Posted on Jun 10, 2020

Dr. Tim provides listeners current evidence based, cutting-edge topics to improve the health and performance of their clients, family members, and themselves.

Do you want to avoid sudden death or illness of a loved one or yourself? Then this episode on how to return to exercise and sports post COVID-19 was engineered for you. Dr. Robert Huggins from the Korey Springer Institute discusses strategies for a safe return during this COVID time. The in with Dr. Tim highlights key recommendations from an expert consensus paper and how both the soccer mom and elite athlete can benefit. 


  • You are at great risk for heatstroke and death if you live in a cooler environment. 
  • Social distancing measures may be putting athletes at greater risk for an adverse health event.
  • Heat acclimatization and workout intensity recommendations that might surprise you.

Video or Audio:


Dr. Tim: Hello and welcome to The In with Dr. Tim. I’m Dr. Tim Speicher, your host. The in brings listeners cutting edge topics to improve their health and performance. I have been dedicated to my career in rehabilitation health sciences over the last 25 years to really advance the health and performance of others through research, teaching, publication and direct clinical practice. Currently, I own and operate the Positional Release Therapy Institute in Ogden Utah, a company that provides PRT instruction and certification to health care providers worldwide and also direct patient care. And we are super psyched today to have Dr. Robert Huggins from the Korey Stringer Institute at the University of Connecticut. And we are kicking off our podcast in The In with Dr. Huggins with some super, super, timely information related to the COVID crisis and Dr. Huggins today is going to be speaking about how best do we safe guard returning to sports and athletics and providing us some real strategies and obviously some really up to date current research and expert consensus opinion. And so, we’ll discuss how athletes should be acclimatized to the heat and sport activity during this COVID crisis.

Dr. Huggins is currently the President of Research and Athlete Performance and Safety at the Korey Stringer Institute and Assistant Research {rofessor in the Department Kinesiology at the University of Connecticut. His responsibilities include supervision, management, and coordination of research initiatives, currently conducted by KSI. Dr. Huggins focuses on two major areas of research, athlete health and safety and athlete performance, an absolute match for The In! And from an athlete performance perspective, his research interests include, heat illness prevention, thermal regulation, hydration, monitoring physiological biomarkers, exercise stress, training load, and injury prevention in soccer, football and elite endurance athletes. He has been a lead or co-author on approximately 39-40 publications including the 2013 IATF, preventing sudden death in secondary school athletics programs, best practices and recommendations document and serves on the NATA appropriate medical coverage for the secondary school aged athlete task force. Dr. Huggins has been a licensed athletic trainer since 2007 and his research is focused on approving AT services, athletic training services, at the secondary school level, emergency best practices in youth athletes, and the economic impact of medical services rendered by athletic trainers. He is the project leader of the athletic training locations and services or ATLAS project and Dr. Huggins has experience, he’s a great clinician as well at the Marine Corps Marathon where he has treated more than 50 cases of exertional heat stroke. He received his bachelor’s degree in athletic training from the University of Connecticut in 2007. His Masters in AT from the University of Virginia in ’08, and his doctoral degree, his PHD, from the University of Connecticut in 2014. And he completed a post-doctoral fellowship as well with the Korey Stringer Institute at the University of Connecticut from 2014 to 2017.

Now, on a side note, Rob and I go way back. Rob and I actually were colleagues and worked together, taught sports medicine and some other things at the Sacred Heart University in Fairfield Connecticut. And so, I had a great opportunity to work with Rob and see his amazing skills as not only a researcher, teacher, but also a clinician. And so, I’m super psyched to have Rob on today to talk about getting athletes heat acclimatized during and following the COVID-19 pandemic. So, thank you Dr. Huggins for joining us, and maybe Dr. Huggins you can provide maybe a little context about the Korey Stringer Institute. You know just for those who may not be aware of KSI and what you guys do and what we are maybe going to accomplish with some of this latest consensus and research around COVID-19.

Dr. Huggins: Yeah absolutely Tim, again thanks for having me and inviting me to be on this podcast. Thank you for the fantastic introduction there. I’m honored and humbled to be here. I worked at the Korey Stringer Institute for the last 10 years, since we opened our doors, and for folks who don’t know Korey Stringer was an offensive lineman for the Minnesota Vikings who died of a heat stroke back in 2000. He unfortunately was not treated appropriately by the medical staff that was present that day, and there is actually a picture of him on the front page of the Minnesota local newspaper on day one of the pre-season training camp of him vomiting on the center of the field, bent over, and when he came into training camp that year he was a little over-weight, I’m talking like 20-30 pounds in a 320 pound linemen already, but he was a senior pro-bowl tackle on the team. So, I think he kind-of pushed on and there were reports of him taking a Ephedra to try and reduce his weight because I think he knew that he wasn’t in the best physical fitness. However, none the less he did suffer a heat stroke on a day when agricultural farmers were being tasked by the department of agriculture to bring horses and cattle indoors on the day that the Minnesota Vikings were still having practice.

