[Heat-related illnesses: advice for clinicians and healthcare professionals]. / Maladies liées à la chaleur : conseils aux médecins et professionnels de santé.

The increase in heatwaves, a significant consequence of global warming, represents a major public health issue and is the main cause of death related to hyperthermia. The seriousness of such exposure to extreme ambient temperature lies in the difficulty to the general population to identify the warning signs and take appropriate protective measures. This article therefore presents guidelines for the prevention, recognition and treatment of heat-related illnesses, and thus arms clinicians and healthcare professionals who are on the front line in protecting the general population from this 'silent killer'.

L'augmentation des épisodes de canicule, conséquence notable du changement climatique, constitue un enjeu majeur de santé publique et représente la principale cause de mortalité liée à l'hyperthermie. La gravité de ces épisodes de chaleur extrême réside dans la difficulté pour la population générale d'identifier les signes avant-coureurs et de mettre en place des mesures de protection adéquates. Cet article présente des directives pour la prévention, la reconnaissance et le traitement des maladies liées à la chaleur, afin d'équiper les médecins et professionnels de santé qui sont en première ligne pour protéger la population générale de ce « tueur silencieux ¼.

High-level performances following low altitude training and tapering in warm environments in elite racewalkers.

Current guidelines for prolonged altitude exposure suggest altitude levels ranging from 2000 to 2500 m to optimize an increase in total hemoglobin mass (Hbmass). However, natural low altitude locations (<2000 m) remain popular, highlighting the interest to investigate any possible benefit of low altitude camps for endurance athletes. Ten elite racewalkers (4 women and 6 men) underwent a 4-week "live high-train high" (LHTH) camp at an altitude of 1720 m (PIO2 = 121 mmHg; 20.1°C; 67% relative humidity [RH]), followed by a 3-week tapering phase (20 m; PIO2 = 150 mmHg; 28.3°C; 53% RH) in preparation for the World Athletics Championships (WC). Venous blood samples were withdrawn weekly during the entire observation period. In addition, blood volumes were determined weekly by carbon monoxide rebreathing during altitude exposure and 2 weeks after return to sea level. High-level performances were achieved at the WC (five placings among the Top 10 WC races and three all-time career personal bests). A slight but significant increase in absolute (+1.7%, p = 0.03) and relative Hbmass (+2.3%, p = 0.02) was observed after 4-week LHTH. In addition, as usually observed during LHTH protocols, weekly training distance (+28%, p = 0.02) and duration (+30%, p = 0.04) significantly increased during altitude compared to the pre-LHTH period. Therefore, although direct causation cannot be inferred, these results suggest that the combination of increased training load at low altitudes with a subsequent tapering period in a warm environment is a suitable competition-preparation strategy for elite endurance athletes.

Apnoea as a novel method to improve exercise performance: A current state of the literature.

Acute breath-holding (apnoea) induces a spleen contraction leading to a transient increase in haemoglobin concentration. Additionally, the apnoea-induced hypoxia has been shown to lead to an increase in erythropoietin concentration up to 5 h after acute breath-holding, suggesting long-term haemoglobin enhancement. Given its potential to improve haemoglobin content, an important determinant for oxygen transport, apnoea has been suggested as a novel training method to improve aerobic performance. This review aims to provide an update on the current state of the literature on this topic. Although the apnoea-induced spleen contraction appears to be effective in improving oxygen uptake kinetics, this does not seem to transfer into immediately improved aerobic performance when apnoea is integrated into a warm-up. Furthermore, only long and intense apnoea protocols in individuals who are experienced in breath-holding show increased erythropoietin and reticulocytes. So far, studies on inexperienced individuals have failed to induce acute changes in erythropoietin concentration following apnoea. As such, apnoea training protocols fail to demonstrate longitudinal changes in haemoglobin mass and aerobic performance. The low hypoxic dose, as evidenced by minor oxygen desaturation, is likely insufficient to elicit a strong erythropoietic response. Apnoea therefore does not seem to be useful for improving aerobic performance. However, variations in apnoea, such as hypoventilation training at low lung volume and repeated-sprint training in hypoxia through short end-expiratory breath-holds, have been shown to induce metabolic adaptations and improve several physical qualities. This shows promise for application of dynamic apnoea in order to improve exercise performance. HIGHLIGHTS: What is the topic of this review? Apnoea is considered as an innovative method to improve performance. This review discusses the effectiveness of apnoea (training) on performance. What advances does it highlight? Although the apnoea-induced spleen contraction and the increase in EPO observed in freedivers seem promising to improve haematological variables both acutely and on the long term, they do not improve exercise performance in an athletic population. However, performing repeated sprints on end-expiratory breath-holds seems promising to improve repeated-sprint capacity.

