IOC consensus statement on recommendations and regulations for sport events in the heat.

This document presents the recommendations developed by the IOC Medical and Scientific Commission and several international federations (IF) on the protection of athletes competing in the heat. It is based on a working group, meetings, field experience and a Delphi process. The first section presents recommendations for event organisers to monitor environmental conditions before and during an event; to provide sufficient ice, shading and cooling; and to work with the IF to remove regulatory and logistical limitations. The second section summarises recommendations that are directly associated with athletes' behaviours, which include the role and methods for heat acclimation; the management of hydration; and adaptation to the warm-up and clothing. The third section explains the specific medical management of exertional heat stroke (EHS) from the field of play triage to the prehospital management in a dedicated heat deck, complementing the usual medical services. The fourth section provides an example for developing an environmental heat risk analysis for sport competitions across all IFs. In summary, while EHS is one of the leading life-threatening conditions for athletes, it is preventable and treatable with the proper risk mitigation and medical response. The protection of athletes competing in the heat involves the close cooperation of the local organising committee, the national and international federations, the athletes and their entourages and the medical team.

Methods for epidemiological studies in competitive cycling: an extension of the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sport 2020.

In 2020, the IOC released a consensus statement that provides overall guidelines for the recording and reporting of epidemiological data on injury and illness in sport. Some aspects of this statement need to be further specified on a sport-by-sport basis. To extend the IOC consensus statement on methods for recording and reporting of epidemiological data on injury and illness in sports and to meet the sport-specific requirements of all cycling disciplines regulated by the Union Cycliste Internationale (UCI). A panel of 20 experts, all with experience in cycling or cycling medicine, participated in the drafting of this cycling-specific extension of the IOC consensus statement. In preparation, panel members were sent the IOC consensus statement, the first draft of this manuscript and a list of topics to be discussed. The expert panel met in July 2020 for a 1-day video conference to discuss the manuscript and specific topics. The final manuscript was developed in an iterative process involving all panel members. This paper extends the IOC consensus statement to provide cycling-specific recommendations on health problem definitions, mode of onset, injury mechanisms and circumstances, diagnosis classifications, exposure, study population characteristics and data collection methods. Recommendations apply to all UCI cycling disciplines, for both able-bodied cyclists and para-cyclists. The recommendations presented in this consensus statement will improve the consistency and accuracy of future epidemiological studies of injury and illness in cycling.

Athlete health and safety at large sporting events: the development of consensus-driven guidelines.

All sport events have inherent injury and illness risks for participants. Healthcare services for sport events should be planned and delivered to mitigate these risks which is the ethical responsibility of all sport event organisers. The objective of this paper was to develop consensus-driven guidelines describing the basic standards of services necessary to protect athlete health and safety during large sporting events. By using the Knowledge Translation Scheme Framework, a gap in International Federation healthcare programming for sport events was identified. Event healthcare content areas were determined through a narrative review of the scientific literature. Content experts were systematically identified. Following a literature search, an iterative consensus process was undertaken. The outcome document was written by the knowledge translation expert writing group, with the assistance of a focus group consisting of a cohort of International Federation Medical Chairpersons. Athletes were recruited to review and provide comment. The Healthcare Guidelines for International Federation Events document was developed including content-related to (i) pre-event planning (eg, sport medical risk assessment, public health requirements, environmental considerations), (ii) event safety (eg, venue medical services, emergency action plan, emergency transport, safety and security) and (iii) additional considerations (eg, event health research, spectator medical services). We developed a generic standardised template guide to facilitate the planning and delivery of medical services at international sport events. The organisers of medical services should adapt, evaluate and modify this guide to meet the sport-specific local context.

Medical encounters (including injury and illness) at mass community-based endurance sports events: an international consensus statement on definitions and methods of data recording and reporting.

