Archive for category: Swim Anxiety

Among the many physiological responses to swimming in cold water that have been suspected of contributing to the high incidence of deaths in the swim portion of triathlon are three unusual entities: two of which are uncommon (less than 2% of the population), and one which is quite rare. Now, take a deep breath: no need to be afraid of either of these, but the medical terminology gets thick here.

The Long QT Syndrome/Torsades de Pointes.
The “LQTS” is an uncommon electrical disturbance of the heart that can be inherited or acquired, that can adversely affect the contractile functions of the heart. It is often referred to as a “channelopathy”, as it is characterized by abnormalities of the ion channels that pass ions (such as potassium, sodium, calcium and chloride) across the cell membranes in the process of depolarization and repolarization. When these channels operate abnormally, the repolarization of the cardiac process on an EKG is prolonged (the QRS complex, followed by the T wave), hence the name long QT interval. When the repolarization process is prolonged, the risk of re-entrant ventricular arrhythmias is increased; the most dangerous one is called torsade de pointes, so-called because it looks like twisting up and down spikes, an unstable cardiac rhythm which is usually symptomatic (dizziness, fainting or seizure) and can just as quickly revert back to normal or lead to a fatal arrhythmia called ventricular fibrillation. Symptomatic LQTS is more common after age 40, and is somewhat more common in women.

Most people who have the LQTS are unaware that they have this vulnerability, but it is relatively easy to screen for it, with 85% of them appearing on a routine EKG, and simple genetic blood testing can be considered in other suspected cases. If there is any family history of LQTS, of sudden death, or other genetic cardiac abnormality, a cardiac assessment including an EKG and possibly a stress test would be a good first step in most cases.

However, where LQTS gets interesting is when it is realized that the majority of LQTS incidence is acquired. According to the Mayo Clinic, more than 50 medications are known to lengthen the QT interval (many more are suspected): Antihistamines, decongestants, antidepressants, some antibiotics (macrolides and quinolones), cocaine, diuretics, heart medications, cholesterol-lowering medications, some diabetes medications, some antifungals and some antipsychotic drugs make the list. Electrolyte imbalances such as low levels of potassium, magnesium, and calcium are also common triggers of LQTS, and can be the result of poor nutrition, anorexia nervosa, and even a simple diarrheal illness.

Besides a pre-screening EKG, a medication review with a physician or pharmacist is useful to confirm that there is no risk from medication use and a consideration of a stress test to see if the LQTS or any cardiac ischemia develops under conditions of increasingly intense exercise. With both training and racing, be well nourished, and avoid discretionary medication use, especially on the same day of your activity.  And if you have been ill, potentially starting your event energy- or nutrient-depleted, dehydrated or exhausted, you should reconsider your participation until you are better.

Wolf-Parkinson-White (WPW) Syndrome.
This cardiac syndrome is a congenital cardiac disorder that is relatively common and usually asymptomatic; it is found in about 2-4 people per 1000 population and is more common in males—and it is suspected that many do not know that they have it. In WPW, there is an extra connecting pathway between the atria and the ventricles in the heart, that can at times “pre-excite” the ventricles to contract prematurely, leading to palpitations, tachycardia, dizziness, weakness, and shortness of breath. These symptoms can first appear at almost any age: The tachycardia can be provoked by exercise, and can provoke various secondary arrhythmias, including supraventricular tachycardia, atrial fibrillation, and atrial flutter – these in turn increase the risk of ventricular fibrillation and sudden death. WPW is usually easily detected on a routine EKG, and symptoms can be elucidated further in a cardiac stress test.

Becoming dizzy, short of breath and with low blood pressure while swimming can be disastrous, especially when at race pace, since it not easy to rest, recover, or get help quickly; being at risk of ventricular fibrillation because of an abnormal congenital electrical pathway as in the case of WPW while in open water is potentially lethal.

If you have had previous undiagnosed spells of dizziness, fainting, palpitations, or tachycardia, having a routine EKG is prudent. If you have further suspicions, then seeing a cardiologist for more testing would be useful to confirm the diagnosis. Once familiar with the diagnosis, there are several treatments available, including cardiac medications, or electrical cardioversion; if the WPW is persistent or recurrent, there is a definitive, potentially curative treatment: the destruction of the abnormal electrical pathway by radiofrequency catheter ablation.

Commotio Cordis.
This is a Latin term meaning “concussion of the heart”, and is a very unusual event caused by direct, blunt, non-penetrating trauma to the chest, perfectly timed to a vulnerable phase of the cardiac cycle (such as when ventricular polarization occurs), causing a spontaneous, sudden, fatal arrhythmia. It is suspected that the blunt force causes a significant transfer of kinetic energy to the heart, enough to disrupt the cardiac rhythm. Resuscitation of this event has been poor, even on land-based occurrences, such as with a baseball, a hockey puck or other blow striking the chest.

Although such a blow has never been witnessed in a mass start swimming event (frankly, it is hard for anything to be observed out in open water), open water swimmers need to be aware that being struck on the chest by another swimmer’s heel kick could, at least in theory, have lethal consequences. The solution: steer clear of other swimmers, especially when overtaking someone slower.

