Breath-hold time during cold water immersion: effects of habituation with psychological training

Habituation of the cold shock response: A systematic review and meta-analysis

Cold water immersion (CWI) evokes the life-threatening reflex cold shock response (CSR), inducing hyperventilation, increasing cardiac arrhythmias, and increasing drowning risk by impairing safety behaviour. Repeated CWI induces CSR habituation (i.e., diminishing response with same stimulus magnitude) after ∼4 immersions, with variation between studies. We quantified the magnitude and coefficient of variation (CoV) in the CSR in a systematic review and meta-analysis with search terms entered to Medline, SportDiscus, PsychINFO, Pubmed, and Cochrane Central Register. Random effects meta-analyses, including effect sizes (Cohen's d) from 17 eligible groups (k), were conducted for heart rate (HR, n = 145, k = 17), respiratory frequency (fR, n = 73, k = 12), minute ventilation (Ve, n = 106, k = 10) and tidal volume (Vt, n = 46, k=6). All CSR variables habituated (p < 0.001) with large or moderate pooled effect sizes: ΔHR -14 (10) bt. min-1 (d: -1.19); ΔfR -8 (7) br. min-1 (d: -0.78); ΔVe, -21.3 (9.8) L. min-1 (d: -1.64); ΔVt -0.4 (0.3) L -1. Variation was greatest in Ve (control vs comparator immersion: 32.5&24.7%) compared to Vt (11.8&12.1%). Repeated CWI induces CSR habituation potentially reducing drowning risk. We consider the neurophysiological and behavioural consequences.

Training methods for maximal static apnea performance: a systematic review and meta-analysis

INTRODUCTION

Currently, there is an increase in people practicing freediving (FD) both in competition and leisure. As a sports practice, its modalities are grouped into static, dynamic, and constant weight apnea. The aim of this systematic review and meta-analysis (PROSPERO-CRD42021230322) was to identify the training methods used to improve the static apnea time (AT) performance.

EVIDENCE ACQUISITION

Ten training protocols were analyzed from eight studies published until March 09, 2022. The effect size (Hedge's g) and its confidence interval (CI<inf>95%</inf>) were calculated from the AT measured pre- and post-training.

EVIDENCE SYNTHESIS

Three different apnea training methods were verified, the breath-hold (BH) that uses BH exercises, physical training with strength and cardiorespiratory exercises, and cross training that combines BH exercises with physical training. These training methods were applied to 138 participants of both sexes with or without experience in apnea episode or diving practice. In general, the AT improvement showed a large effect after the interventions (g=1.30, CI<inf>95%</inf>=0.85-1.76, P<0.01).

CONCLUSIONS

All three methods were effective in improving static AT, however from the existing protocols is not possible to recommend an ideal to improve AT and therefore FD performance.

Sex Difference in Female and Male Ice Swimmers for Different Strokes and Water Categories Over Short and Middle Distances: A Descriptive Study

Background

Winter swimming developed from a national tradition into a health-improving sport with international competitions. The difference in performance between women and men was thoroughly examined in various sporting disciplines; however, there is little data on winter swimming events. Therefore, this study aims to compare the sex differences in female and male winter swimmers for a distinct stroke over distances of 25 m and 200 m in ice water, freezing water and cold water in the multiple stages of the Winter Swimming World Cup, hosted by the International Winter Swimming Association (IWSA) since 2016.

Methods

All data included in this study were obtained from the official results of the Winter Swimming World Cup, published on the “International Winter Swimming Association” (IWSA) website. The Mann–Whitney U test was used to compare race time between sexes in different swimming strokes and categories of water. In contrast, the Kruskal–Wallis H test was used to compare differences between swimming strokes or water categories for the same sex.

Results

For 25 m and 200 m events of the “IWSA World Cup,” male athletes were faster than female athletes, regardless of stroke and water temperature category. However, the effect size of the difference between the sexes was greater in 25 m than in 200 m for all strokes and water temperatures. Swimming speed for the same-sex differed between the swimming stroke in relation to the water temperature category. Head-up breaststroke was found to be the slowest stroke (p < 0.05).

