Sport Health Volume 39 Issue 3 - Heat in Sport

Sport

health VOLUME 39 ISSUE 3 2022

Heat in Sport FEATURING

• Location Matters – Heat in Sport in Australia • Strategies to support athletes competing in the heat • Defining adverse health events from heat in sport and recreation • Climate Disruption: Australian Summer Sport and Our Health at Risk

Contents REGULARS

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From the Chair

Defining Adverse Health Events from Heat in Sport and Recreation

SMA Board Chair, Professor Gregory Kolt, looks forward towards our first face-to-face Conference since COVID-19 and examines what SMA has achieved to date in 2022

Dr Lauren Fortington talks about the effects extreme heat can have on athletes and the common signs and symptoms.

03 From the CEO SMA CEO, Jamie Crain, welcomes our members and wider sports medicine community to our first face-to-face conference since 2019.

FEATURES

10 Strategies to Support Athletes Competing in the Heat Jess Rothwell and Avish Sharma from the Victorian Institute of Sport explore strategies for managing athletes health and wellbeing in thermally challenging conditions.

22 Climate Disruption: Australian Summer Sport and Our Health at Risk

05 Location Matters: Heat in Sport in Australia

Dr Martin Rice writes about the effects of climate change and the possible repercussions on sporting events and athletes in Australia.

Marlon Gonsalves looks at the increasing heat rise in Australia and how we can measure this in relation to sports.

Opinions expressed throughout the magazine are the contributors’ own and do not necessarily reflect the views or policy of Sports Medicine Australia (SMA). Members and readers are advised that SMA cannot be held responsible for the accuracy of statements made in advertisements nor the quality of goods or services advertised. All materials copyright.

On acceptance of an article for publication, copyright passes to the publisher.

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VOLUME 39 • ISSUE 3 2022

Publisher Sports Medicine Australia Melbourne Sports Centre 10 Brens Drive Parkville VIC 3052 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028

Copy Editors Jack Sullivan and Archie Veera PR, Communications and Marketing Manager Cohen McElroy Design/Typesetting Perry Watson Design Cover photograph mihtiander/ gettyimages Content photographs Author supplied; www.gettyimages.com.au

Volume 39 • Issue 3 • 2022

INTERVIEWS

32 5 Minutes with Professor Ollie Jay

34 People who Shaped SMA: Michelle Bergeron

37 Sports Medicine Around the World: The Netherlands

40 Sports Trainer Highlight: Nic Radoll

VOLUME 39 • ISSUE 3 2022

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FROM THE CHAIR

FROM THE CHAIR

Getting back into Sport in 2022 SMA BOARD CHAIR, PROFESSOR GREGORY KOLT, LOOKS FORWARD TOWARDS OUR FIRST FACE-TO-FACE CONFERENCE SINCE COVID-19 AND EXAMINES WHAT SMA HAS ACHIEVED TO DATE IN 2022.

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elcome to the latest edition of Sport Health.

As we move further away from 2021, we look into the business section of 2022.

Slowly but surely, we are moving back into a “new normal” with more face-to-face events being scheduled and the return of professional and community sport across the country.

Much of our membership base and readership will now be in the thick of their work environments, many alongside the sporting teams and athletes that are returning to play.

This year has already been very busy for SMA and its members. We have hosted a number of in-person events to coincide with the return of normal scheduling of sport across the country. This has been implemented as part of the SMA Events Series 2021/2022 as well as the continuation of the highly successful ‘virtual’ events which have become a way for nationwide accessibility to experts in the field of sports medicine.

Alongside this, we have also secured exciting partnerships with companies such as Strapit and Gallagher who have joined and renewed their sponsorships, respectively. We must also recognise the continuation of our

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VOLUME 39 • ISSUE 3 2022

The implications of a rising temperature have major repercussions for sport in Australia, with a multitude of sports returning to full-time schedules this year, we want to look at the research being done in this area. longstanding partnership with ASICS. It is a testament to the strength of the organisation and the work being done by the SMA team to provide these opportunities for our members.

A special mention goes to our CEO, Jamie Crain, the rest of the SMA team across the country, and to our many volunteers across State Councils and other Committees.

This year, we welcome back the faceto-face version of the SMA Annual Conference, being hosted at the picturesque RACV Royal Pines Resort on the Gold Coast, Queensland. It is the first time since 2019 that we have had the pleasure of hosting an in-person conference and we look forward to seeing everyone return. The conference will provide a unique opportunity for our members to network with fellow sports medicine professionals and hear from some of the industry leaders and experts in our field.

This edition of Sport Health focuses on Heat in Sport which is of particular interest in a climate such as Australia’s.

With global temperatures rising, there is an increasing research being done into this area and focusing on how we can best prepare athletes for the conditions ahead.

I want to thank my colleagues on the Board of Directors who have been working tirelessly to ensure the success and vision of the organisation.

I thank the authors for their submissions and their time in putting together the articles for this edition, and I hope you all enjoy reading the publication.

Professor Gregory Kolt

FROM THE CEO

FROM THE CEO

Heading to the Gold Coast for Conference 2022 WE WELCOME OUR MEMBERS AND WIDER SPORTS MEDICINE COMMUNITY TO OUR FIRST FACE-TO-FACE CONFERENCE SINCE 2019.

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elcome to the latest edition of Sport Health!

Exciting news this quarter as we confirm that the annual SMA Conference is back in person and is heading to RACV Royal Pines Resort in Gold Coast, Queensland. We are thrilled to welcome members of the sports medicine community nationally and internationally to join us in the premier networking event for our community.

We are also pleased to have worldrenowned speakers joining us such as Dr Susan White who will be the Sir William Refshauge Lecturer for 2022. In the coming weeks, we will be announcing other high profile keynote speakers across our social channels.

We look to build off the success that was the 2021 e-Conference, which saw us host almost 500 delegates from across the globe in a virtual setting and facilitated a number of world-class lectures and workshops with unprecedented access for our members. With the conference moving to a face-to-face format, we now have the opportunity to network with fellow professionals across a large number of disciplines and backgrounds.

To this end, we are seeking submissions

specific sports medicine audience.

The details for advertising, sponsorship and trade are also on the SMA website.

Heat in Sport has become a major issue internationally due to climate challenges and it is paramount that we look at how to face this.

for abstracts and symposia/workshops for this iteration of the conference. This is an opportunity to have your work featured at the leading sports medicine event in the southern hemisphere and the chance to compete with the best in your field for a large number of prizes. The submission details can be viewed on the SMA website.

We’d also like to invite all interested parties to explore sponsorship and trade opportunities for this year’s conference. With thousands of people involved across the four-day event, this opportunity is uniquely positioned to showcase your product or brand to a

Alongside preparation for the upcoming conference, we are in full swing at SMA providing the 2021/2022 Event Series through numerous online webinars as well as getting back into in-person events across the country. We are also in the process of providing over 100 safer sports courses and running these in a multitude of locations around Australia.

This edition of Sport Health will look at one of the most serious concerns for sports in Australia. We have compiled the foremost experts on Heat in Sport to discuss the numerous challenges to a heating climate and how as medical and sporting professionals we can adapt to this.

We hope that you are engrossed in the upcoming articles and interviews, and you enjoy this publication of Sport Health.

Jamie Crain jamie.crain@sma.org.au VOLUME 39 • ISSUE 3 2022

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FEATURE: LOCATION MAT TERS – HEAT IN SPORTS IN AUSTRALIA

Location Matters

Photo: ikick/ gettyImages

Heat in Sport in Australia

BY MARLON GONSALVES

Why did we do it?

With significant global climatic changes, athletes are competing under increasingly warmer environmental conditions. Over the last two decades, new temperature records have been set and reset regularly. The last decade was warmer than any preceding decade, with a rise of 0.2°C over the previous decade. Today, the earth is 1.1°C warmer compared to pre-industrial time. While global temperatures are rising, in Australia the temperature rise is accelerating (Figure 1). Since 1910, Australia has warmed by 1.44°C which is greater than the global average, and over the last decade recorded a rise of 0.33°C. Sporadic periods of elevated temperatures outside average ranges of variability, i.e., heat waves, are projected to become more frequent and intense in the future. Climate change has increased the risk of experiencing severe heatwaves by two to threefold. These trends amplify the risk of exertional heat illness (EHI) in the physically active and sporting population.

EHI is a result of an uncontrollable rise in core body temperature arising from a dysfunction in thermoregulation.

Humans only absorb heat from the environment if the ambient air is warmer than skin temperature.

Figure 1: A comparison between global annual mean temperature anomalies (1850-2019) and Australian annual mean tempearture anomalies (1910-2020).

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FEATURE: LOCATION MAT TERS – HEAT IN SPORTS IN AUSTRALIA

Location Matters

Heat in Sport in Australia

Consequently, body temperature inevitably increases during exercise as the heat generated exceeds the heat lost affecting sport and exercise performance and potentially resulting in EHI that may affect the individual’s health.

An analysis of hospitalisations and emergency department presentations in Victoria Australia found lawn bowls and golf had a higher EHI risk than any other individual sporting code.

In response to the rising incidence of EHI, safety factsheets, guidelines and policies have been published by multiple sporting organisations.

