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Summer 2016

Theme: Heat & Altitude in High Performance Sport

Also Inside: Profile: Canadian Sport Centre Atlantic

Editorial Welcome to the Summer 2016 issue of the High Performance SIRCuit. Our athletes and coaches

are ready to travel to Brazil for the Rio Olympic and Paralympic Games and Canadians everywhere will be cheering them on.

“Their incredible performances make wearing the maple leaf even more significant. Canadians are inspired by our athletes … Being in a position to walk into a stadium behind the Canadian flag pushing for an Olympic or Paralympic podium takes a lot of work – and a lot of teamwork.” - Honourable Carla Qualtrough, Minister of Sport and Persons with Disabilties

Debra Gassewitz President & CEO SIRC

This issue recognizes the numerous environmental factors our athletes will need to consider within their training and competition performances. Canada’s leading sport science and coaching experts as well as the NSSMAC editorial team have done a great job providing insights and highlighting recent research relating to heat and altitude training. In particular we have some excellent articles on: • Iron supplementation and nutrition recommendations for altitude training; • Heat acclimatization for team sports featuring the women’s national soccer team; • Core temperature and heat load in wheelchair basketball; • The relationship between heat and altitude in high performance; and

Jon Kolb, PhD

• Highlights from NATA’s position statement on heat exertion illnesses.

Director, Sport Science, Medicine and Innovation Own the Podium

Special thanks to the Canadian Paralympic Committee for sharing the ParaTough Training Series, the Canadian Sport Centre Atlantic for allowing us to showcase their leadership role in the Atlantic region, and to the NSSMAC and SIRC/OTP teams for reviewing and recommending some excellent articles for coaches and ISTs to read in our recommended readings. So cheer on our athletes as they take the field and climb on the podium this summer! Go Canada Go!

Debra and Jon

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WHAT’S INSIDE Iron Supplementation & Nutrition Recommendations for Altitude Training Heat Acclimatization and Team Sports

Monitoring changes in core temperature and heat load in wheelchair basketball athletes

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Canadian Sport Centre Atlantic Leading High Performance Sport in Atlantic Canada

Iron Supplementation & Nutrition Recommendations for Altitude Training

Altitude can provide an alternative stimulus for adaptation; however, as with training, the stress of altitude needs to be strategic and mitigated by optimal nutrition interventions to ensure peak adaptation.

Monitoring changes in core temperature and heat load in wheelchair basketball athletes during major competitions

This research demonstrated the need to monitor core temp in WCB athletes as great variability in response to heat stress exists, with athletes in a lower class exhibiting greater heat stress than higher playing classes, and those with greater on-court playing time also demonstrated increased risk.

Heat Acclimatization and Team Sports

The purpose of the study was to use novel and non-invasive field-based monitoring metrics throughout HA to observe the physiological and performance adaptive response of all team members of the women’s national soccer team.

Recent Research Explores the Relationship between Heat and Altitude for High Performance Sport

Reflecting the theme of this issue we take a look at how heat and altitude have individual and combined effects on athletes and their ability to achieve optimal performance.

Canadian Sport Centre Atlantic Leading High Performance Sport in Atlantic Canada The CSCA continues to evolve to meet the needs of Atlantic Canada’s high performance athletes and coaches. With a primary hub in Halifax, over 70 carded athletes are supported annually as well as many additional sports through the CSCA’s training group programs.

National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses

The primary goal of the recommendations is athlete health and safety during performance in hot/humid conditions. The commentary presents highlights of the Position Statement.

Must Reads … Read, Learn, Excel

• IST Journal Club Reviews • Recommended Research Readings from SIRC & OTP • New Books @ SIRC


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ALTITUDE TRAINING Trent Stellingwerff, PhD; Susan Boegman, RD; and Padraig McCluskey, MD


ptimal training adaptation is a balance between stress and recovery and altitude training causes an increase in both training and systemic stressors to the athlete. Altitude can provide an alternative stimulus for adaptation; however, as with training, the stress of altitude needs to be strategic and mitigated by optimal nutrition interventions to ensure peak adaptation. It is now well established that altitude training not only provides a stimulus to potentially increase red blood cells (RBC), (measured in studies as hemoglobin mass (HBmass)) [1, 2], but it can also positively impact nonhematological factors, such as muscle buffering and mitochondrial biogenesis [3]. Currently, the vast majority of our knowledge on the physiological effects of altitude training relate primarily to aspects of HBmass/RBC production with a series of studies having established that the optimal hypoxic dose is approximately 3 to 4 weeks at altitudes of ~2000 to 2500m [4, 5]. If these hypoxic doses are satisfied, athletes can expect, on average, an approximate 1% increase in HBmass for every 100hrs at altitude [2]. However, altitude RBC responses are highly individual [6], with some athletes showing 10% increases in HBmass and others showing no increases over the same altitude training camp. These individual variations in HBmass responses to altitude likely reflect the many positive and negative impactors to RBC production (see Figure 1 below). Interestingly, several of the ‘controllable’ factors to RBC production are nutritionally based, and coupled with some very new publications in this area, provide the impetus of the current nutrition and iron recommendations for altitude.


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Iron Status and Supplementation Before and During Altitude One of the impactors on RBC production is iron status and availability. The International Olympic Committee consensus group suggests athletes should have iron status assessment ~6 to 10 weeks prior to altitude, and ideally, serum ferritin concentration should be >30 μg•L-1 for females and >40 μg•L-1 for males with normal hemoglobin values (e.g. not anemic; [7]). It has been suggested that athletes with ferritin below these values may have increased potential for mal-adaptation and lower red blood cell production. However, the newest data suggests that iron supplementation before and during altitude is possibly more important for RBC production than incoming iron stores (ferritin), as long as hemoglobin is within normal ranges [14, 15]. This contemporary research shows a near dose-response relationship with increasing iron intake (up to 200mg of elemental iron/day) and subsequent increases in HBmass (RBC’s) while training at altitude (NOT SEA LEVEL!). In this series of studies, Govus et al. [14] and GarvicanLewis et al. [15] examined 178 athletes who participated in altitude camps and found that those athletes who did not supplement with iron had minimal HBmass increases of only +1.2% (within HBmass measurement error), Français

Trent Stellingwerff Trent is an applied sport physiologist with a specialization in the area of performance nutrition. He earned a Bachelor of Science in Human Nutrition and Exercise Physiology at Cornell University and he earned his Ph.D. from the University of Guelph in Exercise and Skeletal Muscle Physiology. At the Canadian Sport Institute Pacific he focuses on providing his physiology and nutrition expertise to Canada’s national rowing, track and field and triathlon teams, as well as leading Canadian Sport Institute’s Innovation and Research division.

Figure 1. A proposed schematic of some of the positive (green circles) and negative (orange circles) impactors to red blood cell production while at altitude. References highlighted in figure include: [1, 5, 7-13]. 3) POST ALTITUDE: ~6 to 10 weeks after the altitude camp: Have another iron status assessment, ideally within a few days/weeks. As above, aim to be rested and healthy, prior to bloodwork. a. If ferritin <75 μg•L-1, or with a history of iron deficiency continue with 100mg of elemental iron per day. Regular bloodwork monitoring (2 to 3 times per year) is recommended. b. If ferritin >75 μg•L-1, and with no history of iron deficiency, iron supplementation no longer needed.

athletes that supplemented with 105mg of elemental iron per day increased HBmass by +3.3% and those that supplemented with 210mg of elemental iron per day increased HBmass by +4.0%. Given this new information the following is recommended: 1) PRE ALTITUDE: ~6 to 10 weeks prior to altitude camp: Have an iron status assessment via blood test: hemoglobin, serum ferritin, iron saturation and total iron binding concentration. As ferritin is an acute phase reactant, for more accurate results aim to have blood work completed when rested (i.e. >24hs after a hard workout) and healthy (no recent illness). If serum ferritin concentrations are <75 μg•L-1 consult with a medical, nutrition and/or physiology expert, but consider starting supplemental iron immediately aiming for 100mg of elemental iron per day. Please see section below on optimizing iron bioavailability. 2) DURING ALTITUDE: ~2 weeks prior to altitude and throughout the entire altitude camp: a. If ferritin <100 μg•L-1 at pre-altitude blood check [14], the following is recommended:

i. If not already taking an iron supplement, 2 weeks prior to the camp take100mg elemental iron/day for 7 days (see info on optimizing iron bioavailability below). ii. 1 week prior to the camp increase to 200mg of elemental iron/day, but split the dose throughout the day (e.g. 100mg in morning or afternoon and 100mg in the evening). If gastrointestinal issues are present (e.g. constipation, diarrhea) for more than 7 days, lower the dose to 100-150mg of elemental iron (or the highest dose tolerated) per day and contact a nutrition expert to review your iron supplementation strategy. b. If ferritin is between 100 and 133 μg•L-1 [15] at pre-altitude blood check: i. 2 weeks prior to and throughout the altitude camp, supplement with 100mg elemental iron/day (see info on optimizing iron bioavailability below). c. If ferritin >133 μg•L-1 at pre-altitude blood check- please contact a medical, nutrition or physiology expert for individual advice.