Conclusion

In water temperatures between − 2° and + 9 °C, men were faster than women in all stages of the “IWSA World Cup,” regardless of the swimming stroke, but the effect size of the difference between the sexes was greater in shorter than in longer events.

Human cold habituation: Physiology, timeline, and modifiers

Habituation is an adaptation seen in many organisms, defined by a reduction in the response to repeated stimuli. Evolutionarily, habituation is thought to benefit the organism by allowing conservation of metabolic resources otherwise spent on sub-lethal provocations including repeated cold exposure. Hypermetabolic and/or insulative adaptations may occur after prolonged and severe cold exposures, resulting in enhanced cold defense mechanisms such as increased thermogenesis and peripheral vasoconstriction, respectively. Habituation occurs prior to these adaptations in response to short duration mild cold exposures, and, perhaps counterintuitively, elicits a reduction in cold defense mechanisms demonstrated through higher skin temperatures, attenuated shivering, and reduced cold sensations. These habituated responses likely serve to preserve peripheral tissue temperature and conserve energy during non-life threatening cold stress. The purpose of this review is to define habituation in general terms, present evidence for the response in non-human species, and provide an up-to-date, critical examination of past studies and the potential physiological mechanisms underlying human cold habituation. Our aim is to stimulate interest in this area of study and promote further experiments to understand this physiological adaptation.

Acute Anxiety Predicts Components of the Cold Shock Response on Cold Water Immersion: Toward an Integrated Psychophysiological Model of Acute Cold Water Survival

Introduction: Drowning is a leading cause of accidental death. In cold-water, sudden skin cooling triggers the life-threatening cold shock response (CSR). The CSR comprises tachycardia, peripheral vasoconstriction, hypertension, inspiratory gasp, and hyperventilation with the hyperventilatory component inducing hypocapnia and increasing risk of aspirating water to the lungs. Some CSR components can be reduced by habituation (i.e., reduced response to stimulus of same magnitude) induced by 3–5 short cold-water immersions (CWI). However, high levels of acute anxiety, a plausible emotion on CWI: magnifies the CSR in unhabituated participants, reverses habituated components of the CSR and prevents/delays habituation when high levels of anxiety are experienced concurrent to immersions suggesting anxiety is integral to the CSR.

Purpose: To examine the predictive relationship that prior ratings of acute anxiety have with the CSR. Secondly, to examine whether anxiety ratings correlated with components of the CSR during immersion before and after induction of habituation.

Methods: Forty-eight unhabituated participants completed one (CON1) 7-min immersion in to cold water (15°C). Of that cohort, twenty-five completed four further CWIs that would ordinarily induce CSR habituation. They then completed two counter-balanced immersions where anxiety levels were increased (CWI-ANX) or were not manipulated (CON2). Acute anxiety and the cardiorespiratory responses (cardiac frequency [f_c], respiratory frequency [f_R], tidal volume [V_T], minute ventilation [_E]) were measured. Multiple regression was used to identify components of the CSR from the most life-threatening period of immersion (1^st minute) predicted by the anxiety rating prior to immersion. Relationships between anxiety rating and CSR components during immersion were assessed by correlation.

Results: Anxiety rating predicted the f_c component of the CSR in unhabituated participants (CON1; p < 0.05, r = 0.536, r²= 0.190). After habituation immersions (i.e., cohort 2), anxiety rating predicted the f_R component of the CSR when anxiety levels were lowered (CON2; p < 0.05, r = 0.566, r²= 0.320) but predicted the f_c component of the CSR (p < 0.05, r = 0.518, r²= 0.197) when anxiety was increased suggesting different drivers of the CSR when anxiety levels were manipulated; correlation data supported these relationships.

Discussion: Acute anxiety is integral to the CSR before and after habituation. We offer a new integrated model including neuroanatomical, perceptual and attentional components of the CSR to explain these data.