            Dr. Tim: That’s amazing right? Because we often, because obviously professional athletes, football players you know, they’re not animals right. We are taking animals out of the heat but keeping the athletes in the heat. Which is really interesting parallel which you brought up.

            Dr. Huggins: So ultimately, unfortunately, Korey’s situation and his death, you know, good came from it, that is in the Korey Stringer Institute, which is housed at the University of Connecticut in the department of Kinesiology, and it is run by Dr. Douglas Cassa. For those of you who don’t know is a leading expert in heat stroke care and treatment and prevention and he has served as an expert witness on over 60 cases of legal sudden death in sport, not just heat stroke but others such as cardiac and exertional sickling and what not. Our institute, our mission is really to educate, to advocate, and to conduct research in the areas of sports safety and performance. And we have a couple of different areas that we focus on with heat stroke being our bread and butter, but one of the big things that kind-of spawned this document was many looked to us as a third party organization to disseminate a cohesive kind-of approach to the prevention of sudden death in sport and unnecessary injury or illness, and with the COVID-19 pandemic and side-lining many athletes for several months we knew that this would pose a threat to the starting of organized athletics. So, you know many states across the country are hoping to return as they are now to collegiate and high school athletics you know this fall. But during the period of physical distancing we know that it is very likely that athletes are going to become or have become less active, you know not having access to gyms, not having access to training coaches and facilities. And while there are administrative concerns it is also really important from our perspective and what the impetus behind this document was to look at it from an injury and illness standpoint. At the Korey Stringer institute we track the sudden deaths in this country along with the University of North Carolina at Chapel Hill and the University of Washington and the three of us are together on a consortium to track deaths and investigate them and what the epidemiology in previous years have shown us is that deaths are increasing and we only suspect that due to inactivity and lack of fitness, in addition to COVID, those who have been COVID positive or have had signs and symptoms associated with it, they may have an increased risk for injury or sudden death, so including ankle sprains and ACL tears. So that was kind-of the reason behind this document, and we got together with some really key folks, the key players, NFHS, Gatorade, Sports Science Institute, the National Center for Catastrophic Sports Injury Research Center, the NSCA, the Strength and Condition Net, the CSCCA, among the NFHS I believe I mentioned and KSI kind-of championed, the National Athletic Trainers Association as well, I don’t want to leave anybody out here, but I apologize If I am. But we all got together to really push this agenda.

            Dr. Tim: Yeah and everybody stop and think about this for a minute, this is amazing foresight don’t you think, because you know, we are coming out of this pandemic, most all of us have been pretty darn inactive. Here at the institute I can’t tell you how many athletes tell me, they are kind of concerned, they don’t know what to do, how to return to training. And while the document that Dr. Huggins is speaking about, which will be available to you after this podcast, it’s geared towards high school and collegiate athletics however, but we have to think that the summer is starting to heat up we’re all going to be returning to physical activity even the soccer moms with their kids in soccer, and those of us who want to engage in running and different activities and so I think really today as we get into this document, we get into this really national consensus document about how best to manage this COVID return to sports participation and exercise, we probably all really need to step back and think about are we in the best position to re-engage in exercise and sports and how best do we need to do that so that we don’t become ill, injured, or unfortunately put ourselves at greater risk for death. So I’m super appreciative that this consensus document has come out because it really provides a guide and really some sign posts about how we should really think about returning because you know, Rob, you might probably agree with this, I didn’t exercise for the last two months like I should and with all the gyms being closed down and athletics being closed down, I mean how many of us are really, including our athletes and organized sports, how many have really engaged in the necessary sort of activity to be ready to handle the heat, to handle the exercise. And so, I’m curious Dr. Huggins, how did this document, what out of your research around this COVID-19, would you say puts us at risk, puts our athletes at greatest risk. I noticed in the document you had mentioned that we might actually be putting ourselves at risk with some of these social distancing measures, which is kind-of a shocker, because if you think about it right, that’s what they recommend is to maintain social distance. So, can you speak to that, like, what is it that you guys are thinking about, this social distancing and how it puts us at risk