Note: The following altitude ferritin cutoffs of 100 μg•L-1 [14] and 133 μg•L-1 [15] for subsequent iron supplementation are the same levels identified by two recent publications on ferritin values, iron supplementation and HBmass responses of athletes going to altitude. It is important to note, that in one study [14], athletes supplemented with 105mg of elemental iron per day still had a 13.8% drop in ferritin throughout an altitude camp, and thus, a decrease in total body iron storage. Also, the gold standard for measuring the effects of altitude on RBC/Hemoglobin response is to have hemoglobin mass measured prior to and after an altitude camp via the carbon monoxide rebreathe technique. In Canada this method is only available at CSI Pacific and CSI Calgary. It is also available in Flagstaff, Arizona. Finally, it is strongly recommended that each athlete prioritizes the development of an individual blood profile over time that includes the outcomes of all iron status assessment blood tests featuring a complete blood count (e.g. hemoglobin etc.) as well as iron studies (e.g. ferritin, ,iron saturation, etc.), along with notes on any supplemental iron doses consumed. An individual profile better informs professionals as to ideal iron supplementation protocols.

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Types of Supplemental Iron There are many types of iron supplements (iron salts), with varying amounts of elemental iron (Table 1). Athletes respond very individually to the various iron supplements in terms of both their response to increasing iron stores as well as gastro-intestinal sideeffects. If an athlete’s iron stores have not appreciably changed (less than a 10 unit change in ferritin) over 2 to 3 months on a given iron supplement, the athlete is in energy balance (see below) and all steps to maximizing iron bioavailability have been taken (see below) it may be valuable to try a new form/source of iron. The authors of this paper have had consistent positive outcomes with the major brand Palafer/Palafer CF (ferrous fumarate). Athletes should always inform their sports physician and/or nutrition/physiology support personnel of any changes to iron status and supplementation protocols. In rare cases an athlete may have to undergo an iron infusion; but this is only warranted once oral iron bioavailability has been optimized, energy balance is optimal and several forms of oral iron have been tested. In Canada this can only be arranged by a physician. Be aware that any infusion greater than 50ml per 6 hour period is banned under the current World AntiDoping Agency (WADA) Code as a prohibited method and therefore requires a Therapeutic Use Exemption (TUE). The request for a TUE will either be through a sport’s international federation or through the Canadian Centre for Ethics in Sport (CCES). The TUE application process (application and review) usually takes at least one month and therefore should be started early.

Optimizing Iron Bioavailability and Status There are numerous factors that can impact dietary/iron supplement bioavailability [16, 17] and iron stores. Be sure to follow these “rules” to enhance iron absorption and iron status: • Calcium and iron compete with each other for absorption in the gut. Do not consume an iron supplement with a calcium supplement or dairy products (milk, yogurt, calcium fortified non-dairy products). Whenever possible avoid calcium intake for at least 1 hour before or 2 hours after taking iron.


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Table 1. Overview of the various types of iron sources

Feramax = Polysaccharide-iron complex Ferrous fumarate = Palafer or Eurofer brands Proferrin – Heme Iron Polypeptide – 11mg (all heme)-but limited research data as of yet. • Tannins in black tea and red wine and polyphenols in coffee can also inhibit iron absorption. Do not take iron supplements with tea, red wine or coffee, and drink tea and coffee between, rather than with meals. Whenever possible avoid drinking these beverages for at least 1 hour before a meal and 1 hour (for tea) to 2 hours (for coffee) after a meal/supplemental iron. • Antacids, Vitamin E and tetracycline partially block iron absorption therefore do not take within 2 hours of each other. • Increase absorption of iron supplements by consuming with a Vitamin C source. • High intensity/prolonged and hard training causes inflammation and the release of the hormone hepcidin, which has been shown to block iron absorption. It is best to periodize iron supplement intake at least 4 to 6 hours after, and at least 2 hours prior to, very hard workouts [18, 19]. • Given that hard training decreases iron absorption, rest and recovery phases, or easier training phases, are the ideal times to increase iron stores (ferritin). Continue to take supplemental iron during rest and recovery phases if low serum ferritin is an ongoing issue. • Menstrual cycles cause only small blood (iron) losses per month in females and normal female sex hormone levels actually decrease total hepcidin release, potentially increasing the amount of iron that can be absorbed [18]. • Workouts on hard surfaces, in spikes, and in the heat (increased inflammation) can also cause increases in foot strike


hemolysis (micro-bleeding) and a greater chance of decreasing iron stores [20]. Thus, be especially aware of iron status (obtain blood work) around precompetition and competition phases of the training year. • When taking more than 100mg elemental iron per day, or if historical adverse gastro-intestinal (GI) issues with iron supplementation, we recommend: • increase iron absorption and minimize potential GI side effects by dividing the doses (e.g. 100mg in the afternoon and 100mg before bed). • Start supplementation with half the recommended amount for 1 to 2 weeks, increasing over several weeks to a full dose as tolerated. • Ideally the iron supplement is taken on a near empty stomach, but if GI issues present, take with food. • If adverse GI symptoms persist (>1 week), consider a different type of iron supplement. • Ensure optimal energy balance (see below). Note: Athletes who have been in prolonged negative energy balance have an increased risk for systemic adverse GI issues. Correct energy balance to correct GI symptoms. The human body absorbs food iron better than synthetic supplemental iron, thus be sure to “iron optimize” the diet [16, 17], with tips such as: • Heme-iron from animal sources is more bio-available than non-heme iron from plants.

• Increase non-heme and synthetic (supplement) iron absorption by adding vitamin C rich foods to meals and snacks. • Non-vegetarians can also count on muscle protein factor (MPF) found in meat, fish and poultry to increase nonheme iron absorption. • Optimal energy availability/balance is vital for optimal training adaptation, bone health, illness prevention and prevention of vitamin and mineral deficiencies, such as iron. Furthermore, not only is energy availability/balance important for altitude and red blood cell production (see below) it has also been indicated in gastro-intestinal health and optimizing iron absorption. Athletes should aim to be in energy balance for the majority of the training year (details in section below) to enhance iron absorption, and subsequent RBC production. Finally, long-term use of NSAID’s (antiinflammatories) and iron supplements are contraindicated – please consult a physician.

Energy Availability / Balance to Optimize RBC Production Muscle protein synthesis can drop as much as 20% when the body is put into an energy deficient state [21], and like muscle, blood constituents (e.g. hemoglobin and albumin) are also proteins. Interestingly, these blood based proteins have been shown to behave similarly to muscle, in that protein intake post-exercise [22] and positive energy balance stimulate the synthesis of additional blood proteins. Although there is very limited research on the effects of negative energy balance and RBC production in athletes while at altitude, there are many indications that it will be less than ideal. For example, one 18hr fasting period in rats at simulated altitude dropped EPO production by 85% [23]. Furthermore, unpublished observations have shown that negative energy availability/

balance in elite male and female runners resulted in doubling of the amount of accumulated injury and illness days over a year of monitoring [24]. Finally, it is well established that an injury or illness while at altitude can cause a massive 5 to 30% reduction in HBmass [13]. Therefore, staying in optimal energy balance will not only allow for optimal RBC increases, but will also decrease the risk of injury and illness. Some measured and indirect markers that may indicate an athlete is in suboptimal energy availability and/or negative energy balance, as highlighted by the IOC consensus statement on Relative Energy Deficient in Sport (RED-S; [25]), can include: • Reduced sex hormones via a blood test (e.g. estrogen or testosterone), which in females translates into an abnormal menstrual cycle. In males the most prominent symptom may be loss of libido. • Reduced bone mineral density (BMD; < -1 SD of Z-score). • Prolonged energy availability below 35kcal / fat free mass / day as assessed by dietary intake and exercise recording over 5 to 7 days. • History of multiple stress fractures (>2 over career). • Disordered eating and eating disorders. • Excessive injury and illness rates (>2 to 3 per year) especially when combined with prolonged low body weight and very low body fat.

Increased Carbohydrate & Hydration Needs at Altitude Although high altitude exposure (>3,500m) may cause increases in basal metabolic rate, appetite suppression and shifts toward increased carbohydrate utilization, studies on these effects at moderate altitude are lacking [26]. On the other hand, carbohydrates are the primary fuel source to sustain exercise


regardless of elevation and adequate carbohydrate intake at altitude may increase carbon dioxide production, ventilation, and heart rate improving hemoglobin saturation levels at altitude [27]. At the same time altitude training results in increased fluid requirements due to altitudeinduced diuresis, increased ventilation (shallower and more frequent), and low humidity induced respiratory losses and impaired thirst [26, 28]. Thus, given that the hypoxia of altitude causes a shift in fuel use from fat to a greater reliance on carbohydrates for energy and that total water losses from the urinary and respiratory systems may be as high as 2 L/day, athletes need to pay particular attention to both carbohydrate and fluid intakes [28]. Monitoring urinespecific gravity, body mass changes as well as training quality and consistency are all useful strategies to prevent dehydration and inadequate carbohydrate/energy intakes during altitude training.

Conclusions While it has been decades since endurance athletes began using altitude to provide an alternative stimulus for training adaptation it is only recently that understanding of the various nutritional approaches to maximize this adaptation has come to the forefront. Additional information in this area will certainly evolve recommendations on how to possibly enhance the effects of altitude training stimulus. Currently, we can appreciate the positive impact that optimal iron and energy availability has on red blood cell production and training adaptation while at altitude. ∆ References available on request.

