An Updated Panorama of "Living Low-Training High" Altitude/Hypoxic Methods

Impact of Altitude Training on Athletes' Aerobic Capacity: A Systematic Review and Meta-Analysis

Purpose: This study systematically evaluated the effects of altitude training on athletes' aerobic capacity, focusing on optimal training modalities and intervention durations. Methods: Eight databases (CNKI, CSPD, PubMed, Ovid Medline, ProQuest, Cochrane Library, Embase, and Scopus) were searched for randomized controlled trials on altitude training and aerobic capacity following PRISMA guidelines, covering publications up to 15 October 2024. The risk of bias was assessed using Cochrane tools, and a meta-analysis was conducted using Review Manager 5.4 with a random-effects model. Sensitivity and subgroup analyses were performed to identify heterogeneity and influencing factors. Results: Thirteen studies involving 276 participants (aged 18-35) were included. Meta-analysis revealed that compared to low-altitude training, altitude training significantly increased hemoglobin (SMD = 0.7, 95% CI: 0.27-1.13, p = 0.03) and hemoglobin mass (SMD = 0.49, 95% CI: 0.1-0.89, p = 0.16) but had no significant effect on maximal oxygen uptake (SMD = -0.13, 95% CI: -1.21-0.96, p = 0.68). Altitude training also improved performance in trial tests (SMD = -28.73, 95% CI: -58.69-1.23, p = 0.002). Sensitivity analysis confirmed the robustness of hemoglobin and trial test results. Subgroup analysis showed that the "live high, train high" (LHTH) approach and interventions lasting longer than three weeks were most effective in enhancing aerobic capacity. Conclusions: Altitude training improves athletes' aerobic capacity by enhancing hematological indicators and trial test performance, though its impact on maximal oxygen uptake is minimal. LHTH and interventions exceeding three weeks yield superior outcomes. However, the findings are limited by the number and quality of the available studies.

Living High-Training Low on Mice Bone Parameters Analyzed through Complex Network Approach

The aim of this study was to investigate the effect of 8 weeks of hypoxic exposition and physical training on healthy mice femur outcomes analyzed through conventional statistic and complex networks. The mice were divided into four groups, subjected to physical training (T; 40 min per day at 80% of critical velocity intensity) or not (N), exposed to hypoxic environment ("Living High-Training Low" model - LHTL; 18 h per day, FIO2=19.5%; Hyp) or not (Nor). The complex network analysis performed interactions among parameters using values of critical "r" of 0.5 by Pearson correlations to edges construction, with Fruchterman-Reingold layout adopted for graph visualization. Pondered Degree, Betweenness, and Eigenvector metrics were chosen as centrality metrics. Two-way ANOVA, t-test and Pearson correlation were used with P<0.05. Femur phosphorus of T-Hyp was higher than all other groups (P<0.05) and correlated with bone density (r=0.65; P=0.042), bone mineral density (r=0.67; P=0.034) and% of mineral material (r=0.66, P=0.038). Overall, the complex network demonstrated improvements in bone volume, % of mineral material, bone density, and bone mineral density for T-Hyp over other groups. Association of physical training and hypoxia improved bone quality for healthy mice.

Genetic Determinants of Endurance: A Narrative Review on Elite Athlete Status and Performance

This narrative review explores the relationship between genetics and elite endurance athletes, summarizes the current literature, highlights some novel findings, and provides a physiological basis for understanding the mechanistic effects of genetics in sport. Key genetic markers include ACTN3 R577X (muscle fiber composition), ACE I/D (cardiovascular efficiency), and polymorphisms in PPARA, VEGFA, and ADRB2, influencing energy metabolism, angiogenesis, and cardiovascular function. This review underscores the benefits of a multi-omics approach to better understand the complex interactions between genetic polymorphisms and physiological traits. It also addresses long-standing issues such as small sample sizes in studies and the heterogeneity in heritability estimates influenced by factors like sex. Understanding the mechanistic relationship between genetics and endurance performance can lead to personalized training strategies, injury prevention, and improved health outcomes. Future studies should focus on standardized classification of sports, replication studies involving diverse populations, and establishing solid physiological associations between polymorphisms and endurance traits to advance the field of sports genetics.

Intermittent Hypoxic-Hyperoxic Training During Inpatient Rehabilitation Improves Exercise Capacity and Functional Outcome in Patients With Long Covid: Results of a Controlled Clinical Pilot Trial

INTRODUCTION

Long COVID-19 illness is a severely disabling disease with shortness of breath, weakness and fatigue as leading symptoms, resulting in poor quality of life and substantial delay in return to work. No specific respiratory therapy has been validated for patients with long COVID. The intermittent hypoxia-hyperoxia training (IHHT) is a respiratory therapeutic modality to improve exercise performance via controlled respiratory conditioning. The purpose of the present study is to investigate the therapeutic effect of IHHT on functional and symptomatic recovery of patients with long COVID syndrome.

METHODS

A prospective, controlled, open-treatment interventional study was conducted in patients with long COVID who were admitted to an inpatient rehabilitation programme. Patients were assigned nonrandomized to receive IHHT in addition to the standardized rehabilitation programme (IHHT group) or standard rehabilitation alone (control group). The IHHT group received supervised sessions of intermittent hypoxic (10-12% O2) and hyperoxic (30-35% O2) breathing three times per week throughout the rehabilitation period. Primary endpoint was improved walking distance in a 6-min walk test (6MWT) between study groups. Secondary endpoints were change in stair climbing power, dyspnoea (Borg dyspnoea Scale), fatigue assessment scale (FAS) and change in health-related quality of life (HRQoL) assessed by patient global assessment (PGA), EQ-5D analogue scale and the MEDIAN Corona Recovery Score (MCRS). Further assessments included maximum handgrip strength, nine hole peg test, timed up-and-go, respiratory function and functional ambulation category (FAC), serum analyses and safety of the intervention.

RESULTS

A total of 145 patients were included in the study (74% female, mean age 53 ± 12 years) and assigned to IHHT (n = 70) or standard care (n = 75). The 6MWT distance improved 2.8-fold in the IHHT group compared to the control group (91.7 ± 50.1 m vs. 32.6 ± 54.2 m, ANCOVA p < 0.001). Stair climbing power improved 3.7-fold in the IHHT group compared to controls (-1.91 ± 2.23 s vs. -0.51 ± 1.93 s, p < 0.001). Secondary endpoints on dyspnoea, fatigue and HRQoL (PGA, EQ-5D and MCRS) improved significantly in the IHHT group compared to controls. The IHHT group exhibited a significant decrease in blood pressure, heart rate and increase in haemoglobin levels that was not observed in the control group. No adverse events were observed.

CONCLUSION

Respiratory treatment with IHHT in addition to a multidisciplinary rehabilitation programme improves functional capacity, symptomatic status and quality of life in patients with disabling long COVID. IHHT has been demonstrated to be safe, well tolerated and feasible to be integrated in an inpatient rehabilitation programme to improve outcome in long COVID.

Cardiorespiratory and muscle oxygenation responses to voluntary hypoventilation at low lung volume in upper body repeated sprints

PURPOSE

To investigate the impact of voluntary hypoventilation at low lung volumes (VHL) during upper body repeated sprints (RS) on performance, metabolic markers and muscle oxygenation in Brazilian Jiu-Jitsu (BJJ) athletes.

METHODS

Eighteen male well-trained athletes performed two randomized RS sessions, one with normal breathing (RSN) and another with VHL (RS-VHL), on an arm cycle ergometer, consisting of two sets of eight all-out 6-s sprints performed every 30 s. Peak (PPO), mean power output (MPO), and RS percentage decrement score were calculated. Arterial oxygen saturation (SpO2), heart rate (HR), gas exchange, and muscle oxygenation of the long head of the triceps brachii were continuously recorded. Blood lactate concentration ([La]) was measured at the end of each set. Bench press throw peak power (BPPP) was recorded before and after the RS protocol.

RESULTS

Although SpO2 was not different between conditions, PPO and MPO were significantly lower in RS-VHL. V ˙ E, HR, [La], and RER were lower in RS-VHL, and VO2 was higher in RS-VLH than in RSN. Muscle oxygenation was not different between conditions nor was its pattern of change across the RS protocol influenced by condition. [La] was lower in RS-VHL than in RSN after both sets.

CONCLUSION

Performance was significantly lower in RS-VHL, even though SPO2 was not consistent with hypoxemia. However, the fatigue index was not significantly affected by VHL, nor was the neuromuscular upper body power after the RS-VHL protocol. Additionally, [La] was lower, and oxygen consumption was higher in RS-VHL, suggesting a higher aerobic contribution in this condition.

