Oct 11, 2019Debunking heat illness myths
Examining 11 common misconceptions in athletic programs
Exertional heat illness (EHI) awareness today is far greater than anytime in history. It’s a regular part of athletic training education curriculums. Coaches are informed about the risks and dangers of EHIs at clinics, and through mandatory training in some states. Athletes themselves are constantly reminded about the importance of proper hydration and looking out for their teammates.
Despite all of this, it’s important for athletic trainers and other sports medicine professionals to understand that while knowledge of heat illness is common, not all of this knowledge is complete and accurate. Athletes, their parents and coaches often carry misconceptions about heat illness. These myths may contain a grain of truth, but erroneous or incomplete information can leave athletes at greater risk for heat illness or compromise the effectiveness of treatment should heat illness occur.
As those working closest with athletes, athletic trainers must be aware of the most common myths surrounding heat illness and implement best practices to ensure their athletes have accurate and complete information. It’s especially important at the high school level, where athletes are training on their own during the summer, away from the watchful eye of sports medicine professionals. Educating these young athletes is at the core of EHI prevention.
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“Athletics trainers should make sure their athletes are properly educated about the dangers and risks presented by heat illness,” said Susan Yeargin, PhD, ATC, associate professor in the athletic training education program at the University of South Carolina. “Team meetings are a great time to go over the facts of heat illness, and make sure athletes and coaches are armed with the proper information. Getting athletes to understand the risks and dangers of heat illness will help keep them safe, and enable them to reach their performance goals.”
“Athletic trainers are doing all they can to provide a safe environment for athletes to workout in despite hot conditions,” said Michael Ferrara, PhD, ATC, FNATA, dean and professor of kinesiology at the University of New Hampshire. “Part of that effort is offering proper education about heat illness so they can reduce, and hopefully eliminate, heat stroke deaths in athletes.”
Here are common myths surrounding exertional heat illness in athletes and ways to counteract these misconceptions.
Myth No. 1: You can’t suffer heat illness if you’re properly hydrated.
Thanks to ongoing education and reminders, athletes generally get the message about the importance of hydration. But some athletes may take it too far, assuming that as long as they’ve been fueling themselves well and drinking enough fluids, they have nothing to worry about when training in the heat.
Athletic trainers know there’s nothing further from the truth.
“Heat stroke is multidimensional and cannot be prevented simply by hydrating to the proper level,” Ferrara said. “Being completely hydrated is certainly a good thing, but acclimatization, environmental conditions, the intensity of activity, duration of activity, and the type of equipment being worn are all major factors when it comes to heat stroke and other heat illnesses.”
While this may be obvious to athletic trainers, young athletes need to be reminded that hydration is not a magic pill. Coaches need to plan workouts accordingly.
“In addition to providing a good atmosphere for healthy hydration habits, athletic trainers need to preach the importance of scheduling sufficient rest/cooling breaks and practicing at the appropriate time of the day,” Yeargin said. “Those steps are critically important to preventing heat stroke.”
Myth No. 2: If a person is sweating, they’re not experiencing heat stroke.
This common misconception is especially dangerous, but Yeargin understands why it may have taken hold.
“I think this myth developed because in cases of ‘classical’ heat stroke — such as a child locked in a hot car, or an elderly person in a non-air-conditioned room during a heat wave — the skin may be red or flushed, but dry,” Yeargin said. “However, I don’t know of any published cases of exertional heat stroke where the athlete stopped sweating. On the contrary, most athletes in heat stroke will be sweating profusely.”
The danger lies in fellow athletes or bystanders downplaying the gravity of the situation and failing to quickly get proper treatment for an exertional heat stroke victim.
“Someone who believes this myth may see an athlete falter or struggle,” Yeargin said, “but because the athlete is sweating, they may think it’s not a serious matter when in reality they should be calling 911 for immediate help.”
Skin condition is of little use when an athlete is in heat stroke. Common signs include dizziness, irrational behavior, confusion, weakness, vomiting, diarrhea and hyperventilation. Ferrara said the best way to determine if an athlete is experiencing heat stroke is by getting a core body temperature. A reading of 104 or greater indicates heat stroke, “And it’s best to get that core temperature rectally instead of orally, tympanically or axillary,” he said.
