Responses to exercise in normobaric hypoxia: comparison of elite and recreational ski mountaineers

Echinacea Supplementation Does Not Impact Aerobic Capacity and Erythropoiesis in Athletes: A Meta-Analysis

Athletes are increasingly relying on natural supplements to improve athletic performance. Echinacea, a common herbal supplement, has been studied for its potential erythropoietin-enhancing effects, with mixed results in the literature. The purpose of this meta-analysis is to determine whether echinacea supplementation has erythropoietic or ergogenic effects in athletes. A search strategy was developed to identify trials studying the impact of echinacea supplementation on erythropoiesis and maximal oxygen uptake. The database search yielded 502 studies, 496 of which were excluded in the two-reviewer screening process. Six studies with a total of 107 athletes were included in the analysis. For hemoglobin and hematocrit levels, there were small, positive effect sizes when comparing the difference in pre- and post-intervention levels between the echinacea and placebo groups, at 0.38 (p = 0.02, 95% CI -0.04-0.80, I2 = 70%) and 0.34 (p < 0.01, 95% CI -0.10-0.78, I2 = 86%), respectively, though they did not reach statistical significance. There was also no statistically significant change in erythropoietin (effect size -0.29, p = 0.05, 95% CI -0.75-0.17, I2 = 67%) or maximal oxygen uptake (effect size -0.20, p = 0.95, 95% CI -0.60-0.21, I2 = 0%). Echinacea supplementation did not influence erythropoietin, hemoglobin, hematocrit, or maximal oxygen uptake in athletes; however, the evidence base is limited.

Case Report: Muscle Wasting during Severe Sustained Hypoxia in Two Professional Mountaineers

PURPOSE

Chronic exposure to hypoxia can induce muscle wasting in unaccustomed individuals. Detailed assessment of the effects of hypoxia on muscle tissue adaptation in elite mountaineers has not been performed. This study aims to assess muscle volume after exposure to normobaric hypoxia.

METHODS

Two professional mountaineers (A and B) participated in a 35-d intervention of graded normobaric hypoxia with the aim of 14 d exposure to 8% oxygen corresponding to 7112-m altitude. Volume of the shank, thigh, and hip muscles was assessed by magnetic resonance imaging pre- and postintervention. Dietary intake and physical activity were monitored throughout the study from food images and accelerometry analysis, together with blood analysis and anthropometric measurements.

RESULTS

Hypoxia reduced total leg muscle volume by 3.3% ± 6.0% in A and by 9.4% ± 7.3% in B. A lost 288 g and B 642 g of muscle mass, whereas dietary intake only declined by ~23% in the last intervention week. Arterial oxygen saturation declined from 95% and 86% to 77% and 72% in A and B, respectively. In hypoxia, participants could not maintain their physical activity levels. Notably, muscle loss varied substantially across muscle groups amounting to 5.4% ± 3.0%, 8.3% ± 5.2%, and 4.1% ± 8.6% for hip, thigh, and shank muscles, respectively.

CONCLUSIONS

Our results indicate that hypoxia and resultant reductions in physical activity and caloric intake lead to substantial loss of muscle mass that was accentuated in proximal muscle as opposed to distal muscles. Surprisingly, thigh muscle wasting during this intervention is comparable with that observed during strict 56-d bed rest.

Ski Mountaineering-Scientific Knowledge of This New Olympic Sport: A Narrative Review

ABSTRACT

Ski mountaineering (skimo) has been accepted as a new sport for the 2026 Milan-Cortina Olympics. The equipment used in this competitive ski mountaineering varies from leisure ski mountaineering equipment mainly in one point: the minimal weight. At the elite athlete level, skimo demands both maximal endurance performance and a high-intensity anaerobic capacity for the sprint and vertical races. Race time significantly correlates to V˙O2max, body mass index and racing gear mass. Available literature only rarely comments on competitive skimo injuries. Injuries are not only due to falls in downhill skiing but also can result from external hazards, such as avalanches and cold. The high training load of athletes in combination with a low body weight, low body fat, and exposure to cold cause high rates of respiratory infections in athletes. The inclusion of skimo into the Olympic program is expected to result in certain changes, such as higher training loads for the athletes and increased scientific interest into training methods.

