Difference between revisions of "Heat Acclimation Training"

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Heat acclimation training can improve performance in hot and cold conditions. It also helps protect against heat injury and is particularly important when training for spring races.  
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[[File:2013 Badwater.jpg|right|thumb|500px|I've done quite a bit of [[Running in the Heat]], from North Carolina's brutal summers, to winning the [[2010 Keys 100]] or pacing Chris Moon at the [[2013 Pacing Badwater 135| Badwater 135]].]]
==Introduction==
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Heat acclimation training can improve performance in hot and cold conditions. It also helps protect against heat injury and is particularly important when training for spring races. However, heat adaptation training can be dangerous, and care must be taken to avoid injury or death.  
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=Introduction=
 
Training for a spring race requires extra caution as you will have been training through the winter and be unprepared for warm conditions. While a spring race may be cool, there is also a risk of conditions that are warm enough (above 40f) to impair performance (see [Impact of Heat on Marathon Performance] for more details). Heat acclimation training, sometimes called heat adaptation training, can prepare you for these warmer conditions. This type of training is also valuable if you are traveling to a warmer climate for a race, or if you are training in the cool part of the day for a race in the warmer times. In addition, heat acclimation can improve cold weather performance. One study<ref name="performance"/> showed that heat acclimation improved performance in the cold by 6% and by 8% in heat.  
 
Training for a spring race requires extra caution as you will have been training through the winter and be unprepared for warm conditions. While a spring race may be cool, there is also a risk of conditions that are warm enough (above 40f) to impair performance (see [Impact of Heat on Marathon Performance] for more details). Heat acclimation training, sometimes called heat adaptation training, can prepare you for these warmer conditions. This type of training is also valuable if you are traveling to a warmer climate for a race, or if you are training in the cool part of the day for a race in the warmer times. In addition, heat acclimation can improve cold weather performance. One study<ref name="performance"/> showed that heat acclimation improved performance in the cold by 6% and by 8% in heat.  
==Background==
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=Background=
 
Exercise becomes harder as the temperature rises, with 40 degrees Fahrenheit being close to optimal. Exercise in the heat causes blood vessels in the skin to expand to help with cooling. The demands of the extra blood for cooling creates added stress on the cardiovascular system<ref name="Caso"/>.  The athlete's body will also sweat to produce cooling; in dry conditions evaporation of sweat provides 98% of cooling and in humid conditions 80%<ref name="Caso"/>. The loss of fluids due to sweating can lead to dehydration that also impairs performance. The impact of dehydration is in addition to the impact of the heat<ref name="Caso"/>.  
 
Exercise becomes harder as the temperature rises, with 40 degrees Fahrenheit being close to optimal. Exercise in the heat causes blood vessels in the skin to expand to help with cooling. The demands of the extra blood for cooling creates added stress on the cardiovascular system<ref name="Caso"/>.  The athlete's body will also sweat to produce cooling; in dry conditions evaporation of sweat provides 98% of cooling and in humid conditions 80%<ref name="Caso"/>. The loss of fluids due to sweating can lead to dehydration that also impairs performance. The impact of dehydration is in addition to the impact of the heat<ref name="Caso"/>.  
==Danger of Death==
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=Danger of Death=
 
A dedicated athlete can push themselves hard enough to raise their core temperature to dangerous levels, leading to heatstroke, which can be fatal<ref name="Binkley"/>. Heatstroke can be the result of prolonged exercise in hot conditions, but it can also be the '''result of shorter periods of high intensity exercise, especially in the untrained or overweight'''. It is vitally important that heat acclimation training is started gradually. You must become aware of how your body is adjusting to the heat, and to learn the warning signs of elevated core temperatures. Training in heat suits (see below) is especially dangerous, as the heat will not escape even after you collapse! Generally, an athlete reaches 'voluntary exhaustion' when their core temperature reaches about 39c/102f<ref name="Nielsen"/>, so never push hard with heat acclimation.  I would take it as a personal favor if you could avoid killing yourself.  
 
A dedicated athlete can push themselves hard enough to raise their core temperature to dangerous levels, leading to heatstroke, which can be fatal<ref name="Binkley"/>. Heatstroke can be the result of prolonged exercise in hot conditions, but it can also be the '''result of shorter periods of high intensity exercise, especially in the untrained or overweight'''. It is vitally important that heat acclimation training is started gradually. You must become aware of how your body is adjusting to the heat, and to learn the warning signs of elevated core temperatures. Training in heat suits (see below) is especially dangerous, as the heat will not escape even after you collapse! Generally, an athlete reaches 'voluntary exhaustion' when their core temperature reaches about 39c/102f<ref name="Nielsen"/>, so never push hard with heat acclimation.  I would take it as a personal favor if you could avoid killing yourself.  
==Symptoms of Heat Stroke==
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=Symptoms of Heat Stroke=
 
If you have any of the following symptoms while performing heat acclimation training, you should stop and cool off. Taking your internal temperature, ideally with an in-ear thermometer will allow you to double check if this is heat stroke. Heat stroke is caused by an internal temperature of >40.6 °C (105.1 °F), is extremely dangerous and can be fatal. The following can be symptoms of heat stroke:
 
If you have any of the following symptoms while performing heat acclimation training, you should stop and cool off. Taking your internal temperature, ideally with an in-ear thermometer will allow you to double check if this is heat stroke. Heat stroke is caused by an internal temperature of >40.6 °C (105.1 °F), is extremely dangerous and can be fatal. The following can be symptoms of heat stroke:
* [[Nausea]] or vomiting. These symptoms can occur before true heatstroke, as running makes digestion harder.  
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* [[Nausea]] or vomiting. These symptoms can occur before true heatstroke, as running makes digestion harder.
* Weakness. An unusual muscular weakness could be due to low blood sugar, but elevated core temperature also creates weakness.  
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* Weakness. An unusual muscular weakness could be due to low blood sugar, but elevated core temperature also creates weakness.
* Headache. This can also be caused by dehydration, or low blood sugar. Having had headaches from each of the three causes, I have found the type of headache is different. My limited experience is that a headache cased by heat is particularly painful and intense.  
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* Headache. This can also be caused by dehydration, or low blood sugar. Having had headaches from each of the three causes, I have found the type of headache is different. My limited experience is that a headache caused by heat is particularly painful and intense.
* Dizziness or confusion. This is a serious symptom that suggests either extremely low blood sugar or heatstroke.  
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* Dizziness or confusion. This is a serious symptom that suggests either extremely low blood sugar or heatstroke.
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* Panting. My personal experience is that when my core temperature rises, I start to breathe more rapidly. The panting can occur at rest in a sauna, or during exercise where my breathing rate is far deeper and faster than would be typical for the exercise intensity. This panting may be a reflect that attempts to cool the body in the same way as a panting dog. I find this is the first warning of problems and a sign that I have to reduce the heat stress rapidly.  
 
