Rebecca L. Stearns

National athletic trainers' association position statement: preventing sudden death in sports

OBJECTIVE To present recommendations for the prevention and screening, recognition, and treatment of the most common conditions resulting in sudden death in organized sports. BACKGROUND Cardiac conditions, head injuries, neck injuries, exertional heat stroke, exertional sickling, asthma, and other factors (eg, lightning, diabetes) are the most common causes of death in athletes. RECOMMENDATIONS These guidelines are intended to provide relevant information on preventing sudden death in sports and to give specific recommendations for certified athletic trainers and others participating in athletic health care.

Influence of Hydration on Physiological Function and Performance During Trail Running in the Heat

CONTEXT Authors of most field studies have not observed decrements in physiologic function and performance with increases in dehydration, although authors of well-controlled laboratory studies have consistently reported this relationship. Investigators in these field studies did not control exercise intensity, a known modulator of body core temperature. OBJECTIVE To directly examine the effect of moderate water deficit on the physiologic responses to various exercise intensities in a warm outdoor setting. DESIGN Semirandomized, crossover design. SETTING Field setting. PATIENTS OR OTHER PARTICIPANTS Seventeen distance runners (9 men, 8 women; age = 27 +/- 7 years, height = 171 +/- 9 cm, mass = 64.2 +/- 9.0 kg, body fat = 14.6% +/- 5.5%). INTERVENTION(S) Participants completed four 12-km runs (consisting of three 4-km loops) in the heat (average wet bulb globe temperature = 26.5 degrees C): (1) a hydrated, race trial (HYR), (2) a dehydrated, race trial (DYR), (3) a hydrated, submaximal trial (HYS), and (4) a dehydrated, submaximal trial (DYS). MAIN OUTCOME MEASURE(S) For DYR and DYS trials, dehydration was measured by body mass loss. In the submaximal trials, participants ran at a moderate pace that was matched by having them speed up or slow down based on pace feedback provided by researchers. Intestinal temperature was recorded using ingestible thermistors, and participants wore heart rate monitors to measure heart rate. RESULTS Body mass loss in relation to a 3-day baseline was greater for the DYR (-4.30% +/- 1.25%) and DYS trials (-4.59% +/- 1.32%) than for the HYR (-2.05% +/- 1.09%) and HYS (-2.0% +/- 1.24%) trials postrun (P < .001). Participants ran faster for the HYR (53.15 +/- 6.05 minutes) than for the DYR (55.7 +/- 7.45 minutes; P < .01), but speed was similar for HYS (59.57 +/- 5.31 minutes) and DYS (59.44 +/- 5.44 minutes; P > .05). Intestinal temperature immediately postrun was greater for DYR than for HYR (P < .05), the only significant difference. Intestinal temperature was greater for DYS than for HYS postloop 2, postrun, and at 10 and 20 minutes postrun (all: P < .001). Intestinal temperature and heart rate were 0.22 degrees C and 6 beats/min higher, respectively, for every additional 1% body mass loss during the DYS trial compared with the HYS trial. CONCLUSIONS A small decrement in hydration status impaired physiologic function and performance while trail running in the heat.

The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations.

Douglas J. Casa, PhD, ATC, FNATA, FACSM (Chair)*†; Jon Almquist, VATL, ATC*; Scott A. Anderson, ATC*; Lindsay Baker, PhD‡; Michael F. Bergeron, PhD, FACSM§; Brian Biagioli, EdD||; Barry Boden, MD¶; Joel S. Brenner, MD, MPH, FAAP#; Michael Carroll, MEd, LAT, ATC*; Bob Colgate**; Larry Cooper, MS, LAT, ATC*; Ron Courson, PT, ATC, NREMT-I, CSCS*; David Csillan, MS, LAT, ATC*; Julie K. DeMartini, MA, ATC†; Jonathan A. Drezner, MD††; Tim Erickson, CAA‡‡; Michael S. Ferrara, PhD, ATC, FNATA*; Steven J. Fleck, PhD, CSCS, FNSCA, FACSM§§; Rob Franks, DO, FAOASM||||; Kevin M. Guskiewicz, PhD, ATC, FNATA, FACSM*; William R. Holcomb, PhD, LAT, ATC, CSCS*D, FNATA, FNSCA§§; Robert A. Huggins, MEd, ATC†; Rebecca M. Lopez, PhD, ATC, CSCS†; Thom Mayer, MD, FACEP¶¶; Patrick McHenry, MA, CSCS*D, RSCC§§; Jason P. Mihalik, PhD, CAT(C), ATC##; Francis G. O’Connor, MD, MPH, FACSM††; Kelly D. Pagnotta, MA, ATC, PES†; Riana R. Pryor, MS, ATC†; John Reynolds, MS, VATL, ATC*; Rebecca L. Stearns, PhD, ATC†; Verle Valentine, MD††