Utility of hypoxic modalities for musculoskeletal injury rehabilitation in athletes: A narrative review of mechanisms and contemporary perspectives

Recent evidence suggests that different hypoxic modalities might accelerate the rehabilitation process in injured athletes. In this review, the application of hypoxia during rehabilitation from musculoskeletal injury is explored in relation to two principles: (1) facilitating the healing of damaged tissue, and (2) mitigating detraining and inducing training adaptations with a reduced training load. Key literature that explores the underlying mechanisms for these themes is presented, and considerations for practice and future research directions are outlined. For principle (1), passive intermittent hypoxic exposures might accelerate tissue healing through angiogenic and osteogenic mechanisms. Experimental evidence is largely derived from rodent research, so further work is warranted to establish whether clinically meaningful effects can be observed in humans, before optimal protocols are determined (duration, frequency, and hypoxic severity). Regarding principle (2), a hypoxia-related increase in the cardiometabolic stimulus imposed by low-load exercise is appealing for load-compromised athletes. As rehabilitation progresses, a variety of hypoxic modalities can be implemented to enhance adaptation to energy-systems and resistance-based training, and more efficiently return the athlete to competition readiness. While hypoxic modalities seem promising for accelerating musculoskeletal injury rehabilitation in humans, and are already being widely used in practice, a significant gap remains regarding their evidence-based application.

Hypoventilation training including maximal end-expiratory breath holding improves the ability to repeat high-intensity efforts in elite judo athletes

Purpose

To investigate the effects of a repeated-sprint training in hypoxia induced by voluntary hypoventilation at low lung volume (RSH-VHL) including end-expiratory breath holding (EEBH) of maximal duration.

Methods

Over a 4-week period, twenty elite judo athletes (10 women and 10 men) were randomly split into two groups to perform 8 sessions of rowing repeated-sprint exercise either with RSH-VHL (each sprint with maximal EEBH) or with unrestricted breathing (RSN, 10-s sprints). Before (Pre-), 5 days after (Post-1) and 12 days after (Post-2) the last training session, participants completed a repeated-sprint ability (RSA) test on a rowing ergometer (8 × 25-s "all-out" repetitions interspersed with 25 s of passive recovery). Power output (PO), oxygen uptake, perceptual-motor capacity (turning off a traffic light with a predetermined code), cerebral (Δ[Hbdiff]) and muscle (Δ[Hb/Mb]diff) oxygenation, cerebral total haemoglobin concentration (Δ[THb]) and muscle total haemoglobin/myoglobin concentration (Δ[THb/Mb]) were measured during each RSA repetition and/or recovery period.

Results

From Pre-to Post-1 and Post-2, maximal PO, mean PO (MPO) of the first half of the test (repetitions 1-4), oxygen uptake, end-repetition cerebral Δ[Hbdiff] and Δ[THb], end-repetition muscle Δ[Hb/Mb]diff and Δ[THb/Mb] and perceptual-motor capacity remained unchanged in both groups. Conversely, MPO of the second half of the test (repetitions 5-8) was higher at Post-1 than at Pre-in RSH-VHL only (p < 0.01), resulting in a lower percentage decrement score over the entire RSA test (20.4% ± 6.5% vs. 23.9% ± 7.0%, p = 0.01). Furthermore, MPO (5-8) was greater in RSH-VHL than in RSN at Post-1 (p = 0.04). These performance results were accompanied by an increase in muscle Δ[THb/Mb] (p < 0.01) and a concomitant decrease in cerebral Δ[THb] (p < 0.01) during the recovery periods of the RSA test at Post-1 in RSH-VHL.

Conclusion

Four weeks of RSH-VHL including maximal EEBH improved the ability of elite judo athletes to repeat high-intensity efforts. The performance improvement, observed 5 days but not 12 days after training, may be due to enhanced muscle perfusion. The unchanged oxygen uptake and the decrease in cerebral regional blood volume observed at the same time suggest that a blood volume redistribution occurred after the RSH-VHL intervention to meet the increase in muscle perfusion.

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

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

Recent advances in predicting acute mountain sickness: from multidimensional cohort studies to cutting-edge model applications

High-altitude illnesses, encompassing a spectrum of health threats including Acute Mountain Sickness (AMS), pose significant challenges to individuals exposed to high altitude environments, necessitating effective prophylaxis and immediate management. Given the variability in individual responses to these conditions, accurate prediction of high-altitude illnesses onset is of paramount importance. This review systematically consolidates recent advancements in research on predicting AMS by evaluating existing cohort data, predictive models, and methodologies, while also delving into the application of emerging technologies. Through a thorough analysis of scholarly literature, we discuss traditional prediction methods anchored in physiological parameters (e.g., heart rate, respiratory frequency, blood pressure) and biochemical markers, as well as the integration and utility of novel technologies such as biosensors, genetic testing, and artificial intelligence within high-altitude prediction research. While conventional pre-diction techniques have been extensively used, they are often constrained by limitations in accuracy, reliability, and multifactorial influences. The advent of these innovative technologies holds promise for more precise individual risk assessments and personalized preventive and therapeutic strategies across various forms of AMS. Future research endeavors must pivot decisively towards the meticulous identification and stringent validation of innovative predictive biomarkers and models. This strategic re-direction should catalyze intensified interdisciplinary cooperation to significantly deepen our mechanistic insights into the pathogenesis of AMS while refining existing prediction methodologies. These groundbreaking advancements harbor the potential to fundamentally transform preventive and therapeutic frameworks for high-altitude illnesses, ultimately securing augmented safety standards and wellbeing for individuals operating at elevated altitudes with far-reaching global implications.

Review of Athletic Guidelines for High-Altitude Training and Acclimatization

Ramchandani, Rashi, Ioana Tereza Florica, Zier Zhou, Aziz Alemi, and Adrian Baranchuk. Review of athletic guidelines for high-altitude training and acclimatization. High Alt Med Biol. 00:000-000, 2024. Introduction: Exposure to high altitude results in hypobaric hypoxia with physiological acclimatization changes that are thought to influence athletic performance. This review summarizes existing literature regarding implications of high-altitude training and altitude-related guidelines from major governing bodies of sports. Methods: A nonsystematic review was performed using PubMed and OVID Medline to identify articles regarding altitude training and guidelines from international governing bodies of various sports. Sports inherently involving training or competing at high altitude were excluded. Results: Important physiological compensatory mechanisms to high-altitude environments include elevations in blood pressure, heart rate, red blood cell mass, tidal volume, and respiratory rate. These responses can have varying effects on athletic performance. Governing sport bodies have limited and differing regulations for training and competition at high altitudes with recommended acclimatization periods ranging from 3 days to 3 weeks. Discussion: Physiological changes in response to high terrestrial altitude exposure can have substantial impacts on athletic performance. Major sport governing bodies have limited regulations and recommendations regarding altitude training and competition. Existing guidelines are variable and lack substantial evidence to support recommendations. Additional studies are needed to clarify the implications of high-altitude exposure on athletic ability to optimize training and competition.

Four-week experimental plus 1-week taper period using live high train low does not alter muscle glycogen content

This study aimed to investigate the effects of a 4-week live high train low (LHTL; FiO2 ~ 13.5%), intervention, followed by a tapering phase, on muscle glycogen concentration. Fourteen physically active males (28 ± 6 years, 81.6 ± 15.4 kg, 179 ± 5.2 cm) were divided into a control group (CON; n = 5), and the group that performed the LHTL, which was exposed to hypoxia (LHTL; n = 9). The subjects trained using a one-legged knee extension exercise, which enabled four experimental conditions: leg training in hypoxia (TLHYP); leg control in hypoxia (CLHYP, n = 9); leg trained in normoxia (TLNOR, n = 5), and leg control in normoxia (CLNOR, n = 5). All participants performed 18 training sessions lasting between 20 and 45 min [80-200% of intensity corresponding to the time to exhaustion (TTE) reached in the graded exercise test]. Additionally, participants spent approximately 10 h day-1 in either a normobaric hypoxic environment (14.5% FiO2; ~ 3000 m) or a control condition (i.e., staying in similar tents on ~ 530 m). Thereafter, participants underwent a taper protocol consisting of six additional training sessions with a reduced training load. SpO2 was lower, and the hypoxic dose was higher in LHTL compared to CON (p < 0.001). After 4 weeks, glycogen had increased significantly only in the TLNOR and TLHYP groups and remained elevated after the taper (p < 0.016). Time to exhaustion in the LHTL increased after both the 4-week training period and the taper compared to the baseline (p < 0.001). Although the 4-week training promoted substantial increases in muscle glycogen content, TTE increased in LHTL condition.