Test-retest reliability of gastrocnemius medialis fascicle force-length relationship.

Fascicle force-length relationship is one major basic mechanical property of skeletal muscle, subsequently influencing movement mechanics. While force-length properties are increasingly described through ultrafast ultrasound imaging, their test-retest reliability remains unknown. Using ultrafast ultrasound, and electrically evoked contractions at various ankle angles, gastrocnemius medialis fascicle force-length relationship was assessed twice, few days apart, in sixteen participants. The test-retest reliability of the resulting fascicle force-length relationship key parameters - i.e., maximal force (Fmax), and optimal fascicle length (L0) - was evaluated considering (i) all the trials obtained at each ankle joint and (ii) the mean of the two trials obtained at each tested angle. Considering all trials, L0 indicated a 'high' test-retest reliability, with intra-class correlation coefficients (ICC) of 0.89 and Fmax a 'moderate' reliability (ICC = 0.71), while when averaging the two trials L0 reliability was 'very-high' (ICC = 0.91), and Fmax reliability 'moderate' (ICC = 0.73). All values of coefficient of variation and standard error of measurement were low, i.e., ≤7.7 % and ≤0.35 cm for L0 and ≤3.4 N for Fmax, respectively. Higher absolute reliability was reported for L0 than Fmax, with better reliability when averaging the two trials at each angle. All these parameters, in accordance with the limit of agreement, demonstrated that L0 and Fmax test-retest reliability is acceptable, particularly when averaging multiple points obtained at a given angle. Interestingly, the shape of the fascicle force-length relationship is more variable. Therefore, L0 and Fmax can be used to compare between days-effects following an intervention, while a comparison of fascicle operating lengths may require more precautions.

Implications of Heat Stress-induced Metabolic Alterations for Endurance Training.

Inducing a heat-acclimated phenotype via repeated heat stress improves exercise capacity and reduces athletes̓ risk of hyperthermia and heat illness. Given the increased number of international sporting events hosted in countries with warmer climates, heat acclimation strategies are increasingly popular among endurance athletes to optimize performance in hot environments. At the tissue level, completing endurance exercise under heat stress may augment endurance training adaptation, including mitochondrial and cardiovascular remodeling due to increased perturbations to cellular homeostasis as a consequence of metabolic and cardiovascular load, and this may improve endurance training adaptation and subsequent performance. This review provides an up-to-date overview of the metabolic impact of heat stress during endurance exercise, including proposed underlying mechanisms of altered substrate utilization. Against this metabolic backdrop, the current literature highlighting the role of heat stress in augmenting training adaptation and subsequent endurance performance will be presented with practical implications and opportunities for future research.

Individual In-Situ GPS-Derived Acceleration-Speed Profiling: Toward Automatization and Refinement in Male Professional Rugby Union Players.

