Facing pressure to train for victory, warfighters and athletes encounter numerous health risks that are directly related to their regular physical training. The concept of universal training precautions (UTPs) signifies universal processes designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Although no formal guidelines exist for collectively implementing a defined set of UTPs to address a broad scope of exercise-related health risks, recommendations and guidelines have been published relating to preventing sudden death during high school sports and collegiate conditioning sessions. A long list of critical topics must be considered as UTPs, including physical fitness factors, transition-period accommodation, hydration, environmental factors and acclimatization, appropriate recovery, use of medications and dietary supplements, and importantly, leadership. In this article, we outline in detail, with corresponding Strength of Recommendation Taxonomy ratings, what should be considered universal recommendations to minimize the risk of warfighters and athletes coming to harm when participating in group physical activities.

Key Points
  • Preventing the diverse array of injuries and harms that may befall warfighters and athletes during exercise requires a comprehensive approach, both in scope (injury types) and application (all warfighters and athletes).

  • A proposed set of universal training precautions includes proper exercise prescription and load progression, recovery, sleep, work-rest cycles, transition-period accommodation, hydration, environmental acclimatization, and organizational leadership and culture.

  • Medical professionals must prudently tailor universal training precautions to each unique population and setting, noting that many of the pertinent factors exist on a continuum (eg, physical fitness levels, climate, altitude), yet all must be carefully considered.

Achieving victory on the playing field or battlefield depends pivotally on physical training and conditioning. However, the risks of physical training may at times be overshadowed by a win-at-all-costs mentality, which could in turn tragically result in exertional sudden death. Some military commanders confront an especially challenging task of preparing for the threats of the battlefield, where the stakes are much higher than in sporting competition. Facing pressure to train for victory, warfighters and athletes encounter numerous health risks directly related to physical training, including exertional injuries (rhabdomyolysis, heat illness, hyponatremia, exertional collapse associated with sickle cell trait [ECAST]), musculoskeletal injuries, concussion and traumatic brain injury, and death. Although an immense amount of research has been conducted to define the most effective strategies to prevent training-related health risks,113  many gaps remain, and hence, many strategies continue to be largely based on expert opinion. By reviewing and highlighting the clinical relevance of each recommendation and its supporting evidence base (whether scant or robust), we aim to assist health care providers on the sidelines and at training facilities integrate the diverse scope of training precautions, instead of focusing on one or a few preventive measures while neglecting other vulnerabilities. Finally, in this review, we hope to facilitate further research to fill existing gaps.

The concept of universal training precautions (UTPs) signifies universal processes that are designed to prevent unnecessary bodily harm, including injury, illness, and death, during physical training programs. Kark and Ward14  introduced this term in the 1990s after several people with sickle cell trait experienced what we now call ECAST.1  Those in leadership believed some of these events were associated with dehydration and exercise in the heat, and the result was a series of recommendations to mitigate adverse events during military training.

When we consider the term universal precautions, the processes for preventing transmission of bloodborne infections immediately come to mind.15  However, the term is also associated with health literacy when a universal-precautions approach is taken by assuming that all patients—regardless of their health literacy level—may experience difficulty understanding and using health information.16  Thus, all health information developed is supposed to be easy for patients to understand and help them navigate the health care system.16  Yet to date, no set of UTPs for sports, exercise, and physical training has been proposed or defined. No formal guidelines exist for collective implementation of a defined set of precautionary strategies to address a broad scope of exercise-related health risks. Interassociation task force (IATF) recommendations related to preventing sudden death during high school sports and collegiate conditioning sessions,2,6  as well as specific IATF guidelines for preseason heat acclimatization (HA) in high school athletics,17  have been published. Although it is reasonable to infer that these guidelines may help prevent many types of exercise-related harm, the concept of UTPs must be more inclusive. Ideally, UTPs would apply to all warfighters and athletes and should reduce the risk of all exertion-related events. If we consider the spectrum of precautions that might be taken to protect any warfighter or athlete from exertion-related health risks, a long list will emerge. The most common considerations are presented in Table 1. The goal of our review was to provide a detailed outline of what should be considered a universal recommendation to minimize the risk for warfighters and athletes coming to harm when participating in group physical activities.

Table 1

Strength of Recommendation Taxonomy for Precautions Related to Physical Fitness and Exercise Design That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Physical Fitness and Exercise Design That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Physical Fitness and Exercise Design That Should Be Universally Applied During Physical Training

Each of these recommendations and the supporting medical literature were reviewed in detail during 1 or more formal roundtable discussions among top subject matter experts:

  1. ECAST Summit, October 201913;

  2. Marine Corps Marathon Medical Algorithm annual review panels, 2005 to present43;

  3. Expert panel for best practices for prevention of sudden death in US Air Force Basic Military Training, November 20143;

  4. Military injury-prevention roundtable discussions18,44 ; and

  5. American College of Sports Medicine expert consensus panel on exertional heat illness, 2021.45 

After reviewing each conference or discussion, we again studied the literature pertaining to each topic and cited relevant articles in preparing this manuscript. The MEDLINE database was searched via PubMed using the following terms: sudden cardiac death athletes, prevention sudden cardiac death, exercise collapse sickle cell trait, exertional heat stroke, exertional heat illness prevention, concussion prevention, hydration athletes, high altitude illness, altitude sickness prevention, exercise prescription, musculoskeletal injury prevention, resistance training progression, aerobic training progression, exercise warm-up, post-exercise recovery, sleep injury risk athlete, sleep athletes, caffeine heat illness, herbal dietary supplement safety, dietary supplement safety, medication heat stroke, emergency action plan athlete, emergency action plan cardiac, and emergency action plan leadership. Emphasis was placed on the most recent interassociation consensus statements, organization position statements, expert summits, systematic reviews, and controlled trials from the primary research. We searched bibliographies of key articles for additional resources, and similar articles recommended by PubMed were also searched. Finally, Strength of Recommendation Taxonomy (SORT)46  tables were created to summarize the recommendations in each section. These SORT tables were first drafted by the lead author (N.S.N.). All recommendations were then reviewed and scored independently by all coauthors. When scores were discordant, additional review of the literature was conducted to clarify the level of evidence supporting the recommendation until a consensus among all authors was reached. The recommendations presented in this article are intended to pertain to athletes and physically active people in both civilian and military settings unless otherwise specified. Hereafter, the term athletes will be used in reference to both civilian and military athletes. The term warfighter signifies any member of the armed forces. It is important to recognize that all military servicemembers are required to maintain physical fitness standards; however, some training pipelines and career fields such as special operations entail much higher physical demands than others.

Physical conditioning levels and proper training-load progressions are extremely important for mitigating exertion-related events.19  The appropriate exercise modality, intensity, duration, and progression should guide anaerobic and aerobic fitness training to improve performance and lower the risk of injury.20,21,47  Current exercise guidelines are briefly reviewed here and include individualization, accounting for acute and chronic medical conditions, a proper warmup, strength training, endurance training, high-intensity interval training, stretching, cooldown, and transition-period accommodation. Additional details can be found in current position stands from the National Strength and Conditioning Association28,48  and the American College of Sports Medicine.27  Recommendations are summarized in Table 1.