Eager to set a record in a vertical race? Test your VO2max first!

We investigated the relationship between maximal oxygen consumption (VO_2max) and performance in vertical races (VRs). In total, 270 performances, from 26 VRs, and cardiopulmonary data of 64 highly-trained mountain runners (53 M, V O_2max: 75.7±5.8 mL/min/kg; 11 F: 65.7±3.4 mL/min/kg), collected over a 11-year period (2012-2022), were analysed. The relationship between performance and VO_2max was modelled separately for national (NVRs), international (IVRs), and VRs of current pole-unassisted and pole-assisted vertical kilometre (VK) records (RVRs). Three different (p<0.001) exponential models described the relationship between performance and VO_2max in IVRs (R²=0.96, p<0.001), NRs (R²=0.91, p<0.001) and RVRs (R²=0.97, p<0.001). Estimated VO_2max requirements (with 95% CI) to win/set a record time in IVRs were 86.2(85.3-87.1)/89.4(88.2-90.5) and 74.0(73.6-74.4)/76.8(76.4-77.3) mL/min/kg, for males and females, respectively, 86.1(85.0-87.1)/90.4(89.0-91.8) and 74.8(74.2-75.3)/77.1(77.6-77.7) mL/min/kg in RVRs, decreasing to 83.7(82.5-84.9)/87.6(86.0-89.2) and 66.8(65.9-67.7)/70.7(70.1-71.4) mL/min/kg in NVRs. Our study also suggested a tendency towards a non-uniform variation in the metabolic demand of off-road running, likely attributable to the different features of the VRs (e.g., terrain, technical level, use of poles). These data provide mean VO_2max requirements for mountain runners to win and establish new records in VRs and stimulate new research on the energy cost of off-road running.

Left Ventricular, Left Atrial and Right Ventricular Strain Modifications after Maximal Exercise in Elite Ski-Mountaineering Athletes: A Feasibility Speckle Tracking Study

Eleven world elite ski-mountaineering (Ski-Mo) athletes were evaluated for pronounced echocardiographic physiological remodeling as the primary aim of our feasibility speckle tracking study. In this context, sports-related cardiac remodeling was analyzed by performing two-dimensional echocardiography, including speckle tracking analysis of the left atrium (LA), right ventricle (RV) and left ventricular (LV) global longitudinal strain (LV-GLS) at rest and post-peak performance. The feasibility echocardiographic speckle tracking analysis was performed on eleven elite Ski-Mo athletes, which were obtained in 2022 during the annual medical examination. The obtained data of the professional Ski-Mo athletes (11 athletes, age: 18-26 years) were compared for different echocardiographic parameters at rest and post-exercise. Significant differences were found for LV-GLS mean (p = 0.0036) and phasic LA conduit strain pattern at rest and post-exercise (p = 0.0033). Furthermore, negative correlation between LV mass and LV-GLS (p = 0.0195, r = -0.69) and LV mass Index and LV-GLS (p = 0.0253, r = -0.66) at rest were elucidated. This descriptive reporting provided, for the first time, a sport-specific dynamic remodeling of an entire elite national team of the Ski-Mo athlete's left heart and elucidated differences in the dynamic deformation pattern of the left heart.

Ski Mountaineering: Perspectives on a Novel Sport to Be Introduced at the 2026 Winter Olympic Games

Ski mountaineering is a rapidly growing winter sport that involves alternately climbing and descending slopes and various racing formats that differ in length and total vertical gain, as well as their distribution of downhill and uphill sections. In recent years, both participation in and media coverage of this sport have increased dramatically, contributing, at least in part, to its inclusion in the 2026 Winter Olympics in Milano-Cortina. Here, our aim has been to briefly describe the major characteristics of ski mountaineering, its physiological and biomechanical demands, equipment, and training/testing, as well as to provide some future perspectives. Despite its popularity, research on this discipline is scarce, but some general characteristics are already emerging. Pronounced aerobic capacity is an important requirement for success, as demonstrated by positive correlations between racing time and maximal oxygen uptake and oxygen uptake at the second ventilatory threshold. Moreover, due to the considerable mechanical work against gravity on demanding uphill terrain, the combined weight of the athlete and equipment is inversely correlated with performance, prompting the development of both lighter and better equipment in recent decades. In ski mountaineering, velocity uphill is achieved primarily by more frequent (rather than longer) strides due primarily to high resistive forces. The use of wearable technologies, designed specifically for analysis in the field (including at elevated altitudes and cold temperatures) and more extensive collaboration between researchers, industrial actors, and coaches/athletes, could further improve the development of this sport.