            Dr. Huggins: Yeah,  I think there are two types of athletes we need to talk about here and those are those who have had COVID right, and those who have not, and once they have cleared COVID and have no more signs and symptoms does not mean they are out of the woods when it comes to the consequences. We do not know yet what the long-term effects are of being COVID positive are. We do know there are many issues related to cardiovascular and pulmonary potential stressors that we just don’t know about yet—so, we are kind of doing the best we can with the information that is at hand. There are experts in those fields that have come out with some great documents in the last couple of weeks, but to speak to masses you are speaking to- we have become inactive because of the structure that has been provided through sport and going to school and being involved with coaches. I think it comes down to resources and comes down to socioeconomic status and disparities. We had to think [about these groups] in this article from everyone from Division I NCAA football athletes all the way down to high school football player in rural North Dakota—thinking about they might need to go help their families. They may need to be working right now to help them get through this because their parents have lost their jobs. So, there is no activity that these athletes are really having from an outdoor environmental [aspect]—getting exposure to the environment, as well as exposure to strength and conditioning or aerobic or anaerobic training- so, we really wanted to try to address as much as we could, but the real thing here is that we are asking coaches and we are asking medical staff and administrators just to be smart about this. This document is meant for you to consider these things if you haven’t thought about them you know, thus far. We have even created a COVID policy template that is located in the same spot as the document on the Korey Stringer Institute website for folks to consider the policies that might need to go into place and trying to be proactive rather than reactive to this entire approach.

            We know that fitness, physical fitness is one of the biggest factors in preventing sudden death in sport. The top three causes are cardiac, heat stroke, and exertional sickling and those three factors account for 90% of the deaths that occur in sport. When you look at football specifically, the article I am quoting from right now, Bowdin et al. When we get athletes that are fit, there are adaptations that are going to cross over to the different realms of sudden death. If I get an athlete really fit, my cardiovascular stress is going to reduce because there are adaptations that take place. Those cardiovascular adaptations also help when it comes to heat stroke, so if I can pump that blood around my body and cool my body efficiently, I am going to reduce that risk for heat stroke as well. These are some of the key things we tried to focus on.

            Dr. Tim: I would imagine, reducing this risk for illness, for sudden death, would translate as well into, you know, other sports, beyond just college and high school and what kind of stunned me a little bit when I read the document, and just for everyone, it is called: Return to Sports and Exercise During the COVID-19 Pandemic: Guidance for High School and Collegiate Athletic Programs. Well, there is 10 million high school and collegiate athletes returning very soon to training and while there is a huge focus and we often see Korey Stringer and others on TV, others are at risk as well and that is something to keep in the back of mind as we talk about some of these recommendations that there use might be applicable as well to your high school athletes but also maybe for those participating in community sports, even yourself when you are starting to think about how do I get geared up to go back to training for a marathon or just going back to physical activity. So, with that Rob, what do you think is more important, do you think its more important as we move into this heat environment to stay hydrated or is it more important to sort of ramp up our activity in kind of a coordinated way, is both important? What do we focus on as we start to think about moving our athletes back into physical activity?

            Dr. Huggins: Yeah, I think people need to focus on getting fit first. There is a great document that came from the Strength and Conditioning Journal that is titled: CSCCa and NSCA Joint Consensus Guidelines for Transition Periods: Safe Return to Training Following Inactivity—that is targeted for the collegiate environment but there are many pieces from it just like this document that can be carried over to high school athletes or any recreationally active athlete. I think the big thing is how we resume training and people being honest. The lay person being honest with themselves where they are at, where their physical fitness is- obviously having a strength and conditioning coach who is certified or an Athletic Trainer or medical staff to guide you is ideal but that is not the case even in our high school’s, right? The ATLAS Project which I am involved with [has found that] nearly 34% of high schools nationwide with athletics DO NOT have Athletic Trainers (ATs) they really rely on.

Dr. Tim: Wow!, so Rob, my question as a parent who has a child in high school right now—if they don’t have an Athletic Trainer or medical personnel at the high school whose protecting them, whose setting these policies about how to return to sport and exercise and how to get fit, who is responsible for that?

Dr. Huggins: You know, unfortunately, our coaches are responsible for it and you know, many times in these situations, the coach is an educator at the school or a volunteer or someone in the community who has played football in the past and wants to coach and may receive some training related to proper return to sport, return to play—you hope that the policies within a state and the guidelines set forth by the high school athletic associations within a state and their sports medicine advisory committees to those associations are implementing policies right now based on this document that will help with this transition and they need to disseminate this knowledge in a way that is impactful and received well by the coaches, but ultimately, parents need to step up, they need to be aware of this document, they need to go to their coaches and give it to them, give it to their athletic director, I guess the athletic director is ultimately responsible and the school district, but they need to know how to properly implement workouts, they need to know how to do it in a phased approach, they need to account for kids who might not have been training at all during the summer and are starting from the couch. This document is meant to try to really focus on the high school and collegiate but like I said there is a lot that the lay person can take from this going forward. There are some kids who do not know what it’s like to not be fit. They have been playing year around different sports, multi-sport athletes that have been playing every weekend since they were 8 years old and they do not know what it’s like to be untrained and this might be the first time that they are feeling that because they do not have the structure or organizational structure surrounding their training and the motivation that comes from being on a team with coaches and with peers, so I am worried about that when they return because a really good athlete last year, a top football player, lets say a tight-end, can think they can be at the same level they were prior to this whole COVID thing—and they are going to go as hard as they can, that’s in their ability and coaches need to be able to see that and knock it down. They need to do this in a safe and stepwise progression because the last thing we need is another case, like a Max Gilpin, in Kentucky, who was not allowed water but gave his best effort and it ended up being a civil and criminal investigation.

