The Heat is On

You can lead them to water, but even if you could force them to drink, that’s only the first step in keeping your athletes free from heat illness.

By Guillermo Metz

Guillermo Metz is an Associate Editor at Training & Conditioning.

Training & Conditioning, 13.5, July/August 2003, http://www.momentummedia.com/articles/tc/tc1305/heat.htm

Today’s forecast: Hot and humid. Ozone at dangerous levels. Limit outdoor activities as much as possible.

Unfortunately, that’s the weather report that often coincides with preseason practice for fall sports. Limiting outdoor activities usually isn’t a realistic option, so you have to take other steps to keep your student-athletes safe.

Football athletes are the hardest hit—a full uniform including pads and helmet limits sweat evaporation from more than 60 percent of the body—which is why the NCAA recently revised its rules for these critical first days of preseason camp. But the conditions can be nearly as brutal for soccer, field hockey, and cross country athletes, especially if summer jobs have kept them indoors with air conditioning. And if you think it’s solely a problem for fall sports, try traveling from Maine to Miami for an early spring baseball game.

There are several things you can do to make the adjustment easier for your athletes, however. Preventing heat illness entails educating athletes and coaches about the dangers of high heat and humidity and the importance of acclimatization, having strategies in place to keep athletes hydrated, and spotting minor problems before they become major.

Leading Them To Drink
Most athletes have a pretty good sense of how to prevent heat illness, but that doesn’t mean they always do what’s best for them. “To me it’s kind of like drugs,” says Paul Mock, ATC, Head Athletic Trainer at Mississippi State University. “Everyone knows they shouldn’t take drugs. We’ve all had that preached to us. But some people are still willing to try them.

“I think the kids understand the basic dangers of heat illness,” he continues. “The key is to make athletes more aware of, and responsible for, their personal condition.”

“The hardest thing is getting them to understand how important it is to follow our guidelines,” agrees Joan Reed, MAT, ATC, CSCS, Assistant Director of Athletics and Recreation for Sports Medicine at Emory University. “We use several methods to get the information to them so that it really sticks. When the freshmen come in, we show them a video on the importance of hydration to performance. We also put up posters in the training room.”

Many athletic trainers also use urine and weight charts to bring the point home. “When someone told me about the urine chart, I thought it was a good idea, but I wondered if it would really work,” says Mock. “I’ve been surprised by how many of our guys come in and say, ‘Well, my pee was this color right here.’ It’s one thing to tell them to drink eight glasses of water, it’s another thing to show them what happens when they don’t.”

And even though it may seem simple, don’t assume athletes know what to do with a weight chart. Spell it out for them: Losing two to three percent of body weight during exercise can be compensated for with plenty of fluids; a weight loss of four to six percent may require a reduction in training; and anyone who loses more than six percent needs to see you or a doctor. In order to make up the lost weight, they’ll need to drink eight ounces of water for each pound of body weight lost during exercise.

“We have a scale readily available in the training room so they can weigh themselves before and after they work out,” says Matt Walser, MS, LMT, ATC/L, Associate Head Football Athletic Trainer at the University of Florida. “And we talk to them about what those numbers mean in terms of the water they’ve lost over the course of that workout. We’ve been very successful educating our athletes that way.”

“We try to get people to hydrate earlier in the day,” Mock adds. “They don’t just drink an extra glass right before practice, they start drinking early in the morning. To me, that’s where the pee-color chart helps. Even when they feel fine, it makes them see they may have to push more fluids down.”

Many schools have a simple policy to get athletes in the mindset of drinking all day long. “We hand out water bottles to all the athletes when they first get here,” says Reed. “And we tell them to carry that water bottle around with them all day.”

Gary Diehm, MS, ATC/L, Head Athletic Trainer at Midwestern State University, gets a sponsor to pay for his athletes’ water bottles. And to keep student-athletes away from sodas, he has the cafeteria staff switch some machines. “During fall camp, they turn the cola machine off and put in a machine that dispenses sports drinks,” he says. “That was a really simple thing to do and it’s made a big difference.”

Size can also make a difference. “Big cups was one of the best moves we made,” says Walser. “We went from a small cafeteria cup to big 32-ounce Styrofoam cups, which promote drinking.”

Many athletic trainers also stress the importance of a good diet. “One of our athletic trainers meets with athletes at various points during the preseason to talk about what to eat,” says Jack Marucci, MA, ATC, Director of Athletic Training at LSU. “During two-a-days, she tells them to cut back on fats, and talks about the importance of the morning meal. She stresses the importance of simply eating. Because of the heat, a lot of these kids don’t feel like eating when they’re at camp.”

