Ten days of simulated live high:train low altitude training increases Hbmass in elite water polo players

Recommendations for Women in Mountain Sports and Hypoxia Training/Conditioning

The (patho-)physiological responses to hypoxia are highly heterogeneous between individuals. In this review, we focused on the roles of sex differences, which emerge as important factors in the regulation of the body's reaction to hypoxia. Several aspects should be considered for future research on hypoxia-related sex differences, particularly altitude training and clinical applications of hypoxia, as these will affect the selection of the optimal dose regarding safety and efficiency. There are several implications, but there are no practical recommendations if/how women should behave differently from men to optimise the benefits or minimise the risks of these hypoxia-related practices. Here, we evaluate the scarce scientific evidence of distinct (patho)physiological responses and adaptations to high altitude/hypoxia, biomechanical/anatomical differences in uphill/downhill locomotion, which is highly relevant for exercising in mountainous environments, and potentially differential effects of altitude training in women. Based on these factors, we derive sex-specific recommendations for mountain sports and intermittent hypoxia conditioning: (1) Although higher vulnerabilities of women to acute mountain sickness have not been unambiguously shown, sex-dependent physiological reactions to hypoxia may contribute to an increased acute mountain sickness vulnerability in some women. Adequate acclimatisation, slow ascent speed and/or preventive medication (e.g. acetazolamide) are solutions. (2) Targeted training of the respiratory musculature could be a valuable preparation for altitude training in women. (3) Sex hormones influence hypoxia responses and hormonal-cycle and/or menstrual-cycle phases therefore may be factors in acclimatisation to altitude and efficiency of altitude training. As many of the recommendations or observations of the present work remain partly speculative, we join previous calls for further quality research on female athletes in sports to be extended to the field of altitude and hypoxia.

Physiological and performance effects of live high train low altitude training for elite endurance athletes: A narrative review

Altitude training has become an important training application for athletes due its potential for altering physiology and enhancing performance. This practice is commonly used by athletes, with a popular choice being the live high - train low approach. This model recommends that athletes live at high altitude (1250-3000 m), but train at low altitude or sea-level (0-1200 m). Exposure to altitude often leads to hypoxic stress and in turn stimulates changes in total haemoglobin mass, erythropoietin, and soluble transferrin receptors, which alter further underlying physiology. Through enhanced physiology, improved exercise performance may arise through enhancement of the oxygen transport system which is important for endurance events. Previous investigations into the effects of altitude training on exercise performance have been completed in a range of contexts, including running, cycling, swimming, and triathlon. Often following a LHTL altitude intervention, athletes realise improvements in maximal oxygen consumption capacity, time trial performance and peak power outputs. Although heterogeneity exists among LHTL methodologies, i.e., exposure durations and altitude ranges, we synthesised this data into kilometre hours, and found that the most common hypoxic doses used in LHTL interventions ranged from ∼578-687 km h. As this narrative review demonstrates, there are potential advantages to using altitude training to enhance physiology and improve performance for endurance athletes.

Hematological Adaptations Following a Training Camp in Hot and/or Hypoxic Conditions in Elite Rugby Union Players

PURPOSE

To investigate the effects of a training camp with heat and/or hypoxia sessions on hematological and thermoregulatory adaptations.

METHODS

Fifty-six elite male rugby players completed a 2-week training camp with 5 endurance and 5 repeated-sprint sessions, rugby practice, and resistance training. Players were separated into 4 groups: CAMP trained in temperate conditions at sea level, HEAT performed the endurance sessions in the heat, ALTI slept and performed the repeated sprints at altitude, and H + A was a combination of the heat and altitude groups.