If you have any doubts, stop and check your temperature. Never do [[High Intensity Interval Training]] as part of heat acclimation; the intense work can spike your core temperature too high too quickly for you to recover.  
 
If you have any doubts, stop and check your temperature. Never do [[High Intensity Interval Training]] as part of heat acclimation; the intense work can spike your core temperature too high too quickly for you to recover.  
==Practical Heat Training==
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=Practical Heat Training=
 
The following advice should be used as guidance for heat acclimation training. Please use caution and common sense.  
 
The following advice should be used as guidance for heat acclimation training. Please use caution and common sense.  
* Like any new training routine, start off slowly and build up both duration and intensity over time.  
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* Like any new training routine, start off slowly and build up both duration and intensity over time.
* Be aware of how you are feeling and avoid pushing hard.  
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* Measure your core temperature, ideally with an in-ear infrared sensor<ref name="EricksonKirklin1993"/><ref name="DevrimKara2007"/><ref name="NimahBshesh2006"/>. I use a Braun ThermoScan and I've been pleased with it.
* Build up to exercising at 50% [[VO2max]] or above<ref name="Armstrong-1991"/>. 50% of [[VO2max]] is about 70% of maximum [[Heart Rate]]<ref name="swain"/> or "very slow running"<ref name="brianmac"/>.  
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* Beware a rapid rise in core temperature. Your temperature could continue to rise for a while after you stop exercising, which can be dangerous.
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* Aim for a core temperature of 38.5c/101.3f and do not let your core temperature go over 39.0c/102.2f. This is based on my review of heat adaptation studies shown below.
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* Your core temperature should rise over about 30 minutes to your target core temperature.
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* In addition to monitoring your core temperature, be aware of how you are feeling and avoid pushing too hard.
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* Build up to exercising at 50% [[VO2max]] or above<ref name="Armstrong-1991"/>. 50% of [[VO2max]] is about 70% of maximum [[Heart Rate]]<ref name="swain"/> or "very slow running"<ref name="brianmac"/>.
 
* Use gradually increasing periods from 30 to 100 minutes over 10 to 14 days<ref name="Shapiro"/>
 
* Use gradually increasing periods from 30 to 100 minutes over 10 to 14 days<ref name="Shapiro"/>
 
* Acclimation is fully developed after 7 to 14 days<ref name="Armstrong-1991"/>, but up to 75% of acclimation is reached after 5 days <ref name="Shapiro"/>.
 
* Acclimation is fully developed after 7 to 14 days<ref name="Armstrong-1991"/>, but up to 75% of acclimation is reached after 5 days <ref name="Shapiro"/>.
* Reduce your training load to compensate for the added stress of the heat. The heat can make you far more tiered than you would expect.  
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* Reduce your training load to compensate for the added stress of the heat. The heat can make you far more tired than you would expect.
 
* Consider alternating heat acclimation training and cooler training to preserve intensity<ref name="Noakes"/>
 
* Consider alternating heat acclimation training and cooler training to preserve intensity<ref name="Noakes"/>
 
* Training in a warmer environment is ideal, but creating a microclimate (see Heat Suit below) by overdressing also works<ref name="Noakes"/>
 
* Training in a warmer environment is ideal, but creating a microclimate (see Heat Suit below) by overdressing also works<ref name="Noakes"/>
* Exercise in heat produces better acclimation than passive heat<ref name="ismj"/>, but passive heat (sauna) following exercise can also be quite effective<ref name="postsauna"/>.  
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* Exercise in heat produces better acclimation than passive heat<ref name="ismj"/>, but passive heat (sauna) following exercise can also be quite effective<ref name="postsauna"/>.
==Fellrnr Heat Suit==
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* Maintain hydration levels, as dehydration may impair key adaptations, such as increased sweat rate<ref name="TraversNichols2020"/>.
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* Once gained, heat adaptation can be maintained for at least a month by training in the heat every five days<ref name="PryorPryor2019"/>. Without continued heat exposure, it's estimated that 2.5% of adaptation is lost each day<ref name="DaanenRacinais2017"/>.
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* Don't combine heat and altitude training as the altitude may impair heat adaptation<ref name="McCleaveSlattery2019"/>.
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=Fellrnr Heat Suit=
 
This 'heat suit' will allow for heat training even in quite cool conditions.  
 
This 'heat suit' will allow for heat training even in quite cool conditions.  
 
<table style="margin: 0px 10%; border: 1px solid #aaa; border-left: 10px solid #a00000; background: #fbfbfb;">
 
<table style="margin: 0px 10%; border: 1px solid #aaa; border-left: 10px solid #a00000; background: #fbfbfb;">
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<td class="mbox-image"> [[File:Ambox warning pn.svg|42px]]
 
<td class="mbox-image"> [[File:Ambox warning pn.svg|42px]]
 
<td class="mbox-text"><div>
 
<td class="mbox-text"><div>
This heat suit works by preventing the body cooling itself, so it increases the risk of heat stroke. If you overheat wearing this heat suit, you may not cool off after you collapse. Please be careful taking this approach, and start off with very low intensity exercise. Please be careful, as I've had some close calls using this technique and it is dangerous.  
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This heat suit works by preventing the body cooling itself, so it increases the risk of heat stroke. If you overheat wearing this heat suit, you may not cool off after you collapse. Please be careful taking this approach and start off with very low intensity exercise. Build up the duration and intensity very gradually and monitor for warning signs. Please be careful, as I've had some close calls using this technique and it is dangerous. See "Symptoms of Heat Stroke" above.  
 
</div>
 
</div>
 
</table>
 
</table>
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|[[File:HeatSuit4.JPG|none|thumb|x300px|A second waterproof or windproof layer that traps the body's heat in the insulation layer. In addition, wear hat, gloves and ideally a neck warmer or face mask.]]
 
|[[File:HeatSuit4.JPG|none|thumb|x300px|A second waterproof or windproof layer that traps the body's heat in the insulation layer. In addition, wear hat, gloves and ideally a neck warmer or face mask.]]
 
|}
 
|}
This combination will prevent the majority of heat escaping your body.
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This combination will prevent most of the heat escaping your body.
==Steam Shower==
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=Steam Shower=
 
[[File:SteamShower.JPG|none|thumb|300px|My steam shower, with a nice mosaic and a bench to relax on.]]
 