Dr. Tim: I remember as sidebar, when I was playing football in high school and sports, that I do remember that water while it was available, was not always encouraged or it was viewed as a weakness that you needed more water. Hopefully, we have come a long way since then, but I know we still have challenges, but with that being said, how should it be done? I know in the document, it talks about a few rules and it definitely focuses on heat acclimatization as well as strength training, so can you speak to that a little bit—I guess the overarching recommendations how we should approach this return back?

Dr. Huggins: Yeah, let me speak to the hydration piece first. Hydration is critical to reducing risk and allowing the body to sweat. We sweat to remove heat. Just like the radiator in your car, if you do not have that water on board, that engine will overheat. Our athletes have, some have, Indy car engines and others diesel truck engines, but all of them need hydration to allow for blood volume to be maintained. So, essentially, hydration is critical, but that does NOT mean that I cannot drive an athlete to heat stroke even if they are very well hydrated, so, it’s all about the intensity. The intensity is the biggest factor and the environment is the second biggest factor. So, making sure we have the proper work to rest ratios based on the environmental conditions is critical and that is outlined in our document. You know there are many wet-bulb globe temperature, which is a fancy heat index, which many are used to now days that can be calculated or looked at using a devise that will tell you what it really feels like on that field for that athlete and we have different flags and different conditions. A black flag would be oppressive heat, cancel activity, whereas, a green flag, heat risk is low, activity resume as normal and when you get into yellow, orange and red, there is increased breaks, access to water, removal of equipment—these are all things that are going to help that athlete get rid of that heat that is being trapped by their equipment potentially, but also with the intensity of the practice. So, usually when athletes start out its good to have them start out at a work to rest ratio of 1:4, especially during the first week of training and in the second week of training, it can be a 1:3 or greater. Never a 1:1, like 10 minutes on. 10 minutes off—we know we don’t want that.

Dr. Tim: So, in the context Dr. Huggins, lets break that ratio down a little bit, because 1:4 sounds to me like a 50% reduction- would that be appropriate? Yes. So, for example, let’s say the mom and dad are observing their kid at high school and they are taking him to practice and the kid comes home at the end of the day and the Dad says, how was it, did they work you hard? Oh yeah, Dad, Mom, we sprinted the whole time on the first day, we did plyometrics, we lifted, we wore our pads…and we had one break. So, that’s not probably a 50% reduction, not a workload reduction.

Dr. Huggins: That is what we call the upper limit. The upper limit is not where these athletes are right now. The upper limit will be established later in their training as they become more fit, but some will argue that conditioning testing must be done, well, we just need to let folks know that if you are going to do conditioning testing, which we discourage, especially at the high school level. We would rather they increase their training at on a gradual fashion and not have testing at the beginning, but in collegiate levels, you have the fortitude of having medical care there. You have specific drills at specific loads and access to hydration and things like that which can help and places to rest and remove equipment. That may not be the case for the high school athlete in a rural location. So, essentially what we are asking is to keep intensity low, okay, especially during the first two weeks, allow adequate rest breaks, allow optimal hydration and with the hydration piece, you should be monitoring that. Athletes and parents take onus on weighing yourself before and after practice. Look at the position statements right now that show how you should replace and replenish fluids. I have to tell people, get naked, right, get naked. Get on a scale before and after your athletic activity. Whatever you lost was fluid and if you drank during that time, you need to subtract that weight, but whatever you lost, or add that, excuse me, that is how much hydration you need to replace before your next activity and you can’t take two gallons of water to the face, you really need to hydrate over a period of time before that next practice and what that will do is ensure you are well hydrated and you should really consume electrolytes. You cannot sweat without losing sodium and chloride. Water follows salt so that is why you see that cakey appearance on your kids face or your face after an activity—you are just dumping those electrolytes and if you don’t replace those, and Gatorade and other performance beverages might not be concentrated enough, so hot sauce, soy sauce, soup and Tostito Chips and you name it—get the salt into your body so that you can replenish those stores allowing your engine to cool efficiently via sweat.

Dr. Tim: So, let’s say the coach, you know, we got about 70% of coaches out there are now responsible for medical care of our children in a high school environment and then you got the parents kind of looking out for their kids, and so let’s say the kid comes home and says oh yeah I lost four pounds, three pounds, mom-dad after practice. And then the next morning they do the hydration and whatsoever and they say well, I’m still two pounds down. What would you recommend, what would KSI recommend for that parent or athlete to do if they are still like halfway down and in their sort of weight?

