The Peter Attia Drive - #132 - AMA #16： Exploring hot and cold therapy

00:00:00.000 Hey everyone, welcome to a sneak peek, ask me anything or AMA episode of the drive podcast.

00:00:16.500 I'm your host, Peter Atiyah. At the end of this short episode, I'll explain how you can

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00:00:25.440 or you can learn more now by going to peteratiyahmd.com forward slash subscribe.

00:00:31.140 So without further delay, here's today's sneak peek of the ask me anything episode.

00:00:39.200 Welcome to ask me anything or AMA episode number 16. In today's episode, we do a real deep dive

00:00:47.840 discussion into all things hot and cold therapy. Now coming into this call, we actually intended

00:00:53.040 to cover many more questions that we probably only covered by topic 20% of what we intended to

00:00:59.720 cover. But you know, once we got into the groove of going into this, we just decided that we were

00:01:04.160 going to stay with hot and cold and we basically ran out of time. Now this is a topic we get asked

00:01:08.420 about all the time. And frankly, it's a topic we've spent a lot of time doing research on. We did our

00:01:13.940 first internal report on this back in 2013 or 2014, and then did an enormous rehash of it in December

00:01:23.880 of 19, January of 20. And it's sort of on the heels of that, that Bob and I basically try to offer as

00:01:32.820 much insight as we have into the ins and outs of hot and cold therapy. Again, if you're, you know,

00:01:37.420 really not interested in this topic, I'm going to be honest with you. I don't think there's a lot in

00:01:40.720 this episode, you're going to find that interesting. But that said, I would encourage you to give it a

00:01:44.940 thought because this is something that my mind has changed quite a bit on over the past couple of

00:01:49.600 years. I think the data have become much stronger, at least in favor of one of these therapies. So

00:01:55.240 without further delay, I hope you will enjoy AMA number 16.

00:02:04.680 Bob, how are you, man?

00:02:06.400 Doing well, Peter. How are you?

00:02:08.400 Well, it's great to be doing another AMA. I feel like we haven't done one in a while. We missed

00:02:12.960 our last cycle. Since we last spoke, as you know, I've had this move, which has created a little

00:02:19.960 bit of stress in the short term, joy in the long term.

00:02:24.960 Moving's super easy, right?

00:02:26.940 Yeah. Have you ever had to do a move with kids? Like I know you've moved across the country a bunch

00:02:31.320 of times as a young man, but have you had to do the family?

00:02:35.760 No, totally different. I remember a family business. I had to get secret clearance. So

00:02:41.540 you had to do this whole form and it said like, where have you lived in the last 10 to 20 years?

00:02:45.360 And it covered college years. And so I probably did 10 to 20 moves in 10 to 20 years, but never

00:02:51.520 with the kids. Totally different situation where I probably could pack everything up into one of

00:02:55.640 those little pods versus, yeah, kids and moving from house to house. How's that working for you?

00:03:03.360 No, I mean, it's fine now, but it was, it was really challenging, much more so than I expected.

00:03:07.780 And I remember about two months before the move, everybody saying things, including my therapist

00:03:14.380 saying, you know, just to set your expectations, a move like of this nature is among the three most

00:03:20.020 stressful events to a marriage. And I was like, come on, what are you talking about? They're like,

00:03:24.680 yep, it's on par with divorce, death and something else. And I was like, that is not even possible.

00:03:31.800 I don't know what kind of mental midgets you're dealing with here, but there's no way that's going 1.00

00:03:37.040 to be stressful. And in the weeks leading up to the move, all of a sudden my body just started 0.96

00:03:44.180 hurting. My QLs were totally fired up. I just didn't feel good when I was lifting. Everything

00:03:51.360 in my body felt horrible. And amazingly, after the move was done, all of that stuff almost overnight

00:03:58.440 changed. And that was kind of an aha moment of, it's such a cliche to say we hold stress in our body,

00:04:04.060 but we do. I can't actually mechanistically explain what it is about stress and why higher levels of

00:04:12.440 cortisol or catecholamines or things like that would actually lead to physical pain in my body,

00:04:18.420 but there's no question about it. So glad it's over.