Mass participation endurance sports events are popular but a large number of participants are older and may be at risk of medical complications during events. Medical encounters (defined fully in the statement) include those traditionally considered 'musculoskeletal' (eg, strains) and those due to 'illness' (eg, cardiac, respiratory, endocrine). The rate of sudden death during mass endurance events (running, cycling and triathlon) is between 0.4 and 3.3 per 100 000 entrants. The rate of other serious medical encounters (eg, exertional heat stroke, hyponatraemia) is rarely reported; in runners it can be up to 100 times higher than that of sudden death, that is, between 16 and 155 per 100 000 race entrants. This consensus statement has two goals. It (1) defines terms for injury and illness-related medical encounters, severity and timing of medical encounters, and diagnostic categories of medical encounters, and (2) describes the methods for recording data at mass participation endurance sports events and reporting results to authorities and for publication. This unifying consensus statement will allow data from various events to be compared and aggregated. This will inform athlete/patient management, and thus make endurance events safer.

Physical exercise during muscle regeneration improves recovery of the slow/oxidative phenotype.

INTRODUCTION: As skeletal muscle mass recovery after extensive injury is improved by contractile activity, we explored whether concomitant exercise accelerates recovery of the contractile and metabolic phenotypes after muscle injury. METHODS: After notexin-induced degeneration of a soleus muscle, Wistar rats were assigned to active (running exercise) or sedentary groups. Myosin heavy chains (MHC), metabolic enzymes, and calcineurin were studied during muscle regeneration at different time points. RESULTS: The mature MHC profile recovered earlier in active rats (21 days after injury) than in sedentary rats (42 days). Calcineurin was higher in the active degenerated than in the sedentary degenerated muscles at day 14. Citrate synthase and total lactate dehydrogenase (LDH) activity decreased after injury and were similarly recovered in both active and sedentary groups at 14 or 42 days, respectively. H-LDH isozyme activity recovered earlier in the active rats. CONCLUSIONS: Exercise improved recovery of the slow/oxidative phenotype after soleus muscle injury. Muscle Nerve 55: 91-100, 2017.

Effects of Postexercise Protein Intake on Muscle Mass and Strength During Resistance Training: Is There an Optimal Ratio Between Fast and Slow Proteins?

While effects of the two classes of proteins found in milk (i.e., soluble proteins, including whey, and casein) on muscle protein synthesis have been well investigated after a single bout of resistance exercise (RE), the combined effects of these two proteins on the muscle responses to resistance training (RT) have not yet been investigated. Therefore, the aim of this study was to examine the effects of protein supplementation varying by the ratio between milk soluble proteins (fast-digested protein) and casein (slow-digested protein) on the muscle to a 9-week RT program. In a double-blind protocol, 31 resistance-trained men, were assigned to 3 groups receiving a drink containing 20g of protein comprising either 100% of fast protein (FP(100), n = 10), 50% of fast and 50% of slow proteins (FP(50), n = 11) or 20% of fast protein and 80% of casein (FP(20), n = 10) at the end of training bouts. Body composition (DXA), and maximal strength in dynamic and isometric were analyzed before and after RT. Moreover, blood plasma aminoacidemia kinetic after RE was measured. The results showed a higher leucine bioavailability after ingestion of FP(100) and FP(50) drinks, when compared with FP(20) (p< .05). However, the RT-induced changes in lean body mass (p < .01), dynamic (p < .01), and isometric muscle strength (p < .05) increased similarly in all experimental groups. To conclude, compared with the FP(20) group, the higher rise in plasma amino acids following the ingestion of FP(100) and FP(50) did not lead to higher muscle long-term adaptations.

Epidemiology of injuries at the 2023 UCI cycling world championships using the International Olympic Consensus: a protocol for a prospective cohort study.

