Rock Sauce, made by RockTape, Campbell, Calif, has been the consistent choice for my practice because of its multifunctional use, strength of pain relief, and ease to use with RockTape. Sore No More, Moab, Utah, produces an all-natural topical gel for pain relief. New Mexico-based Sombra Professional Therapy Products also produces all-natural topical products for warm and cool therapy.

Topical Use in the Clinic

The simplest way to use topicals is to apply them directly to the skin in isolation for muscle pain and joint soreness. The majority of brands call for applying 1 milliliter per 200 square centimeters of skin area, three to four times per day. Because it can be applied directly to the skin, unlike an oral pain reliever, the effect is much quicker and more specific. Oral pain relievers must be digested and travel through the body before being effective. Unlike dangers of oral NSAIDs (ie, stomach ulcers, gastrointestinal bleeding, increased liver enzymes, and risks when combined with other medications such as ACE inhibitors and blood thinners), there are no inherent risks when topicals are applied. Patients can use Rock Sauce as an adjunct to the care provided in the clinic and as an alternative to oral medications for pain relief.

Another application is in the substitution of emollient during instrument-assisted or manual soft-tissue therapies (ie, Graston or ART). Like traditional emollient, a cream topical allows for decreased friction to help protect the skin while breaking up scar tissue underneath it. However, unlike the usual cocoa butters, topicals offer an added bonus—local pain relief during soft-tissue therapies. This could allow for greater patient pain tolerance during soft-tissue therapies, allowing for a slightly more intense therapy session. Rock Sauce can be utilized in this manner and also provides pain relief in addition to being a very good emollient.

Using topicals in conjunction with laser therapy has also been shown to be beneficial. Not only does it allow for easier maneuvering of the laser head along the patient’s skin, but topicals improve the anti-inflammatory effects of the laser itself. de Alameida et al5 found that although laser therapy decreases inflammatory markers in an area after trauma, that effect is increased when used with a topical sodium diclofenac (ingredient found in topical NSAIDs). Rock Sauce used in this manner makes the laser therapy more effective and can even be used on top of an area that has already been taped.

Phonophoresis and iontophoresis are additional methods of application. Both are used to enhance the delivery of the active ingredients in the topical. Phonophoresis utilizes ultrasound to push the active ingredient molecules through the dermal layer, thus facilitating absorption. Iontophoresis works in a very similar fashion, but uses an electrical field to push positively or negatively charged particles through the skin. Both phonophoresis and iontophoresis allow for a noninvasive, but deeper absorption. Rock Sauce used in this manner is very effective and prepares the skin for further modalities. The Chattanooga, Tenn-based company Richmar is one such provider of iontophoresis products and equipment as well as laser and electro-therapy equipment, such as ultrasound devices.

Empi, a DJO Global company, Vista, Calif, produces the Dupel Dual-Channel Iontophoresis System. This dual-channel device allows simultaneous treatment of two sites for efficient treatment time and includes an active electrode for drug delivery. The Utah-based company ActivaTek is also a manufacturer of iontophoretic devices, including the ActivaDose II.

Both competitive athletes and weekend warriors like to have the feeling of warmed-up muscles prior to activity. The use of warming topicals can be applied prior to working out or competition to increase blood flow. In addition, some athletes like the feeling of warmed muscles, which makes them feel they can perform at a higher level.

There are vast methods of application for topical creams, and increasing research shows their positive effects. Higashi et al1 found that “menthol has been reported to be effective in relieving pain with mild to moderate muscle strains.” Zhang et al4 agreed with Higashi’s findings and determined that “topical application of menthol gel along with the chiropractic adjustment showed significant reduction in low back pain.” In fact, Johar et al2 determined that menthol-based topicals were “more effective than ice for relieving soreness associated with DOMS [delayed onset muscle soreness] while at rest or during muscle contractions…and permitted greater evoked tetanic forces produced as compared to ice.” Considering topicals work at a much faster rate than icing, it’s possible they are more efficient for sprains and strains.

Risk Versus Reward

Although overuse of topicals is possible, it is rare. Unlike oral medications and injections, topicals are typically made with naturally occurring plant compounds and, therefore, have a reduced risk of side effects. Because topicals are applied locally, there is little to no systemic effects as there are with oral medications that must travel throughout the body. Therapists and individuals who use topicals at home must keep in mind that the use of topicals should be avoided if the person on whom they are applied is allergic to aspirin, since methyl salicylate is the active ingredient.

Most clinicians agree that patients respond well to treatment with topicals. They are cost-efficient, easy to use, have minimal side effects, and have little to no risk. Moore3 concluded that patients who use topicals tend to have increased activities of daily living, improved mood, less fatigue, better sleep, better functioning, greater ability to work, and an overall improvement in quality of life. PTP

Stuart Wilson, MSPT, is a physical therapist and director in Littleton, Colorado. Wilson began his own clinic in Denver specializing in endurance and power athletes. He utilizes movement and biomechanical evaluations with manual therapy and functional exercise progression to get the patient back in their game, race, or life. Wilson is an affiliate faculty member and PT alumni of Regis University. Wilson also teaches about motion and treatment strategies such as fascial movement taping. For more information, contact [email protected]
Special Acknowledgement: The author wishes to thank Edward Lecara for his assistance with this article.