“The training table helps with recovery, and we also have a lot of foods on there that help with hydration—we’ve really been pushing a lot of fruits on our athletes,” says Walser. “It’s also important to consider when they eat. We want them eating within an hour of working out, because that’s when the body needs to start repairing itself.”

Reed suggests keeping an eye on athletes who may try to cut corners or rely on bad habits. “We stress to all our athletes the importance of a balanced diet and, especially for our female athletes, not just relying on nutrition bars for breakfast or lunch,” she says. “And we talk to them at length about the importance of getting enough rest and staying away from caffeine.”

Some athletic trainers also tie performance supplements to the discussion of heat illness, since several are known to compound heat problems. “We do not want any of our players on any [performance-enhancing] supplements during those hot summer months—even non-banned substances like creatine—especially during two-a-days, when they’re strenuously working out,” says Walser. “We educate them on the effects of these things and the possible harmful side-effects.”

Teaming With Coaches
Every athletic trainer who’s been around for a while has a story about what it used to be like—coaches running practices during the hottest part of the day, passing out salt tabs like they were candy, withholding water, making athletes run extra laps if they took a drink, and so on. It’s rare to come across that mindset today, but coaches still need to be educated regularly about heat illness.

“Our job as athletic trainers is to remind the coaches to continually bring it up with the student-athletes,” says Kent Scriber, EdD, ATC, PT, Professor and Supervisor of Athletic Training at Ithaca College. “We sell the importance of hydration by telling coaches that it will help their players do better, both from a safety standpoint and a performance standpoint.”

The next step is working with coaches to make practices safe. “Making sure coaches schedule specific times for water breaks during the practices seems to make the most impact,” says Reed. “And make sure athletes have to drink water during that time. Don’t give them the option to just stand around and talk.

“It also helps to get the team captains and upperclassmen to lead by example,” she continues. “If you get through to them you’ve got the whole team.”

And rather than just emphasizing the importance of grabbing a drink, remind coaches that the break itself can be as important as getting the fluids. “Letting the body recoup is important,” says Scriber, “particularly with football, where they’re wearing a lot of equipment. Let them take their helmets off, and maybe even their shoulder pads, for a minute.”

Another key is working with coaches to make sure practices are safe when weather conditions turn dangerous. Most athletic trainers feel some latitude to cancel practices when they deem it necessary, but most say that it’s unlikely they would ever take that path. The more desirable solution is to develop alternate plans.

“In the eight football seasons I’ve been here, I don’t think we’ve ever had to cancel a practice,” says Walser. “We’ve been in some hot ones, but you can almost always modify things.

“Last year we had a really hot summer, so we practiced early in the morning and fairly late in the evening,” says Walser. “That meant really, really long days, but it was one of the best things we could have done.”

Walser says they’ll be sticking to the same schedule this year, even if it’s not a particularly hot summer. “The workouts were actually more productive, because we were able to give the athletes more time to recover between practices, and they were able to work out when it wasn’t as hot. Our injury rate went down and our dehydration problems were reduced.”

Marucci offers these suggestions: “You might have to have more breaks. You might have to move practice to later in the day. Or you might have to shorten a practice,” he says. “Another option is to forego the full pads and practice in shorts and shoulder pads.”

Finally, you might suggest modifying the warmup. When it’s cool out, the warmup serves to elevate body temperature and increase blood flow to the muscles and connective tissues. But, Ronald Maugham, PhD, and Susan Shirreffs, PhD, from the University Medical School in Aberdeen Scotland, in Sports Science Exchange (Vol. 10, No. 2, 1997), suggest that “in hot climates, the body temperature should not be markedly increased during the warmup due to the very real possibility of reduced performance because of hyperthermia and dehydration. In explosive events of short duration, this advice may be disregarded, but where exercise discontinues for more than two to three minutes, body temperature should not be markedly increased before exercise begins.” Your athletes will be better served by going right into the practice, as long as they ease into it.

When presenting concerns about the heat to your coaches, it’s important to do so carefully. Although Marucci has never had problems with the coaches he’s worked with, part of that could be attributed to his approach.

“You have to always remember that it’s the coach’s program, it’s not the athletic trainer’s,” Marucci says. “So you have to be diplomatic about presenting your information. If you present it in the right way, it’s going to make sense. If the conditions have the potential to really affect the athletes, it’s always worthwhile to speak up. But conditions have to be pretty darned severe to cancel a practice.”

Getting Used to the Heat
Educating coaches about the effects of the heat can also remind them to emphasize the importance of acclimatizing before preseason camp to their athletes. The NCAA-mandated changes to football—establishing a five-day acclimatization period, starting with limited equipment before working up to full pads and helmets, and doing away with consecutive two-a-days—are intended to give student-athletes a chance to get used to working out in the heat. While athletic trainers agree these measures will help, the research shows that athletes need to start acclimatizing to the heat well before the first day of practice.