00:04:22.660 That was actually one of the questions was around that. How has your move been?

00:04:27.260 I haven't even seen the questions.

00:04:29.080 Yeah. This one was on location and time change, which I don't think you're necessarily a stranger

00:04:33.420 to. So this is probably a layup for you as far as any adjustment, as far as changing a time zone and

00:04:39.280 changing of location. No, it hasn't been an issue for me, but I think we knew that for the kids it

00:04:44.400 would be. And it was a bit complicated because the kids started virtual school in Texas while still in

00:04:51.360 California a couple of weeks before the move because we moved August 31st, but they really

00:04:58.820 start early in Texas for school. So I think 10 or 12 days before that, two of the three were doing

00:05:04.440 virtual school. So that's actually where things started. So two weeks prior to that, I put them

00:05:10.120 on a different sleep schedule because they would be starting school at 620 California time, which was

00:05:17.480 820 Texas time. And my daughter had spent say a month prior to that being like a normal 11 year old

00:05:25.480 and sleeping till nine o'clock or eight o'clock in the morning. So we just created a sleep schedule

00:05:31.520 where we bumped her go to bedtime and wake up time by about 15 minutes a day, such that she would be 1.00

00:05:38.560 getting up around 530 in the morning, California time, which would give her enough time to kind of

00:05:44.100 have breakfast and not show up to class two minutes after waking up, go to class. So by doing that,

00:05:51.500 the move was actually really easy because she had already done the heavy lifting of acclimating

00:05:56.520 via jet lag prior to actually coming out here. And it was easy, but I think the same principle

00:06:02.560 applies. So for example, Bob, so you're on the East coast. If you knew you had to go to London

00:06:07.680 in two weeks or something like that. And I can't remember, I think London's probably five hours

00:06:12.660 ahead of Eastern standard time. You could take a page out of that book. Now you wouldn't go all the

00:06:17.700 way there. You wouldn't ratchet it back. So you're literally five hours off, but you could certainly

00:06:23.020 ratchet two and a half hours off. And then as I think I may have discussed, we have that jet lag

00:06:28.440 protocol for our patients. We basically on the day of travel, take the entire gap out of it.

00:06:35.500 So for example, let's say you're departing. I don't do that trip often, but let's say you're departing.

00:06:42.460 Well, actually they sometimes do that as a red eye, but let's say you're departing at two o'clock in the

00:06:46.560 afternoon. I don't know if you would even depart at that time. So that means it's already say seven

00:06:53.740 there. And it's probably a six hour flight. You'd be getting in really late London time.

00:06:59.400 I would get up super early that morning. I mean, super early, like 3 AM local time,

00:07:06.080 which is functionally 8 AM in destination time, force yourself awake. And that makes it easier for

00:07:13.000 you to go to bed. Cause the challenge you're going to have when you're flying East, assuming you don't

00:07:17.840 cross the date line is you're not going to want to go to bed when you get there. And you're going to

00:07:21.980 get into that vicious cycle of having a hard time falling asleep and therefore having a hard time

00:07:27.100 waking up. And then you're basically just doing the reverse on the way back. But to answer the

00:07:31.160 question, a two hour time zone jump is generally not that difficult, even if you just sort of willy

00:07:37.500 nilly flow to it, but you can make it a no issue if you are proactive about bedtime and wake up time.

00:07:43.000 Okay. So we got a bunch of questions on hot and cold therapy. What are the benefits,

00:07:49.380 et cetera. Those are two separate topics really. And you did a little project too,

00:07:55.240 where you went to a cold environment. We did a little deep dive on cold and we've done a dive

00:08:00.600 on the heat as well. Yeah. I mean, I think that's putting it mildly. It was an extensive amount of work

00:08:06.900 we did on it. And I think you're right. I think these get lumped in together as one topic constantly.

