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Kelly A. Fiala, Douglas J. Casa, and Melissa W. Roti

The purpose of this study was to assess the influence of rehydration with a caffeinated beverage during non exercise periods on hydration status throughout consecutive practices in the heat. Ten (7 women, 3 men) partially heat-acclimated athletes (age 24 ± ly, body fat 19.2 ± 2%, weight 68.4 ± 4.0 kg, height 170 ± 3 cm) completed 3 successive days of 2-a-day practices (2 h/ practice, 4 h/d) in mild heat (WBGT = 23 °C). The 2 trials (double-blind, random, cross-over design) included; 1) caffeine (CAF) rehydrated with Coca-Cola® and 2) caffeine-free (CF) rehydrated with Caffeine-Free Coca-Cola®. Urine and psychological measures were determined before and after each 2-h practice. A significant difference was found for urine color for the post-AM time point, F = 5.526, P = 0.031. No differences were found among other variables (P > 0.05). In summary, there is little evidence to suggest that the use of beverages containing caffeine during non exercise might hinder hydration status.

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William M. Adams, Yuri Hosokawa, and Douglas J. Casa


Although body cooling has both performance and safety benefits, knowledge on optimizing cooling during specific sport competition is limited.


To identify when, during sport competition, it is optimal for body cooling and to identify optimal body-cooling modalities to enhance safety and maximize sport performance.

Evidence Acquisition:

A comprehensive literature search was conducted to identify articles with specific context regarding body cooling, sport performance, and cooling modalities used during sport competition. A search of scientific peer-reviewed literature examining the effects of body cooling on exercise performance was done to examine the influence of body cooling on exercise performance. Subsequently, a literature search was done to identify effective cooling modalities that have been shown to improve exercise performance.

Evidence Synthesis:

The cooling modalities that are most effective in cooling the body during sport competition depend on the sport, timing of cooling, and feasibility based on the constraints of the sports rules and regulations. Factoring in the length of breaks (halftime substitutions, etc), the equipment worn during competition, and the cooling modalities that offer the greatest potential to cool must be considered in each individual sport.


Scientific evidence supports using body cooling as a method of improving performance during sport competition. Developing a strategy to use cooling modalities that are scientifically evidence-based to improve performance while maximizing athlete’s safety warrants further investigation.

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Riana R. Pryor, Robert A. Huggins, and Douglas J. Casa

The aim of the recent Inter-Association Task Force held in Washington, D.C. at the 2013 Youth Safety Summit determined best practice recommendations for preventing sudden death in secondary school athletics. This document highlights the major health and safety practices and policies in high school athletics that are paramount to keep student athletes safe. The purpose of this commentary is to review the findings of the document developed by the task force and to provide possible areas where research is needed to continue to educate medical practitioners, players, coaches, and parents on ways to prevent tragedies from occurring during sport.

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Yuri Hosokawa, William M. Adams, and Douglas J. Casa

Context: It is unknown how valid esophageal, rectal, and gastrointestinal temperatures (TES, TRE, and TGI) compare after exercise-induced hyperthermia under different hydration states. Objective: To examine the differences between TES, TRE, and TGI during passive rest following exercise-induced hyperthermia under 2 different hydration states: euhydrated (EU) and hypohydrated (HY). Design: Randomized crossover design. Setting: Controlled laboratory setting. Participants: 9 recreationally active male participants (mean ± SD age 24 ± 4 y, height 177.3 ± 9.9 cm, body mass 76.7 ± 11.6 kg, body fat 14.7% ± 5.8%). Intervention: Participants completed 2 trials (EU and HY) consisting of a bout of treadmill exercise (a 10-min walk at 4.8-7.2 km/h at a 5% grade followed by a 20-min jog at 8.0-12.1 km/h at a 1% grade) in a hot environment (ambient temperature 39.3 ± 1.0°C, relative humidity 37.6% ± 6.0%, wet bulb globe temperature 31.3 ± 1.5°C) followed by passive rest. Main Outcome Measures: Root-mean-squared difference (RMSD) was used to compare the variance of temperature readings at corresponding time points for TRE vs TGI, TRE vs TES, and TGI vs TES in EU and HY. RMSD values were compared using 3-way repeated-measures ANOVA. Post hoc analysis of significant main effects was done using Tukey honestly significant difference with significance set at P < .05. Results: RMSD values (°C) for all device comparisons were significantly different in EU (TRE-TGI, 0.11 ± 0.12; TRE-TES, 1.58 ± 1.01; TGI-TES, 2.04 ± 1.19) than HY (TRE-TGI, 0.22 ± 0.28; TRE-TES, 1.27 ± 0.61; TGI-TES, 1.16 ± 0.76) (P < .01). Across the 45-min bout of passive rest, there were no differences in TRE, TGI, and TES between EU and HY trials (P = .468). Conclusions: During passive rest after exercise in the heat, TRE and TGI were in good agreement when tracking body temperature, with a better agreement appearing in those maintaining a state of euhydration versus those who became hypohydrated during exercise; however, this small difference does not appear to be of clinical significance. The large differences were observed when comparing TGI and TRE with TES.

