Abstract
El golpe de calor por esfuerzo (GCE) es una de las causas principales de muerte súbita durante el deporte y la actividad física. Solamente en el fútbol americano han ocurrido 46 muertes documentadas en los EE.UU. entre 1995 y 2010. En el 2003, la asociación responsable por los deportes universitarios de los EE.UU. estableció pautas obligatorias de aclimatización al calor, las cuales tuvieron como resultado una disminución exitosa en el número de muertes por golpe de calor en ese deporte. Sin embargo, a pesar de los avances en la atención médica moderna y una mayor conciencia sobre medidas de seguridad para el calor, la falta de atención adecuada en el sitio para los pacientes continúa contribuyendo GCE, especialmente a nivel juvenil. Está debidamente establecido en las publicaciones científicas que es posible, en gran medida, prevenir las muertes por GCE en los contextos de deportes organizados, si se brinda una educación apropiada y se dispone de personal médico entendido en el reconocimiento y tratamiento del GCE. En este documento se hace una revisión de las mejores prácticas médicas actuales y de la evidencia sobre la epidemiología, fisiopatología, factores de riesgo, reconocimiento, tratamiento, prevención y recomendaciones sobre el regreso a la práctica deportiva para el GCE, específicamente en lo pertinente al contexto del deporte organizado.
References
Adams, W. M., Ferraro, E. M., Huggins, R. A., & Casa, D. J. (August, 2014). Influence of body mass loss on changes in heart rate during exercise in the heat: a systematic review. Journal of Strength and Conditioning Research, 28(8), 2380–2389. doi: http://dx.doi.org/10.1519/JSC.0000000000000501
Armed Forces Health Surveillance Center (AFHSC). (2014). Update: Heat injuries, active component, U.S. Armed Forces, 2013. MSMR, 21(3), 10–13.
Armstrong, L. E., Casa, D. J., Millard-Stafford, M., Moran, D. S., Pyne, S. W., & Roberts, W. O. (2007). Exertional heat illness during training and competition. American College of Sports Medicine position stand. Medicine and Science in Sports and Exercise, 39(3), 556–572. doi: http://dx.doi.org/10.1249/MSS.0b013e31802fa199
Armstrong, L. E., & Maresh, C. M. (1991). The induction and decay of heat acclimatisation in trained athletes. Sports Medicine, 12(5), 302–312. doi: http://dx.doi.org/10.2165/00007256-199112050-00003
Arngrïmsson, S. A., Petitt, D. S., Stueck, M. G., Jorgensen, D. K., & Cureton, K. J. (2004). Cooling vest worn during active warm-up improves 5-km run performance in the heat. Journal of Applied Physiology, 96(5), 1867–1874. doi: http://dx.doi.org/10.1152/japplphysiol.00979.2003
Bergeron, M. F., McKeag, D. B., Casa, D. J., Clarkson, P. M., Dick, R. W., Eichner, E. R., … Rowland, T. W. (2005). Youth football: heat stress and injury risk. Medicine and Science in Sports and Exercise, 37(8), 1421–1430. doi: http://dx.doi.org/10.1249/01.mss.0000174891.46893.82
Biery, J. C., Blivin, S. J., & Pyne, S. W. (May/June, 2010). Training in ACSM black flag heat stress conditions: how U.S. marines do it. Current Sports Medicine Reports, 9(3), 148–154. doi: http://dx.doi.org/10.1249/JSR.0b013e3181df102d
Binkley, H. M., Beckett, J., Casa, D. J., Kleiner, D. M., & Plummer, P. E. (2002). National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses. Journal of Athletic Training, 37(3), 329–343.
Bouchama, A., & Knochel, J. P. (2002). Heat stroke. The New England Journal of Medicine, 346(25), 1978–1988. doi: http://dx.doi.org/10.1056/NEJMra011089
Bracker, M. O. (1991). Hyperthermia: man’s adaptation to a warm climate. Sports Medicine Dig, 12, 1–2.