00:08:13.620 We've been looking at this topic internally for at least five years. I think in 2015 was the first

00:08:21.320 time Dan Pelichar internally did a very deep dive on cold therapy. This was actually through the lens

00:08:28.500 of cryotherapy versus ice bathing for DOMS, delayed onset muscle soreness. And that extended

00:08:34.740 into heat therapy. I think you picked up the mantle on that a year later. And then you're right in late

00:08:40.720 2019, in anticipation of this project I was doing that involved a lot of work around hot and cold

00:08:47.540 therapy, we just decided to assume we knew nothing, go back to the drawing board and from a clean slate

00:08:55.040 effectively relearn all of this. And I think at this point, the list of people who are more familiar

00:09:01.500 with this literature than you, that's a pretty short list. I basically gave you a pretty clear

00:09:07.320 mandate, which was Bob, you need to know everything about this and distill it into 10 pages for me.

00:09:13.820 Yeah. Especially on the, recently on the cold immersion cryotherapy, things like that. And

00:09:18.480 I mean, the upshot I think was Peter telling Bob, like, throw me a bone here. Is there anything that we

00:09:24.180 can find here that's reliable evidence that shows some type of health span, lifespan benefit? And

00:09:30.480 I don't know if it was a complete goose egg, but one of the papers I actually looked at that I was

00:09:35.280 looking at this morning was this editorial that we were talking about, like lumping the two in. And

00:09:39.520 this editorial was talking about the benefits of, this is local or whole body heating, cooling,

00:09:44.560 or a combination of both. And it goes on to say, they're beneficial for a wide range of physiological

00:09:49.240 responses, including the following. And then he goes on to list one person writing this editorial,

00:09:55.460 resistance to cardiovascular disease and mortality, endothelial function and arterial stiffness,

00:10:00.220 walking ability and lower limb perfusion, sheer pattern, blood pressure and circulating endothelium

00:10:06.940 one concentrations, glucose metabolism, autonomic nervous activity, cerebral protection,

00:10:14.220 and stress resistance. So I looked at those and then I looked at, followed the papers. So the,

00:10:19.300 the supporting evidence for each one of those claims, there were 10 papers or 10 studies. So I looked at all

00:10:25.620 those 10 studies and then just categorized them by, are these heat or cold? And in those first 10 papers,

00:10:32.340 they were all heat. The next statement that was within the same paragraph, it said, furthermore,

00:10:37.080 both hot and cold water exposures have been reported to improve mental health. There was three papers,

00:10:42.500 but one of the papers was essentially a editorial to the other paper, which was a study on cold. And then

00:10:48.660 the other one was a study on heat. And I think the heat study was actually, it was a randomized

00:10:52.920 controlled double, I was a blinded study too, which is interesting. A blinded heat study.

00:10:57.960 Well, how do you do that?

00:10:59.060 Yeah, I don't know. I think it was like, it was warmth and they said they were giving him green light

00:11:02.340 therapy and they told the participants that it was beneficial. So it was really like a sham protocol.

00:11:08.220 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,

00:11:13.060 one 24 year old woman who had major depressive symptoms and anxiety. And she started engaging in

00:11:19.880 one to two times a week, open water swimming. And they reassessed after three months and

00:11:24.820 it looked like her depression went away and her anxiety went away. So from the swimming or from the

00:11:31.680 cold water? Good question. It's hard to tease those out. If you're telling those up, there's essentially

00:11:38.400 12 studies that are making these claims and 11 of those studies are in heat. One of the studies

00:11:43.040 was in cold. And that one study was N equals one of somebody. And maybe the effect is real,

00:11:48.860 but it's very, very hard to understand. Is it the effects of exercise or is it the effects of cold

00:11:53.400 when somebody's engaging in open water swimming? I don't even think that really counts, right?

00:11:58.380 I mean, that's not a study. There's no control. That's simply one person's story of going swimming

00:12:02.920 for two hours a day. I mean, let's put that in perspective for anybody who's exercised two hours a

00:12:07.000 day, which I'm no stranger to, you're no stranger to. I think it's pretty hard to feel bad if you're

00:12:12.660 exercising two hours a day. I mean, I think the endorphin high of two hours a day of exercise will

00:12:17.520 overcome most forms of dysthymia. So, I mean, I would take that case study, fold it up neatly,

00:12:26.760 package it appropriately in the trash. Let's go a little deeper on cold because that's, I think we

00:12:32.560 should save the best for last, which is heat. Let's start with the greatest hit. I think

00:12:37.620 there's certainly evidence that cold therapy will reduce delayed onset muscle soreness, correct?

