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Does Precooling With Whole-Body Immersion Affect Thermal Sensation or Perceived Exertion? A Critically Appraised Topic

Timothy M. Wohlfert and Kevin C. Miller

Evidence-based Medicine (CEBM) 1 level-2 evidence or higher, with PEDro scores ≥5 Exclusion • Studies that used passive heating techniques rather than exercise to induce hyperthermia • Studies that cooled subjects during exercise (ie, percooling) • Studies that cooled subjects between exercise bouts

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Do Alternative Cooling Methods Have Effective Cooling Rates for Hyperthermia Compared With Previously Established CWI Cooling Rates?

Kailin C. Parker, Rachel R. Shelton, and Rebecca M. Lopez

Question Do alternative cooling methods have effective core body temperature cooling rates for hyperthermia compared with previously established CWI cooling rates? Summary of Key Findings We searched for randomized clinical trials that used alternative methods of cooling that were applied on exercising

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Does Gender Affect Rectal Temperature Cooling Rates? A Critically Appraised Topic

Kayla E. Boehm and Kevin C. Miller

recommendations for exertional heat stroke (EHS) victims (ie, 0.15°C/min). 5 Table 1 Characteristics of Included Studies Authors Armstrong et al 3 DeMartini et al 4 Lemire et al 2 Patients, n 8000 athletes. 21 (35 [3] y) were diagnosed with extreme hyperthermia and either heat exhaustion or EHS. 17 males (age

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A Case Report of Idiosyncratic Hyperthermia and Review of U.S. Army Heat Stroke Hospitalizations

Robert Carter III, Samuel N. Cheuvront, and Michael N. Sawka


We report our observations on one soldier with abnormal hyperthermia during exercise in the heat compared with prior exercise and following acute local (non-febrile) infection. Also, we report on 994 heat stroke hospitalizations in the U.S. Army. It is known that prior infection is a risk factor for heat illness and some of the 37 heat stroke deaths cited infections (eg, pneumonia, influenza) in the medical records.


This case report illustrates complete recovery from abnormal hyperthermia, which occurred in a laboratory setting during mild, low intensity exercise. In a field setting, this case may have resulted in serious heat illness. As with most of the heat stroke cases, rapid medical attention (ie, cooling and rehydration) and the age group (19 to 26) that represents majority of the heatstroke cases in U.S. Army are likely factors that contribute successful treatment of heatstroke in the field environment.


We conclude that acute inflammatory response can augment the hyperthermia of exercise and possibly increase heat illness susceptibility. Furthermore, it is important for health care providers of soldiers and athletes to monitor acute local infections due to the potential thermoregulatory consequences during exercise in the heat.

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Acute Care for Exercise-Induced Hyperthermia to Avoid Adverse Outcome from Exertional Heat Stroke

Tal Marom, David Itskoviz, Haim Lavon, and Ishay Ostfeld


Exertional heat stroke (EHS) is a major concern in military trainees performing intense physical exercise, with substantial morbidity rates. Prehospital diagnosis of EHS is essentially clinical. Thus, soldiers, command personnel, and medical staff are taught to recognize this injury and immediately begin aggressive treatment to prevent further deterioration.

Patients and Methods:

During 2007, 5 otherwise healthy Israeli Defense Forces (IDF) soldiers were diagnosed with EHS while performing strenuous exercise. They were treated vigorously according to the IDF EHS-treatment protocol and were referred to the emergency department.


On arrival at the emergency department, physical examination including rectal temperature was unremarkable in all soldiers. Blood and urine workup showed near-normal values. No other medical conditions that could have explained the clinical presentation were found. All soldiers were discharged shortly afterward, with no further consequences. A heat-tolerance test was performed several weeks after the event and was interpreted as normal. All soldiers returned to active service.


Because the initial clinical findings were very suggestive of EHS and because no other condition could have explained the prehospital transient hyperthermia, we suggest that these soldiers were correctly diagnosed with EHS, and we propose that rapid vigorous cooling prevented further deterioration and complications. We suggest calling this condition aborted heat stroke.