Brady, E. (2011, August 15). Heat-related illness still deadly problem for athletes. USA Today. Retrieved from: www.usatoday.com/sports/2011-08-15-heat-stroke-still-causing-death-in-athletes_n.htm
Brewster, S. J., Oʼconnor, F. G., & Lillegard, W. A. (1995). Exercise-induced heat injury: diagnosis and management. Sports Medicine and Arthroscopy Review, 3(4), 260–266. doi: http://dx.doi.org/10.1097/00132585-199500340-00002
Cabanac, M., & White, M. D. (1995). Core temperature thresholds for hyperpnea during passive hyperthermia in humans. European Journal of Applied Physiology and Occupational Physiology, 71(1), 71–76. doi: http://dx.doi.org/10.1007/BF00511235
Casa, D. J., Almquist, J., Anderson, S. A., Baker, L., Bergeron, M. F., Biagioli, B., … Valentine, V. (2013). The inter-association task force for preventing sudden death in secondary school athletics programs: best-practices recommendations. Journal of Athletic Training, 48(4), 546–553. doi: http://dx.doi.org/10.4085/1062-6050-48.4.12
Casa, D. J., Anderson, S. A., Baker, L., Bennett, S., Bergeron, M. F., Connolly, D., … Thompson, C. (2012a). The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations. Journal of Athletic Training, 47(4), 477–480.
Casa, D. J., Armstrong, L. E., Ganio, M. S., & Yeargin, S. W. (December, 2005). Exertional heat stroke in competitive athletes. Current Sports Medicine Reports, 4(6), 309–317. doi: http://dx.doi.org/10.1097/01.CSMR.0000306292.64954.da
Casa, D. J., Armstrong, L. E., Kenny, G. P., O’Connor, F. G., & Huggins, R. A. (May/Jun, 2012). Exertional heat stroke: new concepts regarding cause and care. Current Sports Medicine Reports, 11(3), 115–123. doi: http://dx.doi.org/10.1249/JSR.0b013e31825615cc
Casa, D. J., Becker, S. M., Ganio, M. S., Brown, C. M., Yeargin, S. W., Roti, M. W., … Maresh, C. M. (2007a). Validity of devices that assess body temperature during outdoor exercise in the heat. Journal of Athletic Training, 42(3), 333–342.
Casa, D. J., Clarkson, P. M., & Roberts, W. O. (2005b). American College of Sports Medicine roundtable on hydration and physical activity: consensus statements. Current Sports Medicine Reports, 4(3), 115–127. doi: http://dx.doi.org/10.1097/01.CSMR.0000306194.67241.76
Casa, D. J., Csillan, D., Inter-Association Task Force for Preseason Secondary School Athletics Participants, Armstrong, L. E., Baker, L. B., Bergeron, M. F., … Yeargin, S. W. (May/June, 2009). Preseason heat-acclimatization guidelines for secondary school athletics. Journal of Athletic Training, 44(3), 332–333. Retrieved from: http://natajournals.org/doi/abs/10.4085/1062-6050-44.3.332 doi: http://dx.doi.org/10.4085/1062-6050-44.3.332
Casa, D. J., Guskiewicz, K. M., Anderson, S. A., Courson, R. W., Heck, J. F., Jimenez, C. C., … Walsh, K. M. (2012c). National athletic trainers’ association position statement: preventing sudden death in sports. Journal of Athletic Training, 47(1), 96–118.
Casa, D. J., Kenny, G. P., & Taylor, N. A. S. (July, 2010). Immersion treatment for exertional hyperthermia: cold or temperate water? Medicine and Science in Sports and Exercise, 42(7), 1246–1252. doi: http://dx.doi.org/10.1249/MSS.0b013e3181e26cbb
Casa, D. J., McDermott, B. P., Lee, E. C., Yeargin, S. W., Armstrong, L. E., & Maresh, C. M. (July, 2007). Cold water immersion: the gold standard for exertional heatstroke treatment. Exercise and Sport Sciences Reviews, 35(3), 141–149. doi: http://dx.doi.org/10.1097/jes.0b013e3180a02bec
Casa, D. J., Stearns, R. L., Lopez, R. M., Ganio, M. S., McDermott, B. P., Walker, S., … Maresh, C. M. (2010b). Influence of hydration on physiological function and performance during trail running in the heat. Journal of Athletic Training, 45(2), 147–156. Retrieved from: http://natajournals.org/doi/full/10.4085/1062-6050-45.2.147?= doi: http://dx.doi.org/10.4085/1062-6050-45.2.147
Casa et al. (2014). National Athletic Trainers’ Association Position Statement: Exertional Heat Illnesses [In Print]. Journal of Athletic Training.
