A 28-year-old man with significant ongoing intercostal neuralgia following endoscopic thoracic sympathectomy found immediate, complete, and lasting pain relief after an open-water swim in very cold water, UK researchers report.
While an incidental chance association is possible, “the clear temporal proximity linking the swim with pain remission makes a causal relationship possible,” write Tom Mole, MD, University of Cambridge, and Pieter Mackeith, University of East Anglia.
They describe the case online February 12 in BMJ Case Reports.
Unexpected Relief
The patient underwent endoscopic thoracic sympathectomy for severe primary facial blushing refractory to conservative management. He had no other significant medical history. The surgery was uneventful, with no postoperative complications other than severe bilateral radiating intercostal pain.
He was discharged with a course of graded physical therapy (PT) and combination analgesics, including nonsteroidal and opiate medication. They didn’t help much. Ten weeks after surgery, the patient continued to report only limited benefit from analgesics and PT.
The patient reported that exercise and movement exacerbated the intercostal neuralgia and prevented him from fully engaging in PT. The ongoing pain caused him significant distress and prevented him from returning to preoperative levels of recreational sport.
Before his surgery, the man was a triathlete and had swum competitively in open water. Thinking that a cold open-water swim would at least provide some distraction from his pain, he returned to the site of a prior triathlon.
Unbeknownst to his physician, he plunged from a rocky outcrop into the water and was forced to swim for about 1 minute before being able to climb safely back ashore. The temperature of the water was about 11°C (51.8°F).
“Interestingly, contrary to the patient’s expectation of severe pain, the patient unexpectedly reported no provocation of pain during swimming,” write Mole and Mackeith. Since taking the cold water plunge, the patient has had no further bouts of intercostal neuralgia and is able to move and exercise freely without pain.
The cold water swim seems to have provided “immediate and lasting analgesia,” the authors note. The patient has since returned to his presurgery levels of mobility, sport, and quality of life and is no longer taking any painkillers.
Although there is considerable literature on water rehabilitation and cold water baths in sports medicine, cold water swimming has not been described in the context of postoperative care, the authors point out.
It’s possible, they add, that the shock of the sudden cold water immersion might have induced a wave of sympathetic activity, perhaps leading to altered pain perception, offering instant relief and, in turn, increased mobility.
Postoperative intercostal neuralgia is a “significant treatment challenge,” which may not respond well to analgesics and carries significant psychosocial morbidity.
“Further prospective explorative investigation is needed to assess the replicability and feasibility of forced cold-water swimming as a potentially effective, natural intervention to enhance recovery outcomes from common postoperative complications,” Mole and Mackeith write.
Distraction a Pain Remedy?
Reached for comment, Mohammad Piracha, MD, pain management expert and anesthesiologist at Weill Cornell Medicine and NewYork-Presbyterian, New York City, said this is a “very interesting” case report and not completely unexpected.
“Sometimes things that distract from pain, particularly those that involve a physical change like temperature or pressure, can reset the body’s interpretation of that pain. So this case is not completely out of the ordinary,” Piracha told Medscape Medical News.
Piracha also said it’s not surprising that the patient’s mobility improved after the pain was gone.
“His mobility would be better. People in pain don’t move as much and they are much more guarded because they are afraid that if they move too much they will re-elicit their pain. A lot of people really underestimate how much restriction pain causes and the loss of functionality related to pain,” he said.
This published case report, he added, is “important because it re-emphasizes how many factors play into pain and especially with the climate today surrounding opioids, it’s always good to hear about ways to tackle pain without any medicines, particularly controlled substances.”
BMJ Case Rep. Published online February 12, 2018. Abstract
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