Effects of various living-low and training-high modes with distinct training prescriptions on sea-level performance: A network meta-analysis

This study aimed to separately compare and rank the effect of various living-low and training-high (LLTH) modes on aerobic and anaerobic performances in athletes, focusing on training intensity, modality, and volume, through network meta-analysis. We systematically searched PubMed, Web of Science, Embase, EBSCO, and Cochrane from their inception date to June 30, 2023. Based on the hypoxic training modality and the intensity and duration of work intervals, LLTH was divided into intermittent hypoxic exposure, continuous hypoxic training, repeated sprint training in hypoxia (RSH; work interval: 5-10 s and rest interval: approximately 30 s), interval sprint training in hypoxia (ISH; work interval: 15-30 s), short-duration high-intensity interval training (s-IHT; short work interval: 1-2 min), long-duration high-intensity interval training (l-IHT; long work interval: > 5 min), and continuous and interval training under hypoxia. A meta-analysis was conducted to determine the standardized mean differences (SMDs) among the effects of various hypoxic interventions on aerobic and anaerobic performances. From 2,072 originally identified titles, 56 studies were included in the analysis. The pooled data from 53 studies showed that only l-IHT (SMDs: 0.78 [95% credible interval; CrI, 0.52-1.05]) and RSH (SMDs: 0.30 [95% CrI, 0.10-0.50]) compared with normoxic training effectively improved athletes' aerobic performance. Furthermore, the pooled data from 29 studies revealed that active intermittent hypoxic training compared with normoxic training can effectively improve anaerobic performance, with SMDs ranging from 0.97 (95% CrI, 0.12-1.81) for l-IHT to 0.32 (95% CrI, 0.05-0.59) for RSH. When adopting a program for LLTH, sufficient duration and work intensity intervals are key to achieving optimal improvements in athletes' overall performance, regardless of the potential improvement in aerobic or anaerobic performance. Nevertheless, it is essential to acknowledge that this study incorporated merely one study on the improvement of anaerobic performance by l-IHT, undermining the credibility of the results. Accordingly, more related studies are needed in the future to provide evidence-based support. It seems difficult to achieve beneficial adaptive changes in performance with intermittent passive hypoxic exposure and continuous low-intensity hypoxic training.

Recommendations for Women in Mountain Sports and Hypoxia Training/Conditioning

The (patho-)physiological responses to hypoxia are highly heterogeneous between individuals. In this review, we focused on the roles of sex differences, which emerge as important factors in the regulation of the body's reaction to hypoxia. Several aspects should be considered for future research on hypoxia-related sex differences, particularly altitude training and clinical applications of hypoxia, as these will affect the selection of the optimal dose regarding safety and efficiency. There are several implications, but there are no practical recommendations if/how women should behave differently from men to optimise the benefits or minimise the risks of these hypoxia-related practices. Here, we evaluate the scarce scientific evidence of distinct (patho)physiological responses and adaptations to high altitude/hypoxia, biomechanical/anatomical differences in uphill/downhill locomotion, which is highly relevant for exercising in mountainous environments, and potentially differential effects of altitude training in women. Based on these factors, we derive sex-specific recommendations for mountain sports and intermittent hypoxia conditioning: (1) Although higher vulnerabilities of women to acute mountain sickness have not been unambiguously shown, sex-dependent physiological reactions to hypoxia may contribute to an increased acute mountain sickness vulnerability in some women. Adequate acclimatisation, slow ascent speed and/or preventive medication (e.g. acetazolamide) are solutions. (2) Targeted training of the respiratory musculature could be a valuable preparation for altitude training in women. (3) Sex hormones influence hypoxia responses and hormonal-cycle and/or menstrual-cycle phases therefore may be factors in acclimatisation to altitude and efficiency of altitude training. As many of the recommendations or observations of the present work remain partly speculative, we join previous calls for further quality research on female athletes in sports to be extended to the field of altitude and hypoxia.

Three sessions of repeated sprint training in normobaric hypoxia improves sprinting performance

The objective of the present study was to evaluate the impacts of three-session repeated sprint training conducted in normobaric hypoxia with 48-h intervals on sprint performance, arterial oxygen saturation (SpO2), and rating of perceived exertion (RPE) scores. A total of 27 moderately trained male university students voluntarily took part in this study. In this single-blind placebo-controlled study, subjects were assigned into normobaric hypoxia (FiO2: 13.6%; HYP), normobaric normoxia (FiO2: 20.9%; PLA), and control group (CON). The HYP and PLA groups underwent three repeated sprint training sessions (a total of four sets of five times 5-s sprints with a 5-min rest between sets and a 30-s rest between each sprint) on a cycle ergometer in normobaric hypoxia or normoxia conditions. Pre- and post-tests were performed 72 h before and after the training period. Three participants were excluded from the study, and the data from twenty-four participants were analyzed. Contrary to what was observed in the pre and post tests, no time and condition interactions were observed in the relative peak power output (PPO), mean power output (MPO), percentage of sprint decrement score (Sdec%), and RPE parameters. Time effect was found in all observed variables respectively; relative PPO (F = 5.784, p = 0.045, η2 = 0.74), relative MPO (F = 3.927, p = 0.042, η2 = 0.66) and large time effect found for Sdec% (F = 11.430, p = 0.046, 0.83), and RPE (F = 14.990, p = 0.008, η2 = 0.96). A notable increase in relative peak power output (PPO) and mean power output (MPO) was observed in the post-test in comparison to the pre-test values, indicating statistical significance. The increase in PPO was in HYP 13.44% (p = 0.006), in PLA 7.48% (p = 0.264) and in CON 2.66% (p = 0.088). The decrease in Sdec% was in HYP -13.34%% (p = 0.048), PLA -10.54 (p = 0.577) and CON -4.83 (p = 0.644) at post-test. The results show that although there were no statistical differences between the groups, notable differences in performance-related variables were observed in the HYP group after 3 sessions of repetitive sprint training in hypoxia.

Effect of 4-week intermittent hypoxic exercise training for repeated vertical jump performance in untrained males

BACKGROUND

To be successful in sports, it is critical to maintain a high level of muscular power throughout a game. Physiological adaptations induced by hypoxic exercise training would provide benefits for fatigue-resisting ability during repeated explosive exercise. The aim of this study was to determine whether a 4-week intermittent hypoxic exercise training program is more effective in improving power endurance during repeated vertical jumps (VJs) when compared with a normoxic counterpart.

METHODS

Eighteen young adult males were divided into two training groups: 1) normoxic training group (NT, FiO2: 20.9%, N.=9); and 2) hypoxic training group (HT, FiO2: 13.7%, N.=9). For both NT and HT, participants performed three sessions per week for four weeks. Each session consisted of a 60-min exercise session including strength and power training. A repeated VJ (40 reps/set, 2 sets with 5 min rest given between them) was performed before and after the training (pretraining and post-training).

RESULTS

The HT group displayed an improvement in repeated VJ performance in a later phase of set 1 following the training (25-30 rep: pretraining 26.49±6.20 vs. post-training 30.55±5.37cm, P=0.0285; 30-35 rep: pretraining 25.08±5.29 vs. post-training 29.56±5.37cm, P=0.0064; 35-40 rep: pretraining 25.05±5.51 vs. post-training 29.28±5.71cm, P=0.0161). In set 2, repeated VJ performance in the later phase was also enhanced in HT following the training (P<0.05 for all). No changes in repeated VJ performance were seen in NT following the training (P>0.05 for all). Also, the HT group showed a trend towards a decrease in Fatigue Index in set 1 (pretraining 23.51±13.27 vs. Post 11.87±12.51%, P=0.1308) and set 2 (pretraining 29.11±13.66 vs. post-training 17.81±17.97%, P=0.1588) following the training.

CONCLUSIONS

Hypoxic exercise training can be an effective training modality to improve fatigue-resisting ability during repeated explosive exercise.

Combining Heat and Altitude Training to Enhance Temperate, Sea-Level Performance

BACKGROUND

Repeated exposure to heat (ie, plasma volume expansion) or altitude (ie, increase in total hemoglobin mass), in conjunction with exercise, induces hematological adaptations that enhance endurance performance in each respective environment. Recently, combining heat and altitude training has become increasingly common for athletes preparing to compete in temperate, sea-level conditions.

PURPOSE

To review the physiological adaptations to training interventions combining thermal and hypoxic stimuli and summarize the implications for temperate, sea-level performance. Current Evidence: To date, research on combining heat and hypoxia has employed 2 main approaches: simultaneously combining the stressors during training or concurrently training in the heat and sleeping at altitude, sometimes with additional training in hypoxia. When environmental stimuli are combined in a training session, improvements in aerobic fitness and time-trial performance in temperate, sea-level conditions are generally similar in magnitude to those observed with heat, or altitude, training alone. Similarly, training in the heat and sleeping at altitude does not appear to provide any additional hematological or nonhematological benefits for temperate; sea-level performance relative to training in hot, hypoxic, or control conditions.

CONCLUSIONS

Current research regarding combined heat and altitude interventions does not seem to indicate that it enhances temperate, sea-level performance to a greater extent than "traditional" (heat or hypoxia alone) training approaches. A major challenge in implementing combined-stressor approaches lies in the uncertainty surrounding the prescription of dosing regimens (ie, exercise and environmental stress). The potential benefits of conducting heat and altitude exposure sequentially (ie, one after the other) warrants further investigation.