Comparison of Body Cooling Methods on Physiological and Perceptual Measures of Mildly Hyperthermic Athletes

DeMartini, JK, Ranalli, GF, Casa, DJ, Lopez, RM, Ganio, MS, Stearns, RL, McDermott, BP, Armstrong, LE, and Maresh, CM. Comparison of body cooling methods on physiological and perceptual measures of mildly hyperthermic athletes. J Strength Cond Res 25(8): 2065-2074, 2011—Hyperthermia is common among athletes and in a variety of environments. The purpose of this study was to evaluate the effectiveness of cooling methods on core body temperature, heart rate (HR), and perceptual readings in individuals after exercise. Sixteen subjects (age: 24 ± 6 years, height: 182 ± 7 cm, weight: 74.03 ± 9.17 kg, and body fat: 17.08 ± 6.23%) completed 10 exercise sessions in warm conditions (WBGT: 26.64 ± 4.71°C) followed by body cooling by 10 different methods. Cooling methods included cold water immersion (CWI), shade, Port-a-Cool® (FAN), Emergency Cold Containment System® (ECCS), Rehab. Hood® (HOOD), Game Ready Active Cooling Vest™ (GRV), Nike Ice Vest™ (NIV), ice buckets (IBs), and ice towels (IT). These cooling modes were compared with a control (SUN). Rectal temperature (Tre), HR, thermal sensation, thirst sensation, and a 56-question Environmental Symptoms Questionnaire (ESQ) were used to assess physiological and perceptual data. Average Tre after exercise across all trials was 38.73 ± 0.12°C. After 10 minutes of cooling, CWI (−0.65 ± 0.29°C), ECCS (−0.68 ± 0.24°C), and IB (−0.74 ± 0.34°C) had significantly (p < 0.006) greater decreases in Tre compared with that in SUN (−0.42 ± 0.15°C). The HR after 10 minutes of cooling was significantly (p < 0.006) lower for CWI (82 ± 15 b·min−1), ECCS (87 ± 14 b·min−1), and IT (84 ± 15 b·min−1) when compared with SUN (101 ± 15 b·min−1). The thermal sensation between modalities was all significantly (p < 0.006) lower (CWI: 1.5 ± 0.5; Fan: 3.0 ± 1.0; ECCS: 4.5 ± 1.0; Hood: 4.5 ± 0.5; GRV: 4.0 ± 0.5; NIV: 4.5 ± 1.0; IB: 4.0 ± 1.0; IT: 3.0 ± 1.0) when compared with SUN (5.5 ± 0.5), except for Shade (5.0 ± 1.0). There were no significant differences (p > 0.006) in thirst sensation between modalities. The ESQ scores were significantly (p < 0.006) lower for CWI (1 ± 6), Fan (4 ± 5), and IT (3 ± 8) compared with that for SUN (13 ± 12). In conclusion, when athletes experience mild hyperthermia, CWI, ECCS, and IB resulted in a significantly greater decrease in Tre. These cooling strategies are recommended to decrease Tre during a brief recovery period between exercise bouts.

Effectiveness of cold water immersion in the treatment of exertional heat stroke at the Falmouth Road Race.