[[File:SteamShower.JPG|none|thumb|300px|My steam shower, with a nice mosaic and a bench to relax on.]]
I have a steam shower which I also use for heat acclimation, and it's wonderful. We put in the [http://www.amazon.com/Thermasol-PRO-240-240-Cubic-ProSeries-SmartSteam/dp/B00133Y9HS Thermasol Smart Steam]] system that was expensive, but well worth it. It provides rapid steam, with the initial steam after just a minute or so, and serious heat stress after about 5-10 minutes. If you turn it up, it will exceed your ability to cope quite quickly, or provide extended exposure at more moderate levels.  
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I have a steam shower which I also use for heat acclimation, and it's wonderful. We put in the [http://www.amazon.com/dp/B002YPUN2E Thermasol Smart Steam] system that was expensive, but well worth it. It provides rapid steam, with the initial steam after just a minute or so, and serious heat stress after about 5-10 minutes. If you turn it up, it will exceed your ability to cope quite quickly, or provide extended exposure at more moderate levels.  
==The Science of Heat Acclimation==
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=The Science of Heat Acclimation=
 
For those who want to know more details about heat acclimation, here is a summary of the scientific data.  
 
For those who want to know more details about heat acclimation, here is a summary of the scientific data.  
===Changes with heat acclimation===
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==Core Temperature for Heat Acclimation==
Heat acclimation will produce a number of benefits
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While most studies specified an ambient temperature and humidity, there are some that specified a target core temperature and time. This suggests that a core temperature of 38.5c/101.3f is a reasonable target and should be safe. You should keep your core temperature under 39.7c/103.4f and you should rapidly cool off if you hit that level. Your core temperature can continue to rise after you finish exercising, and if your core temperature goes too high you may be mentally impaired, so think ahead.
* Sweating occurs at lower temperatures<ref name="Noakes"/>
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* Target core temperature of 38.5c/101.3f for 90 minutes, with the target temperature reached over about 30 minutes<ref name="GarrettGoosens2009"/><ref name="GarrettCreasy2011"/><ref name="NealCorbett2016"/><ref name="PattersonStocks2004"/>.
* Sweat contains less electrolytes<ref name="Noakes2"/>
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* Target core temperature of just over 39.0c/102.2f, for 2x 50 minutes with 10-minute recovery<ref name="KuennenGillum2011"/> or for 2 hours<ref name="KirbyConvertino1986"/>
* Sweating is more profuse<ref name="Nielsen"/>
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* Target core temperature of 38.5c/101.3f or 39.0/102.2f for 90 minutes <ref name="GibsonMee2015"/> (similar results.)
* Increased cardiac output in hot conditions<ref name="Nielsen"/>
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* Passive heat exposure with core temperatures of 38.5c/101.3f to 39.0/102.2f for 2 hours<ref name="BeaudinWalsh2012"/>
* Reduced core temperature for given exercise time and intensity<ref name="Nielsen"/>
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* One study explicitly set a core temperature limit of 39.7c/103.4f<ref name="GibsonTurner2015"/> but didn't give the rationale for that cut off. This is close to heat stroke temperatures, and it's not clear why the cutoff was chosen to be so high.
* The athlete becomes psychologically prepared for heat stress. <ref name="ismj"/>
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* The diagnostic criteria for heat stroke is 40c/104f<ref name="Expert2016"/>/ Obviously this is a clear upper limit for core temperature. 
* The ability to consume and absorb more fluids (anecdotal evidence only)  
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==Changes with heat acclimation==
===Notes on Heat Acclimatization ===
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Heat acclimation will produce several benefits
* Younger runners do better in the heat than older runners but training can negate this<ref name="Armstrong-1991"/>
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* Increased blood volume<ref name="NielsenHales1993"/>.
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* Sweating occurs at lower temperatures<ref name="Noakes"/>.
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* Sweat contains less electrolytes<ref name="Noakes2"/>.
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* Sweating is more profuse<ref name="Nielsen"/>.
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* Increased cardiac output in hot conditions<ref name="Nielsen"/>.
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* Reduced core temperature for given exercise time and intensity<ref name="Nielsen"/>.
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* The athlete becomes psychologically prepared for heat stress. <ref name="ismj"/>.
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* The ability to consume and absorb more fluids (anecdotal evidence only).
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==Notes on Heat Acclimatization==
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* Younger runners do better in the heat than older runners, but training can negate this<ref name="Armstrong-1991"/>
 
* Acclimation is faster in fitter athletes<ref name="Armstrong-1991"/>
 
* Acclimation is faster in fitter athletes<ref name="Armstrong-1991"/>
 
* On return to a cool climate, acclimation lasts for about a week, then decays<ref name="Armstrong-1991"/>
 
* On return to a cool climate, acclimation lasts for about a week, then decays<ref name="Armstrong-1991"/>
 
* People who have always lived in hot climates are believed to have superior adaptation<ref name="Noakes"/>
 
* People who have always lived in hot climates are believed to have superior adaptation<ref name="Noakes"/>
==See Also==
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* A sauna will produce similar heart rate and cardiac stress as 60-100w of exercise<ref name="KetelhutKetelhut2019"/>. My experience matches that estimate for heart rate, though my respiration tends to be much higher as my body attempts to pant to cool off.
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=See Also=
 
* Running calculators
 
* Running calculators
 
** [[Running Heat Model]]
 
** [[Running Heat Model]]
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* [[Running in the Heat]]
 
* [[Running in the Heat]]
 
* [[Impact of Heat on Marathon Performance]]
 
* [[Impact of Heat on Marathon Performance]]
== references ==
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=References=
 
