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Physiological Implications of Altitude Training for Endurance Performance BrJ7 Sports Med 1997;31:183-190 183 Physiological implications of altitude training for Br J Sports Med: first published as 10.1136/bjsm.31.3.183 on 1 September 1997. Downloaded from endurance performance at sea level: a review Damian M Bailey, Bruce Davies Summary decreases in absolute training intensity,'0 de- Acclimatisation to environmental hypoxia initi- creased plasma volume," depression ofhaemo- ates a series of metabolic and musculocardio- poiesis and increased haemolysis,12 increases in respiratory adaptations that influence oxygen sympathetically mediated glycogen depletion transport and utilisation. Whilst it is clear that at altitude,'3 and increased respiratory muscle adequate acclimatisation, or better still, being work after return to sea level.'4 In addition, born and raised at altitude, is necessary to there is a risk of developing more serious medi- achieve optimal physical performance at alti- cal complications at altitude, which include tude, scientific evidence to support the poten- acute mountain sickness, pulmonary oedema, tiating effects after return to sea level is at cardiac arrhythmias, and cerebral hypoxia. 5 present equivocal. Despite this, elite athletes The possible implications of changes in im- continue to spend considerable time and mune function at altitude have also been resources training at altitude, misled by subjec- largely ignored, despite accumulating evidence tive coaching opinion and the inconclusive of hypoxia mediated immunosupression." findings of a large number of uncontrolled In general, altitude training has been shown studies. Scientific investigation has focused on to improve performance at altitude, whereas no the optimisation of the theoretically beneficial unequivocal evidence exists to support the aspects of altitude acclimatisation, which in- claim that performance at sea level is improved. clude increases in blood haemoglobin concen- Table 1 summarises the theoretical advantages tration, elevated buffering capacity, and im- and disadvantages of altitude training for sea provements in the structural and biochemical level performance. properties of skeletal muscle. However, not all This review summarises the physiological aspects of altitude acclimatisation are benefi- rationale for altitude training as a means of cial; cardiac output and blood flow to skeletal enhancing endurance performance after return muscles decrease, and preliminary evidence to sea level. Factors that have been shown to has shown that hypoxia in itself is responsible affect the acclimatisation process and the sub- for a depression of immune function and sequent implications for exercise performance increased tissue damage mediated by oxidative at sea level will also be discussed. stress. Future research needs to focus on these Studies were located using five major data- less beneficial aspects of altitude training, the base searches, which included Medline, Em- http://bjsm.bmj.com/ implications of which pose a threat to both the base, Science Citation Index, Sports Discus, fitness and the health of the elite competitor. and Sport, in addition to extensive hand Paul Bert was the first investigator to show searching and cross referencing. All published that acclimatisation to a chronically reduced English studies, dating back from the present inspiratory partial pressure of oxygen (PIo,) day to 1956, that included physiological meas- invoked a series of central and peripheral urements during exercise before and after adaptations that served to maintain adequate hypoxic training were incorporated in the over- on September 28, 2021 by guest. Protected copyright. tissue oxygenation in healthy skeletal muscle,' all analysis. Ninety one investigations were physiological adaptations that have been subse- selected, which included 772 hypoxically quently implicated in the improvement in exer- trained experimental and 209 normoxically cise performance during altitude acclimatisa- trained control subjects. tion. However, it was not until half a century The investigations were subdivided accord- later that scientists suggested that the additive ing to whether a normoxically trained control stimulus of environmental hypoxia could po- group was incorporated into the experimental tentially compound the normal physiological design. Other classifications were made de- adaptations to endurance training and acceler- pending on the characteristics of the hypoxic ate performance improvements after return to stimulus, which included type (normobaric or sea level. This has stimulated an exponential hypobaric hypoxia; continuous or intermit- School ofApplied increase in scientific research, and, since 1984, tent), duration, and magnitude (calculated Sciences, University of 