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IN WHEELCHAIR BASKETBALL ATHLETES DURING MAJOR COMPETITIONS Heather Logan-Sprenger, PhD, Lead of Physiology, Research & Innovation, Canadian Sport Institute Ontario


heelchair basketball (WCB) is one of the most popular and acclaimed sports within the Paralympic Games and is played by athletes who have a physical disability such as an amputation, spinal cord injury (SCI), cerebral palsy, and/or others (multiple sclerosis, muscular dystrophy, polio, and spinal bifida) which prevents them from playing able-bodied (AB) basketball1. WCB is an intermittent, high-intensity and physically demanding sport, with 28% of the active game being high intensity and anaerobic, 24% aerobic, and 48% recovery2.

Temperature regulation during exercise appears to be a challenge among athletes, even during moderate ambient temperatures (~21°C)3-5. During exercise, the subsequent elevation in metabolic rate results in increased muscular power (~20%) and heat production (~80%)6,7. Thus, temperature regulation processes must act to dissipate the heat produced to maintain core body temperature (Tc) over a narrow range8. A rise in Tc occurs when the increased heat production exceeds the maximal capacity of heat dissipation9. If Tc increases to ≥40°C, hyperthermia develops9 and results in a reduction in exercise performance and/or the development of heat related illnesses (heat exhaustion, heat cramps, and heat stroke)10,11. In comparison to AB athletes, many para-athletes exhibit a reduced or impaired ability to regulate Tc, often due to a reduced afferent input to the thermoregulatory centre12,13. Athletes with an amputation or SCI


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experience an impaired sweating capacity and vasomotor control below the level of injury14. Heat stress may also lead to adverse outcomes, such as exacerbating side effects associated with the disability, as in athletes with multiple sclerosis, cerebral palsy, muscular dystrophy, and polio12,15,16. Indoor WCB has been categorized as possessing an intermediate risk for heat-related illness12. Thus, any attempt to delay the rise in Tc during exercise may support both optimal performance and the health and well-being of the para-athlete. Moreover, much of what we know regarding thermoregulation has been studied using AB athletes, while some may argue the need for research is greater for para-athletes. Therefore, in preparation for future competitions held in hot climates, in particular the upcoming 2016 Olympic and Paralympic Games in Rio de Janeiro, the objectives of this study were as follows:


1) To identify players on the women’s National WCB team who may be at a greater risk of heat-related illness and fatigue in the later quarters of a game due to high heat accumulation. 2) To implement appropriate cooling strategies to mitigate the effects of a high sustained core temperature on performance. 3) To assess the effectiveness of the cooling intervention on Tc responses during a follow-up game.

METHODS Eleven women’s National WCB team members (n=11, 18-41yr) were monitored twice over a four-game series versus Germany. Athletes were grouped according to the International Wheelchair Basketball Federation classification system1. The temperature of the gymnasium was 22.1±1.2°C (mean ± SD) with a relative

humidity of 55 ± 2%. Subjects were informed both verbally and in writing of the experimental protocol before giving their oral and written consent to participate. Approval for this study was granted from the Canadian Sport Institute Ontario Research Ethics Board (Toronto, ON). All telemetric pills (Equivital (EQ02)) were activated and calibrated at two temperatures (20°C, 40°C) in distilled water to ensure valid readings prior to each use. Based on the variable gastrointestinal transit time of the para-athletes, each athlete swallowed a Tc pill at different times (3 ± 2hr) prior to training and competition. Each athlete wore an EQ02 Sensor which recorded and processed data measured from the person and transmitted the data in real-time over a wireless interface. This device recorded realtime Tc, skin temperature (SkT), heart rate (HR), breathing rate, and electrocardiogram. Upon arriving to the court, athletes voided their bladder and provided a small mid-stream urine sample for the determination of urine specific gravity (USG <1.20=hydrated). The sample was analyzed for the determination of pre-training and competition hydration status. Athletes were then weighed on a calibrated SECA scale (±0.01kg) and pregame body mass (BM) was recorded. A post-game BM measurement was repeated to determine the change in BM due to sweat loss. Each athlete’s water bottle(s) were measured pre- and post-game to determine


the volume of fluid consumed using a portable food-grade scale accurate to 0.01g and the composition of fluid was recorded to account for carbohydrate-electrolyte consumption. A pre-game (baseline) Tc, SkT, and HR measurement was taken before the game warm-up. Tc, SkT, HR, and breathing rate were tracked in real-time throughout the game. At the end of each game all data from the SEM devices was downloaded and analyzed using Equivital Manager software. Athlete playing time over the game was determined by video analysis software. Athletes at risk for heat-related fatigue were identified as those players sustaining a Tc >39°C for longer than 15 min of play. Athletes identified as being ‘at risk’ were provided with an individualized cooling and hydration strategy. Each ‘at risk’ athlete was monitored over a third game to determine the effectiveness of the cooling intervention on Tc response.

RESULTS All of the athletes were hydrated upon arriving to each game (USG=1.011 ± 0.03) and all effectively replaced lost sweat through their habitual drinking behaviors (-0.4 ± 0.1% BM) throughout the course of a game. The athletes who had the greatest playing time exhibited the greatest BM loss (~1%) due to a reduced opportunity to drink on the sidelines.

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Figure 1. Mean core and skin temperature responses throughout a National women’s wheelchair basketball game versus Germany (n=11). Core and skin temperature significantly rose after the warm-up from rest (p < 0.01). SkT, skin temperature. WU, warm-up. Q, basketball quarter. HT, half-time.

Heather Logan-Sprenger, PhD, CSCS Heather is the Lead of Physiology, Research & Innovation at the Canadian Sport Institute Ontario. Her passion lies in applying her love of physiology to optimizing athlete performance and success. Being a two-sport National Team athlete herself, in both ice hockey and road cycling, Heather’s current research is focused on multi-disciplinary applied sport science research initiatives to improve podium potential and performance in Canadian athletes. Heather has published in such journals as Applied Physiology, Nutrition, and Metabolism, Medicine and Science in Sports and Exercise, Journal of Strength and Conditioning Research, American Journal Physiology, Endocrinology and Metabolism, and the International Journal of Sports Nutrition and Exercise Metabolism.

As expected, Tc and SkT significantly rose from baseline to post-warm-up (Figure 1, p<0.01) and became relatively stable for the majority of the athletes throughout the game. The rise in SkT occurred to a lesser extent than Tc, with the mean gradient difference of 2.8°C (Tc>SkT) throughout the game and was minimized in the later stages of the game (difference of 2.1°C, Figure 1). It is speculated that this gradient difference is primarily due to the loss and subsequent conversion of plasma volume during times of moderate to high sweat loss, which


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minimizes the extent of evaporative cooling at the skin resulting in a greater SkT. This finding is consistent with other published research which has suggested that the magnified Tc to SkT gradient may occur due to environmental temperatures which are advantageous to convective heat loss and from an increased sweat rate13. A significant difference in Tc responses between athletes who had more playing time versus those with less playing time (p<0.05) was also found. Athletes with a classification of 1-1.5 (n=3) had a highest mean rise in Tc (+1.3°C (range 0.5–1.9°C)), followed by athletes in class 2.5-3 (n=3) (+1.0°C (range 0.44–1.4°C)) and class 4-5 (n=4) (+0.71°C (range 0.44–0.84°C). This is consistent with other published research demonstrating the differences in the extent of heat accumulation based on classification14. There were two identified female athletes who had a sustained Tc ≥39°C (39.6, 39.5°C) for the last two quarters of the game. One athlete was a class 1 and the other a class


4.5 athlete. Both played the majority of each game when monitored (>18 min). The athlete with a SCI reported feeling extremely hot and felt the heat was impacting her on-court performance. During the follow-up (Game 3), it was reported to the coaching staff when this athlete was at ~38.5°C. The coach then substituted the athlete off the court for 3-4 min to allow time to drink cold fluid and have ice packs placed on her neck. For this athlete, this intervention prevented a Tc rise ≥39°C and resulted in the athlete reporting decreased fatigue and a greater ability to maintain a higher intensity with better mental acuity when on the court.

Since HR was collected along with Tc data, we are in the process of determining the sustained HR response that elicits a Tc >39°C for the two identified athletes. Since the Tc unit will not be used at the upcoming Rio Olympics/Paralympics, this is the indirect means of identifying when the athlete needs a break to cool-down during the game. HR is a game metric monitored courtside by a member of the support staff who can provide feedback to the coaches about the approximate Tc responses based on playing time and the athlete’s sustained HR responses. This will allow the cooling intervention to be implemented throughout the Olympics/Paralympics. Aside from the two identified athletes who may be at a higher risk of heat related fatigue, this project disclosed that athletes who do not get much playing time (<8 min/40

min game) are losing a significant amount of heat on the sidelines (from the heat they acquired during their game warm-up), and may have a Tc in the later stages of quarter two and four that is similar to their baseline Tc. Research has shown an increased risk of injury and potential performance decrements associated with an inadequate athlete warm-up15. This data revealed a potential performance issue if an athlete is substituted into the game without much prior playing time. This drives the importance of doing an appropriate court-side warm-up to prepare for the athlete’s substitution into the game. This can be done by using an arm ergometer setup on the sidelines, or if available, utilizing a large enough space beside the court to push around. As well, it is imperative for these athletes to utilize the 15 min half-time to warm-up again on the court with shooting and movement drills. This information has led the coaching staff and support team to customize half-time routines for each player based on their playing time.



11. Siegel R, Laursen PB. Keeping your cool: possible mechanisms for enhanced exercise performance in the heat with internal cooling methods. Sports Med. 2012;42(2):89-98.