<references>
 
<references>
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<ref name="PattersonStocks2004">Mark J. Patterson, Jodie M. Stocks, Nigel A. S. Taylor, Sustained and generalized extracellular fluid expansion following heat acclimation, The Journal of Physiology, volume 559, issue 1, 2004, pages 327–334, ISSN [http://www.worldcat.org/issn/00223751 00223751], doi [http://dx.doi.org/10.1113/jphysiol.2004.063289 10.1113/jphysiol.2004.063289]</ref>
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<ref name="KirbyConvertino1986">C. R. Kirby, V. A. Convertino, Plasma aldosterone and sweat sodium concentrations after exercise and heat acclimation, Journal of Applied Physiology, volume 61, issue 3, 1986, pages 967–970, ISSN [http://www.worldcat.org/issn/8750-7587 8750-7587], doi [http://dx.doi.org/10.1152/jappl.1986.61.3.967 10.1152/jappl.1986.61.3.967]</ref>
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<ref name="Expert2016">Expert consensus on standardized diagnosis and treatment for heat stroke, Military Medical Research, volume 3, issue 1, 2016, ISSN [http://www.worldcat.org/issn/2054-9369 2054-9369], doi [http://dx.doi.org/10.1186/s40779-015-0056-z 10.1186/s40779-015-0056-z]</ref>
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<ref name="GibsonTurner2015">Oliver R. Gibson, Gareth Turner, James A. Tuttle, Lee Taylor, Peter W. Watt, Neil S. Maxwell, Heat acclimation attenuates physiological strain and the HSP72, but not HSP90α, mRNA response to acute normobaric hypoxia, Journal of Applied Physiology, volume 119, issue 8, 2015, pages 889–899, ISSN [http://www.worldcat.org/issn/8750-7587 8750-7587], doi [http://dx.doi.org/10.1152/japplphysiol.00332.2015 10.1152/japplphysiol.00332.2015]</ref>
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<ref name="BeaudinWalsh2012">Andrew E. Beaudin, Michael L. Walsh, Matthew D. White, Central chemoreflex ventilatory responses in humans following passive heat acclimation, Respiratory Physiology & Neurobiology, volume 180, issue 1, 2012, pages 97–104, ISSN [http://www.worldcat.org/issn/15699048 15699048], doi [http://dx.doi.org/10.1016/j.resp.2011.10.014 10.1016/j.resp.2011.10.014]</ref>
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<ref name="NealCorbett2016">R. A. Neal, J. Corbett, H. C. Massey, M. J. Tipton, Effect of short-term heat acclimation with permissive dehydration on thermoregulation and temperate exercise performance, Scandinavian Journal of Medicine & Science in Sports, volume 26, issue 8, 2016, pages 875–884, ISSN [http://www.worldcat.org/issn/09057188 09057188], doi [http://dx.doi.org/10.1111/sms.12526 10.1111/sms.12526]</ref>
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<ref name="GibsonMee2015">Oliver R. Gibson, Jessica A. Mee, James A. Tuttle, Lee Taylor, Peter W. Watt, Neil S. Maxwell, Isothermic and fixed intensity heat acclimation methods induce similar heat adaptation following short and long-term timescales, Journal of Thermal Biology, volume 49-50, 2015, pages 55–65, ISSN [http://www.worldcat.org/issn/03064565 03064565], doi [http://dx.doi.org/10.1016/j.jtherbio.2015.02.005 10.1016/j.jtherbio.2015.02.005]</ref>
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<ref name="GarrettCreasy2011">Andrew T. Garrett, Rob Creasy, Nancy J. Rehrer, Mark J. Patterson, James D. Cotter, Effectiveness of short-term heat acclimation for highly trained athletes, European Journal of Applied Physiology, volume 112, issue 5, 2011, pages 1827–1837, ISSN [http://www.worldcat.org/issn/1439-6319 1439-6319], doi [http://dx.doi.org/10.1007/s00421-011-2153-3 10.1007/s00421-011-2153-3]</ref>
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<ref name="GarrettGoosens2009">Andrew T. Garrett, Niels G. Goosens, Nancy G. Rehrer, Mark J. Patterson, James D. Cotter, Induction and decay of short-term heat acclimation, European Journal of Applied Physiology, volume 107, issue 6, 2009, pages 659–670, ISSN [http://www.worldcat.org/issn/1439-6319 1439-6319], doi [http://dx.doi.org/10.1007/s00421-009-1182-7 10.1007/s00421-009-1182-7]</ref>
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<ref name="KuennenGillum2011">Matthew Kuennen, Trevor Gillum, Karol Dokladny, Edward Bedrick, Suzanne Schneider, Pope Moseley, Thermotolerance and heat acclimation may share a common mechanism in humans, American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, volume 301, issue 2, 2011, pages R524–R533, ISSN [http://www.worldcat.org/issn/0363-6119 0363-6119], doi [http://dx.doi.org/10.1152/ajpregu.00039.2011 10.1152/ajpregu.00039.2011]</ref>
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<ref name="McCleaveSlattery2019">Erin L. McCleave, Katie M. Slattery, Rob Duffield, Philo U. Saunders, Avish P. Sharma, Stephen Crowcroft, Aaron J. Coutts, Impaired Heat Adaptation From Combined Heat Training and "Live High, Train Low" Hypoxia, International Journal of Sports Physiology and Performance, volume 14, issue 5, 2019, pages 635–643, ISSN [http://www.worldcat.org/issn/1555-0265 1555-0265], doi [http://dx.doi.org/10.1123/ijspp.2018-0399 10.1123/ijspp.2018-0399]</ref>
 
<ref name="Armstrong-1991"> LE. Armstrong, CM. Maresh, The induction and decay of heat acclimatisation in trained athletes., Sports Med, volume 12, issue 5, pages 302-12, Nov 1991, PMID [http://www.ncbi.nlm.nih.gov/pubmed/1763248 1763248]</ref>
 
<ref name="Armstrong-1991"> LE. Armstrong, CM. Maresh, The induction and decay of heat acclimatisation in trained athletes., Sports Med, volume 12, issue 5, pages 302-12, Nov 1991, PMID [http://www.ncbi.nlm.nih.gov/pubmed/1763248 1763248]</ref>
 
<ref name="Shapiro">  Y. Shapiro, D. Moran, Y. Epstein, Acclimatization strategies--preparing for exercise in the heat., Int J Sports Med, volume 19 Suppl 2, pages S161-3, Jun 1998, doi [http://dx.doi.org/10.1055/s-2007-971986 10.1055/s-2007-971986], PMID [http://www.ncbi.nlm.nih.gov/pubmed/9694427 9694427]</ref>
 
<ref name="Shapiro">  Y. Shapiro, D. Moran, Y. Epstein, Acclimatization strategies--preparing for exercise in the heat., Int J Sports Med, volume 19 Suppl 2, pages S161-3, Jun 1998, doi [http://dx.doi.org/10.1055/s-2007-971986 10.1055/s-2007-971986], PMID [http://www.ncbi.nlm.nih.gov/pubmed/9694427 9694427]</ref>
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<ref name="postsauna"> GS. Scoon, WG. Hopkins, S. Mayhew, JD. Cotter, Effect of post-exercise sauna bathing on the endurance performance of competitive male runners., J Sci Med Sport, volume 10, issue 4, pages 259-62, Aug 2007, doi [http://dx.doi.org/10.1016/j.jsams.2006.06.009 10.1016/j.jsams.2006.06.009], PMID [http://www.ncbi.nlm.nih.gov/pubmed/16877041 16877041]</ref>
 
