#132 - AMA #16: Exploring hot and cold therapy

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Hey everyone, welcome to a Sneak Peek, Ask Me Anything or AMA episode of the Drive podcast. I'm your host, Peter Attia. At the end of this short episode, I'll explain how you can access the AMA episodes in full, along with a ton of other membership benefits we've created. Or you can learn more now by going to Peteratti md.com subscribe so without further delay, here's today's sneak peek of the Ask Me Anything episode.

Welcome to Ask me anything or AMA episode number 16. In today's episode, we do a real deep dive discussion into all things hot and cold therapy. Now, coming into this call, we actually intended to cover many more questions. We probably only covered by 20% of what we intended to cover. But, you know, once we got into the groove of going into this, we just decided that we were going to stay with Hot and Cold and we basically ran out of time. Now, this is a topic we get asked about all the time, and frankly, it's a topic we've spent a lot of time doing research on. We did our first internal report on this back in 2013 or 2014 and then did an enormous rehash of it in December of 19, January of 20. And it's sort of on the heels of that. Bob and I basically try to offer as much insight as we have into the ins and outs of hot and cold therapy. Again, if you're really not interested in this topic, I'm going to be honest with you, I don't think there's a lot in this episode you're going to find that interesting. But that said, I would encourage you to give it a thought because this is something that my mind has changed quite a bit on over the past couple of years. I think the data have become much stronger, at least in favor of one of these therapies. So without further delay, I hope you will enjoy AMA number 16. Bob, how are you, man?

Doing well, Peter, how are you?

Well, it's great to be doing another ama. I feel like we haven't done one in a while. We missed our last cycle since we last spoke. As you know, I've had this move which has created a little bit of stress in the short term, joy in.

The long term, moving super easy, right?

Yeah. Have you ever had to do a move with kids? Like, I know you've moved across the country a bunch of times as a young man, but have you had to do the family?

No, totally different. I remember family business. I had to get secret clearance, so you had to do this whole form and it said, like, where have you lived in the last 10 to 20 years? And it covered college years. And so I probably did 10 to 20 moves in 10 to 20 years, but never with the kids. Totally different situation where I probably could pack everything up into one of those little pods versus kids and moving from house to house. How's that working for you?

No, I mean, it's fine now, but it was really challenging. Much more so than I expected. And I remember about two months before the move, everybody saying things, including my therapist saying, just to set your expectations. A move of this nature is among the three most stressful events to a marriage. And I was like, come on, what are you talking about? They're like, yep, it's on par with divorce, death, and something else. And I was like, that is not even possible. I don't know what kind of mental midgets you're dealing with here, but there's no way that's going to be stressful. And in the weeks leading up to the move, all of a sudden, my body just started hurting. My qls were totally fired up. I just didn't feel good when I was lifting. Everything in my body felt horrible. And amazingly, after the move was done, all that stuff almost overnight changed. And that was kind of an aha moment of. It's such a cliche to say we hold stress in our body, but we do. I can't actually mechanistically explain what it is about stress and why higher levels of cortisol or catecholamines or things like that would actually lead to physical pain in my body. But there's no question about it. So glad it's over.

That was actually one of the questions was around that, how has your move been?

I haven't even seen the questions.

Yeah, this one was on location and time change, which I don't think you're necessarily a stranger to. So it's probably a layup for you as far as any adjustment as far as changing a time zone and changing of location.