Physiological Responses to Supramaximal Running Exercise with End-Expiratory Breath Holding up to the Breaking Point

This study aimed to assess the physiological responses to repeated running exercise performed at supramaximal intensity and with end-expiratory breath holding (EEBH) up to the breaking point. Eight male runners participated in two running testing sessions on a motorized treadmill. In the first session, participants performed two sets of 8 repetitions at 125% of maximal aerobic velocity and with maximum EEBH. Each repetition started at the onset of EEBH and ended at its release. In the second session, participants replicated the same procedure, but with unrestricted breathing (URB). The change in cerebral and muscle oxygenation (Δ[Hbdiff]), total haemoglobin concentration (Δ[THb]) and muscle reoxygenation were continuously assessed. End-tidal oxygen (PETO2) and carbon dioxide pressure (PETCO2), arterial oxygen saturation (SpO2) and heart rate (HR) were also measured throughout exercise.On average, EEBH was maintained for 10.1 ± 1 s. At the breaking point of EEBH, PETO2 decreased to 54.1 ± 8 mmHg, whereas PETCO2 increased to 74.8 ± 3.1 mmHg. At the end of repetitions, SpO2 (nadir values 74.9 ± 5.0 vs. 95.7 ± 0.8%) and HR were lower with EEBH than with URB. Cerebral and muscle Δ[Hbdiff] were also lower with EEBH, whereas this condition induced higher cerebral and muscle Δ[THb] and greater muscle reoxygenation. This study showed that performing repeated bouts of supramaximal running exercises with EEBH up to the breaking point induced a fall in arterial, cerebral and muscle oxygenation compared with the URB condition. These phenomena were accompanied by increases in regional blood volume likely resulting from compensatory vasodilation to preserve oxygen delivery to the brain and muscles.

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

PURPOSE

To investigate the effect of cycling-based repeated-sprint training in hypoxia versus in normoxia on single overground running sprint performance and associated force-velocity (F-V) profile in world-class female rugby sevens players.

METHODS

Eighteen world-class female rugby sevens players were randomly assigned to repeated-sprint cycling training in normobaric hypoxia (n = 9) or normoxia (n = 9) groups. Training consisted of 4 sessions of repeated-sprint cycling training in normobaric hypoxia or in normoxia (4 × 5 × 5-s cycle sprints-25-s intersprint recovery performed in simulated altitude of ∼5000 m or in normoxia with 3-min interset rest in normoxia for both groups) in addition to rugby sevens training and strength and conditioning sessions within a 9-day intervention period before an international competition. Before and 1 day after the intervention, single 50-m overground running "all-out" sprint performance and associated F-V-related mechanical output were assessed.

RESULTS

No interaction (group × time; all P > .088), time effect (before vs 1 d after; all P > .296), or group effect (repeated-sprint cycling training in normobaric hypoxia vs in normoxia; all P > .325) was detected for 50-m overground running sprint performance and any derived F-V profiling variables.

CONCLUSIONS

Four sessions of repeated-sprint training either in hypoxia or in normoxia performed over 9 days had no influence on single 50-m overground running sprint performance and associated F-V profile. In world-class female rugby sevens players, the intervention (training camp before an international competition) might have been too short to induce measurable changes. It is also plausible that implementing a similar program in players with likely different F-V profile may result in negligible mechanical effect.

Anaerobic threshold using sweat lactate sensor under hypoxia

We aimed to investigate the reliability and validity of sweat lactate threshold (sLT) measurement based on the real-time monitoring of the transition in sweat lactate levels (sLA) under hypoxic exercise. In this cross-sectional study, 20 healthy participants who underwent exercise tests using respiratory gas analysis under hypoxia (fraction of inspired oxygen [FiO2], 15.4 ± 0.8%) in addition to normoxia (FiO2, 20.9%) were included; we simultaneously monitored sLA transition using a wearable lactate sensor. The initial significant elevation in sLA over the baseline was defined as sLT. Under hypoxia, real-time dynamic changes in sLA were successfully visualized, including a rapid, continual rise until volitionary exhaustion and a progressive reduction in the recovery phase. High intra- and inter-evaluator reliability was demonstrated for sLT's repeat determinations (0.782 [0.607-0.898] and 0.933 [0.841-0.973]) as intraclass correlation coefficients [95% confidence interval]. sLT correlated with ventilatory threshold (VT) (r = 0.70, p < 0.01). A strong agreement was found in the Bland-Altman plot (mean difference/mean average time: - 15.5/550.8 s) under hypoxia. Our wearable device enabled continuous and real-time lactate assessment in sweat under hypoxic conditions in healthy participants with high reliability and validity, providing additional information to detect anaerobic thresholds in hypoxic conditions.

The effects of intermittent hypoxic training on the aerobic capacity of exercisers: a systemic review and meta-analysis

OBJECTIVE

To systematically review the effects of intermittent hypoxic training on the aerobic capacity of exercisers.

METHODS

PubMed, Embase, The Cochrane Library, and Web of Science databases were electronically searched to collect studies on the effects of intermittent hypoxic training on the aerobic capacity of exercisers from January 1, 2000, to January 12, 2023. Two reviewers independently screened the literature, extracted data, and assessed the risk of bias of the included studies. Then, meta-analysis was performed by using Stata SE 16.0 software.

RESULTS

A total of 19 articles from 27 studies were included. The results of the meta-analysis showed that compared with the control group, the intermittent hypoxic training group had significantly increased maximal oxygen uptake [weighted mean difference = 3.20 (95%CI: 1.33 ~ 5.08)] and hemoglobin [weighted mean difference = 0.25 (95%CI: 0.04 ~ 0.45)].

CONCLUSION

Intermittent hypoxic training can significantly improve the aerobic capacity of exercisers. Due to the limited quantity and quality of the included studies, more high-quality studies are needed to verify the above conclusion.

Inter-effort recovery hypoxia: a new paradigm in sport science?

High-intensity interval training (HIIT) is a popular method for optimising sports performance and, more recently, improving health-related parameters. The inclusion of hypoxia during HIIT can promote additional gains compared with normoxia. However, reductions in the effort intensities compared with the same training performed in normoxia have been reported. Studies have reported that adding hypoxia during periods of inter-effort recovery (IEH) enables maintenance of the intensity of efforts. It also promotes additional gains from exposure to hypoxia. Our call is for researchers to consider IEH in experiments involving different models of HIIT. Additionally, we consider the need to answer the following questions: What is the clinically relevant minimum dose of exposure to hypoxia during the recovery periods between efforts so that favourable adaptations of parameters are associated with health and sports performance? How does the intensity of exertion influence the responses to hypoxia exposure during recovery periods? What are the chronic effects of different models of HIIT and hypoxia recovery on sports performance?

Intermittent Hypoxia Conditioning: A Potential Multi-Organ Protective Therapeutic Strategy

Severe hypoxia can induce a range of systemic disorders; however, surprising resilience can be obtained through sublethal adaptation to hypoxia, a process termed as hypoxic conditioning. A particular form of this strategy, known as intermittent hypoxia conditioning hormesis, alternates exposure to hypoxic and normoxic conditions, facilitating adaptation to reduced oxygen availability. This technique, originally employed in sports and high-altitude medicine, has shown promise in multiple pathologies when applied with calibrated mild to moderate hypoxia and appropriate hypoxic cycles. Recent studies have extensively investigated the protective role of intermittent hypoxia conditioning and its underlying mechanisms using animal models, demonstrating its potential in organ protection. This involves a range of processes such as reduction of oxidative stress, inflammation, and apoptosis, along with enhancement of hypoxic gene expression, among others. Given that intermittent hypoxia conditioning fosters beneficial physiological responses across multiple organs and systems, this review presents a comprehensive analysis of existing studies on intermittent hypoxia and its potential advantages in various organs. It aims to draw attention to the possibility of clinically applying intermittent hypoxia conditioning as a multi-organ protective strategy. This review comprehensively discusses the protective effects of intermittent hypoxia across multiple systems, outlines potential procedures for implementing intermittent hypoxia, and provides a brief overview of the potential protective mechanisms of intermittent hypoxia.

A study of survival strategies for improving acclimatization of lowlanders at high-altitude

Human Acclimatization and therapeutic approaches are the core components for conquering the physiological variations at high altitude (≥2500 m) exposure. The declined atmospheric pressure and reduced partial pressure of oxygen at high altitudes tend to decrease the temperature by several folds. Hypobaric hypoxia is a major threat to humanity at high altitudes, and its potential effects include altitude mountain sickness. On severity, it may lead to the development of conditions like high-altitude cerebral edema (HACE) or high-altitude pulmonary edema (HAPE) and cause unexpected physiological changes in the healthy population of travelers, athletes, soldiers, and low landers while sojourning at high altitude. Previous investigations have been done on long-drawn-out acclimatization strategies such as the staging method to prevent the damage caused by high-altitude hypobaric Hypoxia. Inherent Limitations of this strategy hamper the daily lifestyle and time consuming for people. It is not suitable for the rapid mobilization of people at high altitudes. There is a need to recalibrate acclimatization strategies for improving health protection and adapting to the environmental variations at high altitudes. This narrative review details the geographical changes and physiological changes at high altitudes and presents a framework of acclimatization, pre-acclimatization, and pharmacological aspects of high-altitude survival to enhance the government efficacy and capacity for the strategic planning of acclimatization, use of therapeutics, and safe de-induction from high altitude for minimizing the life loss. It's simply too ambitious for the importance of the present review to reduce life loss, and it can be proved as the most essential aspect of the preparatory phase of high-altitude acclimatization in plateau regions without hampering the daily lifestyle. The application of pre-acclimatization techniques can be a boon for people serving at high altitudes, and it can be a short bridge for the rapid translocation of people at high altitudes by minimizing the acclimatization time.