<ref name="postsauna"> GS. Scoon, WG. Hopkins, S. Mayhew, JD. Cotter, Effect of post-exercise sauna bathing on the endurance performance of competitive male runners., J Sci Med Sport, volume 10, issue 4, pages 259-62, Aug 2007, doi [http://dx.doi.org/10.1016/j.jsams.2006.06.009 10.1016/j.jsams.2006.06.009], PMID [http://www.ncbi.nlm.nih.gov/pubmed/16877041 16877041]</ref>
 
<ref name="performance"> S. Lorenzo, JR. Halliwill, MN. Sawka, CT. Minson, Heat acclimation improves exercise performance., J Appl Physiol (1985), volume 109, issue 4, pages 1140-7, Oct 2010, doi [http://dx.doi.org/10.1152/japplphysiol.00495.2010 10.1152/japplphysiol.00495.2010], PMID [http://www.ncbi.nlm.nih.gov/pubmed/20724560 20724560]</ref>
 
<ref name="performance"> S. Lorenzo, JR. Halliwill, MN. Sawka, CT. Minson, Heat acclimation improves exercise performance., J Appl Physiol (1985), volume 109, issue 4, pages 1140-7, Oct 2010, doi [http://dx.doi.org/10.1152/japplphysiol.00495.2010 10.1152/japplphysiol.00495.2010], PMID [http://www.ncbi.nlm.nih.gov/pubmed/20724560 20724560]</ref>
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<ref name="NielsenHales1993">B Nielsen, J R Hales, S Strange, N J Christensen, J Warberg, B Saltin, Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment., The Journal of Physiology, volume 460, issue 1, 1993, pages 467–485, ISSN [http://www.worldcat.org/issn/00223751 00223751], doi [http://dx.doi.org/10.1113/jphysiol.1993.sp019482 10.1113/jphysiol.1993.sp019482]</ref>
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<ref name="KetelhutKetelhut2019">S. Ketelhut, R.G. Ketelhut, The blood pressure and heart rate during sauna bath correspond to cardiac responses during submaximal dynamic exercise, Complementary Therapies in Medicine, volume 44, 2019, pages 218–222, ISSN [http://www.worldcat.org/issn/09652299 09652299], doi [http://dx.doi.org/10.1016/j.ctim.2019.05.002 10.1016/j.ctim.2019.05.002]</ref>
 +
<ref name="PryorPryor2019">J. Luke Pryor, Riana R. Pryor, Lesley W. Vandermark, Elizabeth L. Adams, Rachel M. VanScoy, Douglas J. Casa, Larry E. Armstrong, Elaine C. Lee, Lindsay J. DiStefano, Jeffrey M. Anderson, Carl M. Maresh, Intermittent exercise-heat exposures and intense physical activity sustain heat acclimation adaptations, Journal of Science and Medicine in Sport, volume 22, issue 1, 2019, pages 117–122, ISSN [http://www.worldcat.org/issn/14402440 14402440], doi [http://dx.doi.org/10.1016/j.jsams.2018.06.009 10.1016/j.jsams.2018.06.009]</ref>
 +
<ref name="TraversNichols2020">Gavin Travers, David Nichols, Nathan Riding, José González-Alonso, Julien D. Périard, Heat Acclimation with Controlled Heart Rate, Medicine & Science in Sports & Exercise, 2020, pages 1, ISSN [http://www.worldcat.org/issn/0195-9131 0195-9131], doi [http://dx.doi.org/10.1249/MSS.0000000000002320 10.1249/MSS.0000000000002320]</ref>
 +
<ref name="DaanenRacinais2017">Hein A. M. Daanen, Sebastien Racinais, Julien D. Périard, Heat Acclimation Decay and Re-Induction: A Systematic Review and Meta-Analysis, Sports Medicine, volume 48, issue 2, 2017, pages 409–430, ISSN [http://www.worldcat.org/issn/0112-1642 0112-1642], doi [http://dx.doi.org/10.1007/s40279-017-0808-x 10.1007/s40279-017-0808-x]</ref>
 +
<ref name="EricksonKirklin1993">Roberta S. Erickson, Sharon K. Kirklin, Comparison of ear-based, bladder, oral, and axillary methods for core temperature measurement, Critical Care Medicine, volume 21, issue 10, 1993, pages 1528–1534, ISSN [http://www.worldcat.org/issn/0090-3493 0090-3493], doi [http://dx.doi.org/10.1097/00003246-199310000-00022 10.1097/00003246-199310000-00022]</ref>
 +
<ref name="NimahBshesh2006">Marianne M. Nimah, Khaled Bshesh, Janice D. Callahan, Brian R. Jacobs, Infrared tympanic thermometry in comparison with other temperature measurement techniques in febrile children, Pediatric Critical Care Medicine, volume 7, issue 1, 2006, pages 48–55, ISSN [http://www.worldcat.org/issn/1529-7535 1529-7535], doi [http://dx.doi.org/10.1097/01.PCC.0000185476.35550.B2 10.1097/01.PCC.0000185476.35550.B2]</ref>
 +
<ref name="DevrimKara2007">??lker Devrim, Ate?? Kara, Mehmet Ceyhan, Hasan Tezer, Ali Kerem Uluda??, Ali B??lent Cengiz, ??nci Yi??itkanl, G??lten Se??meer, Measurement Accuracy of Fever by Tympanic and Axillary Thermometry, Pediatric Emergency Care, volume 23, issue 1, 2007, pages 16–19, ISSN [http://www.worldcat.org/issn/0749-5161 0749-5161], doi [http://dx.doi.org/10.1097/PEC.0b013e31802c61e6 10.1097/PEC.0b013e31802c61e6]</ref>
 
</references>
 
</references>
 +
[[Category:Training]]
 +
[[Category:Science]]

Latest revision as of 07:07, 18 April 2020

I've done quite a bit of Running in the Heat, from North Carolina's brutal summers, to winning the 2010 Keys 100 or pacing Chris Moon at the Badwater 135.