Cold acclimation and cognitive performance: A review

Athletes, occupational workers, and military personnel experience cold temperatures through cold air exposure or cold water immersion, both of which impair cognitive performance. Prior work has shown that neurophysiological pathways may be sensitive to the effects of temperature acclimation and, therefore, cold acclimation may be a potential strategy to attenuate cold-induced cognitive impairments for populations that are frequently exposed to cold environments. This review provides an overview of studies that examine repeated cold stress, cold acclimation, and measurements of cognitive performance to determine whether or not cold acclimation provides beneficial protection against cold-induced cognitive performance decrements. Studies included in this review assessed cognitive measures of reaction time, attention, logical reasoning, information processing, and memory. Repeated cold stress, with or without evidence of cold acclimation, appears to offer no added benefit of improving cognitive performance. However, research in this area is greatly lacking and, therefore, it is difficult to draw any definitive conclusions regarding the use of cold acclimation to improve cognitive performance during subsequent cold exposures. Given the current state of minimal knowledge on this topic, athletes, occupational workers, and military commands looking to specifically enhance cognitive performance in cold environments would likely not be advised to spend the time and effort required to become acclimated to cold. However, as more knowledge becomes available in this area, recommendations may change.

Habituation of the cold shock response is inhibited by repeated anxiety: Implications for safety behaviour on accidental cold water immersions

INTRODUCTION

Accidental cold-water immersion (CWI) triggers the life-threatening cold shock response (CSR) which is a precursor to sudden death on immersion. One practical means of reducing the CSR is to induce an habituation by undergoing repeated short CWIs. Habituation of the CSR is known to be partially reversed by the concomitant experience of acute anxiety, raising the possibility that repeated anxiety could prevent CSR habituation; we tested this hypothesis.

METHOD

Sixteen participants (12 male, 4 female) completed seven, seven-minute immersions in to cold water (15°C). Immersion one acted as a control (CON1). During immersions two to five, which would ordinarily induce an habituation, anxiety levels were repeatedly increased (CWI-ANX_rep) by deception and a demanding mathematical task. Immersions six and seven were counter-balanced with another high anxiety condition (CWI-ANX_rep) or a further control (CON2). Anxiety (20cm visual analogue scale) and cardiorespiratory responses (cardiac frequency [f_c], respiratory frequency [f_R], tidal volume [V_T], minute ventilation [V̇_E]) were measured. Comparisons were made between experimental immersions (CON1, final CWI-ANX_rep, CON2), across habituation immersions and with data from a previous study.

RESULTS

Anxiety levels were sustained at a similar level throughout the experimental and habituation immersions (mean [SD] CON1: 7.0 [4.0] cm; CON2: 5.8 [5.2] cm cf CWI-ANX_rep: 7.3 [5.5] cm; p>0.05). This culminated in failure of the CSR to habituate even when anxiety levels were not manipulated (i.e. CON2). These data were different (p<0.05) to previous studies where anxiety levels were allowed to fall across habituation immersions and the CSR consequently habituated.

DISCUSSION

Repeated anxiety prevented CSR habituation. A protective strategy that includes inducing habituation for those at risk should include techniques to lower anxiety associated with the immersion event or habituation may not be beneficial in the emergency scenario.

Cold Stress Effects on Exposure Tolerance and Exercise Performance

Cold weather can have deleterious effects on health, tolerance, and performance. This paper will review the physiological responses and external factors that impact cold tolerance and physical performance. Tolerance is defined as the ability to withstand cold stress with minimal changes in physiological strain. Physiological and pathophysiological responses to short-term (cold shock) and long-term cold water and air exposure are presented. Factors (habituation, anthropometry, sex, race, and fitness) that influence cold tolerance are also reviewed. The impact of cold exposure on physical performance, especially aerobic performance, has not been thoroughly studied. The few studies that have been done suggest that aerobic performance is degraded in cold environments. Potential physiological mechanisms (decreases in deep body and muscle temperature, cardiovascular, and metabolism) are discussed. Likewise, strength and power are also degraded during cold exposure, primarily through a decline in muscle temperature. The review also discusses the concept of thermoregulatory fatigue, a reduction in the thermal effector responses of shivering and vasoconstriction, as a result of multistressor factors, including exhaustive exercise.

