Do Compresses Really Work? An Orthopedic Surgeon Explains the Correct Types, Selection, and Usage

“Which is more effective, a cold compress or a warm compress?”
“I bought a compress at the pharmacy, but I don't feel like it's doing much!”

Hello. I am Dr. Uta.
In the orthopedic outpatient clinic, I often hear these questions.
Since compresses are easily available at pharmacies, many people just 'stick one on' whenever they feel pain. In fact, patients often come to the clinic saying they just want to have plenty of compresses on hand.

Compresses are popular with everyone from children to adults, but many people may not know which one to choose at the pharmacy or what kind of compresses are prescribed at the hospital.
In this article, I will explain the effects, types, and how to choose compresses step-by-step from the perspective of an orthopedic surgeon.

Conclusion: There are 3 levels of compress strength!

When the goal is local pain relief, the strength of compresses is divided into three levels.
1. Cooling/Warming compresses
2. NSAID-containing (local action type)
3. NSAID-containing (systemic action type)

You can think of 'NSAID-containing (like Loxonin)' as roughly meaning a compress that contains pain-relieving ingredients. Generally, the ones we prescribe most often in outpatient clinics are type 2. If those are ineffective, we use type 3. In reality, types 2 and 3 are the ones that are effective, and I almost never have the opportunity to prescribe type 1.

If you want to relieve pain with a compress, I recommend purchasing a Loxonin-containing compress sold over the counter. If over-the-counter medication is ineffective, or if the pain is so severe that you cannot walk or move, be sure to visit a hospital without enduring it.

*Note: There are other topical agents for pain such as lidocaine tape or fentanyl tape, but these are omitted here as they are rarely used in the orthopedic field or have different indications, such as for cancer pain.

How do compresses (topical patches) work on the body?

The medicinal ingredients contained in a compress are absorbed into the body through the skin.
This absorption mechanism is called 'percutaneous absorption'.
Unlike oral medication, it has the advantage of putting less strain on the gastrointestinal tract and delivering the medicine from a location close to the affected area. However, the skin acts as a barrier to protect the body.
The amount of medicine that reaches deep muscles or joints is limited, so it is not a panacea for all types of pain.
First, you need to know that 'sticking it on does not guarantee it will work deep down'.

Types of compresses and their functions

Should you choose a warm compress or a cold compress?

There are 'cold compresses' and 'warm compresses'.
Cold compresses contain menthol, which gives a cooling sensation when applied.
In contrast, warm compresses contain capsaicin, a component derived from chili peppers, which makes you feel warm.

These compresses only differ in how they feel when applied; they do not actually cool or warm the affected area. Furthermore, the compress itself has no effect on suppressing local pain.
Conversely, while they have no effect, they also honestly have no side effects from medicinal action. (Though you might get a skin rash from applying the compress...)
'If I put on a compress, I feel like it's somehow better!!' For people who are afraid of side effects but want to keep wearing a compress for peace of mind... these might be the most effective compresses for them, haha.

NSAID-containing compresses
-- Loxonin tape, Diclofenac tape, etc.

NSAIDs suppress the production of substances called 'prostaglandins' that cause inflammation and pain.
These are drugs intended to locally suppress inflammation at the site of application.
The ingredients are the same as oral Loxonin, but the amount transferred into the blood is kept low. While this reduces the burden on the stomach and kidneys, the effect is also limited to the area where it is applied.
I often prescribe these to people with kidney or stomach issues, as the risk is considered lower with this type of compress.

NSAID-containing compresses
-- Zictor tape, Rocoa tape

These are relatively new types of compresses.
They are drugs with more efficient absorption, and although they are compresses, they work systemically just like taking oral Loxonin.
They might be the strongest compresses we prescribe in the orthopedic outpatient clinic. (Excluding narcotics.)

Many people feel a greater analgesic effect compared to Loxonin tape.
However, because they are strong drugs, they are more likely to put a strain on the kidneys and stomach just like Loxonin, so they are not sold over the counter.
Also, the indicated diseases are limited. Currently, they are indicated for osteoarthritis, chronic low back pain, periarthritis of the shoulder, cervical spondylosis, and tenosynovitis. (Indications differ between Rocoa tape and Zictor tape, so please consult your doctor.)

Cataplasms and Tape patches

There are two types of compresses: 'cataplasms' and 'tape patches'.
Cataplasms are white, thick, and gel-like.
Because they contain a lot of moisture, they are less irritating to the skin and tend to cause fewer rashes. On the other hand, they peel off easily and are not suitable for moving parts like joints.