Dr. Huggins: Yeah, I think that it matters on whether or not you are a three-hundred-pound lineman, or you are a hundred-pound high school wide receiver. Obviously two pounds in the lineman versus two pounds in the wide receiver might be very different, so, kind of using the percent’s that someone is down is what we look at. So, if you are greater than two percent, dehydrated from your normal body weight, we recommend that an athlete try get down to you hydrated or zero percent prior to maybe even hyper hydrate, over hydrate, before the next activity. So, this athlete, let’s say he is a lineman, and he’s down a pound in a half, two pounds, before that activity. He needs to try to get some of those fluids in within the four hours that lead up to his or her practice. So, you know, consuming sodium, and people forget that there is fluid in the food that we eat, so you know, watermelon and vegetables and fruit and all of those are going to have water content in them but not as optimal as actually just replacing that fluid via water or sport beverage or something of that nature, so really focusing and taking an ownness on getting that hydration. Having a plan, I think is the most important. So, if he weighed himself or she weighed herself after that activity, saw you were four pounds, look at the amount of time that they have between that and waking up or going to practice the next day. Add an extra water bottle before bed, add an extra one upon waking and that will really help in the long run, but one of the cool things is as our body becomes heat acclimatized you hold onto fluids better.

Dr. Tim: That’s a really good point and I hadn’t really thought about that. So, as we become acclimatized and kind of get more used to exercising in the heat, or get used to being in the heat, were probably not going to sweat as much, right? So, with that being said, what’s more important to do first? Is it more important to make sure that you are hydrated or more important to ramp up your exposure heat activity, or should we kind of be trying to coordinate both at the same time?

Dr. Huggins: So, both at the same time is the key message here Tim. So, heat acclimatization is a process that takes about 10 to 14 days for the full adaptations to occur. And when I say adaptations, I’m talking about my heart rate is reduced at a given intensity. So, it’s supposed to be at 180 beats per minute, I’m down to 170 at the same exercise intensity in the heat. My core body temperature, how hot I am on the inside, is down a degree Celsius right? My sweat rate, actually you said something that sweat rate decreases, it actually increases when you are heat acclimatized so you are a more efficient sweater though because the content of that sweat has less sodium in it. So, it evaporates more readily off that microclimate that is created on your skin to cool you. Another thing too is, another adaptation that occurs is, like I said that sweat rate, and then your thermal skin temperature actually goes down as well so when skin temperature is down, we feel less hot because all of our sensors, our thermal sensation, is in our skin. When our skin feels really wet and humid you feel really hot but if you are in a dry climate like in Arizona or hiking in the mountains that water that is evaporated off your skin, you don’t feel it and you feel less hot even though you are just as dehydrated and just as hot, but it’s just the way that your skin is giving that feedback to your brain. So what we recommend and what most high schools and colleges, NCAA has mandated this already and as have many states, is there is seven days that are specifically dedicated to Phasing in activity in the heat, and those are policies that the Korey Stringer Institute has actually worked in concert with the NFL and the NATA (National Athletic Trainers Association), you know to go state by state and work with them on these policies, to look at their policies, track them, which we do, and identify areas of improvement when it comes to heat acclimatization specifically.

Dr. Tim: Let me ask you this, can I ask you this real quick because, you know, we are here in Utah, however we don’t get like, the crazy heat and humidity like the south. Being said, I’m concerned that maybe parents or coaches like in an environment that’s in the north, be like, oh I don’t have to worry, I don’t have to worry about heat acclimatization, I don’t have to worry about really ramping up, you know, the right work-rest ratios because it’s kind of cool. Is that like faulty thinking Dr. Huggins? Or is that correct or is there modifications based on location? What’s the follow up?

Dr. Huggins: So yes, it’s a massive myth and one of the kids that I’m worried about the most are those in the north east and those who do not have routine and regular outdoor exposure to the heat like those in the south, so your body is constantly adapting to the environment that it’s been in for the past 3,5,7, you know, one month, the days and months that you live in, you reside in, that you train in. So, there are region specific, environmental wet bulb globe temperature, which I mentioned before, modification guidelines that are specific to different regions of the United States for medical folks to, and coaches to follow and implement. So again, it goes back to monitoring that environment and making sure that its, you know, cause’ a 90-degree day for a kid in Connecticut might feel pretty darn hot for them, right? You know, training on a football field. Whereas a 90-degree day down in Georgia is like full out let’s go, practices on, games are on, there are no issues. These kids have been used to that and they’ve become acclimatized in that environment, so you know, that is a big myth. And people need to know.