22 major reviews have summarised the physio- ambient Po,), and timing of physiological test- Glamorgan, logical implications ofaltitude training for both ing after the descent to sea level. Pontypridd, aerobic and anaerobic performance at altitude The continued popularity ofaltitude training Mid-Glamorgan, United Kingdom and after return to sea level. Of these reviews, has been influenced by two factors. Firstly, D M Bailey only eight have specifically focused on physical hypoxia in itself increases blood haemoglobin B Davies performance changes after return to sea level,2-9 (Hb) concentration, which has been shown to the most comprehensive of which was recently improve endurance performance. Secondly, Correspondence to: written by Wolski et al. 9 several of the best endurance runners in the D M Bailey. Few reviews have considered the potentially world have originated from East African coun- Accepted for publication less favourable physiological responses to tries that are based at altitude (1500-2000 m). 8 May 1997 moderate altitude exposure, which include Is it possible that either living and/or training at 184 Bailey, Davies Table 1 Physiological changes during altitude acclimatisation in native lowlanders; time from athletes who were born and raised at a course and theoretical implications for exercise performance at sea level median altitude of 2000 m above sea level. This Br J Sports Med: first published as 10.1136/bjsm.31.3.183 on 1 September 1997. Downloaded from Response phenomenon has prompted several compara- Physiological advantages time Physiological disadvantages Response time tive investigations into what, if any, physiologi- Increased free fatty acid Weeks Increased ventilation Immediate cal adaptations mediated by hypoxia could mobilisation contribute to their superiority in distance run- Increased haemoglobin Days Decreased cardiac output Days ning events. Much interest has focused on the Increased capillarity Months/ Decreased blood flow Days years? four steps of the oxygen transport system, Increased oxidative Weeks Immunosupression Immediate?/ namely alveolar ventilation, lung diffusion, cir- enzyme activity days culatory oxygen transport, and tissue oxygen Increased mitochondrial Weeks Increased oxidative stress and tissue Immediate volume damage extraction. Studies have shown that the native Increased dehydration Immediate highlander is characterised by a larger pulmo- Jet lag Immediate nary diffusion capacity32 and adaptations in the Decreased training intensity Immediate Acute mountain sickness Days structural and metabolic organisation of skel- Sunburn due to increased ultraviolet Immediate etal muscle that result in a tighter coupling B (290-320nm) between ATP hydrolysis and oxidative Catecholamine mediated glycogen Days-weeks depletion phosphorylation.33 These are the major factors Increased haemolysis Weeks that facilitate oxygen transport and utilisation. The significance of these adaptations has been altitude may contribute to their running elucidated in a series of investigations that have success? reported higher values for VO2MAXI,34 power output,35 arterial oxygen saturation,36 and cer- rationale for altitude ebral oxygen delivery37 during maximal exercise Physiological and decreased blood lactate33 3 and ammonia training concentrations38 for a given submaximal work AUTOLOGOUS BLOOD REINFUSION AND rate. ENDURANCE PERFORMANCE One of the most documented physiological To what extent these physiological adapta- adaptations to a reduced Ppo2 is the increased tions are acquired as the result ofinheritance or release of erythropoietin, which causes a hypobaric hypoxia is not well defined. The transient increase in red blood cell mass.'7 The influence of genetic factors on quantitative implications of secondary polycythaemia to oxygen transport was recently investigated in a both submaximal and maximal indices of unique study by Beall et al.39 They identified a endurance performance have been clearly major gene that enhances arterial oxygen satu- shown by studies that have artificially induced ration in sedentary Tibetan natives. The physi- erythrocythaemia after either autologous blood ological significance of this was shown by reinfusion' or subcutaneous injections of Niermeyer et al,40 who concluded that genetic recombinant human erythropoietin.'9 20 Table adaptations to hypobaric hypoxia resulted in 2 the research It improved oxygenation and conferred resistance summarises major findings. to subacute infantile mountain sickness. These has been reported that absolute maximal http://bjsm.bmj.com/ oxygen uptake (Vo2MAx) values are increased adaptations were more pronounced in a cohort by about 200 ml/min per g/dl increase in Hb, of Tibetan newborns whose ancestors have irrespective of the methods by which poly- resided
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