Heat acclimation training can improve performance in hot and cold conditions. It also helps protect against heat injury and is particularly important when training for spring races. However, heat adaptation training can be dangerous, and care must be taken to avoid injury or death.

1 Introduction

Training for a spring race requires extra caution as you will have been training through the winter and be unprepared for warm conditions. While a spring race may be cool, there is also a risk of conditions that are warm enough (above 40f) to impair performance (see [Impact of Heat on Marathon Performance] for more details). Heat acclimation training, sometimes called heat adaptation training, can prepare you for these warmer conditions. This type of training is also valuable if you are traveling to a warmer climate for a race, or if you are training in the cool part of the day for a race in the warmer times. In addition, heat acclimation can improve cold weather performance. One study[1] showed that heat acclimation improved performance in the cold by 6% and by 8% in heat.

2 Background

Exercise becomes harder as the temperature rises, with 40 degrees Fahrenheit being close to optimal. Exercise in the heat causes blood vessels in the skin to expand to help with cooling. The demands of the extra blood for cooling creates added stress on the cardiovascular system[2]. The athlete's body will also sweat to produce cooling; in dry conditions evaporation of sweat provides 98% of cooling and in humid conditions 80%[2]. The loss of fluids due to sweating can lead to dehydration that also impairs performance. The impact of dehydration is in addition to the impact of the heat[2].

3 Danger of Death

A dedicated athlete can push themselves hard enough to raise their core temperature to dangerous levels, leading to heatstroke, which can be fatal[3]. Heatstroke can be the result of prolonged exercise in hot conditions, but it can also be the result of shorter periods of high intensity exercise, especially in the untrained or overweight. It is vitally important that heat acclimation training is started gradually. You must become aware of how your body is adjusting to the heat, and to learn the warning signs of elevated core temperatures. Training in heat suits (see below) is especially dangerous, as the heat will not escape even after you collapse! Generally, an athlete reaches 'voluntary exhaustion' when their core temperature reaches about 39c/102f[4], so never push hard with heat acclimation. I would take it as a personal favor if you could avoid killing yourself.

4 Symptoms of Heat Stroke

If you have any of the following symptoms while performing heat acclimation training, you should stop and cool off. Taking your internal temperature, ideally with an in-ear thermometer will allow you to double check if this is heat stroke. Heat stroke is caused by an internal temperature of >40.6 °C (105.1 °F), is extremely dangerous and can be fatal. The following can be symptoms of heat stroke:

  • Nausea or vomiting. These symptoms can occur before true heatstroke, as running makes digestion harder.
  • Weakness. An unusual muscular weakness could be due to low blood sugar, but elevated core temperature also creates weakness.
  • Headache. This can also be caused by dehydration, or low blood sugar. Having had headaches from each of the three causes, I have found the type of headache is different. My limited experience is that a headache caused by heat is particularly painful and intense.
  • Dizziness or confusion. This is a serious symptom that suggests either extremely low blood sugar or heatstroke.
  • Panting. My personal experience is that when my core temperature rises, I start to breathe more rapidly. The panting can occur at rest in a sauna, or during exercise where my breathing rate is far deeper and faster than would be typical for the exercise intensity. This panting may be a reflect that attempts to cool the body in the same way as a panting dog. I find this is the first warning of problems and a sign that I have to reduce the heat stress rapidly.

If you have any doubts, stop and check your temperature. Never do High Intensity Interval Training as part of heat acclimation; the intense work can spike your core temperature too high too quickly for you to recover.

5 Practical Heat Training

The following advice should be used as guidance for heat acclimation training. Please use caution and common sense.

  • Like any new training routine, start off slowly and build up both duration and intensity over time.
  • Measure your core temperature, ideally with an in-ear infrared sensor[5][6][7]. I use a Braun ThermoScan and I've been pleased with it.
  • Beware a rapid rise in core temperature. Your temperature could continue to rise for a while after you stop exercising, which can be dangerous.
  • Aim for a core temperature of 38.5c/101.3f and do not let your core temperature go over 39.0c/102.2f. This is based on my review of heat adaptation studies shown below.
  • Your core temperature should rise over about 30 minutes to your target core temperature.
  • In addition to monitoring your core temperature, be aware of how you are feeling and avoid pushing too hard.
  • Build up to exercising at 50% VO2max or above[8]. 50% of VO2max is about 70% of maximum Heart Rate[9] or "very slow running"[10].
  • Use gradually increasing periods from 30 to 100 minutes over 10 to 14 days[11]
  • Acclimation is fully developed after 7 to 14 days[8], but up to 75% of acclimation is reached after 5 days [11].
  • Reduce your training load to compensate for the added stress of the heat. The heat can make you far more tired than you would expect.
  • Consider alternating heat acclimation training and cooler training to preserve intensity[12]
  • Training in a warmer environment is ideal, but creating a microclimate (see Heat Suit below) by overdressing also works[12]
  • Exercise in heat produces better acclimation than passive heat[13], but passive heat (sauna) following exercise can also be quite effective[14].
  • Maintain hydration levels, as dehydration may impair key adaptations, such as increased sweat rate[15].
  • Once gained, heat adaptation can be maintained for at least a month by training in the heat every five days[16]. Without continued heat exposure, it's estimated that 2.5% of adaptation is lost each day[17].
  • Don't combine heat and altitude training as the altitude may impair heat adaptation[18].

6 Fellrnr Heat Suit

This 'heat suit' will allow for heat training even in quite cool conditions.

Ambox warning pn.svg

This heat suit works by preventing the body cooling itself, so it increases the risk of heat stroke. If you overheat wearing this heat suit, you may not cool off after you collapse. Please be careful taking this approach and start off with very low intensity exercise. Build up the duration and intensity very gradually and monitor for warning signs. Please be careful, as I've had some close calls using this technique and it is dangerous. See "Symptoms of Heat Stroke" above.

The key to the Fellrnr Heat Suit comes from two waterproof layers. A traditional sweat suit uses a single waterproof layer to trap your sweat and preventing it from cooling your body. The problem with the single layer is that the sweat soaks through any clothing and reduces the insulation. In cooler conditions the sweat soaked clothes can become chilly even with the waterproof layer. The Fellrnr Heat Suit approach traps the sweat away from the insulation layer, preventing this cooling effect. The Fellrnr Heat Suit has the following layers over both your top and legs.