Chalmers, S., Esterman, A., Eston, R., Bowering, K. J., & Norton, K. (July, 2014). Short-term heat acclimation training improves physical performance: a systematic review, and exploration of physiological adaptations and application for team sports. Sports Medicine, 44(7), 971–988. doi: http://dx.doi.org/10.1007/s40279-014-0178-6
Chen, T.-I., Tsai, P.-H., Lin, J.-H., Lee, N.-Y., & Liang, M. T. (2013). Effect of short-term heat acclimation on endurance time and skin blood flow in trained athletes. Open Access Journal of Sports Medicine, 4, 161–170. doi: http://dx.doi.org/10.2147/OAJSM.S45024
Cheuvront, S. N., Montain, S. J., & Sawka, M. N. (April, 2007). Fluid replacement and performance during the marathon. Sports Medicine, 37(4-5), 353–357. doi: http://dx.doi.org/10.2165/00007256-200737040-00020
Cleary, M. (2007). Predisposing risk factors on susceptibility to exertional heat illness: clinical decision-making considerations. Journal of Sport Rehabilitation, 16(3), 204–214.
Coris, E. E., Ramirez, A. M., & Van Durme, D. J. (January, 2004). Heat illness in athletes: the dangerous combination of heat, humidity and exercise. Sports Medicine, 34(1), 9–16. doi: http://dx.doi.org/10.2165/00007256-200434010-00002
Costrini, A. (February, 1990). Emergency treatment of exertional heatstroke and comparison of whole body cooling techniques. Medicine and Science in Sports and Exercise, 22(1), 15–18. doi: http://dx.doi.org/10.1249/00005768-199002000-00004
Davidson M. (1985). Heat illness in athletics. Athl Train J Natl Athl Train Assoc, 20, 96–101.
DeMartini, J., Casa, D. J., Belval, L., Crago, A., Davis, R., Jardine, J., & Stearns, R. (July/August, 2014). Environmental Conditions and the Occurrence of Exertional Heat Illnesses and Exertional Heat Stroke at the Falmouth Road Race. Journal of Athletic Training, 49(4), 478-485. doi: http://dx.doi.org/10.4085/1062-6050-49.3.26
DeMartini, J. K., Casa, D. J., Stearns, R., Belval, L., Crago, A., Davis, R., & Jardine, J. (2014). Effectiveness of CWI in the Treatment of EHS at the Falmouth Road Race. Medicine and Science in Sports and Exercise. doi: http://dx.doi.org/10.1249/MSS.0000000000000409
DeMartini, J. K., Ranalli, G. F., Casa, D. J., Lopez, R. M., Ganio, M. S., Stearns, R. L., … Maresh, C. M. (August, 2011). Comparison of body cooling methods on physiological and perceptual measures of mildly hyperthermic athletes. Journal of Strength and Conditioning Research, 25(8), 2065–2074. doi: http://dx.doi.org/10.1519/JSC.0b013e3182259b1d
Distefano, L. J., Casa, D. J., Vansumeren, M. M., Karslo, R. M., Huggins, R. A., DeMartini, J. K., … Maresh, C. M. (June, 2013). Hypohydration and hyperthermia impair neuromuscular control after exercise. Medicine and Science in Sports and Exercise, 45(6), 1166–1173. doi: http://dx.doi.org/10.1249/MSS.0b013e3182805b83
Drezner, J. A. (2012). Prevention of Sudden Cardiac Death in Young Athletes. In D. Casa (Ed.), Preventing Sudden Death in Sport and Physical Activity (pp. 15–31). Sudbury, MA: Jones & Bartlett.
Epstein, Y., Hadad, E., & Shapiro, Y. (October-December, 2004). Pathological factors underlying hyperthermia. Journal of Thermal Biology, 29(7–8), 487–494. doi: http://dx.doi.org/10.1016/j.jtherbio.2004.08.018
Epstein, Y., & Roberts, W. O. (2011). The pathopysiology of heat stroke: an integrative view of the final common pathway. Scandinavian Journal of Medicine & Science in Sports, 21(6), 742–748. doi: http://dx.doi.org/10.1111/j.1600-0838.2011.01333.x
Gagnon, D., Lemire, B. B., Casa, D. J., & Kenny, G. P. (2010). Cold-water immersion and the treatment of hyperthermia: using 38.6°C as a safe rectal temperature cooling limit. Journal of Athletic Training, 45(5), 439–444. doi: http://dx.doi.org/10.4085/1062-6050-45.5.439
Galaski MJ. (1985). Hyperthermia. Journal of the Canadian Athletic Therapy, 12, 23–26.