RESULTS

Blood volume across all groups increased by 140 mL (95%CI, 42-237; P = .006) and plasma volume by 97 mL (95%CI 28-167; P = .007) following the training camp. Plasma volume was 6.3% (0.3% to 12.4%) higher in HEAT than ALTI (P = .034) and slightly higher in HEAT than H + A (5.6% [-0.3% to 11.7%]; P = .076). Changes in hemoglobin mass were not significant (P = .176), despite a ∼1.2% increase in ALTI and H + A and a ∼0.7% decrease in CAMP and HEAT. Peak rectal temperature was lower during a postcamp heat-response test in HEAT (0.3 °C [0.1-0.5]; P = .010) and H + A (0.3 °C [0.1-0.6]; P = .005). Oxygen saturation upon waking was lower in ALTI (3% [2% to 5%]; P < .001) and H + A (4% [3% to 6%]; P < .001) than CAMP and HEAT.

CONCLUSION

Although blood and plasma volume increased following the camp, sleeping at altitude impeded the increase when training in the heat and only marginally increased hemoglobin mass. Heat training induced adaptations commensurate with partial heat acclimation; however, combining heat training and altitude training and confinement during a training camp did not confer concomitant hematological adaptations.

"Living High-Training Low" for Olympic Medal Performance: What Have We Learned 25 Years After Implementation?

BACKGROUND

Altitude training is often regarded as an indispensable tool for the success of elite endurance athletes. Historically, altitude training emerged as a key strategy to prepare for the 1968 Olympics, held at 2300 m in Mexico City, and was limited to the "Live High-Train High" method for endurance athletes aiming for performance gains through improved oxygen transport. This "classical" intervention was modified in 1997 by the "Live High-Train Low" (LHTL) model wherein athletes supplemented acclimatization to chronic hypoxia with high-intensity training at low altitude.

PURPOSE

This review discusses important considerations for successful implementation of LHTL camps in elite athletes based on experiences, both published and unpublished, of the authors.

APPROACH

The originality of our approach is to discuss 10 key "lessons learned," since the seminal work by Levine and Stray-Gundersen was published in 1997, and focusing on (1) optimal dose, (2) individual responses, (3) iron status, (4) training-load monitoring, (5) wellness and well-being monitoring, (6) timing of the intervention, (7) use of natural versus simulated hypoxia, (8) robustness of adaptative mechanisms versus performance benefits, (9) application for a broad range of athletes, and (10) combination of methods. Successful LHTL strategies implemented by Team USA athletes for podium performance at Olympic Games and/or World Championships are presented.

CONCLUSIONS

The evolution of the LHTL model represents an essential framework for sport science, in which field-driven questions about performance led to critical scientific investigation and subsequent practical implementation of a unique approach to altitude training.

Four weeks of hypoxia training improves cutaneous microcirculation in trained rowers

Hypoxia training can improve endurance performance. However, the specific benefits mechanism of hypoxia training is controversial, and there are just a few studies on the peripheral adaptation to hypoxia training. The main objective of this study was to observe the effects of hypoxia training on cutaneous blood flow (CBF), hypoxia-inducible factor (HIF), nitric oxide (NO), and vascular endothelial growth factor (VEGF). Twenty rowers were divided into two groups for four weeks of training, either hypoxia training (Living High, Exercise High and Training Low, HHL) or normoxia training (NOM). We tested cutaneous microcirculation by laser Doppler flowmeter and blood serum parameters by ELISA. HHL group improved the VO(2peak) and power at blood lactic acid of 4 mmol/l (P(4)) significantly. The CBF and the concentration of moving blood cells (CMBC) in the forearm of individuals in the HHL group increased significantly at the first week. The HIF level of the individuals in the HHL group increased at the fourth week. The NO of HHL group increased significantly at the fourth week. In collusion, four weeks of HHL training resulted in increased forearm cutaneous blood flow and transcutaneous oxygen pressure. HHL increases rowers' NO and VEGF, which may be the mechanism of increased blood flow. The increased of CBF seems to be related with improving performance.