Photo Credit: Lambrini2010

Open water swimmers transitioning from the pool will have some new equipment variables: primarily this is about a wetsuit, but even goggles and a swim cap have to be reconsidered.

Wetsuit

Since most swimming in open water is colder than the average pool, a wetsuit becomes necessary for insulation, especially for longer swims, since the average body temperature of 37°C, is about 15-20° warmer than most Northern hemisphere swims. A wetsuit has other advantages as well: A wetsuit improves floatation, which is an added safety feature for open water swimmers, and it improves the body position. Most open water swimmers have faster swim times in open water due to wearing a wetsuit for this reason.

A wetsuit however ‘can’ have some potential problems, especially for newbie open water swimmers. There can be a feeling of chest and/or neck constriction to get comfortable with, and this may be worsened if the wetsuit is ill-fitting, which commonly happens when someone borrows a friend’s wetsuit. Given that a wetsuit creates a feeling of overall body constriction even before entering the water, it can contribute to swimmers feeling like they can’t breathe as easily. This feeling can cause a swimmer to become anxious and it can undermine an open water swim. Once you make a commitment to regular open water swimming, get a wetsuit properly fitted to your body—many sports shops and wetsuit companies will let you try them even in open water before purchase.

Another common area of restriction is in the shoulders, which, for some swimmers, starts to feel like a fight with your wetsuit with every forward reach or your arm. If your wetsuit is otherwise a good fit, two corrections can help: First, make sure your wetsuit is pulled up into your crotch, to allow as much neoprene as possible for the torso to maneuver in; and second, make sure the sleeves are pulled well up, to allow some redundancy in the shoulders. Try moving your shoulders before getting into the water, adjusting parts of the wetsuit as necessary. Once you have made your shoulder, knee area, and crotch adjustments, lean forward in a toe touching motion. This will provide a little more stretch in the critical areas of shoulder, crotch, and knees.

An old or excessively loose wetsuit can be problematic as well. When excessive leaks or rushes of cool (and especially cold) water continue to affect an open water swimmer, the process can drain the swimmer of energy fighting the cold, and cause more breathing difficulties due to the physiological reflex called the cold shock response. Get a wetsuit that fits, and replace it once the number of holes or zipper problems can no longer be repaired.

Goggles

Although goggles have essentially the same purpose as they do in the pool, there are some considerations here as well. First, consider using tinted goggles to reduce glare, reflections and direct sunshine when in open water. Second, make sure your goggles are good fitting, since a leaky set of goggles are more of a challenge to clear in open water than in a pool, where it is easy to stand, and readjust the goggles. Since all of us have different-shaped faces, a goggle choice that fits your face is personal, but once you find a brand that fits you well, stay with that brand, and always have a relatively new pair in the wings when your old ones are becoming stained, or scratched or easily fogged up. For larger swim events, you need to have reliable goggles. If you do find yourself with a collection of water in your goggles in the middle of an open water swim, roll onto your back, and just pull your goggles off your face to drain the water, and then push them gently back onto your face to reseal them.

Swim cap

There are two considerations in your choice of swim cap in open water for warmth and for visibility. For water temperatures above 20°C, an ordinary latex cap is usually adequate. Between 15-20°C, a silicone cap would provide improved insulation and can be pulled down to cover most of your forehead. Under 15°C, consider double capping with 2 silicone caps. Under 10°C, consider a neoprene cap. Latex caps tend to fit a bit larger so make sure you have a cap that fits your head properly. A sliding cap while you are swimming detracts from your focus and comfort.

Since swimmers are about 80% submerged, are often wearing black neoprene, and can be hard to see in even light swells by watercraft, a brightly-colored swim cap is important to enhance visibility.

Open Water Swim Buoy

In the last 10 years, the International Swim Hall of Fame in Florida has been promoting the use of the safety swim buoy, an inflated, beach ball-sized, dual-chambered, brightly colored marker than swimmers tow behind them to be seen and monitored more easily. Some versions can also carry personal items in a dry inner chamber for point-to-point swims, or to keep personal effects with you. Most swimming events in Asia have long made them mandatory, as has some in England and now in Canada. Although they cannot be sold as a personal floatation device, since they have the theoretical risk of suddenly deflating, they can nonetheless give an anxious swimmer something to hang on to, to rest or calm down. The only company selling these in Canada at this time is at getaswimbuddy.com.

It may seem counter-intuitive, but towing a small inflated open water swim buoy does not actually cause sufficient drag to slow you down. The bow wave that is created by your shoulders and upper body creates an eddy behind you, which actually pushes the buoy forward, virtually eliminating any possibility of drag. And because the short lease attachment allows the safety swim buoy to float over the bend of your knees, it is out of the way of the finish of your hand at the end of your arm stroke; and since it does not reach past the upper calves, your kick is also unaffected.

As safety concerns continue to ramp up in the coming years in the sport of open water swimming, expect to see the personal swim buoy as a fixture in both training and races.

Photo Credit: w:hs