Myth No. 3: Athletes know when they’re experiencing heat stress.
While young athletes sometimes feel they are invincible, this false sense of security may lead to more than just a turnover or penalty on the court or field. It has the potential to lead to an EHI condition that could be fatal.
“This incorporates another myth I’ve heard, which is that that heat illness occurs along a continuum, starting with heat cramps, then progressing to heat exhaustion before developing into heat stroke,” Yeargin said. “While that can happen, they’re independent conditions and usually occur by themselves. An athlete certainly can work themselves directly to heat stroke without ever experiencing any cramps or symptoms of heat exhaustion.”
Then there’s the toll heat illness can take on the central nervous system.
“One of the signs of heat illness is disorientation, which will make it difficult for athletes to recognize the symptoms themselves,” Yeargin said. “This is why it’s important for teammates to watch out for each other. They need to take the buddy system seriously and know the importance of alerting coaches or athletic trainers when they see a teammate acting oddly.”
Ferrara said giving athletes the opportunity to cool off and recover is not the only benefit of well-timed rest breaks. They also allow coaches and athletic trainers the chance to observe their athletes to make sure none of them are acting strangely or showing other signs of heat stress, such as dizziness, nausea or cramps.
Myth No. 4: Athletes could be harmed if their bodies are cooled too quickly.
The 2015 NATA Position Statement of Exertional Heat Illness — which counts both Ferrara and Yeargin as authors — states that cold-water immersion is the most effective treatment for exertional heat stroke. Yet people who have not been educated about its benefits may be reluctant to use immersion because of the way the body normally reacts to being immersed in cold water.
“This myth comes from stories of people with a normal body temperature being immersed in cold water,” Yeargin said. “When that happens, the blood vessels restrict in an attempt to save heat, which may send the person into shock. But the body reacts differently during heat stroke. Since there’s no need to retain heat, the blood vessels to stay open and there’s no risk of shock.”
Timely and proper treatment is vital in cases of heat stroke. Assuring athletes are aware that this treatment is safe, in their best interest, and that best practice includes cooling first and transporting second will decrease confusion and trepidation should this action be taken.
Myth No. 5: Heat index is the best means to determine heat stress conditions.
While the heat index takes into account humidity, thus giving a better indication of environmental conditions than air temperature alone, it was not created to measure heat stress under the strenuous conditions in which most athletes participate. The wet-bulb globe temperature (WBGT) is much better.
“The WBGT also takes into account wind and the radiant temperature, which includes the effects of the sun,” Ferrara said. “Utilization of all of these factors assures a better measure of heat stress than heat index.”
Ferrara helped the Georgia High School Association write its guidelines for hot weather practices. It specifies practice duration limits and mandatory rest periods when the WBGT reaches certain thresholds. It ultimately bans all outdoor workouts when the WBGT reading exceeds 92.
Technology has made it easier to obtain quick and accurate WBGT readings.
“We’ve come a long way from the sling psychrometers we used in the past.” Ferrara said. “We’re fortunate that there are a variety of affordable, reliable and easy-to-use WBGT devices on the market to choose from.”
Measuring WBGT in the precise location where activity takes place is paramount in determining risk. A nearby location will not have equal stressors, including indirect radiation, altitude and geographical structures.
Myth No. 6: Salt tablets can replace electrolytes lost in sweat.
While salt tablets may hearken back to the days of the single-wing and leather helmets, there are still people who rely on them to help athletes participating in hot conditions. Yeargin said that although athletes, especially salty sweaters, need to ensure they’re getting enough sodium to replace the amount lost during hot workouts, it’s usually better to take it in through diet than tablets.
“Adding table salt to food or eating salty foods is probably going to supply enough sodium for most athletes and will likely be tolerated better by their digestive system,” she said. “Some people may want to use salt preventatively before a practice, but if you preload with salt, the body will just pee out any sodium it doesn’t need.”