PURPOSE This study aimed to investigate the effectiveness (speed of cooling and survival rates) of cold water immersion (CWI) in the treatment of patients with exertional heat stroke (EHS). Secondly, this study aimed to compare cooling rates on the basis of gender, age, and initial rectal temperature (Tr). METHODS Eighteen years of finish line medical tent patient records were obtained from the exertional heat illness treatment area at the Falmouth Road Race. Study participants included patients with EHS who were treated with CWI in the medical tent. The number of EHS cases was recorded for each year, and incidence was established on the basis of the number of finishers. Overall cooling rate and differences between initial Tr, age, and sex were evaluated. RESULTS A total of 274 cases of EHS was observed over the 18 yr of collected data. A mean of 15.2 ± 13.0 EHS cases per year was recorded, with an overall incidence of 2.13 ± 1.62 EHS cases per 1000 finishers. The average initial Tr was 41.44°C ± 0.63°C, and the average cooling rate for patients with EHS was 0.22°C·min ± 0.11°C·min. CWI resulted in a 100% survival rate for all patients with EHS. No significant interactions between cooling rate and initial Tr (P = 0.778), sex (P = 0.89), or age (P = 0.70) were observed. CONCLUSIONS CWI was found to effectively treat all cases of EHS observed in this study. CWI provided similar treatment outcomes in all patients, with no significant differences noted on the basis of initial Tr, age, or sex. On the basis of the 100% survival rate from EHS in this large cohort, it is recommended that immediate (on site) CWI be implemented for the treatment of EHS.

Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity.

Lopez, RM, Casa, DJ, Jensen, KA, DeMartini, JK, Pagnotta, KD, Ruiz, RC, Roti, MW, Stearns, RL, Armstrong, LE, and Maresh, CM. Examining the influence of hydration status on physiological responses and running speed during trail running in the heat with controlled exercise intensity. J Strength Cond Res 25(11): 2944–2954, 2011—The purpose of this study was to determine the effects of dehydration at a controlled relative intensity on physiological responses and trail running speed. Using a randomized, controlled crossover design in a field setting, 14 male and female competitive, endurance runners aged 30 ± 10.4 years completed 2 (hydrated [HY] and dehydrated [DHY]) submaximal trail runs in a warm environment. For each trial, the subjects ran 3 laps (4 km per lap) on trails with 4-minute rests between laps. The DHY were fluid restricted 22 hours before the trial and during the run. The HY arrived euhydrated and were given water during rest breaks. The subjects ran at a moderate pace matched between trials by providing pacing feedback via heart rate (HR) throughout the second trial. Gastrointestinal temperature (TGI), HR, running time, and ratings of perceived exertion (RPE) were monitored. Percent body mass (BM) losses were significantly greater for DHY pretrial (−1.65 ± 1.34%) than for HY (−0.03 ± 1.28%; p < 0.001). Posttrial, DHY BM losses (−3.64 ± 1.33%) were higher than those for HY (−1.38 ± 1.43%; p < 0.001). A significant main effect of TGI (p = 0.009) was found with DHY having higher TGI postrun (DHY: 39.09 ± 0.45°C, HY: 38.71 ± 0.45°C; p = 0.030), 10 minutes post (DHY: 38.85 ± 0.48°C, HY: 38.46 ± 0.46°C; p = 0.009) and 30 minutes post (DHY: 38.18 ± 0.41°C, HY: 37.60 ± 0.25°C; p = 0.000). The DHY had slower run times after lap 2 (p = 0.019) and lap 3 (p = 0.025). The DHY subjects completed the 12-km run 99 seconds slower than the HY (p = 0.027) subjects did. The RPE in DHY was slightly higher than that in HY immediately postrun (p = 0.055). Controlling relative intensity in hypohydrated runners resulted in slower run times, greater perceived effort, and elevated TGI, which is clinically meaningful for athletes using HR as a gauge for exercise effort and performance.

Effects of ingesting protein in combination with carbohydrate during exercise on endurance performance: a systematic review with meta-analysis.