Although its importance is paramount, individualizing training is difficult when working with large groups, and consequently, individuals with lower fitness levels who are attempting to keep up with the group are at greatest risk. An athlete with a maximal oxygen consumption (o2max) of 40 mL·kg−1·min−1 cannot safely keep pace for more than a few minutes during an aerobic workout with an athlete whose o2max is 55 mL·kg−1·min−1. The Rating of Perceived Exertion scale is a validated way to measure exercise intensity and should be used when individualizing a training program.49  Whenever available, exercise guidance should be sought from certified athletic trainers, certified strength and conditioning specialists, exercise physiologists, or a combination of these experts.50 

Exercise precautions must account for not only healthy individuals but also those with chronic medical conditions, such as diabetes, cardiovascular disease, and hypertension. This is relevant to both civilian athletes and warfighters. Although warfighters are screened for medical conditions before accession, they often develop chronic medical conditions during their military careers and, in many cases, continue to serve productively. Individuals with chronic medical conditions should plan their exercise under the guidance of their primary and specialty care providers. For the vast majority, the benefits of a reasonable exercise plan far outweigh any risks.26  Whenever possible, medical staff supervising a training event should be aware of the baseline health of their athletes (eg, through a preparticipation physical examination) and must always consider the possibility of a new or undisclosed medical condition presenting during exercise.

An adequate warmup should be used as a UTP. Moreover, warmups have been shown to improve performance and prevent lower extremity injury.22,23  A warmup generally lasts 5 to 15 minutes and is intended to increase core temperature and heart rate, promote increased blood flow to the working musculature, and increase muscle and tendon elasticity. It should be similar to the actions that will be performed in the upcoming workout. A reasonable warmup begins with dynamic stretching and progresses to light- and then moderate-intensity exercise.24,25  The warmup is complete when the athlete has progressed to the sport- or exercise-specific movements for that day of training and is ready for higher-intensity movements.

Strength-training programs vary widely depending on each athlete's experience level, goals, interests, and available resources. Although a comprehensive discussion of proper strength-training principles is outside the scope of this review, several key principles deserve mention as UTPs. First, novices should include a variety of resistance exercises in a balanced program that involves all major muscle groups. These exercises should include concentric, eccentric, and isometric muscle actions and involve bilateral upper and lower extremities. As a starting point, athletes should use lower resistance and a repetition range that corresponds to an 8- to 12-repetition maximum (RM); athletes with more strength-training experience may consider progressing to heavier loads with fewer repetitions (1–6 RM). Generally, 3 to 4 sets of a single exercise are sufficient, and the recommended training frequency for 1 muscle group is 2 to 3 d/wk for novice training, progressing to 4 to 5 d/wk for advanced strength training based on the individual's goals and physical capacity.27,28  At least 2 d/wk of rest (consecutive or nonconsecutive) should be encouraged with even the most advanced strength training.29,30 

The key UTP specific to endurance training is a slow training-load progression. This can be difficult to measure and enforce in many situations. Endurance training should be progressed slowly over weeks to months, building on the individual's current baseline. This allows the cardiovascular and musculoskeletal systems to adapt congruently with increased distance and training volume.31  Various means of workload monitoring, such as the acute-to-chronic workload ratio, have shown promise for injury prevention.32,33  The types of metrics used in workload monitoring and means of gathering and analyzing these data vary widely by sport, and further research is needed. Tissue underloading may also increase the injury risk; therefore, training less is not always safer.34,51 

High-intensity interval training involves repetitive bouts of training at maximal or supramaximal aerobic speeds, thereby engaging anaerobic metabolism, and has been shown to improve o2max.35,36  Before athletes perform high-intensity interval training, their baseline fitness should be assessed, and then athletes may be progressed according to their current fitness levels. Importantly, athletes who carry the sickle cell trait should be educated on the benefits and dangers of high-intensity training, and emergency action plans (EAPs) must be in place. Two similar IATFs provided a valuable set of precautions that should be used with high-intensity training.2,6  They include acclimatizing exercise progressively, never using exercise as punishment, ensuring proper education and credentialing of exercise instructors, confirming that staff are up to date in cardiopulmonary resuscitation training, developing and practicing EAPs, and ensuring that staff members are aware of athletes' medical conditions.2,6 

Cooldown periods are widely used as part of a safe and effective exercise program; however, evidence for their effectiveness in preventing harm is scant. Nonetheless, we recommend this practice as a UTP based on rational experience and expert opinion.37,38  Cooldown periods consist of degressive lower-intensity exercise for 5 to 10 minutes, often incorporating static or dynamic stretching and foam rolling. This cooldown period allows a graded return to the resting heart rate and helps mitigate the ventilation-perfusion disparity and hyperventilation from intense exercise.39  Importantly, it also enables staff to observe and ensure that athletes recover sufficiently after strenuous events.

An emerging area of interest related to exercise progression and exertional injury prevention is the concept of transition-period accommodation or transitioning. Examples of transitioning include an athlete returning after an illness or injury, beginning a new program supervised by individuals who are uncertain of the athlete's physical fitness and capabilities, and returning to duty or play after a vacation or an extended break from training. These can be vulnerable periods for an athlete, especially if the detraining was due to illness or injury. In several studies4042,52  examining physiological changes during transitioning after illness or injury, researchers found negative changes in body composition and decrements in speed, muscle power, and aerobic capacity. Some performance decrements should be expected after a period of detraining or deconditioning, and each athlete needs to be considered individually and intentionally as training advances to prevent a new or recurrent injury.41,42,52 

Hydration is a well-accepted precaution against multiple exertion-related illnesses, and guidelines for both warfighters and athletes have been put forward.9,12,53  Importantly, hydration guidelines must consider the effects of work intensity, specific environments, clothing, and personal protective equipment (PPE).54  When individuals are exposed to heat stress, legislative bodies such as the US Occupational Safety and Health Administration and the American Conference of Governmental Industrial Hygienists recommend replacing fluids frequently, such as consuming 1 cup (250 mL) every 15 to 20 minutes when working in warm environments.54 

Given that self-perception of sweat loss is not an accurate reflection of fluid losses,55  objective measures such as urine studies or body mass changes can better guide hydration strategies. Brake and Bates56  reported that urine specific gravity is a good indicator of hydration status and an effective way to improve workforce awareness of hydration and reduce rates of dehydration. In addition to urine specific gravity, other approaches for measuring or predicting the onset of dehydration are of great interest. For example, wearable sensors for measuring real-time sweat sodium, pH, and other metabolites are emerging.57  Similarly, saliva and tears are being studied for markers of dehydration, but intraindividual and interindividual variability data are needed before these can be used.58 

The composition of the fluid ingested is also important, especially in hot and humid conditions and when meals are inadequate. Electrolyte replacement beverages are recommended during high-intensity exercise in hot weather.45,54  However, because they frequently have a high content of simple carbohydrates, sodium, or both, special consideration may be necessary for athletes with diabetes or hypertension, respectively, warranting individualized hydration strategies. A wide variety of products such as oral rehydration solutions59  and amylose starch–containing sports drinks60  have been studied. Nonetheless, small sample sizes and potential bias from sports drink industry sponsorship make interpreting the data challenging.