Assessment of Maximal Aerobic Capacity in Ski Mountaineering: A Laboratory-Based Study

This study aims to evaluate the agreement in maximum oxygen consumption (V˙O₂max) between a running protocol and a ski mountaineering (SKIMO) protocol. Eighteen (eleven males, seven females) ski mountaineers (age: 25 ± 3 years) participated in the study. V˙O₂max, maximum heart rate (HRmax), and maximum blood lactate concentration (BLAmax) were determined in an incremental uphill running test and an incremental SKIMO-equipment-specific test. V˙O₂max did not differ between the SKIMO and uphill running protocols (p = 0.927; mean difference -0.07 ± 3.3 mL/min/kg), nor did HRmax (p = 0.587, mean difference -0.7 ± 5.1 bpm). A significant correlation was found between V˙O₂max SKIMO and V˙O₂max running (p ≤ 0.001; ICC = 0.862 (95% CI: 0.670-0.946)). The coefficient of variation was 4.4% (95% CI: 3.3-6.5). BLAmax was significantly lower for SKIMO compared to running (12.0 ± 14.1%; p = 0.002). This study demonstrates that V˙O₂max determined with a traditional uphill running protocol demonstrates good agreement with an equipment-specific SKIMO protocol.

Red Blood Cell 2,3-Diphosphoglycerate Decreases in Response to a 30 km Time Trial Under Hypoxia in Cyclists

Red blood cell 2,3-diphosphoglycerate (2,3-DPG) is one of the factors of rightward-shifted oxygen dissociation curves and decrease of Hb-O₂ affinity. The reduction of Hb-O₂ affinity is beneficial to O₂ unloading at the tissue level. In the current literature, there are no studies about the changes in 2,3-DPG level following acute exercise in moderate hypoxia in athletes. For this reason, the aim of this study was to analyze the effect of prolonged intense exercise under normoxic and hypoxic conditions on 2,3-DPG level in cyclists. Fourteen male trained cyclists performed a simulation of a 30 km time trial (TT) in normoxia and normobaric hypoxia (FiO₂ = 16.5%, ~2,000 m). During the TT, the following variables were measured: power, blood oxygen saturation (SpO₂), and heart rate (HR). Before and immediately after exercise, the blood level of 2,3-DPG and acid–base equilibrium were determined. The results showed that the mean SpO₂ during TT in hypoxia was 8% lower than in normoxia. The reduction of SpO₂ in hypoxia resulted in a decrease of average power by 9.6% (p < 0.001) and an increase in the 30 km TT completion time by 3.8% (p < 0.01) compared to normoxia. The exercise in hypoxia caused a significant (p < 0.001) decrease in 2,3-DPG level by 17.6%. After exercise in normoxia, a downward trend of 2,3-DPG level was also observed, but this effect was not statistically significant. The analysis also revealed that changes of acid–base balance were significantly larger (p < 0.05) after exercise in hypoxia than in normoxia. In conclusion, intense exercise in hypoxic conditions leads to a decrease in 2,3-DPG concentration, primarily due to exercise-induced acidosis.