Most interventions and strategies implemented to reduce EHI risk affecting Australian athletes refer to the Sport Medicine Australia (SMA) heat guidelines. Likewise, the American College of Sports Medicine (ACSM) heat policy guides EHI prevention strategies for American-based athletes. Heat policies, like the SMA heat policy and the ACSM heat policy, offer populationbased guidelines that are triggered by exceeding certain environmental thresholds. An analysis of current heat safety guidelines revealed indicators for these thresholds are often ambient 6

VOLUME 39 • ISSUE 3 2022

temperature or Wet Bulb Globe Temperature (WBGT). The WBGT accounts for air temperature, cloud cover, solar radiation, humidity, wind speed and angle of the sun. Based on the WBGT or ambient temperature and relative humidity, activity modification guidelines prescribe activity levels and duration, work-torest ratios, clothing and equipment, and frequency of hydration breaks.

The new SMA heat policy has shifted away from the WBGT and uses ambient temperature and relative humidity to quantify risk. Although, the new policy was updated in 2021, most heat policies still use the WBGT. The standard practice for heat stress monitoring and modification of activity is to conduct the assessment of heat stress risk onsite. Nonetheless, the limited access to measuring equipment has led to measurements from the nearest

weather station deemed acceptable within existing guidelines. Two issues arise when measures of thermal comfort are conducted away from the site of the activity. The first issue is the discrepancy in measurement approaches that undermine the accuracy of human thermal comfort levels. It is recommended that measurements of WBGT should be carried out between 0.9-1.2 m above the playing surface to accurately capture the most representative microclimate experienced by the athlete. However, weather stations measure wind speed at 10m which is not an accurate representation of the microclimate experienced by the athlete. Additionally, the approximation used by the Bureau of Meteorology (BOM) to calculate WBGT does not consider variations in the intensity of solar radiation or of wind speed at the location of the physical activity.

It also assumes a moderately high

Photo: PhonlamaiPhoto/ gettyimages

Photo: Paul Bradbury/ gettyimages

FEATURE: LOCATION MAT TERS – HEAT IN SPORTS IN AUSTRALIA

Given the differences in playing surface design and materials, the translation and application of these findings to other sports is unknown. Therefore, measurements and comparisons of more playing surfaces would provide valuable information for sport specific heat safety guidelines.

radiation level in light wind conditions which may lead to incorrect estimates of thermal stress, particularly in cloudy and windy conditions.

Variations in thermal comfort measurements that occur due to location is the second issue that arises

when measures are not conducted on-site. Previous research has shown WBGT calculated from the nearest weather station (26.85± 2.93°C) underestimated WBGT measured across multiple sports surfaces (27.52± 3.13°C). Differences between the onsite and weather station WBGT

measurements have also been shown to result in misclassification of the heat-safety activity category 45% of the time. (Pryor et al., 2017) Conversely, a smartphone app using weather station data overestimated WBGT (29.0± 4.1°C) when compared to on-site measures (26.4± 3.2°C).

Assessing heat stress within an urban heat island indicated the effects of the urban microclimate and increased exposure to heat stress were not captured when measurements of thermal comfort had been made using data from distant weather stations.

To date, comparisons of on-site and other meteorological measurements have been mostly limited to football.

Methods: How did we do it?

In our study, on-site measurements were collected across multiple artificial surfaces which included an athletics track, a hockey pitch, a lawn bowls turf, a synthetic soccer pitch with black rubberised infill, and a tennis hard court, all located in the City of Ballarat, Victoria Australia. On-site measurements were aligned with corresponding measurements from the nearest Bureau of Meteorology (BOM) weather station and City of Ballarat (COB) environmental monitoring system. As a result, every on-site measurement had a corresponding BOM and COB meteorological measurement. The BOM weather station was located at the Ballarat Aerodrome on the outer fringes of the town, while the COB environmental monitoring system was located at the more central location of Lake Wendouree. The distances between the on-site locations and the BOM weather station and COB environmental monitoring system data varied (Table 1). Measures of thermal comfort, i.e., wet bulb globe temperature (WBGT), were calculated from on-site, BOM and COB measurements using the Liljegren VOLUME 39 • ISSUE 3 2022

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FEATURE: LOCATION MAT TERS – HEAT IN SPORTS IN AUSTRALIA

Location Matters –

Heat in Sport in Australia

Table 1. Distance between the on-site testing locations and alternative sources of meteorological data.

Artificial Surface

Ballarat Aerodrome (BOM data)

City of Ballarat Sensor (COB data)

Athletics

9.26km

4.62 km

Soccer

8.20 km

3.67 km

Tennis

4.94 km

2.79 km

Lawn Bowls

4.88 km

2.59 km

Hockey

4.76 km

0.50 km

Results: What did we find?

In total, 1245 measurements were recorded across the five artificial sports surfaces and paired with the BOM and COB locations. The results show that air temperature measurements were significantly affected by the location of measurement. The COB air temperature was on average 4.19 (±3.28)°C warmer than the BOM air temperature measurements and 1.83 (±3.28)°C warmer than the onsite air temperature measurements.

Also, the on-site air temperature measurements were significantly warmer than the BOM air temperature measurements by 2.36 (±3.28)°C. On-site relative humidity measurements were lower when compared to corresponding COB and BOM relative humidity measurements. The COB relative humidity was on average 5.05% (±0.12) higher than the on-site relative humidity measurements and 1.71% (±0.11) higher than the BOM relative humidity measurements. Unlike air temperature measurements, the BOM relative humidity measurements were significantly higher than the on-site relative humidity measurements by 3.35% (±0.13).

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Table 2. Descriptive statistics of WBGT using multiple sources of data.

On-site

BOM

COB

Field

Mean

± S.D.

Mean

± S.D.

Mean

±S.D.

N

Athletics

22.26

2.19

20.69

1.96

24.11

2.32

241

Hockey

22.20

1.90

20.91

1.77

24.83

2.07

251

Lawn Bowls

22.44

2.11

20.78

2.04

24.32

2.43

251

Soccer

22.12

2.22

20.92

2.24

24.39

2.72

251

Tennis

21.83

2.08

20.48

1.88

24.25

2.34

251

Total

22.17

2.11

20.76

1.99

24.38

2.39

1245

Differences were also observed in measures of thermal comfort (Table 2).

When WBGT measurements were assigned to a WBGT category, 84.3% of on-site WBGT and 98.4% of BOM WBGT were recorded in category 1, with only 54% of COB WBGT recorded in category 1. Overall, on-site measures of WBGT did not agree with external sources of meteorological data.

Implications: So why does this matter?

This study evaluated the concordance of meteorological data of multiple artificial sports surfaces with meteorological data from the nearest BOM weather station and COB environmental monitoring system.

There was a significant variation in air temperature and relative humidity between measurements conducted on-site, at the BOM weather station and COB environmental monitoring system. Additionally, the effect of location on WBGT and heat stress category classification was observed. Variations in meteorological measurements can lead to misclassification of heat stress risk and result in the implementation of inappropriate mitigation strategies.

In Table 3, measurements of air temperature and relative humidity were entered into the updated SMA heat stress policy. If only average air temperature and relative humidity was

Photo: s-c-s/ gettyimages

method for modelling WBGT. The calculated WBGT were assigned a category using an updated regional heat safety guideline. The WBGT category ranged between 1-no activity modification and 5- no outdoor activities.

FEATURE: LOCATION MAT TERS – HEAT IN SPORTS IN AUSTRALIA

Table 3. SMA Extreme Heat Policy predicted heat stress risk associated with location of temperature and relative humidity.

Artificial Surface

Mean (AirTemp, Rh)

max-Rh*

max-AirTemp*

On-site

BOM

COB

On-site

BOM

COB

On-site

BOM

COB

Athletics

1

1

1

2

1

3

3

3

4

Hockey

1

1

2

2

2

4

4

3

4

Lawn Bowls

1

1

1

2

2

3

3

3

4

Soccer

1

1

2

2

2

3

3

2

4

Tennis

1

1

2

2

2

3

4

3

4

Note: 1 Green (Low Risk); 2 Yellow (Moderate Risk); 3 Orange (High Risk); 4 Red (Extreme Risk).

considered across the three sources of measurements in this study, heat stress risk would be similar when using either on-site or BOM measurements.

However, if data was obtained from the COB environmental monitoring system, then activities at the hockey, soccer and tennis would be classified as moderate risk. In the updated SMA Extreme Heat Policy, moving from low risk to high EHI risk would result in additional rest breaks for each sport.

If maximum relative humidity were considered, measurements from the COB environmental monitoring system would once again lead to an overestimation of heat stress risk.

Under these conditions, on-site and BOM measurements would result in a similar assessment of heat stress risk. Heat stress risk would be extreme at the hockey field when using COB environmental monitoring system data.

As a result, play would be suspended, and active cooling strategies would be put in place. The largest variation in heat stress risk would have occurred if measurements of maximum air temperature were considered in predicting heat stress risk. Once again, using COB environmental monitoring system data would lead to an overestimation of heat stress risk. However, in this scenario using BOM weather station data could lead to an underestimation of heat stress risk for hockey, soccer, and tennis. An underestimation of heat stress risk would put the participating athletes at an unnecessary level of risk. Therefore, microclimatic variability

based on location, especially for artificial sports surfaces, should be considered when developing and implementing heat safety policies. *Since peak Rh and air temperature rarely occur at the same time maximum values of each variable were combined with average Rh and AirTemp to ascertain SMA risk category.

Conclusion: What does this all mean?