Salt tablets also won’t help supply any of the other electrolytes lost through sweat, such as potassium, magnesium and calcium. Neither will water. Sports drinks are formulated to supply these essential minerals at the best ratio to be used by the body. For those concerned about calories, these are low-calorie supplements that can be added to water to supply them.
Myth No. 7: Heat illness only occurs when the ambient temperature is above a specific number.
There is no magical temperature where athletes are safe from heat illness. Yeargin said most cases occur when the temperature exceeds 90 degrees Fahrenheit, but there are plenty of recorded cases at lower temperatures, including some in the lower 70s.
Ferrara cautions against relying on any one factor when looking at heat illness.
“Heat illness is multidimensional,” Ferrara said. “The environment certainly plays a big role, but so does the type of practice, its duration, how acclimatized the athletes are, athlete hydration levels, their nutrition, their sleep, and more. And even when one player experiences heat illness, most of their teammates do not, so there is clearly more involved than just the environmental conditions.”
When conditions are more demanding than what an athlete is used to, EHI risk increases exponentially. A heatwave in the Northeast may feel pleasant to a player in Texas or Florida, but it’s more strenuous to those not conditioned to those “extremes.”
Myth No. 8: Heat illness is only a problem for football players.
Football certainly sees the highest number of heat illness events, in part because of the equipment used and the sheer numbers of participants during the summer months. But very few sports are immune. Even swimmers may be at risk.
A 2010 open water swimming event in the United Arab Emirates saw several competitors report heat-related symptoms after the race, and one swimmer died.
“All sports are at risk,” said Yeargin, who added that athletes inside climate-controlled facilities can suffer from heat illness. “If an athlete is not well-hydrated or is ill or has poor nutrition, they can certainly end up with heat illness, even if they’re indoors. Air conditioning greatly decreases the likelihood of heat illness, but athletes and coaches need to be aware that it doesn’t eliminate it entirely.”
Myth No. 9: Acclimatized athletes are safe from heat illness.
The NCAA and many state high school athletic associations have adopted acclimatization periods for fall sports. These guidelines define strict limits on practice duration and activities until athletes have had a chance to acclimate to training in the heat. While these rules help reduce heat illness cases, they also can give athletes a false sense of security. Some athletes may mistakenly feel that once they’ve made it through the acclimatization period, they can safely participate regardless of the heat.
Athletic trainers should remind athletes that while acclimatization is important, it’s just one piece of a very complicated puzzle. Hydration, nutrition, proper rest breaks, and other steps still need to be followed once athletes have become acclimatized. This is especially important should a heat wave follow the acclimatization period.
“Since the body acclimatizes to the conditions it’s been working out in over the past seven to 14 days, any subsequent increase will add new stressors that the body isn’t used to,” Yeargin said. “When this happens, athletic trainers and coaches need to work together so the conditions are similar to what the athletes are used to, maybe by moving practice to a different part of the day. You may even have to take a few steps back and lower the intensity of practice or remove some equipment until the athletes can re-acclimatize to the new conditions.”
Myth No. 10: Time spent in air-conditioned buildings ruins acclimatization efforts.
With all the emphasis on having athletes become acclimatized to the heat, it’s understandable that some of them may believe that spending time in climate-controlled buildings could slow those efforts. But Yeargin said there’s no reason for athletes to avoid air conditioning during the acclimatization process.
“Research show that acclimatization loss is about 3% over five days, so a few hours in air conditioning is not going to set athletes back,” she said. “As a matter of fact, air conditioning can help with the recovery process. Where multiple practice sessions are allowed in a single day, we encourage coaches to provide at least a three-hour break in an air-conditioned building between sessions so the athlete can recover and rehydrate for the second session.”
Bonus myth: Intravenous fluids are better for rehydrating.
Some think intravenous fluids are better than oral fluids when it comes to hydrating. Yeargin said research shows that’s not the case.
“As long as oral fluids can be tolerated — which certainly can be a problem for athletes with heat illness — they are as effective as IV fluids in rehydrating athletes with heat exhaustion or heat cramps,” she said. “IV fluids can help the athlete rehydrate a little more quickly, but otherwise there’s really no difference.”