Tape patches are thin and have strong adhesive power.
The advantage is that they are easy to apply to moving parts like knees and shoulders, and they are less noticeable under clothing. However, compared to cataplasms, they may be more irritating to the skin.
Cataplasms are often suitable for people with sensitive skin or the elderly, while tape patches are suitable for those who exercise or for long-term use.

Do compresses really work?
Considering it from a scientific basis

I honestly understand the feeling that "compresses are just a placebo."
However, there is accumulated scientific evidence for compresses containing NSAIDs.

A Cochrane review is a highly reliable analysis that integrates and evaluates multiple clinical studies. According to this Cochrane review, it is reported that topical NSAIDs show a significant analgesic effect for acute musculoskeletal pain (such as sudden lower back pain or sprains).
Even for chronic pain, their effectiveness has been recognized compared to a placebo.

They are most effective in the following situations:
・Superficial pain close to the skin or joints (knees, wrists, ankles, etc.)
・Acute pain where inflammation is the primary cause

On the other hand, the effect is often limited for pain involving deep muscles or nerves, or for chronic neuropathic pain.
If you feel that "applying a Loxonin tape doesn't work," it is possible that the nature of your pain is not suited for a compress.

The difference between compresses you can buy at a pharmacy and those prescribed at a hospital

The amount of active ingredients differs

The biggest difference between over-the-counter products and prescription drugs is the content of the active ingredient.
Taking loxoprofen-containing tape as an example, the amount per sheet in over-the-counter products is regulated to be lower than in prescription drugs.
This is due to regulations intended to ensure safety when used without a doctor's supervision.

The size and areas where they can be used differ

Prescription drugs include large-sized versions that can cover wide areas like the lower back. Over-the-counter products have limited size options, which can sometimes make it difficult to achieve the same effect.

Comparison in terms of cost

Compresses prescribed under health insurance have a 30% co-pay, but there may be limits on the number of sheets. For mild symptoms, over-the-counter products are often sufficient, so which is more advantageous depends on the situation.
For chronic conditions or when using them over a wide area, prescription drugs may sometimes keep total costs lower.

What criteria does an orthopedic surgeon use to choose a compress?

A compress is not a "drug to prescribe just in case." When prescribing, I make a judgment based on the cause of the pain, the location, and the patient's overall physical condition.

Having said that, compress medications have fewer risks compared to oral Loxonin, and many patients do not want to increase their oral medication but still want a compress, so the hurdle for prescribing them might be relatively low.
While these are my personal criteria, I often prescribe Loxonin compresses (local) for pain caused by local inflammation where the skin condition is not poor. For those who still do not see results, I prescribe systemic-acting Loxonin compresses. (I limit the indications because I occasionally see side effects.)
As for warming or cooling types, they are only requested by the rare person who specifically wants that type of compress. I don't recall prescribing them recently.

Conversely, the only people I don't prescribe compresses to are those with systemic pain due to conditions like collagen diseases, or those prone to skin problems such as dermatitis or thin skin, or those with allergies...

Things to know to use compresses effectively

I have summarized points to keep in mind daily to bring out the effectiveness of compresses.

・Follow the usage instructions: Follow the product's directions regarding the number of daily applications and timing for replacement.
・Apply to clean skin: Dirt or sweat reduces drug absorption and can cause rashes.
・Remove immediately if a rash occurs: Continuing to use it forcibly can worsen dermatitis.
・Shift the application position slightly: Repeatedly applying to the same spot causes damage to accumulate on the skin.
・See a doctor if there is no improvement after 1–2 weeks: The type may not be suitable.
・Do not expose to sunlight: Light stimulation can cause skin problems or pigmentation, so be sure to keep it out of direct sunlight.

Occasionally, there are people who say they apply them to every painful part of their body and use one whole pack (7 sheets) a day. I understand the feeling, but that is definitely too much, and they will run out immediately, so in such cases, we should adjust using other means such as oral medication.

Summary

Compresses containing NSAIDs have analgesic effects based on scientific evidence. However, the effectiveness varies significantly depending on the cause, location, and type of pain. Simply applying them without a clear purpose often fails to provide sufficient relief.

Knowing which type to choose and how to use it is the most important step in making the most of compresses.
If you do not see improvement, please consult an orthopedic surgeon rather than continuing to rely on self-judgment.

References

1. Massey T, Derry S, Moore RA, McQuay HJ. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev. 2010;(6):CD007402.

2. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2016;4:CD007400.

3. Japanese Orthopaedic Association Clinical Practice Guideline Committee, Low Back Pain Clinical Practice Guideline Committee. Clinical Practice Guideline for Low Back Pain 2019 (Revised 2nd Edition). Nankodo; 2019.