Based on the 1245 measurements across the five sites and paired comparisons with measurements at the BOM weather station and COB environmental monitoring system, on-site measurements provided the most accurate assessment of thermal comfort. Differences were observed between the individual meteorological measurements, the WBGT measurements and the heat stress categorisation. The variances between

individual meteorological variables would result in an overestimation of heat stress risk for measurements by the COB environmental monitoring system across all five sports. Similar variances in maximum air temperature would lead to an underestimation of heat risk for BOM measurements compared to on-site measurements at the hockey, soccer, and tennis artificial sports surfaces. For WBGT measurements, differences arose between the three sources of data and significant variations existed between on-site, BOM and COB heat stress risk categorisation. Overall, a significant discordance exists for both individual meteorological variables and WBGT modelled from multiple sources of available data. Therefore, for the safety of the participants on artificial sports surfaces, direct local measurements of heat stress indicators are essential to accurately assess heat stress risk.

Author Bio Marlon Gonsalves Marlon is currently pursuing his doctoral studies at Federation University Ballarat. He has a background in physical therapy and sports science. His research from his early physical therapy days to his current doctoral research has focused on injury prevention and athlete safety. His doctoral research has specifically focused on heat-related injuries within Australian sport. With the increasing challenges of a warming climate, his research focuses on both the policy and physiology of heat-related sports injuries and has implications for the wider sporting community.

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FEATURE: STRATEGIES TO SUPPORT ATHLETES COMPETING IN THE HEAT

Strategies to support athletes

competing in the heat VICTORIAN INSTITUTE OF SPORT EXPERTS JESS ROTHWELL AND AVISH SHARMA HAVE HELPED AUSTRALIAN RACE WALKERS AND MARATHON ATHLETES TO PERFORM IN GRUELLING HOT CONDITIONS AT THE WORLD’S BIGGEST STAGES.

R

ecent major benchmark events held in Qatar, Japan and Oman have been hot!

These thermally challenging environments have required athletes, in particular endurance athletes to be as well prepared as possible to ensure their health, safety and performance is optimised.

Victorian Institute of Sport (VIS) Sports Dietitian Jess Rothwell helped prepare the Australian Race walkers and Marathon athletes to perform at the 2020 Tokyo Olympic Games (held in 2021) and was joined by VIS Performance Scientist (Physiology) Avish Sharma in 2022 to aid in preparations for other 10

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recent major international events such as the World Race Walking Championships in Oman.

The strategies that the VIS experts applied to the athletes’ preparation and event strategy included the use of baseline physiological data, training data, and heat acclimation/ acclimatisation practices, pre- and inrace cooling and nutritional strategies, and Games race performance data.

Events in thermally challenging conditions The World Athletics Climatic Monitoring uses the WGBT 1 (Wet Bulb Globe Temperature) to assess conditions to inform

their recommendations for athletes competing.

This monitoring system has forced changes to usual race schedules, including the World Championships in Doha in 2019, where athletes across the Marathon and Race Walking events started at 12.00am and 1.00am in the morning.

1 The Wet Bulb Globe Temperature (WBGT) is a measure of heat stress used to estimate the effect of temperature, humidity, solar radiation, and airflow. This index is among other things used to prevent heat disorders during sporting activities. http://www.bom.gov.au/info/ thermal_stress/#wbgt

FEATURE: STRATEGIES TO SUPPORT ATHLETES COMPETING IN THE HEAT

“In the Women’s Olympic Marathon event in Sapporo, Japan, there was literally a last minute change, where the women raced in temperatures between 25 – 29 degrees Celsius and 67-84% relative humidity.”

Embedded research camps, involvement of academic experts within their field and experienced coaches, trial and error, implementation and repeated practise, data collection and athlete preference formed training prescription, heat exposure as well as final performance nutrition strategies.

The following training, nutrition and hydration strategies are a snapshot of preparation methods that have been used by Victorian Institute of Sport (VIS) as well as Athletics Australia (AA) team athletes, to support their preparation and day of competition performances.

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FEATURE: STRATEGIES TO SUPPORT ATHLETES COMPETING IN THE HEAT

Strategies to support athletes

competing in the heat A SNAPSHOT OF STRATEGIES TO PREPARE ATHLETES INVOLVED Heat acclimation and acclimatisation The VIS climate chamber was a popular local destination for most athletes, which included several planned heat exposure training sessions to support their adaptations across the year.

These involved athletes using treadmills under COVID safety procedures to support heat acclimation (the use of artificial heat environments) mostly at easy intensity. Event group camps for Walks, Marathon athletes and staff were organised in far north Queensland, to support heat acclimatisation (the use of naturally hot environments) and to coordinate the opportunity to trial additional nutrition and hydration strategies.

Nutrition and hydration strategies included fluid balance studies, training the gut and pre-exercise hyperhydration, pre-cooling, during race and recovery strategies.

Fluid balance studies Determining and interpreting each athlete’s individual fluid losses in similar environmental conditions to their races, was important to help support tailoring an individualised plan and opportunity for the athletes to understand more about their losses in conjunction with their training session and perception of heat.

Unfortunately, during some of the camps, we didn’t have access to core body temperature pills, however in future heat-based training camps, these will be a useful device to support the interpretation or change to interventions/ personalised strategies for athletes.

Rehydrating fluids, sodium as well as recovery focused foods including carbohydrate and protein after training were not only important 12

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to support recovery, but also to support the continued expansion of blood plasma volume and thermoregulatory adaptations.

Training the gut To support increased gastric emptying and tolerance of higher fluid / carbohydrate intake as practically relevant across different endurance events, enabled athletes to trial different strategies, different sports

FEATURE: STRATEGIES TO SUPPORT ATHLETES COMPETING IN THE HEAT

Strategies to support athletes

competing in the heat nutrition products and to practise ‘training their athletic organ.’

This was important to accommodate for high sweat losses particularly in the humidity, minimise the risk of heat associated gastrointestinal issues and whilst they were not aiming to maintain euhydration, reducing thermal and cardiovascular strain was a priority.

Pre – exercise hyperhydration Leading into these events, athletes had multiple opportunities to trial hyperhydration strategies. These included a combination of osmotic agents, glycerol, and sodium or just sodium, a flavouring agent (sports drink, cordial or flavoured electrolyte tablets) in a large bolus

of water, that was adjusted for each athlete based on their body mass, reported tolerance and preference.

The aim of this strategy is to enhance fluid retention and subsequent expansion of blood plasma volume to support thermoregulation during exercise, particularly where fluid losses are likely to exceed well beyond what an athlete may be able to physically tolerate or access over the course of their race.

Pre – cooling Pre -cooling methods were also trialled and tested at staging camps and event group supported camps, to allow athletes the opportunity to experience feeling ‘cold’ via

Athletes understood the impact of these gels with consideration to managing their pacing strategies following ingestion, which the study found to support a sensory cooling effect from 12 – 19 minutes.

lowering body temperature, before heading into a race pace style of session. On the day of competition, athlete preference determined the combination of external and internal pre – cooling methods used.

External cooling methods including the use of ice baths, or the wet towel method were available to athletes ~ 30mins before entering the call room, alongside an ice vest and an optional favourite flavoured slushie (~ 7ml/kg BM, internal cooling) as part of their final preparations.

During race strategies A combination of strategies to support cooling over the races were available to athletes, including ice slurry water bottles to pour over their head, bags and stockings of ice to hold or place in competition kit, ice and watersoaked towels as well as old vest inserts that were sewn into neck ties.

Athletes also had the opportunity to participate in a menthol gel research

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FEATURE: STRATEGIES TO SUPPORT ATHLETES COMPETING IN THE HEAT

Author Bio Jess Rothwell – VIS Sports Dietitian Jess is an Accredited Sports Dietitian with experience in the hospital and private practice setting.

Her passion and excitement for supporting athletes, as well as individual health, stemmed from her experiences growing up on a dairy farm in regional Victoria, as well as competing internationally in the sport of race walking.

Jess enjoys working with individuals of all ages to develop realistic and achievable strategies that are complementary to their lifestyle and training/competition goals.

Jess works at the Victorian Institute of Sport (VIS) with the Athletics Program and is the High Performance Nutrition Lead for Athletics Australia. She consults two days a week with Olympic Park Sports Medicine Centre and over the last few years, Jess worked with the VIS

study to support sensory cooling, with two of our most successful athletes in Sapporo (Tokyo Olympics) using as part of their performance nutrition plans at strategic time points over the race, where they personally felt a sensory cooling stimulus would mentally aid them.

Women’s Hockey Program, was the in–house Sports Dietitian at Sports

Recovery Ice baths and medical support was available to athletes post training / post event to support their recovery including the initial ingestion of cool fluids.

Avish completed his PhD in altitude training at the Australian Institute

Dietitians Australia (SDA) and also worked with the AFLW Richmond Football team.

Avish Sharma – VIS Performance Scientist (Physiology) Avish joined the Victorian Institute of Sport (VIS) in 2021 as the Performance Scientist – Physiology for the Athletics and Triathlon programs.

of Sport in conjunction with the University of Canberra, which looked at training prescription and periodisation during natural altitude camps in elite runners.

Alongside completing his doctoral research, his time in Canberra had him working predominantly with the sports of Athletics and Swimming

Please refer to the recently published paper by Carr, A et al 2022, ‘Competing in Hot Conditions at the Tokyo Olympic Games: Preparation Strategies Used

by Australian Race Walkers’ for further details across interventions including supporting body composition changes to optimise athlete performance in hot events. https:// www.frontiersin.org/articles/10.3389/ fphys.2022.836858/full

as a junior physiologist, as well as collaborating with the AIS Sports Nutrition department for a series of dietary intervention studies in race-walking.