This research demonstrated the need to monitor Tc in WCB athletes as great variability in response to heat stress exists, with athletes in a lower class exhibiting greater heat stress than higher playing classes, and those with greater on-court playing time also demonstrated increased risk. Using individual cooling strategies, heat stress was mitigated and resulted in improved athlete well-being and performance. For athletes who had less on-court playing time (<8 min/40 min game), a courtside warm-up routine was necessary as heat loss from inactivity may increase the risk of injury and performance when called to play. This research continues to evolve and each cooling and warm-up strategy will be practiced and monitored in the lead-up to the Rio Olympics/Paralympics to support the health and performance of WCB athletes. ∆


1. International Wheelchair Basketball Federation. 2014. Official Player Classification Manual. 2. Bloxham LA, Bell GJ, Bhambani Y, Steadward RD. Time motion analysis and physiological profile of Canadian world cup wheelchair basketball players. Sports Med Train Rehabil. 2001;10:183–198. 3. Hargreaves M, Dillo P, Angus D, Febbario M. Effect of fluid ingestion on muscle metabolism during prolonged exercise. J Appl Physiol. 1996;80:363–366. 4. Logan-Sprenger HM, Heigenhauser GJ, Killian KJ, Spriet LL. Effects of dehydration during cycling on skeletal muscle metabolism in females. Med Sci Sports Exerc. 2012;44(10):19491957. 5. Logan-Sprenger HM, Spriet LL. The acute effects of fluid intake on urine specific gravity and fluid retention in a mildly dehydrated state. J Strength Condit Res. 2013;27(4):1002–1008. 6. Cheuvront SN, Haymes EM. Thermoregulation and marathon running: biological and environmental influences. Sports Med. 2001;31(10):743-762. 7. González-Alonso, J. Human thermoregulation and the cardiovascular system. Exp Physiol. 2012;97(3):340-346. 8. Hardy JD. Physiology of temperature regulation. Physiol Rev. 1961;41:521-606. 9. Kenefick RW, Cheuvront SN, Sawka MN. Thermoregulatory function during the marathon. Sports Med. 2007;37(4-5):312-315. 10. Armstrong LE, Casa DJ, Millard-Stafford M, Moran DS, Pyne SW, Roberts WO. American College of Sports Medicine position stand. Exertional heat illness during training and competition. Med Sci Sports Exerc. 2007;39(3):556-572.

12. Johnson BF, Mushett CA, Richter K, Peacock G. Sport for Athletes with Physical Disabilities: Injuries and Medical Issues. BlazeSports America. 2024. 13. Cuddy JS, Hailes WS, Ruby BC. A reduced core to skin temperature gradient, not a critical core temperature, affects aerobic capacity in the heat. J Therm Biol. 2014;43:7-12. 14. Griggs KE, Price MJ, Goosey-Tolfrey VL. Cooling athletes with a spinal cord injury. Sports med. 2015;45:9-21. 15. Fradkin AJ, Gabbe BJ, Cameron PA. Does warming up prevent injury in sport? The evidence from randomized controlled trials? J Sci Med Sport. 2006;9(3):214-220. 16. Bhambhani Y. Physiology of wheelchair racing in athletes with spinal cord injury. Sports Med. 2002;32(1):23-51. 17. Olgiati R, Jacquet J, DiPrampero PE. Energy cost of walking and exertional dyspnea in multiple sclerosis. American Rev Respir Dis. 1986;134:1005-1010. 18. Richter KJ. Seizures in athletes. J Osteo Sports Med. 1989;3:19-23.

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KIMBERLY BOWMAN MSc Candidate, University of British Columbia Canadian Sport Institute Pacific Sport Physiologist Intern


any elite team sport athletes face the physiological challenge of having to compete in extremely hot weather conditions [4]. Exercising in the heat induces a large stress on the body’s cardiovascular and thermoregulatory system, as metabolic heat generated from intense exercise is coupled with environmental heat [11]. Soccer in particular is a physically demanding sport requiring technical skill, strong endurance, and repeated sprint ability [3,11-12]. Mohr and colleagues (2010) highlighted the impact of an added thermal load when observing soccer match performance in a hot condition (~40˚C) compared to that in mild weather (~21˚C). Specifically, reductions in total distance (-7%), high intensity running (-26%), and running velocity (-3%) [11].

Benefits of Heat Acclimatization Heat acclimatization (HA) involves exercising at a target core temperature stimulus (~38.5˚C) in a hot environmental condition over 1-2 weeks [9]. Repeated heat exposures allow adaptations to develop that attenuate the negative effect of heat stress through improvements in exercise capacity and perceptions of thermal load [4]. More recent studies have shown heat acclimatization to be ergogenic in both mild and hot conditions, therefore, cold weather sports may also benefit from utilizing a heat protocol prior to competition [10]. The magnitude of heat adaptation is determined by: intensity, duration, frequency, number of heat exposures, and environmental condition [4, 9].


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Performance Tests and Monitoring Metrics in Heat Athletes performing at high intensities in Acclimatization Thermoregulatory & cardiovascular adaptation

competitive games commonly have sweat rates ≥2.5L/h [16]. Heat acclimatization improves thermoregulatory efficiency via a lowered sweating threshold and a reduction in the core temperature threshold for sweating (~0.15 to 0.29˚C) [4]. Acute acclimatization regimes have also reported a greater cardiovascular stability while exercising in the heat via a plasma volume increase (3-27%) [9].


Telemetric heart rate (HR) chest monitors (Polar Electro) used to monitor HR response act as an indirect assessment for change in cardiac efficiency, aerobic capacity, and training intensity [1]. Common HR metrics include i) Exercise HR (HRex): the mean HR in the final 30sec of the 5-minute running period and ii) Recovery HR (HRR): the mean drop in HR over a 1-minute rest period post-run [1-2]. Additionally, a GPSaccelerometer (Global Positioning System, Catapult Minimax S4) can be used to track soccer-specific external load metrics in real-time [11, 18]. The S4-GPS device can monitor; total distance covered, meters per minute (m/min), number of high-speed runs (>16.5km/h), and high IMA or accelerations/

deceleration/change in direction (>2.5m/ s2) [11]. These metrics provide meaningful interpretation of the performance outcomes pre-post acclimatization (i.e., magnitude of change)[1, 2].

Current Heat Acclimatization Literature

Figure 1. Overview of the study. Pre Camp: 1d baseline plasma volume (PV) assessment; Phase 1 Pre-Acclimatization: 7d in Los Angeles, 4 training sessions ~100min/day soccer specific training drills and 2 match days ~90min/day; Phase 2 Heat Acclimatization; 6d in Cancun, 5 training sessions ~97min/day; Post Camp: 11d in Toronto.

Male endurance athletes have used HA in controlled lab settings (acclimation), however, there is little evidence specifying the adaptive response in female team sport athletes [4, 9].

Research Overview In preparation for the 2015 FIFA Women’s World Cup (Canada: June 6-July 4, 2015), the Canadian Women’s National Soccer (WNT) completed a two-phase field-based heat acclimatization (HA) protocol (see Figure 1). Sixteen players participated in both phases of the camp over a 25-day period. Phase 1 consisted of seven days in Los Angles, U.S.A (22.1˚C, pre-acclimatization) and Phase 2 consisted of 6 days in Cancun, Mexico (34.5˚C, heat acclimatization). The


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purpose of the study was to use novel and non-invasive field-based monitoring metrics throughout HA to observe the physiological and performance adaptive response of all team members.

Key Objectives 1. To track change in athlete total blood plasma volume in order to observe those who may benefit aerobically to heat acclimatization. 2. To use non-invasive methods of in-field performance testing including both internal and external load metrics (GPS, HR systems) to observe the soccer relevant performance change from heat loading.

Heat Acclimatization Methodology Field Monitoring • A Catapult GPS-accelerometer was used to observe daily training load. • A Polar Team 2 Heart Rate monitoring system was used track HR metrics. • Core body temperature was monitored throughout training using a VitalSense Telemetric Monitoring System (Mini Mitter Philips Respironics) and thermal sensor (JonahTM Ingestible Core Temperature Capsule).

5’-1’ Submaximal Running and HR Response As a component of warm-up on day 1, 9, 14, 16 and 25, all players performed a standardized 5-min running, 1-minute rest submaximal test (12km/h over a 40-m shuttle) [2]. Heart rate response (HRex, HRR) and rate of perceived exertion (RPE, 10-point Borg Scale) were monitored during each test.

4x2 Four Aside Soccer Game Two soccer-specific heat stress tests (4x2 minute small-sided games SSG) (40x35-m) were performed on the first and last day of Phase 2. Both internal and external load metrics were monitored in order to quantify the impact of heat stress on soccer performance.


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Kimberly Bowman Kim was a former National athlete in competitive swimming and has competed for both The Ohio State University and The University of British Columbia. Her passion for competitive sport and working in a high performance environment inspired her to pursue Masters level research at UBC in the field of Applied Sport Science. The research program is an Own the Podium Innovations for Gold Initiative in association with the Canadian Sport Institute Pacific. Her research involves a study of field-based heat acclimatization with the Canadian Women’s National Soccer Team with whom she had the privilege of working with for the past year and half. The results of the research will be used by the Women’s National Team to develop an individualized heat-training program prior to the upcoming 2016 Olympics in Rio de Janeiro, Brazil.

Plasma Volume Assessment

Key Results

Plasma volume was measured for each athlete on four occasions during the study period (Day -16, Day 1, Day 6 or 7, Day 16) (see Figure 1). Baseline absolute plasma volume was assessed using a carbon monoxide rebreathing protocol [15]. The Dill and Costill method (1974) was used to calculate the percentage change in plasma volume at the start and end of training in Los Angeles and at the end of training in Cancun [7].