A close fitting thermal layer near the skin. The purpose of this layer is to hold the sweat and keep your skin relatively comfortable. I wear a Halo hat to prevent the sweat getting in my eyes, plus a thin hat to prevent the waterproof hood sticking to my ears.
A waterproof layer that traps the sweat in the first thermal layer. Ideally this should be a non-breathable waterproof layer.
An insulation layer, such as fleece that prevents any heat escaping. Because it is trapped between the two waterproof layers, it never becomes wet.
A second waterproof or windproof layer that traps the body's heat in the insulation layer. In addition, wear hat, gloves and ideally a neck warmer or face mask.

This combination will prevent most of the heat escaping your body.

7 Steam Shower

My steam shower, with a nice mosaic and a bench to relax on.

I have a steam shower which I also use for heat acclimation, and it's wonderful. We put in the Thermasol Smart Steam system that was expensive, but well worth it. It provides rapid steam, with the initial steam after just a minute or so, and serious heat stress after about 5-10 minutes. If you turn it up, it will exceed your ability to cope quite quickly, or provide extended exposure at more moderate levels.

8 The Science of Heat Acclimation

For those who want to know more details about heat acclimation, here is a summary of the scientific data.

8.1 Core Temperature for Heat Acclimation

While most studies specified an ambient temperature and humidity, there are some that specified a target core temperature and time. This suggests that a core temperature of 38.5c/101.3f is a reasonable target and should be safe. You should keep your core temperature under 39.7c/103.4f and you should rapidly cool off if you hit that level. Your core temperature can continue to rise after you finish exercising, and if your core temperature goes too high you may be mentally impaired, so think ahead.

  • Target core temperature of 38.5c/101.3f for 90 minutes, with the target temperature reached over about 30 minutes[19][20][21][22].
  • Target core temperature of just over 39.0c/102.2f, for 2x 50 minutes with 10-minute recovery[23] or for 2 hours[24]
  • Target core temperature of 38.5c/101.3f or 39.0/102.2f for 90 minutes [25] (similar results.)
  • Passive heat exposure with core temperatures of 38.5c/101.3f to 39.0/102.2f for 2 hours[26]
  • One study explicitly set a core temperature limit of 39.7c/103.4f[27] but didn't give the rationale for that cut off. This is close to heat stroke temperatures, and it's not clear why the cutoff was chosen to be so high.
  • The diagnostic criteria for heat stroke is 40c/104f[28]/ Obviously this is a clear upper limit for core temperature.

8.2 Changes with heat acclimation

Heat acclimation will produce several benefits

  • Increased blood volume[29].
  • Sweating occurs at lower temperatures[12].
  • Sweat contains less electrolytes[30].
  • Sweating is more profuse[4].
  • Increased cardiac output in hot conditions[4].
  • Reduced core temperature for given exercise time and intensity[4].
  • The athlete becomes psychologically prepared for heat stress. [13].
  • The ability to consume and absorb more fluids (anecdotal evidence only).

8.3 Notes on Heat Acclimatization

  • Younger runners do better in the heat than older runners, but training can negate this[8]
  • Acclimation is faster in fitter athletes[8]
  • On return to a cool climate, acclimation lasts for about a week, then decays[8]
  • People who have always lived in hot climates are believed to have superior adaptation[12]
  • A sauna will produce similar heart rate and cardiac stress as 60-100w of exercise[31]. My experience matches that estimate for heart rate, though my respiration tends to be much higher as my body attempts to pant to cool off.