Haematological responses to repeated sprints in hypoxia across different sporting modalities

The aim was to determine the effects of repeated-sprint training in hypoxia on haematocrit and haemoglobin in different sporting modalities. Seventy-two participants were randomly allocated to Active-Repeated sprint in hypoxia (A-RSH, n= 8); Active-Repeated sprint in normoxia (A-RSN, n= 8); Active-Control (A-CON, n= 8); Team Sports-RSH (T-RSH, n= 8); Team Sports-RSN (T-RSN, n= 8); Team Sports-Control (T-CON, n= 8); Endurance-RSH (E-RSH, n= 8); Endurance-RSN (E-RSN, n= 8); Endurance-Control (E-CON, n= 8). Sessions consisted of two sets of five sprints of 10 swith recovery of 20 sbetween sprints and 10 min between sets. Blood samples for haematocrit and haemoglobin concentrations were obtained before and after, and 2 weeks after cessation. Haematocrit and haemoglobin were lower for the E-RSN group following 2 weeks of cessation of protocol compared with E-RSH (p = 0.035) and E-CON (p = 0.045). Haematocrit of the A-RSH group was higher compared with baseline (p = 0.05) and Post (p = 0.05). Similarly, the T-RSH group demonstrated increases in haematocrit following 2 weeks of cessation compared with Post (p = 0.04). Repeated Sprint Training in Hypoxia had different haematological effects depending on sporting modality.

Physiological Responses and Predictors of Performance in a Simulated Competitive Ski Mountaineering Race

Competitive ski mountaineering (SKIMO) has achieved great popularity within the past years. However, knowledge about the predictors of performance and physiological response to SKIMO racing is limited. Therefore, 21 male SKIMO athletes split into two performance groups (elite: VO_2max 71.2 ± 6.8 ml· min^-1· kg^-1 vs. sub-elite: 62.5 ± 4.7 ml· min^-1· kg^-1) were tested and analysed during a vertical SKIMO race simulation (523 m elevation gain) and in a laboratory SKIMO specific ramp test. In both cases, oxygen consumption (VO₂), heart rate (HR), blood lactate and cycle characteristics were measured. During the race simulation, the elite athletes were approximately 5 min faster compared with the sub-elite (27:15 ± 1:16 min; 32:31 ± 2:13 min; p < 0.001). VO₂ was higher for elite athletes during the race simulation (p = 0.046) and in the laboratory test at ventilatory threshold 2 (p = 0.005) and at maximum VO₂ (p = 0.003). Laboratory maximum power output is displayed as treadmill speed and was higher for elite than sub-elite athletes (7.4 ± 0.3 km h^-1; 6.6 ± 0.3 km h^-1; p < 0.001). Lactate values were higher in the laboratory maximum ramp test than in the race simulation (p < 0.001). Pearson's correlation coefficient between race time and performance parameters was highest for velocity and VO₂ related parameters during the laboratory test (r > 0.6). Elite athletes showed their superiority in the race simulation as well as during the maximum ramp test. While HR analysis revealed a similar strain to both cohorts in both tests, the superiority can be explainable by higher VO₂ and power output. To further push the performance of SKIMO athletes, the development of named factors like power output at maximum and ventilatory threshold 2 seems crucial.

On Top to the Top-Acclimatization Strategy for the "Fastest Known Time" to Mount Everest

PURPOSE

To present the acclimatization strategy employed by an elite athlete prior to 2 successful ascents to Mount Everest (including a "fastest known time") in 1 wk.

METHODS

Training volume, training content, and altitude exposure were recorded daily. Vertical velocity was recorded by GPS (global positioning system) heart-rate monitor.

RESULTS

The subject first used a live high-train low and high preacclimatization method in normobaric hypoxia (NH). Daily, he combined sleeping in a hypoxic tent (total hours: ∼260) and exercising "as usual" in normoxia but also in NH (altitude >6000 m: 30 h), including at high intensity. The hypoxic sessions were performed at the second threshold on treadmill in NH at 6000 m, and the pulse saturation increased from 70% to 85% over 1 mo. Then, the subject was progressively exposed to hypobaric hypoxia, first in the Alps and then in the Himalayas. On day 18, he reached for the second time an altitude >8000 m with the fastest vertical velocity (350 m/h) ever measured between 6300 and 8400 m. Afterward, he climbed twice in a week to the summit of Mount Everest (8848 m, including a "fastest known time" of 26.5 h from Rongbuk Monastery, 5100 m).

