Pain: both emotional and physical

Pain is also incredibly subjective. I recall Doug Nelson pointing out, "Anyone who studies pain, knows the patients are in as much pain as they say they are in, they aren't lying" and "there is no diagnostic exam or image that will show pain. It won't show up on a computer screen". 

I've come to understand, in a very broad sense, pain is a symptom signaling something's not right. People who have congenital insensitivity to pain, a rare condition where they can't experience pain, often have miserable, short lived lives.

A few years ago, a coworker of mine (at the time) made the comment, “it seems to me that Massage Therapists should pick only one modality, study it until they master it to the point where that’s the bulk of what they do. It becomes all they’re known for and the only thing they practice.”

This comment bugged me at the time, but I really couldn’t articulate why, so instead of saying “That’s not how I feel about it”, (at the time I really wanted to have a stronger, more justifiable, informed opinion that could explain why I felt a certain way; which feels awkward as I write it, you can't always verbalize a feeling. I digress...) and instead of creating any hostility, I chose silence.  But this comment rebounded in my mind until now.

To jump back a bit, by 2009 at least 80% of my sessions were pain related and this motivated me to study pain more.  I came to learn all of the following information through study and hands-on workshops.  

Here is the definition from the International Association for the Study of Pain (IASP) "Pain is an unpleasant sensory or emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

In The Mystery of Pain, Doug Nelson explores both physical and emotional aspects of pain (with and without tissue damage), phantom limb pain, current treatment strategies (interventions), and a bunch of other really interesting topics. It’s fascinating and written in an accessible style, without a lot of jargon. I’d highly recommend it for both practitioners and those dealing with pain.  

You probably heard that pain is complex, and yes it certainly is, but what does that mean? There are 11 major recognized organ systems in the body (12 if you include the fascial system.  It would be the largest system, it’s certainly the most medically disregarded; however, we will see what the future brings and also that is another blog post.  I digress again…). According to Smithsonian Magazine, there are 37.2 trillion cells in the body (the most current estimate, less if the estimate is by volume and almost 70 trillion if guessing by weight, it’s tricky..)

If by some chance, any 1 of the (12) body's organ systems falter or if how those systems interact with each other isn’t up to par, your brain may receive pain signals (nociceptors).  With 12 organ systems and 37.2 trilIon cells, a lot can go haywire.

If anything in the external environment brushes against your skin and causes any tissue damage, you might receive more pain signals. To include but not limited to falls, scrapes, cuts, or any type of accident or blunt trauma.

These examples only include a physical change and don't consider emotional responses, or how thoughts can create pain. Yes, both thoughts and emotions can be responsible for suffering. What's worse, suffering brought on by mental or emotional stress is often largely dismissed as there's usually no tissue damage and often this is a double whammy of pain and skepticism (especially from others).

In The Biology of Belief, Bruce Lipton, PH. D. shows how your thoughts influence and shape cellular behavior.  The information in The Intention Experiment, by Lynne McTaggart, was a game changer for me and it was chalk full of different experiments people have done that emphasize the power of focused thoughts.

This March I attended a workshop on treating upper extremity neuropathies. All the other attendees were PTs, mostly from chronic pain treatment facilities.  The lecturer spent the final 2.5 hours discussing and showing laterality training, guided imagery, and mirror therapy; it was fascinating. These approaches are all about neuro-reeducation. Witnessing the local PTs embracing this information was super encouraging, it reminded me of Doug Nelson's book and this clip by Lorimer Moseley.

So what do I do?

When focusing on pain treatment, I treat to resolve symptoms from a bodywork perspective. Assessment becomes an essential element because there are so many things that can manifest with similar and often overlapping symptoms.  The client's history is vital. Once the pain symptoms that drove the client to seek therapy in the first place have been addressed and calmed, then I can begin to seek their sources. Some likely sources which I often consider and assess for:

• Trigger points- can often create and refer pain, weakness, and numbness to remote areas, cause a loss in range of motion, swelling, headaches or nausea.  They can neurologically inhibit a muscle to prevent it from doing its work and generally refer a sensation to another area, especially seen with an active trigger point.
• Tender points- They can manifest similar symptoms as trigger point, however, they only cause local sensation. Trigger points refer, tender points do not.
• Fascial restrictions- can do all the things that trigger points can especially diminish range of motion.  Fascia is heavily influenced by emotion and its restriction feels different than a trigger points chord like quality.
• Neuropathies-  Like trigger points, they often refer sensation, cause weakness and can limit range of motion.  However, nerve impingements and entrapments tend to refer sensation along their pathway. They don’t like to be stretched, compressed or friction of any kind.
• Lymphatic Impairment- This can cause pain signals, limited range of motion, mimic nerve compression symptoms, and especially make the extremities heavy.  However, a typical characteristic of lymphatic impairment is swelling/inflammation. Extra fluid in the area can press on pain-sensitive structures like nerves, muscles or periosteum.  When inflammation is present it makes it difficult to tell what’s going on.  Its removal becomes a helpful initial step in identifying underlying causes.  
• Emotional restrictions- (Considered but not palpated for) Not only is fascia highly influenced, but also restricted emotions may be sending a barrage of constant pain signals to the brain.  Without having damaged tissue in need of healing, emotional restrictions can take a longer time to mend. Bodywork can be very helpful at helping to release restricted emotion and beneficial at calming an overstimulated nervous system and restoring emotional well-being
• Somatic pain- often referred to an area of the body by a corresponding organ. Organs are suspended and surrounded by fascia and often supplied by a specific nerve branch.  If they get stuck, if the supplying nerve gets pinched or entrapped, or if they become compressed either by an external force (fall or trauma) or by fascial structures (capable of generating 2000lbs of pressure per square inch) painful signals (nociceptors) will be marshalled.
• Dietary allergies or nutrient deficiency- (Again considered but not palpated for) Often we are lacking in nutrients like vitamin D or magnesium or have an unknown allergy to something in our diet.  While treating this is outside what I do, it is yet another source of pain for many and a thing that a healthcare professional cannot discount when considering treatment.
• The Unknown- There is so much to consider when treating pain and no one knows it all. An integrated approach may be the best option. The unknown variable must always be an option. As technology advances new and exciting discoveries and observations abound, but we should always consider there may be something we don't know about. 

This brings me back to my ex-coworkers comment from the beginning of this post.  Specializing and sticking only to that paradigm feels like an inadequate model when treating something as multifaceted as pain. This can often lead to short-sighted treatments. Having a deeper understanding and more treatment options are boons to both the therapist and client. Our bodies are not simply machines, there are a ton of interrelated parts that work synergistically.  

Bodywork is very sacred. experiencing other people's vulnerability and grace, feeling their trust is truly humbling. Often after the session, I realize very few other people in that person's life touches them in this meaningful way. This thought makes me pause and be grateful that I get to do bodywork. I’m constantly awed by what can be treated manually; it's amazing!

When someone who I’ve never met before, comes into my treatment room and decides to trust me to try to help resolve their painful issues, I become more empowered to do all I can to be of service. I’m so glad I sought out more tools to pull from and to broaden my understanding.  If I hadn’t, I wouldn’t have been able to work with and help so many people with such a variety of issues   If any readers want to serve others through massage therapy or bodywork, I highly recommend you expand yourself as much as you can.  

Enjoy,

Joe

http://myelitemt.com/index.html

CLT, PNMT, John F Barnes MFR practitioner, OMT, BCTMB

5 exercise tips to improve lymphatic efficiency

As I prepare for a house guest by deep cleaning my bathroom, I re-read the instructions on the tile cleaner and kept getting stuck on one line, ‘use in a well-ventilated area’. I figured it was because of fumes. I opened the door all the way and turned on the overhead fan.

After giving that time to set and wiping down the walls, there was still stubborn mildew left in between the tiles and I realized I’d have to scrub. During the scrubbing insanity, I recalled my MLD/CDP (Manual Lymphatic Drainage/ Complex Decongestive Physiotherapy) studies and trainings about treatment of the lymphatic system. I was (and am) so thankful to have learned about the body’s system that’s responsible for filtering out toxins. After this week, I was sure mine would be working overtime.

Between the traffic exhaust fumes I was exposed to earlier this week with my car windows rolled down to enjoy the spring-like weather and the current house cleaning I was doing now, my body had been infused with more environmental and chemical toxins this past week than in the past month. I really appreciate that my body even has a lymphatic system; genius!!

In particular, I recalled Carmen Thompson (my lymphatic educator) discussing exercises to help improve lymphatic efficiency. Since the lymphatic system doesn’t have a dedicated pump, (like how the circulatory system has the heart as a pump) it relies on body movement to help its circulation. So yes, while any movement is helpful for lymphatics, especially when it causes you to sweat, there are certain exercises that better encourage the movement of lymph.