"Float first and kick for your life": Psychophysiological basis for safety behaviour on accidental short-term cold water immersion

INTRODUCTION

Accidental cold-water immersion (CWI) evokes the life threatening cold shock response (CSR) which increases the risk of drowning. Consequently, the safety behaviour selected is critical in determining survival; the present advice is to 'float first' and remain stationary (i.e. rest). We examined whether leg only exercise (i.e., treading water; 'CWI-Kick') immediately on CWI could reduce the symptoms of the CSR, offset the reduction in cerebral blood flow that is known to occur and reduce the CSR's symptoms of breathlessness. We also examined whether perceptual responses instinctive to accidental CWI were exacerbated by this alternative behaviour. We contrasted CWI-Kick to a 'CWI-Rest' condition and a thermoneutral control (35°C); 'TN-Rest'.

METHOD

Seventeen participants were tested (9 males, 8 females). All immersions were standardised; water temperature in cold conditions (i.e., 12°C) was matched ±/0.5°C within participant. Middle cerebral artery blood flow velocity (MCAv) and cardiorespiratory responses were measured along with thermal perception (sensation and comfort) and dyspnoea. Data were analysed using repeated measures ANOVA (alpha level of 0.05).

RESULTS

MCAv was significantly reduced in CWI-Rest (-6 (9)%; 1st minute of immersion) but was offset by leg only exercise immediately on cold water entry; CWI-Kick MCAv was never different to TN-Rest (-3 (16)% cf. 5 (4)%). All CWI cardiorespiratory and perceptual responses were different to TN-Rest but were not exacerbated by leg only exercise.

DISCUSSION

Treading water may aid survival by offsetting the reduction in brain blood flow velocity without changing the instinctive behavioural response (i.e. perceptions). "Float first - and kick for your life" would be a suitable amendment to the water safety advice.

Responses of the hands and feet to cold exposure

An initial response to whole-body or local exposure of the extremities to cold is a strong vasoconstriction, leading to a rapid decrease in hand and foot temperature. This impairs tactile sensitivity, manual dexterity, and muscle contractile characteristics while increasing pain and sympathetic drive, decreasing gross motor function, occupational performance, and survival. A paradoxical and cyclical vasodilatation often occurs in the fingers, toes, and face, and this has been termed the hunting response or cold-induced vasodilatation (CIVD). Despite being described almost a century ago, the mechanisms of CIVD are still disputed; research in this area has remained largely descriptive in nature. Recent research into CIVD has brought increased standardization of methodology along with new knowledge about the impact of mediating factors such as hypoxia and physical fitness. Increasing mechanistic analysis of CIVD has also emerged along with improved modeling and prediction of CIVD responses. The present review will survey work conducted during this century on CIVD, its potential mechanisms and modeling, and also the broader context of manual function in cold conditions.

Integrative physiological and behavioural responses to sudden cold-water immersion are similar in skilled and less-skilled swimmers

We examined the initial physiological responses and subsequent capacity to swim following cold-water immersion. An ecologically-valid model was used whereby immersion was sudden (<2s) and participants had to actively remain afloat. Participants (15 skilled swimmers, 17 less-skilled swimmers) undertook four experimental test sessions: a physiological test and a swimming test in both cold (10°C) water and temperate (27°C) water in a swimming flume (temperature order counter-balanced). For physiological testing, measures of brain perfusion [flow velocity (MCAv, Doppler) and oxygenation (NIRS)] and cardiorespiratory function [ventilation parameters and end-tidal PCO2 (PETCO2)] were recorded whilst treading water for 150s. The swimming test involved treading water (150s) before swimming at 60% (up to 120s) and 90% (to intolerance) of pre-determined maximum velocity. Multifactorial analysis revealed that swimming duration was influenced most heavily by water temperature, followed by respiratory variables and MCAv in the first 30s of immersion. The time course and severity of cold shock were similar in both groups (p=0.99), in terms of initial physiological changes (MCAv down ~20 ± 11%, respiratory frequency increased to 58 ± 18 breaths·min(-1), PETCO2 dropped to 12 ± 9 mmHg). Treading water following cold-water immersion increased MCAv by 30% above resting values despite maintained cold-shock-induced hyperventilation. In comparison to temperate water, swimming capacity was also reduced similarly between groups in the cold (i.e., distance decreased by 34 ± 26% skilled; 41 ± 33% less-skilled, p=0.99). These integrative findings verify that sudden cold-water immersion followed by physical activity leads to similar physiological responses in humans when contrasting between skilled and less-skilled swimmers.