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Michelle A. Cleary and Douglas J. Casa

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Erin E. Dierickx, Samantha E. Scarneo-Miller, and Douglas J. Casa

Emergency action plans (EAPs) are considered best practice for the preparation of catastrophic events in sports and, when adequate, can effectively improve patient outcomes. The EAPs should include a collaboration of all personnel involved in the sporting activities, with high school coaches being well-positioned to implement these plans. Therefore, coaches can have a direct influence on the health and safety of their athletes through their involvement in an emergency response. The purpose of this study was to evaluate the understanding and adoption of EAPs as reported by coaches. A web-based questionnaire assessed adoption of an EAP; decisional stages for adoption of components of an EAP; and various characteristics (e.g., access to an athletic trainer facilitators and barriers). A total of 720 responses were included in this study. Nearly 25% of coaches reported being unaware if their school had an EAP, and coaches were more likely to adopt a comprehensive EAP if their school had access to an athletic trainer. A majority of coaches perceived financial assistance as a facilitator and financial limitations as a barrier for EAP implementation. The findings of this investigation illustrate the need for improved coaches’ educational awareness of emergency preparedness strategies within the high school setting.

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Tutita M. Casa and Douglas J. Casa

Column-editor : Malissa Martin

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Margaret C. Morrissey, Michael R. Szymanski, Andrew J. Grundstein, and Douglas J. Casa

Intense exercise in extreme heat can increase the risk of developing exertional heat stroke (EHS). EHS is 100% survivable with appropriate care, and it is imperative that health care professionals recognize predisposing factors that may increase susceptibility to EHS. Understanding risk factors for EHS will enable clinicians to create effective prevention strategies to improve exercise heat tolerance and mitigate EHS risk. This review addresses new perspectives on risk factors for EHS that focus on hydration, heat acclimatization, medical conditions, climate change and policies, medications, and strength and conditioning sessions.

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Yasuki Sekiguchi, Erica M. Filep, Courteney L. Benjamin, Douglas J. Casa, and Lindsay J. DiStefano

Clinical Scenario: Exercise in the heat can lead to performance decrements and increase the risk of heat illness. Heat acclimation refers to the systematic and gradual increase in exercise in a controlled, laboratory environment. Increased duration and intensity of exercise in the heat positively affects physiological responses, such as higher sweat rate, plasma volume expansion, decreased heart rate, and lower internal body temperature. Many heat acclimation studies have examined the hydration status of the subjects exercising in the heat. Some of the physiological responses that are desired to elicit heat acclimation (ie, higher heart rate and internal body temperature) are exacerbated in a dehydrated state. Thus, euhydration (optimal hydration) and dehydration trials during heat acclimation induction have been conducted to determine if there are additional benefits to dehydrated exercise trials on physiological adaptations. However, there is still much debate over hydration status and its effect on heat acclimation. Clinical Question: Does dehydration affect the adaptations of plasma volume, heart rate, internal body temperature, skin temperature, and sweat rate during the induction phase of heat acclimation? Summary of Findings: There were no observed differences in plasma volume, internal body temperature, and skin temperature following heat acclimation in this critically appraised topic. One study found an increase in sweat rate and another study indicated greater changes in heart rate following heat acclimation with dehydration. Aside from these findings, all 4 trials did not observe statistically significant differences in euhydrated and dehydrated heat acclimation trials. Clinical Bottom Line: There is minimal evidence to suggest that hydration status affects heat acclimation induction. In the studies that met the inclusion criteria, there were no differences in plasma volume concentrations, internal body temperature, and skin temperature. Strength of Recommendation: Based on the Oxford Centre for Evidence-Based Medicine Scale, Level 2 evidence exists.