Following this, he relocated to the Gold Coast to join Triathlon Australia (TA) as National Lead for Physiology in 2018, and it is from here that he joined the VIS. Some of his main responsibilities at TA included delivering the heat strategy for the Tokyo Olympics and Paralympics, leading direct physiology delivery in the DTE, and being involved in system related projects such as categorisation and the Triathlon pathways strategy.

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Photo: SanderStock/ gettyimages

FEATURE: DEFINING ADVERSE HEALTH EVENTS FROM HEAT IN SPORT AND RECREATION

Defining Adverse Health Events from Heat in

Sport and Recreation

T

here is a growing interest in the impact of healthrelated impacts from sport and recreation in the heat.

Most studies on heat, health and sport are sport-specific, focused on performance outcomes or provide advice for recognising risks. Such studies are valuable for planning and management of events and knowledge on individual risks, particularly in elite levels where high performance, despite high temperatures, is a key requirement.

There is much less known about the prevalence and risks of heat in Australian community sport and recreation participants more generally. One reason for the lack of information in community settings is the challenges of collecting data for this health problem.

This definition is easier in theory than action. Below are some recent examples of ‘heat and health and sport’ from our team that each took a different approach to the inclusion of cases, reflecting existing data that were available. A balance of sport specific findings or health diagnoses is needed but currently the scales are tipped to either end (Figure 1).

The worst-case scenario The aim of this research was to describe the number and characteristics of exertional heat deaths from sport and recreation.

The National Coronial Information System (NCIS) is an internet-based data repository of all deaths notified to Australian Coroners since July 2000 (2001 in Queensland). The NCIS stores coded and free text information

Figure 1. Understanding events from heat on health in sport need to consider the balance of detail in the case selection

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FEATURE: DEFINING ADVERSE HEALTH EVENTS FROM HEAT IN SPORT AND RECREATION

Defining Adverse Health Events from Heat in

Sport and Recreation Understanding the impact of heat from sports participation on health requires a clear definition of the health outcomes that are important.

Cases needed to meet pre-specified requirements for the cause of death and the exposure (see original article for inclusion details reporting setting

and time frames). Our search made use of the formal coded cause of death as well as the coroner written cause of death (described as variations of heat stroke, heat exhaustion, hyperthermia). The coded cause of death was recorded as a variant of the International Classification of Diseases code X30 (“exposure to excessive natural heat”) for two thirds of included cases.

Additional diagnoses to this primary cause, included hyponatraemia or dehydration, and infection (different types noted), sepsis or organ failure.

The deceased also need to be considered as active at the time when signs/symptoms commenced or shortly beforehand. There are activity

Photo: PraewBlackWhile/ gettyimages

on a range of items linked to the deceased. Searches of the NCIS are performed by building a query from the stored key words and codes.

For our team to access the relevant fatalities related to exertional heat illness in sport and recreation, three independent searches of the NCIS were conducted and combined. It was a time consuming, detail-oriented process that ultimately, remains imperfect. Our team included a researcher with substantial experience in accessing and understanding information from the NCIS database and a medical professional who was familiar with the diagnoses, and we worked in conjunction with members of the NCIS Unit to design our search strategy.

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codes to help shortlist this inclusion, but manual review of several cases is still required. Essentially, we were asking: had the deceased put on their active wear and decided to head out for competition, practice, or fitness? There were several cases where the deceased had not made this “decision to workout”. As example, those at home engaged in active play or those on recreational trips who had walked to seek help for a brokendown car. These cases were excluded as there are different prevention requirements for these causes.

Signs and symptoms Led outdoor recreation includes bushwalking, kayaking and rock climbing, in essence, activities that are typified by having a group of participants under instruction from a leader.

Figure 2. The existing data used in the studies highlighted tend to favour a health or sport focus in the collection of data.

Data for this study were obtained from the Understanding and Preventing Led Outdoor Accidents Data System (UPLOADS) National Incident Dataset.

A big advantage of this dataset is the case definition includes both near misses and incidents. So, in addition to an outcome of injury or illness, there is information on events that could cause injury/illness but failed to do so because of chance or intervention. As cases are entered into the database (provided as open-text narratives), two researchers review entries and code them using predefined criteria (14 organisational level factors and 107 contributing factors).

Photo: Tomwang112/ gettyimages

For our research, we needed to identify relevant cases from over 2000 incidents, using a systematic and structured process to enable replication as the database grows.

The activity was already confirmed by the database being focused on outdoor recreation, so we only had

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Defining Adverse Health Events from Heat in

Sport and Recreation

Treatment accessed This study sought to report epidemiological data for sport related heat injury treated in hospital (both admission and emergency departments).

Data for this study was obtained from the Victorian Injury Surveillance Unit (VISU) at Monash University.

The VISU provided aggregate data tables on hospital-admissions from the Victorian Admitted Episodes Dataset (VAED) and on emergencypresentations from the Victorian Emergency Minimum Dataset (VEMD).

In this study, we sought to identify the number, nature and contributory factors of heat and sun related incidents in led outdoor activities.

For admissions data (VAED) unintentional, community injury cases were included where they were coded as the International Classification of Disease, Version 10 Australian Modification (ICD-10-AM) T67 (effects of heat and light). For example, “T670” “Heat stroke and sun stroke”, “T671” “Heat syncope”, “T672” “Heat cramp”. These cases were further limited to a range of activities that represented sport and recreation/leisure (“U5000” to “U7100”).

collection including the activity when injured. The primary diagnosis (i.e., reason for attendance as confirmed at the end of treatment in the emergency department) is also supported by up to two additional diagnoses. Cases were extracted where any of the three possible diagnoses related to heat (as above, T67). We suspect based on relatively low numbers of ED presentations (ED was matched with the number of admissions, when 6-10 times higher might be expected), that many sport and heat cases are not considered as injury. For example, fatigue, nausea and headache as reasons for presentation may not be thought of as ‘heat injury’ and therefore the activity code for external causes – and our opportunity for sport injury surveillance – is missed.

Presentations to emergency where there is an external cause (injury) code as the primary diagnosis field, additional data items are required for

Sport>health or health>sport Different terminology and coding are notable across the different data sources. Coronial data favoured the

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Photo: SB Stock/ gettyimages

to identify cases relating to heat exposure. We wanted to include all cases that were linked to sun or heat exposure, and this was best achieved through an initial process of exclusion.

For example, where the narrative did not include terms for diagnoses such as “hot”, “sun” or “heat” or terms for treatment received did not include “cool in shade”, “hydrate”, “icy pole”.

Cases were further refined manually by reviewing the heat descriptions and excluding cases that were not relevant e.g. “it was a warm and sunny day” and “the snake was out laying in sun”.

ICD-10AM code of X30 “exposure to excessive natural heat” while hospital data preferred the T67 injury code “effects of heat and light”. From hospital data, X30 is not given an activity code as it is not part of the external causes chapter of the ICD. Other overlapping conditions also fall in other chapters of the ICD-10-AM such as sunburn (L55), sweat disorders (L74-L75).

Figure 2, star A, represents the data from the NCIS data paper, which leans to health over sport. Because of the case narratives and additional reports within the NCIS files, some sport specific details were able to be obtained so it sits a little off sport as secondary. Figure 2, star B, represents the definition from the outdoor activities paper, leaning much more to sport and recreation than health.

Signs and symptoms of heat were self-reported to activity leaders who entered data into the recording

FEATURE: DEFINING ADVERSE HEALTH EVENTS FROM HEAT IN SPORT AND RECREATION

system. Medical review or validation of diagnoses was not possible. Figure 2, star C, represents the definition from the hospital admissions and ED paper, focused on health with activity very much secondary.

Coronial data is obviously limited to the case worst scenario. This outcome can be avoided and the NCIS should not be used as a routine data source for sport and recreation activities.

Ultimately, our team read over 500 cases to identify 38 preventable deaths in the series over a 20-year period. The value of the cases was found in the detailed narratives which provided insights to what happened and how the situation was managed.

These insights have informed ideas for prevention. UPLOADS gave data with substantial understanding of sport/activity but is limited on medical accuracy. However, it is the participants and leaders within the led outdoor activity sector who manage these adverse events in practice, providing the information in their terms, so there is merit in further investigation as UPLOADS continues to grow. Hospital admissions and ED presentations for heat injury have the lowest direct links to sport / recreation.

Consider the scenario of attending an ED with headache, nausea, and dizziness – all signs of heat exhaustion – but also numerous other conditions.

Emergency physicians may provide a summary of symptoms or signs rather than a specific diagnosis of heat injury. Despite the challenges of these data sources, their ongoing, routine and consistent recording provide huge opportunity for the purpose of heat health in sport.

Agreement on the inclusion criteria, search strategies and reporting of these data is a worthwhile exercise.

While the definition seems like a small issue, we need to work together to common understanding for both existing datasets and original collection.

activity data will tell us why events happen and what opportunities there are for prevention. The studies

summarised are all from existing data sets but original collection in sport settings faces similar challenges to identify what is and is not a sportheat-health problem. Ultimately, we need a comparable starting point to enable surveillance as we expect increasing challenges from safe sport in an unstable future climate. Figure 2, star !!, is the goal. This is where we need to aim to ensure we understand both the health implications and how to prevent or manage them.

Acknowledgements Thanks to my co-authors on the papers described here: Dr Prasanna Gamage, Prof Caroline Finch, A/Prof Lyndal Bugeja, Dr Stephen McMahon, Ms Anna Cartwright, Dr Natassia Goode and Prof Paul Salmon.