The sport of cycling consists of several individual sporting disciplines. Indeed, the world governing body for cycling, Union Cycliste Internationale (UCI), oversees the various cycling disciplines, with each of these disciplines having a number of subcategories. While several sports have undertaken prospective injury surveillance studies to understand the risks of their sport, plan event medical support and develop prevention programmes, limited high-quality studies have been undertaken within cycling. Indeed, this is the first prospective study of cycling injuries, particularly when considering the whole sport of cycling together. This current study will therefore aim to describe the incidence, severity, burden and nature of injuries within elite cycling in those athletes participating across 13 championship events at the inaugural World Championships, Glasgow, August 2023. Injury and exposure definitions will be in line with the IOC Consensus for injury surveillance in cycling. Injury incidence will be reported per 1000 athlete match hours or per number of athletes/cyclists and injury severity will be assessed via estimated median or mean days lost to training/competition. Meanwhile injury burden will be assessed via days of absence/1000 athlete match hours (or per number of athletes exposed) and all these results will be compared between male and female cyclists. This paper will also report the most common specific injuries for male and female cyclists (per 1000 hours of participation or per number of athletes exposed). Statistical differences will be tested for incidence or severity measures between sexes and will be compared to other sports.

Hypoxia transiently affects skeletal muscle hypertrophy in a functional overload model.

Hypoxia induces a loss of skeletal muscle mass, but the signaling pathways and molecular mechanisms involved remain poorly understood. We hypothesized that hypoxia could impair skeletal muscle hypertrophy induced by functional overload (Ov). To test this hypothesis, plantaris muscles were overloaded during 5, 12, and 56 days in female rats exposed to hypobaric hypoxia (5,500 m), and then, we examined the responses of specific signaling pathways involved in protein synthesis (Akt/mTOR) and breakdown (atrogenes). Hypoxia minimized the Ov-induced hypertrophy at days 5 and 12 but did not affect the hypertrophic response measured at day 56. Hypoxia early reduced the phosphorylation levels of mTOR and its downstream targets P70(S6K) and rpS6, but it did not affect the phosphorylation levels of Akt and 4E-BP1, in Ov muscles. The role played by specific inhibitors of mTOR, such as AMPK and hypoxia-induced factors (i.e., REDD1 and BNIP-3) was studied. REDD1 protein levels were reduced by overload and were not affected by hypoxia in Ov muscles, whereas AMPK was not activated by hypoxia. Although hypoxia significantly increased BNIP-3 mRNA levels at day 5, protein levels remained unaffected. The mRNA levels of the two atrogenes MURF1 and MAFbx were early increased by hypoxia in Ov muscles. In conclusion, hypoxia induced a transient alteration of muscle growth in this hypertrophic model, at least partly due to a specific impairment of the mTOR/P70(S6K) pathway, independently of Akt, by an undefined mechanism, and increased transcript levels for MURF1 and MAFbx that could contribute to stimulate the proteasomal proteolysis.

Interleukin-6 contributes to hepcidin mRNA increase in response to exercise.

The iron regulatory peptide hormone hepcidin has been proposed to participate in training-induced iron deficiency. Plasma and urinary hepcidin increase in response to one bout of prolonged exercise, a condition also known to increase plasma interleukin-6 (Il-6). Because Il-6 activates hepcidin transcription and expression during inflammation, our aim was to study the role of this cytokine in hepatic hepcidin mRNA expression during exercise and recovery. We used a rodent model of exhaustive running exercise, where rats were treated or not with cyclosporin A (CsA), a calcineurin inhibitor shown to blunt plasma Il-6 during exercise. Despite similar running intensity and duration, animals treated with CsA had 50% lower plasma Il-6 concentrations at the end of exercise. The concomitant rise in hepatic mRNA levels of two Il-6 responsive genes, suppressor of cytokine signaling (SOCS) 3 and Il-6 receptor alpha, was blunted in CsA-treated group. Finally, hepcidin mRNA levels increased in response to exercise, peaking 2h later, but peak values were significantly lower in CsA group compared to control group. This result strongly suggests that plasma Il-6 is involved in exercise-induced increase of hepcidin gene expression.