Being in good physical condition helps: Intense physical training, even in a cool environment, improves physiologic responses such as heart rate, VO2 max, and the body’s ability to cool itself through sweating, which speeds up the process of heat acclimatization. But the majority of the body’s acclimatization takes seven to 14 days, even in the fittest athletes.

During this time, the body goes through several physiologic changes, resulting in lower core temperature, improved sweating, improved skin blood flow, lowered metabolic heart rate during exercise, reduced cardiovascular strain, improved fluid balance, and increased thermal tolerance. You can’t rush these things. So acclimatization should be a part of every summer conditioning program.

“Our coaches stress to our athletes that they need to get outside over the summer,” says Marc Powell, ATC/L, Head Athletic Trainer at Trinity University, in San Antonio, Texas. “We’re pretty fortunate in that 95 to 98 percent of our football players are from Texas, so they’re used to this, or as used to this as you can get. But that’s not the case with our soccer team. A lot of those kids are from out of state, so I talk to them a little more about preparing for the heat.”

When it comes to acclimatization, Division III athletes may be the hardest to work with. They not only tend to stay on campus less in the summer than Division I and II athletes, but there’s a pretty good chance some of them will travel out of the area for work during the summer. The only thing you can do is emphasize, through the coach, the importance of doing some of their workouts outdoors, especially toward the end of the summer.

“Our athletes have an off-season conditioning program that always includes doing some drills outside,” says Brian Coulombe, MS, ATC/L, Head Athletic Trainer at Texas Lutheran University. “We tell our athletes that three weeks before the start of fall camp they should go out in the heat of the day and run for about an hour. Over the following three weeks, we want them to build that up to two hours. It’s not the same as a full football practice in pads, but it helps.

“And we especially talk to the guys who have suffered from heat problems in the past,” Coulombe continues. “We’ll tell them to start doing the work earlier, in the heat, to get used to it. As those players see that it works, we have more upperclassmen passing that lesson to the lowerclassmen.”

At all levels, more and more athletes are either staying near campus for the summer or returning early. Be sure to take this opportunity to work with them. “We actually go outside all summer, but we build the time gradually,” says Walser. “Toward the end of the summer, instead of running three mornings a week, we run two mornings and one afternoon at a less intense pace. We’ll do that for a couple of weeks and then go to one morning run and two afternoon runs.”

Your Turn for Action
Along with educating others, athletic trainers can help prevent heat illness by conducting thorough preparticipation exams, devising hydration strategies above and beyond just having water available, and always being on the lookout for problems. To discover who might be susceptible to heat illness, ask questions during the preparticipation physical exam that uncover if anyone had problems in the past, did not follow their summer workout program, or didn’t have a chance to become acclimatized to the heat, such as someone who just arrived on campus from a cooler climate.

And while your team doctor will no doubt know about this, you should also be aware that there are several outside factors that can hinder an athlete’s ability to handle the heat. These include such obvious things as dehydration and sickness, as well as skin disorders (even sunburns can seriously impair the body’s ability to regulate its temperature through sweating), and some medications, including anti-cholinergics, diuretics, beta blockers, and tricyclic antidepressants.

Even athletes who don’t fit any of those criteria can struggle with the heat and require special measures. Routinely handing out salt tabs is a thing of the past, because of the long-term health risks of too much salt in the diet, but there are times when a little extra can be helpful. “We’ll have a student trainer identify the athletes who haven’t gained back the weight from the day before,” says Mock. “We have a product that has four or five kinds of salts in it, and if the athletes are right on the edge, we’ll give them some and keep an eye on them.

Whether or not they dispense salts, most southern schools find it necessary to provide electrolyte drinks along with water, as well as ice towels and cold towels. Marucci also recommends having fruit available to give to athletes during their breaks. And some of the larger schools make regular use of cooling mist fans and cold-water immersion tanks.

Once your staff is prepared, then it becomes a matter of keeping a watchful eye to make sure no one is getting hit too hard by the heat. “We’re on alert all the time, looking out for someone who’s lethargic, who can’t stop sweating, who’s weak, whose weight is down considerably,” says Marucci. “It’s not rocket science to spot someone who’s having a heat problem, but you do have to be on the lookout for it.”

While body type can play into it, be wary of jumping to conclusions. “A lot of people will tell you to watch out for the big guys,” Mock says. “But we’ve seen more problems with the really thin, muscular kids. They’re not carrying anything other than muscle and blood.”