1. Any water based movement:

This is the most helpful exercise for lymphatic movement. Water offers external hydrostatic pressure, which assists in lymph movement. Just moving against the pressure of the water (be it moving a limb through water, wading, water walking in the deep end, water aerobics or swimming) will encourage fluid movement. When you get lymph to move, that stimulates the cleansing/purification actions to start as well as stimulating the manufacturing of the "good stuff", the white blood cells to support immunity. Best results happen with active movements, but passive ones are helpful too.

2. Any trampoline or rebounder

This also creates less joint impact than hitting the ground and It’s the second most helpful exercise for your lymphatic system. The jostling motion of this or any vibration moves fluid into lymph vessels. It’s my personal go-to, as I don’t have easy pool access, and enjoy adding rebounding to my workout at least 1-3xs per week.

3. Any movement that targets the deep abdominals

There are roughly 6-700 lymph nodes in the body and about 300 are peppered throughout the gut and trunk. Exercises that engage the hip flexors like squats, lunges, or knee raises are also helpful in moving lymph.

4. Any movement that emphases twisting the trunk

This will also impact the 300 lymph nodes in the trunk. Certain Yoga poses and golf swings (not to mention the walking involved with 9 or 18 holes) will require trunk twist. For a fun neuromuscular challenge, at the driving range try playing from your non-dominant side as well, talk about humbling and building neuropathways!

5. Deep breathing

Deep breathing is good for so many functions. It helps to pacify the nervous system in general, but also specifically the Vagus Nerve, which serves for much of the gut-brain communication. The gut is often called the second brain, as it has its own neural network of about 100k neurons, and sometimes informs the brain of hormones it's decided to release and sometimes receives orders from the brain. The act of deep breathing also increases the internal pressure on the 300 lymph nodes spread throughout the trunk and it’s the first step I take in an MLD session.


I hope sharing what I learned from my training is helpful to you, especially if trying to boost the efficiency of your lymphatic system.  Stay well,

Joe
http://myelitemt.com
CLT, PNMT, OMT, John F Barnes MFR practitioner

Why MLD (Manual Lymphatic Drainage)?

The inspiration for this post came from a client who recently asked, "Why do I treat the lymphatic system? What do you see that inspires you to recommend it?"

Simple questions with a longer answer than I thought. While responding, it occurred to me that a very basic understanding of the lymphatic system is necessary.

The lymphatic system is involved in most (I can't think of any where it's not a major player, but there may be some?) cellular interactions and body functions. It can largely be thought of as a transport system within the body that has 2 main responsibilities:

• deliver nutrients and purification agents to body areas 
• collect and cleanse fluid

Manual Lymphatic Drainage (MLD) is comprised mainly of 2 techniques:

• Strokes to focus on lymph nodes 
• Strokes that focus on vessels and fluid movement 

And
The Lymphatic system does not have a dedicated pump, like the heart, to move body fluids. Instead, it relies on the skeletal muscle movement to generate flow. Movement is essential! I smell a future post...

Here are my reasons for my recommendation:

MLD is useful for anything that has an inflammatory component, words that end in "itis", or any auto-immune condition. It cleans the skin and body tissues and is useful 48 hours before surgery to help provide a clean area for the incision. Also, MLD can be safely used hours after your surgery to remove cellular wastes, speed healing, and promote healthy scar regeneration. It's a great complimentary bodywork to go along with any detox or cleanse and when clients mention suffering from allergies, sinus congestion, puffy eyes or face; MLD is often my initial thought.

When I see any swelling or edema, lymphatic work is extremely useful. MLD along with compression bandaging/garments (CDT), is the gold standard treatment for lymphedema management. Breast cancer survivors and others who've had lymph nodes removed may either have impaired lymphatic movement or swelling. If not experiencing these symptoms now, lymph node removal predisposes the survivor and can set up future impairment. In these cases rerouting normal drainage becomes necessary.

If one arm or leg is bigger than the other, this is another case to consider MLD. When someone comes in and asks me to work on trigger points, scars, or fascial restriction, different techniques treat those concerns. However, once those are addressed, because tissue stiffness will also reduce fluid movement, I'll use MLD to help restore lymphatic flow. This also flushes fluid through the area to remove any cellular debris or nociceptive (pain signaling receptors) substances that have collected because of tissue stiffness.