1. The effect of acclimatization on blood plasma volume.

Statistical Analysis Data are presented as means (±SD) and correlations with (90% confidence limits (CL) and intervals (CI). All data were logtransformed for analysis and then analyzed for practical significance using magnitude -based inferences, as this is most relevant to a change in athletic performance [8]. The interpretation of the standardized change (ES) from performance testing was; <0.2, trivial; 0.2-0.6, small; 0.6-1.2, moderate; 1.22.0, large; 2.0-4.0, very large; >4.0, extremely large [8].


• There was an absolute PV increase of ~8% from the start of training in LA to the end of training in LA (Pre-Post Phase 1) while there was approximately a ~7% increase in absolute PV from the start of training in LA to post training in Cancun (Pre Phase 1-Post Phase 2). 2. The effect of acclimatization on 5’-1’ submaximal performance (see figure 2.) • Submaximal testing on the first training day in Cancun was more stressful than in milder conditions, as there was a substantial increase in exercise heart rate (+5.6bpm) and a decrease in recovery heart rate (-6.5%). • The greatest improvement in aerobic performance was observed 1-week post heat acclimatization in a mild condition (Fig 2.TO2), as there was a large decrease in exercise heart rate (-5.2bpm) and an increase in recovery heart rate (2.3%).

• The lack of response in the first test post acclimatization (TO1) may be attributed to residual fatigue from HA training and travel. 3. Effect of acclimatization on 4v4SSG performance.

• The greatest aerobic improvement was seen 1-week post heat acclimatization, which provides new insight with regards to the heat acclimatization adaptationand rate of decay time-course.

Application to other Olympic and • There was a lower exercise heart rate Paralympic Sports

Figure 2. HR Response: Top: HRex, middle: HRR, and bottom: Rate of perceived exertion (RPE) during the 5’-1’ submaximal test performed in Los Angeles (LA); Cancun (CUN1, CUN2) and Toronto (TO1, TO2).

(-3.5bpm) and a greater recovery heart rate (~6%) during the soccer game prepost heat acclimatization.

• GPS monitoring during the games revealed a greater capacity to increase combined acceleration, deceleration, and change in direction (~20% High IMA/ min) pre to post heat acclimatization. • A change in high IMA is most relevant to a positive change in small-sided game performance as it indicates a greater ability to increase velocity, and therefore, create more goal-scoring opportunities [3].

Athletic Performance Impact Summary • Results from the current study support the utilization of a heat acclimatization protocol at least one month prior to competition to induce physiological changes that positively impact athletic performance (Phase 1-2: ~7% increase in PV)

Any endurance or team-sport (Athletics, Cycling, XC Skiing, Rugby) who does not have the resources to undertake heat acclimation in controlled laboratorychambers, can adopt the monitoring methods utilized in this study to globally observe team responsiveness to heat stress. The GPS (Global Positioning System) Catapult technology and HR response (Polar Team 2 System): i) allow coaches to quantify the magnitude of heat adaptation and ii) are noninvasive, inexpensive, and can be applied simultaneously to a large number of athletes [1-3, 11]. ∆ References available on request. Masters Supervisors: Cesar Meylan, Ph.D. Trent Stellingwerff, Ph.D. Michael Koehle, Ph.D., M.D. Robert Boushel, Ph.D. Acknowledgements Wendy Pethick Josh Trewin

• Meaningful improvements in heart rate response were seen in the 5’-1’ submaximal test and 4v4small-sided game pre to post heat acclimatization.


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ith the Olympic and Paralympic Games in Rio de Janeiro, Brazil quickly approaching, environmental factors that may effect athletic performance are of significant interest. Reflecting the theme of this issue we take a look at how heat and altitude have individual and combined effects on athletes and their ability to achieve optimal performance. Though it is the middle of winter in Brazil, the temperatures in Rio for August and September usually average around the mid 20°C with relative humidity levels approaching 80%. The city of Rio itself is right at sea level, however other parts of the city can see elevations in the 1,000-2,000m range. The Games in Rio will show how athletes from different geographical regions have adapted to the climate and location of this Brazilian city.

Heat’s Effects on Athletic Performance Hot and humid environments are experienced differently by athletes according to a variety of factors including their individual physiology and where they are used to living. Olympic and Paralympic athletes may also have to adapt to heat and humidity as a result of medical conditions and/or impairments affecting their thermoregulatory processes. In general, hot environments have been known to manifest in athletes by a decrease in strength, power, speed, endurance and consequently sport specific neuromotor skill performance (Bergeron et al., 2012). The magnitude of the effects of heat on performance is usually dependent on the duration and intensity of the performance. Recommendations for athletes to combat possible negative effects of exertional heat conditions include: maintaining adequate hydration (prior to, during and recovery)


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and sodium level monitoring; progressive physiological adaptation or acclimatization (1-2 weeks); adaptation of warm up routine to incorporate adequate cool down before competition to reduce core temperatures; and design and wearing of appropriate clothing/ uniforms to maximize sweat evaporation. [Additional detailed information on exertional heat illnesses can be found in the NATA Position Statement summary on page 20 of this issue.]

Altitude’s Effects on Athletic Performance Short term effects of high altitude: lack of oxygen causing increased breath rate (in some cases hyperventilation) which can also lead to respiratory alkalosis (inhibition of the respiratory centre to achieve the necessary respiration rate); increased heart rate, decreased stroke volume and suppression of non-necessary bodily functions.


Long term acclimatization: Compensation for respiratory alkalosis through bicarbonate excretion by the renal system, which allows adequate respiration to increase oxygen without risk of alkalosis. Lower lactate production, decreased plasma volume, increased red blood cells, etc. For those living a significant period of time at high altitudes: the higher the altitude the better the oxygenation of the blood, enlarged lung volumes throughout life, and a higher capacity for exercise. Implications for Athletes: • Higher altitude means less atmospheric resistance for sprint events, long jump and triple jump meaning better performance; for endurance athletes, it means less oxygen in the blood generally decreasing performance. • Though acclimatizing an individual to a high altitude also generally means a better performance at lower altitude,

the impact of de-training (the inability to train at the same high intensity at high altitude) may at the same time hinder performance. • Current literature surrounding the “live-high, train-low” adaptation to these confounding effects of altitude training suggests that the performance enhancing effect comes through increased red blood cell count, more efficient training, or changes to muscle physiology.

Heat Training/Acclimatization vs Altitude Training Recent research (Lee et al., 2016) suggests that heat training may be a more efficient method of improving altitude tolerance and performance than altitude training. Studies of cyclists indicated that heat training showed reduced physical stress on the body

(lower body temperature and heart rate) as well as increased athletic performance. These effects, as well as the cellular stress responses, match the low oxygen training results showing that heat training may be just as effective as altitude training, but at a much reduced financial and time cost. Further research in this area continues in order to validate findings at the high performance level, though preliminary findings are promising.

Combined Affects of Heat and Altitude Similar to heat and altitude training individually, positive physiological responses and performance outcomes have been seen in athletes. However, again similar to the individual applications, heat and hypoxic environments together may exacerbate fatigue and decrease the ability to maintain training intensity. Heat and hypoxia combined have also been shown to “decrease time to exhaustion, elicit faster peak heart rate, and increase rating of perceived exertion (RPE)” compared with the individual modalities (Crowcroft et al, 2014). Girard & Racinais (2014) also saw similar results identifying: a shorter time to exhaustion (reduced by half) with an antagonistic relationship between the two factors (heat and altitude), when both conditions were present. They also noted that combining the two conditions resulted in compromised locomotor capacity. However, they saw no interaction effect when studying physiological, thermoregulatory or perceptual responses to the dual condition. Français

Conclusion It is clear to see that individually, heat or altitude continue to show their impacts on physiological and neurological processes in athletes. Research is also beginning to show that there are inter-related impacts on performance when both heat and hypoxic conditions are present. Current research acknowledges that there are many more factors that need to be examined in regards to the interaction between heat, altitude and performance in order to fully understand these relationships. ∆ References Lee BL, Miller A, James RS, Thake CD. Cross Acclimation between Heat and Hypoxia: Heat Acclimation Improves Cellular Tolerance and Exercise Performance in Acute Normobaric Hypoxia. Frontiers in Physiology, 2016; 7 Bergeron M, Bahr R, Engebretsen L, et al. International Olympic Committee consensus statement on thermoregulatory and altitude challenges for high-level athletes. British Journal of Sports Medicine . September 2012;46(11):770-779. Buchheit M, Racinais S, Coutts A, et al. Adding heat to the live-high train-low altitude model: a practical insight from professional football. British Journal of Sports Medicine . December 2, 2013;:1-12. Crowcroft S, Duffield R, McCleave E, Slattery K, Wallace L, Coutts A. Monitoring training to assess changes in fitness and fatigue: The effects of training in heat and hypoxia. Scandinavian Journal of Medicine & Science in Sports . June 2, 2015;25:287-295. Girard O, Racinais S. Combining heat stress and moderate hypoxia reduces cycling time to exhaustion without modifying neuromuscular fatigue characteristics. European Journal of Applied Physiology . July 2014;114(7):1521-1532. White A, Salgado R, Schneider S, Loeppky J, Astorino T, Mermier C. Does Heat Acclimation Improve Exercise Capacity at Altitude? A Cross-tolerance Model. International Journal of Sports Medicine . December 2014;35(12):975-981.