Inactivity and exercise training differentially regulate abundance of Na+-K+-ATPase in human skeletal muscle

Physical inactivity is a global health risk that can be addressed through application of exercise training suitable for an individual's health and age. People's willingness to participate in physical activity is often limited by an initially poor physical capability and early onset of fatigue. One factor associated with muscle fatigue during intense contractions is an inexcitability of skeletal muscle cells, reflecting impaired transmembrane Na⁺/K⁺ exchange and membrane depolarization, which are regulated via the transmembranous protein Na⁺-K⁺-ATPase (NKA). This short review focuses on the plasticity of NKA in skeletal muscle in humans after periods of altered usage, exploring NKA upregulation with exercise training and downregulation with physical inactivity. In human skeletal muscle, the NKA content quantified by [³H]ouabain binding site content shows robust, yet tightly constrained, upregulation of 8-22% with physical training, across a broad range of exercise training types. Muscle NKA content in humans undergoes extensive downregulation with injury that involves substantial muscular inactivity. Surprisingly, however, no reduction in NKA content was found in the single study that investigated short-term disuse. Despite clear findings that exercise training and injury modulate NKA content, the adaptability of the individual NKA isoforms in muscle (α_1-3 and β_1-3) and of the accessory and regulatory protein FXYD1 are surprisingly inconsistent across studies, for exercise training as well as for injury/disuse. Potential reasons for this are explored. Finally, we provide suggestions for future studies to provide greater understanding of NKA regulation during exercise training and inactivity in humans.

A Physiological Overview of the Demands, Characteristics, and Adaptations of Highly Trained Artistic Swimmers: a Literature Review

Artistic swimming (AS) is a very unique sport consisting of difficult artistically choreographed routines ranging in the number of athletes (one to ten: solo, duet, team, combination, highlight routine) and with elements performed quickly and precisely above, below, and on the surface of the water. As a result, the physical and physiological demands placed on an athlete are unique to the sport with the most pronounced adaptation being the bradycardic response to long apneic periods spent underwater while performing strenuous movements. This indeed influences training prescription and the desired training outcomes. This review paper explores the physiological demands of AS, the physiological characteristics that influence AS performance, and innovative approaches to enhancing training and performance in elite performers.

Influence of combined iron supplementation and simulated hypoxia on the haematological module of the athlete biological passport

The integrity of the athlete biological passport (ABP) is underpinned by understanding normal fluctuations of its biomarkers to environmental or medical conditions, for example, altitude training or iron deficiency. The combined impact of altitude and iron supplementation on the ABP was evaluated in endurance-trained athletes (n = 34) undertaking 3 weeks of simulated live-high: train-low (14 h.d^-1 , 3000 m). Athletes received either oral, intravenous (IV) or placebo iron supplementation, commencing 2 weeks prior and continuing throughout hypoxic exposure. Venous blood was sampled twice prior, weekly during, and up to 6 weeks after altitude. Individual ABP thresholds for haemoglobin concentration ([Hb]), reticulocyte percentage (%retic), and OFF score were calculated using the adaptive model and assessed at 99% and 99.9% specificity. Eleven athletes returned values outside of the calculated reference ranges at 99%, with 8 at 99.9%. The percentage of athletes exceeding the thresholds in each group was similar, but IV returned the most individual occurrences. A similar frequency of abnormalities occurred across the 3 biomarkers, with abnormal [Hb] and OFF score values arising mainly during-, and %retic values mainly post- altitude. Removing samples collected during altitude from the model resulted in 10 athletes returning abnormal values at 99% specificity, 2 of whom had not triggered the model previously. In summary, the abnormalities observed in response to iron supplementation and hypoxia were not systematic and mostly in line with expected physiological adaptations. They do not represent a uniform weakness in the ABP. Nevertheless, altitude training and iron supplementation should be carefully considered by experts evaluating abnormal ABP profiles.

Do male athletes with already high initial haemoglobin mass benefit from 'live high-train low' altitude training?