No, it hasn't been an issue for me. But I think we knew that for the kids it would be. And it was a bit complicated because the kids started virtual school in Texas while still in California a couple weeks before the move, because we moved August 31st, but they really start early in Texas for school. So I think 10 or 12 days before that, two of the three were doing virtual school. So that's actually where things started. So two weeks prior to that, I put them on a different sleep schedule because they would be starting school at 6:20 California time, which was 8:20 Texas time. And my daughter had spent say a month prior to that being like a normal 11 year old and sleeping till 9 o' clock or 8 o' clock in the morning. So we just created a sleep schedule where we bumped her go to bed time and wake up time by about 15 minutes a day such that she would be getting up around 5:30 in the morning California time, which would give her enough time to kind of have breakfast and not show up to class two minutes after waking up, go to class. So by doing that the move was actually really easy because she had already done the heavy lifting of acclimating via jet lag prior to actually coming out here. And it was easy. But I think the same principle applies. So for example, Bob, so you're on the east coast. If you knew you had to go to London in two weeks or something like that, and I can't remember, I think London's probably five hours ahead of Eastern Standard Time. You could take a page out of that book. Now you wouldn't go all the way there, you wouldn't ratchet it back, so you're literally five hours off, but you could certainly ratchet two and a half hours off. And then as I think I may have discussed, we have that jet lag protocol for our patients. We basically, on the day of travel take the entire gap out of it. So for example, let's say you're departing. I don't do that trip often. But let's say you're departing. Well actually they sometimes do that as a red eye. But let's say you're departing at 2 o' clock in the afternoon. I don't know if you would even depart at that time. So that means it's already say seven there and it's probably a six hour flight. You'd be getting in really late London time. I would get up super early that morning. I mean super early, like 3am local time, which is functionally 8am in destination time. Force yourself awake and that makes it easier for you to go to bed because the challenge you're going to have when you're flying east, assuming you don't cross the date line, is you're not going to want to go to bed when you get there and you're going to get into that vicious cycle of having a hard time falling asleep and therefore having a hard time waking up. And then you're basically just doing the reverse on the way back. But to answer the question, a two hour time zone jump is generally not that difficult even if you just sort of willy nilly flow to it. But you can make it a no issue if you are proactive about bedtime and wake up time.

Okay, so we got a bunch of questions on hot and cold therapy. What are the benefits, et cetera. Those are two separate topics really. And you did a little project too where you went to a cold environment. We did a little deep dive on cold and we've done a dive on the heat as well.

Yeah, I mean, I think that's putting it mildly. It was an extensive amount of work we did on it. And I think you're right. I think these get lumped in together as one topic constantly. We've been looking at this topic internally for at least five years. I think in 2015 was the first time Dan Pelachar internally did a very deep dive on cold therapy. This was actually through the lens of cryotherapy versus ice bathing for doms, delayed onset muscle soreness, and that extended into heat therapy. I think you picked up the mantle on that a year later. And then you're right. In late 2019, in anticipation of this project I was doing that involved a lot of work around hot and cold therapy. We just decided to assume we knew nothing, go back to the drawing board and from a clean slate, effectively relearn all of this. And I think at this point, the list of people who are more familiar with this literature than you, that's a pretty short list. I basically gave you a pretty clear mandate, which was, Bob, you need to know everything about this and distill it into 10 pages for me.

Yeah, especially recently on the cold immersion, cryotherapy, things like that. And I mean, the upshot, I think was Peter telling Bob, like, throw me a bone here. Is there anything that we can find here that's reliable evidence that shows some type of healthspan lifespan benefit? And I don't know if it was a complete goose egg, but one of the papers I actually looked at, that I was looking at this morning was this editorial that we talk about lumping the two in. And this editorial was talking about the benefits of says local or whole body heating, cooling, or a combination of both. And it goes on to say they're beneficial for a wide range of physiological responses, including the following. And then he goes on to list one person writing this editorial. Resistance to cardiovascular disease and mortality, endothelial function and arterial stiffness, walking ability and lower limb perfusion, shear pattern, blood pressure and circulating endothelium 1 concentrations, glucose metabolism, autonomic nervous activity, Cerebral protection, stress resistance. So I looked at those and then I looked at, followed the papers. So the supporting evidence for each one of those claims there were 10 papers or 10 studies. So I looked at all those 10 studies and then just categorized them by are these heat or cold? And in those first 10 papers they were all heat. The next statement that was within the same paragraph, it said, furthermore, both hot and cold water exposures have been reported to improve mental health. There was three papers, but one of the papers was essentially a editorial to the other paper which was a study on cold, and then the other one was a study on heat. And I think the heat study was actually was a randomized, controlled double. It was a blinded study too, which is interesting. A blinded heat study.

Well, how do you do that?