Author Bio Dr Lauren Fortington is a Senior Research Fellow in injury epidemiology and sport safety, at the School of Medical and Health Sciences, Edith Cowan University.

Dr Fortington’s research aims to support active Australians to participate safely in sport, work and everyday activity. A better understanding of injuries and their prevention will keep more participants active in their sport, older people in their homes and community, and workers doing their jobs, ultimately reducing the burden on health care.

Health data can best tell us how many people are impacted but the VOLUME 39 • ISSUE 3 2022

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FEATURE: CLIMATE DISRUPTION – AUSTRALIAN SUMMER SPORT AND OUR HEALTH AT RISK

Climate Disruption Australian Summer Sport and Our Health at Risk SPORT PROVIDES OPPORTUNITIES TO LIVE AN ACTIVE AND HEALTHY LIFE. HOWEVER, WORSENING EXTREME WEATHER EVENTS EXACERBATED BY CLIMATE CHANGE ARE MAKING PARTICIPATION IN SUMMER SPORTS INCREASINGLY CHALLENGING.

Sport and Climate Disruption Sport is a major part of Australian culture. Every weekend, millions of Australians participate in, watch or discuss sport. Sporting legends are idolised and our national teams and clubs are revered. Australia punches above its weight, often topping the tables and podium on the international stage. Mega sporting events such as the AFL and NRL grand finals and the women’s T20 World Cup final are watched by millions and the Australian Tennis Open Final, one of the world’s four ‘Grand Slam’ tournaments, is a major event on the global sporting calendar. Our elite and community sports infrastructure is world class.

Many sports are highly dependent on favourable climatic conditions (Dingle and Mallen 2020). For example, skiing and snowboarding rely on the availability of sufficient and reliable snow, enough (but not too much) rainfall is required for good playing surfaces for cricket, football and golf, and athletes must avoid extreme heat for their safety. Climate change thus represents a significant long-term challenge facing sport in Australia. Despite this, the ‘Intergenerational Review of Australian Sport’ (BCG 2017), ‘Sport 2030’ – the Federal Government’s first national sports plan (Commonwealth of Australia 2018) and ‘The Future of Australian Sport’ (CSIRO 2013) all fail to consider climate change and its implications.

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Photo: Steven Giles/ gettyimages

The frequency of extreme heat events is also increasing. 2019 was Australia’s warmest year on record, with 33 days that exceeded 39°C – more than the total number observed in the entire 1960-2018 period (BoM and CSIRO 2020). Cool season rainfall (April – October) has declined by 10-20 percent across mainland southern Australia over recent decades (BoM 2021).

These trends have contributed to an increase in the length of fire seasons and to the severity of dangerous fire weather across large parts of the continent (BoM and CSIRO 2020; Abram et al 2021). On the other hand, the intensity of short duration (hourly) extreme rainfall events, often leading to flash flooding, has increased by around 10% (BoM and CSIRO 2020).

Climate change – driven mainly by burning fossil fuels and land clearing – is worsening extreme weather in Australia, playing havoc with both elite and grassroots-level sport. Australia’s beloved summer sports calendar, which includes Big Bash League (BBL) cricket, AFLW games, the Tour Down Under cycling race, the Australian

Photo: AntonioGuillem/ gettyimages

Australia’s climate has warmed on average by 1.47°C since 1910, with most warming occurring since 1950 and every decade since then being warmer than the preceding ones.

(BoM 2022).

Open tennis, A and W-League football and community sports is under threat from climate change.

HEALTH RISKS OF SPORT IN A SUPERCHARGED CLIMATE Extreme heat and athletes’ health National mortality records in Australia suggest substantial under-reporting of heat-related mortality. Less than 0.1% of 1.7 million deaths between 2006 and 2017 were attributed directly or indirectly to excessive natural heat.

However, recent research indicates that official records underestimate the association at least 50-fold, estimating over 36,000 deaths (Longden 2019; Longden et al. 2020). In 2020, the USbased National Bureau of Economic Research published new projections for the number of people likely to die from climate change-fuelled extreme heat. It concluded that if no action is taken, on average there will be 221 additional deaths per 100,000 people globally each year by 2100 – roughly equivalent to all deaths from cardiovascular disease today. Even after factoring in estimated efforts VOLUME 39 • ISSUE 3 2022

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Climate Disruption

Australian Summer Sport and Our Health at Risk to adapt to a changing climate, the study still projects an extra 73 deaths per 100,000 people annually by 2100, which is greater than the number of people who died from COVID-19 in 2020 (Carleton et al. 2020).

In some notable examples, English cricket captain Joe Root was hospitalised suffering from heat exhaustion after an Ashes test match

in Sydney in 2018 and Australian Open tennis players have retired due to illness brought on by exposure to excessive heat. Extreme heat forced the Australian Open tennis to suspend matches and the 2019 Tour Down Under Cycle race cut almost 30km off the original 149km stage 2 route from Norwood to Angaston to cope with extreme heat in South Australia (Cycling News 2019).

Extreme heat is a major health risk for anyone exposed to increasingly brutal Australian summer conditions, including athletes at their peak fitness.

The ACT Office of the Commissioner for Sustainability and the Environment report notes a need to recognise that heat exposure is a genuine health threat and risk to summer sports. Reducing exposure is a critical challenge as Australia experiences more frequent and intense heatwaves and more days of extreme heat.

Sporting governing bodies and governments at all levels from Federal to local councils play an essential part in building resilience and preparing for the escalating threat of worsening extreme weather (see Auty and Roy 2019). The Victorian Government has issued factsheets to help sports participants avoid heat-related illnesses and the necessary actions to take if symptoms of heat illness occur while playing sport (see VicSport 2021).

Extreme heat policies Sports Medicine Australia has a national policy that governing bodies of Australia’s major summer sports have used to put their own policies in place.

Extreme temperatures play an obvious role in heat stress for athletes, but other factors such as wind conditions, direct solar radiation (which determine temperatures in the sun versus the shade) and humidity levels are also very important (Jay and Chalmers 2018).

Figure 1: Australian sport and climate disruption. Source: Climate Council 2021.

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Temperature: The weather forecast “temperature” is measured in the shade, but physiological strain (rise in heart rate, sweating, body

FEATURE: CLIMATE DISRUPTION – AUSTRALIAN SUMMER SPORT AND OUR HEALTH AT RISK

temperature) differs depending on whether or not an athlete is directly in the sun (“radiant heat”).

Humidity: Sweating is humans’ most important physiological process for keeping cool in the heat. High humidity impairs our ability to sweat, increasing our risk of heat illness.

Wind: Even the lightest breeze brings a reprieve from high humidity because wind promotes evaporation, i.e. it helps replace air directly above the skin saturated with water vapour with drier air. Therefore, the ability of an athlete to cool down is much higher in breezy conditions.

For more information, see ‘Extreme heat in sport: why using a fixed temperature cut-off isn’t as simple as it seems’ (Jay and Chalmers 2018).

AFL, NRL and A-League coaches and player associations have called for improvements in their respective leagues’ heat policies after extreme heat affected games during the 2013, 2014 and 2015 seasons (The Climate Institute 2015).

When designing a heat policy, various factors are considered. For example, sports such as AFL, rugby and soccer require vigorous levels of activity that engage large muscle groups (such as running, jumping, squatting, kicking) and this produces a lot of heat. Sports that are less intense, such as walking and light jogging, generate relatively small amounts of heat. A further consideration is that some sports, such as cricket and field hockey, require protective gear that can act as a barrier for heat loss. Sweat rates are also usually the highest on the head, back, and shoulders.

Therefore, a cricketer wearing a helmet and padding on the upper body is less likely to be able to keep cool because of limited evaporative cooling (Jay and Chalmers 2019).

Figure 2: Symptoms of heatstroke. Source: Climate Council (2021), adapted from Korey Stringer Institute (Professor Ollie Jay, personal communication, 8 February 2021).

Note: While some groups are more at risk than others, everyone is potentially at risk from severe heat-related illness, especially while playing outdoor summer sport in hot weather.

Sports Medicine Australia is currently working on delivering an online tool linked directly to the nearest BoM station, providing 72-hour forecasts (Professor Ollie Jay, personal communication, 8 February 2021).

from a range of respiratory and cardiovascular diseases (Johnston et al. 2011; Martin et al. 2013; Johnston et al. 2014). The health effects associated with exposure to poor air quality range from short-term to lifelong.

Bushfires and toxic smoke Bushfire smoke contains air pollutants including particulate matter, and carcinogens such as benzene and formaldehyde (Bernstein and Rice 2013). There is emerging evidence that even very low levels of air pollution are harmful and can increase the risk of death (see, for example, Yu et al. 2020). Smoke events have been associated with increases in hospital admissions and mortality

Bushfire smoke blanketed population centres including Brisbane, Sydney, Melbourne and Canberra during the 2019-20 Black Summer bushfire crisis. In the Sydney CBD, the Daily Air Quality Index reached over 2000 in December, more than ten times higher than the ‘hazardous’ threshold.

Other parts of Sydney recorded even higher readings. In parts of Canberra (Monash) the Hourly Air Quality Index reached 4,650 on New VOLUME 39 • ISSUE 3 2022

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Climate Disruption

Australian Summer Sport and Our Health at Risk Year’s Day — more than 23 times the hazardous threshold (ABC 2020a). The 2019-20 Black Summer bushfires are estimated to have caused over 400 smoke-related premature deaths in addition to 3,230 hospital admissions for cardiovascular and respiratory disorders and 1,523 emergency attendances for asthma (Johnston et al. 2020), and the associated health costs totalled AU$1.95 billion (Johnston et al. 2020). Physical exertion causes deeper inhalation and so those playing sport in the smoke will have inhaled dangerous air more deeply into their lungs. It is as yet unknown what the long-term consequences of prolonged exposure to the hazardous smoke will be, for athletes and others.