Ganio, M. S., Brown, C. M., Casa, D. J., Becker, S. M., Yeargin, S. W., McDermott, B. P., … Maresh, C. M. (2009). Validity and reliability of devices that assess body temperature during indoor exercise in the heat. Journal of Athletic Training, 44(2), 124–135. doi: http://dx.doi.org/10.4085/1062-6050-44.2.124
Gardner, J. W. (2003). Clinical diagnosis, management, and surveillance of exertional heat illness. In B. R. Pandolf KB (Ed.), Medical Aspects of harsh Environments (Vol. 1, pp. 231–279). Falls Church, VA: Office of Surgeon General, United States Army Medical Department.
Garrett, A. T., Rehrer, N. J., & Patterson, M. J. (September, 2011). Induction and decay of short-term heat acclimation in moderately and highly trained athletes. Sports Medicine, 41(9), 757–771. doi: http://dx.doi.org/10.2165/11587320-000000000-00000
Grundstein, A. J., Ramseyer, C., Zhao, F., Pesses, J. L., Akers, P., Qureshi, A., … Petro, M. (January, 2012). A retrospective analysis of American football hyperthermia deaths in the United States. International Journal of Biometeorology, 56(1), 11–20. doi: http://dx.doi.org/10.1007/s00484-010-0391-4
Hall, D. M., Buettner, G. R., Oberley, L. W., Xu, L., Matthes, R. D., & Gisolfi, C. V. (2001). Mechanisms of circulatory and intestinal barrier dysfunction during whole body hyperthermia. American Journal of Physiology. Heart and Circulatory Physiology, 280(2), H509–521.
Haymes EM, & Wells CL. (1986). Environment and Human Performance. Champaign, IL.
Howe, A. S., & Boden, B. P. (August, 2007). Heat-related illness in athletes. The American Journal of Sports Medicine, 35(8), 1384–1395. doi: http://dx.doi.org/10.1177/0363546507305013
Huggins, R., Martschinske, J., Applegate, K., Armstrong, L., & Casa, D. (2014). Influence of Dehydration on Internal Body Temperature Changes During Exercise in the Heat: A Meta-Analysis. Temperature, In Review.
Johnson, E. C., Ganio, M. S., Lee, E. C., Lopez, R. M., McDermott, B. P., Casa, D. J., … Armstrong, L. E. (2010). Perceptual responses while wearing an American football uniform in the heat. Journal of Athletic Training, 45(2), 107–116. doi: http://dx.doi.org/10.4085/1062-6050-45.2.107
Johnson S. (1993). Central regulation of body temperature. In Exercise, Heat and Thermoregulation (pp. 7–35). Carmel, IN: Cooper Publishing Group.
Judelson, D. A., Maresh, C. M., Farrell, M. J., Yamamoto, L. M., Armstrong, L. E., Kraemer, W. J., … Anderson, J. M. (October, 2007). Effect of hydration state on strength, power, and resistance exercise performance. Medicine and Science in Sports and Exercise, 39(10), 1817–1824. doi: http://dx.doi.org/10.1249/mss.0b013e3180de5f22
Kazman, J. B., Heled, Y., Lisman, P. J., Druyan, A., Deuster, P. A., & O’Connor, F. G. (March/April, 2013). Exertional heat illness: the role of heat tolerance testing. Current Sports Medicine Reports, 12(2), 101–105. doi: http://dx.doi.org/10.1249/JSR.0b013e3182874d27
Kenney W. (1996). Thermoregulation during exercise in the heat. Athletic Therapy Today, 1, 13–16.