Dr. Tim: In a way it sounds to me… correct me if this is wrong it almost sounds like those northern environments not in George might be at greater risk to have an adverse effect to happen to them when they are returning to this hot summer environment.

Dr. Huggins: Yes, I would agree and we are more aptitude to have those spikes in temperature especially early on in the spring especially like we see with the Boston Marathon. Some years its cool and rainy and other years its 86 degrees in April and we are dealing with heat strokes and heat illnesses in the at the finish line medical tent. Same goes for late fall, as well with the Marine Corps Marathon which we see all the time with the end of October. Some days are rainy and cold and other days the radiant load and heat jump up.  My biggest concern is those in the northern states going down south or traveling. I think of elite athletes, you know Iron Man and those who are marathoners going down south. When those events will return will be determined, but I worry most about is those who go down to Mexico or go to Hawaii and they are just not used to that heat and humidity—it plays a big role.

Dr. Tim: We definitely have a lot of that here. We have a lot of people traveling to different marathons and different sporting events all over. So, what is amazing to me and you know I don’t know if parents or coaches even have their head wrapped around this, so, at minimum we are not even ready to go at full go in heat kind of based environment for 7 days minimum, maybe 14, its going to take a full 14? So, once people get there Dr. Huggins, do they need to do anything else, or are they good to go? I have spent my last 14 days ramping up my activity and doing my 50% load on the first week, 30% on the second week, so I am good right, for the rest of the season?  What would you say?

Dr. Huggins: So, it depends on again your environment and where you train on a regular basis. But if you want to hold on to the decay of heat acclimatization and how we hold on to those effects and benefits. What one study had found by Prior et al., I think it was back in 2015 or 16—they found that if you train once every 5 days in the heat that you can maintain 80% of those adaptations even one month after you have obtained them. I think of the soccer teams in the northeast for example, who preseason they are dealing with the heat and September starts to get a little bit cooler, October now we are getting much cooler but yet NCAA Championships and other events are all down south in November and December, so, what we do with one of our teams is we try to expose them to the heat. Our cross-country team, we brought men’s and women’s athletes into our heat chamber once every 5 days to help them maintain the adaptations they have formed on their own through exercise in the summer. So, we try to hold onto those adaptations because someone who exercises in the heat not only performs better in the heat but you also perform better in cool environments as well. So, you are always better off. It is like natural blood-doping so to speak, in that it’s a legal ergogenic aid, it’s a natural thing that one can do to create that artificial environment in their home, put extra clothing on during exercise, but you have to do it safely. I want to really stress this, that you need to get your core body temperature when doing this. And when exercising in the heat to prepare and advance your ability to sweat, and to keep your core temp down and deliver oxygen to your tissues and to your skin—you need to measure you core body temperature, but unfortunately, the only way to get an accurate measure, for all those medical folks out there this is nothing new, but is a rectal thermometer, without doing that, an oral in your mouth or ear temperature devices, these are great at rest, but they are horrible when you are actually exercising because your organs are getting really hot and the only way to get an accurate temperature is inside the body. I have had many elite Iron Man athletes and others who do not perform well in the heat make their own laundry rooms and they are wearing extra clothes, but the caveat is that they have to take their temperature every 20-30 minutes for me during that time so that they can be safe or ideally be observed by an Athletic Trainer (AT), Physical Therapist (PT), someone who is trained, who knows how to interpret core body temperature.

Dr. Speicher: Yeah, that is a pretty good point because that was what was running through my mind. Because as a parent or athlete myself, maybe I should just go sit in a sauna for hours and put on a rubber suit and things of that nature, but then I started thinking, maybe I will get heat stroke if I do that.

Dr. Huggins: Yes, there have been countless articles of people passing out in saunas and wrestlers and boxers wearing additional non-permeable clothing. Those things have their role, you ust need to do it in a safe manner and be with someone else, especially when you are going into a sauna and or, train with others so that you don’t end up in a bad situation. But ultimately taking your core temp is the best. If you want to see the adaptations during heat acclimatization, the most optimal are using like what we call—a recent study by Dr. Courtney Benjamin and Dr. Yaki Saguguchi, two PhD students of ours last year, they coined the term hyperthermic zone heat acclimatization. What they do is they actually bring the athlete or patient up to the highest possible zone that they can and when I say that, that’s between a temperature of 104 and 103 degrees Fahrenheit. Most people might be shocked that I said that, but a normal exercising athlete is between 101.5, 102 and 104. That is where most athletes and body temperatures are during an athletic event. Our body gains that heat really quickly but what Dr. Benjamin and Saguguchi did was that they brought these athletes in and intentionally jacked their temperatures up to those hyperthermic levels and kept them there for 60 minutes a day for 5 days. And in 5 days they saw massive adaptations beyond normal heat acclimatization of these regularly running endurance athletes. They saw added benefits of doing it that way, which were profound. So, you have to do it safely is the moral of the story here and you need to know your core temperature. Some will say, ok, I cant exercise for an hour, I want to exercise for 30 minutes but then can I go into a sauna? Yes, you can to kind of keep that heat doser or heat load that you are trying to get your body to adapt to without getting the stress, pounding, running, or overtraining and lifting and muscle damage and things like that, that don’t have the desired effect. We do recommend folks wear extra clothing or use a sauna or hot tub as a supplement to their heat session, but you go to do so safely, you don’t want to end up in a heat stroke situation.