Effects of Native Whey Protein and Carbohydrate Supplement on Physical Performance and Plasma Markers of Muscle Damage and Inflammation during a Simulated Rugby Sevens Tournament: A Double-Blind, Randomized, Placebo-Controlled, Crossover Study.

The importance of optimized recovery during a sport competition is undisputed. The objective of this study was to determine the effects of recovery drinks comprising either carbohydrate only, or a mix of native whey proteins and carbohydrate to maintain physical performance and minimize muscle damage during a simulated rugby sevens (rugby 7s) tournament. Twelve well-trained male rugby players participated in three simulated rugby 7s tournament days with a week's interval in between. Each tournament comprised a sequence of three simulated matches, interspersed with 2 h of recovery. Three different recovery drinks were tested: a placebo (PLA, nonenergetic chocolate-flavored drink), a carbohydrate drink (CHO, 80 g of carbohydrate) or an isoenergetic carbohydrate-protein drink (P-CHO, 20 g of Pronativ®, native whey protein and 60 g of carbohydrate). A different recovery drink, consumed after each match, was tested during each simulated tournament. Physical performance, muscle damage and muscle pain were assessed before and after each simulated tournament. Regarding physical performance, both P-CHO and CHO drinks had a positive effect on the maintenance of 50 m sprint time compared to the PLA drink (effect sizes large and moderate, respectively). Regarding muscle damage, the P-CHO supplement attenuated the creatine phosphokinase increase at POST6 compared to PLA (effect size, moderate). Finally, P-CHO and CHO drinks reduced the exercise-induced DOMS (effect size, moderate), compared to the PLA condition (effect size, large), while P-CHO only reduced pain on muscle palpation and pain when descending stairs compared to PLA 24 h post-tournament (effect size, small). This study suggests that consuming a recovery drink containing native whey proteins and carbohydrate or carbohydrate only after each match of a rugby 7s tournament may attenuate the exercise-induced increase in markers of muscle damage and maintain physical performance.

Joint position statement of the International Federation of Sports Medicine (FIMS) and European Federation of Sports Medicine Associations (EFSMA) on the IOC framework on fairness, inclusion and non-discrimination based on gender identity and sex variations.

The IOC recently published its framework on fairness, inclusion and non-discrimination based on gender identity and sex variations. This framework is drafted mainly from a human rights perspective, with less consideration for medical/scientific issues. The framework places the onus for gender eligibility and classification entirely on the International Federations (IFs), even though most will not have the capacity to implement the framework. The position of no presumption of advantage is contrary to the 2015 IOC consensus. Implementation of the 2021 framework will be a major challenge for IFs that have already recognised the inclusion of trans and women athletes with differences of sexual development (DSD) using a scientific/medical solution. The potential consequences for sports that need to prioritise fairness or safety could be one of two extremes (1) exclusion of all transgender or DSD athletes on the grounds of advantage or (2) self-identification that essentially equates to no eligibility rules. Exclusion of all transgender or DSD athletes is contrary to the Olympic charter and unlawful in many countries. While having no gender eligibility rules, sport loses its meaning and near-universal support. Athletes should not be under pressure to undergo medical procedures or treatment to meet eligibility criteria. However, if an athlete is fully informed and consents, then it is their free choice to undergo carefully considered or necessary interventions for gender classification for sport to compete fairly and safely in their chosen gender. Free choice is a fundamental human right, but so is the right to fair and safe competition.

Harrogate consensus agreement: Cycling-specific sport-related concussion.