Hydration-monitoring and fluid-replacement strategies must be practical and easy for athletes to implement. Biochemical markers are not feasible in many sports, military, and occupational settings, and the authors61,62  of recent reviews have raised doubts about the accuracy of urine specific gravity or urine osmolality for estimating hydration status. Hypovolemia and increased plasma osmolality result in a consistent internal thirst response in both hot and cold climates. During exercise to which they are accustomed, drinking to thirst is an effective and practical strategy for most athletes to maintain hydration while avoiding hyponatremia. Planned drinking strategies may be optimal for prolonged exercise (>90 minutes), especially in the heat.53,63,64  Alternatively, athletes can be educated on sweat-rate calculations to estimate the amount of fluid losses that will need to be replaced during training or performance.9  The National Athletic Trainers' Association (NATA) encourages the development of individualized hydration strategies that consider the environment, type of sport, duration of activity, and available resources with the goal of maintaining euhydration.9  A summary of current preventive recommendations regarding hydration is given in Table 2.

Table 2

Strength of Recommendation Taxonomy for Precautions Related to Hydration That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Hydration That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Hydration That Should Be Universally Applied During Physical Training

Heat, humidity, and altitude have tremendous influences on the risk for exertional injury and must be accounted for as UTPs. Evidence shows these factors each impose a physiological burden, and the burden is greater when physical fitness is low. Exercising without proper environmental acclimatization can contribute to exertion-related events such as ECAST and exertional heat illness (EHI).45,6570  Athletic trainers, strength and conditioning coaches, and others involved in training should be aware of the risks and be able to provide guidance on how to sufficiently acclimatize to confer protection.7173 

In 2009, the NATA, along with an IATF, published guidelines for preventing EHI in high school sports, including a specific 14-day HA protocol.17  In a subsequent study, Kerr et al74  found that rates of EHI decreased in states mandating adherence to these guidelines. Like the NATA guidelines, the US Army recommends HA consisting of 2 weeks of daily heat exposure for about 2 h/d (that can be broken into two 1-hour exposures) combined with physical exercise (marching or jogging).12  Since the publication of the US Army Guidelines in 2003,12  subsequent systematic reviews and consensus guidelines have recommended approximately 1 to 2 weeks for HA, with heat exposure durations ranging from 60 to 120 min/d.45,71,72 

Regardless of the duration of HA, regular exercise in the heat is required to maintain acclimatization effects. For every day without heat exposure, an estimated decay of 2.5% of the physiological adaptations occurs to heart rate and sweat rate.71  Additionally, aerobic training in the heat confers greater thermoregulatory adaptations for exercise during conditions of uncompensable heat stress than can be attributed simply to an individual's o2max.75  Given that many training scenarios occur under conditions of uncompensable heat stress, aerobic training in the heat is critical and should be considered for any warfighter or athletic training program. Although often limited by resources, individualized HA plans that incorporate physiological status monitoring (eg, heart rate, skin and core temperature) may be beneficial because people acclimatize at different rates (5 to 14 days).71  Other general HA strategic tips are presented in Table 3. Regardless of the HA method chosen, continual study is needed to determine the effect of implementation across various settings and guide policy decisions.74 

Table 3

Strategic Tips for Ensuring Appropriate Heat Acclimatizationa

Strategic Tips for Ensuring Appropriate Heat Acclimatizationa
Strategic Tips for Ensuring Appropriate Heat Acclimatizationa

As for HA, a variety of guidelines exist for acclimatizing to altitude. The risk for high-altitude illness increases when the ascent is rapid and exertion is strenuous. No association has been demonstrated between age and the risk of developing acute mountain sickness.76  In a recent meta-analysis, researchers77  concluded that women may be at a slightly higher risk than men for developing acute mountain sickness (relative risk = 1.24; 95% CI = 1.09, 1.41). The amount of time required for a person to become acclimatized to altitude is a function of individual physiology (eg, aerobic fitness, hydration, concurrent medications) and the magnitude of the hypoxic challenge from the altitude attained. Currently, recommended schedules differ for low, moderate, and high altitudes. Because of the number of variables needed to develop individualized plans for acclimatization, an effective UTP would aid in minimizing high-altitude illness across all exertional activities at higher altitudes.

The US Army's published guideline, TB MED 505,78  provided excellent information for acclimatizing at altitude. The Wilderness Medical Society79  recommended gradual ascent (≤500 m/d at altitudes >3000 m) and a slow increase in sleeping elevation to prevent high-altitude illness. Currently, substantial efforts are focused on identifying biomarkers capable of measuring acclimatization, susceptibility, or both to high-altitude illness,80  which may assist with individualizing acclimatization decisions in the future. Some investigators are also now focusing on exposure to simulated altitude by using intermittent normobaric hypoxia (15%) for acclimatization before altitude exposure. Ghaleb et al81  exposed 10 men to intermittent normobaric hypoxia (15%) and found that 12 days were sufficient for acclimatization based on their cardiorespiratory responses (ie, heart rate, respiratory frequency, minute ventilation). Again, the duration and length of exposures will vary, depending on the anticipated final altitude where the mission or competition will take place. A summary of recommendations is provided in Table 4.

Table 4

Strength of Recommendation Taxonomy for Precautions Related to Environmental Conditions That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Environmental Conditions That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Environmental Conditions That Should Be Universally Applied During Physical Training

Acute and chronic cumulative stress, whether due to heat, exercise, insufficient sleep, or other factors, lowers the threshold for exertion-related injury. Adequate periods for recovery after strenuous exercise are critical as a UTP. The concept of work-rest cycles has been considered for many years in the military and by occupational safety specialists because of its influence on aerobic and anaerobic systems, overall health, and recovery. Work-rest cycles must be based on multiple factors, including exercise intensity, environmental conditions, PPE, clothing worn, and although frequently forgotten, sleep sufficiency.82  Military missions often require continuous operations in remote or austere environments in combination with insufficient or changing sleep patterns.83  Thus, guidelines for recovery from the stresses of physical training in diverse environmental conditions, including work-rest cycles and sleep, are recommended as UTPs.

Many websites offer specific instructions for the appropriate duration of work relative to the requisite rest period, which is typically determined based on temperature, humidity, and clothing or PPE (Table 5). In general, the instructions are to shorten or adjust work periods and increase rest periods in accordance with the following:

  • High temperature,

  • Sun strength or radiation,

  • Wearing protective clothing or gear,

  • High humidity,

  • Limited to no air movement, and

  • High work or exercise intensities.

Table 5

Selected Website Resources for Acclimatization and Other Universal Training Precautions

Selected Website Resources for Acclimatization and Other Universal Training Precautions
Selected Website Resources for Acclimatization and Other Universal Training Precautions

Importantly, new and unacclimatized athletes and workers should be assigned to lighter activity with longer rest periods and close monitoring until they are fully acclimatized. The Figure presents the current hydration or fluid replacement and work-rest cycle recommendations used throughout the military.