Dr. Speicher: It’s very applicable to this COVID situation right now because we just had a massive jump in cases. We went to a yellow level, but now they are talking about taking us to a different level because there are rising cases and deaths, so, what I picked up on the article, which I did not think about was in context of that, was that—say the State or some other organization shuts down training again, shuts down sport activity, then athletes are out doing nothing again for several weeks. And what I saw in the article, which what I saw in the article, which made me think about this COVID break and start, break and start thing, was that you might be acclimatized and you are good to go, you have gone through all that heat acclimatization and your hydrated and fit, but then you take off several weeks because things get shut down and then you have to start all over again, you have to reacclimate. Am I reading that correct, because that is pretty amazing?

Dr. Huggins: Yes, that is correct. You know, it depends on the environment that the athlete is training in, but if you get shut down 7 or more days, you heard me, you have to train in the heat every 5 days to hold on to these adaptations. Well, if you don’t train

For approximately 14 days, you lose all of the adaptation you have gained. So, we have

asked schools and organizations at the collegiate and NCAA level and state levels to really reconsider how that phasing occurs again if there is another break needed. Say you get

COVID positive athlete on your team and now the team is prohibited from participation

against other teams, like what is that process for that athlete who has COVID, what is

that process like for the other athletes? What are sizes of the groups that can at least

keep training together in using physical distancing during training, in smaller groups

that are spread out but yet still be organized with a coach or without? So, the heat ACC process would need to restart prior to resumption of activity, so for that team that has been banned I guess you could say from participation for two weeks, you might as well add a third week for them to get back in to physical fitness and heat acclimatization status before they can return.

Dr. Tim: I would imagine Dr. Huggins similarly, for even the individual who has been quarantined or looking to get back to physical activity because to be honest with you, I have gained the COVID 15 pounds sitting at home and wife doing baked goods all the time—I want to get back to it, I want lose weight, I want to do it quickly, we all do, don’t we? So, even the individual, what I kind of am getting from the take home, yes athletes, maybe a third of athletes in the high school environment are pretty well managed and we have medical services there, but it is really going to fall on us to be educated about how to return, how to return safely, how to return or students, our children safely, and kind of, I guess the big nuggets of what I am hearing is we have to watch our hydration loss or water loss at 2% and we gotta really want us to sweat more as we become more fit and we need that heat acclimatization time period, it needs to be smartly done and with that we need to reach out to a health care professional who has experience in this area and the obviously the resources that KSI provides and with this document, are going to be incredible to set the stage for us to return to athletic activity and exercise in a safe manner. Now, with that though, is there other key things I am missing there or is that’s the nugget of what we should be thinking about as we re-engage in this COVID period.

Dr. Huggins: Yes, I think that those are all correct Tim and you are correct in interpreting many of those. There are a few other aspects of this document though that we have not really mentioned yet. If you have a chance to read the document or look at some infographics that we have produced, for the medical provider and the parent, there is a whole two sections here on physical evaluations and past medical history. We are going to have big issues—many of us know our collegiate and high school athletes are required to have a physical prior to athletics for clearance purposes.

Dr. Tim: And many in competitive sports right?