In Melbourne, hazardous air quality disrupted the Australian Open tennis tournament in January 2020, causing one player to retire with breathing problems and other matches to be delayed or abandoned (The Guardian 2020). In Canberra, a BBL cricket match at Manuka Oval was suspended in mid-over when the umpires deemed it unsafe to continue as a sharp curtain of thick, noxious smoke blew in across the field (ABC 2020b).

Photo: torwai/ gettyimages

Air quality concerns for professional sports have been documented since the 2008 Beijing Olympics, which had the highest levels of air pollution of any measured games (Wang et al. 2009).

Polluted air can impede athletic performance and affect athletes’ health.

As bushfire seasons become

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longer and more intense, sporting organisations will increasingly be confronted by the problem.

“Because they work so hard and breathe so much, athletes actually turn out to be a sensitive subgroup to pollutants” – Professor Ed Avol, clinical preventive medicine and air pollution expert.” University of Southern California (The Verge 2020, online quote) Air pollutants can decrease lung function and reduce blood flow, both of which are essential for optimal athletic performance (Rundell 2012). At the professional level, where athletic performance is separated by very slim margins, any reduction in these physical functions can have a major impact. One study of the topflight German professional football league, the Bundesliga, found that air pollution was linked to poor athlete performance on the field (Lichter et al. 2015).

Mental health and social benefit of sport Climate change affects mental health. Recent research links rising temperatures caused by climate change with poor mental health, including selfharm and suicide (see, for example, Zhang et al. 2020).

As sport becomes increasingly affected by climate changedriven extreme weather events, participation will foreseeably lessen. Given the mental health benefits of physical activity and

sport, reduced participation means that mental health issues will likely increase (ACT Government 2019).

Mental health professionals have also reported an increasing number of patients presenting with ‘climatechange anxiety’, noting feelings of stress, anxiety, dread and uncertainty about the future (ACT Government 2019). As climate change cranks up the intensity of extreme weather, the number of individuals with existing mental illness and those who will develop mental health problems is expected to increase, straining the coping capacity of the mental health care system (Auty and Roy 2019).

Sport is often promoted as an inclusive environment, bringing people of all backgrounds and abilities together to participate and benefit from a range of personal, health and social benefits (Schaillée et al 2019). Sport also plays an especially important role in rural, regional, and remote Australia bringing communities together; contributing positively to community identity and a sense of place; promoting social interaction and community inclusion; and playing an important role in providing opportunities for physical activity and improved health outcomes (Spaaij 2009; Tonts and Atherley 2010; Frost et al. 2013).

Additionally, rural and regional Australian centres are increasingly hosting sporting events that provide economic stimulus and instil a sense

FEATURE: CLIMATE DISRUPTION – AUSTRALIAN SUMMER SPORT AND OUR HEALTH AT RISK

of community pride (Blood 2020).

However, climate change is already threatening community sports and worsening extreme weather events are set to challenge the viability of many community outdoor summer sports, particularly in rural and regional areas on the frontline of climate change. The Government, industry and community all need to work together to respond to this challenge (Auty and Roy 2019).

Protecting Australian Summer Sport and Healthy, Active Lifestyles A major pillar of Australian culture is under threat. Climate change and worsening extreme weather is disrupting sport, and climate inaction has locked in further damaging impacts. Without urgent and decisive action, Australia’s summer of outdoor sport could become unplayable.

Sporting organisations, all levels of government and all Australians need to be aware of the escalating climate risks to a sector worth $50 billion, employing almost a quarter of a million Australians. Other immensely important benefits of sport include improved health and wellbeing and social opportunities for communities, particularly in rural and regional areas. These benefits are also at risk from a supercharged climate of intense, and increasingly destructive extreme weather.

Figure 3: Conditions primed for athlete heat stress. Source: Climate Council (2021) Adapted from ACF and MCCCRH 2020.

switch sponsorship from fossil fuelbacked companies to ones that invest in climate solutions. When it comes to the impacts of climate change that can no longer be avoided, sports can and must work to adapt. Sporting calendars can adapt to a rapidly changing climate by scheduling seasons, matches and events to more favourable times of year or times of day. Science-backed policies on heat, bushfire smoke and other extreme weather events should

also be put in place, and regularly updated by all sporting codes and leagues, to protect both athletes and spectators and the role of sport as a critical part of our culture.

The clock is ticking, climate change is accelerating and we must urgently tackle the climate crisis to protect the Australian summer of sport we love, for current and future generations to enjoy.

Author Bio Dr Martin Rice is former Head of Research for the Climate Council. Previously he was the Co-ordinator of the Earth

The good news is that sport can be a powerful force for change. Using the star appeal and influence of elite athletes, clubs and national teams, as well as global sporting events, sport can call for stronger action and leadership and embed climate solutions in its operations. This includes professional and community teams powering stadiums and venues with renewable energy and battery storage technologies, applying energy efficiency measures, reducing waste, and promoting sustainable transport to and from sporting events. Professional and community clubs and leagues can

System Science Partnership (ESSP) in Paris, France. The ESSP is a global interdisciplinary program with joint projects on the carbon cycle, global water system, human health and food systems.

Prior to working for the ESSP he was a Programme Manager for the AsiaPacific Network for Global Change Research (APN) in Kobe, Japan. The APN is an intergovernmental network that promotes policy-oriented research and capacity-building activities related to global change in the region.

Martin’s PhD research at Macquarie University was on integrated Earth System Science: research practice and science communication. He is an Honorary Associate, Department of Environmental Sciences, Macquarie University and he has published in peer-reviewed journals, books and reports.

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5 MINUTES WITH

5 minutes with

Professor Ollie Jay OLLIE JAY IS PROFESSOR OF HEAT AND HEALTH AT THE UNIVERSITY OF SYDNEY, AND DIRECTOR OF THE HEAT AND HEALTH RESEARCH INCUBATOR IN THE FACULTY OF MEDICINE AND HEALTH. HE ALSO LEADS THE THERMAL ERGONOMICS LABORATORY IN THE SUSAN WAKIL HEALTH BUILDING, AND A MEMBER OF THE CHARLES PERKINS CENTRE (CPC) AND SYDNEY ENVIRONMENT INSTITUTE.

Could you just give us a little bit of background on how you came into your field and into sports medicine in general?

I did my PhD at Loughborough University in the UK, and Loughborough is quite well known for its sport, even though I didn’t do my PhD in sports science. I was doing work on thermal regulatory physiology, and after that I was in Canada for ten years as a post-doctorate firstly in Vancouver and then Ottawa. Then in 2008, I became an Associate Professor which is equivalent of a lecturer, and I was there until the end of 2013 before I moved to Sydney in 2014. During that period, I developed an expertise VOLUME 39 • ISSUE 3 2022

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5 MINUTES WITH

5 minutes with

Professor Ollie Jay in thermal regulatory physiology, particularly with respect to heat stress.

Obviously, when I got to Australia, heat is a big challenge, particularly for people in the sporting industry. That’s when I started getting involved with various sporting organisations who reached out to me to help them out with the challenges that they were having with managing stress risk. The first organisation that I worked with was the NRL and that’s because they had the Rugby League World Cup in 2017 that they were administering and they had some games in Northern Queensland and in Papua New Guinea that they were particularly concerned about because it was in October and it was very hot and humid. I worked with them and then started working with Cricket Australia to develop their revised heat policy and heat management tool. That led to working with Tennis Australia to develop their new heat stress management system associated with the Australian Open.

Is there a particular element of thermoregulatory physiology that drew you to it rather than another area in sports medicine?

I’m a physiologist first and foremost so my expertise was in thermal regulatory physiology, particularly heat stress physiology. There was this need from the perspective within the sports medicine community for evidencebased heat stress management policies and risk assessment approaches and interventions. I think I was probably best placed to provide that expertise because my role is not necessarily the treatment of heat illness or anything like that. It’s the prevention of it and it really requires a deep understanding of how the human body works and how it interacts with the environment. So that was kind 30

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My role is the prevention of heat illness and it really requires a deep understanding of how the human body works and how it interacts with the environment

of where my expertise kind of really complimented the expertise of the sports medicine physicians that I’ve had the privilege to work with, such as Paul Bloomfield for the NRL, John Orchard for Cricket Australia, and Carolyn Broderick for Tennis Australia. They’ve got the medical part taken care of and I have the heat stress part taken care of, that is why we work so well together.

Can you tell us a bit about your work with SMA’s heat policy and upcoming online tools?

I led the development of the new heat policy for SMA, which was released in February of 2021. There were plans at the time to rapidly translate that into an online tool that people could use to assess their heat, to basically make it more usable. Having a paper-based policy is one thing, but actually having an online tool to make it much more usable is an entirely different thing.

We were working on that, but with the kind of transition of leadership and the site reorganisation that took place at SMA that was put on hold for a bit. Now I spoke with Jamie Crain just before Christmas about trying to move that forward and it looks as though that’s going to happen soon. So, I led the development of that, I worked

with Carolyn Broderick again on that, and then James Smallcombe who is a postdoctoral fellow in my research group here at the University of Sydney.

How has being associated with SMA helped you within your research and career so far?