You can also enlist the athletes themselves to keep you informed of any problems. “We educate our athletes on what the effects of heat illness look like,” says Marucci. “So to some extent, we rely on athletes to keep an eye on each other. If you tell them what to look for, they will be able to recognize if there’s a problem. And they know that safety comes first, so they don’t feel like they’re ratting somebody out if they tell us about a teammate who’s having a problem.”


Sidebar: Spring Ain’t No Break
For most northern-climate spring sport teams, trips to the south in late winter are a must for getting in more games and outdoor practice time. But this type of travel can pose acclimatization problems. Going from daytime highs of 40s to mid-80s can be a shock to the system. And time, one of the best tools to ward off the effects of the high heat and humidity, isn’t an option—true acclimatization takes upwards of seven days to kick in.

But there are some things you can do. “From the time the kids get back after Christmas right up to spring break, we have them practicing indoors,” says Paul Culina, MEd, ATC/L, Head Athletic Trainer at the University of Maine. “During that time, a lot of our athletes wear multiple layers when they’re working out. Then, when we go south, all those extra layers come off, which may help a little bit.”

Acclimation—the same process as acclimatization but by mimicking outdoor conditions inside—does indeed seem to work. According to a 1994 study by Brian Dawson, MPE, PhD, of the University of Western Australia-Nedlands, published in Sports Medicine (Vol. 17), it’s not as good as the real thing, but it can confer some of the same benefits.

Also, be aware that even though you may not be able to get athletes fully acclimatized, every little bit helps. “On the way to Florida for spring games, the baseball team will usually stop in the Baltimore area for a couple of days,” Culina says. “That way, athletes get a couple of days where it’s not as hot as it’ll be in Florida, but it’s obviously a lot warmer than it is in Maine.

“The most successful thing we’ve done is reinforce the fact that they need to stay hydrated as much as possible,” he continues. “We take extra water on the bus for the overnight rides. We start pushing the fluids a few hours before they get onto the field, and then again after the game. We’re always reminding them to maintain their hydration levels and checking the color of their urine.”

But problems don’t only occur on trips to the deep south. “Our lacrosse team went out to the University of Denver and played on an artificial surface where it was 80 degrees,” recalls Doug Reeland, ATC, Coordinator of Sports Medicine at Hobart College. “That takes its toll. The elevation and the heat, coming from 40 degrees here, plays havoc.

“If you don’t have a week to acclimatize,” he continues, “you have to practice early in the morning and late in the evening. And with things like lacrosse, you can work with the coach to change up the game a little bit, like revolving people through more often.”

“We had it happen a few years ago with football,” recalls Kent Scriber, EdD, ATC, PT, Professor and Supervisor of Athletic Training at Ithaca College. “We played the championship game in Florida in December. It had been getting pretty cool up here and when we went down to Florida it was 87 degrees every day. So that was a big concern.

“We spent a lot of time reminding the kids to pay attention to their fluids and their weight and to let us know of any symptoms. Obviously, we kept a lot of water and ice available during the practices and games down there. You can’t control the weather, so you just have to make people aware that they’re going into a different environment, and remind them to drink more water.”


Sidebar: Not Just For Athletes
High heat and humidity can have serious health effects for anyone doing strenuous work outside. That includes those shouting out plays, lugging heavy boxes and equipment, and staying highly alert while standing in the sun a large part of the day. That’s right: coaches, managers, and athletic trainers can also suffer from heat illness.

Staff members aren’t wearing full pads and exerting as much effort as their athletes, but the recommendations in this article work for them, too. To begin with, it’s important for athletic trainers, managers, and coaches to start getting used to the heat before the first day of fall camp.

“I don’t work out with the athletes during the summer,” says Gary Diehm, MS, ATC/L, Head Athletic Trainer at Midwestern State University, “so I try to get used to the heat by mowing my yard during the heat of the day.”

Then it becomes a matter of staying hydrated along with the athletes. “I talk to the student trainers and my staff about making sure they stay hydrated during practices,” Diehm says. “Coaches may not be as attuned to it, so we try to educate them as well and try to get them to drink as much water as they possibly can.”

Matt Walser, MS, LMT, ATC/L, Associate Head Football Athletic Trainer at the University of Florida, has a similar strategy, “Our head football trainer, Adrian Melendez, keeps pretty close tabs on the coaches, as well as the athletes,” he says.

Walser stresses the importance of keeping an eye on your staff as well. “They’re working very hard, too—doing heavy lifting, moving the water and ice around, assisting us with injuries,” he says. “And we need them to be as sharp as possible. So we encourage them to drink, and I keep an eye on them to make sure they’re doing okay.”