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LEADING HIGH PERFORMANCE SPORT IN ATLANTIC CANADA The Canadian Sport Centre Atlantic (CSCA) is pleased to play a leadership role in high performance sport in Atlantic Canada. The CSCA continues to evolve to meet the needs of Atlantic Canada’s high performance athletes and coaches. With a primary hub in Halifax, over 70 carded athletes are supported annually as well as many additional sports through the CSCA’s training group programs. Additional hubs are located in Fredericton, NB and St. John’s, NL where full-time staff members provide training services and support to national and provincial level athletes and coaches. World-class sport specific facilities have been created for canoe/kayak and sailing as well. The CSCA head office is located at the High Performance Training Centre housed in the Canada Games Centre in Halifax, NS. The Canada Games Centre (CGC) in Halifax, NS hosts the CSCA Head office and was built as a 176,000 sq. ft. venue in 2011 to host the Canada Winter Games for artistic gymnastics, badminton, and synchronized swimming. CGC has three key areas: • Aquatics Centre with three pools: Competition Pool, Leisure Pool, & Tots Pool • 52,000 sq. ft. Field House with three FIBA sized basketball courts & 200m 6-lane indoor Track • 11,500 sq. ft. Fitness Centre The partnership between the CSCA and Canada Games Centre has allowed for hosting of the men’s national volleyball team, RBC Training Ground, CPC’s Paratough Paralympian search, and FANfit in 2016.


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As part of the legacy plan for the facility, specific spaces required to create a high performance environment were built to complement the public spaces in the facility including the CSCA head office. Some of these high performance spaces include: • Specialized physical training area • Performance laboratory • Technology room • Coaches suite • Nutrition room/Athlete lounge In addition to these spaces, most of the CSCA’s IST (strength and conditioning, mental training, nutrition, sport science), and administrative team members are located onsite to encourage ongoing collaboration with coaches, athletes, and between team members. The result has been a rich environment of current and future Olympians and Paralympians from different sports training in this location on a daily basis.


A similar environment occurs in Fredericton and St. John’s with a total of over 800 NextGen and provincial level athletes supported. The Canadian Sport Centre Atlantic coordinates and delivers services and programs on behalf of Own The Podium, the Coaching Association of Canada, The Canadian Olympic Committee and the Canadian Paralympic Committee to athletes and coaches throughout Atlantic Canada. Our primary relationships are with National Sport Organizations (NSOs) in sports such as canoe/ kayak, gymnastics, women’s hockey, curling, snowboard and sailing. A close partnership with the provincial governments in Atlantic Canada has resulted in the creation of a number of provincial training groups with dedicated full-time coaching leading the programs. The objective of the CSCA is to provide an enhanced daily training environment and comprehensive support to sport specific and generic training locations. Building a positive relationship with our users and partners is a priority and leads to innovation and maximizing opportunities to improve. Leo Thornley, CSCA Director of Sport Science, and Lead Exercise Physiologist remarks that since the head office of the CSCA has moved to the Canada Games Centre location, there has been a culture of expanding the opportunities for success. ∆

Being in a fully equipped training centre creates more opportunities for success. Prior to having a focal point, time and energy was lost on travel and logistics, getting people and equipment to different places. Now more time is spent on what matters most and that is quality training and quality collaboration. Having a well-rounded sport science team and great collaborative coaching means the daily interactions are exciting. New questions are discussed regularly and solid plans reinforced. As the next generation of athletes experience this encouraging environment real progress can be seen. - Leo Thornley, CSCA Director of Sport Science & Lead Exercise Physiologist

T - @CSCAtlantic I - @cscatlantic W -


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n September 2015 the National Athletic Trainers’ Association published their latest position statement built upon scientifically based, peer reviewed research by a team of authors who are experts on the subject of exertional heat illnesses. The objective of the statement is to “present best-practice recommendations for the prevention, recognition, and treatment of exertional heat illnesses (EHIs) and to describe the relevant physiology of thermoregulation” to help certified athletic trainers and other health care providers. The primary goal of the recommendations is athlete health and safety during performance in hot/humid conditions. The following commentary presents highlights of the Position Statement. Casa D, DeMartini J, Yeargin S, et al. National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training (Allen Press). September 2015;50(9):986-1000.

Exertional Heat Illnesses (EHIs) identified within the paper include Exerciseassociated muscle cramps (EACMs), Heat syncope, Heat exhaustion, Exertional heat injury, and Exertional heat stroke (EHS). Keeping in mind that individual responses to environmental conditions and exertion may differ, highlights of the recommendations for Prevention, Recognition, Treatment, and Return to Activity include, but are not limited to the following (consult the full document for detailed recommendations): Prevention • Conduct a thorough physician supervised preparticipation medical screening to identify at-risk athletes. • Acclimatize athletes gradually over 7-14 days. • Individuals should maintain euhydration and appropriately replace fluids lost through sweat during and after training and competition and should have access to fluids on an as-need basis. Encourage sodium replacement. 22

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• Educate relevant personal on prevention and recognition of EHI and particularly EHS.


• Effects of heat are cumulative. Encourage athletes to sleep in a cool environment, eat a balanced diet and properly hydrate before, during and after exercise.

• EAMC – visible cramping in part or all of the muscle or muscle groups, localized pain, dehydration, thirst, sweating, or fatigue. Tend to be short in duration and mild in severity, but some may severely impact performance and require further medical attention.

• Policies on preseason heat acclimatization and event guidelines for hot, humid weather conditions should be developed based upon type of activity and temperature.

• Heat Syncope – brief episode of fainting associated with dizziness, tunnel vision, pale or sweaty skin, and a decreased pulse rate while standing in the heat or after intense exercise.

• Identify high-risk athletes and monitor during stressful environmental conditions taking preventative measures.

• Exertional Heat Exhaustion – excessive fatigue, fainting, or collapse with minor cognitive changes (eg, headache, dizziness, confusion). More serious symptoms may indicate EHS.

• Match rest breaks and work-to-rest ratios to environmental conditions and intensity of activity. • Supplemental sodium ingestion and fluid monitoring or neuromuscular reeducation may help prevent EACMs.


• Exertional Heat Stroke (EHS) – CNS dysfunction and a core body temperature greater than 40.5°C (105°F). Core body temperature may be below this level with EHS still present, immediate treatment is vital if EHS is suspected.


Dr. Gord Sleivert (2010). Beat the Heat. High Performance SIRCuit, 1(2), 10-17. Dr. Sleivert briefly summarises the key factors that limit performance in a hot environment and reviews practical strategies for coaches and athletes to optimize performance and training in hot weather. Primarily these strategies are focused upon minimizing the rise in deep body temperature and reducing the strain the body experiences as a result of exercising in the heat. • Heat Injury – moderate to severe heat illness characterized by end-organ damage but absence of profound CNS dysfunction. Treatment (Highlights only, full details of treatment recommendations should be consulted) • EAMC – immediate treatment related to muscle overload or fatigue is rest and passive static stretching. Icing and/or massage may help. For those relating to excessive sweating and suspected sodium deficit, ingest fluids or foods containing sodium. Recurring EAMCs should be referred to medical professionals for screening of other conditions. • Exertional Heat Exhaustion – remove excess clothing or equipment to increase evaporative skin area. Move to a cool, shaded area with further cooling efforts (fans, ice towels, etc). Monitor vital, raise the legs above heart level while in supine position. Transfer to medical professional or EMS care if condition worsens during or after treatment. • Exertional Heat Stroke (EHS) – Immediately seek emergency medical support during treatment. Core body temperature should be decreased to 38.9°C (102°F) within 30 minutes. Length of time core body temp is above the critical temperature dictates morbidity and risk of death. Treat suspected EHS with quick immersion in pool or tub of cold water (CWI). Remove excess clothing/equipment while performing CWI. Monitor core body temperature.

Return to Activity • EACMs or Heat Syncope – athletic trainer should monitor until signs and symptoms are no longer present. • Heat Exhaustion – same-day return to play not recommended. • EHS – when individuals are cooled effectively and sent home the same day, return may occur on a modified basis within 1 month with physician clearance. With delayed treatment, residual complications may be experienced for months or years. Structured guidelines in the sport context are lacking, but suggest individuals be asymptomatic with normal blood-work results before a progressive return to activity with close monitoring by a medical professional to measure heat tolerance and acclimatization. Environmental risk factors (heat and humidity, barriers to evaporative heat loss, Wet-bulb globe temperature, excessive clothing/equipment, etc.) and non-environmental risk factors (heat acclimatization, exercise intensity, overzealousness, poor physical condition, increased BMI, dehydration, illness, history of EHI, medications/drugs, electrolyte balance, etc.) play a significant role in all aspects of exertional heat illness risk and response. Although these guidelines cover a wide variety of education and action, all athletes who experience EHI should be referred to experienced medical care to determine and/or manage their condition, recovery and return to play. ∆


Advanced preparation is critical and a primary strategy is to ensure athletes are aerobically fit, have adapted to exercising in hot conditions through regular and systematic exposure to the heat (heat adaptation), have appropriate clothing to maximize heat loss and protect against solar radiation and understand the venue hot-spots. Even with an aerobic base, individual responses to exercising in the heat vary widely and a key preparation strategy is to evaluate individual differences by simulating the environment during training or holding a hot-weather training camp. Key factors to monitor include; 1) rate of body heating 2) sweat rate and composition 3) thermal tolerance 4) perception of effort and thermal comfort. With these differences identified then countermeasures and strategies can be implemented to optimize an athlete’s training and performance. Modifying warm-up and using precooling to reduce heat storage prior to competition are key strategies for enhancing performance in the heat. Additionally, using the information gathered through monitoring it is important to work with athletes on hydration strategies to match sweat and salt losses as best they can and adjust tactics and pacing for the conditions. With sufficient advanced preparation and the adoption of some or all of the acute countermeasures presented in this papers those that struggle with the heat will likely improve both their training and performance. For those that are accustomed to hot weather training, these strategies may provide a small performance edge that makes the difference to getting on the podium. ∆ Read the full article from our Fall 2010 issue! HP SIRCuit Summer 2016


MUST READ... Must Reads … Read, Excel, Learn

IST Journal Club The goal of the IST Journal Club is to share ‘must reads’ on cutting edge performance based applications, training/competition variables, and proactive medical interventions, selected by performance service experts representing various professional disciplines associated with Integrated Support Teams.