Figure

Fluid replacement and work-rest cycle guidelines for training in warm and hot environments. a Rest indicates minimal activity and in shade, if possible. b Hourly fluid intake should not exceed 1.5 qt (1.4 L), and daily fluid intake should not exceed 12 qt (11.4 L). Abbreviation: NL, no limit to work time per hour (up to 4 h). Adapted.12 

Figure

Fluid replacement and work-rest cycle guidelines for training in warm and hot environments. a Rest indicates minimal activity and in shade, if possible. b Hourly fluid intake should not exceed 1.5 qt (1.4 L), and daily fluid intake should not exceed 12 qt (11.4 L). Abbreviation: NL, no limit to work time per hour (up to 4 h). Adapted.12 

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Sleep is often overlooked as a factor for health, performance, and injury prevention. It serves a vital role in the repair and growth of tissue and in brain function. Negative performance effects stemming from sleep loss and increased time awake include decreased reaction time, accuracy, vigor, strength, endurance, and ability to move and track objects with the eyes.53,84  Inadequate sleep also impairs cognition and increases the risks for EHI and musculoskeletal injury.85  Authors85  of systematic reviews have suggested that individuals sleeping <8 hours per night or having frequent nighttime awakenings are more likely to sustain musculoskeletal injury. Sleep loss is associated with increased activity of the sympathetic nervous system and hypothalamus, leading to proinflammatory responses and increased stress responsivity, pain, emotional distress, mood disorders, and cognitive and memory deficits.86  In light of these data, sleep must be considered as a UTP alongside work-rest cycles and recovery factors. At least 8 hours of sleep per night is considered optimal for most individuals. However, high-level athletes may require additional sleep for full recovery. Finally, accrued sleep is counted as the actual time spent sleeping and must not include time spent in bed trying to fall asleep.87  A summary of sleep recommendations per age group is shown in Table 6. Ratings from SORT for precautions related to sleep, recovery, and work-rest cycles are supplied in Table 7.

Table 6

Sleep Duration Recommendations as Universal Training Precaution Guidelines

Sleep Duration Recommendations as Universal Training Precaution Guidelines
Sleep Duration Recommendations as Universal Training Precaution Guidelines
Table 7

Strength of Recommendation Taxonomy for Precautions Related to Recovery, Sleep, and Work-Rest Cycles That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Recovery, Sleep, and Work-Rest Cycles That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Recovery, Sleep, and Work-Rest Cycles That Should Be Universally Applied During Physical Training

Given that many drugs and dietary supplements increase the risk for exertion-related injuries, proper limitation or avoidance of these substances must be observed as a UTP. Of particular concern are stimulants and other ingredients that affect the cardiovascular system.8890  Many energy drinks, preworkout supplements, sexual enhancers, and weight-loss supplements contain various sympathomimetics, caffeine, herbal compounds, or other ingredients or drugs that can mediate vasoconstriction and increase heart rate and metabolic heat load, raising the risk for exertion-related injuries.91  All prescription drugs and dietary supplements should be carefully reviewed and cleared, and any product containing >300 mg per serving of caffeine should be prohibited. Medical teams are encouraged to consider educating athletes regarding the risks of taking weight-loss, preworkout, and other drugs or dietary supplements containing ≥1 stimulant and discourage athletes from taking these (Table 8).93 

Table 8

Strength of Recommendation Taxonomy for Precautions Related to Medications and Dietary Supplements That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Medications and Dietary Supplements That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Medications and Dietary Supplements That Should Be Universally Applied During Physical Training

Intangible factors such as motivation,92,9496  peer pressure,97,98  and leadership99  may powerfully influence the risk of injury or harm during physical training. In the military and athletic environments, competition is expected and can be highly beneficial when managed correctly. Similarly, encouragement among teammates is common and generally agreed to be beneficial. However, historically, when motivational techniques or the culture of an organization has become overbearing, toxic, or excessively punitive, individuals or teams have been detrimentally affected.100,101  Recommended precautions related to leadership, culture, and preparedness are summarized in Table 9.

Table 9

Strength of Recommendation Taxonomy for Precautions Related to Leadership, Culture, and Preparedness That Should Be Universally Applied During Physical Training

Strength of Recommendation Taxonomy for Precautions Related to Leadership, Culture, and Preparedness That Should Be Universally Applied During Physical Training
Strength of Recommendation Taxonomy for Precautions Related to Leadership, Culture, and Preparedness That Should Be Universally Applied During Physical Training

As a UTP, teams and military units should adhere to principles of leadership, motivation, and organizational culture that clearly value the well-being of team members and avoid misuse or abuse of motivational techniques. When motivation starts to move beyond producing positive adaptations and instead creates negative ones, including possible health risks, then the technique has been carried too far. The goal is to create a positive milieu throughout practices to ensure readiness for the mission or competition. Because peer pressure can be a powerful motivator and lead to impaired judgment, measures such as education on signs of distress, using buddy systems, and destigmatizing the seeking of medical attention should be considered as UTPs. During sports and military training, adolescents and young adults spend abundant time around their peers. Researchers97  have suggested that peer-related stimuli may excite the reward system to respond to the values of risky behavior. Peer pressure, whether overt or merely internally perceived by young athletes, may influence them to ignore the signs and symptoms of physiological distress during exercise. Moreover, some persons are powerfully internally motivated to perform at any cost and may not pay attention to their internal cues. The primed reward system of making the group proud and pushing through self-warning symptoms might favor short-term benefits over long-term safe alternatives. Therefore, as a UTP, coaches and leaders must destigmatize seeking help or taking a time out for health or safety checks. Buddy systems provide another means of stopping a teammate who may be showing signs of distress but internally driven to continue at all costs.

Some leadership styles may be coercive or perhaps unintentionally perceived as same. Hence, another UTP consideration may be to avoid having a high-ranking superior lead group fitness tests, as additional pressure can be exerted for athletes to finish a high-intensity workout or physical fitness test.104  Investigators97  have noted that adolescents exhibited stronger risk-taking behavior geared at immediate reward when they believed they were being observed. Thus, leaders and coaches have a responsibility to discuss and preempt these types of concerns and ensure that their warfighters and athletes are comfortable raising a flag or seeking medical attention.102 

Finally, a critically important UTP under the auspice of leadership is to create and regularly practice EAPs.103  Whereas much of the responsibility for the EAP rests with leadership, medical staff also have a duty to make recommendations to leaders and take appropriate actions to ensure an EAP is in place and regularly practiced. Properly trained medical personnel, such as certified athletic trainers and emergency medical services personnel, should be involved in EAP development. Training or coaching staff and medical personnel must be educated on the early signs of distress, when to call for onsite medical assistance, and how to activate emergency medical services. The EAP may include “go or no-go” decision criteria for individual athletes or the team based on factors such as current illness or weather conditions. As part of the EAP, leaders and medical personnel should outline relevant aspects of medical coverage, including the specific types of events requiring medical personnel onsite versus on call, the types of medical personnel required, and the equipment and supplies that must be accessible. Except in precluding circumstances, an automated external defibrillator and oxygen must be available in case of emergency.105 

Given the inherent health risks of physical training, especially under pressure to achieve victory, a variety of steps must be taken universally and preemptively to minimize the risk of harm, ranging from minor musculoskeletal injuries to severe exertion-related illness or even death. Termed UTPs, these measures should be used with all warfighters and athletes and across all types of physical training. A collaborative approach, beginning with leadership and including all medical staff and training staff or coaches, will result in the best outcomes. Training precautions should be applied not only universally but also in a rational and systematized manner. Opportunities should be sought for continuous process improvement as changes are made and better methods are discovered. Because each UTP being recommended exists on a spectrum (eg, altitude, baseline fitness level, leadership styles), the specific method of applying each UTP must be determined by trained sports and medical professionals and leaders within each setting. Further research is required to determine the effectiveness and applicability of these UTPs and guide future policy development.