Sport-related concussion (SRC) is a common and increasingly recognised sport-related injury and accounts for between 1% and 9% of all cycling-specific injuries. Attention has been drawn to the difficulty in managing suspected SRC in a fast-paced sport such as road cycling, particularly the lack of an effective and time-efficient assessment protocol. A meeting on cycling SRC was convened in Harrogate, United Kingdom, in an attempt to resolve this problem. The aim was to agree on standard terminology, definitions, diagnostic protocols and return to play protocols for the various differing codes of cycle sport. Seven experts in the field of cycling medicine were invited to participate by the International Cycling Union and are the authors of this report. The panel recognised that the sport of cycling consists of varied disciplines, some of which provide a setting in which a sideline assessment is possible which is in line with the Berlin Consensus statement. However, other disciplines provide challenging circumstances where health care providers have limited access to participants and where participants are unable to discontinue participation and participate in sideline assessment. Consensus-based discipline-specific protocols and guidelines which recognise the limitations posed by these circumstances, but nevertheless, improve on the current situation specific to the sport of cycling are presented as a potential solution to the unique challenges posed by these cycling disciplines.

Endurance Is Improved in Female Rats After Living High-Training High Despite Alterations in Skeletal Muscle.

Altitude camps are used during the preparation of endurance athletes to improve performance based on the stimulation of erythropoiesis by living at high altitude. In addition to such whole-body adaptations, studies have suggested that high-altitude training increases mitochondrial mass, but this has been challenged by later studies. Here, we hypothesized that living and training at high altitude (LHTH) improves mitochondrial efficiency and/or substrate utilization. Female rats were exposed and trained in hypoxia (simulated 3,200 m) for 5 weeks (LHTH) and compared to sedentary rats living in hypoxia (LH) or normoxia (LL) or those that trained in normoxia (LLTL). Maximal aerobic velocity (MAV) improved with training, independently of hypoxia, whereas the time to exhaustion, performed at 65% of MAV, increased both with training (P = 0.009) and hypoxia (P = 0.015), with an additive effect of the two conditions. The distance run was 7.98 ± 0.57 km in LHTH vs. 6.94 ± 0.51 in LLTL (+15%, ns). The hematocrit increased >20% with hypoxia (P < 0.001). The increases in mitochondrial mass and maximal oxidative capacity with endurance training were blunted by combination with hypoxia (-30% for citrate synthase, P < 0.01, and -23% for Vmax glut-succ, P < 0.001 between LHTH and LLTL). A similar reduction between the LHTH and LLTL groups was found for maximal respiration with pyruvate (-29%, P < 0.001), for acceptor-control ratio (-36%, hypoxia effect, P < 0.001), and for creatine kinase efficiency (-48%, P < 0.01). 3-hydroxyl acyl coenzyme A dehydrogenase was not altered by hypoxia, whereas maximal respiration with Palmitoyl-CoA specifically decreased. Overall, our results show that mitochondrial adaptations are not involved in the improvement of submaximal aerobic performance after LHTH, suggesting that the benefits of altitude camps in females relies essentially on other factors, such as the transitory elevation of hematocrit, and should be planned a few weeks before competition and not several months.

Preparticipation medical evaluation for elite athletes: EFSMA recommendations on standardised preparticipation evaluation form in European countries.

Sports medicine is a medical specialty that supports the performance of professional and amateur athletes while maintaining their health. Sports medicine professionals need to ensure the safe participation of athletes in sports activities achieved through a periodical preparticipation evaluation (PPE) and a regular medical monitoring of the athletes' health in accordance with the latest recommendations regarding health condition and medical history, physical working capacity, training period and programme, recovery, nutrition, use of supplements, injuries prevention and safe return to play. In order to harmonise these national variations in the content and application of the PPE, the EFSMA Scientific and Educational Commission proposes a 'gold standard' for elite athletes across Europe. Important objectives of PPE are early detection and prevention of severe complications during sports activities both in leisure time and competitive sports. The PPE should entail the following diagnostic components: health status, anthropometry, functional and exercise capacity. It is of utmost importance to develop and implement preventive strategies such as the PPE. Besides monitoring the health status of athletes, the PPE plays an important role in the selection process, bringing valuable information for coaches and supporting a personalised treatment approach. Screening of athletes through a standardised digital PPE could be beneficial for a better understanding of the impact of long-term physical activity. Furthermore, PPE leads the scientific community to a way of working closer together in the interest of the athletes.