So SMA reached out to us to develop its new heat policy in recognition of the work that we’ve done in other domains or other similar areas solving the similar challenge for other organisations.

We were very happy to do work with SMA, it’s a good opportunity to demonstrate further translation of our work to a larger audience. That’s a nice opportunity to have whereby if you’re developing a new heat policy and new heat management tool for Cricket Australia, let’s say, or for Tennis Australia, that only reaches people who play those particular sports. SMA guidance is adopted across many sports. This new SMA policy covers, I think, 34 or 35 sports at the moment and we have an intention to broaden that out to more sports. The opportunity to translate our work to affect health outcomes of a wider community is good and that’s really what this collaboration with SMA is offering.

5 MINUTES WITH

What does the future look like for you and your research?

The work that I do is not just focused on sport. That is one stream of research that I do. We do a lot of work in the area of public health and trying to help the most vulnerable, to navigate them through heat waves, for example, in different parts of the world. We have an international reach through the different types of work that we’ll do from a health perspective. To that end, I’ve recently established, and I am director of the heat and health research incubator at the University of Sydney. This is a multidisciplinary

collaboration of researchers that recognise that the challenges that are posed in the context of climate change, the problems that are presented by the effects of extreme heat or hot weather on human health and wellbeing, are very complex. In order to develop the most comprehensive and effective solutions that really impact people you need to take a multidisciplinary approach. So, this incubator center is serving as a means to bring people from different research disciplines or expertise in the areas of clinical and Health Sciences and beyond. Bringing those people together and giving

them a platform to work together and to develop and work on these real big picture problems and find solutions for them. That’s what the what the future really is with this heat and health research incubator. Again, you know, sport is an aspect and physical activity is an aspect of that, but it’s only a relatively small aspect of the bigger picture that we need to think about. That is how extreme heat and hot weather is going to impact people’s lives in the future, globally, with climate change, and they’re really quite profound and troubling questions that we need to work on.

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PEOPLE WHO SHAPED SMA: MICHELLE BERGERON

People Who Shaped SMA

Michelle Bergeron MICHELLE BERGERON IS AN SMA BOARD MEMBER AND A PHYSIOTHERAPIST WITH OVER 15 YEARS’ EXPERIENCE. SHE HAS A SPECIFIC INTEREST IN FOOT AND ANKLE INJURIES, EXERCISE, AND SPORTS INJURIES, WITH A CLINICAL BACKGROUND IN ELITE SPORT AND PERFORMING ARTS. INSTAGRAM @MICHELLE.PHYSIO

What made you decide on a career in sports medicine?

Like many of us, I played a lot of sport growing up in Canada, and I got injured a fair bit. I had parents who generally took me to the physio instead of the doctor to get my injuries managed. So, I got exposed to it in my teens and thought that it seemed interesting. I just explored that pathway a bit and something I thought when I was young ended up being something I thought would be good as I got older.

friends who were podiatrists. I had friends across lots of fields and I felt like we weren’t always friendly enough as clinicians. I just got exposed to it in that way where I started going to a lot of the events and really taking in what they were saying. Then I moved back to Canada where I held onto my membership for a bit, and then I let it lapse because internationally there weren’t a lot of webinars at the time. So, I didn’t keep it up. But

I was always disappointed in Canada because we didn’t have an umbrella organisation for sports medicine. We had sports physios, sports doctors, but not together. When I moved back to Australia in 2016, I just knew I wanted to get back with it. I started going to the events again. Then I saw one day that there was an opening for state councillors. So, I put my application in because I thought I’d like to be part of this finally and actually be involved in it.

How did you end up getting involved with SMA? What was your pathway, obviously, from your sports medicine work into the role that you had with the organization?

When I first moved to Australia, I lived in Western Australia and I was a member of the APA, but I had never seen a sports organisation that was an umbrella organisation. In Canada, we didn’t have one, so when I moved to WA and I started seeing some of the courses and the seminars that SMA were doing, like the evening seminars on a Wednesday night, I thought it was really cool to have sports doctors and podiatrists and chiropractors and physios all talking together. It was something that I felt passionate about. My ex-husband was studying chiropractic and I had VOLUME 39 • ISSUE 3 2022

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PEOPLE WHO SHAPED SMA: MICHELLE BERGERON

People Who Shaped SMA

Michelle Bergeron What was something which you feel in your career is a standout moment, or something you’ve worked on that you’re really proud of?

There’s a few moments. I was really proud of working at Cirque du Soleil.

It had been a dream of mine; that was the pinnacle I saw at the time. It was amazing because it exposed me to not only that world, but also to working with coaches, athletic therapists and physicians. We had team meetings every week, and it was really well case managed, so that was great. Then I was really pleased when I moved back to Australia, to get a job at the Australian Ballet. That was another huge goal of mine – to work there. Same thing as Cirque du Soleil, the multidisciplinary team and the cohesion between the medical staff and everyone else just was amazing. I also really enjoyed doing some contract work with some of the footy clubs. It’s just been a real whirlwind of areas, from performing

arts to elite level other sports. But it was fun to transfer those skills across and help some of the AFL players, using the skills that I had from my previous background. I am also very proud of my time as Head Physio and Medical Coordinator of the World under 24 Ultimate championships in Perth in 2018. A weeklong event with 500+ athletes from 20+ countries in 3 divisions (men, women, mixed).

I managed all the Physios, Sports Doctors and emergency services, on a tight budget and we had a great event!

Does working with the circus throw up some unique challenges as opposed to your AFL stuff, or is it very much the same across the two areas?

There are definitely some similarities.

There’s a lot of differences as well, obviously, just even in the field of play and the apparatuses they use. But in early stage of rehab, athletes are all

athletes, you still have to manage the fact that they want to be playing their sport, that their injuries are preventing them from doing their jobs. Obviously, the injuries are a little bit different.

A lot more contact injuries in footy or any kind of contact sport versus performing arts. But it’s really interesting how much they translate across to each other. You just have to be a bit creative in using what you learn in one aspect and pulling it into something that looks quite different. So, a foot injury on a trampolinist, you still have to rehab a certain component of it the same as you would a footy player, until you get to the next stage of their rehab where that starts to differentiate quite a bit.

How has being part of SMA and being involved in the organisation helped you as a sports medicine professional?

When I was the State Council chair, it gave me an opportunity to develop my leadership skills. More often in physio or allied health, we work for ourselves, we work independently, or you might work in a clinic. But there’s not really lots of leadership opportunities in allied health unless you’re working at an elite club, and those are few and far between. So professionally, that was a really nice growth side of it. But I also like the contacts and connections, just meeting people who were like minded but across all different professions. The PhD researchers and the Osteopaths, the Chiropractors and knowing that we all want the same outcome for our

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PEOPLE WHO SHAPED SMA: MICHELLE BERGERON

athletes, we want the same outcome for society and that we can actually work well together. Professionally, just making those contacts and connections is amazing and being able to reach out to people with that as a background and saying I’m from SMA, I’d love to reach out to you and have a chat about something. The brand is well recognised enough that if you’re involved with it, it does open the door a little bit for you to kind of sneak in and have a chat with someone or pull some really interesting people into events as well.

Do you have any advice for people starting out in sports medicine? Is there any bits of wisdom you can pass across?

Something I like to encourage people to do is branch out a little bit. It’s really

easy to think that you played soccer, so you should work with soccer. But, I’ve worked with ultimate frisbee, gymnastics, volleyball, track, triathlons, amongst others. It’s only really by exploring all the different opportunities out there that you actually find what you might be really interested in. It might not be a sport that you knew anything about, but you can enjoy that side of it. So, I think being able to see beyond the few elite sports that people know, like, everyone knows AFL, everyone knows gymnastics and swimming, but there are hundreds of elite sports out there that need really good practitioners. And I spend time with coaches, I spend time with strength and conditioning people at teams with sports that I’ve not really exposed myself to. So be willing to sort of have that opportunity to learn.

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Photo: Bogdan Lazar/ gettyimages

SPORTS MEDICINE AROUND THE WORLD: NETHERL ANDS

Specialist Sport and Exercise Medicine in The Netherlands 36

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SPORTS MEDICINE AROUND THE WORLD: NETHERL ANDS

S

port and Exercise Medicine (SEM) in the Netherlands has its roots in social medicine. Sports physicians have been trained in the Netherlands since 1976, but it took until 1986 before Sports Medicine was recognised as an official branch of social medicine by the Dutch College of Social Medicine (CSG). In 2014, after a long struggle, the Ministry of Health, Science and Sport recognised Sports Medicine as a Medical Specialty and since then the sports physician is allowed to call himself a Specialist Sport and Exercise Medicine. The title Sports Physician is also a protected title in the Netherlands.

Sports Physician expert Sports medicine in the Netherlands is the medical specialty that focuses on restoring, safeguarding, and promoting the health of people who (want to) play sports or exercise. It also focuses on restoring and promoting the health of people with chronic conditions using sport/exercise as an intervention. In both facets, the specific load and loading-capacity of the patient is explicitly considered. The sports physician is the expert regarding the balance between load and loadingcapacity in relation to sport/exercise.

The sports physician is also an expert in analysing sport and exercise related

problems, thereby considering their multifactorial etiology. In cases of a musculoskeletal injury, it is good practice that abnormalities in the entire kinetic chain are assessed. This implies that therapeutic interventions can be aimed at several areas. The analysis and management of the health problem also includes advice about equipment, environmental conditions as well as psychological, social and cognitive factors.