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Can Temperate-Water Immersion Effectively Reduce Rectal Temperature in Exertional Heat Stroke? A Critically Appraised Topic

Tyler T. Truxton and Kevin C. Miller

Clinical Scenario:

Exertional heat stroke (EHS) is a medical emergency which, if left untreated, can result in death. The standard of care for EHS patients includes confirmation of hyperthermia via rectal temperature (Trec) and then immediate cold-water immersion (CWI). While CWI is the fastest way to reduce Trec, it may be difficult to lower and maintain water bath temperature in the recommended ranges (1.7°C–15°C [35°F–59°F]) because of limited access to ice and/or the bath being exposed to high ambient temperatures for long periods of time. Determining if Trec cooling rates are acceptable (ie, >0.08°C/min) when significantly hyperthermic humans are immersed in temperate water (ie, ≥20°C [68°F]) has applications for how EHS patients are treated in the field.

Clinical Question:

Are Trec cooling rates acceptable (≥0.08°C/min) when significantly hyperthermic humans are immersed in temperate water?

Summary of Findings:

Trec cooling rates of hyperthermic humans immersed in temperate water (≥20°C [68°F]) ranged from 0.06°C/min to 0.19°C/min. The average Trec cooling rate for all examined studies was 0.11±0.06°C/min.

Clinical Bottom Line:

Temperature water immersion (TWI) provides acceptable (ie, >0.08°C/min) Trec cooling rates for hyperthermic humans post-exercise. However, CWI cooling rates are higher and should be used if feasible (eg, access to ice, shaded treatment areas).

Strength of Recommendation:

The majority of evidence (eg, Level 2 studies with PEDro scores ≥5) suggests TWI provides acceptable, though not ideal, Trec cooling. If possible, CWI should be used instead of TWI in EHS scenarios.

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Contribution of American Football Uniforms to the Development of Exercise-Induced Hyperthermia: A Critically Appraised Topic

Grace Katt and Kevin C. Miller

.g., sauna) instead of exercise to develop hyperthermia. • Studies where any type of cooling was performed before (i.e., precooling) or during (i.e., percooling) testing. Evidence Quality Assessment Each study was scored independently by the two authors using the 2011 Oxford Center for Evidence-Based Medicine

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Repeated-Sprint Exercise in the Heat Increases Indirect Markers of Gastrointestinal Damage in Well-Trained Team-Sport Athletes

Alice Wallett, Andrew McKune, David Pyne, David Bishop, Olivier Girard, Philo Saunders, and Julien Périard

be the sole factor increasing GI damage, it has been suggested that whole-body heat storage and the resultant hyperthermia is a key factor contributing the rise in GI damage ( Peters et al., 2001 ; Pires et al., 2017 ). Acute Gastrointestinal Response to Repeated-Sprint Exercise in the Heat Heat

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Anthocyanin-Rich Blackcurrant Extract Preserves Gastrointestinal Barrier Permeability and Reduces Enterocyte Damage but Has No Effect on Microbial Translocation and Inflammation After Exertional Heat Stress

Ben J. Lee, Tessa R. Flood, Ania M. Hiles, Ella F. Walker, Lucy E.V. Wheeler, Kimberly M. Ashdown, Mark E.T. Willems, Rianne Costello, Luke D. Greisler, Phebe A. Romano, Garrett W. Hill, and Matthew R. Kuennen

gastrointestinal (GI) mucosa ( Costa et al., 2017 ; Rowell, 1974 ). Splanchnic hypoperfusion and ischemia, alongside localized intestinal hyperthermia, disrupt enterocyte structure and alters the phosphorylation status of intestinal tight junction proteins, increasing small bowel permeability ( Dokladny et

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Changes in Core Temperature During an Elite Female Rugby Sevens Tournament

Mitchell J. Henderson, Bryna C.R. Chrismas, Christopher J. Stevens, Aaron J. Coutts, and Lee Taylor

) recovery tool for rugby sevens athletes, proposed to control hyperthermia, reduce muscle inflammation and damage, and decrease muscle soreness. 9 However, the efficacy of rugby sevens specific CWI protocols, 10 within a real-world elite tournament scenario, is not available (eg, total heat storage as a