NEW FINDINGS

What is the central question of this study? It has been assumed that athletes embarking on an 'live high-train low' (LHTL) camp with already high initial haemoglobin mass (Hb_mass ) have a limited ability to increase their Hb_mass further post-intervention. Therefore, the relationship between initial Hb_mass and post-intervention increase was tested with duplicate Hb_mass measures and comparable hypoxic doses in male athletes. What is the main finding and its importance? There were trivial to moderate inverse relationships between initial Hb_mass and percentage Hb_mass increase in endurance and team-sport athletes after the LHTL camp, indicating that even athletes with higher initial Hb_mass can reasonably expect Hb_mass gains post-LHTL. It has been proposed that athletes with high initial values of haemoglobin mass (Hb_mass ) will have a smaller Hb_mass increase in response to 'live high-train low' (LHTL) altitude training. To verify this assumption, the relationship between initial absolute and relative Hb_mass values and their respective Hb_mass increase following LHTL in male endurance and team-sport athletes was investigated. Overall, 58 male athletes (35 well-trained endurance athletes and 23 elite male field hockey players) undertook an LHTL training camp with similar hypoxic doses (200-230 h). The Hb_mass was measured in duplicate pre- and post-LHTL by the carbon monoxide rebreathing method. Although there was no relationship (r = 0.02, P = 0.91) between initial absolute Hb_mass (in grams) and the percentage increase in absolute Hb_mass , a moderate relationship (r = -0.31, P = 0.02) between initial relative Hb_mass (in grams per kilogram) and the percentage increase in relative Hb_mass was detected. Mean absolute and relative Hb_mass increased to a similar extent (P ≥ 0.81) in endurance (from 916 ± 88 to 951 ± 96 g, +3.8%, P < 0.001 and from 13.1 ± 1.2 to 13.6 ± 1.1 g kg^-1 , +4.1%, P < 0.001, respectively) and team-sport athletes (from 920 ± 120 to 957 ± 127 g, +4.0%, P < 0.001 and from 11.9 ± 0.9 to 12.3 ± 0.9 g kg^-1 , +4.0%, P < 0.001, respectively) after LHTL. The direct comparison study using individual data of male endurance and team-sport athletes and strict methodological control (duplicate Hb_mass measures and matched hypoxic dose) indicated that even athletes with higher initial Hb_mass can reasonably expect Hb_mass gain post-LHTL.

Water Polo Injuries and Training Methods

Water polo is a unique team sport combining swimming sprints and eggbeater kicking, frequent overhead movements and throwing, and regular physical contact with minimal protective equipment. Accordingly, a wide variety of training methods attempt to enhance all of these skill sets. This usually includes some combination of aerobic/anaerobic fitness (via swimming), sport-specific skills, strengthening, and nutrition. In addition, injuries in water polo are somewhat diverse. Physical contact is responsible for the majority of acute injuries, most frequently being injuries to the head and face. The high prevalence of shoulder pain in water polo is likely related to increased shoulder mobility and subsequent instability and stress on shoulder structures, yet the underlying causation is not certain. The unique aspect of shoulder injuries occurring in water polo players is that they may be due to a combination of swimming-related overuse conditions, overhead throwing, and acute trauma-related conditions. Although there is generally minimal evidence-based information available, this article attempts to highlight the current knowledge that we have in regard to water polo injuries and training methods.

Individual hemoglobin mass response to normobaric and hypobaric "live high-train low": A one-year crossover study