BACKGROUND: Recently a proof-of-concept was proposed to derive the soccer players' individual in-situ acceleration-speed (AS) profile from global positioning system (GPS) data collected over several sessions and games. The present study aimed to propose an automatized method of individual GPS-derived in-situ AS profiling in a professional rugby union setting. METHOD: AS profiles of forty-nine male professional rugby union players representing 61.5 million positions, from which acceleration was derived from speed during 51 training sessions and 11 official games, were analyzed. A density-based clustering algorithm was applied to identify outlier points. Multiple AS linear relationships were modeled for each player and session, generating numerous theoretical maximal acceleration (A0), theoretical maximal running speed (S0) and AS slope (ASslope, i.e., overall orientation of the AS profile). Each average provides information on the most relevant value while the standard deviation denotes the method accuracy. In order to assess the reliability of the AS profile within the data collection period, data were compared over two 2-week phases by the inter-class correlation coefficient. A0 and S0 between positions and type of sessions (trainings and games) were compared using ANOVA and post hoc tests when the significant threshold had been reached. RESULTS: All AS individual profiles show linear trends with high coefficient of determination (r2 > 0.81). Good reliability (Inter-class Correlation Coefficient ranging from 0.92 to 0.72) was observed between AS profiles, when determined 2 weeks apart for each player. AS profiles depend on players' positions, types of training and games. Training and games data highlight that highest A0 are obtained during games, while greatest S0 are attained during speed sessions. CONCLUSIONS: This study provides individual in-situ GPS-derived AS profiles with automatization capability. The method calculates an error of measurement for A0 and S0, of paramount importance in order to improve their daily use. The AS profile differences between training, games and playing positions open several perspectives for performance testing, training monitoring, injury prevention and return-to-sport sequences in professional rugby union, with possible transferability to other sprint-based sports. KEY POINTS: AS profiles computed from rugby union GPS data provide positional benchmarks during training and competition. This study provides automatic detection of atypical data and the computation of error measurement of theoretical maximal acceleration and speed components. This refinement constitutes a step forward for a daily use of ecological data by considering data collection and method reliabilities. This easy-to-implement approach may facilitate its use to the performance management process (talent identification, training monitoring and individualization, return-to-sport).

Running 40 Minutes under Temperate or Hot Environment Does Not Affect Operating Fascicle Length.

PURPOSE: Muscle mechanics is paramount in our understanding of motor performance. However, little is known regarding the sensitivity of fascicle dynamics and connective tissues stiffness to exercise duration and ambient temperature during running, both increasing muscle temperature. This study aimed to determine gastrocnemius medialis (GM) fascicle dynamics in vivo during running in temperate and hot conditions, as well as muscle-tendon unit responses. METHODS: Using ultrafast ultrasound, 15 participants (8 men, 7 women; 26 ± 3 yr) were tested before, during (2 and 40 min), and after a running task (40 min at 10 km·h -1 ) in temperate (TEMP; ~23°C) and hot (HOT: ~38°C) conditions. RESULTS: Although core, skin temperatures, and heart rate increased from the beginning to the end of the exercise and in a larger extent in HOT than TEMP ( P < 0.001), the physiological stress elicited did not alter running temporal parameters and GM fascicle operating lengths, with similar behavior of the fascicles on their force-length relationship, over time (2 vs 40 min) or across condition (TEMP vs HOT; P ≥ 0.248). Maximal voluntary force production did not reported statistical changes after exercise ( P = 0.060), and the connective tissues stiffness measured (i.e., passive muscle and stiffness of the series-elastic elements) did not show neither time ( P ≥ 0.281), condition ( P ≥ 0.256) nor time-condition interaction ( P ≥ 0.465) effect. CONCLUSIONS: This study revealed that prolonged running exercise does not alter muscle-tendon unit properties and interplay, which are not influenced by ambient temperature. These findings may rule out potential detrimental effects of heat on muscle properties and encourage further investigations on longer and more intense running exercise.

Effects of Hypoxia Severity on Muscle Oxygenation Kinetics Using Statistical Parametric Mapping During Repeated Treadmill Sprints.

PURPOSE: We examined the effects of increasing hypoxia severity on oxygenation kinetics in the vastus lateralis muscle during repeated treadmill sprints, using statistical parametric mapping (SPM). METHODS: Ten physically active males completed 8 sprints of 5 seconds each (recovery = 25 s) on a motorized sprint treadmill in normoxia (sea level; inspired oxygen fraction = 0.21), moderate hypoxia (inspired oxygen fraction = 0.17), and severe hypoxia (SH; inspired oxygen fraction = 0.13). Continuous assessment of tissue saturation index (TSI) in the vastus lateralis muscle was conducted using near-infrared spectroscopy. Subsequently, TSI data were averaged for the sprint-recovery cycle of all sprints and compared between conditions. RESULTS: The SPM analysis revealed no discernible difference in TSI signal amplitude between conditions during the actual 5-second sprint phase. However, during the latter portion of the 25-second recovery phase, TSI values were lower in SH compared with both sea level (from 22 to 30 s; P = .003) and moderate hypoxia (from 16 to 30 s; P = .001). The mean distance covered at sea level (22.9 [1.0] m) was greater than for both moderate hypoxia (22.5 [1.2] m; P = .045) and SH (22.3 [1.4] m; P = .043). CONCLUSIONS: The application of SPM demonstrated that only SH reduced muscle oxygenation levels during the late portion of the passive (recovery) phase and not the active (sprint) phase during repeated treadmill sprints. These findings underscore the usefulness of SPM for assessing muscle oxygenation differences due to hypoxic exposure and the importance of the duration of the between-sprints recovery period.

