The tragic death of Manly rugby league player Keith Titmuss in 2020 because of exertional heat stroke is a reminder of the life-threatening nature of the condition.
Titmuss died after a pre-season training session which was “more likely than not inappropriate”, in accordance with the magistrate who oversaw a recent inquest.
Deputy NSW coroner Derek Lee made several recommendations in reviewing Titmuss’ death within the hope of reducing the possibility of it happening again.
So, what’s exertional heat stroke, and what should athletes and coaches learn about it?
What is exertional heat stroke?
Exertional heat stroke is essentially the most severe type of a spectrum of conditions classified as exertional heat illness.
During sport and exercise, the body is challenged to take care of a perfect core temperature of about 36-38°C.
This is because exercise produces an enormous amount of internal heat, which must be released from the body to avoid overheating. Hot and humid conditions stress the power of an person to release this internal heat, in addition to potentially adding to the warmth load.
If someone’s body is unable to manage the rise in core temperature during physical activity, it could ultimately display central nervous system dysfunction. Signs of this include lack of muscle control within the legs and arms, combativeness, seizures, or lack of consciousness.
A highly elevated core temperature (typically, but not at all times, above 40°C) and multi-organ damage and failure are also characteristics of exertional heat stroke.
In one study, 27% of individuals suffering severe exertional heat illness died. But even those that survive often face long-term negative health consequences, equivalent to an increased risk of heart problems later in life.
How often does exertional heat stroke occur?
Less severe types of exertional heat illness (termed as heat exhaustion and warmth injury) are more common during sport and exercise than exertional heat stroke. However, the life-threatening nature of the condition means precautions have to be considered, especially for summer sports.
The condition strikes “weekend warriors” through to elite athletes and military personnel. A recent paper published within the Journal of Science and Medicine in Sport reported there have been 38 deaths in Australia from exertional heat stroke from sport and exercise between 2001 to 2018.
However, exertional heat illness cases are regarded as broadly underreported.
In an effort to cut back the chance of future cases of exertional heat stroke in rugby league, Coroner Lee made recommendations following the inquest into the death of Titmuss.
1) Mandatory 14-day heat acclimatisation training
The human body can adapt quickly (in a single to 2 weeks) to repeated gradual exposure to hot and humid environments, which ultimately reduces the chance of warmth illness.
Research shows that pre-season heat acclimatisation protocols reduce the chance of warmth illness in team sport athletes.
2) Consider screening and classifying players for exertional heat stroke risk
The United States National Athletic Trainer’s Association recommends players be screened for warmth illness when competing in hot and humid conditions.
This process seems intuitive, but we lack a standardised and validated questionnaire.
Other essential risk aspects include hydration status, prior history of warmth illness and/or recent viral illness or infection, body composition (high body fat percentage), and age (older people).
3) Identify cooling strategies which are relevant and effective
Cooling interventions that serve each as a prevention (during play) and treatment (for a victim) needs to be considered in hot and humid conditions.
In terms of cooling interventions, the evidence suggests cold water immersion, cold water or ice ingestion, cooling garments (equivalent to ice vests or ice towels), portable fans (with or without additional wetting of the skin), or additional breaks in play can assist.
The variety of sport will influence the choice about which cooling intervention/s are possible.
Other considerations include the extent of resourcing (amount of funds and support staff), variety of sport (the variety of athletes who need an intervention will differ between team vs individual sports) and game demands (continuous exercise vs sports which have regular breaks).
Is there anything that athletes and coaches can consider?
Many elite sport organisations in Australia and abroad are working with researchers to develop modernised heat policies that look to cut back the chance of warmth illness for elite competition.
An example is the revamped Australian Open tennis heat policy.
At the community level, coaches and athletes can seek the advice of Sports Medicine Australia’s online tool. This provides an estimation of risk in accordance with the variety of sport and current geographical location.
Sporting and academic organisations also needs to consider higher education for administrators, staff, and athletes to cut back the chance of exertional heat stroke in players.