The purpose of this research was to compare individual hemoglobin mass (Hb_mass) changes following a live high-train low (LHTL) altitude training camp under either normobaric hypoxia (NH) or hypobaric hypoxia (HH) conditions in endurance athletes. In a crossover design with a one-year washout, 15 male triathletes randomly performed two 18-day LHTL training camps in either HH or NH. All athletes slept at 2,250 meters and trained at altitudes <1,200 meters. Hb_mass was measured in duplicate with the optimized carbon monoxide rebreathing method before (pre) and immediately after (post) each 18-day training camp. Hb_mass increased similarly in HH (916-957 g, 4.5 ± 2.2%, P < 0.001) and in NH (918-953 g, 3.8 ± 2.6%, P < 0.001). Hb_mass changes did not differ between HH and NH (P = 0.42). There was substantial interindividual variability among subjects to both interventions (i.e., individual responsiveness or the individual variation in the response to an intervention free of technical noise): 0.9% in HH and 1.7% in NH. However, a correlation between intraindividual ΔHb_mass changes (%) in HH and in NH (r = 0.52, P = 0.048) was observed. HH and NH evoked similar mean Hb_mass increases following LHTL. Among the mean Hb_mass changes, there was a notable variation in individual Hb_mass response that tended to be reproducible.NEW & NOTEWORTHY This is the first study to compare individual hemoglobin mass (Hb_mass) response to normobaric and hypobaric live high-train low using a same-subject crossover design. The main findings indicate that hypobaric and normobaric hypoxia evoked a similar mean increase in Hb_mass following 18 days of live high-train low. Notable variability and reproducibility in individual Hb_mass responses between athletes was observed, indicating the importance of evaluating individual Hb_mass response to altitude training.

Same Performance Changes after Live High-Train Low in Normobaric vs. Hypobaric Hypoxia

PURPOSE

We investigated the changes in physiological and performance parameters after a Live High-Train Low (LHTL) altitude camp in normobaric (NH) or hypobaric hypoxia (HH) to reproduce the actual training practices of endurance athletes using a crossover-designed study.

METHODS

Well-trained triathletes (n = 16) were split into two groups and completed two 18-day LTHL camps during which they trained at 1100-1200 m and lived at 2250 m (P i O2 = 111.9 ± 0.6 vs. 111.6 ± 0.6 mmHg) under NH (hypoxic chamber; FiO2 18.05 ± 0.03%) or HH (real altitude; barometric pressure 580.2 ± 2.9 mmHg) conditions. The subjects completed the NH and HH camps with a 1-year washout period. Measurements and protocol were identical for both phases of the crossover study. Oxygen saturation (S p O2) was constantly recorded nightly. P i O2 and training loads were matched daily. Blood samples and VO2max were measured before (Pre-) and 1 day after (Post-1) LHTL. A 3-km running-test was performed near sea level before and 1, 7, and 21 days after training camps.

RESULTS

Total hypoxic exposure was lower for NH than for HH during LHTL (230 vs. 310 h; P < 0.001). Nocturnal S p O2 was higher in NH than in HH (92.4 ± 1.2 vs. 91.3 ± 1.0%, P < 0.001). VO2max increased to the same extent for NH and HH (4.9 ± 5.6 vs. 3.2 ± 5.1%). No difference was found in hematological parameters. The 3-km run time was significantly faster in both conditions 21 days after LHTL (4.5 ± 5.0 vs. 6.2 ± 6.4% for NH and HH), and no difference between conditions was found at any time.

CONCLUSION

Increases in VO2max and performance enhancement were similar between NH and HH conditions.

Pre-Altitude Serum Ferritin Levels and Daily Oral Iron Supplement Dose Mediate Iron Parameter and Hemoglobin Mass Responses to Altitude Exposure

PURPOSE

To investigate the influence of daily oral iron supplementation on changes in hemoglobin mass (Hbmass) and iron parameters after 2-4 weeks of moderate altitude exposure.

METHODS

Hematological data collected from 178 athletes (98 males, 80 females) exposed to moderate altitude (1,350-3,000 m) were analysed using linear regression to determine how altitude exposure combined with oral iron supplementation influenced Hbmass, total iron incorporation (TII) and blood iron parameters [ferritin and transferrin saturation (TSAT)].

RESULTS

Altitude exposure (mean ± s: 21 ± 3 days) increased Hbmass by 1.1% [-0.4, 2.6], 3.3% [1.7, 4.8], and 4.0% [2.0, 6.1] from pre-altitude levels in athletes who ingested nil, 105 mg and 210 mg respectively, of oral iron supplement daily. Serum ferritin levels decreased by -33.2% [-46.9, -15.9] and 13.8% [-32.2, 9.7] from pre-altitude levels in athletes who supplemented with nil and 105 mg of oral iron supplement daily, but increased by 36.8% [1.3, 84.8] in athletes supplemented with 210 mg of oral iron daily. Finally, athletes who ingested either 105 mg or 210 mg of oral iron supplement daily had a greater TII compared with non-supplemented athletes (0 versus 105 mg: effect size (d) = -1.88 [-2.56, -1.17]; 0 versus 210 mg: effect size (d) = -2.87 [-3.88, -1.66]).

