Contraindications, dangers, and precautionary protocols to minimize dangers without giving up the benefits of ice baths.
Summary
Although the medical risks of ice baths have likely been exaggerated on social media, there are some contraindications like hypertension (high blood pressure) worth monitoring.
Most of the scientific studies on cold water risks attend to outdoor swimming, where drowning is an important hazard. Ice baths present a narrower set of concerns.
To minimize the dangers during ice bath, follow these precuationary protocols:
no coercion, bullying, or shame,
stay sober & supervise children,
enter the ice bath feet first,
breathe,
allow time for rewarming.
Are ice baths dangerous?
Several popular online articles have suggested that cold plunges are dangerous. Even professional organizations like the American Heart Association (AHA) recently published an article with the sensational title ‘You're not a polar bear: The plunge into cold water comes with risks’ (Williamson 2022) in which they quoted McGill post-doctoral fellow Lee Hill saying "You can survive for up to an hour moving around (in cold water) but for those who are not accustomed to that cold water shock, it can be incredibly risky." Hill, the article explains, was a cold water swimming coach in South Africa before moving to McGill in Montreal Canada, and still practices cold plunging himself. Nevertheless, the article leaves readers with the impression that the benefits of cold plunge therapy are dubious and the risks well established.
In fact, the opposite is true.
The salubrious benefits of cold plunge therapy have been understood for centuries, although more recently more recently science has been catching up with tradition. For example, as far back as twenty years ago a study in Finland discovered that a regular practice of winter swimming improved energy levels (compared to controls) and reduced symptoms of rheumatism, fibromyalgia, and asthma (Huttunen et al. 2004).
By contrast, the science documenting all but a few specific risks is dubious. The same AHA article quotes the official-sounding National Center for Cold Water Safety warning that sudden immersion in water under 60 degrees Fahrenheit can kill a person in "less than a minute." However, a closer look on the Center’s website reveals that they're referring to accidental falls into open cold waters -- not deliberate immersion into an ice bath. When that context is removed, it's easy to confuse the dangers of open water sports like canoeing, kayaking, and whitewater rafting with safer practices like at-home cold plunge therapy.
Professor Tipton's cold water swimming tips
In Depression Cured by Cold Plunge Therapy, I cited the documented case of a British woman who successfully used cold water swimming to resolve a major depression that failed to respond to both drugs and talk therapy. That case was supervised by Professor Mike Tipton, PhD, who directs the Extreme Environments Lab at University of Portsmouth in the United Kingdom (van Tulleken et al. 2018). Her case agrees with several other lines of evidence that suggest the metabolic benefits of cold plunge therapy are associated with improved mental health, reduced risk of Alzheimer’s, better memory, and overall improved brain function. For example, an international team of researchers including Tipton’s colleague, Heather Massey PhD, also at the University of Portsmouth found that 33 adults improved their self-reported emotional well-being after only 5 minutes of whole-body cold bath at a relatively balmy 20C (Yankouskaya et al. 2022). They wrote “the results indicate that short-term whole-body cold-water immersion may have integrative effects on brain functioning, contributing to the improvement in mood.”
In a recent academic journal article in the British Journal of Sports Medicine, Tipton, Massey and others published their advice for managing the risks of cold-water swimming (Tipton et al. 2022). As one of the world’s foremost experts on drowning risks, you might think that the article is required reading for all cold plunge coaches, Instagram influencers, and anybody interested in the practice for health, longevity, and wellness reasons. The problem is that the article is hidden behind a US$60 paywall, so if you don’t have access to a high-powered research library like I do at Arizona State University, it’s not practical or affordable to read Tipton’s tips. So, I’ve taken the trouble of comparing and summarizing those that apply to ice baths here:
complete a medical assessment prior to undertaking a cold plunge,
to minimize cold water shock, enter the water gradually
keep immersions shorter than 10 minutes
adopt post cold exposure measures that improve recovery, such as drying and dressing in warm clothing,
avoid driving 30 minutes post cold plunge i.e. during the rewarming period.
Tipton adds additional tips that apply primarily to open water swimming, such as use of safety whistles and lifeguard supervision, that are not essential for the ice bath. Nonetheless, his advice is in good agreement with the precautionary protocols I prescribed in The Dangers of Deliberate Cold Exposure (Ice Bath Safety). That’s partly because I made a close study of Tipton’s earlier paper ‘Cold Water Immersion: Kill or Cure?’ that is available for free online (Tipton et al. 2017).
Where Tipton goes even further is to add advice for clinicians supervising cold water swimmers. For example, he suggests that medical professional screen participants for pre-existing health conditions that may be contraindications to cold plunge therapy. The most important of these is likely hypertension, because the vasoconstriction of the ice bath will cause a temporary increase in blood pressure. An acute episode of high blood pressure could risk organ damage. Lastly, he advises that clinicians supervising cold plunge therapy should also screen for signs of alcohol or recreational drug intoxication, which reinforces my advice to only "cold plunge sober."
Dr. Iconomidis' Contraindications to Cold
The most comprehensive description of the medical contraindications to cold water immersion I've found is in a book by French physician Dr. Nicolas Iconomidis. In it, he describes his experiences as part of a year-round open water swim club in southern France.
I included Dr. Iconomidis' recommendations in my earlier article, Contraindications to Cold Plunging. Clinicians advising patients who are interested in cold plunges may find these resources useful. Nonetheless, for me the most important contraindication is not wanting to do an ice bath. A fundamental tenet of a healthy practice of ice bathing is no coercion.
To obtain the mental and psychological benefits of cold plunge therapy, it is essential to enter and exit the ice bath of one's own volition, without bullying, shame, or social pressure.
References
Huttunen P, Kokko L, Ylijukuri V. Winter swimming improves general well-being. International Journal of Circumpolar Health. 2004 Jun 1;63(2):140-4.
Knechtle B, Waśkiewicz Z, Sousa CV, Hill L, Nikolaidis PT. Cold water swimming—benefits and risks: a narrative review. International journal of environmental research and public health. 2020 Dec;17(23):8984.
Williamson L. 9 Dec 2022. You're not a polar bear: The plunge into cold water comes with risks. American Heart Association News.
Yankouskaya A, Williamson R, Stacey C, Totman JJ, Massey H. Short-term head-out whole-body cold-water immersion facilitates positive affect and increases interaction between large-scale brain networks. Biology. 2023 Jan 29;12(2):211.
About the Author
Thomas P Seager, PhD is an Associate Professor in the School of Sustainable Engineering at Arizona State University. Seager co-founded the Morozko Forge ice bath company and is an expert in the use of ice baths for building metabolic and psychological resilience.