Stearns, RL, Emmanuel, H, Volek, JS, and Casa, DJ. Effects of ingesting protein in combination with carbohydrate during exercise on endurance performance: a systematic review with meta-analysis. J Strength Cond Res 24(8): 2192-2202, 2010-Coingestion of protein with carbohydrate has been shown to enhance muscle recovery, particularly after intense bouts of exercise. However, performance benefits of ingesting a protein-carbohydrate drink during exercise remains unclear. Therefore, we used a systematic review with meta-analysis to examine the influence of protein ingestion during exercise on subsequent endurance performance. Eleven qualifying studies were included that contained 3 time-trial and 8 time-to-exhaustion cycling protocols. Only 3 of these studies controlled for caloric content and contained an isocaloric trial. Of the 11, 4 reported significant differences between a control and protein trial; however, none of these were isocaloric studies. The 3 time-trial protocols showed no significant improvement with protein. The meta-analysis of the time-trial studies revealed no significant overall effect (p = 0.73), whereas meta-analysis of time-to-exhaustion studies revealed a significant effect (p = 0.008). Of the time-to-exhaustion trials, the isocaloric studies found no significant effect (p = 0.71), whereas the isocarbohydrate studies revealed a significant effect (p = 0.05). The average percent improvement with ingestion of protein was 9.0%. The isocarbohydrate studies reported an improvement of 10.5%, whereas the isocaloric studies revealed a 3.4% improvement. We conclude that compared to carbohydrate alone, coingestion of protein and carbohydrate during exercise demonstrated an ergogenic effect on endurance performance when assessed by time to exhaustion and also where supplements were matched for carbohydrate (isocarbohydrate). Thus, the ergogenic effect of protein seen in isocarbohydrate studies may be because of a generic effect of adding calories (fuel) as opposed to a unique benefit of protein. Further research is warranted before a clear conclusion can be drawn.

Environmental conditions and the occurrence of exertional heat illnesses and exertional heat stroke at the Falmouth Road Race.

CONTEXT The Falmouth Road Race is unique because of the environmental conditions and relatively short distance, which allow runners to maintain a high intensity for the duration of the event. Therefore, the occurrence of exertional heat illnesses (EHIs), especially exertional heat stroke (EHS), is 10 times higher than in other races. OBJECTIVE To summarize the occurrence and relationship of EHI and environmental conditions at the Falmouth Road Race. DESIGN Descriptive epidemiologic study. SETTING An 11.3-km (7-mile) road race in Falmouth, Massachusetts. PATIENTS OR OTHER PARTICIPANTS Runners who sustained an EHI while participating in the Falmouth Road Race. MAIN OUTCOME MEASURE(S) We obtained 18 years of medical records and environmental conditions from the Falmouth Road Race and documented the incidence of EHI, specifically EHS, as related to ambient temperature (Tamb), relative humidity, and heat index (HI). RESULTS Average Tamb, relative humidity, and HI were 23.3 ± 2.5°C, 70 ± 16%, and 24 ± 3.5°C, respectively. Of the 393 total EHI cases observed, EHS accounted for 274 (70%). An average of 15.2 ± 13.0 EHS cases occurred each year; the incidence was 2.13 ± 1.62 cases per 1000 runners. Regression analysis revealed a relationship between the occurrence of both EHI and EHS and Tamb (R(2) = 0.71, P = .001, and R(2) = 0.65, P = .001, respectively) and HI (R(2) = 0.76, P < .001, and R(2) = 0.74, P < .001, respectively). Occurrences of EHS (24.2 ± 15.5 cases versus 9.3 ± 4.3 cases) and EHI (32.3 ± 16.3 versus 13.0 ± 4.9 cases) were higher when Tamb and HI were high compared with when Tamb and HI were low. CONCLUSIONS Because of the environmental conditions and race duration, the Falmouth Road Race provides a unique setting for a high incidence of EHS. A clear relationship exists between environmental stress, especially as measured by Tamb and HI, and the occurrence of EHS or other EHI. Proper prevention and treatment strategies should be used during periods of high environmental temperatures as the likelihood of runners experiencing EHS is exacerbated in these harsh conditions.

Nutritional, physiological, and perceptual responses during a summer ultraendurance cycling event.