00:12:44.400 Yes. Yeah. That's what we found. That was found early on too. I think that was when Dan looked at

00:12:49.100 it. I looked at it as well. I think that was the initial finding as far as delaying DOMS, I would

00:12:54.660 say. That sounds redundant. Let's talk about how some of those studies are done, right? So those

00:12:59.080 studies are typically done in an ice bath. And there's some thinking around how and when you should do

00:13:06.940 that. What's the best insight into my experience with using an ice bath was back when I was riding

00:13:13.360 my bike a lot. And in particular, during a season when you would do lots of rides, like you'd have

00:13:21.500 maybe a hundred mile really hard ride on Saturday and then on Sunday, or you had one Friday, Saturday,

00:13:26.680 Sunday. The combination of just the brutal heat and just the intensity of the riding, I found

00:13:34.280 the ice bath to be one of the most valuable things I could do. Also one of the most uncomfortable

00:13:39.080 things you could do if anyone's sat in a pool of ice water. But truthfully, like all things,

00:13:45.260 you just don't know how much of that benefit is placebo. So do you know how these studies are done?

00:13:49.120 I mean, how do they, because there's no getting around the fact that it's very difficult to control

00:13:54.280 for the placebo effect in a study like this. What do control people do?

00:13:59.820 I think for the most part, I don't know if they engage in some other activity, but yeah,

00:14:03.800 they can't placebo an ice bath and have them feel like they're freezing when they're not.

00:14:09.080 Yeah.

00:14:09.580 You've run into a control issue for sure.

00:14:11.860 That's to me an issue one. And I accepted that because my view was I'll take the placebo effect

00:14:18.120 if it helps me. If the placebo effect is going to make me feel like my legs are better,

00:14:22.900 then so be it. I don't know if you remember the cyclist Jens Voigt. Does that name ring a bell at

00:14:27.900 all? Do you remember his famous words to his legs? No, I don't. It was sort of his classic slogan.

00:14:34.840 It was shut up legs. Just shut up legs. You're not allowed to be talking right now. It doesn't 0.99

00:14:40.740 matter how much you're screaming. Just shut up. If taking an ice bath every night would allow you to 1.00

00:14:46.160 silence those guys a little bit more the next day, we'll take it. I don't recall what the literature

00:14:51.380 showed on strength training. Was there any benefit to reducing DOMS in athletes who are playing

00:15:00.460 football, in the weight room, doing things where you're obviously creating a lot of micro injury to

00:15:07.400 the muscle? And then how do you balance the trade-off with not wanting to overly suppress

00:15:14.140 the inflammation? Because it's that inflammation that actually creates some of the hypertrophy that

00:15:18.860 those athletes are looking for. That's right. That was the trade-off or the issue. So it seemed like

00:15:24.340 the greatest benefits occurred when treated 24 to 72 hours post-exercise, which is I think when you

00:15:31.260 would quote-unquote want to take an ice bath is probably right after you did the exercise. So you're

00:15:35.580 hot. But that being the case, about 24 to 72 hours post-exercise. And then most of the, it seemed like

00:15:43.100 the recommendations based off the other side of the coin with performance and recovery is they would

00:15:48.780 say treatment should not be administered in the first hour post-exercise. And so if you're being,

00:15:54.220 I would say most of the studies showed actually that no benefit for performance and recovery,

00:15:58.840 while other studies suggested that it might be detrimental to strength, which does get into

00:16:04.020 that issue of we're learning about, we call them myokines and things like that, where there's an

00:16:08.840 inflammatory response from exercise. That's more or less, it's a healing response. You think

00:16:14.520 blunting something like that might be beneficial, but it actually might get into the adaptation

00:16:18.040 process, which may be occurring with this, which is pretty interesting.

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The Peter Attia Drive - October 12, 2020

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

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