Why screening tests to predict injury do not work— and probably never will…: a critical review Bahr R. British Journal of Sports Medicine. 2016;0:1–6. Published Online First April 25, 2016

Reviewed by Eugene Liang Periodic health examinations (PHE) or screens have always been a common health monitoring tool of many sport science and medicine practitioners. The recent proliferation of standardized screens have pushed them into the forefront of paramedical assessment protocols and long term athlete development models. In that capacity, the PHE’s are touted as injury prediction, and thus, prevention tools. Current PHE designs are based on the loose relationship between injury etiology and injury risk. Due to this erroneously assumed relationship, even statistically significant association between PHE results and increased injury risk are not valid for injury prediction. Bahr (2016) reviews the most recent literature and challenges the predictive claims of current PHE’s and suggests key recommendations for future PHE’s to be more valid as predictive or preventative injury tools. The author suggests that valid PHE’s need to follow three key steps: (1) a strong relationship must be demonstrated in perspective studies between a marker from a screening test and


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injury risk; (2) the test properties of the marker must be validated in relevant populations, using appropriate statistical tools; (3) an intervention programme targeting athletes identified as being high risk using the marker must be more beneficial than the same intervention programme given to all athletes. Currently there are no PHE’s that meet those criteria. However, the usage of PHE’s as health monitoring tools, measure of baseline performance and health, as well as satisfying medicolegal duties is still recommended. Clinically, the review suggests that incorporating stretching protocols in warm up has no ill effect on performance and can impact ROM in the short term. However, adding dynamic activity immediately post stretching can play a larger role in performance than stretching alone. ∆

Skeletal Muscle Adaptations to Prolonged Exposure to Extreme Altitude: A Role of Physical Activity? Mizuno M, Savard GK, Areskog NH, Lundby C, Saltin B. High Altitude Medicine & Biology. 2008 Winter;9(4):311-7.

Reviewed by Jeremiah Barnert The impact of prolonged exposure to extreme altitudes on skeletal muscle adaptations were investigated in this study by examining skeletal muscle adaptations in high altitudes under different physical activity levels. To evaluate the effects of altitude on the upper and lower body, biopsies were obtained from the vastus femoris and the biceps brachii in 15 male subjects. Samples were collected at sea level and after 75 days at a minimum altitude of 5250m. The primary finding of this study was a mean fiber area reduction in response to altitude regardless of physical activity which meant an unaltered capillary to fiber ratio therefore an increase in capillary density per unit of muscle. Having a clear understanding of the physiology associated with altitude training can allow you to properly periodize the training program and/or prepare athletes for training and Français

competing at altitude. While it seems that muscle fiber atrophy is unavoidable at altitude, it is possible to preserve muscle fiber area at lower altitudes with physical activity and maintenance of a proper diet. By understanding an individual’s response to altitude, it is possible to obtain proper methods and systems that allow the athlete to maintain an ideal body composition that is favorable for their sport. Given the known advantages of altitude training, further development of systems around individual responses need to be known in order to maximize an athlete’s ability to train and perform. ∆

The nested model of wellbeing: A unified approach Hanriques, G., Kleinman, K., & Asselin, C. (2014). Review of General Psychology, 18 (1), 7-18.

Reviewed by Adrienne Leslie-Toogood Reading books such as ‘Unsinkable’ by Silken Laumann and ‘Open Heart, Open Mind’ by Clara Hughes reminds us of the importance of wellbeing in high performance sport. This article reviews the research on well-being and explores the definition of this sometimes nebulous term. This article provides a nested model of well-being that integrates several major approaches from the literature and requires you to consider four domains in evaluating the wellness of a person. These domains include: 1) the subjective domain, 2) the biological and psychological health and functioning, 3) the material and social context, and 4) the values and ideology of the evaluator. The authors suggest that someone is high in well-being when “they are happy and satisfied with their lives, are functioning well psychologically and biologically, have access to necessary and desired material resources and social connections to meet their needs (and the relative absence of damaging or dangerous stressors), and are engaging in life with a purpose and a direction that is deemed by the evaluator to be good and moral “(p.8). This is an excellent article that will provide the reader with several factors that may affect the well-being of those in sport, and as a result provides tools to positively impact the wellbeing of those with whom they interact. ∆

Does ‘altitude training’ increase exercise performance in elite athletes? (Review Article) Carsten Lundby and Paul Robach. Experimental Physiology (2016): published ahead of print. doi: 10.1113/EP085579

New Books @ SIRC SIRC, in collaboration with Human Kinetics, features four books of interest to high performance sport.

Reviewed by Scott Maw Altitude training has been used for many years by elite athletes in an attempt to increase performance in either normoxic (sea level), or hypoxic (‘high’ altitude) environments. Classic forms of altitude training are aimed at inducing central adaptations such as oxygen delivery to the working muscle via increases in blood oxygen carrying capacity. Typical forms of altitude training to elicit such effects include “Live High Train High” or LHTH, as well as “Live High Train Low” or LHTL. A significant body of literature exists in these areas, but is still inconclusive in terms of their efficacy for normoxic performance in elite athletes. Recently, research teams have begun examining a relatively new form of altitude training described as “Live Low Train High” or LLTH. Typically, this type of training is characterized by repeated sprint training in a hypoxic environment using either natural or artificial hypoxia, coupled with living at sea level or normoxia. Theoretically, and experimentally, LLTH is touted to improve peripheral adaptations that could improve sea level performance. This is to say, adaptations at the muscular level related to oxygen utilization and energy production rather than oxygen delivery per se. Although this body of research is limited, a Swiss group lead by Carsten Lundby has recently published a review article examining the results of LLTH studies and whether or not there is evidence for improved performance in elite athletes from this form of altitude training. This review article does a nice job of summarizing the available studies and points out some important flaws with some of the research that has shown an increase in “performance” from LLTH / repeated sprint training in hypoxia. It is important to note that this review and its conclusions are the opinion of its authors, and it is advised that readers interested in this area do their due diligence and evaluate the quality of the research themselves before making conclusions. That said, Lundby and his group do not recommend LLTH or repeated sprint training in hypoxia for elite athletes at this time based on their evaluation of the body of knowledge currently available within the scientific literature.

Practical Guide to Exercise Physiology. Murray, R. and Kenney, WL. (2016). Windsor, Ontario: Human Kinetics

Evidence-Based Practice in Exercise Science: The SixStep Approach Amonette, W, English, K, and Kraemer, W. (2016). Windsor, Ontario: Human Kinetics

Of course, there is always the potential for a positive placebo effect, but let’s not get into that discussion right now! ∆ Consensus Recommendations on Training and Competing in the Heat Racinais S, Alonso JM, Coutts AJ, et al. British Journal of Sports Medicine. 2015;49:1164–1173.

Reviewed by Angela Dufour The intent of this consensus was to provide an overview of the most up-to-date recommendations regarding optimizing exercise capacity during prolonged sporting activities in hot ambient conditions, where the abundance of previous research has supported that performance can be significantly impaired. The consensus reviews the evidence to recommend practical strategies in 3 main areas to minimize the risk of exertional heat illness: Heat acclimatization; Hydration (Pre/During/ Post); and Cooling. Heat Acclimation Adaptations in highly trained athletes may develop more quickly than untrained individuals; however, it may take up to 2 weeks at 60 minutes per day to achieve cardiovascular and sudomotor adaptations to optimize aerobic performance in hot ambient conditions. Français

New Functional Training for Sports2nd Edition Boyle, M. (2016). Windsor, Ontario: Human Kinetics

Best Practice for Youth Sport Vealey, R. and Chase, M. (2016). Windsor, Ontario: Human Kinetics

Hydration • Before training and competition in the heat, athletes should drink 6 ml of fluid per kg of body mass every 2–3 h, in order to start exercise euhydrated. • During intense prolonged exercise in the heat, body water mass losses should be minimized (without increasing body weight) to reduce physiological strain and help to preserve optimal performance. • Athletes training in the heat have higher daily sodium (i.e., salt) requirements and additional sodium supplementation might also be required during exercise. • Simple monitoring techniques such as daily morning body mass and urine specific gravity can provide useful insights into the hydration state of the athlete during multievent situations. • Consuming fluids with electrolytes to offset 100–150 % of body mass losses for rapid recovery will allow for adequate rehydration. Cooling The effectiveness of cooling in competitive settings vs. laboratory conditions remains equivocal. Cold Water Immersion: Cooling of the wholebody for 30 min at a water temperature of 22-30 C or body segment (e.g., legs) at lower temperatures (10-18 C) will decrease nerve HP SIRCuit Summer 2016


conduction and muscle contraction velocities thus affecting pre-warm up adaptations. Cooling Garments: Albeit a smaller effect of cooling than with CWI, it may prevent the excessive cooling of active muscles while reducing overall internal temperatures and cardiovascular strain and athletes can wear them during warm-up or recovery breaks.