Kerr, Z. Y., Casa, D. J., Marshall, S. W., & Comstock, R. D. (2013). Epidemiology of exertional heat illness among U.S. high school athletes. American Journal of Preventive Medicine, 44(1), 8–14. doi: http://dx.doi.org/10.1016/j.amepre.2012.09.058
Lambert, G. P. (October, 2004). Role of gastrointestinal permeability in exertional heatstroke. Exercise and Sport Sciences Reviews, 32(4), 185–190. doi: http://dx.doi.org/10.1097/00003677-200410000-00011
Lambert, G. P. (2008). Intestinal barrier dysfunction, endotoxemia, and gastrointestinal symptoms: the “canary in the coal mine” during exercise-heat stress? Medicine and Sport Science, 53, 61–73. doi: http://dx.doi.org/10.1159/000151550
Leon, L. R. (2007). Heat stroke and cytokines. Progress in Brain Research, 162, 481–524. doi: http://dx.doi.org/10.1016/S0079-6123(06)62024-4
Leon, L. R., & Helwig, B. G. (2010). Heat stroke: role of the systemic inflammatory response. Journal of Applied Physiology, 109(6), 1980–1988. doi: http://dx.doi.org/10.1152/japplphysiol.00301.2010
Lorenzo, S., Halliwill, J. R., Sawka, M. N., & Minson, C. T. (2010). Heat acclimation improves exercise performance. Journal of Applied Physiology, 109(4), 1140–1147. doi: http://dx.doi.org/10.1152/japplphysiol.00495.2010
McDermott, B. P., Casa, D. J., O’Connor, F. G., Adams, W. B., Armstrong, L. E., Brennan, A. H., … Yeargin, S. W. (August, 2009). Cold-water dousing with ice massage to treat exertional heat stroke: a case series. Aviation, Space, and Environmental Medicine, 80(8), 720–722. doi: http://dx.doi.org/10.3357/ASEM.2498.2009
McDermott, B. P., Casa, D. J., Yeargin, S. W., Ganio, M. S., Armstrong, L. E., & Maresh, C. M. (2007). Recovery and return to activity following exertional heat stroke: considerations for the sports medicine staff. Journal of Sport Rehabilitation, 16(3), 163–181.
Montain, S. J., & Coyle, E. F. (1992). Influence of graded dehydration on hyperthermia and cardiovascular drift during exercise. Journal of Applied Physiology, 73(4), 1340–1350. Retrieved from: http://jap.physiology.org/content/73/4/1340
Morrison, S. F., Nakamura, K., & Madden, C. J. (2008). Central control of thermogenesis in mammals. Experimental Physiology, 93(7), 773–797. doi: http://dx.doi.org/10.1113/expphysiol.2007.041848
Moseley, P. L., Gapen, C., Wallen, E. S., Walter, M. E., & Peterson, M. W. (1994). Thermal stress induces epithelial permeability. The American Journal of Physiology, 267(2 Pt 1), C425–434.
Mueller, F. O., & Cantu, R. C. (2011). Annual survey of catastrophic football injuries 1977-2010 (pp. 1–28). National Center for Catastrophic Sport Injury Research. Retrieved from: http://www.unc.edu/depts/nccsi/2010FBCatReport.pdf
Mueller FO, & Colgate B. (2011a). Survey of Football Injury Research: Anuual Report 2010. Chapel Hill, University of North Carolina at Chapel Hill.
O’Connor, F. G., Casa, D. J., Bergeron, M. F., Carter, R., Deuster, P., Heled, Y., … Sawka, M. (2010). American College of Sports Medicine Roundtable on exertional heat stroke--return to duty/return to play: conference proceedings. Current Sports Medicine Reports, 9(5), 314–321. doi: http://dx.doi.org/10.1249/JSR.0b013e3181f1d183
O’Connor, F. G., Williams, A. D., Blivin, S., Heled, Y., Deuster, P., & Flinn, S. D. (2007). Guidelines for return to duty (play) after heat illness: a military perspective. Journal of Sport Rehabilitation, 16(3), 227–237.
Pals, K. L., Chang, R. T., Ryan, A. J., & Gisolfi, C. V. (1997). Effect of running intensity on intestinal permeability. Journal of Applied Physiology, 82(2), 571–576.