Yeah, I don't know. I think it was like it was warmth and they said they were giving them green light therapy and they told the participants that it was beneficial. So it was really like a sham protocol. So then I look at the cold study and the cold study is literally, it's in the BMJ. It's a case report of one woman, one 24 year old woman who had major depressive symptoms and anxiety and she started engaging in one to two times a week open water swimming. And they reassessed after three months and it looked like her depression went away and her anxiety went away from the.

Swimming or from the cold water?

Good question. It's hard to tease those out if you're tallying those up. There's essentially 12 studies that are making these claims and 11 of those studies are in heat. One of the studies was in cold and that one study was n equals one of somebody. And maybe the effect is real, but it's very, very hard to understand. Is it the effects of exercise or is it the effects of cold when somebody's engaging in open water swimming?

I don't even think that really counts. Right? I mean that's not a study. There's no control. That's simply one person's story of going swimming for two hours a day. I mean, let's put that in perspective for anybody who's exercised hours a day, which I'm no stranger to. You're no stranger to. I think it's pretty hard to feel bad if you're exercising two hours a day. I mean, I think the endorphin high of 2 hours a day of exercise will overcome most forms of dysthymia. So I mean, I would take that case study, fold it up neatly, package it appropriately in the trash let's go a little deeper on cold because that's. I think we should save the best for last, which is heat. Let's start with the greatest hit. I think there's certainly evidence that cold therapy will reduce delayed onset muscle soreness, correct?

Yes. Yeah, that's what we found. That was found early on too. I think that was when Dan looked at it. I looked at it as well. I think that was the initial finding. As far as delaying doms, let's say that sounds redundant.

Let's talk about how some of those studies are done. Right. So those studies are typically done in an ice bath and there's some thinking around how and when you should do that. What's the best insight into my experience with using an ice bath was back when I was riding my bike a lot. And in particular during a season when you would do lots of rides. Like you'd have maybe a hundred mile, really hard ride on Saturday and then on Sunday, or you had one Friday, Saturday, Sunday. The combination of just the brutal heat and just the intensity of the riding. I found the ice bath to be one of the most valuable things I could do. Also one of the most uncomfortable things you could do if anyone's sat in a pool of ice water. But truthfully, like all things, you just don't know how much of that benefit is placebo. So do you know how these studies are done? I mean, how do they. Because there's no getting around the fact that it's very difficult to control for the placebo effect in a study like this. What do control people do?

I think for the most part I don't know if they engage in some other activity. But yeah, they can't placebo an ice bath and have them feel like they're freezing when they're not. You've run into a control issue for sure.

That's to me an issue one. And I accepted that because my view was I'll take the placebo effect if it helps me. If the placebo effect is going to make me feel like my legs are better, then so be it. I don't know if you remember the cyclist Jens Voigt. Does that name ring a bell at all? Do you remember his famous words to his legs?

No, I don't.

It was sort of his classic slogan. It was shut up legs. Just shut up legs. You're not allowed to be talking right now. It doesn't matter how much you're screaming, just shut up. If taking an ice bath every night would allow you to silence those guys a little bit more the next day. We'll take it. I don't recall what the literature showed on strength training. Was there any benefit to reducing doms in athletes who are playing football in the weight room, doing things where you're obviously creating a lot of micro injury to the muscle and then how do you balance the trade off with not wanting to overly suppress the inflammation? Because it's that inflammation that actually creates some of the hypertrophy that those athletes are looking for.

That's right. That was the trade off or the issue. So it seemed like the greatest benefits occurred when treated 24 to 72 hours post exercise, which is I think when you would quote unquote want to take an ice bath is probably right after you did the exercise, so you're hot. But that being the case, about 24 to 72 hours post exercise and then most of the it seemed like the recommendations based off the other side of the coin with performance and recovery is they would say treatment should not be administered in the first hour post exercise. And so if you're being I would say most of the studies showed actually no benefit for performance and recovery, while other studies suggested that it might be detrimental to strength, which does get into that issue of we're learning about, we call them myokines and things like that, where there's an inflammatory response from exercise that's more or less it's a healing response. You think blunting something like that might be beneficial, but it actually might get into the adaptation process which may be occurring with this, which is pretty interesting.

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