This project was completed without grants; however, US Department of Defense equipment and facilities were used in data collection, analysis, and writing. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy or position of Fort Belvoir Community Hospital, the Defense Health Agency, Department of Defense, or US Government.

1.
O'Connor
FG
,
Bergeron
MF
,
Cantrell
J
, et al.
ACSM and CHAMP summit on sickle cell trait: mitigating risks for warfighters and athletes
.
Med Sci Sports Exerc
.
2012
;
44
(
11
):
2045
2056
.
2.
Casa
DJ
,
Anderson
SA
,
Baker
L
, et al.
The inter-association task force for preventing sudden death in collegiate conditioning sessions: best practices recommendations
.
J Athl Train
.
2012
;
47
(
4
):
477
480
.
3.
Webber
BJ
,
Casa
DJ
,
Beutler
AI
,
Nye
NS
,
Trueblood
WE
,
O'Connor
FG
.
Preventing exertional death in military trainees: recommendations and treatment algorithms from a multidisciplinary working group
.
Mil Med
.
2016
;
181
(
4
):
311
318
.
4.
Drezner
JA
,
Sharma
S
,
Baggish
A
, et al.
International criteria for electrocardiographic interpretation in athletes: consensus statement
.
Br J Sports Med
.
2017
;
51
(
9
):
704
731
.
5.
Hosokawa
Y
,
Casa
DJ
,
Trtanj
JM
, et al.
Activity modification in heat: critical assessment of guidelines across athletic, occupational, and military settings in the USA
.
Int J Biometeorol
.
2019
;
63
(
3
):
405
427
.
6.
Casa
DJ
,
Almquist
J
,
Anderson
SA
, et al.
The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations
.
J Athl Train
.
2013
;
48
(
4
):
546
553
.
7.
Casa
DJ
,
Stearns
RL
,
eds.
Emergency Management for Sport and Physical Activity. Jones & Bartlett Learning;
2015
.
8.
McCrory
P
,
Meeuwisse
W
,
Dvořák
J
, et al.
Consensus statement on concussion in sport-the 5th International Conference on Concussion in Sport held in Berlin, October 2016
.
Br J Sports Med
.
2017
;
51
(
11
):
838
847
.
9.
McDermott
BP
,
Anderson
SA
,
Armstrong
LE
, et al.
National Athletic Trainers' Association position statement: fluid replacement for the physically active
.
J Athl Train
.
2017
;
52
(
9
):
877
895
.
10.
Molloy
JM
,
Pendergrass
TL
,
Lee
IE
,
Chervak
MC
,
Hauret
KG
,
Rhon
DI
.
Musculoskeletal injuries and United States Army readiness, part I: overview of injuries and their strategic impact
.
Mil Med
.
2020
;
185
(
9–10
):
e1461
e1471
.
11.
Molloy
JM
,
Pendergrass
TL
,
Lee
IE
,
Hauret
KG
,
Chervak
MC
,
Rhon
DI
.
Musculoskeletal injuries and United States Army readiness, part II: management challenges and risk mitigation initiatives
.
Mil Med
.
2020
;
185
(
9–10
):
e1472
e1480
.
12.
Heat Stress Control and Heat Casualty Management
.
Dept of the Army and Air Force; 2003. Army Technical Bulletin, Medical 507/Air Force Pamphlet 48-152(I). Accessed October 9, 2021.
13.
O'Connor
FG
,
Franzos
MA
,
Nye
NS
, et al.
Summit on exercise collapse associated with sickle cell trait: finding the “way ahead.”
Curr Sports Med Rep
.
2021
;
20
(
1
):
47
56
.
14.
Kark
JA
,
Ward
FT
.
Exercise and hemoglobin S
.
Semin Hematol
.
1994
;
31
(
3
):
181
225
.
15.
McGrew
C
,
MacCallum
DS
,
Narducci
D
, et al.
AMSSM position statement update: blood-borne pathogens in the context of sports participation
.
Clin J Sport Med
.
2020
;
30
(
4
):
283
290
.
16.
Mabachi
NM
,
Cifuentes
M
,
Barnard
J
, et al.
Demonstration of the Health Literacy Universal Precautions Toolkit: lessons for quality improvement
.
J Ambul Care Manage
.
2016
;
39
(
3
):
199
208
.
17.
Casa
DJ
,
Csillan
D
;
Inter-Association Task Force for Preseason Secondary School Athletics Participants;
LE
Armstrong
,
Baker
LB
,
Bergeron
MF
, et al.
Preseason heat-acclimatization guidelines for secondary school athletics
.
J Athl Train
.
2009
;
44
(
3
):
332
333
.
18.
Nindl
BC
,
Beals
K
,
Witchalls
J
,
Friedl
KE
.
Military human performance optimization and injury prevention: strategies for the 21st century warfighter
.
J Sci Med Sport
.
2017
;
20
(
suppl 4
):
S1
S2
.
19.
Nelson
DA
,
Deuster
PA
,
Carter
R
,
Hill
OT
,
Wolcott
VL
,
Kurina
LM
.
Sickle cell trait, rhabdomyolysis, and mortality among U.S. Army soldiers
.
N Engl J Med
.
2016
;
375
(
5
):
435
442
.
20.
Kraemer
WJ
,
Ratamess
NA
.
Fundamentals of resistance training: progression and exercise prescription
.
Med Sci Sports Exerc
.
2004
;
36
(
4
):
674
688
.
21.
Scribbans
TD
,
Vecsey
S
,
Hankinson
PB
,
Foster
WS
,
Gurd
BJ
.
The effect of training intensity on Vo2max in young healthy adults: a meta-regression and meta-analysis
.
Int J Exerc Sci
.
2016
;
9
(
2
):
230
247
.
22.
Fradkin
AJ
,
Zazryn
TR
,
Smoliga
JM
.
Effects of warming-up on physical performance: a systematic review with meta-analysis
.
J Strength Cond Res
.
2010
;
24
(
1
):
140
148
.
23.
Silvers-Granelli
HJ
,
Bizzini
M
,
Arundale
A
,
Mandelbaum
BR
,
Snyder-Mackler
L.
Does the FIFA 11+ injury prevention program reduce the incidence of ACL injury in male soccer players?
Clin Orthop Relat Res
.
2017
;
475
(
10
):
2447
2455
.
24.
Safran
MR
,
Seaber
AV
,
Garrett
WE
.
Warm-up and muscular injury prevention: an update
.
Sports Med
.
1989
;
8
(
4
):
239
249
.
25.
Zeno
SA
,
Purvis
D
,
Crawford
C
,
Lee
C
,
Lisman
P
,
Deuster
PA
.
Warm-ups for military fitness testing: rapid evidence assessment of the literature
.
Med Sci Sports Exerc
.