Living high - training low model applied to C57BL/6J mice: Effects on physiological parameters related to aerobic fitness and acid-base balance

There is a scarcity of data regarding the acclimation to high altitude (hypoxic environment) accompanied by training at low altitude (normoxic conditions), the so-called "living high-training low" (LHTL) model in rodents. We aimed to investigate the effects of aerobic training on C57BL/6J mice living in normoxic (NOR) or hypoxic (HYP) environments on several parameters, including critical velocity (CV), a parameter regarded as a measure of aerobic capacity, on monocarboxylate transporters (MCTs) in muscles and hypothalamus, as well as on hematological parameters and body temperature. In each environment, mice were divided into non-trained (N) and trained (T). Forty rodents were distributed into the following experimental groups (N-NOR; T-NOR; N-HYP and T-HYP). HYP groups were in a normobaric tent where oxygen-depleted air was pumped from a hypoxia generator set an inspired oxygen fraction [FiO₂] of 14.5 %. The HYP-groups were kept (18 h per day) in a normobaric tent for consecutive 8-weeks. Training sessions were conducted in normoxic conditions ([FiO₂] = 19.5 %), 5 times per week (40 min per session) at intensity equivalent to 80 % of CV. In summary, eight weeks of LHTL did not promote a greater improvement in the CV, protein expression of MCTs in different tissues when compared to the application of training alone. The LHTL model increased red blood cells count, but reduced hemoglobin per erythrocyte was found in mice exposed to LHTL. Although the LHTL did not have a major effect on thermographic records, exercise-induced hyperthermia (in the head) was attenuated in HYP groups when compared to NOR groups.

Adding heat stress to repeated-sprint training in hypoxia does not enhance performance improvements in canoe/kayak athletes

PURPOSE

The present study investigated the effects of adding heat stress to repeated-sprint training in hypoxia on performance and physiological adaptations in well-trained athletes.

METHODS

Sixteen canoe/kayak sprinters conducted 2 weeks of repeated-sprint training consisting of three sets of 5 × 10 s sprints with 20 s active recovery periods under conditions of either normobaric hypoxia (RSH, FiO₂: 14.5%, ambient temperature: 18 ℃, n = 8) or combined heat and normobaric hypoxia (RSHH, FiO₂: 14.5%, ambient temperature: 38 ℃, n = 8). Before and after training, the 10 × 10 s repeated-sprint ability (RSA) test and 500 m time trial were performed on a canoe/kayak ergometer.

RESULTS

Peak and average power outputs during the RSA test were significantly improved after training in both RSH (peak power: + 21.5 ± 4.6%, P < 0.001; average power: + 12.5 ± 1.9%, P < 0.001) and RSHH groups (peak power: + 18.8 ± 6.6%, P = 0.005; average power: + 10.9 ± 6.8%, P = 0.030). Indirect variables of skeletal muscle oxygen extraction (deoxygenated hemoglobin) and blood perfusion (total hemoglobin) during the RSA test were significantly increased after training in the RSH group (P = 0.041 and P = 0.034, respectively) but not in the RSHH group. In addition, finish time during the 500 m time trial was significantly shortened after the training only in the RSH group (RSH: - 3.9 ± 0.8%, P = 0.005; RSHH: - 3.1 ± 1.4%, P = 0.078).

CONCLUSION

Adding heat stress to RSH does not enhance performance improvement and may partially mask muscle tissue adaptation.

Primum non nocere; It's time to consider altitude training as the medical intervention it actually is!

Sleep is one of the most important aspects of recovery, and is known to be severely affected by hypoxia. The present position paper focuses on sleep as a strong moderator of the altitude training-response. Indeed, the response to altitude training is highly variable, it is not a fixed and classifiable trait, rather it is a state that is determined by multiple factors (e.g., iron status, altitude dose, pre-intervention hemoglobin mass, training load, and recovery). We present an overview of evidence showing that sleep, and more specifically the prolonged negative impact of altitude on the nocturnal breathing pattern, affecting mainly deep sleep and thus the core of physiological recovery during sleep, could play an important role in intra- and interindividual variability in the altitude training-associated responses in professional and recreational athletes. We conclude our paper with a set of suggested recommendations to customize the application of altitude training to the specific needs and vulnerabilities of each athlete (i.e., primum non nocere). Several factors have been identified (e.g., sex, polymorphisms in the TASK2/KCNK5, NOTCH4 and CAT genes and pre-term birth) to predict individual vulnerabilities to hypoxia-related sleep-disordered breathing. Currently, polysomnography should be the first choice to evaluate an individual's predisposition to a decrease in deep sleep related to hypoxia. Further interventions, both pharmacological and non-pharmacological, might alleviate the effects of nocturnal hypoxia in those athletes that show most vulnerable.

Effect of Intermittent Hypoxic Training on Selected Biochemical Indicators, Blood Rheological Properties, and Metabolic Activity of Erythrocytes in Rowers

The study assessed the effect of 3-week intermittent hypoxic training on blood biochemical indicators (blood morphology, fibrinogen), blood rheological properties (erythrocyte deformability, aggregation), erythrocyte enzymatic activity (acetylcholinesterase), and maximal oxygen uptake in competitive rowers. Fourteen male rowers were divided into two equal groups: experimental, training on ergometers under normobaric hypoxia (FiO₂ = 16.0%), and control, training on ergometers under normoxia (FiO₂ = 21%). Fasting blood was taken before and after training. A significant between-group difference in neutrophil levels before training was noted and a significant decrease in white blood cells in the hypoxia group. Both groups exhibited an increase in elongation index. In the normoxia group, a significant increase in erythrocyte aggregation amplitude was revealed. No significant changes occurred in the other biochemical indicators or those evaluating erythrocyte metabolic activity. Normobaric hypoxia increased erythrocyte deformability, improving blood rheological properties. Maximal oxygen uptake significantly increased only in the experimental group.

Repeated-sprint training in heat and hypoxia: effect of exercise-to-rest ratio

AbstractThe aim of this study was to investigate acute performance and physiological responses to the manipulation of exercise-to-rest ratio (E:R) during repeated-sprint hypoxic training (RSH) in hot conditions. Twelve male team-sport players completed two experimental sessions at a simulated altitude of ∼3000 m (F_IO₂ 0.144), air temperature of 40°C and relative humidity of 50%. Exercise involved either 3×5×10-s (E:R_1:2) or 3×10×5-s (E:R_1:4) maximal cycling sprints interspersed with active recoveries at 120W (20-s between sprints, 2.5 and 5-min between sets for E:R_1:2 and E:R_1:4 respectively). Sessions were matched for overall sprint and total session duration (47.5-min). Peak and mean power output, and total work were greater in E:R_1:4 than E:R_1:2 (p < 0.05). Peak core temperature was significantly higher in E:R_1:4 than E:R_1:2 (38.44 ± 0.33 vs. 38.20 ± 0.35°C, p = 0.028). Muscle deoxygenation magnitude during sprints was greater in E:R_1:2 (28.2 ± 1.6 vs. 22.4 ± 4.6%, p < 0.001), while muscle reoxygenation did not differ between conditions (p > 0.05).These results indicate E:R_1:4 increased mechanical power output and core temperature compared to E:R_1:2. Both protocols had different effects on measures of muscle oxygenation, with E:R_1:2 generating greater muscle oxygen extraction and E:R_1:4 producing more muscle oxygenation flux, which are both important signals for peripheral adaptation. We conclude that the E:R manipulation during RSH in the heat might be used to target different physiological and performance outcomes, with these findings forming a strong base for future mechanistic investigation.

Effects of Intermittent Hypoxia-Hyperoxia on Performance- and Health-Related Outcomes in Humans: A Systematic Review

BACKGROUND

Intermittent hypoxia applied at rest or in combination with exercise promotes multiple beneficial adaptations with regard to performance and health in humans. It was hypothesized that replacing normoxia by moderate hyperoxia can increase the adaptive response to the intermittent hypoxic stimulus.

OBJECTIVE

Our objective was to systematically review the current state of the literature on the effects of chronic intermittent hypoxia-hyperoxia (IHH) on performance- and health-related outcomes in humans.