Recommendations for Face Coverings While Exercising During the COVID-19 Pandemic.

In an effort to reduce transmission and number of infections of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2 or COVID-19) virus, governments and official bodies around the world have produced guidelines on the use of face masks and face coverings. While there is a growing body of recommendations for healthcare professionals and the wider population to use facial protection in "enclosed spaces" where minimal distancing from other individuals is not possible, there is a dearth of clear guidelines for individuals undertaking exercise and sporting activity. The present viewpoint aims to propose recommendations for face coverings while exercising during the COVID-19 pandemic that consider physical distancing, the environment, the density of active cases associated with the specific sports activity, and the practical use of face coverings in order to reduce potential viral transmission. Recommendations are provided on the basis of very limited available evidence in conjunction with the extensive collective clinical experience of the authors and acknowledging the need to consider the likelihood of the presence of the SARS-CoV-2 in the general population. We recommend that face coverings should be used in any environment considered to be of a high or moderate transmission risk, where tolerated and after individual risk assessment. In addition, as national caseloads fluctuate, individual sporting bodies should consider up to date guidance on the use of face coverings during sport and exercise, alongside other preventative measures.

Integrating Transwomen and Female Athletes with Differences of Sex Development (DSD) into Elite Competition: The FIMS 2021 Consensus Statement.

Sport is historically designated by the binary categorization of male and female that conflicts with modern society. Sport's governing bodies should consider reviewing rules determining the eligibility of athletes in the female category as there may be lasting advantages of previously high testosterone concentrations for transwomen athletes and currently high testosterone concentrations in differences in sex development (DSD) athletes. The use of serum testosterone concentrations to regulate the inclusion of such athletes into the elite female category is currently the objective biomarker that is supported by most available scientific literature, but it has limitations due to the lack of sports performance data before, during or after testosterone suppression. Innovative research studies are needed to identify other biomarkers of testosterone sensitivity/responsiveness, including molecular tools to determine the functional status of androgen receptors. The scientific community also needs to conduct longitudinal studies with specific control groups to generate the biological and sports performance data for individual sports to inform the fair inclusion or exclusion of these athletes. Eligibility of each athlete to a sport-specific policy needs to be based on peer-reviewed scientific evidence made available to policymakers from all scientific communities. However, even the most evidence-based regulations are unlikely to eliminate all differences in performance between cisgender women with and without DSD and transwomen athletes. Any remaining advantage held by transwomen or DSD women could be considered as part of the athlete's unique makeup.

Skeletal muscle intrinsic functional properties are preserved in a model of erythropoietin deficient mice exposed to hypoxia.

Erythropoietin (Epo)-induced polycythemia is the main factor of adaptation to hypoxia. In this study, we analysed the effects of Epo deficiency on intrinsic functional properties of slow and fast twitch muscles in a model of erythropoietin deficient mice (Epo-TAg(h)) exposed to hypoxia. We hypothesised that Epo deficiency would be deleterious for skeletal muscle structure and phenotype, which could change its functional properties and alters the adaptive response to ambient hypoxia. Wild-type (WT) and Epo-TAg(h) mice were left in hypobaric chamber at 420 mm Hg pressure for 14 days. Soleus (SOL) and extensor digitorum longus (EDL) were analysed in vitro by mechanical measurements, immunohistological and biochemical analyses. The results were compared to those obtained in corresponding muscles of age-matched normoxic groups. Our data did not show any difference between the groups whatever the Epo deficiency and/or hypoxic conditions for twitch force, tetanic force, fatigue, typology and myosin heavy chain composition. Normoxic Epo-TAg(h) mice exhibit improved capillary-to-fibre ratio compared to WT mice in both SOL and EDL whereas no angiogenic effects of hypoxia or combined Epo-deficiency/hypoxia were observed. These results suggest that skeletal muscles possess a great capacity of adaptation to Epo deficiency. Then Epo deficiency is not a sufficient factor to modify intrinsic functional properties of skeletal muscles.