Lastly, When there's a nerve impingement or entrapment, the nerve becomes irritated and causes neuroinflammation. After treating restrictions and tissues along the nerve's pathway, I'll use MLD to pacify this inflammation. When MLD is applied to the full body it provides a relaxation stimulus to the entire nervous system. So when someone's session goal is relaxation, one of my first thoughts is MLD because of its calming effect.

If you use MLD, please let me know why you use it.

Enjoy,

Joe

NCTMB board certified, CLT
myelitemt.com

Therapeutic Interventions: home based strategies

It's been a while, but here's a great subject to break that cycle: therapeutic interventions.

These are things that are done to break a cycle in your body in the attempt to return it to its "normal" function.

When I work with someone in pain, often I ask if they did anything to help change their situation, if so what and was it helpful?  This is a list to give ideas of at home strategies for physical pain that you can try by yourself to make a therapeutic intervention.

Temperature Apps (applications)- these tend to have a shorter effectiveness, but can be very helpful in trying to figure out your pain.

• Ice or cold application- a natural analgesic that helps slow down nociceptor interaction (pain receptor).  This strategy is usually helpful for the first few hours after acute injuries and nerve and trigger points tend to respond well to cold stimulus.  If you tend to tolerate or favor cold outside of an acute injury, this may indicate trigger point or nerve involvement.
• Heat application or hot shower or soak- muscles and fascia typically respond well to heat and this is a great strategy for stiffness.

Mindfulness- beneficial for overall health and especially chronic pain.

• 10-20 minutes of meditation
• 5-10 minutes visualization-  see yourself returning to pain free normal activity 
• puzzles, reading or coloring
• observe well performed activity- activate mirror neurons in the brain and try to feel the motion as though it was a memory
• spend time enjoying music or art

Movement based strategies-  A good way to try to free up stiffness and restriction, keep it gentle.

• stretching
• yoga
• swimming or trmpoline/rebounder
• dance
• tai chi
• light weights, light cardio or light exercise

Pressure based strategies-

• self massage- your hands are wonderful tools you take with you everywhere.  They are great, and my number 1 pressure tool, when you can reach the spot.
• tools- balls, foam rollers, theracane, still point inducers...(etc.) this list is endless.  I'd recommend starting with a softer tool held over a stiff or tender spot, for a minute or a few, and letting the tissue soften around the tool.  You can use a towel if your tool is too pointy or increase the tool density over time as necessary.  Tools can easily become a noxious stimulus to your nervous system, when this happens, your work becomes counterproductive.  Back off on the tools density or your pressure (or both) your next try.

This is only meant to give you ideas about home based interventions and is by no means a complete list. Please feel free to add comments below.

Enjoy,

Joe

myelitemt.com

How Massage Therapy is part Art and part Science

Much like Music and Art, Massage therapy is a very broad, highly subjective and ambiguous term.  Massage therapy like the two hemispheres of the brain, is comprised of two parts: it's both an art form and science.  To add to the confusion of creating definitions of what a Massage Therapist is/should be and what makes a good massage great, Therapists have found homes in a wide variety of venues from hospitals and Chiropractor's offices to gyms and spas.  

The artistic side is comprised more of sense of feel and intuition rather than governed by pure logic.  The therapist may not be able to fully explain how or why they do something or work a particular area of the body; and often times the therapist is "lead"or "drawn" to somewhere because of this feeling.  

Typically the artistic side is seen as having more of a sense of flow and has often been compared to the artistry of a dance.  This work relies on the therapists ability to access their humanistic, compassionate awareness and although in many cases this element is an innate quality; through work and intention it can be developed. This type of work can be very helpful in a situation where someone is seeking comfort or relaxation and is most frequently an Event massage.

Whereas the science portion is more oriented in the analytic side of things; the "hows" and "whys" of massage therapy.  It's concerned with the physiologic principals behind the technical strokes and how those techniques impact the body; it's steeped in anatomy, physiology and kinesiology.  

It is in this capacity that the therapist plays the role of detective, assessing what might be involved, why, what not do, and any technical adaptations that may be required for the given situation.  Often this side of therapy is very useful to those suffering from repetitive strain injuries, chronic or acute pain, or pathology: and it is a Process endeavor, usually requiring multiple sessions for optimal results.  

The science side of massage therapy is not an innate quality and is similar to many Martial Arts and Dance forms in this way: while one can reproduce the technical abilities quite well, the understanding of the philosophy behind the technique is more elusive and requires commitment, dedication, study and experience to fully access its enlightenment.