METHODS

PubMed, Web of Science™, Scopus, and Cochrane Library databases were searched in accordance with PRISMA guidelines (January 2000 to September 2021) using the following inclusion criteria: (1) original research articles involving humans, (2) investigation of the chronic effect of IHH, (3) inclusion of a control group being not exposed to IHH, and (4) articles published in peer-reviewed journals written in English.

RESULTS

Of 1085 articles initially found, eight studies were included. IHH was solely performed at rest in different populations including geriatric patients (n = 1), older patients with cardiovascular (n = 3) and metabolic disease (n = 2) or cognitive impairment (n = 1), and young athletes with overtraining syndrome (n = 1). The included studies confirmed the beneficial effects of chronic exposure to IHH, showing improvements in exercise tolerance, peak oxygen uptake, and global cognitive functions, as well as lowered blood glucose levels. A trend was discernible that chronic exposure to IHH can trigger a reduction in systolic and diastolic blood pressure. The evidence of whether IHH exerts beneficial effects on blood lipid levels and haematological parameters is currently inconclusive. A meta-analysis was not possible because the reviewed studies had a considerable heterogeneity concerning the investigated populations and outcome parameters.

CONCLUSION

Based on the published literature, it can be suggested that chronic exposure to IHH might be a promising non-pharmacological intervention strategy for improving peak oxygen consumption, exercise tolerance, and cognitive performance as well as reducing blood glucose levels, and systolic and diastolic blood pressure in older patients with cardiovascular and metabolic diseases or cognitive impairment. However, further randomized controlled trials with adequate sample sizes are needed to confirm and extend the evidence. This systematic review was registered on the international prospective register of systematic reviews (PROSPERO-ID: CRD42021281248) ( https://www.crd.york.ac.uk/prospero/ ).

Comparisons Between Normobaric Normoxic and Hypoxic Recovery on Post-exercise Hemodynamics After Sprint Interval Cycling in Hypoxia

The aim of this study was to investigate the effects of either normoxic or hypoxic recovery condition on post-exercise hemodynamics after sprint interval leg cycling exercise rather than hemodynamics during exercise. The participants performed five sets of leg cycling with a maximal effort (30 s exercise for each set) with a 4-min recovery of unloaded cycling between the sets in hypoxia [fraction of inspired oxygen (FiO₂) = 0.145]. The load during pedaling corresponded to 7.5% of the individual’s body weight at the first set, and it gradually reduced from 6.5 to 5.5%, 4.5, and 3.5% for the second to fifth sets. After exercise, the participants rested in a sitting position for 30 min under normoxia (room-air) or hypoxia. Mean arterial pressure decreased over time during recovery (p < 0.001) with no condition and interaction effects (p > 0.05). Compared to pre-exercise values, at 30 min after exercise, mean arterial pressure decreased by 5.6 ± 4.8 mmHg (mean ± standard deviation) during hypoxic recovery, and by 5.3 ± 4.6 mmHg during normoxic recovery. Peripheral arterial oxygen saturation (SpO₂) at all time points (5, 10, 20, and 30 min) during hypoxic recovery was lower than during normoxic recovery (all p < 0.05). The area under the hyperemic curve of tissue oxygen saturation (StO₂) at vastus lateralis defined as reperfusion curve above the baseline values during hypoxic recovery was lower than during normoxic recovery (p < 0.05). Collectively, post-exercise hypotension after sprint interval leg cycling exercise was not affected by either normoxic or hypoxic recovery despite marked differences in SpO₂ and StO₂ during recovery between the two conditions.

Breath Tools: A Synthesis of Evidence-Based Breathing Strategies to Enhance Human Running

Running is among the most popular sporting hobbies and often chosen specifically for intrinsic psychological benefits. However, up to 40% of runners may experience exercise-induced dyspnoea as a result of cascading physiological phenomena, possibly causing negative psychological states or barriers to participation. Breathing techniques such as slow, deep breathing have proven benefits at rest, but it is unclear if they can be used during exercise to address respiratory limitations or improve performance. While direct experimental evidence is limited, diverse findings from exercise physiology and sports science combined with anecdotal knowledge from Yoga, meditation, and breathwork suggest that many aspects of breathing could be improved via purposeful strategies. Hence, we sought to synthesize these disparate sources to create a new theoretical framework called “Breath Tools” proposing breathing strategies for use during running to improve tolerance, performance, and lower barriers to long-term enjoyment.

The Acute Effects of Normobaric Hypoxia on Strength, Muscular Endurance and Cognitive Function: Influence of Dose and Sex

The aim of this study was to examine the acute effects of different levels of hypoxia on maximal strength, muscular endurance, and cognitive function in males and females. In total, 13 males (mean ± SD: age, 23.6 ± 2.8 years; height, 176.6 ± 3.9 cm; body mass, 76.6 ± 2.1 kg) and 13 females (mean ± SD: age, 22.8 ± 1.4 years; height, 166.4 ± 1.9 cm; body mass, 61.6 ± 3.4 kg) volunteered for a randomized, double-blind, crossover study. Participants completed a one repetition strength and muscular endurance test (60% of one repetition maximum to failure) for squat and bench press following four conditions; (i) normoxia (900 m altitude; FiO2: 21%); (ii) low dose hypoxia (2000 m altitude; FiO2: 16%); (iii) moderate dose hypoxia (3000 m altitude; FiO2: 14%); and (iv) high dose hypoxia (4000 m altitude; FiO2: 12%). Heart rate, blood lactate, rating of perceived exertion, and cognitive function was also determined during each condition. The one repetition maximum squat (p = 0.33) and bench press (p = 0.68) did not differ between conditions or sexes. Furthermore, squat endurance did not differ between conditions (p = 0.34). There was a significant decrease in bench press endurance following moderate (p = 0.02; p = 0.04) and high (p = 0.01; p = 0.01) doses of hypoxia in both males and females compared to normoxia and low dose hypoxia, respectively. Cognitive function, ratings of perceived exertion, and lactate were also significantly different in high and moderate dose hypoxia conditions compared to normoxia (p < 0.05). Heart rate was not different between the conditions (p = 0.30). In conclusion, high and moderate doses of acute normobaric hypoxia decrease upper body muscular endurance and cognitive performance regardless of sex; however, lower body muscular endurance and maximal strength are not altered.

Methods to match high-intensity interval exercise intensity in hypoxia and normoxia - A pilot study

The aim of this study was to compare high-intensity interval exercise (HIIE) sessions prescribed on the basis of a maximal value (peak power output, PPO) and a submaximal value (lactate threshold, LT) derived from graded exercise tests (GXTs) in normoxia and hypoxia. Methods: A total of ten males (aged 18–37) volunteered to participate in this study. The experimental protocol consisted of a familiarization procedure, two GXTs under normoxia (FiO₂ = 0.209) and two GXTs under normobaric hypoxia (FiO2 = 0.140), and three HIIE sessions performed in a random order. The HIIE sessions included one at hypoxia (HY) and two at normoxia (one matched for the absolute intensity in hypoxia, designated as NA, and one matched for the relative intensity in hypoxia, designated as NR). Results: The data demonstrated that there was significant lower peak oxygen uptake (V̇O_2peak), peak heart rate (HR_peak), PPO, and LT derived from GXTs in hypoxia, with higher respiratory exchange ratio (RER), when compared to those from GXTs performed in normoxia (p < 0.001). Among the three HIIE sessions, the NA session resulted in lower percentage of HR_peak (85.0 ± 7.5% vs 94.4 ± 5.0%; p = 0.002) and V̇O_2peak (74.1 ± 9.1% vs 88.7 ± 7.7%; p = 0.005), when compared to the NR session. HIIE sessions in HY and NR resulted in similar percentage of HR_peak and V̇O_2peak, as well as similar rating of perceived exertion and RER. The blood lactate level increased immediately after all the three HIIE sessions (p < 0.001), while higher blood lactate concentrations were observed immediately after the HY (p = 0.0003) and NR (p = 0.014) sessions when compared with NA. Conclusion: Combining of PPO and LT derived from GXTs can be used to prescribe exercise intensity of HIIE in hypoxia.

Hypoxic preconditioning in renal ischaemia-reperfusion injury: a review in pre-clinical models

Ischaemia-reperfusion injury (IRI) is a major cause of acute kidney injury (AKI) and chronic kidney disease, which consists of cellular damage and renal dysfunction. AKI is a major complication that is of particular concern after cardiac surgery and to a lesser degree following organ transplantation in the immediate post-transplantation period, leading to delayed graft function. Because effective therapies are still unavailable, several recent studies have explored the potential benefit of hypoxic preconditioning (HPC) on IRI. HPC refers to the acquisition of increased organ tolerance to subsequent ischaemic or severe hypoxic injury, and experimental evidences suggest a potential benefit of HPC. There are three experimental forms of HPC, and, for better clarity, we named them as follows: physical HPC, HPC via treated-cell administration and stabilised hypoxia-inducible factor (HIF)-1α HPC, or mimicked HPC. The purpose of this review is to present the latest developments in the literature on HPC in the context of renal IRI in pre-clinical models. The data we compiled suggest that preconditional activation of hypoxia pathways protects against renal IRI, suggesting that HPC could be used in the treatment of renal IRI in transplantation.