2013
;
45
(
7
):
1369
1376
.
26.
Hoffmann
TC
,
Maher
CG
,
Briffa
T
, et al.
Prescribing exercise interventions for patients with chronic conditions
.
CMAJ
.
2016
;
188
(
7
):
510
518
.
27.
American College of Sports Medicine
.
American College of Sports Medicine position stand: progression models in resistance training for healthy adults
.
Med Sci Sports Exerc
.
2009
;
41
(
3
):
687
708
.
28.
Fragala
MS
,
Cadore
EL
,
Dorgo
S
, et al.
Resistance training for older adults: position statement from the National Strength and Conditioning Association
.
J Strength Cond Res
.
2019
;
33
(
8
):
2019
2052
.
29.
Orlando
C
,
Levitan
EB
,
Mittleman
MA
,
Steele
RJ
,
Shrier
I.
The effect of rest days on injury rates
.
Scand J Med Sci Sports
.
2011
;
21
(
6
):
e64
e71
.
30.
Yang
Y
,
Bay
PB
,
Wang
YR
,
Huang
J
,
Teo
HWJ
,
Goh
J.
Effects of consecutive versus non-consecutive days of resistance training on strength, body composition, and red blood cells
.
Front Physiol
.
2018
;
9
:
725
.
31.
Craig
DI
.
Medial tibial stress syndrome: evidence-based prevention
.
J Athl Train
.
2008
;
43
(
3
):
316
318
.
32.
Hulin
BT
,
Gabbett
TJ
,
Lawson
DW
,
Caputi
P
,
Sampson
JA
.
The acute:chronic workload ratio predicts injury: high chronic workload may decrease injury risk in elite rugby league players
.
Br J Sports Med
.
2016
;
50
(
4
):
231
236
.
33.
Soligard
T
,
Schwellnus
M
,
Alonso
JM
, et al.
How much is too much? (Part 1) International Olympic Committee consensus statement on load in sport and risk of injury
.
Br J Sports Med
.
2016
;
50
(
17
):
1030
1041
.
34.
Gabbett
TJ
.
How much? How fast? How soon? Three simple concepts for progressing training loads to minimize injury risk and enhance performance
.
J Orthop Sports Phys Ther
.
2020
;
50
(
10
):
570
573
.
35.
Milanović
Z
,
Sporiš
G
,
Weston
M.
Effectiveness of high-intensity interval training (HIT) and continuous endurance training for Vo2max improvements: a systematic review and meta-analysis of controlled trials
.
Sports Med
.
2015
;
45
(
10
):
1469
1481
.
36.
Weston
M
,
Taylor
KL
,
Batterham
AM
,
Hopkins
WG
.
Effects of low-volume high-intensity interval training (HIT) on fitness in adults: a meta-analysis of controlled and non-controlled trials
.
Sports Med
.
2014
;
44
(
7
):
1005
1017
.
37.
Crowther
FA
,
Sealey
RM
,
Crowe
MJ
,
Edwards
AM
,
Halson
SL
.
Effects of various recovery strategies on repeated bouts of simulated intermittent activity
.
J Strength Cond Res
.
2019
;
33
(
7
):
1781
1794
.
38.
Van Hooren
B
,
Peake
JM
.
Do we need a cool-down after exercise? A narrative review of the psychophysiological effects and the effects on performance, injuries and the long-term adaptive response
.
Sports Med
.
2018
;
48
(
7
):
1575
1595
.
39.
Koyama
Y
,
Koike
A
,
Yajima
T
,
Kano
H
,
Marumo
F
,
Hiroe
M.
Effects of ‘cool-down' during exercise recovery on cardiopulmonary systems in patients with coronary artery disease
.
Jpn Circ J
.
2000
;
64
(
3
):
191
196
.
40.
Silva
JR
,
Brito
J
,
Akenhead
R
,
Nassis
GP
.
The transition period in soccer: a window of opportunity
.
Sports Med
.
2016
;
46
(
3
):
305
313
.
41.
Castillo
D
,
Cámara
J
,
Castagna
C
,
Yanci
J.
Effects of the off-season period on field and assistant soccer referees' physical performance
.
J Hum Kinet
.
2017
;
56
:
159
166
.
42.
Caterisano
A
,
Decker
D
,
Snyder
B
, et al.
CSCCa and NSCA joint consensus guidelines for transition periods: safe return to training following inactivity
.
Strength Cond J
.
2019
;
41
(
3
):
1
23
.
43.
O'Connor
FG
,
Adams
WB
,
Madsen
CM
, et al.
Managing the collapsed runner: Marine Corps Marathon medical triage and algorithms 2020. Consortium for Health and Military Performance. Accessed October 10, 2020.
44.
Nindl
BC
,
Williams
TJ
,
Deuster
PA
,
Butler
NL
,
Jones
BH
.
Strategies for optimizing military physical readiness and preventing musculoskeletal injuries in the 21st century
.
US Army Med Dep J
.
2013
:
5
23
.
45.
Roberts
WO
,
Armstrong
LE
,
Sawka
MN
,
Yeargin
SW
,
Heled
Y
,
O'Connor
FG
.
ACSM expert consensus statement on exertional heat illness: recognition, management, and return to activity
.
Curr Sports Med Rep
.
2021
;
20
(
9
):
470
484
.
46.
Ebell
MH
,
Siwek
J
,
Weiss
BD
, et al.
Strength of Recommendation Taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature
.
Am Fam Physician
.
2004
;
69
(
3
):
548
556
.
47.
Gappmaier
E.
The Submaximal Clinical Exercise Tolerance Test (SXTT) to establish safe exercise prescription parameters for patients with chronic disease and disability
.
Cardiopulmon Phys Ther J
.
2012
;
23
(
2
):
19
29
.
48.
Faigenbaum
AD
,
Kraemer
WJ
,
Blimkie
CJ
, et al.
Youth resistance training: updated position statement paper from the national strength and conditioning association
.
J Strength Cond Res
.
2009
;
23
(
5 suppl
):
S60
S79
.
49.
Kilpatrick
MW
,
Robertson
RJ
,
Powers
JM
,
Mears
JL
,
Ferrer
NF
.
Comparisons of RPE before, during, and after self-regulated aerobic exercise
.
Med Sci Sports Exerc
.
2009
;
41
(
3
):
682
687
.
50.
Strength
Werner G.
and conditioning techniques in the rehabilitation of sports injury
.
Clin Sports Med
.
2010
;
29
(
1
):
177
191
,
table of contents. doi:10.1016/j.csm.2009.09.012
51.
Gabbett
TJ
.
The training-injury prevention paradox: should athletes be training smarter and harder?