CONCLUSION

Overall, this acclimatization was successful and in line with the most recent recommendations: first, using live high-train low and high, and second, using hypobaric hypoxia at increasing altitudes for a better translation of the NH benefits to hypobaric hypoxia. This case study reports the preparation for the most outstanding performance ever acheived at an extreme altitude.

Sildenafil does not improve performance in 16.1 km cycle exercise time-trial in acute hypoxia

Sildenafil is a pulmonary vasodilator that has potential to mitigate the decrement in endurance performance caused by hypoxic pulmonary vasoconstriction. The purpose of this study was to determine the effects of sildenafil on pulmonary artery pressure, cardiac output, pulse oxygen saturation, and exercise performance at moderate simulated altitude. We hypothesized that sildenafil would reduce the decline in exercise performance in hypoxia by blunting the rise in pulmonary artery pressure and causing a relative increase in cardiac output and oxygen saturation. Twelve endurance trained men performed three experimental cycling trials at sea level and simulated moderate altitude of 3,000m (F_IO₂ = 0.147) after ingesting either a placebo or sildenafil 50 mg capsule in a double blinded fashion. Each test consisted of a warmup period, a 15-minute steady state period at 60% of peak power output, and a 16.1 km time-trial. All subjects experienced a decline in maximal exercise capacity in hypoxia that ranged from 6% to 24%. This decline was correlated with the reduction in pulse oxygen saturation in hypoxic maximal exercise. Sildenafil had no effect on pulmonary artery pressure, cardiac output, or pulse oxygen saturation measured during steady state exercise. There was no effect of sildenafil on mean power output during the time-trial. During high intensity cycle exercise in acute, moderate hypoxia pulmonary artery pressure is unaffected by sildenafil and does not appear to influence cardiovascular function or exercise performance.

Is Maximal Heart Rate Decrease Similar Between Normobaric Versus Hypobaric Hypoxia in Trained and Untrained Subjects?

We compared the decrease in maximal heart rate (HRmax) from normoxia to normobaric (NH) and hypobaric (HH) hypoxia, respectively, in trained and untrained subjects (n = 187). HRmax data in normoxia and NH (n = 55) or HH (n = 26) were collected from 81 publications. No study directly compared HRmax in NH and HH. Concomitant arterial oxygen saturation (SaO₂) and HRmax data were found in 60 studies. Overall, the results showed that the higher the desaturation, the greater the decrease in HRmax. Since desaturation appeared to be slightly higher during HH versus NH and was higher in trained than in untrained subjects, the decrease in HRmax tended (p = 0.07) to be higher in trained subjects in HH than in NH (e.g., -12.7 bpm vs. -8.6 bpm at 4000 m), whereas in untrained subjects the difference was negligible (-9.9 bpm vs. -8.3 bpm). To conclude, when compared with normoxia, the decrease in HRmax was slightly higher in HH than in NH in trained subjects. However, this result has to be confirmed and from a practical point of view, one may question the significance of this difference as well as the relevance of using different HR values for prescribing training intensity during exercise performed in NH or in HH.

Limitation of Maximal Heart Rate in Hypoxia: Mechanisms and Clinical Importance

The use of exercise intervention in hypoxia has grown in popularity amongst patients, with encouraging results compared to similar intervention in normoxia. The prescription of exercise for patients largely rely on heart rate recordings (percentage of maximal heart rate (HR_max) or heart rate reserve). It is known that HR_max decreases with high altitude and the duration of the stay (acclimatization). At an altitude typically chosen for training (2,000-3,500 m) conflicting results have been found. Whether or not this decrease exists or not is of importance since the results of previous studies assessing hypoxic training based on HR may be biased due to improper intensity. By pooling the results of 86 studies, this literature review emphasizes that HR_max decreases progressively with increasing hypoxia. The dose–response is roughly linear and starts at a low altitude, but with large inter-study variabilities. Sex or age does not seem to be a major contributor in the HR_max decline with altitude. Rather, it seems that the greater the reduction in arterial oxygen saturation, the greater the reduction in HRmax, due to an over activity of the parasympathetic nervous system. Only a few studies reported HR_max at sea/low level and altitude with patients. Altogether, due to very different experimental design, it is difficult to draw firm conclusions in these different clinical categories of people. Hence, forthcoming studies in specific groups of patients are required to properly evaluate (1) the HR_max change during acute hypoxia and the contributing factors, and (2) the physiological and clinical effects of exercise training in hypoxia with adequate prescription of exercise training intensity if based on heart rate.