Tent versus Mask-On Acute Effects during Repeated-Sprint Training in Normobaric Hypoxia and Normoxia

Repeated sprint in hypoxia (RSH) is used to improve supramaximal cycling capacity, but little is known about the potential differences between different systems for creating normobaric hypoxia, such as a chamber, tent, or mask. This study aimed to compare the environmental (carbon dioxide (CO₂) and wet-globe bulb temperature (WGBT)), perceptual (pain, respiratory difficulty, and rate of perceived exertion (RPE)), and external (peak and mean power output) and internal (peak heart rate (HRpeak), muscle oxygen saturation (SmO₂), arterial oxygen saturation (SpO₂), blood lactate and glucose) workload acute effects of an RSH session when performed inside a tent versus using a mask. Twelve well-trained cyclists (age = 29 ± 9.8 years, VO₂max = 70.3 ± 5.9 mL/kg/min) participated in this single-blind, randomized, crossover trial. Participants completed four sessions of three sets of five repetitions × 10 s:20 s (180 s rest between series) of all-out in different conditions: normoxia in a tent (RSNTent) and mask-on (RSNMask), and normobaric hypoxia in a tent (RSHTent) and mask-on (RSHMask). CO₂ and WGBT levels increased steadily in all conditions (p < 0.01) and were lower when using a mask (RSNMask and RSHMask) than when inside a tent (RSHTent and RSNTent) (p < 0.01). RSHTent presented lower SpO₂ than the other three conditions (p < 0.05), and hypoxic conditions presented lower SpO₂ than normoxic ones (p < 0.05). HRpeak, RPE, blood lactate, and blood glucose increased throughout the training, as expected. RSH could lead to acute conditions such as hypoxemia, which may be exacerbated when using a tent to simulate hypoxia compared to a mask-based system.

Altitude, Exercise, and Skeletal Muscle Angio-Adaptive Responses to Hypoxia: A Complex Story

Hypoxia, defined as a reduced oxygen availability, can be observed in many tissues in response to various physiological and pathological conditions. As a hallmark of the altitude environment, ambient hypoxia results from a drop in the oxygen pressure in the atmosphere with elevation. A hypoxic stress can also occur at the cellular level when the oxygen supply through the local microcirculation cannot match the cells’ metabolic needs. This has been suggested in contracting skeletal myofibers during physical exercise. Regardless of its origin, ambient or exercise-induced, muscle hypoxia triggers complex angio-adaptive responses in the skeletal muscle tissue. These can result in the expression of a plethora of angio-adaptive molecules, ultimately leading to the growth, stabilization, or regression of muscle capillaries. This remarkable plasticity of the capillary network is referred to as angio-adaptation. It can alter the capillary-to-myofiber interface, which represent an important determinant of skeletal muscle function. These angio-adaptive molecules can also be released in the circulation as myokines to act on distant tissues. This review addresses the respective and combined potency of ambient hypoxia and exercise to generate a cellular hypoxic stress in skeletal muscle. The major skeletal muscle angio-adaptive responses to hypoxia so far described in this context will be discussed, including existing controversies in the field. Finally, this review will highlight the molecular complexity of the skeletal muscle angio-adaptive response to hypoxia and identify current gaps of knowledges in this field of exercise and environmental physiology.

Running exercise with end-expiratory breath holding up to the breaking point induces large and early fall in muscle oxygenation

PURPOSE

The goal of this study was to assess the effects of repeated running bouts with end-expiratory breath holding (EEBH) up to the breaking point on muscle oxygenation.

METHODS

Eight male runners participated in three randomised sessions each including two exercises on a motorised treadmill. The first exercise consisted in performing 10-12 running bouts with EEBH of maximum duration either (separate sessions) at 60% (active recovery), 80% (passive recovery) or 100% (passive recovery) of the maximal aerobic velocity (MAV). Each repetition started at the onset of EEBH and ended at its release. In the second exercise of the session, subjects replicated the same procedure but with normal breathing (NB). Arterial oxygen saturation (SpO₂), heart rate (HR) and the change in vastus lateralis muscle deoxy-haemoglobin/myoglobin (Δ[HHb/Mb]) and total haemoglobin/myoglobin (Δ[THb/Mb]) were continuously monitored throughout exercises.

RESULTS

On average, the EEBHs were maintained for 10.1 ± 1.1 s, 13.2 ± 1.8 s and 12.2 ± 1.7 s during exercise at 60%, 80% and 100% of MAV, respectively. In the three exercise intensities, SpO₂ (mean nadir values: 76.3 ± 2.5 vs 94.5 ± 2.5%) and HR were lower with EEBH than with NB at the end of the repetitions; whereas, the mean Δ[HHb/Mb] (12.6 ± 5.2 vs 7.7 ± 4.4 µm) and Δ[THb/Mb] (- 0.6 ± 2.3 vs 3.8 ± 2.6 µm) were, respectively, higher and lower with EEBH (p < 0.05).

CONCLUSION

This study showed that performing repeated bouts of running exercises with EEBH up to the breaking point induced a large and early drop in muscle oxygenation compared with the same exercise with NB. This phenomenon was probably the consequence of the strong arterial oxygen desaturation induced by the maximal EEBHs.

The Effects of Intermittent Hypoxic-Hyperoxic Exposures on Lipid Profile and Inflammation in Patients With Metabolic Syndrome

Background: Patients with metabolic syndrome (MS) tend to suffer from comorbidities, and are often simultaneously affected by obesity, dysglycemia, hypertension, and dyslipidemia. This syndrome can be reversed if it is timely diagnosed and treated with a combination of risk factors-reducing lifestyle changes and a tailored pharmacological plan. Interval hypoxic-hyperoxic training (IHHT) has been shown as an effective program in reducing cardiovascular risk factors in patients with MS even in the absence of exercise. However, the influence of IHHT on the lipid profile and inflammation in this clinical population remains relatively unknown.

Methods: A prospective, single-center, randomized controlled trial was conducted on 65 (33 men) patients with MS aged 29–74 years, who were randomly allocated to the IHHT or control (sham) experimental groups. The IHHT group completed a 3-week, 5 days/week intermittent exposure to hypoxia and hyperoxia. The control (sham) group followed the same protocol but was breathing room air instead. The primary endpoints were the lipid profile (concentrations of total cholesterol [TC], low-density lipoprotein [LDL], high-density lipoprotein [HDL], and triglycerides [TG]) and the inflammatory factors such as high-sensitivity C-reactive protein (hs-CRP), galectin-3, heat shock proteins (Hsp70). The secondary endpoints were alanine aminotransferase (ALT), aspartate aminotransferase (AST), N-terminal pro-hormone of brain natriuretic peptide level (NTproBNP), transforming growth factor beta-1 (TGF-beta1), heart-type fatty acid-binding protein (H-FABP), and nitric oxide synthase 2 (NOS2).

Results: There were no differences between the two groups but the different baseline values have affected these results. The IHHT group demonstrated pre-post decrease in total cholesterol (p = 0.001), LDL (p = 0.001), and TG levels (p = 0.001). We have also found a decrease in the CRP-hs (p = 0.015) and Hsp70 (p = 0.006) in IHHT-group after intervention, and a significant decrease in pre-post (delta) differences of NTproBNP (p < 0.0001) in the IHHT group compared to the control group. In addition, the patients of the IHHT group showed a statistically significant decrease in pre-post differences of ALT and AST levels in comparison with the control group (p = 0.001). No significant IHHT complications or serious adverse events were observed.

Conclusions: The IHHT appears to improve lipid profile and anti-inflammatory status. It is a safe, well-tolerated procedure, and could be recommended as an auxiliary treatment in patients suffering from MS, however, the experiment results were limited by the baseline group differences.

Clinical Trial Registration:ClinicalTrials.gov, identifier [NCT04791397]. Evaluation of the effect of IHHT on vascular stiffness and elasticity of the liver tissue in patients with MS.

Augmented muscle glycogen utilization following a single session of sprint training in hypoxia

PURPOSE

This study determined the effect of a single session of sprint interval training in hypoxia on muscle glycogen content among athletes.

METHODS

Ten male college track and field sprinters (mean ± standard error of the mean: age, 21.1 ± 0.2 years; height, 177 ± 2 cm; body weight, 67 ± 2 kg) performed two exercise trials under either hypoxia [HYPO; fraction of inspired oxygen (F_iO₂), 14.5%] or normoxia (NOR: F_iO₂, 20.9%). The exercise consisted of 3 × 30 s maximal cycle sprints with 8-min rest periods between sets. Before and immediately after the exercise, the muscle glycogen content was measured using carbon magnetic resonance spectroscopy in vastus lateralis and vastus intermedius muscles. Moreover, power output, blood lactate concentrations, metabolic responses (respiratory oxygen uptake and carbon dioxide output), and muscle oxygenation were evaluated.