Br J Sports Med
.
2016
;
50
(
5
):
273
280
.
52.
Marcos
MA
,
Koulla
PM
,
Anthos
ZI
.
Preseason maximal aerobic power in professional soccer players among different divisions
.
J Strength Cond Res
.
2018
;
32
(
2
):
356
363
.
53.
Vitale
K
,
Getzin
A.
Nutrition and supplement update for the endurance athlete: review and recommendations
.
Nutrients
.
2019
;
11
(
6
):
1289
.
54.
Kenefick
RW
,
Sawka
MN
.
Hydration at the work site
.
J Am Coll Nutr
.
2007
;
26
(
5 suppl
):
597S
603S
.
55.
Muth
T
,
Pritchett
R
,
Pritchett
K
,
Depaepe
J
,
Blank
R.
Hydration status and perception of fluid loss in male and female university rugby union players
.
Int J Exerc Sci
.
2019
;
12
(
3
):
859
870
.
56.
Brake
DJ
,
Bates
GP
.
Fluid losses and hydration status of industrial workers under thermal stress working extended shifts
.
Occup Environ Med
.
2003
;
60
(
2
):
90
96
.
57.
Zhao
Y
,
Wang
B
,
Hojaiji
H
, et al.
A wearable freestanding electrochemical sensing system
.
Sci Adv
.
2020
;
6(12):eaaz0007.
58.
Villiger
M
,
Stoop
R
,
Vetsch
T
, et al.
Evaluation and review of body fluids saliva, sweat and tear compared to biochemical hydration assessment markers within blood and urine
.
Eur J Clin Nutr
.
2018
;
72
(
1
):
69
76
.
59.
Schleh
MW
,
Dumke
CL
.
Comparison of sports drink versus oral rehydration solution during exercise in the heat
.
Wilderness Environ Med
.
2018
;
29
(
2
):
185
193
.
60.
O'Connell
SM
,
Woodman
RJ
,
Brown
IL
, et al.
Comparison of a sports-hydration drink containing high amylose starch with usual hydration practice in Australian rules footballers during intense summer training
.
J Int Soc Sports Nutr
.
2018
;
15
(
1
):
46
.
61.
Zubac
D
,
Paravlic
A
,
Reale
R
,
Jelaska
I
,
Morrison
SA
,
Ivancev
V.
Fluid balance and hydration status in combat sport Olympic athletes: a systematic review with meta-analysis of controlled and uncontrolled studies
.
Eur J Nutr
.
2019
;
58
(
2
):
497
514
.
62.
Zubac
D
,
Reale
R
,
Karnincic
H
,
Sivric
A
,
Jelaska
I.
Urine specific gravity as an indicator of dehydration in Olympic combat sport athletes: considerations for research and practice
.
Eur J Sport Sci
.
2018
;
18
(
7
):
920
929
.
63.
Hoffman
MD
.
Proper hydration during ultra-endurance activities
.
Sports Med Arthrosc Rev
.
2019
;
27
(
1
):
8
14
.
64.
Kenefick
RW
.
Drinking strategies: planned drinking versus drinking to thirst
.
Sports Med
.
2018
;
48
(
suppl 1
):
31
37
.
65.
Nelson
DA
,
Deuster
PA
,
O'Connor
FG
,
Kurina
LM
.
Sickle cell trait and heat injury among US Army soldiers
.
Am J Epidemiol
.
2018
;
187
(
3
):
523
528
.
66.
Franklin
QJ
,
Compeggie
M.
Splenic syndrome in sickle cell trait: four case presentations and a review of the literature
.
Mil Med
.
1999
;
164
(
3
):
230
233
.
67.
Sheikha
A.
Splenic syndrome in patients at high altitude with unrecognized sickle cell trait: splenectomy is often unnecessary
.
Can J Surg
.
2005
;
48
(
5
):
377
381
.
68.
Thiriet
P
,
Le Hesran
JY
,
Wouassi
D
,
Bitanga
E
,
Gozal
D
,
Louis
FJ
.
Sickle cell trait performance in a prolonged race at high altitude
.
Med Sci Sports Exerc
.
1994
;
26
(
7
):
914
918
.
69.
Singer
DE
,
Byrne
C
,
Chen
L
,
Shao
S
,
Goldsmith
J
,
Niebuhr
DW
.
Risk of exertional heat illnesses associated with sickle cell trait in U.S. Military
.
Mil Med
.
2018
;
183
(
7–8
):
e310
e317
.
70.
Adams
WM
,
Hosokawa
Y
,
Casa
DJ
, et al.
Roundtable on preseason heat safety in secondary school athletics: heat acclimatization
.
J Athl Train
.
2021
;
56
(
4
):
352
361
.
71.
Daanen
HAM
,
Racinais
S
,
Périard
JD
.
Heat acclimation decay and re-induction: a systematic review and meta-analysis
.
Sports Med
.
2018
;
48
(
2
):
409
430
.
72.
Rahimi
GRM
,
Albanaqi
AL
,
Van der Touw
T
,
Smart
NA
.
Physiological responses to heat acclimation: a systematic review and meta-analysis of randomized controlled trials
.
J Sports Sci Med
.
2019
;
18
(
2
):
316
326
.
73.
Saunders
PU
,
Garvican-Lewis
LA
,
Chapman
RF
,
Périard
JD
.
Special environments: altitude and heat
.
Int J Sport Nutr Exerc Metab
.
2019
;
29
(
2
):
210
219
.
74.
Kerr
ZY
,
Register-Mihalik
JK
,
Pryor
RR
, et al.
The association between mandated preseason heat acclimatization guidelines and exertional heat illness during preseason high school American football practices
.
Environ Health Perspect
.
2019
;
127
(
4
):
47003
.
75.
Ravanelli
N
,
Gagnon
D
,
Imbeault
P
,
Jay
O.
A retrospective analysis to determine if exercise training-induced thermoregulatory adaptations are mediated by increased fitness or heat acclimation
.
Exp Physiol
.
2021
;
106
(
1
):
282
289
.
76.
Wu
Y
,
Zhang
C
,
Chen
Y
,
Luo
YJ
.
Association between acute mountain sickness (AMS) and age: a meta-analysis
.
Mil Med Res
.
2018
;
5
(
1
):
14
.
77.
Hou
YP
,
Wu
JL
,
Tan
C
,
Chen
Y
,
Guo
R
,
Luo
YJ
.
Sex-based differences in the prevalence of acute mountain sickness: a meta-analysis
.
Mil Med Res
.
2019
;
6
(
1
):
38
.
78.
Altitude Acclimatization and Illness Management
.
Headquarters, Department of the Army; 2010. Technical Bulletin Medical 505. Accessed October 9, 2021.
79.
Luks
AM
,
Auerbach
PS
,
Freer
L
, et al.
Wilderness Medical Society clinical practice guidelines for the prevention and treatment of acute altitude illness: 2019 update