During my time as a Therapist I have been fortunate enough to witness, study, receive and learn from people who are very gifted in both the Artistic side of therapy and its Scientific counterpart.  They are fluent in both sides of massage therapy and fully capable of adapting, blending and weaving between both sides at will and as dictated by the receiver and the situation (something that I look for in my therapist).  

While what makes a good massage great will differ from receiver to receiver and time to time, a common thread elevating a good session to a great one (like in any great art work) is the application of knowledge and intention.  The key is to determine what you're looking for as a receiver and to communicate that need with your therapist.

Thanks and stay well!
http://myelitemassagetherapy.com/

A Need for Contact

Everyday I consider that we (in the US) live and operate in a very touch-deprived society. 

My very next thought is both quite humbling and empowering simultaneously; Massage Therapists have the privilege of addressing this depravity with each session.  

There are so many aspects to writing about the importance of touch, volumes of articles in professional journals and entire books dedicated to this subject.  While I cannot cover all aspects, I did want to share some of the ideas and articles I came across that highlight the gravity of the very basic human need to receive compassionate touch and stimulate our sense of well being.  

This excerpt is taken from the September 1999 AMTA (American Massage Therapy Association http://www.amtamassage.org/index.html) Massage Journal article written by Debra Brooks, titled The Hypermobile Client/Therapist.  

In the article Brooks interviews Author, Scientist (medical and psychological), Clinician, and Teacher: Joan Borysenko, Ph.D. 

Borysenko: I think there are actually three important components of massage therapy that complement all forms of healing.

First is actual physical touch. We know a great deal about physical touch, for example, on the immune system. Physical touch releases growth hormones that will help your immune system recover. Without touch, the immune system cannot recharge. Everybody needs to be touched and although most of the massage research literature on touch deals with babies, the need for massage certainly continues throughout life. I do believe we are a touch-deprived culture.

People are afraid of being sued if they touch. You can't even have a teacher any more touch a crying child. What has happened in our society regarding touch is truly pathetic. So going to a place where it is safe to be touched is very, very important. It is effectual at the most basic hormonal, physiological, and immune system level.

The second component is the specificity of the touch. For example, releasing tension in the muscles, causing relaxation, doing trigger-point work, and doing things of that nature. All of this works very well via the work of massage therapy. The effect that massage therapy can have on healing a deeper injury by releasing tension in the muscle is remarkable.

And the third component is the energetic aspect. The research on energy, medicine, and touch that is therapeutic comes down to one very basic thing: when there is a respectful intention to heal, some kind of energy flows from the healer to the one who is being healed. So when a massage therapist has that kind of respectful care in her hands, then more is happening than just at a physical level. Something is happening at an energetic level, as well. 

To read the article in its entirety:  http://www.amtamassage.org/articles/3/MTJ/detail/1829

This next excerpt is taken from an article co-authored by Trish Dryden, M.Ed, R.M.T. and Pamela Fitch, B.A., R.M.T. titled Recovering Body and Soul from Post-Traumatic Stress Disorder in the March 2000 AMTA Massage Journal.  This section highlights the benefits of touch.

Benefits of Touch

There are no specific physical manipulation techniques for working with trauma clients. Swedish massage can be as effective and enlightening to a client as the most advanced fascial mobilization. No matter the technique, massage therapy can inadvertently trigger traumatic memory, which, as massage therapists know, also can be a powerful tool for healing and growth.¹³ For example, there is ample documentation that touch stimulation is essential for babies to thrive. The results of Tiffany Field's research on preterm infants is most compelling, where each was given 15-minute massages three times a day for 10 days while still in incubators.¹⁴ The treated infants gained 47 percent more weight and were hospitalized for 6 days less. They performed better on the Brazelton Neonatal Behavior Assessment Scale.¹⁵ The babies averaged 12 points higher on the mental scale and 13 points higher on the motor scale than the control group. In another experiment,¹⁶ rat pups were stimulated with tiny wet paintbrushes, a procedure designed to mimic the licking of newborn litters by their mothers. The rat pups which were "licked" with the paintbrushes thrived similarly to those which had received normal care by mothers. Those that received no stimulation became ill, had small growth rates, and failed in many instances to thrive.