Pryor, R. R., Casa, D. J., Adams, W. M., Belval, L. N., DeMartini, J. K., Huggins, R. A.,... Vandermark, L. W. (2013). Maximizing Athletic Performance in the Heat. Strength & Conditioning Journal, 35(6), 24–33. doi: http://dx.doi.org/10.1519/SSC.0000000000000016
Rae, D. E., Knobel, G. J., Mann, T., Swart, J., Tucker, R., & Noakes, T. D. (July, 2008). Heatstroke during endurance exercise: is there evidence for excessive endothermy? Medicine and Science in Sports and Exercise, 40(7), 1193–1204. doi: http://dx.doi.org/10.1249/MSS.0b013e31816a7155
Rav-Acha, M., Hadad, E., Epstein, Y., Heled, Y., & Moran, D. S. (August, 2004). Fatal exertional heat stroke: a case series. The American Journal of the Medical Sciences, 328(2), 84–87. doi: http://dx.doi.org/10.1097/00000441-200408000-00003
Roberts, W. O. (September, 2000). A 12-yr profile of medical injury and illness for the Twin Cities Marathon. Medicine and Science in Sports and Exercise, 32(9), 1549–1555. doi: http://dx.doi.org/10.1097/00005768-200009000-00004
Roberts, W. O. (2006). Exertional heat stroke during a cool weather marathon: a case study. Medicine and Science in Sports and Exercise, 38(7), 1197–1203. doi:10.1249/01.mss.0000227302.80783.0f doi: http://dx.doi.org/10.1249/01.mss.0000227302.80783.0f
Rowell, L. B. (1983). Cardiovascular aspects of human thermoregulation. Circulation Research, 52(4), 367–379. doi: http://dx.doi.org/10.1161/01.RES.52.4.367
Saltin, B., & Hermansen, L. (1966). Esophageal, rectal, and muscle temperature during exercise. Journal of Applied Physiology, 21(6), 1757–1762.
Sawka MN, & Wenger CB. (n.d.). Physiological responses to acute exercise-heat stress. In Human performance physiology and environmental medicine at terresterial extremes (Vols. 1-New York, 1-NY, pp. 97–152). Benchmark.
Shapiro, Y., Alkan, M., Epstein, Y., Newman, F., & Magazanik, A. (August, 1986). Increase in rat intestinal permeability to endotoxin during hyperthermia. European Journal of Applied Physiology and Occupational Physiology, 55(4), 410–412. doi: http://dx.doi.org/10.1007/BF00422742
Siegel, R., Maté, J., Brearley, M. B., Watson, G., Nosaka, K., & Laursen, P. B. (April, 2010). Ice slurry ingestion increases core temperature capacity and running time in the heat. Medicine and Science in Sports and Exercise, 42(4), 717–725. doi: http://dx.doi.org/10.1249/MSS.0b013e3181bf257a
Siegel, R., Maté, J., Watson, G., Nosaka, K., & Laursen, P. B. (2012). Pre-cooling with ice slurry ingestion leads to similar run times to exhaustion in the heat as cold water immersion. Journal of Sports Sciences, 30(2), 155–165. doi: http://dx.doi.org/10.1080/02640414.2011.625968
Smith, J. E. (2004). The pathophysiology of exertional heatstroke. Journal of the Royal Naval Medical Service, 90(3), 135–138.
Stearns, R. L., Casa, D. J., Lopez, R. M., McDermott, B. P., Ganio, M. S., Decher, N. R., … Maresh, C. M. (2009). Influence of hydration status on pacing during trail running in the heat. The Journal of Strength and Conditioning Research, 23(9), 2533–2541. doi: http://dx.doi.org/10.1519/JSC.0b013e3181b73c3f
Stearns, R., O’Connor, F., Casa, D., & Kenny, G. (2012). Exertional Heat Stroke. In D. Casa (Ed.), Preventing Sudden Death in Sport and Physical Activity (pp. 53–77). Sudbury, MA: Jones & Bartlett.
Wallace, R. F., Kriebel, D., Punnett, L., Wegman, D. H., & Amoroso, P. J. (June, 2007). Prior heat illness hospitalization and risk of early death. Environmental Research, 104(2), 290–295. doi: http://dx.doi.org/10.1016/j.envres.2007.01.003
Wallace, R. F., Kriebel, D., Punnett, L., Wegman, D. H., Wenger, C. B., Gardner, J. W., & Kark, J. A. (2006). Risk factors for recruit exertional heat illness by gender and training period. Aviation, Space, and Environmental Medicine, 77(4), 415–421.
Werner J. (n.d.). Central regulation of body temperature. In Exercise, Heat and Thermoregulation (pp. 7–35). Carmel, IN: Cooper Publishing Group.
Yeargin, S. W., Casa, D. J., McClung, J. M., Knight, J. C., Healey, J. C., Goss, P. J., … Hipp, G. R. (2006). Body cooling between two bouts of exercise in the heat enhances subsequent performance. Journal of Strength and Conditioning Research, 20(2), 383–389. doi: http://dx.doi.org/10.1519/R-18075.1