9 See Also

10 References

  1. S. Lorenzo, JR. Halliwill, MN. Sawka, CT. Minson, Heat acclimation improves exercise performance., J Appl Physiol (1985), volume 109, issue 4, pages 1140-7, Oct 2010, doi 10.1152/japplphysiol.00495.2010, PMID 20724560
  2. 2.0 2.1 2.2 DJ. Casa, Exercise in the heat. I. Fundamentals of thermal physiology, performance implications, and dehydration., J Athl Train, volume 34, issue 3, pages 246-52, Jul 1999, PMID 16558572
  3. HM. Binkley, J. Beckett, DJ. Casa, DM. Kleiner, PE. Plummer, National Athletic Trainers' Association Position Statement: Exertional Heat Illnesses., J Athl Train, volume 37, issue 3, pages 329-343, Sep 2002, PMID 12937591
  4. 4.0 4.1 4.2 4.3 B. Nielsen, JR. Hales, S. Strange, NJ. Christensen, J. Warberg, B. Saltin, Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment., J Physiol, volume 460, pages 467-85, Jan 1993, PMID 8487204
  5. Roberta S. Erickson, Sharon K. Kirklin, Comparison of ear-based, bladder, oral, and axillary methods for core temperature measurement, Critical Care Medicine, volume 21, issue 10, 1993, pages 1528–1534, ISSN 0090-3493, doi 10.1097/00003246-199310000-00022
  6. ??lker Devrim, Ate?? Kara, Mehmet Ceyhan, Hasan Tezer, Ali Kerem Uluda??, Ali B??lent Cengiz, ??nci Yi??itkanl, G??lten Se??meer, Measurement Accuracy of Fever by Tympanic and Axillary Thermometry, Pediatric Emergency Care, volume 23, issue 1, 2007, pages 16–19, ISSN 0749-5161, doi 10.1097/PEC.0b013e31802c61e6
  7. Marianne M. Nimah, Khaled Bshesh, Janice D. Callahan, Brian R. Jacobs, Infrared tympanic thermometry in comparison with other temperature measurement techniques in febrile children, Pediatric Critical Care Medicine, volume 7, issue 1, 2006, pages 48–55, ISSN 1529-7535, doi 10.1097/01.PCC.0000185476.35550.B2
  8. 8.0 8.1 8.2 8.3 8.4 LE. Armstrong, CM. Maresh, The induction and decay of heat acclimatisation in trained athletes., Sports Med, volume 12, issue 5, pages 302-12, Nov 1991, PMID 1763248
  9. DP. Swain, KS. Abernathy, CS. Smith, SJ. Lee, SA. Bunn, Target heart rates for the development of cardiorespiratory fitness., Med Sci Sports Exerc, volume 26, issue 1, pages 112-6, Jan 1994, PMID 8133731
  10. http://www.brianmac.co.uk/vo2max.htm
  11. 11.0 11.1 Y. Shapiro, D. Moran, Y. Epstein, Acclimatization strategies--preparing for exercise in the heat., Int J Sports Med, volume 19 Suppl 2, pages S161-3, Jun 1998, doi 10.1055/s-2007-971986, PMID 9694427
  12. 12.0 12.1 12.2 12.3 Timothy Noakes, Lore of running, date 2003, publisher Human Kinetics, location Champaign, IL, isbn 0-87322-959-2, pages 188
  13. 13.0 13.1 Taylor, Nigel AS, and James D. Cotter. "Heat adaptation: guidelines for the optimisation of human performance: review article." International SportMed Journal: The Extreme Environment and Sports Medicine: Part 2 7.1 (2006): p-33.
  14. GS. Scoon, WG. Hopkins, S. Mayhew, JD. Cotter, Effect of post-exercise sauna bathing on the endurance performance of competitive male runners., J Sci Med Sport, volume 10, issue 4, pages 259-62, Aug 2007, doi 10.1016/j.jsams.2006.06.009, PMID 16877041
  15. Gavin Travers, David Nichols, Nathan Riding, José González-Alonso, Julien D. Périard, Heat Acclimation with Controlled Heart Rate, Medicine & Science in Sports & Exercise, 2020, pages 1, ISSN 0195-9131, doi 10.1249/MSS.0000000000002320
  16. J. Luke Pryor, Riana R. Pryor, Lesley W. Vandermark, Elizabeth L. Adams, Rachel M. VanScoy, Douglas J. Casa, Larry E. Armstrong, Elaine C. Lee, Lindsay J. DiStefano, Jeffrey M. Anderson, Carl M. Maresh, Intermittent exercise-heat exposures and intense physical activity sustain heat acclimation adaptations, Journal of Science and Medicine in Sport, volume 22, issue 1, 2019, pages 117–122, ISSN 14402440, doi 10.1016/j.jsams.2018.06.009
  17. Hein A. M. Daanen, Sebastien Racinais, Julien D. Périard, Heat Acclimation Decay and Re-Induction: A Systematic Review and Meta-Analysis, Sports Medicine, volume 48, issue 2, 2017, pages 409–430, ISSN 0112-1642, doi 10.1007/s40279-017-0808-x
  18. Erin L. McCleave, Katie M. Slattery, Rob Duffield, Philo U. Saunders, Avish P. Sharma, Stephen Crowcroft, Aaron J. Coutts, Impaired Heat Adaptation From Combined Heat Training and "Live High, Train Low" Hypoxia, International Journal of Sports Physiology and Performance, volume 14, issue 5, 2019, pages 635–643, ISSN 1555-0265, doi 10.1123/ijspp.2018-0399
  19. Andrew T. Garrett, Niels G. Goosens, Nancy G. Rehrer, Mark J. Patterson, James D. Cotter, Induction and decay of short-term heat acclimation, European Journal of Applied Physiology, volume 107, issue 6, 2009, pages 659–670, ISSN 1439-6319, doi 10.1007/s00421-009-1182-7
  20. Andrew T. Garrett, Rob Creasy, Nancy J. Rehrer, Mark J. Patterson, James D. Cotter, Effectiveness of short-term heat acclimation for highly trained athletes, European Journal of Applied Physiology, volume 112, issue 5, 2011, pages 1827–1837, ISSN 1439-6319, doi 10.1007/s00421-011-2153-3
  21. R. A. Neal, J. Corbett, H. C. Massey, M. J. Tipton, Effect of short-term heat acclimation with permissive dehydration on thermoregulation and temperate exercise performance, Scandinavian Journal of Medicine & Science in Sports, volume 26, issue 8, 2016, pages 875–884, ISSN 09057188, doi 10.1111/sms.12526
  22. Mark J. Patterson, Jodie M. Stocks, Nigel A. S. Taylor, Sustained and generalized extracellular fluid expansion following heat acclimation, The Journal of Physiology, volume 559, issue 1, 2004, pages 327–334, ISSN 00223751, doi 10.1113/jphysiol.2004.063289
  23. Matthew Kuennen, Trevor Gillum, Karol Dokladny, Edward Bedrick, Suzanne Schneider, Pope Moseley, Thermotolerance and heat acclimation may share a common mechanism in humans, American Journal of Physiology-Regulatory, Integrative and Comparative Physiology, volume 301, issue 2, 2011, pages R524–R533, ISSN 0363-6119, doi 10.1152/ajpregu.00039.2011
  24. C. R. Kirby, V. A. Convertino, Plasma aldosterone and sweat sodium concentrations after exercise and heat acclimation, Journal of Applied Physiology, volume 61, issue 3, 1986, pages 967–970, ISSN 8750-7587, doi 10.1152/jappl.1986.61.3.967
  25. Oliver R. Gibson, Jessica A. Mee, James A. Tuttle, Lee Taylor, Peter W. Watt, Neil S. Maxwell, Isothermic and fixed intensity heat acclimation methods induce similar heat adaptation following short and long-term timescales, Journal of Thermal Biology, volume 49-50, 2015, pages 55–65, ISSN 03064565, doi 10.1016/j.jtherbio.2015.02.005
  26. Andrew E. Beaudin, Michael L. Walsh, Matthew D. White, Central chemoreflex ventilatory responses in humans following passive heat acclimation, Respiratory Physiology & Neurobiology, volume 180, issue 1, 2012, pages 97–104, ISSN 15699048, doi 10.1016/j.resp.2011.10.014
  27. Oliver R. Gibson, Gareth Turner, James A. Tuttle, Lee Taylor, Peter W. Watt, Neil S. Maxwell, Heat acclimation attenuates physiological strain and the HSP72, but not HSP90α, mRNA response to acute normobaric hypoxia, Journal of Applied Physiology, volume 119, issue 8, 2015, pages 889–899, ISSN 8750-7587, doi 10.1152/japplphysiol.00332.2015
  28. Expert consensus on standardized diagnosis and treatment for heat stroke, Military Medical Research, volume 3, issue 1, 2016, ISSN 2054-9369, doi 10.1186/s40779-015-0056-z
  29. B Nielsen, J R Hales, S Strange, N J Christensen, J Warberg, B Saltin, Human circulatory and thermoregulatory adaptations with heat acclimation and exercise in a hot, dry environment., The Journal of Physiology, volume 460, issue 1, 1993, pages 467–485, ISSN 00223751, doi 10.1113/jphysiol.1993.sp019482
  30. Timothy Noakes, Lore of running, date 2003, publisher Human Kinetics, location Champaign, IL, isbn 0-87322-959-2, pages 214
  31. S. Ketelhut, R.G. Ketelhut, The blood pressure and heart rate during sauna bath correspond to cardiac responses during submaximal dynamic exercise, Complementary Therapies in Medicine, volume 44, 2019, pages 218–222, ISSN 09652299, doi 10.1016/j.ctim.2019.05.002