Acute anxiety increases the magnitude of the cold shock response before and after habituation

Cold immersion evokes the life-threatening cold shock response (CSR). We hypothesised that anxiety may increase the magnitude of (Study 1), and diminish habituation to (Study 2), the CSR. Study 1: eleven participants completed two 7-min immersions in cold water (15 °C). On one occasion, to induce anxiety, participants were instructed that the water would be 5 °C colder (ANX); it was unchanged. The other immersion was a control (CON). Study 2: ten different participants completed seven, 7-min immersions. Immersions 1-5 induced habituation. Immersions 6 and 7 were counter-balanced to produce anxiety (ANX) or acted as a control (CON). Anxiety (20 cm scale) and cardiorespiratory responses (cardiac frequency [f(c)]), respiratory frequency [f(R)], tidal volume [V(T)], minute ventilation [V(E)]) were measured in both studies. Results of study 1: participants were more anxious in the ANX immersion (mean [SD]; CON 5.3 [3.6] and ANX 8.4 [5.0] cm). f(c) peaked at higher levels in ANX (136.4 [15.0]; CON: 124.0 [17.6] b min(-1)) and was higher pre-immersion and in minutes 3 and 5-7 by 7.2 [2.1] b min(-1). ANX [Formula: see text] was higher pre immersion and in minutes 5-6. Results of study 2: repeated immersion habituated the CSR. Anxiety was greater prior to ANX (CON 1.9 [2.3], ANX 6.6 [4.8] cm). f (c) in ANX was higher prior to immersion and in minutes 1-2, 4-6 cf CON; ANX f (c) was not different to the CSR seen in pre-habituation. f (R) was higher in minute 1 of immersion 1 (cf min 1 CON and ANX) following which it exceeded the CSR in CON. The magnitude and duration of CSR (f(c), V(E)) increased with anxiety. Anxiety diminishes CSR habituation.

Recruitment pattern of sympathetic neurons during breath-holding at different lung volumes in apnea divers and controls

We tested the hypothesis that breath-hold divers (BHD) attain higher level of sympathetic activation than controls due to the duration of breath-hold rather than a different recruitment strategy. In 6 control subjects and 8 BHD we measured muscle sympathetic neural activity (MSNA) prior to and during functional residual capacity (FRC) and total lung capacity (TLC) breath-holding. On a subset of subjects we applied a new technique for the detection of action potentials (APs) in multiunit MSNA. Compared with controls, BHD group had lower burst AP content (13±7 vs. 6±3AP/burst; P=0.05) and number of active clusters (5±1 vs. 3±1clusters/burst; P=0.05) at baseline. However, the overall sympathetic AP/unit-time was comparable between the groups (131±105 vs. 173±152AP/min; P=0.62) due to increased burst frequency in BHD group (20±4bursts/min) vs. controls (13±3bursts/min) (P=0.039). The achieved level in total MSNA during FRC breath-holds was higher in divers (2298±780 vs. 1484±575a.u./min; P=0.039). Total MSNA at the end of TLC breath-hold was comparable between the groups (157±50 (controls) vs. 214±41s (BHD); P=0.61). FRC and TLC breath-holds increased AP frequency, burst AP content and active clusters/bursts in both groups but the response magnitude was determined by the type of the breath-hold. The divers used fewer number of APs/burst and active clusters/burst. In both groups breath-holds resulted in similar increases in MSNA which were reached both by an increase in firing frequency and by recruitment of previously silent, larger (faster conducting) sympathetic neurons, and possibly by repeated firing within the same burst.