To read this article in its entirety: http://www.amtamassage.org/articles/3/MTJ/detail/1817

In the Fall 2004 edition of the AMTA MTJ (Massage Therapy Journal).  Dawn Nelson contributed an article titled The Power Of Human Touch In Alzheimer's Care.

Once again, the demand to embrace our very basic human need for contact is underscored; however, this article focuses on the importance of touch as we venture into our twilight years and particularly for those who are debilitated by Alzheimer's Disease and Dementia.  

In a very thought provoking article Nelson writes,"Throughout the progression of AD, the broad, general benefits of therapeutic massage, when appropriately adapted, are beneficial in improving circulation, softening contracted muscles, relieving minor aches and pains, and promoting relaxation.

Perhaps even more importantly, skilled touch sessions provide significant psychosocial benefits to those with AD in residential facilities, including:

• Focused one-on-one attention;

• Companionship;

• Mental stimulation;

• An opportunity for social interaction;

• Skin-on-skin contact;

• Sensory and tactile stimulation;

• Nonverbal communication;

• Nurturing;

• Pleasure.

Intentional, caring touch helps to:

• Reassure those who are confused;

• Calm those who are agitated;

• Increase body awareness;

• Ground the disoriented person in present time and space;

• Provide a touchstone with physical reality;

• Reinforce verbal communication;

• Redirect energy or shift attention;

• Reduce the need for medication and

physical restraints;

• Alleviate feelings of isolation, loneliness or abandonment."

To read this article in its entirety: 

http://www.amtamassage.org/uploads/cms/documents/powerofhumantouchalzheimers.pdf

This was just a slight glimpse into a broad subject I am in awe of, and I wished to share with you.  Feel free to comment on this blog, especially if you feel that I neglected anything important.
Thanks and stay well!
http://myelitemassagetherapy.com/

Heat Pads vs Cold Compressions

Many I've worked with have said that they never know which to use: heat or ice?
Knowing how this impacts the body physiologically can shed light on any confusion out there.   Be prepared for some 10 cent biological terms...ok, ok 5 cent.

Heat acts as a vasodilator, it widens the blood vessels by relaxing the smooth muscles cells within the cell walls.  This allows blood to flow with less vascular resistance.  (Thank you Wikipedia!)
Generally speaking remember: muscles, particularly stiff and rigid ones, love heat and typically respond very well to it.  In fact, muscles that are more chronically rigid and stiff often suffer from impeded blood flow (ischemia) and heat pads can be a very beneficial intervention.  Although, reduced blood flow is usually more of a result of something else and less of a perpetuating or causative factor.

If you decide to break out your heating pad to address your next stiff area, do not exceed 20 minute applications.  Generally, 20 minutes on and 20 minutes off is the most accepted cycle.  I use 10-15 minutes on and the same amount of off-time for my cycles.  Once heated (vasodilated) having a brief time-off allows the tissue to "normalize" (return to a homeostatic state).  When this on-off cycle is repeated it can pump blood through the area, thusly removing debris that could have developed in the ischemic, rigid tissue.
Like I said, remember: stiff muscles love heat.

Ice or cold compresses act as a vasoconstrictor, it narrows the blood vessels by contracting the muscular wall of the vessels.  Blood flow is restricted, thus retaining body heat and increasing vascular resistance (Thanks again Wikipedia!)
In addition, the cold application also slows the signals being sent to the central nervous system particularly the nociceptors (specialized receptor cells that transmit information about pain).  For this last reason, cold compresses act as a natural analgesic and are very helpful interventions for acute pain.

Our bodies are very adept at producing inflammation.  Once the inflammatory response is triggered, the body can easily become overzealous in its production.  Because of its vasoconstrictive properties, cold compresses can help corral and contain the inflammation to the tissues that are in need of its services.  The next time you twist your ankle and it swells up and becomes very painful, you may want to use a cold compress.  Follow the same general rules for time applications as heat, don't apply for longer than 20 minutes at a time and cycle as desired.  Also know that the inflammation stage for most acute injuries is the 48-72 hours period following the injury.  During this time, stay with cold applications; heat is not recommended (you want to contain the inflammation) and if the inflammation stage lasts longer than 72 hours, seek medical intervention.
So remember: if the pain is acute and there's inflammation or swelling, use a cold compress.

Keep in mind, these are physiologic generalities, your case may be different, there are always exceptions.  Both temperature applications are not long standing interventions; they address a more immediate concern and not the perpetuating factor.
Be well and stay healthy!
http://myelitemassagetherapy.com/