Women at Altitude: Sex-Related Physiological Responses to Exercise in Hypoxia.

Sex differences in physiological responses to various stressors, including exercise, have been well documented. However, the specific impact of these differences on exposure to hypoxia, both at rest and during exercise, has remained underexplored. Many studies on the physiological responses to hypoxia have either excluded women or included only a limited number without analyzing sex-related differences. To address this gap, this comprehensive review conducted an extensive literature search to examine changes in physiological functions related to oxygen transport and consumption in hypoxic conditions. The review encompasses various aspects, including ventilatory responses, cardiovascular adjustments, hematological alterations, muscle metabolism shifts, and autonomic function modifications. Furthermore, it delves into the influence of sex hormones, which evolve throughout life, encompassing considerations related to the menstrual cycle and menopause. Among these physiological functions, the ventilatory response to exercise emerges as one of the most sex-sensitive factors that may modify reactions to hypoxia. While no significant sex-based differences were observed in cardiac hemodynamic changes during hypoxia, there is evidence of greater vascular reactivity in women, particularly at rest or when combined with exercise. Consequently, a diffusive mechanism appears to be implicated in sex-related variations in responses to hypoxia. Despite well-established sex disparities in hematological parameters, both acute and chronic hematological responses to hypoxia do not seem to differ significantly between sexes. However, it is important to note that these responses are sensitive to fluctuations in sex hormones, and further investigation is needed to elucidate the impact of the menstrual cycle and menopause on physiological responses to hypoxia.

Four Sessions of Repeated-Sprint Cycling Training With or Without Severe Hypoxia Do Not Modify Overground Running Sprint Force-Velocity Profile.

PURPOSE: To investigate the effect of cycling-based repeated-sprint training in hypoxia versus in normoxia on single overground running sprint performance and associated force-velocity (F-V) profile in world-class female rugby sevens players. METHODS: Eighteen world-class female rugby sevens players were randomly assigned to repeated-sprint cycling training in normobaric hypoxia (n = 9) or normoxia (n = 9) groups. Training consisted of 4 sessions of repeated-sprint cycling training in normobaric hypoxia or in normoxia (4 × 5 × 5-s cycle sprints-25-s intersprint recovery performed in simulated altitude of ∼5000 m or in normoxia with 3-min interset rest in normoxia for both groups) in addition to rugby sevens training and strength and conditioning sessions within a 9-day intervention period before an international competition. Before and 1 day after the intervention, single 50-m overground running "all-out" sprint performance and associated F-V-related mechanical output were assessed. RESULTS: No interaction (group × time; all P > .088), time effect (before vs 1 d after; all P > .296), or group effect (repeated-sprint cycling training in normobaric hypoxia vs in normoxia; all P > .325) was detected for 50-m overground running sprint performance and any derived F-V profiling variables. CONCLUSIONS: Four sessions of repeated-sprint training either in hypoxia or in normoxia performed over 9 days had no influence on single 50-m overground running sprint performance and associated F-V profile. In world-class female rugby sevens players, the intervention (training camp before an international competition) might have been too short to induce measurable changes. It is also plausible that implementing a similar program in players with likely different F-V profile may result in negligible mechanical effect.

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.

Effects of 2 Different Protocols of Repeated-Sprint Training in Hypoxia in Elite Female Rugby Sevens Players During an Altitude Training Camp.