.
Wilderness Environ Med
.
2019
;
30
(
4S
):
S3
S18
.
80.
Paul
S
,
Gangwar
A
,
Bhargava
K
,
Khurana
P
,
Diagnosis
Ahmad Y.
and prophylaxis for high-altitude acclimatization: adherence to molecular rationale to evade high-altitude illnesses
.
Life Sci
.
2018
;
203
:
171
176
.
81.
Ghaleb
AM
,
Ramadan
MZ
,
Badwelan
A
,
Mansour
L
,
Al-Tamimi
J
,
Aljaloud
KS
.
Determining the time needed for workers to acclimatize to hypoxia
.
Int J Biometeorol
.
2020
;
64
(
12
):
1995
2005
.
82.
Vitale
KC
,
Owens
R
,
Hopkins
SR
,
Malhotra
A.
Sleep hygiene for optimizing recovery in athletes: review and recommendations
.
Int J Sports Med
.
2019
;
40
(
8
):
535
543
.
83.
Good
CH
,
Brager
AJ
,
Capaldi
VF
,
Mysliwiec
V.
Sleep in the United States military
.
Neuropsychopharmacology
.
2020
;
45
(
1
):
176
191
.
84.
Tong
J
,
Maruta
J
,
Heaton
KJ
, et al.
Degradation of binocular coordination during sleep deprivation
.
Front Neurol
.
2016
;
7
:
90
.
85.
Gao
B
,
Dwivedi
S
,
Milewski
MD
,
Cruz
AI
.
Lack of sleep and sports injuries in adolescents: a systematic review and meta-analysis
.
J Pediatr Orthop
.
2019
;
39
(
5
):
e324
e333
.
86.
Medic
G
,
Wille
M
,
Hemels
ME
.
Short- and long-term health consequences of sleep disruption
.
Nat Sci Sleep
.
2017
;
9
:
151
161
.
87.
Chaput
JP
,
Dutil
C
,
Sampasa-Kanyinga
H.
Sleeping hours: what is the ideal number and how does age impact this?
Nat Sci Sleep
.
2018
;
10
:
421
430
.
88.
Brown
AC
.
An overview of herb and dietary supplement efficacy, safety and government regulations in the United States with suggested improvements, part 1 of 5 series
.
Food Chem Toxicol
.
2017
;
107
(
pt A
):
449
471
.
89.
Martinez
M
,
Devenport
L
,
Saussy
J
,
Martinez
J.
Drug-associated heat stroke
.
South Med J
.
2002
;
95
(
8
):
799
802
.
90.
Mladěnka
P
,
Applová
L
,
Patočka
J
, et al
TOX-OER and CARDIOTOX Hradec Králové Researchers and Collaborators. Comprehensive review of cardiovascular toxicity of drugs and related agents
.
Med Res Rev
.
2018
;
38
(
4
):
1332
1403
.
91.
Ely
BR
,
Ely
MR
,
Cheuvront
SN
.
Marginal effects of a large caffeine dose on heat balance during exercise-heat stress
.
Int J Sport Nutr Exerc Metab
.
2011
;
21
(
1
):
65
70
.
92.
Ramme
AJ
,
Vira
S
,
Alaia
MJ
,
Van de Leuv
J
,
Rothberg
RC
.
Exertional rhabdomyolysis after spinning: case series and review of the literature
.
J Sports Med Phys Fitness
.
2016
;
56
(
6
):
789
793
.
93.
Figueredo
VM
.
Chemical cardiomyopathies: the negative effects of medications and nonprescribed drugs on the heart
.
Am J Med
.
2011
;
124
(
6
):
480
488
.
94.
Mousavi
SH
,
Hijmans
JM
,
Minoonejad
H
,
Rajabi
R
,
Zwerver
J.
Factors associated with lower limb injuries in recreational runners: a cross-sectional survey including mental aspects and sleep quality
.
J Sports Sci Med
.
2021
;
20
(
2
):
204
215
.
95.
Abenza-Cano
L
,
Chung
LH
,
Vaquero-Cristóbal
R
,
Mateo-Orcajada
A
,
Encarnación-Martinez
A.
Psychological profile in female cyclists and its relationship with age, training parameters, sport performance, and injury incidence
.
Int J Environ Res Public Health
.
2021
;
18
(
7
):
3825
.
96.
Renton
T
,
Petersen
B
,
Kennedy
S.
Investigating correlates of athletic identity and sport-related injury outcomes: a scoping review
.
BMJ Open
.
2021
;
11
(
4
):
e044199
.
97.
Albert
D
,
Chein
J
,
Steinberg
L.
Peer influences on adolescent decision making
.
Curr Dir Psychol Sci
.
2013
;
22
(
2
):
114
120
.
98.
Tjong
VK
,
Baker
HP
,
Cogan
CJ
,
Montoya
M
,
Lindley
TR
,
Terry
MA
.
Concussions in NCAA varsity football athletes: a qualitative investigation of player perception and return to sport
.
J Am Acad Orthop Surg Glob Res Rev
.
2017
;
1
(
8
):
e070
.
99.
Scott
SJ
,
Feltwell
DN
,
Knapik
JJ
, et al.
A multiple intervention strategy for reducing femoral neck stress injuries and other serious overuse injuries in U.S. Army Basic Combat Training
.
Mil Med
.
2012
;
177
(
9
):
1081
1089
.
100.
Acevedo
N.
University of Maryland settles with family of football player who died of heatstroke: parents of Jordan McNair, 19, who died of heatstroke in 2018 after an off-season football workout, to receive $3.5 million. NBC News. January 16, 2021. Accessed October 18, 2022.
101.
Eichner
ER
.
Football team rhabdomyolysis: the pain beats the gain and the coach is to blame
.
Curr Sports Med Rep
.
2018
;
17
(
5
):
142
143
.
102.
O'Connor
FG
,
Grunberg
NE
,
Harp
JB
,
Deuster
PA
.
Exertion-related illness: the critical roles of leadership and followership
.
Curr Sports Med Rep
.
2020
;
19
(
1
):
35
39
.
103.
Drezner
JA
,
Courson
RW
,
Roberts
WO
,
Mosesso
VN
,
Link
MS
,
Maron
BJ
.
Inter-association task force recommendations on emergency preparedness and management of sudden cardiac arrest in high school and college athletic programs: a consensus statement
.
J Athl Train
.
2007
;
42
(
1
):
143
158
.
104.
Raleigh
MF
,
Barrett
JP
,
Jones
BD
,
Beutler
AI
,
Deuster
PA
,
O'Connor
FG
.
A cluster of exertional rhabdomyolysis cases in a ROTC program engaged in an extreme exercise program
.
Mil Med
.
2018
;
183
(
suppl 1
):
516
521
.
105.
Drezner
JA
.
Preparing for sudden cardiac arrest–the essential role of automated external defibrillators in athletic medicine: a critical review
.
Br J Sports Med
.
2009
;
43
(
9
):
702
707
.