Armstrong, LE, Casa, DJ, Emmanuel, H, Ganio, MS, Klau, JF, Lee, EC, Maresh, CM, McDermott, BP, Stearns, RL, Vingren, JL, Wingo, JE, Williamson, KH, and Yamamoto, LM. Nutritional, physiological, and perceptual responses during a summer ultraendurance cycling event. J Strength Cond Res 26(2): 307–318, 2012—Despite the rapid growth of mass participation road cycling, little is known about the dietary, metabolic, and behavioral responses of ultraendurance cyclists. This investigation describes physiological responses, perceptual ratings, energy balance, and macronutrient intake of 42 men (mean ± SD; age, 38 ± 6 years; height, 179.7 ± 7.1 cm; body mass, 85.85 ± 14.79 kg) and 6 women (age, 41 ± 4 years; height, 168.0 ± 2.9 cm; body mass, 67.32 ± 7.21 kg) during a summer 164-km road cycling event. Measurements were recorded 1 day before, and on the Event Day (10.5 hours) at the start (0 km), at 2 aid stations (52 and 97 km), and at the finish line (164 km). The ambient temperature was >39.0° C during the final 2 hours of exercise. The mean finish times for men (9.1 ± 1.2 hours) and women (9.0 ± 0.2 hours) were similar, as were mean gastrointestinal temperature (TGI), 4 hydration biomarkers, and 5 perceptual (e.g., thermal, thirst, pain) ratings. Male cyclists consumed enough fluids on the Event Day (5.91 ± 2.38 L; 49% water) to maintain body mass within 0.76 kg, start to finish, despite a sweat loss of 1.13 ± 0.54 L·h−1 and calculated energy expenditure of 3,115 kcal·10.5·h−1. However, men voluntarily underconsumed food energy (deficit of 2,594 kcal, 10.9 MJ) and specific macronutrients (carbohydrates, 106 ± 48 g; protein, 8 ± 7 g; and sodium, 852 ± 531 mg) between 0530 and 1400 hours. Also, a few men exhibited extreme final values (i.e., urine specific gravity of 1.035–1.038, n = 5; body mass loss >4 kg, n = 2; TGI, 39.4 and 40.2°C). We concluded that these findings provide information regarding energy consumption, macronutrient intake, hydration status, and the physiological stresses that are unique to ultraendurance exercise in a hot environment.

Cold-water dousing with ice massage to treat exertional heat stroke: a case series.

INTRODUCTION We sought to determine the rate of cooling via a novel water ice therapy (WIT) as an alternative to cold-water immersion for the acute treatment of exertional heat stroke (EHS). METHODS Observations were made at the 2004-2008 Marine Corps Marathons (mean +/- SD: 16.3 +/- 4.9 degrees C dry bulb, 32 +/- 6% RH). Nine (seven men, two women) EHS patients (33 +/- 6 yr of age; 268 +/- 54 min average race time for six who finished) were observed during on-site treatment. Patients were treated while lying supine on a porous stretcher resting on a tub filled with cold water (approximately 10-12 degrees C). Medical personnel monitored T(re), doused the patient with water and massaged major muscle groups with ice bags until T(re) decreased to 38.9 degrees C. Patients were not immersed in water. Serial T(re) and time were used to calculate cooling rates. RESULTS Final T(re) (39.12 +/- 0.63 degrees C) was significantly lower than initial T(re) (41.43 +/- 0.71 degrees C, P < 0.05). Cooling rates were 0.13 +/- 0.04 degrees C min(-1). The decrease in T(re) for the initial 6 min of WIT (0.38 +/- 0.13 degrees C) was significantly less than for the subsequent 6-min time period (1.31 +/- 0.34 degrees C, P < 0.001). Cooling rates for these time periods were significantly different (0.06 +/- 0.02 degrees C x min(-1) and 0.22 +/- 0.06 degrees C x min(-1), respectively, P < 0.05). Initial T(re) was not correlated with overall cooling rate (r = 0.434, P = 0.244), or total cooling time required (17 +/- 4 min; r = 0.207, P = 0.593). Survival rate was 100%. CONCLUSION WIT provided cooling rates that were 70% as effective as those published for cold-water immersion with 8 degrees C water (0.19 degrees C x min(-1)) and resulted in 100% patient survival.