OBJECTIVES: Repeated-sprint training in hypoxia (RSH) is an effective way of improving physical performance compared with similar training in normoxia. RSH efficiency relies on hypoxia severity, but also on the oxidative-glycolytic balance determined by both sprint duration and exercise-to-rest ratio. This study investigated the effect of 2 types of RSH sessions during a classic altitude camp in world-class female rugby sevens players. METHODS: Sixteen players performed 5 RSH sessions on a cycle ergometer (simulated altitude: 3000 m above sea level [asl]) during a 3-week natural altitude camp (1850 m asl). Players were assigned to 2 different protocols with either a high (RSH1:3, sprint duration: 8-10 s; exercise-to-rest ratios: 1:2-1:3; n = 7) or a low exercise-to-rest ratio (RSH1:5, sprint duration: 5-15 s; exercise-to-rest ratios: 1:2-1:5; n = 9). Repeated-sprint performances (maximal and mean power outputs [PPOmax, and PPOmean]) were measured before and after the intervention, along with physiological responses. RESULTS: PPOmax (962 [100] to 1020 [143] W, P = .008, Cohen d = 0.47) and PPOmean (733 [71] to 773 [91] W, P = .008, d = 0.50) increased from before to after. A significant interaction effect (P = .048, d = 0.50) was observed for PPOmean, with a larger increase observed in RSH1:3 (P = .003). No interaction effects were observed (P > .05) for the other variables. CONCLUSION: A classic altitude camp with 5 RSH sessions superimposed on rugby-sevens-specific training led to an improved repeated-sprint performance, suggesting that RSH effects are not blunted by prolonged hypoxic exposure. Interestingly, using a higher exercise-to-rest ratio during RSH appears to be more effective than when applying a lower exercise-to-rest ratio.

Environmental heat stress offsets adaptation associated with carbohydrate periodization in trained male triathletes.

PURPOSE: Carbohydrate (CHO) intake periodization via the sleep low train low (SL-TL) diet-exercise model increases fat oxidation during exercise and may enhance endurance-training adaptation and performance. Conversely, training under environmental heat stress increases CHO oxidation, but the potential of combined SL-TL and heat stress to enhance metabolic and performance outcomes is unknown. METHODS: Twenty-three endurance-trained males were randomly assigned to either control (n = 7, CON), SL-TL (n = 8, SLTemp ) or SL-TL + heat stress (n = 8, SLHeat ) groups and prescribed identical 2-week cycling training interventions. CON and SLTemp completed all sessions at 20°C, but SLHeat at 35°C. All groups consumed matched CHO intake (6 g·kg-1 ·day-1 ) but timed differently to promote low CHO availability overnight and during morning exercise in both SL groups. Submaximal substrate utilization was assessed (at 20°C), and 30-min performance tests (at 20 and 35°C) were performed Pre-, Post-, and 1-week post-intervention (Post+1). RESULTS: SLTemp improved fat oxidation rates at 60% MAP (~66% VO2peak ) at Post+1 compared with CON (p < 0.01). Compared with SLTemp , fat oxidation rates were significantly lower in SLHeat at Post (p = 0.02) and Post+1 (p < 0.05). Compared with CON, performance was improved at Post in SLTemp in temperate conditions. Performance was not different between any groups or time points in hot conditions. CONCLUSION: SL-TL enhanced metabolic adaptation and performance compared with CON and combined SL-TL and heat stress. Additional environmental heat stress may impair positive adaptations associated with SL-TL.

Repeated-Sprint Training at 5000-m Simulated Altitude in Preparation for the World Rugby Women's Sevens Series: Too High?

PURPOSE: The objective of this study is to investigate the effectiveness of novel repeated-sprint training in hypoxia (RSH) protocol, likely maximizing hypoxic stimulus (higher than commonly used) while preserving training quality (interset rest in normoxia). METHODS: Twenty-three world-class female rugby sevens players performed four repeated-sprint training sessions (4 sets of 5 × 5-s cycle sprints-25-s intersprint recovery and 3-min interset rest) under normobaric hypoxia (RSH, exercise and interset rest at FiO 2 of 10.6% and 20.9%, respectively; n = 12) or normoxia (repeated-sprint training in normoxia; exercise and interset rest at FiO 2 of 20.9%; n = 11) during a 9-d training camp before international competition. Repeated-sprint ability (8 × 5-s treadmill sprints-25-s recovery), on-field aerobic capacity, and brachial endothelial function were assessed pre- and postintervention. RESULTS: Arterial oxygen saturation (pooled data: 87.0% ± 3.1% vs 96.7% ± 2.9%, P < 0.001) and peak and mean power outputs (sets 1 to 4 average decrease: -21.7% ± 7.2% vs -12.0% ± 3.8% and -24.9% ± 8.1% vs -14.9% ± 3.5%; both P < 0.001) were lower in RSH versus repeated-sprint training in normoxia. The cumulated repeated-sprint distance covered significantly increased from pre- to postintervention (+1.9% ± 3.0%, P = 0.019), irrespective of the condition ( P = 0.149). On-field aerobic capacity did not change (all P > 0.45). There was no significant interaction (all P > 0.240) or condition main effect (all P > 0.074) for any brachial artery endothelial function variable. Only peak diameter increased ( P = 0.026), whereas baseline and peak shear stress decreased ( P = 0.014 and 0.019, respectively), from pre- to postintervention. CONCLUSIONS: In world-class female rugby sevens players, only four additional repeated-sprint sessions before competition improve repeated-sprint ability and brachial endothelial function. However, adding severe hypoxic stress during sets of repeated sprints only did not provide supplementary benefits.