Complementary to other specialties Sports physicians have a complementary and synergistic role in relation to other medical specialists

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SPORTS MEDICINE AROUND THE WORLD: NETHERL ANDS

Specialist Sport and Exercise Medicine in The Netherlands

such as orthopedic surgeons, cardiologists, pulmonologists, physicians for rehabilitation medicine, surgeons, doctors for internal medicine, and general practitioners.

For example, there is collaboration with orthopedic surgeons for maximising conservative treatment of sports injuries and for optimising recovery and return to performance after surgical interventions of the musculoskeletal system, and the use of sports and exercise by patients with chronic musculoskeletal disease, e.g., osteoarthritis.

In several hospitals cardiologists and sports physicians work together in the rehabilitation of cardiac patients.

Sports physicians have specific expertise in physiological aspects of training (heart failure, angina pectoris).

They often use cardiopulmonary exercise testing to design an effective personalised training intervention.

They also cooperate in the diagnostic work-up and management of more complex exercise-related symptoms (e.g., unexplained fatigue).

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Specialists at the training hospitals teach and train the resident in Sports Medicine to become a sports physician based on the National Training Plan, translated into regional and local training plans.

Sports physicians work together with pulmonologists, by athletes and patients with sports/exercise related lung problems. Sports physicians perform elaborate lung function tests themselves in the context of preventive sports medical examinations, however they often refer athletes with exerciseinduced asthma or other lung-related symptoms to a pulmonologist.

Sports physicians, with their specific knowledge in exercise physiology and cardiopulmonary exercise testing, can design and prescribe personalised training programs for specific target groups in the rehabilitation setting. Especially patients who are deconditioned because of their (chronic) disease or treatment. Exercise testing is used to determine the individual loading-capacity and excluding cardiopulmonary pathology. These diagnostic findings are used to develop training programs that aim to increase the load capacity of the patient/ athlete in question. The knowledge and expertise of the sports physician is also increasingly used in the field of pre-operative training, also known as preconditioning/prehabilitation.

Sports physicians also collaborate with internal medicine doctors in prevention and management of diabetes mellitus, oncological rehabilitation, and exercise prescriptions for people with all forms of chronic diseases. General practitioners refer to the sports

SPORTS MEDICINE AROUND THE WORLD: NETHERL ANDS

Photo: Sean Pavone/ gettyimages

conditions. Exercise prescriptions are given during consultations as well as during preventive sports medical examinations.

physician for sports medical problems that cannot be solved in primary care as well as for clinical diagnostics and conservative treatment of sports-related injuries and secondary prevention.

Exercise is Medicine Exercise is used worldwide as a ‘medicine’ for primary and secondary prevention of chronic disease.

The Dutch government has also recognised the importance of lifestyle factors including physical activity in the prevention of chronic disease.

The Netherlands Association for Sports Medicine (VSG, the scientific association) has the ambition that the sports physician will be the medical specialist in the field of ‘exercise is medicine’. How this translates to the daily practice of sports physicians will become clearer in the coming years.

In relation to the sports medicine specialist training this means that the resident learns the principles of how to prescribe exercise to patients with various chronic

The specialist training of Sports Physicians An independent organisation The Foundation for Professional Training for Sports Physicians (SBOS) specifically designated for this purpose by the Ministry of Health, Welfare and Sport: is responsible for the education and training of the sports physicians. This is different from other specialties in the Netherlands, whereby the teaching hospitals are responsible. The SBOS financially supports and facilitates the sports medicine specialist training as well as fulfilling the role of employer.

Sports Medicine residents are employed by the SBOS ​​and are trained at accredited teaching hospitals based on a distribution plan established by the government. The Netherlands Association for Sports Medicine (VSG) is responsible for developing and regularly updating the National Training Plan (LOP).

Sports medicine specialist training consists of compulsory residencies / teaching on the job in relevant disciplines (Sports Medicine, Cardiology, Pulmonary Medicine, Orthopedics and General Practice) in combination with national and local (cross-discipline) education including courses on various topics both within and outside Sports Medicine.

Declarations of Competency The sports medicine specialist training program has been described in the form of Entrusted Professional Activities (EPAs). In the nine EPAs, the competencies are operationalised in observable behavior. EPAs fit in well with the daily work of the sports

physician resident in practice. The order in which the resident learns these EPAs has not strictly been determined, as this can differ per training region. By issuing phased declarations of competence, residents in Sports Medicine are gradually growing towards professional independence and responsibility.

After their training they can work in several places. In addition to the normal training program, in-depth specialist training can be included in the final year of the training.

The training plan pays explicit attention to several current social and organisational themes to properly prepare the Sports Medicine resident for the various roles that the sports physicians fulfill in addition to their clinical activities.

Competency-orientated The nominal duration of the training is four years and since 1 July 2014 it is possible to personalise the duration of the training for the individual resident.

The aim of this regulation is to make it possible for the resident to be trained for as long as necessary and as short as responsible. This makes it possible to create a tailor-made competencybased training. As a result, the duration of the training is determined by what the resident has developed in terms of competences prior to and during the training. To properly prepare residents in Sports Medicine for the various roles that sports physicians fulfill in daily work in addition to clinical activities, the Sports Medicine program pays explicit attention to several current social and/or organisational themes such as medical leadership, patient safety, efficiency, vulnerable elderly people, chronic ailments, scientific research and education as well as communication, collaboration, management and health advocacy.

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SPORTS TRAINER HIGHLIGHT

Sports Trainer Highlight with

Nic Radoll How long have you been a sports trainer and what got you into this profession?

I joined SMA and did a Level 1 Sports Trainer course in July 2017, and then I started doing work for SMA straight after my Level 1 course. I played quite a few sports growing up from 2011 right up to 2016. I was playing Quidditch and I was involved in team sports until I copped a concussion in late 2016. I was looked after by the Canberra Cohort of sports trainers at the time. Also, when I was playing roller Derby, I had a guy land on me twice on my head so I copped a few too many concussions for my liking and decided I value my brain. I was also noticing issues relating to concussion such as not being able to retain information and also I was slow to absorb information.

I went from being an HD student at university to failing. I just could not remember information, which was super frustrating. So, I ended up with SMA and thought they did an amazing job. Then, in December 2017, I moved to Melbourne as part of my full-time job and met David Griffiths down here, and we did some stuff in both sports benefit in Australia. That is also when I started Deadly Thought Sports Plus which was around late 2017.

Is there an element of your work that you particularly enjoy?

For me, it’s actually interacting with people and getting to work with them when they are at their worst point in life. I’ve tried to develop skills outside sports training, but for me it’s all about being there for somebody when they need help – whether it be physical or even mental healthrelated. For example, with soccer, I look after soccer teams and here I am stretching out a hamstring. There’s 40

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nothing wrong with it and with the players who have a breakdown in the middle of the field. So, I am out there on the field stretching out a hamstring and saying “it’s okay, we’ll build them back up, you’ll be fine”. That is the sort of environment I enjoy having. It’s that close interaction with players.

Is there a highlight or a moment from your career that has really stood out?

It’s more the overall experiences for me.

I am a lifelong learner and that is what I did. So, after I started sport training, I was thinking about whether or not to go down the allied health aspect and started a massage qualification and ended up with a set of massage therapy degrees. That’s because

that’s what I thought I wanted to do, to build those experiences and build up those teams. Now, I’ve also done a Diploma in Emergency Healthcare to build that trauma side up. For me as an Aboriginal person, it’s that community focus, building up those community interactions and giving back to the sporting community that I went through when I was growing up, and ensuring that safety. In terms of specific examples, I don’t really have any. In 2018, I had one of my first cases of a death and that changed my perspective on how I deal with things, and that professional separation. But in terms of the actual impact and cool things, I like little athletics as I get to hang out with little kids all day and they come in wanting a band aid.

SPORTS TRAINER HIGHLIGHT

But then when you get some really dramatic things, I had one kid in Under Sixes who ran and tried to do the launch up, and he decided halfway through his jump that he’s going to bail. So, I talked to them and ended up that he was fine – just ensuring that comfort for parents for that kid.

How has being a part of Sports Medicine Australia helped you and helped your career up until this point?

I’ve always been interested in the first-aid sphere but the point was that

you do St. John’s or you go down the pathway I’m doing now. First-aid tends to be a real niche area and SMA was an area that I could build my skills up.

Whereas in other fields, you have set procedures, set things, somebody’s injured, here’s what we do for first aid, and here we move them on to somebody else. With sports training, I find it so much more in-depth. I am not only just a first responder but I’m part of somebody’s recovery period.

I’m part of something overarching, and I feel like SMA has given me that opportunity. This is the same as

teaching for me. I came in as a sports trainer with a first-aid background and in May 2018, David got me into teaching with him, and I ended up getting my TAE because of SMA as well.

Do you have any advice for anyone who’s going into sports training or someone who wants to pursue this as a career?

My advice would be sports training isn’t just that clear cut. Sports training comes from a different background.

You’ve got parents or people just interested in this area and you don’t have to just stick with that allied health area. There is so much more to sports training, and there’s so much more diversity in this field that you can build those skills up. We are a Jack of all trades. As medics and allied health, we’re the first point of contact. We do everything from strength and conditioning to massage to first-aid to ongoing health. We are everything, and I think that’s what I love about it. I think people shouldn’t narrow themselves down.

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Publisher Sports Medicine Australia PO Box 78 Mitchell ACT 2911 sma.org.au ISSN No. 1032-5662 PP No. 226480/00028