CONCLUSION

Oral iron supplementation during 2-4 weeks of moderate altitude exposure may enhance Hbmass production and assist the maintenance of iron balance in some athletes with low pre-altitude iron stores.

Comparison of "Live High-Train Low" in normobaric versus hypobaric hypoxia

We investigated the changes in both performance and selected physiological parameters following a Live High-Train Low (LHTL) altitude camp in either normobaric hypoxia (NH) or hypobaric hypoxia (HH) replicating current "real" practices of endurance athletes. Well-trained triathletes were split into two groups (NH, n = 14 and HH, n = 13) and completed an 18-d LHTL camp during which they trained at 1100-1200 m and resided at an altitude of 2250 m (PiO2  = 121.7±1.2 vs. 121.4±0.9 mmHg) under either NH (hypoxic chamber; FiO2 15.8±0.8%) or HH (real altitude; barometric pressure 580±23 mmHg) conditions. Oxygen saturations (SpO2) were recorded continuously daily overnight. PiO2 and training loads were matched daily. Before (Pre-) and 1 day after (Post-) LHTL, blood samples, VO2max, and total haemoglobin mass (Hb(mass)) were measured. A 3-km running test was performed near sea level twice before, and 1, 7, and 21 days following LHTL. During LHTL, hypoxic exposure was lower for the NH group than for the HH group (220 vs. 300 h; P<0.001). Night SpO2 was higher (92.1±0.3 vs. 90.9±0.3%, P<0.001), and breathing frequency was lower in the NH group compared with the HH group (13.9±2.1 vs. 15.5±1.5 breath.min(-1), P<0.05). Immediately following LHTL, similar increases in VO2max (6.1±6.8 vs. 5.2±4.8%) and Hb(mass) (2.6±1.9 vs. 3.4±2.1%) were observed in NH and HH groups, respectively, while 3-km performance was not improved. However, 21 days following the LHTL intervention, 3-km run time was significantly faster in the HH (3.3±3.6%; P<0.05) versus the NH (1.2±2.9%; ns) group. In conclusion, the greater degree of race performance enhancement by day 21 after an 18-d LHTL camp in the HH group was likely induced by a larger hypoxic dose. However, one cannot rule out other factors including differences in sleeping desaturations and breathing patterns, thus suggesting higher hypoxic stimuli in the HH group.

Position statement--altitude training for improving team-sport players' performance: current knowledge and unresolved issues

Despite the limited research on the effects of altitude (or hypoxic) training interventions on team-sport performance, players from all around the world engaged in these sports are now using altitude training more than ever before. In March 2013, an Altitude Training and Team Sports conference was held in Doha, Qatar, to establish a forum of research and practical insights into this rapidly growing field. A round-table meeting in which the panellists engaged in focused discussions concluded this conference. This has resulted in the present position statement, designed to highlight some key issues raised during the debates and to integrate the ideas into a shared conceptual framework. The present signposting document has been developed for use by support teams (coaches, performance scientists, physicians, strength and conditioning staff) and other professionals who have an interest in the practical application of altitude training for team sports. After more than four decades of research, there is still no consensus on the optimal strategies to elicit the best results from altitude training in a team-sport population. However, there are some recommended strategies discussed in this position statement to adopt for improving the acclimatisation process when training/competing at altitude and for potentially enhancing sea-level performance. It is our hope that this information will be intriguing, balanced and, more importantly, stimulating to the point that it promotes constructive discussion and serves as a guide for future research aimed at advancing the bourgeoning body of knowledge in the area of altitude training for team sports.