PURPOSE: The objective of this study is to investigate the effectiveness of novel repeated-sprint training in hypoxia (RSH) protocol, likely maximizing hypoxic stimulus (higher than commonly used) while preserving training quality (interset rest in normoxia). METHODS: Twenty-three world-class female rugby sevens players performed four repeated-sprint training sessions (4 sets of 5 × 5-s cycle sprints­25-s intersprint recovery and 3-min interset rest) under normobaric hypoxia (RSH, exercise and interset rest at FiO 2 of 10.6% and 20.9%, respectively; n = 12) or normoxia (repeated-sprint training in normoxia; exercise and interset rest at FiO 2 of 20.9%; n = 11) during a 9-d training camp before international competition. Repeated-sprint ability (8 × 5-s treadmill sprints­25-s recovery), on-field aerobic capacity, and brachial endothelial function were assessed pre- and postintervention. RESULTS: Arterial oxygen saturation (pooled data: 87.0% ± 3.1% vs 96.7% ± 2.9%, P < 0.001) and peak and mean power outputs (sets 1 to 4 average decrease: −21.7% ± 7.2% vs −12.0% ± 3.8% and −24.9% ± 8.1% vs −14.9% ± 3.5%; both P < 0.001) were lower in RSH versus repeated-sprint training in normoxia. The cumulated repeated-sprint distance covered significantly increased from pre- to postintervention (+1.9% ± 3.0%, P = 0.019), irrespective of the condition ( P = 0.149). On-field aerobic capacity did not change (all P > 0.45). There was no significant interaction (all P > 0.240) or condition main effect (all P > 0.074) for any brachial artery endothelial function variable. Only peak diameter increased ( P = 0.026), whereas baseline and peak shear stress decreased ( P = 0.014 and 0.019, respectively), from pre- to postintervention. CONCLUSIONS: In world-class female rugby sevens players, only four additional repeated-sprint sessions before competition improve repeated-sprint ability and brachial endothelial function. However, adding severe hypoxic stress during sets of repeated sprints only did not provide supplementary benefits.

Medical withdrawals in elite tennis in reference to playing standards, court surfaces and genders.

OBJECTIVES: To examine the relationships between medical withdrawals, playing standards, court surfaces and genders in tennis players participating in all elite tours. DESIGN: Descriptive epidemiology study. METHODS: Medical withdrawals of men and women tennis players from Association of Tennis Professionals, Women Tennis Association, Challengers and International Tennis Federation Futures tours' matches have been identified considering the court surfaces (fast vs. slow). Proportion comparison and the binomial regression model were used to determine the influence of playing standards, court surfaces and genders on tennis players' likelihoods to withdraw. RESULTS: A higher proportion of withdrawals was found for men in Challengers and Futures vs. Association of Tennis Professionals (4.8 %, 5.9 % vs 3.4 %; p < 0.001), but without difference between court surfaces (0.1 %, p > 0.05) whatever the playing standards. Women reported higher proportion of medical withdrawals sustained on slow surfaces (0.4 %, p < 0.001), but without different withdrawal rates between playing standards (3.9 %, p > 0.05). After adjustment, the odds of medical withdrawals were higher for Challengers (1.18, p < 0.001) and Futures (1.34, p < 0.001), with a higher likelihood to withdraw (1.04, p < 0.001) when playing on slow surfaces and with a gender-dependent effect indicating higher odds (1.29, p < 0.001) to withdraw for medical reasons in men in reference to women. CONCLUSIONS: These findings demonstrated a gender-dependent effect on medical withdrawals from an elite tennis tournament with higher likelihood for men participating in Challengers/Futures tours and for women playing on slow surfaces.