Coordination Pattern Variability Provides Functional Adaptations to Constraints in Swimming Performance Seifert, L., Komar, J., Barbosa, T., Toussaint, H., Millet, G., & Davids, K. Sports Medicine. 2014;44(10);13331345.


Reviewed by Ryan Atkison

Based on the available literature from military and occupational fields, athletes should train for at least 1 week and ideally 2 weeks to acclimatize using a comparable degree of heat stress as the target competition. Monitoring body mass losses should be routinely done to ensure commencing exercise in an euhydrated state and minimize body water deficits. Cooling methods can be used to reduce heat storage and physiological strain during competition and training. ∆

In this paper, the authors provide a thorough overview of coordination in human swimming, and using a biophysical approach, they challenge traditional views about “ideal techniques” for expert performance. While this is primarily an article discussing swimming technique, it secondarily provides a review of ecological dynamics (and more specifically dynamic systems theory) and application of those theoretical concepts to a real-world example. The authors discuss in detail the differences in coordination between swimmer skill levels and how expertise in swimming is not the ability to perform an identical “ideal” coordination


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pattern all of the time, but rather the ability to adapt technique to varying organism, task, and environmental constraints. For example, a ubiquitous and multi-factorial constraint that athletes must manage is fatigue. This review discusses in detail how at multiple levels of coordination (intra-limb, inter-limb, inter-cycle) elite swimmers are better able to adapt their technique under fatigue to maintain high swimming velocities compared with developing swimmers. The main take-home point from this article is that there is no single “ideal” coordination pattern in human swimming (or in movement in general), and that swimming technique is determined by organism, task, and environmental constraints. Discussion about the sport of swimming helps the reader to put the theory into applied context and helps to clarify the meaning of the theoretical models that can at times be vague and difficult to understand. Because of this, it is an excellent paper to read to both gain insights into current views on swimming technique and dynamic systems theory. ∆

Recommended Readings In our collaborative effort to bring you the latest research in high performance sport, Own The Podium has selected specific areas of interest to coaches and trainers and SIRC has culled through our resources to provide access to recent research published within these areas.

General Conditioning Johnston R, Gabbett T, Jenkins D, Speranza M. Effect of Different Repeated-High-IntensityEffort Bouts on Subsequent Running, Skill Performance, and Neuromuscular Function. International Journal of Sports Physiology & Performance. April 2016;11(3):311-318. Kümmel J, Bergmann J, Prieske O, Kramer A, Granacher U, Gruber M. Effects of conditioning hops on drop jump and sprint performance: a randomized crossover pilot study in elite athletes. BMC Sports Science, Medicine & Rehabilitation. January 30, 2016;8:1-8. Giroux C, Rabita G, Chollet D, Guilhem G. Optimal Balance between Force and Velocity Differs Among World-Class Athletes. Journal of Applied Biomechanics. February 2016;32(1):59-68. Howatson G, Brandon R, Hunter A. The Response to and Recovery from MaximumStrength and -Power Training in Elite Track and Field Athletes. International Journal of Sports Physiology & Performance. April 2016;11(3):356-362.

Environmental Factors

Guy J, Deakin G, Edwards A, Miller C, Pyne D. Adaptation to Hot Environmental Conditions: An Exploration of the Performance Basis, Procedures and Future Directions to Optimise Opportunities for Elite Athletes. Sports Medicine. March 2015;45(3):303-311. Schulze E, Daanen H, Laursen P, et al. Effect of Thermal State and Thermal Comfort on Cycling Performance in the Heat. International Journal Of Sports Physiology & Performance. July 2015;10(5):655-663.

Nutrition Reid K. Case Study: The Role of Milk in a Dietary Strategy to Increase Muscle Mass and Improve Recovery in an Elite Sprint Kayaker. International Journal of Sport Nutrition & Exercise Metabolism. April 2016;26(2):179-184. Carlsohn A. Recent Nutritional Guidelines for Endurance Athletes. / Aktuelle Ernährungsempfehlungen für Ausdauersportler. Deutsche Zeitschrift Für Sportmedizin. January 2016;67(1):7-12. Spronk I, Heaney S, Prvan T, O’Connor H. Relationship between General Nutrition Knowledge and Dietary Quality in Elite Athletes. International Journal of Sport Nutrition & Exercise Metabolism. June 2015;25(3):243-251.

Hamlin M, Hopkins W, Hollings S. Effects of Altitude on Performance of Elite Trackand-Field Athletes. International Journal of Sports Physiology & Performance. October 2015;10(7):881-887.

Vitale K. Tart Cherry Juice in Olympic and Paralympic Athletes. Olympic Coach. October 2015;26(3):11-20.

Carr A, Saunders P, Vallance B, GarvicanLewis L, Gore C. Increased Hypoxic Dose after Training at Low Altitude with 9h per Night at 3000m Normobaric Hypoxia. Journal of Sports Science & Medicine. December 2015;14(4):776-782.

Gerbing K, Thiel A. Handling of medical knowledge in sport: Athletes’ medical opinions, information seeking behaviours and knowledge sources. European Journal of Sport Science. February 2016;16(1):141-148.



Gawroński W, Sobiecka J. Medical Care Before and During the Winter Paralympic Games in Turin 2006, Vancouver 2010 and Sochi 2014. Journal of Human Kinetics. December 2015;48(1):7-16. Needleman I, Ashley P, Porter S, et al. Oral health and elite sport performance. British Journal of Sports Medicine. January 2015;49(1):1-4.

Coaching Szedlak C, Smith M, Day M, Greenlees I. Effective Behaviours of Strength and Conditioning Coaches as Perceived by Athletes. International Journal of Sports Science & Coaching. October 2015;10(5):967-984. Tracey J, Elcombe T. Expert Coaches’ Perceptions of Athlete Performance Optimization. International Journal of Sports Science & Coaching. December 2015;10(6):1001-1013. Hülyaaşçi F, Kelecek S, Altintaş A. The Role of Personality Characteristics of Athletes in CoachAthlete Relationships. Perceptual & Motor Skills. October 2015;121(2):399-411.

Psychology Moen F, Wells A. Can the Attention Training Technique Reduce Burnout in Junior Elite Athletes? International Journal of Coaching Science. January 2016;10(1):53-64. Macdougall H, O’Halloran P, Sherry E, Shields N. Needs and Strengths of Australian Para-Athletes: Identifying Their Subjective Psychological, Social, and Physical Health and Well-Being. Sport Psychologist. March 2016;30(1):1-12.

Anti-Doping Gee C, West C, Krassioukov A. Boosting in Elite Athletes with Spinal Cord Injury: A Critical Review of Physiology and Testing Procedures. Sports Medicine. August 2015;45(8):1133-1142.

Equipment Hambrick M, Hums M, Bower G, Wolff E. Examining Elite Parasport Athletes with Sport Involvement and Sports Equipment. Adapted Physical Activity Quarterly. January 2015;32(1):118.

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Conference Calendar

For more events, check out the SIRC Conference Calendar.

July 18-22 August 4-5 August 31-September 4 September 14-17 September 19 September 29-October 2

JULY/AUGUST 34th International Conference on Biomechanics in Sports 18th International Conference on Sport, Exercise and Health Sciences Saying Yes to Diversity in Sport SEPTEMBER/OCTOBER World Congress of Performance Analysis of Sport XI Machine Learning and Data Mining for Sports Analytics ECML/PKDD 2016 workshop 34th World Congress of Sports Medicine

Tsukuba, Japan Vancouver, British Columbia Santos / SP, Brazil Alicante, Spain Riva del Garda, Italy Ljubljana, Slovenia

NOVEMBER November 16-18 November 23-24

SPIN Summit 3rd Annual Sportdata & Performance Forum 2016


Contributing Editor

Debra Gassewitz, SIRC

Dr. Jon Kolb, OTP



Nancy Rebel, SIRC


Kim Sparling, SIRC


Josyane Morin


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Ryan Atkison Jeremiah Barnert Kimberly Bowman Angela Dufour Adrienne Leslie-Toogood Eugene Liang Heather Logan-Sprenger Scott Maw Trent Stellingwerff

Calgary, Alberta Berlin, Germany

Special Thanks

Sport Information Resource Centre (SIRC) is Canada’s national sport resource centre, established over 40 years ago.


Mailing address: SIRC 85 Plymouth Street, Suite 100 Ottawa, Ontario, Canada, K1S 3E2

CSC Atlantic Canadian Paralympic Committee Marcel Nadeau

Photos Courtesy of:

Kimberly Bowman Heather Logan-Sprenger CSC Atlantic SIRC

Disclaimer: Author’s opinions expressed in the articles are not necessarily those of SIRCuit, its publisher, the Editor, or the Editorial Board. SIRC makes no representations or warranties whatsoever as to the accuracy, completeness or suitability for any purpose of the content. Copyright © 2016 SIRC. All rights reserved. No part of the publication may be reproduced, stored, transmitted, or disseminated, in any form, or by any means, without prior written permission from SIRC, to whom all requests to reproduce copyright material should be directed, in writing.


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