RESULTS

Exercise significantly decreased muscle glycogen content in both trials (interaction, P = 0.03; main effect for time, P < 0.01). Relative changes in muscle glycogen content following exercise were significantly higher in the HYPO trial (- 43.5 ± 0.4%) than in the NOR trial (- 34.0 ± 0.3%; P < 0.01). The mean power output did not significantly differ between the two trials (P = 0.80). The blood lactate concentration after exercise was not significantly different between trials (P = 0.31).

CONCLUSION

A single session of sprint interval training (3 × 30 s sprints) in hypoxia caused a greater decrease in muscle glycogen content compared with the same exercise under normoxia without interfering with the power output.

Effects of combined hot and hypoxic conditions on muscle blood flow and muscle oxygenation during repeated cycling sprints

PURPOSE

The purpose of the present study was to determine muscle blood flow and muscle oxygenation during repeated-sprint exercise under combined hot and hypoxic conditions.

METHODS

In a single-blind, cross-over research design, 11 active males performed three sets of 5 × 6-s maximal sprints with 30-s active recovery on a cycling ergometer under control (CON; 23 °C, 50% rH, 20.9% FiO₂), normobaric hypoxic (HYP; 23 °C, 50% rH, 14.5% FiO₂), or hot + normobaric hypoxic (HH; 35 °C, 50% rH, 14.5% FiO₂) conditions. The vastus lateralis muscle blood flow after each set and muscle oxygenation during each sprint were evaluated using near-infrared spectroscopy methods.

RESULTS

Despite similar repeated-sprint performance among the three conditions (peak and mean power outputs, percent decrement score), HH was associated with significantly higher muscle blood flow compared with CON after the first set (CON: 0.61 ± 0.10 mL/min/100 g; HYP: 0.81 ± 0.13 mL/min/100 g; HH: 0.99 ± 0.16 mL/min/100 g; P < 0.05). The tissue saturation index was significantly lower in HYP than in CON during the latter phase of the exercise (P < 0.05), but it did not differ between HH and CON.

CONCLUSION

These findings suggest that a combination of normobaric hypoxia and heat stress partially facilitated the exercise-induced increase in local blood flow, but it did not enhance tissue desaturation.

Heat Added to Repeated-Sprint Training in Hypoxia Does Not Affect Cycling Performance

PURPOSE

This study aimed to assess the influence of graded air temperatures during repeated-sprint training in hypoxia (RSH) on performance and physiological responses.

METHODS

Ten well-trained athletes completed one familiarization and 4 experimental sessions at a simulated altitude of 3000 m (0.144 FIO2) above sea level. Air temperatures utilized across the 4 experimental sessions were 20°C, 25°C, 30°C, and 35°C (all 50% relative humidity). The participants performed 3 sets of 5 × 10 seconds "all-out" cycle sprints, with 20 seconds of active recovery between sprints and 5 minutes of active recovery between sets (recovery intensity = 120 W). Core temperature, skin temperature, pulse oxygen saturation, heart rate, rating of perceived exertion, and thermal sensation were collected.

RESULTS

There were no differences between conditions for peak power, mean power, and total work in each set (P > .05). There were no condition × time interaction effects for any variables tested. The peak core temperature was highest at 30°C (38.06°C [0.31°C]). Overall, the pulse oxygen saturation was higher at 35°C than at 20°C (P < .001; d < 0.8), 25°C (P < .001; d = 1.12 ± 0.54, large), and 30°C (P < .001; d = 0.84 ± 0.53, large).

CONCLUSION

Manipulating air temperature between 20°C and 35°C had no effect on performance or core temperature during a typical RSH session. However, the pulse oxygen saturation was preserved at 35°C, which may not be a desirable outcome for RSH interventions. The application of increased levels of ambient heat may require a different approach if augmenting the RSH stimulus is the desired outcome.

Aerobic Continuous and Interval Training under Hypoxia Enhances Endurance Exercise Performance with Hemodynamic and Autonomic Nervous System Function in Amateur Male Swimmers

Hypoxic training is often performed by competitive swimmers to enhance their performance in normoxia. However, the beneficial effects of aerobic continuous and interval training under hypoxia on hemodynamic function, autonomic nervous system (ANS) function, and endurance exercise performance remain controversial. Here we investigated whether six weeks of aerobic continuous and interval training under hypoxia can improve hematological parameters, hemodynamic function, ANS function, and endurance exercise performance versus normoxia in amateur male swimmers. Twenty amateur male swimmers were equally assigned to the hypoxic training group or normoxic training group and evaluated before and after six weeks of training. Aerobic continuous and interval training in the hypoxia showed a more significantly improved hemodynamic function (heart rate, −653.4 vs. −353.7 beats/30 min; oxygen uptake, −62.45 vs. −16.22 mL/kg/30 min; stroke volume index, 197.66 vs. 52.32 mL/30 min) during submaximal exercise, ANS function (root mean square of successive differences, 10.15 vs. 3.32 ms; total power, 0.72 vs. 0.20 ms²; low-frequency/high-frequency ratio, −0.173 vs. 0.054), and endurance exercise performance (maximal oxygen uptake, 5.57 vs. 2.26 mL/kg/min; 400-m time trial record, −20.41 vs. −7.91 s) than in the normoxia. These indicate that hypoxic training composed of aerobic continuous and interval exercise improves the endurance exercise performance of amateur male swimmers with better hemodynamic function and ANS function.

Post-exercise cardiac autonomic and cardiovascular responses to heart rate-matched and work rate-matched hypoxic exercise

Purpose

This study investigated the effect of performing hypoxic exercise at the same heart rate (HR) or work rate (WR) as normoxic exercise on post-exercise autonomic and cardiovascular responses.

Methods

Thirteen men performed three interval-type exercise sessions (5 × 5-min; 1-min recovery): normoxic exercise at 80% of the WR at the first ventilatory threshold (N), hypoxic exercise (FiO₂ = 14.2%) at the same WR as N (H-WR) and hypoxic exercise at the same HR as N (H-HR). Autonomic and cardiovascular assessments were conducted before and after exercise, both at rest and during active squat–stand manoeuvres (SS).

Results

Compared to N, H-WR elicited a higher HR response (≈ 83% vs ≈ 75%HRmax, p < 0.001) and H-HR a reduced exercise WR (− 21.1 ± 9.3%, p < 0.001). Cardiac parasympathetic indices were reduced 15 min after exercise and recovered within 60 min in N and H-HR, but not after H-WR (p < 0.05). H-WR altered cardiac baroreflex sensitivity (cBRS) both at rest and during SS (specifically in the control of blood pressure fall during standing phases) in the first 60 min after the exercise bout (p < 0.05). Post-exercise hypotension (PEH) did not occur in H-HR (p > 0.05) but lasted longer in H-WR than in N (p < 0.05).

Conclusions

Moderate HR-matched hypoxic exercise mimicked post-exercise autonomic responses of normoxic exercise without resulting in significant PEH. This may relate to the reduced WR and the limited associated mechanical/metabolic strain. Conversely, WR-matched hypoxic exercise impacted upon post-exercise autonomic and cardiovascular responses, delaying cardiac autonomic recovery, temporarily decreasing cBRS and evoking prolonged PEH.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00421-021-04678-5.

Effects of Swimming-Specific Repeated-Sprint Training in Hypoxia Training in Swimmers

The aim of this study was to investigate the effect of a 4 weeks in-water swimming-specific repeated-sprint training in hypoxia (RSH) compared to similar training in normoxia (RSN). Following a repeated-measures, counterbalanced cross-over design, 10 swimmers were requested to perform two trials consisting of in-water repeated sprints in hypoxic (RSH, simulated 4,040 m; FiO2 = 13.7%) or normoxic (RSN, 459 m, FiO2 calibrated = 20.9%) conditions. In both conditions, 8 additional exercise including 3 sets of 5 × 15 m "all-out" sprints (corresponding to a total of 625 m), with 20 s of passive recovery between efforts and 200 m of easy swimming between sets were included at the end of their swimming program over a 4 weeks period. Hypoxic condition was generated using a simulator pumping air with lowered oxygen concentration into a facial mask. An incremental maximal test on an ergocycle, as well as 100 m and 400 m freestyle swimming performance (real competition format) were assessed before (pre), 7 days (post-1), and 2 weeks (post-2) after intervention. During training, heart rate (HR) and oxygen saturation (SpO2) were monitored. RSH showed significantly lower SpO2 (70.1 ± 4.8% vs. 96.1 ± 2.7%, P < 0.01), concomitant with higher mean HR (159 ± 11 bmp vs. 141 ± 6 bmp, P < 0.01) than RSN. No significant changes in maximal oxygen uptake, other submaximal physiological parameters, 100 or 400 m swimming performances were found. Although providing additional physiological stress, performing in-water RSH does not provide evidence for higher benefits than RSN to improve swimmers performance.