Influence of Inspiratory Muscle Training on Ventilatory Efficiency and Cycling Performance in Normoxia and Hypoxia

The aim of this study was to analyse the influence of inspiratory muscle training (IMT) on ventilatory efficiency, in normoxia and hypoxia, and to investigate the relationship between ventilatory efficiency and cycling performance. Sixteen sport students (23.05 ± 4.7 years; 175.11 ± 7.1 cm; 67.0 ± 19.4 kg; 46.4 ± 8.7 ml·kg⁻¹·min⁻¹) were randomly assigned to an inspiratory muscle training group (IMTG) and a control group (CG). The IMTG performed two training sessions/day [30 inspiratory breaths, 50% peak inspiratory pressure (Pimax), 5 days/week, 6-weeks]. Before and after the training period subjects carried out an incremental exercise test to exhaustion with gas analysis, lung function testing, and a cycling time trial test in hypoxia and normoxia. Simulated hypoxia (FiO₂ = 16.45%), significantly altered the ventilatory efficiency response in all subjects (p < 0.05). Pimax increased significantly in the IMTG whereas no changes occurred in the CG (time × group, p < 0.05). Within group analyses showed that the IMTG improved ventilatory efficiency (V_E/VCO₂ slope; EqCO₂VT₂) in hypoxia (p < 0.05) and cycling time trial performance [W_{TTmax (W)}; W_{TTmean (W)}; PTF_(W)] (p < 0.05) in hypoxia and normoxia. Significant correlations were not found in hypoxia nor normoxia found between ventilatory efficiency parameters (V_E/VCO₂ slope; LEqCO₂; EqCO₂VT₂) and time trial performance. On the contrary the oxygen uptake efficiency slope (OUES) was highly correlated with cycling time trial performance (r = 0.89; r = 0.82; p < 0.001) under both conditions. Even though no interaction effect was found, the within group analysis may suggest that IMT reduces the negative effects of hypoxia on ventilatory efficiency. In addition, the data suggest that OUES plays an important role in submaximal cycling performance.

Cycling Time Trial Is More Altered in Hypobaric than Normobaric Hypoxia

PURPOSE

Slight physiological differences between acute exposure in normobaric hypoxia (NH) and hypobaric hypoxia (HH) have been reported. Taken together, these differences suggest different physiological responses to hypoxic exposure to a simulated altitude (NH) versus a terrestrial altitude (HH). For this purpose, in the present study, we aimed to directly compare the time-trial performance after acute hypoxia exposure (26 h, 3450 min) by the same subjects under three different conditions: NH, HH, and normobaric normoxia (NN). Based on all of the preceding studies examining the differences among these hypoxic conditions, we hypothesized greater performance impairment in HH than in NH.

METHODS

The experimental design consisted of three sessions: NN (Sion: FiO2, 20.93), NH (Sion, hypoxic room: FiO2, 13.6%; barometric pressure, 716 mm Hg), and HH (Jungfraujoch: FiO2, 20.93; barometric pressure, 481 mm Hg). The performance was evaluated at the end of each session with a cycle time trial of 250 kJ.

RESULTS

The mean time trial duration in NN was significantly shorter than under the two hypoxic conditions (P < 0.001). In addition, the mean duration in NH was significantly shorter than that in HH (P < 0.01). The mean pulse oxygen saturation during the time trial was significantly lower for HH than for NH (P < 0.05), and it was significantly higher in NN than for the two other sessions (P < 0.001).

CONCLUSION

As previously suggested, HH seems to be a more stressful stimulus, and NH and HH should not be used interchangeability when endurance performance is the main objective. The principal factor in this performance difference between hypoxic conditions seemed to be the lower peripheral oxygen saturation in HH at rest, as well as during exercise.