Dr. Huggins: Yes, AAU, premier leagues and Olympic development leagues and things like that all require physical exams for the safety of the athlete and now there is a whole another set of potential areas that the physician or medical provider that needs to delfve into when it comes to COVID. And consider the logistics of getting that exam. If offices are inundated still or they have stay at home orders, telemedicine and all these things, we need to think about the way we encounter these athletes now, how we follow-up on chronic conditions that might pose someone at a greater risk for COVID. Those with COVID, how are we going to make sure they are screened appropriately? Are they getting screenings for their heart and lungs, at cardio biomarkers? You know HS Troponin is an example we mentioned in the document, but there is specific guidance in a publication by Erin Bagash et al., specific to electrocardio or ECG testing that physicians are going to have think about. Kidney function and damage, kidney biomarkers, those with respiratory symptoms—they are going to have to get some pulmonary testing done, but again this is all guided by the physician, so parents and athletes need to be advocates for themselves and be true to themselves about what their feeling internally that could be a COVID related issue, especially, if you have been in close proximity to an individual who has had it. So, often times it is a perfect storm that occurs, so, lets say we have a potential COVID issue, kid has not been training, the coach or the program is not well vetted, its in the heat, they are not hydrated—that is the kid that unfortunately that will succumb, or die, or end up in a bad situation. So, we have to address as many of these areas as possible and that was the point of the document to make sure that we are preventing it, that we are addressing the external and internal factors to the extent that we can and that ultimately we are just being smart people during this phasing in. We can not as much as we want to, we can not just go back to where we were just before this, it is going to take time and coaches and athletes and medical staff need to be extra diligent and professional and not be excessive with their requirements and ultimately we are going to save the lives of these kids and/or long term disability in some that do survive—that is the moral of the document. One last piece if I may is that the education is key. We call upon those who are in a position of authority to have a plan, to have an educational plan to disseminate your plan going forward, with keeping COVID in mind. It is not business as usual. We need to have a point person so whether that is a parent advocacy group, whether it is an Athletic Trainer, whether its a physician, a coach, whether it is an Athletic Director—that point person needs to disseminate this information. They might be following state high school athletic association or collegiate NCAA guidelines that come out, but someone needs to keep a close eye on what those guidelines and recommendations are, deliver it to the target audience in a mode or modes that are going to be impactful and then think about the timing of this, right, the timing is going to matter. You might need to revisit those recommendations to make sure everyone is on the same page and those are some of the key things in terms of the implementation and adoption that is imperative. We could write about this and talk about it until we are blue in the face but if we don’t deliver it in an effective way to the end user it is going to fall on deaf ears.

Dr. Tim: So, I think that is the most critical point to me, right, because we can be aware of all this, but if it is not happening, we are not implementing these things, we are not protecting our students, our children ourselves, its not going to matter.  So, parents out there, coaches, others, please ask your athletic director, your sports teams, your community leagues, your school board—do we have a plan? Do we have a COVID return to sports participation activity plan? Well, fortunately, KSI has provided that for you to a large extent and we are super thankful for them, super thankful and grateful for Dr. Huggins and all the work he does to protect us as human beings and also our children and athletes around the Nation. So, with that Dr. Huggins, where can people find you, how do they get in touch with KSI?  How do they get in touch with you, how do they find you?

Dr. Huggins: Best place to go is our website. That is and you will see on that webpage, different emergency conditions, prevention, research that we are doing, services that we offer to athletes and those who may have suffered heat stroke or near death experiences in the past that are trying to get back to sport. It is a whole another aspect that we did not even talk about here today Tim, is return following heat stroke or an illness. We talk about all of that on our website, there is some great educational videos and tools for everyone, mostly for parents and for sports medicine personnel, so please take a look at our website. We are also on Twitter, Facebook and Instagram as well. So, if you would like to follow us there on Twitter we are @K_S_Institute and you will see, we tweet out a lot of infographics and information, just key things related to health and safety and performance and sport. So, please follow us. We are here, you can call us at our main office as well. We try to get back to people as quickly as possible if they have an inquiry. We are here to help advocate for you in your community. Often times having that third-party expert come in and be a voice of reason for you on what the rest of the country is doing or what is best practice can really go a long way. So, we are here for you to do that and we do that all the time.

Dr. Tim: Awesome, that is great. So, my last parting question Dr. Huggins is or KSI, is what impact do you want to have on humanity?

Dr. Huggins: The big impact is we just want athletes to play, and learn and grow in the sport, or job, or in the military, whatever physical activity setting that you are in—we just want folks to do so safely. We think safety is the most important aspect of any activity that someone embarks on and we just want to be known as the resource and place where research and advocacy for what is right, what is safe and what is healthy during exercise and physical activity—we want to be that place. We want to help health care providers, be that one stop-shop for what is best practice and how to treat and how to keep athletes from dying or from illnesses but also to maximize performance. Performance and safety kind of go hand in hand, right? If you optimize safety, you are also going to optimize performance. If you optimize performance, well, you are probably going to optimize safety at the same time. So, that is what we try to do for athletes, soldiers, laborers, any physically active individual. We want to help them perform at their best.

Dr. Tim: Simply awesome and thanks so much for your contribution to humanity. I think folks out there we have lost enough lives to COVID and we need not to suffer any more loss by improper training, improper return after COVID to exercise and athletic activity. So, we hope that those out there who are listening to this podcast will take hold of this document, will implement these recommendations and will be an advocate for the high-school athlete, the collegiate athlete, the community athlete, yourselves within the environment and look to your leaders and administrators to make these changes and put these plans in place to save lives. Thank you very much and we look forward to having you on another podcast in the future Dr. Huggins.

Dr. Huggins: No, thank you Tim, I really appreciate it.

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